Medical Education Feature - March 2006
By Ken Ortolon
Good news for patients appears to be a mixed blessing for medical education. Financial pressures and new ways of delivering health care are moving more routine care to outpatient facilities and shortening the time patients spend in the hospital. That's good for patients who have access to care closer to home rather than in a hospital or who can go home sooner if they are hospitalized.
Medical educators, however, say it makes it hard for them to come up with the right mix of patients in teaching hospitals to give medical students and residents the breadth of experience they need.
"There has certainly been a change of patient mix - both acuity and length of stay - in the inpatient arena," said Nancy W. Dickey, MD, president of the Texas A&M University System Health Science Center. "The challenge for medical education has been to evaluate and modify our traditional teaching methods."
That means more medical students and residents are going outside hospital walls to get their training.
Out With the Old
"In the old days, when patients were ill they would go into the hospital and spend several days or a week or two," said Steve Lieberman, MD, vice dean for academic affairs at The University of Texas Medical Branch at Galveston (UTMB). "There were no issues related to length of stay or reimbursement. There was ample opportunity for students and residents to learn about patients and learn from patients at a reasonable pace."
But efforts to control rapidly escalating health care costs are redirecting a lot of routine care to physicians' offices or outpatient clinics to keep patients out of the hospital altogether or to get them discharged as quickly as medically prudent.
As a result, the patient mix at some teaching hospitals has trended toward more acute, complex illnesses, and students and residents are missing out on the opportunity to treat milder illnesses or provide routine preventive care.
"To train students and residents, we need to see all spectrums," said John C. Jennings, MD, professor and residency program director for obstetrics and gynecology at UTMB. "You need to see people who come in for preventive health visits, you need to see somebody who's being followed for hypertension, you need to see a female who's in for a routine annual checkup. Sometimes our students are missing out on those because we don't have the volume."
Dr. Lieberman says it can be argued that if a student learns to treat acutely ill patients, it would be "relatively straightforward" to treat those with a milder form of the same conditions.
"That's true to a certain extent, but in fact the nature of what is typically seen in an ambulatory setting is fundamentally different than what is seen in the inpatient setting," he said.
Dr. Jennings says students need a "progressive learning experience," in which they start with the simple and go on to the more complex.
Out and About
The Liaison Committee for Medical Education (LCME) recognized the changing hospital patient mix nearly a decade ago and began requiring medical schools to define the number and type of patients their students need to meet critical education objectives. It also required schools to adopt methods to remedy any gaps.
"Part of the problem is educators haven't had a lot of experience in the outpatient arena," said Michael Ragain, MD, chair of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center. "In family medicine, of course, we're primarily outpatient oriented, so we have a pretty good handle on that. But, in general, medical schools haven't done a lot of that."
Ironically, Dr. Ragain says the Tech family medicine program has the opposite problem from UTMB. Because it is outpatient oriented, students and residents see many routine illnesses and chronic diseases but lack exposure to acute and emergent care.
He says Tech physicians are staffing an urgent care clinic through their academic practice and likely will begin rotating students and residents through to gain exposure to acute illnesses.
Dr. Dickey says the schools and teaching hospitals had to become more flexible to make sure students and residents get the wide range of experiences they need to learn.
For example, A&M sends students on surgical rotation to a surgeon's office to observe preoperative care. They then follow the surgeon into the operating room to watch the surgery and continue to follow the patient through postoperative care.
"Those are all things that used to occur in the hospital, and it requires some logistics and some planning because the students still need to see the pre-op, operative, and post-op," she said. "They're just not going to see it all in the hospital."
Dr. Lieberman says UTMB increasingly partners with community physicians to place students in outpatient rotations in family medicine, pediatrics, internal medicine, and other disciplines. The UTMB Office of Regional Medical Education also works with local preceptor physicians to provide teaching skills workshops and other incentives to host students.
"The fact is these practicing docs enjoy having the students in their offices. It's a treat for them, and the patients seem to like it, too, so it's an enjoyable experience from those two perspectives," he said. "And the students like getting out and seeing what the real world of medical practice is like."
Tech officials recently met with physicians from the Lubbock-Crosby-Garza County Medical Society to discuss placing second-year students in physicians' offices. Local physicians liked the idea, Dr. Ragain says.
Dr. Dickey says heavy reliance on inpatient training in the past was a "failing of medicine" that family physicians recognized more than two decades ago. In fact, the Accreditation Council for Graduate Medical Education has long required family medicine residency programs to offer opportunities to learn in both hospital and ambulatory settings.
"The reality is that there are some things that happen in the ambulatory setting that you would never learn in the hospital," she said. "It's imperative that students see things in the outpatient setting because today probably 80 percent of medicine occurs in the outpatient setting."
Will these trends substantially change how physicians are trained? "There are two questions: will it or should it? I'm not sure the answer is the same to both of those," said Dr. Lieberman. "Will it? I hope so. Should it? Absolutely."
He says the way graduate medical education (GME) is funded could be an obstacle to moving a larger share of physician training.
GME is largely funded through Medicare, and those funds go to teaching hospitals, not the medical schools, Dr. Lieberman says. That creates a "financial incentive geared toward inpatient reimbursement for residency education," he said.
He predicts it would take "quite a political battle" in Congress to change that.
Still, Dr. Lieberman sees a shift to outpatient training as a major step forward in medical education.
"I think that kind of change would be tremendously positive for medical education as a whole because then residents would be coming out of residency with much more practice in doing the things they're going to be doing routinely when they get into an office and set up shop. And students will also have more opportunity to get those experiences."
Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
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