Classes in the (Other) Frozen Tundra

Brynna and I are not, in fact, in New Hampshire in order to escape the cold of Minnesota (though it was 48 degrees here on Saturday!)

I am here taking courses towards a Masters in Public Health (MPH) degree. There are two other fourth-year medical students —from Drexel and Louisville—doing the same thing. We are all living in Concord because we also have some clinical time at the family practice residency here, and then we all carpool up to Dartmouth (1 hour away) for class three times a week.

The MPH at Dartmouth is very focused on quality improvement: learning how to define quality in healthcare, how to measure quality and value, and how to present feedback about quality to individual providers and organizations. We are learning from the people who developed the Dartmouth Atlas of Health Care. The Atlas shows that different geographic areas have very different practice patterns: for example, if you have bad back pain, you are far more likely to get back surgery (which is expensive and usually not any more likely to help you than cheaper, more conservative measures) in certain parts of the country—especially parts of the country where there are a lot of back surgeons. As health care costs continue to rise, everyone is concerned about making sure that we as a country are only paying for treatments that have been proven to work, and the program here is full of experts trying to figure out how to improve the healthcare system in that direction!

This winter, I am taking 3 courses, and I’ll take 9 more and also complete a project, kind of like a thesis, later in residency. One current class is a classic MPH course, Environmental and Occupational Health. We spend a lot of time learning about pollution and workplace exposures. This week, a team came from the Vermont Law School to talk to us about some environmental litigation they are working on, and we've also had a visitor from the Maine department of public health to talk about mercury in fish. The big project for the course is a policy paper about a topic of our choice. I am writing mine on BPA, a chemical that has gotten a lot of press recently for leaching out of plastic baby bottles (Brynna’s are BPA-free, don’t worry!). So I am spending a lot of time reading rat studies, since most of the toxicology work has of course not been done in humans.

Another class is called “Statistical Measurement and Analysis for Quality Improvement.” This sounded awful when I first heard about it, but it is actually a great class. We are learning to create and interpret a kind of graph called a control chart, which shows variation in a process over time. By looking at the chart, you can see if a process (like how long it takes for a blood test to be performed and reported back to the ordering physician) just has an expected amount of random variation or if there are special factors (like a new, slower technician or a power outage in the lab) causing a problem. This keeps you from making all sorts of changes in a process when there’s a different explanation, like a new tech, to blame. When you intentionally make a change in a process (like buying a faster blood testing machine), analyzing these charts also lets you see if the new machine has made a difference by lowering turn-around-times.

Brynna is fascinated by this class as well:

(or at least by the colorful textbook cover)

The last class is Strategic and Financial Management of Health Care Institutions. Taking this course is a lot like going to the dentist. I know I should, and I know it’s good for me, but it’s not that nice. The first half has been essentially an entire accounting degree in five weeks—we’ve covered financial statements, accounting t-tables, ratios used to assess the financial health of companies, budgeting, and so on. Painful! (But also useful.) I’ve had to make flash cards to prepare for the midterm, a task I thought I’d left behind now that anatomy and pharmacology are over. The best part of the class is the guest speaker who comes during the last hour of each session. This week, it was Dartmouth-Hitchcock Medical Center’s Chief Financial Officer. It was fascinating (and a bit scary) to hear him talk about how the current financial crisis is affecting DHMC. We’ve heard from the CEO of New London Hospital, which has really turned itself around over the last few years, from a woman who is uninsured and bargained down the price of her husband’s prostatectomy, and from a family doctor who now works for an insurance company in Minnesota.

So, classes are keeping me really busy, which is good, because otherwise I would just mope around and miss Alex. Brynna gets super excited when we iChat with him every night. She grins at the camera and makes happy shrieks and waves her arms around. I think it’s just in the last few weeks that she has learned how to identify his face on the screen, and respond to it. It’s not just his face, though—last night I was nursing her before bed, and when I finished the book I was reading to her (Madeline), I turned on one of the Sandra Boynton recordings that Alex had made her. She immediately stopped nursing and craned her neck around to look at the computer, so I sat her up on my lap. She stared at the pictures on the screen (Alex scanned them in from the board books, so the pages show up as he does the voice-over) and smiled and chuckled along. In four days, he’ll be reading to her in person!