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

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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





Is the Future of Residency Training Like Avatar?

8 03 2010

During one of the keynote addresses at this past weekend’s ACGME meeting, Dr. Carolyn Clancy, head of the Agency of Healthcare Research and Quality, highlighted the definite need for enhanced patient safety and training on healthcare IT for residents who will be the practicing docs of the future. At the very end, she compared the future of residency training to Avatar – an epic battle followed by enlightenment. Because I am a huge science fiction fan and working in graduate medical education, I was especially struck by that comment. So, I continued to think about this analogy during the meeting –and even after I came home and saw the Oscars and saw James Cameron’s science fiction 3D-blockbuster lose to ex-wife Kathryn Bigelow’s critically acclaimed war movie, The Hurt Locker (interesting article on why it lost here).

So does the Avatar analogy work? Well, in Avatar, you have some militant members of a species (humans) trying to preserve and protect their world. On the other side, you have a new and evolved species who value working in teams and have a symbiotic relationship with their environment. Interestingly, you also have a doctor and a paralyzed soldier who go undercover to initially understand the species and then they both end up becoming one of them in the process, with one of them ultimately leading the new species to victory. I must say that the Avatar analogy is especially interesting in light of the MOST talked about session at the meeting —the implications for residency training from the different generations currently in the medical workplace (note: not the same ppt or speaker but helpful). At one end, you have Baby Boomers who are leading residency education and often long for the ‘way it used to be’. Contrast that to millenials (current interns and students) who are more used working in teams, value balance in their lives, and also have a symbiotic relationship with technology (namely their smartphone). Of course, there are also Gen Xers (this would be me) in the middle who may be trying to understand the millenials…So, are there a few Gen Xers who will literally fall in love with the idea of being a millennial and help them get their way? It’s starting to look possible…

What is the epic battle? Not a surprise here – the epic battle is on – and its about resident duty hours – how long should residents work? That battle was highlighted at the meeting…There is a lot of public pressure being exerted on the ACGME to adopt the IOM recommendations. But there are also a lot of program directors who voiced concerns about what will happen to resident education and where the resources will come from to ensure patients are cared for. Everyone was also trying to figure out if 16 hour limits would be put into place or not… The only thing that anyone could say with certainty is that new proposed standards would be released this Spring (as early as April) with a public commentary period followed by approval in September and full implementation expected by July 2011.

What will the enlightenment be? One possibility is better supervision – or an environment in which it is not about total hours but its about enhanced learning and patient safety through better supervision. In the words of Dr. Bertrand Bell who chaired the Bell Commission in the wake of Libby Zion’s death that ultimately heralded the NY State duty hour restrictions for residents, “Supervision, Not Regulation of Hours, Is the Key to Improving the Quality of Patient Care.” This has led some to suggest that supervision got lost somewhere along the way and the focus has really moved to hours. The tide appears to be turning since even the IOM report includes the title “supervision” and actually goes so far to recommend that there is 24/7 on site supervision by a qualified supervisor (meaning faculty). Will this happen? Well, it already does in some specialties – OB/Gyne and Emergency Medicine to be specific. Will this happen in across the board? I don’t know for sure, but I do know that we could be doing better to train faculty to provide better supervision at night especially. This is one reason we have been working to develop videos and teaching tools to highlight barriers to supervision and how to better address these barriers (See our Supervision: First Day on the Wards film that we debuted at the ACGME this year- note we won’t be winning any Oscars!).

So, does the future of residency training look like Avatar??? Well, it’s certainly better than resembling the critically acclaimed and Oscar winner ‘The Hurt Locker’. Plus, it would be much better funded!





The “Doc Fix” for Medicare Fees: Déjà vu All Over Again…but Worse?

1 03 2010

A 21% cut for Medicare physician fees is set to go into place today.  This year, fixing physician payment has been overshadowed by all the talk about health insurance reform (who can forget the buzz about the public option and death panels?).        

In fact, I remember being invited to talk about healthcare reform on a panel for medical students this past fall.  As part of my remarks, I mentioned the 21% pending cut in physician payment and recall the questions and quizzical looks.  Another panelist said  – oh but that won’t happen – they (meaning Congress) will fix it.  And I said I hope so, but they have not done it yet…and here we are.

Actually, the truth is we believed they would fix it…at least in the short-term.  After all, I have gone to Washington DC for the past 5 years for the American College of Physicians Leadership Day and have taken several residents and students with me through the years.  Each year, we are fortunate to hear Bob Doherty, ACP Vice President and top health policy blogger, give a riveting update on what’s new on the Hill.  And for the past 5 years, the recurring theme has been the need to fix the physician payment system and the ‘flawed formula’ that calls for the cuts.   I was even lucky enough to participate in a Congressional hearing on the issue in 2006.   And every year, Congress has passed a short term fix to the problem.  Unfortunately, that has started the vicious cycle which makes the cuts the following year even worse… hence 21% cut today…unless there is another quick fix this week. 

Believe it or not, there seems to be general agreement that the system for paying doctors needs to be fixed.  The issue is how to pay for it.  As discussed in the Wall Street Journal:

The calculus on this issue is always basically the same. There’s widespread political support for blocking scheduled pay cuts to doctors. But doing so is expensive. So rather than get rid of the formula that keeps calling for the cuts — which would require Congress to acknowledge that the country is going to be on the hook for billions of dollars in additional Medicare costs — Congress keeps passing these short-term patches.

As I have discussed topic over the years with a variety of students and residents, I have noted a lot of confusion on these issues.  That isn’t entirely surprising since health policy isn’t a required course in medical school…but maybe it should be?   To better understand this chain of events and why all of this is really happening, I’ve outlined some basic questions and answers below.    

How are doctors paid?  Doctors are still paid on a fee for service system for their time.  When Medicare initially passed in 1965, to get physician support, Congress agreed to preserve the fee for service system.  To determine the actual value of physician services, a ratio system (RVRS) was introduced in 1992 that determines the value of one service to another and adjusts for geography.  Every five years, an AMA committee (RUC) composed of representatives from each specialty society debates the relative values of physician services and publishes the book that sets these ratios.  It is widely believed that the RUC is overrepresented by subspecialists who have led to undervalue of primary care services.  More recent concerns about the incentives to ‘do more’ in the fee for service system have led to some to argue for the ‘bundling’ of physician payments.

What is the SGR?  The Sustainable Growth Rate is a general marker of inflation.  In 1998, due to concerns of escalating healthcare costs, Medicare payments for physicians were tied to the SGR.  Unfortunately, healthcare inflation outpaces general inflation and since 2002, the cost of physician services has exceeded what would be predicted from the SGR.  Hence, every year a predicted cut in Medicare physician fees to bring it back to the SGR.  Each year, because a temporary fix is passed, the next year the cuts get worse

What is pay-go?  Because of pay-go rules, new legislation that increases spending has to include cuts elsewhere.  In this environment, it makes it harder to pass a costlier bill.  Unfortunately, a long-term fix means getting rid of the SGR and replacing it once and for all is very costly.  So in this environment, it is easier to get a short term fix passed.  This year, the AMA, ACP, and other professional organizations stated they no longer support a short term fix and called for a full repeal of the SGR.  In fact, because the ‘doc fix’ costs so much, it was removed from the calculation of the cost of the health reform bill to make it more likely that the health reform bill will pass.  To get support of physicians for health reform, Democrats said they would pass a long-term doc fix.  The House did pass a bill that repealed the SGR.   It also passed a short term delay on the cuts and in fact paired it with extending unemployment benefits, but the Senate (due to one vote opposing from Senator Bunning –R Kentucky who took a lot of heat for his opposition) did not act.  And that is where we are today.

Why do we have to fix this? As you can imagine, a 21% cut in Medicare physician fees would likely result in limited access for seniors and veterans.  Reports already highlight that doctors will be forced to drop or delay seeing their Medicare patients until they know what will happen.  Although many physicians ‘participate’ in Medicare, it is unknown how many may be limiting the number of Medicare patients they would see.  Since Medicare is the largest payer, it is likely that other insurers will follow suit and cut physician fees.  Lastly, all the money and time that goes into the short term patches have left physicians tired, uncertain of the future and with little faith in the legislative process.  We need to fix this so we can move onto other pressing issues in healthcare.        

 – Vineet Arora, MD

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