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


Comments : 2 Comments »
Tags: , , , , , , , , , , ,
Categories : doctor, medical student, residency training

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

Share


Comments : 4 Comments »
Tags: , , , , , , , , ,
Categories : doctor, medical student, residency training

Hospitalist Haters: Can We Bury the Hatchet?

15 04 2010

Yes, it is true they are still out there.  They believe that students and residents are choosing hospital medicine over primary care so hospitalists are to be blamed for the primary care shortage.  They also believe that the rise of hospital medicine has made primary care less attractive.  Then, there is the salient argument that care transitions are more inherent and vulnerable due to hospitalists.   Of course this hatred is not new.  As a resident, I remember watching Larry Wellikson, CEO of the Society of Hospital Medicine, back in 2002 publicly berated by some very smart people at a conference calling the organization a “SHaM.”  Ironically, this was a conference on how to ‘Revitalize Internal Medicine.’  Given the dramatic rise of hospital medicine since then, it is still surprising when the hatred reemerges in the public domain. It appeared in a recent issue of the Annals of Internal Medicine.  I just returned from the Society of Hospital Medicine conference, and learned there are now 30,000 hospitalists.  Hospitalists are here to stay – so what to do?  Well, let’s explore these myths one by one.

Is the declining interest in primary care due to hospital medicine? While I am very concerned about the lack of interest in primary care, the answer to this question is no.  If hospitalists did not exist, there would still be declining interest in primary care among medical students and residents.  The decline in entry into primary care among medical residents is largely explained by the rising interest in subspecialty medicine, in which 2/3 of internal medicine residency graduates intend to enter.  This choice is largely driven by the financial disparity between high paying subspecialties and you guessed it, primary care physicians.  In fact, hospitalists are losing candidates left and right to subspecialty fellowships also!  As a result, most residents are not deciding between hospitalist and primary care- but between one of them and pursuing a fellowship.  Is it all financial?  Well, I personally believe that residents are also uncomfortable with knowing ‘a little about a lot’ and desire a focused area of practice in the ever expanding domain of medical knowledge.  And, who could blame them?  As a hospitalist, I feel that way often- this is something we need to prepare our residency graduates for – caring for the undifferentiated patient – whether it be in the outpatient or inpatient settings.

It is important to note that the primary care problem starts much earlier than residency!  A widely cited report shows that only 2% of graduates are interested in entering general internal medicine, and less than 20% overall in primary care fields.  The biggest competition is the “ROAD” - Radiology Ophthalmology Anesthesiology or Dermatology – or any other competitive specialty that is lifestyle oriented – meaning high pay with controllable hours.  For any nonmedical person in the world, who would not pick the high paying job with controllable hours?  This is why we need to reduce the disparity between physician specialties in the US and ensure that both primary care and hospital medicine are seen as viable and yes, glamorous careers. 

Has hospital medicine made primary care less attractive? For the sake of argument, let’s imagine the answer is yes – what would that mean? It would mean that a busy primary care physician would desire to go to the hospital to follow their patients early in the morning before clinic and after clinic to round.  They would constantly get pages from the nurses during the day even though they were off premises.  The hospital would require that the primary care physician participate in the latest quality improvement project to improve CMS metrics.  While this may still be possible in more rural areas with less acute patients, the reality is that hospitalized patients today are sicker than ever before.  Hospitals and frankly the government are demanding that physicians are in house to help meet their quality metrics improve patient safety as opposed to rounding on an as needed basis.

 A new analysis shows that the probability of hospitalization for a patient who was cared for by a primary care physician fell before the hospitalist movement started.  Hospitalists emerged as a way to make it easier for primary care physicians to work in the office and not go through the trouble of going on rounds.  So in other words, hospitalists appear to be helping primary care physicians since not many of their patients are in the hospital.  Not surprisingly, a survey demonstrated that 2/3 of primary care physicians thought hospitalists were in fact a good idea.

Do patients prefer seeing their own doctor in the hospital? This question was recently put forth by GlassHospital.  While they may long for the early days of that type of continuity, most patients and their families want to see a doctor immediately when their family member is sick.  Poignant stories from patient safety advocates (Sorrel King, Helen Haskell and others) highlight the need for emergent evaluation by a physician when their loved one is ill.  They can’t wait until clinic ends.  Care by hospitalist is also cheaper and associated with better outcomes, certainly something desirable in healthcare.  Lastly, there is some data from our group that suggests that roughly 1/4 of patients prefer their PCP to see them in the hospital, 1/4 prefer their hospital doctor, and the remaining have no preference.  Patients are also not willing to pay for their primary care physician to see them.   

Are hospitalists responsible for suboptimal care transitions? Well, this is the great sticking point for hospital medicine.  In that same survey where 2/3 of PCPs liked hospitalists, only 1/3 felt they received timely communication about a patients discharge.  A recent review in JAMA supports this assertion. Since that time, however, hospitalists have realized this problem and have adopted care transitions as part of their core mission.  Care transitions are a core competency of hospital medicine.  With funding from the Hartford Foundation, the Society of Hospital Medicine has launched Project BOOST – Better Outcomes for Older Adults Safe Transitions which has been implemented nationwide and in a consortium of hospitals in Michigan and is about to go live in California.  So, while this is the one area that continues to be “unfinished business” in hospital medicine, it is also the area where the greatest progress and improvements for patient safety are being made.

So, can hospitalist haters bury the hatchet?

I hope so.  After all, hospitalists need primary care physicians.  This year, when I’ve been on service, I’ve noted that a primary care physician who accepts new patients is an endangered species.  As a result, I have begged some of my colleagues or other members in the community to follow some of these complex patients.  Since the patients have to leave the hospital when they are medically clear even if their follow-up is spotty, I continue to sign home health orders, receive pages from patients to field their questions, and field questions from subspecialists who are seeing the patient in follow up.  As a result, I have a handful of patients who actually identify me as their physician when they go to an ER in our community.  While I am suddenly reminded of the great pride it is to be known as someone’s doctor, I know that what we all really need is a good primary care physician.

Vineet Arora, MD

Share


Comments : 10 Comments »
Tags: , , , , , , , , ,
Categories : doctor, hospital life, medical student, residency training

« Previous Entries Next Entries »


Follow

Get every new post delivered to your Inbox.

Join 9,959 other followers