Friday, February 25, 2011

Educating Med Students About Health Care Systems and Advocacy Should Not Rest Solely On Med Schools

Yesterday, MedScape News posted an article titled "Med Schools May Be Neglecting Health Policy in Age of Reform".  It looked at a couple of articles from the New England Journal of Medicine ("Advancing Medical Education by Teaching Health Policy" and "The State of Health Policy Education in U.S. Medical Schools") and provided a summary of the results
A survey of medical school deans conducted by 4 students at Harvard Medical School reveals that although 94% reported some form of policy instruction at their institutions, the average amount was only 14 hours over 4 years. In the lowest quartile of schools, students received 6 hours or less of formal schooling on issues such as quality improvement, medical economics, and health insurance design.
 ....physicians at the University of Pennsylvania and the University of Michigan conclude in an article in the current issue of NEJM that "medical education has failed to keep up with policy changes as the US healthcare system has evolved" and that without some catching up, "healthcare reform will not be able to achieve its greatest possible impact." 
When the AAMC was approached about this area, their response was the following:
...medical students receive instruction in practice management, medical record-keeping, quality improvement, healthcare systems, medical economics, and medical licensure and regulation — all grist for policymaking — as evidenced by annual AAMC questionnaires completed by medical school graduates. Those same questionnaires, however, point to room for improvement. In the 2010 questionnaire, a majority of graduates said that instruction in practice management, medical economics, and medical licensure and regulation was inadequate, and almost half said the same about managed care. 
With the medical environment forever changing, providing hours upon hours of information about health care policy, systems, etc. would be a difficult task - much like trying to hit a moving target.  To ensure an adequate education in these areas, medical schools would need to either bring in new faculty or pile more work on existing faculty (and probably with very little additional salary)  - I would put money on it being the latter.  Moreover, with a Congress that has no idea what to agree on, our information in these areas have more of a chance of being outdated tomorrow than many of the things we are learning in the basic sciences.

Some may argue that clinical medicine also changes from day-to-day, which is true - though our faculty do not really have much of a choice to remain up-to-date on changes in clinical medicine.  Are we going to ask them, who we piled additional curriculum on, to also remain current in our health care system?  Will medical schools that bring in more faculty to develop and maintain curriculum in this area also find that another reason to increase medical school tuition?  This, instead of the administration possibly taking less of a pay increase or possibly a pay decrease (blasphemy!) to make up for it?

On the medical student side, we would be accountable to learn more information on top of an ever-growing medical science foundation that is already out-growing the four years we are given to learn, master, and eventually maintain in medical practice.  I whole-heartedly disagree that it should be up to medical schools to be held accountable for being the primary educators in these areas of education.  Our faculty are already stretched thin by the bureaucracy of academic medicine.

My recommendations:

1 - Educate medical students on the basics of ADVOCACY: Instead of focusing on the details of our medical system, why not just educate medical students on how to advocate for health care in the interests of clinicians, the medical team, and our patients?  Advocacy is one thing that does not change that much, whether it is by grassroots advocacy involving government, insurance companies, federal/state health care programs, etc.

2 - Effective hours are more important than total hours: These studies point out the number of hours spent learning about health care systems, delivery, management, etc. but fail to objectively analyze the subjectivity of the hours spent learning this information.  If we really wanted to be most effective at teaching these complex topics, we would expand medical school education by at least one year and have students graduate with an MBA, MPH, etc.  Options exist to do this, but are exactly that - options, not requirements.  I have personally seen a large number of 1-2 hour presentations on these topics at conferences and learned a TON more than I learned at my medical school, which does provide several lectures on these topics...  leading to my last point

3 - Stop trying to reinvent the wheel!  Much how residencies provide CME and time away for conferences, medical schools should budget time and money for medical students to attend advocacy conferences by medical academies/societies/associations of their choice.  Medical students who find a way to these conferences often have to use vacation time or time away from rotations (excused and unexcused).  This time should be built into the curriculum, not taking away from much-needed vacation time.

As an attendee at various conferences put on by my state and national organizations, I have learned an incredible amount of knowledge and information about the basics of our system and how to effectively advocate for medicine, specific specialties, and patients.  Additionally, these meetings provide leadership development opportunities, something that these studies fail to mention as being vital for our future involvement within the health care system.  As future physicians, we are going to be looked at as role models and leaders in our communities that we practice within.  These conferences provide leadership development to help prepare us as future leaders in our community.

Here are some examples of conferences/meetings that students can attend:
AAFP Family Medicine Congressional Conference
AMSA Annual Convention and Advocacy Day
AMA National Advocacy Conference
ACP Leadership Day
The best part is that at some of these conferences, we actually head out with other students, residents, and physicians and meet with leaders of these medical associations as well as members of Congress.  This benefits medical schools and students in many ways.  First and foremost, medical students get a chance at a change of scenery.  We also get to network with other students, physicians, and leaders which helps advance our professional careers - there is only so much we can do to network with our own institution.  Next, we get to hear effective, concise presentations by people who live/eat/breathe medical systems, health care, and advocacy.  Medical schools would not have to hire more faculty, further stretch other faculty, or try to incorporate more educational time during the school's curriculum - usually at the expense of something else that may be important (nutrition, humanities, clinical skills/simulation, and maybe learning how to do an effective physical exam instead of relying on a pan-scan).

In summary, we do have deficits in our learning of the health care system.  However, by outsourcing this education to those already proficient while including opportunities for advocacy, networking, and leadership development, future physicians will be armed with the knowledge to not only understand the system, but with the ability to change it to better serve our patients.


  1. Great points, mdstudent31. The medical school may be too busy with other obligations to fully expose students to the subject areas mentioned in your post. Organized medicine has a vast array of learning opportunities as you mention. I remember the National Rural Health Ass'n meeting when I was a student (sent by my med school in 1974-THE OSU COM) at which I got to hear legendary Robert Rakel, MD speak. He dazzled a room full of med students with the famous Kerr-White diagram, freeing us forever from brains that suffered from University Medical Center over-exposure to the wrong patient population.
    Now we also have the FMEC NE meeting where you finalized plans for this blog. Hundreds of med students and family medicine faculty attend that meeting each year, willing to share to inspire "the future of family medicine." And a Blog of the same name. Blog On!

  2. I agree with this post so much. As someone at a medical school which does have policy as a substantial part of the new curriculum, I can see the school experiencing some "growing pains" in terms of the actionable opportunities for the students being able to catch up with the didactic component generously provided by passionate physician-advocates and their colleagues from the policy schools that we are very fortunate to have right on campus.

    The classes are, on the whole, comprehensive and extensive and many hours beyond the national average. However, at the end of the day, how many tools do our teachers give us to go out and effect change in the community? How much do they encourage us to speak out in favor of policy change? On the individual level (especially if the individual medical student goes out to seek it), there are great mentors and community projects available in my area - as there likely are at many other schools. But in terms of money to support those projects and travel to these conferences where we really get hands-on experience to speak out for policy change, the resources are much more limited.

    There are lots of issues here. I think I may have to write a blog post about this.. will back-link it to you when it's complete!

  3. I admire what you have done here. I like the part where you say you are doing this to give back but I would assume by all the comments that this is working for you as well.