Sunday, September 18, 2011

Love Education and Like Education

I am a Program Director for a Residency.  That means that I oversee the training of physician residents training in my field: from what material they are educated on, to how they are educated.  There are certain rules that must be followed, such as providing a minimum amount of vacation per year, designing models for appropriate supervision, how they document the number of patients they see, and the duty hour rules. 
I just finished a half-month of duty on the inpatient ward service.  I always enjoy this time, as it gets me back to why I went into medicine in the first place: to care for patients.  I was able to see firsthand how residents and students are taking histories, are interacting with patients and colleagues, and are performing physical examinations.  In addition, I feel privileged to teach “this is how one can think like a doctor.”
Suffice it to say: I “love” education.  Most of us who have part of our salary dedicated to education (all program directors must have this) would likely get lumped into this “Love Education” bucket.  Others in this category would include clerkship directors (those physicians who oversee required rotations for 3rd year or 4th year medical students), fellowship directors for subspecialties, and Deans of Student Affairs, to name just a few.  These types of physicians still constitute a small percentage of the entire faculty.
The majority of the faculty I would lump into the other bucket: “Like Education”.  These are physicians who primarily see patients and/or direct programs, or are involved in research.  Their jobs include primarily seeing patients in either the inpatient or the outpatient settings.  They may also direct certain clinical programs (e.g., Medical Director of the Cystic Fibrosis program, Director of Outpatient Dialysis Program).  In other words, they are not directly responsible for the oversight of education of residents or students, but have a key role in providing that education, by hosting students or residents in the venues where they care for patients.  They are the ones doing the majority of the actual day-to-day teaching.  They may be (and usually are) phenomenal teachers, and certainly enjoy interacting with residents or medical students. 
Here is my concern: we are losing more “Like Education”-doctors to the reality of the ever-increasing requirements such as the duty hours. 
“Well, I’m just too busy now to take a resident; gotta see more patients, you know.” 
“I enjoy having students in the office, but they slow me down, and thus I can’t see as many patients” 
“I would love to host a medical student now, but unfortunately, just cannot do so, as the documentation requirements just keep going up and up.” 
These are NOT bad people: they like educating our future physicians, but external forces (whatever they are) prevent them from being able to continue their “like” of educating the future physicians.
My concern is that these are the physicians who really make a difference for the training, who really are the ones that the trainees see interacting with patients, and who mentor the trainees.  I hope that the regulatory requirements will eventually hit a tipping point, and can eventually be lessened, so that we will have enough doctors who like educating future doctors to actually do so. 
The “Love Education” physicians will continue to educate no matter what (mostly because it is part of their job).  It is the “Like Education” physicians that need encouragement to continue to be great educators.  Let’s continue to support “Like Education” physicians, in order to keep training alive and well.  They are a necessary component of education, are truly the backbone of what is needed to educate physician trainees, and should be rewarded as such.

Saturday, September 3, 2011

Tough Love and Administrative Professionalism

When doctors and other health care personnel care for patients, it is important to establish a relationship in which the patient feels comfortable in opening up about his/her health.  This can include sensitive discussions, such as the sexual history, the use of illegal substances, and mental health issues.
When certain conditions are due to patient’s “lifestyle”, then it is the doctor’s duty to discuss lifestyle modification.  This may include, for example, counseling on smoking cessation, eating a healthy diet, exercise, practicing safe sex, refraining from harmful substances such as cocaine, and other discussions.  The medical professional may use motivational interviewing as one method to deliver these difficult conversations.
How far do we need to go, though?  For patients with peripheral vascular disease who continue to smoke, when we know that the ONE thing that will help the patient as much as any other intervention is smoking cessation, what are we obligated to tell our patients, and how do we say it without alienating the patient?  Do we discuss how much personal responsibility the patients need to take? 
The same concepts are true when we are working with learners who are struggling in some dimension of their training.  Sometimes it is a medical student who is chronically late for clinic, but we know who is otherwise excellent with regards to patient communication, and spends that extra time so many patients crave.  How do we say that the student needs to be on time, when we know that she is probably taking time with other patients in a different setting?  Which patient is “more important” and how do we relay that to the learner?
What do we say to the resident who never completes his administrative duties, such as completing duty hour forms, logging their required number of patients, or turning in vacation requests on time?  What is the tough love there?  I have found that those same residents who struggle with “administrative professionalism” are also the ones who, after they graduate, will then suddenly call, email, or even page me, needing credentialing papers done immediately, “because if you don’t do them by the end of today, then I can’t start working”.  Is there a version of tough love for those discussions? 
I am a firm believer that what is “most important” is the care of the patient.  I know that Francis Peabody, who stated The secret of the care of the patient is in caring for the patient,  never had to deal with EMRs, competencies, clinical documentation improvement programs, credentialing papers, milestone documentation, RRC site visits, or other administrative duties which come part and parcel with being a medical educator.  But the times have changed.
With this piece, I realize that I raise more questions than answers.  What are your thoughts on this topic?