The old “sink or swim” adage can be applied to most aspects of life but is particularly relevant in the lives of third-year medical students. As rotations begin, most students jump in blindly, their eyes still attempting to adjust from staring at UWorld questions for 25 hours every day while studying for board exams. The wards do not provide any solace with unfamiliar and incessant alarms screaming in all directions, hostile stares from veteran nurses as you try to obtain overnight patient information and the slow pace it takes you to complete tasks as you attempt to navigate the hospital labyrinth.
However, the moment I personally felt the most unprepared and destined to sink was when I began to attend Bedlam Longitudinal clinic, which is a clinic designed to manage chronic diseases such as diabetes, hypertension, hyperlipidemia and depression for the uninsured population. The clinic is essentially run by medical, nursing and social work students at the University of Oklahoma School of Community Medicine in Tulsa. While attending physicians volunteer to lead groups of medical students throughout the year, the students act as the patients’ primary care doctors, taking on the role of a resident physician while in the third year of medical school. Needless to say, this concept generated a large amount of anxiety for me as I pretended to be confident in advice I was doling out to patients, struggled to traverse the semi-complicated electronic medical record and keep my appointment times on track so I would not have to face the angry middle-aged man who had been waiting for an hour. I was participating in another old maxim, “fake it until you make it”.
But, I slowly became more comfortable with the operations of the clinic as the year progressed and felt, maybe foolishly, worthy of my position as a care provider. Fear gradually morphed into a sense of confidence in managing the many chronic illnesses my patients faced, and I attempted to keep in mind the lessons I learned along the way. As a medical student, my main goal is to see every experience as educational, allowing me the freedom to reflect on what works and does not work in the practice of effective medicine and how I will apply these lessons in my future career as a physician. While I could list close to 100 lessons, I believe focusing on three of the most important ones would aid other future health professionals in managing and ultimately treating the chronic illnesses that will become even more prevalent in many of our future patients. As a disclaimer, I do not claim to be an expert on this topic, but these ideas spring from my own personal reflections. So, here they are:
Lesson #1: There is no quick cure with chronic disease. The care provider must view management as a time-intensive process when failure is not personal and setbacks are not permanent.
When medical schools select the few stand-out applicants from the thousands that apply, they take into account numerous factors including grades, test scores, extracurricular activities and how certain applicants fit into their respective programs. Usually, a “Type A” personality is an unstated requirement as well. The majority of medical students, myself included, desire control over every situation, having known success in the past from this attitude.
Unfortunately, medicine enjoys humbling us, and chronic disease management is a particular subset of medicine that has frustrated students and physicians alike. The control shifts away from the grasp of the doctor and remains with the patient. A physician can prescribe the correct medications, give the right advice on lifestyle modifications and even provide excellent resources to aid the patient in achieving his or her goal; however, the efforts put forward by the doctor can be nil if the patient does not take the medication, adhere to necessary behavior changes or follow-through on helpful resources.
I have felt personally responsible for the rising of several of my Bedlam clinic patients’ hemoglobin A1c numbers and the consistent elevation of their blood pressures despite delivering the standard of care. This sense of failure lead to frustration and contributed to the early development of cynicism, which is a commonly shared sentiment among those in the medical community.
However, I also had successes as well, rejoicing with my patients who I had the privilege of lowering the amount of insulin they had to inject daily or decreasing the dosage of an anti-hypertensive medication they took every morning. I began to see patients who remained stagnant slowly improve along with those who gradually progressed in the right direction fall two steps back. The sinusoidal path most of my patients followed helped me to understand the nature of chronic disease management: there is no such thing as a quick fix. Instead, the practice of slow medicine, requiring patience and a non-judgmental approach on my part and trust placed in the care provider on the patient’s end, allowed for viewing the diseases as large obstacles that could be overcome with slow, incremental changes. I started to emphasize setbacks as temporary, rather than visualizing them as the beginning of an inevitable decline. I scheduled appointments closer together for those patients I realized needed consistent encouragement and revisited each patient’s struggles and successes at each encounter.
While I wish I could claim this change in my mindset affected the A1c and blood pressure numbers in a positive direction for every patient, I continued to see some declines. However, resolving to eat the elephant one bite at a time encouraged me to continue providing the best possible care for those ‘difficult’ patients and avoid the dangerous trap of cynicism.
Lesson #2: The best way to manage chronic illnesses is by an integrative, team-based approach, especially in the underserved population.
As I began to spend enough time caring for those with chronic diseases, especially patients with limited resources, I concluded there are many barriers to health care outside the realm of traditional medicine, including financial and social hurdles, which a fifteen minute clinic visit is unable to address. Some examples include lack of transportation to appointments or the pharmacy, inability to afford medication and daily stresses that lower the priority of managing an illness. These social determinants of health require different areas of expertise to overcome them, thereby necessitating the development of a team-based approach.
In the Bedlam clinic, I work alongside nursing and social work students in addition to a ‘care manager’ who will consistently call or visit my patients to ensure they have the resources to best manage their diseases. The care manager will link the patient to prescription assistance programs, bus tokens, and organizations that provide housing assistance. Also, before each afternoon clinic, I attend a thirty minute meeting with the nursing students, social workers, care managers, attending physician and other medical students on my team to discuss our patients who require the most attention. Assignments are arranged for each team member to play their vital role in the care of the patient, from medication changes by the medical student to depression screening by the nursing students to ensuring information for local counseling services are given by the social work students.
As payment models shift toward reimbursement for health outcomes, chronic diseases such as diabetes, hypertension and depression will need to be effectively managed, requiring integrative care. Spreading the responsibility for different aspects of patient care to various members of a ‘care team’ is the correct first step to improving outcomes. Although there are many innovative health care delivery models being developed currently, I believe those that incorporate some aspect of team-based care will prove to be the most effective.
Lesson #3: Listening to the patient will lead to greater satisfaction and allow you to discover the obstacles the patient faces in managing his or her chronic disease that may have not been evident to you.
This last lesson may be the most obvious of the three, as we are taught Sir William Osler’s proverb from the first year of medical school that you will gain the diagnosis by listening to the patient. However, it can also be regarded as the most difficult of my observations to practice. When I have to check a blood sugar log, revise a medication list and provide important educational information during the span of a short clinical visit, I quickly recognize I am the primary speaker throughout the appointment.
During one clinic afternoon, I resolved to prepare for each visit with a pre-set checklist of items I wanted to discuss with the patient. This checklist helped me to organize myself in order to maximize my time. Then, I began each appointment by asking the patient how they thought they were doing with the management of their illnesses. The answers I was given showed me how the patients saw their illness and how, sometimes, their view was radically different from my own. While their diabetes or high blood pressure was my main concern, these diseases were just another small part of their lives. Other issues, such as obtaining custody of grandchildren, a recent divorce or losing a job, took a more prominent role. I had been ignoring the patient and focusing on the disease.
While I was encouraged to direct the patient away from the tangential thoughts they may have over the course of a visit, gaining the perspective of a patient about their illness, particularly a chronic illness, lead to a greater care provider and patient relationship and allowed me to tailor the patient’s management to give them the best chance of success. My discovery of what prevented the patients from properly managing their diseases guided me to identify what I needed to focus on at each visit. For example, a patient who recently lost his job and was left by his girlfriend may need a greater portion of the appointment discussing how well his depression is being managed rather than spending the majority of the visit explaining how poorly he had been controlling his blood pressure. Also, by exhibiting willingness to understand their daily obstacles and frustrations, I was hoping to gain their trust that I was concerned of their well-being. These developing bonds gave me satisfaction in what I was doing and showed me the value in spending more time listening than directing.
Chronic illness is a subset of medicine every future physician will encounter. With the changing landscape of health care in our country and particular focus on health outcomes, effective management of these diseases is vital. Therefore, it is important to continue to reflect on how we can better serve our patients in this capacity.