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Archive for the ‘Medical School’ Category

Sunday, March 9th 2014


Fourth year medical students are trying to get The Ellen Show to their Match Day in San Antonio. Help this go viral. To that end that have a pretty talented mock up of Pharrell William’s ‘Happy’.


Monday, December 9th 2013

More Medical Students, More Residency Spots?

I’ve been a critic of my home state for its rapid expansion of undergraduate medical education opportunities without concurrent expansion of graduate medical education opportunities. But to be fair, such isn’t unique to Texas.

We continue to enroll record number of medical students across the country.

There was…a 3 percent increase from 2012 in the number of students who enrolled in their first year of medical school. That number, 20,044, exceeded 20,000 for the first time.

Not in itself a bad thing. We just need the residency spots to go along with such.

[T]he Resident Physician Shortage Act was introduced in the U.S. Senate, and the bipartisan Training Tomorrow’s Doctors Today Act was introduced to the U.S. House of Representatives. The bills aim to help meet the nation’s increasing demand for new physicians by funding an additional 15,000 Medicare-supported graduate medical education (GME) positions over the next five years.

While broad bipartisan support the issue isn’t ‘urgent’ enough that these bills are likely to become law before this Congress is finished. Which is a sad state.

Nor are many states doing much to aid graduate medical education expansion.

We should be skeptical of the modeling of the coming physician shortage. But it makes no sense to increase medical school spots without making residency training available.

Thursday, October 31st 2013

A Medical Education Bubble

There’s a nice, brief editorial ahead of publication in the New England Journal of Medicine. Everyone needs to consider this when discussing American physician earnings; especially as compared to the rest of the world.

[I]f we aim to reduce the costs of health care, we need to reduce the costs of medical education. We don’t have to believe that the high cost of medical education is what causes increases in health care costs in order to develop this sense of urgency. We just have to recognize that the high costs of medical education are sustainable only if we keep paying doctors a lot of money, and there are strong signs that we can’t or won’t. Only about 20% of health care costs are attributable to physician payments, and many of the current efforts to reduce costs are aimed elsewhere, such as hospital payments, and have only indirect effects on physicians’ earnings. But physicians’ and dentists’ earnings have been sluggish since the early 2000s.3,4 Even if prospects for physicians’ income fall fast, a burst bubble can be averted if schools see it coming before their students do and lower their prices.

Monday, October 21st 2013

The Fourth Year of Medical School Is Unnecessary

Several schools around the country are offering trails of doing medical school in three years, instead of four.

In general medical school consists of two years of true lectures (or increasingly didactics) focused on the rote learning of the science – anatomy and biochemistry and physiology and pathology and pharmacology and the like. This is followed by a year of core clinical rotations in hospitals and clinics. And then, finally, a fourth year of largely elective clinical rotations and considerable time off.

It is that fourth year that is the most questionably necessary. There’s some benefit to considerable elective time to be sure. It is difficult to get a feel for all the specialties of medicine in your short medical school career. And yet, based on a limited view you decide what you want to specialize in in residency. Might I have been more interested in internal medicine if I had gotten a feel for cardiology or heme/onc or have been more interested in radiation oncology or in opthalmology or radiology if I had more than the vaguest sense of those specialties?

The answer might be in continuing to allow some elective time by compressing the classroom time at the beginning of medical school. Several schools already do away with break time in the first two years of medical school and compress the basic sciences into 18 months without losing anything I think.

The fourth year of medical school has a limited contribution to training adequate physicians. It is considered an easy year, a break and reward for the past three. But it isn’t like you’re paying less to attend school in that year. Or that you’re getting any younger in your journey to being a physician. As said, there’s some benefit to the electives you get to do early in your fourth year. But those can probably be preserved somewhat by reducing your time in the classroom.

I think these trail programs of cutting medical school to three years are going to be largely successful and you’re going to see three year medical schools grow enormously over the next generation. It might even be the new norm in my lifetime.

Saturday, October 12th 2013

More Undergraduate Medical Education For Texas

I went on a rant a while ago about the University of Texas system promising two new medical schools. One for Austin and one for the Rio Grande Valley.

[P]lenty of money will come from state general revenue afforded to the university systems. That is money from tax payers across the state who are likely to see no to nominal benefit from these new schools.

New medical schools in Texas are unlikely to improve our statewide physician shortage and may even do little to correct disparities in the communities they’re joining. We’re already graduating enough medical students and in a strong position to continue to do so for our growing population without new medical campuses. The schools will bring new graduate medical education funding, in the form of new Medicare dollars, but such will not keep pace with the new medical school graduates they promise. The costs of these new medical schools would be much better put towards improving graduate medical education in the state. That is something that would truly improve Texas’ doctor shortage and potentially the public’s health.

IN 2011 Texas’ had 2.36 medical school seats per 10000 population. That was 10th in the nation. Since then the state has opened a new public medical school in El Paso, expanded the class size of every existing medical school in addition to the two new University of Texas schools currently in planning.

Now, my hometown, San Antonio, is looking to get a new school of osteopathic medicine.

The City Council voted unanimously Thursday to approve a $7.7 million funding agreement for infrastructure improvements and job incentives, some of which will literally help pave the way for the University of the Incarnate Word to build an osteopathic medical school in downtown San Antonio.

With too few GME spots this will do nothing to help the physician shortage in Texas or San Antonio and is likely to have little impact on health in the surrounding community. Of course it has some economic and prestige effects but there should be more skepticism about the long term goals of such a school. Even more so in terms of the choice of an osteopathic focus.

Monday, January 7th 2013

Foreign Medical Students In Texas

It is a medical education themed day as I return to blogging after a month off.

We’re potentially awaiting this month a ruling from the Texas Higher Education Coordinating Board on January 24th whether medical students at the for profit American University of the Caribbean can do clinical clerkships during their third and fourth years in Texas hospitals. This ruling following the Attorney’s General office giving an opinion that THECB does have the authority to grant or deny AUC’s request.

To be clear, this wouldn’t require hospitals to take these students but if the THECB rules in AUC’s favor it would allow the university to negotiate with hospitals in the state to allow their medical students to come through. Considering the money AUC is likely flash to secure spots for their students it is almost a forgone conclusion there will be a number of opportunities for their students in Texas.

I’ve written previously about growing opposition to foreign medical students rotating in the United States in states that already allow such. And there is much opposition amongst Texas medical schools and organized medicine and legislators.

Texas medical schools, charged with increasing enrollment to meet the state’s physician shortage, are already “starting to stumble over each other” finding their students the right clerkships, said Dr. Cynthia Jumper, who heads the Texas Medical Association’s medical education council and chairs the internal medicine department at Texas Tech University Health Sciences Center. While there may be a few extra positions available now, Jumper said, there won’t be for long. 
“What extra room there is now has already been spoken for,” she said.

Senate Higher Education Chairwoman Judith Zaffirini, D-Laredo, also voiced opposition. In a letter to Fred Heldenfels, the chairman of the coordinating board, she said approving AUC’s request would set a precedent opening the door to a slew of foreign schools, and she questioned the board’s authority to approve private professional programs. “May God bless you and inspire you to agree with my perspective,” she wrote.

It isn’t merely a matter of physical capacity, in the sense of how many medical students Texas hospitals can support. There is a limiting factor in that Texas medical students cannot, for all practical purposes, rotate on the same teams within hospital that AUC foreign medical students are on. Examples exist of citations from the Liaison Committee on Medical Education, the body that accredits all allopathic U.S. medical schools, for mixing of LCME and non-LCME medical students on clinical rotations. A summary of the accredidations standards of the LCME can be found here (PDF).

Personally, I hope to keep foreign medical students out of Texas hospitals. That may be a little bit of a surprising stance from me. I think, however, that the primary concern here should be in protecting the education of Texas’ own medical students, which the state already has significant investment in. I think foreign medical students taking up clinical clerkships in Texas hospitals may put that at risk.

Monday, January 7th 2013

Osteopathic and Allopathic Education in Texas

Osteopathy has an interesting history in the United States. Unlike other ‘opathies’ and rejections or alterations of allopathic medicine which arose in the eighteenth and nineteenth centuries, the history of Dr. Andrew Still’s treatment philosophy, is remarkable in the turn it took back towards biomedical principles and how leaders of osteopathic medicine in the twentieth century fought allopaths and the entrenched medical community to broaden their scope of practice until today when a D.O. degree is an equivalent of an M.D. degree anywhere in the United States.

I’ll ignore whatever debate remains over the benefits of osteopathy and manipulative medicine. Largely because the founding principles of osteopathy are largely nowhere to be found in the everday practices of doctors of osteopathic medicine. Very few D.O.s use manipulative medicine in their practices. And while there are some other distinctions between allopathic and osteopathic medical education in the United States, such continue to shrink. There has been a gradual infolding of osteopathy back into allopathic medicine; an irony of the fact osteopathic leaders at the beginning of this century worked so hard to be accepted by their counterparts in medicine. Nearly 70% of graduates, or perhaps more nowadays, of osteopathic medical schools do residencies sponsored by institutions focused on allopathic education.

No wonder there are irregular questions about the continued necessity of osteopathic medical education. From a 1993 article in the Journal of the American Osteopathic Association,

[T]hese changes…raise a number of disturbing questions for the profession. Foremost is the continued existence of or a need for osteopathic medicine in our society. Why should the United States support parallel medical systems on the assumption that osteopathic medicine is different when, after graduation, most DOs choose to train in the allopathic medical profession?

It’s a legitimate question, still being played out even twenty years after that article. On the one hand the number of osteopathic graduates, as all medical schools, continues to grow and new osteopathic medical schools continue to open. I’m not sure that hints at some unfilled need for osteopathy as it remains most of those graduates will largely shun such in their real world practice. And, on the other hand, slowly schools of osteopathic medicine are looking to award doctors of medicine in addition to, or as replacements of, their current doctor of osteopathic medicine degrees.

Such is the case at the school of osteopathic medicine in Texas. Several years in the works, and somewhat of a political nightmare to this point, the University of North Texas’ Health Science Center Texas College of Medicine is likely to have a bill introduced in the next legislative session to allow the school to offer an M.D. degree. So focused were some at the school on approval for an allopathic track that it created discord over a parallel move to merge the health science center with the University of North Texas at large.

Merger talk became a distraction, with questions raised about whether one effort hinged on the other or one would take precedence over the other.

When the merger issue came before the regents again in November, it was taken off the agenda. Jackson said it’s been tabled indefinitely.

Any change to the governing structure of the Fort Worth and Denton campuses would require approval from the Legislature, governor and Texas Higher Education Coordinating Board.

With the 2013 session starting Jan. 8, [UNT Chancellor] Jackson said

The president of the health science center seems to have voiced such a belief – that asking the legislature for the merger at the same time as asking them to approve the M.D. degree would be a distraction and reduce the chances of approval for the M.D. degree – in his contentious opposition to the merger. Such opposition eventually cost him his job last month.

Seeking permission for the M.D. degree I think heightens the question of purpose that continues to surround osteopathic medicine.

The D.O.s I know are largely excellent physicians. There is nothing in their education that distinguishes them. I also don’t personally know a single D.O. who has ever let it be known to me they routinely use something unique to osteopathy in their everyday practice. I’m not sure why then we continue to pay lip service to osteopathy and to distinguish ostoepaths and allopaths by the letters after their names. Maybe its time we were just all the same. Maybe if UNTHSC wants an M.D. degree for TCOM, then that should also be the end of its D.O. degree.

Friday, October 19th 2012

Game Theory Got Residents To Where They Are Today

The National Residency Matching Program is a process almost all medical residents go through. Since 1952 the program has strived to match graduating medical students to residency training programs. Medical students are offered interviews at a number of residency programs. The medical students then rank all the residency programs they interviewed at in terms of preference, while the residency programs do the same for all the medical students they interviewed.

The algorithm the NRMP then uses to match medical students with residency programs isn’t terribly complicated to understand, but I’m sure the math behind it and proving its efficiency were.

Now two American economists whose work centered on such matching algorithms and game theory have won the 2012 Noble Prize for Economics. As the NRMP website itself describes the contributions of Lloyd Shapley and Alvin Roth,

Shapley and his colleague, David Gale, developed the “stable marriage” algorithm in which men and women rank each other as potential mates and a series of offer rounds produces a best match. The Gale-Shapley algorithm is the basis of the matching algorithm used by the NRMP, and Roth worked with NRMP to adapt it so that it proposes matches on the basis of the applicant rather than the program rank order lists.

While others built off Dr. Shapley’s work for the debut in 1952, Dr. Roth worked directly with the NRMP in the 1990s to tweak the match, especially as it related to match married couples.

For the fourth year medical students going through interviews for residency right now and the match, just remember however frustrating the process is it was complicated enough to warrant a Noble Prize. So, some respect.

Saturday, September 29th 2012

How Many Medical Schools Does Texas Need?

The state of Texas is very close to opening two new free standing medical schools. One in the Rio Grande Valley and one in Austin. While still hurdles to jump through for these two new schools they look to be part of Texas’ relatively rapid expansion in undergraduate medical education capacity. In the past two decades Texas has seen both new schools and an aggressive expansion of the capacity of its current schools. But such is of questionable necessity. Below is data from 2006 U.S. Census Bureau estimates of state populations and 2006 AAMC medical school enrollment numbers for public medical schools.

State 2006 Public Medical School Enrollment 2006 Estimated Population Public Medical School Seats Per 10000 Population
Alabama 971 4599030 2.11
Arkansas 605 2810872 2.15
Arizona 492 6166318 0.79
California 2899 35457549 0.79
Colorado 611 4753377 1.28
Connecticut 346 3504809 0.98
Florida 1283 18089888 0.71
Georgia 749 9363941 0.8
Hawaii 255 1285498 1.98
Iowa 630 2982085 2.11
Illinois 1722 12831970 1.34
Indiana 1164 6313520 1.84
Kansas 703 2764075 2.54
Kentucky 1026 4206074 2.44
Louisiana 1122 4287768 2.61
Massachusetts 450 6437193 0.7
Maryland 650 5615727 1.15
Michigan 2363 10095643 2.34
Minnesota 924 5167101 1.79
Missouri 767 5842713 1.31
Mississippi 427 2910540 1.47
North Carolina 1024 8856505 1.15
North Dakota 246 635867 3.87
Nebraska 491 1768331 2.78
New Jersey 1402 8724560 1.6
New Mexico 329 1954599 1.68
Nevada 218 2495529 0.87
New York 2480 19306183 1.28
Ohio 3908 11478006 3.4
Oklahoma 617 3579212 1.72
Oregon 516 3700758 1.39
Pennsylvania 1236 12440621 0.99
South Carolina 931 4321429 2.15
South Dakota 207 781919 2.64
Tennessee 861 6038803 1.42
Texas 5243 23507783 2.23
Utah 429 2550063 1.68
Virginia 1803 7642884 2.35
Vermont 426 1945482 2.2
Washington 805 9047320 0.89
Wisconsin 664 5556506 1.19
West Virginia 663 1818470 3.64

Texas public medical school numbers include Baylor College of Medicine which recieves some public funding in return for giving preference to Texas residents.
Washington’s population includes Alaska, Idaho, Montana and Wyoming. Residents of those states receive preferential admission to the University of Washington School of Medicine.
Vermont’s population includes Maine. Residents of that state receive preferential admission to the University of Vermont.

While Texas does not top the list in per capita public medical school seats it isn’t far behind.

    States With Most Per Capita Medical School Seats
    1. North Dakota
    2. West Virginia
    3. Ohio
    4. Nebraska
    5. South Dakota
    6. Louisiana
    7. Kentucky
    8. Virginia
    9. Michigan
    10. Texas

It is slightly disingenuous to compare a state like Texas with smaller states on the list above including Nebraska, South Dakota, North Dakota and West Virginia. There are considerable relatively flat infrastructure costs to running an institution like a medical school. If those states with small populations are going to make a commitment to public undergraduate medical education it is nothing to say they’re going to enroll 200 students instead of 30, and so of course their per capita rates will be higher. In light of that Texas’ per capita numbers are even more favorable.

Texas has the most public medical school students in the country and, perhaps more importantly, the most public medical school campuses in the country. While I don’t have the data, with so many freestanding health science campuses and so many medical students it would not surprise me if Texas already spent more on public undergraduate medical education than any state in the union. And while Texas population continues to grow so has the number of medical students enrolling in the state with every medical school increasing its class size since 2006 and a new medical campus opening in El Paso since the data above.

In 2011 the growth in medical school enrollment in Texas had more than kept up with Texas’ impressive population growth and left the state with 2.36 medical school seats per 10000 population. The new slots in the Rio Grande Valley and Austin promise to continue that trend and boost Texas’ per capita numbers higher. I would argue that while we need to prepare our undergraduate medical education capacity to keep pace with our growing population, that the number of current graduates, even for the foreseeable future, is completely adequate for the health care needs of Texas.

The more substantial problem may be in training these medical students after they graduate. The 2010 medical school graduating class in Texas had 1404 medical students competing for 1390 first year resident positions. Nearly half of Texas medical school graduates, their education subsidized considerably with Texas tax payer dollars, leave the state for residency and are unlikely to return. Texas’ contribution to graduate medical education is abysmal as compared to many other states. From the Houston Chronicle article linked to above,

[T]he state’s coffers are a relatively small part of funding — $79 million was allotted last session. The lion’s share comes from Medicare, which is, if anything, in potentially worse shape than Texas.

Unlike many states the medicaid program provides no direct graduate medical education funding in Texas.

There are many arguable benefits of medical campuses. They bring a likely economic benefit to the local economy and they promote prestige and contribute to the local academic community. They also likely help promote community health. But their primary mission, indisputably, is education and undergraduate medical education is not something we need more of in Texas. The press for these medical schools represents local politics and activity within the university system they are poised to be a part of; egos from Austin and the Rio Grande Valley looking at these campuses as a matter of benefit for their local communities.

[T]o hear [state Senator Kirk Watson] speak these days, nothing is more important — and, perhaps, more career-defining — than establishing a medical school at the University of Texas, as well as a new teaching hospital, comprehensive cancer-care center and other elements of what supporters call “Watson’s 10 in 10” — 10 health care goals to achieve in 10 years.

“We have so many good people ready to do it that success is immensely possible, and to not do it and not get started on the path would be extraordinarily regrettable,” Watson said last fall. “This is big. It’s going to be hard. But it needs to be done.”

Some of the costs of these academic healthcare endeavors will be borne by these communities – Travis county’s health district is asking voters in November for a property tax increase – but plenty of money will come from state general revenue afforded to the university systems. That is money from tax payers across the state who are likely to see no to nominal benefit from these new schools.

New medical schools in Texas are unlikely to improve our statewide physician shortage and may even do little to correct disparities in the communities they’re joining. We’re already graduating enough medical students and in a strong position to continue to do so for our growing population without new medical campuses. The schools will bring new graduate medical education funding, in the form of new Medicare dollars but such will not keep pace with the new medical school graduates they promise. The costs of these new medical schools would be much better put towards improving graduate medical education in the state. That is something that would truly improve Texas’ doctor shortage and potentially the public’s health.

Sunday, June 17th 2012

International & For Profit

For profit medical schools outside of the United States which tailor to U.S. citizens have become an increasingly important part of the pipeline of American physicians. But these schools, most prominently in the Caribbean, draw their share of opposition. Beyond their for profit status, which as the broader debate on for profit education has drawn considerable ire from opponents, the graduates of these offshore (not regional) schools, largely American citizens who traveled abroad for their education, tend to do worse on a whole range of standardized tests that lead to things like licensure and board certification as compared to graduates of American schools.

Increasingly though these medical schools are drawing complaints from established American medical education institutions over the issue of third and fourth year clinical rotations for students. Many of these Caribbean medical schools in particular are multi-campus affairs; students do their first two years of medical school in the Caribbean and then come back to the United States to do clinical rotations at hospitals throughout the country.

By far the most clerkship spots for foreign based medical students to rotate are in New York and yet for the past two years there has been an intermittent struggle to cut the flow of Caribbean based students training in the state.

New York State’s 16 medical schools are attacking their foreign competitors. They have begun an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses.

The changes, if approved, could put at least some of the Caribbean schools in jeopardy, their deans said, because their small islands lack the hospitals to provide the hands-on training that a doctor needs to be licensed in the United States.

The dispute also has far-reaching implications for medical education and the licensing of physicians across the country. More than 42,000 students apply to medical schools in the United States every year, and only about 18,600 matriculate, leaving some of those who are rejected to look to foreign schools. Graduates of foreign medical schools in the Caribbean and elsewhere constitute more than a quarter of the residents in United States hospitals.

Similar struggles are taking place in other states where international medical schools are trying to expand or establish their presence. In Texas currently no hospitals train Caribbean based medical students but that could soon change.

The American University of the Caribbean, a for-profit medical school owned by DeVry Inc., has requested authorization from the coordinating board to allow its students — and in particular those from Texas — to have the opportunity to spend years three and four of medical school in Texas hospitals, clerking or taking clinical electives.

Amongst opposition from organized medicine, leaders at public medical schools in Texas and the legislature the THEC has postponed a decision on AUC’s application.

In March, leaders from the state’s public medical schools sent a letter to Texas Higher Education Commissioner Raymund Paredes, who has recommended that the board grant AUC approval. The school leaders argued that allowing students from foreign schools into Texas clerkships would “displace Texas medical students in already limited clinical training settings at hospitals in our state.”

It doesn’t seem the fight over stateside clerkship spots for international based medical students is close to being finished.