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.

Wednesday, August 13, 2014

What’s new in Academic Medicine this month?

There were several interesting articles in the August issueof Academic Medicine

The first was a retrospective study by Norcini, et al (1) that actually tries to connect performance on a high-stakes examination (USMLEStep 2 CK) with some real patient outcomes. The authors looked at about 61,000 patients who were hospitalized in Pennsylvania for Congestive Heart Failure (CHF) or Myocardial Infarction (MI). They were looking at admitting physicians who were graduates of an international medical school and had taken the Step 2 Clinical Knowledge (CK) examination. The authors found that an increase of one point on the examination was associated with 0.2% decrease in the mortality of their patients (95% CI: 0.1—0.4%).  The authors recommended using the Step 2 CK as part of the licensure process but that seems premature. It would also be interesting to look at physicians who were graduates of US Allopathic and Osteopathic medical schools.

The second study, by Nixon, et al (2), evaluated students on the Internal Medicine clerkship at the University of Minnesota. Students were instructed on using educational prescriptions to create PICO-formatted questions (Patient-Intervention-Comparison-Outcome) and then answers to those questions for a bedside case presentation. The content and quality of the questions and answers was then analyzed by the authors. They found that 59% (112/190) of the questions were about therapy, and 19% (37/190) were related to making a diagnosis. They also saw that 61% (116/190) were scored 7/8 - 8/8 on the PICO conformity scale. The quality of answers was pretty high with 37% (71/190) meeting all criteria for high quality.

And finally, a really cool study by Watson (3) that analyzed hand motion patterns using an inertial measurement unit. The author looked at 14 surgical attendings and 10 first- and second-year surgical residents. They were asked to do a simulated surgical procedure while wearing an inertial measurement unit on their dominant hand. They used the pattern of movements to train a classification algorithm with expert and novice patterns. The classification algorithm (which is similar to an artificial neural network) is good at identifying patterns. In this case, when the authors gave the classification algorithm blinded hand motion patterns, it did a pretty good job of classifying them as expert or novice. Its accuracy was 83%, with a sensitivity of 86% and specificity of 80%. The classification algorithm was able to reliably classify surgical hand motion patterns as expert or novice. This could be used in the future to make an objective assessment of procedural or surgical proficiency.

This was a good month in Academic Medicine. Some pretty good studies!

(1)       Norcini J, et al. The Relationship Between Licensing Examination Performance and the Outcomes of Care by International Medical School Graduates.  Acad Med  2014; 89(8): 1157-1162.
(2)       Nixon J, et al. SNAPPS-Plus: An Educational Prescription for Students to Facilitate Formulating and Answering Clinical Questions. Acad Med 2014; 89(8): 1174-1179.

(3)       Watson R. Use of a Machine Learning Algorithm to Classify Expertise: Analysis of Hand Motion Patterns During a Simulated Surgical Task.  Acad Med  2014; 89(8): 1163-1167.

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