Medical Education: What Should We Teach?

http://www.latimes.com/opinion/commentary/la-oe-rekhi-medical-education-policy-20140103,0,2359257.story#axzz2pMQl1ym1

Medical education is an unscientific exposure to medical science which results in physicians with, hopefully, enough common sense, to question what they have been taught. Today’s LA Times, Mr. Rekhi highlights the lack of training in health care policy. How can a doctor work in a system without understanding its outside forces? Yes. This point has been an aggravation of mine for some time now, given that my medical education never made sense to me, but nor does the current educational environment. In the 80’s I was in school for forty  hours a week for two years, with homework and assignments added on top of that. I enjoyed it, but apparently, UCLA has now become the school with the least demand for classroom activities. The reversal is striking, and questionable. That medical education needs an overhaul is clear. There is so much to learn; so little time to learn it. Prioritizing learning is a very complicated, and unclear endeavor. Mr. Rekhi says, and I agree, that with the change in healthcare delivery, physicians should have a sophisticated understanding of the impact of that change on how they practice medicine. UCLA is a gem in that students rotate through a multitude of settings, giving them exposure to a range of patients and health-care delivery systems. This, thankfully, has not changed. Perceptive students learn by experience how different settings result in kinds of care, but it would be better if this understanding was enhanced by providing the research on health care policy and the resulting  impact on patient outcomes. He makes an obvious point, and yet, as with many important decisions, sometimes the obvious needs to be stated.

 

Play Class: Update

My class is called the “Clinical Practicum,” but I would like to rename it the “Play Class.” I love that I am teaching students, hovering thirty, with so much education under their belts (along with huge debt), and yet we are talking about how to play, both for our own enjoyment and for the therapeutic benefit of our patients of all ages. We lament together how play has somehow gotten lost in our society of overscheduled children and adults. “What happened to the public schools?” One student asked. This seemed to be the central question. With parents extremely anxious about where their child goes to school, has come a pressure on children to justify the additional effort of either a private school or a public school which is a burden geographically. Now that most children are driven to school, this creates a dependency on adults in which the child is then driven to after-school activities. The social norm, at least in West LA, seems to dictate that if the child is not learning a new language, involved in a sport, and learning an instrument, then he/she is somehow going to suffer as he/she enters into the “real world.” “We need to remind parents that children need play time to expand their imaginations and develop creativity.” I say firmly and repeatedly. “Yes, but we don’t have time to do that with our fifteen minute appointments,” they respond with frustration. “Yes, so we need to lobby for more time with patients.” I say, again, feeling argumentative, even though we are all on the same page. “There are not enough child psychiatrists to play with all the children that need our help,” another student says. “Yes, that is true, but we can promote the value of play such that we can help other professionals play with children in a therapeutic manner.” I say, alluding to the idea that our job needs to be much broader than psychopharmacology. The class ends with what I call “positive frustration.” We all want to see the field change. We all want to play with our patients.

Electronic Medical Records: Do You Want Fries With That?

  The Affordable Care Act, the digitization of our world, and the changing delivery of health care all comes together to roll out electronic medical records, now active at Kaiser, and soon to be active in almost every primary care setting, certainly by 2014. To be clear, I think that this will be a net positive for patient care. Medical information will be helpful to emergency room visits, doing health maintenance, and tracking prescriptions. I am optimistic about the benefits for the vast majority of patients who now have fragmented care, or no care at all. My concern is how will electronic medical records change the joy in the practice of medicine. Will taking care of patients retain the fun, if a menu comes down for every patient, reminding the provider to remind the patient to wear his seatbelt when he drives in his car? Again, I think it is a good idea, and it will help, for the computer to prompt the physician to remember preventive medicine questions, as preventing accidents, for example, is a very important part of health care. Now, though, that conversation, stems from a general concern for the patient, usually discussed, at a visit where critical medical issues have already been addressed. Yes, of course, the computer eliminates the human error, inherent in trying to remember too many things, especially when the provider has too many patients. At the same time, the fun in patient care, at least for me (and I am not a primary care doctor, I understand that) is the spontaneity of conversation, which is based on a deep training of important questions which are well-timed to the moment of most open communication. For example, there is a big difference if you tell a patient to stop smoking in a rote fashion, as opposed to telling them to stop smoking after they just told you that their uncle died from lung cancer. I fear that this art of persuasion will be lost with the advent of electronic medical records. In so doing, I fear the fun of patient care will diminish considerably. Sure, there is an upside. Efficiency is going to make the doctors feel better, as inefficiency, in the current system is degrading and demoralizing to physicians. Balancing it out though, I still fear that this roll out will be a net gain for patients and a net loss for providers. As with so many of my grim predictions, I really hope I am wrong.

Field Trips…

 

In my effort to expose my Family Medicine Residents to community resources, here is where we have been, in reverse chronological order. I am open to suggestions for further community exposure!

 

Place	Tour Guide	Date
Edelman Community Mental Health Clinic	Nancy Nowlin-Finch MD	Monday, October 31, 2011
Culver City Senior Center	Darren Uhl	Monday, October 24, 2011
UCLA Family Commons	Cynthia Webb	Monday, October 10, 2011
UCLA Early Childhood Center	Dane Fitzsimmons	Monday, October 3, 2011
Our House	Fredda Wasserman	Monday, September 26, 2011
UCLA Early Childhood Center for Autistic Children	Juliann Gonzalez	Monday, August 29, 2011
Step Up on Second	Jackie Huett	Monday, August 22, 2011
Didi Hirsch	Curley Bonds MD	Monday, August 15, 2011
Maple Center	Sharon Schwartz	Monday, August 8, 2011
Westside Regional Center	Barbara Lotus	Monday, August 1, 2011
Ocean Park Community Center	Vivian Zaat	Monday, July 11, 2011
UCLA Geriatric Inpatient Psychiatry	Stephen Chen MD	Monday, June 6, 2011

Senior Center-Yay!

    Primary Care Physicians need to learn psychopharmacology; they also need to learn how to help people enhance their lives through behavioral change. This is the old saw: nature and nurture. The medications address the nature, the environmental change targets the nurture; both are important, at every stage of life. Consequently, I have taken a new route to training Family Medicine Residents to guide patients towards healthier, happier lifestyles. A physician recommendation is powerful. A friend or family member may suggest to their loved one to pursue a community resource, yet when this same suggestion comes from their doctor, there is often more impact.  Further, when a physician has seen the resource themselves, they are more likely to explain the benefits in a way which is compelling. So, Monday mornings are now consumed with what I jokingly refer to as “field trips,” but more seriously refer to as “community medicine”. The Culver City Senior Center was our focus. My residents and I were overwhelmed by the scope and accessibility of all that they had to offer. There were computer classes, trips to museums (they were going to the Getty Villa that day), Tai Chi, and a knitting group. Lunch is offered, requiring a voluntary donation of a nominal amount. The physical, mental and social stimulation available was really exciting. My group bemoaned the fact that we did not make their age cut-off. If one patient a month follows through on the recommendation to expand their world by joining the Culver City Senior Center ($10.00/year), then I have done my job, both in terms of helping residents understand community resources to improve mental health, and in terms of helping patients improve their physical and mental well-being. My “field trips” are win-win-win. I “win” because I expand my world of social services. The residents “win” because they are shown experiences which can’t really be described, they have to be seen. The patients “win” because they are given recommendations which can potentially improve the quality and the duration of their lives. A triple gain-not bad! Sometimes nurture is underrated.

 

See also….https://shirahvollmermd.wordpress.com/2010/04/07/growing-old/

Health Care Disparities

Rant alert-I am angry! In teaching my Family Medicine Residents about the delicate and complex role of benzodiazepines in the treatment of anxiety, one of my students informed me that at the low-income clinic where many of my students work, they have eliminated this class of drugs from their formulary. I could hardly contain my rage. In fact, I did not contain it and I began to try to turn my rage into an important teaching point. That is, regardless of income level, patients are entitled to have access to medication which can make their lives significantly better. Instead, this policy has made it so getting treated for anxiety is now a middle to upper middle class possibility, but lower-income folks have to find other means of dealing with anxiety. The unfairness of this discrepancy is hard to understand. The medications are cheap. There is no cost barrier.

  I do see how prescribing benzodiazepines are time intensive and therefore costly in that way. The medications need to be monitored. As with prescribing any medication, there is a risk of liability. Yet, it is a clinic, and the mission of the clinic is to help low-income people receive health care. Treating anxiety with available medications is part of that mission-I would think. Second, and terribly obvious, how are my residents supposed to learn how to prescribe these anti-anxiety agents if where they work does not allow them to use these agents? Yes, they do get experience with the likes of Xanax, Klonopin and Ativan on their other rotations, but they should also be able to learn to see how these medications impact people who are struggling with unemployment, foreclosures, and high intensity exposure to violence and substance abuse. Helping someone with anxiety, whether with medication and/or behavioral techniques, enables the patient to cope with what might otherwise feel like impossible situations. Further, anxiety causes medical problems to get worse, so if the doctors can’t treat their anxiety with psychotropics then they will be treating their medical problems, such as their increased blood pressure, their increased sugars, and their irritable bowel disorder. Treating the mind, helps the body, and treating the body helps the mind. Why is that not clear to policy makers?

Psychiatric Curriculum

I imagine a curriculum where a leader asks me to teach to the medical students, residents, and/or fellows, topics which this thoughtful person has deemed important for the education of these particular students, given where they are in their training. Yet, in my various volunteer teaching activities, the common theme is “there is no curriculum. Professors come and talk about something that the professor thinks is important.” I am stunned and disturbed. Further  I question my complicit role in these educational systems. Universities, in general, are well known for this problem. Professors get paid to publish, not to teach. Teaching is supposed to be something they “squeeze in” to their paid responsibilities. Consequently, there is no quality control on the teaching or the content. Not only is no one paid to teach, no one is paid to coordinate the teachers. Sure, there are administrators who email confirmations and make sure the audio-visual equipment is up to speed, but there is no thought leader pulling the train forward.

Last week, I gave medical students a lecture entitled “Psychiatric Emergencies.” I thought it was an interesting and relevant topic. The forty students seemed to laugh at my  jokes; I did not see anyone sleeping. This was an improvement from last year. Yet, there seemed to be a lack of interest in the topic. Questions at the end always mean the students have to sit there longer, so I can see that if they wanted to get up and stretch their legs then they would not engage me in conversation when I was finished with my lecture. Sometimes, people come up and ask questions on their own-not this year. Sure, I can take it personally and say that I need to change my delivery and/or my content. Yet, I do not think that is the problem. I think that without a curriculum, the students are forced to learn on random topics, such that they feel that they just have to “show up” and then they can get back to what they really want to be doing-whatever that might be. Every year I think, maybe I won’t do this again. There is a system problem that needs changing, I think to myself. Yet, every year I go back, with the small hope that maybe if I can gain some traction with the students, then maybe I can be heard at a higher level in the system. As I say that, I know I am kidding myself. I will go back next year. I will have a similar angst. Still, I will hope that maybe, just maybe, one student will spark a fire in the administration to create a better learning experience. I know this is my imagination, but sometimes dreams come true.

Medical Training: How Did We Lose Our Way?

  Raphael is a thirty year old hispanic male, working hard as an internal medicine resident. He is  the first person in his family of ten siblings to graduate high school. His father washed dishes for a high-end restaurant. His mother took care of the family. His siblings have had many social problems including drug abuse, teenage pregnancies, and truancy. Raphael has persisted in school despite the odds against him. His father passed away when he was sixteen. His mother has chronic medical problems. Raphael began residency as a strong resident, but along the way, he stopped showing up for work. He got depressed. He did not know how to reach out for help. The residency directors worried about him, but he did not respond to emails or phone calls. Eventually Raphael surfaced and he agreed to get help. He consulted with prominent mental health experts and to his surprise, they told him he had a substance abuse problem, even though he said that he drank “like every other college student.” Raphael was sent to a rehabilitation program for substance abusers, even though he, and many other professionals did not agree with the diagnosis. Raphael was then ready to return to work, but at the same time, he was applying for his medical license. The board that issues the licenses became concerned about his “substance abuse” history and so then refused to issue him a medical license, even though he met all the other qualifications.  Now, Raphael cannot go back to work. At the moment, he cannot learn to practice medicine, despite his ten years of diligent work preparing for his career. Raphael needed help to get back on track, but he did not need a substance abuse rehabilitation program. Raphael has the potential to serve the community in a unique way because his background is unusual for physicians. Is it too naïve to think that if he had a little mental health support during his rough patch, and not a formal substance abuse rehabilitation program, that maybe, just maybe, this mess that he is now in could have been avoided? I do not think so. Tragic.