WASHINGTON -- As a medical student, Aaron Kulick heard all about the evils of managed care. His teachers at Temple University School of Medicine in Philadelphia repeatedly warned him that health maintenance organizations were staffed by penny-pinching bureaucrats who prized profits over patients and would subvert his efforts to practice good medicine.
But two years ago when it was time to choose a residency, Kulick disregarded his mentors' advice to steer clear of managed care. Instead he picked a new four-year training program in internal medicine and pediatrics sponsored by Georgetown University Medical Center and Kaiser Permanente, the nation's oldest and largest HMO. Kulick and five other residents in the "med-peds" program divide their time between the wards at Georgetown University Hospital and Kaiser's West End Center, a large outpatient facility on Pennsylvania Avenue NW, a few blocks from the White House.
"I don't think health care has to be expensive to be good," said Kulick, a lanky 29-year-old Pittsburgh native. "There's a tremendous gap between education and reality. In an academic institution you're removed from the cost-containment aspect. So many studies get ordered and probably needlessly just because we can do them. My experience (at Kaiser) is that as long as appropriate justification is given, you're not restricted. I'm comfortable with that."
When he sees Kaiser patients, Kulick is expected to consider the evidence for, and cost of, a particular treatment, as well as the ethical implications of providing or withholding treatment.
He must decide when to refer patients to a specialist. And he's supposed to stick to an appointment schedule. In his last year of residency, Kulick will be responsible for managing a panel of patients and will spend six months as a full-time physician in the outpatient clinic. Periodically he will receive a physician profile that includes patient comments as well as an analysis of his referrals to specialists, drug-prescribing patterns and his success at meeting certain targets for immunizations and specific screening tests.
While the environment in which Kulick is being trained at Kaiser is familiar to many of the 130 million Americans who are covered by some form of managed care, the Georgetown-Kaiser partnership is a radical departure in medical education. Although managed care has transformed the health-care system, it has barely penetrated the insular world of medicine's most hallowed institutions: academic medical centers.
For most of the 20th century, medical training has occurred primarily in large teaching hospitals. With the singular exception of family practice, which for decades has emphasized outpatient training, most residencies have focusing on teaching new doctors how to take care of inpatients.
Three years ago the Pew Charitable Trusts launched a network of pilot residency programs called Partnerships for Quality Education to improve the training of young doctors. These partnerships, funded by an $8.3 million grant, are designed to train primary-care residents to practice high-quality medicine in managed-care settings by pairing academic institutions with managed-care companies. Participants include Georgetown and Kaiser, Harvard Medical School and Harvard Pilgrim Health Care and Cornell University Medical College and Empire BlueCross Blue Shield.
The 400 residents enrolled in the 66 partnership programs around the country represent a fraction of the more than 100,000 doctors-in-training. Critics say that many of these fledgling physicians trained in conventional residencies will find themselves poorly prepared to practice in the managed-care environments that will be a major source of jobs.
Training residents in hospitals for office-based practice "is like training people to be foresters by having them work in a lumber yard," said Pew program director Gordon T. Moore, a professor of medicine at Harvard Medical School. "Most programs, even the most prestigious, are training residents for a world of medical practice that no longer exists."
A study published in 1996 in the Journal of the American Medical Association found that it takes one to two years of additional experience beyond residency for doctors to learn how to practice effectively in a managed-care setting. Although the health-care system is "changing at warp speed," the authors noted, most residencies have not begun to keep pace.
"A lot of ambulatory skills are still being taught in a clinic in a hospital," said John Hurley, a pediatric nephrologist who is director of medical education for Kaiser's Mid-Atlantic region. "These clinics are typically very inefficient, very slow and residents order the tests they want. These residents come out and they get report cards and there are guidelines, and they're expected to have some skills they were never taught. They discover that if they have to refer the patient to someone else, they lose money. That is not the world of the university. But it is the real world."
Recently the Council on Graduate Medical Education, a federally funded group that oversees medical education, recommended that in addition to good clinical skills, primary-care doctors in the 21st century must be computer literate; be able to analyze scientific evidence critically, work in teams, and allocate limited resources intelligently; and possess an understanding of both epidemiology and the economics of managed care.
The Kaiser-Georgetown residency also explores ethical issues that surface in managed care.
"These residents face a lot of things that people might not think of as ethical questions," Hurley said. "We try to focus on ethics at the outpatient level, to get away from the idea that ethics only comes up when somebody's on a ventilator. It may have to do with someone who comes in and wants a work excuse for a legitimate illness or more time off to recuperate. What's the responsibility to an employer who is paying for part of the health insurance?"
The residencies are not trying to teach "managed-care medicine," said David B. Nash, an associate director of the Pew program and director of health policy at Thomas Jefferson University School of Medicine in Philadelphia. "We're teaching the cost-effective use of resources. We want our residents to ask, 'What is the evidence that what I'm about to do is going to improve the care of this patient? If it's not going to change what I'm going to do, why do it?' "
Most doctors fresh out of residency "have never encountered 90 percent of what they're going to see in outpatient practice" such as sprains, urinary tract infections and stress-related complaints, said Moore. The reason: About 80 percent of residency training in internal medicine and pediatrics occurs in hospitals. Yet at least 90 percent of a primary-care doctor's time is spent in an office or clinic where the skills a physician needs and the illnesses he or she sees are fundamentally different. In the past few years, inpatient and outpatient medicine have become so dissimilar that a new specialist called a hospitalist, an internist who sees only hospital patients, has emerged.
Physicians' ignorance of managed care poses significant problems not only for them and their employers, but also for patients who depend on them to be both healers and advocates. The sometimes Byzantine bureaucracies established by managed-care companies that limit access to specialists, diagnostic tests and prescription drugs in an effort to cut costs and improve care sometimes require the assistance of a physician-guide.
Because managed-care plans have also moved all but the sickest patients out of hospitals and have dramatically cut length of stay, residents are no longer able to observe the natural course of an illness over time and the healing process.
"When I trained in the 1960s," said Moore, "people with (heart attacks) spent three weeks in the hospital. You had time to get to know them, to talk to them about things like sexual function before they left." Now, Moore notes, most heart-attack survivors are discharged after less than a week and residents are so busy with the technical aspects of care that they don't have the time to talk about nonclinical concerns.
In addition, many problems for which patients were once hospitalized, such as diabetes, one of the most common chronic conditions in ambulatory medicine, may never be seen by residents in the hospital.
"One of the unique aspects of residency education is that you basically study and learn on the job what patients bring to you," said John M. Eisenberg, formerly chief of medicine at Georgetown and now director of the federal Agency for Health Care Policy and Research. "It's very much dependent on what happens to come in over the transom."
Eisenberg said that when he was a resident in the 1970s, people who were newly diagnosed with diabetes were routinely admitted to the hospital, sometimes for as long as two weeks, until their glucose levels were well controlled and their condition stabilized.
Today diabetics are enrolled in outpatient disease-management programs staffed by skilled nurses who teach them how to control their illness. "A resident wouldn't see that and wouldn't know how to take care of that," Eisenberg said.
Even one of the most basic and essential clinical skills, taking a history and physical, has changed.
"If you're a resident in a hospital it doesn't matter if you take two hours to do a history and physical on a patient," because the patient isn't going anywhere, noted Sheri Keitz, a director of a Pew residency at Duke University School of Medicine.
"But when you get out and you have 20 minutes to talk to the patient, listen to the patient, get to know the patient and figure out what the problem is and what to do, you don't have a clue as to where to begin. It's just overwhelming. There's so much more that they need to navigate and manage than before."
"We do a lot of trying to teach residents how to get answers rather than pretending that we know all the answers," said Keitz. "That's a real shift from thinking that there's a body of information that they can master," which has been the prevailing view in medicine.
The recent alliances between academic medical centers and managed-care companies represent a major shift in the relationship between traditionally bitter enemies.
It would be hard to overstate the intense enmity between the two groups, said health-policy analyst Emily Friedman, who teaches at Boston University. The antipathy dates back nearly a century, Friedman said, from an era when the earliest cooperative ventures in medical practice, the forerunners of HMOs, were condemned by the American Medical Association and other pillars of the medical establishment as "medical Soviets." Solo practice was king and group practice, now the norm, was viewed with such suspicion that some states passed laws barring it.
"One of the more violent head-on crashes is occurring between a couple of hard cases," Friedman wrote in a 1997 article published in the journal Academic Medicine. "For each it is a holy war."
Managed-care organizations, she wrote, have been portrayed by their enemies in academic medicine as "money-grubbing, socially irresponsible, profit-mad, care-rationing bullies," while teaching hospitals and their senior faculty have been painted as "wasteful, arrogant, self-serving and hypocritical."
The current truce reflects the extraordinary changes that have roiled medicine. Managed-care organizations now have the bulk of the patients, while academic medical centers have the residents and the money to train them, an expensive responsibility most managed-care companies have eschewed. These new physicians also represent a fertile pool of new staff for managed-care companies, which are increasingly resentful about having to "retrain" them.
"One of the things we're trying to do is lower the bogyman factor," said David Nash. "We want to show academic medicine and managed-care organizations that they're not Arabs and Israelis, or at least that there's a Wye (Accord) in their future."
But the truce does not obscure profound differences between the two cultures.
"Managed care believes in population-based medicine, which is essentially prevention, which means pooling resources in order to have a maximally fair distribution of resources," Friedman said. "The ethic in managed care is to do what works and only what works."
Academic medicine, she says, has an entirely different set of values.
"The traditional ethos in medicine," she said, "is that you do everything you possibly can for an individual patient who is your primary focus and that you keep trying" even when a situation looks futile.
Another key difference, said Moore, is that "doctors are trained to be autonomous decision-makers. That's a very important part of training and anything that suggests that might be taken away gets their hackles up."
That autonomy also has resulted in huge variations in the quality of care and little in the way of effective standardized treatment, sometimes called "evidence-based medicine."
"The problem is that the average doctor doesn't keep up that well," Moore observed. Most doctors' information on drugs is generated by pharmaceutical representatives, and "they don't know what's in the literature."
The collision of values is apparent to some residents.
"Since I started this residency, I've noticed even more what a culture clash there is between academic medicine and managed-care organizations," said Betsy Boatwright, a second-year resident in the Georgetown-Kaiser program.
"I was wary when I was interviewing. I worried, 'Am I going to become an HMO clone?' " recalled Boatwright, 31, a graduate of Harvard Medical School and Andover-Newton Theological Seminary who said she debated whether to choose a managed-care residency or opt for a more-conventional program. She chose the Georgetown residency in part because she is interested in practicing in the Third World and believes the experience of providing care within a fixed budget would be good preparation.
"The rap about HMO physicians is that they are less academically inclined or they just want to get the work done and go home and have another life," she said. "The rap is that they don't want to work very hard, whereas in academic medicine your life is medicine."
"In medical school you hear only negative things about managed care," Boatwright added. "But I think both sides have a lot to offer each other.