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When Laennec invented the stethoscope in 1816 and physicians no longer had to put their ear to the patient’s breast, health care delivery changed. Asepsis, effective treatments for syphilis, and other breakthroughs soon followed. By 1910, medical education needed to move on as well.
Scientific breakthroughs had altered the values held by the public and the medical profession: clinical and laboratory research had exposed the irrationality of “heroic” treatments (such as blistering, bleeding, and purging) and had proven the therapeutic efficacy and rational scientific basis of modern practices, such as antiseptic surgery, vaccination, and public sanitation. Most of the public and virtually all physicians now believed in the superiority of scientific medicine
Medical education underwent a transformation that lasted until very recently. The first two years were heavily influenced by science and the medical students were taught, not by physicians but by “basic scientists” whose training was in anatomy, histology, biochemistry, physiology, and other “hard sciences.” Students were then allowed access to patients, with whom they would presumably spend the rest of their lives.
Does it work today? The LCME, the board that governs the majority of the medical schools in this country, looked at just that (report found here). The good news: Doctors trained under this system are knowledgeable and technically proficient in providing care for acute disease; they wish to do what is best for their patients; and patients respect them as credible sources of information.
The bad news? Again to paraphrase from the report:
- Physicians are not prepared to evaluate the care they provide in their own practices and to use the results to improve patient safety and the quality of care provided.
- Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession.
- Physicians often lose altruism and qualities of caring as they proceed through training and enter the practice environment.
- Because of their training, physicians find it difficult to deal with the inevitable uncertainty arising from incomplete or conflicting information. Additionally, they are not typically prepared to convey their uncertainty when interacting with patients and colleagues.
- Many physicians are not prepared to utilize information technology to assist in information acquisition and management.
- Physicians are trained to be autonomous. This can be a barrier to providing patient-centered care, where patient values and desires are an integral part of shared decision-making. The expectation of autonomy diminishes the ability of physicians to act as team players with other physicians and other health professionals.
- Physicians are not prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless.
- Graduates do not acquire skills in cultural competence/awareness and to recognize that some patients may have health literacy issues.
So, what’s the problem, you say? Teach the science and teach the humanism (like having chocolate and peanut butter together). The limiting factor is time and the explosion of factoids that are considered “vital” for a physician to know. Or, to put it another way by someone who thinks things are just fine:
Increasing emphasis on apprenticeship-based education and increased focus on the non-medical knowledge competencies inevitably will be at the expense of rigorous training in the basic sciences if the existing number of hours available for teaching are maintained.
In addition, the teaching of the lacking humanism skills will require another type of medical education specialist, one much more skilled in communication than in versed in scientific discovery. The basic scientist may be on the way out when it comes to educating physicians. The article referenced above is a plea for not allowing the science education of our nascent physicians to be diminished. The author expresses concern that though care may improve and patients may be more satisfied, we as a profession and our society may be poorer as a result. I would argue the system begun in the 1910s has left us with an expensive and not very effective care delivery platform and is destined for failure. I would also argue that we must improve the value (cost, quality, and efficiency) of our clinical care, a challenge that will require all physicians to be versed in the skills identified above as lacking. We need to teach smarter. If we do not, we may be seen as upholding our scientific standards as we bankrupt our society.
As a southerner, I really like colorful expressions. “That dog won’t hunt” is one that I use when I am hanging with my Yankee friends and I want them to give me a “what is he talking about” look. “I wouldn’t know him from Adam’s off ox” is one that I love but I find I have to explain it way too often as I am not usually hanging with people familiar with oxen team terminology. One that I find more useful as I get older is “lipstick on a pig” as in “That’s just putting lipstick on a pig.” The expression, per Wikipedia, describes “making superficial or cosmetic changes in a futile attempt to disguise the true nature of a product.”
The medical education process seems to have taken a “lipstick on a pig” approach to reform. I have written about what people want in a doctor before (found here) and here is WebMD’s list from an article in the Mayo Clinic Proceedings:
Traits listed by the patients, along with the patients’ definitions of those traits:
- Confident: “The doctor’s confidence gives me confidence.”
- Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
- Humane: “The doctor is caring, compassionate, and kind.”
- Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
- Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
- Respectful: “The doctor takes my input seriously and works with me.”
- Thorough: “The doctor is conscientious and persistent.”
Contrast that with the criteria for selection for medical school (grades and scores on a single standardized test) and the criteria for selection for residency training (grades and scores on a series of 2 standardized tests). It is my experience that test scores often don’t correlate with the things patients want in a doctor.
Recently, post-medical school training has attempted to emphasize qualities other than test-taking skills. The ACGME Outcomes Project, for example, has been in effect for 14 years and requires residencies providing post-medical school training to measure growth in characteristics such as those listed above. Efforts to change the medical student curriculum, though emphasizing the behavioral buzzwords found in the WebMD article, continue to have an assessment component focused using multiple choice type questions. Growth as a person is subordinated to acquiring knowledge for assessment via multiple choice testing, rendering the curriculum change efforts “lipstick on a pig.”
I have focused most of my career attempting to mold learners in their post-medical school years and have found that attitudes are set. Where residents come into the program from medical school regarding their attitudes towards patients is where they tend to stay. I was excited to recently come across this article, implying that it may be our educational efforts in the early training years that are lacking, not the learners’ ability to change. The authors suggest that the learners’ ability to store and regurgitate knowledge (IQ) was fixed, but their ability to incorporate professional values such as compassion and integrity (EQ) is fluid. To accomplish changes in behaviors and attitudes is going to mean not applying more lipstick but getting rid of a lot of the pig. Picking “listen to the patient” from a multiple choice answer list will no longer be a sufficient assessment. Assessing the learner at baseline (even prior to admission), establishing a set of non-negotiable standards, measuring behaviors using Standardized Patients as well as real patient encounters on multiple levels, using peer evaluations to capture attitudes not observed in formal settings, and forcing reflection on the part of the learner with the learner at risk of failure for not performing up to par will be necessary to effect these changes. It will mean changes in the training milieu as well. No more “Butt Boxes,” lists of words mispronounced by illiterate patients, comments about patients’ lack of “personal responsibility” to justify providing substandard care, or other activities that belittle or dehumanize patients in public or (more insidiously) private.
The authors suggest that establishing a strict standard and enforcing a “zero tolerance” for learners and faculty are necessary to drive this type of reform. I can only wonder if we can meet this standard or if we will quickly run out of faculty and students while trying to do so.
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.
I will share some good news regarding the primary care workforce that came out today in the AAFP News Now
The news is particularly good for family medicine and primary care. Seventy-five percent of the medical schools questioned have current or future plans to institute programs or policies to encourage student interest in primary care, including new or expanded elective clinical rotations, refined admissions criteria, modified required clinical rotations, modified preclinical curriculum, expanded primary care faculty and/or resources, and new or expanded extracurricular opportunities.
An object with a large mass moving at high-speed (such as a Navy ship) requires a lot of effort to turn as shown here. Health care consumes almost 20% of the economy, has a lot of momentum, and changing the direction is going to take a lot of energy. The Affordable Care Act includes several provisions that will move healthcare, discussed here. Many practices are experimenting with changes in care delivery and mechanisms of payment, documented by the Patient Centered Primary Care Collaborative here. The American Academy of Family Medicine has posted resources on practice change for established practices and residency training sites here. We are graduating 16000 physicians every year, though, that may not be exposed to any of this. The AAMC has identified 12 medical schools (out of approximately 120) who are trying to expose students to different types of care delivery, discussed here, but we are not trying to influence medical students in an organized fashion. Because of the 8 to 12 years needed from admission to practice, turning this ship will require new educational materials, new faculty skilled in different types of care delivery, and new methods of educating physicians-to-be.
The American Academy of Family Physic ians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association have put together a list of educational skills that they feel should be adopted by medical schools and used to teach American physicians-to-be, found here. Th reason for this, as identified by Perry Pugno of the AAFP is
“Training for PCMH practice has been embraced by the graduate medical education community, but at the medical school level, the response has been less — hence, the development of these principles to guide development at the medical school level of training,” said Pugno.
The reason these were developed is to help turn the health care ship around
It’s important for medical schools to recognize the need to invest in the future to provide these educational opportunities, Pugno said.
“We know that the current model of health care isn’t financially sustainable,” said Pugno. “We need at least some medical schools and their academic medical centers to show leadership and make some difficult choices — and change how they do business. In the short term, it will cost, but the dividends will come in the future.”
Maybe not “All Engines Reverse” but perhaps moving off “All Ahead Full.”
I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.
The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.
One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”
The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”
The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.
So three candidates and three conversations that give me hope for our specialty and the future of medicine.
The Archives of Internal Medicine published an article questioning the conventional wisdom regarding physician selection. In this article they tried to correlate a number of variable with a number of indicators of “quality care” (more on this, later). The authors did find that female sex, board certification (indicating completion of a residency and ability to pass an exam on set intervals), and graduation from a domestic medical school correlated with “significantly” better performance. Medical malpractice history, interestingly, did not indicate poor medical practices.
When looking more closely at this data, it shows some of the weaknesses of using statistics on numbers to describe behavior. The authors looked at 10,000 physicians and over a million patient encounters. They apparently analysed all of this information with a statistical package and then looked to see if any of the better performance was seemingly due to something other than chance. They found that all physicians did 62% of the activities that were expected. Female physicians for example were 1.6 percentage points higher than male physicians in regards to performance as a group (and the other differences were equally small). Because of sheer numbers this was seen to be “statistically significant” but given that based on this a random male doctor would be correct 61% of the time compared to the females 63% I think I would find a different way to pick a doctor.
This story was picked up in the lay press by the LA Times. In fairness to the writer, she did point out the weaknesses of the study, pointed out how limited information was for doctor selection, and pointed the reader to an AHRQ website with some pretty good advice:
Look for a doctor who:
[x] Is rated to give quality care.
[x] Has the training and background that meet your needs.
[x] Takes steps to prevent illness-for example, talks to you about quitting smoking.
[x] Has privileges at the hospital of your choice.
[x] Is part of your health plan, unless you can you afford to pay extra.
[x] Encourages you to ask questions.
[x] Listens to you.
[x] Explains things clearly.
[x] Treats you with respect.
The site goes on to explain quality care and offers a checklist to use when interviewing a physician to see if they meet your criteria.
This came up because Blue Cross/Blue Shield of Alabama has decided they are going to try to reward us primary care physicians for delivering “quality care” by increasing the visit fee by 5%. To find out whether I would qualify I decided to look on their Find-A-Doctor website to see where I stand. I was somewhat hesitant because I am an educator in a teaching practice. As such, all of the patients seen by learners while I am a teaching attending are counted against me in addition to those patients I am personally caring for. I would like to believe our learners are delivering excellent care but belief often is trumped by evidence.
Going beyond the user friendliness of the site (too many poorly categorized physicians with incorrect practice addresses) I am pleased to say that we are delivering good (and sometimes great) care. When measured on screening for certain types of cancer as well as diabetes care we were at or above the national and Alabama average. On the other hand, we do not perform as well as we could.
This measure is done on patients who have come to our office for care. They are not asked if they want for us to provide these services nor are we paid for providing such services. Although my staff, my residents, my colleagues, and myself are certainly motivated to deliver quality care, wouldn’t it be easier if we could dedicate staff to assure quality happened? Wouldn’t it be nice if we could enroll patients to incorporate their wishes and beliefs regarding their healthcare rather than assigning patients to me based on (perhaps) a single visit and assuming they want me to take responsibility for the care plan? Wouldn’t it be better if we were paid well for delivering care for acute illness and equally well for handling chronic illness and preventive services that don’t require a visit. Oh well, at least I’m liked (search for Perkins) by all 7 of the people who bothered to filled out the survey.
As Family Physicians, strong supporters of structural change in healthcare, and the Family Medicine Department of the 8th most socially conscious medical school in the country we are not content to sit on the sidelines and wait to see “what form health care takes.” The Department has undertaken several initiatives that help us to demonstrate to students the full impact an engaged family medicine team can make in the health of a community. I sat down with each of the faculty over the past month and asked them to brief me on how these initiatives are progressing. Below I have chosen to highlight three of these initiatives:
First, at the entry level into medical school and throughout the preclinical year, it is important to identify those students interested in being a family physician. Dr Carol Motley is working with the 1st and 2nd year students (and lower) to develop an early interest in Family Medicine. I had the privilege of attending the organizational meeting for the Family Medicine Interest Group and was pleased to see the level of commitment and enthusiasm. The group will offer additional instruction for those interested in Family Medicine as well as an opportunity to interact with peers who share this interest. One of the things our specialty has done well is developed an infrastructure to assist departments such as ours in developing and maintaining interest. However, without dedicated students it doesn’t make much difference. I am excited to see committed, engaged students who want to be someone’s doctor.
Second, the medical students have a very intense clinical year where they learn the basics of clinical medicine and determine which type of doctor they want to be. Dr Ehab Molokhia has transformed our educational experience for our third year students. He has chosen to emphasize the Patient Centered Medical Home as his core curriculum. To that end, all of the educational activities that are not patient focussed targeted to teaching the students about what advantage a Patient Centered approach would bring to the patient in the exam room and collective ly to all te patients served by a Patient Centered practice. In addition, he is using actors to demonstrate effective care of the patient with chronic conditions to the learners. The evaluations are very good and the criticism that Family Physicians only take care of minor illnesses is being debunked.
Thirdly, it is important that we model care unique to the new model of Family Medicine. Dr Shyla Reddy, our resident geriatrician, is delivering care to elderly in a clinic without walls. She is partnering with the Mobile Housing Board to deliver care on site to elderly, home-bound residents in one of the need based elderly housing units. She will be using our electronic health record, practice resources, and resources from the community to allow seniors living in the complex to “age in place.” What she has found so far is that the residents of this complex (like elderly everywhere) are plagued by poorly coordinated care that often results in poorer health. She will make a real difference as will the rest of the team.
The faculty who work with me (I consider myself to be a member of their team, although I do get to set tone and direction) are dedicated to the delivery of high-end primary care. They are now finding ways to instruct students in these new methods of care delivery and model this care delivery to the populations who need it the most. This is happening in almost every College of Medicine with a Family Medicine department in the country. These are exciting times.
I was pleased to read a student impression of the National Conference for Family Medicine Residents and Medical Students. I go almost every year and am impressed by the student interest and the efforts of those of us in Family Medicine to get students to the conference. This year South Alabama sent 11 students to the conference and they all seemed to come away with good knowledge about the specialty and an excitement about Family Medicine. The Medical RNinja reported on one session on the Patient Centered Medical Home where prospective residents were given a list of questions to ask prospective programs when interviewing. It is a very good list, so good that I will reproduce it below and encourage anyone applying for Family Medicine residencies to look at it before your interviews…
Access to Care
1. How does your practice provide patient-centered enhanced access (e.g., evening or weekend hours, open-access (same day) scheduling, e-visits)?
Electronic Health Records
1. What aspects of your medical home are electronic (e.g., medical records, order entry, e-prescriptions)?
2. Does your practice use a Personal Health Record that allows patients to communicate their medical history from home to the healthcare team?
1. Do you use patient registries to track your patients with chronic diseases and monitor for preventive services that are due?
2. Does your practice use reminder systems to let patients know when they are due for periodic testing (e.g., screening colonoscopy, PAP smear, mammogram) or office visits (e.g., annual exam)?
1. Who comprises your medical home team and how do they work together to deliver comprehensive care to your patients?
2. What services can non-physician members of the team (nurse practitioners, medical assistants, social workers, etc.) provide for patients (e.g., diabetic education, asthma education)? How do you train them and ensure competency?
Continuous Quality Improvement
1. How do you monitor and work to improve the quality of care provided in your medical home?
2. How do you monitor your ability to meet patients’ expectations (e.g., patient satisfaction surveys)?
3. Are residents involved in helping to enhance practice quality and improve systems innovations?
1. How does your practice ensure care coordination with specialists and other providers?
2. How does your practice ensure seamless transitions between the hospital and outpatient environment?
1. What procedural services are offered in your medical home (e.g., obstetrical ultrasound, treadmill stress testing, x-rays)?
2. Does your medical home provide group visits (e.g., prenatal group visit)?
As I was driving back from a very nice long week-end with my extended family (fireworks, festivals, baseball, wings, and art in a gritty urban setting) in metro Atlanta, I heard an NPR story on “the July effect.” This effect is a suspicion (now with some evidence behind it) that health care in teaching hospitals is worse in July because of the inexperience of the new learners (or as I tell my residents “You are moving from a very experienced physicians at one level to a very inexperienced physician at the next level”). The report cites an increase in deaths in counties with teaching hospitals and lack of a similar effect in counties with non-teaching hospitals in July as evidence for this effect. It only finds the effect with medical errors. I am grateful to Dr Carol Motley who traded calls with me so I could be with my family and she could work with the newly promoted physicians on this worst weekend of the worst month of the year.
From experience I will agree that the learning curve for a newly promoted physician is steep. I unfortunately know of no better method of training physicians. The author of the study in his interview cited a lack of surgical effect as evidence that surgical training is superior. I would argue that this suggests a certain randomness to his findings and we probably need to look more closely before discarding the entire training process. It does point out the need for close supervision of neophyte learners and the importance of good processes coupled with an assessment of outcomes to determine if the desired effect is being achieved.
It also identifies a need for continuation of an extensively supervised period of learning prior to neophyte physicians being transitioned into the “real world”. This process (known as residency training) is labor intensive if done correctly. It involves ongoing assessment of the learners progress towards achieving six types of competence which the prototypical physician is expected to demonstrate in practice. We do this in part through close supervision of the learner in hopes of detecting potential errors before they are made. We also do this by collating thousands of individual observations on each of our learners and using them to assess progress towards achieving these competencies. This process is time consuming and expensive.
The current way of paying for this instruction is for the payor (usually Medicare) to give money to the hospitals and hope that they pass this money on to those of us providing the instruction. The hospitals tend to see the cost of training residents as including a lot of costs not involving direct supervision and assessment residents by attending physicians (in part because we can bill for the service which covers a small part of the total cost). Consequently, we don’t see much of that money. Perhaps if more people are aware of the “July problem” the allocation of money to pay for supervision of neophyte residents will be seen as important.