colonoscopy5Student (to friend while walking to hotel): All of these programs compete on the number of procedures they claim to teach. I don’t see how you have time to learn all of that in a three year residency. They are going to have to go to four years, like Med-Peds.

I spent a couple of days with our team in Kansas City at the National Conference of Family Medicine Residents and Medical Students this past week, as I do every year. We sat in a booth and interacted with young physicians-to-be who were looking for residency training information as well as information regarding Mobile (our fair city) Alabama. We did not discuss the upcoming mayor’s race  but instead talked about what we thought would attract young people (mostly the beach). All residency programs in Family Medicine are required to have about 27 of the 36 months in common. The 300 or so programs that also had booths at this conference  were also trying to show their programs’ differences in the best light possible. Thus, the emphasis on teaching procedures such as colonoscopy.

Medical students apply to medical school with surprisingly little knowledge of what the future will hold in the way of medical practice. They enter medical school, for the most part, secure that they are very smart, enjoy science, and (as they invariably will tell me when asked) “want to help people.” The initial medical school experience is rather generic and very few students enter into it knowing what kind of a doctor they want to be when they grow up. My experience, back up with some data, is that potential income plays a large role in student career choice when they start paying attention to the residency selection selection process. Thus the emphasis on teaching procedures.

Forever, doctors and medical students have liked performing procedures. Partly, this the nature of the job. Allopathy (also known as heroic medicine), the lineage from which the M. D. degree was derived in the early 1800s, emphasized purging, blood letting, and other very aggressive manners of curing illness. Partly this is the nature of students. Liking science and wanting to help people goes hand in hand with “doing stuff to people.” We on admissions committees don’t look for shrinking violets. Partly, as was recently pointed out in the Washington Post, doing stuff to people pays more per hour than not doing stuff. A LOT more. The American Medical Association has been entrusted since 1965 to give Medicare time estimates on how long a procedure should take. Medicare uses that information to set the reimbursement rates which end up being the standard by which every insurance company sets rates.  The Post’s investigation revealed that the time component was overestimated by 100% in some cases. Meaning that physicians who do a lot of procedures are packing into 8 hours what Medicare considers to be 26 hours worth of work. The payment follows. Thus the emphasis on teaching procedures.

We spend twice as much on healthcare in this country than the average industrialized country and though we get more stuff done to us we do not live as long nor find ourselves healthier (in fact we find ourselves less healthy) than our peer countries. Our program is teaching the tenets of the Patient Centered Medical Home, emphasizing care that is of high quality, evidence based, and focused on the patient needs as opposed to income generating. These concepts and skills we can teach in 3 years. Although, I will admit, we do teach our share of procedures.

I am hopeful that the price we pay as a country for “procedures” will become less over time. I am also hopeful we will select students who really want to improve people’s lives. It turns out that high quality primary care often improves health much more than a procedure does.

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