BY: AARON MICHELFELDER, MD
The landscape of medicine is continually changing, and with so many advancements in technology and the increasing emphasis on patient-centered care, the pace of change can be dizzying. As medical educators, our role is to ensure that the doctors of tomorrow are ready for the future we can see coming and prepared to adapt to the changes we cannot even dream of today.
For example, we can see health care moving from a model in which a single provider — usually a physician — takes care of an individual patient to one in which a team of health care professionals collectively takes responsibility for an individual patient's care and well-being. Where every decision about a patient used to be routed through the physician, in the new model leadership is fluid. Everyone on the health care team is responsible for taking charge of the patient's care within his or her own level and area of expertise.
The current growth of the patient-centered medical home concept is moving patient care in this team-driven direction. Here is how it works: I recently saw a patient who had lost her health insurance due to a change in marital status. Before that office visit, a nurse arranged for the patient to work with one of our health system employees who specializes in helping people explore their coverage options under the new Affordable Care Act. Then, the nurse assessed the patient's health maintenance needs — had she gotten a flu shot? Did she need medication refills? By the time of our appointment, the patient was signed up for health insurance through the Illinois health exchange and had received all recommended vaccines.
In the new model of health care, the nurse identifies a health need from his or her perspective, as do other team members such as a nutritionist or social worker. We are intentionally building teams centered on the needs of the patient so that the collective expertise and wisdom of the team work to determine the best care, rather than leaving sole responsibility with a single physician.
The team approach means, more than ever before, a physician needs to know how to be a good team member and how to communicate effectively. At Loyola University Chicago's Stritch School of Medicine, we believe physician education, therefore, must include team communication and leadership skills, along with interprofessional experiences. We believe physicians, nurses, social workers, pharmacists, physical therapists — in fact, all health care team members — need to start training together early in their education so that they are prepared to be high-functioning team members.
Interprofessional education occurs "when two or more professions learn with, from and about each other to improve collaboration and the quality of care."1 Schools of nursing have been teaching these skills to their own students for many years, and Loyola's nursing school has been a leader along the way. Through Loyola's new Health Sciences Division interprofessional education initiatives, Loyola's health professions schools are collaborating to provide these critical interprofessional interactions.
One of our interprofessional activities is a day in which undergraduate and graduate nursing students train with third-year medical students to learn — and practice — communicating with each other in a standardized way about a patient's care. Similar to a pilot's conversation with a control tower, standardized communication leads to ensuring that all the important details are accurately and completely relayed among health professionals.
During this particular session, nursing and medical students work side by side in teams co-facilitated by a nurse professor and physician professor to use the technique of SBAR — Situation, Background, Assessment and Recommendations — as the template to convey patient information to each other. Students begin the morning by observing a physician and nurse model the SBAR technique, and the students assess the effectiveness of the interactions and provide feedback. Then, the students role-play similar interactions while receiving an evaluation and feedback from their peers and facilitators.
Another interprofessional activity focuses on better understanding what a holistic approach to patient care means. It goes without saying that, just like any of us, a patient is a person with a life beyond his or her illness. As a patient care team, however, we need to start recognizing and looking at all the factors that are affecting the patient's life and health. We think one of the best ways to accomplish this is to walk a mile in someone else's shoes.
In February 2014, Loyola hosted a poverty simulation in our community of Maywood, Ill., which is a relatively impoverished, predominantly African-American business and residential area surrounding Loyola's Health Sciences Division campus. Loyola faculty, staff, nurses and students met in a Maywood church and worked in teams to role-play and take part in exercises exploring the challenges impoverished patients face that might contribute to poor physical or psychological health.
We need to help our doctors of tomorrow to not just understand diagnosis and treatment, but to understand all of the social, biological, psychological and spiritual aspects of illness and health for individual patients. These issues are just as important to a patient's care as cholesterol or blood sugar levels.
For example, an elderly patient might be losing weight because she is socially isolated and, because she is alone, she doesn't eat properly. Or, as happened to me, a patient frequently arrives so late for her office visits that she has to reschedule. One day I picked up the phone and called her about it. That's when I learned she had no car and needed to take several buses over a long distance to get to me. The buses were rarely on time.
So, my patient's blood pressure was uncontrolled, because she could not get in to see me, because a bus was running late. Her social situation's direct impact on her health is exactly the kind of thing her health care team needs to understand, in order to care for her as a whole human being. With this new knowledge of the patient's situation, the staff could be ready to squeeze her in to see me on appointment days even if she arrived very late.
Along with participating in holistic care of the individual, physicians, health care teams and hospitals more and more are moving away from the fee-for-service model. Compensation will be a bundled payment system in which health care teams will be paid by quality incentives or disincentives. This model will require us to become more creative about administering care and allow us to move interactions to an outpatient setting, such as Skype, email, even home visits
At a recent patient care team meeting at Loyola, for example, discussion centered on a patient who made many visits to the emergency department because she could not afford continual asthma medication. Between paychecks, when she ran out of refills for her inhalers, she would go without. Without treatment, her condition got worse, and she would wind up in the emergency room. Her physician had tried to change her to more inexpensive medications, but they just didn't work as well.
The solution: Loyola paid for her asthma medication, giving our patient better health, a better life, fewer visits to the emergency room — and significantly less health expense overall.
TECHNOLOGY
Our students are technology-savvy, and innovations such as smartphone apps to track daily blood pressures or blood sugars offer exciting possibilities for monitoring chronic conditions. In the pursuit of new avenues — and best uses — for technology in patient care, however, security remains a huge issue. Currently, email is not a secure way for patients to communicate with physicians, since email is easily hacked. We use a patient portal called MyLoyola where patients can log in to their electronic medical record at Loyola and request prescription refills, schedule appointments, view test results and ask health-related questions which go directly to their physician and nurse. Patients often say they are surprised at how quickly they receive an electronic response.
PHYSICIAN WELLNESS
It is an integral part of our curriculum to prepare students for the transitions health care is making, a changing scene encompassing more care in outpatient settings and fewer individual private practices. The business trend is toward consolidated health systems. Many hospitals are closing, and many outpatient centers are under the umbrella of health systems, allowing physicians access to numerous specialists in a variety of fields as close as a phone call, email or a few steps down the hall.
In giving up the administration of individual practices, physicians are gaining more free time, more work-life balance and more opportunity to address their own physical and psychological health. There is growing recognition that health care is a high-stress, high burnout occupation, and we health care providers need to learn to take care of ourselves before we can take care of others.
Every year, about 300 physicians commit suicide, more than any other education-matched profession. At Loyola, we are set on working to prevent these horrible tragedies. Our medical students are now trained in "physician wellness," which focuses on developing skills to ensure career and life satisfaction. Suicide prevention, exercise, meditation and reflective writing are all important components.
As a Jesuit and Catholic medical school, our university ministry is focused on the overall well-being of our students, and it is in constant contact with them. Our curriculum has built-in, required weekly reflection and advising sessions for first- and second-year students, and every six weeks for third-year medical students.
We also teach a course called "The Healer's Art," created by Rachel Remen, MD, at the University of California, San Francisco School of Medicine, as a method to build burnout-prevention skills. Taught at more than 100 U.S. medical schools, the course teaches first- and fourth-year medical students such self-care practices as how to grieve, how to connect with awe and wonder, deep listening and how to examine their own reasons for choosing medicine, among other skills.
The changes in managing the health of populations in accountable care organizations, along with the new models of team-based health care within patient-centered medical homes, interprofessional and new models of medical education, are transforming health care into an exciting, diverse, robust, innovative and creative field. However, the most important skill we can instill in our physicians of tomorrow is the ability to adapt to an ever-changing world while remaining grounded in what matters most: the care of our patients.
AARON MICHELFELDER, MD, is professor and vice-chair of the Department of Family Medicine at the Loyola University Chicago Stritch School of Medicine and associate director of the Institute for Transformative Interprofessional Education, Loyola University Chicago Health Sciences Division.
NOTE
- Centre for the Advancement of Interprofessional Education, http://caipe.org.uk/resources/defining-ipe/ accessed on Feb. 18, 2014.