February 21, 2014
When I was a medicine resident at the University of Florida, the cheapest place to buy cigarettes in Gainesville was the Veterans Administration Hospital. The great irony of this was not lost on my colleagues and me.
We covered inpatient units filled with servicemen (there were few women at that time), many with chronic lung disease, head and neck malignancies, cardiovascular disease, lung cancer and permanent tracheostomies. Our efforts to make them well were seemingly counterbalanced by the large “Smoking Lounges” on each floor – complete with large screen (at the time – 26 inches!) TV’s, comfortable seating and ashtrays where the cigarettes purchased on the lower level of the hospital could be savored.
Eventually, the VA discontinued this practice as more and more data appeared about the risks of smoking. And while the first Surgeon General’s report (www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm) on the adverse consequences of tobacco usage appeared five decades ago, we only just now see a major tobacco retailer, CVS Caremark, halting sales in its stores. Change takes time.
CVS, the current leader in sales nationally among all drugstore chains, has gotten into the business of providing health care. With CVS’s almost 8,000 U.S. stores and nearly a thousand MinuteClinics® – providing medical care delivered by primary care nurse practitioners and physician assistants, pharmacist-administered vaccinations, medication counseling, blood pressure monitoring and routine laboratory testing (no appointments needed and most insurance accepted – thank you very much!)- combined with millions of people now able to access care through the Affordable Care Act, the company is clearly positioned for expansion of care delivery services. So, CVS has come to the same conclusion as the Department of Veterans Affairs – albeit decades later – providing health care and selling tobacco are incompatible.
The financial losses resulting from ceasing their tobacco sales will be substantial, but as number 13 on the Fortune 500 list, CVS likely understands economics. So kudos to them for aligning social responsibility and business.
For those who have historically purchased tobacco from CVS, there are too many alternative options to count. But what about when the next drugstore chain or big box franchise or convenience store network does the same thing? And the next one after that? Incremental, but very public, changes in the availability of tobacco products such as this one will continue – “peer” pressure is very powerful.
While tobacco usage in our country has significantly declined since the first Surgeon General’s report, this improvement is far from uniform across age group, gender, race, personal income and educational level. There is still much to do. Let us hope that the other businesses see the wisdom in CVS’s decision.
P.S. While we are on the topic of health promotion, perhaps we can discuss the snack food, sugar-containing soda and beer sold at CVS. Associations with adverse health outcomes exist for these too, right? Shouldn’t that stop as well? A thought for a future blog…
Paul Katz, MD
Cooper Medical School of Rowan University
February 4, 2014
“The function of education is to teach one to think intensively and to think critically. Intelligence plus character – that is the goal of true education.”
Dr. Martin Luther King, Jr.
Last month, our students arranged a “Martin Luther King, Jr. Day of Service” just as the Charter Class had done the previous year. Entirely student-organized and -led, nearly 80 young people ages 3-18 from the City of Camden were welcomed to CMSRU. The sessions planned were intended to be both educational and fun: reading food labels, the “new” food plate, exercise, the sugar content of soft drinks, anatomy of the brain, microscopy and more.
Not surprisingly the youngsters were captivated by what they witnessed as they were exposed for the first time to practical demonstrations of science and health. I am very proud of our students – they are truly committed to the City of Camden and to helping it regain its past glory – a commitment that we all share. Imagine what outstanding physicians they will become!
The children of our city, like all children, have the right to high quality education, and while Camden has struggled in this and many other areas, the signs of hope are there. New charter schools (K-12) are imminent and the “meds and eds” are helping to drive much-needed change which brings hope and opportunity to Camden’s residents.
I recently finished reading a remarkable book, “First Class: The Legacy of Dunbar, America’s First Black Public High School” by Alison Stewart (Chicago Review Press, 2013). Stewart, whose parents are Dunbar graduates, relates the history of the Paul Laurence Dunbar High School in Washington, DC – the country’s first public high school for black students. From humble beginnings during post-Civil War Reconstruction, Dunbar became an “elite” school in the nation’s capitol after the turn of the century. Ironically, it lost this distinction when desegregation occurred. The list of those who attended Dunbar is remarkable – political leaders, high-ranking military officials, educators, lawyers, business heads - and the academic rigor of the high school propelled the school’s graduates into top colleges and universities.
It is hard to imagine now, but Washington was a sleepy southern town until the Kennedy family arrived and it was plagued with the same prejudices seen throughout the U.S. Prior to the creation of what would eventually become Dunbar High School, education for black children was almost non-existent in the District of Columbia, so the creation of a school that attained this stature is truly remarkable.
Unfortunately, desegregation led to the redistribution of Dunbar students and this, plus the politics of the city’s school system, resulted in hard times – poor academics, dilapidation of the building and the myriad of problems that continue to plague our cities’ public schools. And while hope remains that Dunbar will eventually return to its glory days, its future, and the future of its students, remains uncertain.
Such is the same in Camden, and it will take time, perseverance, money and commitment to get the schools to a place where students thrive and opportunities for success become the rule, rather than the exception. In the last blog, I wrote about the disturbing paucity of African-American men in our country’s medical schools – but the problem does not primarily reside with the medical schools, but with our system of public education that is lacking in so many ways.
So I hope that the MLK Day of Service at CMSRU will help depict to the children of Camden what is possible. It is incumbent upon all of us to help provide them with the education that will allow their dreams to become reality.
Paul Katz, MD
Cooper Medical School of Rowan University
January 7, 2014
It’s barely 2014 and there has already been considerable talk about the year ahead. This is a time where speculation and resolutions are rampant. Predictions about the economy, the impact of the Affordable Care Act (ACA) and mid-term elections accompany our own individual “promises” for the next twelve months. I heard last week that the typical New Year’s resolution lasts until January 17 – whether valid or not, we all know from personal experience the transience of our annual commitment to self-improvement.
So rather than speculate or resolve, I’m going to make five wishes for medical education in 2014. While nothing new, the medical education “industry”, both undergraduate and graduate, faces significant challenges that seem unlikely to be easily resolved. There are no answers in this blog, trust me. Here goes:
Wish 1 – Reduce medical student debt. Far from solved, the problem of the massive debt that graduates face needs to be addressed. Whether through loan forgiveness programs, increased Federal and state funding or other initiatives, we need to make medical education more affordable. Medical schools are under pressure to address this problem, but we cannot do it alone – there is just not enough money. Let’s keep medical school from being accessible to only those with means.
Wish 2 – Increase the number of African American males enrolled in medical school. Despite the focus on and resultant successes in improving diversity among matriculants, there is still much to be done. Disturbing and equally perplexing are the disarmingly low number of African American males applying and being accepted to our schools, lower in 2011 than 2002. That this is solely reflective of the lower percentage of African American males receiving college degrees seems unlikely. One can venture that the focus needs to be on getting elementary and middle school students interested in both college and careers in science. Perhaps now is the time for a national task force to address this issue.
Wish 3 – Reduce the time from high school to practice. Also not a new dilemma, the time required to become a practicing physician in the U.S. is considerably longer than most countries. Reduction in the time from college to medical school and from medical school to post-graduate training has been undertaken – but it may not be for every student. Factors such as individual maturity, the benefit of life experiences and the importance of non-science courses as components of an undergraduate curriculum are among the arguments against a compressed time frame. But basing these transitions on “time served” rather than content mastery may be a flawed approach to shortening training. While considerably more complex, asynchronous learning in college, medical school and residency – where learners progress by achieving milestones, both educational and developmental – may be a solution. As we know, for many medical students, four years is adequate; but for some, it is too short and, for perhaps a smaller group, it may be too long. The same could apply to graduate medical education (GME) as well. A huge undertaking, no doubt, but perhaps worth consideration.
Wish 4 – Increase the number of GME positions. On second thought, allow me to qualify this: Increase the number of GME positions to meet national workforce needs. In 2013, we saw a brief glimpse of the collision that awaits us – too many graduates and not enough residency positions. But this is not true for all specialties, especially the primary care disciplines, where funded slots go unfilled. Many have requested that the federal government increase the number of GME slots, but not everyone is buying that approach. Plus, where will the dollars come from? Medicare? Perhaps what is needed is a new methodology for governmental funding of GME positions based on market need. With the number of Medicare-supported residency slots frozen at 1996 levels and likely not to increase, maybe the slots should be reallocated based on the regional need for certain disciplines – for example, more primary care program positions and fewer in oversubscribed specialties. No option is ideal, but those newly insured by ACA must have access to care.
Wish 5 – Push innovation in medical education. Yes, we are doing better in both undergraduate and graduate medical education, but we need to do more. Some would posit that innovation is limited by the accrediting agencies – I think this is an excuse. Change is up to us, to those who deliver medical education. No question, this is hard work and the obstacles are many, but we have to do this. We must. This is true not only in how we deliver content (e.g., massively open online courses [MOOCs], “flipped” curricula) but also in terms of what we are teaching. Let us continue to expand our teaching and experiences in interprofessional education and care, quality and safety, technology, leadership, systems thinking, medical economics and those other areas that will allow future physicians to provide better and more efficient care.
We’re nearly two weeks into 2014 – let’s get started!!
Paul Katz, MD
Cooper Medical School of Rowan University
December 17, 2013
Time has flown. It’s hard to believe that it has been a year since I wrote about 2012 in this blog. The past twelve months have been remarkable, indeed, and, as we celebrate the year behind us and plan for 2014, I want to extend my sincere gratitude to all those (and there are many!) who play such an important part in CMSRU’s success.
In 2013, the Charter Class completed its first year, a year that introduced our innovative curriculum; and we welcomed the 64 members of Class of 2017 last summer. We were very pleased with the educational program; as a fairly “nimble” organization, we made some enhancements along the way. Included among these was the introduction of “flipped” course work, where students review materials outside of class and then utilize classroom time for interactive exercises and team-based learning— all of which enhance retention. Our Ambulatory Clerkship, based in the student-run clinic, was a highlight for all of us. Now, functioning with teams of first and second year students supervised by our clinical faculty, the clinic is providing to care to Camden’s underserved populations and exposing our students to other health professionals as they train side-by-side with peers from other disciplines.
Service learning experiences also exceeded our expectations. Every student is required to complete 40-hours of non-health care-related service in Camden. Tutoring, coaching, serving meals and working in community gardens were among the contributions to the city. All told, the students far exceeded 2,000 hours of community service, equivalent to 40 hours of “paying it forward” every week.
CMSRU added faculty and staff to meet the needs of our growing number of students. We now number over 85 faculty and staff, not including our over 400 clinical faculty members based at the Cooper Health System. Add to this our faculty colleagues from the Coriell Institute and the University of the Sciences— our strong partners in education and research.
Considerable time was spent in 2013 in “planning” – planning for 2014 and planning for the continued growth of our school. We successfully concluded our initial philanthropic campaign – The 2012 Legacy Society – which raised almost $6 million for CMSRU. And we began planning for the early launch of our new development initiative – The Promise Campaign – which will conclude with the graduation of the Charter Class in May, 2016. (You can learn more about this campaign here.)
Significant preparation and effort went in to preparing for the Liaison Committee for Medical Education Provisional Accreditation visit in March 2014; this week, over 3,000 pages of material were submitted, culminating 18 months of preparation by dozens of CMSRU, Cooper Hospital, and Rowan colleagues and all of our second year students.
At the same time, our team has been hard at work creating the third year student experience – the Cooper Longitudinal Integrated Clerkship (CLIC). We are very excited by this longitudinal approach to clinical medicine; our students will participate in the care experiences of their individual cohort of patients as they traverse the continuum of care inside and out of the hospital. We’ll be writing more about this as the summer approaches.
Our novel admissions program continued to have great success, both in the recruitment of our current first year students and in the still ongoing process to enroll the 72 members of the Class of 2018 who will join us in August. While our interviews continue now, we have closed our application process as of December 15; for our incoming class, we had almost 5,300 applications, roughly 75 for every position.
There is so much more I could write, and in the weeks ahead we’ll talk about the many great things that are going on in Camden, the city invincible. We are equally proud of these and we are privileged to be a part of the rejuvenation of our hometown.
To you and yours, best wishes for the holidays and for a happy and healthy 2014. And special “thanks” to those who play a part in CMSRU – let us all celebrate our success.
Paul Katz, MD
Cooper Medical School of Rowan University
November 5, 2013
Welcome to Philadelphia! It’s another great day at the AAMC Annual Session – and Election Day! If you are local, don’t forget to vote, and if you are not, we hope you remembered to send in your absentee ballot! We’re still learning a lot still here…
Leadership Plenary: Embracing Changes in Culture – Driving Organizational Success by Building a Culture of Contributors
A strong session to start Tuesday morning (and the last of the plenary sessions) brought Adam Grant, PhD to the group to discuss givers, matchers, and takers – and which type is best for organizations. Happily, it Dr. Grant’s work appears to have shown that “givers” are, in the long run, the best type for both individual and organizational success (although perhaps NOT in the short term, surprisingly). The most important points not only were to encourage givers (who can influence matchers and even takers to give more), but to prevent takers from “getting on the bus.” Tips for recruitment were discussed, and opportunities to bring out the “giver” in all were suggested. Uplifting, energetic, and informative start to the day!
MedEdPORTAL and MedAPS Update
Great resources for staff, faculty and students. Check out the websites!!
RIME Invited Address
This was an excellent invited dress by Clarence Braddock, vice Dean at UCLA, about patient centeredness as an organizing framework for medical education research. He made a strong case that patient outcomes should be a principal measure of the success of our medical education program. He said a good medical education program graduates excellent doctors, but a great one improves health outcomes for patients and populations.
Digitized poster session: Curriculum
This session offered seven posters related to curriculum innovations or daily practice in UME. Topics for this session covered LCME as a vehicle for continuous quality improvement through an innovative obesity curriculum for M2 students that incorporated an SP encounter to discuss weight loss options for patients. Great ideas for all of us to consider!
Light Years beyond Flexner: Academic Medicine in 2033
Discussed team based models of care for patient needs, training structure and continuum of med education, technology in medicine and impact on patient physician relationship. Beyond….Information science, decision science, social science and art back into medicine??
In the future, most of what physicians do today will be done by others. Physicians will deal with complexity and ambiguity, become the designer, innovator and navigator as well as the leader or coordinator. Other possibilities- “ultrasound on steroids”, holographic and lifelike robotic mannequins and situational simulation with telepresence. Leaders will need both critical and creative thinking, competency based evaluation will take on another look and individualized medical education will be what occurs including self phased curriculum and blurring of UME and GME
November 4, 2013
AAMC Town Hall
Dr. Kirch again took us through a variety of audience generated topics, including global health (GHLO - https://www.aamc.org/services/ghlo/), GME, MOOCs, and one that generated lots of buzz online and off… this conference, and what it should look like. Should the AAMC annual session split out educational focus from other topics (lots of concern about this one) – or research, etc.? No one wants to give up the opportunities to network, learn about areas a bit peripheral to one’s own expertise – all available in a large, multi-focus conference. However… conference is super-sized and getting unwieldy for some (and venue can be challenging – as we have all seen these past few days). Chicago AAMC meeting next year is shorter, different formats (more broad, user driven) and there will be more targeted conferences separately. More info and more feedback is certainly needed!
GME: What next?
A hot topic at this year’s conference. Attendees heard a variety of viewpoints – health sciences VP, medical student (arguably the best speaker!), and DIO. If we focus on just the student views – paints a challenging picture. Students come to medical school NOT as pluripotent stem cells, but as individuals with already molded expectations of careers in medicine. Can we expect them to create “parallel paths” to residency in less-competitive specialties if that is not what they are cut out to do? As it was so perfectly put by the Dartmouth student, “If you take 100 competitive people and put them in a room together, you should expect that they are going to compete.” Flip side is that some of those “competitive” students are not going to be able to compete, and options will be lots of debt and no ability to become a physician… No easy answers generated today…
Innovative Organizational Models in a Time of Rapid Change
Heerad Sabeti took the audience through his perspective on an emerging new, fourth sector (after business/for profit, government, and not-for-profit) – the “for-benefit” organization. This type of organization melds the income-generating/revenue-earning focus of the business sector with the societal benefit focus of the not-for-profit and governmental sectors. Unlike govt and not-for-profits, these organizations are not funded primarily by grants, taxes, or donations, but by earning their income. However, unlike the business sector, their goal is not income/wealth for their owners, but societal benefit. Current legal and other structures are challenged by this model; we need new regulatory and legal approaches to this type of organization to make it work. AMCs already have some of the characteristics of the for-benefit corporations, but need to push further along the spectrum.
Enhancing the Sustainability of Postbaccalaureate Programs in Medical Education: outcomes and collaboration
This fairly recent national collaborative described the development of the group with the AAMC. The types of postbacc programs that exist, as well as the student groups most likely to benefit from their curricula were outlined. The goals of the collaborative include the development of shared resources, support for the development of new programs, collaboration in research efforts, and sharing best procedures.
This session went over the updates of the various student surveys including the MSQ. Student wellness is now a focus of these surveys including time management and use of stimulants. The survey is anonymous but the response rate was only 18 percent. There are sexual identity questions for the first time. Females noted generally higher social support and the answers were more positive than other groups. 13 to 20 percent report using stimulants and alcohol use is even higher – obviously a very concerning statistic for us.
Innovative Uses of Clinical, Research, Education, and Multipurpose Space: A Virtual Tour
Six terrific virtual tours of new and reconstructed spaces were reviewed, including:
The Change Imperative Plenary Session: Embracing Changes in Culture
Daphne Koller, co-founder of Coursera, discussed the work in MOOCs. Presented a variety of fascinating strategies and actual data on outcomes and benefits of the pedagogy. Of interest –
Also discussed the potential to use technology to replace and/or supplement individual tutoring (which has best outcomes to learning).
Questions – what about massive offering of medical content for medical schools!
November 3, 2013
Welcome to Philadelphia! Day 3 of the 2013 AAMC brought a fascinating array of topics – and lots of great ideas for the present and future!
Plenary Session: Envisioning Changes in Health Care
Fascinating, frustrating, and somewhat frightening session on the future of the health care system in the age of ACA and HIX. Futurist Ian Morrison took us on a tour of the potential futures, with his prediction that the US will end up with massive healthcare provider consolidation, ultimately ending up with 100-200 large regional centers. The question is will all AMCs be in that group, just some, or none? Private exchanges are likely to take off, and healthcare is likely to go the route of pensions: defined contribution instead of defined benefit.
Four potential scenarios were proposed:
Khan Academy for PreHealth Preparation, the MCAT 2015 and Beyond
This session provided some history of the joint effort between the Khan Academy, AAMC groups, and the Robert Wood Johnson Foundation to produce high-quality, open access educational materials specific to concepts tested on the new MCAT. The work to create a freely accessible content library for premedical students is part of the larger effort to remove barriers to medical school, and has been strongly supported by The AAMC and the general academic medicine community. The balance between fact retention and problem solving within a conceptual framework on the new MCAT was a point of question, but no clear answer emerged during the session.
Many admissions officers spoke of their concerns regarding the removal of the recruitment activities from future AAMC national meetings. Future recruitment events and related logistics will require all involved groups to work together.
Social media experts from med ed discussed approaches to online media and the new AAMC “Toolkit” (available at https://www.aamc.org/members/gir/gir_resources/359492/digitalliteracytoolkit.html) for digital literacy. The group reviewed several of the case studies and had a lively discussion on the “right” answers… and discussed the ongoing and dynamic nature of how physicians and their patients communicate – both online and in person. Educators have an obligation to prepare our students for the world of communication with patients – beyond the one-on-one.
This session discussed research leading to the potential use of a new medical schools admissions test that is comprised of situational judgment tests that address interpersonal and interpersonal competences. There is also potential to use this as a measure of ability to move from one level of medical education to another – i.e., from preclinical to clinical training.
All around a wonderful (and jam-packed) session. Journalist Anna Quindlen compared the gap between providers and consumers to that between newspapers and consumers. Neither have met the changing needs, but unchanged wants, of readers/patients.
She challenged the notion of “MDieties” and asked the profession to focus on “just being kind.” Patients ask their doctors, “Do you know who I AM?” We need to be able to answer yes.
We must teach quality improvement across the curriculum. Schools can combine didactic and experiential learning, link with health system improvement efforts, assess education outcomes in this area, and have role models for quality improvement in educational processes.
A task force has identified 13 core Entrustable Professional Activities for entering residency. The project was initiated to address the international focus on transitions (UME to GME to CME) and the gaps that were identified between expectations of program directors and entering resident skills, and what residents were asked to do without supervision and what was documented that they were competent to do.
Entrustable is defined as “without direct supervision” which is different from a practicing physician. Activities should be viewed as a floor (minimum competency ), not a ceiling, and should not replace mission-critical activities.
EPAs were selected as they represent day to day activities of residents, and are observable. Competencies are abstract and granular. However, there is a connection between EPAs and competencies. All selected EPAs spanned more than one competency.
The task force document identifies the EPA, aligns the EPA with competencies, and provides vignettes of “entrustable ” and “nonentrustable” students.
The longitudinal integrated clerkship was viewed as a better organizational structure for documenting EPAs.
The site team went through a demo of the site. It can now be offered to accepted students prior to arrival using their AMCAS number with school assignment at the time the SRS is complete. We can also now offer the site with tools to our faculty mentors and greater tools to Advisory College Directors. The new site is easier to access and integrates the newsletters and sites for further information on specialties. There are plans for further expansion as well.
Transformative student initiated innovations and developments in medical education.
This session focused on five innovative student led projects in medical education that immersed students in the healthcare of their communities. CMSRU’s own CCCP Ambulatory Clerkship is already at the forefront of best practice. One idea presented was the concept of students as health coaches – with students empowering patients with chronic health conditions to navigate the health care system. This is very similar to what CMSRU does in Ambulatory Clerkship and what we plan for our CLIC. Add in our commitment to service learning and our students are learning and serving our community as part of our innovative curriculum!
The Future of Healthcare and the Learning Environment
This session saw four presentations from panelists discussing new programs for quality improvement and GME expansion. Wayne State and Duke both instituted QI programs that involved UME and GME that also aligned with the hospital’s needs. Duke’s program financially incentivized housestaff to achieve specific metrics. Both programs found success through aligning educational program targets with goals that the health systems desired. FIU and the University of Georgia discussed programs to increase GME in their own states through partnerships/funding from managed care (in FIU’s case) and the state (in UG’s case). Both were in the early stages – more to come!
State healthcare exchanges launched fairly well, but there were very few. Estimates are that 10,000 people will be added to Medicare rolls per day for the next 19 years. Emphasis will need to be on quality, efficiency, and cost reduction. Expected M&A activity will raise anti-trust concerns. With GME, teaching hospitals will no longer be able to count the time residents spend at critical access hospitals for IME or DME purposes.
Personal Competencies: the SJT
The AAMC has a project underway to create a test to measure skills and attributes not seen in the MCAT and in grades. The test will be a balance between cognitive and behavioral issues. This is a aimed at the selection step and is at least five years from implementation. The concerns surround the effects of coaching and faking on outcomes over time and the difficulty in creating enough scenarios.
Keynote Address: Joe Scarborough and Mika Brzezinski
An entertaining hour of political discourse ranging from the adversarial but still collegial relationship between Ronald Reagan and Tip O’Neill to the full-on war between the parties in Washington today. Mika and Joe talked about their own upbringings – including Mika’s dinners with the Pope and Deng Xiaoping, and Joe’s father’s refusal to vote for him when he ran for Congress. Finally, a few predictions for the 2016 elections (with a lot of hedging)… an entertaining evening presentation!
October 31, 2013
Welcome to Philadelphia! We are looking forward to this year’s AAMC Annual Session – a little closer to our home across the Ben Franklin Bridge this year. Follow us as we live blog and learn together!
Saturday, November 2
Leadership Plenary: Our Moment of Truth
AAMC President & CEO Dr. Darrell Kirch discussed his own “moments of truth” through his career, and asked us to consider our own – and how we made decisions in tough situations. And how sometimes we avoided making decisions – and how this was a decision itself.
We will have shared moments of truth together over the coming years – when we must make the difficult decisions that will impact the health of the nation.
Leadership Plenary: Leading the Dance of Change
Dr. Valerie Williams took the crowd through the options of the pace of change by way of a tour of dancing: The Waltz (traditional, stable, organized – as long as everyone moves in the same direction); The Twist (all about personal style – no matter if everyone dances on their own – but inefficient and non-cooperative); the Line Dance (structured and orderly, but one misstep by an individual impacts everyone else – structure and order are necessary, but not adequate); The Tango (powerful, fearless – a combination of order and risk-taking).
We must adapt our leadership skills to the challenges – we must be prepared for “sustained disequilibrium”, ongoing experimentation, and a changing environment.
Annual Address on the State of the Physician Workforce
The past ten years have seen a decrease in the number of rural and African Americans entering medical schools. If the current increase in residency slots of 1% per year continues we will have 2000 less positions than graduates by 2021. 35% of the IMGs applying for residency slots are now from Carribbean schools. There has been an increase in nurse practitioners by 60%. Studies show that 50% of patients do not mind seeing an extender and that number increases if it means being seen sooner. The prediction is that 50% of the physician shortage will be in primary care areas. Schools should give students good role models in primary care. The decline in interest in primary care may be ending. The ACA will amplify the physician shortage numbers.
Education meets Analytics
What we need from analytics: Competency verification (of students AND faculty); Counseling for individual learning needs – help students self-assess; Behavior Modification – help students/faculty see how and why different areas are important in the curriculum; Accreditation – of course; Curriculum evaluation
Hazards: Overwhelming people with data; Unhealthy competition among students; Heisenberg effect
Colleges are great at collecting data, but not very good at dispensing that information back to the students. What data should be shared with students, and who makes that decision? In a perfect world, students should be able to have access to their data (it is their data after all) whenever possible.
Preparing Your Institution for a Post Fee-For-Service World
Provided an interesting set of principles to lead health care organizations from fee-for-service to a value-based system. An emphasis was placed on communications, preparing systems, empowering people, customized strategic planning, and rewards and recognition. The value of visiting places that are innovators in this area was emphasized. The importance of getting an idea of true costs vs charges was presented. Accurate knowledge of costs unlocks opportunities in process improvement. Some articles from Harvard Business Review were cited and discussed.
Evidence-based approaches to promoting diversity in the academic medicine workforce
Great session presenting three different studies examining factors that impact career trajectories for clinical and research faculty. Controlled studies/analyses of existing mentoring approaches, academic milestones, and implementation of new “coaching” models all addressed current successes and failures in building diverse faculty at academic medical centers. One study highlighted that actual conversations are central to promoting change, and virtual or distance efforts to address practices/attitudes do not effectively pave the way for true discussions regarding culture change.
A healthcare delivery model that integrates legal care directly into patient healthcare, and uses three levels of legal intervention: 1) at the patient, 2) at the clinic, and 3) at policy levels — to address and prevent health-harming legal needs. Concepts for interprofessional education of medical and law students were discussed. An outline for a 4 year curriculum was presented. Great ideas for our schools
Six year elections are typically difficult for the party in power in the white house – so, expect loss of democratic seats in both houses of Congress. Very few house seats will be likely to change due to redistricting/gerrymandering and the resulting “safe” seats for both parties – only around 15% of seats are up for grabs. Polling shows that 47% of respondents thought ACA was a bad idea, but only 24% thought it should be completely repealed.
As Ohio goes, so goes the Nation: Shift in statewide elected officials from Democrat -> Republican in 2010 – Democrats lost ability to control redistricting… Gerrymandering created the model of “safe districts” for parties – heavily weighted towards R.
Efficiency, Accountability, and Sustainability: Alternative Models of Medical Education
Buzzwords in this session title were expanded upon – presenting three models of med ed that addressed combining M4 with residency in primary care, an accelerated back to MD, and an accelerated PhD in basic science to MD. Each presented possibilities that are creative and sustainable, but are complicated by the current structure of GME. Key to success in med ed innovation begins with the ACGME. “Competence, not time, should be the benchmark of med ed” — a Sal Khan-esque approach to medical education! We must continue to be innovative in our approach – particularly to the M4 year.
The Jaws are closing on Unmatched Students: Engaging National and Local Perspectives
Lively and busy session today!
Unfilled positions are decreasing as more students are applying. Students don’t match for a short list of reasons: 1) competitiveness (didn’t rank enough programs, too competitive specialty), 2) USMLE scores too low, 3) poor interview/interpersonal issues, 4) overly aggressive rank order list. Schools must counsel students – especially those “at risk” (competitive specialty, below average performance, couples match, etc.) to have a “parallel” plan for less competitive specialty or other option (MPH, etc.). VCU uses match survey, identifies students by red/yellow/green with regard to risk of not matching – identify EARLY and counsel on options, etc.
Council of Faculty and Academic Societies (CFAS)
The inaugural session of this group was held today. CFAS was created to provide a voice for medical school faculty (128,000 strong nationwide!) within AAMC. A few key issues affecting faculty that were identified in today’s session:
1) Increased emphasis on faculty clinical productivity over research and teaching
2) Effects of health system aggregation on the role/value of academic faculty
3) Federal fiscal crisis impact on sustainable research agenda
Implementing the Health Care and Diversity Imperatives in the Post-Fisher World
Successful policy development includes the following: sound educational basis, support by key stakeholders, clear mission/goals, and is lawful. The goal should be preparing effective, culturally competent physicians. Institutions need to develop metrics and track the benefit of a diverse, inclusive student body, in order to demonstrate efficacy of holistic admissions measures. Evidence can include student surveys, alumni surveys, patient outcomes, etc. Metrics matter!
Bridging the industry-academia divide to advance discovery
84% of drug discovery over last decade is from academia. There is a revenue stream from this – and institutions must manage the conflict of interest. Implicit in the push for translational research is commercialization (per the NIH). The curriculum must include instruction in conflict of interest. (and CMSRU has this embedded in our Scholar’s Workshop course!)
Health Care Improvement: effecting and Studying Change Thru Continuing Education, Professional Development, and Lifelong Learning
Important link all three of these approaches. The new equation is Value = Quality/Cost + Pt Centeredness. Consider changing “CME Office” to “Office of Integrated Professional Development”. It’s critically important to focus on the continuum of medical education – undergraduate, graduate, and continuing.
Friday, November 1
Working Within a Team: Navigating Difficult Conversations
This session dealt with preparing students for difficult conversations in the health care setting. How should they respond as members of the health care team when they observe something that isn’t standard of care or something occurs that is a patient safety issue? How do we empower students to speak up without fear of reprisal? Simulation would be a good venue to learn and practice having crucial conversations. OSCEs would a good way to assess student skill in this area.
Future of Medical Education: Opportunity, Innovation, and You—Sponsored by the GRMC.
Regional campuses may be ideally suited for innovation. A variety of innovations were discussed: LIC implementation at regional campuses, interprofessional education, early learners as patient navigators, restructuring the fourth year, faculty development in 10-15 minute sessions posted on U tube, and partnering with other schools to develop a digital library of lectures by premier faculty.
The four sections of the new MCAT for 2015 were reviewed. A validity study is in progress. In 2013 there were 48,014 applicants to allopathic schools in the US and for the first time enrollment was > 20,000. Applicants apply to 15.4 schools on average. Applications from Hispanic/Latino students have increased to 1826 and women comprise ~47% of the pool. 26% of enrollees are socio-economically/ educationally disadvantaged based on parental education and occupation. 19% are first generation college graduates.
October 10, 2013
The last two weeks have indeed been interesting ones nationally and locally. The all too familiar Washington gridlock leading to the government shutdown and the launch of the Affordable Care Act (ACA) highlighted the political turmoil surrounding access to care and how it is funded. While enrollment data are scant so far, the federal health insurance marketplace website (www.healthcare.gov) had over 8.5 million visits during the first week; this should remind us that, in order to care for these patients entering the healthcare system, we must address the present and looming physician and health care provider shortage.
As a quick refresher, we face a 90,000-doctor gap in the year 2020. Despite the appropriate recent focus on primary care, half of this number is specialists. This deficit is projected despite the number of new U.S. schools (of which CMSRU is proud to be one) and the expanded enrollment in most existing schools – even so, we still won’t get there. (In my last blog, I wrote about the collision of the increase in medical school graduates and the insufficient number of graduate medical education positions which will further complicate the issue). Not surprisingly, the physician shortage worsens the challenges of access to care among underserved citizens, both urban and rural.
In New Jersey, we won’t fare any better; New Jersey is 2,800 physicians short of what is needed, most of whom – 1,800 – are specialists. The Garden State, now with four medical schools and 26 hospitals and health systems with residency/fellowship programs, has disturbingly poor retention of these physicians once they complete their education. We rank 30th among states in keeping these groups – not a reassuring statistic in terms of meeting the looming provider shortfall.
Why stop here? Let’s layer another problem on top of this – medical student debt, a topic that’s also appeared in this space. The numbers are staggering: 85% of medical students graduate with an average debt of $162,000. These graduates may feel forced to select higher paying specialties and choose practice locations where the cost of living may be lower or where insured patients predominate.
An option that is gaining popularity nationally is a loan repayment program – after completion of training, physicians with debt can agree to practice for a certain number of years in a state in return for a reduction in debt. In New Jersey, we currently have a program, the “Primary Care Loan Redemption Program of New Jersey”. This plan allows primary care physicians who are NJ residents to obtain $120,000 of loan forgiveness by practicing full time in an underserved area for four years. Some have felt that this program is too restrictive in terms of practice sites and populations, and it has not had the anticipated effect on access to care.
And now, a bill has emerged from the NJ Senate Education Committee, S162. “Physician Loan Redemption Program”, will create a program with greater impact on reaching those citizens most in need of care. The bill will allow graduates of the state’s medical schools and residency programs to have full loan repayment after ten years of practice in New Jersey in underserved urban and rural locations. The bill, co-sponsored by Senators Singer and Vitale, prorates the percentage of loan repayment over the ten years – lower percentages early (5%) and higher proportion (20%) toward the end of the time frame, thereby encouraging participants to continue in the program until completion.
An added, and I believe intended, goal of this plan is this: physicians who remain in plan for the full time will be more likely to stay in the region, serving those same populations most in need of care. And while the sponsors are aiming for approval in 2014 rather than this year, this needs to happen as soon as possible. Every day, more of our citizens are seeking access to care and we must respond.
It’s awfully hard not to like this bill, although some have suggested that this should be left to “the market.” However, it is clear that “the market” has not effectively provided adequate physician coverage for the growing demand. Yes, the state will have to fund the loan repayment, but imagine how much money the state will save in costs of care, especially when these physicians improve the health status of our citizens?
We need this program; we need this bill to get to Governor Christie’s desk for signature. The physicians who enroll in this pay back plan, the patients for who they provide care and the state will benefit. I urge every Garden State citizen to support this bill. Let’s make this happen.
Paul Katz, MD
Cooper Medical School of Rowan University
August 27, 2013
In previous blogs (February 6 and April 15 of this year) I’ve written about the challenges this country faces in graduate medical education (GME) – that is, too many U.S. medical school graduates for too few available residency positions. The physician shortage in our country is accelerating, and despite the projections of a 90,000 doctor shortfall in 2020, many areas of the country and many specialties are already feeling the crunch.
The medical schools have responded – 15 new M.D.-granting schools have started since 2008, and many existing schools are increasing their class size. But the challenge remains at the GME level; most residency positions are supported by Federal funding through Medicare and Medicaid – almost $12 billion annually – but the number of residency positions funded through this program was “capped” at 1996 levels with the passage of the Balanced Budget Act of 1997. Currently, approximately 10,000 residency positions are funded from non-Federal sources—generally by hospitals and health systems eager to expand the GME workforce.
This year’s “match” – the process by which fourth year medical students apply for residency through the National Residency Matching Program and are “matched” by the program that ranks them the highest – showed an increase in applications of 5.8% from M.D. degree schools to a total of over 17,000, constituting half of the total number of applicants (the rest of the applicants are from osteopathic schools and non-U.S. medical schools). After the match, 528 U.S. grads (MDs and DOs) were without residency positions – that is, they did not match. These applicants then enter the Supplemental Offer and Acceptance Program (SOAP), whereby unmatched students vie for unfilled residency positions, a process facilitated by their medical school.
At the end of the SOAP this past year, there remained 61 unfilled residency positions, with 42 in the core disciplines of family medicine, internal medicine, pediatrics, psychiatry and neurology (child and adult). What does this mean for the future of primary care? One can imagine that in certain highly competitive specialties, American graduates may have to travel overseas to receive training. Or perhaps pay “tuition” to enter U.S. programs. Even today, it is likely that some graduates choose primary care residency positions only because they are available, not because that’s what they really want to do. This does not bode well for a long-term career in primary care.
So what awaits us? The intersection – or perhaps more descriptive, the collision— between an increasing number of medical school graduates and an insufficient number of residency positions is upon us, only to worsen as even more students graduate (see this article from John Iglehart from a 2013 NEJM). The obvious response is more Federal funding of GME positions. However, the Obama Administration’s recommended reduction in GME support of more than $11 billion in the next ten years is not a cause for optimism. Alternative mechanisms of funding (for example, contributions by insurers; new legislation) seem unlikely.
The Council on Graduate Medical Education (COGME) released its twenty-first report this month (here); COGME is an almost 30-year old group authorized by the Congress to address physician workforce issues. Its 17 members issued this report recognizing the looming crisis in GME, not just in terms of number of physicians but also with regard to the nature of the training, the primary care shortage and the remarkable changes that are occurring in care delivery. COGME developed six recommendations – increase GME funding; focus funding on those specialties currently under represented in the workforce; improve the efficiency of training; revise criteria for recruiting medical students and GME training based on populations served; revise curricula for students and residents maximize quality and safety; and increase the funding in medical education research.
COGME should be commended for these recommendations – we can only hope that they are taken seriously by those in a position to effect these changes and support them with the requisite funding. Ironically, since 1997, the funding of new GME slots has largely been due to the response of states, communities, and hospitals and health systems rather than the Federal Government. This decentralized approach has not resulted in growth of nationally underrepresented specialty workforce, and has also missed the mark on educating students and residents on critical issues of patient safety and quality.
In order for the COGME’s recommendations to be followed (as one example), Medicare funding for residency positions could be weighted – that is, more funding for a family medicine resident than an orthopedic resident. To push the agenda of patient safety and quality, GME sponsoring institutions could be required to demonstrate outcomes for their trainees based on quality measures, efficiency of care and post-residency practice location. Each of these methods would not require more Federal funding but rather would effect a redistribution of the current allocation.
Historically, GME funds have been provided without concomitant insistence upon demonstration of utility and efficacy. Now is the time for a change.
Paul Katz, MD
Cooper Medical School of Rowan University
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