In the class I teach on chronic illness for UC Davis medical students, I am trying to get my students to see illness in a new way. I want them to be more pro-active rather than simply re-active, to anticipate their patients’ diseases and conditions, and to help their patients stay healthy, rather than treating them only when they are sick.
I believe this is not only the right thing to do. It may also be the only way our family medicine physicians will be able to cope with the rising pressures coming with an aging population and an expanded workload brought about by the recently passed federal health reform, which will broaden access to health care for millions who have not had it.
I am the instructor for Chronic Illness Studies, a senior elective for UC Davis medical students. The rotation draws those interested in primary care as a career. My students come to me in a context in which nearly all of their clinical rotations during the latter half of medical school center on direct, one-on-one patient encounters within the confines of the examination room or hospital bed.
In the outpatient setting, much of chronic care focuses on titrating medications to specific endpoints of blood pressure, cholesterol, or glucose. In the hospital, the chronic condition experience extends to symptomatic organ dysfunction, such as heart attack, stroke, or kidney failure. Invasive treatments are par for these encounters–dialysis, intubation or surgery.
For generations, educators have threaded the refrain “see one, do one, teach one” throughout patient rounds. In turn, the process of learning is perpetuates a self-contained, episodic, and reactive approach to decision-making.
I frame the course differently, as a reassessment of perspectives and perceptions, starting with “see the big picture; do seek out non-medical personnel; and teach thinking.”
Upon entering residency after graduating from medical school, students will face the charge of managing chronic conditions with legislated mandates demanding efficiency, effectiveness, and innovation. Beyond knowledge, they need skill sets in leadership and coalition building, elements not prioritized in medical school or in residencies.
I bring UCD Chronic Disease Management programmer Larry Taylor into the curriculum. Larry sits down with the students and asks how they want to manage their panel of patients with chronic conditions.
While doing so, Larry quickly points out that he is not a physician. The students must therefore understand the scope of a programmer’s work and how to integrate those skills into improving health outcomes for their patients. With guidance from Larry, students began to formulate questions that provide insight into their patient population.
How many patients with diabetes have not had an eye exam in the last year? Which patients have not picked up their cholesterol medications within the past six months? Do patients’ blood pressures differ based on zip codes? Once the students provide Larry with direction, he generates reports that students can share with nurses, health educators, and other health care providers. Now, students are armed with resources that facilitate their emergence as team leaders.
Next, we take a field trip to Sacramento Municipal Utility District’s [SMUD] office to see their employee health/wellness program. Daily, employees may spend eight to ten hours at their workplace, and likely eat at least one meal there.
Compared to the average quarterly 15-minute appointment for patients with chronic conditions, the worksite is an overlooked ally in influencing patients’ decisions for healthy behaviors. This setting is an opportunity for working towards shared goals: the employee/patient improves his health; the employer reduces expenditures through lower health insurance premiums and decreased employee absenteeism from illness; and, the physician is able to manage chronic diseases in a population-based approach.
Under the guidance of Wellness Program Director Joy MacPherson, SMUD has made a concerted effort to improve the health of all of their employees, those with chronic conditions and those who can prevent the development of such conditions. The SMUD program has won a state Wellness Task Force award for their comprehensive program.
The students’ eyes widen and their minds open as they see the atrium-like exercise center, the roving movement coaches, and the onsite reduced sodium/fat cooking classes. The students begin to consider the possibilities of working with employers in improving health conditions for a shared patient/employee population. This may have even greater application if a physician practices in a non-urban area with only one to two major employers.
I provide these experiences as a fulcrum instead of a counter-balance. My intention is not to undue or to minimize the value of clinical skills in the traditional patient-physician relationship. Rather, my goal is to expand routes of interaction with patients so that students have the ability to navigate around barriers of myopic models of health care delivery.
Dr. Ronald Fong, M.D., M.P.H. is director of the Family Medicine Residency Network at the UC Davis School of Medicine.