Medicine, Teach Me Chronic Disease
Call me crazy (”Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.
One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.
But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.
What should change? A couple ideas:
- Focusing on trends, not on specifics
- Focusing more on prevention if the disease will be life-long
- Time management with patients
- Changing the culture so that patients expect to come in when they’re well and when they’re sick
- How to stay energized and avoid burnout
- How to maintain relationships with patients over years
- How to work efficiently and effectively with other specialists/generalists
- The differences between acute care and chronic care
- Explaining chronic versus acute care to patients
A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.
Running the risk that you are tired of hearing from a semi-retired orthopedic surgeon, I am going to respond to this posting.
1. I don’t understand what this means. When a physician is seeing patients, the doctor doesn’t have the option of looking at “trends” unless you mean, “this is the flu season” or something like that. Patients present to the doctor’s office with what ever is effecting them at that time.
2. Trying to get patients to give up self destructive habits is obvious. But, in most cases, a patient already has a “disease” when they walk into the doctor’s office. Patients don’t seem interested in “preventive medicine” because they have too many other things to do. One example is the epidemic of obesity that is present in our society. The best way to prevent Type II diabetes is keeping one’s weight under control and exercising. Trying to get people to do that is next to impossible.
3. Time management with patients is a function of how much the physician is being reimbursed for his/her time. In order to make a living doctors have to see a lot of patients and that means less time with each one.
4. Trying to accomplish this, except for the annual physical, would take a sea change in thought by the patients.
5. Don’t devote all your time to medicine. There is life
outside of medicine. Cultivate it.
6. Treat patients with dignity and show them that you care about them and you won’t have to be worried about this. I took care of some children, when I was early in my practice, and years later I took care of their children.
7. Respect your colleagues. Cultivate professional relationships with those specialists that you know to be good physicians. When you refer a patient call or send a letter to the specialist ahead of time.
8. The main difference is in the intensity of how you treat the patient. There is much more stress and concern about treating a patient the night that he/she sustains an open fracture of the tibia, than two months later when you are waiting for the fracture to unite. The doctor has to have more patience taking care of a patient with chronic back pain than when the back pain is acute.
9. This is not as difficult as it would appear. When you have treated a patient for a problem that has gone from the acute to the chronic stage, it requires empathy, patience, and concern. This is difficult to “teach.” A doctor mainly has to learn this as he/she matures.
A long response to a long post.
Often I find that the differential diagnosis tool isn’t that useful–a patient comes in with a set of diseases already diagnosed, and needs help managing them, not getting them diagnosed.
By trends, I meant, the patient’s own lab values, weights, behaviors–over time.
hi, i guess it just depends on your university… the curriculum set here sorta trains us to treat patients as a whole, as in not just the current ailments but what he/she might be at risk for. also the psychosocial aspect of things… there is so much more to a patient than just acute vs chronic. i guess it’s how you look at them that determines how you treat them.
What a great post! I think a lot of the problems with patients is that they feel rushed and not cared about, especially when it comes to chronic problems. I understand the need to take care of the monetary side of medicine but I would rather have a doctor or practitioner who took a little extra time. It would encourage me to follow their advice.
2 points.
Medical students seem to believe that a differential diagnosis has its value in direct proportion to its length. Not so.
A better approach is to take the patients complaint and relate it to the appropriate anatomic or physiologic system, not try to memorize endless lists for every complaint.
For example, in the ER, lower abdominal pain in a female has, as a start, only 4 systems; GI, Urinary, reproductive, and musculoskeletal. Who cares about musculoskeletal until the others are evaluated and the UA is such a simple test. The physical exam and key complaints distinguish GI vs. reproductive. The experienced physician does not consider everything. It’ a honing-in process.
Second, and I’m willing to be critized for this view, physicians are not health-care professionals but are disease managers. As human beings we should all have empathy with those we interact with but physicians are first and formost technicians. My model is William Osler. Read one of his texts. He was personable but a technician first
No, medical students seem to be taught that a differential diagnosis has its value in direct proportion to its length. Comes directly from the Medicine clerkship.
In approaching a patient, I find our mentors have made us focus on subtleties and nuances not differentials. That is to say, explore on history/exam to the max (hone-in as Hubbard said) before starting to come up with a differential.
But, more importantly, I wanted to comment:
I do think that medicine does stress and practice caring for chronic disease.
Last summer, I had the luck to start a clerkship July 1st at the same time as the new resident. As we saw new patients, she made arrangements for them to be seen in her ‘continuity clinic’ where they would be followed by her over the next 4-5 years.
Another example, is in an MS clinic, the physician was calculating her patients’ vitamin D supplement levels for the coming winter. It was something pro-active she was doing but of note, it was on HER part not her patients.
As Doc Thompson wrote, it would take a sea change for patients to be pro-active about their conditions to a satisfactory level. The MS clinic example shows a better route, if the resources exist, to let the healthcare team take the pro-active lead.
I’d say also that patients DO come in when they are well not just ill. Chronic disease patients have follow-up specialist appointments every 6 months, for example, whether they are well or not.
Furthermore, caring for chronic disease does not require a doctor. Specialist nurses are better positioned to offer patients what is required on a day-to-day management of their disease.
A physician’s life will never be an easy one and medical school curriculums respond slowly. Meanwhile, primary prevention at the community level can be effective. Check out the provincal and nationwide project in Finland and CardioVision 2020 project in Olmsted County, MN. CardioVision 2020 and Healthy Greenville (Greenville County, SC) have an informal health challenge. It takes a dose of individual responsibility and community commitment. Health professionals as a group can play an active leadership role.
Governor Huckabee is chairman of the National Governors Association and he has selected the topic of Healthy America for the NGA Forum later in Fenruary in Washington DC. Arkansas and SC have statewide initiatives
Excellent point. I teach patients (except we don’t call them patients, but rather people living with chronic conditons) in community setting about how to manage their conditions. The curriculum has been developed at Stanford and shown to improve health outcomes and reduce hospitilizations in randomized controlled clinical trials (Lorig, et al.) On average, by age 55 most of us have 2.2 chronic conditions, so that pretty much blows the differential diagnosis modlel out of the water, doesn’t it?–trying to pin causation on a single diagnosis.
But the bottom line may not be the model, so much as the role that clinicians are taught to follow in acute care vs. chronic care. In acute care, clinicians are taught to isolate a diagnosis so they can select an appropriate treatments that will lead to cure. In chronic care, in which cures are rare if not non-existent, what then is the clinicians role?
Based on the Stanford experience, it would seem that the physician’s time is best spent helping the person living with a chronic condition figure out how best to adapt, adjust and overcome it’s challenges–improve their quality of life & feel empowered to take actions that will slow progression of the condition. Perhaps, if available, the physican will select treatments, if any are available, best suited to the patient, that will ameleriorate symptoms, unless or until the condition is no longer chronic and can be cured and becomes an acute conditions. Again, the goal being to allow the person to take actions to slow progression.
Unfortunately, for many chronic conditions, cures that make them treatable so that they can fit the acute care model. This is humbling, I believe for many of clinicians to accept. Humility is not a trait that the medical community is known to embrace….with good results for progress on new frontiers, but not so with regard to accepting its limitations, especially when it comes to dealing with end of life or chronic condition issues.