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I spent the last several days engaged in a discussion over immigration policy enforcement in Alabama. I had worked to get the national meeting of the Association of Departments of Family Medicine to schedule their 2013 meeting in Mobile. Upon announcing Mobile as a site, the group was immediately made aware of the passage, enactment, and subsequent enforcement of HB 56. Living and working in downtown Mobile, I had always thought of us as described by the Downtown Mobile Alliance:

Mobile is the most cosmopolitan city in the state of Alabama, home to several international corporations that have enjoyed wonderful relationships with the city and its citizens. The Downtown Mobile Alliance actively seeks to create an atmosphere where diverse cultural, ethnic and demographic groups are welcome and encouraged to enjoy our 300 years of hospitality.

Instead, I had to admit that the reality is:

H.B. 56 requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.

 In addition, there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future):

It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.

In short, if you “look illegal” in Alabama, the police will have the right (if this law is upheld) to detain you until you can prove you belong in America. This concerned ALL of our Latino members, who felt they could not be assured safe passage.

These are not idle concerns. The most recent issue of Mother Jones magazine details some of the consequences of the law, including:

As of this writing, under the new guidelines of the law, Tuscaloosa police have arrested 141 people for driving without proper identification: 97 blacks, 34 Latinos, and 10 whites. Twenty-eight people were handed over to ICE, though officials could not confirm how many, if any, have been deported

Among the arrested was a German executive from Merecedes Benz, so I guess it isn’t all about brown people. The organization elected to move the meeting from Alabama, at a significant loss to the organization and to the city. This prompted a reader of the local coverage to post the following comment about undocumented workers:

Don’t tell me that they pay taxes, I know, they pay taxes on purchases but not on income. So, as you say, and I am a Christian, whatever you do to the least of these, you also do unto me. That knife cuts both ways.

In the book Educating Physicians, which is being used as a template for medical school reform, the importance of physician advocacy on behalf of patients is emphasized. Examples of this advocacy included volunteering time at local school events, volunteering on local boards which further the health of the community, as well as collective action to produce better policy. The authors feel that through these collective actions the professional values and identity of the professional group is continually refined. The organizational logo of ADFM includes the statement “Vision, Voice, Leadership.” The actions of the organization in this case speak even louder.

The state of Alabama has a generous retirement system for teachers and other public employees. After working for 25 years (regardless of age), you can retire. This has been a boon for teachers (by far the largest employee group in the state). The legislature was successful this past session  in putting into place an increase in the employee match over the strong objections of the teachers. The problem was not the cost of the pension itself, which has been relatively secure as a result of investments on the behalf of the System. What will bankrupt us is the cost of health insurance. If a teacher retires at 47 (possible under the current system), he or she will be retired for 15 years longer than his or her working life. The health insurance product that is offered (PEEHIP) is a PPO. This means that the beneficiary pays a fixed amount and if he or she goes to a preferred provider there is little or no “skin in the game” for either one. As health care costs have risen, the premium paid by the retiree (about $4,000 annually for family coverage if not Medicare eligible) is only 30% of the total premium ($12,000 annually) with the rest paid by the state. Back when high health care costs were economic multipliers that were  GOOD, a report identified that

…healthcare payments surpassed $1.4 billion and over $1.3 billion went to Alabama providers and facilities.

Now that health care costs (for PUBLIC EMPLOYEES) are bad

Alabama’s PEEHIP program needs an immediate comprehensive strategy for cost containment and pre-funding of PEEHIP benefits for future retirees. Of the three options available—raising taxes, reducing government spending, and reforming PEEHIP—only the latter two have the potential to both save the state money and keep the state’s economy from further harm.

I would argue that health care costs are what they are, they are very expensive for certain people in Alabama, and they are possibly most expensive for retired teachers. There are many things that we can do to reduce the cost of health care, but the first rule of change is that people have to want change for it to happen. In an editorial on the Kaiser Family Foundation website, Drew Altman talks about the realm of the possible. The regulations surrounding the Affordable Care Act are being written and put forward for public comment at a fairly rapid pace. As he points out

The regulations give states substantial flexibility in structuring exchanges, should they choose to set them up. (If a state doesn’t establish an exchange, then the Federal Government will operate one in the state.) In crafting the draft regulations, federal policymakers had to weigh how prescriptive to be. For example, they had to decide whether to prohibit insurance company representatives from serving on the boards of exchanges, or require exchanges to aggressively negotiate with insurers. In general, they erred on the side of less, rather than more, requirements.

My dream is that Alabama Medicaid, Alabama Blue Cross (the folks that manage PEEHIP) and our Republican physician governor will get in a room and petition CMS to allow a grand experiment on how we can do better. We should be able to provide adequate care for our poor, cost effective care for our retirees, and allow choices such that if you want to pay for excessive care, you can (at the risk of hastening your own death). If only Richard Nixon had gotten this law passed the first time around.

I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.

Earlier I spoke of nine things we can do in Alabama as consumers to strengthen rural health care. Having spent a couple of days in Austin at the National Rural Health Association conference, Dale Quinney and I brainstormed and came up with four things the state of Alabama can do to improve the health care delivery system in rural Alabama right now:

The pipeline for rural primary care providers needs to be strengthened rapidly and effectively. There are opportunities to strongly encourage (pressure) Academic Health Centers in Alabama to produce sufficient primary care providers of the right background who are committed to practice in rural Alabama. These providers should include not only physicians who will go into Family Medicine, RURAL pediatrics or RURAL Internal Medicine but should also include mid level providers to be a part of the health care team. Alabama programs are leaders in selective admissions, pipeline programs, and rural tracks in both UAB and USA, wiht examples found here and here. Considerable expansion coupled with measurable outcomes (entrance into primary care specific post-graduate training, entrance into practice in rural Alabama, continued practice at 5 and 10 years) should lead to more providers very quickly.

Enhancing primary care delivery quickly will result in an improvement in health outcomes. The Office of Rural Health/Office of Primary Care or another agency in the Alabama Department of Public Health needs to become a leader in facilitating practice transformation. Physicians in rural Alabama will need more than just computers in their offices to practice in the new age of accountability and quality improvement. The Office should have sufficient staff and resources to functionally coordinate efforts by a myriad of agencies including AQAF, BC/BS, Al-REC and other HIE entities. The goal should be that every primary care practice in rural Alabama has the opportunity to participate in practice improvement activities and deliver measurably enhanced primary care. The goal should be that every primary care practice should be able to qualify for NCQA Patient Centered Medical Home Level 3 status within 5 years

The rules for licensure and practice protocols need to be scrutinized.  There are numerous instances where professional organizations or trade organizations have been allowed to make rules that while making sense on the face, serve to reduce the efficiency of rural practice. This is more true as technology changes.  An example is the Board of Dental Examiners which only tests once a year and does not grant reciprocity such that should a dentist consider relocating to Alabama he or she would have only one opportunity to do so annually. Given the ease of giving a test at a testing center, this seems antiquated. Another is the Alabama Board of Pharmacy’s rules limiting or preventing  telepharmacy, which would be a boon to rural hospitals. A third example is one of Psychiatry. There are acute mental illness needs in every state. In Alabama, these are exacerbated by a chronic shortage of mental health professionals. Several times over the past 10 years we have had natural or man made disasters where voluntary mental  health professionals have desired to come and assist with the acute crisis only to be thwarted by the Board of Medical Examiners. There are many  such instances that need to be addressed. There needs to be attention paid to this rapidly as technological advances have already outpaced many of these rules.

Technology such as telehealth offers tremendous opportunity to transform care delivery but there needs to be a local infrastructure in place. There are many examples of telehealth  and other technologies reducing disparities, eliminating costly transportation, and improving care. For the most part, these technologies are coupled with robust primary care and community hospital resources. It is vital to leverage technology to improve care. It is clear, however,  and supported by data that without the “high touch” component best exemplified in primary care practices outcomes will remain below that of the country and the rest of rural America. There needs to be an office whose responsibility is to assure that technology is leveraged to its fullest but that the outcome is always improved health for the citizens of Alabama.

Last week I spoke of a goal for care delivery in Alabama that I believe is achievable.  This goal is not Alabama specific although given some of our health markers I suspect we have more “opportunities” than most. This goal was long on vision but short on specifics. Today I want to offer nine specific challenges to us all (targeted to consumers because we are all health care consumers) that I believe will help push the health care delivery system in Alabama towards that goal. If we as patients and/or a provider demand care in this manner, it will happen (maybe).

1) If quality care exists in your community, use it

This is the most important point of them all. We all know that people choose a physician based on affability, availability, and ability is assumed. Unfortunately in rural America ability is not assumed. The phenomena of bypass is a testament to this fact. Patients need to be educated regarding certification by accrediting bodies and the implication regarding “ability. This means the JC for hospitals and NCQA for ambulatory sites.  Physicians need to demand transparency. Post practice data and encourage others to make practice data available. Hospitals are now making hospital data available hospitalcompare.hhs.gov.  Patients need to be educated to be vocal if demands are not met and most importantly, not to just vote with their feet

2) Demand improved  primary care (and be willing to pay for it)

Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. The academic work can be found here and a resource can be found here.

3) Seek out and use “Medical Homes” for health care

The American Academy of Family Physicians has been working for the past 5 years on creating a type of primary care practice for the future. They refer to their model as the Patient Centered Medical Home (PCMH) and more information can be found here. Family physicians have been called America’s best kept secret. The majority of them are changing over their practices to Patient Centered Medical Homes.  In a PCMH quality care is documented, measured and improved. The patient experience is enjoyable and patients are encouraged to communicate and self-manage problems. Technology is used to improve the care experience. The care experience is continuously improved. There will be a certification process that will probably be through NCQA.

4) Find physicians who have conquered the digital divide

Without electronic health records, it is almost impossible to accomplish chronic disease management. With an electronic health record, however, a VA in rural West Virginia showed a significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol).  There are now Health Information Exchanges being developed that will facilitate E-prescribing, receipt of structured lab results, and sharing patient care summaries across unaffiliated organizations. In addition, congress has directed the development of Regional Extension Centers to help physicians “get connected.” Alabama’s Center is Al-Rec. These centers are charged with providing education and outreach to providers, assist with vendor selection and purchasing for electronic health records, and provide workflow design consultation. In addition, these centers are tasked with promoting interoperability.

5) Find a doctor comfortable with telehealth/telemedicine

Telemedicine is effective but expensive, We have very  good evidence for improved outcomes in toxicology (Poison Control) where Every $1 spent on manning phones saves more than $7 in avoided health care charges. We also have evidence for ophthalmology, orthopedics and fracture care,  telemetry, stroke treatment, and dermatology. Unfortunately, the expense is difficult for many practicing physicians to cope with but if patients were to demand remote access there are effective solutions.

6) Demand a focus on quality

Rural hospitals that use established guidelines, such as the American Heart Association’s  GWTG-CAD performance measurements,  mortality is same as in urban settings. The performance measures mentioned above include recommendations such as early aspirin use, smoking cessation counseling, and use of certain drugs at discharge that are very easy to follow. Better systems, not more expensive equipment, save lives and are easily achievable in rural America.

7) Demand provides in your community to collaborate, collaborate, collaborate

If there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration. Only 19% of critical access hospitals  report  a collaborative relationship with CHCs. Barriers include a lack of knowledge about the other and competition for patients. In communities where this collaboration happens, there are improved primary and preventive health services, improved Inpatient care, better 24 hour emergency care and  better access to specialty care.

8 ) Encourage mental health and primary care to work together

Primary care is already used 50% of the time for those seeking care for mental illness. Persons with mental illness are more likely to make a visit to their primary care doctor to receive care than they are to go purposefully to a mental health professional.  Primary care doctors do have a lack of recognition of mental health issues based on billing data but this may be an artifact of the billing system. Although there is currently a lack of integration of general medical and mental health services, there is a groing trend for physicians in private practice as well as rural health clinics to offer mental health services on site. This needs to be encouraged.

9) Work to build a healthy community

Health care delivery can only go so far. A healthy community is needed to move a community to being full on chronically ill individuals to one full of individuals who are chronically well.

I posted a week ago on health care and the market for rural America (and by extension, Alabama). I wanted to share with this group a vision that some of us at the Alabama Rural Health Association have. I will share some thoughts I have on how to achieve that vision later.

An Achievable Vision for Alabama

By 2021 Alabama will have a rural health infrastructure characterized by excellence in ACCESS and QUALITY. This system will have the following characteristics:

Access

  • Every rural Alabamian will have one or more primary care providers within 10 miles of his or her home offering acute care, chronic disease care, and preventive services for 60 hours a week
  • Every rural Alabamian will have a hospital within 30 miles offering critical need access 24/7/3
  • Every rural Alabamian will have ready access to needed specialty care within the state

Quality

  • Care provided in rural Alabama will be characterized by excellence
  • Primary care will be accessible to all residents regardless of ability to pay
  • Primary care will offer ongoing continuous care as characterized by stability of providers over time
  • Care will reflect coordination among physicians, hospitals, and other healthcare providers using electronic and other means
    • Primary care will coordinate care across all domains and facilitate access to needed services not located within the community
    • Care available within the community will be comprehensive, offering care beginning at pre-conception and ending with natural death
    • Care within the community will be characterized by use of accepted quality and safety measures, the results of which will be readily available to the members of the community
  • Care provided will reflect and enhance the culture of the community
  • Providers will understand the unique needs of the community and will provide services targeted to those needs
  • Providers will deliver services outside of the traditional office setting when needed, including at occupational sites, home and businesses, and other settings as needed


Beginning to sound like a broken record, the newly elected Alabama Republican state representatives are once again demonstrating their “market” credibility. They are quoted in the paper today as  identifying the state funded teachers health insurance as the place to insert needed market reforms. The legislators and the governor are quoted as having this as a priority:

Starting health savings accounts for teachers and state agency employees. An employee and the state could put money into a person’s account, which would belong to the employee and could be used to pay medical costs. Together with the accounts, the state would offer high-deductible health insurance, which would save the state money.

  Such a plan, which Bentley championed on the campaign trail, could cut the number of insurance claims paid by the state because people, in theory, would be less likely to seek medical care that wasn’t absolutely necessary if they had to pay more of their own money for it, said William Ashmore, chief executive of the State Employees’ Insurance Board.

As I have discussed before, HSAs are good theory but haven’t been shown to improve health or reduce risk taking behavior.  This was looked at more in-depth here and here (subscription required) with the following observations from the literature.

  • Cost savings for a care event have never been documented. For the most part the health costs seem lower because healthier people tend to use HSAs and spend their health care dollars on things such as dental work, vision care such as lasik, braces, cosmetic procedures, and maternity care.
  • Chronic illness care costs more in these types of plans and the “catastrophic” coverage often doesn’t kick in leaving people to make “hard decisions” regarding life saving treatments
  • People using these types of plans tend to disregard preventive recommendations leading to fewer immunizations, PAP smears, and mammograms and more late stage and preventable illness
  • People tended to make poor decisions about seeking care for serious symptoms (such as chest pain)

So why does this idea not die? Possibly because it is consistent with the  constant message from groups like the Heritage Foundation denying the benefit of all government oversight and extolling market solutions (regardless of the supporting evidence). For the most part I think it has traction because it seems intuitive that if people have “skin in the game” when it comes to their health purchases they will make better decisions. We would all like to believe that humans will make rational decisions, in particular when in comes to health, as no one wants to lose one’s health. Unfortunately, as my friend Josh Freeman has pointed out, most people use very little health care so have little opportunity to make decisions and influence the market. When folks need it, however, they really need it:

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

What HSAs do is encourage those people who are low utilizers to spend more on things that provide a marginal benefit, thus raising healthcare costs. A better way would be to work within the confines of the Affordable Care Act to create efficiencies within our state (as is being done in other states). If we are lucky our legislators will come to this conclusion as well before the HSA lobbyists sell them a new policy for the teachers and folks like me are left to clean up the mess.

A note for clarification: Apparently, state employees already can opt into an HSA. Someone should probably brief the Governor-elect on the existing options.

As I was poking around the AHRQ website looking at funding opportunities I ran across a state specific health “dashboard” that highlighted some different findings. I’m used to seeing Alabama not fare well when compared to other states. This set of measures hit closer to home as they are looking at measures that are more specific to primary care. While we did very poorly on some measures (48th best in colon cancer deaths, 35th best in care for congestive heart failure), we also had a notable exceptional measure (7th in communication with providers for certain Medicare beneficiaries).

This is the healthcareometer from the site for Alabama. You can see that unfortunately we are doing measurably worse than we were at baseline. I hope our physician governor will challenge those of us involved in care delivery to shoot for “strong” or “very strong” when the next snapshot is taken.

Jonathan Cohn has a very nice piece in the New Republic about Blue Cross, the transition from community rating to risk rating, and the transition from not-for-profit to ginormous profits. I recommend reading it as it explains better than I can why we’re in this mess. In sum, this is a very skewed market. A market based overhaul, while possible, would require a rethinking of our national sense of “goodness” (would we really be willing to let people die on the streets for the sin of being sicker?).

The question for those of us in Alabama is why, when Alabama Blue Cross is a not-for-profit, are our costs not lower. It would seem that not paying attention to the stock prices would make it a kinder, gentler company. After reading this article, I feel I gained a little insight into our unique problems.

First, apparently it may be that competition from the other insurers might be bad. When BC/BS of Alabama was the only game in town, it could afford to offer community ratings because it was a sole source provider. With other insurance companies bidding on insurance for businesses, Blue Cross claims (and they are probably correct) that they must offer rates and packages competitive with these insurers otherwise the HR folks won’t choose BC/BS. This was explained to me by the medical director of a HMO I used to work with when I was pushing him to offer more comprehensive care. he said he could push quality for an entire presentation and then the CEO would point out that the competitors rates were $1.00 per employee lower and what was he going to do about that? Without a benefits floor, it’s all about price.

Secondly, BC/BS is competing with itself. Every year or so, it goes to the client and discusses the new cost of care based on what happened in the company last year. The companies, for the most part, pay for all of their own costs and BC/BS takes a cut off the top (called a third-party adminstration fee). Don’t think the CEOs aren’t aware of which employees have cost them health care dollars and aren’t asking what can be done to alter benefits and render health care less expensive. Again the answer may be “nothing” but my bet is that if BC/BS offers that answer, United Health gives a different answer that may be more than a little draconian.

Lastly, we (Americans and Alabamians) are already paying for the most expensive health care utilizers. Almost 50% of the health care dollar is funded through our taxes and much of that goes to Medicare and Medicaid. Everyone (well 96%) of folks over 65 are Medicare eligible and consume quit a bit of health care in their last 20 – 30 years. Medicaid in Alabama covers the vast majority of premature infants. The goal of all good companies is to reduce risk. The best way to reduce health care risk is to move people who will consume health care completely out of the risk pool. Again, done potentially through manipulating copays and other means.

It looks like some of the tools to reform this system may make it to the President’s desk for signature. If not, the current system is still far from market based despite what some people  claim.

I was at a meeting of Family Medicine Department Chairs in Tuscon Arizona this past week. This is an exceptional meeting for hearing what other departments are doing regarding educating medical students, developing research activities around primary care, and learning about topics of importance to primary care (the Patient Centered Medical Home was the featured topic of the meeting). The reason to go to these meetings is to 1) confirm that you are doing stuff that others are doing and doing it better than they  2) confirm that you were correct in not doing stuff that seemed important at the time but you were convinced it would lead to disaster or 3) figure out how to make up for lost time when starting a task that should have been initiated several years ago.

This particular meeting featured a panel of exceptional students from the University of Arizona College of Medicine in Tuscon talking about what we (as educators) can do to foster interest in primary care. They were all committed to primary care and it was refreshing to hear from these idealistic students. Many of them were from rural Arizona or had life experiences that led them to enter medicine to make a difference in their patient’s lives. They did confess to being an exception in their class, with the majority of their fellow students focusing on materials needed for the test (the here and now) as opposed to the big picture.

 I confess to having a pang of regret. Our students did not to me seem so idealistic when our department faculty attempt to offer instruction in social issues as a part of the Fundamentals of Doctoring course here in Mobile. I wondered if perhaps our school is not as effective as other schools in fostering an attitude of social justice. I wondered if our students were too focused on the high stakes exam (NBME Step I) to get the big picture we were trying to draw for them. That was why I was pleased to receive a very nice e-mail today thanking my department for the perspective we bring to the 1st and 2nd year of medical school. It made me feel that maybe our efforts are worthwhile.

A long way of asking you to thank one of your teachers today…it’ll make them feel better.

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