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  • What Kind of Physician Will You Be? How Variation in Health Care Impacts Your Training

    By Anita Arora, MD Geisel School of Medicine at Dartmouth’s Class of 2012, and Alicia True, Geisel School of Medicine at Dartmouth’s Class of 2015

    When fourth-year medical students choose which residency programs to rank highly in the Residency Match, various factors play an important role: a hospital’s reputation, the training curriculum, and the student’s own geographical and lifestyle preferences. But there’s something else America’s next wave of doctors should consider: the differences in care provided by even the most elite teaching hospitals, and how these differences affect the way we will practice medicine.

    During residency training, we learn by observing faculty who make decisions regarding how to treat chronically ill patients or whether to recommend elective surgeries. A new report from the Dartmouth Atlas Project, which examined the care provided by 23 top academic medical centers, found considerable variation in both the intensity of care provided to chronically ill patients at the end of life as well as the frequency with which patients undergo surgery when other treatment options are available. It also showed that quality, safety, and patient experience ratings did not increase with increased intensity of care. These variations in the way care is delivered are not trivial, and may very well affect the future practice of medicine.



    For instance, complex patients are often cared for by multiple physicians, each having a specific set of recommendations. Primary care physicians and resident teams are frequently charged with the task of coordinating these instructions and organizing the patient’s care. This is a challenging responsibility, and can be difficult for both patients and providers to integrate the advice from so many physicians. Residents at hospitals where patients have multiple physicians will need to make a special effort to manage these recommendations to avoid potential consequences of fragmented or disorganized care.

    Another example involves patient preferences for how they would like to spend their last six months of life. When asked, many patients prefer to be cared for in a home-like setting. However, data show that for many patients, it is not their preferences that determine how they spend the last few months of life, but the practice styles of the hospitals where they receive care. While it’s true that more time in the hospital and more physician visits provide residents with more information, longer and more frequent hospital stays have their own risks for patients and don’t always lead to a longer or better quality of life.
    Hospitals providing higher intensity care are not necessarily providing higher quality or better patient experiences, and in turn, training at hospitals with less intensive utilization patterns may better prepare us to provide care that respects patient preferences.

    Understanding these patterns of care is particularly important for future doctors, especially to practice successfully in the new environment created by health care reform. We encourage other physicians who are early along in their training to research programs that emphasize learning how to use health care resources wisely, provide high-quality care, and incorporate patient preferences into care plans.

    Our choice of a residency program can shape the care we provide to patients for years to come. It can also present opportunities to lead improvements in health care by learning to provide the right care, in the right way, at the right time.

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  • Patient Safety & Quality Symposium

    In the 1980’s, the Harvard Medical Practice Study found that 4% of hospitalized patients were injured and that two-thirds of those injuries were preventable. In 1999, the Institute of Medicine issued a report, To Err Is Human, which found that there were between 44,000 and 98,000 preventable deaths in the U.S. each year. Since these findings, health care has gone through major changes.

    With these changes, patient safety problems have become increasingly evident. According to the white paper, Unmet Needs, published by the Lucian Leape Institute at the National Patient Safety Foundation, medical education and training institutions have found themselves struggling to keep up with the need to assure that student physicians are properly equipped with the skills, attitudes, knowledge and behaviors (i.e., patient safety competencies) that will make them capable of becoming part of the patient safety solution.

    The Patient Safety and Quality Symposium offered by the American Medical Student Association, in partnership with the National Patient Safety Foundation with funding support through AHRQ, and being held September 7-8 at Jefferson School of Population Health, will address the critical steps needed to successfully position students and the institutions they attend to function safely and effectively in health care delivery. View the tentative schedule here.

    Spots are incredibly limited. Register Today!

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  • Personal Reflection: Research Elective

    Sajeet Sohi, M.D.

    This past fall I had the opportunity as a visiting fourth year medical student to complete a research elective in Pediatric Hematology within Johns Hopkins Medicine. I have been inspired by the dedication the residents, fellows, and attending physicians show towards patient care and advancing medical knowledge. Being exposed to the research process and clinical excellence offer a physician-in-training like myself a goal of what the ideal medical practitioner would be.

    I still remember my first day on the campus walking to the Registrar’s Office and awaiting my placement. I was impressed by the size of the campus and I tried to absorb the history I was surrounded with. Clinical clerks from medical schools in the U.S. and around the world participate in the program and I would recommend an elective in a large academic center to my fellow clinical clerks. I look forward to further clinical research opportunities in the future.

    It was a terrific learning experience and I gained a new appreciation for academic medicine. I will always remember my experiences as I progress through my career. As I reviewed the records of the patients; especially since it was a pediatric population I have realized the long-term consequences our actions can have on our patients. Improving patient education compliance, access to care, preventative medicine, and public health can produce better outcomes especially at academic centers where patients have significant comorbidities.

    Prior to my experience there, I completed my clerkships within community hospitals. Unintentionally, in this setting research and education is sometimes secondary due to “market forces”. The healthcare reform process has introduced Accountable Care Organizations, Healthcare Innovation Zones, and the Centers for Medicare and Medicaid Innovation. With these new organizations academic medical centers may integrate further with the community healthcare systems and allow for increased educational opportunities.

    Medical students are the next generation of leaders and patient care providers. The key decision we make early in our careers is during the residency selection process and choosing a career in private or academic medicine. I personally plan on applying for Internal Medicine residencies for the 2012 Match. What drives an individual to a specific career path is the basis of significant scholarly debate and inquiry. I think that among the primary factors driving the medical student decision making process is the experience during the clinical clerkships and the viewpoints of clinical preceptors. The clinical elective program offers medical students a new insight into medicine and may assist individuals in exploring new career paths.

    Sajeet Sohi, M.D. is a recent medical school graduate.

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  • I'm back!

    Andrea Knittel
    AMSA Member
    7th Year MSTP/M3
    University of Michigan

    Post #8 of the  "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    Yesterday marked the start of my outpatient pediatrics rotation, the first of my third year of medical school, and the end of this series of posts on my transition from doctoral work in the School of Public Health to my third year clerkships. As I interacted with my M3 colleagues during general orientation last week, and pediatrics orientation yesterday morning, I was struck by the overall high level of anxiety. In spite of my perception that everyone (except maybe the other returning MD/PhD students) should be calmer than me because of their more recent completion of things like clinical competency assessments and Step 1 of the USMLE, all of us were talking nervously about seeing real patients, presenting histories and physicals in the inpatient and outpatient setting. Many of us noted with some trepidation that we don’t do any pediatric exams during our first two years of medical school. While I still believe that many of my colleagues were much more prepared than they believed themselves to be, orientation was nonetheless an important reminder that no matter how large or small the period of time between the pre-clinical and the clinical years of medical school, the jump in expectations (both self-imposed and outlined in the ever present learning objectives for each rotation) is daunting. None of us felt truly ready for the challenges that Monday afternoon would bring.

    Despite all this, Monday afternoon was great. I can only speak for myself, as I haven’t had much time to debrief with other students, but although I didn’t have all of the answers at my patients’ well-child exams, or ask all of the questions I needed to at sick visits, I made it through and presented what I did know to an understanding and friendly attending. I tried not to hesitate to ask questions and highlight the gaps in my own knowledge. In some ways, I think that doctoral work was great preparation for the wards. Who better, after all, than a PhD student to give a succinct outline of what is known, highlight the gaps, and attempt to make a conclusion anyway? At the same time, I felt myself struggling as I dusted off my medical vocabulary, only to find it a little rusty and perhaps a bit smaller than last time I trotted it out, and I often came up blank as I tried to expand my differential diagnosis.

    Looking forward, I see a lot of reading and asking of clarifying questions as my rotation progresses. Just in the past few days I have absorbed a great deal in clinic, and am recognizing the value of applied and practical learning structured around the patients I see. I think my time away will ultimately make me a better doctor, but first, I’ve got to get to studying!

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  • One small step for a current student, one giant leap for me

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #7 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    On Monday and Tuesday of this week, an incredibly gracious current M3 let me shadow him on the first two days of his inpatient pediatrics rotation. I would highly recommend this before returning from an extended absence, as it not only gives you a better sense of what will happen in the months to come, but gives the more advanced student a unique opportunity to demonstrate everything he/she has learned and to teach a newer student.

    The logistics: The MD/PhD program identified a willing volunteer who was on an inpatient pediatrics rotation this month, which is what I’ll be doing in either May or June, and put me in touch with him. I decided not to go to orientation, as I knew I’d get my own orientation soon enough, but met up with him following orientation before rounds started for the day. I only spent a few hours with the team on Monday, but I got a good sense of how the team works in the hospital, and when I showed up for pre-rounding on Tuesday, I got a real sense of what medical students do with patients who’ve already been in the hospital for a while. I went on rounds again, saw the med students present, and helped with the tasks that followed.

    The lessons: Do this! No amount of shadowing can prepare anyone completely for anything, but it can substantially decrease anxiety. I learned that even after eleven months of clinical rotations, there are still new things to learn and different approaches to adapt to on each service. I saw some great medical students in action, and learned that even folks who haven’t taken a break are constantly learning new things. I also learned that interns, residents, and even attendings are not scary (which should not have been surprising, as many of them were my med school classmates!), and are nice and helpful and willing to teach if you work hard, try new things, and aren’t afraid to ask questions. I also learned that “work hard” includes spending long hours at the hospital. I had a good sense before that this was the case, but spending just two half days in the hospital drove it home.

    The bottom line: I need to start believing folks that this will all be fine! There will be long hours, and lots of work, but nothing insurmountable. I’m certain that as crazy as next month may be, at the end of it, I’ll join the chorus reassuring you that you too, will be fine.

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  • Hello history taking

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #5 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

     

    Last week I saw a real patient by myself for the first time. Granted, my actions had absolutely no bearing on his care as I was only seeing him as part of my program's official reentry clinical experiences, but nonetheless, I saw a patient by myself. It was profoundly different from every other experience I’d had conducting a history and physical examination. Unlike practicing with a friend or a standardized patient, this patient wasn’t directly evaluating my skills.  There would be no debriefing with him at the end of the afternoon to discuss whether or not he thought I had adequately checked for organomegaly on the abdominal exam (aka, enlarged liver or spleen), or how I might have more carefully guided him through a recounting of his past medical history. Unlike previous sessions where I was observed directly by an attending physician, there was no doctor present. There was no instructor correcting my percussion technique or reminding me to ask about medication allergies, or noting carefully that I should have been more diligent about screening for domestic violence. Unlike clinical examinations, and unlike many of my clinical experiences to come, there was no time limit. I had as much time as necessary to meander through a history and struggle through a physical exam. All of these differences did make the whole experience less stressful, but highlighted for me the value of having patients who are either truly performing (as my colleagues and standardized patients had done), or those who recognize that they are being watched by a doctor as part of a clinical exercise and put on their best helpful patient facade. Instead, I got a friendly and talkative gentleman (carefully selected for me by the charge nurse) who assumed I was a nurse and wound his way through a baffling series of events that proved to comprise his entire life history, occasionally touching on episodes related to his medical condition.

    As a student training in public health, I firmly believe that the social determinants of health are as important as any explicitly medical issue. You’ll note that in the previous sentence, however, that I place those two things on equal grounding, indicating that a good history has to lead to a good understanding of what medical issues and interventions led the patient to the current state, as well as the social issues and interventions along the way. At this point, I can safely say that I am not a good history taker. I am excellent at establishing rapport with the patient, am careful not to interrupt too soon, aware that data suggest that responding too soon to the first things a patient says can lead the history taker astray (possibly missing more urgent problems further along in the patient’s story), and generally leave the interaction with a vast knowledge of the patient’s children, eating habits, and hospital preferences.  I am not yet excellent at knowing when to redirect a conversation in a more productive direction (say, to illuminate some aspect of the past medical history), or how to suggest that a topic of conversation may be inappropriate (for example, the patient’s perception that an outside hospital is inferior and begins listing examples). Striking the balance between empathic confidante and authoritative information-seeker is difficult, and I’m convinced that this is not made easier by small stature, female sex, and clinical inexperience, none of which is easily disguised on the wards. So what is the rusty and inexperienced clinician (dare I even call myself that at this point) to do? Fortunately, interactions with those further along in this process suggest that ultimately, clinical experience overcomes most additional barriers, and that it becomes easier to matter-of-factly state, “No, I am the medical student/doctor.” This, fortunately or unfortunately, depending on how you look at it, leaves me with only one option, and only one recommendation for you, dear readers, should you find yourselves in a similar position: practice. That’s right. As in all things, I can only hope that if I try and try again, eventually I’ll succeed.

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  • Changing great expectations

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #4 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations. 

    When I started medical school, there was substantial debate swirling about changing residency work hours, particularly for interns who were putting in untold hours at the hospital clearly to the detriment of their personal wellbeing, and potentially to the detriment of patient care.  These arguments sparked discussions of the best way to train physicians to work independently, how to maintain continuity of care without endless work hours, and even how to measure progress on these issues.  Ultimately, resident work hours were limited to 80 hours per week and shifts limited to 30 hours.  AMSA helped to draft the legislation that implemented these first changes, and continues to advocate for better conditions for residents and students. 

    As I’m preparing to return to the wards, the controversy has flared again, though this time regulations have already passed.  The 80 hour work week remains in place, but first year residents (interns) may only work 16 consecutive hours.  (In addition, as detailed in news articles here and here, stricter rules for how residents should be supervised were added, and other regulations to improve patient care and resident safety were also included.)  On the whole, I’m happy to see medicine becoming a safer and more user-friendly profession, and hope that reduced physician burn-out will be a additional consequence of these regulations. 

    In spite of these hopes, I nonetheless struggle with what a friend recently termed “competitive suffering.”  We’ve all experienced it before.  It’s what happens when you moan that you didn’t get enough sleep because you were writing a paper or studying for a test, and a colleague counters that he/she hasn’t slept in a week because of all of the work that needed to be finished.  Similarly, it occurs when one med student complains about an overnight shift on an OB/GYN rotation, and someone immediately pipes up that their transplant surgery rotation has required an unendingly flexible schedule and many sleepless nights.  Lately, I’ve noticed that it also happens when I express trepidation at the nights of call and night float I’ll be expected to work as a medical student, and my friends remind me that when they were in medical school, they were frequently in the hospital overnight, and that call expectations for medical students were much greater.  This often follows with exclamations of how much they learned at night because no one else was there, or of how amazing the patient was that they admitted in the morning and followed for a full 24 hours.  How is a returning student to deal with this, as medical student expectations are shifted with those of residents?  Certainly stepping back and saying “Wow, you had a rough go of it.  They sure do things differently now!” rarely feels like the right option, but most of the time, I think it is.  I try to remind myself that I learn more when I’m awake, and that my retention is laughable when I haven’t been able to sleep.  If that’s not enough, I think about the friends I’ve been lucky enough not to lose to drowsy driving accidents, or patients they’ve been lucky enough not to lose because of a sleepless error, and remind myself that these regulations mean that I’ll need to rely a little less on luck.

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  • Looking forward by looking past

    Andrea Knittel
    AMSA Member
    6th Year MSTP
    University of Michigan

    Post #3 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

    As I contemplate returning to the medical school and starting my clinical rotations, I’ve come up with a few strategies along the way to calm myself down and turn my anxiety into anticipation.  These include reminding myself of how much support I will have over the next few months to regain my clinical skills, evaluating potential sequences of rotations to maximize early learning but minimize early embarrassment in front of future colleagues (by choosing to start with a field I don’t plan to call my career), and spending time with my resident/doctor friends, who all assure me that I will be fine and that no one will remember my first few awkward weeks/months on the wards.  The strategy I’ve been using most during the last few weeks, however, is looking forward by looking past.  I’ve been motivating myself to gear up for the third year of medical school by contemplating potential away rotations, research experiences, and vacations I would like to take during my fourth year of medical school.  Although I have come up with a volume that would not fit into another four years of medical school, much less a single year, the process of thinking about what comes after the exhausting, but hopefully rewarding ordeal of third year makes thinking about that exhausting ordeal a little bit easier.

    I really embraced this strategy at the American Public health Association Annual Meeting in Denver earlier this month.  As I prepared for my own presentation, I worked hard to attend the presentations of other scholars in my field, to introduce myself afterward, and to a few with interesting research or clinical connections, suggest the possibility of an away rotation in a unique clinic or a scholarly collaboration on a project that would extend my dissertation research.  Honestly, until I was at the conference and sitting in a particularly inspiring session, I hadn’t thought much about the next big transition after PhD-years to MD-years: school to the “real world.”  As scary as it might seem to think about finally leaving the happy bubble of Ann Arbor and my alma mater, it was exciting to think about what is coming next.  I think that holding on to the exciting possibilities beyond my clinical rotations just may get me through the worst of it.

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  • What's science got to do with it?

    by Ken Williams
    Graduate Special Student
    The Johns Hopkins University Bloomberg School of Public Health

    This is the first of what will be a series addressing the current state of premedical education in the United States and the debate that surrounds it. We will explore the role of the natural and social sciences, humanities, and the arts and how they relate to both the education of physicians-in-training at all levels of their schooling and to life as a doctor. With this year being the 100th anniversary of the Flexner Report, the seminal work that caused the educational requirements for physicians to be codified, it is the perfect time to ask questions about what, if anything, should be changed with the path we have to take to get into med school? Are the requirements creating better physicians? How are we measuring that?

    For the record, my first degree was in philosophy, where I focused on ethics and logics. Since then, I have studied all sorts of things: health policy, graphic design, architecture, culinary arts, religious studies, and environmental studies, among others. All of these have helped to color my current perspective on both life in general and health care specifically. I believe that they have made me a better prepared applicant for med school, even though the path has taken me quite a bit longer than most.

    What do you think about the current state of affairs for premedical education in the US? Let me know and we can explore it together over the next few months...

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  • Health Justice Fellowship: Call for Applications

    By Carol Williams-Nickelson, PsyD
    AMSA Executive Director
    AMSA is now accepting applications for its 2011-2012 Health Justice Fellowship. This is an exceptional opportunity for a medical student to spend a year focusing on issues such as physician work re-design; student-labor solidarity in the health care sector; physician workforce supply, especially in the practice of primary care; disparity and equity in health care access and medical debt.

    The AMSA/CIR Health Justice Fellowship is sponsored by the Committee of Interns and Residents (CIR). The objectives of the fellowship include learning and refining the fellow’s skills in medical student organizing, leadership development, strategic planning and advocacy.

    AMSA Fellows work at the AMSA National Office, in Reston, Virginia. The Health Justice Fellow’s work will center on organizing two or more major projects to engage students and strengthen programming. These projects should support the strategic priorities of AMSA and CIR, and increase both organizations’ visibility to medical students. The fellowship is paid, full-time and include full employment benefits and complimentary housing. 

    This will be the most memorable year of your medical training! But don’t just take my word – check out what past AMSA Fellows have said about their experiences. You can also check out AMSA Rotations, to listen to a podcast interview with AMSA’s current Health Justice Fellow, Sonia Lazreg!

    For complete information on eligibility, compensation, core components of the AMSA Fellowship Program, click here. This is a very competitive process. If you are interested, please submit your application by November 19, 2010.

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