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Credibility, medical education…other highlights at Annual Session

From the May 1997 ACP Observer, copyright 1997 by the American College of Physicians.

Listen to your patients-or risk losing credibility

The medical profession is "inviting obsolescence" if it continues to fail to listen to its patients and take the time to explain in understandable and credible language what is making them sick, said Jordan J. Cohen, MACP, president of the Washington-based Association of American Medical Colleges, during his Keynote Address at Annual Session.

"Doctors simply must have the courage to stand up to those who are driving a wedge of clock-punching between them and their patients," Dr. Cohen told the thousands of internists and guests in attendance. "In my view, doctors have not yet pushed back hard enough. They have not exerted the enormous latent power available to them by acting in concert to defend their patients' interests."

During his address, Dr. Cohen told members of the audience that today's science-empowered doctors, although currently dominant among health care providers, do not hold a monopoly on patient care. If patients do not get adequate answers to their questions about their health, they will begin to seek out alternative providers who best address their burning questions.

When male and female health issues overlap

A slim, elderly male patient who smokes comes to you with chronic morbidity and low mobility. Should you consider him at risk for osteoporosis?

According to experts at a special presentation on issues in men's and women's health, the answer is yes. Despite popular belief, osteoporosis and menopause may affect the health of men as much as that of women.

While physicians have become aware of the need to monitor post-menopausal women for decreasing bone density, the incidence of osteoporosis in men is rarely recognized. "Osteoporosis is often not considered in men," said Jeane Ann Grisso, ACP Member, a professor of medicine and director of Focus on Women's Health Research at the University of Pennsylvania.

Because both elderly women and men are at risk for fractures, Dr. Grisso suggested that physicians encourage prevention through regular weight-bearing exercise and increased calcium intake.

Difficult diseases, 'undertreatment' plague inner city health

Physicians working in the inner city face challenges not only from a formidable list of diseases, but also from the attitudes of many of their patients toward the health care system.

At a Meet-the-Professor presentation on critical care issues in the inner city, Stephan L. Kamholz, FACP, chair of the department of medicine at the State University of New York Health Science Center at Brooklyn, gave an update on some of the difficult diseases that physicians in inner city hospitals are treating. Diseases include asthma, substance abuse, tuberculosis, HIV, sickle cell disease and infectious diseases imported from abroad such as malaria, parasitosis, hemorrhagic fevers and dengue fever.

But as Dr. Kamholz stressed, treating these conditions typically involves more than clinical skills. "Some of the main issues—and the barriers to care—are access issues and patients' reluctance to seek care," Dr. Kamholz said.

For example, the incidence of asthma has skyrocketed in many cities. "People avoid the emergency room because of the long wait, so ultimately many come in cardiorespiratory arrest in an ambulance," Dr. Kamholz said.

A threat to medical education?

Medical education is in the early stages of a revolution, one that threatens to undermine the advances gained during the last 50 years in the way medical students learn.

According to Kenneth Ludmerer, FACP, from Washington University in St. Louis, as medical schools and residency programs adapt to managed care's cost-cutting tactics, they are transforming the focus of their educational programs from clinical learning to vocational training.

Speaking during the Nicholas E. Davies Lecture, Dr. Ludmerer compared the breadth of the current changes in medical education to that of the revolutionary changes that took place through World War II. A big difference is that physicians are not spearheading this round of changes. "Unlike the first revolution, which came from within the profession, this [revolution] is coming from outside the profession," he said. "The conditions imposed by managed care are destroying the learning environment."

Plus, academic medical centers, in an effort to survive, are exacerbating the problem. While institutions have been able to keep their doors open and even save faculty jobs, educational goals are hurt.

Following guidelines may not be the answer

"If you're not deviating from [a practice] guideline, something is wrong with you," Brent C. James, MD, told physicians at the C. Wesley Eisele Lecture on physician leadership in building health systems.

Dr. James, executive director of the Institute for Health Care Delivery Research at Intermountain Health Care in Salt Lake City, explained that many guidelines aren't backed by scientific data and may not represent the best care. At best, he said, guidelines are 20% scientific evidence and 80% consensus.

As a result, Dr. James said he would question a physician who completely followed all clinical guidelines. In fact, he encouraged physicians to view deviating from guidelines as an opportunity to learn about differences in clinical thought and to work toward improving patient outcomes. "[Deviations don't mean there is] something wrong. It means we need to change protocol."

Deviating from guidelines also gives physicians the chance to help redefine managed care. "It's our choice," Dr. James said. "In the face of managed care, can we return to the roots of good patient care? ... We must come together as peers and regain the moral foundation to allow us to control the debate."

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