American College of Physicians: Internal Medicine — Doctors for Adults ®


Preparing residents for the real (managed care) world

From the April 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Edward Doyle

BROOKLINE, Mass.--In a conference room, a resident describes his struggle to deal with a patient and her family. When the woman, who is pregnant, asked for an ultrasound, her HMO physician said the procedure was medically unnecessary. The next day, the woman's husband was on the phone with the resident, furious that the physician would not provide the test. He claimed the physician denied his wife the ultrasound because she is Hispanic, and threatened to sue the physician and the HMO for discrimination.

Upset by the man's reaction, the young physician spent almost two hours on the phone trying to explain why the procedure was not medically necessary. Now, a few days later at a conference on physician-patient communication, the resident wonders if he should have proceeded differently. How do you do the right thing medically, yet defuse someone's anger in such a situation, he asked his colleagues.

It's a dilemma that would probably not bother many residents. Most would instead take what they consider the best clinical course of action and move on. But at Harvard Community Health Plan (HCHP), the HMO where the residents gathered for today's conference are doing a monthlong rotation, the emphasis is not just on giving patients the best possible clinical care, but also on making sure that they are satisfied with their outcomes.

The residents are learning that the task is not always an easy one. In addition to seeing patients who are non-compliant and others who are just plain difficult to work with, the residents at HCHP also have to deal with the occasional patient who demands a diagnostic test he read about in the newspaper or wants the new wonder drug being praised by the media.

HCHP's program teaches residents that taking the time to talk to patients and learning even a little about what they really want from their physician is often revealing. "In traditional practice, there was always the incentive to do the test if the patient came in asking for it," explained associate program director Steven Pearson, ACP Member. "We try to teach that when patients come in asking for a fancy test or a referral to a subspecialist, they usually want something, either relief from pain or the reassurance that something is being done. We try to get at that underlying concern."

This focus on talking to patients, on learning more about them and building long-term relationships, is a dominant element of HCHP's residency program. A resident at today's seminar on communications, for example, explained how a patient asked for a note excusing her from work for three days because, she said, she did not feel well. While the resident knew that the right thing to do clinically was to deny the request, she worried how the decision would affect an already fragile relationship with the patient, a diabetic who often did not take her medicine or come in for follow-up visits. So she explained to the patient that she couldn't give her the note (she invoked her Hippocratic oath), but she also took the opportunity to explain how she could help the patient feel better--through follow-up visits and preventive care.

It is this focus not just on clinical medicine but on customer service principles in a clinical environment that makes the rotation through HCHP unique, according to program officials. "If you went to a medical clinic at a major teaching hospital," said program director Andrew Epstein, MD, "I don't think you'd hear preceptors telling their residents to both provide good medical care and satisfy their patients. But the culture here is different."

Because they are not working just with the elderly ill, young physicians like Christopher Crenner, MD, a junior resident at HCHP, say that they get more time to practice good primary care medicine. "The goal with my patients is to find something I can help with to keep them healthy," Dr. Crenner explained. "The pace is slower than in the hospital, but I'm learning a lot about rapport and continuity of care."

It is exactly these skills that internists will need in the changing practice environment, Dr. Pearson explained. "The amount of time that typical internal medicine residents spend learning how to manage a septic immunocompromised patient with a rare syndrome is just way out of proportion to what they will ever need in the real world," he said. "We can still give them the skills they need to handle those patients and train them to do so many other things."

HCHP also works on building these skills with the practicing physicians it hires. Even experienced internists new to the HMO must spend about 130 hours (spread out over 30 mornings) during their first year attending seminars on topics such as physician-patient communication. To date, more than 35 internists have gone through the program.

And to better prepare its residents for practice, HCHP is revamping its residency program, starting with the group of residents who began in July. Those residents will see patients full time during almost every month when they reach their second and third years of residency. (HCHP's current second- and third-year residents see HMO patients full time for only four months during their second and third years of training.) Residents will learn subspecialty medicine, but they will work with subspecialist preceptors in an outpatient setting for long periods. The goal is to give them continuity of care experience in a subspecialty environment.

Perhaps even more important than teaching residents about long-term relationships and customer service, HCHP is teaching its residents some valuable lessons about working in modern American medicine. When one of Dr. Crenner's patients went to a non-HMO hospital with a non-critical condition, for example, the young physician gently convinced the patient's mother to get her son to the HMO-affiliated hospital. "It's better to keep your care under one system," he advised the woman. "We're better-connected there, which will be better in the long run." Dr. Crenner then arranged to have the patient transported to the affiliated hospital.

Not all situations are handled so easily, however. As the resident who spent two hours trying to calm his pregnant patient's husband discovered, defending an HMO when it doesn't cover some services is not always easy.

But it is a task that the residents realize they will probably have to live with, and at the seminar on communication, they discussed how to handle such a situation. Their conclusion: Explain that the decision was made by the HMO, but state why you agree with it and how the patient can live with it. Explained one resident: "Otherwise they'll think that you're not really a doctor, that you're just a cog in the system." And that, they all agreed, would hurt the physician-patient relationship.

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