Obamacare transforms med school

Ranjodh Singh, a first-year medical student at Weill Cornell Medical College, trains every few weeks not with his classmates but with nursing, public-health and social-work students from Hunter College.

Together, they talk to patients, analyze case studies and write papers.

"[We're] learning the skills and strengths of other professions," said Mr. Singh. "Now it's 'How can I help them?' "

Medical students typically have been left to figure out how to work with nurses and other health professionals, usually by osmosis in their third and fourth years. But Obamacare and the shifting economics of medicine are changing that. Today's first-year medical students, the first to train since the Supreme Court ruled Obamacare to be constitutional, will probably not end up working as sole practitioners but as pieces in a much more complex, and possibly more integrated, health delivery system.

"We're no longer the captain of the ship that we always thought we were," said Dr. Joseph Murray, associate professor of clinical psychiatry at Weill Cornell and course director of Medicine, Patients and Society I, a first-year course that focuses on the physician-patient relationship. "If people are going into the profession to be the boss, to tell patients what to do and to order people around, that profession is gone."

Runaway costs and declining reimbursements have sent nearly half the physicians in the United States running to group practices, where they are paid under a complex formula that includes incentive and productivity pay. At least 20% are employed by hospitals, which are buying up private practices to bolster declining revenue from inpatient stays.

Those trends are gathering speed under Obamacare as government spurs the creation of new health care models like medical homes and accountable-care organizations, which make doctors responsible for soup-to-nuts care and patients' health over the long term.

Schools like Weill Cornell are teaching would-be doctors how to work more effectively with other health professionals so that they may lead the changes rather than get swept up in them. They are putting a heavy premium on teamwork among doctors, nurses, nurse practitioners, social workers, health aides and physician assistants. Doctors prescribe the medicine, but it may be the nurse, the social worker or the home health aide who makes sure it gets taken.

Interpersonal skills

Weill Cornell drills the new ethos into students at every turn. The course that Mr. Singh is taking, Interprofessional Training and Education at Cornell-Hunter, trains medical and other students to value each other's expertise and to work in teams.

Patient-centered care is now the mantra, and personal skills will carry financial reward. In other courses, students, who will be judged on their bedside manner, are learning how to talk to patients and families about once-taboo subjects such as end-of-life care.

"If care is to be transformed, that can't happen unless we transform the process of training physicians," said Carol Aschenbrener, chief medical education officer of the American Association of Medical Colleges.

The looming physician shortage is also changing the med-school landscape. A national shortage of 92,000 primary-care physicians is expected by 2020 as an estimated 30 million more patients become insured under Obamacare. Weill Cornell is looking at whether it can expand its student roster to help meet the shortage and is shifting more clinical work into the first and second years, the better to meld the science with patient care.

NYU Langone has a new three-year path to an M.D. in addition to its traditional four-year school. The fast-tracked program will save a year's worth of tuition and living expenses, around $75,000, and allow students to start caring for patients sooner. One hope is that by relieving them of some of the financial burden and the time commitment, more students will go into lower-paid primary care.

NYU is designing its joint degrees in public health, business and public administration to focus on training doctors to manage new kinds of care organizations. Already, the M.B.A.-M.D. program is oversubscribed, said Dr. Steve Abramson, vice dean for education, faculty and academic affairs.

"Obamacare is moving to accountable-care organizations or medical homes," he said. "We think physicians should be the leaders of these organizations."

Sessions on physician pay and organization, cost control and health policy, a mainstay at Weill Cornell for several years, now include Obamacare primers on topics such as reimbursement and electronic records.

"We're asking them to be experts in health care reform and to learn how to work as a team because we're looking now at integrated medicine, not fragmented care," said Weill Cornell Dean Laurie Glimcher. "There are a finite number of health care dollars, and you've got to have the wisdom and the training and the courage to utilize them most effectively."

Mutual trust

Another Weill Cornell program that got off the ground this year has a team of first- and second-year students follow a cohort of patients for their four years of medical school. Students get to know the patients and the physical, social and psychological aspects of their illnesses. That kind of knowledge will help them develop the mutual trust needed for patients to take their meds or go through with a treatment.

"It allows students to understand the longer context of what illness and disease mean and to understand who these people are, as opposed to 'That's the kidney stone in room one,' " said Dr. Keith LaScalea, associate professor of clinical medicine and vice course director of Medicine, Patients and Society I.

Most medical students are idealistic. They strongly support Obamacare, according to surveys, even though many know little about it. First-year Cornell student Cindy Parra, who worked in a community health center in San Diego before medical school, wants to work in immigrant Hispanic communities. Andrew Milewski will spend next summer working with underserved populations overseas in Weill Cornell's global health program. Chioma Enweasor, who with her family immigrated to the United States from Nigeria, plans to become a pediatrician.

"Anything that alleviates some of the concerns that a lot of patients have when they walk through the door is a good thing for health care even if that means you're going to see a lower salary," Ms. Enweasor said. "But I'm also saying that without really understanding what my debt means, so maybe that will change."

Will their education prepare them for the complex, fast-changing world—and $140,000 in debt—that awaits them? Amid their excitement at becoming doctors, they're also nervous about what it will mean to eventually practice under Obamacare.

"We're all a little bit on edge, waiting to see what the next steps are," said Ms. Parra.



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