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The Health-Economics Teaching Gap in Med Schools

Does It Effect the Quality of Patient Care as Well as Cost?

PHILADELPHIA -- At the same time new federal laws are reorganizing the nation's $2.5 trillion health care business, U.S. medical students are not being adequately trained to understand how their future practices will run in this complicated new system.

That's according to Dr. Mitesh S. Patel, who began studying the subject several years ago when he was still in medical school at the University of Michigan. His February article in the New England Journal of Medicine says medical education has failed in this area and "this failure may well have unfortunate consequences for both physicians and patients."

Patel, who went on to earn his MD at the University of Michigan and an MBA at the University
medical tools
U.S. med students are well versed in the symptoms and treatment of disease but are they adequately trained in health economics and policy?
of Pennsylvania's Wharton School, is now a resident physician at the Hospital of the University of Pennsylvania.

"Back in medical school I realized most of the training was about medicine and not about how to practice medicine," said Patel. "I knew the signs, symptoms and treatment of disease; but when I went and met the patient, I didn't know how to apply that within the context of the health care system I was working in."

Rather than just grouse about his frustrations, Patel joined with two medical school professors -- Dr. Matthew M. Davis and Dr. Monica L. Lypson -- to conduct a scholarly study of how medical students across the country felt about their training in health care systems.

Students' concerns
The findings of that first study, published in 2009 in the journal Academic Medicine, detailed how less than half the nation's graduating medical school students felt they had received adequate training in health care systems and medical economics.

"There's huge gap here," said Patel. "I think the overlying thing is that we can't expect people to learn how to practice medicine 'on the go.' We need to start training physicians in the core principles of health policy when we start teaching them about the core principles of anatomy, physiology and pharmacology."

The issue of whether medical school students need to understand the system they are about to enter has been debated since the early 1980s, when managed health care, an explosion of new medical technologies, and growing tangles of government regulation caused the complexity of the health care business to rise almost as steeply as its out-of-control costs.

'Economic underpinnings'
In the early 1980s, growing numbers of authorities warned that "Medical students must understand the structural and economic underpinnings of the U.S. health care system to function optimally" in that system.

Thirty years later, not much appears to have changed.

One point of the second and latest article by Patel, Davis and Lypson is that there is still no national standard for a medical school curriculum focused on health policy. This, even as passage of the Affordable Care Act set in motion sweeping changes that will make the health care system larger and more complicated than ever before. Thus, as they begin their careers, young physicians with no formal grounding in the business side of medical practice face a greater challenge as they attempt to kick start their careers.

But aside from the effect on their own career potential, what is the impact of these new doctors' health policy naivetè on patients?

Comparative effectiveness research
As one example, Patel cites the new emphasis on comparative effectiveness research -- the process of determining and standardizing the use of the most effective drug or procedure for treating any given condition.

"Physicians are now expected to utilize comparative effectiveness research, but if they can't understand the context in which they are working, that's difficult to do and, ultimately, can harm patient care," he said.

Beyond patient care is the delicate and controversial issue of cost control. After all, the daily decisions of physicians constitute the central engine of health care spending.

A year ago in the New England Journal of Medicine, Dr. Molly Cooke, director of the Academy of Medical Educators at the University of California in San Francisco, argued for a heightened cost consciousness in medical education. But before that can be achieved, she wrote, "We must ensure that all students acquire a basic understanding of how medical care is financed, where national health care policies come from, and the politics that shape financing and workforce choices."

Faculty voids
One reason many medical schools have been unable to devise and execute a comprehensive health policy curriculum is because they lack the needed disciplines on their own faculties.

"To teach this sort of curriculum," said Patel, "you need health economists, people trained in business and organizational management, and people from the insurance and health care systems."

He and his co-authors suggest this problem could be overcome by designing a national curriculum supported by online discussion networks and virtual lectures that would establish a pool of medical-business authorities available for long-distance teaching.

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