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Archive for June, 2011

Tuesday, June 14th 2011

Paying Medical Students For ‘Clinical’ Services

There’s a minor scandal being carried on at the major teaching hospital of UT Southwestern’s medical school and the public hospital for Dallas, Parkland. The Dallas Morning News is reporting that up to recently UT Southwestern was paying medical students to work in the psychiatric emergency room at Parkland during their off time.

What exactly they were being paid to do is in some dispute according to the article but there’s major contention over paying medical students for any sort of clinical care. If they were interacting with students, documenting clinical care in notes or essentially doing anything but delivery food trays to them, there is likely a serious problem with paying medical students, who are not yet clinicians, for any sort of patient interaction. And so there is minor drama.

I don’t know the truth about what medical students were doing, but I will agree wholeheartedly that the way medical education is organized now in the United States, there is something unethical about paying physicians to play clinicians.

Monday, June 13th 2011

Surviving Rabies

I remember back in 2004 when a Wisconsin girl became one of the singular, confirmed and well documented cases of an individual surviving rabies without the vaccine.

A girl being treated at the teaching hospital of UC Davis has achieved the same feat it seems to become the third person in the U.S. to survive rabies without the vaccine.

Tests in early May revealed she had the disease after Precious’s grandmother took her to the doctor because of flu-like symptoms that grew so serious her grandmother said they began to resemble polio.

The hospital said doctors followed the protocol first established [in Wisconsin]. Precious was placed in a drug-induced coma as she received anti-viral medications.

She spent two weeks in intensive care undergoing the treatments, and immediately showed that her immune system was strong. She was then moved to the hospital’s general pediatric unit, where she remained Sunday.

Although rabies claim only approximately a dozen people in the United States a year it is a terrifying disease. Failing the vaccine, even best care, the “Wisonsin protocol,” bodes for a poor prognosis. Anyone with open skin exposure to feral or suspicious mammals, including bites or scratches, should certainly seek immediate care.

The 2004 reported survival with coma is found in NEJM.

Sunday, June 12th 2011

Giffords Doing Well

Gabrielle Giffords, the United States Congresswoman from Arizona who was shot in the head in an attempted assassination, has photos out of her at her rehabilitation facility after her cranioplasty, the surgery to replace the piece of skull she lost in the shooting and subsequent surgery with an artificial piece of “bone.”

It looks pretty good as far as cranioplasties go.

As for the Congresswoman’s recovery, it has apparently been slow but progressing. When Gifford’s was first shot and little information was available I was extremely relieved when it became clear the bullet had not crossed the midline or violated the ventricles in any meaningful way. However, there was and remains a lot of concern that the bullet did significant damage to the Congresswoman’s major hemisphere. As with most people Mrs. Giffords is likely left sided dominant, so that, most importantly, her speech can be localized to that hemisphere. And such seems to have been, not unsurprisingly, impacted by the injury,

Her chief of staff said that Gifford’s ability to communicate has been badly affected by the accident.

“We do a lot of inferring with her because her communication skills have been impacted the most,” Carusone said. “She is borrowing upon other ways of communicating. Her words are back more and more now, but she’s still using facial expressions as a way to express. Pointing. Gesturing. Add it all together, and she’s able to express the basics of what she wants or needs. But, when it comes to a bigger and more complex thought that requires words, that’s where she’s had the trouble.”

Her and her family will remains in my prayers as she continues to recover.

Monday, June 6th 2011

Peter Bach and Robert Kocher Call For Free Medical School

In an op-ed appearing in the New York Times on May 29th, Drs. Bach and Kocher lay out a plan for making primary care more attractive to medical students. They propose the following,

Under today’s system, all medical students have to pay for their training, whether they plan to become pediatricians or neurosurgeons. They are then paid salaries during the crucial years of internship and residency that turn them into competent doctors. If they decide to extend their years of training to become specialists, they receive a stipend during those years, too.

But under our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average. Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.

It’s novel and I think worth discussion.

But sitting in a specialty poised to be burdened the most under such a plan I have some reservations. Neurosurgeons have perhaps the longest training of any specialty. The majority of neurosurgical residencies are 7 years and with fellowship training the burden for future neurosurgeons could be upward of $450,000 under the current proposal at $50,000 a year.

There are a number of other specialties as well, where the average income falls well short of the median cited in the op-ed. In a specific example, neurosurgeons who go on to do 1-2 years of fellowship in pediatric neurosurgery take a significant pay cut as compared to those neurosurgeons who go into practice straight out of residency and treat adults. Or consider the infectious disease specialty where the average income is hardly more than that of a primary care physician but require extra fellowship years. The point is that while the average income for a primary care physician is has a shorter distribution and is more homogemous, there is great variability in income for specialists. The proposal is likely to drive medical students and graduating residents, now forgoing primary care, out of certain specialties including infectious disease, physical medicine and rehabilitation and many pediatric surgical specialties to name a few.

My second contention is that, for the most lucrative specialties, I’m not sure the incentive will be enough. Let us consider the numbers given in the op-ed concerning the median specialty and primary care incomes. They cite $325,000 and $190,000 respectively. It may not be totally realistic but will serve my point if we have a pediatric neurosurgeon earning the former and a primary care physician earning the latter.

Let’s say the pediatric neurosurgeon takes 8 years of training and owes $400,000 at the end. The primary care physician does 3 years of training and owes nothing. Assuming some level of government guarantee of the loans used by the pediatric neurosurgeon and he or she is paying them off over 15 years at a 6.8% rate.

Over a 20 year period (from the time the primary care physician enters practice after completing his or her free training to the time the pediatric neurosurgeon is finished paying his or her loans) the gross numbers stack up like this:

Primary Care Physician 20 Year Earnings
20 years x 190,000 = 3,800,000

Pediatric Neurosurgeon 15 Year Earnings
Remember the specialist will be in training for five years while the primary care physician is out earning.

15 years x 325,000 = 4,875,000 – 640,000 loan payments = 4,235,000

On the sum there is still incentive for medical students and residents to choose a high paying specialty.

Finally, I’ve discussed this before, but self reported surveys continue to show that medical student’s decisions concerning primary care are only partly related to future earning potential and other factors are more important. This plan doesn’t address the appearance problems that primary care suffers and the expectations of health care in this country which, in addition to the comparatively low earning potential, make primary care unattractive to American medical students.

I am A strong proponent of strengthening primary care. The reality is we need to normalize primary care and specialist reimbursement and dramatically reduce the number of specialist training positions in order to force a more tertiary health care system more in line with the rest of the western world.

I have serious doubts making medical school free will significantly bolster the future of primary care.