Getting Primary Care on the ROAD: Charting a New PATH

24 05 2010

I just returned from ACP Leadership Day where 375 internal medicine physicians and future physicians from all over the country descended on Capitol Hill to advocate for primary care.  Before I left, one of my colleagues asked me what we would have to talk about since healthcare reform already passed and includes some boosts for primary care.   Well, we had plenty to talk about!   While the main goal of healthcare reform was to provide coverage and insurance reform, the ultimate question is will newly insured Americans be able to access care?  Even if they have insurance coverage, they may not be able to see a doctor if there are not enough primary care doctors to see these patients.

Therefore, the focus of our efforts this year was to ensure that we have a primary care workforce to meet the demands of the newly insured.   Because of the long dwell time to train primary care physicians, we need to start now to ensure we have doctors for the future.   One staffer told us that he heard that medical students wanted to go into lucrative specialties to pay back their debt, and I asked if they had ever heard of the “ROAD” (aka Radiology, Ophthalmology, Anesthesiology, Dermatology) which refers to the desired lifestyle and highly reimbursed specialties.  He responded we needed to get primary care back on the ROAD or maybe make it “P-ROAD.”   I don’t think P-ROAD makes a great acronym, but PATH may work better: Primary care = Access To Healthcare.    While healthcare reform law (aka PPACA) includes many boosts to primary care, there are a few key omissions that can easily undermine healthcare reform.  Moreover, the question is now what provisions will be funded and at what level.  To get Primary Care back on the ROAD, we need to create a new PATH that includes fixing every step of the pipeline for physician workforce so future and current doctors can see themselves providing this valuable service.  

  • Medical student:  Debt relief so students can go into primary care  Medical students cannot pursue careers in primary care if they continue to carry an average debt burden of roughly 160,000 dollars upon graduation.  The initial healthcare reform bill included loan repayment programs for those who enter primary care, but this was stricken due to the cost of these provisions.  While the National Health Service Corps is the most widely recognized loan repayment program, it is very competitive and will not fill the primary care shortage alone.  Therefore, expansion of this program or creation of new loan repayment programs are needed.   Medical students are especially adept at making the case for loan repayment – and the health legislative aides that we met with were especially sympathetic to them since they may be able to relate to them (they are also closer in age).
  • Residency:  Expand primary care spots & create new training models  With new medicals schools designed to train primary care physicians, it is unclear if there will be enough residency spots for these newly minted physicians to match into.  As I’ve stated before, the supply of US graduating medical students will overtake the number of residency positions in a few years if there is no increase in residency spots.  Moreover, if residency slots aren’t ‘slated’ for primary care, one can imagine that new graduates will gravitate to the specialties.  There are provisions to reallocate 65% of unused residency positions to primary care, but that still won’t be enough due to the shortfall of primary care physicians.  The ACP recommends 90% of these spots go towards primary care.  In addition to creating slots, residency programs must be given the latitude to design new models to train primary care physicians.   Since funding for residency training is given to hospitals, currently residency programs face significant challenges in getting residents experiences in ambulatory settings.  This may change with healthcare reform legislation that supports the creation of new ‘Teaching Health Centers’ in the community to train primary care physicians, provided that these programs get the funding they need.  
  • Practicing Physicians:  Reward & redesign primary care work  Lastly, entering and staying in primary care will not be possible as long as the income disparity continues to persist.  Moreover, with a pending 21% cut in Medicare physician fees kicking in on June 1st if nothing happens will not help things.  This is why we need to ultimately reform the payment system (for how we ended up here, see this earlier post).  The House has just introduced legislation HR 4213 which would stop the cuts and provide 3.5 years of stable Medicare payments and reward primary care doctors.   Certainly, this will help things in the short term.  However, several of the trainees I spent time with in DC firmly stated that it was not just about the money, but also the hard work associated with primary care.  This point was eloquently illustrated by Dr. Richard Baron in a recent New England Journal  of Medicine article in which the primary care physicians in his practice responded to a telephone call or a lab test an average of 43.2 times a day!  All of this care goes uncompensated in our current system.  As one physician writes, it is time to reward coordination and communication of care.   One possible way to do this is to adopt the new patient-centered medical home, which is a way to redesign practice to promote a team approach (with physicians and other allied health professioanls) supported by technology to deliver primary care to a group of patients.  Another solution was featured in a recent issue of Health Affairs devoted to primary care, which contains an article which poses the provocative question: what would martians think about primary care?  The answer is a more radical redesign to overhaul the entire physician workday to see fewer patients and compensate the uncompensated care such as email and phone calls.

Unfortunately, as one of the other staffers said, “there is a lot of healthcare fatigue on the Hill” so this may take time.   Moreover, the big barrier is cost especially given the high price tags of these bills in a fiscally challenged environment.  While these reforms will cost money in the short term, its important that we highlight that fixing these things later on will cost exponentially more — if it can be fixed at all.   This is why its important that physicians and medical trainees need to make the case now about the importance of these issues to ensure physicians for the future.  

To learn more, sign up to be a Key Contact for the American College of Physicians for breaking updates on these issues.  More information on ACP positions on physician pipeline here

–Vineet Arora, MD

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What Not to Wear: Hospital Edition

17 05 2010

At a recent meeting I attended, a vigorous discussion broke out about what medical students, residents and attendings should wear, and more importantly what they should not wear.   Interestingly, patients have been asked to weigh in on this discussion.  What to wear is also on the mind of many current second year medical students who may find themselves trying to take study breaks from USMLE1 to go buy clothes for the wards.  I also remember doing this as a rising third year student and wondering what to get.  Here are some tips from our Associate Dean of Student Advising and Professional Development Dr. Shalini Reddy (@md2b_advisor).

  1. Don’t break the bank. Stores like Target, Marshalls, Sears or JCPenney are all fine places to get clothes for the hospital. You’ll be wearing your white coat over your clothes.  Save your money for your fourth year interview suit.
  2. The hospital is a messy place. Buy clothes which you wouldn’t mind throwing out if you were drenched in body fluids. (Not likely to happen but would be devastating if you’re wearing Prada or Valentino).
  3. Buy comfortable shoes.  You’ll be on your feet most of the day. There are actually studies that demonstrate that residents (who you’ll be following around) may walk up to 6 miles when on call!   It’s hard to answer “pimp” questions if you’re developing bunions and wondering when the heck you can take off those shoes. You’re feet will thank you…
  4. Get a waterproof, inexpensive watch.  You’re going to be washing your hands a lot. Being late to rounds is never good, but you may also lose your watch after you take it off to scrub in. A watch with an alarm can be very handy when you have to get up at 4 in the morning to pre-round for surgery. 
  5. Scrubs are for the hospital not for home.  As a New York Times article pointed out, no one wants to sit next to someone on the subway wearing scrubs, particularly those with uncharacterizable stains on them.  Scrubs are there, in part, to keep you from taking hospital germs into the community. It’s also hospital policy.  Unless a resident or student is staying overnight or involved with procedures, scrubs are a ‘dressed down’ look. So plan to change from scrubs to regular clothes before you wander around outside the hospital.
  6. Stock up on detergent, soap and deodorant. You’re going to be getting up close with your patients and if your clothes (or you) smell, they will feel even sicker than they already do.
  7. Buy a bleach pen.  This is very helpful for spot cleaning blood stains until you can get your coat back to your house for laundering. Peroxide works too.
  8. White coats (and ties for men) are still part of the uniform. Yes, there are studies showing white coats and ties spreading infection.  In the UK, they are already banning white coats.  However, for now in the US, they are considered part of the standard attire for physicians and medical trainees and what patients have come to expect.  In addition to washing your coat often, washing your hands is the #1 thing you can do to prevent infection.
  9. Wash that white coat. Those aforementioned uncharacterizable stains are really gross on white coats. Not a great way to instill confidence in your abilities with patients…or attendings.
  10.  No perfume or cologne. Remember the triggers for asthma? Perfume is one of them. Stick to “eau de soap and water.” Beware the overly scented deodorant too. Unscented soaps are typically the best for combating malodors while avoiding elicitation of bronchospasm.

 And some more tips especially for women

  1. Save the ‘Hospital Honey’ look for Halloween: Buy clothes for the hospital, not for going out: cover your cleavage, make sure your skirts reach at least mid-knee when you sit; shirts and pants/skirts should cover your midriff even when you raise your arms above your head.  Remember, you are not dressed to kill, but dressed to heal.  A patient actually called one of our attendings out for wearing loud, high heeled boots. An embarrassing reminder that we’re dressing for our patients not for each other.
  2. Minimize jewelry.  Make sure you don’t wear anything too expensive to work especially if you know you’ll have to take it off (e.g. engagement ring gets taken off whenever you put on gloves). Get a safety deposit box if you’re worried about leaving your jewelry at home. Stay away from hoop or dangling earrings. Your stethoscope will pull off the hoops and kids will pull off the danglers. Besides, you’ll get germs on anything that’s not attached closely to your body (e.g. stud earrings).
  3. Wear OSHA compliant Shoes (no open toe).  We know this is especially hard in the summer, when all the high fashion sandals and pedicured feet aching to show themselves.  Do everyone a favor and keep your toes covered and save your fashion forward footwear for an evening out with friends.  One of us actually took care of a female healthcare worker who had an IV pole run over their foot and contracted a MRSA foot infection – not fun!   As a result, every summer, we are on the hunt for comfortable but good looking pair of “OSHA shoes”- it’s harder to find that it looks!   DSW shoe warehouse is a good bet and won’t break the bank.  Dansko clogs are also a safe bet and Crocs are now making comfy shoes without holes. Stay away from Crocs with holes which just provide pores for body fluids and needles To get to your feet.
  4. Hold off on the fancy manicures. Your nails have to be short and you’ll be washing your hands often. Nail polish does not stand up well to frequent hand washing/Purell.

Lastly, for all the 2nd year medical students out there, good luck on Step 1 and starting the wards!

 Dr. Shalini Reddy & Dr. Vineet Arora





Shadow Doctoring: Tips for Future Docs

10 05 2010

This Saturday, I rounded in the hospital.  I met up with Zainab, the president of the minority premed association for the University of Chicago, who asked to shadow me.  While she was doing research at the hospital, she had not ever rounded in the hospital before.  It was Saturday so our team was mostly off so it was just me and my very capable resident who is about to graduate and take a primary care job in the community. 

But, yesterday’s rounds was different and it was because Zainab was there.  Patients were excited to meet her giving her the thumbs up.  Medical students walked by and asked her if she was going into medicine and scurried away but said ‘definitely do it.’   My resident, in face, told her it’s a great career.   These positive endorsements were occurring in the middle of some difficult patient issues (one patient who wanted to leave against medical advice).  It is also May – meaning the students, interns, and residents are tired.   Even I felt energized as she was asking me about why I do this job and how I got here.

It was not the first time that I had taken shadower on rounds.  I run a program for high school students to get clinical exposure and research experience.  Interestingly, one of the high school students in the program was also in the hospital today interviewing a patient for one of the large studies we direct.  He looked so professional as he was preparing to go find a patient to interview for the study.  These students also shadow in the clinic and the hospital during the summer while they are doing research.  So, it had been about a year since I had a shadower with me. 

Shadowing is an important part of learning what being a doctor is like and doctors need to provide students opportunities to do so.  It is also a factor that medical schools consider at when making decisions about who to admit – does the candidate have an understanding about what a medical career is like?

So how do you shadow a doctor? Here are some quick tips for premeds looking to shadow.

  1. Leverage connections – Zainab found me through her other summer job where someone I work with through the College told her to contact me.  If you are on a college campus with a medical school, use your contacts through your premed office or via research opportunities.  If you are not on a college campus with a medical school, you could offer to shadow your doctor in your hometown or contact local hospitals through their volunteer or community affairs office to see if they have a shadowing program.
  2. Be flexible with when you can come – It may be the best time for you to observe is either early in the morning or during off hours, like weekends or evenings.   In the hospital, weekend rounds are sometimes easier to observe since many people are off so there are not as many learners on each team.  In addition, things are usually not so rushed since attendings don’t have to rush to clinic usually.  They may want to keep rounds short so they can get back to their weekend but they will probably appreciate that you are volunteering your time to do this on a weekend.
  3. Bring a notebook to take notes on what you don’t understand – I forgot to tell Zainab to do this so I gave her some paper and notes so that she could jot things down and afterwards we reviewed the questions one by one.  On rounds, doctors also use a lot of abbreviations so you may not be able to follow everything but you can jot these down and ask about them later.  Zainab later asked me what a “RTA” is to which my resident responded not to worry since he didn’t really understand renal tubular acidoses until this past year. 
  4. Wait to ask questions until rounds are over The focus of clinical encounters is the patient, not the student.  This is unlike routine classroom interactions and can be difficult to get used to but it is the reality of patient care.  Complex decisions are often being made and you don’t want to interrupt the doctor-patient conversation.  Remember you can ask not only about the medical jargon but about what else you observed.
  5. Wear comfortable closed-toe shoes and appropriate dress– This is very important since you may be on your feet for a while and its important to project a professional image as a visitor.  It’s also important that your shoes are not open-toed (sorry ladies) since your feet are at risk of coming into contact with equipment, body fluids, or sharps.  A helpful power point with some tips on dress here. 
  6. Reflect on your experience afterwards– During your medical school interview, you may want to recall your experience, the types of cases you saw or just generally how you felt.  Writing a short reflection on your thoughts is a good way to keep those memories fresh (but remember not to include any identifying information – see # 8).
  7. Don’t forget to follow up– Don’t forget that you were a guest on rounds so its good to follow up with a thank you for the doctor.  They may send more opportunities (shadowing or otherwise) your way if things went well.  Yesterday, I got a great thank you from Zainab and invited her and her group to a medical student research poster session open to the University community. 
  8. Respect patient privacy– There may be a patient who doesn’t want you in the room.  And remember, everything you see in the hospital is private and not to be repeated or written about in a manner that could lead to the identification of the patients involved.  If you aren’t already affiliated with the hospital in some capacity (i.e. doing research), some doctors and hospitals will require that you sign a form for HIPAA stating that you will respect patient privacy.

Good luck future docs and happy shadowing!

–Vineet Arora MD

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Mean Girls in Medicine? Time to Get SMARTer

3 05 2010

meangirls11I recently moderated the women’s networking luncheon at the American College of Physicians with Temple Program Director and dynamo Darilyn Moyer, whose enthusiasm is infectious.  In planning this luncheon, I began to think are these things necessary?  Females now account for nearly 50% of entering medical students.  I don’t think I ever really thought about going to a luncheon like this until this year – and it happens to be the year that I am going up for promotion and thinking about being a women hoping to rise up the academic ranks.  Of course, there is still a glass ceiling, especially in academia, and women are underrepresented in the upper echelon of faculty – like Professors and Department Chairs.  In my department, there is one female division chief.  While one could presume that say this will correct in time with all those younger women entering the medical workforce, many believe that this is not happening and women are being left behind. To make matters worse, new research suggests academic medical women work more but also make less than their male counterparts. 

So what can women do?  Well, Darilyn had some great tips for women who were negotiating to make us Get SMARTer.  (She apparently loves acronyms as much as I do).

S is for Strategic- timing, understand how the other party negotiates, choose battles wisely, get unfulfilling work off plate

M is for Mentors- use them, internal/external, personal/professional

A is for Achieve- common ground, a successful negotiation requires give and take with no party feeling smug at the end! Remember your BATNA (Best Alternative To a Negotiated Agreement)

R is for Rehearse- your negotiation with your toughest critics who know the other party and can anticipate responses

T is for Timeout- plan a pager/bathroom break about halfway through, timeout to check on short- and long-term goalsa set time as a ‘safety net’  (yes we have all done this)

In addition to negotiation, I also highlighted the need for women to celebrate each other’s accomplishments in the workplace since women don’t usually brag.  All too often, I also observed women undercutting each other and NOT being nice.  Apparently, I was not the only one who thought this – several women came up to me after and thanked me for brining this up, including the president of AMWA (American Medical Women’s Association) who said we definitely need to be nicer to our female counterparts.  So, I got to thinking why do women do this and when does it begin?  Every women has high school tales, but I distinctly recall being the sole female intern with all male interns, residents, and attendings in the ICU with – you guessed it female nurses.  I felt like I was not going to have as an easy of a time as my male counterparts, so I tried to stay under the radar, learn from the ICU nurses who knew way more than I did, and generally ‘kill them with kindness’ as a close friend says. 

Interestingly, there is a plethora of internet resources out there that highlight that women are not so nice to their female counterparts in ALL workplaces, not just the medical one.  A study by the Workplace Bullying Institute (who knew?) demonstrated that female workplace bullies (those who commit verbal abuse, sabotage performance or hurt relationships) target other women more than 70% of the time while males are more equal opportunity bullies.  To make matters worse, it’s not just at work either – women are equally mean to each other about motherhood as noted by CNN in an article that describes the “Mommy Mafia” quick to pass judgment about how others in the mommy brigade raise their kids, choose their childcare, and balance their work and life.  As one article so poignantly pointed out….

But to this day, a pink elephant is lurking in the room, and we pretend it’s not there. For years, I have heard behind closed doors from women — young and old, up and down the ladder — that we can be our own worst enemies at work.

So why do women do this?

Well, one theory is the scarcity excuse — the idea that there are too few spots at the top, so women at more senior levels are unwilling to assist female colleagues who could potentially replace them.  This could be especially true in medicine, given the lack of females at the top.

Another explanation is the D.I.Y. Bootstrap Theory,” which goes like this: “If I had to pull myself up by the bootstraps to get ahead with no one to help me, why should I help you? Do it yourself!”  Note that this theory is also often used to justify all of medical training to today’s younger hipper generation that values work life balance.

There’s even a biological explanation, which highlights that women may be uber-competitive with the other XX’s in the room during days 12-21 of their menstrual cycle, when their estrogen levels are the highest.  Apparently, in studies, women rated other women’s attractiveness much lower than when they were outside this phase of their cycle.

So, what should women in academic medicine do to avoid falling in to the mean girl trap? Here are some of the things that I have learned largely from trial and error in navigating this domain.

  •   Celebrate each other’s accomplishments.  Women are not good at bragging and can sometimes be perceived as arrogant or the ‘b’ word if they toot their own horn.  Pair up with female colleagues and let your friends know so they can brag for you.  Not only does it seem less weird, it also shows that you work in a collegial atmosphere.
  • Work as a team  Let’s face it – there is not enough time in the day to do the job in medicine.  Teaming up can not only boost your academic productivity but can also improve your morale since you’re not facing that uphill battle looking at the glass ceiling by yourself.  Moreover, when you work as a team, you can take turns taking the lead so that you’re not swamped all the time with all the hard work!
  • When in doubt, keep it professional Remember, you don’t need to be BFF with all of your female work colleagues.  You also don’t feel like you need to reveal EVERY detail of your intimate life to your work colleagues.  The more you keep it about work, the better you’ll feel.  It takes time to form true friends in the workplace so let time run its course to figure out who will help you out of a jam in the long haul.
  • Remove yourself from dangerous relationships  Some relationships are beyond salvage.  It may not be overtly obvious, but you probably have a ‘frenemy’ in your workplace.   If you find yourself in this situation, time to exit gracefully.   This can often be accomplished by letting someone know that you are swamped with work (usually not a lie), dealing with some family stuff or personal issues (code for need some time off), or taking another direction with your work.
  • Seek guidance from a mentor  Your mentor can be a man or a woman –but it should be someone who knows you, gives advice that you trust, and has your best interest at heart.  While many traditional mentors are very senior, they may be scarce so you may need to consider other types of mentoring (like mentoring from peers, groups, or teams) or even reverse mentoring (mentoring from a trusted junior colleague) for these issues.
  • Seek professional development opportunities The Executive Leadership in Academic Medicine (ELAM) (run out of Drexel University) and the Association of American Medical Colleges offer formal programs for women to enhance their leadership potential.  Many professional societies (like ACP) have resources for women in medicine like career profiles and tips for advancement.  Lastly, most academic institutions also have women’s committees to help promote networking with other women and discuss women’s issues.  The more secure you are in your own position in your organization, the better you’ll be able to help other women succeed too.

 After all ladies, if we’re not nice to each other, how can we expect anyone (especially the men on top) to take us seriously?   Despite the infamy, no one wants to work with a gossip girl.

–Vineet Arora, MD

For more detailed data see AAMC’s Women in U.S. Academic Medicine: Statistics and Benchmarking Report 2008-2009

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