By John J. LoCurto, JD and Adam V. Ratner, MD, FACR

Educating the Whole Physician:

THE CASE FOR TEACHING THE BUSINESS OF MEDICINE

By John J. LoCurto, JD and Adam V. Ratner, MD, FACR

The century-old medical education paradigm emphasizes the basic sciences and clinical training. While this traditional approach churns out physicians with deep knowledge and technical proficiency, it does not prepare them for the business of practicing medicine. By omitting the business of medicine from their curricula, medical schools squander a chance to ready their students for the commercial, regulatory and legal environments in which they will treat patients. The cost of this omission is more than just a missed opportunity. Unprepared students are prone to exploitation, frustration and burnout. While there may be no easy way to bridge the gulf between how medicine is taught and how it is practiced, integrating the business of medicine into the four-year curriculum would surely help.

Traditional medical education begins with the basic sciences. During their first two years, medical students examine the body, its structures and the systems those structures comprise. They study biochemistry to understand their future patients at the cellular and molecular levels. And they are immersed in ologies – microbiology, physiology, histology, pathology, pharmacology and so forth. When they emerge from their first two years, medical students embark on a two-year stint of practical training. Rotating through hospitals and clinics, they encounter core disciplines, specialties and patients – the embodiment of the scientific principles they have studied for so long. And when their four years are up, they are rewarded with even more training, in the form of internships, residencies and graduate medical education. This system, which dates to 1910 and the Flexner Report, produces “a high level of excellence.”1 After 112 years of experience in this educational paradigm, it is fair to ask – is excellence enough?

New physicians must, of course, be knowledgeable and clinically skilled. Our medical education system excels at fostering essential competencies. Medical students grow into new physicians who, by and large, are prepared to diagnose, prescribe, treat and operate. What our traditional system does not do quite so well – or perhaps at all – is prepare medical students for the business of practicing medicine. New physicians may be able to distinguish nephritic from nephrotic syndrome, but they cannot differentiate a nose from a tail or a claim from an occurrence. They can identify neoplasia but not read an employment contract, much less identify the contractual terms (like a non-compete provision) that could metastasize out of control. New physicians may be able to perform a procedure but not bill for it. They are, in short, equipped to treat but not to practice.

When they finally join the health care system and workforce after roughly a decade of training, new physicians are vulnerable. Unaware of the commercial, regulatory and legal complexities that await, they run a gauntlet of pitfalls that range from the simple and personal (living too far from the hospital during residency) to the consequential and career-altering (referring patients in exchange for gratuities). The aspirations that called so many to careers in medicine evaporate and are quickly replaced by the stress of educational debt and preoccupation with Relative Value Units (RVUs). The difference between the way that medicine is taught and how it is practiced is jarring and leads to disillusionment, burnout and even moral injury.2

Viewed against this backdrop, it may seem that a sea change – a fundamental reorganization of how we educate and train new physicians – is necessary. Perhaps. But even small adjustments will help. Incorporating the business of medicine into medical school curricula would be a good place to start.

At the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM), the business of medicine is threaded into the curriculum. It shows up in small-group case studies that learners encounter weekly in their first two years. The vignettes that learners analyze often introduce facts about a patient’s insurance coverage, the price of drugs or programs available to defray the cost of care. While these issues are not central, learners absorb them, ask questions and develop awareness. The business of medicine surfaces again during third year when learners attend periodic sessions on an array of practical issues, ranging from the revenue cycle to conflicts of interest. And it returns during the fourth year. Learners may elect to pursue a non-clinical clerkship in the business of medicine that allows them to explore topics of interest, such as loan repayment, investing during residency, moonlighting, medical malpractice, federal health care programs, third-party payers, concierge medicine, the direct primary care delivery model and more.

This litany probably sounds more radical than it really is. UIWSOM is not trying to remake medical school into business or law school; nor does it aim to produce PhDs in health care economics. The objective is rather more modest: to prime learners for what lies ahead. UIWSOM strives to ready its learners and trigger their curiosity, all without disrupting the basic science and clinical education that medical school imparts. The hope is that, by supplementing the traditional curriculum, learners will evolve into physicians who are able to spot issues, respond effectively and recognize when they need assistance. By introducing its learners to the business side of their vocation, UIWSOM endeavors to form physicians who are more adept at negotiating the demands of the environment in which they will practice medicine, and who are able to protect their consciences and aspirations while doing so.

UIWSOM’s integration of the business of medicine into its curriculum should come as no surprise. Osteopathic medicine is holistic, focusing on the whole patient rather than discrete symptoms, injuries or diseases. Just as osteopathic medicine embraces the whole patient, osteopathic medical education at UIWSOM seeks to educate the whole physician. And that means preparing medical students for the challenges and opportunities of the business of medicine.

References 1. Cooke, M., Irby, D. M., & O'Brien, B. C. (2010). Educating Physicians: A Call for Reform of Medical School and Residency. Stanford, California: Jossey-Bass. 2. Talbot, S. G., & Dean. W. (2018, July 16). Physicians aren't 'burning out.' They're suffering from moral injury. STAT. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/.

John J. LoCurto, JD is Assistant Professor of Medical Jurisprudence and Health Policy at UIWSOM.

Adam V. Ratner, MD, FACR is Professor of Radiology, Health Policy & Medical Humanities and Assistant Dean of Strategic Initiatives at UIWSOM, and served as the 2019 President of the BCMS.