Today's doctors are many things, but teaching or teacher aren't words generally associated with them (except perhaps in academic medicine). The word "doctor" invokes a particular set of images in popular culture - white coat, scrubs, stethoscopes, always doing something - but the word may not so often invoke the more unglamorous image of patient education. It's my belief that every med student and resident chooses to become their own unique "kind" of doctor, their own way of interpreting the art and the science. Thus it's my belief, and my choice, that doctors should be teachers.

During my one-year foray into public health, one of the greatest experiences of my life was teaching several discussion sections of the undergrad intro to genetics course, alongside other grad student instructors (GSIs, also called teacher's assistants or TAs elsewhere) and the professors of the course. Standing by the blackboard in front of a room of 20-30 undergrad students kept me on my toes (figuratively and literally) and oddly energized. Here I was, imparting knowledge onto students, clarifying concepts and facts, elucidating materials from lecture more in depth, intently watching for the wheels in their minds to turn. Everything I said mattered, mistakes and incorrect knowledge could backlash with great fury, so I had to be sure and confident of what I said. At the end of the day, I hoped that I had sparked that interest in someone to take the knowledge they learned from me and do something great with it.

In my opinion, medicine (particularly primary care) isn't so different. Doctors impart health knowledge onto patients, clarify misconceptions on health issues, answer questions, recommend medication and treatment plans, and hope the patients comply and carry through because they understand and trust their doctors. At the end of a visit, I would hope a patient would take the knowledge he/she learned and do something great with it - keep themselves healthy, improve their health, or even educate others. I feel many students go into medicine because it's a decisive field - you're sure (or at least act sure) of the medicine or treatment you give your patients. Truth be told, you'll never know if your patients actually take their medication or follow through with your recommendations after they leave your sight. And so proper education, communication, and trust are vital.

Already I've had a couple experiences in med school that can attest to the role of doctors as teachers. About a month ago I went to a nearby high school with another M1 med student. We were to give a presentation on obesity and diabetes to a 10th grade health class. My love of teaching instantly rushed back. At the end of the presentation there was still 5-7 minutes left before the end of the class, so we opened it up for the students to ask us any question. One student asked me, "What do you want to do after med school?" Which I initially thought was an odd question, so I answered, "Umm . . . become a doctor." He continued with something like, "Do you want to keep doing stuff like this? Coming into classrooms and teaching about health?"

That struck me. Of course I would love to go to a high school a few times a year into a health class and give a talk on some health topic. I would love that kind of community interaction as a practicing physician. I then realized how uncommon it must be for doctors to take a day or half-day off work and go into the community and do just what I did as a med student. I couldn't recall in all my years of primary education of seeing a doctor come in and give us students a health presentation. There's definitely a role, and sometimes perhaps a need, for doctors to go into the community, talk to a group of people, and educate them on some common health issue. This is certainly one role of doctors within public health.

This isn't to discount the important and integral role of the one-on-one patient-physician relationship. A couple weeks ago while volunteering as a "patient educator" at a free clinic, I saw a late middle-aged gentleman who wanted to discuss smoking cessation and depression. It was a wonderful opportunity for me to interact with patients outside of the rigid "medical interview, physical exam, diagnosis, and treatment" template. We talked rather freely as I asked him questions about what he's done, his personal and social environment, and how we can "tailor" a way to help him with these two issues that works with his life situation rather than against. I felt that to a certain degree, a more relaxed medium of communication between physicians and patients may yield better adherence to medical/health advice, as opposed to a more didactic approach commonly found in medicine. Then again, I've certainly no research to support this.

Lastly, a doctor is a life-long student and teacher. The field of medicine changes so rapidly it's mind-spinning. It can take a lot of work just to keep up and learn the newest updates, and at the same time relay this information to colleagues and patients. But it's a challenge we signed up for the moment we set foot in med school. As future doctors, I believe it's our duty to educate our patients so they may make the best and healthiest decisions for themselves.

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Money, dollars, bills - those green pieces of paper with numbers and faces on them, are what's on everyone's mind these days, especially in the healthcare field. With the so-called economic crisis, resources are scarce in the medical community. I've heard many stories concerning the use of the emergency room as a way for patients to get over-the-counter meds, but I have never experienced it myself until my clinical preceptorships at the ED (emergency department). Now I realize how hard it is to be non-judgemental.

Many times I would see patients come in for conditions such as a common cold and ask to be prescribed tylenol or motrin. They would wait many hours in the waiting room with a fever and a cough, and use up not only medical resources but also their own precious time. When doing social histories, I'd ask patients whether they smoke or use alcohol. Oftentimes the answer to both is yes. With a pack of cigarettes costing $4 and alcohol being on a range of prices, people can end up spending a lot on these two amenities many consider essential in life. Being a non-smoker myself, I sometimes find it hard to be non-judgemental, for patients would spend on cigarettes yet not for medication for their condition.

After many such encounters, I talked with one of my preceptors about the situation. He responded that I can't be judgmental; if I grew up in similar situations as the patients, then the patient might be the 2nd-year medical student and I could be the smoker and alcoholic. I realized the importance of education, and what "don't judge the book by its cover" truly meant. With the healthcare in great need of reform, more attention should be placed on implementing earlier education in schools. Instead of the majority of attention being focused on where funds should be allocated or how to better manage the ED, funding should be placed in sexual education, health courses, and lifestyle-related courses in middle and high schools.

I don't know if what I'm advising is doable or valid, but I feel like it would be a step in the right direction in solving the healthcare crisis we are facing. Although this is easier said than done, with more attention placed in this field, perhaps we can shift our attention to better, more feasbile, and smarter methods in solving the education crisis.

My first rotation, in August, was supposed to be about pharmacy compounding. As it turns out, though, compounding pharmacies tend to do a LOT of alternative medicine, herbal medicine, supplements, weird off-label uses of drugs with no evidence to support them...whatever you want to call it. This one, in particular, also had a clinic where "alternative medicine" doctors came to see patients.

I won't get into how unhappy I was about my situation, or how ethically compromised I felt. What I do want to talk about is one of the first questions that came to mind. Most of our patients were from Ann Arbor, and they were fairly homogenous. They were well-educated, upper middle class, and typically (though not always) women in their 40s and 50s. And so I wondered. What was it that made these people come to us? What made them turn from their doctors and from normal medical practice? Why were they more willing to trust someone who charged $200 for a consultation than someone they could see for a $15 copay?

The inevitable conclusion was that these were people who, for one reason or another, had lost faith in the medical system. They all had PCPs, who they were disillusioned with. They all had medical problems that could not be or had not been solved. They were intelligent, well-educated, independent people and you knew that they had thought, well, if my doctor can't

fix me, maybe someone else can. One of the most common questions we got was, why couldn't my doctor diagnose this? Why didn't they know about this (weird, alternative) diagnosis?

As a healthcare provider, this disturbed me very much. All the good we do is based on the assumption that our patients trust us. If they don't trust us, they won't come back for followup appointments, they won't take their meds, and they won't do the things necessary for staying healthy.

So what is the problem here? Why didn't these patients trust their doctors? Three points come to mind.

1. We don't spend enough time with our patients. This goes for both doctors and pharmacists, and probably other providers as well. Our days are busy- we see lots of patients and we deal with a seemingly endless stream of paperwork and insurance issues. It's sometimes easier to just tell the patient, this is what you have and this is what you need to do, and not spend any time explaining why, or going through the risks and benefits of treatment (or no treatment).

We had a patient, in the compounding pharmacy, who came to us because she had been having some generalized symptoms- headache, fatigue, lack of energy, etc, and also had some weird rash/dermal thing on her foot. When the pharmacist asked her if she'd seen a dermatologist, the patient said, "well, no, that's just it. My doctor didn't even look at it! She just told me to go see a dermatologist." That was probably a reasonable reaction on the part of the doctor- if the patient described this rash thing, it probably would have sounded like something outside the realm of a PCP. And if any specialty work were to be done on it, she would have to go see a dermatologist anyway. But all the patient heard was that the doctor was brushing her off, or didn't have time for her, or didn't care about her. If the doctor had taken the time to stop and look at this rash, or to explain to the patient that she wasn't really trained to deal with this sort of thing, and that a dermatologist might be better able to help her, then maybe our patient wouldn't have abandoned the entire medical system.

Those consultations were a full hour for new patients, or half an hour for repeat patients. How many normal doctors have time to spend more than 15 minutes talking with a patient? How many pharmacists have time to spend more than 15 seconds talking with a patient?

2. Educated patients like to have some say in their care. In the pharmacy world (and probably in the medical world as well) we call this "patient autonomy." If you give patients options, discuss treatments, discuss disease states and let the patient decide that treatment is necessary, they are more likely to follow through with it. Not to mention that in most cases the patient does have a right to have some input into what their treatment will be.

And if your patient has done some Internet research and has come up with some alternative treatment, it then becomes necessary to acknowledge that treatment and explain why it is unlikely that it will work, rather than just brushing it off.

We had a case where a women came to us for hormone replacement therapy (HRT) after her doctor put her on estrogen alone, and the patient thought that this was the wrong decision. As it turns out, she was right to an extent- using estrogen alone, without progesterone, can increase your risk of breast cancer. Now, progesterone itself has side effects, and without knowing the details of the patient's history and family history I can't say whether it was the right decision or not. But our patient came to us because she felt that she didn't have any say in her treatment.

3. We don't communicate clear expectations for patients of what medical treatment has to offer. The classic case is the patient taking an anti-depressant, which can take up to 6-8 weeks to reach its full effect, who stops taking the medication after a week because it's not helping. Many of our patients at the compounding pharmacy had been put on antidepressants for those general physical symptoms, depressed mood, and lack of energy. Only very rarely did these patients stay with the antidepressants for more than a few weeks. Maybe it would have helped, maybe not- but no one ever told these patients that we wouldn't know for a while.

In the end, like some many things, it comes down to communication. We in the healthcare world have a responsibility to communicate with our patients, to tell them what we are doing and why, and what they should do and why. Equally, our patients have a responsibility to come to us when they have questions, or problems, or side effects, or treatment failures. This is one of the best ways in which we can build trust in ourselves, our patients, and the medical system in general.