Holiday Wish List for Medical Education

24 12 2010

It’s the holidays which means that the students are on vacation and faculty have a little more time to unwind.  Unfortunately, residents are still hard at work but celebrate the holidays in their own way in the hospital as we have discussed before.  I’ll be joining them January 1st but for the moment get to enjoy some time off as well. 

Even though medical schools have closed their doors for 2010 and faculty are getting much needed rest, it is time to reflect on what is needed for medical education in the New Year and beyond.  While it’s been a banner year for healthcare reform, there are still some issues that are looming large for medical education, especially graduate medical education.  It’s important to revisit these issues and especially focus on what the ‘wish list’ as medical education prepares for the ‘twenty-tens’.

  1. Funding to Meet the ACGME 2011 Duty Hour Requirements   With 6 months and counting to the implementation of shorter hours for resident physicians, budgets are getting made now for the new fiscal year.  On top of that list in teaching hospitals is how to make ends meet with residents who work shorter hours.  Residents are low cost labor compared to hospitalists and physician extenders who are their most likely work substitutes.   With the overall price tag set at over 1 billion for duty hour compliance, obtaining funding is not easy.  However, securing the appropriate financing for these solutions is critical to ensuring that residents are not doing the same or more work in less time.  Increasing resident work intensity may undermine any potential improvements in patient safety and resident education.   To make matters worse, funding may be harder to obtain than ever since funding for graduate medical education by CMS is under threat of redirection.  
  2. A Curriculum to Teach Doctors to Practice Cost Conscious Medicine  With an unprecedented focus on how to contain costs and ‘ration’ care, we are missing one key piece of the puzzle – how to teach young physicians and physicians-in-training how to do this effectively.   Most faculty physicians do not know the costs of the tests that they order making it necessary to create off-the-shelf curricula in this area.  To make matters worse, cost of laboratory tests can vary by region and hospital, making a standard curriculum challenging to implement.  Nevertheless, overreliance on medical testing has run rampant in teaching hospitals, largely due to the lamented “demise of the physical exam”.  If one way to teach cost-conscious medicine is invest in the low cost physical exam skills, we can all learn from the Stanford 25 that is being resurrected by acclaimed physician author educator Abraham Verghese.   While we improve physical exam skills and hopefully change the incentives, we will still need new tools and tips for how to train the cost conscious doctors we wish to produce.  One possibility is through the use of narratives – A new group called Costs of Care launched an essay contest to and will be periodically posting stories to help raise awareness. 
  3. More Residency Spots – As we’ve discussed, without more spots for all those new medical schools opening their doors, medical school graduates will soon face unprecedented competition during the Match without a corresponding increase in residency positions.  While the assumption is that the International Medical Graduates will be squeezed out at the expense of the US graduates, this is not entirely a given.  More than a few program directors of IMG exclusive residency programs say they will continue to take International Medical Graduates.  Regardless, it’s the US that loses in the end given the projected doctor shortage and the only pathway to licensure is via a US residency.  While CMS is exploring ‘redistributing’ spots to primary care, the general consensus is that more will be needed.
  4. Student Debt Relief  Medical student debt continues to plague US education.  While some programs, such as the National Health Service Corps, have been expanded to help address this issue, it is still important to expand such programs to reach a larger audience of medical students.  One novel way to do this is to pair student debt relief with service, an idea put forth by the Editor of Academic Medicine as this year’s “Question of the Year.”  Many schools responded, including our own, which created the REACH (Repayment for Education to Alumni in Community Health) Program to help.  To achieve a larger scale impact, more programs on a federal and state level are needed.  In the interim, the AAMC “FIRST” initiative is a terrific resource to help students navigate their debt and keeps up to date stats about the situation.
  5. Making Primary Care as a Desired Career  The shortage of primary care physicians will devastate the US as more patients become insured and the population ages.  One of the central models for healthcare reform is the spread of the patient-centered medical home, led by a primary care physician.   While the future roles of nursing is explored and potentially expanded to meet this need, it will not be enough to care for complex patients with multiple disease and medications which require care coordination.  So, if primary care is so important, why are more students not choosing to go into it?  One striking finding in the recently released 2010 survey results of all entering medical students is the number of students who declared they would subspecialize.  12% were already on the “ROAD” (rads, ophtho, anesthesia, derm) while an additional 9% were budding orthopedic surgeons.  Meanwhile, 8% were interested in family medicine.  Although 18% declared an interest in internal medicine, 2/3 of these will ultimately subspecialize too.   So what do entering students already know about these specialties?  Well, the elephant in this room here is the income gap between primary care and specialists.   As long as this disparity exists coupled with the debt discussed above, it is difficult to dissuade career decisions, especially when they are made this early!   No one wants to discuss this since it pits doctor against doctor but the time for this discussion is long overdue.

While it would not be wise to wait up for Santa to deliver on these wishes tonight, keeping our focus on these issues in the New Year will surely help usher in the next decade of medical education.      

–Vineet Arora, MD





Personal Statement Do’s and Don’ts

22 07 2010

It is summertime for medical students.  While second and third year students are conducting summer research, leading service activities, or starting clerkships, senior students are on their subinternships in search of a story to share in their personal statement.  In an editorial in this week’s Annals of Internal Medicine, leaders in medical education actually propose retiring the time honored tradition of the personal statement.  These concerns come amidst a new report demonstrating that upwards of 5% of personal statements are plagiarized.  While the merits of personal statements are debated, current residency applicants are still stuck trying to create the perfect one.  So, for the MS4’s, here are the top Do’s and Don’ts for your personal statements and some ways to get started. 

DO’s

  1. Remember your audience. You are writing for program directors and selection committees. They want interns and residents who are hard working, competent team players who are good with patients. They are also reading hundreds to thousands of personal statements in one application period. (Case in point – one IM residency program director may read upwards of 1,500 personal statements).
  2. Follow three basic principles. Keep it succinct, clear and cohesive. The personal statement (PS) should be no longer than 1 page and should include paragraph indentations. 
  3. Be prepared to talk about anything you write in your statement. Interviewers often use the personal statement to help get a conversation started. The personal statement will, in some sense, be a way for you to introduce yourself to your interviewer and to the program.
  4. Make the statement about yourself. Avoid the habit of describing how great the field of X is or perseverating about a lengthy patient story without mentioning much about yourself. It’s easy to go on and on about one experience, but you have a lot of ground to cover.  We generally recommend a “hook” to open, followed by 2-3 paragraphs describing one or two experiences or activities that helped cultivate your interest or prepared you for the field you are entering. These experiences should be put into chronologic order and might be a college activity, medical school service and/or research project or an experience on a clinical rotation. 
  5. Think long and hard about your first line or ‘hook.’ The first line of your personal statement is most likely to be remembered so spend some time on it. If your first line is about Mrs. H’s CHF, it may not result in the best ‘meet and greet’ conversation.  Embedding a patient story later into your statement is appropriate, but is not an exciting start given that you’re writing to doctors.  For memorable ‘hooks,’ think about what makes you unique and what might be a good conversation starter.  This could be the ‘a-ha’ moment you experienced while volunteering abroad or something interesting about yourself such as your first career, an unusual hobby, an athletic or professional achievement.  Your job is to relate this to your passion for the field.   
  6. Make sure your personal statement matches your application. If you are opening with a discussion about the major impact that a global health experience or service activity has had on you, it should be in your ERAS application.  Select the most substantive experiences to discuss – the one hour per month volunteer activity is probably not going to make the cut. You should not ‘rehash’ your application but go into more detail about how and why certain experiences shaped your interest. 
  7. End with your future goals. The last paragraph of your statement should have some clues or keywords about things you are interested in (academics, medical education, research, and subspecialty).  Often times, this will enable the program to try to personalize your visit by bringing these issues up during the interview or even matching you with interviewers that have similar interests.

DON’Ts

  1. Don’t plagiarize. Program directors and faculty have read a lot of personal statements and are acutely aware of the many on-line sample personal statements out there. Resist the urge to “borrow” from these sites. The NRMP specifically notes that you must give credit for anything that you didn’t personally write. 
  2. Don’t make it to ‘too’ personal. Sounds odd we know…but your personal statement is meant to highlight your positives.  Refrain from discussing intimate details of your life that you are uncomfortable discussing with others. You’ll be asked about material in your personal statement over and over. If it is not something you would have brought up in an interview, you should probably not talk about it in a personal statement. Likewise, be careful with revealing too much about personal illnesses. Remember you are meeting people for a job interview – so you may not want to reveal your deep thoughts or memories. 
  3. Don’t dish about dirty laundry if you don’t have to.  You have faced hardships, have blemishes on your application, or you may not be certain you want to go into field X.  Reserve these topics for discussion with your peers, family or trusted advisors…but not for your statement.  Be prepared to discuss these issues in your interview knowing they may not even come up. There is no need to call attention to these issues before you even get a question about it.  Likewise, stories of how you were stressed (either emotionally or physically) will likely raise doubts about whether you are ready for the rigors of medical training.  You may need to consult with a faculty advisor here since this may vary from situation to situation.
  4. Don’t try to win a literary award. Remember doctors are used to reading abbreviations and not reading prose.  If your sentence exceeds 3 lines, think about rewriting it.  Look for the easiest way you can say what you want to.  Ironically, the statement is often harder to write for those with a background in creative writing. 
  5. Don’t diss others. Specifically, don’t talk about what’s wrong with other specialties, the difficulties your medical center may be facing, or other programs.  It just makes you look bad.
  6. Don’t go over a page. You’re writing for busy doctors, enough said.

 

Stuck? How to get beyond writer’s block with personal statements:

  • Look at the essay you submitted to get into med school. Chances are many of the characteristics you possessed then are still with you.
  • Start somewhere. It doesn’t have to be with the first line. You might have to start writing what ultimately ends up being in the middle of your statement. It’s often hardest to write the “who am I” first paragraph so it’s okay to start with why you chose the specialty to which you are applying.
  • Jot down random thoughts that come into your mind (preferably about your career) then put them into a sequence that makes sense.
  • Write your statement on paper or on the computer. Don’t feel obligated to use technology in the early stages. You may be better able to overcome writer’s block by writing on paper. Ultimately, you will want to transfer your personal statement into a notepad file in 10 point courier. If you cut and paste from a word document into ERAS, you will get strange formatting changes. It’s easier to cut and paste from a notepad file.

The Five Draft Personal Statement

  • Draft 1: Write something down (see “Stuck” if you don’t know where to start).
  • Read it aloud to yourself and fix what doesn’t sound good (like this sentence).
  • Draft 2: Have someone who knows you well and is a good writer read it with the following questions in mind: “Does this personal statement accurately represent me?” and “Is it well written?”
  • Draft 3: Ask your advisor to read it. This should either be the one assigned to you or a faculty member who knows you well. 
  • Don’t look at it for a day or two to let it simmer.
  • Draft 4: Ask an advisor in your field to read it and give you feedback.
  • Draft 5: Final version!

–Vineet Arora MD and Shalini Reddy MD





Getting Primary Care on the ROAD: Charting a New PATH

24 05 2010

I just returned from ACP Leadership Day where 375 internal medicine physicians and future physicians from all over the country descended on Capitol Hill to advocate for primary care.  Before I left, one of my colleagues asked me what we would have to talk about since healthcare reform already passed and includes some boosts for primary care.   Well, we had plenty to talk about!   While the main goal of healthcare reform was to provide coverage and insurance reform, the ultimate question is will newly insured Americans be able to access care?  Even if they have insurance coverage, they may not be able to see a doctor if there are not enough primary care doctors to see these patients.

Therefore, the focus of our efforts this year was to ensure that we have a primary care workforce to meet the demands of the newly insured.   Because of the long dwell time to train primary care physicians, we need to start now to ensure we have doctors for the future.   One staffer told us that he heard that medical students wanted to go into lucrative specialties to pay back their debt, and I asked if they had ever heard of the “ROAD” (aka Radiology, Ophthalmology, Anesthesiology, Dermatology) which refers to the desired lifestyle and highly reimbursed specialties.  He responded we needed to get primary care back on the ROAD or maybe make it “P-ROAD.”   I don’t think P-ROAD makes a great acronym, but PATH may work better: Primary care = Access To Healthcare.    While healthcare reform law (aka PPACA) includes many boosts to primary care, there are a few key omissions that can easily undermine healthcare reform.  Moreover, the question is now what provisions will be funded and at what level.  To get Primary Care back on the ROAD, we need to create a new PATH that includes fixing every step of the pipeline for physician workforce so future and current doctors can see themselves providing this valuable service.  

  • Medical student:  Debt relief so students can go into primary care  Medical students cannot pursue careers in primary care if they continue to carry an average debt burden of roughly 160,000 dollars upon graduation.  The initial healthcare reform bill included loan repayment programs for those who enter primary care, but this was stricken due to the cost of these provisions.  While the National Health Service Corps is the most widely recognized loan repayment program, it is very competitive and will not fill the primary care shortage alone.  Therefore, expansion of this program or creation of new loan repayment programs are needed.   Medical students are especially adept at making the case for loan repayment – and the health legislative aides that we met with were especially sympathetic to them since they may be able to relate to them (they are also closer in age).
  • Residency:  Expand primary care spots & create new training models  With new medicals schools designed to train primary care physicians, it is unclear if there will be enough residency spots for these newly minted physicians to match into.  As I’ve stated before, the supply of US graduating medical students will overtake the number of residency positions in a few years if there is no increase in residency spots.  Moreover, if residency slots aren’t ‘slated’ for primary care, one can imagine that new graduates will gravitate to the specialties.  There are provisions to reallocate 65% of unused residency positions to primary care, but that still won’t be enough due to the shortfall of primary care physicians.  The ACP recommends 90% of these spots go towards primary care.  In addition to creating slots, residency programs must be given the latitude to design new models to train primary care physicians.   Since funding for residency training is given to hospitals, currently residency programs face significant challenges in getting residents experiences in ambulatory settings.  This may change with healthcare reform legislation that supports the creation of new ‘Teaching Health Centers’ in the community to train primary care physicians, provided that these programs get the funding they need.  
  • Practicing Physicians:  Reward & redesign primary care work  Lastly, entering and staying in primary care will not be possible as long as the income disparity continues to persist.  Moreover, with a pending 21% cut in Medicare physician fees kicking in on June 1st if nothing happens will not help things.  This is why we need to ultimately reform the payment system (for how we ended up here, see this earlier post).  The House has just introduced legislation HR 4213 which would stop the cuts and provide 3.5 years of stable Medicare payments and reward primary care doctors.   Certainly, this will help things in the short term.  However, several of the trainees I spent time with in DC firmly stated that it was not just about the money, but also the hard work associated with primary care.  This point was eloquently illustrated by Dr. Richard Baron in a recent New England Journal  of Medicine article in which the primary care physicians in his practice responded to a telephone call or a lab test an average of 43.2 times a day!  All of this care goes uncompensated in our current system.  As one physician writes, it is time to reward coordination and communication of care.   One possible way to do this is to adopt the new patient-centered medical home, which is a way to redesign practice to promote a team approach (with physicians and other allied health professioanls) supported by technology to deliver primary care to a group of patients.  Another solution was featured in a recent issue of Health Affairs devoted to primary care, which contains an article which poses the provocative question: what would martians think about primary care?  The answer is a more radical redesign to overhaul the entire physician workday to see fewer patients and compensate the uncompensated care such as email and phone calls.

Unfortunately, as one of the other staffers said, “there is a lot of healthcare fatigue on the Hill” so this may take time.   Moreover, the big barrier is cost especially given the high price tags of these bills in a fiscally challenged environment.  While these reforms will cost money in the short term, its important that we highlight that fixing these things later on will cost exponentially more — if it can be fixed at all.   This is why its important that physicians and medical trainees need to make the case now about the importance of these issues to ensure physicians for the future.  

To learn more, sign up to be a Key Contact for the American College of Physicians for breaking updates on these issues.  More information on ACP positions on physician pipeline here

–Vineet Arora, MD

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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





Making a Match List & Checking it Twice…

14 02 2010

Past, Present, and Future on the Residency Match & Some Last Minute Tips with 48 hours to go
Every 4th year medical student you know is making a list and checking it twice.  This is because rank lists are due to the National Resident Matching Program (NRMP) on Wednesday February 22rd 2012 at 9pm EST.

The history of the Match is actually very interesting.  Historically, physician training in medieval days was arranged when craft guilds matched apprentices with physician masters for their training.  Modern history of the US Match actually describes the situation where hospitals were pressuring students as early as 2nd year to sign up for internship before students knew where else they were competitive for and before hospitals had adequate information about student clinical performance.  In 1952, when the match was first proposed, medical students actually protested the initial algorithm since it penalized students for ranking a hospital who did not want them.  The students proposed the alternate algorithm, the “Boston Pool Modification,” which favored students rank preferences and was ultimately adopted.  Since that time, the growing number of preliminary positions and the need for a couples match has led to redesign of this algorithm, but always preserved favoring the student.

More recently, the Match has persevered in the face of a recent lawsuit that which accused the Match of violating the nation’s antitrust law. The Supreme Court ultimately dismissed the case due to an amendment that was made to antitrust law that exempted the Match.  While the lawsuit painted the NRMP as the evil player, the Court actually concluded that the NRMP and the hospitals’ participation in the Match “are so interdependent that the Court cannot separate them” in the allegations.   One benefit of the match is students are able to make decisions on a standard schedule, without being pressured to commit to a program prematurely.  Both applicants and programs must sign a Match Participation Agreement (MPA), which states that one party cannot solicit a commitment from the other or suggest that ranking is contingent on such a commitment.  Despite this, there is recent concern that these agreements are being violated.

Today, the Match has become even more competitive as the number of US medical graduates has increased with new medical schools and expanded class sizes (a result of the call by the AAMC) while the number of residency slots across the nation remains constant.  Leaders in medical education project that without any increases in residency spots, the number of US medical school graduates will eventually surpass residency spots in 2016.   While calls for increased residency spots continue, for the moment, strategy to optimize successful matching has become increasingly important for US students.  (Update:  2012 is the first year of the “SOAP” or Supplemental Offer and Acceptance Program that will take the place of the prior Scramble.  It is also the first day in recent memory Match Day is on a Friday!)

Here are my top tips for students in the final days of creating their match list:

1. Think twice before leaving off a program that you interviewed at.  Before leaving off a program, consider whether you would rather enter the scramble (aka SOAP) or go to the program.  The length of the rank list is the strongest predictor of matching.  This means you should not “suicide” match – or just list 1 place due to false assumption that you are definitely ‘promised a spot’ there.

2. Consider where you want to live and other non-program factors when constructing your list. When faced with programs that look very similar, think of locations that you would be happy.  Many people settle in the city that they do their residency training in. It may be especially difficult to distinguish between programs the further you go down your list – so definitely consider location at that point.

3. Don’t worry about where the program ranks you.  Remember – the match algorithm works in your favor – so its to your benefit to rank programs in the order you want to go to them and not try to ‘guess’ where they will rank you or reorder your list.

4. Avoid 11th hour changes. These will likely be motivated by faulty reasoning.  Instead, talk over your decisions with your friends and family well before so you can relax

5. Don’t forget to press “certify”! The last thing you want to do is be undone by failure to press this button before February 22nd at 8pm Chicago time.   

 

A video of some of good rank list tips here by Dr. Reddy:

 I should also add that because everyone’s case is different, its important to consult with a faculty member who is knowledgeable about the field and advising you on the process.   Good luck!  I’ll be rooting for you on Match Day.

-Vineet Arora

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