The pace of American medical training
Tags: Travis Bias, Kenya, Uganda, Milken Institute School of Public Health, George Washington University, @Gaujot, globaltablechat.com
Tuesday, December 5, 2017 5:30:00 AM
By Travis Bias, DO, MPH, DTM&H
In his commencement address at Kenyon College in 2005, the late author David Foster Wallace told the story of two young fish swimming along. They pass an older fish swimming the other way who greets them: "Morning boys. How's the water?" As they swim on, one of the younger fish responds to the other: "What the hell is water?"
Feeling and appreciating your body of water takes experience, maturity, and occasionally someone else making you aware of your daily surroundings. It was not until a few years into my career as a family medicine physician that I realized the furious pace at which American physicians learn to swim, insulated in a system that operates in stark contrast to that of other countries around the world.
What kind of young physicians is our system creating?
Six months into my first year of residency, I was on a rotation with an energetic orthopedic surgeon. Our residents looked forward to our time with him. Residency training is a time for young physicians to drink from a fire hose of information during long work hours, learning not just clinical medicine but also the business of health care. As we stood outside the exam room preparing to see the next patient, the topic of medical malpractice came up.
"Every time I walk into a patient room, I see the patient in front of me, the insurance representative on the right, and the malpractice lawyer to the left," he said.
At our morning report following nights on call in the hospital, we would present each admitted patient to our attending physician who taught us clinical pearls and also regaled us with stories regarding malpractice cases that had arisen from similar situations. He helped us refine our documentation and ensure our trail of charting and medical care would back us up in the event of a lawsuit.
Several times faculty physicians reinforced my plan to order studies to ensure a life-threatening condition was ruled-out. Many could have been reliably excluded with physical exam signs or patient risk factors, but I had been trained to rely on technology to definitively prove my clinical hunch. I have never been the subject of a medical malpractice lawsuit, but I practice as if I have.
So each month, I gathered nuggets of information from my professors regarding medical business practice, detailed documentation, and using technology to prove diagnoses. These lessons all slowly seeped deep into my practice habits. And, much like an older brother repeating a parents' teachings to a younger impressionable sibling, I taught these to junior residents and medical students.
Then came several stints in a rural health center in Kenya and a three-month course in tropical medicine put on by the London School of Hygiene and Tropical Medicine in Tanzania and Uganda. My classmates were from the United Kingdom, Australia, Germany, Tanzania, Uganda, and even Botswana, among other countries. Out of the 57 young physician students from around the world, I was the only American. Through work in the resource-limited health center in Kenya and a subsequent year of teaching medicine in East Africa, and discussions with my tropical medicine classmates, I started to see my water more clearly.
Fear of medical malpractice lawsuits and defensive medicine are unique American system attributes. The private fee-for-service system without a firm foundation of public care is an American trait. Patient cost sharing having no basis on the actual cost of care makes the US health sector unlike any other. Mountains of educational debt following medical school are only found in the American system. The large pay increase in that first year as an independently practicing physician after postgraduate training is a massive incentive only present stateside.
How do these elements affect health care delivery in one of the strongest economies on the planet?
In the documentary film "Escape Fire," former Centers for Medicare and Medicaid Services Administrator Donald Berwick says he does not blame anyone in the American system for doing what they are doing. Hospitals fill hospital beds because they are incentivized to do so. Physicians enter lucrative sub-specialties at times partially motivated by the need to pay off educational debt, and many go straight through medical school and residency eager to absolve that debt. Seventy-six percent of American physicians graduate medical school with an average of almost $190,000 of educational debt. Can we blame them for sometimes seeking more profitable specialties and blazing straight through training? I finished training as quickly as possible at the age of 29 with just over $200,000 in debt and no savings, and then entered practice in the fee-for-service system. And the path of least resistance was to follow the volume-based carrots laid out by my predecessors.
The lessons of older physicians are percolating down to breed younger physicians with similar attitudes. And that should be concerning. What were once young idealistic physicians, are now caregivers entering a post-Affordable Care Act system with the same views as a physician who was raised in the fee-for-service scheme.
How do we incentivize young physicians to enter the right mix of specialties and shape them to serve an aging population in a changing system?
We must start by addressing the cost of medical education. Without the heavy debt burden, financial incentives lose their power. Next, improve the pay during postgraduate training, while encouraging extended breaks in training, if the physician so chooses, through funding or built-in time away from the home institution. This time away could be used for international rotations, administrative or policy placements, or exploring research opportunities that interest them.
For example, young British physicians take months, sometimes years, away from their postgraduate medical education to work with non-governmental organizations or in academic settings in low-income countries. During this time out of their comfort zone, physicians have more time for self-reflection while pursuing personal interests. This may very well extend the length of training, but without debt creating the race to finish, this would be less bothersome to young physicians. In fact, many young physicians start out craving these seemingly extracurricular experiences, but there is currently little time or support for what would be key to a physicians' personal and professional growth.
When the system of education changes to encourage outside perspective-gathering experiences, our system may well end up with physicians whose incentives better align with the most important health care player of all: the patient. That physician will be more confident in her physical exam skills rather than relying on technology, which will in turn lower costs in the most expensive health care system in the world. That physician will be more in tune with herself and the need to care for herself before caring for others, thus lowering chances for burnout and improving longevity. That physician will be more empathetic to patient needs, leading to higher quality care.
One must smell poverty to recognize the stench of inequality. You have to be confronted with true hopelessness to detect suffering. You must feel, at some point, uncomfortable to identify vulnerability.
Learning medicine takes years of study, sacrifice, and repetitive pattern recognition. Caring for another human takes a self-awareness that requires an intimate full-sensory appreciation of your surroundings. And only with these skills sharpened can the leaders of our health system take that vital swim alongside their patient.
Travis Bias, DO, MPH, DTM&H, is a family medicine physician, a former professorial lecturer at the Milken Institute School of Public Health at the George Washington University, and a former visiting lecturer in Kenya and Uganda. He used to live in Texas, but alas, he moved to California. Tweet him @Gaujot and read his posts at https://globaltablechat.com/.
Buprenorphine and the elimination of the X-waiver
Tags: buprenorphine, opioid crisis
By Larry Kravitz, MD, Chris Allen, and Matthew Seghers
As primary care physicians, we all want to help end the opioid crisis. But the options for family physicians in this epidemic have been limited. Most of us are not addiction specialists. Most of us do not work in substance abuse rehab clinics. Within the traditional primary care clinic setup is the undercurrent of our daily struggles, as our patients succumb to progressive illness, and with that, often the emergence of chronic pain conditions. Tackling chronic pain can be one of the most vexing issues in medicine, and primary care is at the frontlines of handling these patients.
Statistics from the National Institute on Drug Abuse are staggering: Roughly 21-29% of patients prescribed opioids for chronic pain misuse them, between 8-12% of people using an opioid for chronic pain develop an opioid use disorder, and approximately 80% of people who use heroin first misused prescription opioids. COVID-19 only exacerbated opioid-related consequences, with several publications from prominent organizations such as the Journal of the American Medical Association and the American Medical Association outlining the harrowing spikes in both non-fatal and fatal overdoses. Texas has not been immune to these trends, as highlighted in a KHOU segment from December 2020 that describes a record-breaking number of calls to first responders for overdoses.
Texas Physicians for Social Responsibility releases report on health and climate change
Tags: Texas Physicians for Social Responsibility, climate change, public health
Monday, November 22, 2021 4:12:00 PM
By Samantha White
A new report on the disastrous health impacts of climate change was recently released by the Texas Physicians for Social Responsibility. The organization's report, "Texas Climate 2040: How Climate Change Impacts the Health of Texans," examines the various consequences of the climate crisis and the public health problems they create.
"Climate change is the greatest public health threat of our time," said Dr. Lisa Doggett, a family physician and president of Texas PSR. "Urgent global action is needed to reduce its impact and mitigate its effects. We need a massive shift to renewable energy to protect the health and future of Texas families and communities."
Funded delegate spots and scholarships available for NCCL
Tags: NCCL, 2021, texas academy of family physicians, TAFP, delegate, alternate delegate
Tuesday, November 16, 2021 3:43:00 PM
Each year, AAFP holds the National Conference of Constituency Leaders and Annual Chapter Leader Forum together in Kansas City, Missouri. NCCL representatives and ACLF attendees from across the nation gather to discuss various issues, suggest policies and programs to AAFP, and receive leadership training. In 2022, the conferences will be held April 28-30 and TAFP is looking for members to serve on the delegation or apply for scholarships to attend.
Texas Delegation to NCCL
Spots are available for 10 TAFP members to represent each of the five constituencies: new physicians (physicians who have been out of residency for seven years or fewer), women, minorities, international medical graduates, and LGBT physicians. TAFP reimburses up to $1,200 for expenses for each of the five delegate and five alternate delegates. In addition, TAFP offers two other opportunities to attend NCCL with funding. These scholarships will be awarded to one third-year resident and one minority physician.
Interested? Please fill out this form and send a current curriculum vitae to Kathy McCarthy at kmccarthy@tafp.org by Friday, Dec. 17, 2021.
Time to triumph over the trials of burnout
Tags: Anticipate Joy, burnout
By Anticipate Joy
It all started with a dream. Maybe it was to make the world a better place. Maybe it was to save lives. Maybe it was to help others. Or maybe it was just to make a nice paycheck. Whatever it was, you had a dream of becoming a doctor, and you did it. Your dream came true! But unlike fairytales, achieving our dreams doesn't always mean "happily ever after." In fact, sometimes our dreams can seem nothing like how we always imagined they'd be.
One of the biggest problems physicians struggle with today is burnout. With 44% of doctors experiencing this issue and 96% of medical professionals believing burnout is a problem, there clearly needs to be something done about this topic. However, despite nearly half of doctors undergoing feelings of burnout, 40% of physicians are reluctant to seek out mental health treatment, and 41% of physicians choose to isolate themselves as a method of coping. These are things that will only lead to more difficulty for doctors, both in their work and in taking care of themselves. Here are some symptoms that might indicate you're struggling with feeling burnt out.
Texas Family Physician of the Year urges House committee to invest in rural primary care workforce
Tags: Adrian Billings, testimony, House Public Health Committee, border health
Thursday, October 7, 2021 3:20:00 PM
By Jonathan Nelson
The House Public Health Committee of the Texas Legislature held a hearing this week focused on addressing health care access for communities along the Texas-Mexico border. TAFP's Family Physician of the Year, Adrian Billings, MD, PhD, made the drive from his home in Alpine to Austin to provide his perspective on the great need for primary care investment in rural Texas.
"My work, although rewarding in so many ways, has been both exhausting and challenging because of the incredible need for care in my communities," Billings told the committee. "Rural health care organizations such as critical access hospitals and rural clinics are like small football teams. We have very few, if any, additional staff on reserve sitting on the bench for relief. For example, our Alpine clinic today does not have a provider because I am here testifying."