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.
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.”
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.
“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.”