Preparing the doctor of the future: Medical school and residency program evolution

 

Health care consumers are looking for the same quality of service that they get in other industries, while doctors find they increasingly need business skills: leadership, marketing, communication. Harry Greenspun discusses how physicians and medical schools are responding to these different pressures in the current health care environment.

I get notifications when our dog Tarot is supposed to get his medications, his vaccinations, his well visit appointments—all of that. Yet I don’t get those same reminders from my doctor—because physicians and health care systems have really been geared to dealing with people when they’re in front of their provider, but not really thinking about the broader issue of preventative care, wellness, and managing people before they need care.

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TANYA OTT: Health care is undergoing massive changes now, with consumers and hospital CEOs demanding more from physicians. But how will doctors respond?

I’m Tanya Ott and this is the Press Room, Deloitte University Press’s podcast on the issues and ideas that matter to your business today. But let’s forget about today for just a moment—and rewind to the early 20th century.

In 1910, when a guy named Abraham Flexner was researching the state of medical education, he found that only 16 of the 155 medical schools in the US required more than a high school education for admission. Many medical schools were unaffiliated with a college or university, and [were] run to make a profit. Laboratory work and dissection weren’t necessarily required, and regulation by state governments was minimal or nonexistent. In short, there were a lot of “quacks,” and a person was just as likely to be harmed by medical treatment as helped.[1] Nearly a hundred years later, in 1999, the Institute of Medicine published a report called To err is human. It estimated that up to 98,000 people die each year in the US from medical errors.[2] More recent studies put that number even higher.[3]

Those alarming stats—plus things like health care reform and the changing expectations and, frankly, demands of patients—mean health care has had to evolve quite dramatically in the last 5–10 years. There’s an increased push for value over volume.

HARRY GREENSPUN: And that’s changed the way health care’s being practiced, and is requiring hospitals and physicians to work quite differently and do things they’re not very good at.

TANYA OTT: Harry Greenspun would know. He was still a teenager when he became an EMT and firefighter. He then went to medical school, worked in medicine for a large defense contractor, [was a consultant] to the Centers for Disease Control in biosurveillance and bioterrorism, and was the chief medical officer for one of the largest computer companies in the world. Today, he’s managing director of Deloitte’s Center for Health Solutions, a research arm of Deloitte LLP.

HARRY GREENSPUN: I think fundamentally the issue is that we’re paying too much for health care, and we’re not getting what we need out of the system—certainly when you compare us to other countries about how much we pay per capita, and the way health care costs have gone up, not only for our country, but also for employers and individuals. So the thought is, if you can change the incentives around how health care is paid for, you can get better value added. Instead of paying orthopedic surgeons for the number of joint replacements they do, you pay them for the quality of the work that they do, such that the valuation is not just based on how efficiently they get someone in and out of the operating room but also, six months later, how ambulatory were they? Was it a successful operation? Similarly, if you’re taking care of people with diabetes, you don’t judge how efficiently you can cut people’s feet off when they get diabetic foot neuropathy, but instead look at, how do you prevent the progression of disease, and judge providers based on that.

TANYA OTT: Was that evolution forced by the industry itself in recognition of long-term gain looking at value rather than volume? Or was that forced by consumers saying we want something different?

HARRY GREENSPUN: It was really pushed by a lot of forces—changes with the Affordable Care Act (ACA) and most recently with MACRA.

TANYA OTT: What is MACRA?

HARRY GREENSPUN: MACRA is going to be the change in how Medicare pays physicians, and it’s really going to be [based on] outcomes and lots of other quality measures. The government is changing how Medicare is going to pay doctors.

TANYA OTT: Just wanted to clarify that before you go on: So you were talking about changes in ACA, changes in MACRA . . .

HARRY GREENSPUN: Right, but we’re also seeing employers, who pay a lot for health care, trying to find ways to control those costs. And with employers shifting more of the cost of health care onto individuals, who are having higher deductible plans and paying more out of pocket, everyone is trying to see, how do I actually get more value when I’m paying for health care?

TANYA OTT: The Deloitte Center for Health Solutions, which you lead, surveys physicians, health care consumers, and health system CEOs to talk about what they need from physicians in this new medical world. Let’s start with the consumers: What do they say that they want?

HARRY GREENSPUN: One of the interesting conundrums about health care consumers is that consumers want better quality, but when you dig deeper into asking consumers about their view of quality, a lot of what they view as quality is actually service. It’s not how good was their outcome; it’s, what was it like to go to the doctor? Were they efficient? Were they courteous? Did the doctor listen to me? Did I get what I was interested in? Was it a comfortable experience? Was it a good environment? So one of the challenges we have is that consumers want better quality, but the quality measures that they look at [are] different than what a hospital CEO or the government or an employer might look at.

TANYA OTT: So it’s more about being consumer-centric from a customer service standpoint, less a health care standpoint.

HARRY GREENSPUN: Right. Consumers’ expectations of a service are formed based upon their experience in every other industry: how they shop, how they travel, how they’re able to get information about anything else, and how they interact with providers. When they come to a hospital or go to a doctor’s office, and they can’t make their own appointments; they can’t understand what their bill is going to be; they can’t get the information they want; they can’t change things easily; and they can’t communicate in the way they want to communicate, they begin to see that as lesser service quality.

TANYA OTT: So if I’m a consumer, and I really want to be able to communicate with my doctor via email or text, but he or she’s not willing to do that, I see that as an issue of quality?

HARRY GREENSPUN: It’s beginning to shift that way. For a while, people were willing to tolerate that gap but more recently, particularly with younger patients and Millennials, they know what they can achieve in other industries, and they’re beginning to wonder why they can’t get that in health care, and they’re beginning to shop for that.

TANYA OTT: I would imagine, for instance, they might look at scheduling an appointment: Why do I really have to pick up a phone and go through a voicemail system and click #3 and ask for the appointment desk and talk to the nurse to schedule something, when I should just be able to go to a website and see, oh look, Thursday afternoon at 3:30, there’s an appointment open. Click. I’ve got it.

HARRY GREENSPUN: Precisely. A lot of our experience with clients is really centered around this almost low-hanging fruit, this basic customer service that has nothing to do with delivery of clinical care. It’s really around, how do you manage the basic consumer interactions. I think what’s also interesting is there’s been an upsurge in rating sites by consumers where, through social media and other things, the data that’s typically available on those about the quality of physicians is really tied, inextricably, [to] the service experience.

TANYA OTT: So that’s what consumers want. What do hospital CEOs expect?

HARRY GREENSPUN: Hospital CEOs are facing a challenge. They’re going through very dramatic changes in how health care’s going to be delivered. They’re having to shift to value, shift to doing population health—[caring] for the health of large populations. And what CEOs need are really better leaders. They need their clinicians to be team leaders and team members, and bring innovation and new ways of providing care in a way that’s responsive to consumers, delivers better quality, and also delivers better financial performance. When you look at how doctors are trained and what they do, they really historically have lacked the kinds of skills—leadership skills, marketing skills, communications skills—that’s necessary to be effective in this kind of environment. And doctors realize this as well.

TANYA OTT: So that leads us to the physicians themselves, because they’re kind of the focal point of all of this. When you talk with the physicians in your survey, what do they say? Do they feel like they have a little bit of a target on their back, or are they excited about the opportunity to expand the services and the way they think about providing their services?

HARRY GREENSPUN: Doctors are pretty clear on what their needs are. They understand they need better business training. They also need better data analytics tools. Those things are very important to them. You know, we need data. We need the right tools. You’re asking a lot of us, but you don’t give us the resources to make that easy to do. So they’re asking for those things.

TANYA OTT: When you say asking for data analytics tools, what exactly is it that they want, and what would they be doing with [the tools] that would make their service to customers better?

HARRY GREENSPUN: One of the issues is that simply converting from paper records to electronic records has allowed for data to be collected, but very often it’s difficult for physicians to get information out of the records—for them to understand, how can I identify all of my patients who are over the age of 50, who haven’t gotten their screening colonoscopy? Or, if a drug’s been recalled, how can I tell what patients are on it and have refilled their prescriptions or are actively taking it? And how can I better understand who of my patients are at risk for diabetes or at risk for hypertension or at risk for stroke, and haven’t had the necessary screenings? Those types of analytics and predictive analytics tools are the kinds of things that are necessary to make effective decisions.

TANYA OTT: Just an aside, I’ve heard from more than one person that they get more notification from their veterinarian about their pet being ready for an appointment or needing to be checked on something than they do from their own human doctors—which I think is kind of frustrating for a lot of consumers.

HARRY GREENSPUN: Yeah, and it’s, I think, kind of interesting. I’ve actually had that same kind of conversation, where I get notifications when our dog Tarot is supposed to get his medications, his vaccinations, his well visit appointments—all of that. Yet I don’t get those same reminders from my doctor—because physicians and health care systems have really been geared to dealing with people when they’re in front of their provider, but not really thinking about the broader issue of preventative care, wellness, and managing people before they need care.

TANYA OTT: How are medical schools changing their approach to teaching new doctors to meet all of these demands that we’ve been talking about?

HARRY GREENSPUN: It’s a slow process, unfortunately. I wrote an article recently where I talked about my own son Benjamin, who is applying to medical school this year. The application process for him has been almost identical to what it was when I was applying to medical school almost 30, 35 years ago.

TANYA OTT: Really?

HARRY GREENSPUN: Yeah. We take the same course, and it’s a very similar test that you take after it to prove that you’ve got all the necessary knowledge. There are some differences. But the key thing is that medical schools are appreciating that they’re going to be releasing physicians out into the world who are going to be working in environments where data is important; they’re going to have to communicate effectively; they’re going to have to be leaders and team players; and working in a very complex regulatory and financial environment.

So we’re slowly seeing a shift toward this, but there are so many demands on students right now, and [on] doctors, for what they need to be taught. You don’t even have to look beyond the news in the last couple of weeks: What you see is calls for physicians to be better trained on gun violence or opioid abuse or mental health issues or global health with infectious disease. So there are lots of changes going on in health care and lots of pressures. Medical schools are trying to balance what those things are.

TANYA OTT: I used to be a health care reporter, and when I was covering that beat, I did a fair amount of reporting on the culture in medical schools and particularly teaching hospitals. In particular, I was doing a lot of coverage on the number of hours residents worked and whether or not that was dangerous for their patients, and perhaps for new doctors themselves. At least at that time there was a fair amount of pushback from some of the old guard, who said, you know what, working long hours is a test of our will. It’s an initiation into our business. We did it. They should be able to do it. What kind of pushback do you see or do you anticipate seeing around these new approaches to teaching new doctors?

HARRY GREENSPUN: I was part of that old guard, and I remember one day going to work at 6:30 in the morning on Monday and working pretty much nonstop until about 9 p.m. on Wednesday. It was definitely brutal, and there was a recognition in the ’90s, unfortunately while I was training, that people were working hard . . .

TANYA OTT: Not soon enough for you, right?

HARRY GREENSPUN: It wasn’t soon enough for me, but what was interesting about that is that they limited residency hours to try to make people fresher, right, so they could make decisions better. But recent data show that actually as a result of doing that, we didn’t really impact patient safety. We took away the fatigue factor in decision making, and we traded it for this increased number of turnovers that you did for patients—where you had doctors turning over patients to other doctors, people coming on from shift after shift, as opposed to continuity. So the safety issue really wasn’t resolved. We sort of traded one thing for another.

And one thing we have to wonder about is, when you prioritize new things—whether it’s business or analytics or leadership skills—there’s only so many hours in the day. You’re going to have to do less of something else. It’s like whack-a-mole: You improve one thing while inadvertently impacting another.

TANYA OTT: So how do you balance that when you have hospital CEOs saying, I want you to have more business acumen? I want you to be a better leader. I want you to be a better communicator. And then you have consumers saying, I need to have a really quality customer service experience with you. How do you balance all of that either for younger doctors that are just coming out of medical school or for existing ones?

HARRY GREENSPUN: I think it’s going to be a mixture of things. No. 1, I think we’re going to have to spread this across different areas. It’s not only going to be in medical school; it’s going to be in internships, in residencies. And it’s going to become more and more specific to the type of care that people deliver. Obviously, primary care providers may be doing more of these types of things than surgical specialists, as an example. So I think we’ll see, rather than a peanut butter spreading of these kinds of skills across every type of student, every type of specialty, it will become more part of how training is done depending on which route people take.

At the same time, I think we’ll also see better modeling of behavior. I had the benefit of working alongside the cardiac surgeons at Johns Hopkins as a chief resident faculty. That was a department that was very responsive to individuals and very respectful of other members of the team. I would contrast that to other specialties even within the same hospital. The modeling of behavior on physician leadership is very important: how people are expected to behave, but also what they’re expected to concentrate on and how discussions take place.

Even when I was a medical student, we had discussions about cost. People like to think about doctors not being aware of cost, but even back when I was a medical student in the late ’80s, we were thinking about, is it necessary to order this test? Is it necessary to add this extra day in the hospital? And what is it going to cost? Giving people more information, making that part of the conversation can certainly help us. The encouraging thing about this transition toward value is that it really begins to align the incentives of everyone to do the right thing for the right reason at the right time. That’s why I’m very encouraged about the future of doctors, the future of medical school, and, really, the future of our health system.

TANYA OTT: But change is hard. It’s difficult to make changes to medical school curricula, even when med school leaders know it’s necessary. That’s because in order to teach new doctors about cost and public policy and public health and leadership, you’ve got to have faculty who are qualified to teach that—and that’s not always the case with existing med school faculty.

It’s also expensive. There are the upfront investments needed to make big changes in curricula and systems. But Harry Greenspun says there are positive things happening on that front. He explores them in his article Preparing the doctor of the future at dupress.com.

When you find something that makes you think, something that makes you smarter, be sure to share it! Tell your colleagues, tweet about it. Tweet us @du_press, or email us as podcasts@dupress.com.

I’m Tanya Ott. Thanks for listening, and have a great day!

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