The New Age of Medicine: Musings of an Itinerant Doctor

George Clooney wielded immense power in the very popular TV show ‘ER’. The uber confidence he exuded probably factored into my decision for that field. After all there is a certain charm in being part of an adrenaline-driven ER team that is resuscitating an adult trauma victim or a baby suffering from septic shock.

I think the emergency room is a microcosm of what the outside world is really like. Working in an ER of a major metropolitan area provides a fascinating view of humanity, irrespective of location of the ER under consideration. Whether inner or outer city of a developing or developed nation, you tend to manage not only the emergent needs of your patients, but also get to learn about effective and ineffective health systems.

Armed with the above awareness, I recently travelled to Dallas, Texas to attend the annual meeting of the Society of Academic Emergency Medicine. I had thought that in addition to learning about improving efficiency of the emergency department through research and advocacy, I would be learning cutting edge emergency medicine-related techniques that might be applicable to Pakistan. I did learn all of that but what really struck me was new age medicine, that is, the fast changing landscape of healthcare in the U.S. in face of ongoing reform.

Here I highlight some of my findings.

(1) The U.S. health landscape is changing and Obamacare is here to stay. The much debated and discussed, often derided, affordable healthcare act (AHA), mellifluously called “Obamacare”, has created a flurry of activity in the healthcare and non-healthcare domains in the U.S. Although difficult to get an exact handle on the AHA, perhaps some of the confusion around it is intentional. Whatever the situation, it potentially impacts emergency care as well as non-emergent care of the sick and injured, given that it is expected to bring more than 25 million uninsured Americans into its fold. With the baby-boomer generation becoming old and the resultant increase in the number of Americans requiring healthcare, having more folks insured appears to me to be a good thing. It has the potential to affect job markets (short and long term) and choice of specialty training given the encouragement for pursuing primary care fields. Under the AHA, I speculate that biomedical research agendas (with inherent funding streams) will likely also change over time.

(2) Generational and gender-based issues are here to stay. At the medical workplace there is a new generation of students and employees – the millennials (those born in the 80s and 90s). These new age people, although they might seem to be from outer space where I am concerned, need to be dealt with in a language they understand. These young people, presumably ‘Twitter and Facebook medicine’ junkies / techies, heavily rely on social media usage in medicine and academia. They expect swift communication, i.e., giving and receiving quick feedback at the workplace in real time while avoiding conflict or resolving it adequately. Gender-based considerations have to be kept in mind - whether feedback is given (or received) by a male or female because they react and adapt to such ‘feedback’ differently.

(3) The team is more important than the individual, leader included. The bottoms up approach to team dynamics in which each person is considered worthy, and therefore all are equally effective change agents.

(4) Patient-centered, compassionate, culturally sensitive care is back with a vengeance. Patient satisfaction surveys are becoming more integral parts of physician performance indicators. When you are culturally sensitive to the needs of the patient then you are more likely to be compassionate in caring for them versus considering them mere numbers in lines.

There were many other things that were discussed in concurrent sessions, but while I was taking notes, I found myself both excited and daunted. Excited because health reform, if positive and sustainable, makes much sense. I am daunted because I wonder how the fast-paced fast changing landscape of healthcare reform in the U.S. might impact foreign doctors. I was part of that workforce not too long ago. Historically, there tends to be a certain number of international medical graduates (IMGs) in residency and fellowship positions across the U.S. However, with U.S. medical school graduate numbers increasing and fewer residency positions available for IMGs, there is more than a theoretical concern. Here’s why: an increase in medical school positions in the U.S. is not being accompanied by an increase in residency positions due to 1997's residency position cap instituted by Medicare, the national social insurance program which pays for many of these positions. Thus, more U.S. medical students (reflected in a 30% increase by 2016) will be competing for more or less the same number of residency positions (projected to be evident as early as 2015). This shows that in the future more U.S. graduates applying for a disproportionate increase in residency slots will mean stiffer competition for IMGs, not only Pakistani, but also those from India, Bangladesh, Africa, and so on.

As I go about practicing medicine in Karachi after a decade of doing so in Houston, I wonder how the future will pan out for my current batch of medical school mentees in Pakistan. Although many are formatting their training towards the U.S., how many are actually destined to get there? I feel that most medical students that I come across in Karachi or elsewhere, might still be focusing too much on the low hanging fruit, like USMLE scores and U.S. electives. Both are important, but the game has changed significantly from the time I applied for further training in the U.S.

A few recommendations and suggestions below are based on what I have learned from my recent trip to Dallas – and I am happy to debunk those who might believe that nothing useful can be learned from Texas.

(1) Although most IMGs have a good grasp of what they want for the short term, i.e., USMLE "success" in terms of top notch scores (as alluded to above), they might want to embrace that healthcare in the “U.S. world” is rapidly evolving. They could learn much from this new age medicine, acquire a new lingo and be prepped for what is here and still to come.

(2) Non-U.S. med students and IMGs could be part of the U.S. healthcare think tank by becoming more active in a few of those online Twitter and Facebook medicine, pediatrics, emergency medicine, etc. groups and platforms. This diversification into interest groups will help develop new age leadership skills. It will also assist innovative and creative thinking about health systems, as distinct from ivory tower approaches to healthcare and biomedicine.

I believe proactive engagement in the fast changing healthcare debate might give them an edge in their U.S. pursuits of higher medical education and training. Although their generation will have the short end of the stick as my generation (gen X) is phasing out, what the millennials have got going for them is extreme optimism for the future. And hope is a good thing.

[from Health & Disease] 

Acknowledgment: Faysal Subhani MBBS class of 2015 at AKU extracted relevant data in support of this article. This article was first published by the Dawn Newspaper blogs.