Pop Quiz: You’ve just been in a car accident, or been diagnosed with cancer, or struck by lightning, or you’re coming to your doctor’s office as sick as a dog with something you got last week and you haven’t been able to keep anything down for the past 48 hours. What’s your top priority with respect to what you want your doctors to know? Do you want her to be: (a) culturally sensitive; (b) financially aware; or (c) know how to fix you? If you answered (c), you’re clearly behind the times.
One of the strangest things about efforts to “reform” the U.S. healthcare system is how easily people seem to forget the purpose of the whole endeavor. For example, based upon the key provisions of the Affordable Care Act (aka, “ObamaCare”), one could easily conclude that the purpose of the healthcare system is to provide health insurance coverage, even if that coverage is as inherently defective and unsustainable as Medicaid. At least one self-described “liberal” blog has accused “right-wingers” of thinking that:
“The purpose of a health care system is to support a profitable health care industry. For example, regulations that mandate insurance companies insure people with pre-existing conditions are bad, because they are bad for business.
On the other hand, if your underlying assumption is that the purpose of a health care system is to provide health care to people who need it, you must be a liberal.”
Unspecified in the “liberal” definition are, of course, many details including what one can or should define as “health care”, whether one person should be required to pay for the care of another, or how many healthcare goods and services any individual should be entitled to.
But these are simply a couple of exhibits that demonstrate that our national discussion of healthcare “reform” is increasingly missing the point. The real purpose of any healthcare system can and should be getting patients and physicians and other clinicians together in an effort to impose chemical, structural and biological changes that will result in better, longer lives for the patients affected. The inimitable Dr. Rich produced a good and purposeful definition in the course of writing his first book on the subject:
“The purpose of healthcare services [i.e., the healthcare system] is to maintain or restore the individual’s health when possible or to optimize functional capacity, control symptoms, and compensate for restrictions when a disease or disability cannot be cured or prevented.”
In other words, the single most important purpose of any healthcare system can and should be to minimize the ravages that nature would otherwise impose upon our bodies and lives. Most notably you can’t fight nature with insurance, you can’t fight it with profits, and you can’t even fight it with the utmost in empathy, cultural awareness and good intentions. At its very core one can only fight the infirmities wrought by a completely objective and indifferent Mother Nature, with science.
We’re forced to remind our readers of this reality as a result of recent changes and proposed changes to the medical education, candidate selection and training process. Like many aspects of modern culture, these changes seem to be the result of an effort to replace logic and science with something warmer, fuzzier and more politically correct. For a few weeks ago, the American Association of Medical Colleges (AAMC) announced that it was changing the content of its Medical College Admissions Test (MCAT) to de-emphasize scientific knowledge and skills, and instead concentrate on ensuring that physicians of future are more in touch with their sensitive side than anatomy, biochemistry or statistics. As reported in MedPage Today:
“The change means that the MCAT will stop focusing solely on biology, physics, statistics, and chemistry, and also will begin asking questions on psychology, ethics, cultural studies, and philosophy.
The announcement of the change — made Thursday by the Association of American Medical Colleges (AAMC), which administers the test — represents a major shift in thinking on what makes a good doctor. Instead of training doctors that can spout off disease causes and treatments with encyclopedic knowledge, the new test is meant to begin training doctors to empathize and communicate better with patients, and to improve their bedside manner.
According to AAMC president and CEO Darrell Kirch, MD, a recent survey showed that the public has high confidence in the medical knowledge and ability of doctors, but feels physicians often lack the basic social skills required to really connect with a patient.
‘Bedside manner is a complex mix of understanding people, where they come from, and why they behave the way they do, and we think this shift in emphasis [of the test] will actually help us round out that dimension of a good doctor,’ Kirch said on a Thursday afternoon call with reporters.
The MCAT was created in 1928 and has been used for decades as a crucial component of getting into medical school. The standardized test hasn’t seen a major change since 1991, when a writing sample was added. The current test has two natural science sections (including concepts taught in college biology, organic chemistry, biochemistry, and physics classes), as well as a reasoning and a writing portion.”
The new test will add a section called “Psychological, Social, and Biological Foundations of Behavior,” which includes questions on behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”
Far be it from us to be pessimistic party poopers, but let’s think for a second about what the good Dr. Kirch just said. Patients currently feel quite confident about the medical knowledge and ability of physicians selected and trained under the previous system, so the AAMC thinks that it’s a good idea to potentially jeopardize those qualities in order to recruit doctors who may be medically ignorant and inept, but have a great perspective on the cultural differences between Puerto Rican Hispanics, Cuban Hispanics and Mexican Hispanics. Too bad a Clostridium difficile infection doesn’t much care whose gastrointestinal tract it’s infected any more than an auto accident cares whose chest it’s traumatized. They’ve all got to be treated properly or all the sensitivity in the world isn’t going to result in a patient who is any less dead.
In fact given the exponential increase in the rate of scientific knowledge and clinical data, one could argue that even the nerdiest dual biology and chemistry major is still going to be struggling to catch and keep up throughout the course of their medical career. As just one example, a recent article in the Annals of Internal Medicine took doctors to task for their frequent inability to interpret cancer screening statistics with a high degree of accuracy. An editorial on the topic in the same issue bemoaned a lack of statistical expertise in medical students and physicians that has now gone unaddressed for decades:
“Medical students do not understand statistical concepts well, and Wegwarth and colleagues’ study in this issue suggests that fully trained physicians do not either. A decade ago Sheridan and Pignone reported that despite a relatively high level of numeracy among medical students, (77% correctly answered 3 numeracy questions), only about half correctly interpreted risk-reduction data for the treatment of a hypothetical disease… Physicians clearly do not understand how to interpret cancer screening statistics themselves – expecting them to communicate this information to patients is a stretch.”
The editor might well have added that it is a stretch regardless of how culturally sensitive a given physician might happen to be. (Incidentally, Dr. Elaine Schattner has written a nice commentary on this recent article on her Medical Lessons blog.)
But perhaps we’re being too harsh and concrete in our thinking about whether people of Slovak ancestry would like to get an appropriate diagnosis and treatment as much as those who are Native American. Clearly there is merit in the idea that individuals vary tremendously with respect to their cultural attitudes, education, intelligence, religion and a host of other factors. In our clinical experience, for example, many Native Americans seek and receive services from both conventional medical doctors and native medicine men. Devout Muslim men are reluctant to have their wives and daughters examined by male physicians. Why shouldn’t all professionals in every walk of life benefit from a culturally sensitive and socially aware educational background, and have the nation modify all school curricula to require these courses for plumbers, hair stylists, attorneys and politicians as well as physicians? Our legislators have the power. After all, the State of California is now requiring that gay, lesbian and transgender history be included in all social studies courses. Requiring all Americans to receive a similar cultural education (but modified to include the particular foibles of every race, creed, color, country, size, shape, disability and a host of other factors) is just a simple law away. Why not make this change for all Americans with the very best of intentions?
But why stop there? The healthcare system doesn’t simply operate in a medical and social environment, but also an economic one. Shouldn’t our medical professionals also be required to be proficient in the sciences of economics and business management?
It should come as no surprise that this has already been proposed by Dr. Frederic W. Hafferty, PhD., professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, and colleagues in a recent paper in the journal Academic Medicine. Assuming that these authors are serious (and we believe that they might be, although we ourselves could easily have offered up the same paper as an instructive piece of sarcasm), we must allow them to speak for themselves:
“The nation teeters on the precipice of financial insolvency. Health care costs darken the economic horizon. Public trust in medicine is at an all-time low…
Key to this alienation is that physicians lack insight into the economic and social burden of the services they orchestrate. As a consequence, the most pernicious threat to health care and medical education in the United States today is not patient safety, nor the lack of an evidence-based practice, but rather the alienation of trainees and physicians from the financial cost to patients of their work.
We propose, therefore, a training process organized not around disciplines, organ systems, diseases, or clinical problems, but around cost. Beginning with the admission process, all medical school applicants will be required to demonstrate proficiencies in micro-, macro-, behavioral, and health care economics, and to document community service and related shadowing experiences in clinic business offices or sites related to the recording and payment of medical charges. A new MCAT exam, Kaplan course work, and premed advising will all mirror this shift…
…The first two months of medical school (with preexisting courses taxed to create this curricular space) will be devoted to the economics of care. This block will involve multiple pedagogical approaches from traditional didactics and problem-based learning to simulation and social networking. Instructors will range from topic experts to patients and members of the public whose lives are being bludgeoned by health costs. Preceptorships will be community based and will focus on student experiences in educating the public on the cost of both schooling and health care. Once this competency is mastered, students will begin to meet with patients upon discharge (clinic or hospital) to explain all charges. There will be no traditional “patient care” contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients. As students enter the biomedical side of their training, patient meetings will begin to add explanations of diagnoses and treatment options to those of cost. No student will be admitted to the care side of the educational continuum until he or she is fully able to explain to patients what has been done to them and why.”
And there you have it. If we put all of these requirements together the physician of the future will be culturally sensitive, empathetic, well-rounded and financially eloquent. They may also have received some actual medical training along the way, although perhaps not enough to actually diagnose and manage your particular problem.
Obviously this can’t go on forever, so where do we draw the line?
What we have here is completely classic problem in economics. Resources are finite. In this case the relevant resources are the time and tuition that any prospective physician must spend in order to stuff information into his or her head. On the other hand people’s wants are infinite. In this case people want every medical doctor to be a renaissance person – medically perfect, culturally sensitive, financially aware, gentle, understanding, self-sacrificing and (incidentally) typing 120 words per minute and completely skilled in the use of computerized medical records. Every time we expand the non-medical training requirements or place other political, social and bureaucratic demands on clinicians, it comes at a cost. The most obvious trade-off is that we will have culturally sensitive doctors who have an increasingly difficult time acquiring and keeping the skills they need to deal with actual medical conditions. Few if any of these conditions really care about the social graces, yet all of them answer to science.
This leads to the obvious question: Exactly how many additional days of illness, lost productivity and death are we willing to trade in exchange for the cultural and financial sensitivity gained by diverting physician training in this direction? We know that there must be a tradeoff – the only question is how much. Did the AAMC estimate what this potential impact might be? Did those calling for these changes even consider that it might be their friends and loved ones who might be adversely affected when the time came? We can only hope so. Unlike people, Mother Nature doesn’t mess around.