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The Doctor is Out

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Students aren't sure. Nationwide, almost 61 percent of graduating medical students say they received inadequate instruction about managed care, according to the 1998 Medical School Graduation Questionnaire just released by the Association of American Medical Colleges. In a 1995 survey, SLU med students complained they'd received insufficient information about managed care and insufficient experience with its offshoots, family medicine and outpatient care. (Now SLU includes a section on managed care in one of its required courses, although it hasn't gone as far as, say, the University of British Columbia, which rewrote its goals for medical students to include the ability to "consider the cost and societal implications of their approach to providing health care.")

"Have we had a huge change in the amount of time we spend teaching managed care? No," says Dr. Alison Whelan, associate dean of Washington University School of Medicine. "But we have begun to increase the amount of teaching about the practice of management. Students receive at least a couple hours of lectures about the business aspects, and we've started a biannual managed-care symposium.

"Students see the way the practice of medicine is altered by the way health care is managed," remarks Whelan, "the amount of time physicians spend on paperwork, the office personnel required to submit it all. They see that as part and parcel of the care of the patient." They also spend more time learning to plan for discharge, she adds, because patients go home less well.

Whelan doesn't see students fretting about the increased business aspects of clinical practice, but Navarro has seen just how unprepared some of her clients are for those challenges. In her opinion, "it's not bad for them to get a couple courses in accounting, marketing, strategic thinking. And they have to have the capacity for teamwork, the capacity to manage bureaucratic politics."

Ask Galofre whether students are taught teamwork, and he shrugs genially. "Teamwork -- that is a tough one. It deals with being socialized to the profession, which happens gradually. We can teach our students how certain things should be done, but what really changes them is when they go into a clinical situation and see it done differently. What I hear from our students is that some areas are better for teamwork; in others, people say, 'Look, I am the one who is responsible, so I will say how it should be done."

Galofre thinks "today's students are going to be much better adapted" than physicians of his own generation, which he dubs "the Romantic period of medicine. You did everything you could for the patient, and you were treated as a god." He adds candidly, with a Latin twinkle, "I would think twice to go into the system we have now.

"Is there going to be a difference in the interaction between patient and physician?" Galofre asks abruptly. "In some ways, that is what we are seeing. But I hope in other areas it will be even better. An HMO in the long run cannot tolerate bad medicine, because the patient comes back and back and back. So good medicine should prevail."

Search consultant Lyons travels the country, looking for signs that it will prevail. "I hear scarily few success stories," she admits. "Where good things are happening, the single common denominator is the presence of a positive physician culture. Physicians understand why they are there, what their role is. They are committed to providing the best possible care." She pauses. "That describes very few health-care forums. It does describe a large number of physician-driven group practices, because physicians feel very empowered in those settings. I also found it at a hospital where seven of the eight board members were physicians."

Does this mean physicians need the reins back? Maybe so, but Lyons warns that they won't each get their own sets. "Physicians are more powerful than ever, but not on their own," she remarks. She's weary of their individual "bellyaching, the spiral of negativity that siphons off energy year after year." Her voice brightens temporarily. "You could send them all off to a career consultant ... but I don't know that there are enough career consultants.

"Physicians really have to do some soul-searching," she concludes. "If they absolutely must have autonomy, then they need to get out of medicine.

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