What do we need in Health reform?

Just read this article in the NY times by Pauline Chen M.D. Also I just recently completed my in-patient rotation in the hospital where I was very disheartened by the fact that almost every patient I saw had been in the hospital recently and was very likely to get readmitted in the next 6 months.

Our burden of chronic disease is huge and growing. In a lot of cases the patients' lifestyles contributed to the chronic disease. We are spending huge chunks of health care dollars to treat these patients and keep looking at ways to cut this spending to decrease health care costs - the totally useless "length of stay" parameter comes to mind.

What we need to do is invest in the future so we can change lifestyles before they lead to chronic diseases. Also, we need to provide early treatments of chronic conditions like hypertension before we get into renal failure, heart failure and strokes. This will let us have a healthier productive tax-paying population that will help balance the budget.

The article points out how frequent contact between physician and patients may help in changing lifestyles and improve compliance with medications. With the advent of social networking tools we don't need to physically bring the patient into the office for this purpose. We can repurpose/create secure social networking tools for this.

The barriers:

1. Physicians are inundated with work... a lot of it due to bureaucracy - filling out forms, documenting for purpose of billing, multiple pharmacy call backs due to multiple/illogical formularies
2. There is no model for reimbursement for physician-patient contact outside of the office. And the payment is for the complexity of the office visit. Thus if you call and talk to the patient 15 times in a year and get him to take his meds, exercise and lose weight, you would be paid zilch! But if you see him twice a year, give him more medications as his diabetes and blood pressure go up and he gains weight, and then see him in the hospital when he get a heart attack you gets tons of money.
3. Due to point # 2 the health care system is too top heavy with more specialists than generalists. Hospitals have invested huge amounts of money into high tech and not much into prevention.
   

If we want physicians to work with patients to prevent onset of chronic disease or complications of chronic disease, we need to change our financial model for reimbursement. We need to pay health center to prevent outcomes. We need a secure networking tool that can allow patient - physician communication, motivational "interviewing", and a way to pay for this.

Do our medical schools need to adopt new education technology?

A recent article in Campus Technology by Trent Batson "Horns of the Dilemma for Faculty: Legacy Demands and Technology Expectations" discusses how universities have failed to change while educators have adopted all the web 2.0 technologies at home. Also there is this terrific presentation.

Purdue Tlt 09 Robbins

View more presentations from Sarah Robbins.

How does this apply to medical education? Is it important to adopt new technology for teaching our medical students? I love technology but I find myself thinking that the battle we need to fight is to make medical school education more student centered and not necessarily the immediate adoption of new technology.

Going from lectures to problem based learning is more important than changing the old chalkboards to electronic whiteboards! Getting our medical schools to move from grades to portfolios would be worthwhile cause to fight for but Portfolios can be done on paper. Students can use a paper textbook, they don't have to start medical school with a Kindle DX loaded with all their textbooks. Students can go to a "real" classroom as long as the "teacher" promotes active collaorative learning, they don't need the presentations loaded on their iPod or a virtual classroom.

Once we get our faculty to adopt a more collaborative and active learning approach, the adoption of the appropriate technology will follow. Technologies will be superseeded by newer ones, but the key principles of education should be more enduring. The current web 2.0 applications seem to be designed perfectly for collaborative learning and it would be great to integrate these into our curriculum delivery and assessments as we make adopt a more constructivist approach to medical education. But if I were to have one or the other, it would have to be the collaborative learning approach and not the technology! It does not have to be a dilema.

Collaborative learning in Medical Education - Where is the Patient?

For a while now I have been muddling over a few thoughts in my head. These were prompted by

1. Medicine's incredible success at treating acute problems and thus bringing chronic problems to the forefront e.g. patient survives a stroke but is left with bed sores, incontinence OR survives an acute heart attack and is left with congestive heart failure. A William Schwab put it at a recent grand rounds, "Success brings failure" and thus our success in treating acute problems has brought us an excess of chronic problems.
   
2. Increasing popularity of social media tools like Facebook, Twitter and Second Life. A recent study that I discussed earlier showing students were more likely to use Facebook for a course discussion than the University's learning management system.
   
3. Medical education moving from a traditional "talking to the boards" model to a small group collaborative problem solving model - can we use this momentum for including patients into the learning "group"? This thought was resurrected by a post I read by Anne Marie Cunningham.
   

It seems that learning how to treat an acute problem is something we can do well in our current model of education which has minimal involvement of the patient (in most schools). As our population ages, has more chronic problems, a model that does not involve the patient in the learning process is not going to succeed.

Thus we know what an obese patient with poorly controlled diabetes needs to do to bring his/her condition under control and maintain it there. Patient also often knows this. Still optimal outcome occurs only rarely and if it does, it is not sustained.

In managing chronic conditions, the patient has to learn to take control of his/her condition and the physician is only a part of the solution to make this happen. Our medical students learning is designed to occur either in classrooms or in hospitals - both of which are perfect for acute condition management. The exposure to outpatient chronic condition management where they can interact with the same few patients longitudinally does not occur in most schools.

The reasons for this are mostly logistic. Scheduling students to be in the clinic the same time as specific patients is a logistic nightmare. How about a model using social media?

Can we have students create limited, private accounts in a social media site like Facebook or create a specific site using Ning and invite consenting patients to be their "friends". We could have a list of patients with different conditions and abilities to use these social media tools. The sites would not be accessible except to invitees. The students would collaborate with a set of patients over their entire medical school experience. The patients would post/tweet about their symptoms, office visits, hospitalizations, test results and the students would learn/read up about these and explain these to the patients. In addition, they would work on skills like motivational interviewing, negotiated goal setting to help the patients take better control of their conditions.

This model will allow students to learn the role they have to play in management of chronic conditions and prepare them for the future!