Future Docs 6: Facing an older, sicker nation

Feb 7, 2013

Medical student Peter Kaminski works through a patient scenario with team members from local nursing, social work, and pharmacy schools.
Credit Photo by: Kristin Gourlay / RIPR

As a nation, we’re getting older, and we’re getting sicker. More of us than ever are over the age of 65. And more of us are suffering from at least one chronic disease. Next in our Future Docs series, how medical schools are trying to prepare students for these new realities.

“Hello, this is the family doctor!”

This was the ideal doctor, this loveable character who entertained radio audiences of the 1930s on a show called “The Family Doctor.” He made house calls. He knew your family. He knew where you worked and how you lived. And it probably didn’t cost a fortune to see him.

Health care’s gotten a lot more complex – and more expensive – since then. And we’ve gotten sicker, as patients. The Centers for Disease Control estimates that nearly half of all Americans now have at least one chronic disease – like diabetes – that requires ongoing management. But we’re not managing those diseases very effectively right now, which means they’re making us sicker and costing a lot more to treat.

Some experts think we need to bring back a little bit of that family doctor in the form of more primary care. And that’s changing the way we train future doctors.

Sicker, more complex patients require teamwork
“We want our medical students to understand what a nurse does, what a pharmacist does, what a social worker does,” says George.

Paul George, MD oversees the second year curriculum for medical students at Brown University.

“…And to be able to say, ‘hey, I don’t know something. I’m going to consult my social work colleague or I’m going to consult my nurse colleague or my pharmacist colleague.’”

To accomplish this goal of having medical students work well on teams, students from local pharmacy, social work, and nursing schools have joined them on the second floor of Brown’s downtown Providence medical education building. They’ve broken into teams and scattered into conference rooms.  Second year Brown student Peter Kaminski is here, looking smart in a tie and short white lab coat. You might remember he’s one of the future doctors we’re following this year. He’s working with his team through a set of problems about a patient with chronic obstructive pulmonary disease.

“Do you think we also need to add inhaled corticosteroids?”
“What do you guys think would be the most appropriate one? I know nothing about it.”

Kaminski asks a pharmacy student about the most appropriate antibiotic to start. The nursing students weigh in about showing the patient how to take care of himself at home. Second-year curriculum chief Paul George checks in with the teams to make sure the workshop runs smoothly. He says this kind of training – they call it “interprofessional” – wouldn’t have happened when he was a med student just 10 years ago.

Kaminski interviews a "standardized" patient, an actor who's been coached to display symptoms of COPD.
Credit Photo by: Kristin Gourlay / RIPR

“The whole way that we teach medical students has changed significantly,” George says. “When I was a medical student, we learned histories and learned physical exams in the hospital. It was in silos. We never interacted with nurses, never interacted with pharmacists. There was no formal curriculum. So this is all brand new over the last five or six years.”

And that’s pretty much been true for most medical schools, although it’s changing.

The students get ready to put what they’ve learned into action. An actor who can put on fake symptoms –called a standardized patient– is waiting for each team in an authentic-looking exam room. Kaminski and his team discuss their strategy outside the door.

“All right, I think we have a good game plan...Hi, Mr. Jones, correct? My name is Peter Kaminski. I’m a second year medical student working with Dr. Levine. So, you have an entire team of health care providers here for you. If it’s alright with you we’re going to try to work together in order to try to go through the aspects of your case. Does that sound OK to you?”

Kaminski and a nursing student assess the patient.
Credit Photo by: Kristin Gourlay / RIPR

“Oh yeah, please. I want to find out what’s going on!”

“Most definitely.”

Kaminski runs through Mr. Jones’ basic symptoms. He listens to his breathing, his heart. The pharmacy student asks about the patient’s medications. A social work student learns more about Jones’ job, his health habits at home. Each student helps reveal something new about the patient’s history or health that might help them come up with a better treatment plan.

Of course, it probably won’t ever happen exactly like this in real life – an entire team of health care professionals showing up in the exam room to analyze your cough. But program head and practicing physician Paul George says teams are working together in other ways to keep patients healthier and –most importantly—out of the hospital. It’s what patient-centered, primary care should look like, he says.

“So, I see patients one day a week at a patient-centered medical home in Pawtucket,” says George. “And we found that when we discharge patients and we have our nurses follow up with those patients and make sure that they’re doing OK and really work as part of a team with us, both the nurses and the pharmacists, we reduce hospital readmissions."

He says that’s one way they’re saving money.

“And so we’re hoping that, by teaching our students early to work in teams with nurses, pharmacists, social workers, we can reduce health care costs down the line.”

The Affordable Care Act actually makes new funding available for these kinds of collaborations between doctors and other professionals focused on community health and disease prevention. It’s part of a larger trend you might already be experiencing, as a patient in a medical home, or at a community health center.

And more medical schools are joining that trend, finding ways to train future doctors to take care of us better, for cheaper.

Getting older
But there’s something else that’s changed about us. And it’s changing the way we train doctors. We’re getting older.

“The world now understands that this is the century of worldwide aging,” says Dr. Richard Besdine. He heads the Center for Gerontology and Healthcare Research at Brown University, and he’s devoted his career to geriatrics.

“We’re recognizing that not only health care, but virtually every aspect of commerce, and science, and humanities is being profoundly influenced by the age boom.”

By the year 2030, about one in five Americans will be 65 years or older. Besdine says that means doctors will be busy.

“Old people will be the majority of work for physicians in every specialty with the exception of pediatrics and obstetrics.”

Faced with that reality, a growing number of medical schools are paying more attention to preparing future doctors to care for the elderly. It’s a pretty big departure from the past. Besdine says geriatrics wasn’t really even a medical specialty until the 1970s, a decade after he was in medical school.

“The only thing I learned about aging as a medical student is to try to avoid having elderly patients to learn on,” says Besdine, “because their stories were endless, their problems were infinite, and it would take forever!”

But medicine has come to recognize that aging affects the body in unique ways. At Brown, Besdine led the charge to weave aging into an already packed program of study. He says they dive right in to the aging body – literally - their first semester in medical school, when they study a cadaver’s anatomy, because most donors are over 80 when they die.  But Besdine says he’s not trying to turn every student into a specialist.

“My emphasis here is on educating the non-geriatricians who are going to take care of 99-plus-percent of older Americans. And if they’re not competent, I’ll wind up in a nursing home way too soon.”

That’s hard to imagine, even with the most incompetent doctors.  At 72, Besdine is trim and vigorous. Rumor has it he’s a killer on the squash court

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