American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, June 12, 2014

Are we really training learners to manage diseases?

If you pay close attention to medical education and training, you have surely read something like this as an goal or learning objective: “Manage inflammatory bowel disease and its complications.”

However, this is not exactly what our goals should be. One push in the patient-centered care community has been changing the focus from managing the disease to managing the patient who has (or might have) the disease. The difference in wording is subtle, but it gets more closely at what we are trying to get our learners to do.

The diseases about which we teach and train do not occur in isolation. They do not occur ex vivo. For all intents and purposes, doctors cannot “manage” GERD, nephrotic syndrome, or an abnormal ANA. But we can manage the patient with GERD, nephrotic syndrome, or the abnormal ANA.

I can teach someone to how to manage a disease: Take history, do an exam, maybe do some tests, decide on treatment. That’s the end of it. But it doesn’t get at the goal of medical education and training, which is manage the patient. Understand their anxieties. Counsel a patient about the risks & benefits of various treatment options. And certainly, figure out if the disease itself explains their clinical concerns.

Why could this be important distinction?

It reduces anchoring: Anchoring plagues the medical profession. As much as I hate to say it, we give patients too many labels. These labels are often known as the “diagnosis.” Diagnostic precision is considered one of the hallmarks of a great clinician, but how often do we really know the patient’s “diagnosis”?
• The diagnosis can be based on symptoms (e.g., fibromyalgia), signs (e.g., hypertension), findings upon diagnostic testing (e.g., cancer), or occasionally the response to a treatment trial (e.g., GERD, when the patient improves with a proton pump inhibitor). Nonetheless, the diagnostic label we have placed upon this patient is based on our own current understanding of the biology of the disorder, as well as the examination skills (including the accuracy and precision) of the person making the diagnosis, including the physician, pathologist, radiologist, endoscopist, etc.
• When we see a patient with a previously-diagnosed disease (i.e., “past medical history) that may be pertinent to the presentation at hand, the details need to be sussed out, or we risk using information (the diagnosis) that is incorrect or incomplete. The most common example of when I use this in my own practice follows is when I see a patient with “refractory GERD“.

It puts the patient at the heart of our care, instead of the disease: To date, disease management strategies & algorithms rarely incorporate patient values and concerns into the process. Here’s an example I come across every time I see a patient with achalasia.
• The optimal treatment for achalasia traditionally is either laparoscopic cardiomyotomy (Heller) or pneumatic dilation. We tend to reserve Botox treatment and medical therapy for patients with limited life expectancy, severe comorbidities, or unwillingness to accept the risks of and/or undergo pneumatic dilation/Heller.
• However, there really are several other management options:
1. Per oral endoscopic myotomy (POEM): I personally still consider POEM investigational in the U.S., although some practitioners are offering it as routine. Some patients may want to get a treatment that is at the cutting edge, or may have strong desires to enter research protocols.
2. Aggressive surgical management: For patients with “end-stage achalasia“ could include a more aggressive surgical option, such as resection, transposition, or interposition.
3. Gastrostomy: What if a patient decides that they really don’t want to do any of the other possibilities? A gastrostomy (aka feeding tube) can potentially provide adequate nutrition and bypass the need to take food & liquid orally. Yes, there are still the risks that the patient can aspirate on ingested material, but if the patient is willing to either forgo eating/drinking or accept the risk of aspiration, should we not abide by such a value?
4. Do Nothing: How many times have you offered this to your patient? In a patient with achalasia, I regularly add this as an option. Why? Because it is a patient’s prerogative to decline any intervention, or “informed refusal.” As physicians we often make the assumption that patients are coming to us to get better. Yet there are patients who are just following their doctor’s orders, by taking medication, having surgery, or seeing consultants, without the knowledge or understanding that it is their prerogative to refuse any recommended treatment. Although we talk about medical necessity as if it is absolute, medical necessity in fact is relative. I suggest always offering this option, even when you do not necessarily agree that it is the best course of action.

What is my plea to educators?

When writing curricula, goals, learning objectives, and so forth, I suggest tweaking the titles ever so slightly. For example, the learning objective above could be changed to: “Manage a patient with inflammatory bowel disease, including the extra-intestinal manifestations.”

Or in the case of a patient whose diagnosis based significantly on symptomatology: “Manage a patient whose findings suggest GERD.”

I know it’s subtle, but the more we put the patient at the focus, the better we will get at the heart of what we are trying to do in training: help trainees improve the health & care of their patients, not just their diseases.

Ryan Madanick, MD, is an ACP Member, a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain. This post originally appeared at his blog, Gut Check.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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