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The latest Main Residency Match (registered Trade Mark) results are in. Officially it is an impartial venue for matching applicants’ preferences for residency positions with program directors’ preferences for applicants. Unofficially it reflects a lot more, as I have discussed before (found here). For those of you living in towns with medical schools, it is the day that the hometown paperbloggythingy is filled with pictures of medical students crying because they are so happy to be leaving their current God-forsaken burg for one of better value (in Mobile, typically one several states away). To make a long story short, without successfully working in a residency position for several years, a young physician will never be allowed to practice medicine in the United States (how much time in residency is required varies by state).
There has been discussion on e-mail by my colleagues about the Early Results (term not trademarked, results found here). The good news for family medicine is that of the 3037 positions offered, 2914 were filled (about 95%). That bodes well for primary care, say some, and thus the glass is half full. The bad news for Family Medicine is that out of the 17, 487 graduates of traditional US (allopathic) medical schools, only 1356 chose Family Medicine, filling only 44% of our positions and comprising only 7% of the graduates of these schools. 1097 graduates of these schools did not match into any program and though there were Family Medicine positions available, did not apparently want these either. They have chosen, I presume, to sit out a year and try for the specialty of their choice again rather than seek three years of training to make a nice living (over $200,000 a year after completion) as a family physician. Looking at it that way, the glass is half empty.
Our society needs physicians practicing primary care, and graduates of family medicine residencies are the most likely to practice this kind of medicine. Graduates of traditional medical schools tend to seek the “ROAD to success” (Radiology, Ophthalmology, Anesthesia, Dermatology) specialties, so named because the average work week is less than 40 hours and the mean pay is over $400,000. So, where do we look?
One place is Osteopathic schools. The students who attend these schools tend to have a lower MCAT (24, average for most allopathic schools 30-31) and lower GPA but more life experience. (MCAT and GPA beyond a threshold value have been found to only predict success on the first of three standardized tests and have no bearing on clinical ability.) The students are typically committed to a distributed education model and often chosen for interest in primary care practice. Previously, osteopathic schools were seen by some as the domain of those not “smart enough” to be admitted into allopathic medical school. For those interviewing with us this year, it was decidedly not the case. In our experience, osteopathic candidates for our residency resemble allopathic students in their knowledge base. Their clinical skill set is a little different than the allopathic students’ but different can be better. In our experience they are bright and committed to going back to their community to practice (often an underserved community). There were 2677 total applicants in the Main Residency Match and 2019 got a position. How many went into family medicine is unknown.
Another place is the Caribbean. Medical schools there have exploded in the past 10 years. This seems to be at the expense of the old 5th pathway program (US citizens going to Mexican medical schools a la Bad Medicine) and non-US citizens looking to come to America (the J-1 programs, as seen here). It used to be that applicants with a marginal application (relatively low grade, MCAT, or both) would have a application with the following pattern: apply to allopathic school with a marginal MCAT/grades, get wait-listed, “make your application look better” by retaking the MCAT and bumping it up two points, work as a hospital orderly, reapply, repeat until accepted or life passes you by. This is dead. Many students give US schools one shot then apply to a Caribbean school.
Coincidentally, many of these students with marginal applications also have a strong interest in primary care. Many of them have parents who are in primary care and who did not go to US schools. Their children are not looking for prestigious medical school but for training that allows them to qualify to take the ECFMG test. Passing this test allows them to give residency training a shot, often in family medicine. In 2009 there were 3390 applicants from these schools and only 1600 matched. This year there were 5095 and 3601 matched. That is 15% of the matched pool. For these schools the standardization of testing for graduates of non-US schools (ECFMG, NBME, and clinical skills evaluation) has been the great levelers. These graduates are a large part of our current workforce and have filled our training programs for the past 10 years.
Can we look to traditional medical schools to supply a larger percentage of the primary care workforce? Allopathic schools expanded their classes by 10% several years back to fill a “need.” That 10% was supposed to be selected to correspond to the needs of the “community.” The additional allopathic students, unfortunately, tend to look like the other 90%, overwhelmingly white, overwhelmingly privileged, overwhelmingly looking for a ride on the “ROAD.” Telling to me were the results for the 1487 allopathic graduates who did not get a position last year. I am assuming they have not been working as a physician for the past year (because they can’t). They applied for positions in this year’s match. 758 of them were unmatched for a second time. This means that rather than “settle” for a primary care residency that will net them $200,000 a year at the end of 3 years, they are going to sit out another year, presumably looking to get on the ROAD.
So, in our class we have 2 osteopathic physicians, 2 physicians who are from a Caribbean school, one traditional resident, and one resident who did not match last year and elected to apply in family this year. We are excited about training them and, since 60% of residency graduates tend to stay within 100 miles of where they are trained, I’m happy to welcome them to the community.
When Laennec invented the stethoscope in 1816 and physicians no longer had to put their ear to the patient’s breast, health care delivery changed. Asepsis, effective treatments for syphilis, and other breakthroughs soon followed. By 1910, medical education needed to move on as well.
Scientific breakthroughs had altered the values held by the public and the medical profession: clinical and laboratory research had exposed the irrationality of “heroic” treatments (such as blistering, bleeding, and purging) and had proven the therapeutic efficacy and rational scientific basis of modern practices, such as antiseptic surgery, vaccination, and public sanitation. Most of the public and virtually all physicians now believed in the superiority of scientific medicine
Medical education underwent a transformation that lasted until very recently. The first two years were heavily influenced by science and the medical students were taught, not by physicians but by “basic scientists” whose training was in anatomy, histology, biochemistry, physiology, and other “hard sciences.” Students were then allowed access to patients, with whom they would presumably spend the rest of their lives.
Does it work today? The LCME, the board that governs the majority of the medical schools in this country, looked at just that (report found here). The good news: Doctors trained under this system are knowledgeable and technically proficient in providing care for acute disease; they wish to do what is best for their patients; and patients respect them as credible sources of information.
The bad news? Again to paraphrase from the report:
- Physicians are not prepared to evaluate the care they provide in their own practices and to use the results to improve patient safety and the quality of care provided.
- Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession.
- Physicians often lose altruism and qualities of caring as they proceed through training and enter the practice environment.
- Because of their training, physicians find it difficult to deal with the inevitable uncertainty arising from incomplete or conflicting information. Additionally, they are not typically prepared to convey their uncertainty when interacting with patients and colleagues.
- Many physicians are not prepared to utilize information technology to assist in information acquisition and management.
- Physicians are trained to be autonomous. This can be a barrier to providing patient-centered care, where patient values and desires are an integral part of shared decision-making. The expectation of autonomy diminishes the ability of physicians to act as team players with other physicians and other health professionals.
- Physicians are not prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless.
- Graduates do not acquire skills in cultural competence/awareness and to recognize that some patients may have health literacy issues.
So, what’s the problem, you say? Teach the science and teach the humanism (like having chocolate and peanut butter together). The limiting factor is time and the explosion of factoids that are considered “vital” for a physician to know. Or, to put it another way by someone who thinks things are just fine:
Increasing emphasis on apprenticeship-based education and increased focus on the non-medical knowledge competencies inevitably will be at the expense of rigorous training in the basic sciences if the existing number of hours available for teaching are maintained.
In addition, the teaching of the lacking humanism skills will require another type of medical education specialist, one much more skilled in communication than in versed in scientific discovery. The basic scientist may be on the way out when it comes to educating physicians. The article referenced above is a plea for not allowing the science education of our nascent physicians to be diminished. The author expresses concern that though care may improve and patients may be more satisfied, we as a profession and our society may be poorer as a result. I would argue the system begun in the 1910s has left us with an expensive and not very effective care delivery platform and is destined for failure. I would also argue that we must improve the value (cost, quality, and efficiency) of our clinical care, a challenge that will require all physicians to be versed in the skills identified above as lacking. We need to teach smarter. If we do not, we may be seen as upholding our scientific standards as we bankrupt our society.
I was in a meeting today of the Alabama Family Practice Rural Health Board. Their primary charge is to improve health delivery in Alabama by targeting resources to improve health manpower, specifically by increasing the number of Family Physicians in rural Alabama. The conversation soon turned to Elba, Alabama. Elba was founded as a ferry crossing site on the Pea River. Health care delivery in Elba has been problematic at least since the turn of the last century. From the Elba website:
The story of “Little Noah Tucker” is one of the most often remembered and retold. Eleanor Talbot Tucker and her husband Ed Tucker became the parents of Noah at the Elba Hotel during the flood. The mother had to be moved from room to room during the birthing because room after room crumbled and fell into the swift water currents. The baby was named Noah since he lived through the flood like the biblical Noah.
While things may never get that bad again, there are problems on the horizon
The Board of Directors of the Health Care Authority of Elba, Alabama has announced that Elba General Hospital will close its Emergency Room and discontinue accepting new inpatients as of January 31, 2013. Officials say they’re working with area hospitals to transfer any patients who will need continued hospitalization.
The hospital completed a renovation exactly one year ago. The nearest hospital is appoximately 17 miles away.
The conversation at the meeting was about the closure and the story not told.
Rural hospitals are in trouble under the best of circumstances. The hospital in Elba provided limited services so many prospective patients did not even stop there, electing to go to Andalusia or Enterprise which provided a more comprehensive range of services. This had been going on for a while so was likely not the proximate cause. The reimbursement in Alabama is done in such a way that Critical Access designation, a lifeline for many rural hospitals in other state, is not a viable option for many hospital in Alabama. The fact that this hospital was less than 35 miles from its competitors may have precluded this option but, again, not a new problem
The death knell for this particular hospital was an older medical staff, unexpected illnesses, and no one in the pipeline set to return to Elba and practice Family Medicine, or any specialty for that matter.
The Office for Family Health, Education, and Research at the University of Alabama Birmingham, Huntsville Campus has just published an amazing study. They plotted out every rural Alabamian and every primary care doctor (87% are Family Docs). This report finds flaws in the current “pipeline” way of thinking, flaws that are exemplified by the situation in Elba. The report offers the following solution:
Its goal must be, at a minimum, to admit rural pipeline and BMSA awarded students to in-state family medicine residencies (Henderson et.al. 2003) and, during residency, promote resident/rural community relationships. Within the infrastructure of Alabama’s medical schools and current primary care pipeline initiatives, there is the potential to increase medical student selection of in-state family medicine residencies. However, there is no established method for directing graduated residents to rural communities other than the BMSA’s requirement of serving in an underserved community of less than 50,000 people and independent private based enterprises.
Nick Saban would never allow Alabama high schools to drop football in all but the largest cities. He knows that talent needs to be developed in many settings. The majority of medical students in state schools are from Jefferson, Mobile, and Madison Counties. The majority of Alabamians do not live in these counties. The pipeline has to start and end in the community.
The beauty of e-mail is you can watch conversations unfold over time (as opposed to Facebook where conversations are gone in 2 minutes). Some of my colleagues are trying to describe who Family Physicians are for a broader audience in 100 words or less. To be honest, it is unclear who this audience is and why they want to know what I do so I haven’t been that engaged in the exercise. I got sucked in for a brief period this morning so went back to the beginning of the conversation to get my bearings back.
100 words are not a lot to describe anything. It is an elevator pitch. In other words, what the group is trying to do is put together a set of ideas that could be used by me for this:
Me: “Hold that elevator”
Bill Gates: “You look like a smart man who could use some money. I have a lot of money. While we ride up to the 40th floor, tell me what you do and how a lot of money would change that.”
Me, pulling out a piece of paper with 100 words on it,”Well…”
The format is typically: For (target customer) who has (customer need), (product name) is a (market category) that (one key benefit) unlike (the competition). The product (unique differentiators).
The elevator pitches that are being sent around now all focus on the key benefit. “Family Physicians are…” We are either are the best thing since sliced bread or (in something termed the foil position) we are the teats on the boar of healthcare. I would suggest a different format. Here is my pass at what I would tell Bill:
We have convinced Americans that, once broken, modern medicine can rebuild them better than new. Americans destroy themselves with tobacco and other poisons. America destroys its own with unhealthy societal choices such as our firearm policies. Our medical-industrial complex has taken advantage of goodwill engendered by the introduction of antibiotics and relatively safe surgery and is rapidly depleting our national treasure under the guise of “health care.” We must retool the entire system. Family physicians, as a consequence of their generalist training and mindset, are the least co-opted physicians in the current system. If we must use physicians, give me money to train generalist physicians such as FPs in team based, patient centered care focused on rational resource utilization and let’s use them to reformat the entire delivery system, as the ACA allows us to do.
Oh, well, 140 words…maybe he’ll hold the door…
A fun fact: If Jesus were to go home for Christmas, He would not go to Nazareth (his boyhood home where all of His toys and books were) but to Loreto, Italy where the His house is now found:
According to some shepherds, it was seen on December 10, 1294, being borne aloft by Angels across the Adriatic sea and came to rest in a wooded area four miles from Recanati, Italy. The news spread fast and thousands came to examine the tiny house which resembled a church. The House became a place of pilgrimage and many miracles took place there. Bandits from the nearby wooded area began to plague the pilgrims, so the House was borne to a safer spot a short distance away. But the spot where the House was finally to rest was still not settled since the two brothers who owned the land were quarreling. The House was moved a third time to the site it now occupies. The brothers became reconciled as soon as the House settled in its final location. Incidentally, wherever it landed, the Holy House rested miraculously on the ground, without a foundation.
Once again miracles attended the presence of the House, and the townspeople sent a deputation of men to Tersatto and then to Nazareth to determine for certain the origin of the Holy House. Sixteen men, all reliable citizens, took with them measurements and full details of the House, and after several months arrived back with the report that in their opinion, the House had really come from Nazareth.
In the 1300s, towns and cities competed to get people to come to their market. The great cathedrals, the importation of important relics associated with the Holy Lands (such as the Holy House of Loreto), the appearance of markets, festivals, and spectacles were are intended to magnify the economic importance of the place. Today, we strongly suspect that the house came from Nazareth via boat, a dowry for the daughter of Angeli Commeno. It almost certainly was brought over as an attraction, needed to build a market and attract artisans for economic survival
My children and their friends are home for the holidays. I had a discussion with one of them disruptive technology, specifically the role of the horse:
The heavy plow made it possible to open up the fertile but heavy bottom lands of Europe, and to plow lands with a single pass rather than the criss-cross pattern the lands demanded of the scratch plough. The heavy plow required greater tractive power, and the development of metal horse-shoes, padded horse-collars, and tandem harnessing made it possible to use horses as draft animals. Horses were not only faster (plowing 30+ % more in a day than oxen) but were more intelligent than oxen and so did not need the attention of a man wielding a goad to direct them. The peasants discovered the value of leguminous crops (peas and beans) in restoring soil fertility, and — although they did not realize it — improved the human and animal diet of western Europe with the addition of the relatively high grade of protein provided by peas and beans. The deep plow and the use of legumes made it possible to change the two-field system, in which 50% of the arable land was put in fallow each season, to a three-field-system, in which only 33% of the land needed to be in fallow in order to restore its fertility and to kill off the growth of weeds.
The ability to feed so many people with so little labor opened up the concept of commerce, created an artisan class, and ultimately lead to the downfall of the existing social structure. The need to get people, who were much more mobile, to come to your town created great competition. This competition lead to dramatic changes in building, arts, and commerce. The Renaissance happened, in part, as a result of this disruption in the social order.
American medicine is undergoing a period of disruptive innovation. The development of data interpretation (analytics) will allow us to deliver care much more efficiently and effectively. In fact, where healthcare currently uses up 18% of our domestic economic output, it could go down to as little as 4% (the amount Singapore spends to achieve health outcomes better than ours) freeing up folks who “labor” in healthcare to do other things. One has to wonder; what will come as a result?
1) you have to pick the right people
2) You have to educate them in the right environment
3) You have to provide an early nurturing practice environment
Fortunately, we already have a model for #1 in Alabama. Over 20 years ago, what is now the University of Alabama College of Community Health Sciences started putting together programs to try and make things better. Eventually these became, among others, the Rural Health Scholars Program for high school students and the Rural Medical Scholars Program for those who need a helping hand to get into medical school.
The Tuscaloosa News has a very good article on these programs today (found here). The article follows the story of several folks from rural Alabama. It talks about the many obstacles faced by these students. It also offers this from a third year resident who is soon to enter practice
“Growing up in Greensboro, I know there is limited health resources. I’ve seen people come and go because of it,” she said. “For me, it’s a win-win. I get to be with my family and it gives me an opportunity to give back to the community that has supported and been behind me. I’m proud to be able to take care of my community, the people I know, the people that watched me grow up. I also would like to serve as an example to the young people there. Show them it is possible to do this.”
Clearly, they are picking the right people.
I got an email from Dale Quinney, the Executive Director of the Alabama Rural Health Association. He has put together a data set describing the primary care workforce in Alabama (found here). Dale is a data geek, and likes to put data together in interesting ways for folks to use to make value observations. These data demonstrate, among other things, that the primary care workforce in Alabama is old. Of the 3000 odd doctors, not only is the median age 52, but there are about 150 (or about 5%) above the age of SEVENTY. Many of these live in rural areas. Per Dale:
While the median ages are the same (52 years) in 2012 for rural and urban physicians, it is interesting to note that the average or mean ages for rural and urban physicians were higher than the median ages in 2006, emphasizing the older ages in both areas. However, by 2012, the average or mean age for urban physicians (51.4 years) was lower than the median age (52 years), emphasizing the younger ages among urban physicians.
At the very least, they can initiate policies to target state funding of medical teaching programs to institutions focusing on primary care training and provide greater financial support (as through loan forgiveness) to physicians who specialize in primary care. They also can encourage or mandate lower payments to specialists for patient visits NOT made by referral from a primary care practitioner. Additionally, they can increase reimbursement rates to providers who demonstrate that they deliver primary care in ways to achieve its benefits; instruments are available to document the primary care orientation of practices.
As a southerner, I really like colorful expressions. “That dog won’t hunt” is one that I use when I am hanging with my Yankee friends and I want them to give me a “what is he talking about” look. “I wouldn’t know him from Adam’s off ox” is one that I love but I find I have to explain it way too often as I am not usually hanging with people familiar with oxen team terminology. One that I find more useful as I get older is “lipstick on a pig” as in “That’s just putting lipstick on a pig.” The expression, per Wikipedia, describes “making superficial or cosmetic changes in a futile attempt to disguise the true nature of a product.”
The medical education process seems to have taken a “lipstick on a pig” approach to reform. I have written about what people want in a doctor before (found here) and here is WebMD’s list from an article in the Mayo Clinic Proceedings:
Traits listed by the patients, along with the patients’ definitions of those traits:
- Confident: “The doctor’s confidence gives me confidence.”
- Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
- Humane: “The doctor is caring, compassionate, and kind.”
- Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
- Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
- Respectful: “The doctor takes my input seriously and works with me.”
- Thorough: “The doctor is conscientious and persistent.”
Contrast that with the criteria for selection for medical school (grades and scores on a single standardized test) and the criteria for selection for residency training (grades and scores on a series of 2 standardized tests). It is my experience that test scores often don’t correlate with the things patients want in a doctor.
Recently, post-medical school training has attempted to emphasize qualities other than test-taking skills. The ACGME Outcomes Project, for example, has been in effect for 14 years and requires residencies providing post-medical school training to measure growth in characteristics such as those listed above. Efforts to change the medical student curriculum, though emphasizing the behavioral buzzwords found in the WebMD article, continue to have an assessment component focused using multiple choice type questions. Growth as a person is subordinated to acquiring knowledge for assessment via multiple choice testing, rendering the curriculum change efforts “lipstick on a pig.”
I have focused most of my career attempting to mold learners in their post-medical school years and have found that attitudes are set. Where residents come into the program from medical school regarding their attitudes towards patients is where they tend to stay. I was excited to recently come across this article, implying that it may be our educational efforts in the early training years that are lacking, not the learners’ ability to change. The authors suggest that the learners’ ability to store and regurgitate knowledge (IQ) was fixed, but their ability to incorporate professional values such as compassion and integrity (EQ) is fluid. To accomplish changes in behaviors and attitudes is going to mean not applying more lipstick but getting rid of a lot of the pig. Picking “listen to the patient” from a multiple choice answer list will no longer be a sufficient assessment. Assessing the learner at baseline (even prior to admission), establishing a set of non-negotiable standards, measuring behaviors using Standardized Patients as well as real patient encounters on multiple levels, using peer evaluations to capture attitudes not observed in formal settings, and forcing reflection on the part of the learner with the learner at risk of failure for not performing up to par will be necessary to effect these changes. It will mean changes in the training milieu as well. No more “Butt Boxes,” lists of words mispronounced by illiterate patients, comments about patients’ lack of “personal responsibility” to justify providing substandard care, or other activities that belittle or dehumanize patients in public or (more insidiously) private.
The authors suggest that establishing a strict standard and enforcing a “zero tolerance” for learners and faculty are necessary to drive this type of reform. I can only wonder if we can meet this standard or if we will quickly run out of faculty and students while trying to do so.
I was given a copy the movie version of “House of God” which I watched the other night. I read the book in 1984 before I started my clinical rotations and reread it in 1990, so it has been a while since I have been exposed to it.As I watched it, it struck me that there are aspects of the movie (and by extension the book) that are extremely relevant 30 years later.
The emphasis in the movie was placed on the construction of the new “Wing of Zock.” In the movie, the Wing denoted progress. It was going to be a modern setting to provide access to technological advances in health care, financed by grateful and wealthy benefactors.However, in the movie as well as in medicine today, there is a tension. The adminstration realized that having such a Wing meant paying for the care delivered in the Wing. The Interns in the movie were encouraged to “Putzelize” patients. This was a term for admitting a patients with no known medical illness to the hospital solely for attention and their ability to pay for the care rendered. Although it was unnecessary and expensive, it was clear that these patients were an important part of the business plan to pay for the new wing.
The other overarching theme was the replacement of a caring doctor with technological intervention. The Fat Man, kind of a Zen Master for the Interns, instructs the Interns on the importance of doing less rather than more at the beginning of their training. So important is this, in fact, that the last of the Fat Man’s Rules is “THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.” Unfortunately, as in medicine today, the Fat Man loses to the sterile, technologically driven world of modern health care. To bring home the point, Wayne Potts, who is an Intern from Charleston, South Carolina, does not perform the technologically correct (at the time) therapy of giving steroids to a patient dying of fulminate hepatitis and the patient eventually does die. Wayne has a very touching scene where he and Roy (the main character and also an Intern) discuss why they went into medicine. Wayne poignantly discusses how “All I wanted to be was a country doctor.” Ultimately, the hierarchy at the House of God are unable to forgive him for making their numbers look bad, he is unable to forgive himself for the patient’s death, and he commits suicide by jumping off the Wing of Zock.
In a new blog named “Wing of Zock,” the LCME, the organization of medical schools, identifies the needs for medical education in the new era:
Academic medical centers and teaching hospitals are at a crossroads in redesigning our health care system and examining how they educate medical professionals. They are experiencing tremendous discontinuity: Current payments, incentives, and value systems don’t reward excellence in care delivery and medical education. They are constantly engaged in building the next Wing of Zock as they seek to define a future that signifies hope.
In creating the next Wing of Zock, I hope we can avoid “putzelizing” America in hopes that it will pay for the education of medical students and residents. In addition, we in medical education need to support the Wayne Potts of this world. We need to nurture those who want to be “someone’s doctor.” Turns out that steroids in the case of the “yellow man” would really not have made a difference in his survival. Putting a Wayne Potts in a country town for 40 years makes a huge difference. Now more than ever we need to figure out how to teach the right people to deliver exceptional care and hopefully the money will follow.