AMSA Rodeo: And Now, a Word from Our Sponsors
For some time, there have been various efforts made to organize interns and residents under the auspices of a union. While I’m not aware of any hospital in the US with unionized physicians or trainee-physicians, that doesn’t mean there isn’t a union waiting for them… and for us at AMSA registration.
In our registration packets was a survey from SEIU-CIR asking about attitudes towards unionization. The demographic questions were quite entertaining. They clearly know what kind of medical student attends an AMSA convention.
Of course, seeing the SEIU logo brought to mind a recent chapter in the annals of medical unionization. I wonder how people here would feel about this one?
Baby Steps
It seems that I still need to work on announcing my hiatuses (hiati?) from blogging prospectively. If even CMS has agreed to assign Medicare beneficiaries to ACOs on an ex ante basis, I really have no excuse.
*crickets chirping*
In my defence, I am a second-year medical student, though you might not know it from my taste in health reform jokes.
It isn’t that the content of medical school is intrinsically difficult. In a refreshing change from my previous education in economics and social sciences, there are usually right answers. Unambiguously right answers that rest on a foundation of the (usually) internally consistent logic of human pathophysiology. There are fewer clinically-relevant “models” per se, and their assumptions rarely engender as much bitter controversy as those in… say… macroeconomics. To be fair, my contention that the kidney only makes sense if you posit the existence of a sodium/unicorn dust exchanger in the loop of Henle took a while to gain acceptance.
*more crickets chirping*
What makes medical school hard isn’t the material. It’s the volume that gives us a run for our money. Not only do we have to learn “everything” in two years or less, we have to remember it. For Step 1.
(If you’re a second-year medical student, consider stopping here. For your sanity, of course)
Physicians in the United States are licensed, as are physicians in countries like Canada, the UK, Australia… probably most others. As one might expect, physicians in the US are expected to pass a nationally standardized exam to qualify for licensure. As in Canada, there is one part that is taken before entering post-graduate training, and another part that is taken after at least one year of residency.
However, as politicians are quick to remind us, the US is exceptional. Because in my poking around medical licensure systems of similar countries, the United States Medical Licensing Exam is the only test with anything like Step 1.
(I said it again. Second years, I warned you.)
The simplest way to describe Step 1 of the United States Medical Licensing Exam is as follows: a seven hour long, 322 multiple-choice question, 78 seconds-per-question final exam for the first two years of medical school.
An exam with sacred texts known to medical students across the country: First Aid; Goljan; Robbins Review; the Q-Books; BRS; High Yield…
An exam for which completing a few thousand practice questions is considered “barely enough.”
An exam that plays a significant role in whether you’ll get accepted into the residency program, or even the specialty, of your choice.
An exam for which most students are given 5-8 weeks of time off in which to study full-time right before taking it.
An exam for which many students start studying six months in advance. Which for me is… now.
I tell you all of this because between now and mid-May (when 5 week journey of discovery and practice questions begins in earnest) my posting will be even more infrequent than before, and those posts that are written may well feature less of the policy commentary you’ve grown accustomed to and more… “medical student stuff.” That said, I assure you it will continue to be worth your time.
As for your intrepid blogger/test-taker… despite my flair for the dramatic, I’ll be fine. Just under six months from today, I take the next step on the road to licensure. I will take that seven-hour, 322-question exam. And I will crush it. You heard it here first.
AMSA Follies: By Reader Demand
I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”
Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).
AMSA Follies: Primary Care and Health Policy
A pair of physician-researchers from an AAFP-funded research institute spoke about integrating a career in medicine with a career in policy research. That was interesting to me as a medical student, but of general policy interest was their take on the future of primary care:
- They were surprisingly genial about specialists, and avoided playing the blame and recrimination game. This was welcoming and refreshing. Medicine is divided enough as it is.
- They count Nurse Practitioners and Physician Assistants as primary care providers. I would think that this undermines their cause slightly (“hey, if non-physicians can do the job…”), but I’m sure they have their reasons.
- I overheard one of the speakers talking to a student in the hallway after the main presentation. I caught a bit of their discussion about Qliance. They were both of the opinion that that sort of market-based, patient-centred model will be important to revitalizing primary care. The AAFP speaker was trying to cram the Qliance model into the “ACO” box, but hey… no one’s perfect. It’s great to see some of the professional societies recognize the need to get off the government-dependence gravy train before it derails completely.
Also of note was the following… special moment: one of the students in the audience objected strenuously to the speakers’ use of “industrial,” “corporate” terms like — wait for it! — “supply,” “demand,” “surplus.” He wanted to know how the sky would keep from falling so long as we keep referencing “that paradigm.”
Oy.
AMSA Follies: The Upside
The conference isn’t all shenanigans that raise my ire (or at least my vehement disagreement). This morning’s keynote speaker, Marshall Ganz, is a professor at Harvard who took 31(!) years off from college to participate in the civil rights movement in the South, then the labour rights movement led by Cesar Chavez in California.
Highlights from his talk:
- “Leadership is the practice of accepting responsibility for enabling others to achieve a common purpose under uncertainty.” [Perhaps the best definition I’ve ever encountered.]
- Raising “awareness” and starting “dialogue” are rarely useful in situations where different parties have different goals. [something that my generation seems to forget, with the ease of meaningless “awareness” campaigns limited by Facebook/Twitter accessibility]
- The cause of Wisconsin public-sector unions and Egypt’s popular uprising are meaningfully similar/equivalent. [ooookaaaaaay]
- Some of the reasons for the success of the American conservative movement in recent decades are their ability to organize at the grass-roots (e.g. the National Rifle Association), to clearly articulate their values and principles, and their persistence. The left is unable to consistently do this.
Right now: the common purpose of the conference attendees is lunch and swag, with great certainty. Lots, lots, lots of swag to be had. There will be photos.
AMSA Follies: Marketing Misadventures
[My efforts at live-blogging/tweeting have been foiled by the fact that this conference occurs two levels below ground where there is no connectivity of any sort. I guess this means the hotel has me on tape delay…]
The first talk of the morning was by a second-year medical student (Shahram Ahari, UC Davis)who spent some time as a sales rep for Eli Lilly after graduating from Rutgers. He went into sales because he thought it would be an opportunity to connect with clinicians at an intellectual level and discuss the science. Because that’s what a private-sector sales job is all about. Needless to say, he was somewhat disillusioned, especially upon finding that most of his salesforce colleagues weren’t scientists, but… salespeople. Go figure.
The presentation wasn’t irrationally hostile to pharm companies, though I might have caught the suggestion at the end that physicians have an “obligation” to vote the interests of their patients. He explained the many ways in which pharm sales people use the same techniques employed by salespeople in any industry: appeals to emotion backed up by data about the client that is never overtly mentioned.
The discussion was focused almost entirely on the prescriber-marketing interface; I was hoping for some evaluation of the appropriate nature of researcher-industry relationships, which is where (in my view) the controversy is much hotter. Nonetheless, it was an entertaining talk that explained the psychological basis behind all sorts of marketing techniques such as giving away free stuff…
Oh, right! Free stuff! AMSA might claim to be pharm-free, but a quick visit through their exhibition hall revealed a whole host of characters whose money AMSA was more than happy to accept in exchange for a booth. Some of these groups are more savoury than others.
Details to come… truly extraordinary.
AAMC Follies: The New MCAT
The Association of American Medical Colleges made a splash this week with the release of preliminary recommendations for changes to the Medical College Admissions Test (MCAT), to take effect in 2015. The proposal getting the most press is the expansion of the scope of the test to include material from the social sciences, statistics, ethics, philosophy, “cross-cultural studies,” and other assorted non-science topics.
Given that the AAMC is one of the organizations raising the alarm about a looming physician shortage, it’s interesting to see that one of their responses is to ever-so-slightly raise the barrier to entry to medical school. That’s one heckuva cartel I’ve got on my side!
Of course, given the enormous mismatch between the number of medical school applicants and medical school spots, this change will not actually reduce the number of medical students (and as readers of this blog know, the real bottleneck is the number of residency slots). It will, however, increase the amount of time, effort, and money needed in order to meet the basic requirements for medical school admission. I suspect the test prep companies will fare especially well.
That said, I’m skeptical that the proposed MCAT changes are that worthwhile. I would be surprised if they do much, if anything, to address the concerns that seem to be motivating them. Here’s why.
1) Unless implemented very thoughtfully, inclusion of social science content will trivialize it by making it simply “another box to check” while studying. The USMLE has had limited success with this; can AAMC really do better?
The two recommendations from the the “MR5” report that seem to be driving much of the hubbub are these two:
I’m on record as a fervent supporter of making statistical fluency a pre-requisite for entry to medical school (or a college degree, for that matter). If this change leads to an increase in the statistical literacy of future medical students, that’s a plus. Similarly, as a former economics major, I am fully aware of the applicability of various social science concepts and techniques to the medical field. If a standardized test can assess the ability to analyze ethical and philosophical problems, so much the better (though I would imagine that it would be more likely to measure familiarity with the key buzzwords from each discipline).
The risk of including these topics on the MCAT is that by making these disciplines part of “just another hoop to jump through,” the test won’t be able to adequately evaluate the analytical ability and engagement with the material that the AAMC seems to value. Lest you dismiss this as an idle concern, here’s an actual question from a gold-standard review book for the US Medical Licensing Exam. Step 1 of the USMLE includes questions on sociocultural topics, ethical topics, the doctor-patient relationship, and the same “cross-cultural studies” that will soon be added to the MCAT.
The chapter for which this question was written is entitled “Culture and Illness;” it reads like a checklist of stereotypes about various ethnic and cultural groups. I have yet to figure out what real value this adds to my skills and maturation as a physician. If this sort of content is to be included on the MCAT, the AAMC will have to do a much better job for it to be worthwhile and meaningful.
2) The MCAT is not the tool by which to evaluate candidates’ personalities. That’s what interviews, essays, and recommendations are for.
The MR5 recommendations continue.
Lots of people think medical schools should look “beyond test scores” and focus more on “personality” when judging applicants. Dr. Pauline Chen, writing at the New York Times, thinks so. The UChicago medical student with whom I discussed this on Twitter thinks so. Many of my classmates think so. I probably think so as well, but then I can’t pretend to know how these decisions are actually made in real life as it is.
The idea that mastery of social science content (or lists of stereotypes, as seen above) correlates meaningfully to personality is dubious, to put it charitably. Also, with pre-meds being who they (we?) are, I’m skeptical that any dedicated “personality test” section on the MCAT would last more than a couple of years without being dissected, gamed, studied-for, and meaningless as a gauge of an applicant’s character.
If it’s personality that you want in your medical students, the MCAT is not how you’re going to sort them. If the AAMC wants to create standardized tools to help medical schools evaluate applicants without actually needing to interview them (as recommendation #14 seems to imply), then they should go for it. I would think, though, that different medical schools might want different types of students. A one-size-fits all assessment might not serve every school’s needs equally well.
If the MCAT is over-weighted in the admissions process, then the real issue is how it’s used, not what it tests. It’s also worth pointing out that as long as medical school deans care about their US News & World Report rankings, they will place non-trivial emphasis on their entering students’ MCAT scores. That’s a pretty big counterweight to any movement to increase the weighting of “personality” in medical school admissions.
(Briefly discussed later in this post: what personality traits do we want in all of our medical students, why do we want those traits, and are medical schools really being flooded with so many applicants who lack them?)
3) Medicine is about service, but it’s still an applied science.
A common theme in the reactions of some of my classmates (and Dr. Chen’s NY Times piece) is that the MCAT and/or the medical school admissions process is too heavily focused on mastery of science. (Did I mention that I was an Economics major?). While the science content of the MCAT could certainly stand to be tweaked, I would hesitate to write it off completely. It is still the best predictor of success in medical school (where “success” is “not failing out during the preclinical years”), and the only standardized means of comparing science ability across applicants. What has helped me get through the first year of medical school has not been my social science background (though it has helped). It’s been the solid science foundation that I got in undergrad alongside my economics coursework.
If students want to help others and save the world without needing to take those pesky, difficult science courses, there are plenty of other career options open to them. Medicine still requires comfort with science, and that is the reality that we’re stuck with for the foreseeable future.
(For more on why science should not be viewed as an “obstacle” to medical school admission, I urge you to consult the ever-worth-reading David Gorski at Science-Based Medicine).
3a) Barriers to entry to medicine should not be arbitrarily and artificially increased, but it’s worth pointing out that medicine is a field that requires dedication… or at least that’s what they told me.
This is a minor point, but an important one. In my cynical estimation, there are three sorts of people who would want to become practicing physicians in this day and age: the naive; the passionate; and the crazy. Medical training is a long and arduous process, and the practice of medicine in the US isn’t about to get easier in our lifetimes. If someone is discouraged from going into medicine because of the MCAT… what would they do when confronted with Step 1 of the USMLE? The MCAT isn’t a personality test and shouldn’t be used as one, but at the same time, my inner curmudgeon has to question the bona fides of those who claim they would go into medicine “but for the MCAT.” When my classmates tell me that these proposed changes will make the MCAT more accessible to students who otherwise wouldn’t have taken it, there is a part of me that wonders whether that is really an unalloyed good.
4) Is there another agenda at play here? (WARNING: SPECULATIVE)
Even as the debate goes on between social science upstarts and science purists, between those who think that “personality” is over- or under-represented as an admissions criterion, one could be forgiven for wondering what the fuss is all about.
Medical schools aren’t lacking for applicants. There isn’t, to my knowledge, an epidemic of death, destruction, bad outcomes, or other horrors brought about by physicians insufficiently knowledgeable about the social sciences. I doubt that most medical school graduates are uncaring, unsympathetic, offensive brutes.
The main “problem” with medical students today, as far as I can tell, is that too few of them are willing to go into primary care careers. At least… some people see it as a problem with the students. I don’t.
There’s been a lot of attention focused on the primary care shortage over the past few years, some of it focused on delivery reform (think ACOs and PCMHs), and some of it focused on supply (e.g. the medical students). One noteworthy report authored by the American Medical Association in 2007 intimated that the primary care shortage could be solved by finding medical students who are more “service-oriented” and “altruistic,” better able to “be advocates for […] social justice,” and less “autonomous.” The report proposes including “social accountability issues” among admissions criteria.
Implicit in all of this is the assumption that the problem with the health care system, and the cause of the primary care shortage, is that we’re the wrong kinds of medical students. I’ve blogged about this report before, and why its premises and conclusions on this issue are utterly wrong; I don’t need to re-hash this here.
I can’t help but wonder how much of this line of thinking went into the recommended MCAT changes. No one — not the AAMC, not the many commentators whose responses I’ve read — has explicitly made this connection. But the rhetoric is the same. The implicit assumptions seem to be the same. The same misguided goals via the same misguided methods.
I hope I’m reading too much into things, but if not I can only despair at the solutions that organized medicine has found for our problems.
Heckuva cartel, eh?