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How can Dr Carson be leading in a national poll for president and get a pass on a some, well, scientifically suspect beliefs such as “his statement in the wake of the Oregon mass shooting that it would be advisable to attack an armed gunman during a mass shooting ‘because he can’t get us all‘?” Or. how can folks want a president who is doing infomercials on neutraceuticals which misrepresent scientific fact and when called on it, deny having been paid for what was almost certainly a paid gig?

The New York Times gives a plausible answer to this question today. Ishani Ganguli, a Boston internist with an interest in health policy, points out that, pretty much, physicians get a bye:

  • He points out that we are trained to speak authoritatively regardless of the certainty of the situation or the strength of the evidence. In other words, as I tell my residents, “patients and attendings smell fear.”
  • He points out that surgeons are trained to believe that their skill is what stands between the patient and death and the loss of that faith leads to a crisis, one that a successful surgeon may never experience. He or she may not be good (and there is now a scorecard to look at) but will never admit defeat.
  • Doctors should never be politically correct, or so they are portrayed in the media (see House, MD),
  • There is a long line of physicians who are given a pass (see Dr Oz for the latest example)

Dr Ganguli points out that we as a society feel the need to ascribe trust to the MD. Our Hippocratic sales pitch has been an effective marketing strategy. He goes on to point out that self reflection and knowing our limits are keys to maintaining this trust. I am afraid that these are qualities Dr Carson does not have.

ask_your_doctor-cartoon-david_sipress_the_new_yorker

Me: Ms G, you have atrial fibrilliation and a lot of other medical problems. That means that your heart can form blood clots that go to your brain It is REALLY important that you take the blood thinner the cardiologist put you on.

Ms G: I know but he gave me this Elliquis and I just can’t afford it. My Blue Cross charges me $140 a month for the medication and that’s just too much

Me: There are much cheaper alternatives. Warfarin, for example, can be used very safely and keep you from getting a stroke.

Ms G: He never even mentioned that to me. Can you talk to him?

When this happened this past week, I was a little irritated. Ms G is not the easiest patient to care for and now I was having to deal with a problem not of my making. After making several phone calls we switched the Elliquis ($275 a month, $140 out of pocket to my patient) to warfarin ($6.50 a month plus $24 in monitoring costs, less than $10 a month to my patient) and everybody left happy (and late). Eliquis and other expensive blood thinners offer only a marginal improvement over warfarin and they do it in a very expensive manner. They reduce of the risk of stroke over 3 years from 16 stokes per 1000 people treated with warfarin to 12 stokes for people taking the newer medications. Of those 1000 patients, an extra one (2 vs 3) on warfarin will have a major bleeding problem. While an advantage, my patient chose not to trade $1200 in food money to do this and instead made the decision on her own to triple her risk of stroke (10 strokes per 1000 annually in those untreated with atrial fibrillation and her other conditions) by not taking anything. My patient is now on warfarin and presumably much better protected from having a stroke. Why was my patient not offered the opportunity to make a choice between the new improved method OR the tried and true method?

May have had something to do with marketing. As was pointed out last night, Americans have an expensive ($330 billion) prescription drug habit. The habit not only pays for the pills (a very small part of the cost) but also the payments to doctors who do the “education” of their colleagues. In 2013 this education cost Americans $24 billion, with marketing accounting for more than research in 9 of 10 companies. In the words of John Oliver “Drug companies are like high school boyfriends: they are more interested in getting inside you than in being effective once they are there.” Bristol Meyer Squibb spent an estimated $20 million in 2013 to “educate” physicians regarding the advantages of Elliquis over warfarin in stroke prevention, with about $15 million going to physicians to extol its virtues to other physicians. I don’t know if that was the reason for the oversight. To be honest I suspect in my patient’s case it was mostly ignorance of my patient’s social situation by the cardiologist that caused my long day.

At least my patient didn’t die from an overzealous sales force. Every day, 46 people die of prescription narcotic overdoses in the US. In Alabama in 2012 there were 140 narcotic prescriptions written for every 100 people. We really don’t need folks selling doctors on selling more narcotics. However, in 2012 a potent narcotic (Fentanyl) was introduced in a sublingual spray to compete with others similar preparations (Fentora and Actiq). These medications typically have, as their very specific indication (the reason to give to a patient), cancer pain not responding to around the clock narcotics. Insys, the company that makes Subsys, spent an estimated $6 million to educate physicians about this drug in 2013. I have to admit, until I read the Propublica article, I had not heard of it. As I don’t treat many patients with intractable cancer pain, that did not particularly surprise me. They only spent $44 a meal to educate 5,000 physicians. They did pay for 775 educational events (paying a physician $2,500 to talk about the drug every time) and hired 189 consultant physicians at $2,370 each. I guess they had to get the word out. Problem is they were and are getting the word out to the wrong people. Less than 1% of the prescriptions were written by oncologists. The product was a high potency narcotic of which there were already others on the market (a “me too” drug):

The former sales employees said that while the company targeted some oncologists, it placed more focus on high prescribers of competing products like Actiq and Fentora, regardless of whether those doctors treated cancer patients. They also said they were trained to mention the restriction to cancer pain at the beginning of the sales pitch and then to move on to a more general discussion of “breakthrough pain” in the doctors’ other patients.

Not only did Insys not worry about its drug getting into the wrong hands, it kind of counted on it:

Comments from a Wall Street analyst underscore that view. “As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”

The company used physicians who had problems with the DEA as their speakers and unorthodox methods to motivate its sales force. A cursory review of the Opiophiile forum reveals that their product is a success, with many addicted individuals enjoying the convenience and simplicity of the medication, with some even ingeniously discovering they can use it intravenously…just like heroin. Also the boards attest to the effectiveness of the marketing strategy.

Shelley, my doctor recommended it to me pretty much as soon as it came out. He said that the company that makes them wanted him to be a representative for them or something like that.

No wonder sales have increased 400% in the most recent quarter over last year and people are bullish on Insys’s prospects. in fact, investors only got skittish when a physician in Michigan who accounted for 20% of the drug sales lost his license. Fortunately for investors, their “medical marijuana” product is about to come to market to broaden the Insys portfolio and the market cap is back up.

Don’t get me wrong, I am by no means anti-medication. In fact, only 30% of people who would benefit from warfarin or related blood thinners receive them in the correct dosage and we need to work to use this inexpensive drug more effectively. I would personally prefer to find a different way to get the Opiophile readers their fix (with entries such as “Fentenyl patch, shootable” I am concerned their might be a lot of misuse in that community). Most importantly, as a profession, let’s stop shilling for Wall Street. I’m sure they’ll do fine without us.

When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”

This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.

Medical training, though, is changing.

A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment.  While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities.  The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.

And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)

While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”

A far cry from the boys needing thyroids.

Primum non nocere

Attributed to Hippocrates (more likely Thomas Sydenham)

During the health care debate, much was made about the ranking of the United States among nations regarding out system’s performance. In fact, we ended up Number 37 in World Health Organization rankings, a fact that was celebrated in song. While many feel that the poor performance of our health care system is the result of an inefficient system that rewards the wrong aspects of care, others argue vociferously that the system is the best in the world but that Americans are somehow sicker than other homo sapiens in ways that are difficult to measure.

An article was published in Health Affairs (subscription required but summarized here) that puts to bed the myth of “sicker” Americans. In this study the survival of folks ages 45-65 in United States was compared to survival in other countries with at least 7 million people and a GDP similar to America. This list included Australia, Austria, Belgium, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom. The study use 1975 as an index year and compared it to 2005. Although I’m not an expert in international comparisons, this one seemed pretty well put together.

The investigators found that between 1975 and 2005, American health care spending increased at a much greater pace than the other countries and Americans were more likely to die prematurely than the citizens of the other countries. This we already knew. What is news is the magnitude of the difference and the aspects of American society that do and do not contribute to the difference.

Population Diversity – As opposed to the deeply held believe that we have to spend so much on health care because of our sickly poor population, it turns out that our diversity does not contribute to our poor health standing.

Smoking Status – Americans actually smoke less than the residents of the comparison nations so it turns out that smoking status does not contribute to our poor health standing.

Obesity – Americans are more overweight than the residents of the other countries. America was proportionally as overweight when compared to the other countries in 1975 as it is today. If it is obesity that is the cause of our excessive health care spending, it should have increased proportionally (not logarithmically) over the past 20 years. Obesity is not the cause of our excessive health care cost.

Traffic Accidents and Homicides – Much was made of the perceived excessive costs of violence in American society during the recent health care debate, in particular among the underclass. The contribution of violence has in fact been stable over the past 20 years (and is relatively low) so these are not the cause of our excessive health care costs.

So what is the cause? The authors of this study speculate that the health care delivery mechanism in this country has become an expensive self-perpetuating system that directly contributes to poor outcomes. This is potentially a consequence of inefficiencies that occur with rising costs and relative underinsurance as well as absolute uninsurance. Excessive spending on individual health care consumption may have led to inadequate investment in public health and education initiatives. Unintended excessive care may lead to fragmentation and an increase in medical errors.  Intended excessive care leading to life-shortening complications is a very real problem. In America the belief that the the “market” must dictate health care purchases may so distort consumption that people are unaware of just how poor the choices that they make actually are. Until they die, that is…

In a companion article summarized on the Commonwealth website, some of the specific reasons for the poor health of Americans as related to our healthcare system were listed:

  • One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands.
  • One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
  • Thirty-one percent of U.S. adults reported spending a lot of time dealing with insurance paperwork, disputes, having a claim denied by their insurer, or receiving less payment than expected. Only 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany—all countries with competitive insurance markets that allow consumers a choice of health plan—reported these concerns.
  • The study found persistent and wide disparities by income within the U.S.—even for those with insurance coverage. Nearly half (46%) of working-age U.S. adults with below-average incomes who were insured all year went without needed care, double the rate reported by above-average-income U.S. adults with insurance.
  • The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults.
  • U.S. , German, and Swiss adults reported the most rapid access to specialists. Eighty percent of U.S. adults, 83 percent of German adults, and 82 percent of Swiss adults waited less than four weeks for a specialist appointment. U.K. (72%) and Dutch (70%) adults also reported prompt specialist access. 

In summary, it isn’t that America has more poor people and poor people are sicker. It’s that our system for the 20 years prior to the passage of the Affordable Care Act became efficient at transferring money into the Medical-Industrial complex at the expense of the health of our citizens. We can only hope that the change occurs rapidly.

The Archives of Internal Medicine published an article questioning the conventional wisdom regarding physician selection. In this article they tried to correlate a number of variable with a number of indicators of “quality care” (more on this, later). The authors did find that female sex, board certification (indicating completion of a residency and ability to pass an exam on set intervals), and graduation from a domestic medical school correlated with “significantly” better performance.  Medical malpractice history, interestingly, did not indicate poor medical practices.

When looking more closely at this data, it shows some of the weaknesses of using statistics on numbers to describe behavior. The authors looked at 10,000 physicians and over a million patient encounters. They apparently analysed  all of this information with a statistical package and then looked to see if any of the better performance was seemingly due to something other than chance. They found that all physicians did 62% of the activities that were expected. Female physicians for example were 1.6 percentage points higher than male physicians in regards to performance as a group (and the other differences were equally small). Because of sheer numbers this was seen to be “statistically significant” but given that based on this a random male doctor would be correct 61% of the time compared to the females 63% I think I would find a different way to pick a doctor.

This story was picked up in the lay press by the LA Times. In fairness to the writer, she did point out the weaknesses of the study, pointed out how limited information was for doctor selection, and pointed the reader to an AHRQ website with some pretty good advice:

Look for a doctor who:

      [x] Is rated to give quality care.

      [x] Has the training and background that meet your needs.

      [x] Takes steps to prevent illness-for example, talks to you about quitting smoking.

      [x] Has privileges at the hospital of your choice.

      [x] Is part of your health plan, unless you can you afford to pay extra.

      [x] Encourages you to ask questions.

      [x] Listens to you.

      [x] Explains things clearly.

      [x] Treats you with respect.

The site goes on to explain quality care and offers a checklist to use when interviewing a physician to see if they meet your criteria.

This came up because Blue Cross/Blue Shield of Alabama has decided they are going to try to reward us primary care physicians for delivering “quality care” by increasing the visit fee by 5%. To find out whether I would qualify I decided to look on their Find-A-Doctor website to see where I stand. I was somewhat hesitant because I am an educator in a teaching practice. As such, all of the patients seen  by learners while I am a teaching attending are counted against me in addition to those patients I am personally caring for. I would like to believe our learners are delivering excellent care but belief often is trumped by evidence.

Going beyond the user friendliness of the site (too many poorly categorized physicians with incorrect practice addresses) I am pleased to say that we are delivering good (and sometimes great) care. When measured on screening for certain types of cancer as well as diabetes care we were at or above the national and Alabama average. On the other hand, we do not perform as well as we could.

This measure is done on patients who have come to our office for care. They are not asked if they want for us to provide these services nor are we paid for providing such services. Although my staff, my residents, my colleagues, and myself are certainly motivated to deliver quality care, wouldn’t it be easier if we could dedicate staff to assure quality happened? Wouldn’t it be nice if we could enroll patients to incorporate their wishes and beliefs regarding their healthcare rather than assigning patients to me based on (perhaps) a single visit and assuming they want me to take responsibility for the care plan? Wouldn’t it be better if we were paid well for delivering care for acute illness and equally well for handling chronic illness and preventive services that don’t require a visit. Oh well, at least I’m liked (search for Perkins)  by all 7 of the people who bothered to filled out the survey.

Bob Bowman has sent me the rest of his thoughts about my post regarding the Family Medicine’s role in the health care delivery system and I will share these with you (with a little commentary from me):

We started with “all he saw was a family practice doctor” – this was a comment that could have been made any time in the past 80 years. For the first twenty of those years medical educators such as Osler, Flexner, and various deans would defend the general practitioner as essential and of great value. The medical education leadership began with a perspective that was predominantly generalist and steadily transitioned to physicians more focused on subspecialty, hospital, and research areas.

 One of the consequences of separations between types of physicians was the somewhat derogatory term LMD or Local MD. Town versus gown is another descriptive phrase for the competitive situation although in more recent decades, both town and gown physicians have been losing out. Control of accreditation, training, exclusive markets, health policy influences, associations, and journals has moved steadily toward physicians born, raised, educated, trained, and practicing in top concentrations. Over 70% of US physicians or more arise from about 25% of the population.

Josh Freeman has done a lot of work on this. He points out that not only are physicians-in-training overwhelmingly from caucasian families but also 15.7% of students had one or more parents who was a physician and 24.1% more had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…”  Bob goes on to point out:

Read the rest of this entry »

As I was driving back from a very nice long week-end with my extended family (fireworks, festivals, baseball, wings, and art in a gritty urban setting) in metro Atlanta, I heard an NPR story on “the July effect.”  This effect is a suspicion (now with some evidence behind it) that health care in teaching hospitals is worse in July because of the inexperience of the new learners (or as I tell my residents “You are moving from a very experienced physicians at one level to a very inexperienced physician at the next level”). The report cites an increase in deaths in counties with teaching hospitals and  lack of a similar effect in counties with non-teaching hospitals in July as evidence for this effect. It only finds the effect with medical errors. I am grateful to Dr Carol Motley who traded calls with me so I could be with my family and she could work with the newly promoted physicians on this worst weekend of the worst month of the year.

From experience I will agree that the learning curve for a newly promoted physician is steep. I unfortunately know of no better method of training physicians. The author of the study in his interview cited a lack of surgical effect as evidence that surgical training is superior. I would argue that this suggests a certain randomness to his findings and we probably need to look more closely before discarding the entire training process. It does point out the need for close supervision of neophyte learners and the importance of good processes coupled with an assessment of outcomes to determine if the desired effect is being achieved.

It also identifies a need for continuation of an extensively supervised period of learning prior to neophyte physicians being transitioned into the “real world”. This process (known as residency training) is labor intensive if done correctly. It involves ongoing assessment of the learners progress towards achieving  six types of competence which the prototypical physician is expected to demonstrate in practice. We do this in part through close supervision of the learner in hopes of detecting potential errors before they are made. We also do this by collating thousands of individual observations on each of our learners and using them to assess progress towards achieving these competencies. This process is time consuming and expensive.

The current way of paying for this instruction is for the payor (usually Medicare)  to give money to the hospitals and hope that they pass this money on to those of us providing the instruction. The hospitals tend to see the cost of training residents as including a lot of costs not involving direct supervision and assessment residents by attending physicians (in part because we can bill for the service which covers a small part of the total cost). Consequently, we don’t see much of that money. Perhaps if more people are aware of the “July problem” the allocation of money to pay  for supervision of neophyte residents will be seen as important.

Fitzhugh Mullins published an article this week in which he evaluates the ability of medical schools to respond to the “social mission.” In it, he uses a metric to measure the medical schools contribution to solving the following societal problems: an insufficient number of primary care physicians, geographic maldistribution of physicians, and the lack of a representative number of racial and ethnic minorities in medical schools and in practice. Using only physicians who have been in practice for 10 years, he determines which schools are good at this and which schools…um… not so good.

I bring this up not just because my school (the University of South Alabama) is the 8th best in our students doing the right thing, but also because it is an important story. As was pointed out on NPR’s healthcare blog

Medical schools, Chen explains, often claim whether students choose primary care has a lot more to do with financial worries – including paying off student loans – than with how the schools operate. “But the variation shows that some medical schools are obviously doing it better than others,” she says.  “It allows us to give credit to medical schools that are doing the hard work, the good work, the social mission work. Medical schools have traditionally not gotten a lot of credit for this work.”

We will debate the relative importance of the many missions of the Academic Health Center for several years yet but is is good to be in the top 10 of something.

The value of experience is not in seeing much, but in seeing wisely.
William Osler

My neighbors by now have learned not to come over and recount bad health care they have received unless they want to see it analyzed in print. One of my neighbors made such a mistake yesterday. She came over to recount her experience with a local emergency room and some unexplained symptoms. After several hours in the emergency department and many thousands of dollars of tests she left with continued unexplained symptoms, no answers from this myriad of tests, and an unclear path for future care (should I go back to the emergency department, she asked).

I have outlined before the problems with seeking care at urgent care centers as well as the well-heeled Mobile method of physician selection but I have not yet written of “emergency” care. I have to admit to a love-hate relationship with my emergency medicine colleagues. On the one hand I like sleeping at night and  having the option of having another physician who is working a shift deliver hyper-acute care to my patients while I’m with my children or doing yard work.

On the other hand, we have done a poor job of educating patients about how to seek care in such hyper-acute settings. Patients like having immediate access.  As one focus group participant put it

“Now is the time when I want service, I may have been sick for two weeks but now is the time I want my Big Mac and fries so I’m going to the walk-in clinic to get it now.”

Also, the motives of Emergency Medicine physicians may not be the purest:

The increasing utilization of technology in diagnostics is also tightly linked to increased ED utilization. The rapid accessibility of MRI, CT, nuclear imaging, etc, is only available in the ED setting. Of patients evaluated in the ED in 2003, 33% got a CBC and 43% received X-rays. Utilization of CT and MRI in the ED are up 103% in the last seven years. Only 9% of patients in the ED receive no diagnostic testing. As long as EDs retain the relatively exclusive access to real-time, after-hours diagnostic and therapeutic technology, ED utilization will continue to grow. Academic Emergency Departments are usually on the cutting edge with diagnostic and therapeutic applications, and are therefore better equipped with diagnostic technology than their community counterparts, leading to a disproportionate share of the technology-driven growth of academic emergency services.
Finally, the continued specialization of medicine favors the growth of academic Emergency Medicine. Patients with specific complaints related to their specific illnesses, when given a choice, prefer access to specialists for their treatment. Patients with chest pain, for instance, would prefer going to an institution capable of performing cardiac catheterization center rather than an urgent care center if they are concerned about a heart attack. This preference for specialization favors the continued growth of Academic Emergency Departments, where access to specialists of all types is more possible.

I am editing a volume on rheumatic illness for Elsevier. In the process of doing this I have been reminded of the fact that the human body does not respond like a car. When a person calls “Click and Clack” and describes the noise his or her car is making, the Car Talk boys will have a pretty good idea of what the problem might be and how it might be fixed. When a patient describes a collections of symptoms it might signal a response from me that is anything from “don’t worry, it’ll probably go away soon” to “Oh, that sounds bad.” Mostly, unless it’s  chest pain or some other clearly hyper-acute complaint it I will often use “try this and see, if you’re not better come back and we’ll run some tests.” Not the answer you’ll get from the average car mechanic or Emergency Physician but one that fits human pathophysiology.

It all comes down to incentives. In the “new law,” the Healthcare Innovation Zone section is designed to change the way doctors and hospitals are paid, hopefully with the result of an improved health system. One of the changes is to make diagnostic imaging more difficult to obtain. Perhaps this will incent us to see “wisely.”

An interesting month for healthcare in Alabama. First, Southeast Alabama Medical Center in Dothan announced a $40,000,000 investment in Osteopathic medical education. Scheduled to enroll 150 students in the fall of 2012, this school will “pay back” the investment through tuition. The stated purpose of this school is to develop physicians for the delivery of primary care in Alabama. According to the hospital CEO “The backdrop for all this is the scarcity of primary care physicians. The state’s medical schools, UAB and the University of South Alabama, produce specialists, cardiologist and surgeons, but there is a need for family-care physicians, especially in rural Alabama.”

The primary for Governor was Tuesday here in Alabama. On the Democratic side, the very bright and articulate Artur Davis lost to Ron Sparks, in part by alienating his base with a vote against healthcare reform. On the Republican side, Dr Robert Bentley came out of nowhere to (if the recount doesn’t change anything) challenge Bradley Byrne for the Republican nomination. Dr Bentley is one of the few candidates who responded to the Alabama Rural Health Association’s questions to the candidates. He too feels that the answer is more doctors. He told ARHA ” We want to establish the Alabama Health Service Corp which will set aside 25% of the seats in our medical schools for primary care this includes family medicine, internal medicine, pediatrics obgyn, and general surgery. These students will be given full scholarships and a place in medical school without lowering the quality of the emission standards. Upon completion of their residencies these physicians will give back to Alabama four years of full time service in an area of need. I was involved from the beginning in the Alabama Medical Education Consortium. This program deals with the education of Alabama students in osteopathic medical schools throughout the country. This summer we will have our first group of graduates that will enter practice most of these are primary care physicians. At present we have over 150 students in this program. We are working towards evolving the AMEC program in cooperation with certain hospitals in the wiregrass are to form an osteopathic medical school. This will give us a larger number of potential primary care physicians for the state of Alabama.”

It is a shame that the state of Alabama is providing tax-payer subsidized medical education to almost 300 students annually through its two existing medical schools, and yet we have such a need that we are going to have another medical school established just to put doctors in primary care in Alabama. This school will not be subsidized but instead will require the students to pay the entire cost of their education (about $50,000 annually vs about $17,000 for the state schools).

Until we change our delivery system, I suspect these students won’t go into primary care either. In Alabama we continue to have a delivery system that rewards episodic fee-for-service care over comprehensive patient centered primary care. We are not training medical students at USA and UAB to work with the medical team in a collaborative manner . I suspect that without delivery system reform, the increases in physicians promised by AMEC will likely not translate into increased numbers of primary care physicians in Alabama just as the formation of the University of South Alabama in the 1970s didn’t relieve the shortage. It will take the primary payors (Blue Cross/ Blue Shield of Alabama and Alabama Medicaid) making delivery system reform a priority, disregarding opposition from other interests, for the shortage to be resolved.

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