By PAULINE W. CHEN, M.D.
Published: February 4, 2010
During my training, I took care of a man in his 50s with a devastating surgical complication: His abdominal incision had split open a week after an emergency operation. Even after we had taken him back to the operating room, sewn the deepest layer of his abdominal wall closed and treated the infection that had caused his wound to fall apart in the first place, he still had a three-inch long crevice along the middle of his belly. Until the edges contracted and the gaping expanse filled in on its own, he and his wife would have to pack damp gauze into the wound every day to keep it clean and help it heal.
But on a visit a few weeks after his discharge from the hospital, I noticed that the gauze had been packed more loosely and changed less frequently than we had instructed. What should have been white and fluffy looked dried and yellowed, and his wound was no longer clean and healthy but covered with crusty patches.
When I started to lecture him on the importance of dressing changes, he leaned over to interrupt. “Hey, Doc,” he said, pointing to the pile of unopened gauze I had brought into the room to re-dress his wound. “Do you think I could have the extra? This stuff isn’t cheap.”
My patient had been cutting back on the gauze and changing the dressing less often because he couldn’t afford the supplies. And while I had been careful to recite the science behind the treatments, I had no idea how much he had to pay or if he could afford the expense.
As I stuffed a few packages into my patient’s pocket, I realized that in the busy day-to-day pursuit of becoming a good doctor, I had telescoped in on the clinical details, neglecting my once-cherished ideal to embrace the social and economic aspects of health care. By the time I was in residency, as was so apparent that afternoon, I had completely lost touch with my patient’s economic reality.
I believed that being a good doctor meant knowing the clinical facts down cold. And I somehow had led myself to believe that it would’ve taken much more time and effort to pay closer attention to those other details.
It was as if there had to be some kind of trade-off.
But I was wrong, on two counts. It was possible to learn about the economic and social aspects of health care while immersed in the details of biology, physiology and pharmacology. And it was impossible to become a good clinician without doing so.
Last fall the journal Academic Medicine reported that the vast majority of students felt they had received adequate clinical training during their four years of schooling. But fewer than half felt they had had adequate exposure to health care systems and practice, an area of study that extends to subjects like medical economics, managed care, practice management and medical record-keeping.
When the researchers compared the five-year results from two medical schools, they found that students who had attended the school with more of these types of courses were significantly more satisfied with their education than students from the school with fewer. Moreover, regardless of how much of their school’s curriculum was devoted to these nonclinical topics, students remained equally satisfied with their clinical preparation.
“If you only have one system, one payer and one set of hospitals in your country, there’s not much you need to know about health care systems,” said Dr. Matthew Davis, an associate professor of pediatrics, internal medicine and public policy at the University of Michigan and the senior author of the study. “But when you have hundreds of insurance plans and thousands of insurance groups and different hospitals, you have to be really smart about the health care system.
“Our findings suggest that we are not preparing them nearly as well for that challenge as we are for their clinical work.”
What was surprising to the researchers was how relatively little time was required to train students in these broader health care issues. “There was a difference of maybe 16 or 17 lectures” between the two schools, said Dr. Mitesh S. Patel, lead author and a resident in the internal medicine training program at the Hospital of the University of Pennsylvania. “But the impact on how properly people felt they were being trained was dramatic.”
That impact on students’ perceptions and the kind of care they offer is obvious to Madelon L. Finkel, a professor of clinical public health at Weill Cornell Medical College in New York City, who has led medical students in a required two-week intensive course on the health care system since its inception a decade ago.
“The course opens their eyes to issues they haven’t been focusing on,” Dr. Finkel said. “At the beginning, I always ask if students routinely ask their patients about drug coverage. But none of them ever does.”
The goal of the course, which includes discussions and lectures, as well as mornings spent with officials at various hospital systems, health care organizations and government agencies, is to have all the students asking questions like that one and “understanding the complexities of being a doctor.”
Learning about the economics and practice of health care does not always require separate courses; educators can have the same kind of impact by integrating the lessons into the standard medical curriculum. “Oftentimes,” Dr. Davis observed, “people look at a curriculum in terms of time rather than ideas.” But a discussion about a new group of high blood pressure medications can include not only biochemistry and pharmacology but also health care costs and outcomes research.
“These are incredibly important topics,” said Dr. John E. Prescott, chief academic officer for the Association of American Medical Colleges, the group that has sponsored the national questionnaire used by the researchers. “Physicians knowing about the system and the environment in which they work allows them to be better doctors. And that in turn allows them to take better care of their patients.”
“It’s a pay-off,” Dr. Davis added, “not a trade-off.”