Rethinking how physicians learn to prevent, manage chronic disease

Amy Farouk , Past News Editor

As the number of patients with chronic conditions continues to climb, so do the rates of burnout among physicians. Fundamental changes to how physicians approach chronic care are taking shape in medical schools across the country—and these changes may improve the health and well-being of both patients and physicians.

Physician educators from nearly two dozen medical schools recently came together for an AMA Accelerating Change in Medical Education Consortium meeting to hear from population health experts and learn about each other’s efforts to enhance chronic disease curricula so students are equipped to thrive in their profession and help their patients lead healthier lives.

“Almost half of all Americans have at least one chronic disease, and 13 percent have more than three,” said Omar Hasan, MD, vice president of Improving Health Outcomes at the AMA.

Dr. Hasan pointed to data showing that the number of people between 25 and 44 years of age who had more than one chronic condition more than doubled between 1996 and 2005. Those numbers are only expected to further increase, with 157 million Americans predicted to have more than one chronic disease by 2020.

The most common chronic conditions are diabetes, mental and behavioral disorders, heart disease and cancer. Many of the risk factors for developing these conditions reflect the modern lifestyle—dietary risks, smoking, high body mass index, physical inactivity, alcohol use, high blood pressure and high fasting plasma glucose.

Whether patients already have a chronic condition or are at risk of developing one, patient care today should look vastly different from several decades ago when most care was focused on acute medical needs. But most physicians still go through training under a model concentrated on the care of acute conditions.

Having a chronic disease—especially if a patient has more than one condition—also “adds considerable complexity to the office experience,” Dr. Hasan said. “The more medications patients come in with, the more time it takes to reconcile …. That adds a lot of complexity to health care delivery.”

And that complexity is only compounded by operating in a care delivery model or office space that is based on providing care for acute conditions.

“What are the skills our folks would need in the real world?” said Pamela Allweiss, MD, medical officer for the Division of Diabetes Translation at the Centers for Disease Control and Prevention. “We have to interact with patients in a different way.”

Dr. Allweiss spoke about her experience working with academic medical centers to make hands-on clinical changes in the resident curriculum around diabetes care management. The care took on a form different from traditional residency training, putting an emphasis on team-based care, incorporating group visits into care plans and building patients’ involvement in their own care.

The results showed that patients with diabetes received more care to keep them healthy, leading to better health outcomes. For instance, the program led to a 300 percent increase in the number of patients who received two Hemoglobin A1c tests each year. Residents, meanwhile, mastered important competencies, such as interacting with patients in a more engaging way and collaborating with an interprofessional care team that can provide more comprehensive care without overly burdening the physician.

Trainees also need to get first-hand experience with the realities of outpatient care for patients with chronic diseases. Whereas traditional training often instills a sense of professional accomplishment in seeing a patient through an acute episode of care, day-to-day care for patients with chronic diseases means ongoing management of conditions from which patients may never recover and overlapping issues that could land a patient in the hospital.

Christine Sinsky, MD, AMA vice president of Professional Satisfaction, noted that there are five main challenges for chronic care:

  • Chaotic office visits with overfull agendas
  • Inadequate support for patient care
  • Poorly functioning health care teams
  • Vast amounts of time spent on documentation and administrative requirements, which leaves many physicians feeling as though they spend more time on these activities than delivering patient care
  • Electronic health record work that often has become the physician’s responsibility when it previously could have been handled by other members of the health care team

“Care of the patient requires care of the providers,” Dr. Sinsky said. “The only way we can get to the Triple Aim … is to consider the fourth aim of professional well-being.”

And that depends on operational efficiencies designed around today’s health care needs, she said. For physicians in ambulatory care, that means customizing the care delivery model with chronic care in mind—from the configuration of the team to set-up of the office space.

Dr. Sinsky said it’s also important to train students and residents in these sorts of environments. “How can medical schools expose medical students to the most functional forms of practice? Right now, we expose our students to some of the least functional modes of care delivery. And then we wonder why they aren’t choosing the specialties we need.”

Marshall H. Chin, MD, the Richard Parrillo Family Professor of Healthcare Ethics, who specializes in health disparities at the University of Chicago Pritzker School of Medicine, said it’s important for students to really understand the problems in patient care if they are to thrive in the new health care paradigm.

“For most of us in medical school,” Dr. Chin said, “we teach students very little of how often we fall short of the mark.” He also noted the danger of students feeling disempowered, which is why the University of Chicago also embeds “an advocacy component into addressing chronic disease and health disparities.”

Exposing medical trainees to the shortcomings of the current system and activities that can help improve how care is delivered can cultivate an openness to change that can better serve both patients and physicians.