By Glenn Laffel, MD, PhD
Senior Vice President, Clinical Affairs
Practice Fusion

Not too long ago, it seemed safe and reasonable to define health information technology (HIT) narrowly as the management of health information and its secure exchange between patients, providers, and insurers.[1]

For many, the definition effectively compartmentalized HIT. It was for someone else, not me.

That began to change when quality initiatives started forcing physicians to deal with performance data and patients began showing up with reprints of journal articles they hadn’t read themselves.

But nothing could have prepared physicians to handle the flood of HIT that inundates them today, a flood that threatens to sweep away established codes of professional conduct and disrupt the very processes by which care is rendered and doctors communicate with patients.

Consider these examples:

1) Dr. Jain, a medical intern[2] receives a friend request on Facebook from Erica Baxter. As a medical student, Jain helped deliver Baxter’s baby. Is Baxter simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives 120 emails per day. The assortment reflects her busy life. There’s one from her child who needs a lift at 6:30. Her dentist has an opening for her prophylaxis, and her secretary just added a patient to her afternoon schedule.

And then there are emails from her patients, some of which require immediate attention.

Problem is, Dr. Margolis can’t read all her emails. She has a thousand unread messages in her inbox. She worries that some contain time-sensitive information from patients.

3) Dr. Tapscott, nearing the end of his career in family practice, is convinced by office personnel to adopt an electronic health record (EHR).

But the implementation goes poorly. He can’t get the hang of it and believes it puts a barrier between himself and his patients. Five months and $20,000 later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new innovations, but the HIT Deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

The Impact of EHRs on Medical Education

EHRs are a prime example of this. They have begun an inevitable march into the lives of all physicians, stimulated by the American Recovery and Reinvestment Act, which allocated $21 billion to encourage “meaningful use” of such systems[3].

The Fed’s largesse is based on the premise that EHRs will improve quality and reduce the costs of care, but the move will impact the health care system in other ways as well. One such area is medical education.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but in others, the impact appears to be negative.

Benefits
Two studies suggest that EHRs improve documentation[4] by medical students. In the first, Morrow and Dobbie found that first-year students who used an EHR to document a history recorded more features of pain [5]than those using paper charts.

In another survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR.

These authors also assert that EHRs make it easier for faculty to give feedback to students[6], track the procedures they perform and store records of interesting cases for future use.

Beyond this, EHR speeds access to the medical literature which should facilitate learning and encourage students to rely on medical evidence.

Risks
EHRs have some negative impact as well, particularly relating to the learning environment and patient-physician communication.

EHRs can disrupt the learning environment by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

One example of this is the process by which trainees copy and paste chart notes and other information created by others, and send them to supervisors for feedback. This discourages critical thinking by the trainee[7].

The potential negative impact of EHRs on physician-patient communication is particularly acute for medical students who are just finding their voices as professionals. Inserting a terminal into the middle of a student’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from seeing how her words and body language affect her patients.

Tweaking Medical Education to Leverage EHR Benefits

As these issues show, the quality-improving, cost-reducing benefits of EHRs can only be realized by aligning multiple systems and user-based factors. Educators can begin the alignment in three ways:

Begin EHR Education Early
The process should begin in Year 1. Non-science oriented courses like “Introduction to the Patient,” present ideal opportunities to introduce the medium.

If students master EHR skills before their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis and so on.

What to Teach
Students should be taught how to use basic EHR functions like order entry, lab look-up, messaging and charting. This exposure should occur away from patients so students can focus on the EHR itself.

They should also be exposed to the nuances of physician–patient communication in the presence of an EHR. Specific communication techniques include:

-        adjusting the spacing between patient, physician and computer so the patient can see what the physician is doing on the computer,

-        encouraging the physician to walk-through data on the screen with patients,

-        spending no more than 30 seconds at a time typing into the computer,

-        making eye contact with the patient; assessing the patient’s emotional status and understanding of the information provided

Don’t Forget Faculty
Most medical school faculty have received no EHR training, yet until they become facile, they can’t be good role models for students. This topic is beyond the scope of this article.

Social Media: Disruptive Force in Medicine

In medicine, social media including Facebook, Twitter, YouTube, blogs and virtual physician communities has grown explosively.

Enterprising providers have deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic, for example, maintains several blogs[8], a Facebook fan page[9] (which has 8,800 fans), a library of YouTube videos and a Twitter stream[10] (7,120 followers)[11].

Many physicians also leverage social media to help patients access support networks, a heretofore difficult undertaking for homebound or geographically isolated patients, or those with rare diseases.[12]

But social media also creates challenges for physicians.

In some ways, the challenges are most acute for the youngest physicians, who grew up with Facebook. Unlike their counterparts, they are familiar with social media, but some have become ensnared by it.

Thousands of young physicians have created personal social histories and exposed them on Facebook. Their challenge is to manage this archive while forging identities as professionals.

A study by Thompson and colleagues the University of Florida sheds light on the challenge. They found that of the 44% of students at the UF Medical School who maintained Facebook profiles, only 37% made their entries private. More than half shared information regarding their sexual orientation, while 58% shared their relationship status and half shared political opinions.

A closer inspection of the profiles of 10 randomly-selected medical students revealed that 7 included photos showing them drinking alcohol. Five of these implied excessive drinking. Three students had joined groups that were flagrantly sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).[13]

The boundary-blurring effects of social media extend in every direction since medical students, nurses, housestaff, fellows and faculty are linked[14], and the chain is only as strong as its weakest link.

What has been done to mitigate risks associated with social media?

Many have issued warnings. “Caution is recommended,” wrote Jules Dienstag in an email to Harvard medical students. The Dean for Medical Education explained that when “using social networking sites such as Facebook…items that represent unprofessional behavior that are posted by you reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended consequences.”

Similarly, Drexel University College of Medicine warned students that information on social-networking sites can impact decision making regarding their applications to residency programs[15].

Warnings like these are analogous to a “Dangerous Rip-Currents” sign at the beach. By the time people read it, they have arrived in wet suits, having driven an hour to get there.

Some believe the challenges posed by social media are large enough to warrant promulgation of guidelines for its use in health care, modeled after AMIA’s “Guidelines for the Use of Electronic Mail with Patients” which were published just as providers began relying on that medium.[16]

Such an approach begs questions like who has the authority to issue such guidelines, or whether they could impact behavior without an associated means for enforcement. And since no one believes that social media utilization in healthcare should be regulated, the alternative is to modify medical school curricula and beef-up CME.

With social media, the genie is out of the bottle.

Innovations That Make a Difference

Even though EHRs and social media have had a large impact on medicine, it does not necessarily follow that medical education should be modified to account for them.

After all, thousands of technologies have disseminated into the mainstream; medicine accommodates them organically.

To some extent, this is happening with social media. In the Florida study of Facebook utilization for example[17], 64% of medical students were found to have fully public Facebook accounts, whereas only 12% of residents did.

It’s also true that finding space to teach HIT in a packed medical school curriculum means subtracting time from something else.

Still, we argue that the HIT Deluge presents unprecedented challenges to patient-physician communication and while blurring social boundaries in ways that generate ethical challenges and legal risks that cannot be ignored.

Medical schools including Harvard, Stanford, Vanderbilt and UCSF approach the conundrum by offering elective courses in HIT, often in conjunction with other graduate schools.

HST.921, “Information Technology in the Health Care System of the Future,”[18] is an example. The course is open to all graduate students at Harvard and MIT, including those at Harvard Medical School.

In it, students learn how HIT improves health care quality and provides new options for patient education and self-care.

Florida State University College of Medicine, one of the nation’s newest medical schools, has taken a more aggressive approach. Bypassing the above-mentioned incremental approach, its  Internet-age curriculum has HIT woven into its fabric.

FSU students receive laptops upon arrival. Their textbooks are on line. During orientation and first semester, they learn to access library resources on line and gain exposure to decision support tools.

In the second semester, they receive PDAs and learn how to carry out literature reviews and manage bibliographies on line.

In their fourth semester, FSU students learn to use SOAPware, a laptop-supportable EHR. During their third year, they use SOAPWare during supervised patient encounters and receive feedback from supervising physicians.

And what about all the physicians who graduated medical school years ago and have had no HIT education whatsoever? That’s where Russ Cucina, an associate medical director of IT at UCSF plays a vital role. Cucina, you see, teaches a CME class called, “Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs to Know.”

We hear it’s filling up fast.

[2] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[3] http://www.ehrbloggers.com/2009/07/meaningful-use-take-ii.html

[4] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[5] http://www.stfm.org/fmhub/fm2008/July/Heidi462.pdf

[6] http://www.biomedcentral.com/bmcmededuc/

[7] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[8] http://www.mayoclinic.org/blogs/index.html

[9] http://www.facebook.com/pages/Mayo-Clinic/7673082516

[10] http://twitter.com/mayoclinic

[11] http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=219200127

[12] http://www.nytimes.com/2009/06/11/health/11chen.html?_r=1

[13] http://news.ufl.edu/2008/07/10/facebook/

[14] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[15] ibid

[16] http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9452989

[17] http://news.ufl.edu/2008/07/10/facebook/

[18] http://www.hst921.org/home/

Glenn Laffel is Senior Vice President of Clinical Affairs for Practice Fusion.  Practice Fusion addresses the complexities and critical needs of today’s healthcare environment by providing a free, web-based Electronic Health Record (EHR) application to physicians.

“Is there a doctor in the house?” is a Hollywood cliche.  But when it comes to the houses of the United States Congress, the answer is always “Yes.”  Physicians have served in every Congress from the first in 1789 through the current 111th Congress.(1)

Currently, there are 16 physicians who serve as members of Congress (1), 14 in the House of Representatives and two in the Senate (2). With health care reform a pressing issue currently facing the United States, several additional physicians are seeking election to Congress this year in races across the country (3).

Dr. Ami Bera

The Student Doctor Network recently spoke with physician candidate Ami Bera about what health care professionals bring as candidates, and what life is like on the campaign trail for a physician.

Dr. Ami Bera is a Clinical Professor of Medicine and former Associate Dean of Admissions at the UC Davis School of Medicine. He also served as former Chief Medical Officer for Sacramento County, CA where he directed SacAdvantage, a program providing access to care for 200,000 uninsured.

Tell me about the office that you seeking.

I am running for the Democratic nomination for the 3rd U.S. Congressional District in California. The seat is currently held by Republican Congressman Dan Lungren, who has served eight terms and is a former California attorney general. There are three candidates running in the Democratic primary so far: myself, Elk Grove City Councilman Gary Davis and Sacramento Municipal Utility District Director Bill Slaton.

What motivated you to enter the race?

Honestly, it was never a stated goal for me to run for elected office. But after I stepped down from my position as Associate Dean of Admissions at UC Davis, I found myself looking for a way to serve. In the past I have done service behind the podium and have been disappointed by the follow-up on important issues by our elected officials. I realized that I have a desire to change the political conversations we have been having: to move away from doing what is best for one’s polling and promotion to advancing some of the great work on issues that is done by those behind the scenes and at non-profits.

What steps did you take before entering the race?

The idea of entering this race first occurred to me last October. I decided that I would explore the idea instead of focusing on “why shouldn’t I do this.” I started by speaking with some friends who are in the state legislature. They told me I had a great resume on healthcare, and that my experience growing up in an immigrant family would make me a compelling candidate. But they encouraged me to run for city council first and to work my way up the political escalator.

I had no desire to be a career politician and when looking at the race from an intellectual perspective it seemed like the time was right for me to enter. This district is now 40% Republican and 38% Democratic. The demographics have shifted with an increase in minority voters and migration from the Bay Area. With approval ratings for elected officials at record lows and the focus on healthcare, this is the perfect election to run as a non-career politician and a physician. It is a potentially winnable race, an opportunity for me to change our political conversations, and to fix healthcare.

What is your day-to-day life like as a candidate?

After filing in April, the first phase in a campaign was to establish legitimacy. A sad reality of the U.S. political system is that legitimacy is measured by fundraising ability. Generally a day starts around 5:30 am with email and internet communication. I meet with people for coffee and lunch. It is essential to build relationships with potential donors. Also, we have focused on getting people engaged with the campaign and on collecting small donations of $5-$20.

This next quarter ends September 30 and we are still focused on fundraising. I am going to Washington, D.C. to meet with Democratic leaders and to build a buzz about the race.

We have been able to focus more on voter outreach through townhalls and house parties. In the evening I usually attend multiple events. I am working as hard as I did during residency and I do miss having some quiet evenings at home to relax. But I love what I am doing.

What do you love about being a candidate?

When I first started in the race I had to see if I enjoyed being a candidate. I very quickly found that I love it. Being a candidate and talking with voters is a lot like what we are trained to do as physicians. I listen to other people sharing their suffering, ask questions, listen, and reflect back to them. As a physician I am trained to engage with people in tough subjects and this has been an asset as a candidate, especially when discussing controversial topics that can inspire passionate responses in voters.

What have been the most rewarding and challenging aspects of the campaign so far?

It has been very rewarding to put my ideas out there and to see them resonate with people. I try to present my ideas in an authentic way and I want to understand where people in the community are coming from. I have found that by doing this communities have really let me into their lives. This has been a very humbling experience.

The greatest challenge with campaigning is that it involves a lot of talking about myself. I know I have a healthy ego, but I always want it to be less about myself and more about the voters. So I try to find a balance by focusing on my values, telling my story, and presenting the stories of other people I meet. It has been hard because I am not a “sound bite” guy. How do you focus on a topic as complex as healthcare reform in a sound bite? But I have focused on stories and hope that they will stick better than sound bites.

How has being a candidate affected your work as a physician and educator at UC Davis?

I took a leave of absence from UC Davis at the end of June to focus on the race. The medical school has been supportive but as an apolitical organization, they cannot overtly support me.

The students are mostly aware that I am running. I would love to get the students more engaged in the race because I think it is a unique opportunity. But I am very conscious not to push myself on them. I will be teaching periodically, but am largely removing myself from the medical school’s daily activities.

How have your wife and daughter responded to your candidacy?

When I first verbalized my idea to run this past December and January, Janine, my wife, was in disbelief. But after she realized I was serious, she raised questions about how it would impact our family. Would we have to move to Washington, D.C.? To split time between two locations? She did not embrace it at first, but as she has seen it unfold she is in it with me to win. Janine is my best asset and I expect that as we get busier she will represent the campaign at events.

My daughter just started 7th grade, so she does not fully grasp the implications of my candidacy yet. As we get further along we will have lots to talk about and some big decisions to make if I win. In the end I am most concerned about being authentic and running as hard as I can. If I do that and I lose, it is okay. But I am not willing to compromise my self, my values, or my family to win.

Have you always had an interest in politics?

Most of the people in my life who have known me well are not surprised that I am running. I have always been engaged in politics, mostly focused on the politics of change and how to move forward on issues that I care about. My mom would say that I was a pain as a child, always questioning and exploring new ways of doing things. I was very fortunate to grow up in a family that allowed exploration and offered safety and support whenever I fell down.

How have the positions that you have held in the past helped to prepare you for elected office?

My experiences as a physician have given me perspective on all aspects of healthcare delivery. My life has unfolded unexpectedly and I have taken opportunities as they have presented themselves. As chief resident I realized I was interested in working on systems issues. After residency I spent four years in practice at the county medical clinic and as the medical director of care management for the five hospital Mercy system. This experience allowed me to focus on systems issues and way to increase efficiency in care delivery.

I then served as the Chief Medical Officer for Sacramento County and worked on ways to increase coverage for the uninsured. I was then offered the opportunity to look at how we train the next generation of physicians by serving as the Associate Dean of Admissions at the UC Davis School of Medicine. While I never planned to set up these experiences, they have built upon each other and given me a very unique perspective on healthcare.

Tell me more about the program you started to increase coverage for the uninsured.

Using two million dollars from the county and one million from the federal government, we created a program called SacAdvantage that targeted low wage workers and small businesses with two to fifty employees that had not previously offered health insurance. It was built on the employer-based model of care and provided a subsidy from the county to make it affordable for small businesses to cover their employees.

The main problem I see with it now is that it still ties coverage to employers and people could lose coverage if they moved to another state or changed jobs. I now favor offering all Americans a compassionate baseline of health care that is not tied to employers. Additional coverage could then be provided by employers or purchased by individuals.

What do you see health professionals being able to bring to elected office?

All of the training that we have will help us in politics. What makes a good doctor—having compassion, good listening ability, the ability to make hard decisions quickly, and leadership skills—are all essential in politics. As physicians we have a particular ability to articulate the story of healthcare in this country. If voters ask me about “death panels” at a townhall I can tell them about what happens in the ICU regarding end-of-life issues. I find it embarrassing how silent physicians are given that we are held in high esteem by many. As a group physicians need to step up to the plate on healthcare.

If health professional students have interests in politics what do you advise they do to pursue a career in this realm?

I think it is most important for students to discover their passions and what is most important to them. Too often students look decades into the future and try to plan out every step of their career. But it is better to focus on the present than to try to be calculating. Look at what you are passionate about today and work on issues within your sphere of influence, for example resident work hours. It takes courage to address these issues and the skills you build will help if you choose to run for office later. You will learn by doing.

It is also important to know your strengths and weaknesses. Embrace your flaws and your ignorance. That way you will know when to delegate tasks and to let others with greater knowledge take over for you.

How can health professionals with limited time get involved in politics?

I would advise that they find a local organization that does work on an issue that they really care about. Focus on finding one project that can be done to really make an impact. The skills that one builds working at the local level are the same ones that are used in elected office. In politics there is just a bigger stage.

References

1. “Doctors on Hill seek voice in reform debate”, June 15, 2009, AMEDNEWS.com, http://www.ama-assn.org/amednews/200…5/gvl20615.htm

2. http://www.ama-assn.org/amednews/200…3/gvsa0223.htm

3. http://www.beraforcongress.com/, http://www.trivediforcongress.com/, http://www.jayfleitman.com/,  http://wargotzforussenate.org/

Dr. Al Berg

by William Burnett

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding that science is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health. 

Dr. Conrad Fischer

Despite the growing number of scientific advances over recent years, the ability of doctors to cure or deal with diseases that were fatal not ten years ago, and heightened recognition by patients for those in the medical profession, a study conducted by Dr. Conrad Fischer suggested that many in the medical field were highly dissatisfied with their careers. Armed with these alarming results, Dr. Fischer set out to let everyone know that now is an exciting era in medical history and, quite possibly, the best time to be in medicine. The result is his book, Routine Miracles.

Dr. Conrad Fischer, author of Routine Miracles, is an infectious diseases specialist and a prolific teacher of medicine; he has published twelve books for the medical community. He is also an influential medical advocate. He was instrumental in the construction and passage of legislation that led to the near eradication of pediatric AIDS in the United States. He was formerly the Associate Chief of Medicine for Educational and Academic Activities at SUNY Downstate School of Medicine. He has been Chairman of Medicine for Kaplan Medical since 1999, and has held Residency Program Director positions at both Maimonides Medical Center and Flushing Hospital in New York City. He lives in New York City with his two boys.

Dr. Fischer recently sat down to talk to the Student Doctor Network about his research.

Please explain a little about your research for Routine Miracles and what surprised you the most?

There is an enormous disconnect between patients who feel the “miraculous” nature of what they receive in terms of treatments and a near-numb “routineness” of flat emotionality from doctors.  I can’t help but feel the root of the problem stems from our own medical school faculty and senior physicians poisoning the minds of medical students.  In our own research data it shows that 80% of medical students feel that medicine was better 25 years ago and that the public does not trust them. They identify senior physicians and faculty as the source of this impression. So, our best role models for a life of practicing medicine, and pursuing a life of investigation turn out to be the most damaging influence of all.

Why is this the best time to be practicing medicine and why is it the worst time?

Treatment is the best it has ever been by far.  We now have brain operated artificial limbs, hearing restoration, cancer cures, corneal transplants in four minutes, and cures that seemed like science fiction a few years ago.  It is hard to write good science fiction because the facts catch up so fast. Paradoxically, a recent study showed that more than 90% of primary care doctors are dissatisfied.  There is an unprecedented level of demoralization at a time when we can heal people in so many amazing new ways.  The worst news is that our freshest and newest members, students, interns and residents firmly believe medicine was better before and we are devolving as a profession.  They are not motivated to follow a life of investigation that will give us the next generation of scientific and medical breakthroughs.

You work with students every week. How are they different from you and your colleagues 20 years ago?

Students and especially residents are less cynical, less sarcastic and more professional than they were 20 years ago.  This is because of the mandatory decrease in resident work hours. You couldn’t possibly expect the same energy and compassion when you were up for 36 hours straight.  Now residents rest a little and you are kinder, warmer, and not burnt out and cynical.  Most MDs do not see this.  They look down on new students telling them it was better before.

Students on the other hand seem more concerned with personal economic issues.  They think the sky is falling in medicine, so they should find a nice high paying subspecialty to hide in.  There is virtually NO drive to consider careers of investigation that might lead to new cures.  So, you have nicer and kinder people taking care of patients, but who rarely question how they might find a cure.  In 20 years I predict the rate of medical advancement will be dramatically diminished.

In your opinion what three things need to happen quickly to help fix our healthcare system?

1. Universal coverage
2. Doubling of the research budget at National Institutes of Health
3. Decrease or supplement the cost of Medical education so that students choose a future that is not based on income potential or concerns about paying off student loans.

Why are you such a fervent advocate of universal health insurance coverage for all U.S. citizens?  How do you respond to arguments against—and fears surrounding—implementing a system of socialized medicine?

First off, universal coverage is just the right thing to do. I think the concern about financing is ludicrous. We did not worry about financing when the military budget went from 350 billion to 750 billion, which is considerably in excess of the amount needed for healthcare reform.

“Socialized medicine” is a scary word to frighten ignorant people. We have Medicare as a government run system as the largest insurer in the country. We have the veteran’s hospitals as the largest system in the country and it all works well.

Doctors are scared for their paychecks. Other people are, frankly, just unconcerned with people who will be sick if they think they have to pay for it.

If we are to live in a Great Civilization, we MUST take care of all our citizens, Period.

Routine Miracles

As you stress in Routine Miracles, young doctors are frequently weighed down by hundreds of thousands of dollars in student loan debt.  What would you change about how we finance medical school education?

I would subsidize the medical schools to lower tuition and I would add trading a year of tuition for every year you spend in a lab during research. We do it for the military, why not for research?

It only costs about $2.4 billion a year for EVERY student in the country.  That is about what we paid for ‘cash for clunkers’ car program.

What is your relationship with insurance companies like?

This is the only thing that 95% of MDs and students agree on – it is HORRIBLE!  If I had to deal with insurance companies full time, I would drop out of medicine.  I also find it unconscionable that while facilities are closing because of budget gaps, the CEO of Aetna insurance is getting a 32 million dollar salary.

What do you hope people will take away from reading Routine Miracles?

Unless we take better care of the emotional well being of our best and brightest students and trainees, in terms of seeing the grandeur of finding new cures and treatment, the amazing advancement in medicine will screech to a near stop.   There is action to take here. It is about fixing the disconnect between breakthroughs and the complete lack of excitement and engagement of the “Best and Brightest” new doctors.  Routine Miracles is about how, in an age of extraordinary advances, we need to get our students into the lab and in a life of investigation and discovery.  If we don’t do this now, the future will be a lot less bright.

Dr. Talya Miron-Shatz

Talya Miron-Shatz, PhD, is a decision scientist, studying the way people interpret medical information. She teaches consumer behavior at Wharton and is a keen public speaker, advocating the importance of understanding the psychological aspects of medical decision making.

She recently sat down to speak with SDN about how consumers and health care providers make medical decisions.

What is decision science, and how does it apply to health care decisions that consumers make?

Imagine you are designing a sticker promoting flossing. Should you say, “Flossing helps you prevent gum disease,” or should you emphasize the loss of protection that results from neglecting to floss? It turns out that people are more motivated to act when something they have is about to be taken away from them. So, when you’re in the bathroom at night, being aware of the potential risks to your gums might prompt you to dedicate a few extra minutes to the fine art of flossing. This, in a nutshell, is what decision science is about.

Decision scientists make sense of people’s judgment and decisions, even when these seem random, erroneous or irrational. Decision science was developed by Amos Tversky and Daniel Kahneman, Nobel Laureate of Economics, 2002, with whom I had the honor of working closely at Princeton University. This science draws on psychology and, rather than concluding that people are unpredictable, or just plain dumb, helps explain their behavior.

A really cool thing that decision science does is that it incorporates emotions into the equations. After all, the facts don’t change in the flossing example – what matters is how the information is presented. We show that the way alternatives are presented often dictates, or at least influences, how people feel and the choices they make.

Does this apply to every medical setting?

I always tell my students that there is no such thing as a neutral way of presenting information. The beauty of decision science is that the principles apply across the board, even where you least suspect it.

Consider an expectant mother who arrives at a prenatal clinic. The genetic counselor presents her with a list of the available screening tests for the fetus. Some tests are standard at the clinic, while others need to be specifically opted into. This varies across clinics. When a woman receives a list of, say, seven standard tests and five optional ones, adding the optional tests seems unnecessary, perhaps even overly anxious.

Now consider an expectant mother who arrives at a clinic where all 12 tests are standard, and the counselor tells her she can opt out of five of them. Opting out feels different from opting in. The woman may feel that by neglecting to take some of the tests, she is jeopardizing her unborn child. Thus, she will keep all 12 tests.

Most people tend to stick with the standard option or the default, which means that medical students need to be mindful of what they set as the standard.

What trends do you see in health care decisions by consumers that will impact current health professional students?

The emerging trend is patient autonomy – delegation of choice and decision to patients.  The premise is that, given sufficient information, patients will make the health choices that are best for them. This shift poses a huge challenge to doctors, who are trained to treat patients but not to explain treatment options in a way that patients will easily comprehend. Medical students and residents seldom receive training on these types of communication skills.

Nowadays patients have access to online medical information. Does this make a provider’s work any easier?

You would think that greater availability of information should relieve some of the burden off of doctors’ shoulders, but such is not always the case. Medical information is often presented in a way that is confusing and hard to grasp. Probabilities, which are key in risk evaluation, are a particularly tricky concept.

I showed people text from reputable websites that supposedly cater to a wide audience. It is distressing that fifty percent of the participants misinterpreted what lifetime risk probability means – and this concept is broadly applied.

I also inquired about a test for the BRCA 1 or BRCA 2 gene mutations, associated with increased risk of breast cancer. Half the participants knew that the test could not tell them with certainty whether they will develop breast cancer. Yet about a third of the participants expected this kind of certainty from the test. Just imagine how misguided they were.

Doctors cannot assume that their patients are in the know just because there’s more information out there.

Don’t issues of misunderstanding apply only to certain patients?

People with low numeric skills and low health literacy are more prone to misunderstandings. However, doctors are not so good at detecting patients with low health literacy. Moreover, patients are good at hiding their bafflement, because it is embarrassing to tell your doctor you do not know what he or she is talking about.

Recently I heard about a man who had a prostatectomy. Before the surgery the doctor said, “You are going to be impotent,” to which the man replied, “It’s ok. I already have children.” The doctor had assumed that “impotent” is a common term.

The same thing happens when a doctor explains how to titrate medication. The patient nods, then returns weeks later having never increased the dosage.

Are doctors and medical students themselves immune to miscomprehensions and judgment biases?

Not quite.  In one of the most inventive studies, conducted by Gerd Gigerenzer and his colleagues, a healthy heterosexual white male went to a few dozen doctors’ appointments with a positive HIV test result. Almost all of the doctors told him he had HIV. Only a minority remembered that the test is not 100% diagnostic, that there is a 1:10,000 chance of a false positive result. Various ways of presenting probabilities and risk information help medical students and doctors understand those concepts.

How did you become involved in medical decision making?

I was a grad student in psychology, studying decision science, when the mission of making medical information comprehensible snuck up on me.  One of my professors asked if I might be interested in teaching a decision making course to Masters’ students of genetic counseling. I accepted, then realized I had no idea what knowledge would most benefit my future students.  So I sat in on genetic consultations.

I will never forget the first couple I encountered. The father was albino, and both parents were hearing impaired, so they were accompanied by an interpreter. They also brought their two year old, for want of a babysitter. The wife was pregnant, and the couple wanted to know what to expect from the newborn – what were the chances that he or she would also lack pigmentation and/or be deaf. They just wanted to know. They were also curious as to whose “fault” the baby’s condition would be, mom or dad. It mattered to the mother-in-law, who constantly blamed the husband for the first child’s lack of hearing.

The genetic counselor was just the kind of health expert you would want to meet – highly professional, well-prepared, and very caring. She spread out the charts of paternal and maternal heritage, then methodically explained how genetics worked, starting with chromosomes and genes.

None of this was redundant for me despite my education. I did not major in science and had not taken a biology class since, I believe, the 9th or 10th grade – it had been quite a while. Remembering which was the bigger unit, chromosome or gene, was not easy. I had to dig in my memory to figure out that there were 23 pairs of chromosomes and, well, lots of genes.

Meanwhile, the counselor was explaining this to the translator, who would explain it all to the couple. The interpreter seemed no less bewildered than I was. Information just kept coming in, which had to be conveyed to the couple through sign language. I could not help but wonder what they would say if we asked them to translate back what they’ve just been told.

The couple was physically there, but they were not really listening, and it wasn’t because they required hearing aids. They had gotten lost fairly early. You could see it in their faces. Chromosomes, genes, dominant, recessive – lots of terms, but not a lot of meaning.

Of course, the confusion had nothing to do with being hearing-impaired or albino. It had everything to do with being a patient. For all my fancy graduate training, I don’t think I would have fared any better than they did. The added layer of concern for the baby certainly did not make things easier.

Knowledge doesn’t just pour out of the medical system and into the patients’ minds, I realized. It has to be understood, processed, and dealt with emotionally. It was the counselor’s job to explain and the patient’s job to get it. Leaving the medical center that day, I still thought I was just going to teach decision making to genetic counselors. I did not realize that making medical information comprehensible was going to take over my interests to become my vocation. I did not realize it just then, but that was when my mission began.

For more information on medical decision making, please visit “Baffled by Numbers”, Dr. Miron-Shatz’s blog published on the Psychology Today website:

http://www.psychologytoday.com/blog/baffled-numbers

“Boutique” or “retainer” medical practices have been steadily growing since 2005.  In this practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. (1)

While it is growing in popularity, some physicians, ethicists, and policy makers are concerned about the trend. (2)

“Concierge care…is like a new country club for the rich,” Representative Pete Stark, Democrat of California, said at an economic committee hearing to Congress in April 2004. “The wealthy will pay for exclusive access to quality care, and everyone else will continue to have inferior access to primary care physicians, specialists, and basic medical advice.” (3)

Proponents of concierge medicine, on the other hand, say that it enables doctors to provide the best possible care and remain in a clinical setting.  Dr. Bernard Kaminetsky, an internal medicine physician in Florida, told the New York Times he would be working for a pharmaceutical company if he hadn’t been able to move to a concierge model.  “I’m really helping a lot of people.  I feel good about what I do,” he stated. (2)

To learn more about this growing trend, the Student Doctor Network spoke with Arney Benson of SignatureMD located in Santa Monica, California.  SignatureMD helps primary care physicians transition their practice to a retainer medicine model.  He is a graduate of the Massachusetts College of Pharmacy & Allied Health, and has over 25 years of healthcare consulting experience. He currently serves as President of AB Consulting and Senior Vice-President for Physician Development for SignatureMD.

How do you define “concierge” or “retainer medicine”?

Retainer medicine, sometimes referred to as “concierge” or “boutique” medicine, is a different type of care delivery experience in which physicians limit the size of their patient panel in order to provide more proactive health care services and greater convenience and access to their patients.  Patients pay a defined fee to experience this type of care, the specifics of which vary among physician practices.

How do retainer practices fit into the current health care structure (i.e., Medicare, insurance companies, etc.)?

A retainer practice focuses on patients in a proactive continuum of care.  You get to know your patients well and help them to coordinate their healthcare.  Instead of building your practice up to a panel with thousands of patients, you will have a panel between 300-500 patients.  While you can still accept insurance, you will also assess a yearly membership fee from your patients.

This retainer model typically requires fewer supporting personnel because of the lower patient load.  Therefore, you will have fewer patients and fewer staff to manage.

The retainer practice also offers a different service level that might include cell phone and/or e-mail access, same day appointments, longer physicals and routine appointments, coordination with fitness and nutrition providers and 24/7 access.

However, any practice continuing to participate in insurance plans must take into consideration the view of retainer fees by those insurance providers.  When the legality of retainer medicine comes into question, it’s typically because an insurance provider has a provision that does not allow the patient to be billed a fee for such management.  It is wise to work with a team of legal advisors, or a company like SignatureMD, to mitigate your risk.

One needs to always remember that a retainer fee is for non-covered services. If you stick to that, there should be no added issues for the current carriers.

Arney Benson

What do you see as the benefits of the retainer medicine model for patients?

Many patients complain today that by the time they get in to see their primary care physician, they have 10 to 15 minutes to explain their concerns before the physician is exiting the exam room.  Your patients need a relationship and a physician that knows them and thinks about the bigger picture.  A retainer practice allows for more time and more questioning.  A retainer practices focuses on prevention and the overall continuum of care.  Many physicians who practice in this manner also include their patient in the process in a more educational manner so they work on wellness plans together and discuss options in an informed (and un-rushed) manner.  If you were the patient, wouldn’t this type of care be what you prefer?

What do you see as the benefits of the retainer medicine model for physicians?

Here are the benefits we find:

• Increased income
• More time to spend with patients:  This increased time available to spend with each patient will allow you to address all of their problems, rather than just one or two. It also gives you the luxury of having the time to truly explain their diagnosis and treatment, which will enhance the patient’s trust, education, compliance, and satisfaction.
• More compliant patients
• Patients who value and respect their physician
• Less time at the office

Our company, and others like it, also provide help with practice management, such as:

• Secure online electronic medical records (EMR)
• Ongoing patient marketing
• Help with business operations
• Help with regulatory and legal issues

What types of personalities enjoy a retainer practice versus a more traditional structure – do your doctors tend to be more entrepreneurial, for example?

Not necessarily more entrepreneurial … but what that physician is: a forward thinking healthcare service provider that wants to deliver a quality of care model, and not the run of the mill reimbursement model (which is) stealing the only commodity necessary to function well in medicine, and that is the time factor.

The typical physician, if there is such a thing, that would do well has to have a driving force to change the status quo and deliver the kind of medicine and diagnostics as he or she sees fit and not be buried under the bureaucracy of the reimbursement model of short time diagnostics and paperwork equal to the time, and sometime more, than the treatments the physician delivers.

Is this a model that a physician could enter immediately out of residency?

Typically no. However, one could start a retainer practice, advertise the concept and build it from there. Realistically, that would take the better part of 24 months to 36 months to get to a reasonable patient enrollment to support the overhead of an office and earn a living. However, a better suggestion would be to seek out a retainer medical clinic for employment to build a relationship with patients so in 3-5 years, once your “affinity” relationship is such to support a retainer model, you can consider a boutique or concierge model.  By the affinity relationship I mean, would the patient be willing to pay a retainer to keep you as their primary care physician.  We find that a good professional relationship takes between 3 to 5 years to establish.

How would you anticipate retainer medicine changing if universal healthcare is implemented?

I think that’s it’s not a matter of if universal healthcare were to be implemented but a matter of when.

That being said, the retainer practice model will continue to gain popularity, as it has, as an example, in Massachusetts where healthcare for all has been implemented for the last two years. The reasons are many, but the driving force for many patients is that they are already frustrated with the existing system, including the wait times and care they receive from a 5 to 10 minute appointment.

The system will be a tiered system where everyone will have healthcare and those that wish a different service offering will seek out an alternatives, i.e. retainer model or a different delivery option for their primary healthcare needs.

Footnotes:

1)    Jeff Levine, “Boutique Medicine: For Your Well-Being?  Or the Doctor’s?”, AARP Bulletin Today, April 18, 2008 (http://bulletin.aarp.org/yourhealth/policy/articles/boutique_medicine.html)

2)    Abigail Zuger, “For a Retainer, Lavish Care by ‘Boutique Doctors’”, New York Times, October 30, 2005 (http://www.nytimes.com/2005/10/30/health/30patient.html)

3)    Congress of the United States – Joint Economic Committee Hearing, Opening Statement, Representative Pete Stark, April 28, 2004 (http://www.jec.senate.gov/archive/Documents/Releases/starkopenstate28april2004.pdf)

As an active member and advisor on the Student Doctor Network forums, I’ve received countless questions from medical students (and recent graduates) about jobs and opportunities in the non-clinical world of medicine. There are many medical students who are seriously asking themselves whether clinical medicine is really the “right fit” and they want to learn more about the various types of non-clinical opportunities available. Some may choose radiology or pathology to avoid patient contact. Others pursue non-clinical jobs in healthcare industries that avoid the clinical setting completely.

Why Consider Non-Clinical Options?

Why look at non-clinical opportunities?  Some medical students were pressured into attending medical school. I personally know some who went to medical school because it was an expectation while they were growing up. Now, they’re looking for other opportunities because they never really wanted to pursue a medical career.

Do you see yourself enjoying a lifelong career in medicine based on your unique strengths, talents, interests, and personal qualities? Some may feel like they’re stuck in medicine because they can’t imagine any other type of career. After all, where can you go to learn about non-clinical opportunities? Plus, if you have significant student loans, then you may feel like you have to find a high-paying job so you can make loan payments and still survive.

Additionally, academia tends to look down on non-clinical opportunities.  When I was a medical student, one of our attending physicians left the world of academia to work for a pharmaceutical company. This individual was criticized by others for moving over to the “dark side.” You’ve probably heard that euphemism before, even if you’ve never watched Star Wars.

Residency and Non-Clinical Jobs

Let me start with the most common question I get from medical students who don’t see themselves practicing medicine: “Should I do a residency?” Residents often ask: “Should I complete my residency?”

I generally try to encourage every medical student to pursue residency because I’ve found that physicians have many more non-clinical opportunities if they complete a residency and become board certified in a specialty. At a minimum, complete an internship so that you can gain some clinical experience. This way, you won’t look back and wonder “what if I had done a residency?”

I realize that some students are completely convinced that they want to get out of medicine. They have no plans of pursuing a residency. As a result, they often approach me with questions about non-clinical opportunities for medical school graduates who lack residency experience.

In this article, I will focus on opportunities in the world of medical writing.

Medical Writing 101

What is medical writing? This field is so broad that I could write several articles about it. In a nutshell, the world of medical writing can be many things at once. It can be: flexible, lucrative, enjoyable, boring, stressful, and mundane. If you’re confused, you should be. Most people don’t understand what medical writers do.

If you enjoy writing and you consider yourself to be a strong writer, then you may wish to pursue this career.  I recommend starting by joining the American Medical Writers Association (AMWA) and learning more about the field of medical writing. Keep in mind that most medical writers are not physicians. However, physicians make some of the strongest medical writers, especially when it comes to projects that involve a heavy amount of clinical science and first-hand patient experience.

Allow me to expand on this a bit further by providing you with a few examples of medical writing opportunities.

• Professional medical communications and medical education: There are many small, medium, and large companies that focus on medical communications. Some are large print publishers. Others like WebMD are mainly online publishers. There are also many private companies that develop medical education activities. It’s important to clearly delineate between promotional medical education and certified medical education.
  • Promotional medical education: This is also commonly known as marketing, but promotional sounds better though, doesn’t it? This ranges from content presented at promotional “dinner meetings” (which are not occurring as frequently due to budgetary constraints), journal advertisements, to direct-to-consumer (DTC) television advertisements. Companies may be called “promotional medical education companies” or even “ad agencies.” Publishers also get involved in this space.
  • Certified medical education, also called Continuing Medical Education or CME: In the past, CME was a loose term that people threw around when they were talking about any type of formal or informal education that took place after residency completion. Today, CME specifically refers to certified education that meets the criteria set forth by the ACCME (Accreditation Council for Continuing Medical Education). CME dinner meetings still occur and they are clearly labeled “CME” or even “certified CME.” Private companies that develop CME activities are not allowed to develop promotional activities. The only exception to that rule applies to entities that declare themselves to be “publishers.” You’ll still find CME in medical journals like JAMA along with full-page drug advertisements (but they won’t be on the same pages as the CME activity). Universities and professional medical societies produce a large amount of CME, so you may find some opportunities there as well.
• Consumer-level health education: WebMD is well-known for educating patients about health topics. These types of companies rely on medical writers and reviewers for content that is written on a consumer level. This can sometimes mean a fourth to sixth grade reading level. There are many other companies that offer similar services and most jobs in this area would fall under the “medical writing” category.
• Clinical research: Research opportunities for medical school graduates are abundant in university settings. In fact, this is how many foreign medical graduates enter the U.S. if they are unable to secure a residency. Research can obviously also occur in academia or in government institutions. Be prepared to write grants, research papers, abstracts, posters, and more. You can also find opportunities within Contract Research Organizations (also known as CROs). Medical writing in the world of research often involves regulatory writing, drug safety reports, protocols, etc. Once you gain some experience in this space, you may have the chance to work in pharma/biotech.
• Freelance/contract medical writing: Many successful medical writers work from home or telecommute. In fact, a large number of writers have a busy freelance business that keeps them busy all-year long. The nice thing about freelancing is that it gives you tremendous flexibility. The major downside is the potential for unsteady income. However, if you want to work on various types of writing projects, you may enjoy the life of a freelance writer.
• Market research and survey writing: I actually meet medical students who don’t know what the term “market research” means, so if you happen to be one of them, you’re not alone. These types of students typically have no business training prior to medical school. Market research is often performed through surveys that are written by clinicians or medical writers. If you have an analytical mind, then you may enjoy writing market research survey questions and analyzing the data for marketing purposes.
• Medical blogging: Yes, you can be hired to write for medical blogs (or even non-medical blogs). You don’t have to be a professional writer, but it helps if you have a unique communication style. You may have read the NY Times article about a nephrologist who left clinical medicine to go into full-time blogging (about Apple rumors).

Other Non-Clinical Opportunities

If you don’t enjoy writing, then keep in mind that there are other non-clinical opportunities in industries such as public health, venture capital, executive search, health information technology, public health, consulting, pharma/biotech, and more. You can learn more about these types of opportunities by visiting www.NonClinicalJobs.com.

Preparing For Non-Clinical Work

Finally, let me provide a few tips for those medical students who don’t plan to go into residency (or if you’re thinking about quitting in the middle of your residency – which I do not recommend to anyone):

• It’s critical that you grow your social network if you plan to look for non-clinical jobs immediately upon graduation. This may be the most important step in determining what type of position you land.
• Connect with executive recruiters. You may have heard of them as “head hunters.” These individuals can be very helpful in providing you with job leads and they are eager to help you. They shouldn’t charge you anything since they get their commission from the hiring company.
• There are many positions that may be considered “springboard” jobs. In essence, these jobs will provide you with the necessary corporate experience to then “jump” you into another career or industry. You may gain tremendous experience by working in a “springboard” position for 2-3 years before making a major move. Consider the gains if you’re willing to make such a sacrifice (sounds like residency).
• As you work in the non-clinical setting, you’ll meet more and more people who may become invaluable leads and contacts for the future. Continue to grow and maintain your social network because you never know when you may to find a new job.
• Enhance your computer and technical skills. You’ll be expected to be very proficient and productive on the computer. You’ll be working in Microsoft Outlook, Word, Excel, and PowerPoint. You probably won’t carry a pager, but you may be expected to use a mobile e-mail device like a smartphone.

Have specific questions? I’m a volunteer advisor on the SDN forums and I welcome your questions and comments. Please note that this article is not meant to discourage medical students from pursuing a career in clinical medicine. This article is also not meant to encourage residents to leave residency. Rather, the purpose of this article is to provide some education about non-clinical options so that students can make informed decisions about their career path.

About Joseph Kim, MD, MPH

Dr. Joseph Kim is an active physician blogger and he blogs daily about non-clinical issues at www.NonClinicalJobs.com. He is a strong proponent of strategic social networking and he has used his personal network in various situations to help people find non-clinical opportunities in different healthcare industries.

by Laura Turner
SDN Staff Writer

U.S. health care reform is shaping up to be a key activity for lawmakers in 2009. The Obama administration is mobilizing its volunteer base from the campaign to lobby Congress for change. Politicians on both sides of the spectrum are putting forth their vision for the future of medicine.

In order to provide our membership of future health care providers with the latest reform ideas, the Student Doctor Network will be publishing a series of articles on health care policy. These articles will include interviews from policy makers and details on technical and structural innovations aimed at reducing costs and improving outcomes.

Previously, SDN interviewed Dr. John Geyman, author of Do Not Resuscitate, who espoused a need for a single payer nationalized health care system.

Additional articles in the series, to be published in the coming months, will include the following:

• Interview with Dr. David Sundwall, who served as President Reagan’s Director of the Health Resources and Services Administration at the U. S. Department of Health and Human Services
• The role of health information exchanges in improving health care delivery

We invite our membership to submit ideas for other articles in this area. Please provide your comments below.

Setting the Goal:  A Journey Toward Innovation in Medicine

The Student Doctor Network is pleased to announce the following online presentation to our membership:

Dr. Maria Siemionow

Kaplan Publishing in conjunction with Kaplan Medical is proud to present an evening with Dr. Maria Siemionow, a medical pioneer in facial transplant surgery.

When Dr. Siemionow announced in December 2005 that she had been granted approval to perform this revolutionary surgery, she was bombarded with media attention and moving requests from people wanting to know who would be eligible for the operation. In December 2008, it was announced that she had completed the nation’s first face transplant.

Please join us for an evening with Dr. Siemionow as she discusses her journey toward innovation in the medical field through setting goals and determination.

Event Information

Date: June 3, 2009
Time: 7:00 p.m. EST

This event will take place exclusively online. Registration for this event is mandatory.  Click to register:http://kaptest.acrobat.com/face_to_face/event/registration.html

Special Offer: The first fifty registrants will receive a free copy of Dr. Siemionow’s upcoming book Face to Face: My Quest to Perform the First Full Face Transplant.

About Dr. Siemionow

Maria Siemionow, MD, PhD, was awarded her medical degree by Poznan University of Medical Sciences in 1974, after which she completed her residency in orthopedics, and then earned a PhD in microsurgery. In 1985, she completed a hand surgery fellowship at the Christine Kleinert Institute for Hand and Microsurgery in Louisville, Kentucky.

Today she is director of Plastic Surgery Research and the head of Microsurgery Training in the Plastic Surgery Department of Cleveland Clinic. She is on staff at the Clinic’s Transplantation Center and in the orthopedic surgery and immunology departments. For her research on facial transplant, she received the 2004 and 2007 James Barrett Brown Awards from the American Association of Plastic Surgeons. Dr. Siemionow has been featured in the media including ABC News, CNN, BBC and the New York Times.

In this election season, healthcare has been an increasingly pressing issue for American voters.

In an August 2008 TNS Healthcare survey, nearly 60% of voters age 18-29, and 75% of voters over the age of 65 agreed that healthcare issues would play a major role in their presidential election choice.

The feeling that our current system is a “failure” predominates, and thus healthcare reform is seen by many as a mandate for the new president.

Healthcare professionals must understand the issues involved in the politics of health in order to move towards reform – and that brings us to one of the most contentious issues, that of single payer healthcare.

A single payer system would clearly be a radical change. In the current system, private insurance companies independently negotiate payments with healthcare providers, which are different than the payments made by government programs like Medicare and Medicaid. These, in turn, are different than the payments that a patient would make out of pocket if uninsured. This system has made the costs of healthcare services seem mysterious and fluid in nature, numbers drawn out of a hat.

Those from the left side of the political spectrum tend to advocate single payer systems as a curative solution for this bureaucratic nightmare, pointing out that eliminating complex billing and administrative procedures from healthcare offices and centers would be a huge cost-saver and tool for simplification. Those who approach the issue from the right tend to advocate transparency in billing as a free market approach to the problem, reasoning that if patients were able to act as customers of a healthcare business, they could then shop around for lower cost services and understand far more clearly the actual cost versus benefit equation for proposed therapies.

There are major challenges to both these views. For example, though a single payer system might be able to greatly reduce healthcare costs through elimination of complex billing procedures, many suspect that it could just as easily reduce healthcare costs through reducing payments to physicians and other providers. Medical professionals, already angered by the inability of Medicare to cover the costs of patient care, are understandably fearful of the idea of governmental disbursement of all patient care costs.

Though Medicare is efficient in terms of administration and billing, it is often accused of reducing access to healthcare. Many doctors already have stopped taking Medicare patients in their practices, and more are poised to do the same. In fact, the AMA has estimated that 60% of physicians would limit their Medicare patients if the payment cuts continued. The current political situation is that there will be a meager 1.1% raise in payments in January 2009, which seems unlikely to keep pace with inflation. Since the underlying formula that directs payment increases and cuts has not been corrected, a 20% cut is pending for 2010. The Medicare and Medicaid programs already cover a third of Americans, and with costs on the rise, they already consume 40% of our federal budget. Single payer is often referred to as “Medicare for all” – clearly not a thrilling prospect considering the challenges the program has faced.

To look critically at the conservative viewpoint, it is difficult to see how a free market philosophy could be easily applied to the healthcare industry. After all, sick patients are often not in a position to shop for the cheapest care. A patient often is geographically limited in terms of the healthcare facilities that are available. And a patient who chooses to “save” by shunning preventative healthcare or by avoiding purchasing health insurance can drive up costs for others by then incurring an avalanche of unpaid costs when disaster strikes. Thus the idea that we can exist as independent healthcare consumers is a bit misleading, since in fact we may have an interest in keeping our neighbors healthy.

So what is single payer, specifically? Conservatives who disapprove of increased government intervention into healthcare often refer to single payer as socialist. As Michael Moore pointed out in the documentary “Sicko,” common public institutions such as police departments and libraries are more truly socialist than a single payer healthcare system because they are not only government financed, they are also government run. But they don’t generate the same amount of controversy. Some countries, such as Cuba, have a socialist healthcare system run by the government. Single payer specifically refers to a system that is paid for by one entity, generally understood to be the government, but does not specify how the healthcare system is run. A proposal in the United States for the government to run all hospitals and medical offices seems unlikely to meet with success.

Even single payer itself seems less than mainstream. Democratic presidential candidate Barack Obama does not have it as part of his platform (he has stated, though, that he would support single payer for building a healthcare system “from scratch”). But if single payer healthcare becomes a reality, strict accountability and quality measures will be crucial to track how taxpayer money is being spent.

Single payer is gaining popularity as a concept. A 2003 Pew poll found that 72 percent of Americans favored government-guaranteed health insurance for all. Whether it could realistically be successful in the United States, where employer-based, private health insurance is an entrenched concept, is another question. Look for increasing debate on the pros and cons of single payer as healthcare reform looms as a legislative priority.