Posted by: notdeaddinosaur | March 20, 2016

“System” Nonsense

Being a doctor is hard. There’s a lot you have to know, whatever specialty you go into, and that includes rote information about how the body is put together, how it works, how it goes wrong, and how to fix it. We also must always keep in mind that these are people we’re dealing with, not just bodies, so we need to learn how to take care of sick people.

As doctors, our job is to figure out what is wrong with our patients (diagnosis) and what to do about it (treatment.) We don’t necessarily do this all by ourselves. We have colleagues who help us by performing consultations, studies, and procedures. But the bottom line about being a doctor is we are the ones who make the diagnosis and figure out the treatment, even if then carried out by others.

We can also turn to many other people who can help us take care of our patients: nurses, physical therapists, social workers, home health aides, and so forth. They can help provide us with information, sometimes crucial, that help us make the diagnosis or refine the treatment. But diagnosis and treatment is the definition of medicine. It is our job as doctors.

Medical school is where we begin learning how to be a doctor. It’s a process that continues through postgraduate residency training, and throughout decades of practice. It is laughable to think that medical school is the only place we’ll ever learn what we need to know. It’s four years that seem forever at the time, but in retrospect seem scarily short. Same thing for residency. Looking back, Imposter Syndrome seems entirely justified.

Of course it’s vitally important that those four years are used wisely. Which is why things like this really piss me off:

Many medical school students don’t know the difference between Medicare, which is for seniors, and Medicaid, which is for the poor.

It doesn’t hold them back in medical school. But after they become doctors, not knowing the basics of the health care system can prevent them from understanding why their patients can’t do or get the things needed to be healthy….

The AMA’s Dr. Susan Skochelak said “what [doctors] haven’t been good at is often what patients care the most about.” That includes things like finding their way through the health care system, understanding what their health care providers are telling them, and overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders.

In addition to everything else we have to know, med schools are adding “Health System Fluency” in order to fix this grievous defect in medical education. Students will now be:

[S]ent to a local family medical practice, and given the role of health care “navigator” for three patients.

Her role involved becoming familiar with the patients’ ailments, talking to them on the phone and visiting them at home. In the case of one who claimed to be taking prescribed medications, but whose blood work suggested otherwise, a home visit by [the student] revealed the patient’s neurological condition prevented the patient from opening childproof bottles, resulting in missed doses. Contacting the pharmacist provided a remedy.

Another patient who had a high sodium level told of regularly dining on spaghetti with red sauce, which didn’t seem like a problem. But [the student] in her navigator role discovered the patient was eating canned spaghetti that was very high in sodium.

Leaders of the effort say doctors need such glimpses into the real lives of patients in order to fully grasp their illnesses and fully serve them.

Hey, I get it that home visits provide tons of information. Even though we may not have done them in medical school (mainly because we were still too busy learning all the basic stuff we didn’t know yet) of course we were taught that the hospital environment was terribly different for our patients. I did house calls in residency, where they taught me how to function in an environment other than the exam room or hospital ward.

Look again at what Dr. Skochelak lists as things doctors haven’t been good at that patients care about most:

  • Finding their way through the health care system
  • Understanding what their healthcare providers are telling them
  • Overcoming financial and other barriers that might prevent them from taking medications and otherwise following their doctor’s orders

Everyone talks about the “health care system” as if it’s a thing. What the hell is the “health care system” anyway? One of the most important things to help people “find their way” would be hospital signage. Where do they park? Where do they check in? Where are they supposed to go? I can and do give people very detailed directions and instructions, but a lot of this “system” stuff isn’t medicine and doesn’t require 7+ years of post-college training to provide.

Understanding what we’re telling them? All through medical school, even as we learned the specialized terminology of our profession, our jargon, we were also told not to use it when talking to patients. Some of us are better at it than others. I often listen to other doctors talking to my patients and cringe. But just because many people don’t use clear enough language when speaking with patients doesn’t mean we weren’t taught it. Keep teaching it, by all means, but don’t kid yourself that this is something unique to 21st century medicine.

And what about these barriers? Already in medical school we are taught to use simple regimens (once daily medication dosing whenever possible), generic medications, easy-open pill bottles. We know this stuff. Again, we may not always do it as well as we could; some more than others. But there’s nothing innovative about it, despite the fact that medical schools are finding new ways to siphon away precious curriculum hours.

Here’s what I want to know, though: how is doing the work of a visiting nurse or social worker going to help medical students with any of those three things, or anything else, for that matter? You can list objectives, but what good is it to design a program that doesn’t address any of them? It may achieve different objectives, but are they worthwhile ones? Seems like rather a bait-and-switch to me.

Here’s their bottom line:

Without a solid understanding of the health care system, doctors can’t fully function as “change agents,” said Dr. Jed Gonzalo, the associate dean of health systems education at Penn State Hershey College of Medicine.

I’m a doctor, dammit, not a “change agent.” Whatever the hell that is. Medical students need to learn to be doctors, and not let themselves be sucked into the “system.”

In the end, the best way — the ONLY way — to help the patient is to be the best damn doctor you can.





  1. Very interesting indeed. What struck me is that what you say applies not only to doctors but also to those in other professions. Three years of law school do not make one an expert lawyer and lawyers, accountants, real estate agents, stock brokers and those in other professions must continue to increase their knowledge and develop their skills after they have completed whatever formal training they had to complete in order to be certified or licensed.. Along the way they must learn of legal , technological and other changes and they must learn from their own experiences and the experiences and knowledge of others, including those who are younger and who may well have seen and done things one has not yet seen or done. They should, moreover, continue to strive in improving their ability to interact with their clients or customers and meeting their needs. Finally, there is no limit to learning because even as one approaches the end of one’s career there are always new things to learned.

  2. The health care system truly is complicated and I would be in favor of students learning more about it. These examples unfortunately do not illustrate the problem. What about the patient who calls with a problem which you think requires an urgent MRI? Who do you call and where do you send them, and do they need a prior authorization or not, and how could you expedite it? Does it matter if they are Medicare, HMO, or PPO? What if they have no insurance? Should they go to the ER which is already crowded? This is much more valuable knowledge than learning all the steps in the Krebs cycle, in my opinion.

  3. George [amusing, as I happen to know the xCOG’s given name]:
    Although information about the mechanics of accessing specific services within the “system” is helpful, I think it’s more important for students to be learning WHY a given patient needs an MRI, what that patient looks like, what kind of history, exam findings, lab studies, and other information to expect, along with the reasons why the study cannot wait. Especially since that’s the kind of stuff you need to know to get the pre-cert. (Hm; followup post idea.)

  4. “Change agents” my foot. Just another crock of you now what foisted on us by nondoctors who think they should tell doctors what to do. And the hell of it is, a lot of us let them.

  5. Dinosaur:
    Good news: You are 100% correct.
    Bad news: That train has left the station.
    Worse news: I don’t think there is another one coming.

  6. […] as what should be taught, and when, and who should teach it. But recent calls for students to “gain fluency in [health] systems” are completely misplaced. Here’s […]

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