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Archive for the ‘Medical School’ Category

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 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.

Friday, December 26th 2008

The Time Has Long Come

I’m in my fourth year of medical school. In a matter of months I’m going to be a physician. Until October of 2008, thirty-seven months into my education as a medical student, I had never even seen a paper medical chart. My only rotations were at a county hospital with a strong commitment to EMR and at government sites. I rotated at both VA and DoD hospitals both with strong nationally connected electronic medical record systems. I had also never seen any numbers on the prevalence of electronic medical records and so I assumed that most major hospital systems, at the least ones with integrated physician practices such as in much of academia, must also have full fledged EMR systems.

But over two months, doing away rotations, I learned hard and fast the reality. I rotated at institutions which, like most of the country, still rely on paper charts for the majority of the patient’s record. Sure they often times have lab data on the computers and certainly, nowadays everyone has a PACS. But they’re missing out on so much more.

Over those two months I had to teach myself certain skills which really should no longer be a part of the delivery of health care in this country. I taught myself how to write quick, illegible and uninformative notes by hand. I taught myself how to fight off nurses and social workers for patient’s charts and then hoard them. I taught myself to just give up hope of trying to decipher the handwriting on a consult note and just page the service to hear their recommendations over the phone. I taught myself to memorize my resident’s provider numbers because I knew the nurses were going to be paging to confirm orders which they couldn’t read. I taught myself the most likely places for “missing” charts to be. I taught myself the most likely places for various documents to be filed in the chart.

Nowadays I’m on the interview trail. It is the long and arduous journey to find out where I’ll do residency. And I laugh a little bit inside when residents try to convince the interviewees that it is a good thing their primary teaching sites still use paper charts because it’s “faster and easier” to write notes by hand. That’s novice talk.

The Myth Physician Handwriting Is Worse Than The General Public’s Persists…

Virtually all computerized note writing systems allow templates or, at the least, click at you go note building forms. With three key strokes a resident in my home neurosurgery department can bring up a virtually completed consult note on a patient with any major, common neurosurgical issue. A few buttons on the keyboard to personalize the note for that specific patient and the note is done at least as quickly as if they had scribbled it on a piece of paper down in the emergency room. There is a learning curve and it represents one of the largest non-financial obstacles to the implementation of EMR systems. But I simply refuse to believe, that once the system is known to all and full implemented, that a electronic medical records system does not improve the efficiency of just about any practice environment. From the huge general hospital to the small rural primary care practice.

Beyond efficiency EMRs offer significant patient safety benefits. Poor handwriting or misinterpretation of orders are certainly a source of medical errors. No, electronic order systems, don’t eliminate these in full but they do reduce the risk. Handwriting becomes a non factor. Most major EMRs offer physicians advice on drug-drug interactions, limit physicians’ ability to order too much of a medication and/or check orders against a patients list of diagnoses and try to make sure the physician is ordering what he or she really wants to. Linked dispensary systems, like Pyxis, can limit the risk of nurses or others giving patients the wrong medication. And electronic patient identification (such as barcodes on patient arm bands) can significantly limit the delivery of medication or therapy to the wrong patient.

Obviously there are some major hurdles to the widespread implementation of electronic medical records. Included amongst these are technical issues and of course, in large part, the initial expense of implementation.

But these expenses are far offset by the benefits and most providers who are calculating it otherwise are fudging the benefits.

For hospitals the investment in well designed and implemented electronic medical records pays for itself in pretty fashionable time as some experiences have demonstrated. For private practices the initial overhead can be more daunting, admittedly. But private practitioners shouldn’t delude themselves that the benefits aren’t there. Yes, the patient safety issues for a largely ambulatory practice are less pressing than in the inpatient setting, if still present, but other benefits abound. Consider a new Annals of Internal Medicine study which may demonstrate that physicians who use EMRs may be less likely to pay malpractice claims.

I am a strong proponent of electronic medical records. However my point, in conclusion, is a nuanced one. For major medical centers, especially academic ones with integrated physician practices, to not have full fledged electronic medical records at the present time is inexcusable. For private practitioners, we should be working to bring electronic medical records as a reality. The lifting of Stark law restrictions was a good start, if the current economic conditions mean health systems are currently not as inclined to invest in EMR systems for their physicians as would be ideal. Hopefully federal subsidization will help the spread of electronic medical records into the private sector at an increased pace. Indeed P4P efforts should include the implementation of EMRs for increased reimbursement. Of course we all know how CMS’ P4P plans are doing. Still, I can dream

I’m serious about this issue. Ever residency interview I’m at I ask about the hospitals’ computer interface and what the physicians can and cannot do from the computers. A more substantial roll out of electronic medical records is long overdue.

Sunday, June 26th 2005

White Coat

The White Coat Ceremony is a relatively recent tradition, which has, in a short time, taken on considerable prestige and honor at the majority of U.S. allopathic medical schools and even some international medical institutions.

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