Evolution of Medical Education

In 1910, Abraham Flexner evaluated 155 medical schools to note how students were learning. He also made various recommendations based on these findings, which shaped medical school training afterwards.

•  Medical schools should require students to have studied biology, chemistry and physics at the college level before admission.
• First-year curriculum should include lecture and laboratory instruction in anatomy, histology, embryology, physiology and biochemistry.
• Second-year curriculum should include pharmacology, pathology, bacteriology and physical diagnosis.
• Students should have access to hospitals and dispensaries where they can get supervised clinical experience.
• Medical schools should have salaried faculty in both the basic and clinical sciences devoted to teaching and research.

~ "Abraham Flexner and the era of medical education reform"

Since that time, medical education has been evolving and changing to incorporate the additional tools made available to it. Live, classroom training has given way to remote, online training. Books are now accessed through IPads. And the geographic location of students is no longer a prevention when it comes to practicing interviewing skills for Standardized Patients. It is important that medical schools collectively keep up with the changing world of medical education.

"It's our job to make sure future physicians are prepared to deliver nothing but absolute excellence in patient care. Educational standards need to be refreshed, refined and improved as technology changes and the data fog thickens." ~ Dr. Cecil B. Wilson (AMA President)


By shifting the focus from simply emphasizing outcome measures to also including the competencies of physicians, medical schools have the ability to train the next generation of providers to be well-rounded and more able to treat patients from a variety of backgrounds.

Promoting Rural Healthcare

The need for PCPs in rural communities continues to be an issue, especially with healthcare reform becoming a reality. While more urban areas have a wealth of available physicians, rural residents may not have a physician in their immediate area and be forced to travel long distances to receive care.

“In the current health care reform debate, if health insurance coverage increases, residents in areas with an inadequate physician supply will have greater difficulty receiving timely and appropriate clinical care, and this could create poorer population health indicators.” ~ Dr. Kara Odom Walker (Assistant Clinical Professor of Family and Community Medicine, University of California)

The question is how to prompt medical students to practice in these geographic locations. A new study by researchers at UCLA indicates that selection from within the community would be a viable option. Those students who live and are educated within these areas are more likely to stay there to practice. And they may feel an obligation in a sense of self-identity and personal responsibility to provide care for the population. By identifying with their patients, or having their patients feel a connection to them in the sense of shared background, it can create a more viable healthcare system. It is important that medical schools and contributive systems utilize these indicators to provide a physician workforce to the areas that may need them the most.

Leading By Example

In pursuit of good health, it is preferable when the physician is practicing the same health measures that they are teaching. Doctors who lead a healthy lifestyle are more likely to recommend such measures to their patients, according to a recent study.

“Physicians who exercised more were more likely to counsel their patients on the importance of exercise.” ~ Dr. Elizabeth Jackson (Assistant Professor of Medicine,  University of Michigan Health System)

The study, conducted March-April 2009, asked University of Michigan Health System physicians to respond to questions about personal health measures. Of the 183 that responded, answers varied in comparison between attending physicians and trainees. Those still in training had unhealthy habits such as lower consumption of fruits and vegetables, as well as less time spent exercising as compared to attending physicians. This may be related to the time constraints those in training have when compared to those in practice. However, it is essential to begin good habits early so that physicians can lead by example. It is also important to become more confident in your own abilities to counsel, as the study found that was lacking among respondents. More research may be warranted to find ways this improvement can be achieved.

Follow-Ups Work

With the growing demands of time upon medical professionals, it's often difficult to cover everything needed in the 15 minutes allotted for patient encounters. However, the care should not end when the visit is over. A new study by the University of Michigan Health System looked at non-office-based follow-up care for depressed patients conducted by care managers. Those who received phone calls as follow-up on their care, as well as being given the tools to self-monitor their condition, were more likely to be in remission over a year later.

“They key is to keep patients engaged in treatment...Patients have a human contact, somebody who can help them become more actively involved in their own care.” ~ Michael Klinkman, M.D., M.S. (Professor of Family Medicine,  University of Michigan Medical School)

By conducting follow-up care outside the office, problems can be noticed earlier. Additionally, by utilizing the physician's office as a home base and having the care managers as the contact person, the time constraints upon the physician was lessened. It is important to help patients become an active, engaged, participant in their own health. It becomes a team effort to provide the best care possible.

Doctor Visits For Men

The American Osteopathic Association (AOA) recently conducted a survey on men's health. The findings indicate that more older men make doctor visits than younger men. Among those aged 18-29, 63% of men indicated that they've seen a PCP in the past year. That percentage rose to 85% in men 60 or older.

"While older men may have more reasons to see a physician, younger, healthy men who wait too long between routine physicals and who pass on screenings, such as blood pressure or diabetes, miss the opportunity to detect precursors to heart disease and other illnesses. Addressing these early warning signs is often the easiest and most cost-effective way to stop illness before it starts." ~  Joseph A. Giaimo, DO (AOA Trustee, Board-Certified Internist and Pulmonologist)

The reasoning behind younger men not visiting the doctor is the perceived lack of need, but also some respondents said that lack of insurance played a part. Both of these reasons have the potential to be counteracted through proper education. Promoting the benefits of proper screenings, coupled with the advantage of early detection, can do well to enforce the need for men of all ages to go see their doctor. On the issue of insurance, patients can look into options provided by the Affordable Care Act or Medicare/Medicaid. Additionally, medical schools sometimes offer low-cost healthcare as a learning scenario for their students.

It is important that everyone take their healthcare seriously and utilize medical professionals not only when there are problems, but also in prevention of them.

Pharm Money in CME

Much discussion has taken place to separate pharmaceutical money from influencing individual physicians in practice. The industry had previously given lavish gifts in exchange for physicians pushing their products. Now, to get around the increased guidelines, other avenues are being explored to influence the medical industry.

One problem of pharmaceutical influence is through their infiltration of the continuing medical education industry. Healthcare providers must take a certain number of CMEs every year to maintain their license. The problem comes when the education they are receiving has been heavily influenced by a certain drug company, in turn promoting them above all others.

While the ACCME has guidelines in place to curtail the promotion of singular products within courses, this does not stop the pharmaceutical industry from providing benefits through other avenues. Drug companies may pay CME providers to offer their courses for a lower price or even free. This not only eases the access by physicians to the education, but also promotes the drug company as the benefactor. $880 million of the $2.2 billion spent on CME courses in 2009 was provided by the pharmaceutical industry. It's estimated that 60% of CME providers took industry money last year. That's a phenomenal amount of influence the drug companies have over the healthcare industry.

How can medical students and professionals seek to separate themselves from this influence? Be conscious of the disclosures made by those involved in the CME courses you take. Taking responsibility of your own educational choices will go a long way in weaning the medical industry from its dependence on pharmaceutical money.

Increasing Longevity

With the graying of the population, the area of geriatrics is becoming more important. People are living three decades longer than they were just a century ago. With this longevity comes prevalent health issues. It is important that medical students and professionals are well-prepared to take them on.

However, even with this increase in longevity, it is commonly known that the United States lags behind other countries in terms of lifespan. Researchers at Mailman School of Public Health (Columbia University) looked at the cause of this disparity earlier this month. One might think that smoking or obesity, both large health issues, are to blame. However, the study found that instead the healthcare system itself might be the problem. The US relies on a system which does not regulate the fees charged for services and with the reliance on specialists, patients may be spending more, but they're not receiving the perceived benefits from such care because of lack of communication and coordination between healthcare providers.

Perhaps this gap will be helped by the Affordable Care Act. With the expansion of health insurance, as well as improvement in primary care and more accountability for physicians, patients should see an improvement in their healthcare system. However, it's important that physicians seek to make improvements on their own. Providing the best care possible is what each healthcare provider should seek to achieve.

Americans Accessing Mobile Health Information

Recently, results of a Pew Survey were released which focused on mobile health in the United States. The California HealthCare Foundation aided the organization in conducting the survey between August and September 2010.

• Of the 3,001 adult respondents, 85% were found to own a cellphone.
• 17% of these cellphone owners of all ages have looked up medical information on their phones. This percentage increased to 29% among those 18-29.
• 9% of cellphone owners of all ages have healthcare apps. The number was larger for the 18-29 age group at 15%.

The number of iPhone and Android apps are ever-increasing. Coupled with that, the number of medical education portals found online are numerous.With the increase in mobile technology and accessibility of information, it's important that medical professionals and educators utilize the opportunity to inform health consumers in this arena.

Using Virtual Reality For Medical Education

The push to incorporate more case-based education into medical school curriculum also calls for a more interactive experience. The limitations of live training has inspired some educators to explore areas outside the classroom. Some educators are not only branching into the online market, but also the virtual reality market as well. One of these VR opportunities is Second Life. This is a virtual world that participants can access online and interact with others via avatars.

Dr. Peter Yellowless uses Second Life to teach about various medical issues, such as psychosis and bio-terrorism. He joins many other medical organizations which have sought to teach about various topics through a virtual reality interaction. The expanded possibilities of virtual surroundings can immerse a student into scenarios that would be limited within the real world. It also opens up the interaction opportunities to a worldwide audience instead of being limited to those in the immediate geographic area.

The use of Second Life as a teaching tool indicates an opportunity to incorporate technology into education. It is important that educational opportunities which may not fit within traditional roles are explored. The benefits of new technology seeks to enrich the benefits of teaching, as well as making a fuller learning situation for students today.

Don't Make Assumptions

Human nature leads us to make quick assumptions based on interactions. First impressions often allow us to build a mental image of what we're being presented with and then we proceed from there. However, we should not to let that mental image prevail over the complete interaction as we may miss important information if we're not careful.

It is important not to assume that your initial assumption based on visuals is correct. It is possible that a patient may have issues that are not immediately seen or discovered. First impressions do not necessarily tell the complete story. Additionally, the written patient summary may not tell the whole story either. Patients may be uncomfortable talking about certain issues or they may deem certain issues irrelevant to what they're coming into the office for. It's important to gather as much information as possible from your patient as the seemingly unrelated issues may indeed be connected. On the opposite side of that, not all issues are connected. It's important to gauge what is or is not pertinent. By reviewing all available information, physicians can make the best decision in patient care.

Minorities Entering Med Schools

The Association of American Medical Colleges released information on Wednesday which highlights an increase in medical school enrollment for minority students. Compared to 2009, overall applicants among all populations increased by 1.1% and first-year enrollment increased by 1.5%. Within the minority population, Hispanics saw a 9% increase in enrollment compared to 2009, African Americans saw a 2.9% increase, and Asians saw a 2.4% increase. These increases will be beneficial to improving the health of various minority communities.

"You don't improve the health of communities without having a workforce that reflects the diversity of those communities." ~ Darrell G. Kirch (AAMC President and CEO)

With the physician shortage still a very prominent issue, an expanded workforce can serve to curb that looming problem. Additionally, as some patients prefer to have physicians who are their same gender or race, the amount of physicians capable of serving such a role can increase. It is hoped that these increases continue as we move forward into the future.

Doctor Shortage Coming Soon

The Association of American Medical Colleges released information earlier this month that highlighted the real possibility that the United States will have a shortage of physicians in the coming years. With the aging of the population, as well as changes in the healthcare industry, demand for medical professionals is constantly rising. However, the amount of physicians available is not keeping up. By 2025, the supply of physicians will fall below the demand by 130,000.

In order to counteract this problem, changes in training must occur. Opening up training opportunities, especially in PCP preparation, would allow for more physicians to enter the workforce over the coming years. According to Dr. Grover, who is an Assistant Clinical Professor of Medicine (George Washington University School of Medicine and Health Sciences), if we increased the number of residency positions available by just 15%, the medical field could have 4,000 more physicians every year. Additionally, those who are already within the medical workforce must collaborate more effectively with others in order to provide the best service possible. Better communication and treatment skills would improve current issues.

Access to Doctor's Notes

Since the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, patients have been allowed to access doctors' notes on their case. This has mostly been beneficial in that patients can better understand their care, as well as share information between medical professionals to enhance treatment.

"I think it's important for patients to have access to their notes. It's also important that they have guidance from physicians so they can actually understand." Dr. Natasha Eaddy-Rose (NeuroRehabilitation Specialists)

However, there's also a downside in possible misinterpretation of the notes by patients. Physicians may use shorthand that is hard to decipher or have double meaning. Noting SOB on a patient's chart is not a slight against their character, but instead a mention of them having shortness of breath. Anorexia does not mean that the patient has Anorexia Nervosa, but instead is reporting weight or appetite loss. Patients may not easily understand this.

It is important that medical professionals make clear, when sharing chart information with the patient, what their notes actually mean. Over time, medical professionals may change the way they note symptoms, in response to the potential for patients and outside persons to access such information. Either way, it's essential that patients and physicians have open communication and everything is made clearly understandable.

Watch What You Say

With the expansion of social media outlets, it is important to remember that what you write can be re-appropriated and used in ways that are changed from the original intention. The Ohio State Medical Association has put out Guidelines for Physicians, Office Staff, and Patients in terms of Social Networking and the Medical Practice.

It is worthwhile to consider what you write and how it may be perceived by others. A personal opinion may be construed as an endorsement, a general mention of a patient may be seen as breaking confidentiality, and what is meant to be shared in private can very easily become public.

Medical professionals and employers should set out a clear social media standard that they adhere to. Those involved should be held accountable for what they write, as well as being respectful and honest with others. By setting up the rules ahead of time, it is much easier to deal with problems that may arise rather than trying to retroactively correct them.

The Physical Exam

Does your medical school really teach the physical exam? The New York Times reports of one physician who is re-introducing the art of the physical exam at Stanford. Dr. Verghese has noticed over the years that more and more residents and attendings prefer lab tests or scans, rather than the simple, yet essential physical exam. The physical exam should be a vital part of any patient examination, as it can yield clues that can determine which, if any, of the more expensive tests should be performed. With today's health care costs spiraling out of control, perhaps the physical exam can see a resurgence in use.

Community Clinics

A free community clinic has been set up in Lubbock, Texas. The community clinic is staffed by volunteer physicians and medical students from Texas Tech. Not only does the clinic provide free care to those without health insurance, but medical schools, especially those in the preclinical years, gain valuable experience working one-on-one with patients. If your community/school has a similar volunteer clinic, have you volunteered?

Simulations

The University of California at Irvine recently opened a new Simulation Center, which is stocked with Sim Man mannequins. The SimMan can react to a variety of stimuli, and are increasingly used in medical schools for training, often in emergency situations. The Sim Man can be programmed to do things like have a heart attack or stroke, and can provide valuable practice for future physicians. Does your school use simulations like Sim Man, or have you primarily been exposed to live standardized patients?

Be Aware of Toasted Skin Syndrome

As students increase their use of technology, a new health problem is arising. In a study published Monday in the Pediatrics journal, Swiss researchers have shed light onto "Toasted Skin Syndrome."

The condition creates skin damage (reddened/brown skin, mottling of the skin, markings, etc) as a result of prolonged heat or infrared exposure. Commonly found among workers who work in front of ovens or kilns on  a daily basis, since 2004 ten cases have resulted from using a laptop on your lap/exposed skin. There is a small risk that this skin damage could develop into cancer.

To circumvent the damage, it's advised to use measures such as placing the machine on a surface other than your lap or when that's not possible you should use a heat resistant barrier between your laptop and your skin. As technology use expands, it's important to keep yourself healthy!

Balancing Class Time

The amount of time available to cover topics in the medical school curriculum is decreasing, which has a negative effect on the overall educational value of training. Dr. Lloyd Sederer pointed out this fact in his Huffington Post article today, as he noticed the amount of time devoted to anatomy labs had dwindled from a full year to a mere eight weeks. So, instead of having time to devote to the topic over the long-term, students are getting the briefest of highlights so that the curriculum can encompass even more subjects in the limited amount of time available.

One of these added topics vying for attention is the Standardized Patient interview. The SP experience is worthy of the attention curricula are devoting to it. However, is valuing communication skills over hands-on anatomy skills doing a disservice to education? That's a question that must be considered when medical schools are developing a well-rounded educational experience.

One solution to these time issues is to allow for some topics be covered online, outside the classroom. Online educational courses, including SP experiences, can be used to supplement the classroom education provided by medical schools. The utilization of other outlets of education, in addition to in-person classroom training, can allow the student to get a richer and more fulfilling experience rather than rushing to cover everything with only brief highlights.

SP Programs at Medical Schools

Today, the Pittsburgh Post-Gazette had an article focusing on the University of Pittsburgh's Standardized Patient Program. Pitt, like many medical schools across the country, utilize Standardized Patients (SPs) to teach medical students about proper interviewing techniques. By utilizing actors to represent real cases, medical students are learning how to properly interview and diagnose.

"Some of [the medical students] say, 'Well, this is obvious, I don't need a class to teach me about this stuff ... but I think that's the minority." ~ Jason Rosenstock, University of Pittsburgh Instructor of Psychology and Medical Interviewing

But in-person SPs are not the only avenue available to medical schools. Remote Live Standardized Patients (RLSPs), such as those provided by Clinical Tools, allows for medical students to access this type of training no matter where they are located geographically. This allows schools which may not be able to support a full-time SP program to still share in the benefits of such training. It is also a good training situation in preparation for the Step 2 exam, which requires an SP interview as a component.

Keeping the Patient Informed

Patients are often forced to make medical decisions about their care, but are they able to make informed decisions from the information they have? That was the question posed by a survey conducted by the ISR Survey Research Center. They questioned 3,000 adults in the United States about 9 common medical decisions that they'd be likely to make in their lives. The survey found that Americans aren't well-informed in their healthcare. Additionally, patients are often pushed to take medication or have a procedure, but many are not told of the reasons against such a decision.

"I want to raise the awareness of how important medical decision making is in the lives of all Americans and how unprepared most people are to make these decisions. I see this as a public health issue." ~ Brian Zikmund-Fisher (Assistant Professor, Internal Medicine, U-M Health System)

• 80% of those considering breast cancer screenings and 51% of those considering taking blood pressure medication in the study never heard of a reason they shouldn't agree to such medical intervention. 

• 50% of patients considering taking cholesterol medicine in the study reported that they were never asked if they wanted to be prescribed the medication. Hispanics and African-Americans were more likely to let their doctor make the decision for them.

• Patients are less informed than they think they are and do not use the Internet in seeking out knowledge, instead utilizing their healthcare provider as their main source of information.

It is important that physicians-in-training assure that their patients get the best care possible. Discuss with them what each medical procedure or medication is for, why they need it, and any reasons why they may choose not to have it. It is not simply medical care, but patient care.