The Profession of Medicine Samantha Hudson MD MEng Department of Internal Medicine VCU School of Medicine Based on a presentation by Rita M. Willett MD This is Samantha Hudson, one of the internal medicine chief residents, discussing the profession of medicine.

Learning objectives After 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.

Physician Training - Overview Medical school (4 years) “The basics” for all physicians Leads to professional degree Allopathic (MD) Osteopathic (DO) Residency (3-7 years) Supervised practice Specific field of practice Leads to specialty certification Fellowship (1-5 years) Optional Additional specialization Training 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.

MD and DO Degrees MD degree = medical doctor DO concepts Patient-centered, holistic, hands-on approach to diagnosing and treating illness and injury Allopathic ~ 80% of medical students are MD track Osteopathic manipulative techniques DO degree = doctor of osteopathic medicine Help patients achieve a high level of wellness by focusing on health education, injury & disease prevention. Osteopathic Generally no difference in privileges A 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. http://www.aacom.org/about/osteomed/pages/default.aspx

Medical School (VCU SOM ’10-’11) Both years: Clinical Skills Year 2: Pathophysiology Pharmacology Microbiology Year 1: Healthy Human Hematology Population medicine Endocrine Biochem, Genetics Systems, such as Pulmonary, Neurology and Cardiology Anatomy & Physiology Human behavior Women’s health Behavioral health In describing medical school, I am using the Virginia Commonwealth University School Of Medicine curriculum in 2010-2011 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.

Medical School (VCU SOM ’10-’11) Year three – clinical clerkships Year four – individualized Internal medicine Prepare for specialty Pediatrics “Acting” internship Family medicine Critical care Obstetrics and gynecology Electives Surgery Psychiatry Neurology In 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.

National Tests While In Medical School USMLE Step 1 Generally basic science After 2nd year of med school USMLE Step 2 CK (Clinical Knowledge) Written exam based on clinical experience After 3rd year of med school USMLE Step 2 CS (Clinical Skills) Observed, standardized patient encounters COMLEX is a similar test for DO’s Tests 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.

Residency Supervised practice with increasing autonomy Specialization Internal Medicine Pediatrics Family Medicine Surgery & subspecialties Anesthesiology Emergency medicine Neurology Psychiatry Radiology Pathology Physical medicine / rehabilitation Following 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.

Internal Medicine Residency at VCU HS PGY1 (Intern) year: “Learner” Begin Continuity Clinics (Primary Care) Always under the supervision of a resident on Wards and ICUs PGY2 year: “Manager” Given more autonomy while still supervised Learn to manage patients before supervising interns PGY3 year: “Teacher” Continue to develop autonomy while progressing into teaching role Residency 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.

Fellowship Added specialization in practice field Internal medicine Cardiology, oncology, endocrinology… Obstetrics and gynecology High risk ob, oncology… General Surgery Transplant, 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.

National Tests In, and after, Residency USMLE Step 3 Taken during or after Intern year All physicians must take prior to receiving medical license Boards for specialty Boards for subspecialty, if applicable, after Fellowship Of 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.

Credentials & Continuing Medical Education Licensure – state government State law governs practice Board of Medicine regulates Degree, Steps 1 - 3, one year residency required Continuing medical education (CME) for renewal Does not designate specialty training Board certification – professional National specialty boards (i.e. pediatrics, surgery, psychiatry) Requires residency completion and specialty exam Re-certification on periodic basis Hospital credentials and privileges Physician 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.

Career Paths of Physicians Community practice Ambulatory, hospital, long term care Private, managed care, health center, VA Academic medicine Clinician, educator, researcher Industry Government Policy Public health Career 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.

What 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.

Physician challenges: Patient Care Time pressures Office visits Hospital length of stay Aging population Multiple chronic illnesses Declining functional status Care for under-served Rural and inner-city settings Uninsured and under-insured Limited mental health and dental care The 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.

Physician challenges Help from Pharmacy Insurance formularies Medicare Part D complexity Prior authorizations Uninsured / under-insured patients Medication from multiple physicians Controlled substances New pharmaceuticals Physicians 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.

Physician challenges Help from Health Psychology Mental Health diagnoses Behavior change necessary to manage chronic diseases Smoking cessation Sleep Obesity Many other medical problems Motivational Interviewing and Behavior Change Plan While 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!

Thank 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!