Saturday, October 29, 2011

Advocacy in Medical Education

Doctors spend a long time in training.  In the United States, this involves 4 years of medical school, and usually 3-7 years in residency (4 for my specialty of Medicine-Pediatrics, or “Med-Peds”).  Those that pursue fellowship spend even more time learning their craft.  It is truly a privilege to be able to care for patients.  However, in today’s environment, doctors need to know so much more.  Motivational interviewing, managing obesity, and other skills are critical for physicians to do the best for their patients.  Today’s medical students and residents have a lot on their plates to learn, and with the duty hour changes, it is even more of a challenge.
Our government is at a crossroads right now.  Our country’s spending is truly out of control, for many reasons.  Health care costs a lot of money, and it seems to be getting even more expensive year after year.  Doctors don’t know how much things actually cost.  Insurance costs more and more for less and less nowadays.  Given the current state of medicine, it is time that doctors become advocates for their patients in different ways.  They’ve been doing it all along (for example, writing letters to insurance companies stating why a patient needs a medicine not on formulary).  But shouldn’t we be advocates at a larger level, such as in Washington?  Shouldn’t we be telling our stories and those of our patients to our constituents?
What is the reason for this lack of advocacy at a national level?  Is it because we are not teaching advocacy?  The American Academy of Pediatrics has intense advocacy efforts in Washington to advocate for the care and health of children, as does the American College of Physicians for adults.  It is interesting: pediatric training requires learning about advocacy within the community (see page 26 of this link).  Internal medicine training, however does not require formal learning about advocacy.  It should, in my opinion.  Some programs offer curricula in advocacy, and do it well.  There are certainly wonderful venues within internal medicine that focus on advocacy in the care of adults: the ACP, SGIM and AAIM are three such organizations, but awareness by trainees in these areas is limited.
What can we do to help medical trainees advocate for patients nationally?  First, have residents learn about advocacy efforts and how they can get involved.  Second, mentor residents who have an interest in advocacy, which includes giving them the opportunity to go to national meetings that have an advocacy focus.  The CATCH grants through the AAP, or ACP’s Leadership Day are wonderful examples.  Third, physicians need to be stewards related to costs of care, and education on the costs of care must become front and center, not just as a “formal curriculum”, but rather in the day-to-day care of patients.  This means talking about costs while we care for patients, not in isolation.
Let’s inform the "Super-committee" about the issues that are important for doctors-in-training and patients.  First,  GME is a public good (I've been Tweeting this for several weeks now, and heard the same quote from Bob Doherty at the Indiana ACP meeting yesterday as well).  Second, continued funding of GME should not be dropped, whether the funding comes from the federal government or distributed among other payers.  Third, doctors need to be given time to spend with patients, not complete more paperwork.  Fourth, please reward and support training in the primary care fields, which has been shown to improve care and lower costs.  And lastly, and probably most importantly, let doctors who sacrifice so much to be given the privilege of caring for patients be able to actually care for patients, as quoted by Dr. Francis Peabody many years ago: “ … for the secret of the care of the patient is in caring for the patient.”


  1. I'm with you, let's turn this system upside down and get one that pays more for thinking than for doing!

    I think part of the problem is that there is still a conception in this country that doctors make buckets and buckets full of money. I am in no way trying to cry poverty, as we as a whole do very well. However, with the large debt burden that we take on, and the fact that we are a good 10 years behind our college classmates in terms of accrued earning power (among other issues) it's not like we are lighting our expensive cigars with $100 bills and going swimming in our money filled pools. All of this to say, that when non-medical people see things like the government paying to educate medical residents or doctors asking to be reimbursed more by CMS, we look like fat cats trying to get fatter. We look like an easy and safe target for cutting. These things are not seen as an investment in the public good or the basic health of our nation.

  2. well stated and great minds think alike today about GME & Advocacy!

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