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Physicians

Mistakes are every doctor’s nightmare, but what to do about them?

Dr. Howard Cohen spent nearly 30 years as an infectious disease physician in Atlanta.

He treated people with everything from the flu to malaria.

He was a highly respected doctor, recognized in his field. But about a decade ago, Cohen made a mistake that he has never forgotten. And he doesn’t want to forget.

At the time it happened, he was far from a rookie. He was a seasoned professional at the top of his game.

As Atul Gawande — a Boston surgeon and bestselling author — put forth in a 1999 article in the New Yorker magazine, “When Doctors Make Mistakes,” many medical mistakes are made by good, highly regarded doctors, not by the habitually negligent.

And critical mistakes occur often. A recent study in the Journal of Patient Safety said that  210,000 to 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death.

YouTube Preview ImageCohen’s mistake was simply a mix-up, but a troubling one. It all started when two of his patients, whom he calls A. Jones and B. Jones, visited his private practice office at about the same time.

The two women had the same last name, but different first names and very different prognoses.

A. Jones was a patient of Cohen’s with a known blood abnormality, and Cohen ordered laboratory tests to determine whether her condition had worsened.

B. Jones, on the other hand, was a healthy woman who had come in for a periodic check-up. Cohen found nothing out of the ordinary during an examination, but as matter of routine, he had a sample of her blood drawn and sent to a lab for testing.

In the rush of a busy practice, mix-ups can happen.

Numerous lab reports arrived at the office every day and were stuffed into patients’ charts, where doctors read them and acted on them. In the hurried atmosphere, most doctors never questioned whether a particular lab report was in the right folder.

When Cohen looked at the test results in B. Jones’ folder, they showed significant abnormalities suggesting leukemia, even though she had seemed healthy a few days earlier. He immediately reached out to her and asked her to come in for a face-to-face consultation.

B. Jones came in the next day and got the totally unexpected news that she appeared to have a serious illness.

“I feel fine,” she said, but she was also stunned and frightened.

But then her gaze focused on the chart in Cohen’s hand, and she saw that something was amiss on the lab paperwork. The birth date was not hers.

As it happened, the worrisome test result actually belonged to A. Jones, the patient with a history of blood abnormalities. The result had mistakenly been put into B. Jones’ folder.

A wave of relief swept over B. Jones as she realized she was healthy after all and that her doctor had mistaken her for another patient. Cohen was quick to apologize for the blunder.

“I said, ‘I’m so sorry. I’m so sorry I made you feel so stressed for 24 hours,’ ” Cohen recalls. “I said we made a mistake.”

Within 24 hours, Cohen notified A. Jones of her test result. It signaled a turn for the worse in her condition. But given her previous problems, she was disturbed by the news but not overwhelmed by it.

 

Apologizing may go a long way

Cohen felt horrible for the false alarm he had given B. Jones.

“For a night there, I’m sure this lady didn’t sleep,” he says today.

To his surprise, the woman was so relieved when she was told about the mix-up that she gave him a big hug.

This is not as surprising as it seems. A 2010 study from researchers at the University of Michigan and Brigham and Women’s Hospital showed that when doctors apologize for their mistakes, it can actually prevent malpractice lawsuits.

In fact, there are entire organizations devoted to this philosophy.

Sorry Works! Consulting, a company in Glen Carbon, Ill., provides training and resources to health care professionals to teach them to disclose when they have committed an error and apologize to patients and their families.

The company was started in 2005 by consultant Doug Wojcieszak. He had lost a brother to medical errors in 1998, and his goal was to reduce malpractice lawsuits as well as medical errors.

“It’s often not bad individuals, it’s poor systems that get in the way,” says Dr. Scott Richardson, campus associate dean for curriculum at the GRU-UGA Medical Partnership in Athens.

Richardson mentions systems redesign, an approach to health care championed by the Agency for Healthcare Research and Quality (AHRQ), as an important factor in reducing medical errors.

It includes mechanisms like electronic health records and checklists to limit the potential for human error. This strategy has been used to reduce medication errors, delays in performing surgery, and paperwork mix-ups like Cohen’s, says Richardson.

In the New Yorker piece, Gawande described an error he made as a surgical resident in an emergency room. A car crash victim came into the ER with a blockage in her airway, and after Gawande and his medical team made repeated attempts at intubating her, she was no closer to breathing on her own.

She needed a tracheotomy to have the breathing tube inserted through her windpipe rather than orally.

Gawande, who blamed himself for the mistake, said he should have been preparing the patient for a tracheotomy, and instead let the emergency medicine attending physician continue attempting to intubate the patient.

This made her vocal cords swell, and her airway shut down. Eventually, the intubation was successful, but the long period of time she went without oxygen made it unclear how much brain function she would have when she regained consciousness.

In August 2012, Cohen put down his stethoscope to become a full-time medical school professor in Athens at the GRU-UGA Medical Partnership.

Immediately after the mix-up in his office a few years ago, he met with the office manager and the staff to go over their policy for handling abnormal test results and verifying information before calling patients. A clearly defined procedure for notifying patients of lab results can prevent patients from being alarmed unnecessarily.

And ever since that day, says Cohen, he has been more careful himself. He always double-checks in any situation where an error might occur.

He believes that electronic health records — which are increasingly being used in the United States and will become even more widespread under the Affordable Care Act — will reduce the likelihood of medical mistakes. But they will not eliminate them completely.

There is still the human factor.

“Computers may be infallible, but the data put into the computer may not be,” he says.

 

Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at www.ianbranam.com.

 

Who likes the ACA? Top Medicare official says law is boon for seniors

Recent problems with the Affordable Care Act — a poorly functioning insurance exchange website and an uproar over canceled policies — have dominated headlines and reignited political debates.

But Jonathan Blum has a positive message to deliver about the ACA and its effect on the Medicare program, which covers about 1.4 million Georgians.

Jonathan Blum

Jonathan Blum

Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services, says the 2010 health care law has led to better quality of care and more benefits for seniors while containing the costs of the federal program.

GHN recently interviewed Blum about the ACA’s benefits changes, hospital readmission penalties, accountable care organizations, and Medicare Advantage growth, along with medical education funding and possible scams that seniors should avoid.

Q: We’re right in the middle of open enrollment for Medicare beneficiaries. What are your main messages for seniors?

A: The Medicare program is stronger today than in recent memory. The Affordable Care Act has [given] the program more generous benefits, and quality of care is improving by various measurements. And at same time, costs remain very manageable.

There used to be the notion that there was a tradeoff between more benefits and higher quality and costs. What we are seeing in Medicare is growing evidence that we can add more benefits and increase the quality of care while keeping cost growth very manageable.

Medicare Part B premiums for 2014 are going to be the same amount as 2013, primarily due to lower-than-expected cost growth. With the Affordable Care Act’s framework for quality improvements, and to add preventive benefits, we’re seeing growing signs that the strategy is working both for beneficiaries and also for taxpayers who fund the program.

Q: Talk about these new benefits.

A: The two main categories of benefits really change the emphasis of the program. The first is free cost-sharing [i.e., no co-payments] for preventive benefits. Medicare beneficiaries for the first time have the opportunity to have an annual wellness visit with a physician. Screenings like colonoscopies and recommended preventive care have free cost-sharing.

For those who have the drug benefit, the coverage gap is now being narrowed. There is growing evidence that beneficiaries are complying with their drug regimens. Their drug regimens are coordinated with their overall care. They avoid hospital stays and other significant health care events.

The free preventive benefits, and the part D benefit becoming more complete, [constitute] a change in emphasis in how Medicare is oriented — from being a program that only pays for people when they’re sick [to] a program that [also] is keeping beneficiaries healthy for a longer period of time.

Q: When Medicare Advantage was first started, there was a lot of pushback against it. Now these private health plans serving Medicare patients have becoming increasingly popular.

A: I think if you followed the debate on the Affordable Care Act, the notion was the president’s proposal and the act’s ultimate policies to reduce payments for the [private] plans would decimate the program.

Quite the opposite has occurred. We’re at an all-time high in beneficiaries — in [raw] numbers and percent — who have chosen private plans to receive their Medicare benefits. Premiums have fallen on average since the Affordable Care Act. We’ve seen no signs on average that plans have reduced their benefit offerings. The quality of the plans has significantly changed for the better.

Q: This is an example of more pay for better performance by providers?

A: Before the act, we had about 16 percent of beneficiaries with a private plan choose a 4-Star or 5- Star [rated] plan. Today, for 2014, more than half of beneficiaries who have chosen a private plan are in a 4-Star or 5-Star plan.

Q: What percentage of Medicare recipients are in Advantage plans?

A: It’s close to 30 percent. Before the Affordable Care Act, it was about 21 or 22 percent.

Q: And the plans are getting less money for serving patients?

A: As a share of the fee-for-service program. Prior to the Affordable Care Act, on average, the plans were receiving 13 percent to 14 percent more than the fee-for-service program [for a total of 113 percent to 114 percent]. Now it’s down to 103 percent, 104 percent. It’s going to continue to phase down.

The plans on average are being paid less, they’re still offering competitive benefits. Premiums are lower on average than before the act was passed. It’s part of our key strategy to achieve our quality-of-care goals. It’s really pleasing to us that so many more beneficiaries who have chosen a private plan are in a 4-Star or 5-Star-rated plan.

Q: Many seniors are confused about whether to sign up for an exchange, as part of the ACA.

A: The key message for Medicare beneficiaries is the exchanges are not part of the Medicare system.

The Medicare system will operate the same way it has always operated. Medicare beneficiaries should go to their same sources of information — medicare.gov or 1-800-MEDICARE.

They will receive their benefits the same way. They don’t have to apply for anything through the exchanges. If you receive Medicare benefits, you don’t need to think about the exchanges.
Medicare beneficiaries should not fall for any scams or false information about signing up for a plan in the health insurance marketplace.

What the Affordable Care Act has done is . . . [add] benefits and . . . [elevate] the overall quality of care.

Q: Talk about the effectiveness of the penalties for hospitals that have too many readmissions [of discharged patients].

A: We have put in place payment penalties for hospitals that have higher-than-expected readmission rates. The readmission rate for the past year and a half, for the first time in [the] five years the agency has tracked it, is falling. It’s about a percentage point lower than it was the previous five years.

What that means is about 70,000 fewer hospital readmissions are paid for by the Medicare program on a monthly basis. That’s a real impact for beneficiaries. My dad was in the hospital last year. His care was not well coordinated and he had a hospital readmission — a classic case. It was very traumatic for him and for our family. Everybody was very worried.

It’s tangible, meaningful changes in the health care system.

Q: Is it improving nursing home care?

A: What the readmission [rule] has done is force hospitals and nursing homes to have better systems of coordination. It used to be the incentive for nursing homes was to send the patient back to the hospital. So Saturday night, if the patient had an issue, the automatic response was to send the patient back to the hospital. Very traumatic for the patient and the family.

These pay-for-performance systems are changing behavior and building stronger relationships, so beneficiaries have more care coordination, there are not just single episodes of care or silos of care.

Q: Seniors often talk about the lack of dental care in Medicare.

A: Well, really it’s an artifact of the statute when it was created; it’s not something that we do purposely. Some managed care plans that participate in the Medicare program offer dental coverage as a supplemental benefit.

There are some gaps in the Medicare benefit package. Lack of coverage for hearing aids, that’s a statutory prohibition. Dental care, the same thing. Some managed care plans offer them as supplemental benefits.

President Lyndon Johnson signing the Medicare law with former President Truman looking on.

President Lyndon Johnson signing  Medicare legislation with former President Truman (right) looking on.

Q: Is that something that could be changed, that could lead to better health?

A: There’s good research that good dental health is a key factor in good overall health. Our limitation is that we’re bound to the statute.

Q: Evaluate the progress of Accountable Care Organizations [combinations of doctors, hospitals and/or insurers created to lower costs and improve quality of care].

A: One of the changes in the Affordable Care Act was to bring about organizations that acted like systems of care rather than silos of care. I would describe it as groups of physicians who are coming together and promising to be accountable for a population of Medicare beneficiaries.

It’s a notion that team-based care is better than individual care. Care is coordinated across different office and hospital settings. With care coordination, duplication of lab tests and other tests would be reduced.

We’ve been overwhelmed . . . [at] the response by the physician community in participation. We have more ACOs today operating in the Medicare program than we anticipated.

It doesn’t change how beneficiaries interact with the health care system. It doesn’t change how we pay physicians on a service-by-service basis.

At the end of the year, ACOs can demonstrate they met the quality benchmark and they can demonstrate that overall total health care costs have been reduced, and the organization can share in the savings.

Q: How many beneficiaries are being served by ACOs?

A: We estimate that about 4 million beneficiaries are being served by ACOs across the country.

Q: Are they saving money?

A: It’s too early to state with certainty whether the program has saved money [for the taxpayer]. But to me, if we are paying the same and the quality of care has improved, that’s a huge win.

Q: Where do you see the ACO trend going?

A: I see the share of Medicare-participating physicians and Medicare beneficiaries served by ACOs continuing to grow. Clearly the Congress is very interested in trying to . . . [encourage] more physicians to participate with ACOs.

Beneficiaries seem to understand this model, seem to understand that it works for their care. We notify beneficiaries that their doctor is participating in an ACO, and they have the opportunity to opt out.

Q: How will they see their care is different?

A: Their care will be coordinated. When they go to the hospital, their physician will know that. Senior groups tell these stories — that one doctor orders a blood test, then another one orders the same test. Why can’t their doctors talk to each other?

Our expectation is that patients will have more time with their doctors rather than less.

We had assumed that beneficiaries would complain and choose to opt out of the data-sharing. Very little of that complaining and opting out of that data-sharing has gone on.

Q: Are you concerned about doctors dropping out of Medicare?

A: No. Those physicians who have dropped out are a very small share of physicians and tend to be those physicians who don’t treat Medicare patients. I think there are some pockets across the country that we have to be mindful of. Some of those [news] stories that came out this summer were not using accurate data.

Q: An article recently described how Medicare isn’t paying uniformly for physician education across the country.

A: There’s been a long history in the law for how payments are sent to teaching hospitals. This is another example in the Medicare program where history matters, and that has created differences across the country, where we’re paying a lot more, say in New York City, than [some other places] across the country.

It’s not a policy choice, it’s an artifact of the statute, how the system has been created to establish these payments.

Right now it’s true that Medicare doesn’t necessarily set standards for graduate medical education for the funds paid across the country. That’s a growing policy trend to watch. A question I hear more and more is, ‘Should the Medicare program demand more accountability for the significant share of graduate medical education that it’s funding?’ It’s a question that the Congress will have to ultimately answer.

Q: Anything you want to add?

A: It’s a hard message right now obviously to convey, with everything going on with the exchanges, but I do think one of the really good news stories of the Affordable Care Act is the impact on costs and quality, as primarily seen through the Medicare program.

Some say the Affordable Care Act didn’t do anything to reduce costs. Well, yes it did.

Look at the Medicare program now. It’s the biggest health care program in the country. Quality of care has increased. Benefits have been added. I believe it is possible to add benefits and improve quality while lowering costs. The past three years we have demonstrated that it’s possible in the Medicare program.

What do med students learn in the ER? Valuable lessons indeed

Dr. Sam Kini teaches emergency medicine to fourth-year med students in Athens.

Dr. Sam Kini (right) teaches emergency medicine to fourth-year med students in Athens.

Emergency medicine is unique.

At any time of the day or night, practitioners in an ER must be ready to treat any kind of problem, said Dr. Sam Kini, a veteran emergency physician. Patients rush in with everything from chest pains to vaginal discharge. Among the common problems are back pains, abdominal cramps, fevers, bruises and sprains.

Kini, who now teaches and supervises fourth-year medical students at the Georgia Regents University-University of Georgia Medical Partnership in Athens, said the ER is a blend of specialties, and that makes it an invaluable place to teach.

“We see patients with all kinds of complaints, and we want the students to have that experience of just seeing all patients, all types, all ages, all hours of the day and night,” he said.

In 2010, Medicaid patients made up the majority of ER visits in Georgia, according to state data. The American College of Emergency Physicians (ACEP) said it expects ER visits to increase nationwide as the Affordable Care Act triggers Medicaid expansion in a number of states. (About half the states, including Georgia, have opted not to pursue expansion.)

“Increasing the number of patients on Medicaid without an equivalent increase in the number of physicians willing to take that insurance will surely increase the flood of patients into our nation’s ERs,” former ACEP board President David Seaberg said in a statement.

Emergency medicine has grown in popularity among graduating medical students. Data from the Association of American Medical Colleges showed that the average of emergency medicine residency applications increased from 28 percent in 2010 to 31 percent in 2011. In 2012, the number increased to 35 percent.

Yet Kini said that only five of his 40 students plan to complete an emergency medicine residency after graduating in 2014.

Georgia was reported to have a shortage of emergency physicians in 2008. As of 2012, the state had an estimated 1,110 emergency doctors, while Michigan, a state with a similar population, had twice that number, according to Kaiser Family Foundation data.

During their fourth and final year of medical school, students have three required, month-long clerkships, also called rotations, to complete in addition to three electives and a sub-internship. Students spend one day each week in the classroom and up to four days at hospitals throughout northeast Georgia.

The emergency medicine rotation will be valuable to students regardless of what specialty they choose or where they practice. An emergency can happen anywhere,
including in a routine medical setting such as a physician’s office or an orthopedic clinic. When patients experience frightening symptoms — such as chest
pain or sudden numbness — they expect physicians to know how to react.

Fourth-year medical student Bree Berry completed her emergency medicine rotation at Eastside Medical Center in Snellville. She was barely into her second week there when she had an unexpected but unforgettable experience.

“On Labor Day I saw a guy who had an accident with his table saw and nearly amputated [all] five of his fingers on his right hand,” Berry said.

Berry plans to go into primary care, so she probably won’t see such severely injured patients often, but she recognizes how the rotation will be useful to her.

“Since I don’t plan to be working in an emergency room, I think it will be valuable for me to know which patients I need to send to the emergency room,” Berry said, “and which I can safely treat in my office.”

Surprises can teach good lessons

Some patients who come into an ER have valid emergencies, while others misuse the ER as a replacement for primary care. This is one reason why emergency physicians never really know what to expect from the unscheduled patients who come through their door.

YouTube Preview ImageThis element of surprise may be frightening for some medical students, but for Xiao Li it was exciting and helped him grow as a physician. He said he enjoyed knowing only a name and an age when first entering a patient’s room.

“When it comes to emergency medicine, what I like most about it is that you never know who or what’s coming in,” said Li, who completed his clerkship at St. Mary’s Hospital in Athens and plans to specialize in radiology.

At least once a week, Kini visits his students at their rotation site to note their progress and assist ER physicians with teaching. He and the ER physicians teach students to recognize common and serious diseases and order the appropriate tests. Students also learn how to determine the correct treatment and decide which patients need to be admitted to the hospital and which can go home.

When Kini works with a student in the ER, he lets the student take the medical history and perform a physical examination first while he asks the student questions about the procedure.

Once the student has completed these tasks, Kini will perform the same tasks on his own, while the student notes the differences in the way Kini handled the patient. Afterward, the two go outside the patient’s room to exchange thoughts and notes privately.

Kini said playing the role of both student and instructor helps students appreciate what they did right as well as understand what they should have done differently. He said when students recognize why he asked certain questions that they did not, they are able to learn from their mistakes.

“It gets the student to think, as to why I asked this question [and] why they missed it,” Kini said, “and they won’t miss it in the next room.”

 

April Bailey is pursuing a master’s degree in health and medical journalism at the University of Georgia. She currently holds a bachelor’s degree in print journalism from Middle Tennessee State University.

With medical mistakes all too common, educators focus on prevention

Dr. Stephen Lucas (left), with medical students, emphasizes the importance of having checklists to prevent errors.

Dr. Stephen Lucas (left), with medical students, emphasizes checklists to prevent errors.

Consider this alarming scenario: A doctor prescribes the wrong dosage of a drug for a patient. The nurse working the case does not spot the doctor’s error. The pharmacist also fails to notice the problem, and fills the prescription as written.

Who’s at fault for putting the patient in danger?

More than any individual, flaws in the system are most likely to blame for costly, sometimes tragic medical mistakes, according to professors at the Georgia Regents University-University of Georgia Medical Partnership.

“Any time an error occurs, it occurs because not just one person made an error, but because there probably were a series of errors,” says Don Scott, director of essentials of clinical medicine at the partnership.

Scott teaches first- and second-year students the skills essential for being doctors, or as he describes it, “everything but the basic science.”

“To Err is Human,” a 1999 report from the Institute of Medicine, estimated that medical errors kill as many as 100,000 people a year. A follow-up report in 2009 found no noticeable improvement in patient safety.

But now it appears that the 100,000 number may be low.

A study in the current issue of the Journal of Patient Safety looks at people who receive some type of preventable harm when they go to a hospital to receive care. The new study estimates that each year, 210,000 to 440,000 such people are harmed sufficiently that it contributes to their deaths.

Given these statistics, it’s understandable that reducing fatal blunders is a prime goal of medical educators.

At the Athens partnership, professors teach students to think critically and act deliberately. They do this with a mix of mental calisthenics, including exercises in “root cause analysis,” and the use of checklists in operating rooms and other clinical settings.

Root cause analysis exercises require students to consider all the possible factors that could be contributing to an individual patient’s illness; checklists remind doctors to take every step required for high-quality care.

Like students working their way through a root cause analysis, Scott said, doctors and other health providers must consider all the options and identify the root causes of medical mistakes.

 

A less punitive, more positive approach

The fight against medical errors, in Scott’s view, is not so different from using a carrot and a stick to motivate a mule pulling a cart. The mule goes faster for two reasons at once: getting the carrot and avoiding the stick. In medicine, rewards for safe, high-quality care would be the carrot and punishments for mistakes would be the stick.

But until recently, Scott believes, health policy has focused too much on the stick and not enough on the carrot. Health care providers are punished for making mistakes but are not given enough incentives to provide quality care.

The Affordable Care Act will make “carrots” more common. The Medicare Shared Savings Program provides new financial rewards to health care providers who meet benchmarks for quality care.

But preventing errors involves more than rewards and punishments. Sometimes the issue is as simple as the routine for using medical devices.

YouTube Preview ImageA machine as basic as the one used to deliver drugs through an IV can be a source for errors, says Dr. Stephen Lucas, a professor of quality and safety at the partnership and clerkship director for Athens Pulmonary Associates.

When he investigated a case involving a hospitalized patient given a dangerously high dose of medication, he tracked the root cause not to an individual practitioner, but to a misunderstood feature of a bedside pump.

Proper drug dosage depends on a patient’s weight, and the pump allowed doctors to enter that weight in either pounds or kilograms. A kilogram is more than twice the weight of a pound. On one occasion, a doctor thought he was entering the patient’s weight in pounds when in fact the machine was set for an entry in kilograms. As a result, the patient received a significant overdose of the drug.

Rather than going after the person who made the mistake, Lucas says, it was more important to stop offering doctors the choice between pounds and kilograms. Instructing physicians to enter weights exclusively in pounds can cut down on errors, he says.

If it’s on the list, do it!

Checklists are another of Lucas’ favorite strategies for making hospital care safer. Being required to use a checklist reminds doctors to make sure they do simple things, such as washing their hands before every patient encounter, wheeling the right patient into the operating room, and operating on the right organ.

Long considered essential in such fields as aviation, checklists have been used off and on in medicine for decades. They’ve been in the spotlight since 2010, when Dr. Atul Gawande, a Boston surgeon and best-selling author, wrote about them in the New Yorker and later in a book focusing on their effectiveness in the operating room.

There is ample evidence that they work. When the World Health Organization studied hospitals in eight cities across the globe, researchers found that using surgical checklists lowered the incidence of surgery-related deaths and complications by one-third.

Putting checklists into every hospital, however, has proved difficult despite their benefits. And Lucas says that once checklists are in place, their effectiveness hinges on teamwork.

“I think the real leap forward is going to be when every doctor and every nurse and every person who has anything to do with the patient takes very committed and total responsibility for making sure that patient’s safe,” says Lucas.

“If your surgeon’s going to sit over in the corner and say, ‘You guys do your checklist, and let me know when I can start,’ that’s not good.”

 

 

Ian Branam is a second-year master’s student in health and medical journalism at the University of Georgia. He is interested in developing health and medical content for the web and spent the summer developing a social media campaign for smoke-free workplaces. He particularly enjoys writing about health policy, health disparities and chronic diseases. Follow him on twitter at @ianbranam or visit his website at www.ianbranam.com.

To specialize or not to specialize? Doctors’ choices affect many people

Fourth-year medical student Travis Smith, along with his fiancee Chelsea.

Fourth-year medical student Travis Smith, along with his fiancee Chelsea.

When Travis Smith was an undergraduate, he shadowed doctors at health clinics in the Central African nation of Zambia. He saw a need that couldn’t be met.

People lined up for days, waiting to be seen. Mothers held crying babies. Nurses quickly recorded vital signs and asked about symptoms. Sometimes antibiotics were available. Most times, nurses could only console families and urge them to drink clean water, find clean sources of food, and wait.

That was summer 2008. Now Travis plans to study emergency medicine.

“You see the complete spectrum of people because anyone can go to the emergency department, and they must be treated,” he said. “As the doctor, you have to figure out what the problem is and help them.”

Smith, 25,  is one of 40 fourth-year students in the first graduating class of the Georgia Regents University-University of Georgia Medical Partnership. Like most of his classmates, Smith applied for a specialty that will take him through additional training after medical school.

The United States faces a shortage of 90,000 primary care doctors   by 2020 and 130,000 by 2025, says the Association of American Medical Colleges. About 48 million Americans live in areas where more primary care doctors — such as family physicians, internists  and pediatricians — are needed. The demand will grow as the Affordable Care Act provides help to millions of previously uninsured patients.

Georgia’s population, meanwhile, has been increasing faster than its supply of primary care doctors.

Without “immediate statewide cooperation” in Georgia, the outlook is even worse and “the state may never again have an adequate supply of physicians,” according to a report by the association’s Center for Workforce Studies. Without changes, “Georgia will rank last in the United States in physicians per capita by 2020.”

Despite this nationwide demand for more family medicine doctors, Smith and medical students around the country still pursue specialties and subspecialties for their careers. The number of medical students considering primary care training, including family medicine, general pediatrics and general internal medicine, is falling. But at the same time, the need for such physicians is growing.

Between 2001 and 2010, the number of medical students increased by 13.6 percent, but those expected to enter primary care fields decreased by 6.3 percent.

YouTube Preview ImageSmith and his classmates talk about these trends in class. But they clearly don’t like the notion of weighing one category of doctors against another. They say specialties contribute as much to solving the nation’s health problems as do careers in family medicine.

“In a lot of ways, emergency medicine is a primary care profession,’’ Smith said. “So many people come in for reasons that they very easily could have gone to their primary care doctor for but couldn’t get in for an appointment or waited too long.’’

 

Why do they do what they do?

When Bree Berry was a child, and adults asked her what she wanted to be when she grew up, she said “pediatrician.’’

“I had a great one when I was little, and I’ve always been interested in that aspect of primary care and being the person who patients seek when they’re sick,’’ she said. “I like the idea of building long-term relationships with patients.’’

After a summer internship in pediatrics research and a pediatrics rotation, she confirmed what she already knew.

“I feel lucky that what I want to do with general outpatient pediatrics will help with the doctor shortage,’’ she said. “It’s not self-sacrificing on my behalf. I’m able to do what I want to do.’’

Earlier this year, several academic journals investigated how today’s medical students choose their specialties, and what factors influence their decisions. Some say money, some say debt, and others say it boils down to student personality.

“The choice of a specialty is a complex and important one for the student that has significant implications for the health care and health of the community,’’ David Mirvis, a public health professor at the University of Tennessee, wrote earlier this year. Many decisions “reflect student needs and values.’’

These needs and values include lifestyle, intellectual stimulation and income. Other factors — such as work hours, attitudes of the community, and prestige — play into the decision as well.

There is a direct correlation between the specialties that students choose and how much they expect to earn, reported University of Georgia professor Mark Ebell in 2009.

“Unfortunately, less than 15 percent of graduating medical students will be in primary care practices,’’ he said. “In most countries, about half of students are in primary care practices, and those countries consistently have better health outcomes and provide care more efficiently than in the U.S.’’

Among the major factors that students consider when choosing which specialty to pursue, student loan debt is actually the least important, according to an Association of American Medical Colleges survey released in February. But most of the 14,000 survey respondents did say future salary is a major part of the decision.

“Money and the lifestyle that goes with it do play a role in people’s decisions,’’ said Berry, 24. “Students may enjoy their family practice rotation just as much as cardiology, but if you look at the long hours for not as great of a reimbursement, it’s easy for students to lean toward a specialty instead.’’

A sense of place

For Clay Hartley, location is what matters most. Born and raised in southwest Georgia, he plans to practice there and has already asked for rotations in that area.

“It’s one of the most severe areas in terms of the shortage of primary care doctors and doctors in general,” he said. “I feel a sense of responsibility to go back and help.’’

Hartley, 24,  is still deciding what this means in terms of specialization, but as long as he’s in the right location, he’ll be happy.

“This is the thing you’re going to do in the morning and even in the middle of the night sometimes,’’ he said. “If you’re not happy, it’s not going to last.’’

If Hartley steers his career toward primary care, he may be eligible for incentive programs aimed at bringing more doctors to rural areas. The American Medical Association offers some financial incentives, including loan interest caps and several tuition assistance and loan-forgiveness programs.

In February 2013, $10 million in federal funding helped 87 medical students repay their loans if they worked full time for three years or part time for six years under the National Health Service Corps Program.

As long as certain specialties — such as surgery or emergency medicine — help families as a whole, Hartley believes they should be considered part of the solution to the primary care shortage.

“These fields may not fall under the textbook definition of primary care, but they all deal with annual visits, blood pressure, and cholesterol,’’ he said. “To me, primary care should be about what your everyday people need, and they need all kinds of doctors and surgeons.’’

 

Carolyn Crist is pursuing her master’s degree in Health and Medical Journalism from the University of Georgia. She graduated from UGA in 2010 with degrees in newspapers and English and worked at The Times in Gainesville  as an education and political reporter.

 

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