Physician … Prepare Thyself

I’m Richard Heffner, your host on The Open Mind … and our subject today is once again one especially and necessarily close to us all: our health, and the care we provide it … seen today through the perceptive lens of a recent, rather disturbing Commonwealth Fund study of physician preparedness supported by the fund’s distinguished Task Force on Academic Health Centers.

Now some months ago, the “Journal of the American Medical Association” reported on the Commonwealth Fund study that “One tenth of medical residents (are) unprepared to manage clinical issues they will likely face in practice.” That’s disturbing.

And since my guest today is currently the Executive Director for The Commonwealth Fund Task Force on the future of Academic Health Centers as well as Professor of Medicine and Professor of Health Care Policy at Harvard Medical School, I want to ask Dr. David Blumenthal what in the world this all portends for us.

What does it imply about medical training? And what does it mean about the medical treatment that American patients regularly receive? It must have some real meaning. What is it?

BLUMENTHAL: Well, obviously if you’re a patient of one of those physicians you would like them to be prepared to everything that you might present to them. And I think there are some consistent areas where our, our training system does not prepare physicians as well as we might like.

HEFFNER: What are those areas?

BLUMENTHAL: Those areas tend to be things that aren’t traditional areas of teaching. That is, they’re not the core in-patient skills, they’re kinds of things that people in hospitals present with. So they are often psycho-social problems like depression, in the case of a primary care physician. Or an eating disorder. Or a, a family violence situation … something that appears in an out-patient setting in the routine course of primary care practice. And occasionally also something that occurs in a highly specialized setting within the hospital, such that it may not be part of the routine exposure of a resident in an average hospital.

HEFFNER: Should it be?

BLUMENTHAL: I think that in some cases, yes; and in some cases, no. When this is really often a matter of judgment. There are some things that we asked about, complex surgeries, which may not be appropriate for all physicians to do. It ought to be done by people who have additional training. And I think that was one of the things that we detected in this work.

That there are some things that now have become the province of specialization which, a decade ago, might not have been. But I think there are other things of the kind that I’ve mentioned that ought to be part of the routine training of physicians who take care of the great bulk of the patients who need care in this country. And I think there is opportunity and a need for the training of, of our graduate physicians to be modernized and up-dated so that these skills are better known.

HEFFNER: It’s a strange kind of question I think, but perhaps it’s not a, an unfair one. What has been the impact of the identification of these areas, the downside of medical training, upon those who train doctors, the medical schools themselves?

BLUMENTHAL: Well, I think it’s a little early for our work, published just a few months ago, to have had a major impact upon curricula. I think it is fair to say that the sensitivity of the profession to these issues is growing. And has grown in recent years. There are groups of professional organizations that are considering, actively, ways of improving the curricula that are taught to the graduate physicians in our country. That is the Residents and Interns who staff our teaching hospitals around the country. And I’m optimistic that changes will be made in the directions that are needed.

I think there has been too little formal assessment of the skills of American physicians at their time of graduation from training. It’s been assumed that if you went to a good program, put in your time, that you left prepared to handle just about anything that you might need to handle. And I think that that level of … that relaxed approach to assessing the competence of our physicians is out-dated. That we ought to make sure, when people leave their training that they not only have been exposed to things, but that they’ve mastered and can demonstrate their mastery of the skills that they should have.

HEFFNER: But it’s rather astounding that that observation hasn’t been incorporated in the medical profession’s …

BLUMENTHAL: Yeah.

HEFFNER: … the way it goes about things.

BLUMENTHAL: Well, there are a lot of things about the medical profession which are slightly antique, if you will. We are in many ways a profession that has its roots in a kind of craft, rather than in science. We are highly autonomous and we have not, in some ways, in certain aspects of our self-monitored and self- … and autonomous behavior, come to grips with the changes that have occurred in this century. And I think accountability for the care that we as a profession provide as in the routine course of our professional lives, well after graduation, and accountability for the results of training have not been a … really part of the professional ethos, up to now.

HEFFNER: “Up to now” you say …

BLUMENTHAL: MmmmHmmm.

HEFFNER: … what indication is there that accountability …

BLUMENTHAL: Yeah.

HEFFNER: … is now part of that ethos, as you call it.

BLUMENTHAL: Well, I wouldn’t say it’s a mainstream value yet. But I think there are many voices that are calling for it. The best example might be the, something called the Accreditation Council in Graduate Medical Education. It’s a … sounds like a very technical term, and it’s a somewhat obscure body. But a very important one. And this is where all the professional associations come together to decide what ought to be part of the training of graduate medical physicians. And that group right now is going through a very thorough attempt to quantify and decide how to measure the competencies of physicians at the time of graduation. So I think that shows a new sensitivity to the need for accountability. And I think that the conversation in that group is very much about accountability and how to assure it.

The effort to reduce medical errors, that has been discussed a great deal in the last year or so, the emphasis that is increasingly put within the professional and by purchasers of care, on quality of care, measuring quality of care; those are other demonstrations of the emphasis on accountability.

Now those have been mostly developed outside the profession and suggested for the profession, rather than emanating from within. But there are voices from within the profession as well. Not as loud as we might like, not as numerous as we might like, but I think they’re growing.

HEFFNER: Where are these voices heard? Whose voices are they?

BLUMENTHAL: They are the voices, in some cases of the leadership of particular groups, groups of physicians. Mostly I would have to say at this point, they are a modest number of leaders who make it their business to worry about quality and accountability. And who are trying to educate, teach, convince their peers that these are core professional values that need to be demonstrated, not just spoken to, but demonstrated concretely.

I would say that they’re … that the language of … the language in which the medical profession does its business has come to include quality in a new and positive way in many forms. I don’t think that the average physician yet is very involved in quality improvement or accountability for their work. By the way, that’s another skill that we found that physicians had not been instructed in. That is the skills needed to examine the quality of the work they do and improve it. We would think that would be a very core part of the repertoire that people would leave a professional school with.

HEFFNER: One. Number one?

BLUMENTHAL: Yes. But it’s not something. You know, our set of skills, they’re concrete. They’re learnable, they’re not part of the curricula of medical schools, they’re not part of the curricula of residencies. They need to be inserted. And then this dialogue about accountability, that we’ve been talking about would be a much more robust and informed dialogue.

HEFFNER: Is there any opposition to accountability?

BLUMENTHAL: I think there is. I think there’s opposition to … in the sense that it is some times thought to be imposed from without. I think there is a legitimate concern that measurement may not always capture the important. That is, we can measure, perhaps a blood level of a chemical, but we can’t measure the personal skills, the interpersonal skills, the art of medicine. And I think that’s a fair concern. One that people have to deal with and address.

There’s this cliché about the measurable driving out the important. And I think that is a legitimate concern. But in this day and age with consumers as informed as they are. With the Internet as powerful as it is. With employers as conscious as they are of the costs of health care, with constraints on the resources available in all segments of our society. We need to be able, as a profession to demonstrate that we’re providing value for the resources we consume.

HEFFNER: I would assume that it’s not a matter of the old versus the young. Or is it?

BLUMENTHAL: I don’t think it’s that simple. I think that there are older physicians who have always been sympathetic to this point of view. And there are younger physicians, just struggling to get established who are as defensive as anyone. I do think that the young are hopefully going to be more receptive to this message. But I don’t think we can expect them to be receptive unless we give them the tools. The tools to participate in these activities in a way that feels comfortable for them. And also it’s critical that older physicians, the role model, this sense of responsibility for the work they do and the measurable outcomes of the work that they do. Rather than discouraging it. And I think that there are times when physicians feel beset by pressures.

Managed care was blamed for many things that, both good and bad, that were in some cases associated with it, in some cases not. And this emphasis on accountability was one of the things that was attributed to managed care. I think mistakenly. I think it’s a trend that’s independent of managed care and one that will long, long succeed it.

HEFFNER: Are they foundations in particular that are … enough outside the profession so that they can push in this direction?

BLUMENTHAL: There are a number of foundations that are encouraging this kind of work. The Commonwealth Fund is one that you mentioned. The Robert Wood Johnson Foundation is another. The Federal government has been a very important sponsor of work, research on how to measure quality of care. How to measure the quality of training. And I think they are another important source of pressure. Ultimately though I think the physician, the profession, has to embrace this message for it to be meaningful.

HEFFNER: How sympathetic are you, though, to the notion that outside forces will, that accountability will is a means by which non-medical, or at least outside forces will make you or him or her as a practitioner, adhere to a line that has individual practitioners you don’t want to adhere to.

BLUMENTHAL: I think it’s, it’s helpful, it maybe even necessary, but far from sufficient. I think if you leave the professional to their own devices, if you don’t create tension between them and the environment in which they, they work and live, the likelihood is they will not change in ways that are as constructive as you’d like.

HEFFNER: Is your report creating tension?

BLUMENTHAL: I hope so. The Report on Graduate Medical Education training you mentioned is one, is part of a series of reports that we’ve been issuing. I think that those reports were especially influential and well-listened to a couple of years ago when hospitals were in even more trouble than they’re in right now. Financially. And especially teaching hospitals.

We’re going now with the recession of, with the receding of manage care, with the rising health care prices that providers are charging now that managed care is less influential. I think we’re going to go through a period where there’s danger that some complacency will, will set in again and that some of the pressure that physicians and other providers felt in the last few years won’t, won’t be there and that the opportunity for constructive change won’t be as great as it was.

HEFFNER: Dr. Blumenthal, what about other countries? I began by asking what concern the American patient should have for what you reveal in your report. Are there those concerns, need there been those concerns in other leading countries, too?

BLUMENTHAL: Absolutely. This is a problem that affects the relationship between professionals, medical professionals and their … the societies in which they exist throughout the industrialized world. We may bemoan at times the fact that we’re not perfect, but I think we do about as well, and we may be more active in trying to change things than is true of a number of other countries.

The professions are equally autonomous in virtually every other Western country and the ability to measure quality, the ability to measure the adequacy of education is probably less well developed than it is here. So, in … if you look at Britain, if you look at France, if you look at Germany, you will find that by and large, the professions are … and haven’t been until recently, with some exceptions, pretty much left alone to run the internal business of what measuring the quality, assuring the quality of care, and defining what training needs to consist of.

HEFFNER: What’s the profile of your report in the sense of, are there geographic areas, are there other demographic breakdowns from which one can draw a sense of solace? If I go to the Midwest …

BLUMENTHAL: MmmHmmm.

HEFFNER: … if I go to Salt Lake City, if I do this or that, I’m going to find people who don’t quite fit the mold you have created.

BLUMENTHAL: No, I don’t want to create the impression that the average physician that people are likely to encounter isn’t prepared to handle many of the illnesses that they present with. Because I don’t think that is true. I think that most physicians are well prepared to handle, when they leave their training, and by our measurements, well prepared to handle many or most of the common problems that people present with. We did not look at this from a geographic standpoint.

HEFFNER: Could you?

BLUMENTHAL: We could.

HEFFNER: data??

BLUMENTHAL: There is … our data is about training. And those physicians leave training and they spread out across the country.

HEFFNER: I’m talking about where they’re trained.

BLUMENTHAL: What we found was that there were differences between the types of hospitals … in how people were trained by the types of hospitals in which they trained.

HEFFNER: Tell me what you mean.

BLUMENTHAL: Well, if you look at the hospitals that are the most eminent and prestigious. Let’s say you look at the hospitals that the US News and World Report …

HEFFNER: [Laughter]

BLUMENTHAL: … ranks highly. Okay? And the US News and World Report gets to its rankings by asking other physicians. So, it’s not perfect, but it’s not completely erroneous. And actually there has been good research that shows that the well ranked hospitals in the US News profile often provide care of superior quality to those that aren’t. But let’s put that aside for now.

The most eminent teaching hospitals do a better job of training people to do esoteric things. And do less well at training people to do some of the bread and butter things. Not perhaps surprising when you think about it. I mean these are places that pride themselves on the specialized care they provide. And they may not put as much investment in the out-patient care of routine illness. If you go to a less eminent hospital, you may … you’re more likely to find that the training will emphasize the routine bread and butter conditions that physicians will face as they go out into practice. But may not provide the highly specialized care … training in highly specialized care that you would get at a, in the city, Mt. Sinai or a New York Cornell hospital.

HEFFNER: In that part of medical care that has to do with dealing with patients, not caring for them medically, but …

BLUMENTHAL: MmmHmmm.

HEFFNER: … dealing with them and caring for them perhaps as human beings, what’s the ranking there in the, in the US News & World Report?

BLUMENTHAL: Well, I don’t think that’s been looked at in precisely that way. What I could say is that the, the perception on the part of the graduates of their capabilities to do things like manage domestic violence, manage depression, or take care of a family issue … people who leave training in the less prestigious hospitals feel more comfortable with those problems than people who leave training in the more prestigious hospitals. Now, can you infer from that their interpersonal skills are better? I’m not sure. We were looking at competence in a technical sense rather than competence in a relational sense. So, I think that that work … the question that you’re asking remains to be answered in a direct way.

HEFFNER: What are the, what are the hopes and aspirations of the profession along these lines?

BLUMENTHAL: I think the profession says, will say, appropriately that it’s interested in training complete physicians. There are some skills that are not necessary for every physician to master. It’s not necessary for every physician, even every surgeon, even every heart surgeon to be able to do every conceivable heart surgery … surgical heart procedure. Increasingly we are realizing that for highly technical specialized things that concentration is important to quality. But there are a set of skills that the profession is coming to grips with, trying to outline, that ought to be part of the repertoire of every graduating physician.

I don’t think we’ve reached full agreement on what those are. They’re the kinds of things that are being discussed right now among leaders of the different specialties. The fact that they are consciously looking at those things I think is a positive development. The task of implementing, of continuing to assure the public and their peers that physicians not only graduate from their training with those skills, but maintain them, over the course of a lifetime, that is a big challenge. And that I don’t think we yet have come to grips with in terms of what to do about it.

HEFFNER: What role does technology play in, in this question?

BLUMENTHAL: MmmHmm. Technology will change the capabilities of physicians over time and I think help make the quality of care better in lots of different ways. One kind of technology is remote care. So the ability to provide care at a distance in the most, perhaps one of the most distinct forms would be remote surgery. We now have the capability to do surgery remotely and I think that will become increasingly the case. So that means that people can, of great skill, can spread their talents geographically. More mundanely, or more routinely, information technology is going to make it possible for everyone to have access to the latest information, that is every physician have access to the latest information on-line, in real time, so that memory won’t be as important in the delivery of competent care as it used to be.

HEFFNER: Do you find that in general, young people being trained as physicians now welcome that …

BLUMENTHAL: Yes.

HEFFNER: … aid to memory?

BLUMENTHAL: Absolutely. Absolutely. It’s astonishing to be in a teaching setting in the modern medical teaching hospital, to see the way in which on-line resources are integrated into the daily decision making. Physicians in training will turn around, there will be a computer present during the review of a patient’s condition and you can go on-line and reference a textbook or reference a journal in real time as a question comes up. And that’s a terrific assist to quality and to teaching.

HEFFNER: We have only two, two and a half minutes left … and now I raise the question of dollars. And financing medicine. What is your own feeling about the way we are going to have to deal …

BLUMENTHAL: MmmHmmm.

HEFFNER: … with the question of financing medicine.

BLUMENTHAL: Well, my own personal view is that we should have universal entitlement to a basic package of health care services. And that that needn’t involve the control of the day-to-day work of physicians or hospitals, but it should be an essential part of the safety net that government offers the American people. Now that means some level of accountability to government as a result. And I think that that is going to be … that’s one of the reasons why we’ve been so slow in getting to that. I think the suspicion that we have as a people of government and the lack of trust that we have in government, and perhaps in the post 9/11 world, now that we’ve come to see that government can play a positive role in people’s lives, there’ll be a great receptivity to that.

HEFFNER: You say the, the reluctance of the American people … do you mean the reluctance of the medical profession?

BLUMENTHAL: I think both. I think both. I don’t think that the profession is strong enough, as it was in the 1960’s, the 1950’s, or 1940’s to unilaterally prevent the adoption of this … of legislation. I think that there’s a deep seated distrust of government that is ready to be tapped by groups that are antagonistic toward universal coverage. And I think that’s what happened in the course of the Clinton health care debate.

HEFFNER: I know you’re talking about a single pair.

BLUMENTHAL: I’m talking about … a single pair implies a lot. It’s become a buzz word. I’m talking about universal entitlement to insurance. And there are many mechanisms for ensuring that.

HEFFNER: Okay, that’s fair. Which means that that’s a whole question for us to deal with at another time. Dr. Blumenthal, thank you so much for joining me today on The Open Mind.

BLUMENTHAL: You’re welcome.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.