Friday, March 31, 2006

Comments about Deficiency of clinical skills

Dr. RW's post referencing Dr. Herb Fred's editorial in the Texas Heart Journal generated several negative responses in KEVINMD's march 30.2006 blog following his reference to that piece.

Several ad hominem comments accused Dr. Fred of being basically a disgruntled, out of date, grumpy old doc who-in the words of one such writer-never practiced in the real world. Ad hominem arguments are -well -just that and usually do not warrant detailed refutation.

Unlike some of the commenters' suggestions, Dr. Fred seems quite aware of the calling-the-shots nature of managed care and the time restriction brought about by the third party payers' domination. He says that the HMOs force physicians to care for a maximum number of patients, in a minimum number of minutes for the lowest number of dollars.

His rant is about the decline of clinical skills and the factors responsible.He believes that values and priorities are not what they used to be.
When he trained in the mid-1950s ( and also when I trained in the 1960s) :

"... hard work,self pride,devotion to duty, strict accountability and pursuit of excellence were the norms" .

To expand on that-Things were framed in the relationship between the individual doctor and the individual patient.We did not speak about or -except in extreme circumstances-consider the " greater good" or conservation of some abstract and apparently collectively owned "resources".It seems that the core competencies of the ACGME do espouse-at least in part-values other than the one-on-one doctor patient relationship.

The ACGME core competences speak of :

..Responsiveness to the needs of patients and society

...practice cost effective health care and resource allocation

...understand how their patient care and other prorfessional practices affect...the health care organization, and...the larger society.

If I were managing an HMO, those "values" are certainly those that I would have inculcated into the doctors who are allocating my resources.

5 comments:

Anirban said...

"Dr. Fred seems quite aware of the calling-the-shots nature of managed care and the time restriction brought about by the third party payers' domination"

So are the doctor's criticizing him( myself being one of them) for his idea of profesional competance.The mode of practice he advises suits well for the fee for sevice regime, presently totally eaten up by the third party paying system,in
whatever form it may be.But nostalgia aside HMO's are here to stay, which came into existance under the backdrop of widespread fraud and overbilling,in earlier regime, courtsey few doctors who perhaps belong to Dr. Fred's generation.
The age old tussle between the care provided and reality of health care dollers is never gonna stop.May be the curriculum should change to adapt a doctor to face the challenge.otherwise sooner or later they would end up being one 'rip van winkle'

Anonymous said...

Well said.

Anonymous said...

“Things were framed in the relationship between the individual doctor and the individual patient.We did not speak about or -except in extreme circumstances-consider the " greater good" or conservation of some abstract and apparently collectively owned "resources”.

The old way you’re talking about here is gone. GONE. I’m currently a student at a top 15 medical school with a heavy emphasis on primary care. We’re being taught the new way. “The greater good” “limited resources” “community at large”. This is the party line now. I hear the word “community” more than I hear the word “patient”.

james gaulte said...

to anonymous 8:33 pm- I can easily beieve that your observation is valid.I cannot tell from your comments if you agree with this "paradigm shift". I would be interested in other med students' views on the "new way",i.e is that what they hearing and if so should it be that way.

enrico said...

I'm a medical student in Mexico in an international program (will go back to states after 4th year), and I can definitely say that the method here is precisely what's NOT being taught at the "top 15" medical schools. We learn exhaustive clinical exams and with each semester, more maneuvers/exams are learned with less time in which to perform them under examination.

There are obvious fiancial reasons to not over-order studies (patient's can't usually afford an MRI just because it's ordered, and hospitals, which charge fractions of what US hospitals charge, often can't afford to buy enough high-end equip. to meet demand), but there are cultural ones, too. The doctor is the expert; the patient comes to the doctor for advice and counsel. Patient is free to not heed advice and counsel, but there is no topsy-turvy world where doctor has to defend his/her position to placate patient's need to feel like doctor is not incompetent "just because." The doctor's responsibility is to be the best practitioner s/he can be, move out of the way when need be, and above all, remember his/her role as healer in the truest, complete sense.

Now don't get me wrong, there are a lot of messed up things here about their medical system, both academically and financially, but in the case Dr. Fred makes, they have it right on the money here. I'll need to learn some newer technology when I get back, I'm sure, and I'm sure there's long lectures from the general counsel's office, etc. to properly let us know what's different and all that, but that stuff one can learn on the job--that's simple adjustment. Having never learned to really listen to a patient and then know what to follow up with on a physical exam, that can't be learned in an orientation seminar when your internship starts. Sure, the real world doesn't always give you enough time, but the "standard" should be thorough analysis, testing hypotheses, not "let's see what the CT says," because you don't need to think anymore once you see the film.

Sorry so long--don't know if this helps provide some perspective, but I feel strongly about applying the best technology has to offer (I'm a major computer/technology person), but also realizing that technology is what you use to extend your abilities, not replace them.