Acad Psychiatry DOI 10.1007/s40596-014-0141-8
IN DEPTH ARTICLE: COMMENTARY
An Evolving Identity: How Chronic Care Is Transforming What it Means to Be a Physician Alyssa L. Bogetz & Jori F. Bogetz
Received: 1 February 2014 / Accepted: 21 April 2014 # Academic Psychiatry 2014
Abstract Physician identity and the professional role physicians play in health care is rapidly evolving. Over 130 million adults and children in the USA have complex and chronic diseases, each of which is shaped by aspects of the patient’s social, psychological, and economic status. These patients have lifelong health care needs that require the ongoing care of multiple health care providers, access to community services, and the involvement of patients’ family support networks. To date, physician professional identity formation has centered on autonomy, authority, and the ability to “heal.” These notions of identity may be counterproductive in chronic disease care, which demands interdependency between physicians, their patients, and teams of multidisciplinary health care providers. Medical educators can prepare trainees for practice in the current health care environment by providing training that legitimizes and reinforces a professional identity that emphasizes this interdependency. This commentary outlines the important challenges related to this change and suggests potential strategies to reframe professional identity to better match the evolving role of physicians today.
Keywords Residents: professional development . Medical students: socialization
An Identity in Evolution Physician identity and the role physicians play in health care is rapidly evolving. Transformations in the epidemiology, prevention, and treatment of many diseases along with profound changes in the delivery of health care are challenging what it means to practice medicine. These factors give new meaning to the experiences that establish and legitimize physicians’ professional identity [1]. Physician identity includes the intrinsic attitudinal factors related to professionalism and the behavioral attributes related to patient care that shape how physicians understand their societal roles [1]. Once held as the center of the health care universe, physicians now play only one part in determining the allocation, distribution, and delivery of health care. Throughout the education continuum, physicians must prepare for these new roles [2]. For medical trainees, experiences will include working with patients with increasingly complex and chronic medical conditions, collaborating with multidisciplinary teams, and engaging in more patient-centered care and shared medical decision-making [2]. While core values of altruism, integrity, compassion, and fidelity must continue to be cultivated in trainees, an explicit redefinition of physician’s professional identity is needed and must be openly discussed with trainees as they prepare to enter the health care workforce.
Medical Education’s Challenge
A. L. Bogetz (*) Stanford University School of Medicine, Palo Alto, CA, USA e-mail: [email protected] J. F. Bogetz Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, CA, USA
The principal aim of medical education has long been to prepare young doctors for the safe, independent practice of medicine upon completion of medical school, residency, and/ or fellowship [3]. To achieve this goal, the Liaison Committee on Medical Education (LCME) and the Accreditation Council on Graduate Medical Education (ACGME) have defined core competencies for medical trainees in the USA [4, 5]. These
Acad Psychiatry
frameworks establish developmental benchmarks for trainees over time and set standards for assessing performance, clinical knowledge, and skills. In recent years, their utility has been recognized and translated into institutional guidelines for medical education which delineate the everyday activities physicians are expected to master prior to launching independent careers [6]. Although these frameworks play a formative role in training, they only peripherally address the competencies needed to become a fully functioning physician in today’s health care environment [1]. To truly become a physician is a complex and diverse process influenced by formal curricula, clinical experiences, “hidden” curricula, and the educational milieu [7]. It extends beyond the assimilation of medical knowledge and the mastery of clinical skills. At its core is the issue of physicians’ professional identity—which manifests in all aspects of a doctor’s work [8]. The conceptualization of identity as once a distinct and fixed entity has moved to a dynamic conception situated in social relationships [9]. This process of identity formation is adaptive over time and involves individual and collective experiences. At the individual level, clinical experiences during clerkships or residency foster awareness for what it means to engage in medical practice and heighten the self-regulation needed for complex medical decision-making and interprofessional communication. At the collective level, interactions with mentors, patients, families, and “communities of practice” [10] legitimize the “physician” title and define how such a role is situated within the context of medicine and society [1]. To develop one’s identity as a physician demands a deep internalization of the values and roles of the profession, a commitment to lifelong learning, approaches for professional and personal growth, and a profound understanding of systemic health care needs and the realities of practice with patients. Professional identity formation has garnered recent attention from medical educators and researchers due to the expanding influence of the social and behavioral sciences in medical education [11]. The purpose of this attention is to create physicians who are ideally suited to contribute to new models of care, biomedical discovery, and systems improvement to advance the health of patients and communities. Ultimately, the goal is to promote the broader transformation of medicine towards a more integrative and patient-centered approach [9, 12]. Traditionally, these processes have placed a premium on the attributes of autonomy, authority, and expert objectivity. We believe these attributes no longer meet the needs of patients or the current health care system.
Epidemiologic Changes in Disease Burden There are over 133 million people in the USA with at least one chronic illness [13]. This number is projected to increase to
nearly 160 million by 2020, with approximately 50 % of people being affected by multiple chronic conditions [13]. Estimates show that chronic disease care accounts for 78 % of total health care spending nationally and that by 2023, this will equate to 4.2 trillion dollars [14]. While the increase in chronic disease prevalence is largely due to an aging population, the incidence of chronic conditions is rising in children as well. Children with complex chronic diseases (e.g., prematurity, sickle cell disease, cerebral palsy) account for the majority of pediatric hospital costs and have complex health care needs that will persist throughout their lifetime [15]. Patients with complex chronic diseases are also significantly affected by social and economic factors that impact their health (e.g., housing and food insecurity) [16]. These social and economic disparities contribute to poorer overall quality of care, delayed receipt of treatment, and/or complete lack of treatment for chronic health conditions [16]. In addition, psychological and social issues may directly impact how well patients are able to manage their illnesses and can interfere with adherence to medical regimens and treatments [17]. Moreover, the psychological and social aspects of chronic disease itself may impact quality of life and adaptation to illness [17]. It follows that optimal care for these patients requires attention to the whole patient and greater interface between physicians, patients, families, and the larger community.
Chronic Care and Its Relationship to Physician Identity Formation With the rollout of the Affordable Care Act, more people with chronic diseases will be able to access and receive health care. To safeguard greater access from translating into an exacerbation of existing challenges, such as care fragmentation and poor health care quality, direct collaboration between patients and health care providers is required [2]. While the importance of this collaboration has been recognized for all patients [18], fundamental differences in care for those with chronic diseases exist and may heighten the impact of such an approach. Treatments for these patients often do not offer cures, but rather aim to reduce symptoms, prevent complications, and improve overall functioning. Common chronic diseases such as heart disease, diabetes, and cancer require daily management through lifestyle changes, medication administration, and the use of medical technology. Previously, physicians might have had sole access to the intricacies of treatment and palliation. Today, patients and families often have indepth knowledge of their illnesses, their long-term consequences, and the resources required for self-management. In addition, the availability of medical information has enabled many patients to function as educated consumers and active decision makers about their care. Patients also continue to
Acad Psychiatry
bridge health care silos by transferring information from different providers and relaying information about the impact of their home environment and communities on their health. To be effective, physicians should welcome and encourage care planning that includes patients’ knowledge, input, and preferences. Close partnerships with patients can enable physicians to better understand how patients’ health functions within the context of their families, cultures, and communities. Taking the time to elicit patients’ health beliefs, preferences, and concerns is essential for effective care delivery and the promotion of adherence to complicated disease management regimens. Moreover, direct collaboration and goal setting have enormous potential to increase the value of care by making patients themselves more accountable and committed to their personal health outcomes. Studies have shown that adults with chronic illness want to participate actively in choosing among treatment options, and those who engage in shared decision-making with their physicians are more satisfied with and adherent to care [19]. We believe physician attitudes of receptivity, openness, and humility are necessary to engage patients and families more fully in medical decision-making.
Reframing Physician Identity: Teaching Interdependency Medical educators must think more deeply about what it means to be a physician in today’s health care environment. Traditional notions of physician autonomy and authority must be replaced with philosophies of interdependency and shared responsibility between medical providers and patients. The education of trainees must foster a critical understanding of the physician’s role and how each physician operates within the context of the health care system and within the context of their patient’s lives. The search for practical and effective methods to build competencies in interpersonal communication and patient-centered care must also include instruction on strategies to invite patients to educate physicians about their needs and treatment goals. Educators must teach physicians to ask their patients to identify what matters most to them and to utilize this information to inform health care decisions. Initiatives that promote interprofessional education should be encouraged, but may not be enough to prepare trainees to successfully care for a patient population with increasingly complex and chronic medical conditions. We believe new pedagogical models for shared responsibility between health care providers and stronger tools that enable physicians to understand and address their patients’ sociocultural needs and the psychosocial impacts of chronic disease are still needed.
Concrete approaches to prepare trainees for the twentyfirst century health care exist and may contribute to this new understanding of professional identity and physician role formation (Table 1). Classroom learning that integrates foundational sciences with the social and behavioral sciences necessary to understand patient illness, disease trajectories, and therapeutic strategies may show particular promise by emphasizing how biological, behavioral, social, and psychological pathways interact to promote health and prevent disease complications [2]. Other emerging and distinct approaches that may allow this instruction to come to life include engaging students in social work activities such as case management and care coordination [20] and encouraging home, school, or nursing home visits for high-risk or medically complex patients [21]. These system-based experiences may broaden how trainees think about their patients’ diseases, the ways they affect their patients’ lives, and what therapeutic strategies will contribute to their patients’ wellness. For example, home visits for medically complex patients can build skills in functional assessments and home safety evaluations and may provide insight into patients’ medication errors and prompt orders for medication changes or referral to additional services [21]. Another strategy may be to train physicians to become patient navigators [22]. These programs can address how advocacy is applied directly to patient care and can motivate trainees to screen patients for housing, mental illness, or other social risk factors affecting patient health in their future practice. This knowledge can also be leveraged into the development of interventions that address these issues or be used to refer patients to existing programs such as transportation services,
Table 1 Strategies for teaching interdependency Strategies 1. Concrete experiences a. Engagement with social workers and case managers around patient care issues b. Home, school, or community visits for high-risk and/or medically complex patients c. Simulation training in shared decision-making d. Volunteer work as patient navigators e. Continuity with patients to better understand diseases over time and in context f. Relationships with mentors to role model high-quality chronic care 2. General practices a. Integrate biological science with social and behavioral science education b. Honesty and openness with learners about challenges of complex care delivery c. Focus on interprofessional education and teamwork d. Cultivate humility and patient-centeredness in patient care experiences
Acad Psychiatry
support groups, or financial services. Finally, initiatives that integrate and seek to improve mentorship to trainees at the undergraduate and graduate level may support the development of the reflective capacity, self-awareness, and emotional intelligence needed for the medical decision-making, communication, and systems-based thinking required of today’s physician. While evidence regarding the efficacy of these approaches is still growing [20–22], we believe these experiences have the potential to deepen trainees’ empathy towards their patients and facilitate a more accurate understanding of their patients’ needs, which can contribute to improved overall health outcomes.
Looking Forward: An Evolved Professional Identity The education of physicians is marked by profound changes in knowledge and personal growth. Today, medical trainees are asked to assimilate vast amounts of medical information, have an increasingly complex understanding of their patients’ needs, and address these needs in a timely, efficient, and patient-centered manner. We believe that early training about the physician’s role, the strategic use of professional power, and the effective utilization of patients as members of the health care team should be a required component of all medical training. This education should be introduced early and be explicitly reinforced over time as trainees enter new stages of their professional development. As medical educators, we must develop and implement pedagogical models that emphasize shared responsibility, collaboration, and systems-based practice. Additionally, we must cultivate in trainees a willingness to act as humble partners with patients through concrete clinical experiences that broaden thinking about diseases and the physical, social, and psychological impact they have on their patients’ lives. We believe these strategies will help build the knowledge, skills, and empathy needed to practice medicine with an increasingly complex and chronic population. With training that promotes humility, collaboration, and interdependency with patients, new professional identities can form to improve patient care. Implications for Educators & Physicians’ professional identity formation provides the backbone of medical education. & Chronic disease and modern health care delivery have changed the experiences that legitimize this identity. & Concepts of interdependency, shared responsibility, and physician humility must be explicitly integrated into medical education to prepare doctors for the complex, patient-centered, and systems-based care required of today’s physicians.
Implications for Academic Leaders & Competencies outlined by the LCME for medical students and ACGME for residents do not sufficiently address the attitudes, values, or core belief systems required for physicians to deliver optimal care in the current health care environment. & Pedagogical models for interdependency and shared responsibility between physicians, patients, and families must be developed and integrated into medical education programs to address changes in the roles and responsibilities of physicians today. & Concrete experiences within and outside of the medical setting may need to become a required component of all medical training to broaden trainees’ understanding of disease trajectories and their impact on patients’ physical, social, and psychological well-being.
Acknowledgments The authors thank David Bergman, M.D., for reviewing this manuscript and the physicians, clinicians, and researchers who generously offer their time and service in support of their patients and communities. Disclosures The authors have no conflicts of interest or disclosures, including financial or personal relationships with individuals or entities that may be related to this manuscript.
References 1. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough. Acad Med. 2012;87(9):1185–90. doi:10.1097/ACM.0b013e3182604968. 2. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173(17):1639–43. doi:10.1001/ jamainternmed.2013.9074. 3. Stern DT, Papadakis M. The developing physician—becoming a professional. N Engl J Med. 2006;355(17):1794–9. doi:10.1056/ NEJMra054783. 4. Liaison Committee on Medical Education. Available at: http://www. lcme.org/. Accessibility verified 30 Jan 2014. 5. Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org. Accessibility verified 30 Jan 2014. 6. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012;366(11): 1051–6. doi:10.1056/NEJMsr1200117. 7. Monrouxe LV. Identity, identification and medical education: why should we care? Med Educ. 2010;44(1):40–9. doi:10.1111/j.13652923.2009.03440.x. 8. Hilton SR, Slotnick HB. Proto-professionalism: how professionalisation occurs across the continuum of medical education. Med Educ. 2005;39(1):58–65. doi:10.1111/j.1365-2929.2004.02033.x. 9. Burford B. Group processes in medical education: learning from social identity theory. Med Educ. 2012;46(2):143–52. doi:10.1111/ j.1365-2923.2011.04099.x. 10. Wenger E. Communities of practice. Cambridge: Cambridge University Press; 1998. 11. Schuwirth L. Medical education and other disciplines. Med Educ. 2010;44(1):13–4. doi:10.1111/j.1365-2923.2009.03538.x. 12. Pershing S, Fuchs VR. Restructuring medical education to meet current and future health care needs. Acad Med. 2013;88(12): 1798–801. doi:10.1097/ACM.0000000000000020.
Acad Psychiatry 13. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Aff. 2009;28(1):64–74. 14. Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(S3):391–5. doi: 10.1007/s11606-007-0322-1. 15. Berry JG, Hall DE, Kuo DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA. 2011;305(7):682–90. doi:10.1001/jama. 2011.122. 16. Adler NE, Rehkopf DH. U.S. disparities in health: descriptions, causes, and mechanisms. Annu Rev Public Health. 2008;29(1):235–52. 17. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient selfmanagement of chronic disease in primary care. JAMA. 2002;288(19):2469–75.
18. Braddock III CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282(24):2313–20. 19. Parchman ML, Zeber JE, Palmer RF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Ann Fam Med. 2010;8(5):410–7. doi:10.1370/afm.1161. 20. De Los Santos M, McFarlin CD, Martin L. Interprofessional education and service learning: a model for the future of health professions education. J Interprof Care. 2014:1–2. doi:10.3109/13561820.2014.889102. 21. Patel S, Bachhuber M, O’Brien B. An interprofessional home visit curriculum for high-risk patients. Med Educ. 2013;47(11):1138–9. doi:10.1111/medu.12331. 22. Wells KJ, Battaglia TA, Dudley DJ, et al. Patient navigation: state of the art or is it science? Cancer. 2008;113(8):1999–2010. doi:10.1002/ cncr.23815.
IN DEPTH ARTICLE: COMMENTARY
An Evolving Identity: How Chronic Care Is Transforming What it Means to Be a Physician Alyssa L. Bogetz & Jori F. Bogetz
Received: 1 February 2014 / Accepted: 21 April 2014 # Academic Psychiatry 2014
Abstract Physician identity and the professional role physicians play in health care is rapidly evolving. Over 130 million adults and children in the USA have complex and chronic diseases, each of which is shaped by aspects of the patient’s social, psychological, and economic status. These patients have lifelong health care needs that require the ongoing care of multiple health care providers, access to community services, and the involvement of patients’ family support networks. To date, physician professional identity formation has centered on autonomy, authority, and the ability to “heal.” These notions of identity may be counterproductive in chronic disease care, which demands interdependency between physicians, their patients, and teams of multidisciplinary health care providers. Medical educators can prepare trainees for practice in the current health care environment by providing training that legitimizes and reinforces a professional identity that emphasizes this interdependency. This commentary outlines the important challenges related to this change and suggests potential strategies to reframe professional identity to better match the evolving role of physicians today.
Keywords Residents: professional development . Medical students: socialization
An Identity in Evolution Physician identity and the role physicians play in health care is rapidly evolving. Transformations in the epidemiology, prevention, and treatment of many diseases along with profound changes in the delivery of health care are challenging what it means to practice medicine. These factors give new meaning to the experiences that establish and legitimize physicians’ professional identity [1]. Physician identity includes the intrinsic attitudinal factors related to professionalism and the behavioral attributes related to patient care that shape how physicians understand their societal roles [1]. Once held as the center of the health care universe, physicians now play only one part in determining the allocation, distribution, and delivery of health care. Throughout the education continuum, physicians must prepare for these new roles [2]. For medical trainees, experiences will include working with patients with increasingly complex and chronic medical conditions, collaborating with multidisciplinary teams, and engaging in more patient-centered care and shared medical decision-making [2]. While core values of altruism, integrity, compassion, and fidelity must continue to be cultivated in trainees, an explicit redefinition of physician’s professional identity is needed and must be openly discussed with trainees as they prepare to enter the health care workforce.
Medical Education’s Challenge
A. L. Bogetz (*) Stanford University School of Medicine, Palo Alto, CA, USA e-mail: [email protected] J. F. Bogetz Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, CA, USA
The principal aim of medical education has long been to prepare young doctors for the safe, independent practice of medicine upon completion of medical school, residency, and/ or fellowship [3]. To achieve this goal, the Liaison Committee on Medical Education (LCME) and the Accreditation Council on Graduate Medical Education (ACGME) have defined core competencies for medical trainees in the USA [4, 5]. These
Acad Psychiatry
frameworks establish developmental benchmarks for trainees over time and set standards for assessing performance, clinical knowledge, and skills. In recent years, their utility has been recognized and translated into institutional guidelines for medical education which delineate the everyday activities physicians are expected to master prior to launching independent careers [6]. Although these frameworks play a formative role in training, they only peripherally address the competencies needed to become a fully functioning physician in today’s health care environment [1]. To truly become a physician is a complex and diverse process influenced by formal curricula, clinical experiences, “hidden” curricula, and the educational milieu [7]. It extends beyond the assimilation of medical knowledge and the mastery of clinical skills. At its core is the issue of physicians’ professional identity—which manifests in all aspects of a doctor’s work [8]. The conceptualization of identity as once a distinct and fixed entity has moved to a dynamic conception situated in social relationships [9]. This process of identity formation is adaptive over time and involves individual and collective experiences. At the individual level, clinical experiences during clerkships or residency foster awareness for what it means to engage in medical practice and heighten the self-regulation needed for complex medical decision-making and interprofessional communication. At the collective level, interactions with mentors, patients, families, and “communities of practice” [10] legitimize the “physician” title and define how such a role is situated within the context of medicine and society [1]. To develop one’s identity as a physician demands a deep internalization of the values and roles of the profession, a commitment to lifelong learning, approaches for professional and personal growth, and a profound understanding of systemic health care needs and the realities of practice with patients. Professional identity formation has garnered recent attention from medical educators and researchers due to the expanding influence of the social and behavioral sciences in medical education [11]. The purpose of this attention is to create physicians who are ideally suited to contribute to new models of care, biomedical discovery, and systems improvement to advance the health of patients and communities. Ultimately, the goal is to promote the broader transformation of medicine towards a more integrative and patient-centered approach [9, 12]. Traditionally, these processes have placed a premium on the attributes of autonomy, authority, and expert objectivity. We believe these attributes no longer meet the needs of patients or the current health care system.
Epidemiologic Changes in Disease Burden There are over 133 million people in the USA with at least one chronic illness [13]. This number is projected to increase to
nearly 160 million by 2020, with approximately 50 % of people being affected by multiple chronic conditions [13]. Estimates show that chronic disease care accounts for 78 % of total health care spending nationally and that by 2023, this will equate to 4.2 trillion dollars [14]. While the increase in chronic disease prevalence is largely due to an aging population, the incidence of chronic conditions is rising in children as well. Children with complex chronic diseases (e.g., prematurity, sickle cell disease, cerebral palsy) account for the majority of pediatric hospital costs and have complex health care needs that will persist throughout their lifetime [15]. Patients with complex chronic diseases are also significantly affected by social and economic factors that impact their health (e.g., housing and food insecurity) [16]. These social and economic disparities contribute to poorer overall quality of care, delayed receipt of treatment, and/or complete lack of treatment for chronic health conditions [16]. In addition, psychological and social issues may directly impact how well patients are able to manage their illnesses and can interfere with adherence to medical regimens and treatments [17]. Moreover, the psychological and social aspects of chronic disease itself may impact quality of life and adaptation to illness [17]. It follows that optimal care for these patients requires attention to the whole patient and greater interface between physicians, patients, families, and the larger community.
Chronic Care and Its Relationship to Physician Identity Formation With the rollout of the Affordable Care Act, more people with chronic diseases will be able to access and receive health care. To safeguard greater access from translating into an exacerbation of existing challenges, such as care fragmentation and poor health care quality, direct collaboration between patients and health care providers is required [2]. While the importance of this collaboration has been recognized for all patients [18], fundamental differences in care for those with chronic diseases exist and may heighten the impact of such an approach. Treatments for these patients often do not offer cures, but rather aim to reduce symptoms, prevent complications, and improve overall functioning. Common chronic diseases such as heart disease, diabetes, and cancer require daily management through lifestyle changes, medication administration, and the use of medical technology. Previously, physicians might have had sole access to the intricacies of treatment and palliation. Today, patients and families often have indepth knowledge of their illnesses, their long-term consequences, and the resources required for self-management. In addition, the availability of medical information has enabled many patients to function as educated consumers and active decision makers about their care. Patients also continue to
Acad Psychiatry
bridge health care silos by transferring information from different providers and relaying information about the impact of their home environment and communities on their health. To be effective, physicians should welcome and encourage care planning that includes patients’ knowledge, input, and preferences. Close partnerships with patients can enable physicians to better understand how patients’ health functions within the context of their families, cultures, and communities. Taking the time to elicit patients’ health beliefs, preferences, and concerns is essential for effective care delivery and the promotion of adherence to complicated disease management regimens. Moreover, direct collaboration and goal setting have enormous potential to increase the value of care by making patients themselves more accountable and committed to their personal health outcomes. Studies have shown that adults with chronic illness want to participate actively in choosing among treatment options, and those who engage in shared decision-making with their physicians are more satisfied with and adherent to care [19]. We believe physician attitudes of receptivity, openness, and humility are necessary to engage patients and families more fully in medical decision-making.
Reframing Physician Identity: Teaching Interdependency Medical educators must think more deeply about what it means to be a physician in today’s health care environment. Traditional notions of physician autonomy and authority must be replaced with philosophies of interdependency and shared responsibility between medical providers and patients. The education of trainees must foster a critical understanding of the physician’s role and how each physician operates within the context of the health care system and within the context of their patient’s lives. The search for practical and effective methods to build competencies in interpersonal communication and patient-centered care must also include instruction on strategies to invite patients to educate physicians about their needs and treatment goals. Educators must teach physicians to ask their patients to identify what matters most to them and to utilize this information to inform health care decisions. Initiatives that promote interprofessional education should be encouraged, but may not be enough to prepare trainees to successfully care for a patient population with increasingly complex and chronic medical conditions. We believe new pedagogical models for shared responsibility between health care providers and stronger tools that enable physicians to understand and address their patients’ sociocultural needs and the psychosocial impacts of chronic disease are still needed.
Concrete approaches to prepare trainees for the twentyfirst century health care exist and may contribute to this new understanding of professional identity and physician role formation (Table 1). Classroom learning that integrates foundational sciences with the social and behavioral sciences necessary to understand patient illness, disease trajectories, and therapeutic strategies may show particular promise by emphasizing how biological, behavioral, social, and psychological pathways interact to promote health and prevent disease complications [2]. Other emerging and distinct approaches that may allow this instruction to come to life include engaging students in social work activities such as case management and care coordination [20] and encouraging home, school, or nursing home visits for high-risk or medically complex patients [21]. These system-based experiences may broaden how trainees think about their patients’ diseases, the ways they affect their patients’ lives, and what therapeutic strategies will contribute to their patients’ wellness. For example, home visits for medically complex patients can build skills in functional assessments and home safety evaluations and may provide insight into patients’ medication errors and prompt orders for medication changes or referral to additional services [21]. Another strategy may be to train physicians to become patient navigators [22]. These programs can address how advocacy is applied directly to patient care and can motivate trainees to screen patients for housing, mental illness, or other social risk factors affecting patient health in their future practice. This knowledge can also be leveraged into the development of interventions that address these issues or be used to refer patients to existing programs such as transportation services,
Table 1 Strategies for teaching interdependency Strategies 1. Concrete experiences a. Engagement with social workers and case managers around patient care issues b. Home, school, or community visits for high-risk and/or medically complex patients c. Simulation training in shared decision-making d. Volunteer work as patient navigators e. Continuity with patients to better understand diseases over time and in context f. Relationships with mentors to role model high-quality chronic care 2. General practices a. Integrate biological science with social and behavioral science education b. Honesty and openness with learners about challenges of complex care delivery c. Focus on interprofessional education and teamwork d. Cultivate humility and patient-centeredness in patient care experiences
Acad Psychiatry
support groups, or financial services. Finally, initiatives that integrate and seek to improve mentorship to trainees at the undergraduate and graduate level may support the development of the reflective capacity, self-awareness, and emotional intelligence needed for the medical decision-making, communication, and systems-based thinking required of today’s physician. While evidence regarding the efficacy of these approaches is still growing [20–22], we believe these experiences have the potential to deepen trainees’ empathy towards their patients and facilitate a more accurate understanding of their patients’ needs, which can contribute to improved overall health outcomes.
Looking Forward: An Evolved Professional Identity The education of physicians is marked by profound changes in knowledge and personal growth. Today, medical trainees are asked to assimilate vast amounts of medical information, have an increasingly complex understanding of their patients’ needs, and address these needs in a timely, efficient, and patient-centered manner. We believe that early training about the physician’s role, the strategic use of professional power, and the effective utilization of patients as members of the health care team should be a required component of all medical training. This education should be introduced early and be explicitly reinforced over time as trainees enter new stages of their professional development. As medical educators, we must develop and implement pedagogical models that emphasize shared responsibility, collaboration, and systems-based practice. Additionally, we must cultivate in trainees a willingness to act as humble partners with patients through concrete clinical experiences that broaden thinking about diseases and the physical, social, and psychological impact they have on their patients’ lives. We believe these strategies will help build the knowledge, skills, and empathy needed to practice medicine with an increasingly complex and chronic population. With training that promotes humility, collaboration, and interdependency with patients, new professional identities can form to improve patient care. Implications for Educators & Physicians’ professional identity formation provides the backbone of medical education. & Chronic disease and modern health care delivery have changed the experiences that legitimize this identity. & Concepts of interdependency, shared responsibility, and physician humility must be explicitly integrated into medical education to prepare doctors for the complex, patient-centered, and systems-based care required of today’s physicians.
Implications for Academic Leaders & Competencies outlined by the LCME for medical students and ACGME for residents do not sufficiently address the attitudes, values, or core belief systems required for physicians to deliver optimal care in the current health care environment. & Pedagogical models for interdependency and shared responsibility between physicians, patients, and families must be developed and integrated into medical education programs to address changes in the roles and responsibilities of physicians today. & Concrete experiences within and outside of the medical setting may need to become a required component of all medical training to broaden trainees’ understanding of disease trajectories and their impact on patients’ physical, social, and psychological well-being.
Acknowledgments The authors thank David Bergman, M.D., for reviewing this manuscript and the physicians, clinicians, and researchers who generously offer their time and service in support of their patients and communities. Disclosures The authors have no conflicts of interest or disclosures, including financial or personal relationships with individuals or entities that may be related to this manuscript.
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