So what does healthcare reform mean for how we train doctors?

30 03 2010

Clearly last week was historic. There was a lot of hoopla after the healthcare reform bill passed to highlight this history.  But, after the festivities, we all woke up Monday morning and wondered, what’s in this bill and how does this affect us?  Students and residents are wondering this question too – after all this is the system they will inherit and practice in.  It’s important to highlight that the health reform bill is really “health insurance” reform.  However, there are some unresolved questions for how we train doctors for this future system.

Will medical education start to produce primary care physicians? Apparently to meet the demands of the newly insured, we need 13,000 extra PCPs! Well, the bill does include some things to make a dent in this problem – expanded loan and debt-forgiveness options and more money for community health centers, where many primary-care residents train.  New medical schools also hope to solve this problem.  Last, but not least, the Center for Medicare & Medicaid Services (CMS), the ultimate payer of residency programs, is also concerned that they are not getting their money’s worth and are considering mandating primary care curricula in residencies.  Unfortunately, none of these solutions will actually result in meeting the increased demand of primary care physicians in the short term due to the at least 7 years it takes to train a primary care doctor.  So what else can be done now? 

Well one idea is to Offset work of primary care physicians to other non physician clinicians. For example, routine health care maintenance like screening could be done by nurse practioners working in teams with primary care doctors.   This is not unlike going to the dentist’s office and seeing the dentist (who oversees your dental care) and then making an appointment with the dental hygienist (who does the routine cleanings).   This is the idea behind having primary care physicians work in teams through a medical home model that has been encouraged by several medical societies.  Working in such teams to get all the work done may actually make it more desirable to be a primary care physician.  Of course, none of this will matter if we don’t fix the 21% cut in Medicare doctor pay.      

Will teaching hospitals be financially viable? In the bill, there are dramatic cuts to teaching hospitals as a way to offset the cost of expanding access.  This does not bode well for our already cash strapped hospitals.  Specifically, payments for “Disproportionate Share Hospitals” are being cut, which is money to teaching hospitals to offset the cost of care for the indigent and underserved.  To compound this, the Center for Medicare and Medicaid services is exploring ‘redirection’ of the “Indirect Medical Education” payment given to residency teaching hospitals.  CMS views this money as ‘extra’ money that is not being translated into education.   Here is a quick aside on the ‘ABCs’ of how residency is financed primarily by Medicare and what is at stake.  You can also look up what your hospital receives here (by state).

  • DME (Direct Medical Education) payment is per resident and for salaries primarily (note that most hospitals supplement the salary Medicare gives to make it competitive and account for cost of living)
  • IME (Indirect Medical Education) payment is a fudge factor for the fact that teaching residents costs money and patients are sicker
  • DISH is another fudge factor for the percentage of indigent patients a hospital cares for. Not exclusively for teaching hospitals but most teaching hospitals qualify

What will happen to student run free clinics? This is an interesting question – since student run clinics are considered valuable clinical exposure for students.   Since not everyone is covered, these clinics will still provide care to undocumented immigrants and those who are still not able to get care elsewhere.   I recently read an interesting essay from Canada that goes so far as to say these clinics are actually a disservice and medical schools should invest their time in lobbying for a health system that cares for all patients.  While I don’t think these clinics are going away, folding the patients they see into the new system will certainly present interesting challenges.

Movie Legends & their Medical Problems

22 03 2010

the Mad Hatter of  ‘Alice’, the Vampires and Wolves of Twilight, and the Na’vi of Avatar

After the frenzy of Match Week and in between trying to understand whether health reform would pass this weekend, I went to see the still #1 movie in the land Alice in Wonderland in 3D.  This epic creation by part genius – part disturbed director Tim Burton features the wickedly talented method actor Johnny Depp as the ‘Mad Hatter.’  As I was watching Johnny Depp’s orange hair and freakish eyes, it occurred to me that some of the most popular fiction movies over the last several years have featured some notable legends and their medical problems.  For example, the cult sensation Twilight franchise features Edward and the Cullens (a clan of friendly neighborhood vampires) and introduced us to wolves with the recent release of the New Moon (on DVD this weekend).  Lastly, who could forgot the blue Na’vi people of Avatar earlier this year.  Interestingly, these movies are all in some way linked to very rare medical conditions.   

Mad Hatter-  The Mad Hatter as played by Johnny Depp is clearly disturbed individual but comes to Alice’s rescue.  The Hatter is “mad” due to chronic mercury poisoning.   Hatters used to use mercury, an orange liquid, to make felt for hats.  The liquid was often absorbed through the skin and could result in symptoms of mercury poisoning including confusion and confabulation (Korsakoff’s syndrome also seen with chronic alcohol use).  Other symptoms could include nervousness, irritability, insomnia, tremors, weakness, skin discoloration and eye problems among others.  The most common cause of mercury poisoning today is contaminated fish.  Upon reading about mercury poisoning, it was Depp’s idea to use orange hair for the Mad Hatter.  Burton loved the idea since orange hair is associated with some creepy fixtures of our imagination (who isn’t scared of clowns for example?)  Interestingly, the original Mad Hatter is based on an eccentric furniture dealer and not someone with mercury poisoning.

Vampires  Vampires, like Edward Cullen, are blood thirsty, pale, photophobic, and hate garlic, which are all symptoms associated with porphyria, a group of rare, largely hereditary blood diseases.  Porphyria is a family of disorders of heme (necessary for hemoglobin) synthesis which leads to anemia (low blood count) and leads to pale skin.  In some types of porphyria (cutanea tarda), the nonfunctional heme structures that cannot be made into hemoglobin, if hit by light, result in rashes, leading those individuals to want to avoid sunlight.  The connection between vampires and porphyria went mainstream in 1985 when biochemist David Dolphin explored whether vampires may have suffered from porphyria. Unfortunately, this publicity has resulted in a lot of stigma for porphyria sufferers.  Mary Queen of Scots and King George III are some of the famous sufferers of porphyria (the acute intermittent type). 

Wolf-man or “werewolf” It is true that humans with congenital hypertrichosis lanuginosa look like wolves.  Unlike Jacob, this unfortunate syndrome involves massive amounts of hair on the face and body, resulting in some of the people with this disorder to tour as circus performers.  Interestingly, porphyria, more commonly associated with vampires, can also lead to hypertrichosis, leading some to link the disease to werewolves.  However, another hypothesis is that werewolves and vampires actually suffer from rabies, which can also lead to similar symptoms (including the garlic!).

Na’vi or “blue people”  Although blue skin is considered ‘alien’ in Avatar 3D, there are actually ‘blue people.’  Methemoglobinemia is a blood disorder in which blood cells can’t bind with oxygen which impairs the oxygen supply to parts of the body, resulting in cyanosis (blue skin).   Fortunately, the treatment of methemoglobinemia is actually a blue dye, ‘methylene blue,’ which converts methemoglobin back to to hemoglobin.  There is an acquired form and also a congenital form.  The most famous carriers of this hereditary genetic error are the blue Fugates of Troublesome Creek from Kentucky who dated back to 1800. Their disorder was eventually diagnosed and treated in the 1960’s and the story is incredible.

With these movies, who says learning medicine can’t be fun?

–Vineet Arora


Insiders Guide to Biggest Week in Medical Education: the First Friday Match Day

14 03 2010

Match Day 2011 fell on St. Patrick's Day

This post was updated for Match Week 2012 – starting on Monday March 12th 2012.  This year, for the first time, Match Day is on a Friday.  See below for some of the reasons why…  

This coming week is Match Week – the culminating event of the residency application process for all senior US medical students (and many international medical grads too).  Many people have heard of Match Day, but may not realize the carefully orchestrated and at times chaotic events in the week leading up to Match Day, which for the first time falls on a Friday breaking tradition.  Here is a guide so you can congratulate all the future doctors in your life.

Black Monday – As ominous as this day sounds, most students receive the good news that they did indeed match.  At 11am CST/ 12pm EST, 4th year students receive emails from the National Resident Matching Program letting them know if they matched.  For most students who receive the coveted “Congratulations, you have matched” email from NRMP, there’s nothing to do but attend Friday’s festivities – see below.   However, for those students that find out they didn’t Match – there is much to do before Friday.

This new process is dubbed “SOAP” (Supplemental Offer and Acceptance program).  The SOAP was created due to the chaos of free-for-all Scramble, and hence it is sometimes called the “managed scramble” as applicants will have to apply through the Electronic Residency Application Service (ERAS).  Believe it or not, one of the main ways unmatched applicants would transmit their application to programs that are unfilled was using a fax machine!   In any case, the list of unfilled programs will be released ONE HOUR after students find out they did not match and students can start “applying” via ERAS to the unfilled programs.

This process will still be stressful as students have usually never visited the program and maybe even the city that they will be considering.  Moreover, the programs listed may not be in the specialty that the student even applied for.  For example, in the competitive specialties (Dermatology, Radiation Oncology, etc.), there are no unfilled spots.  This is in contrast to 1 year preliminary programs in general surgery which constituted and Family Medicine which accounted for most of the unfilled spots.  (NRMP houses data from past Matches here).

This year, one interesting thing is that programs can ‘contact’ unmatched candidates who applied to their program in the SOAP to discuss the program or ‘interview’ the candidate.   One key change from prior is that the program MUST initiate contact to the applicant, not vice versa.

Tuesday – Unfilled programs begin ranking the unmatched applicants – Programs with spots to fill can start officially entering a list that ranks the unmatched applicants who have applied to them.  Programs can continue to contact unmatched applicants who have applied to their program via SOAP.

Wednesday and Thursday – Unfilled programs submit final rank list and SOAP offers made.  Candidates will be notified which programs have “offered” them a spot.  This process will occur in rounds, with the applicant will have 2 hours to make a decision, making it important to weigh the options carefully.  Some people have forecasted a continued decrease in number of unfilled spots available as the Match increases in size due to increasing US medical school size without a corresponding increase in residency slots.   Although the SOAP ends Friday at 5pm, the process may be over before it begins with many of the spots getting “sopped” up in the first or second round of the SOAP.  Since this is the first year of the SOAP, it will be interesting to see how it goes and is perceived by all those involved.

Friday -  MATCH DAY! – Most schools have a ritual or a party, including some really unique rituals like this one at EVMS!  Some schools make students stand up and read where they are going to their classmates and faculty so that students are literally reading aloud their surprise.  Other schools may think this may be a bit cruel and unusual and opt for passing out envelopes with simultaneous opening of envelopes for a big frenzy.   Other schools, like ours, have their own ritual:

Bag of money awaits as Dr. Abelson hands out envelopes on Match Day

The Pritzker Ritual  Prior to calling names to retrieve envelopes, every student puts money into a bag.  Once the envelopes are presented, they put on a table in the front of an auditorium and tossed around so they are in no particular order.  As envelopes are drawn from the pile one at a time, students names are called to come down to retrieve their envelope.  Everyone returns to their seat to wait  patiently since  the student who is called last wins all the money!  Then, everyone opens their envelopes at once and massive celebrations ensue.

Following the Match, students often receive calls or emails welcoming them from their residency program leaders (Chief Residents or Program Directors).  Then, comes the Match Party – which could either be school-sponsored, or more ‘underground’ social event set up by the class.

Saturday – REST!  The students need to rest up for their upcoming internships.  The faculty also need to rest since a few weeks later, they will be busy preparing the current third years (rising 4th years) to enter the residency application process!

The Future of the Match - Next year, we will probably have the biggest Match ever as the NRMP implements the “All -in” Match so that even International Medical Graduates MUST go through the match to get a U.S. postion. With medical school enrollment rising and new medical schools opening, there will be increasing numbers of students who go through the Match. Without increased positions, the number of medical graduates will exceed available first-year residency positions by 2016 (some doomsayers are saying even sooner!).   You don’t need to be a math guru to know that we need to increase the numbers of residency positions to make sure that future medical students can enter residency training.    More on history of the Match here.

–Vineet Arora, MD


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