Why Neurology Residents Need to Get Involved in Health System Reform
At this year's AAN annual meeting, it was gratifying to see neurology residents express an interest in advocacy. Many said the passage of the health reform bill had motivated their interest, but they knew little about the details of the legislation. I too remember being enthusiastic about getting involved, but at the same time, feeling daunted by having to learn the new language of policy-speak and a new set of three letter acronyms.
My journey began when I became the AAN resident and fellow delegate to the AMA in 2008. The more I participated in the process, the more I transitioned from a passive bystander to an impassioned advocate. With health care reform our new reality I hope other neurologists — especially those just beginning their careers — will become activists, as well.
Clearly, the passage of the Patient Protection and Affordable Care Act will fundamentally alter the landscape in which we practice. These changes will affect our graduate medical education and the way we care for our patients. Most importantly, many of the law's provisions will be implemented as we enter practice or start our academic careers.
FOCUS ON TRAINING
To start, neurology residents should review their curriculum to make sure it meets their needs as a 21st century neurologist. Current neurology resident education focuses on knowledge of the nervous system and neurological disease. But will that fully prepare us for the new law's emphasis on evidence-based medicine? We will need to get onboard this trend as Medicare's Physician Quality Reporting Initiative (PQRI) increasingly encourages physicians to adhere to quality care guidelines.
The opportune time to learn and practice these evidence-based guidelines is during our training. The AAN publishes one of the most comprehensive set of practice parameters of any specialty organization. Yet, many residents, including myself, have little formal exposure to these guidelines. I can count on one hand the number of times these parameters have been mentioned at a noon conference. It is currently up to individual residents to look up the parameter at the bedside. As we move forward, it is critical that we infuse the resident curriculum with these parameters as our clinical practice will be graded based on how well we follow them.
In addition to increasing training focused on evidence-based medicine, we need to do a better job of educating residents about health system policy. In conversations with fellow residents, I've learned that many are interested but lack familiarity of pertinent policy issues. My own personal experience is that the education is ongoing; at every American Medical Association meeting I learn about new issues facing residents.
This literacy can be enhanced by adding several policy sessions within the curriculum. The study of health system literacy would best be covered within the Accreditation Council for Graduate Medical Education (ACGME) systems-based competency but this competency has not been emphasized previously. Given the information overload residents are exposed to, it is easily missed. Health system literacy will be a key to preventing additional shortcomings in future legislation.
The newly created online AAN communities offer a step in the right direction, providing us with a forum to share information about regulatory and policy matters at the federal, state, and local level, and discuss matters germane to neurology residents. (For more information about the AAN communities, see www.aan.com/go/education/residents.)
HOW WE CARE FOR PATIENTS
Finally, this bill is likely to change how we take care of our patients. The legislation will expand patient coverage as well as finance demonstration projects testing care models that improve quality and slow the rate of growth of Medicare. This is likely to lead to many more patients seeking medical care as well as exacerbating the primary care shortage.
I hope that removal of the insurance barrier will improve access to needed neurological services. I have seen several patients without insurance whom I have diagnosed with multiple sclerosis. By the time these patients had sought care they had symptoms for years and thus suffered chronic disability that was irreversible. Once the diagnosis was made, there were additional barriers in arranging for medication coverage, rehabilitation services, and referrals for disability benefits as these patients were no longer able to work. Health system reform ought to provide these patients earlier access to our services and facilitate our ability to coordinate care, thus improving the overall quality of care.
But I am concerned too that this will place increasing burden on neurology practices. Improving access to neurological care may increase the demand for our services. We need to evaluate our clinic model to assure that all patients have access to timely care. For patients with neurological disease, the worsening shortage of primary care physicians means resident continuity clinics and other neurology practices will be obligated to provide a broader scope of practice. Attention to comprehensive care during the residency training continuity clinic will provide a more rewarding experience for both our patients and the neurologists who care for them.
One of the most exciting legislative developments is the creation of a center to fund demonstration projects for alternative methods of care. Like most residents, I have been exposed to physicians who have been forced to increase their volume to cover overhead costs and been left burned out. The current fee-for-service model creates a volume-based system that may sacrifice quality. I look forward to participating in an alternative care model that emphasizes quality of care. As residents, we can play a role in shaping the model in which we practice.
For example, we might advocate for better, more coordinated systems for sharing medical information and, more specifically, electronic medical records. I often see patients who come in without their prior records of testing or medication records. On the inpatient consult service, we duplicate an extensive evaluation done by a community neurologist. These practices force us to work with incomplete knowledge, and ultimately, contribute to the rising health care costs. Many of our patients have chronic conditions that require frequent admission to the hospital.
An alternative model of care should address some of these challenges by creating an electronic record that is widely available to all consulting physicians. Rather than create a division from the outpatient to the inpatient setting, this model should work to integrate the outpatient neurologist with the inpatient team. This model should provide reimbursement to the entire team, encouraging the accountability of each member. We, as neurologists should work with other involved parties to improve this model. Many of these proposals start at the state level; this provides an excellent opportunity to interact with the state neurological and medical societies. These organizations are easily accessible, don't typically require significant traveling, and are looking for interested residents.
I hope residents take the time to participate in the AAN advocacy programs, as well. They provide opportunities for residents to have an impact on important policy issues and to stay informed about legislation and regulations that will affect them. The AAN Action Alerts provide a quick and easy method to address Congress on matters of import. Many of these alerts take less than a minute to send and go a long way to educating our legislators. Take the time to participate in the annual AAN Neurology on the Hill event, which sends 100 members, including residents, to meet and lobby their congressman and provides training in lobbying, education about key issues, and interaction with congressional staff. Apply for the Palatucci Advocacy Leadership Fellowship, a four-day intensive training program for neurologists on how to pursue advocacy matters important to them.
As we enter this evolving health care landscape — buoyed by the 2010 health reform law — there are ample opportunities for neurology residents to get involved. Clearly, the new legislation will have an impact on our success as we begin our careers. And so we must assume leadership as advocates to shepherd neurology as we enter and participate in the new and changing health system.
Dr. Johnson is a fourth-year neurology resident at the University of Rochester Medical Center in New York.
For more information about the Palatucci Advocacy Leadership Forum, visit www.aan.com/go/advocacy/active/palf. The 2011 Forum will take place Jan. 13-16 at the Rancho Bernardo Inn in San Diego, CA. The application deadline is Sept. 19, 2010.
For more information about advocacy programs through the AAN, see www.aan.com/go/advocacy