Foreigners are people too

This is the second of two posts prompted by Dr. Robert Centor’s critique of a recent New York Times Magazine article accusing America of “stealing [sic] the world’s doctors.” In the first post, I show how US immigration policy for physicians is a boondoggle of near-comedic proportions that doesn’t even constitute an effort at “theft,” given that it’s hard-pressed to hold onto me after I graduate (as I explain, I should be one of the easier doctors to “steal”).

Now let’s look at the counterfactual situation. Suppose the it were actually easy and straightforward for physicians to immigrate to the US (or to remain, in my case), gain licensure, and be certified in their specialties. Suppose the immigration and licensure systems were designed with this very goal in mind. Would this be a bad thing?

The conventional wisdom is that the emigration of skilled professionals from less to more-developed countries is bad for the less-developed countries: this process is often referred to as “brain drain.” Critics argue that “brain drain” harms poorer countries by preventing the development of local talent, skills, and professionals that are often sorely needed. They also point to the fact that many countries subsidize education at least to some extent, only to see the investment in their citizens’ human capital slip away beyond their shores.

The conventional wisdom is wrong. As the 19th century economist Frederic Bastiat pointed out, it is best “not to judge things solely by what is seen, but rather by what is not seen.“

What is “not seen” when it comes to emigration of skilled professionals? Networks of diaspora spread ideas and expertise, strengthen economic and social ties between countries, promote peace, and promote advances in the standards of living both at “home” and “abroad.” Emigrants usually earn much more in their new country, and their remittances home are not only better able to support their family and community, but are often enough (over a lifetime) to dwarf the amount their home government spent on their educations. The option of emigration to higher-income countries creates incentives for poor countries to invest in education, and for their citizens to take advantage of it. In short, emigration of skilled professionals to richer countries enhances their productivity, which in turn has positive effects for their home country, their adopted country, and all of us along the way.

Yet even this analysis misses the fundamental point. To insist, as the New York Times does, that foreign physicians somehow “belong” to their home countries is to objectify and commodify them. When you think about it, it’s a remarkable assumption for anyone to make. Foreigners are people too. We’re not chess pieces to be pushed around a board, traded for promises of foreign aid, trade preferences, or anything else one might imagine. The Canadian government has no more claim on me and my career than the American government does on anyone who has ever attended a public school in this country.

This is a universal principle. I don’t care how poor the country is, no government can claim to “own” its people in this way. It’s absurd to suggest that the United States government should alter its immigration policy to cater to other countries’ desire to engage in this form of subtle repression, and even more absurd to think that this would actually benefit anyone.

Physicians who voluntarily leave one country for another in the hopes of making a better life are not “being stolen.” Not unless you think they’re owned by someone other than themselves. At its core, that’s what this discussion is all about. And that’s why, in my mind, there should be no ambiguity as to the right conclusion.

Some Friendly, Unsolicited Advice for PNHP

Physicians for a National Health Plan (PNHP), as the name suggests, is the biggest and best-known group of American physicians who support replacing the current health care system with a national single-payer. I used to be a big booster of this idea, but it doesn’t take much poking around this website to figure out that my feelings towards American single-payer reform have cooled considerably (to say the least).

I’ve been fortunate to attend a number of events run by senior PNHP officers at SUMS and at other venues (e.g. the AMSA conference back in March). At one of the more recent events, I had the privilege of speaking at length to some of their representatives at length. As you might expect, the resulting discussion was direct but cordial.

Though I disagree with their proposed policies, I do respect PNHP as an organization. It is one of the biggest mobilizers of physicians and medical students who are in favour of radically changing how American health care operates. Their passion is palpable at even the most informal event. They do have a contribution to make to the health policy conversation. Unfortunately, while there is an intellectually-coherent case to be made for single-payer (a mistaken case, in my view, but respectable and honest), I have yet to hear it from anybody at PNHP (n=small).

I harbour no illusions about my ability to persuade hard-core single-payer believers in a short blog post. I do, however, have some friendly and hopefully helpful advice on how to talk to the uninitiated and the un-converted more productively:

1) Don’t try to twist the data to support your case. It shows. At best, data on Medicare-vs.-private administrative costs are equivocal, cross-country infant mortality comparisons are spurious, life expectancy at birth captures a lot of mortality that is out of the hands of the healthcare system, and so on. The empirical case for single-payer superiority is thin gruel.

2) When someone asks whether you’d trust a Republican President and Congress to implement single-payer well, don’t duck the question. It’s a more important one than you seem to acknowledge. If you want to centralize control in government, be prepared to talk about how you will deal with your ideological opponents who tend to win elections every now and then.

3) Your moral argument is a lot stronger than your empirical argument. Why not make it explicit? Americans don’t tend towards collectivism, but neither are most people data-oriented policy wonks. Instead of making a weak case based on weak data, you should be prepared to talk about the moral strengths of single-payer relative to the alternatives. Where are the mentions of equity, obligation, and collectivism? (I ask this seriously, not passive-aggressively)

4) Be fluent in the language business, politics, and economics. When your executives are being matched point-for-point by medical students who majored in biochemistry and similar fields, you know you have a problem. If you’re going to call for the dismantling of private insurance, have some idea of how the sector actually operates. If you want to give control of the health system to government, be able to discuss the nuances of Washington power structures. Be able to respond to phrases like “deadweight loss,” “price-vs.-income problems,” and “underwriting” with more than a blank stare.

5) Anecdotes are rarely dispositive of policy questions. When someone points this out about anecdotes involving people you know, don’t get offended; this rarely advances discussion. When you introduce your friend’s problems to the debate, it’s not your opponent who’s trying to use them to score “cheap points.”

6) Milton Friedman is said to have told an up-and-coming Walter Williams, after the latter appeared on TV to discuss school choice, that “[Williams] was right about everything but [had] made one mistake […], when you talk about liberty, you have to smile.” You may not be talking about liberty as Friedman understood the term, but his advice is every bit as applicable.

 

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:

3. Test examinees’ knowledge and use of the concepts in behavioral and social sciences, research methods, and statistics that provide a solid foundation for medical students’ learning about the behavioral and socio-cultural determinants of health.
4. Test examinees’ ability to analyze and reason through passages in ethics and philosophy, cross-cultural studies, population health, and a wide range of social sciences and humanities disciplines to ensure that students possess the necessary critical thinking skills to be successful in medical school.

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.

A 40-year-old woman who recently had back surgery does not complain of pain, although magnetic resonance imagery (MRI) reveal re-herniation of the disc with significant nerve involvement. Of the following, this woman is most likely to be of

(A) Welsh descent
(B) Puerto Rican descent
(C) Greek descent
(D) Italian descent
(E) Mexican descent

[(A) is the correct answer, because “Anglo Americans tend to be more stoic and less vocal about pain than to Americans of Mediterranean or Latino descent”]

(from Fadem, B. Behavioral Science in Medicine. LWW, 2004. p. 326)

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.

To help medical schools consider data on integrity, service orientation, and other personal
characteristics early in student selection, the AAMC should:
13. Vigorously pursue options for gathering data about personal characteristics through a new section of the AMCAS application, which asks applicants to reflect on experiences that demonstrate their personal
characteristics, and through standardized letters that ask recommenders to rate and write about behaviors that demonstrate applicants’ personal and academic characteristics.
14. Mount a rigorous program of research on the extent to which applicants’ personal characteristics might be measured along with other new tools on test day, or as part of a separate regional or national event, or locally by admissions committees using nationally developed tools.

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?

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).

BREAKING NEWS: AMA Throws Support Behind Note-Forging Physicians in Wisconsin

For immediate release:
February 22, 2011

Washington, D.C. – The American Medical Association (AMA) announced late last night that it wholeheartedly supports the pro-union protest activities of certain physicians from the University of Wisconsin School of Medicine’s Department of Family Medicine.

Pro-union demonstrators — notably public school teachers — have flooded the state capital, Madison, to voice their displeasure with proposed cuts to pay, benefits, and collective bargaining ability. Meanwhile, a group of idealistic, enterprising physicians have set up shop to aid the protesters in their efforts. Given that these protests have been, fortunately, free from the violence wracking demonstrators in other parts of the world, these inspiring doctors have been using their special expertise for the benefit of the local protester community by writing the “sick notes” that will allow these teachers to keep their pay and jobs after having skipped work to attend the demonstrations.

They are, in short, ”providing real doctor’s notes for people who miss work.”

As has been captured in many of the videos of the protests, these heroic physicians have been able to assess their new ”patients” in mere seconds, doubtlessly utilizing the speed-H&P skills learned by practicing medicine under the AMA-supported system of RVU-based payment.

While some commentators have accused these doctors of ”stealing,” ”lying,” ”falling short of the public’s ethical expectations,” and ”demeaning the doctor-patient relationship,” the AMA would like to commend the work of these courageous physicians, who truly represent the best of American medicine and the future of primary care in this country. They truly are a shining example of what the AMA thinks that medical practice should be.

In addition to showcasing the near-lightspeed pace at which the AMA believes outpatient medicine should be practiced, these doctors — from unlicensed resident to grizzled veteran of community practice alike — exemplify the values that will need to become more commonplace if primary care in the United States is to be revitalized.

In 2007, the AMA’s Initiative to Transform Medical Education (ITME) released its Recommendations for Change in the System of Medical Education, concluding that the current shortage of primary care physicians in the United States is due to a cohort of medical students who are insufficiently altruistic, unwilling to be advocates for social justice issues, and too fixated on problem-solving and intellectual pursuits to be the effective community organizers that primary-care physicians ought to be.

In the view of the AMA, the model of ”primary-care-physician-as-community-organizer-for-social-justice” must replace the model of ”primary-care-physician-as-healer-and-problem-solver” for there to be a future for primary care in this country, especially given the reluctance of the federal government to increase physician payment under the AMA-supported RVU system.

As the voice of America’s doctors, and as the champions of primary care’s bright future as social justice advocacy, we are thrilled to see these Wisconsin physicians living up to the ideals espoused in the ITME recommendations, if not the Hippocratic Oath. The future of primary care is not in practicing medicine; it is in political agitation. These family practitioners are pioneering the way forward for their specialty. They are organizing for their community, and they are advocating for their patients’ sense of social justice, entirely unbound by the conventional problem-solving, clinical-assessment mentality that persists among primary care physicians at their own peril.

The American Medical Association stands with these brave primary care practitioners, and urges them to continue to practice primary care medicine in the best way possible. Only by following in their example can family physicians, outpatient internists, and pediatricians ”win the future” for their specialties in this environment of harsh RVU economics.

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In case you haven’t realized by now, this is not an AMA press release. It is a satire/parody of the AMA’s positions on medical education and physician supply in the context of the primary care shortage. Use of the AMA name is protected fair use. For more disclaimers, see my ”About” page.

A bad feeling

According to famed bioethicist Leon Kass, we should listen to “the wisdom of repugnance.“

Revulsion is not an argument; and some of yesterday’s repugnances are today calmly accepted — though, one must add, not always for the better. […] In crucial cases, however, repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it.

If I held myself to such high standards, I would tell you that I find the thrust of what I see as mainline bioethical thought to be “icky,” and from there res ipsa loquitur. However, I’d like to think that my distaste has more than mere “revulsion” behind it, and as such the matter is not so easily disposed of.

In the “standard” ethics and professionalism lectures, medical students are taught that medical ethics rest on three foundational pillars: non-maleficence (“do no harm”); beneficence (“do what’s best for your patient”); and autonomy (“act in accordance with your patient’s wishes”).

Who decides what’s best for the patient, or what constitutes harm? Logically, it should be the patient! When the stakes are high, so too should be the barriers for a physician to substitute his or her goals and values for the patient’s.

SUMS has a thriving medical ethics program, and we’ve had the opportunity to hear clinicians and medical ethicists from SUMS and from farther afield talk about ethical conundrums they’ve seen on the wards. Every presentation has shared one feature, without fail: it’s only an ethical conundrum (usually meriting a call to the bioethics committee) when the physician doesn’t agree with a patient’s choice, and has been unable to successfully use persuasion or coercion to change the patient’s mind.

This seems like a trivial observation at first. After all, why call the ethics committee to adjudicate a matter where the physician and patient are in perfect agreement (aside from rarer edge cases where this happens, usually involving experimental procedures)? It makes perfect sense!

What this means though, is that the medical ethicist has become the person to provide cover for a physician to override the patient’s autonomy. By virtue of selection bias in the cases they are asked to adjudicate, and the ever-present threat of regulatory capture, the role of “medical ethics” runs the risk of devolving into Paternalism 2.0. “We know what’s best for you, and if you don’t believe us, we’ll make you.” What’s more, when the medical ethicist is nothing more than the cudgel with which the physician forces his goals onto his patient, what claim does the ethicist then have to support his monopoly on decision-making in this sphere?

Admittedly, this image of medical ethics is a caricature. But to see the danger that lies in store, look no further than their cousins: the bioethicists.

At every turn I can think of, bioethics has established itself as the true “Ideology of ‘No.'” Whether dealing with BRCA gene testing for breast cancer susceptibility, assisted reproduction technologies, APOE4 screening for Alzheimer’s susceptibility, or “cosmetic” fetal ultrasound, mainstream bioethical opinion always seems to come down on the side of denying information to patients. Hardly the patient-empowering mindset that marked the field’s nascent days.

So why has the medical ethics / bioethics enterprise come to undervalue patient autonomy so extensively? I offer two preliminary hypotheses.

First is the fact that medical ethics and bioethics are situated in an academic-institutional environment that usually leans left-liberal (Progressive). Whether the institution makes the people, or the people make the institution, it comes out to the same thing: the setting is one that inculcates a predilection for top-down technocratic control. I think that this assessment is valid, regardless of what you think of the merits of different political philosophies.

The second one is, in my mind, more interesting. Public choice theory reminds us that bureaucrats, leaders, institutions, and their people do not exist in a world devoid of incentives and personal agendas. As an ethicist, when you say “no,” you entrench the need for your services… there needs to be someone with the authority to say “yes,” and what better way to establish your authority then by saying “no?” When you posit increasingly more complex models for evaluating ethical dilemmas — “autonomy, beneficence, and non-maleficence” just don’t cut it — you create an institutional need for someone with expertise in dealing with these complex rules to act as interpreter, and thereby increase your own power and prestige. Giving full weight to patient autonomy would undermine the need for your services.

This isn’t to say that ethicists make decisions with an explicit eye to entrenching their influence in the medical setting. It is, however, a reminder that we should always be asking ourselves: quis custodiet ipsos custodes? Who watches the watchers?

That, and the “wisdom” of repugnance is only as valid as the reasoning that supports it. Having “a bad feeling” about something doesn’t cut it when lives are on the line.

Think not, want not

There’s a central intellectual tension to be navigated during the first few months of medical school.  On the one hand, there’s the desire to critically engage with the material, to think about it, and in some cases to challenge what we’re learning.  On the other hand, there are some things you just have to know.  All sorts of estimates abound as to the number of new terms to be learned in the first year of medical school — I’ve heard numbers in the thousands — and there comes a point where it doesn’t matter “why,” or “what more,” or “what if”… there are some things you just have to know.

This tension has so far manifested itself most clearly in the “soft” courses:  the ones that try to teach ethics, professionalism, policy, “cultural competency,” “humanism,” and so on.  SUMS has structured its ethics and professionalism courses quite interestingly.  Small “discussion” groups get together to consider scenarios and watch media clips — some chosen from mass media, some from actual clinical practice — designed to prompt “discussion.”  Invariably, these clips have been trite, facile, and chosen to allow only one “correct” answer:  be nice to nurses; care about the patient; the patient is more than a disease; you need to see the patient to learn from the patient; don’t get in the attending’s way during a tricky surgery; etc.

If you’ve never been told these sorts of things before, it’s important to hear them, intuitive though they should be.  Given the abundance of rhetoric from SUMS administrators about the importance of “reflection” in medical education, it’s a shame that no such opportunities are provided when considering the maxims of professionalism handed down from on high.  After all, it’s the exceptions that prove* rules, and it’s the exceptions that give rise to the hardest questions, deepest thought, and ultimately the best engagement with and internalization of these norms.

Take, for instance, one of the many clips from medical shows depicting an arrogant young intern ignoring and/or being rude to nurses and other support staff.  Obviously, one should not ignore or be rude to nurses or support staff.  But what happens when there’s a legitimate difference of opinion?  Who’s ultimately accountable for the patient’s care, and how should the decision-making and teamwork process go from there?  What if someone is advocating for something that is just plain wrong?  These things happen.  Hiding behind a series of feel-good maxims about professionalism doesn’t prepare anyone for the tradeoffs they will encounter in the real world.

The reason I started thinking about this again was because of some remarks made by a SUMS assistant dean at our latest class meeting.  As I’ve written before, at SUMS the threshold for “official professionalism incident reports” to be placed in the files that get sent to residencies can potentially be pretty low; even minor lateness to class or with administrative deadlines could potentially be punished this way.

At this meeting, the dean provided, sua sponte, an attempted justification for the breadth of this policy, and the school’s apparent willingness to make use of it (fortunately, this isn’t known to me firsthand).  According to him, studies have found correlations between medical school disciplinary action and state medical board action; the biggest predictors of subsequent license sanctions for medical students are apparently” irresponsibility” and “diminished ability to improve or take criticism.”

These are bad things, and it’s not surprising that these traits in medical students would be correlated with subsequent disciplinary action as physicians.  Nonetheless, part of me still wonders if this correlation might not suggest causation.

When ethics and professionalism are treated as Platonic Maxims to be taken as dictated from the Faculty Above, with no room for thought, discussion, criticism, or engagement, might not a medical student facing sanction for unprofessional conduct — particularly if that conduct is a minor instance of tardiness — become disengaged from the entire set of ideals that professionalism is supposed to represent, thereby becoming more prone to major breaches later in life?

When ethics and professionalism, instead of representing the ideals of meaningful commitment to patients, come to be associated with arbitrary-seeming exercises of power by medical school administrators or as ways of stifling legitimate discussion about the role and behaviours of physicians, might not a student learn to distrust these concepts later in life?

When students are threatened with inflated artificial sanctions in lieu of facing the actual consequences of their actions, what does it teach them about autonomy?

I usually don’t display these sorts of blatantly anti-authoritarian leanings, and I’m not asking these questions to cause a ruckus or make a point of any sort.  I’m legitimately curious, and mildly concerned, about the implications of this approach to the teaching of ethics and professionalism to medical students.

These are the sorts of questions I would have loved to have asked him.  I might have even started a conversation that would have been so informative as to alleviate my concerns entirely, or maybe raise them in his mind.  Such potentially valuable exchanges of ideas, however, will have to wait until I’m actually permitted to initiate them.

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* – I use “prove” here in the sense of “demonstrating the existence of the rule” but also in the sense of “testing the boundaries, applicability, and viability of the rule.”

Retainer medicine and medical students

Earlier this month, Dr. Bob Centor posted one in a long line of posts explaining the appeal and merits of retainer medicine, especially in the outpatient general medicine context.  Retainer practices free both physicians and patients from the constraints of third-party payment systems, putting the patient firmly in control and allowing for the development of resilient physician-patient relationships that are more difficult to establish when visit length is otherwise effectively limited to 15 minutes (though these days I keep seeing “10 minutes” bandied about; is this a sign?).

What is fundamentally subversive about retainer practice, however, is that it represents a renunciation of dependence on government (or private insurers).  So many primary care physicians in academia and the community still feel that the best way to “save” primary care is to run crying into Congress’s arms, to beg for even more money, and thus to enhance the dependence on Congressional whim that currently characterizes any practice that is largely dependent on Medicare or Medicaid.

As you might imagine, this wresting of autonomy tends to get some interest groups riled up.

But let’s look at retail clinics!  Capitalizing on patient discontent with the current primary care model, these clinics have been expanding at a rapid clip, and are apparently doing a pretty good job of providing medical care.  This may well be a desirable innovation in the provision of medical services, but that discussion is beyond the scope of this post. Perhaps what’s most surprising:  many of them require patients to pay out of pocket without the possibility of insurane reimbursement.  And patients do!  Patients want to!

What this tells us is really what we knew already:  primary care in the US is not working for patients.  We knew that it’s not working for physicians either.  It’s hard to see how stay-the-course pleading for government largesse is expected to work “this time, really!”

Of course, primary care doesn’t seem to capture much interest among medical students, either.

It’s interesting to think about these debates on how best to save primary care while reflecting on recent conversations with other first-year students.  Somehow, through the crush of almost 200 now-forgotten introductions repeated over the course of the week, I managed to strike up a few conversations on preliminary specialty choice.  Lots of students here, myself included, believe strongly in the importance and the role of primary care medicine.  We just don’t want any part of it in the current system.  What’s more, most of the classmates I asked weren’t entirely familiar with the concept of retainer practice, and it’s doubtful that we’ll be exposed to many role models who function in such a practice.

And that’s a shame.  Orientation was full of lofty verbiage about role models and mentors.  What better way is there to reinvigorate medical student interest in primary care than to expose them to role models who have chosen a practice structure that minimizes the hassles, overhead, and constraints of third-party payment, and instead is focused on what drew all of us to medical school in the first place:  working for the patient?

While it’s too early to talk meaningfully about a specialty decision (though you’re more than welcome to start a betting pool…) it’s not too early for me to say this:  the only way I would seriously consider paediatrics, general internal medicine, or family practice residency in the US is if the retainer model of practice is still viable when it comes time to decide (i.e. hasn’t been banned by law or marginalized by organized medicine).

Of course, I’m fortunate to have Canada as a relatively easy alternate option.  And here’s the kicker.  The phrase “lifestyle specialties” in the US usually refers to the “ROAD to happiness:”  radiology; ophthalmology; anaesthesiology; and dermatology.  [Medical students are big on the mnemonic acronyms]  In Canada?  Well, according to my own physician… it’s family practice.

So close together, but so many worlds apart.

Around the Mediverse: August 18, 2010

What with this whole commencement of medical school, it’s been a while since the last edition.  So I bring you slightly more than usual

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• Worthwhile Canadian Initiative reminds us that counterintuitive though it may be, there is an optimal amount of forgetting.  Dr. Bob Centor suggests that proposed performance payment for physicians forgets the role of patient preferences in steering therapy.  Sticking with patient preferences, two posts at KevinMD argue that the long-term viability and feasibility of the PCMH care model should be determined by patient desires.  That is, if the PCMH model is workable to begin with… an arguable proposition.  Of course, if recent trends with retail clinics are any indicator… well, it could indicate many things.  You be the judge.

• Beware economists bearing dynamic stochastic general equilibrium macroeconometric models!  Beware surrogate endpoints in clinical research!  Beware constitutional challenges to the PPACA!  Beware Robin Hood… libertarian rebel?  Beware overly alarmist bullet points!

• End-of-life spending has gotten some attention.  The DMCB and Health Affairs alike aren’t convinced that reducing this spending will be easy, or that the savings are in fact possible to realize, at least as conventionally measure.  Relatedly, a guest poster at KevinMD points out that in medicine, sometimes “more is more.”  Not all potential cost-savings are “free lunches.”

• The Happy Hospitalist argues that data on physician reporting on impaired colleagues shows that the profession’s ethical standards are quite high.  Dr. Wes points out the ethical shortcomings of conducting large-scale policy experiments without any concept of research subject welfare as found in clinical research.  Arguably least ethical of this bullet point is Congressional exemption of the SEC from most FOIA requests.

• Pretty pictures!  Congressional Republicans give us charts explaining new government agencies created by the PPACA and the criteria for obtaining small business health insurance tax relief under the act.  The Denver Post posts some extraordinary colour photos from the Depression era.  Of course, sometimes making use of pretty pictures (and text) will cause one to run afoul of the federal government, as with the ADA actions taken against universities piloting Kindle usage among their students.

• Let’s talk unintended consequences of government actions.  Start by guessing which Senator takes exception to certain provisions of the PPACA?  Hint:  his name rhymes with “Hairy Reed.”  Elsewhere, the recession has forced two entrepreneurs to decamp to Canada because of the arcana of the E-2 visa.  What happened to new bond issues after the passage of the Dodd-Frank financial reform bill?  Would “disaster” be hyperbolic?  Becker and Posner ponder the effects of the administration’s pro-union attitude on business uncertainty and the recovery.  Megan McArdle discusses the optimal level of regulatory enforcement, whereas another blogger discusses the “tyranny of big ideas” in the context of regulatory change and improving human welfare.

• On lighter notes, we have a farmer who reminds the world that old-school farming isn’t all it’s cracked up to be, and a brief history of Tibetan Buddhism that is markedly different from the sort of thing you’d probably expect.

• Rounding out this week’s edition…  Medical schools, broadly speaking, do three things.  They educate physicians, produce research, and care for patients.  As someone just starting medical school, it’s nice to read things like this post from Dr. Centor arguing that the primary mission of medical schools should in fact be medical education.
  

Around the Mediverse: July 17, 2010

Fun tidbits, health-related and otherwise, from around the ‘tubes:

• How do the media deal with new research?  How should the media, or anyone else for that matter, interpret new research?  Unfortunately, the New York times only devotes a couple of paragraphs to this first question, but even that is enough to illuminate the complex web of incentives facing those in the science communications industry, and what it means for the science coverage that you see.  A blogger at Foreign Policy provides some useful advice in response to the second question.

• The Placebo Journal Blog takes on a proposal to save family practice… by extending the residency to 4 years from 3 (in contrast, FP residency in Canada is 2 years).  The comments are harsher than the post itself.  A family practitioner blogging at Better Health gives an example of how opting out of Medicare can be win-win for the doctor and the patient.  This strikes me as a better option than an extended residency.  Even if primary care can be saved, it probably won’t happen soon enough to stave off what could be a massive increase in Emergency Department utilization by newly insured patients as a result of the PPACA.

• File these under “overutilization” for sure:  Dinosaur accuses the American College of Obstetrics and Gynecology of “usurping” primary care’s scope of practice with new guidelines recommending OB/GYN visits for younger teenagers; MD Whistleblower blows the whistle on various “pre-emptive” CT scans that are being advertised to patients despite the fact that they don’t do much good for anyone.

• Science-Based Medicine writes a rebuttal to a Slate piece linked to in the last edition of AtM:  Why Big Pharma should not buy your doctor lunch.  SBM also featured some well-written commentary about new CMS head Don Berwick, touching on his lax attitude towards pseudoscience, and the Central Berwick Paradox of supporting unlimited patient choice and top-down government rationing.  Or something like that.

• Via EconThoughts and Megan McArdle, we find a story in the WSJ describing how some unions hire non-union labour to staff their picket lines.  Delicious.  Less delicious is the story told by House Appropriations Committee Chairman David Obey (D-Wis) of how the White House suggested paying for spending on teachers by cutting food stamp benefits.  Does anybody remember who the largest donors to federal Democrats are?  I’m having trouble, but I don’t think it’s food stamp recipients.

• TJIC and Coyote Blog talk about “big picture jobs,” adding real value through real work, and what Scott Greenfield would call the “Slackoisie” that is much of my generation (I hope not to fall in with that crowd).  We have critiques of  recent NY Times letter-writer Arielle Eirienne, Washington Post interviewee “little-miss-altruist Beth Hanley,” and “big-picture jobs” and the people who think they should have one.  They use lots of harsh words (well, TJIC does), but honestly… they’re right, painful as it may be for some of my contemporaries (heck, a number of my former classmates) to acknowledge.

• Let’s talk safety.  It’s important, right?  Important enough to flex some muscle and shut down a business just for the hell of it?  Coyote finds that some agencies would say “yes” to that.  Toyota and the NHTSA, in a move that didn’t surprise those who cared to think about the issue, announced that virtually all of the so-called “sudden acceleration” issues are attributable to driver error “pedal misapplication.” Whoops.  Coyote asks “how safe is safe enough” in the context of dioxin, pointing out that new EPA efforts at regulation are probably superfluous, as is their existing safety standard.  Lastly, can we afford to hire government employees to supervise children’s dietary intake?  What’s scary is that there are people out there who take the question seriously.

• Doctors aren’t the only ones who deal with emergencies.  There is such a thing as a legal emergency as well.  Why not regulate emergency legal services in the same we that we do emergency medical care?  Of course, like physicians, sometimes lawyers can be breathtakingly, hilariously incompetent.

• Economic mismanagement was a common theme this past week.  From EconThoughts we have Obama’s Dirty Dozen; InsureBlog explains how his state is implementing the PPACA’s high-risk pool provision (not very well, it seems).  Coyote explains why a government program’s popularity is a terrible metric by which to judge it, just as high corporate profits can sometimes spell bad news for the larger economy.

• Ending on a lighter note, we have an interpretation of Toy Story 3 as a libertarian-inspired parable, and an animation of an orthopedist consulting with an anesthesiologist.  “There is a fracture.  I need to fix it.”  Hilarious.