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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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  • 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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  • Applications Now Being Accepted for ERF

    By Carol Williams-Nickelson, PsyD
    AMSA Executive Director
    We at AMSA are excited to announce the application process for the 2011-2012 Education & Research Fellow (ERF), a unique position for a medical student to spend a year augmenting their formal medical training with the opportunity to delve deeply into select issues affecting the quality and content in medical education.

    AMSA’s Fellowship Program is an intensive one-year long educational immersion experience. Fellows completing this program will be uniquely situated to deal with the challenges of a complex healthcare system and reform their profession through education and advocacy.

    The ERF will serve multiple roles at the AMSA National Office, working closely with staff and national leaders to enhance educational programming initiatives throughout the organization. The successful candidate will contribute to the strategic direction of AMSA in many ways, including holding primary responsibility for AMSA’s research initiatives, developing high-quality programming for AMSA Conferences, mentoring and assisting in the management of the AMSA Intern Program and designing a successful array of external educational programming with the goal of developing knowledge and skills in areas that are not traditionally included in medical school curricula.

    I promise an exciting year! But don’t just take my word – check out what past AMSA Fellows have said about their experiences. For complete information on eligibility, compensation, core components of the AMSA Fellowship Program, click here. Applications are due on November 12, 2010.

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  • Easy, Exciting Engagement

    By Ben Goold
    AMSA Vice President of Programming Development

    Every year, a crowd of new premedical and medical students head to school, unsure of what they'll find when they get there. Everyone is in a new environment. Incoming freshmen in college and incoming first years in medical school are trying to figure out where they fit.

    AMSA is a place where diversity matters, where people who care about social justice and medicine come together. We find meaning in our shared struggle as students. We all want to see a better world than the one we live in now. And we refuse to wait until we have an MD/DO behind our names to start working towards that better world.

    If you want to empower the students around you to make a better world, then you're in luck. AMSA's national leaders have done something extraordinary this year--they have put together all their passions into one place. Every chapter officer searching for a program, every student looking for a way to get involved in making a better world can find a current, ready-to-use program online, at AMSA's E3 page.

    E3 stands for Easy, Exciting, Engagement Programming. Each program listed there is designed to help students gain a sense of belonging to something bigger than themselves. Each one is designed for students, by students.

    I invite every chapter officer or new student who wants to make a difference, empower their fellow students, and do it on their schedule, to check it out. More programs will be added soon, so check back often.

    Welcome to another wonderful year of making things better!

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