This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.

Monday, May 12, 2014

How money influences specialty choice

Does it bother anyone that the top billers from the CMS are also specialties that students have chosen for the ROAD? If you don’t remember, I wrote about the ROAD in my November 5, 2013 post “The ROAD less traveled or why don’t med students choose primary care?”  The short version is the ROAD is the high pay, nice lifestyle choices for specialties that have become very popular with medical students. The ROAD includes: Radiology, Ophthalmology, Anesthesiology, and Dermatology.

As many of you have probably already heard, the Centers for Medicare and Medicaid Services or CMS has after many years released billing data from almost all of the physicians that billed Medicare for patient care in 2012. As I read the articles in the Wall Street Journal  and in the New York Times, I started thinking about the implications of the data as applied to student specialty interest. The New York Times reported that 100 physicians received a total of $610,000,000 from Medicare. The top biller was an ophthalmologist who received $21M from CMS.

There is a great chart from CMS that was in the NYT article. I have recreated it here and it is based on data from CMS. It shows the breakdown of billing.  But I would like to look in more detail at the Top 2 percent. That group billed CMS for 15.1 billion dollars in 2012. Almost every specialty was represented (except pediatrics which does not bill Medicare very often). 

The specialty that has gotten the most attention was ophthalmology. Maybe for good reason—lots of high billers. But let’s go back to my blog from November “The ROAD less traveled or why don’tmed students choose primary care?”  In it, I wrote about a survey of medical students by Clinite and colleagues.(1) They found that students with a higher interest in Primary Care specialties were less concerned about the average salary, and vice versa, students with less interest in Primary Care were more concerned about a specialty’s salary. So, it might follow that a specialty that has a lot of high billing providers, would be more attractive to some students. Particularly those students who were already more concerned about a specialty’s salary.

With that in mind, we should look more carefully at the top 2 percent of CMS billers again. When we break down the Top 2 percent of Medicare billers we find some striking differences among specialties.

Opthalmology had 2,995 physicians who were in the top 2 percent of CMS billers. Those physicians were 15.5% of all the practicing ophthalmologists.

Dermatology had 1,142 physicians who were in the top 2 percent of CMS billers. Those physicians were 9.3% of all the practicing dermatologists.

On the other end of the spectrum, family medicine had 302 physicians who were in the top 2 percent of CMS billers. Those physicians were 0.003% of all practicing family doctors.

I am not saying that any of these doctors did anything wrong. I understand that many of the high billers to CMS are practicing in groups, with multiple locations, doing difficult procedures, etc. But the differences are so large that it is hard for a student who is making a decision about what to do with his or her life to ignore. 

Think about this again. In the case of ophthalmology, 15 percent of all their doctors would be considered high billers by any measure. A specialty that has a lot of high billing providers is more attractive to students who are more concerned about a specialty’s salary. There is some support for this in the NRMP Match data.(2) In the 2013-2014 Match, the average percentage for a specialty matching a US allopathic seniors was about 62 percent. Family medicine (with a very small number of high billing providers) was able to fill 44 percent of its residency spots with US allopathic seniors. On the other hand, 91 percent of ophthalmology positions and 88 percent of dermatology positions were filled by US allopathic seniors. Radiology (68%) and anesthesiology (69%) while not as high were both above the mean.

At some level this goes back to the admissions process. We have to get the right students into medical school. We (the US taxpayer) pay for this system. We think it is a great system, but it is not really that great. We have created high reward and thus high demand for some parts of the system, and low reward and thus low demand for other parts. Until the system is readjusted (like the Canadians did a few years ago), (3) there will continue to be a lack of students entering primary care.

1) Clinite KL, et al. Primary Care, the ROAD Less Traveled: What First-Year Medical Students Want in a Specialty. Academic Medicine  2013;88(10):1522-1528.
3) Kruse J. Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income. Family Medicine  2013;45(4):281-3

Thursday, April 10, 2014

Medicine, Humanism, and Social Accountability: How the Values of the Gold Humanism Honor Society and Community Capstone projects collide

The following is the script of a talk that I gave last night at the induction ceremony for the Florida International University Herbert Wertheim College of Medicine’s 2014 Gold Humanism Honor Society.

Thank you so much for the opportunity to speak to you this evening.

The Gold Foundation was formed in 1988 with the purpose of nurturing and preserving the tradition of the caring physician. There was a concern then (as there is now) that the outcome of our medical education process was doctors who no longer had compassion for patients. The patients that were, for the most part, the very reason that we went into medicine in the first place.

The Gold Foundation proposed that the humanistic doctor, not just has, but displays on a daily basis certain attributes, described as IE CARES

Integrity – the congruence between expressed values and behaviors
Excellence in clinical care
Compassion – awareness of the suffering of others but also working to relieve it
Altruism – the capacity to put the needs of another before your own
Respect – regard for the autonomy and values of another
Empathy – the ability to put oneself in another’s situation
Service – sharing with those in need

These core attributes have real value and meaning in the care that we provide to our patients on a daily basis.
When the Gold Foundation was first formed, they asked several important questions.
1.    Can we identify students who are both scientifically proficient and compassionate?
2.    Are we selecting idealistic and humanistic young people for medical school, but then discouraging their spirit of caring through the education process?
3.    If we select students who don’t have the right characteristics, can we through education, teach them to be?
I would like to spend the next few minutes talking about each of these questions. As I speak, I believe that you will see the relevance of the Community Capstone project to this discussion.

So, the first question was:

Can we identify students who are both scientifically proficient and compassionate?

Before we answer that question, you need to ask yourself an important question: do you believe that it is important to be both scientifically proficient and compassionate?

Patients definitely do. A Health magazine survey (1) a few years ago found that the number one thing that patients wanted was a doctor who listens to them. Number two was being up to date on the most recent information in the medical field. Did you hear that? A doctor who listens was first, then being up to date.

Patients don’t want to see a really smart doctor who is a jerk
But they also don’t want a caring doctor who doesn’t know anything.
Both attributes are important.

In February of last year, the Association of American Medical Colleges’ (AAMC) Committee on Admissions endorsed a list of nine core personal competencies that medical students should have prior to beginning medical school.(2) These included ethical responsibility, dependability, a service orientation, social skills, the capacity for improvement, resilience, cultural competence, oral communication and teamwork. These seem like important characteristics that have some commonalities with the Gold characteristics even though it does not specifically mention compassion.

A survey of medical school deans done in 2007 (3) found that 90 percent thought that “Caring Attitudes” were emphasized during the pre-clinical and clinical years. 93 percent of the schools asked admission interviewers to assess the caring attitudes of their applicants. But do they do that?

I am sure that you remember the application process to come to medical school here at FIU. We started out looking at your college grades and your MCAT scores. Every school does that. Most every school in the country also uses an in-person interview to determine if you get into medical school. The interview’s purpose is try to figure out what kind of person you are. Do you have those other characteristics that will make you a caring and compassionate physician?

A specific type of interview, known as a semi-structured interview, is actually pretty good at predicting performance in medical school. And importantly, is better and figuring out if an applicant has those important personal characteristics such as compassion and ethical attitudes.(4)

So, the answer to the first question is yes, we can identify students who are scientifically proficient and compassionate.

The second question was:

Are we selecting idealistic and humanistic young people for medical school, but then discouraging their spirit of caring through the education process?

To answer this question, I want to tell you a true story that took place 23 years ago.This story is from my medical school experience. 

My first rotation was surgery. I was assigned to the VA hospital. It was across the street from the medical school and everyone wanted to go there. Remember, this was back in the old days. We never saw a faculty physician! So as a student you actually got to do a lot while you were working with the residents.

The surgical residents ran everything. And the Chief Residents were like gods. They could do anything, they knew everything, and could handle any problem that came along. We had one surgical chief that everyone was terrified of: Dr. X *. And as luck would have it, I was assigned to his team. The Red surgery team. I have no idea where he is now but back then he was the Chief Resident and ran the entire surgical floor.

Every morning we arrived at about 4:30 to pre-round on our patients. Each student carried five or six patients and we had to present each of them on rounds. At six o’clock AM, we met with the junior residents and went over all of the patients, updating them on any issues from the night before. We went to surgery in the morning and surgical clinic in the OPD in the afternoon.  And then we would wait. We had to wait for Dr. X to finish his case or clinic or his coffee (whatever he was doing) so that we could round again with him.

When he was ready, we would get a page. Back then it was just a voice page (there was no such thing as cell phones or text messaging). The page said “RED DOGS to the ICU, RED DOGS to the ICU”. We were the dogs, the medical students. At this point, it was usually 7 or 8 at night and you had been in the hospital since 4:30 or so.

Rounds with Dr. X were an exercise in terror.  If you talked to long, he would tell you to shut up. If he asked you a question and you got the answer wrong, he would just shake his head and say, “Stupid Medical Student”. If you tried to talk about family history or what the patient’s spouse was worried about or gave any social history he would cut you off. “I’m not interested in that…”

Was that discouraging?  Yes it was.

Experiences like this can cause you to develop a hard external shell. It is like a callous that develops on your psyche, to keep you from getting harmed. A survey of medical students found that they identified empathy, communication, integrity, and honesty as the most important qualities of a doctor.(5) But Morley and colleagues at SUNY Upstate in Syracuse New York found that idealism begins to decline as early as the end of the first year of medical school. (6) Empathy begins to decline as soon as you start to see patients and declines across all of the years of medical school.(7) You start out as caring people and then the weight of the medical education system begins to wear you down.

So the answer to the second question, is yes. We do things during the educational process that can damage you.

The third question was:

If students lose (or never really had important characteristics) can we through education, help them to develop or learn them?

From my perspective, this gets to the heart of the issue. 

This is the intersection of the Gold Humanism Honor Society and the Green Family Foundation NeighborhoodHELPprogram

If you want students to learn to be caring and compassionate physicians, it is important to see patients in the communities where they live.  As a student it is easy to get jaded by the difficulties of the patients around you.
Why did that patient miss his appointment?
Why doesn’t she get out of her house and walk more?
Why don’t they eat more healthy foods?

People smoke. People drink. People are obese, they don’t exercise, they don’t eat right. They don’t take their medicine. It is easy to get to the point where we believe that every medical problem that our patients have is their own fault. Rather than seeing and understanding that people’s lives are complicated and difficult. More difficult than our lives. Far more difficult than my life.

The only way to see that is to go out into the community.  Get to know patients in their own world, not in the artificial world of the clinic or the hospital. But in their home.

That is the simple brilliance of the NeighborhoodHELP program. You have the opportunity to see patients and families in their own home. Where they live. In their neighborhood. Their community.

The Community Capstone projects, build on that experience. The best Capstone projects, such as some of these that are honored here tonight, are the ones in which a student or group of students was impacted by something that they saw in the community, an issue. They found a community partner who was also interested in that issue. And they worked to address the issue.

We know that the humanistic qualities that are held up by the Gold Foundation can be nurtured through exposure to mentors who also have those qualities. Through experiences that encourage you to care for people not just take care of them. And through opportunities to reflect on those experiences.

When you applied for medical school, all of you said something about how you wanted to help people. You wrote in your personal essays about your motivations for going into medicine. I have read thousands of those essays over the years. Everyone says that right things, but many don’t follow through on those words.

You have the opportunity to do something different.

To care for people

To make a difference in their lives

Congratulations and thank you again for the opportunity to talk to you today

(2) Koenig TW, et al. Core Personal Competencies Important to Entering Students’ Success in Medical School: What are they and how could they be assessed early in the Admission process? Acad Med  2013; 88(5): 603-613.
(2) Lown BA, et al. Caring attitudes in medical education: perceptions of deans and curriculum leaders. J Gen Intern Med 2007; 22(11):1514-1522.
(4) Pau A, et al.  The Multiple Mini-Interview (MMI) for student selection in health professions training - a systematic review. Med Teach. 2013; 35(12): 1027-41.
(5) Hurwitz S, et al. The desirable qualities of future doctors—a study of medical student perceptions.  Med Teach  2013; 35(7): 1332-1339.
(6) Morley CP, et al. Decline of medical student idealism in the first and second year of medical school: a survey of pre-clinical medical students at one institution. Med Educ Online  2013; 18.
(7) Neumann M, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011; 86(8): 996-1009. 

* (name removed to protect his identity)