What Can the Unmatched Seniors Tell Us?

18 03 2013

Yesterday, after the mayhem and jubilation of celebrating a successful match at the Pritzker School of Medicine with our students, I went onto Twitter to follow the #match2013 hashtag to understand what the reactions were.  Most were positive, but one headline caught my attention ‘In Record-Setting ‘Match Day,’ 1,100 Medical Students Don’t Find Residencies.”

It is true this was the largest match because it was “All-in” – programs either were in the match for all their positions (including international medical graduates or IMGs) or they were not.  Obviously, many programs put more positions up for grabs in the Match.  After I reposted this article to Twitter, there were many theories and questions about who these unmatched students were and why  – some of which I have tried to answer to the best of my ability below.  I welcome your input as well.

  • Are these IMGs?  This number is US Senior medical students who have been admitted and graduated from US medical schools but now have no place to go to practice medicine.
  • Does this include those that entered the “scramble” now called SOAP. Technically, those that entered SOAP and were successful would have been counted as “matched” on Friday.   Last year,  815 Us seniors went unmatched after the SOAP.
  • Did they choose to go into competitive specialties? We have to wait for the 2013 NRMP statistics, which will likely address this.  The 2012 data shows that more unmatched seniors did choose to go into competitive fields.  Last year, the % unmatched is much higher for students applying to radiation oncology, dermatology, and competitive surgical fields for example.
  • Did they go unmatched to due to poor strategy or poor academic performance? While poor strategy such as ‘suicide’ ranking only one program is related to the risk of going unmatched, the truth is getting into residency is competitive and there are some who will not match because of poor academic performance. Some even argue that medical schools have little incentive to fail students and a portion of these students should not be graduating to begin with.
  • If they had gone into primary care, would they would have matched?  I hear this myth that program directors in primary care fields only take international medical graduates (IMGs) since not enough US medical graduates apply.   This is due to the largely untested assumption that any US Senior would be preferred to an IMG.  However, I personally know program directors who would definitely take a seasoned and high performing IMG over a below-average US Student.   The reason this is important is the rationale for not lifting the GME cap is that we have 50% of certain fields filled by IMGs and those spots would naturally be filled by US grads. Interestingly, many of these spots happen to be primary care driven fields.   Yet, it is still unclear if US Seniors will displace IMGs for spots in IMG oriented residencies.  It is also unclear if they will be willing to apply to programs that typically cater to IMGs, since they are often not considered as prestigious or geographically desirable to US students.
  • Is this related to the lack of GME spots? Certainly, it is true that more effective career advising may have resulted in applicants being more strategic about their rank list and not reaching for a competitive field.  However, we cannot ignore the supply/demand side of this equation.  At a time when there is a shortage of physicians and a call to increase the number of physicians, the US medical school system by responded to this call.   New medical schools have opened.  Existing medical schools have increased their enrollments.  So, there are now more US Seniors entering the match and there will be even more in the future as new medical schools mature their entering classes to graduating students over the next four years.  Given that the supply of matched candidates includes both foreign-born IMGs and US-born IMGs, there are more candidates than spots.  And while many believe IMGs will be the ones that get “squeezed out” in this shortage situation, again this is an untested assumption.  It is also important to recognize that IMGs often play a significant role in ensuring primary care for rural populations and underserved communities,which are often not geographically desirable by US graduates.

 We are left with a fundamental question:  Do we owe it to our entering medical students who successfully graduate from medical school to have a residency spot?   At a time when we have a shortage of physicians and a call for medical schools to increase in size, should we not expand our residencies?   Unfortunately, GME funding is on the chopping block because of the belief that too much money is being wasted on residency training.  Moreover, hospitals seem less enthusiastic about expanding residencies, as it is not as much of a bargain due to caps on hours residents work, and all the other new accreditation standards for residency training.

There is a potential solution.  The “Training Tomorrow’s Doctors Today Act” by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.), and the “Resident Physician Shortage Reduction Act of 2013” sponsored by Sens. Bill Nelson (D-Fla.), Charles Schumer (D-N.Y.), and Majority Leader Harry Reid (D-Nev.) would enable training 15,000 more physicians over 5 years.   Moreover, spots would be distributed to programs and specialties in critical shortages, like primary care.

Given the time that it takes to train a physician, now is the time to act to ensure we have the doctors we need for the future.

 –Vineet Arora MD MAPP





Love Letters for Med Students Follow-Up

27 01 2013

futuredocs:

For any students wondering what to do if they write or receive love letters from residency programs, here is an oldie but goodie to help. Since this post, we conducted a 7 school study in 2010 of graduates that showed that almost one-fifth reported feeling assured by a program they would match there but did not despite ranking that program first. Nearly one-fourth said they changed their rank order list based on communications with programs. The conclusion “Students should be advised to interpret any comments made by programs cautiously.” And of course be mindful that the 2013 Rank order list certification deadline is Feb 20th at 8pm Central Time. Good luck!

 

Vineet Arora MD

Originally posted on FutureDocs:

While Valentine’s Day is coming soon, a different sort of ‘love letter’ may be sent or received by senior medical students.  As recruitment season draws to a close, residency programs and applicants may be busy exchanging notes of interest, affectionately dubbed “love letters” by scores of medical students and on StudentDoctor.net.

What do these love letters mean?  Some students have asked us whether it is a Match Violation to get or send a love letter.  Others have worried they did not send enough or what type of language they should use.  Well, here are some quick tips on how to approach this somewhat awkward situation.

  1. Is it a Match Violation? It is not a Match Violation for a program or a student to express interest in the other.  However, these statements of interest cannot be binding (i.e. we will only rank you highly if you rank us #1).  If there is any part of it…

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Cultivating Creativity in Medical Training FedEx Style

14 01 2013

Over the holidays, I took full advantage of this opportunity to read a book from start to finish.  I chose Daniel Pink’s Drive.  It was actually recommended by @Medrants and I read it partly to understand why pay-for-performance often fails to accomplish its goals for complex tasks, such as patient care.  However, the thing I found most interesting about this book was the way in which creativity is deliberately inspired and cultivated by industry.

I could not help but think about why we don’t deliberately nurture creativity in medical trainees.  Why am I so interested in creativity?  Perhaps it is the countless trainees I have come across who are recruited to medical school and residency because of their commitment to service who also happen to have an exceptionally creative spirit.  Unfortunately, I worry too many of them have their spirit squashed during traditional medical training.   I am not alone.  I have seen experts argue the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity.   Apart from the criticism, it is of course understandable why medical training does not cultivate creativity.  Traditional medical practice does not value creativity.  Patients don’t equate ‘creative doctors’ as the ‘best doctors’.  In fact, doctors who may be overly creative are accused of quackery.

So, why bother with cultivating creativity in medical training? Well, for one thing, creativity is tightly linked to innovation, something we can all benefit from in medical education and healthcare delivery.   While patients may not want a ‘creative approach’ to their medical care, creativity is the key spice in generating groundbreaking medical research, developing a new community or global health outreach program, or testing an innovative approach to improving the system of care that we work in.  Lastly, one key reason to cultivate creativity in medical trainees is to keep all those hopeful and motivated trainees engaged so that they can find joy in work and realize their value and potential as future physicians.  In short, the healthcare system stands to benefit from the changes that are likely to emanate from creative inspired practicing physicians.

So what can we do to cultivate and promote creativity among medical trainees? While there are many possibilities including the trend to implement scholarly concentrations programs like the one I direct, one idea I was intrigued by was the use of a “FedEx Day”.  FedEx Days originated in an Australian software company, but became popularized by Daniel Pink and others in industry.  For a 24 hour period, employees are instructed to work on anything they want, provided it is not part of their regular job.  The name “FedEx” stuck because of the ‘overnight delivery’ of the exceptionally creative idea to the team, although there are efforts being undertaken to provide this idea with a new name. Some of the best ideas have come from FedEx Days or similar approaches, like 3M’s post-its or Google’s gmail.  I haven’t fully figured out how duty hours plays into this yet… so before you report me or ride this off, consider the following.  Borrowing on the theories of Daniel Pink, we would conclude that trainees would gladly volunteer their time to do this because of intrinsic motivation to work on something that they could control and create.  And to all the medical educators who can’t possibly imagine how would we do this during a jam packed training program, lets brainstorm a creative solution together!

Vineet Arora MD





Making the Most of the iPad Mini on Medicine Rounds

20 12 2012

On my birthday several weeks ago, I was lucky to get an iPad Mini from my husband. I already have an iPad and have shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), and documented an improvement in efficiency on the wards. So why the Mini? What is all the fuss? Well, after finishing 2 weeks on service, I can finally tell you why the Mini is the new must-have for doctors and future doctors.

  1. It fits in your white coat! Yes, while there were entrepeneurs who started creating the iCoat, the truth is who wants to wear a coat with a huge pocket on the side? This means that you also don’t need to wear the “strap’ that we require our residents to wear for the iPad since we did not yet invest in the iCoat.
  2. You can hold it in one hand! This for me is the best part and very underappreciated point in the blogs and reviews I have read. This means you can tough the screen with one hand while you are palming it with the other. I don’t even have the largest hands so I would say it definitely was just at the reach of my palm grasp but I can imagine it would be perfect for my male colleagues.
  3. It fits in your purse! While the female docs may find palming the iPad mini not as easy as the men, never fear…since this one is for the ladies. Many female doctors are always on a quest to find the right handbag/workbag combination. Owning an iPad always meant buying boxy “folio” type purses or shoving it to barely fit in a handbag. The mini is the PERFECT size for a medium size handbag – hobo or satchel. This means that you can go from day to night without carrying your “work bag” to the restaurant. And for the men out there, you can always get a “murse” this holiday season. I hear that they are making a big splash.
  4. You’ll carry it more. Number 1 through 3 really boil down to the fact that it is hard to carry the iPad. Because it is so easy to carry, you won’t find yourself without access to the electronic health record or paging directory. You may be more apt to show patients their images or X-rays or look something up because it is not as hard to use.
  5. You’ll make friends. Basically the minute I brought out the Mini, everyone…nurses, social workers, residents, students, and yes patients were interested in seeing it – “Mini envy” as my students called it. It’s a conversation starter that can improve collegiality and teamwork. When I visited floors that I did not usually work on (overflow patients), I met a nurse who asked me about the Mini – and the next day, she came to our rescue when we were trying to decipher the timing of a patient’s medication and a potential new allergy.
  6. It is more discrete to use at a conference (once everyone stops staring). The Mini is smaller so a bit more stealth in terms of answering a text page or checking a lab while you are sitting in case conference, and you can easily stash it back in your purse as noted above.

Some things to think about. The Mini is not without its pitfalls – many of which are predictable due to its size and interface.

  1. For the visually challenged, it can be hard to see. Sure… you can always “magnify” things with the correct gestures. But, if you are in your Citrix Client looking at your electronic health record, it may not be so easy to magnify and you may have to hold it up closer to your face which can be awkward. Maybe I just need to get my vision tested? Either way, something to be aware of.
  2. Easy to lose. As part of the residency program project, the nice thing about the iPad with strap is you an see it on the resident and its harder to walk off with. The Mini could disappear in a snap. Could someone even “pick-pocket” a doctor coat? Very possible.
  3. It is not a complete substitute for a workstation or pen and paper. This is not unique to the Mini. There is a reason that mobile tablet computing is not a complete substitute for a workstation – the lack of a keyboard. As a result, some our residents carry “paper notes” with their iPad – the paper notes are to take notes of the to-do list that is created on rounds -nothing like checking all those boxes off as an intern. The iPad does not replace that so readily – and while there others thinking about this space, its worth noting that the preference for pen and paper to organize one’s thoughts is very strong. I have to admit, watching the catchy commercial for the Windows Surface, there is still something so appealing about an external keyboard.

So what is the verdict for the Mini? Well, as we say in medicine, the risks of the Mini are outweighed by its benefits making it the perfect prescription for all the physicians or physicians to be in your life. And there’s still a few shopping days left before Christmas…

Happy Holidays!

Vineet Arora MD





Time to Fight Horrors of Healthcare Costs by Taking Charge of Teaching Value

31 10 2012

This Halloween, several creative costumes have emerged from the zingers of the Presidential debates – Big Bird costumes are selling out like hotcakes. For a more do it yourself look, here’s a recipe for Binders full of women.  The debate over the best way to contain healthcare costs have also been a central part of the debates, and yet medical bills do not seem to make popular costumes. Maybe that is because that unaffordability of healthcare is too horrifying for ironic humor – even on Halloween.

As we head into the election, patients are increasingly being terrorized by runaway healthcare costs.  Americans outspend our peers two to one and still seem to be worse off. We overtest and overtreat to the point of absurdity.   According to a recent report, “The U.S. did 100 MRI tests and 265 CT tests for every 1000 people in 2010 — more than twice the average in other OECD countries.”  The causes are multifactorial but the solutions can’t be left to presidents and policymakers alone. An important part of the responsibility rests with healthcare professionals and the educators who train them.

Experts in health professions education and economics have lamented the poor state of education on healthcare costs.  Over 60% of U.S. medical graduates describe their medical economics training as “inadequate.”  Not only are medical trainees unaware of the costs of the tests that they order, they are rarely positioned to understand the downstream financial harms medical bills can have on patients.  More recently, Medicare, the largest funder of residency training in the United States, is concerned that we are not producing the physicians to practice cost-conscious medicine in an era of diminished resources.

We have been scared in the dark too long and this Halloween the time has come to Take Charge.

Join us now at http://teachingvalue.org/takecharge

About Teaching Value: the Costs of Care Teaching Value Project is an initiative of Costs of Care that is funded by the ABIM Foundation.  Our team is comprised of medical educators and trainees who believe it is time to transform the American healthcare system by empowering cost-conscious caregivers to deflate medical bills and protect patients’ wallets.  Our web-based video modules are designed to be easy to access for anyone anywhere and provide a starting point for tackling this problem. It’s time to emerge from the darkness and do our part to tame the terror of healthcare costs.





Teaching Crucial Conversations: The Curse of Knowledge & the ASK Problem

4 09 2012

One of the most interesting conversations that I had recently was at the ABIM Foundation Summer Forum Open Space Sessions.  The ABIM Foundation Summer Forum is a summit of thought leaders and experts representing healthcare organizations, policymakers, patients, payers, doctors, and trainees who come together to tackle a major problem in healthcare.  The topic of this year’s forum was in keeping with the launch of the new ABIM Choosing Wisely Campaign and aptly named “Choosing Wisely in an Era of Limited Resources.”

The Forum has a unique format, employing a mix of routine panel discussions, but also “Open Space” conversations where participants actually drive the agenda, deciding what they want to work on.  One of the Open Space topics that I ended up joining was on how to train physicians to have crucial conversations with patients.   After forming this group, there were some immediate questions raised– why only physicians?  What about other members of the care team, including the patient?  Moreover, individuals in our group each had a different definition of what  “crucial conversations” were.  One clear theme was around end-of-life conversations with patients, but that was not the only one.  For example, how to talk to a patient who is asking for a medical test that is not indicated?

As I returned home, I reread some of the literature I have become acquainted with on why we (humans) don’t communicate as well as we should.  Using this framework, it’s worth considering why doctors and patients may not communicate as well as they should.  Drawing from the knowledge communication literature when an ‘expert’ is communicating to a ‘decision maker’, two distinct problems can arise:

  • Curse of Knowledge– The curse of knowledge, otherwise known as the paradox of expertise, represents the difficulty of experts to use commonplace jargon to communicate their ideas to those that are not experts.  Because experts tend to surround themselves with other experts, it can be very difficult for an expert not to use technical jargon when communicating with people who not experts.  This is easily evident in a variety of scenarios – most notably in the first few seconds of the trailer for the movie Contagion when doctors try to tell Matt Damon that his wife, played by index case Gwyneth Paltrow, is dead.  The doctor starts by saying “I am sorry…she failed to respond”.  On cue, Matt Damon responds, “OK can I go talk to her?” clearly missing the meaning of what the doctor has just tried to communicate.  Likewise, one of the patient advocates at our table shared the story of how she came to know she had cancer – “It’s malignant” …so she deduced from “Mal” and all the words that start with “mal” are bad (malice, malpractice…to name a few) so she thought “Mal … bad”.
  • ASK Problem – the ASK Problem stands for the Anomalous State of Knowledge.  This is a problem that arises when the decision maker does not have the knowledge that it takes to ask questions, since asking questions often relies on having intimate knowledge of the subject at hand.   This is particularly salient since we have major campaigns that often are directed at patients to “ask more questions” of their doctor.  However, it may be very hard for a nonexpert to ask a question of an expert if they don’t have a set of common knowledge to go on.  Asking questions is so difficult that our work shows its rare for even physicians to ask other physicians questions, and instead they opt for what is known as “back-channeling” or saying “Uh-huh” to indicate their agreement.  The only problem with this is that back-channeling is that it can be exhibited by demented patients so it is not necessarily a confirmation of comprehension or understanding.  To make matters worse, a recent study shows that patients may not ask questions for fear of being labeled “difficult”.

How can we get around these problems? Well, improving a conversation requires training on all sides. Patients can also be coached to take a more active role in their care. However, healthcare personnel also need to be prepared so that their newly empowered patients are not an unwelcome surprise. Physicians and other healthcare personnel need to be trained in how to speak to patients about difficult decisions in a sensitive way.   One model curriculum we can learn from has been developed by oncology fellowship directors and is called OncoTalk.  One of the key tenants is the principle of NURSE, which describes how to respond to patient emotions during complex decision-making.

  • Naming the emotion “It sounds like you are afraid of X”
  • Understanding the emotion  “I can understand the fear that goes along with X.”
  • Respecting  “You are asking the right questions…”
  • Supporting  “I am here to support you through this decision…”
  • Exploring  “What are you thinking about now?”

Of course, the age-old question is can you teach empathy? Well, according to one recent study, empathy wanes throughout medical school.   So we should, at the very least, try to at least preserve it.

Vineet Arora MD





Teaching Costs of Care: Opening Pandora’s Box

27 07 2012

Last week, I tried something new with our residents…we tried to talk about why physicians overuse tests.   This is the topic of the moment, as the American College of Physicians (ACP) just dropped their long-awaited new High Value Cost Conscious Curriculum for what has now been dubbed the “7th competency” for physicians-in-training.   In addition to the ACP curriculum, which I served as one of the reviewers for, I also am involved with another project led by Costs of Care to use video vignettes to illustrate teaching points to physicians-in-training called the Teaching Value Project.  With funding by the ABIM Foundation , we have been able to develop and pilot a video vignette that that depicts the main reasons why physicians overuse tests.   The discussion was great and the residents certainly picked up on the cues in the video such as duplicative ordering, and that the cost of tests are nebulous to begin with.  But, before I could rejoice about the teaching moments and reflection inspired by the video, I must admit that I felt like Pandora opening the dreaded Box.   Many of the questions and points raised by the residents highlight the difficulty in assuming that teaching doctors about cost-conscious care will translate into lower costs and higher quality.

1)   What about malpractice?  One of our residents mentioned that really the problem is malpractice and that test overuse was often a problem due to the “CYA” attitude that physicians have to adopt to avoid malpractice.   It is true that states with higher malpractice premiums spend more on care.  However, this difference is small and does not fully explain rising healthcare costs.  More interestingly, the fear of being sued is often more powerful than the actual risk of beingsued.  For example, doctors’ reported worries about malpractice vary little across states, even though malpractice laws vary by state.

2)   What about patients who demand testing? Another resident highlighted that even with training, it was often that patients did not feel like anything was done until a test was ordered.  Watchful waiting is sometimes such an unsatisfying ‘treatment’ plan.  As a result, residents reported ordering tests so that patients would feel like they did something.  In some cases, patients did not even believe that a clinical history and exam couldlead to a ‘diagnosis’ – as one resident reported a patient asked of them incredulously, “well how do you know without doing the imaging test?”

3)   What can we do when the attending wants us to order tests? All of the residents nodded their head in agreement that they have had to order a test that they did not think was indicated, because the attending wanted to be thorough and make sure there was nothing wrong.  I find this interesting, since as an attending, you are often making decisions based on the information you are given from the resident – so could it be that more information or greater supervision would  solve this problem?  Or is it that attendings are hard wired to ask for everything since they never thought about cost?

4)   Whose money is it anyway that we are saving?  This is really the question that was on everyone’s mind.  Is it the patient’s money?  After all, if a patient is insured, it is easy to say that it’s not saving their money because insurance will pay.   Well, what about things that aren’t even reimbursed well..doesn’t the hospital pay then?  Finally, a voice in the corner said it is society that pays – and that is hard to get your head around initially, but it is true.  Increased costs of care are eventually passed down to everyone – for example, patients will be charged higher premiums from their insurance companies who are paying out more.  Hospitals will charge more money to those that can pay to recover any losses.

5)   Will education really change anything?  So, this is my question that I am actually asking myself at the end of this exercise.… Education by itself is often considered a weak intervention, and it is often the support of the culture or the learning climate that the education is embedded in.  The hidden curriculum is indeed powerful, and it would be a mistake to think that education will result in practice change if the system is designed to lead to overordering tests.  As quality improvement guru and Dartmouth professor Paul Batalden has said (or at least that’s who this quote is often attributed to when its not attributed to Don Berwick) “Every system is perfectly designed to achieve the results it gets.”  Therefore, understanding what characteristics of systems promote cost conscious care is a critical step.

However,  before we dismiss education altogether from our toolbox, it is important to note that education is necessary to raise awareness for the need to change.  And in the words of notable educational psychologist Robert Gagne, the first step in creating a learning moment is getting attention.  And, by that measure, this exercise was successful – it certainly did get attention.  Yet, it also did something else…it created the tension for change, a necessary prerequisite for improvement.  It  certainly cultivated a desire to learn more about how to achieve this change….which is what our team is currently working towards with the Teaching Value Project.    So while learning why tests are overused is a first step… judging by Pandora’s box, it is certainly not the last.

–Vineet Arora MD

Special thanks to Andy Levy and Neel Shah for their hard work on this module.








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