COMMENTARY

More Than Ever, Doctors Need More Time to Learn

Andrew N. Wilner, MD

Disclosures

May 18, 2017

Introduction

As attending faculty at a large community hospital, it's my job to teach medical students and residents while ensuring state-of-the-art patient care. The other day we consulted on a patient with schizophrenia and a question of new-onset seizures. Physical examination was normal except for prominent oral facial dyskinesias. The patient had tardive dyskinesia, a sequela of years of antipsychotic treatment.

Some Background

Tardive dyskinesia was observed several years after the introduction of antipsychotics in the 1950s.[1] Tardive dyskinesia develops in about 5% of patients per year treated with older antipsychotics, perhaps less so with atypical antipsychotics. Although patients often tolerate tardive dyskinesia remarkably well, involuntary facial grimaces, tongue protrusions, choreoathetoid movements, and other symptoms stigmatize patients and compromise quality of life.[1] Remission rates are low, even after the offending drug is discontinued.[2] I lamented to the medical students and residents that despite the half million or so affected patients in the United States and the more than half century of experience with antipsychotic drugs, there was still no Food and Drug Administration (FDA)-approved treatment.

What a Difference a Day Makes

The next day, the FDA announced the approval of valbenazine (Ingrezza™), a novel, selective vesicular monoamine transporter 2 (VMAT2) inhibitor and the first FDA-approved drug for the treatment of tardive dyskinesia. I eagerly shared the news with the team on morning rounds.

The recent FDA approval of valbenazine is just one example of how the breadth of treatment options in the practice of medicine keeps increasing. When I was a resident, there was only one drug for multiple sclerosis; now there are at least 15. Similarly, since residency days, 15 new drugs have received FDA approval for the treatment of epilepsy. All of these new medications have their own clinical indications as well as unique side effects. That's 30 new drugs to master, just for these two diseases!

Vanishing Time for Study

Every physician recognizes that the practice of medicine requires lifelong learning. For a large number (if not all) physicians, the intellectual stimulation of learning is one of the factors that drew them to medicine in the first place. However, finding time to study amidst increasing demands for productivity and administrative work has become increasingly difficult. Texting, typing, and clicking now occupy more time than direct patient care.[3] A recent visit to a neurology private practice revealed 30-minute new-patient visits scheduled back to back throughout the day. No time was set aside for study—or lunch, for that matter.

Conclusions

The rapid pace of therapeutic advances requires physicians to learn benefits and risks of many new treatments. The integration of these therapies into actual practice is another step that requires thoughtful consideration. For private-practice physicians, the traditional 1 week of continued medical education (CME) is woefully insufficient. Even for physicians at academic centers, documentation requirements and other administrative tasks gnaw away at time previously reserved to keep up with (and contribute to) advances in medical care. Time for learning must be granted equal if not greater importance as "productivity" if the latter is to offer optimal value. A growing and aging population requires physicians who practice up-to-date medicine. The alternative isn't very appealing.

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