Whitcomb, Michael E. MD
Everyone agrees that new doctors must be able to establish effective relationships with patients if they are to give them high-quality care. Most of the articles and research reports in this month's journal will be useful to those faculty who are helping students and residents learn how to establish good doctor–patient relationships. There is a variety of important information in these papers, and each deserves careful reading.
But my focus in this editorial is on a somewhat different topic—the one addressed in the article by Finkel and Fein, who describe an innovative approach for teaching students about the U.S. health care system. These authors raise an important question for the medical education community: What should future doctors learn about the country's health care system? This is a topic of growing importance that medical educators have not paid enough attention to. Let me explain.
In their article, Finkel and Fein state that to their knowledge the required “clerkship” experience they describe is unique. I suspect they are correct in making that claim. I do know that there are schools that require students to participate in experiences similar to those described in their article, but I am unaware of any others that have created a block of time in the clinical curriculum —a clerkship, if you will—devoted solely to those kinds of experiences and the course work associated with them. Of course, schools might well be employing other approaches for exposing their students to the issues. But as far as I can tell by searching the CurrMIT database and by querying the associate deans responsible for curriculum issues, very few schools are presenting material on the health care system or health policy in any truly meaningful way. As a general rule, the curricula of most schools contain only a few lectures related to relevant topics, most often in a course about the roles of doctors in society. The curricula of many schools have no sessions devoted specifically to health system or health policy issues. These observations suggest that the faculty of most schools see little reason for medical students to learn about these issues or have not yet determined how to integrate the material into their curricula.
No one can reasonably argue that health policy issues are unimportant. Anyone who doubts this needs only to note the attention paid to a variety of health policy issues by politicians and the prominence given to coverage of the issues by the national media. Most people in this country are concerned about the cost of health care, and many worry that they may be unable to afford to purchase the insurance needed to protect them and their families from the potentially devastating impact of medical bills. And senior citizens are concerned, of course, about the future of the Medicare program. Among other things, they worry that changes in the program may require them to shift their care from the doctors they now trust to other providers they don't know. Those who receive health insurance as an employment benefit have the same concern when their employers present benefit options during each year's open enrollment period. Granted, these are serious issues, but is there any reason why students and residents should be exposed to them in any depth during the course of their studies?
As a general rule, those who reply “Yes” to this question tend to believe that knowledge of the issues would make doctors more effective advocates for specific policy positions that might benefit society at large. For example, they would argue that if doctors were more knowledgeable, they would be strong advocates for universal health insurance coverage so that everyone in this country would have access to needed health care services. I agree that this is a sufficient reason for integrating health policy and system issues into the medical school curriculum. But let me suggest an additional reason why it is important for doctors to understand the issues better than they do now.
I believe that doctors who are better informed about our health care system and about contemporary health policy issues could use that knowledge to help their patients deal with specific issues that concern them. Unfortunately, statements made by politicians who support or oppose specific legislation, and the rhetoric of political campaigns, often lead individuals to believe that they may be in jeopardy of losing access to the care they need or access to those currently providing their care. Doctors need to be able to educate their patients about the issues so that their care is not complicated by undue anxiety. Doctors who have a good understanding about how medical care is organized and financed, and the various insurance options available, could help alleviate some of the anxiety patients have about the cost of their care. I think it would also allow them to be more open in discussing with patients the cost implications of various options available for the diagnosis and management of their conditions. This would enable patients to be more involved in making decisions about their care. What I am suggesting is that if health policy and health system issues were more integral parts of medical education, physicians would be better able to help their patients deal with concerns about how specific aspects of policy and the system might affect them.
So I would like to see future doctors learn how health care is organized and financed in this country; how our health care system evolved to be what it is; how our system contrasts with those of other industrialized countries; and what might be done to influence changes in the system over time. Let me emphasize that I do not want medical students and residents immersed in health policy studies for the primary purpose of becoming advocates for positions that would be in their self-interest as practitioners or for positions likely to benefit the medical profession. I want them better educated about health policy and health system issues because this would enhance their ability to help their patients.
I am not alone in believing that this is an important issue for the medical education community to address. In recent years, several expert panels have recommended that doctors learn more about contemporary health policy issues. For example, the first Medical Schools Objectives Project (MSOP) report—a report that provides guidance to medical school deans and faculties about the content of their curricula— includes a set of learning objectives related to health policy issues. Those objectives were delineated further in the second report issued by the MSOP expert panel on population health. More recently, the Healthy People Curriculum Task Force, a multidisciplinary group convened jointly by the Association of Academic Health Centers and the Association of Teachers of Preventive Medicine, has identified health services and health policy as one of four relevant domains that should be covered in the curricula offered by health professions schools. Similarly, a committee charged by the Institute of Medicine to examine the teaching of the behavioral and social sciences in medical schools also has concluded that medical students should learn about the health care system and health policy issues.
I hope the article by Finkel and Fein will stimulate medical school deans and faculties to consider how they might best expose their students to these important issues and then to take steps to see that appropriate material is integrated into the curricula offered by their schools. If they do, we will all benefit.
Michael E. Whitcomb, MD