What do doctors need to learn in school to take the best care of you? Clearly, they need advanced medical and scientific knowledge. But should we expect doctors to know something about how our health care system works? How about the Affordable Care Act – one of the most important changes in health care policy in a generation? We continue our ongoing series Future Docs with some answers.
Dr. Anne Kuritzky is about five hours into her shift on the trauma unit at Rhode Island Hospital when the next call comes.
“You never know exactly what you’re going to get," says Kuritzky, speed-walking through the hospital corridor. "Could be a car crash. In the winter we have a lot of falls.”
Kuritzky is a third year surgical resident we’ve been following this year as part of our series Future Docs. She’s heading into an emergency room to see a patient who’s just been brought in by paramedics.
“Any pain where I’m touching?" Kuritzky asks the patient. "How about pain over here? Nothing?"
Kuritzky and a team of doctors and nurses fly into well-practiced routines to examine this young man. Turns out he was in a car accident, but it’s not too bad.
“Alright I’m going to push on your back," says Kuritzky. "Let me know if where I’m pressing it hurts. Just say yes or no, ok? Anything when I press right here?"
Between a resident’s typical 12-hour days and occasional overnight shifts, Kuritzky barely has time to read a newspaper, let alone read up on all the changes the Affordable Care Act will bring. No doubt she’s smart enough to learn what she needs to know as different aspects of the ACA start impacting her patients and her surgical practice.
But some medical students think the time to learn what this giant piece of legislation means for their future is now.
“My name is Tyler Winkelman, and I’m a second year internal medicine and pediatrics resident at the University of Minnesota.”
Winkelman worked in a community health clinic and got to know patients with no insurance, people who could benefit from one of the ACA’s big provisions: expanding health insurance to more than 30 million uninsured Americans. He says he started wondering why his professors weren’t talking about that in med school.
“It seemed like, to me, as an outsider that had no background in health care policy that this thing called the Affordable Care Act was a big deal.”
The biggest deal, he says, since Medicare and Medicaid.
“And there was no discussion of it in medical school and there seemed to be a basic unawareness of it, that this was a problem for the future of medicine.”
So Winkelman decided to conduct a survey of medical students in Minnesota. He wanted to find out what they knew about the Affordable Care Act. He figured there’d be some gaps. (See Winkelman's results in the November 2012 issue of JAMA Internal Medicine.)
“But we were surprised by the magnitude of that gap in knowledge," said Winkelman. "Forty percent of students, so nearly half of future physicians are uninformed about the biggest piece of health care legislation in their lifetime.”
So why is that? It’s partly because medical schools are mostly focused on teaching medicine and science, not so much on things like how the nation’s health care system works. That nebulous stuff was reserved for the likes of public health PhDs and policy wonks. But Winkelman says that’s changing.
“Medical education is starting to think about teaching policy and health care reform in medical school. And there are a few schools that are certainly leading the charge.”
Brown University’s medical school offered an elective course this year called Health Care in America. Dartmouth just revamped its curriculum, offering a new section on health care innovation. And Quinnipiac University just cut the ribbon on a new medical school focused on primary care, which is a big focus of the Affordable Care Act. But it’s often students like Tyler Winkelman who are the ones calling for change in medical education.
Joanne Conroy is chief health care officer with the Association of American Medical Colleges. She knows a student who realized it was medical residents who were ordering some of the most expensive tests and treatments in the hospital.
“And just was amazed at the lack of information about the costs of medical care, and how really residents and medical students at a number of different levels really didn’t have this information, even if they wanted to use it to make really, or help their patients make, value-based decisions.”
And that lead to a project to educate medical students about how much health care actually costs – like which expensive tests and treatments are probably unnecessary. (Learn more about that project at costsofcare.org). It’s something medical schools haven’t really talked about before. But Conroy says they’re starting to. And more need to – if their graduates are going to play a role in keeping health care costs down while keeping quality up. One way is by teaching med students to work on teams of health care providers – including nurses, pharmacists, and even social workers.
“This is a natural progression with the Affordable Care Act," said Conroy, "to think about how do you take team-based training and content knowledge and apply it to the care of a population.”
The ACA is funding some pilot projects that reward doctors for keeping a population of patients healthy – rather than paying them a fee for every service they provide. And while plenty of med school grads won’t be involved in those particular kinds of projects for now, most will feel the pulse of a swiftly changing health care system one way or another. They’ll feel it in big ways: like when 30 million uninsured Americans become eligible for health insurance next year. And they’ll feel it in smaller ways, like how they get paid. Resident Tyler Winkelman says med schools can either continue business as usual, or they can prepare students to navigate all this change. He says it comes down to this question:
“Do we want to create physicians or physician leaders?”