Monday, November 22, 2010

Newsflash: Medical Students Assist in Medical Care at Teaching Facilities

About a week and a half ago, The Dallas Morning News published an unfortunate case of medical mismanagement, mainly dealing with a lack of oversight from attending physicians over residents and medical students.
"Even students – who have yet to graduate from medical school – provide key care, sometimes without direct supervision....
...(the) surgical consent form had warned that (the patient) could face 'blood vessel or nerve injury' complications. It also noted that students might be involved in (their) 'surgery and surgical care'."

They also released a spin-off article stating that ethicists generally feel that patients around the country are not made aware of medical student involvement in their care.
Many hospital patients don't know who's caring for them at any given moment, said Dr. Lisa Soleymani Lehmann, a Harvard Medical School assistant professor who runs the Center for Bioethics at Brigham and Women's Hospital. Many don't distinguish between residents, who are degreed doctors getting paid, on-the-job training, and students, who are unlicensed and still in medical school.

"There's a tremendous amount of confusion," Lehmann said.

She has surveyed about 200 Boston-area patients who underwent operations in which students participated. Half of the patients didn't even realize that medical students had been in the operating room, she said.

Lehmann said many hospitals' consent forms have improved in recent years and now tell patients that medical students will be "involved" in their care. But patients "don't know what that means," and many don't even read the forms, she added.
Over the past week and a half, I have had an internal struggle about what to write about this event. The specifics of this case are quite tragic and should never happen anywhere. At first I was rather annoyed that the author of the original article happened to release the spin-off right away while generalizing all medical students and implying a general lack of communication around the country. Could the author use such an unfortunate case as a stepping block to create generalized anxiety throughout the nation?

As previously mentioned in my burnout blog post, our medical education is already compromised by a feeling of uneasiness from our attending physicians with their practice of defensive medicine. If we place further restriction on our medical training because of a select number of medical mismanagement cases, will we continue our travel down the slippery slope and overall loss of educational opportunities? Will intern year be the new 3rd and 4th year of medical school? (not to mention the possibility of increasing the number of years of residency!?)

Take a look at AMA Opinion 8.087 - Medical Student Involvement in Patient Care. It basically states that medical students need to be identified and patients need to be disclosed as to how the students will be involved in their care, whether it is in the community health center taking an H&P or simply "driving the camera" in surgery.

After taking some time to settle down and think about my own medical training experiences, I have realized that there are definitely ways to improve communication with all members of the team towards patients.

From attending physicians to medical students, it is quite helpful to know the extent of our involvement, especially in surgery. This is not an easy task, as some attending physicians may provide student opportunities during procedures on the fly at their own discretion. Again, this is a difficult task as there is always a first time for doing something and assessing ability is impossible unless the task actually occurs in real-time.

When is it appropriate to drill a pin into a broken bone? How do we know when a student is ready to suture? Are students more prepared to advance their skills on the last rotation of 4th year or as a resident during the first week of internship?

From attending physicians, residents, and medical students, we all need to communicate better towards patients in regards to our role in patient care. Consent forms that are vague and do not provide specific detail are not adequate for patient satisfaction or overall patient safety. We need to identify ourselves to our patients and not just disclose the side effects of medication or the risk of infection and bleeding, but each of our roles in providing safe and effective care.

Monday, November 15, 2010

The correlation between research and policy: not statistically significant

For years, research has shown us that more primary care physicians per capita leads to better population health outcomes. As a corollary, more subspecialists in a given geographic area leads to poorer health outcomes. A perfunctory look at specialty choice by medical students shows that decreasing numbers of students are choosing primary care.

Likewise, research shows that team based, patient-centered care creates better health outcomes and potentially higher patient satisfaction. We also know that this approach can decrease ER visits and ultimately decrease costs.

Then, why haven't we enacted policies and laws to support these and many other findings? Reporting live from the North American Primary Care Research Group Conference (NAPCRG) this week, I have attended seminars and seen posters with outstanding research in chronic disease management, health delivery/services, medical education, you name it. Early yesterday afternoon, I was in the paper session for Health Care Delivery/Health Services Research and it was standing room only. One of the co-authors to a paper couldn't even get into the room because it was so full. Then, I attended a workshop on "Advocacy Skills for the Primary Care Researcher." 10 people in attendance (not counting the 5 workshop leaders and 3 organization staff members in the room).

This disconnect is the fundamental problem with why our research doesn't translate into policy. Researchers do research; the majority never set foot in a legislator's office, don't understand and shun politics, and focus on the statistics. On the other hand, legislators generally don't make evidence-based decisions; most legislators don't understand what a p-value is (forget picking up "Health Affairs" or "NEJM"). They base their decisions on what their constituents want, personal stories, interest groups and media reports.

In my Community and Consumer Organizing class at Harvard School of Public Health, we learned about Kingdon's Open Window Model for change. People generally sit in 1 of 3 streams:
  1. Problem Stream: identifying and validating problems through research
  2. Policy Stream: identifying and narrowing down solutions to short list of technically feasible policies
  3. Political Stream: enacting laws during favorable political climate for solutions
In this model, those who are able to get things done are those who sit at the borders of the streams and can align the streams to create an open window of opportunity.

So, how can we get our researchers more interested in advocacy and politics? How can get legislators excited about the policy implications of research? Addressing these issues and creating more translational research will be fundamental as we pursue reform in primary care, in chronic disease management, in health systems... as we pursue a healthier and better America.

Sunday, November 14, 2010

Advocates of Independent Nurse Practitioner Practice Losing Focus Within Current Scope of Practice

One of the hot topics occurring in the health care debate deals with figuring out appropriate leaders of the Patient Centered Medical Home (PCMH). With the recent report by the IOM advocating for independent practice by nurse practitioners, many physician groups, including the AAFP and AMA, have come forth with strong statements advocating against the IOM report and independent practice by CRNPs.

A recent editorial by the AAFP, titled "Nurse Practitioners Are Team Members, Not Leaders, in the PCMH" points out some very disturbing numbers and trends. It begins by pointing out that the IOM and nursing organizations are correct in their analysis that there is a primary care physician shortage and that the role of CRNPs and the medical team could be increased to help with this shortage. However, it provides numbers produced by the American Association of Colleges of Nursing (AACN) that the IOM, CRNP advocates, and the media fail to mention when talking about the expansion of the current scope of practice and independent practice:
"the U.S. nursing shortage is projected to grow to 260,000 registered nurses by 2025...U.S. nursing schools turned away 54,991 qualified applicants from baccalaureate and graduate nursing programs in 2009 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. In addition, almost two-thirds of nursing schools say faculty shortages are the reason they cannot accept more entrants into their programs."
When thinking about faculty shortages as a medical student, we look to attending physicians as our faculty to help us along our pathway in becoming physicians. In turn, nursing students look towards nursing leaders to help in their training to ultimately become nurses at all levels of nursing education. What better nursing leaders to help in this shortage than CRNPs? Better yet, the Doctor of Nursing Practice (DNP) was originally developed for nurses to have a PhD for academic and faculty purposes to educate future nurses. Are DNPs solely practicing academic nursing as faculty to the extent at which this degree was originally developed?

Why focus so much effort on increasing scope of practice when there are such deficiencies within the current scope of practice? One of the issues that a CRNP or DNP faces by going into academic nursing is a pay decrease and that may keep potential academic nurses away from becoming faculty. I hope that is not the case, especially when encountering all of the physicians that are faculty at academic medical centers that take large decreases in salary to remain in academic medicine instead of private practice.

Let me offer a different and possibly refreshing argument against the independent practice of CRNPs which goes against the usual argument pointing out disparities in education and standardized training/certification.

Medical students, nursing students, physician assistants, physicians, nurses... the entire medical team can agree that patient care comes first. A lot of focus goes into resident working hours and sleep deprivation but what about the bedside nurses that take on extra shifts and patients all the time because there are not enough nurses for coverage?

Expanding the scope of practice for nursing without addressing the current shortage of nurses within the current scope of practice will only spread the nursing workforce even thinner - and in my opinion, will only compromise patient care further than it already does. Increasing advocacy efforts for independent practice and encouraging current nurses to pursue higher education to provide outpatient primary care in the PCMH without increasing the amount of resources and faculty to contribute to a larger nursing workforce will lead to adverse unintended consequences.

Monday, November 8, 2010

Medical Student Burnout and Unprofessional Conduct

Recently, AAFP News Now released an article titled
Unprofessional Conduct Among U.S. Medical Students Linked to Burnout
It focused on an article recently released in JAMA entitled
Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students

I had the opportunity to be interviewed for this article and was featured on an inset within the article that shared a minority of my interview. As I am currently rotating on inpatient medicine at a local community hospital, I am once again experiencing our health care system at its finest - a lot of wasteful spending and unnecessary testing. I am taking a look back at what I had wrote down for the interview and decided to paraphrase the majority of my response into the following blog post regarding the health care system and medical education.

When looking at the advances we have made in biochemistry, genetics, and molecular biology, we are being asked to know so much more information in much greater detail – and still within these 4 years worth of medical school.As more requirements are created and more scientific advances are brought forth, more time is needed in lecture and studying for tests like the USMLE and shelf exams. Most traditional programs are 4 years with 2 years of foundational science and 2 years of
clinical experience.

For one, I believe that medical school admissions do not do a good job
at identifying candidates that will provide an adequate workforce and/or will be good for medicine. It must be extremely difficult to screen applicants to figure out who is genuine about the profession – who is going into medicine because they truly want to go into medicine... on the other hand, who is going into medicine because they test well, and/or because their parents forced them into it throughout childhood. This is definitely a minority of students but nevertheless, takes away seats from other potential medical students who may choose to serve a better purpose and population within our health care system's needs.

Maybe we are not bringing enough students into medicine that come from
underserved areas; maybe we are not screening correctly in the
admissions process to accept students who display genuine altruistic views
and who do not fabricate an artificial personality in an interview
and/or on a personal statement. The 40 MCAT, 3.9 pre-med GPA and 5
publications may look good on paper but may fail miserably at
developing into an altruistic and compassionate physician.

It would be interesting to figure out specific determinants that make
students less altruistic and less likely to serve the medically
underserved. As medical students, we are molded by the experiences we
are faced with during clinical rotations. Were these students who had more
contact with patients who manipulate the health care system for
primary or secondary gain? In most cases, our attitude in respect to
patient populations trickles down from our attending physicians,
residents and interns.

With defensive medicine taking precedence in many situations, medical students take notice of the frustrations felt by our superior members of the team. Are these attitudes more likely to occur in underserved areas? If so, medical students are not only discouraged, but definitely overwhelmed at the amount of follow-up
required of the large volume of unnecessary testing that occurs. We spend so much time trying to cover our back that the amount of quality learning that actually occurs is dramatically reduced.

If we took just half the amount of time we waste on defensive medicine
and documentation and shifted that towards more time for teaching
rounds and instructional time by attending physicians and residents, I
believe medical students would feel more satisfaction with their
education and clinical experiences. As it is, medical students spend
most of their time trying to help the interns and residents with
non-educational work (what we refer to as “scut work”) so that we may
eventually have time at some point for educational purposes.

Additionally, because there is so much more hand-holding by attending
physicians towards the residents and all the way down to the medical
students, it is difficult for medical students to convince themselves
that they are actually contributing to the care of patients. Taking
all of this together, it does not surprise me that studies are showing
that medical students are burning out, documenting non-factual
clinical findings, lacking altruism and altogether becoming
unprofessional throughout the process.

The medical community as a whole needs a “face-lift” in regards to everybody’s attitude towards health care delivery. I do not think this will be possible until the health care system undergoes a much more meaningful reform to address the issues that attending physicians, residents, and medical students face due to the current clinical environment. The current political environment is not going to alleviate any of these issues because nobody is willing to commit to long-term changes in health care delivery and tort law.

Without meaningful tort reform, proper emphasis and payment for primary care, and population education about meaningful health care reform and personal responsibility, we will not peel through the layers and fix any of the intended and unintended consequences that have accumulated throughout years of failed policy and legislation.

Wednesday, November 3, 2010

Understanding the impact of 2010 mid-term elections

Yesterday during the mid-term elections, the Republicans gained the majority in the House of Representatives and increased representation in the Senate (where they are still in the minority). As the Obama Administration spent ~1.5 yrs of the past 2 yrs implementing health care reform, the Affordable Care Act is (ACA) sure to be targeted. Here are some of the ways family medicine and health care reform may be affected:

One of the campaign promises that Republicans ran on was repealing health care reform, i.e. the Affordable Care Act. The full repeal of the ACA is unlikely since:
(a) any legislation that is introduced and passed in the House by a Republican majority would not pass the Senate and even if it did would be vetoed by the President.
(b) many Republicans were supported financially during the campaign and continue to be supported by special interest groups such as insurers and pharmaceutical companies who stand to benefit from the ACA since there will be increased numbers of individuals insured under ACA

Likely actions to affect the bill:
  • repeal of individual sections of bill that are unpopular with Republicans, moderate Democrats, independents
  • attempts to block funding for new programs and provisions of the ACA
  • attempts to delay implementation of parts of ACA

Other actions that may occur with the new House are:
  • attempt to pass comprehensive tort reform legislation (as promised during campaigning)
  • subpoenaing Don Berwick of CMS and Kathleen Sebelius, HHS Secretary to testify about health care reform process
  • implementing budget cuts to primary care research such as Title VII, NIH and AHRQ funding (Republicans have pledged to cut $100 billion from discretionary spending)

Many of my projections are informed by discussion in my Community Organizing Health Policy class at HSPH; my discussion with Bob Blendon, a health policy analyst; and a memo to members of the Academic Family Medicine Advocacy Committee (AFMAC).

What do other people think? Thoughts or predictions?

Impact of 2010 Elections on Health Care Reform

Check out this webcast on Friday, November 5 from 1:30-2:30 pm EST as three experts discuss the impact that this week's elections will have on health care reform.

Discussing will be:
  • Douglas Holtz-Eakin, President of American Action Forum and former Director of Domestic and Economic Policy for the John McCain Presidential Campaign
  • David Cutler, Harvard Professor of Applied Economics and former Senior Health Advisor to Obama's presidential campaign
  • Bob Blendon, Professor of Health Policy and Political Analysis at Harvard School of Public Health and Executive Director of the Harvard Opinion Research Program