Thursday, May 26, 2011

Advice for a First Year Medical Student

I recently had quite a long conversation with a college senior that was just accepted into medical school for this coming fall. As a rising fourth year medical student myself, I would like to think that I have navigated the waters of academia and figured out both efficient paths to success and avoidance of roadblocks and setbacks. However, I was quite overwhelmed with the number of questions and concerns that this particular student had. But in retrospect, I can recall my own naivete and fear of the unknown that is medical school.

After answering all of his questions, I realized that many soon-to-be first years may not have the advantage of mentors or advisers. Lacking guidance, students are willing or forced to charge forward and hope for the best. These are the same students that suffer the inevitable fatigue and burnout. But I believe that there is a smart and efficient way to approach medical school. That is not to say there are any shortcuts or cheats. Rather, I wanted to share with you my advice on 5 easy steps to being a better medical student from day 1.

1) Be willing to be selfish

You must be willing to prioritize personal time and to continue to do the unique things that make you who you are. And trust me, the time can be found in any rigorous program. Doctors aren't robots, and you should never plan to train like one. Medical school must be a time for you to continue to develop your hobbies and your personality. These are the individual characteristics that will make your patients love you one day. More importantly, these are the activities that will keep you both sane and free from stress.

2) Get 8 hours of sleep

No debating this one. First the benefits – you will study better, be healthier, and feel happier. There are enough distractions and obstacles built into the medical education that you should not be adding to the list. Sleeping in class, rereading text, and mental sluggishness are not paths to engaging the curriculum. Turn off the light, set your alarm, and keep track of your sleeping schedule. After all – you are training to be a doctor who will one day advise patients on healthy practices. Limit the sacrifices you make in your own health along the way. Healthy eating and regular exercise follow, as well.

3) Subscribe to just one health policy daily email or news blog

Medicine, particularly in the modern world, has much importance beyond the realm of clinical information. As a doctor, you will one day be called to be a leader, and your understanding of health policy and health systems will drive your success. You do not have to understand every sentence, or even read every word. But be open to absorbing what you can so you will be better aware of health care on-goings. The future of medicine is in dynamic health delivery systems. While you're cramming over the Krebs cycle, take a five minute break to review the latest info on real-world medicine issues. ACOs are being built and discussed right now – embrace that change and learn as the systems are being designed. (Feel free to email me for the full list of my daily subscriptions – Read during rounds when your attending is off ranting about something esoteric and his back is turned. Read it while your on the bus or in the bathroom. Again, time can be found if you look for it.

4) Study Smart

There is a difference between studying for a test and studying to be a doctor. While these two goals sometimes coincide, they are often very different in nature. I find that, for some reason, medical students have difficulty wrapping there minds around this concept. Here is what I mean – medical students often look to prepare for exams as if they need to know everything about a given subject. Buying multiple textbooks and review guides is more than common. Gaining this knowledge is the right thing to do, and will make them a better doctor in the long run. But it may distract you from your goal of doing your best on given test – and worse, it may lead to burnout. If an exam has questions that are drawn from lecture, then information outside of lecture is irrelevant for the scope of that test. You need to make a personal decision as to how much supplemental information you need to be successful. I'm not telling you to take any shortcuts in learning medicine, I am telling you to be prepared for what matters. You have at least 7 years to go through medical school and residency, and then a lifetime to practice. You cannot possibly learn everything in a day, month, or year. Don't sweat the details during your first year, anymore than is already forced on you.

5) Smile

As easy as this simple act sounds, this may be the most difficult of my suggestions. But stick with me! I am a firm believer in the power of positivity and confidence. You will get through medical school. That is not in question. But you have a choice as to HOW you get through medical school – to complain, suffer, and grieve through the process.....or to enjoy the ride. I believe that smiling, appreciating the best that you have, and keeping a positive attitude effects you in two ways. In the first, you will have the advantage of internal confidence and lower stress. From a medical standpoint, you will be less rattled on test day and benefit from decreased cortisol - both can go a long way! The second effect of positivity is the external impact you will have on those around you. How do you think nurses respond to medical students that complain or look upset during morning rounds. I know that a genuine smile and greeting has led to nurses and residents that have been willing to go the extra mile to offer me support. How do you think an attending or residency coordinator will respond to the stolid student, versus the upbeat one? The truth is that letting in negativity and suffering through complaint are a means of externally expressing defeat. You do not want to be that kind of medical student. Smile, you are living your dream!

I genuinely want all of you to do well, and to be great and successful doctors. After reading many other medical school advice posts on more tangible or “hard” skills, I wanted to offer a different perspective. As always, you have to do what works best for you, and everyone will find success with different methods. But I do hope that some of my advice gives you a different perspective on how to achieve that success. Good luck!

Tuesday, May 10, 2011

Thoughts from the 2011 Family Medicine Congressional Conference

Ok, I'll start out with a cheat sheet on the important issues and "asks" that we brought to Capitol Hill today. There was a definite sense of urgency to act, and our proposals focused on opportunities to incentivize primary care, without significant budgetary increases.

1) Fix the SGR. Stop kicking the can down the road and get realistic payment stability.
2) In regards to GME, consider a model that would secure a portion of funds specifically to primary care community and out-patient residency facilities.
3) Encourage investment in Title VII funding (specifically section 747) and further support for National Health Service Corps
4) Decrease the gap that exists between primary care and specialty salaries

Now for some reflections on the issues and discussions for family medicine here in Washington, D.C. at the FMCC:

7:00am: Wow, breakfast buffet is great! The AAFP really takes care of their own. Next, I walk into a room of over 200 family doctors convened and eager to descend on Capitol hill tomorrow and breakfast becomes an afterthought. Talk about wow - I'm speechless. I wish every medical student could be here for this program and for the good of the future of medicine.

Hot issues:

Monday, 8am: Models, models, model. You'd think with all the talk of models, their would be a Paris runway close by. Then again, I wouldn't complain if some Hawaiian tropic spokespeople walked through the doors right now.

In all seriousness, there is so much talk of models and systems. I can see that this sort of dialogue is important, as a means of establishing a strong foundation. The reality is that a 400+ pg proposal has been put forward, and we are still in the comment period prior to the final product. But the frustrating aspect is that family physicians function at the ground floor of health care delivery. Its tough to listen to mostly generalized and broad goals, when we all know how important the details really are. I do very much look forward to the proverbial "meat" at the heart of these proposed systems. I am eager to move forward and to see how these models function and to see them in place.

10am: AMA question and answer forum. This session quickly turned into a soundboard for comments. This tells me that family docs know the facts, and are more prepared to have their voice heard than the need to have questions answered. The people in this room have done their homework, and family doctors are hungry for parity and a successful balance in medicine. I'm encouraged by all of this discussion.

11am: Robert Phillips, MD, Director Robert Graham Center. This man is a visionary and his poise is inspirational. He first offers the difference between "Reducing costs vs restraining costs". This a perspective that isn't often considered. Everyone is looking for ways to lower cost, when in fact we should be looking for opportunity to curb spending growth.

Workplace continues to be framed in terms of supply and demand. Figures are often thrown around at the national level that "this many tens of thousands" of physician workforce shortage. The paradigm shift on this is to consider the implications of physician distribution. In fact, when you look at physician demographics, it is apparent that the number of physicians serving in areas of excess could cover the areas that demonstrate a shortage.

That said, it seems that the focus has shifted away from workforce and on to economic impact. That is fantastic news for the primary care front - their is amazing data on the number of local jobs, the economic impact, and cost effectiveness of family physicians. Most importantly, it has been shown that an increase in family physicians in a community led to a correlative decrease in readmissions. Every other specialty showed increases in readmissions with increased workforce in community.

Thought: data, data, charts, graphs and data. Proof and facts are the name of the game in directing change.

One thing that really sticks out to me is the continual rhetoric and future tense employed by many speakers. It seems that words such as "planning", "committee" "considering" "taking suggestions" "reviewing proposals" far outweigh any directions or indication of activity. Right now its a waiting and planning, and few seem to want to take the first step. Which is counter intuitive to the needs of medicine. We have an outmoded system that is functioning on an outdated payment schedule. In order to meet the demands of the modern health care climate, we need to stop the rhetoric and start the reaction. It was clear from the medical student voice, that we demand as quick resolve to act as any group.

2pm: Panel on health reform movement. After spending the better part of the past year and a half focused on health reform, it seems that their is a general health care fatigue on Capitol Hill. On top of this, the magnitude of the funding deficit makes any movement in the positive direction extremely challenging.

Two of the COGME recommendations that struck me: to adequately meet the needs of American health care, it is recommended that the physician workforce be composed of at least 40 percent primary care. The second recommendation was to encourage enhancement in medical school social accountability in training. See my most recent post on this site for some of my thoughts that are right in line with this.

Some other random thoughts:
1). Check out Wellmed a non-hospital aco based in san antonio that is producing outlier numbers in reduced mortality, cost saving, and family physician salaries. (
2). Its inspiring to meet and see all of the energetic and engaged medical students here. Debt is a huge issue, but these passionate students are willing to sacrifice for the goals of primary care. More apparent is the medical student urge for activity. We are saying, we can't wait, we can't put things off - we need to act now.

Saturday, May 7, 2011

Leading New Models of Practice - Accountable Care Organizations

ACO - the newest mysterious acronym from Washington. Just when most of us were getting familiar with the last big organizing acronym, PCMH. Maybe we weren't actually familiar with the 7 joint principles of the Patient-Centered Medical Home (PCMH) and their implications, but we were at least getting comfortable throwing the term around in discussions, networking sessions and conferences, hoping that no one would ever ask us: "So, what is a PCMH?" Now we've been hearing about the Accountable Care Organization (ACO)... is this just the newest street language in health policy or is there more to it than that?

Last Wednesday, I attended a full-day workshop sponsored by the Society of Teachers of Family Medicine on the ACO. We started by reviewing the basic premise of the PCMH: central places to coordinate care focused on patients’ needs and relationship-building. Industry leaders who were fed up with poor care options in America created the concept of the PCMH, which was jointly supported by all national primary care organizations. The PCMH model emphasizes a strong primary care foundation in which primary care providers take responsibility for providing, coordinating and integrating care across the health care continuum. Pilots of the PCMH have shown improvements in quality and reductions in spending when implemented in large provider settings.

The conceptualization of ACOs is separate from the PCMH but there are many parallels. ACOs are organizations that can use payments:
  • to incentivize physicians and hospitals to provide care coordination,
  • to invest in infrastructure and redesign care processes and
  • to provide high-quality and efficient services.
Patient-specific metrics are being developed to evaluate outcomes and quality. An example of a metric would be A1c <9% in those with diabetes or providing a post-discharge physician visit. Participation in ACOs is optional. Providers and hospitals that participate would be accountable for a defined population across care continuum. Benefits for participating? You would also get a share in the cost-savings from this model.

You may be thinking right now - this all sounds great. But what you've given me is a bunch of fancy concepts. Where are the examples? Well, the answer is that there aren't really any good examples yet. The ACO is a new model that was outlined in the Affordable Care Act. ACO rules were just released last month by the Center of Medicare and Medicaid Services (CMS). These rules are still open for comments until June 6, 2011 and then are to be implemented by January 1, 2012. Providers and hospitals at that point can apply to be ACOs.

What does this mean for family medicine and for the PCMH model that we helped develop?

It’s an opportunity to get involved! The weakness of the PCMH model is that there is no incentive for specialists and hospitals to get involved because they don’t participate in the savings. Secondly, there’s little financial incentive for even primary care doctors to get involved because the money saved on emergency room visits, tests and procedures isn’t reflected directly in the pocketbooks of primary care doctors unless payment structures are transformed from the traditional fee-for-service to more innovative payment mechanisms. The ACO model helps align these incentives to achieve much of what the PCMH model desires.

However, the ACO model makes no explicit mention of the centrality of primary care. As future primary care doctors, we must lead in the development and implementation of ACOs if we are to remain relevant in the 21st century and to continue serving our patients.

Thursday, May 5, 2011

Retooling the MCAT, Rethinking the Goals of Academic Medicine

Think quick –

If a man running at 12 miles per hour in a northern direction on a horizontal plane grabs hold of a bird traveling at 18 miles per hour moving in a westward direction at 45 degrees above horizontal, what will be the final speed and direction of the pair? (just typing this was exasperating, phew!)

The better question should be, what does this have to do with medicine, or the training of an able-minded and bodied physician? In all honesty, I couldn't answer that directly. For good measure, I couldn't answer a very similar question to the one proposed above on my official MCAT, either.

I'm sure some would argue that this sort of questioning tests critical thinking skills, determination, and the ability to work under pressure and time constraints. That is reasonable. But then again, I also spent countless hours memorizing physics equations in college - hours that could have been spent studying pharmacological interactions or anatomic details. Or better yet, hours spent studying medical ethics, health law, health policy, communication skills, or the history of medicine. Wouldn't intense courses in those topics push critical thinking skills? I'm not arguing that there is a perfect system. But then again, I haven't needed to measure the work and force of a spring anytime recently.

Without a doubt, questions like this weed out the competition. I can recall countless classmates that fell to the wayside during physics, organic chemistry, and MCAT preparation. Some that I thought would have otherwise made excellent physicians. So, is our system weeding out the right students? Well, it looks like the AAMC might not think so. A recent announcement indicates that a change in the emphasis of the MCAT examination may be in the works.

“In the next several months, the MR5 Committee will continue its dialogue with stakeholders on the proposed recommendations, leading up to final approval by the AAMC Board of Directors in February 2012. If approved, the recommendations will be introduced with the 2015 MCAT examination.”

The overall goal of the proposed MCAT changes would reflect a greater emphasis on the social sciences, medical ethics, and evaluation of thought processes.

If the AAMC believes that the MCAT may need modification – what other areas of academic medicine could be addressed? How about the requisite pre-medicine courses? Or lecture topics and areas of focus in medical school? Residency structure? CME and physician licensing? I believe that the success of the future of medicine demands a robust review of each of these areas of medical training.

Our health care system must embrace a new academic aim of integrating longitudinal experiences and enhancing the team-based approach. I believe that the future of health care leadership is dependent upon development of leaders now that are adept at both technical and non-technical competencies - communication, effective team-management, time-management, emotional intelligence, awareness of policy and current affairs, to name a few.

Along these lines, MedPAC has laid out recommendations in their June 2010 report to Congress to modify GME payment schemes to create incentive toward just this sort of health care development at the residency level. Their is some indication that MedPAC will go even further in more specific terms for these recommendations in their coming June 2011 report.

"The standards established by the Secretary should, in particular, specify ambitious goals for practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, including integration of community-based care with hospital care."1

I am encouraged that groups like AAMC, MedPAC, and others recognize and support these needs. This demonstrates a recent shift in ideals of physician character and workforce expectations. In the past, the four year academic medical track focused almost entirely on the preparation of physicians that could meet the myriad of pathologic disease. While bedside manner and patient communication were emphasized in this training, left out were business skills, political awareness, health system development, personal leadership, and development of non-technical competencies.

All of this speaks to what I believe – that there is a fundamental difference between developing clinicians for the sole focus of patient care, and developing physicians that have the skills to be both team-members and leaders in the future of health care. Clearly, in the past, academic medicine has focused on the former. The modern health care climate, and the rapid transition of health reform demand attention to the latter. In the future, we need to more fully consider this balance between service and education.

This begs the question - are we developing great clinicians or are we training health care leaders?

Considering this question is absolutely imperative for the success of the future of family medicine. As we look towards advanced systems of health care delivery – the ACOs and PCMHs of the world will hinge their success on the leadership of those family doctors at the center of patient care. Family physicians in these models MUST have strong communication skills, the ability to manage a team, an appreciation for the business of medicine and health system development. Ever increasing political involvement in health care necessitates a comfort with health policy, legislation, and the political process – not to mention advocacy. Single-minded family physicians cannot expect to be efficient and successful providers of care for their patients. And I believe it is up to our academic institutions to encourage development and growth in these areas.

The problem is that I do not necessarily see these characteristics in many of my classmates, or in the residents with whom I train. My colleagues remain content to stick their heads in the proverbial sand for the duration of their medical school and residency years – with the expectation that they will peek out at the end of the hibernation and everything will be perfect. This is largely a product of a medical education and residency structure that encourages these sorts of behaviors. Textbooks, tests, and H&Ps are the name of the game in these outdated models.

We need to continue to encourage efforts like those of the AAMC's and MedPAC. We should embrace medical school projects such as Dartmouth's approach to engaging students in systems development and quality improvement. And we should look to continue to find ways to balance service with education in the longitudinal structure of residency programs. These goals will continue to streamline and advance the process of developing a successful and productive family physician in modern health care. The kind of family doctor that is best for his patients, his community, and his profession.

1. MedPAC Report to Congress, Aligning Incentives in Medicare. June, 2010. Pages 103-125

Sunday, May 1, 2011

Bringing It All Back Home

In the scope of history, medicine has a definite tendency towards cyclical trends through generations. Recently, I've been considering the moves to incentivize preventative medicine, as well as those to reduce admissions and lengths of hospital stay. These factors are driving health care out of the hospital, and into the home. But looking though the lens of the past – we've been there before.

For the overwhelming majority of American history, health care delivery was centered around the home. Only recently, with the rise of the hospital system, have we witnessed an explosion of inpatient care. Far from this, the only care done outside the house was in charitable centers for the destitute. Further, physicians rarely maintained private offices. Early American medicine was a diminutive practice, and professional physicians viewed as a whole, were considered inconsistent at best.

Throughout the 18th and 19th centuries, the center of health care delivery was definitively the home. It was considered a familial responsibility to care for the sick of the household, and it was often beyond thought to send an ill family member outside for care. There was great tradition in caring for one's own family and considerable comfort and dignity in dying in one's home. In rare or advanced circumstances, a doctor could be summoned to the house to offer guidance. But, by and large, patients remained in bed and the extent of care was entirely within the confines of the family house.

The rise of the professional hospital system and the association of physician licensing to health facilities did much to initiate the movement of medicine outside of the home. Increased urbanization and longer work hours also limited the ability for families to care for themselves. The final blow was cast by the rise of individual health insurance, and the co-committal necessity to seek professional care. By the 1930s and 1940s, the public perception had shifted and American expectations aligned with hospital and office-based care. Since that time, health care delivery has become overwhelmingly associated with these entities.

Modern medicine is now seeing a rejuvenation in health care in the home, and a movement away from the hospital and office. Equipping patients with home blood pressure cuffs, glucose monitors, and sensitive scales allow regular monitoring of health. Many large health systems have developed integrated patient tracking programs, in which these devices automatically transmit information into the system database for that patient. Red flags are recognized by the system, and a phone call to the patient allows immediate evaluation and intervention. Further, the rise of direct care physicians has seen a sharp return to “house calls”. In the near future, a continued increased emphasis on preventative care will keep patients out of waiting rooms and tele-medicine will allow many to confer with doctors from the comfort of own living rooms.

Looking at the cyclical nature of American health care, I am reminded of the importance of remembering our roots. With the current debates and projections in health reform, perhaps it would be prudent to more fully consider the past as a means of plotting the trajectory of the future?

Another thought, which may be somewhat tangential, is no less important for the future of family medicine. As we move into this increasing technological world of health care delivery, it becomes ever more paramount that we stick tightly to our foundations. We must be resolute in our commitment to our patients and present in our compassion. We must practice a delicate and humanistic bedside manner. For that is the one thing that computers and precision medicine can never replicate – a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1. For an extensive and enjoyable review on this subject, I would encourage EVERY medical student to read Paul Starr's The Social Transformation of American Medicine. If we understand where we are coming from, we can better be prepared for where we are going.

2. Quality of care and patient satisfaction seem to be hot topics in medicine at present. Certainly, the importance of a bedside manner cannot be underestimated. However, I find it intriguing that we are still striving for perfection in this area in the 21st century. After all, the basics of bedside manner were outlined 2000 years ago in the works of Hippocrates. Nearly 400 years ago, Thomas Sydenham wrote extensively on the details and the art of patient care. Again, with the cyclical nature of health care – before so eagerly looking toward the future and waiting for new solutions to arise, perhaps we should more often delve into the past.