AM Rounds

Beyond the pages of Academic Medicine, journal of the AAMC


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Looking Back: One Year of AM Rounds

It’s been a great first year for AM Rounds, and we’re excited about the year ahead, when we will continue to offer compelling supplements to and unique perspectives on our published journal content.

As we move ahead into 2014, let’s take a look back at the ten most-read posts from 2013:

  1. Medical School Admissions and the MCAT: A Modest Proposal, from Dr. David Muller, commenting on Academic Medicine’s May collection on the new MCAT.
  2. Beyond the “Bob Effect”: Why Your Rank List is Less Accurate than You Think, by Dr. David A Ross, describing in further detail how he devised a new approach to the Match.
  3. The Fallacy of Medical School Rankings, by Drs. William C. McGaghie and Ralph P. Leischner, Jr., reflecting on a better way to rank medical schools than the U.S. News & World Report annual ranking.
  4. Preparing to Take the MCAT: A Step-by-Step Guide, by Jen Page and Abby Thomsen at the Association of American Medical Colleges.
  5. What’s Missing from the Flipped Classroom Model? by Dr. Debra DaRosa, sharing her experiences with the flipped classroom model at the Northwestern University Feinberg School of Medicine.
  6. The Power of Humanities and Storytelling in Medical Education, by Dr. Daniel George, on a non-pharmalogical approach – storytelling – to treating patients with dementia, and the value of students’ participation in it.
  7. What’s the Price of Committing to a Career in Primary Care? by Dawn Pruett, a medical student at the Oregon Health & Science University School of Medicine, reflecting on her motivations for choosing primary care (hint: it wasn’t about the money).
  8. What Are We Missing? Why Holistic Admissions Matter, by Dr. Leland Husband, on what it means to be a “non-traditional” medical school applicant.
  9. Do Medical Students Really Just Follow the Money? by Jay Youngclaus at the AAMC, on how and why students select their specialties.
  10. Intern Boot Camp: Preparing Residents for Practice, by Dr. Jeremiah Wasserlauf, sharing his experience at Northwestern University Feinberg School of Medicine’s “intern boot camp” program, designed to prepare students before starting their residencies.

Thanks for reading!


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Right-sizing the Nation’s Workforce for the Affordable Care Act

By Sheldon M. Retchin, MD, MSPH, vice president for health sciences, Virginia Commonwealth University, and chief executive officer, VCU Health System, and Alan Dow, MD, MSHA, assistant vice president of health sciences for interprofessional education and collaborative care, assistant dean of medical education, and associate professor of medicine, Department of Internal Medicine, Virginia Commonwealth University

In the last several years, numerous controversies from the Affordable Care Act (ACA) have coated the health care landscape with uncertainty. Partisan viewpoints and judicial decisions have left states grappling with whether and how to expand coverage. More recently, technical flaws in the rollout of the health exchanges have left the public and policymakers wondering whether appropriate mechanisms for implementation are in place.

Overshadowed by the hullabaloo surrounding the ACA is the substantive issue of whether the nation’s health care workforce is adequate to accommodate its coverage expansion goals. With 40 million potential new beneficiaries under the ACA, existing health care labor shortages will only worsen as health reform is fully implemented. And yet, not enough is known about the unmet needs of the uninsured to predict the number or type of health professionals needed and how to structure health care delivery to meet these needs.

In the December issue of Academic Medicine, we describe our 13-year experience with the Virginia Coordinated Care (VCC) to model the additional workforce that might be required with the coverage expansion from the ACA. The VCC uses the infrastructure of a Medicaid HMO to manage the care for approximately 30,000 uninsured. The punchline? The data reveal that one size does not fit all. For instance, more than half of VCC individuals use only episodic care, and never visit a primary care physician. Moreover, while these individuals are provided access to primary care through the program, they continue to seek care for non-urgent, episodic problems in emergency departments. In addition to being expensive, this pattern does not support preventive care that could avert or delay future illness. After all, the emergency room is an abysmal setting for vaccination, screening, and health counseling. Therefore, policymakers may need other approaches to promote the health of newly covered beneficiaries.

Like those with insurance, costs among the uninsured are concentrated in a disproportionately small number of individuals with complex chronic illnesses. Thus, about 20 percent of the VCC population account for approximately 70 percent of the total cost.  However, since we have struggled to effectively and efficiently manage complex care for insured super-utilizers, exporting the same ineffective model to the uninsured would be folly. With this subpopulation, we have an opportunity to create new models of care, whereby these complex patients can be triaged to interdisciplinary teams specifically trained and structured to care for patients with multiple chronic illnesses.

Regardless of the controversy of the moment, the ACA represents the most profound coverage expansion in almost half a century. And yet, for the full spectrum of care with the uninsured, there are clearly workforce challenges. Whether it involves steering newly covered individuals to primary care for health promotion and disease prevention, or managing chronic illnesses with a multidisciplinary team, the workforce model needs a makeover. Clearly, imposing the current delivery system from the insured onto the care of the newly insured would squander this chance to transform health care. In the end, both sides may even agree on that.


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Sneak Peek from the December Issue: The Effects of Expanding Primary Care Access for the Uninsured

Later this month, Academic Medicine will post the published ahead-of-print articles from the December 2013 issue. To tide you over until then, here’s a preview of an article by Alan Dow and colleagues:

The Effects of Expanding Primary Care Access for the Uninsured: Implications for the Health Care Workforce Under Health Reform

Alan W. Dow, MD, MSHA, Arline Bohannon, MD, Sheryl Garland, MHA, Paul E. Mazmanian, PhD, and Sheldon M. Retchin, MD, MSPH

Abstract

The Patient Protection and Affordable Care Act seeks to improve health equity in the United States by expanding Medicaid coverage for adults who are uninsured and/or socioeconomically disadvantaged; however, when millions more become eligible for Medicaid in 2014, the health care workforce and care delivery systems will be inadequate to meet the care needs of the U.S. population. To provide high-quality care efficiently to the expanded population of insured individuals, the health care workforce and care delivery structures will need to be tailored to meet the needs of specific groups within the population. To help create a foundation for understanding the use patterns of the newly insured and to recommend possible approaches to care delivery and workforce development, the authors describe the 13-year-old experience of the Virginia Coordinated Care program (VCC). The VCC, developed by Virginia Commonwealth University Health System in Richmond, Virginia, is a health-system sponsored care coordination program that provides primary and specialty care services to patients who are indigent. The authors have categorized VCC patients from fiscal year 2011 by medical complexity. Then, on the basis of the resulting utilization data for each category over the next fiscal year, the authors describe the medical needs and health behaviors of the four different patient groups. Finally, the authors discuss possible approaches for providing primary, preventive, and specialty care to improve the health of the population while controlling costs and how adoption of the approaches might be shaped by care delivery systems and educational institutions.


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Hoping to Inspire

By Stephen M. Petrany, MD, Family and Community Health, Marshall University Joan C. Edwards School of Medicine

As I considered Academic Medicine’s invitation to comment on the creative efforts of medical educators to engage the imagination of their students and residents with respect to rural and small town practice, I could not help but ponder just how this native of Brooklyn, New York, ended up deeply entrenched in a department and medical school committed to changing the landscape of rural health. I find myself in West Virginia surrounded by extraordinarily talented people who share an uncompromising dedication to that important mission. I am just one positive outcome of a specific program (the National Health Service Corp Scholarship Program) that sparked the fire that has become my passion for rural and underserved health care.  This experience underlies my confidence that efforts to encourage quality medical students and residents to fill the national need for rural practitioners can and will be successful.

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The Fallacy of Medical School Rankings

By William C. McGaghie, PhD, Director, and Ralph P. Leischner, Jr., MD, Institute for Medical Education, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois

Nearly everyone in the academic medical community knows that the U.S. News & World Report (USN & WR) annual rankings of American medical schools (and other higher and professional education programs) are defective.  Scores of journal articles have been published that criticize USN & WR for its flawed methods in producing the annual rankings and ignoring the academic backlash.  Medical school deans and academic thought leaders acknowledge the dubious quality of the rankings, despite occasional remarks (usually from highly ranked schools) to the effect that, “. . . the USN & WR rankings are all we have . . . there are no other measures to gauge medical school quality.”  I disagree.  Mission based metrics that address the values and goals of individual medical schools (e.g., public health, research, health care team training, student and faculty diversity, religious convictions, educational excellence and value) are more valid benchmarks to gauge school success.

More than a decade ago, in 2001, Jason Thompson and I concluded our critique of the USN & WR rankings of American medical schools with this statement:

“The annual U.S. News & World report rankings of U.S. medical schools are ill-conceived; are unscientific; are conducted poorly; ignore the value of school accreditation; judge medical school quality from a narrow, elitist perspective; do not consider social and professional outcomes in program quality calculations; and fail to meet basic standards of journalistic ethics. The U.S. medical education community, higher education scholars, the journalism profession, and the public should ignore this annual marketing shell game.”

My conclusions have not changed, despite the staying power of the USN & WR rankings.  One would think that the report authored by Drs. Dan Tancredi, Klea Bertakis, and Anthony Jerant titled, “Short-term stability and spread of the U.S. News & World Report Primary Care Medical School Rankings” in the August 2013 issue of Academic Medicine, accompanied by the commentary “From Rankings to Mission” written by Drs. Darrell Kirch and John Prescott would close the door on this sad legacy.  These reports show once again the fallacy of arbitrary medical school rankings.  They advance the argument for mission based metrics – medical school outcome measures that show leadership can be expressed in many different ways.

Such metrics acknowledge the uniqueness of individual medical schools toward the universal goal of educating a highly competent medical workforce to provide for the health care needs of the nation.  Several illustrations include the “health of the public” emphasis at the University of New Mexico; education of minority physicians at Howard, Morehead, and the University of Illinois; and the education of medical missionaries at Loma Linda.  These are all special and valued missions that attract faculty, students, and resources to reach their goals.  These and other missions don’t show up in the USN & WR rankings.

But don’t expect the rankings to go away.  The USN & WR medical school rankings will stick around as long as they sell magazines and make money from a gullible public.  This is not an academic, public policy, or altruistic enterprise.  It’s all about commercial profit. Maybe P.T. Barnum was right with his observation, “There’s a sucker born every minute!”  To me, members of the academic medical community who believe that the USN & WR medical school rankings accurately reflect the quality of medical education offered at each school only strengthen and promote Barnum’s claim.


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A New Method of Estimating Primary Care Output

By Paul Jolly, PhD, senior director, Special Studies, Association of American Medical Colleges, Washington, DC.

There is a serious concern that the pipeline for the production of the physician workforce is inadequate to meet future needs, especially for primary care.  Using the database on residency training sponsored by the Association of American Medical Colleges (AAMC) and American Medical Association (AMA), which contains annual data on individual residents, it is possible to monitor the size and shape of this pipeline.  Because we can follow individuals longitudinally, we can determine who does and does not enter subspecialty training, implying that they will not practice primary care. Of course, some physicians trained in a subspecialty nevertheless practice primary care, and some who have not been trained in a subspecialty become hospitalists or limit their practice to a subset of patients in a subspecialty of their discipline.

AAMC has been measuring primary care output in this way for some time.  The blue line in the graphic below shows how this works.  We start with the number of new categorical residents in internal medicine or another primary care discipline, and we follow them through their graduate medical education, using the GMETrack database.  For those beginning internal medicine in 2000, a small number are reported in a fellowship in 2002; most of the residents who will subspecialize have their first opportunity to enter a fellowship in 2003.  As the blue line on the graph indicates, however, more than one third of those who will subspecialize are not reported in a fellowship until 2004, 2005, or even later.  In order to determine the eventual number who will subspecialize, we need at least eight years of data, which is the problem with this longitudinal method.  Although we can determine what fraction of a cohort will subspecialize and thus how many may be assumed to be planning a primary care practice, we can’t tell what is happening in recent years.

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Specialty Choice in Graduate Medical Education

Over the past year, I have had the opportunity to meet with residents at national meetings as well as during my time in Washington when they participated in their specialty advocacy meetings. In general I have noted that Congressional staff would listen intently to the stories of residents and ask them about their career goals and intended sites of practice. Residents tended to express themselves clearly, succinctly, and confidently, perhaps as an extension of their daily requirements for succinct and effective presentations during rounds. They discussed their hopes for improving health, uncertainty about the impact of health reform as well as loans, debt, family stress, and concern about the amount of information they had to master.

Eventually we would get around to where the residents intended to practice and what they hoped to do. Were they going to practice primary or specialty care in rural or urban underserved areas? How would their intentions align with the anticipated needs of the Affordable Care Act? As I would listen to them, I noticed certain recurring themes. Many residents preferred to continue training after completing their core residency. It did not matter what the initial specialty training might have been. The orthopedists were planning to do foot, hand, spine, or sports fellowships. The general surgeons were going to do fellowships in trauma or colon or breast surgery. The internal medicine residents were becoming cardiologists or gastroenterologists. Family Medicine seemed to be the only exception, and even some of them were considering sports medicine or women’s health.

My informal survey has reinforced the data presented by Jolly and colleagues in the April issue of Academic Medicine. In their analysis of residency specialty choice trends over ten years, they showed that residency training positions were rising more slowly than the increases in medical student positions, and the increases that did occur were in the area of subspecialties or subsubspecialties. There was a 6.3% decrease in those expected to enter primary care practice over the ten-year period, although, according to the report, “the number and percentage of new program year 1 residents expected to enter primary care for the most recent year are essentially unchanged from the prior year, offering some hope that the declining interest in primary care careers may be ending.” General surgery also demonstrated substantial decreases in the number of residents intending a general surgery practice.

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Do Medical Students Really Just Follow the Money?

By James “Jay” Youngclaus, AAMC

In his recent book, Thinking, Fast and Slow, Daniel Kahneman, a Nobel Prize winner in Economics, explains the two systems central to thinking. He depicts “System 1” as “fast, intuitive, and emotional” while “System 2 is slower, more deliberative, and more logical.” The book “is about the working of System 1 and the mutual influences between it and System 2.” This fascinating work has affected how I think about debt and specialty choice.

I think most people are quick to believe that debt plays a key role in specialty choice, driving physicians away from primary care with its comparatively lower salaries versus specialists. It seems to make such intuitive sense. The current median debt level is $170,000; with the interest that accrues during residency, this will be expensive and time-consuming to repay. Most specialties have a starting salary after residency one and a half to two times that of primary care. How can that difference not play a critical role? This is classic System 1 thinking.

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What’s the Price of Committing to a Career in Primary Care?

Dawn Pruett, Medical Student, Oregon Health & Science University School of Medicine

I’ll be matching into a family medicine residency this spring and, true to what the literature says, the potential earnings of a family physician played little part in my specialty choice. I can honestly say (perhaps naively) that I didn’t choose primary care for the money.

When I entered medical school, I was aware of how much debt I’d be taking on, but I don’t think I had a true understanding of its impact. At that time, I couldn’t imagine what it’d be like to make anything close to $100,000 a year, nor could I grasp what it’d be like to owe three times that amount. I would often hear, “You’ll be a doctor, you’ll be able to pay it off,” and “Medical student loans are ‘good debt,’” implying negligible future financial impact.

Even now, as I’m about to start residency and begin repayment on my loans, it’s difficult for me to feel the true burden of my debt. However, the conversations are changing.

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Journal Club: January 2013

Can Medical Students Afford to Choose Primary Care? An Economic Analysis of Physician Education Debt Repayment
James A. Youngclaus, MS, Paul A. Koehler, PhD, Laurence J. Kotlikoff, PhD, and John M. Wiecha, MD, MPH
Academic Medicine. 88(1):16-25, January 2013.

About Medical Student Debt and Specialty Choice

Most U.S. medical school graduates have education debt—79% with $100,000 or more in 2012. In addition, the median level of education debt is increasing—up 5% from 2011-2012 to $170,000. Controlling for inflation, the average education debt for an indebted medical school graduate in 2011 was nearly 3.5 times what it was in 1978. Some discussions of physician specialty choice suggest that indebted medical students don’t choose primary care because repaying their debt seems economically unfeasible.

Article Summary 

The authors analyzed whether a physician earning a typical primary care salary can repay the current median level of education debt and meet standard household expenses without incurring additional debt. The authors used comprehensive financial planning software to model the annual finances for a fictional physician’s household to compare the impact of various debt levels, repayment plans, and living expenses across three specialties. In total, they analyzed 384 different scenarios: 16 repayment plans at 4 different debt levels for 3 different career tracks in 2 different locations.

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