It started as a joke, but it has become a mantra. I discuss this phrase on the Curbsider’s podcast.
Our medical students pay (in my opinion) an obscene tuition. They are buying a medical education. Therefore we should remember that they are customers who have paid for our service.
As a clinician educator, I try to remember every day that I owe the learners my best effort. I have a wonderful career caring for patients and teaching those learners. The learners make my patient care responsibilities much simpler. But my job involves helping all the learners grow each day.
Learning internal medicine requires persistence and hard work. Our field is vast and complex. We start with naive 3rd year students, have fun with acting interns (4th year students), help interns through that difficult year and have the pleasure of fine tuning our excellent residents.
Inpatient rounding and clinic attending require us to strive that our patients receive high quality care. During patient care delivery we provide role models and work daily to stretch our learners. We owe them our best effort at helping them grow.
Each day I ask myself, did I give them adequate value. Ask yourself and your learners. Did you give them their money’s worth?
Discussing internal medicine education on a podcast – The Curbsiders
That was a lot of fun. The Curbsiders invited me to answer questions on a podcast. Before we knew it, it turned into 2 podcasts. They released the first one today, in which I answer questions about my philosophy of ward attending rounds, feedback, bedside teaching and writing.
Next week they will publish our discussion of adult pharyngitis.
I have become a big fan of podcasts. Good podcasts tell stories and expand ideas to provide granularity. I have listened to many of the Curbsiders podcasts (available on their website and iTunes). They have a great concept and obviously have much fun doing the interviews. They intersperse solid questioning with delightful irreverence (especially for each other).
Please check out their website and podcasts. You might even learn something!
More thoughts on primary care and all that other care
Spend time talking with non-medical friends and acquaintances. Ask them about their medical experiences. Imagine what they want, or ask them what they want.
People want to feel that their physician has spent adequate time talking, examining and explaining. They want to look into the physician’s eyes. They want the best possible care, but caring matters.
Our “system” discourages such care implicitly. Physicians do not get paid to spend time with patients. Too often part of our payment includes performance measures. Too often we must enter data into computer systems designed to analyze data rather than to make our job better.
Our notes are no longer meant to communicate our thought process, but rather include physical exam points and review of systems points that make the note bulky and often unreadable. These “points” add nothing to the note, but CMS and many insurance companies believe that the note documents our work.
CMS and insurance companies, legislation and many administrators seemingly have no understand of the impact of their rules on the patient-doctor relationship. I purposely listed patients first, because they suffer much from how these external forces treat physicians.
Each rule, each administrative annoyance grew from a reasonable concern, but as usually happens, the instigators ignore the unintended consequences of their impositions. Yes, they add impositions on physicians and therefore the patient-doctor partnership. We spend too much time worrying about and fudging billing codes. We try to meet performance measures, even when they produce dangerous overuse.
Being a physician is a great privilege. We really do want to help our patients. Will someone let us? Will someone stop this madness?
And I do not want to hear that a train left a station or a horse left a barn. Of course when the horse left the barn, you know what was left behind.
Solving the primary care crisis
We do have a primary care crisis. We believe that primary care delivers better care for less money. But primary care is under siege.
Why The Government Tried To Fix Primary Care And Failed
Many physicians do not believe in government solutions. As I understand the government solutions, they have great complexity.
One cannot “fix” primary care unless one really understands those features that make primary care advantageous. The key is time. Our current payment system discourages spending adequate time with patients.
While we cannot prove it, many believe that primary care physicians order tests and order consults to save time.
I would happily argue that until we pay primary care physicians for spending appropriate time with patients, we will not decrease health care costs. We need to encourage physicians to spend time with patients. Complex systems are unlikely to work.
Tips for IM attendings – Chapter 18 – learning is more difficult than teaching
As a newly minted journal faculty member rounding on the wards, I had great internal pride in my teaching ability. Like many residents and junior faculty I assumed that my teaching would result in the learners growing dramatically (especially since I had delivered the messages so brilliantly {please read that phrase with true sarcasm}).
During my growth as an educator I learned that teaching can help, but not as dramatically as I would have liked.
Try this yourself. Teach something to your learning group. Wait a week or two and then quiz them. At first you will be despondent, but then take time to reflect. How long did it take you to learn things?
About 15 years ago, the housestaff helped care for an unfortunate young woman with Wilson’s disease. One resident presented the story at morning report, and I missed the diagnosis. I had never seen Wilson’s disease, and really did not know much about how patients with Wilson’s disease presented.
Approximately 2 weeks later, a different resident presented her story at a different morning report. I missed the diagnosis again.
The third time (yes this patient’s story was recycled for a variety of presentations), I did remember the story. I now know the big clue is the very low alkaline phosphatase in a young patient with new liver disease.
Learning is complex. We learn better with repetition. We learn better with the use of different sensory inputs.
What should this mean for our teaching?
First, never apologize for repetition. Just yesterday I quizzed my team on something I had taught the previous week. One of four remembered the concept. So we repeated the key teaching points.
Second, encourage your learners to read about what they learn each day. I recommend that learners keep a small notebook (or enter notes into their smart phones). Each day they should pick 2 topics to reinforce. Spend 10-15 minutes on the topic. Reading about something that you just heard helps solidify the memory.
Understanding the difficulty of learning medicine should inform educators. Our job is to help our learners grow. This growth requires repetition. We owe our learners a great deal. Understanding and repetition are a good start.
The statin controversy
A friend asked me recently about statins. He takes a statin for primary prevention, but is concerned that he has muscle pain and weakness as a side effect. So he posed the question: “How important is the statin?”
The Washington Post had this recent article – Who should take statins? A vicious debate over cholesterol drugs.
But while nearly all experts agree that statins are beneficial for people at a substantial risk for heart disease, some medical researchers argue that statins do little or no good — and possible harm — for people at lower risk of heart disease. The conflict has burst into public view in the United Kingdom — and is likely heading here, too.
A bruising battle has played out for several years between Britain’s two leading medical research journals, the Lancet and the British Medical Journal (BMJ), which have accused each other of endangering public health. The debate has gotten so heated that it has made tabloid headlines (“STATIN WAR,” blasted the Daily Mail). It began when BMJ first questioned statins’ usefulness in 2014, publishing two articles that argued that the drug was being overprescribed to people with low risk of heart disease. It also claimed that the side effects from the drugs were worse than previously thought.
Statins have two major effects. First, they lower cholesterol levels. Lowering cholesterol likely decreases plaque size, therefore patients will less likely have atherosclerotic complications. Second, they stabilize plaques, making plaque rupture and therefore clot formation less likely.
In patients with known atherosclerotic disease (previous myocardial infarction, atherosclerotic stroke or symptomatic peripheral vascular disease), statins clearly decrease the probability of further events. Some patients with significant genetic predispositions, and most patients with type II diabetes mellitus also fit into this secondary prevention category. For these patients we really have no debate.
For the remaining patients, the debate becomes much more complex. Primary prevention (prevention in patients who do not fit into the previous paragraph) has a minimal impact. Statins do decrease the risk of coronary artery disease, but the risk reduction is rather small. Statins (like almost all drugs) are not benign. They have side effects. The question therefore becomes the classic one – how does one balance the potential of the benefits and risks? (or more simply put, is the juice worth the squeeze).
I explained this as best I could to my friend. I would not encourage statins for true primary prevention. Strong genetic predisposition and type II diabetes fit into a separate category. Statins help many patients and the benefits are strong as a secondary prevention medication. But the side effects are real and make the primary prevention question much more difficult. Currently I do not favor primary prevention.
What is next for the Affordable Care Act?
This well consider NY Times article is a “must read” – Ailing Obama Health Care Act May Have to Change to Survive.
Some have claimed great success for the ACA, because 20 million people now have insurance. These proponents emphasize the increased in “insured” and minimize the importance of the continued problems in the individual insurance markets.
Opponents of the ACA emphasize the problems, and ignore the benefits of 20 million more insured citizens.
The truth almost always resides between our polarized democracy. The act has helped some people (especially those with pre-existing conditions and young adults 26 and younger who can remain on their parents’ policies). In states that have adopted the Medicaid expansion, many greatly disadvantaged citizens now have some health insurance.
But
Many previously insured people are paying more for similar policies. Many people now have limited access to insurance because the insurance companies have lost too much money (or at least that is their excuse).
And both sides will likely admit that the act did nothing to prevent the unbridled greed of the pharmaceutical industry.
The act is too complex and too nuanced at this time. Too many compromises occurred with the insurance industry to get the act passed.
“Even the most ardent proponents of the law would say that it has structural and technical problems that need to be addressed,” she said. “The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don’t have enough young healthy people in the exchanges.”
The next administration will have much to do to address this cumbersome, well-intentioned act. Hopefully, with modifications we can provide coverage for more patients, and coverage that actually works for all patients.
