When Daniel Henderson was a first-year medical student at the University of Connecticut, he wanted to take a class on health care policy. But between his core requirements and an elective in community-based research methods, he didn't have room in his schedule. His only encounter with policy was a pair of dull lectures in his second year. "Most people did work for other classes or played games on their computer," Henderson recalls.
For all the schooling future doctors undergo—as much as 11 years from pre-med through residencies—very little of it focuses on health care policy. That's understandable. Medicine is complicated enough without having to worry about who gets it or how we pay for it. But as a result, many students graduate with little understanding of how our health care system works. "People I graduated with couldn't tell you the difference between Medicare and Medicaid," says Jaclyn Albin, a recent grad of the George Washington University School of Medicine and Health Sciences.
The problem isn't always the classes. Most medical schools offer at least one elective that covers the basics of health care policy—how providers work, private vs. public insurance, drug legislation, etc. Many of them offer entire courses of study in policy.
The hard part is getting students to take them. Most first- and second-year students are so frazzled from their regular course work that they barely have time for sleep, let alone wonk out. "Things that are not required of med students, they're not going to do," Albin explained.Nor does it help that medical school is so competitive. "Everyone wants to be the best," says Henderson. Faced with a choice between learning about a high-paying specialty like radiology or gastroenterology or cardiology—all of which have limited residency slots—and public policy, there is no choice.
Some medical schools are trying to change that. Last year, all 170 third-year medical students at GWU spent a day on Capitol Hill listening to health experts—from congressional staffers to Medicare executives to pollsters—talk about health care policy and learning how they, as future doctors, could influence it. A few years ago, GWU added a health policy track—basically a minor—for students interested in learning about legislation. About a dozen students have enrolled every year—hardly a flood, but an improvement nonetheless. Some of them have written legislation by the time they graduate.
More drastic still are recent changes at Harvard Medical School. In 2006, HMS started requiring every student to take a semester-long class in health care policy. The series of 13 lectures covers the different types of managed care, entitlement programs, the economics of insurance, medical malpractice, and even health care reform. (See the syllabus here.) In smaller discussion sessions, students confront tough decisions. Say you've got a drug that may extend an elderly woman's life for a few months but costs thousands of dollars. Do you prescribe it? "We want them to understand the trade-off," says professor Haiden Huskamp, who co-teaches the class.
Meanwhile, both GWU and Harvard have begun incorporating policy into their standard curricula. If you're taking a cardiology class, for example, you'd learn not only about bypass surgery but about when it's covered and where you can send the patient once the procedure is done. Or say you're treating a hypothetical patient who has asthma. You might learn not just about which drugs are available but about health disparities—why asthma is so prevalent among urban minorities compared with other groups—and the policies that address them.
This kind of integration may seem obvious. But for decades, it was overlooked. "Ten or 15 years ago, most schools did not have anything involving health care policy," says professor Matthew Mintz of GWU. "Medicine was medicine and policy was policy and why would doctors want to learn anything about policy?"
Now, though, some schools are trying to teach doctors to think holistically about their profession. "You're trained in medical school to think about treating this one patient in a very narrow vision," says Huskamp. "But we want people to think at the societal level, the health system level." That means weighing the interests of the patient against the interests of the system as a whole.
The goal here is not to convince students that health care reform is necessary, says Huskamp: "We think about it more from an analytical point of view, than an opinion point of view." After all, students can agree that there's a problem but disagree about the solutions.
But sympathy for reform may well be the result. Refusal to think holistically about health care—to figure out why costlier care is often worse or which treatments work best—is largely what has driven costs up. "Doctors not being engaged in policy is a big problem, and one reason our health care system is in such bad shape," says Henderson, who now serves as health justice fellow for the American Medical Students Association.
Perhaps the first step in fixing the system, therefore, is for every medical school to require health policy classes. That might not make an activist of every doctor. But it would show students how influential they are—politicians love hearing from M.D.s—and inject more informed voices into the debate. "Health care professionals have not been traditionally involved [in policy debates]," says Albin. "It's something we've handed over to legislators and politicians." Educating med students about the system could also tip the debate in favor of reform. The American Medical Association may have come out against a public option. But the American Medical Students Association is pushing hard for it. Whoever wins, doctors—and aspiring doctors—should at least know what they're talking about.