Presentation on theme: "The Profession of Medicine"— Presentation transcript:
1The Profession of Medicine Samantha Hudson MD MEngDepartment of Internal MedicineVCU School of MedicineBased on a presentation by Rita M. Willett MDThis is Samantha Hudson, one of the internal medicine chief residents, discussing the profession of medicine.
2Learning objectivesAfter this learning activity, you should be able to:Describe how physicians are trained.Discuss career paths of physicians.Discuss the layers of credentials for physicians.Describe the continuing education requirements for physicians.Discuss current challenges in medicine.In this presentation, we will be discussing how physicians are trained, and what career paths they might follow. We will discuss the layers of credentials for physicians and the associated continuing education requirements. We will also discuss the current challenges facing physicians today.
3Physician Training - Overview Medical school (4 years)“The basics” for all physiciansLeads to professional degreeAllopathic (MD)Osteopathic (DO)Residency (3-7 years)Supervised practiceSpecific field of practiceLeads to specialty certificationFellowship (1-5 years)OptionalAdditional specializationTraining for physician takes many years. To enter medical school, a college degree is required, and many students will have other graduate degrees or work experience prior to beginning their medical traninig. Medical school is the basic foundation for all doctors. Medical school leads to a professional degree, either allopathic (MD) or osteopathic (DO) degrees. More on that in a moment.Following medical school, physicians separate into different residencies. This is a time of supervised practice in a specific field that leads to specialty certification in a particular type of practice such as pediatrics or psychiatry.Some physicians enter practice from the end of their residency; others go on to do a fellowship which gives them additional training in a particular, more narrrow, specialized area.
4MD and DO Degrees MD degree = medical doctor DO concepts Patient-centered, holistic, hands-on approach to diagnosing and treating illness and injuryAllopathic~ 80% of medical students are MD trackOsteopathic manipulative techniquesDO degree = doctor of osteopathic medicineHelp patients achieve a high level of wellness by focusing on health education, injury & disease prevention.OsteopathicGenerally no difference in privilegesA physician, by necessity, has earned a degree from a medical school. About 80% of these degrees are MD, or medical doctor degrees. These degrees emphasize the scientific basis of medicine, with increasing focus on “evidence-based medicine.”The other 20% of students receive a DO, or doctor of osteopathic medicine, degree. The science background is quite similar. However, osteopathic medicine also emphasizes a patient-centered, holistic, hands-on approach to diagnosing and treating illness and injury. These students learn osteopathic musculoskeletal manipulative techniques.Currently, there are generally no differences in physician privileges. Medical residents here at VCU may have either degree.
5Medical School (VCU SOM ’10-’11) Both years: Clinical SkillsYear 2: PathophysiologyPharmacologyMicrobiologyYear 1: Healthy HumanHematologyPopulation medicineEndocrineBiochem, GeneticsSystems, such as Pulmonary, Neurology and CardiologyAnatomy & PhysiologyHuman behaviorWomen’s healthBehavioral healthIn describing medical school, I am using the Virginia Commonwealth University School Of Medicine curriculum in as an example. Amongst different medical schools, the material is essentially the same, but the organization may differ. In fact, VCU is reorganizing its curriculum for upcoming years.In the first year, medical students study the healthy human from many perspectives: a population basis, the scientific essentials of anatomy and physiology, and normal human behavior.In the second year of medical school, students learn about diseases, or pathophysiology, and their treatments. Most of the year is divided into systems. Notice that pharmacology is the first course of the year - the basis on which therapies are taught throughout the year. There is also a specific behavioral health course.THroughout the first two years, medical students have an introduction to basic clinical skills such as medical interviewing and examination. As they continue to become more sophisticated, medical problem solving is introduced such as developing differential diagnoses.
6Medical School (VCU SOM ’10-’11) Year three – clinical clerkshipsYear four – individualizedInternal medicinePrepare for specialtyPediatrics“Acting” internshipFamily medicineCritical careObstetrics and gynecologyElectivesSurgeryPsychiatryNeurologyIn third year of medical school, students actively participate in the practice of medicine by rotating through clerkships in the major specialties as listed here in inpatient and outpatient settings. They are the most junior member of the team, but they do have responsibility both for patient care and learning.The fourth and final year of medical school is where the curriculum becomes individualized to the interest and career goals of the student. During this year, they prepare for their specialty of choice including applying and interviewing for residencies. They do an acting internship during which their responsibilities are increased close to that expected in early residency. They are required to gain experience in critical care, and are free to pursue many electives.
7National Tests While In Medical School USMLE Step 1Generally basic scienceAfter 2nd year of med schoolUSMLE Step 2 CK (Clinical Knowledge)Written exam based on clinical experienceAfter 3rd year of med schoolUSMLE Step 2 CS (Clinical Skills)Observed, standardized patient encountersCOMLEX is a similar test for DO’sTests are a way of life for medical students. Everyone endured the entrance test, the MCAT, prior to medical school. The United States Medical Licensing Exams, or “steps,” as they are lovingly known, are high-stake national tests, most of which are taken during medical school. Step 1 is a computerized, rigorous examination of basic science knowledge and is generally taken after the second year of medical school; many students take 1-2 months just to study for this test full time.Step 2 Clinical Knowledge (CK) is a computerized test taken just after the third year of medical school which is more clinically based; VCU students do very well on this after spending a year with our complex patient population. Steps 1 and 2 CK each cost $525.Step 2 Clinical Skills (CS) is an in-person,\ test of observed, standardized patient encounters. This test requires a student to travel to one of only 5 testing centers in the nation (the two closest are Philadelphia and Atlanta) for the full-day test. Students are observed for their patient interaction skills including a mastery of the English language. Step 2 CS costs $1355 plus travel.For DO students, there is a similar test called COMLEX.
8Residency Supervised practice with increasing autonomy Specialization Internal MedicinePediatricsFamily MedicineSurgery & subspecialtiesAnesthesiologyEmergency medicineNeurologyPsychiatryRadiologyPathologyPhysical medicine / rehabilitationFollowing graduation, a young doctor has their MD (or DO) degree but virtually every medical school graduate proceeds to additional training in a residency. Residency is the practice of medicine in a supervised setting. As they move through training, residents have increasing autonomy.Residencies are separated into specialties such as those seen here. The length of residency may vary from as little as 3 years in Internal Medicine, Pediatrics and Family Medicine, to as much as 7 years for Neurosurgery.
9Internal Medicine Residency at VCU HS PGY1 (Intern) year: “Learner”Begin Continuity Clinics (Primary Care)Always under the supervision of a resident on Wards and ICUsPGY2 year: “Manager”Given more autonomy while still supervisedLearn to manage patients before supervising internsPGY3 year: “Teacher”Continue to develop autonomy while progressing into teaching roleResidency training varies widely, depending on both the specialty and the institution. I will give you a very brief overview of the Internal Medicine Residency program here at VCU.Training is three years, and residents are supervised throughout, but have increasing autonomy as they progress. Our program is the second in the country to embrace the “learner-manager-teacher” model that formalizes this process.The first year of residency is also called the “intern” year. The learning curve is steep. Interns work hard on inpatient wards, doing the vast majority of data gathering and patient interaction, and in the Intensive Care Units where the sickest patients of the hospital are. They also begin their Continuity Clinics, either at ACC or at the Veterans Administration; they immediately take on the mantle of the Primary Care Physician. In these roles, they are the “Learner” – balancing the care of their patients with the need to learn an amazing amount of medical knowledge, systems navigation, and how to deal with the stress of it all. Their teachers are attending physicians, older residents, nurses, pharmacists, psychologists, and patients, just to name a few. This year is exhausting, challenging on so many levels, and hopefully ultimately one of the most rewarding experiences of a lifetime.By the second year of residency, these young physicians have mastered data gathering and begin to make management decisions, all while closely supervised. Before they are allowed to supervise interns, they are given the chance to become comfortable managing the medical decisions, the social issues, the hospital and clinic systems, and all the other details it takes to successfully take care of patients. Near the end of the year, they are trained on how to be efficient and effective supervisors.Finally comes the third year, and the residents take on the role of “Teacher.” They are given interns to supervise while still managing patients. They will graduate as expert clinicians, but also prepared to mentor the next generation of physicians.
10Fellowship Added specialization in practice field Internal medicine Cardiology, oncology, endocrinology…Obstetrics and gynecologyHigh risk ob, oncology…General SurgeryTransplant, oncology…After residency, some physicians proceed into their career paths immediately. Others choose further specialization in their field of practice. For example, someone who has trained in internal medicine may pursue a fellowship in cardiology, oncology, or geriatrics, just to name a few; there are fellowships for every specialty.You may have noticed areas of subspecialty can bring physicians from various specialties together; for instance, an Internal Medicine Oncologist, Surgical Oncologist, and Radiation Oncologist may all work closely with a single patient.
11National Tests In, and after, Residency USMLE Step 3Taken during or after Intern yearAll physicians must take prior to receiving medical licenseBoards for specialtyBoards for subspecialty, if applicable, after FellowshipOf course, during and after residency there are even more tests. Step 3 is the final USMLE step, designed to assess if an individual can apply medical knowledge and understanding essential for the unsupervised practice of medicine. Thus, this test is required prior to receiving a permanent medical license. This is a two-day, 16 hour computerized test which includes 480 multiple-choice questions and nine clinical case simulations. This test costs $730.After finishing residency, a physician becomes “Board Eligible,” meaning they are now qualified to sit for their final test for their specialty, such as Internal Medicine or Surgery. Some practices allow physicians to practice without having passed their specialty boards, but this is becoming more rare. This board is a single-day, computerized test that physicians study for as hard as any test they’ve ever taken. The Internal Medicine test costs $1345. And, if a physician completes fellowship, they have to take similar boards for that subspecialty as well.
12Credentials & Continuing Medical Education Licensure – state governmentState law governs practiceBoard of Medicine regulatesDegree, Steps 1 - 3, one year residency requiredContinuing medical education (CME) for renewalDoes not designate specialty trainingBoard certification – professionalNational specialty boards (i.e. pediatrics, surgery, psychiatry)Requires residency completion and specialty examRe-certification on periodic basisHospital credentials and privilegesPhysician are credentialed on both governmental and professional levels. It is, admittedly, confusing.At the state level, each physician is required to be licensed, and this license is regulated by individual states, the board of medicine, and other legislation. Licensure in any state is dependent upon having a degree, having passing the general exams already mentioned, and completing at least one year of residency (ie the intern year). Note that a state licence does not designate specialty training or practice (that this license does not differentiate between a primary care doctor, a surgeon, a psychiatrist, and so on).The difference in physician training is designated by board certification. National specialty boards certify individual specialty fields such as pediatrics, internal medicine, or surgery. This requires completion of an approved residency program and passing one or more specialty examinations as already described. Re-certification on a periodic basis is required.As medicine is a rapidly changing field, continuing education is important. Licensure can only be renewed by completing continuing medical education. This is also required to maintain privileges at institutions where physicians practice as well as recertification of professional board certification.
13Career Paths of Physicians Community practiceAmbulatory, hospital, long term carePrivate, managed care, health center, VAAcademic medicineClinician, educator, researcherIndustryGovernmentPolicyPublic healthCareer paths of physicians may take them to a variety of settings. They may be solely in an outpatient setting, hospital, or long-term care setting, or may combine them.Their practice type may be a small private practice, a large managed care organization, a community-based health center, or the Veteran's Administration.A physician who chooses Academic Medicine could become a clinician, educator, and researcher. In industry, physicians may serve as consultants or pursue research. In the government, physicians may work in policy or public health.
14What do Physicians do?Your ideas about what physicians do may have come from a variety of sources.You yourself have interacted with physicians for your own healthcare, and possibly for family members.We see images in the media of physicians – from quaint Norman Rockwell paintings to current movies and TV shows. (Really, residency is nothing like “Grey’s Anatomy”!)In general, physicians receive rigorous education & training and work to promote health and prevent, diagnose and treat disease.They practice in a variety of settings and are clinicians, researchers, administrators, teachers, and, of course, life-long learners.
15Physician challenges: Patient Care Time pressuresOffice visitsHospital length of stayAging populationMultiple chronic illnessesDeclining functional statusCare for under-servedRural and inner-city settingsUninsured and under-insuredLimited mental health and dental careThe care of patients presents many challenges.Time pressure is increasing from limitations on outpatient office visits and inpatient stay.Our population is aging, so we are caring for patients with multiple chronic illnesses and declining functional status.Lately, there has been a lot of attention toward uninsured and under-insured patients, in rural and urban settings. It is difficult to find many services for them.
16Physician challenges Help from Pharmacy Insurance formularies Medicare Part D complexityPrior authorizationsUninsured / under-insured patientsMedication from multiple physiciansControlled substancesNew pharmaceuticalsPhysicians have a hard time keeping up with the ever-changing world of pharmaceuticals.Individual insurance formularies and Medicare Part D are complicated for patient and physician alike. Prior authorizations are frustrating and time consuming. Finding medications for uninsured or under-insured patients may be difficult, as is organizing medications for a single patients from multiple physicians to avoid the dangers of polypharmacy. And especially in the patient population we serve at VCU, controlled substance management takes up a huge amount of time and physician energy. Not to mention the huge number of new pharmaceuticals each year!We appreciate help and guidance from our pharmacy colleagues with these and many other challenges.
17Physician challenges Help from Health Psychology Mental Health diagnosesBehavior change necessary to manage chronic diseasesSmoking cessationSleepObesityMany other medical problemsMotivational Interviewing and Behavior Change PlanWhile many, if not most, of our patients have mental health needs, many physicians have received little formal training in this. The time pressures noted before only further encourage us to skip these often difficult but extremely important topics. We often find ourselves needing assistance, and turn to our Health Psychology colleagues to help us diagnose our patients correctly. We also benefit from their help in discussing with patients the need for behavior change in managing many chronic diseases. We often cannot give enough time to these topics and appreciate our experts’ assistance!
18Thank you!Of course, each person’s path is unique, but hopefully this gives you a place to start when you think about the Profession of Medicine. Thank you for your time, and we look forward to working closely with you!