Letters to the Editor  |   August 2010
Author Affiliations
  • Debra A. Smith, DO, MIHM, MBA
    President-elect, American Osteopathic College of Occupational and Preventive Medicine
Article Information
Medical Education / Preventive Medicine / Professional Issues / Curriculum
Letters to the Editor   |   August 2010
The Journal of the American Osteopathic Association, August 2010, Vol. 110, 485-487. doi:10.7556/jaoa.2010.110.8.485
The Journal of the American Osteopathic Association, August 2010, Vol. 110, 485-487. doi:10.7556/jaoa.2010.110.8.485
I wholeheartedly agree with Dr Fredericks that we need to train osteopathic medical students and physicians in the business of medicine. I have publicly advocated for this type of training.1 As a profession, we take intelligent, capable people and, in the course of their training, we essentially turn them into idiot savants in their respective specialties. It is all that many in our profession can do to run a successful and profitable practice in an increasingly challenging healthcare market—let alone lead positive change within physician groups, hospitals, and healthcare systems. 
This deficit of business skills, political savvy, and “big-picture” economic knowledge even extends to our national organizations. As a result, our profession has the economic status of a market taker rather than a market maker—that is, we must take whatever price is offered for our services rather than receive the price we deserve. We have succeeded in making ourselves little more than a commodity at our own expense. 
Traditionally, physicians have viewed the business of medicine with disdain, delegating it to someone else. In doing so, they have unwittingly delegated their voice and authority. Practitioners can no longer afford this attitude if they are going to meet their expenses, let alone get paid a decent wage. 
I must respectfully disagree with Dr Fredericks' estimation of 5 to 10 hours of instruction being adequate for learning the business of healthcare. Acknowledging the age-old struggle to find time in the curriculum and considering that a number of medical schools are moving toward a 3-year program,2-4 I believe that we need to reexamine curriculum design and integrate the business of medicine into it. The American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) has assembled a core body of knowledge (CBK) that lays out the basic rules of “the game” in which we have been engaged. The ABQAURP has collaborated with the National Board of Medical Examiners to plan, develop, and administer examinations for demonstrating mastery of that CBK.5 However, the ABQAURP CBK covers only the bare minimum of what schools should have taught young physicians about the business of medicine 20 years ago—if they wanted their student-customers to have a basic understanding of the system. This curriculum is a gross underestimation of what is needed for physicians to acquire the needed skill set for the 21st century. 
Solving the Problem
It has become fashionable for physicians to enter executive education masters programs in business administration, public health, or medical management in hopes of attaining the needed business skills. In surveys of physicians conducted by Sermo, Inc, an online physicians' community, many respondents expressed disappointment in such programs.6 I believe the reason for this disappointment is that unlike medical school, where societal necessity and board examinations dictate the creation of a fairly uniform product (ie, the physician), business school does not require such a product. Thus, there is a huge difference between top-tiered business schools and lower-ranked institutions. Unfortunately, many physician-oriented programs “dumb down” management classes to the level of psychology 101, and the requirements for accounting and finance classes are equivalent to a financial statement reading class. 
In medicine, there are a limited number of conditions that have a given symptom or complaint. We proceed to create a differential diagnosis, given the patient's history, and we work our way through the algorithms until we hone in on a definitive diagnosis. However, good business skills require that we widen our field of view to find our focus. In order for physicians to be effective in leading quality healthcare, we need to take into account many changing factors, including—but not limited to—the political economy of medicine, health policy, the regulatory environment, the behavior of competitors (both domestic and foreign), and paradigm shifts in technology. We then need to apply our knowledge and understanding of those interrelating factors to solve problems at hand. The top schools do not merely teach facts, which may soon become obsolete, but they also teach students how to critically analyze; how to develop strategies that properly account for, weigh, and mitigate risk; and how to collaborate with colleagues to carry out the objectives set forth. 
One area that physicians need to understand is how to approach entrepreneurship. Whether starting a practice, seeking venture capital to produce or commercialize a modification to a piece of equipment, or effectively lobbying the local hospital to purchase a new piece of expensive equipment, the same skills are required. These skills are related to analyzing market demographics, competition, payor mix, reimbursement levels, time frames for plan implementation and return on investment, opportunity costs, and continued sustainability. 
As a profession, we must have the skills needed to address the systemic problems in healthcare, especially costs, rather than simply shift those responsibilities to someone else or to another place or time. As a former chief medical officer who has medically underwritten catastrophic care cases, I must vehemently disagree with Don Berwick MD,7 the new administrator of the Centers for Medicare & Medicaid Services, who said the following: 

...any health care funding plan that is just, equitable, civilized and humane must—must—redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.

I would like to point out that insurance by definition is risk-sharing, not wealth redistributing. 
As a physician, economist, and health administrator, I felt an obligation during this past year to my profession and the American people to help see that healthcare is reformed in a responsible manner—saving money and improving quality and efficiency, rather than just shifting costs. As a starting point, I published a plan8 and contacted three major physician organizations about assembling a team of leading physician administrators (including many DOs) from major employer groups, insurers, pharmaceutical companies, medical device manufacturers, hospitals, and government agencies to collaborate on developing a comprehensive physician-led reform proposal. 
One of the physician organizations that I contacted replied that it had already decided in favor of the healthcare legislation then being considered by Congress, stating that the legislation wasn't perfect but it was better than nothing. Another organization said that it planned to wait to see the content of the final bill and then lobby for changes accordingly. The third organization said that it was afraid to get “political” for fear of losing its section 501(c)3 taxexempt status. I found this latter response to be especially perplexing. We all would like everyone to have the best healthcare available, and the best healthcare would get patients better in a faster and cheaper manner. Advocating that is not political; it is just logical and practical. 
The responses I received were nothing short of astonishing. Perhaps an explanation for these attitudes lies in the following statement by Jean-Marc C. Haeusler, MD,9 regarding medical leadership: 

Identifying and changing problematic values, habits and structures in the medical community requires collective learning and causes uncertainty and loss. That is why the allure of a technical solution is high.

Practical Measures to Initiate
Because we know that continuing the present course will doom physicians to being the proverbial cog in the healthcare wheel and to experiencing ever greater frustration, I propose that we initiate the following four measures: 
  1. Grant Category 1-A continuing medical education credit for osteopathic physicians to learn the business of medicine. (These credits fall under the core competencies of the specialty of public health.)
  2. Integrate the business of medicine into curriculum design.
  3. Use the premier peer-reviewed journal of our profession—JAOA—The Journal of the American Osteopathic Association—as a vehicle for explaining the healthcare issues of the day, as well as for analyzing policies that have proven effective and sustainable both here and in other industrialized countries.
  4. Move our national organizations from developing only talking points to writing legislation for sustainable policies that improve delivery of healthcare. It is important to recognize that in the current political climate, politicians do not write the bills. At most, they merely sponsor and tweak them.
Working through the specific mechanics of these initiatives may not be easy, but that should not hinder us. It is essential that we dispense with the fatalism that has plagued the medical profession and focus on pursuing the steps that will allow us to credibly lead healthcare management from a cost and administrative standpoint, as well as from a clinical standpoint, at local, regional, national, and international levels. Such leadership will help osteopathic and allopathic physicians regain a strong moral, political, and economic position. 
I have spoken with representatives from one of the world's leading business schools to develop a program that teaches physicians the critical thinking skills required in business. Personally, I would be willing to serve as a curriculum development consultant for medical schools that are anxious to reform the educational process for physicians now in training. 
Is This Still Osteopathic Medicine?
Osteopathic medical tradition continues to focus on the interrelatedness of the body's systems and the mind-body-spirit connection as related to the patient's state of health. The 20th century brought acceptance and recognition to the osteopathic medical profession, but with that advance came complacency regarding new ideas and directions for the profession. As the last century ended, osteopathic physicians and the medical profession as a whole became entangled in the great healthcare debate and the need for reform, though no real solutions were brought to light. 
A.T. Still, MD, DO, said that we need to treat the disease, not just the symptoms. By applying this logic to our current national healthcare problems, we can see that skyrocketing costs are mere symptoms of a sickly healthcare system. The focal point must be finding a better method of delivering healthcare and implementing that method. 
By right of heritage, the osteopathic medical profession should take the lead in this noble endeavor. And so, the legacy Still lives! 
 Editor's Note: Dr Smith is conducting an online survey to gauge osteopathic physicians' interest in learning the business of medicine. Osteopathic physicians can participate in the survey at The survey is designed to investigate the demand for courses in the business of medicine and to gather information on survey participants' preferences for the format and forum of such courses. In addition, Dr Smith invites osteopathic physicians who already have the necessary skills and experience and who have an interest in teaching the business of medicine to also participate in the survey.
Smith DA. The business of osteopathic medicine. Paper presented at: 113th Annual Convention and Scientific Seminar of the American Osteopathic Association, American Osteopathic College of Occupational and Preventive Medicine Section; October 28 ,2008; Las Vegas, NV.
Bell HS, Ferretti SM, Ortoski RA. A three-year accelerated medical school curriculum designed to encourage and facilitate primary care careers. Acad Med. 2007;82(9):895-899.
Flegel KM, Hébert PC, MacDonald N. Is it time for another medical curriculum revolution [editorial]? CMAJ. 2008;178(1):11,13. Accessed August 5, 2010.
Jaschik S. The 3-year MD. Inside Higher Ed Web site; March 25, 2010. Accessed July 22, 2010.
About ABQAURP. American Board of Quality Assurance and Utilization Review Physicians Web site. Accessed July 22, 2010.
Posts (9109, 11199, 17507, 22118, 35578, 49481). Sermo Inc Web site. Accessed July 22, 2010.
Lucas F. Gibbs evades question of whether Obama agrees with his Medicare director that health-care system must redistribute wealth. Web site; July 8, 2010. Accessed July 22, 2010.
Smith DA. Healthcare Solved—Real Answers, No Politics. Charleston, SC: BookSurge/CreateSpace;2009 .
Haeusler JM. Medicine needs adaptive leadership. Physician Exec. 2010;36(2):12-15. Accessed July 22, 2010.