Rural Health

Doctors seem to be in abundance in city centers. Medical students often move to areas with high populations and a higher wealth distribution, thus increasing their own pay. However, this leaves rural areas lacking and in dire need of medical coverage. This need will only increase as healthcare laws change to bring in more patients.

The population of rural areas is currently 50 million Americans. These people must often travel long distances in order to be seen by a healthcare provider and may not have adequate health coverage for proposed treatments. This puts a strain on their already-stretched finances, as well as their time availability, and may contribute to the amount of rural residents who do not see a physician as often as they need to. Healthcare reform seeks to lessen the financial burden in terms of lack of coverage. Current estimates show that 5 million residents in rural areas will gain Medicaid or another type of government assistance for their healthcare costs. While this is good for those who have avoided treatment because of lack of insurance, this puts added strain on an industry that is already showing a gap among provider availability for rural areas.

It is essential to broaden the medical coverage area to all geographic regions, especially rural areas, prior to the influx of new patients from the coming healthcare reform. Medical schools must increase their efforts to steer students towards rural areas and it's important that the benefits of rural distribution be emphasized. The system must support everyone and provide treatment opportunities that are both accessible and affordable for all Americans. Having to travel more than 60 miles to be seen by a physician is not viable for the health of this country.

Medical Volunteers: Children

The amount of medical research aided by adult volunteers is tremendous for medicine. A poll conducted by the University of Michigan C.S. Mott Children's Hospital National Poll on Children's Health in 2011 shows that over 11% of adults (1 in 9) have taken part in some type of medical research. This participation inevitably leads to advances in treatment and understanding about medications and illness.

However, children are not afforded this same benefit. In the survey, parents indicated that only 5% of their children (1 in 20) have participated in medical research. It's not that parents are necessarily against medical research involving children, but instead that they are unaware that opportunities exist for their children to aid in medical advancements. 84% of parents polled had no idea about any medical volunteer opportunities for children.

"Medical research is the backbone of improving medical care. Without volunteers, medical research cannot move forward. Awareness about research opportunities, which is a necessary step before participation, is reasonably high among adults but strikingly low for children's research. To improve participation rates among children, researchers and institutions evidently need to do a better job of getting the word out to parents." ~ Matthew Davis, M.D., Associate Professor (Child Health Evaluation and Research Unit, University of Michigan Medical School)

There have been prior complaints about the lack of understanding in the realm of medical treatment in children. Drugs and other treatments affect children differently than adults, so the research done on adult patients cannot be simply downsized for younger patients. By making volunteer opportunities more accessible and publicized, parents have an increased chance of agreeing to their children taking part in such contributions. And with the involvement of children, more targeted advances can be made in the arena of child health, thus improving patient outcomes for medication and other treatments.

Limited Hours Mean Less Training Time

The hands-on experience that medical students gain throughout their training has proven to be invaluable. Students often spend long hours observing and taking part in various medical procedures in order to put their training into practice. Now, however, that time may be limited with new guidelines put in place by the Accreditation Council for Graduate Medical Education.

As of July 1st, first year residents cannot work longer than 16 hours in a single shift. Those who are 2nd and 3rd year residents are allowed more time per shift--24 hours. These changes were put into place for health and safety reasons, both for the patient and the caregiver. Sleep deprivation on the part of the provider has an increased likelihood of causing treatment mistakes, which put patients into danger. By making sure that medical students are not forced to work past the time of efficiency, it's hoped that this will cut down on patient endangerment. But does this trade-off actually put patients in long-term danger, as medical students will have less hands-on training time during training before embarking onto their medical career?

"[Working long hours] was a good learning experience. It makes you feel like you can endure when put to the test. [But u]ltimately it comes down to patient care, and that comes before anything." ~ Dr. Shilpa Babbar, EVMS Obstetric-Gynecology 3rd Year Resident

The debate continues among medical students and their teachers, as there are positive and negative outcomes on both sides of the discussion. With the new guidelines in place, medical training must reorganize and have more relevant educational opportunities available during the time medical students are active. Patient safety is of the utmost importance and the medical field must assure that this is maintained through whatever reorganization is put in place.

Inspire Early

While much focus is placed upon students already admitted to medical school and those who have recently entered the workplace, it's also important to reach out to those who are pre-med or even younger, perhaps still contemplating their career path. By presenting information early, it may better prepare those who are getting ready to enter medical school and inspire those who are getting ready to enter college for the first time.

Information sessions help students become better suited for certain levels of their educational path. Recently, deans from the area Georgia medical schools talked with pre-med students to give them information on how to apply and give them a better advantage to get admitted to medical school. This is just one example of how medical schools can reach out into the community to garner interest in the medical field. The same presentation could be made to high school students, in order to steer them towards a pre-med track early on. Even those already in college, but not necessarily on the medical path, may be a potential audience for these information sessions. Well-rounded medical students come from a variety of different educational backgrounds, not just the pre-med track.

It's important to reach out to a variety of individuals to garner interest in the medical field. With a looming physician gap, it's even more vital that the medical field be seen as a worthwhile option. Medical school faculty who are accessible and willing to share their knowledge with others may well see the benefits returned in the form of new students.

Training Needs

Medical students right out of college come into the field prepared to take their learning and apply it to real-world situations. As they practice, they gain more hands-on experience. It would then stand to reason that the longer the physician has practiced, the better they would be for patient outcome. However, this doesn't seem to be the case, according to a recent survey.

The records for 6,500 patients who were hospitalized at New York City's Montefiore Medical Center between 2002 and 2004 were looked at for the study. The 59 attending physicians who saw these patients were then divided into sections, according to how many years they practiced: 5 or less years, 6-10 years, 11-20 years, or over 20 years. A comparison was then made between those that had been in practice 5 or less years and those who had been in practice more than 20 years. The study found that among the sickest patients who were seen by the most experienced doctors, they had a 70% more likelihood of dying while at the hospital and a 50% more likelihood of dying within 30 days of their stay than compared to patients being treated by the least experienced doctors.

What does this indicate? One area of exploration should be the re-training physicians get as they progress through their careers. Physicians just out of medical school have the most up-to-date information in their minds as they confront a case, while more experienced doctors' information may be dated or relying solely on what they've seen before. The continuing medical education that is required for physicians to maintain their licenses are helpful, but are not as extensive as full medical training. Additionally, many of the oldest physicians in practice today are actually exempt from re-certification requirements, so they are not getting the benefit of updated information.

It is vitally important that physicians keep up to date on current information in their field. The hands-on training they get on the job is not enough to make sure they are providing the best care possible for their patients. Suggested changes include requiring all doctors to maintain updated training when they practice and to provide more intensive training that goes above and beyond the current lecture attendance. By making sure physicians have the most information possible, patients can be assured that their health and safety are of the utmost importance as they go in for care.

Adoption of Technology

The new generation of medical students are being exposed to mobile tools and the integration of technology into their training and practice. They are adopting and using various tablets and apps in their medical ventures. Now, a survey of physicians shows that this adoption is not restricted to just younger physicians.

QuantiaMD surveyed 3.798 physicians about their use of mobile technology. Among those who have practiced more than 30 years, 19% used a tablet in their practice and 25% were likely to get one soon. On the opposite side of the spectrum, 20% of those who have practiced less than 10 years use a tablet and 38% were likely to get one soon.

Why have the older generation taken to the tablet, especially the iPad which has a higher user rate among those surveyed? One explanation is the fact that it has a large screen and keyboard, which makes it accessible. Additionally, it's easy to learn how to use the iPad quickly, thus allowing the physician to gain the most advantage out of its use soon after acquiring it. And they're using them for reference materials more so than patient data. While 20% do use their tablets to access patient records, 69% reference materials on treatment and medication that they can use with their patients.

There may be more patient data access as the tablets become more common, but the fact that the tool is already helping in the medical field is important to note. Tablet use in medicine is set to become even more widespread over the years, so it will be interesting to see how the younger and older generation will bridge the gap of users in order to spread tablet use among all age groups.

Genome Wower

Medical students learn about genetic structures and disease genes throughout their training. Now, these students can become more hands-on in their learning by downloading the free Genome Wowser app to their iPad. Created by the Center for Biomedical Informatics (CBMi) at The Children's Hospital of Philadelphia, the app allows users to enter a gene's name in its search box and then be shown where it lays on the human chromosome as well as annotations provided by the UCSC Genome Bioinformatics Group.

"With this app, I can hear about an interesting disease gene at a seminar and see its genomic and functional contexts in a few screen touches, including epigenetic and variation profiles, neighboring genes,  and other critical associations you can't determine from a simple web search. Then, I can walk over to a colleague and share it with them, all in a few seconds." ~ Peter White, PhD (Director of CBMi)

Since the app is available on the iPad, the larger view area allows the ability to see the structures clearly. Also, the app allows for zooming in and out, as well as drag-and-swipe navigation. You can find more information about Genome Wowser on their iTunes page or their webpage. This is  a great resource for learners to bring abstract concepts into focus through mobile tools.

Personal Interactions: Medical Students

Medical students must know a lot of information in order to succeed. Hands-on training, recalling information from multiple books, and putting all the knowledge into practice are all components of medical students becoming medical professionals. However, another key component is the ability to successfully interact with patients. Good grades and impressive test scores go far in making a good impression for potential schools, but students must be well-rounded as well. In order to successfully gauge the ability of students for successful social interaction, many medical schools have begun integrating multiple mini interviews (MMI) into their potential student interviews.

MMIs are integrated into eight medical schools across the US already and thirteen in Canada. These interviews consist of a speed-dating-like scenario where candidates quickly review a morally questionable scenario, then have a limited time to discuss their approaches to solving these issues. They are not necessarily judged whether their answers are right or wrong, but how they approach the problem solving and their ability to listen to differing opinions in order to reach a mutually beneficial solution.

"We are trying to weed out the students who look great on paper but haven’t developed the people or communication skills we think are important." ~ Dr. Stephen Workman, Associate Dean for Admissions and Administration (Virginia Tech Carilion)

These scenarios allow for a variety of circumstances so that the potential student can be seen by a number of interviewers and a consensus of opinion can be reached. This feedback has also proven to be predictive of how the student will fare on their later licensing exams where they'll be tested once again on the abilities being focused on for MMIs. Medicine is no longer a solitary career, as the ability to work in a team is just as important as the ability to remember pages of information from medical texts. Medical schools must be able to train and prepare potential physicians to be a strong addition to the medical field.

Anatomy Technology

The study of anatomy has long been reliant on the use of donated bodies that are used for teaching. Medical students have often talked about the experience of entering the anatomy lab for the first time and cutting into a donated body. Now, that experience may be brought into the digital age with virtual cadavers.

Stanford University of Medicine is using a table that was made by Anatomage, which creates a 3-D cadaver that the students can virtually dissect, as well as zoom into certain structures for more in-depth learning. All images are based on actual scans from CTs and MRIs. There is tremendous potential to expand this technology into more medical schools across the country, based on Stanford's feedback, and so far it's been very positive.

“You can see really specifically how certain organs connect, which can be really hard to see in a cadaver. It’s very intuitive.” ~ Meghan Bowler, Stanford Medical Student

While it is not meant to replace dissecting actual cadavers, as the hands-on approach cannot be fully replicated, but this virtual tool will allow a compliment to this type of learning as well as giving more focus on certain areas that students can use to expand their learning. Additionally, the inclusion of technology in medicine is an overall positive approach as students are taught to be more comfortable with technology and its inclusion into practice. This will allow them to be better suited for patient treatment once they become a provider.

Physician Gap May Be Filled

With the coming changes in healthcare, more primary care physicians will be needed to treat the influx of new patients. The Association of American Medical Colleges (AAMC) released a report back in 2006 stating that a 30% increase would be needed to keep up with the demand. Four years later, the AAMC shows that this gap between supply and demand will likely be filled by 2016. This is good news for those who feared that primary care had lost ground compared to specialty care.

Medical students often choose to become specialists because they have a large amount of school debt and they are likely to make more money as a specialist than a PCP. However, medical schools are attempting to emphasize the importance of primary care in order to increase the number of students choosing this path in medicine. Medical schools are modifying clinical rotations, refining their admissions criteria, and expanding the amount of PCPs they employ as instructors. With these changes in place, medical schools hope that students will be re-energized to pursue this career path.

It is vitally important that medical schools work towards making sure the next generation of physicians can adequately cover the needs of patients, including the increased demand that will occur when healthcare reform brings a large amount of new patients into the system. Primary care will remain the first-line in treatment, so there must be enough providers to cover the demand. Now there's hope that this coverage will actually take place.

Nurse Practitioners Filling the Gap

The coming changes in the healthcare industry means that more healthcare professionals will be needed. There are not enough doctors to fill the gap, but there are other types of providers who can help with these needs. One such health professional is a nurse practitioner. NPs can prescribe, treat, diagnose, or order necessary labs. By performing these necessary tasks, patients can be treated without the need for waiting for the already-overworked physician to see them. This speeds up the processing time and allows more cases to be seen every day. Therefore, the cases that truly require physician attention can be focused on more in-depth since physicians will not have to be rushing from room to room in order to process everyone who comes into the office.

"The idea is that not every patient visit needs to be with a physician. The physician culture for decades was that doctors have to do everything, that that's the only person who can do that care, and that's probably not true. With multiple other team members -- nurse practitioners, physician assistants, but also just regular not advanced practice nurses, medical assistants -- with these folks working together, they can do the care that doesn't require the physician, therefore it extends the practice." ~ Dr. Glen Stream, President-Elect (American Academy of Family Physicians)

There is also the aspect of billing costs. Since NPs make less than physicians, it is less costly for them to treat patients because of billable hours and they can also afford to spend the time in one-on-one sessions educating the patient on their illness and how to get healthy. With estimates showing that 30-60% of current healthcare can be provided by NPs or other non-physicians, it makes sense to look into these areas for the future of medicine. By utilizing as many health providers as possible in a variety of roles, the influx of new patients will not overwhelm the system and care will not have to be compromised. In the end, patient care is the most important aspect of medicine.

Happy Fourth of July!

Clinical Tools hopes that everyone has a safe and happy 4th of July! Normal posts will resume after the holiday.

Burnout

The risk of medical student burn-out is very real. The pressures of learning and putting knowledge into practical use can often stretch students to their limits. KevinMD's blog has an article that speaks to this topic. The author, James Haddad, highlighted a number of similarities between experiences he's observed when looking at medical student experiences.

Lack of Continuity: Students are bumped from department to department, which is great in sharing a variety of experiences, but there's also the lack of connection between students and trainers in situations such as this. There's also a lack of consistency when it comes to varying teaching styles. Feedback and allowing the student to "learn by doing" is often not a part of the process. This causes students to feel lost as they try to soak up as much information as possible and try to glean what is or is not correct.

Emotional Engagement: Professionalism is important in a "learn by observing" situation. However, when medical students witness their peers and their superiors treating each other badly, at times belittling each other, it does not set a good example for others. Additionally, when mistakes are made, to observe these situations being blown up to epic proportions rather than dealt with in a civilized manner can do damage to the medical student's learning.

Taking the Blame: As the lowest person in the chain of command, medical students are often left to take the blame for any problems that arise. When medical professionals are discovered to be cutting corners or doing something not by protocol, they can shift the blame down rather than acknowledging their own mistakes. This creates a tremendous weight on the shoulders of medical students, as well as teaching them the incorrect process for taking the blame for their own mistakes.

Medical students are often required to have an expansive amount of patience and wealth of knowledge as they learn how to be doctors. Those who are in the role of training must remember that these students will become the next generation of health professionals and they learn by what they observe. Make sure these students are observing the best that medicine can offer.