Advocate to Preserve Residency Funding

30 10 2011

bills,budgeting,businesses,cash,cost cutting,currencies,dollars,savingsSo, you have probably heard about the Supercommittee (gang of 12) and the need to brace for massive cuts to control federal spending.  But, do you know that the chief target is RESIDENCY TRAINING!   That is right.   Funding for residency largely comes from Medicare, and the general concern is that they are paying too much and not getting their money’s worth.  Of course, this comes at a time when there is a shortage of residency spots given the expansion of US medical schools, and a dire need for physicians, especially in primary care, to meet the needs of healthcare reform.

So, in this perfect storm, 40 medical groups (yes, there was that much consensus) sent a letter to the Supercommittee pleading with them not to cut GME funding.   Now the situation is dire enough that the AAMC advocacy leaders are in high gear encouraging those in graduate medical education to encourage their residents to write to their Congressman.  (And yes, if you live in a Supercommittee state, its even more important for you to do this).

So if you are a resident or future resident or can sympathize with the need to have future physicians, now is the time to take action.   For my fellow medical educators out there, you don’t need to be left out.  The American College of Physicians has a very broad (don’t need to be an internist)  easy-to-use advocacy website to shoot of a quick note to your Representative and Senator about the need to preserve GME funding.

Medical educators have actually started a dialogue about the role of advocacy in medical education.  Specifically, the Editor of Academic Medicine has challenged us to come up with how advocacy should properly be integrated into medical training.  I can think of no other way than advocating for preserving funding for the system by which we train our nation’s future physicians.

Vineet Arora MD

(AAMC email encouraging residents to take action)

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Dear Resident:

I encourage you to take a few minutes to  visit the AAMC Legislative Action Center (http://capwiz.com/aamc/home/), select “Residents”,  and send an electronic letter opposing cuts in Medicare funds that support residency programs.   With the zip code you enter, the letter will be sent automatically to your Senators and Representatives urging them to oppose GME cuts as part of deficit reduction.  PLEASE USE YOUR PERSONAL EMAIL ADDRESS (eg, gmail.com), AND NOT YOUR INSTITUTIONAL EMAIL ADDRESS.

Congress is discussing a deficit reduction proposal that would cut funding by as much as 60%, or $60 billion, for Graduate Medical Education (GME) and jeopardize residency training programs across the country. Given the current and growing shortage of physicians, GME cuts will reduce access to health care and threaten the well-being of all Americans.

It is most important that residents enrolled in programs in Arizona, California, Washington State, Massachusetts, Ohio, Pennsylvania, Montana, Michigan, Maryland, Texas, or South Carolina, voice your concerns.    You are represented by members of the “Super Committee” that will finalize the deficit reduction plan.

Thank you for your help.

Atul Grover, M.D.
Chief Advocacy Officer
AAMC


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Categories : residency training

Whittling Costs in White Coats

10 08 2011

At the beginning of last week, I was excited to be invited to take part in the ABIM Foundation Summer Forum, where the who’s who in medicine convened to discuss how to create a sustainable healthcare system, where costs are controlled and quality of care is preserved.   We heard some bold vision and ideas, many of which were focused on badly needed policy levers or system redesign.  However, as I ended my week on Sunday with investing Pritzker’s new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part.  As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it…and also the learning that takes place in it.  So, in that vein, here are some thoughts for what students and residents can do.

  • Read up on the topic – some excellent resources I heard about at the meeting
  1. Physician Stewardship of Health Care in an Era of Finite Resources– a recent article in JAMA by Drs. Chris Cassel and David Reuben regarding the various levels of stewardship
  2. Personal Reflections on the High Cost of American Medical Care – a recent article in Archives of Internal Medicine by Dr. Steven Schroeder
  3. The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy – a classic by noted economist Uwe Reinhardt
  4. Less is More Series – a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.
  • Listen to the patient  Of course, this sounds simple…but the truth is that more times than not, the answer is in the patient history.   With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient.  One approach is to start with two open questions:  (1) Tell me about yourself; and (2) What are your healthcare goals?   Often, the key is to try to understand the baseline.  I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years.  When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go!   By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups.  As I’ve mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!
  • Learn the physical exam Often times, we rely on tests since we do not trust our physical exams.   It is too easy to get an echo when you are wondering if you are truly hearing a murmur.  The lore here is that you need to  listen to a lot of normals to be able to detect the abnormal.  Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams.  Usually by the end, they are more confident in their ability to detect crackles or murmurs.  As stated by our white coat speaker, the stethoscope is indeed a powerful tool.  Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution.   Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.
  • Don’t just check boxes but ask why the test is indicated Trainees can ask the difficult question – why are we ordering this test or medication?  Is it indicated?   An even better question to research is whether there is a CHEAPER (we can’t shy away from using that word anymore) alternative that would provide the same information?   For example, before every PE protocol CT or Doppler to rule out DVT, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is.  In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging.  It is easy to check boxes, it is harder to question why you are checking them.
  • Try to find out how much the test costs While the answer is elusive, the goal is to start the conversation in your own backyard.  There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost.  Moreover, greater knowledge of costs will change practice patterns as we’ve discussed before.
  • Counsel patients One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care.  While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more.   In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.

Unfortunately, whittling healthcare costs is not as easy as teaching trainees.  As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for NOT doing something.  Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say “Don’t just do something, stand there.”

–Vineet Arora, MD


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Categories : hospital life, medical student, residency training

The 5 F’s for Futuredocs and New Interns

26 06 2011

 

Yesterday, a tweet caught my attention from @JasonYoungMD who stated “My Five Foundations of Felling Fine: Food, Fitness, Friends & Family, Falling Asleep, Fulfillment.”  This seemed like the best advice I had heard for the newbie interns taking teaching hospitals by storm as well as the rising third year medical students who are about to be unleashed on the wards (if they haven’t already).  It also is a great starting point for program directors who are wondering how to ensure that their residents are “Fit for duty” according to the new ACGME rules.

 

  1. Food – While this is basic part of sustenance, finding food sometimes in the hospital can be challenging, especially at odd hours.  Fortunately, this has gotten better, but the choices may not be healthier.  In my own hospital, I’ve seen the front lobby transform from a small coffee kiosk (Java Coast which was celebrated when it arrived) to a full fledged Au Bon Pain (ABP as we affectionately refer to it).  While ABP was a welcome addition, it is easy to consume a lot of empty calories eating muffins or breakfast sandwiches!  To make matters worse, research from one of our very own sleep research gurus has shown that the more sleep deprived you are, the worse food choices you make!  Therefore, the thing you will reach for after a night shift is going to be the carbohydrate loaded Danish.  Residency programs must know this and usually have morning reports full of this type of food. So, consider how you will make healthy food choices – whether that be bringing your own food, or finding out where the healthy options are.  Lastly, don’t forget about the empty calories that come with beverages, especially coffee-related drinks.  For you Starbucks fans, there is an app for that – and I guarantee you may change your choices.
  2. Fitness – Like food, fitness can be hard to come by.  Interestingly, working in the hospital can actually be a way to get exercise.  For example, some studies demonstrate that residents walk as much as 6 miles on call!   However, its also just as easy to sit behind a computer and take a “mission control” approach to your call night where you are monitoring all your iPatients.  So, think about this and consider wearing a pedometer and most importantly getting into a routine.  When time is of the essence, find a way to work fitness into your day like taking the stairs in lieu of the elevator, or parking farther away.  If you join a gym, you have to make sure you go…and one easy way of doing this is to make sure your gym is on your way home from work and that is your first stop.  During residency, I actually switched to a gym that was directly on my route home that had a parking lot so I literally had no excuse and actually felt guilty while I drove by and did not stop there.  Others opted for 24hour gym craze that that could work for anyone’s schedule.  Lastly, exercising with a friend will likely lead to greater results than the solo work out.
  3. Friends & Family – Speaking of friends and family, this is the support system that gets interns through residency.  Fortunately, another omnipresent F can be helpful here – Facebook.   Busy interns or students can at least get reminders to electronically wish your friends happy birthday or log in on that random Monday off to reconnect with friends.   It’s also important to set appropriate expectations with your friends and family, for example when you are starting on a time intensive rotation that can be demanding.   Because of the intense nature of working in the hospital, some of you will form fast friendships with your co-interns and residents which can be helpful to get you through.  However, even your closest friends (including those at work) will ask you to choose between them and sleep- which can be very tough when you are running low on sleep.
  4. Falling asleep –So, speaking of sleep, my first question was where do I sleep?   Sounds silly I know, but I actually did not know where the call rooms were or did not have the call room key for my first call night ( I actually can’t remember which) so I ended up going to sleep for an hour in an unoccupied hospital bed.  So, this may not be possible today for 2 reasons: (1) interns are not likely sleeping when working the jam packed 16h shifts; and (2) hospital beds are nearly always filled! Still the challenge for today’s interns is getting sleep when working odd hours, especially if starting night shifts on night float or ‘night medicine’ as programs are evolving to include more night rotations.  If this means you have to invest in window treatments or wear an eyeshade at night, just do it.  There is nothing better than sleep for a resident and the more the better.  While your sleep at home may be limited regardless due to your other family obligations, its important to know your limits and set aside nights where you will recover.
  5. Fulfillment – Last but not least, its important to figure out how to keep yourself happy and fulfilled during your residency.  In some cases, that is a particular hobby or loved one that you need to stay in touch with.  In other cases, fulfillment is more complex.  It is not uncommon to have doubts about your future career as you stand by the fax waiting for outside hospital records, wait on the phone to schedule a follow up appointment for a discharged patient, or even transport a sick patient to get a needed test.  While many are working on ways to reduce the burden of this largely administrative work, interns and medical students are still straddled with a large amount of scut which can be demoralizing.  So, where do you find the fulfillment in your work? Well, you will find it when you least expect it – in the words of a patient who is eternally grateful.  In other cases, you will meet a mentor or role model who shares your passion and interest in medicine, whatever that may be, and can inspire you to keep you going. Whatever it is, find it and hang on to it for dear life during your darkest hours and it will pull you through.

I do need to add one more F to this fine list –  So provided that you are keeping up with the first 5 F’s, the best thing is that being in the hospital, learning medicine, and caring for patients is actually FUN!  So, don’t forget to pause and enjoy it…these tips will also serve you will in the FUTURE!

–Vineet Arora, MD

Other helpful posts to conquer any FEARS of starting on the wards:

What NOT to Wear on the Wards

How to Present to Your Attending


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