Teach healthcare, not just medicine
A FEW WEEKS back, a 48-year-old man arrived at a local free clinic where I sometimes work. He’d lost his health insurance two years ago and recently enrolled in Medi-Cal, the state health insurance program for the poor. Now he receives care for his diabetes, high blood pressure, heart failure and depression at our clinic, primarily staffed by resident physicians like me.
“Every time I come here, I meet a new doctor. Don’t make me tell you everything about me all over again,” he said. But the rotating staff wasn’t his main concern. After his last visit, he hadn’t been able to get all his medicine. Medi-Cal caps the number of prescriptions that can be filled at six per month, so he got only a portion of the drugs he needed.
By his next visit to the clinic two months later, several prescriptions had run out despite the pharmacist’s efforts to find other ways to fill them. The patient complained about frequent headaches and dizziness; his blood pressure and diabetes were out of control. “That last doctor, he was nice and all,” he told me, “but he didn’t know I wouldn’t get all my medicines.”
He was probably right. Resident physicians -- who are getting post-medical-school clinical training to be certified in a specialty such as internal, pediatric or family medicine -- provide the bulk of the care for the poor or uninsured at local clinics and hospitals. In general, our clinical training is excellent. Yet we’re not taught about important aspects of our healthcare system, such as Medicare or Medi-Cal, even though their policies profoundly affect our patients.
National surveys of medical students and residents confirm this critical knowledge gap. In a 2005 national survey of medical students by Harvard University researchers, 96% of respondents agreed that understanding healthcare policy is important for their work and careers. Yet fewer than 30% of them could estimate the number of uninsured Americans.
A separate group of Harvard researchers found that half of physicians had no training during residency in dealing with patients from different cultures -- a particular concern in diverse Los Angeles. UCLA researchers, including myself, are currently surveying Los Angeles County residents to understand the training gap here. The results so far are not encouraging.
Why is this important? Resident physicians, along with nurses and other allied health professionals, form the backbone of the medical workforce that disproportionately cares for the poor. Nationwide, academic teaching hospitals provide care to nearly 40% of the nation’s 46 million uninsured and to many of the underinsured -- the working poor who periodically gain and lose health insurance benefits.
The social contract that binds resident physicians to the health of the nation’s underserved is not just a moral one, it is financial. The federal government pays academic hospitals nearly $70,000 per year per resident that they train. (There are more than 1,000 such doctors-in-training in Los Angeles County’s teaching hospitals, with an average first-year salary of about $38,000.) Medicare is the biggest contributor, chipping in nearly $5.5 billion per year to help train future doctors and care for patients.
If we, as resident physicians, don’t understand the healthcare system and its disparities, how can we begin to address the health of our poorest patients? The Institute of Medicine estimates that 18,000 people die unnecessarily each year because they don’t have health insurance. As resident physicians, how do we begin to prevent those deaths if we don’t even know how to get eligible patients signed up for Medi-Cal, or about other programs available to the poor and uninsured?
Closing this gap will require concrete changes in the curriculum of medical training. A growing number of academic medical groups are calling for changes -- creating partnerships with community groups, incorporating social science education focusing explicitly on care for the underserved -- and the residents I’ve talked to seem ready and eager to learn. Some models, such as UCLA’s pediatric Community Health and Advocacy Training program, already exist. But so far the pace of reform has been too slow.
Everyone has a connection to this dilemma in medical education. We all pay the price when patients who lack access to primary-care services visit emergency rooms instead, or when preventable diseases such as tuberculosis spread among those in the shadows of our healthcare system. All physicians -- from Beverly Hills cardiologists to internists at inner-city clinics -- trained by taking care of poor, uninsured patients in academic hospitals. All their subsequent patients also benefit from that education.
If residents don’t address the challenges to the health of the underserved as we learn from them, we belittle the already marginal benefit they receive for their contributions to medical education. We can start by making better care of the underserved an explicit goal of all residency training programs in Los Angeles.
