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The DO | In Training | Training Ground

Grads: DOs tell you a few things you probably didn’t learn in med school

With four years of concentrated learning behind them, the hard part is over for this year’s osteopathic medical graduates, right? There are fewer written tests to worry about. They can now crack open a book without an -ology suffix somewhere in the title. They can lend some attention to learning how to grow rhubarb.

Yet, these well-earned privileges notwitstanding, the important learning—the kind that will directly bear on their day-to-day work—is just beginning. The DO informally queried a few DOs in practice to find out the kinds of skills they had to learn on the job.

J. Michael Herr, DO, a proponent of lifelong learning

“I still see something a few times every year that I have never seen before.”
Dr. Herr

The good news is critical skills, such as medical insight, can only be gained from experience. So well-prepared graduates haven’t missed out on anything. Moreover, many other abilities—practice management and other business skills, for example—can easily enough be picked up in the clinic. But that doesn’t mean DOs aren’t haunted by wishes that they had learned these skills before they went into practice.

“The one thing I wish we would have learned more about in med school is coding,” says Anthony F. Human, DO, who earned his osteopathic medical degree in 2002. “That’s why I give the students who rotate with me a little introduction to the topic.”

A family physician in Dacula, Ga., Dr. Human discusses with rotating students the differences between Current Procedural Terminology (CPT) coding and ICD-9 diagnostic coding, lets them know that ICD-10 will replace ICD-9 by the time they’re in practice, and explains the various levels of evaluation and management (or E&M) coding within CPT. Some of his students have expressed their gratitude for this brief exposure to the business of medicine, he says.

Family physician Elizabeth M. Kronlage, DO, of Tucson, Ariz., wishes she would’ve learned more about nutrition as a med student.

“There was an absolute dearth of information on the subject,” says Dr. Kronlage, who graduated from medical school 10 years ago. “We had lectures on nutrition on just two different days. That was it.”

Given that family physicians must continually counsel their patients about the importance of healthful eating and understand the dietary constraints of certain patient populations, Dr. Kronlage had to learn a lot about nutritional issues on her own, she says.

Dr. Kronlage also would’ve appreciated more information on the underlying principles of osteopathic manipulative medicine. As a DO student, she was taught many osteopathic manipulative treatment techniques. “I wish I would’ve learned more about the principles behind all of those techniques,” she says. “I have since educated myself on those principles. But learning osteopathic manipulation based on principles instead of specific techniques the first time around would have really helped.”

What’s more, Dr. Kronlage didn’t realize that many of the terms she learned in osteopathic medical school are specific to osteopathic medicine. “I would like to have learned better how to discuss OMM with MDs and other colleagues not trained in it,” she says. “It wasn’t until I was out in practice that I realized the difference between our language and theirs.

“At that point, I was already behind in my ability to educate others about osteopathic medicine and, thus, less able to bridge the gap that has plagued the relationship between allopathic and osteopathic physicians for decades.”

Lifelong learning

J. Michael Herr, DO, for one, has been astounded by what he has learned clinically in practice compared to what he was taught in med school.

“You go through the first two years of intense book-learning, then two years of on-the-job training, then three or more years of honing your skills. But when you are finally out in the real world, rarely do things occur like you learned them,” says Dr. Herr, a family physician in West Hartford, Conn. “The variety of presentation and depth of patients’ experiences are breathtaking in their scope.”

But, of course, there is no way to learn everything a doctor needs to know during medical school and graduate medical training. Physicians need to be humble yet enthusiastic lifelong learners, Dr. Herr insists, especially given the explosion in basic science and clinical knowledge and ever-expanding regulations and guidelines.

“The lesson is to cultivate the attitude of keeping an open mind and not assuming that the letters after your name imply that you know it all,” says Dr. Herr, who became a DO in 1978. “It never ceases to amaze me that even after almost 36 years since graduation, I still see something a few times every year that I have never seen before. And things I thought I knew ‘cold’ are really not as they seem.

“I would like to have learned better how to discuss OMM with MDs and other colleagues not trained in it.”
Dr. Kronlage

“New knowledge is blowing away some of my standard assumptions.”

Most valuable lessons

Graduates frequently say they would like to have learned more about job hunting, contract negotiation and medical billing during med school, observes Jarrod T. Eddy, DO, a general internist in Doylestown, Pa., who earned his DO degree in 2005. “I would take an alternate approach and suggest that everything I need to know about being a good doctor—and didn’t learn in medical school or residency—I learned from my mother,” he says. “In an era when ‘computer-enhanced’ office notes maximize billable items and ‘patient encounters’ are viewed as an opportunity to ‘check all the boxes,’ I believe the most important things we didn’t learn in medical school relate to personal interaction.”

Growing up, Dr. Jarrod learned how to be an excellent listener and treat others with compassion, he says.

“My mother taught me to respect people—all people,” he notes. “As a result, I realize the importance of simple things like sitting down during an interview so that patients do not have the sense that you are about to rush off to do something far more important. I also learned from my mother the importance of eye contact—with the patient, not the computer screen—and actually listening and then answering questions as they pertain to that specific patient, as opposed to giving generalized answers that would apply to every patient with hypertension or every patient with diabetes.”

Physicians should have developed good basic interpersonal skills before medical school, and they need to continue developing their communication and listening skills throughout their practice lives, Dr. Herr agrees. He offers these tips to new doctors: “Don’t start to assume a diagnosis when you hear the first words out of patients’ mouths. Give patients an uninterrupted two minutes to talk totally about what’s happening to them.”

Today, given easy access to medical information online, many patients attempt to diagnose themselves. Physicians need to understand the reasoning behind a patient’s self-diagnosis and be empathetic, Dr. Herr says. “After listening to the patient’s thoughts, either confirm that the diagnosis is correct or gently explain to the patient why you think it something else,” he suggests. “You need to work within a patient’s psychological response.”

Osteopathic physicians pride themselves on treating the whole patient, points out Dr. Eddy. “To me, this means actually interacting with Ms. Jones during her visit and not just checking her blood pressure and making sure it fits the guidelines.

“We learn a great deal about disease, illness, diagnosis and patient management throughout medical school and residency. What we sorely lack is instruction in personal contact, attentive listening and respect for the decisions and desires of others.”

cschierhorn@osteopathic.org

3 Responses

  1. Stacey on June 5, 2014, 9:26 p.m.

    I am a graduate of an osteopathic medical school and am now a professor at a different osteopathic medical school. As far as coding, Medical students will likely not remember much until they truly use this skill in internship and residency; just like pharmacology, it made more sense with real life use. This should be introduced in medical school, but as stated, it is changing. Many medical students will not pay much attention to things that are not immediately vital to their exams, boards, or residency applications. At the institution where I work now, OMT coding is discussed and tested on their exam and they have only learned this information to pass the exam.

    I do agree that nutrition should be incorporated into medical education. It is usually learned in internship and residency in regards to inpatient medicine, which is important, but not where most of us spend the remainder of our professional lives.

    As far as osteopathic terminology, I do not believe that this is a great barrier in communication with allopathic physicians. This topic is frequently discussed with patients that are unaware of osteopathic medicine. I have my students think about how to describe osteopathic medicine to patients who are naive; they have already practiced, as I previously and currently have, to explain the practices and principles to family members and acquaintances. It should be easier to describe the principles to allopaths who should understand the medical terminology used. Furthermore, at least in my geographic area, allopaths are interested in and seek further education and training in osteopathic techniques and principles.

    Though listening skills and having an open mind needs to be cultivated prior to medical school, it was definitely focused on in my training and what is provided at my current institution, it is the responsibility of individual students to cultivate these skills further.

    I do agree with the need to at least introduce job hunting, contracts, and coding, though this would be better placed in the years of internship and residency. Individuals are most interested in learning and putting things into practice that pertain to them in more imminent events.

    I would also like to add the importance of an introduction to malpractice insurance terminology. This should be discussed in depth in residency, which I did not experience. I have recently discovered my lack of knowledge about the topic.

    Overall, a lot of these topics should be introduced in medical school, but discussed in depth in internship and residency.

  2. Stacey on June 5, 2014, 9:28 p.m.

    I would like to alerted of follow-up comments

  3. Bill on June 12, 2014, 12:35 p.m.

    I completed my degree at KCOM in 1975. After many years of practice and teaching students I still believe as I was taught that we must “listen to the patient” because he really is telling us what is wrong with him. Communication skills are slipping in our students as they text rather than talking. Medical knowledge is expanding and we must all be lifetime learners or we become dangerous in our ignorance. I firmly believe that EMRs and “meaningful use” are turning us into mere technicians as non medical people take control. Students need to learn to synthesize information and arrive at conclusions in making a diagnosis. Coding, billing and management are things we need after we learn how to figure out what is wrong with the patient or sometimes that there is really nothing wrong at all.

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