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Doctor 醫生 | Researcher 研究員 | Writer 作者 | Editor 編輯 | Dreamer 夢想者
One of the most interesting aspects of the transformation occurring in medicine is the effort that some organizations have committed to reexamining the scope of their business. As payment and delivery reform change the landscape of clinical care, some have expanded their reach beyond the delivery of health care into the realm of promoting overall health.
The domain of health care involves what occurs within our clinic and hospital walls, for example, vaccinations, cancer screenings, and care during episodes of acute illness. In contrast, the domain of health requires clinicians to move beyond those walls into the surrounding communities, working with partners to address aspects of health such as food options in schools, the adequacy of services for pregnant women and the elderly, and the like. This movement equates to increased focus on public health and social determinants of health.
As an internal medicine trainee taught to care for patients holistically, I am encouraged by many of the early changes occurring around me. However, early examples are far from perfect, and as health care organizations extend their reach into communities, they must answer several important philosophical and economic questions about the extent of their responsibility. Nonetheless, the effort is laudable.
By now, many people know that our country’s health care costs are unsustainably high, and rising. But the component details — the prices for testing, medications, procedures and hospital stays — have remained arbitrary and opaque even to most health care leaders and physicians, not to mention patients.
Of the many drivers behind our high health care costs, low transparency and consumer awareness are particularly intriguing ones. The idea is straightforward: Without accurate, usable knowledge about how much health care services cost, patients can’t make choices that satisfy both their health needs and their pocketbooks, like they could if they were purchasing cars or refrigerators. For decades, patients have received care without really knowing what it costs.
Access to more information, on the other hand, could allow people to make the economically sensible decisions that drive prices down to more competitive, market-dictated levels. For example, patients needing knee surgery could compare prices from multiple hospitals and choose the highest value option, while providers would have to increase quality and reduce cost to compete for business. The movement towards added transparency and awareness create the potential for patients to shop for their care in ways that have never before been possible.
Some believe that we have made strides over the last few years. Medicare released nationwide information about what prices hospitals and clinics charge, and actually get paid, for everything from joint replacement surgeries to hospitalizations for pneumonia or heart attacks. It then upped the ante by publishing information about what individual doctors charge medicare for their services. With these two releases, anyone can now go to the Medicare website, pull information for a number of doctors or hospitals, and compare their charges against each other.
At least for now, however, shopping thoughtfully for your health care will remain far more difficult than the click of a few buttons. My piece in the Huffington Post about why the price isn’t quite right yet.
I recently received news that one of my professors from medical school—a man who taught tirelessly, with uncommon fire and enthusiasm—stepped down because of a health condition. Like many of my former classmates, my first reaction was one of shock, followed quickly by sadness.
In reflecting on my memories of him and his impact in the weeks since, however, I have also gained a renewed appreciation for the power of mentorship. He was a consummate and effective educator, and has reminded me of a few important lessons to keep in mind as I transition into my final year as a resident.
In my early days as a medical student, the promise of electronic health records (EHRs) was all the rage. In some circles, it was all some researchers, IT leaders, and clinicians could talk about. These enthusiastic conversations touted EHRs as a way to improve clinical decision support, centralize patient information, reduce administrative costs, and share information across health systems (among other reasons). Some saw this new technology as the silver bullet that could help fix health care.
(image from Medtech Boston)
In the years since, the medical community has matured in its understanding of what EHRs can and can’t do. Now that we are pursuing a fuller spectrum of solutions and endpoints – including more business intelligence and patient empowerment – we are faced with a challenging, but worthy, effort.
In this effort, we have to forge forward thoughtfully, careful not to excitedly place our hope in the newest, slickest innovation that claims to improve care (particularly since all of them seem to). Instead, we should utilize the lessons we have learned thus far from EHRs and soberly assess each new innovation. Only then can we remain objective among the myriad of new technologies marketed to improve health, separating real solutions from the promises of new, would-be silver bullets.
As healthcare organizations address issues of inconsistent quality, high rates of harm, and rapidly rising costs, there has been growing interest in how residents physicians - medical school graduates but still doctors in training - contribute to these problems.
Reviewing and acting on performance-related data is an essential competency, but training programs have traditionally not provided housestaff with reliable information about the quality of their clinical performance. Implementation is complicated in a number of ways, but the effort is still crucial.
Several solutions can help educators address this issue, including being transparent about how data will be used, and gaining broad leadership support. My full thoughts here via an article with UCSF’s Bob Wachter.
Empathy is a crucial element to good care and improved patient outcomes.
This isn’t exactly surprising. Within the medical community, and particularly among educators, there has long been an explicit appreciation for humanism and compassion. There has also been a tacit understanding of its importance to doctoring: Empathy is the core quality that every medical applicant tries to convey, the one that admissions committees attempt to identify in candidates.
If the data are to be believed, however, medical education doesn’t always promote empathy, despite all of the recognition of its importance. Reports show that medical students lose measures of empathy as they transition from classroom teaching to clinical clerkships, and other data showing that students can quickly acclimate to unprofessional clinical cultures and behaviors without even recognizing them as such. Reports and anecdotal evidence suggest that this process is likely to continue, or even accelerate, in residency training. Between what we are teaching through explicit didactics and the “hidden curriculum,” the collective messages we transmit to learners in everyday words, actions and behaviors, we may be losing our grip on a sacred professional value and significant gains in our patients’ health outcomes, due to a lack of empathy.
How can we find a better way forward? My thoughts here.
America the beautiful.
In residency, new physicians must learn to appropriately address and handle acute sickness.
In situations involving catastrophic disease (e.g., in intensive care settings), this often requires them to absorb measures of emotion associated with illness while shielding themselves from its full weight. Balanced steadiness in the face of severe illness is crucial—a core competency in its own right—because remaining calm and collected in crisis is often as important to decision making as clinical acumen. Thankfully, most residents learn to find steadiness and focus amid chaos.
This steadiness, however, must also be thoughtfully directed. It is clearly helpful for young physicians who frequently spend long hours dealing with the sickest patients with the most complex medical and social problems. But increased exposure can also ingrain steadiness to the point where it progresses insidiously into something perceived as detachment, particularly by patients on the receiving end of bad news or poor prognoses.
This issue - the cynicism and emotional insulation that can prevent illness from meaningfully moving and affecting residents as people - is something that has concerned medical educators for some time now. Finding balance can be difficult.
There is a curriculum that is at work in medicine that goes beyond the formalized teaching that students receive in the classroom. This “hidden curriculum”—the collection of implicit messages about professional values and practices that are transmitted through everyday words, habits, and interactions—powerfully shapes the attitudes and behaviors of learners, for both better or worse.
While the hidden curriculum can transmit positive messages (e.g. professionalism, humanism, etc), it can unfortunately also create dynamics in which team members, especially those lower in the medical hierarchy (students, trainees), are afraid to speak up about their concerns. In such situations, the hidden curriculum threatens patient safety as well as clinical learning.
This is an important issue within medical education, as well as patient safety. My recent article about this issue here, in Health Affairs.
For over three decades, George Vaillant directed a study out of Harvard, one of the longest running longitudinal studies about human development ever.
Recently, in summarizing the interesting trends and findings from the study, he had this to say in conclusion:
“The seventy-five years and twenty million dollars expended on the Grant Study points … to a straightforward five-word conclusion: ‘Happiness is love. Full stop.’ ”
A more in-depth review of the findings here at the Atlantic.