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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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