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Larry Bauer has once again posed questions to a group of us “Family Medicine Bloggers.” I find them interesting questions because, as someone who trains family Physicians, I often get asked about training philosophy. In addition, because of changes in accreditation requirements and work hours, there is often a question among educators as to whether we are leaving out the best part of medical training. Larry has posed two questions:
In your training, what 3 things (maximum) were stressed/emphasized to you regarding how to take good care of people?
In your experience, what 3 (maximum) lessons have you learned about taking good care of people? (if you had just three suggestions to pass on to students and residents regarding how to take good care of people, what would you say?)
My medical school training was at Tulane and my clinical training was mostly at Charity Hospital (also known as “The Big Free”) in the mid 1980s. It was a different time and a different place. There were no work hour restrictions, there was very little contact with attending physicians in conjunction with patient care, and as a student you had the distinct impression that you were an important part of the health care team (and occasionally the only thing standing between your patient and death).Everyone, from the dean down to the intern on the serviced stressed one thing:
“Know Your Patient!”
In a place like Charity, this could not be overemphasized as to call the “health care team” stressed would be a generous understatement. Although the health care environment our resident learn in today is quite different, I still cannot overemphasize the importance of this.
The hospital had open bay wards where everyone could see everything. I still have a distinct memory of me as a 3rd year medical student watching a gangly white medicine resident trying to describe in very technical terms (using the barium enema image as a teaching tool) what Crohn’s Disease was to an impoverished African-American patient who clearly did not believe that the image was of his insides, much less that his insides were defective in some way. It was clear to me from that day forward that I had to:
“Speak the patient’s language.”
It may be through a translator or to the patient and a parent, or to the child of an elderly patient, but it is less important for me to be accurate than it is for me to be understood.
I did my first year of residency at Portsmouth Naval Hospital in Internal Medicine and stayed on working the Emergency Department for a year waiting to become a Diving Medical Officer. As a ED doc walking in with one year of post-graduate experience, I could not be accused of being over-confident in my abilities. Many of the residents who had been with me throughout my PGY1 year were still in training and I interacted with them on a regular basis. I was functionally the “admit resident” and they were my consultants. The ED staff and my colleagues hammered home to me the lesson that:
“Medicine is a team sport.”
Never be afraid to ask for help. Always accept criticism and try to improve. Know what your role is in the health care team and hope that everyone else does as well. Put a good team in place and good care follows.
After I finished dive school, I was stationed in the clinic in Kaneohe, Hawaii. I got the job because no one else wanted it, based on rumors of what the job might entail. At the end of three years I had made a bit of money on a condo, seen almost everything to see in Hawaii, made friends for lifetime, learned I wanted to do Family Medicine, and had a wealth of experience in leadership positions. In other words:
“Make the best of the hand you are dealt.”
Admittedly, raising your hand to volunteer to go to Hawaii isn’t like agreeing to fight “a land war in Asia” but it might have turned out badly.
I did my residency in Family Medicine at South Alabama. Ellen Sakornbut knew that I wanted to do Academics and challenged me to acquire and maintain OB skills (I still take OB call 20 years later). In her words:
“OB keeps your practice young.”
As I find myself caring for an increasingly aging patient base (despite miraculously not aging myself!), I am grateful for that piece of advice when I see a pregnant patient in my practice (often, these days, the child of one of my older patients).
The last lesson that I learned in medical school and had emphasized in my internship, Navy career, and residency is this one:
“Always do the right thing.”
Of course, trying to figuring out what that is can be tricky!
As I have said before, I don’t like selecting colleagues through the Match. The process was established to allow students to get the best opportunity available and I feel that our program (and our patients who rely on our trainees to provide care) is in jeopardy every year. It always turns out better than I anticipate, so I shouldn’t complain. However, we have to interview 60 prospective residents to fill our six slots so I have a lot of conversations with prospective applicants. Our interviews are about 20 minutes (we have each applicant have a discussion with about 6 faculty, staff, and residents). Most of these interviews are very pleasant and informative to me (and I hope to the applicant). Others, not so much. In order to give you, the applicant, more “bang for your buck,”here is some unsolicited advice to those interested in a Family Medicine position in our program:
1) Avoid the “If it’s Tuesday, this must be Belgium” phenomena – I know that you are under a lot of pressure to obtain a position and have applied to a number of programs but it isn’t like we are one big program. Just a little time on Google and you can find out some information regarding Mobile, Alabama, the South, and even more specific information about our program. This way, when I ask the question “Why our program?” we can have a conversation and not just stare silently across the desk at each other.
2) Understand the specialty of Family Medicine and our unique training environment – We are the only specialty that offers extensive training in the outpatient setting. We offer experiences in the broader community. This means that the broader community is important ot our programs. While you may ask about the hospital, PLEASE ask about the community, the population we serve, and the unique activities our residents have the privilege to participate in.
3) Be able to articulate a vision for 3 years in the future – A three year training program is very concentrated. You will be expected to enter into training with an understanding of what the future will hold for you upon completion as that will help us. If you know what experiences you may want, I can tell you if we can provide the training environment. “I want to go to a third world country and do surgery as well as primary care” requires different training than “I want to work with patients with chronic illness in a suburban practice.” I am happy to have this discussion but ask that you be able to initiate it when I ask “Where do you see yourself three years from now?”
4) Understand Family Medicine “Fellowships” – We are different than Internal Medicine. Our “fellowships” are intended to enhance our generalist skill set, not limit our practice. More importantly, you can’t get into an Internal Medicine fellowship such as Cardiology from a Family Medicine training program. If you tell me you want to be a cardiologist, I have trouble believing you really want to be in my program.
5) If you don’t want to be here, don’t come – There are over 2700 Family Medicine entry level positions. Almost everyone that wants one has gotten one in their top three for the last 10 years. Pick three places and programs you REALLY want to be at and work on impressing those program directors. Applying to and interviewing at 30 programs makes you tired and makes me tired as well.
November 17 has been designated National Rural Health Day. Why do we need a day? As outlined by the State Offices of Rural Health,
Today more than ever, rural communities must address accessibility issues, a lack of healthcare providers, the needs of an aging population suffering from a greater number of chronic conditions, and larger percentages of un- and underinsured citizens. And rural hospitals – which are often the economic foundation of their communities in addition to being the primary providers of care – struggle daily as declining reimbursement rates and disproportionate funding levels make it challenging to serve their residents.
Why should you care? Rural health care is not just for rural residents. Anyone from any area can suddenly find themselves or someone very important to them in need of health care service in a rural area. Illnesses have a way of happening when visiting relatives. Automobile accidents happen in rural areas. 30 rural counties have motor vehicle accident death rates that are more than double the national rate with eight having rates that are more than triple the national rate. While there are a number of reasons for this disparity, the great variation in emergency medical service among the counties must be recognized as a contributing factor.
Here is Alabama, Governor Bentley will use the Day to draw attention to these problems but also highlight the successes:
- The Alabama Rural Development Office is focused on expanding the use of telehealth in rural hospitals, community health centers, nursing homes, and schools to bring specialty medical care to rural areas.
- The Rural Medical Scholars program at the University of Alabama and the Rural Medicine Program at Auburn University encourage rural students to practice primary care in rural and underserved communities throughout Alabama.
- The Alabama Office of Primary Care and Rural Health offers scholarship and loan repayment programs to primary care providers who choose to practice in health professional shortage areas.
- Safety net providers such as rural hospitals, federally qualified health centers, rural health clinics, county health departments, and volunteer free clinics provide primary care services to vulnerable populations who would otherwise not have their health care needs met.
Click here to learn about successes from around the country as well as what you can do to help Celebrate the Power of Rural.
I was asked to prepare for a discussion on what the role of primary care in our Academic Health Center should be. This will happen tomorrow. I have spent the better of 2 days trying to decide exactly what that role is.
I’ve decided to begin with the definition that the American Academy of Family Physicians uses:
- Primary care providers offer a wide range of services including diagnosis and treatment of acute and chronic illnesses, disease prevention services and patient education.
- A primary care practice serves as the patient’s first point of entry into the health care system.
- A primary care practice is the continuing access point for all needed health care services
I decided to start here because I don’t know that my bosses have ever thought of primary care as other than another service line.
I plan to emphasize the second bullet point. We, like many other Academic Health Centers, have not taken the role of the primary care doctor in “entry into the health center” seriously. That has resulted in under-utilization of some of our specialty services and when I have conversations about care delivery they tend to go along these lines:
Surgeon: Why don’t you send me more patients.
Me: Only so many people need their gallbladders out.
Surgeon: You need to work harder.
I plan to spend the bulk of my time, though. not on where we’ve been but on where we are going.
My plan is to make the following points and let the discussion ensue:
- Although the Affordable Care Act (Obamacare to some in the audience) will increase the number of “covered lives” through the exchanges, increased Medicaid coverage, and allowing parents to keep their children on their insurance policy, there will be less money in health care in aggregate. There is no way we can justify spending over 17% of the gross domestic product on health care, especially given the outcomes the system produces.
- The Affordable Care Act has made system based approaches workable. Accountable Care Organizations and other forms of shared savings are being developed thanks to changes in CMS and in particular the Center for Medicare and Medicaid Innovation
- Good primary care decreases costs and improves care. The way that primary care doctors are going to be paid is going to be different, though. We are not going to be paid on fee-for-service but instead on managing chronic illness and keeping people out of the hospital.
Decreasing costs is not necessarily a good thing for an Academic Health Center. AHCs tend to rely on high margin services to offset training costs.It may be that we decide not to invest in primary care, relying instead on traditional appeals to “local medical doctors” and developing high margin profit lines. If we elect to develop primary care, it will need to be with an eye to improving care, increasing quality and improving safety. I hope we don’t do it with an eye to putting patients into my specialty colleagues’ exam rooms.
When I was growing up the economy was terrible. The recession of the 1970s (with effects lasting until 1983) was characterized by both high unemployment and high inflation, leading to the presidency of Jimmy Carter and subsequently the presidency of Ronald Reagan. The last 30 years have been characterized by economic growth but at the expense of an increase in the wealth of the top 10% of the population and a concomitant decrease in the incomes of the bottom 50%. When this trend began, those who were the recipients of the increase were unapologetic in the display of their wealth, with Madonna’s Material Girl becoming an anthem of sorts. Acquiring wealth and displaying it was encouraged.
When I entered medical school in the 1980s, although it was understood that we would do well financially, financial incentives were not supposed to influence our decision making. Doctors made money but making money was not what being a doctor was about. We were told by our mentors to do the right thing by the patient and the money would follow. We were not guaranteed entry into the top 1%.
Today the top 1% of American households make more than $380,000 (US). As you can see from this survey, this level income is easily within the reach of most non-primary care specialists. As chronicled by Atul Gwande, in ways subtle and not -so-subtle, physicians are able to influence patients (consumers?) to purchase health care such that today THEY ARE THE 1 PERCENT.
I have my own set of thoughts regarding the discussions of wealth redistribution, progressive taxation, and the value to society of certain types of work as measured by income. I (probably selfishly) believe that physicians deserve to be valued by society. I worry that physicians (like Wall Street executives) confuse income with value to society. I discussed the spectacle of Michael Jackson’s life previously but really had convinced myself that this was a “one-of” episode. Conrad Murray and his obsession with money and willingness to (allegedly) commit murder to maintain a client was an aberration, right?
Today’s news brings more evidence that physicians are willing to be participants in harming people in exchange for money. Reported by Bloomberg and picked up by the AP, the market for stealing solid organs for transplant has moved from an urban legend status to reality:
[B]rokers use deception, violence and coercion to buy kidneys from impoverished people, mainly in underdeveloped countries, and then sell them to critically ill patients in more-affluent nations. The middlemen form alliances with doctors in leading hospitals who do these transplants for a fee, no questions asked.
Although the real bad guys are the gangs who kidnap the potential donors, the article lets the doctors off VERY EASY. In describing one transplant evaluation:
They took him to Metropolitano Hospital, where kidney specialist Gustavo Salvador sat down with Yafimau. Salvador, who did his medical training at Central University of Ecuador, says Yafimau showed him the document saying he wanted to donate a kidney.
“If someone comes to me and says, ‘I come to voluntarily say that I want to donate,’ then that’s as far as we go,” says Salvador, sitting in an office adorned with Salvador Dali prints. “I can’t investigate the life of the person. That’s not my job.”
Salvador says he was paid $800, his normal fee for referring a patient to a surgeon.
This scandal is not, for the most part, American in origin in the traditional sense. I do believe we have some culpability. First, in the same way those who trained the pilots who flew on 9/11 should have asked about the purpose of the training, our Graduate Medical Education system trains physicians with little to no discussion of manpower needs and ultimate outcome of training. If we train an excess of transplant surgeons they are going to have to practice somewhere and their skill set is limited. Our training should reflect manpower needs. Second, medicine as a commodity leads to poor decision making on the part of the physician and on the part of the patient. Third, physicians apparently need a set of rules imposed to prevent them from behaving badly. It was the Nazi atrocities that led to the reform of research ethics. What is it going to take to reform the ethics of clinical practice?
To get the point of this story you need to know the following:
1) A lot of teaching is done in the Socratic method where the teacher (that’s me) asks the resident (Andres in this case) questions to which the teacher knows the answer. In theory the teacher is trying to get the resident to remember the answer because of the active learning required to retrieve the answer from distant memory cell. Many residents suspect that often the teacher is asking something to which only he or she knows the answer and the resident will never answer correctly. This makes makes the teacher (me) look really smart and is known as “pimping the resident.”
2) Pitocin is a medicine which is given in small doses to women who are in need of delivery to cause contractions and hasten labor and in large doses to those already delivered to clamp down the uterus
3) A twin pregnancy occurs naturally in about 1 in every 100 pregnancies
4) Evidence-based medicine is the practice of medicine using empirically derived evidence as opposed to anecdotes and clinical experience. The Cochrane database is an accepted place to go for evidence based medicine. The evidence for the use of Pitocin prior to the placenta coming out is that bleeding associated with childbirth might be reduced but other risks might outweigh the benefit…
Andres to nurse: Placenta is out!
Nurse: Pitocin is going!
Me (pimping): Andres, do you know why we wait until after the placenta is out to hang the pitocin at this hospital?
Me: The evidence is that if you give it before the placenta is out you will reduce bleeding. Because of the theoretical risk to an undiagnosed twin, we wait. If you give such a large dose of Pitocin you could kill a twin. Now that everyone gets ultrasounds I suspect it isn’t a concern and is a holdover from when you never knew how many babies were coming until the last placenta was out.The risk of undiagnosed twins today is probably overrated. I do remember when I was a medical student at Charity…
Nurse (clearly wanting to stop the story): We’ve had 3 undiagnosed twins this year that I know of. Some folks just don’t get prenatal care…
All my deliveries this weekend were singletons….
I was asked to speak to the pre-med honors society at the University of Alabama about the new health care law (either the Affordable Care Act or ObamaCare depending on your preferred news channel) but that is a story for another day. On the way back to Mobile, being untroubled by an Interstate highway in that part of the state, we decided to take the (way) back roads to eat lunch at an out of the way “fish camp.” While sitting down at Ezell’s Fish Camp (“The Holy Grail and standard bearer of catfish camps.”) in Laveda Alabama I spy a person walking in with what is clearly a medical office staff who I think I recognize. It turns out that it was Bernita Mims, MD who graduated from our residency and is now working in Butler. It is a very small state!
I later was speaking to the waitress and she reminded me that Karen Manning, MD, a family physician who is one of our community faculty, has an office in Toxey, Alabama (Population 152). As we were driving through Toxey anyway, I stopped by to say hello. Dr Manning has an Rural Health Clinic which she shares with a Nurse Practitioner. I had a long conversation with her a couple of years ago where (as she recalls) I encouraged her to set up the practice and break away from the hospital system that was supporting her at the time. I was able to tour her new office and was impressed by the efficiency of the design, the effectiveness of the staff, and the ability of the office to bring medical care including lab, x-ray, and now ultrasound to a very rural part of the state. I was also impressed by the built-in child care arrangement that facilitates employee attendance and I’m sure accounts for the high employee morale.
As I finished my drive through rural Alabama and hit other towns where we have placed physicians, I was reminded of why I went into academic medicine. As a physician I can only reach so many people but as an academician I can extend that reach. Although we still have profound shortages in this state, at least we as a department are doing our part.
Being a Tulane Medical School alumni, I get a lot of information regarding my alma mater (mostly implying I should donate money). I was heartened to be spammed with a story about the growing clinical presence in community health centers. I have written in the past about the possibilities in such partnerships and have been following Tulane’s progress for several years. They are now involved in multiple sites (website found here) and have plans to expand even further.
I sent a copy of the article to my boss and he wanted to hear what I thought we could do if we chose to emulate Tulane. After some thought, I decided we might focus on these areas:
- Tulane made a decision to partner with Community Health Centers in part because they were able to draw down resources for caring for the poor better than they could through the old Charity Hospital system . USA Family Medicine should consider partnering with a Community Health Center and creating a Teaching Health Center under their umbrella. This would enable us to work with Medicaid/Medicare more effectively and use the additional resources to improve the program.
- Here in Mobile, the community safety net needs to focus on health, not illness (as happened in New Orleans after Katrina). South Alabama needs to be the leaders in this. Someone needs to initiate and carry out a discussion regarding the health of our community, and who better than a medical school. We at South Alabama have focused our energy on taking care of sick people in the hospital and that is not where care will take place in the future.
- Our medical school should add an emphasis on training learners to care for folks with chronic illness in a non-hospital setting and what better location to do it in than a well run Community Health Center. An article published last week in NEJM demonstrated excellent diabetic care could be accomplished in Community Health Center settings. Why shouldn’t students learn about this first hand?
In short, health care delivery is changing. New Orleans, as a result of a man made tragedy, has had to face some tough choices. Regarding health care delivery, the city seems to be better for it. I hope it doesn’t take a tragedy for the rest of us to take a hard look at our care delivery efforts.
I have had a busy week with meetings in Montgomery and Selma Alabama (including a flat tire by a sign labelled Double Tree Alabama that must indicate a town but doesn’t appear on Google maps, that’s how rural it was). At the meeting in Selma (which I meant to post on Wednesday but was preoccupied trying to figure out how Volkswagen could sell a car without a jack but with lug nuts that require a special not-included tool to get off, thus requiring me to sit and watch deer while waiting for the tow truck) Mike Harrington presented the work of the AMC-21 Primary Care Steering Committee. This committee presented suggestions to the UAB dean regarding improving primary care in Alabama. I could quibble with the definition of primary care but all in all these suggestions are very good and applicable to all interested in improving primary care. They are as follows:
- Create Primary Care scholars program
- Increase scholarships/loan repayment programs
- Add Associate Dean of Primary Care to the Dean’s council
- Increase rural pipeline slots from 20 to 40
- Work on obtaining AHEC
- Develop primary care leadership academy and expand faculty to function as mentors
- Increase primary care GME positions
- Increase collaborations with FQHCs as Teaching Health Centers
- Incorporate intensive Primary Care exposure in ICM
There is an interesting article in the New York Times (found here) about sleep deprivation and physicians-in-training. A new set of work rules for doctors in training (residents) took effect on July 1st of this year. There was one rather odd requirements where the 1st year resident can work up to 16 hours but must then get 10 hours off, causing those of us involved with training to do a little head scratching about how to make that work. Did that mean residents come in 2 hours later every day? Talk about a screwed up circadian rhythm.
The article in the Times pointed out that despite severe reductions in work hours over the past 10 years, care related errors have not decreased and have in fact increased. The implication was that perhaps the hours, themselves, were not to blame. The comments accompanying the article were predictable. Many were from older doctors (likely my age) relating how they were able to resurrect folks from the dead but only after working for 35 hours straight. Some were from physicians who are currently in training (and thus only know the work-limited training model) talking either talking about how they would never learn resurrection without being allowed to work 30 hours straight or conversely how they disbelieved the older doctors stories. I trained in a time and setting where the hours were unlimited. I do not recall any specific abilities granted me by virtue of working long hours. I do recall being bone-tired after a day in the office, a night of working to fix some very sick people, followed by a day in the office. I certainly never felt I was doing my best at hour number 36.
The real story is not about one young woman (Libby Zion) who died in New York and her dad’s efforts to affix blame and correct a common sense problem (working for 36 hours straight can never be good). It is about system change:
But all of these hospital reforms ignore what may be the biggest problem in physician training today: the yawning chasm between what most doctors learn during the 80 hours a week they spend training in hospitals and what they actually do after leaving their residencies. Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.
The old method of physician training is dead. We used to think we could put physicians in training and really sick poor people in the same building, and poor people would get at least some care and learners would get training. It was this model that Medicare put money into in the 1960s. This evolved into a different model. In the current model some (if not all in some teaching hospitals) of the inexpensive trainee labor is re-purposed to provide help for physicians providing complex care for paying patients. As we ratchet back the inexpensive labor, changes are going to have to happen.
As I have discussed here and here and as Dr Sanghavi discusses much more eloquently, the current training system does not prepare learners for practice and now is shown to contribute to fragmented, error prone care. It is time to re-think the entire process. In the words of the man who sets policy:
“For people who came out of the old training system, it may be hard to imagine one that works better,” says Donald Berwick, the director of the Centers for Medicare and Medicaid Services and former president of the Institute for Healthcare Improvement. “The point is, it’s all about design and coming up with optimizing models.”
Poor people need care other than in the hospital provided by over-tired trainees. Trainees need to learn about care delivery in settings that prepare them for a future of error free practice. Hospitals need to wean themselves from cheap labor provided in the name of training.
Also, I kind of think the resurrection stories were exaggerated.