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


New book educates young docs in practical aspects of practice

Editor David B. Nash, FACP, reflects on past and future of medicine

From the October ACP Observer, copyright © 2007 by the American College of Physicians.

By Stacey Butterfield

David B. Nash, FACP, has been compiling advice for young physicians for more than 20 years. The first book he edited, "Future Practice Alternatives in Medicine," published in 1986, guided physicians through many of the contemporary non-clinical aspects of medical practice.

David B. Nash, FACP

David B. Nash, FACP

His latest offering, "Practicing Medicine in the 21st Century," published by the American College of Physician Executives (ACPE), offers similar assistance to today's young physicians. In the new handbook, Dr. Nash and his co-editors have gathered more than 20 articles from experts in medical and related fields on topics ranging from achieving positive patient-physician relationships to understanding the referral process.

A board-certified internist, Dr. Nash is the Raymond C. and Doris N. Grandon Professor and Chair of the Department of Health Policy at Jefferson Medical College in Philadelphia. He currently chairs the Technical Advisory Group of the Pennsylvania Health Care Cost Containment Council, and serves on numerous health care company boards. From 1984-89, he was deputy editor of Annals of Internal Medicine.

ACP Observer recently talked with Dr. Nash about his books, how the practice of medicine has evolved in the past 20 years and what changes he expects to see in the future.

Q: How have the important topics of medicine changed or stayed the same since you edited "Future Practice Alternatives in Medicine" in 1986?

A: In some respects, this is the grandson or granddaughter of that book. Some of the themes are eerily the same—IT, public accountability. Some of the crucial things that we predicted actually did occur. We talked about beware the tech imperative, which was a fancy way of saying, "Don't put all your eggs in one basket." Now we talk about cardiologists who are worried that an MRI of the cardiac situation is going to be more accurate than a cardiac cath. We said that the pharmaceutical industry's influence is going to grow exponentially. That definitely has occurred. We looked at the beginning of the feminization of medicine. Now that's a given.

What we could not have talked about is the Internet, Google, patient empowerment. All of that is new. We just couldn't foresee that level of technology back then. Something else that happened is physician leadership. We do mention in the first book the need for more doctors to be engaged in the public policy conversation. Clearly, this book coming from ACPE fulfills that mandate to some extent.

Q: Your introduction talks about the "Golden Era of medicine." What happened to the Golden Era and what era are we in now?

A: The Golden Era existed for physicians currently over 60-65 years old who were there at the birth of Medicare, who fought Medicare. It turned out to be the goose that laid the golden egg. It gave doctors incomes 7, 8, 9 times the American national average and it gave them unprecedented power, wealth, social prestige, position in society. They were unchallenged by the evidence. There was not technology to track the obvious variation in what doctors do.

What would we call the new generation? The era of accountability, which are of course, the words of Arnold S. Relman, MACP, from 1988, when he crystalized that the future would be based on public accountability.

Q: How will the drive for greater accountability affect physicians in practice?

A: The toughest change is going to be that doctors are going to have to look in the mirror and undergo a vigorous, painful self-evaluation about who they are and what they're all about and then be subjected to public scrutiny about the outcomes of their work.

In this era of accountability, there will be no hiding, no longer any acceptance of the rubric that only doctors know what quality is. Health care has become such a big part of our economy it can't be left to doctors anymore. It's going to be a struggle. Not everyone will successfully complete this self-evaluation.

Q: Your book offers advice for young physicians and medical students. What is the primary message that you want to convey to future physicians?

A: Very regrettably, the message that even middle-aged doctors like myself give to their children is, "Don't go into medicine." I totally reject that. My view is that we need all the help we can get. What we need is a different type of student. Yes, we need biology majors but we more desperately need religion majors, sociology majors, economists going into medicine. Look at the mess we've created. Only a fool commits to continuing the status quo when he sees how bizarre and backward it's become. We need to be way more inclusive.

Q: What future changes do you expect to see in medical education?

A: I expect to see the continued feminization of medicine and greater diversity in the kinds of students we take. I don't mean just racial or ethnic diversity. I mean interests, majors, ages, international students—a complete transformation of who gets into medical school.

I'd love to see greater team-based training and leadership training because if you're going to have team-based care, doctors are likely to be the team leader but they're not taught how to be a team leader. I'm all in favor of bringing leadership training from the outside world into medical education.

Q: How will teamwork with other health care providers change medicine?

A: Today, medicine is a team sport and so we've got to teach teamwork. I'm a very strong believer in interdisciplinary team teaching for the future. We're doing some of that here [at Jefferson]. So we'll have medical students, nursing students, pharmacy students in some way or another mixing it up together while they're trainees.

My dream is in part that this book would be one of the textbooks in an interdisciplinary training environment because it covers so many issues of importance to people beyond just the doctors.

Q: What role will patients take in this team approach to medical care?

A: We could not have predicted that you would be able to get on Google and learn as much about kidney disease as a medical student. So that's going to change everything. Patients come to us with way more detailed questions. Patients want to know a priori what our predicted outcomes are and if they're not satisfied they're going to go elsewhere. Patients want the hotel/motel aspects of care to be better too.

Patient empowerment will transmogrify the field and we had better be prepared for it. For sure, we're not doing a good job teaching about patient empowerment. Doctors and medical schools ought to take the lead in helping patients to become savvier shoppers. Where we would prefer they get that information—from us or from Reader's Digest?

These are things we never could have thought about [at the time of the first book's publication]—consumerism, the Internet, the safety conversation. We've come a long way in some respects.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.


What's inside

A sample of what's included in "Practicing Medicine in the 21st Century"
Practice Innovation, Michael S. Barr, FACP
What Every Doctor Needs to Know About Medicare and Medicaid, Joshua J. Gagne, PharmD and Vittorio Maio, PharmD
Documenting Coding and Billing: Getting It Right the First Time, Brian M. Aboff, FACP, Rosemary Bell, RN
Preparing for Pay for Performance, David A. MacKoul, MD
Ambulatory Information Technology, Albert G. Crawford, PhD


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