May 14, 2013
Dean Katz and I recently attended the last meeting of the New and Developing Medical Schools funded by the Josiah H. Macy, Jr. Foundation. The group was first convened in 2009 when the Association of American Medical Colleges (AAMC) sponsored a conference of “new and developing medical schools.” In 2010, the Macy Foundation provided a generous grant to support meetings and activities of the 16 new schools. Over the years, the group has served many functions beyond merely giving advice and support on Liaison Committee on Medical Education (LCME) accreditation. It has served as a support group and sounding board for those with like experiences; a place to network; and a forum for innovation and problem-solving. CMSRU has been a beneficiary of the largess and camaraderie of the group. On a personal level, friendships have been forged. This particular meeting was somewhat bittersweet because it was the last meeting that will be funded by the Foundation.
George E. Thibault, MD, President of the Macy Foundation, made opening remarks that called for the need to make more of a “push for innovation.” He also proposed that this is an opportunity for us to change educational models and, in essence, take advantage of the uncertainties in healthcare to advance education. His messaging resonated with the group. Dr. Thibault outlined six areas for focus and change in medical education:
The group went on to hear various reports including observations from Warren D. Anderson, PhD, the ethnographer who visited several of the new schools and gave us new insights into the relatively unique phenomenon of creating a culture de novo. We brainstormed about various writing projects and spoke about our future as a group. While this particular chapter is ending, it is just the beginning of our story.
We will be forever grateful for the support of the Josiah H. Macy, Jr. Foundation and the spirit of collaboration that has been fostered among the new schools. On to the next chapter!
Annette C. Reboli, MD
Cooper Medical School of Rowan University
April 23, 2013
After a week of Spring Break, our Charter Class began gross anatomy. Traditionally, anatomy has heralded the start of one’s medical school career and adds to the “shock and awe” of beginning a career as a physician.
The CMSRU curriculum is different, as chronicled in this blog. In the fall curriculum, when our students traveled through the aptly named Fundamentals course (among others),they were exposed to the basic elements of cell biology, genetics, physiology and the related material typical of the first year.
With the new year began the transition to the organ system blocks that will extend into the second year. With Infectious Diseases and Hematology/Oncology now complete, Skin and Musculoskeletal System coincides with the start of gross anatomy, where dissection will parallel the remaining organ system experiences.
Some three years ago, as the CMSRU curriculum was being planned (concurrent with the design of the Medical Education Building), our discussions focused on whether dissection and anatomy as most of us experienced in the past were still necessary. With the associated costs, required infrastructure and regulatory requirements, as well as the increasing availability of skilled prosections and elaborate virtual tools, there has been a trending away from “classical” gross anatomy.
Ultimately, we at CMSRU decided to retain this traditional model of student dissection (albeit with a very different timing and integration with organ-based courses). We believe that only part of what occurs and is learned in the gross anatomy laboratory is really about anatomy. If one thinks about what should occur in the lab, the opportunity to learn about professionalism, dignity, respect, teamwork, communication and personal reflection clearly trumps the memorization of the branches of the facial nerve or the location of the Ligament of Treitz. And it is those “competencies” that are learned during this time that will hopefully long endure in our graduates, far beyond their recollection of most anatomical details.
As has become customary at many medical schools, CMSRU held a ceremony to mark the start of gross anatomy. As has been the case with all of our “first time” events, there was much anticipation about this session for students, staff and faculty. And, like our other inaugural gatherings, we wanted to make it special and memorable. I was asked by our faculty director of gross anatomy to make some opening remarks that prompted considerable thought on my part.
Much has been written about the significance of this course. Phrases such as the “humanity of anatomy” and “dissect with respect” are frequently found. As I have toured guests through our building over the past nine months, I always talk about a physician’s medical school anatomy experience as one that is never forgotten – it is a defining moment of becoming a practitioner. The sites, the sounds, the textures and the smells remain with us forever, as well they should.
I asked the students to think about those people, now deceased, who will leave an indelible imprint on them. They were mothers, fathers, sister, brothers and parents. They are now “paying it forward” by serving as a resource for the education of those who will spend hours and hours with them over the ensuing months. I suggested to the students that the term “cadaver” was impersonal and somehow commoditized those who now lay before them at the dissection table. Their hopes, their dreams, their failures and successes, were unknown to all of us, but no less tangible than those of the next “real” living patient each class member will encounter.
An unintended consequence of this ceremony was visible of the faces of the physician faculty in attendance – this event, this CMSRU event, crystallized for each of us what it has meant to have the privilege of being in our profession. Of course, we recalled our experiences in our own gross anatomy labs. But more important for me at least, was thinking about the wonderful, magical careers that await our students and the special moments that they will share with those for whom they provide care. I wish them well.
Paul Katz, MD
Cooper Medical School of Rowan University
April 15, 2013
The men’s and women’s NCAA basketball tournaments are now over, after spilling into April. March was filled with a number of other memorable events – the sequestration of the Federal budget in Washington, DC and the sequestration of the Roman Catholic Cardinals in Rome; at least one of these is now over.
But the other big event in March, certainly for the nation’s medical students who will graduate next month, is the National Resident Matching Program (NRMP), known to those in medicine simply as “The Match”.
In this process, fourth year medical students “rank” the residency programs in a given discipline (e.g., medicine, psychiatry, etc.) that interest them, following a national application process. Residency programs do the same, ranking the applicants in order of preference. Following some electronic gymnastics, each student “matches” their highest ranked program with the program that ranked them the highest and, voila! The next three to five years of your life are locked in.
Previously in this blog, I have written about the impending shortage of Graduate Medical Education (GME) “slots” in the U.S. While most residency programs are hospital-based and receive funding from Medicare for the direct and indirect costs of educating residents, the number of federally-funded positions has been “capped” at 1996 levels by the 1997 Balanced Budget Amendment. The result of this cap is that hospitals, health systems and medical schools have had to find alternate sources of funding if they wished to increase their complement of postgraduate physicians-in-training. For many residency-sponsoring organizations, while this has resulted in considerable expense, expansion is still undertaken because of the organizational mission for medical education, and also because residents shoulder much of the workload for patient care.
So now what happens? The dire predictions of the 1980’s (when it was anticipated that there would be a glut of physicians) have not come to pass. Instead, there are a large number of baby boomers approaching retirement age, and post-retirement Americans are staying healthy and living longer. Add to this the Affordable Care Act that will finally and thankfully give new access to insurance for 40 million Americans, and we now have an anticipated physician shortage in 2020 of 90,000. Despite the added number of graduates from 15 new medical schools (such as CMSRU) and despite the expansion in class size at most existing schools, these deficits are still projected.
Now back to today’s issue (and as you’ll read – it really IS today!) – an increasing number of U.S. medical school graduates are trying to enter a fixed number of residency positions.
Guess what? When the music stops on Match Day, there aren’t enough chairs for everyone. So while this logjam has long been expected in the next several years, it is actually here now. We now have (as of this week, just a month after Match Day) slightly over 500 soon-to-graduate U.S. medical students who do not have a residency position for July 1. Almost hard to imagine.
We can explain some of this on the microeconomic principles of supply and demand – graduating students are flocking in large numbers to more lucrative or better work-life balance specialties – dermatology and emergency medicine, for example – and less into primary care programs or disciplines requiring longer residency training. Eager to fill all vacant residency spots (remember, the workload carried by residents is real and critical to the function of hospitals), GME programs have frequently accepted non-U.S. citizens into their programs or, in what is a troubling trend, “selling” these spots to offshore, for-profit medical schools through “partnership” arrangements.
So what’s the solution? Regrettably, none are easy and many are just not feasible. Increasing Federal funding of GME spots or mandating that health plans contribute to supporting new residency positions is often discussed. Both are noble goals and have desirable outcomes, but there is not optimism that this will occur. Two bills in Congress deserve our support and the support of our legislators. Bipartisan Senate Bill S. 577 and House Bill H.R. 1201 speak to adding 15,000 new federally-supported residency positions. Sadly, these bills are unlikely to pass in the current economic climate.
In a previous blog, I wrote about options that might be effected by GME-sponsoring institutions. In an upcoming blog, I’ll try to address some of the options that might be available on the “funder” side, most notably the federal government and the states.
Paul Katz, MD
Cooper Medical School of Rowan University
March 4, 2013
Early in my career as a rheumatologist, treatment options for rheumatoid arthritis (RA) were limited. Drug toxicity and lack of efficacy left us with few good choices for our patients. In desperation, those with RA turned to alternative therapies, many of which were untested, but offered (at best) anecdotal hope. Copper bracelets, bee venom, and sessions in vacant uranium mines were among the “cures” that were untested but available.
As providers of care, our frustration equalled that of our patients, but we had little to defend avoidance of these putative “remedies” without a better understanding of the possible adverse consequences. Certainly, we had scant data to dismiss possible efficacy.
Fortunately, we now have new RA drugs which work and are less toxic. Additionally, the medical community has expanded its acceptance of “non-conventional” medicine based on controlled, scientifically sound studies that show benefit.
We have moved, however, into a new era. No longer are these “miracle cures” just for serious, disabling, or terminal illnesses. Now, an increasing number of interventions are touted to prolong our lives, help us lose weight, prevent disease and promise that we can, in fact, become thinner, healthier, (dare we say) younger, and (of course) happier. The media, internet, television, etc. have fostered this growth – packaged and presented in enticing and attractive ways by equally enticing and attractive hope mongers, and supported by testimonials from those who have made it to the end of the rainbow.
So now we, as health care professionals, face an even larger challenge than in the past: How do we interact with our patients who comprise this very large group of “worried well”? Those patients who want more than just a cure for disease, but now a magic bullet for everlasting wellness?
Consumer driven health care is here and that’s a good thing. Similarly, the national focus on prevention and healthy lifestyles benefits us all. Unfortunately, many new “wellness interventions” are unsupported by any scientific evidence. Nonetheless, our patients frequently dismiss not only our own individual lack of knowledge but also medicine’s lack of scientific support. After all, isn’t Emmy winner Dr. Oz “America’s Doctor”? How can we possible doubt him? (I refer you to the February 4th issue of The New Yorker for a fascinating read).
What we cannot do is close our minds and become glib and dismissive of our patients who are followers of media medicine. We need to encourage them to become “health literate”, of course, and advocate for their wellness. But it is incumbent upon us to be knowledgeable about what’s out there and become “informed providers” about non-traditional approaches to health so we can support and discuss these topics rationally with our patients who are “informed consumers”.
Let’s be honest – promises of miracles and easy fixes (frequently associated with a hefty price tag) aren’t going away. But we need to take this opportunity to educationally arm our medical students, residents, and yes, ourselves with the tools of information literacy, critical thinking, communication skills and business savvy. To paraphrase Jerry Maguire, we need to “help them help their patients” through curricular experiences that address the “Mehmetization” of medicine. Let’s respond to this challenge, not ignore it. We owe it to our learners and to those they will care for.
Paul Katz, MD
Cooper Medical School of Rowan University
February 6, 2013
In a recent “Financial Page” article in The New Yorker, Joseph Surowiecki addresses “…a classic economic dilemma, known as the sunk-cost effect” – that is, the reticence to make changes on the premise that it is tough to move away from previous investments even when performance of the asset is not what it was expected to be.
The example utilized is Mark Sanchez, the beleaguered quarterback of the New York Jets, who has had bad back-to-back seasons. The Jets, now holding a contract that will pay Sanchez $8.25 million dollars next season, face the dilemma of either sticking with him and their already sunk-costs on the hope that his and the Jets’ performance will get better, or cutting their losses and making a change for the potential improvement of the team. Paraphrasing the author, the former choice is one of self-justification masquerading as patience.
By no means am I going to compare the quandary of funding graduate medical education (GME) with the problem faced by the Jets, but there are some similarities – in the absence of a solution by the President and Congress that will avoid (or at least mitigate) the looming reduction in Federal support of GME, what will we, the providers of resident and fellow education, do to respond to these cuts?
Compounding this challenge will be the looming absence of enough GME positions to accommodate the increasing number of medical school graduates. Perhaps U.S. medical school grads will need to leave the country to train in the specialties they desire. Will they now become the new international medical graduates?
So what might some of the on the ground responses be to this crisis? We, like the Jets, can hope that things will work out through patience and perseverance – that is, somehow Federal GME funding, or non-governmental sources of funding, will be enhanced or at least maintained and we can move forward with the status quo approach. Alternatively, institutions with GME programs can, collectively or individually, proactively develop new models of education.
We need to rationally examine our organizations’ distribution of GME positions. Tough choices will need to be made to prioritize based on regional market demand for primary care physicians and selected specialties; reallocation of “slots” from overpopulated specialties to those in greater demand must occur. The argument will be made that “service needs” (i.e., cheap labor) dictate preservation of fellowship training positions and programs. Institutional and leadership commitment to appropriate distribution of positions must be unwavering.
Some medical schools are moving to a reduction from four to three years for students entering primary care residencies. Such trends are laudable and need to be broadened. The subsequent reduction in tuition dollars will negatively impact the finances of such schools. Perhaps partnering with hospitals to provide qualified graduates that will fill those spots – in return for funding to make up the medical school shortfall – might create a “pipeline” into residency programs, mitigate the loss of tuition, reduce hospital costs, and actually build a primary care workforce.
In this regard, medical schools and hospitals need to approach the accrediting bodies for undergraduate and graduate medical education and lobby for change. Let’s begin to think about seamless transitions from medical school to residency with integrated curricula that span the time from matriculation through completion of post-graduate training. If (as most agree) the clinical years of medical school have become merely a preparation for GME, then integration across programs makes much sense, and significant efficiencies can be obtained through collaboration and integration. Similarly, careful scrutiny of both the duration of medical school and GME training is necessary. The Flexnerian four years of medical school may be arcane – the literature is rich with discussions of the “lost” final curricular year to offsite residency “auditions” and electives of marginal value. The Residency Review Committees of the Accreditation Council for Graduate Medical Education should undertake gloves-off reviews of whether reductions in training time will really have any impact on the quality and experiences of trainees.
Institutions with GME programs should consider finding economies of scale and consolidation of activities to reduce expense and enhance value. Generally, individual residency programs operate in camera within a hospital – for example, the development of centralized core curricula (“themes”) across specialty programs can ensure consistency and save dollars. Consolidation and centralization of GME personnel and infrastructure, while certainly accompanied by fears of loss of control by the individual programs, have successfully been implemented.
And there are many other options to consider. Hospitals need to consider ways of delivering care that reduce reliance on physician trainees. One of the alternatives, for example, use of nurse practitioners, may be more costly than the use of residents and fellows. But what about creating “education and care” teams of residents, NP’s, physician assistants, etc? Interprofessional education and team care are now accepted as the future of medical education and care – let’s start creating these environments and partnerships now. All learners, and ultimately, all patients, will benefit.
With all due respect to Mark Sanchez, I believe the Jets need to make the tough call. We in medical education can do so as well.
Paul Katz, MD
Cooper Medical School of Rowan University
January 16, 2013
“Life’s most persistent and urgent question is: ‘What are you doing for others?’” – Martin Luther King, Jr.
As a person whose job revolves around community affairs, January is a very exciting time of year for me. I love hearing all the chatter from family, friends, neighbors, and members of various local organizations about their plans for the Martin Luther King – Day of Service. The ideas, programs and events are many – from feeding the hungry, to visiting the sick, building playgrounds, restoring homes, and holding various services in remembrance of Dr. King. This is the time when the opportunity to make a difference is great. The energy level is high and the passion is there. Yet many organizations find themselves feeling like a priest at Easter Sunday mass – looking at a sea of people and wondering just what the right message is to get them to keep coming back. This is a task our inaugural class will face as they enter into their first Day of Service in Camden next week.
When Congress first passed the King Holiday and Service Act in 1994, they asked that all Americans participate in a national day of volunteer service as a way of celebrating Dr. King’s legacy. The idea was to bring people from different backgrounds together, break down barriers and act on community concerns. These ideas are very much aligned with our mission at CMSRU. Our students have already been engaged in independent service projects in Camden and in their local communities. On January 21st, they will all come together as a team to address one of their biggest concerns – the health and wellness of the nation’s youth. Showing great concern for the increase in childhood obesity, the students have designed a “Healthy Habits – Healthy Community” program in an effort to show kids that they can be active and make good choices in any environment. Through this program, they will engage the youth in exercises and healthy food preparation, and then ask that they share these lessons with their peers, families and communities.
Dr. King dreamed of bringing people and communities together across all boundaries and barriers. As I sit and reflect on the diversity of our class, the service that they have done in the past, are doing at present and planning for the future, I can’t help thinking that they are already living his dream. I look forward to joining our students in their efforts not only on Monday but throughout the year.
As you make your own plans for the MLK Day of Service, remember that Dr. King stood for peace, justice and freedom. He looked for ways to empower others and strengthen communities. How will you make a difference? The time is now.
Jocelyn Mitchell-Williams, MD, PhD
Associate Dean for Multicultural and Community Affairs
Cooper Medical School of Rowan University
December 19, 2012
The unthinkable, mind-numbing events in Newtown, CT leave us with questions without many answers. How did this happen? What could have been done? What can we do to prevent this dreadful nightmare from recurring? And in this regard, what can the medical education community do? At the same time as this story unfolds, our own city of Camden, NJ experienced its 67th homicide for the year – surpassing the old, distressing, “record” of 58. And there are still two weeks left in 2012.
In the coming days and weeks, we will certainly learn more about the tragedy in Connecticut – more about the shooter, his background, his medical history and his guns. But what do we do to prevent another Columbine, another Aurora, another Newtown? What do we do to prevent another gun-related death in Camden?
Much of the discourse will again center on gun control, as politically charged a topic as there is, and let us hope that the outrage over Newtown doesn’t dwindle over the holidays and New Year’s celebrations. This is a political and regulatory matter, yes. As the President said in Newtown on Sunday: “These tragedies must end.” Hopefully, the determination exists to do what is right and what is necessary. While the “right to bear arms” is a civil liberty, isn’t it a civil liberty to be able to send our children to school without concern that they will be massacred? To have the chance for “life, liberty and the pursuit of happiness”?
Gun violence is a health issue. Not merely because the medical community provides care for the victims of shootings and not simply because of the human and economic costs associated with these deaths. But because we, as the medical community, have a responsibility to help prevent this brutality. How can we help?
Let us lobby our legislators with the same fervor as we do when we ask them for physician payment reform and NIH funding. We have an obligation to advocate for measures that will reduce the likelihood of gun-related injuries and deaths. Who better to carry the message about the health of the public?
Let us promote expanded behavioral and mental health services to provide care to those at risk for perpetrating the kinds of acts just witnessed. As providers, let us have the courage to speak up about the patients and families for whom we care and who we believe may injure others.
Let us speak with our patients about guns in the house and the implications thereof, in the same ways that we counsel them about smoking, alcohol, seat belts, and obesity.
Let us visit schools and civic organizations to discuss gun violence and to talk about the bodily damage firearms can do, just as we do when we show them photographs of alcohol-related automobile deaths.
Let us, as the educators we must be, provide curricula and educational experiences that will permit our learners to understand gun violence to the same extent that they know diabetes and heart failure.
Let us seek to understand, to the extent possible, why the U.S. leads all developing nations in gun ownership rate and in gun-related homicides.
And finally, and as painful as it is (and seeing just the partial list – it is very painful), let us not permit ourselves to forget the Newtowns, the Oak Creeks, the Auroras, the Fort Hoods, the Virginia Techs, and the Columbines of our country until we can think of them for something other than these senseless deaths.
Paul Katz, MD
Cooper Medical School of Rowan University
November 28, 2012
In November of this year, Rowan University invited Ms. Rebecca Skloot to campus as part of the President’s Lecture Series. The book was also part of a broader initiative on campus, the RU Reading Together Common Reading Program, which brings together a wide range of educators and students across all of Rowan’s campuses to discuss books with significant cultural and educational impact. Read more about this program here.
Cervical cancer is no stranger to me. I have seen it at its worst. Perhaps that is one of the reasons that I was so intrigued by the book, The Immortal Life of Henrietta Lacks by Rebecca Skloot. It is the true story of a poor black woman who died from cervical cancer in the early 1950’s. Cells from a biopsy taken from her cervix were used to create a cell line (without her consent) that continues to grow today. Used by a broad array of scientists, this cell line has been the key to many medical discoveries, including vaccines and cancer treatments. The continued existence of these “HeLa” cells, as they are called, and the subsequent billion-dollar industry that resulted from their sale, were facts unknown to the surviving members of the Lacks family for decades after her death.
I was part of the committee that invited Ms. Skloot to speak about her book at Rowan University in November. Her audience would include the fifty students from the Cooper Medical School of Rowan University’s inaugural class, as well as over 500 members of the broader Rowan community. The medical, ethical and social issues touched upon in Skloot’s book made it a perfect choice as a required read for our charter class. As an institution that places emphasis on humanistic education in the art and science of medicine, it made sense to have our students read a book that sheds light on the controversial past events that have led to change in research policy, regulation and medical practice today. It also afforded them the opportunity to reflect on their own personal feelings regarding disparate healthcare and social justice.
At CMSRU, we have worked hard to create a curriculum that will expose our students to more than just the science behind medicine. Prior to Skloot’s talk, medical students had the opportunity to discuss issues brought up in the book, including informed consent, patient privacy and financial disclosure, in their course, The Scholar’s Workshop. In another course, Foundations of Medical Practice, key aspects of cultural competency were addressed, especially those dealing with underserved, minority populations. Students have also been working with the uninsured and underinsured at their Ambulatory Clinic and service learning sites. These experiences provide striking real-life examples of the impact of socioeconomic status on access to and utilization of healthcare in our own community. The goal is that our students will use this experience and knowledge gained to become culturally sensitive physicians and leaders of real change in our national healthcare system.
Change, however, is no easy task, nor does it happen quickly. It took Rebecca Skloot nearly ten years to complete her story of Henrietta Lacks. This was in part because of cultural and trust barriers she faced with the community and members of the Lacks family. As I read Rebecca Skloot’s book, it brought back vivid memories of moments during my own ob/gyn residency – memories of diagnosing my first advanced stage cervical cancer patient, and then my second, and then third – all young African American women, diagnosed too late to make a difference. The scariest part – this was just a short fifteen years ago. Even today rates of cervical cancer remain higher in minority populations and it remains difficult to convince eligible patients to be screened and receive the HPV vaccination – a proven way to prevent many cervical cancers.
Despite the regulatory changes brought about by the social wrongs of the Henrietta Lacks case and the Tuskegee syphilis experiments (read more about this here), mistrust of medical care and healthcare research by vulnerable groups persists, and continues to be a major barrier to these at-risk populations receiving adequate health care. The wounds of past injustices are deep, and unless consistent efforts are made to heal, preventative care in general will remain a challenge for our future doctors.
As I listened to Ms. Skloot talk about the relationship she eventually developed with Deborah, the tough-talking, no-nonsense daughter of Henrietta Lacks, it left me hopeful that with persistence, patience, and compassion, today’s medical students can build caring and trusting relationships with those they serve. Engaging our medical students with the community early and often will hopefully accelerate the rate of change, and begin to reverse the many health disparities that exist in “Camden our classroom. Camden our home.”
Jocelyn Mitchell-Williams, MD, PhD
Associate Dean for Multicultural and Community Affairs
Cooper Medical School of Rowan University
November 14, 2012
In the fall of 1969 I entered the Georgetown University School of Medicine. We numbered 120 – thirteen women, (one of whom was African American, two who were Catholic nuns), two African American men, and 105 white men who were largely from the northeastern United States. A pretty homogeneous lot.
In the late 1970’s, Allan Bakke was denied admission to the Stanford’s medical school; at that time, Stanford had set aside about 15% of its medical school slots for “minority” students. Bakke challenged this alleged “quota” practice as unconstitutional and his case made it to the Supreme Court – Regents of the University of California v. Bakke. The court ultimately ruled in favor of Bakke.
Fast forward to 2003. In a Supreme Court case emanating from the University of Michigan’s law school – Grutter v. Bollinger – the Court opined that the race could be a factor in admissions’ deliberations in order to enhance the education of all students through exposure to students from different a variety of backgrounds than their own. – therefore, the The intent was not to enroll minority students via a quota system per se, but rather the goal was to create a diverse educational environment for all students regardless of race.
Last month, the Supreme Court heard oral arguments in the case of Fisher v. the University of Texas. As background, the University of Texas system developed a “Top Ten Percent” plan in 1997; students in the highest decile of their high school class are guaranteed admission to a state university. As a result of this program, racial diversity increased in the system – and filled 80-85% of the entering class. For students not accepted through this plan, a secondary applicant pool was created, where other factors, including race, were evaluated.
Abigail Fisher was initially denied admission to the University of Texas in 2008 since she was not within the top 10% of her high school class. Her application was then evaluated in the second cohort; she was again denied admission. In the case before the Court, Fisher’s attorneys argue that the “Top Ten Percent” plan had already achieved diversity in the University system and that any inclusion of race in the evaluation process (and therefore, her rejection) was discriminatory. A decision from the high Court is expected in the spring.
Justice Elena Kagan has recused herself from this case due to her prior involvement while she was Solicitor General, thereby leaving eight justices to decide the Fisher case. Speculation is considerable on the outcome, but a 4-4 deadlock is a real possibility.
So what are the implications of a decision in favor of Fisher? Profound, indeed. If the Court decides for the plaintiff – and in the discussion brief essentially overturns Grutter – higher education institutions would be unable to use race as a factor in their admission decisions. In many ways, this could cause a reversion to a primarily metric-driven selection system, thereby leaving us with classes of students who have exceeded an admission threshold, but who may not have the background to assist in creating a multidimensional classroom, as the court had supported in Grutter.
Even putting aside the elimination of the option of using race and other variables as means to create a diverse educational environment, we should anticipate a diminution in the caliber of the learning experience. Neither result is positive for anyone.
In 1969, neither my classmates nor the administration of the medical school thought very much— likely not at all— about whether the lack of diversity in our class would limit our capabilities as physicians. I suspect it did have a negative impact on us.
In a new medical school such as ours, where we have embraced diversity in its broadest sense, this outcome would significantly imperil our ability to fulfill our mission. At the end of the day, this reductionist mandate would most severely affect the patients our students will treat – best served by practitioners with varied experiences and backgrounds, they will be cared for by “less complete” physicians.
Can this possibly be a good thing?
Paul Katz, MD
Cooper Medical School of Rowan University
November 2, 2012
Thanks for joining us at the 2012 AAMC meeting in San Francisco – we learned a LOT!
Wednesday, November 7
What Should Faculty Know About Social Media?
In this small group discussion, various consumers (or non-consumers) of social media were discussed (“silent generation”, baby boomers, GenXers, and Millennials). Millennials are the only group that are “digital natives” who are “fluent” in technology. The rest of us are “digital immigrants” and “speak technology with an accent.” (great phrases, no?) As medical educators, we need to define competencies for and strategies around social media education. One of the critical items is the ethical mandate – patient privacy is paramount. However, the positives around social media are many – but need to be shared, taught to faculty. It’s difficult for non-user faculty to teach our students about social media, so we must engage with students who are active users. And find “twentors” (twitter + mentor = twentor).
Tuesday, November 6
An Institution-Wide Approach to Improving LGBTI Health
In a session run by a Vanderbilt medical student and faculty member, the experience of raising LGBTI awareness was discussed. Using forceful advocacy, they convened administrators at the highest levels of the healthcare delivery system and the school to design and implement plans to recognize the rights and needs of this underserved and (in many ways) disadvantaged population. A terrific model for us to follow!
Defining Milestones for Undergraduate Medical Education
Milestones is the next step in meaningful assessment. There is a misconception that competence in an activity is adequate – but competence is only a minimum threshold to allow someone to do something without supervision. Two competencies have been added to the paradigm, 1) interprofessional collaboration, and 2) personal and professional development.
From Vygotsky to videos, from Piaget to puppets – Integrating the art, philosophy and science of teaching and learning to activate learners and promote meaningful learning in many contexts
This highly interactive workshop led the group through the theory of learning, reintroducing the concepts of Piaget, Grow, Bloom, and others. We were then entertained and taught by Sarah Forgie, MD using her creative and fascinating songs, student music videos, and other creative tools – all designed to teach infectious disease topics. The group even got to compose their own creative teaching tools – and resulted in some songs, performance art, and other fascinating takes on (a new word here…) medutainment!
Red or blue, this engaging morning discussion by Dan Schnur was a terrific romp through this election cycle. Think a candidate changes what he says depending on the audience (and don’t they all?) – check out Red Skelton and his two-sided (Confederate/Union) flag in the movie “Southern Yankee.” What was the most important demographic in the 2012 presidential election? According to Schnur, married women. Why didn’t anyone talk about healthcare reform in this election cycle? Too complicated to explain, and no political incentive for either party. Finally, a great question… Why do we need a crisis (e.g., Sandy, Katrina, 9/11) to allow the political sides to cooperate? Whew!
Mini-workshop: Expanding the role of medical educators to the world of social media
Love it or hate it, social media (in some form or another) is here to stay. The three workshop leaders took the group through some actual published and peer-reviewed data on social media use, shared anecdotes from their own journeys into the wilds of Twitter, and gave a tutorial to beginners and intermediates on the topic, including how to use twitter, a primer on hashtags, twitter chats, twitter clients, and building a base of followers. Check them out @MedPedsDoctor @Kind4Kids @RyanMadanickMD Or, join Thursdays at 9pm (Eastern) @MedEdChat
Monday, November 5
Future of Medical Education: Transforming the Health of Our Communities
Social mission is the contribution of a medical student to addressing the unmet health problems of society. Currently there are 50 million people without insurance, access to care. Research in this area – six schools dedicated in a study to social mission. Critical aspects include a mission statement that reflects the social mission, pipeline cultivation, admissions process highlighting social mission match, curricular content, community locale of curriculum, tuition (cost) management, mentoring and role modeling, and preparation for residency.
Saturday, November 4
Engaging the Military in Academic Medicine
Panel discussion on what AMCs should do regarding engaging the military. Key ideas/thoughts:
* To be effective in engagement, AMCs should learn about the defense health system – the largest health system on the planet. When conflict occurs, the national guard and reserve are the primary assets.
* AMCs must listen to needs. Need a stable training platform in the AMC to sustain education and training to wounded military.
* Must provide a GREAT curriculum, applying adult principles in education. Simulation plays a very large role in this.
* Need to have an exchange of value – find the “win-win”.
* Need to think BIG – tie together multiple institutions and functionalities into one space.
Strategies to Address the Generalist Workforce Shortage
Generalist residency programs are struggling – family medicine attracts only 8% of all medical school graduates – an all-time low. There is increasing subspecialization in internal medicine, pediatrics, family medicine, and general surgery. Solutions will include new payment models, new delivery models (patient centered medical home, team-based care, telemedicine, physician extenders), new training paradigms (shortened medical school, generalist tracks, loan forgiveness programs). However, none of these solutions are likely to narrow the gap by 2020.
Simulation Enabling a Learning Health System
Reviewed a live and video simulation done onsite with full patient care staff designed to improve care and patient outcomes. The simulation expanded the reach of simulation “beyond the mannequin” and follows the tenets of interprofessional education. Simulation can be used (for example) to plan movement of patients throughout the hospital during surge. Has the potential to be used during the accreditation process.
Traumatic Brain Injury Education
We learned that traumatic brain injury (TBI) is actually twice as common as stroke, and we have limited ability to treat the 1.7 million new TBI per year. 73% of those in the military today with mild TBI have a diagnosis of PTSD and depression. It is critical to teach TBI across disciplines. (As an aside, CMSRU is covering this topic in multiple areas of our curriculum, including multiple M1 courses.)
Annual Address on the State of the Physician Workforce
AAMC predicts over 90k physician shortage with Affordable Care Act (ACA) – 64% without ACA. Only half of this gap is primary care physicians. AAMC has called for a 30% increase in enrollment by 2020 – and now we are on target to due so, with 1/3 of that growth from new schools.
URM enrollment has increased by 500 per year wince 2002, with new schools as a big driver.
There has been only a 1% increase in GME positions from 2002 through 2012. Currently 7,000 international medical graduates (IMG) enter PGY-1 positions annually in the US. This is equal to the number of additional students entering medical school – so there will undoubtedly be a squeeze on residency slots.
It is predicted that 25% of PGY-1s will become primary care physicians. There has also been a 34% increase in the number of “controllable lifestyle” residency positions since 2002 (great term! – includes emergency medicine, dermatology, anesthesiology). UWashington data says that 1/3 of PCPs in that state are part-time – also considered “controllable”.
Project-based Learning in Clinical Safety & Effectiveness
Much of the session was devoted to descriptions of programs at various institutions aimed at educating practitioners on patient safety, performance improvement, and clinical effectiveness. The programs have variable success rates – and one of the challenges is educating practitioners about the basics of patient safety and performance improvement late in their careers.
Innovation Arc – New Approaches
Fascinating and informative session with Salman Khan – founder of the Khan Academy (KA). Discussed the history of the KA, which started from tutoring sessions for Khan’s cousins in math – and now encompasses videos in 1000 languages with hundreds of covered topics and millions of views. Discussion on how, instead of having a fixed amount of TIME for learning, time becomes a variable, and the FIXED item is knowledge or performance – with the student taking as much time as necessary to learn the building blocks of later learning – i.e., everyone gets an “A” – but some may take longer to get there.
Fisher v. University of Texas
Enlightening discussion of the pending Fisher v. Texas case, currently in deliberations at the Supreme Court. Discussed the background of the case, including Regents of the University of California v. Bakke (1978), and the more recent Grutter v. Bollinger case in 2003 – where the U Mich Law School argued that there was a “compelling case for diversity” in the classroom.
SCOTUS case will look at what the goals of using race in an admissions decision are, and what are the means to this goal. It was generally felt that SCOTUS was unlikely to disagree with the goal (the above “compelling case for diversity”), but could take issue with the means that UTexas has used. Grutter case allowed the reintroduction of race/ethnicity into the equation, and the lower court in Fisher v. Texas upheld the UT methodology on these grounds, among others.
Key issues will be whether there is a) necessity and material impact of the methods, b) a “critical mass” effect, and whether the court is willing to overturn Grutter. One of the biggest challenges is that is is clear that quotas are a no-no, and a vague impact is a no-no – but there exists some in-between that is REQUIRED for the methods to stand. More to come…
Saturday, November 3
Interesting discussion on the state of these programs. Currently only 57 medical schools have these programs – and some have many. Half of those currently in medical school say they decided to be a physician while in high school. 25% of these programs are geared for under-represented in medicine students. Most of these programs are 4+4 agreements. Notable is that there is NO outcome data. Key for schools to examine the goal and mission of the process – what do they want out of it? May not actually be cheaper for enrolled students, since these students would likely receive scholarships from undergrad, and there is less incentive for medical schools to provide scholarships to already-enrolled students.
Facebook, Twitter, the Patient, and You: Social Media in the Healthcare Setting
Use of social media should be expected – by both patients and physicians. This is an excellent tool for physicians to communicate with groups of patients – particularly around specific disease states.
The Multiplier Effect with Liz Wiseman
Liz Wiseman, author of the WSJ best seller “Multipliers: How the Best Leaders Make Everyone Smarter” spoke about differing styles of leaders – multipliers and diminishers. The former enhance and amplify the thinking and work of those around them, generating enthusiasm, productivity, and personal development; the latter dampen their colleagues’ energy, growth, and abilities. Wiseman studied 150 leaders around the world for this research.
Innovation Arc: New Visions
Terrific presentation by Eric Topol, MD on the veritable explosion of information and the challenge of managing it. Patients are taking charge (rightly so!) and asking to be more involved in their care (and this is a very good thing!). The topic of personalized medicine was recurrent – with lower costs, better outcomes, and fewer complications. Technology and computing power are changing the game. Point of care testing and monitoring (think the “heart attack app”) are game-changers. Treatment can then be altered based on this monitoring.
Virtual Tours: Innovative Uses of Building Space in Clinical, Research, Education, and Multipurpose Settings
Fascinating “virtual tours” of simulation labs, libraries, educational spaces, gross anatomy labs from Georgetown, University of Central Florida, Arizona, Ohio State, University of Nevada, and Michigan. Michigan’s GA space was modernized with relatively little cost using HD cameras on booms that could record and display prosecutions for current and future teaching. Georgetown’s library was reborn after the book collection was downsized – creating new, flexible educational and conference spaces without large capital expenditures. Arizona created a heavily utilized, cross-disciplinary simulation lab space and is holding in situ simulation both in the hospital environment and beyond (e.g., multi-victim car accidents with simulators). Nevada created a joint simulation lab in the basement of an old rehabilitation hospital that is state-of-the-art and utilized by multiple institutions for simulation teaching. Highly creative use of space!
Friday, November 2
Hands-on Workshop for Creating an XML Upload to the Curriculum Inventory
In depth discussion of AAMC system to collect curricular data based on standards developed by Medbiquitous. Project intent is to collect data in a standard format that will allow institutions to see how they compare with peer institutions – as well as provide automated info for LCME accreditation.
Holistic Review in Admissions
Our own Dr. McGeehan presented today during this session! The group discussed how to collect and track data in more meaningful ways, and how to construct meaningful outcomes goals. There was agreement that current “metrics” don’t measure or predict who will be the best physician – only who will do well on similar tests. New schools will continue to work together to break new ground together.
Discussed that schools should have access to or begin support groups for LGBT students. Recent study showed that most of gay/lesbian students (85%) are “out”. However, the transgender population is neither “out” nor understood – similar for bisexual students. The fear of discrimination is the leading issue.
There is significant ignorance surrounding the healthcare needs of this population – and students want and need interaction with the population to learn appropriate healthcare approaches.
Social Determinants of Health
This was a terrific session! The average number of sessions on healthcare disparities in the pre-clinical curriculum is eight. One medical school had ALL students complete a 2 hour session in the ED where they determined why a given patient came to the ED that day for a problem – but ONLY addressed social issues. Poverty Simulation was also discussed – structured program that is used at many schools.
We learned about the new GME accreditation system, which will have a “continuous accreditation” model that is updated annually, a self study required every 10 years. Standards will be revised and updated every 10 years. The system will include all important measurement of outcomes – actual measured parameters still under discussion, but will likely include scholarly activity, board pass rates, resident and faculty surveys. This new system will provide a single set of performance and learning expectations for residents, and provide explicit and clear descriptions of what is expected, as well as early identification of underperformers. There will be a greater focus on medical knowledge and patient care skills – including professionalism and interpersonal communication. The final model will be posed on the ACGME website in December of this year.
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