In a few days I will finish my internship. When I look back, I’ve honestly had a good time. It’s been busy, with long hours, and little sleep but I learned a whole lot and enjoyed being able to treat a patient as truly my own, without having to search for a resident to co-sign my orders like I had to in medical school. Although, for my own sanity, I’ll ignore the pages at 3am from nurses informing me their patient hasn’t had a bowel movement in however many days or that they have a “fever” of 99.1F.
There are a lot of thoughts I have at the end of this year. I’d like to relay a few that I think relate to the policy points we talk about on DFA Progress Notes.
1. Disease can strike anyone. Right now on my census are two patients, each around the same age and each with a stroke. One patient has no cardiovascular risk factors, ran marathons, has no family history of early stroke or heart attack, and has an extremely nice and supporting family. My other patient has known severe hypertension that was uncontrolled due to medication noncompliance, is obese, smokes like a chimney, has a strong family history of early cardiovascular events, and occasionally samples some of the street drugs that he deals. In either case we treat the patient with the same quality of care regardless of whether they “were a set up for it”. Indeed, the latter patient needs even more effort on the part of the medical system to ensure he gets the care he needs. At times it seems proposed policies espouse punitive measures against those with the worst habits or specifically try to make savings through cutting programs for those with the least resources. I argue that to promote better outcomes we need to target services to encourage our latter patient to be more like the former – although there’s no guarantee that doing so will ensure they never suffer a stroke or similar adverse event.
2. Residency training should include education in health policy. Rounds, morning reports, and noon conferences at my hospital offer the standard menu of interpreting ABGs and studies on rate versus rhythm control for atrial fibrillation. However, what’s missing is discussion of the “meaningful use” provision for Health IT adoption and what the ACO Shared Savings Program means for solo practitioners. Based on conversations with friends in other programs around the nation, this isn’t unique to my program. American medical practice is soon going to be determined almost as much by the policies that Congress legislates as which antihypertensives has evidence in heart failure management. Seeing as residency is learning to put into practice the basic science we learned in medical school, we should get specific training on what these policies will mean for our practice.
3. Medical residency and fellowship training needs to be streamlined. One of the incoming interns I will be signing off to did the coronary angiography study for a patient I discharged last week. He completed cardiology training in Israel and a fellowship in interventional cardiology at my hospital. But, to practice in the US, he now has to complete an internship and year of residency at our hospital, after his fellowship. How does that make sense? With an ever-increasing emphasis of subspecialization, training in medicine is becoming ever longer and more convoluted. Seeing as residency and fellowship training is essentially indentured servitude, medicine is becoming a luxury profession – in that you have to significant financial support from outside sources (e.g. parents, spouse, loans) beyond your brains and hard work just to be able to practice. This, to me, also doesn’t make sense.