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.”

Wednesday, October 26, 2011

Lifelong Learning: what does it mean to you?

I read a wonderful brief article today about lifelong learning in medicine, specifically in the field of pediatrics.  Our medical school adopted a competency-based curriculum many years ago, and one of the nine competencies is lifelong learning.  But what does this mean?
To me, it means that as physicians, we should never stop trying to learn.  Medicine is changing so rapidly, that the skill of how to learn is as important as the skill of knowing what to do for patients at any given time.  The skill of knowing how to get information is also an essential trait for physicians, and this has definitely changed from not too long ago.  When I did my residency training (1994-1998), we were expected to get “the textbook”, and read it [eventually].  Nowadays, there are way too many textbooks, in addition to online resources, journals, social media outlets and many other sources.
Some people believe that the knowledge stops once someone receives the medical degree.  Nothing could be further from the truth.  Others believe that the knowledge is done after residency training.  This is also false, in my opinion.  This is why there really is a continuum between UME (undergraduate medical education, AKA “medical school”), GME (residency training) and CME (continuing medical education).  The same lifelong learning skills one learns in medical school apply 15 years after completing residency.
But how do we continue to learn?  What is the drive to help us learn?  Is it just knowing?  Is it the feeling of being able to answer questions?  Is it the effect on patient outcomes that drives us to always learn?  I am not sure that there is a correct answer to this for everyone; rather, each person has her/his own answer to these questions.
Whichever is your personal answer, please remember that the zest for more knowledge is a wonderful trait, and is essential for good doctoring in today's era of medicine.  It can make us reflect on how to improve the care we provide for our patients, and will ultimately make our patients better off.

Sunday, October 2, 2011

The Costs of Medical Care

Medical care costs a lot of money.  Most patients do not understand how much care actually cost.  For that matter, most doctors do not understand how much the care that they provide actually costs.  Recently, I participated in a Twitter-chat (#meded, on Thursday nights, 9 pm EST) on issues around the costs of care and how it should be stressed more often than it is.  Several take-home points are worth expanding upon, and other thoughts came to mind after participating in this wonderful online discussion.
Doctors and doctors-in-training should be educated on the costs of the care that they provide.  This is becoming more important given the issues at hand regarding the economy; the percentage of the GDP which is attributed to health care continues to increase.  This increase is not sustainable.
There are others who are making strides to educate health care professionals about the costs of care; here is one such group:
Our medical system in the United States is costing way too much money, yet many feel that reimbursement should be higher than it is.  While I personally understand the views from each side, I do feel that we can lower costs and improve quality, but it will take a team effort to be able to accomplish this laudable goal.
Prevention still costs less than subsequent treatment.  Money invested in prevention is money well spent.
Administrative costs (including time) seem to be taking up more and more of physicians’ time.  Burdensome paperwork requirements are what frustrate many physicians and take them away from what they are trained to do best: care for patients.  Administrative issues might be what drives many away from continuing in the noble profession of medicine.
Doctors are still paid very well in our society compared with other professions.   While some are paid less (e.g. primary care physicians such as myself), they still are paid quite well.
Something ought to be done about the costs of medical care.  As we still need to provide adequate care to all, the million-dollar question is “what”?