There has been somewhat of a recent, increasingly popular, move to promote discussion about the length of medical education. Particularly a discussion of the merits of the fourth year of medical school. Medical school breaks down like this, with some minor variations between schools: You spend the first eighteen months to two years in the classroom and then the third year doing a set of core clinical rotations. The fourth year however is less clearly defined, more amorphous. You do elective clinical rotations. For some students, doing particularly competitive specialties a good chunk of fourth year can be spent doing elective in that specialty, boosting their experience and credentials. And for some students who are not sure, at the start of fourth year, what they want to do the beginning of fourth year provides an opportunity to do electives that help decide what these students want to do for their training. But even in such cases a good chunk of fourth year is essentially spent doing peripheral elective rotations often that are, unwanted by the students themselves, and a waste of time.
In the last five years, at least four schools have initiated or are developing three-year programs:
Mercer will begin its three-year track at its Savannah campus in June.
Lake Erie College of Osteopathic Medicine in Erie, Pa., started its program in 2007 and launched a second three-year track in July 2011 for certified physician assistants who want to become doctors.
Texas Tech University Health Sciences Center School of Medicine in Lubbock began its three-year program with nine students in 2011.
Louisiana State University School of Medicine is developing a three-year program at its campus in Lafayette. The first class is projected to start in 2014 or 2015, said Sam McClugage, PhD, the medical school’s associate dean for admissions.
Personally, while I enjoyed the free time during fourth year as I prepared for the rigors of residency, essentially all but three months of that year for me were wasted. I did no particularly memorable rotations outside of my neurosurgery ones. I think compressing medical school is a worthwhile idea. It will make becoming a physician more economically viable by reducing the costs of school and it will also make the decision easier as the time committment to a career will be reduced.
Beyond getting rid of fourth year, the first two years can also readily, in many school’s experience, be compressed into eighteen months. Three years is a reasonable goal for medical school. Ideally, as in countries other than the U.S. and Canada, I would love for medical education to be something to pursue as undergraduate work, indepdendent of a complete college degree. It is true most medical schools require only a set of prerequisites and not a formal degree. However, I think there is some bias against students who apply without completing their undergraduate work. That should change. Two years of college, three years of medical school and into resident by 23 or 24 for a traditional student would be an ideal way of training the next generation of physicians.
I think the trend is certainly towards shorter, which is not worse.
Claims of malpractice against physicians, even claims that do not lead to payments to the plantiff, implying some level of evidence for the physicians’ care end in significant cost for defense.
[A]lthough the costs of dispute resolution are higher for claims that result in indemnity payments, there is still a meaningful cost of resolving claims that never result in payment
The median cost for claims in this study with no indemnity payment was $22959. To be fair these are costs borne largely by the insurers and not by the providers themselves but not doubt it contributes some small amount to the costs of healthcare.
But that fact shouldn’t lower malpractice reform on our agenda. It isn’t solely a matter of costs but a matter of justice. A reform of the specialty malpractice system should include specialty courts and those courts and systems for mediation should have the power to force the plantiffs, not just in frivolous cases but in all unsuccessful cases, to make the plantiffs take on some or all of the defense costs.
I know that would discourage legitimate malpractice suits but considering the costs in defense, especially the costs of claims that do not lead to payment, I think such would be an important reform.
Yesterday was not a good day for the Obama administration, namely Solicitor General Donald Verrilli, or for the Affordable Care Act. Toobin of CNN gives a great rundown of why it was so bad but here is as the Washington Post described it as well,
The Supreme Court’s conservative justices appeared deeply skeptical Tuesday that a key component of President Obama’s sweeping health-care law is constitutional, endangering the most ambitious domestic program to emerge from Congress in decades. In an intense interrogation of the government’s lawyer, Solicitor General Donald B. Verrilli Jr., the justices posed repeated and largely unanswered questions about the limits of federal power. At the end of two hours, the court seemed split on the same question that has divided political leaders and the country: whether the Constitution gives Congress the power to compel Americans to either purchase health insurance or pay a penalty. The answer is likely to come from Justice Anthony M. Kennedy or perhaps Chief Justice John G. Roberts Jr. Both men fully joined in the rough 60 minutes of questioning for Verrilli. But they indicated that the case might be a closer call for them than for their colleagues.
Portugal was the third European Union member to seek a bailout. As with Ireland, Portugal’s woes are considerably less than those of Greece and yet its austerity measures it had to implement to achieve its bailout, and avoid bankruptcy, are no less painful. And the austerity measures’ effect on the publicly financed health system is interesting. In an admittedly poorly written piece The Guardian newspaper attempts to attribute a rise in mortality figures for the early part of this year to cuts in the health system’s budget.
[O]pposition politicians blame budget cuts for a thousand extra deaths in February, 20% more than usual.
“They hiked the fees in January…Now a visit to the emergency room costs €20 instead of €9. A consultant costs €7.50. People are angry.”
[...]
In the meantime, the government blames flu and cold weather for February’s surprise jump in the mortality rate, but newspapers have begun to publish scare stories about people who claim to have been priced out of the public health service.
Not knowing the specifics it would be difficult to attribute recent cuts to a 20% increase in the monthly mortality rate. That said it isn’t difficult to imagine austerity and cuts in services significantly influencing people’s access to healthcare in countries like Portugal and Greece and Italy and Spain.
The 501 physicians answered a number of questions, the most notable of which included a dichotomous question on whether the Affordable Care Act was “A good start” or “A step in the wrong direction”. The question was split 44% to 44%. All respect for Mr. Pollack and Dr. Murthy writing for The New Republic who find the sum of survey data to date equivocal, including the recent small Deloitte survey, but, it seems to me, despite that single question, that physicians, at least as much as the general public, have a distaste for the ACA which is not improving.
In that same Deloitte report 69% of physicians responded “Yes: I think the best and the brightest who might have considered medicine as a career will think otherwise” when posed to rate the “Impact of health reform on the future of the medical profession.” Previous surveys as the debate over health care reform raged last year found similar dissatisfaction amongst physicians with the Affordable Care Act. The act remains very unpopular, with a plurality of Americans opposing it and a large majority continuing to oppose an individual mandate. Despite implementation of more than a few parts of the law, that opposition amongst the public has barely budged. And neither, seemingly, has the opinion of physicians moved.
Attempts to paint widespread support for the act amongst physicians is misplaced.
A better way to gauge these issues is to examine how physicians and the organizations which represent them actually behaved during last year’s health reform. One wouldn’t know from Pipes’ article that the American Medical Association, the American College of Physicians, the American Academy of Family Physicians, the American College of Surgeons, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American Osteopathic Association, the American Psychiatric Association, and the American College of Cardiology all endorsed last year’s health reform. These groups represent hundreds of thousands of physicians across a wide range of medical sub-specialties.
Its true that, like physicians as individuals, organized medicine’s reasons for supporting the Affordable Care Act were disparate, but at the highest levels of the largest organizations I promise you, pledges by the Obama administration to work towards a full Sustained Growth Rate formula fix and a feeling that physicians would be left out of the table served as the reasons to support reform far more than any true love for the provisions of the Affordable Care Act.
It’s wishful thinking that the public at large or physicians will come around to the Affordable Care Act, even once the most powerful provisions come online in 2014.
We believe that physicians will embrace the Affordable Care Act because the new law helps to address many critical issues that have long concerned physicians and patients—abuses and market failures in the provisions of health coverage, rising numbers of uninsured patients, variable quality, poor coordination of care, the erosion of primary care, and the lack of focus on prevention and public health. As the law’s main provisions kick in, physicians will see that it is, indeed, a big step in the right direction. We are sure that the new law will attract serious criticism. Real on-the-ground progress will provide the best rebuttal.
Here is how I imagine the next few years as it comes to physician and public opinion on the Affordable Care Act. The Supreme Court hears and decides the challenges to the individual mandate this term and strikes it down but allows the rest of the act to stand. Now you’re left, for the physician, with the bureaucracy of ACOs, CMS pushing pay for performance and best practice trials and independent of the ACA, but tainting the opinion of government’s role in health care in general, no SGR fix.
I can’t imagine a majority of physicians having a truly positive opinion of the ACA anytime soon.
The Snooki tax, a 10% tax on indoor tanning services, that appeared as part of the ACA and its sister bills may or maynot be “working,” to reduce the use of indoor tanning services as some of the authors intended.
The impact of the tax on consumer behavior remains unclear. Only 26% of salons surveyed reported experiencing fewer clients after implementation of the tax, and distinguishing the impact of the tax from the current economic climate as the source of decline was difficult. Furthermore, a large number of respondents (78%) reported that clients did not seem to care about the tax.
Study participants frequently reported that the salon’s younger and first-time clients were less likely than its older clients to notice or care about the increased prices resulting from the tax. Taken as a whole, these results may indicate that the demand for indoor tanning services is somewhat inelastic and perhaps insensitive to a 10% tax level.
I’m not a proponent of targeted taxes in general; certainly not those targeted to influence behavior. I don’t support the cigarette tax and I don’t support any hypothetical soda taxes and I don’t support the indoor tanning levy. And I wouldn’t be surprised at all if, at 10%, the influence of the tax was nothing or so small as to be impossible to detect.
A group of public health researchers out of UCSF and Columbia have a piece in the pending edition of Health Affairs. In it they argue that 1c per ounce tax on sugar sweetened drinks would,
prevent 2.4 million diabetes person-years, 95,000 coronary heart events, 8,000 strokes, and 26,000 premature deaths, while avoiding more than $17 billion in medical costs
over the next ten years. If you can’t access the full study on Health Affairs behind the firewall then here’s a write up on a Los Angeles Times blog.
First and foremost I have a major problem with taxation to influence behavior. I don’t even like the federal tax on cigarettes. I understand the public health issues involved in second hand smoke. Even factoring those I think something like the tobacco tax, which is beyond discredit in terms of its success, is beyond the purview of the government.
And the junk food tax is likely to be something less effective than the tax on cigarettes and targets a behavior with far few social costs; even admitting that the bill for diseases associated with obesity is footed in part by society in general it is a far cry from say the public health effects of second hand smoke.
Plenty of previous data finds the conclusions of the Health Affairs paper optimistic.
[A] trio of economists analyzed 16 years of U.S. household health data to study the feasibility of using a soft-drink tax to help Americans lose weight. In a 2008 paper, the researchers calculated that a 1-percentage-point increase in the tax would reduce the average body mass index by just 0.003 units.
In other words, an overweight person with a BMI of 27 would end up with a BMI of 26.997 — still well short of the 20-25 range considered healthy.
Even a soft-drink tax increase of 20 percentage points wouldn’t help much, because soda accounts for only 7% of calories in the American diet.
I am highly dubious rising the cost of a can of soda 12c or a six pack by less than a dollar is liable to significantly discourage use.
Tobacco taxes are also much higher than anything likely to be adopted for food and beverages. Slapping a 10% tax on a $1.50-bottle of Coke would raise the price a mere 15 cents — not enough to persuade most shoppers to drink Diet Coke instead. Many calorie-laden foods are simply too cheap to be priced out of the market by any but the most draconian of taxes.
As well, such a tax would be highly regressive since sweetened drink use is inversely proportional to socioeconomic status (myself excluded of course; I go through 4-5 sodas a day).
In the end though, like I said, I just don’t like the idea of government dictating what we should and shouldn’t be eating and drinking. Their role in such, with agricultural subsidies and regulations of commercial foodstuff is already too big. The idea of a tax to specifically influence or diet is too much to take.
The primary care-specialist income gap isn’t new. But here‘s more data on it:
$100/Hour and More
Neurologic surgery: $132.33
Radiation oncology: $126
Medical oncology: $114.21
Plastic surgery: $113.78
Dermatology: $102.68 $80 to $93/hour
Cardiovascular diseases: $93.74
Gastroenterology: $93.27
Neurology: $92.52
Emergency medicine: $87.47
Obstetrics and gynecology: $83.40 $66 to $75/hour
Neonatal and perinatal medicine: $75.86
Psychiatry: $72.24
Pulmonary diseases $71.67
Pediatrics $69.24
Child and adolescent psychiatry: $67.36 $58/hour and less
Family practice: $58.25
Internal medicine: $58.18
General practice: $57.55
From the future top the discrepancy is ridiculous. For a spine surgeon to be making more than 275% more per hour than some primary care physicians is ridiculous. And you know my opinion is sincere because I used the same adjective twice.
The trouble is I don’t think what the neurological surgeon earn is outrageous or unreasonable. The primary care physician just needs to be earning more.
becoming the largest provider of primary healthcare services in the nation.
Retail primary care physician directed care is nothing new. The first one opened in 2000. But their promise has been largely unfulfilled and, while they may have found a nitch market, the idea of them redefining primary care or supplanting the traditional internist office appears at present as a pipe dream. I know consultants and the industry say differently but I’m of the opinion the retail clinic industry promoted itself as having grown further and achieved more than it has to date. But then again maybe Walmart can do differentially.
I’m not sure I’m convinced of the feasability of some of their goals. For instance, I’m not sure there’s major cost savings to be had in this model. Whatever this model turns out to be.
What it may do, and what I think everyone should be on board with, is expand access to care.
“It’s a really big deal,” says Bob Kocher, a former health policy adviser to President Obama. “We have a shortage of primary care and of access. If Wal-Mart comes in, that creates a lot more access in areas where it’s been hard to find a doctor. This could bring low prices and relaible quality in a way that we don’t really see right now.”
The population attracted to retail clinics, in stores like Walmart, is a population already largely underserved. Even if the cost of health care becomes less of a hurdle as the ACA is implemented, a serious venture into primary care services by a major player like Walmart, if played right, could really expand care to a population that would benefit from it.
The New York Time has a profile of a gentleman, illegally in the country, who spent 19 months in a New York City hospital because there was no funding for the out of hospital assisted care he was going to need.
[T]he hospital admitted Mr. Fok to the intensive-care unit on the third floor, where workers tried to find out more about their patient — not just his medical history, but his insurance or Medicaid status, his address, his Social Security or taxpayer identification number, the location of family members.
Once his condition had stabilized, the hospital moved him to a regular room on the fifth floor, where staff members expected to treat him for 7 to 10 days before discharging him to a sub-acute-care center for rehabilitation, the usual regimen for stroke victims.
Nineteen months later, Mr. Fok, 58, greeted a reporter from his bed in Room 516, eager to have a visitor. In the previous year and a half, perhaps 100 or more patients had come and gone from the room’s other bed, but Mr. Fok had gone nowhere.
Near the border here in Texas this is not an unusual problem. Plenty of illegal immigrants with serious, emergent problems are seen at my primary teaching facility. Many a times they end up in conditions necessitating long term care. With no funding, with no public non-acute health care system in Mexico there really are no options but to keep them in the hospital until charity funding is identified for them.
To be fair the profile goes over the active measures the patient, Mr. Fok, took to impede his placement and his care. Many times the patients I encounter have family and friends who will actively work to help in trying to get the patient to a better place outside the hospital, but with limited resources and unable to provide the care he needs themselves it proves difficult.
Mr. Fok’s immigration status never kept him from receiving treatment, but it helped make sure that his care would be delivered in the most expensive setting possible and in a place no one wants to spend more time than necessary. He was cut off from his family. On several occasions he showed signs of depression or expressed suicidal thoughts.
If he had been insured or immediately eligible for Medicaid or Medicare, he might have gone to a nursing home after a week or two, where the average daily cost in New York is about $350 — and where he might have had steady companionship. Or he might have received a home health aide in his apartment, which could have cost even less, depending on the required hours.
For hospitals like Downtown that treat many illegal immigrants, the health care plan enacted last year does nothing to solve this liability, Mr. Menkes said. During debates about reform, lawmakers insisted that the plan’s benefits not extend to the nation’s 11 million illegal immigrants.
