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.

Theft? Madness is more like it

In the process of catching up on Google Reader post-convention, I came across this recent post from Robert Centor criticizing a recent NY Times Magazine article alleging that ‘America is stealing [sic] the world’s doctors.’ As Dr. Centor rightly points out, this is utter nonsense, on multiple levels. In this post, I want to address the aspect of the “foreign doctor/brain drain” question that applies to students like me; in the next I talk about physician and other “brain drain” more generally.

As a student at an LCME-accredited American medical school, I don’t fall into the “international medical graduate” (IMG) category in quite the same way as those in the article. And despite the fact that I’m “only” Canadian, I’m still foreign enough to have to figure out where my next visa will come from for residency, fellowship, and beyond. This post will not be an extended disquisition on the finer points of American immigration law and visa classifications (subjects with which I am far too familiar). You will, however, get a taste of how dysfunctional the American approach to foreign physicians is, especially at a time marked by widespread predictions of an impending doctor shortage.

Most public medical schools in the US and many private schools will not even consider non-citizen/non-permanent resident (foreign) applicants. Those of us who do get an offer somewhere find that we are not eligible for US government financial aid, and for a great deal of school-based aid as well. Despite this, we still benefit indirectly from taxpayer subsidies. Tuition makes up a minuscule fraction of medical school revenue; according to SUMS‘s tax returns, our tuition barely covers the costs of the medical education and educational technology support staff. Nothing more. The rest comes from patient care revenues and various grants, much of which in turn comes from the taxpayer.

After receiving a medical education at great personal financial cost (debt), yet one that’s also heavily subsidized by the US taxpayer, the expectation is that we go home. Or at least leave the country. Completing post-graduate training in the US requires finding residency programs that are willing to sponsor one of the two main types of visas that can be used for this purpose: the J-1 comes with a 95% iron-clad requirement to leave the US and work in one’s home country for two years upon completion of training before one can come back to this country; the H-1B comes with a 100% iron-clad time limit of six years (for reference, here is a list of residency length by field, not including sub-specialty fellowships). Even assuming one could find and be accepted into a program that will sponsor either visa, neither seems particularly conducive to “theft” of foreign physicians.

Unlike in medical school, foreigners in US residencies and fellowships often do benefit from direct US taxpayer subsidy, as Medicare pays for most residency positions, including salary and benefits. So what happens to foreigners who receive direct government subsidies to train in their specialty?

Again, the expectation is that we will go home (in the case of the J-1 visa), or at least leave the country (in the case of the H-1B). The United States is one of the few, perhaps the only, developed country that requires all long-term immigrants to be sponsored by an employer or a family member. There is no “points” system for independent applicants; no way for someone like me to prove that I’m smart, talented, possess in-demand skills, and probably ought to be allowed to stay indefinitely (not to mention the hundreds of thousands of dollars of subsidy I will have enjoyed by this point). More shockingly, there’s seemingly no desire on the part of the US government to hold on to the medical talent that it paid to develop.

What employer would sponsor a foreign physician? Moreover, what employer would sponsor any employee for permanent residence before at least a few years of full-time employment have passed? The H-1B comes with a six-year time limit; look at the length of various residencies at the link above. We’re short primary care physicians (3 years), yes, but we’ll be short general surgeons (5 years) and cardiologists (6 years) as well.

I, and those in my situation, are the lucky ones, comparatively. We don’t even have to jump through extra hoops for medical licensure and board certification the way “real” IMGs have to. It’s a wonder anyone manages this at all.

If the United States is “stealing” [sic] foreign physicians, it’s one of the most tragically/comically inept thieves I’ve heard of. Even in my “easy” case, after I will have spent 7+ years being educated at world-class American schools (11+ if you count college), the US is happy and indeed seemingly eager to see me go.

Some people would approach this conundrum entirely differently. They would argue that because foreigners in the American medical training process receive indirect and then direct government subsidies, the process should be closed to them in the first place. I understand the logic, but this strikes me as doubling-down on the foolishness of the current system. Getting into medical school and residency is frighteningly competitive. Being a foreigner only makes it harder. I make no claims as to myself, but one would therefore expect the marginal foreign applicant to be at least as good as the marginal American applicant… if not better. That some of them manage to stay in the US to practice medicine even in spite of the numerous hurdles along the way should suggest even more strongly that these are the people you want to hold on to.

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.

The Other “Medicare”

I’m surprised that it’s taken me so long to devote even a cursory post to health care in Canada (or as it’s referred to back home, “medicare”). After all, as my disclaimers page says, “if the blog title didn’t give it away, I’m Canadian.” However, a recent series of posts at Medscape’s medical student blog “The Differential” [free registration required] inspired me to take on the subject.

I want to make clear at the outset that this post is intended to be descriptive. My thoughts on Canadian medicare and its implications for proponents of single-payer in the US can wait for another time.

Before delving into the Medscape commentary itself, we should begin with some general background on health care in Canada.^[1]

***

[1] – Much of this background was assembled while preparing a presentation that for the first  health economics course I took in university. I have done my best to bring things up to date. Depending on the minutiae of when laws are introduced vs. passed (and which of the two you refer to), some of the earlier dates in the History section may be 1-2 years off from what you read in some other sources.

History

Canadians feel strongly about their medicare. Most of them love it, or at least love the idea of it. If you’re a politician wanting to discuss the system in terms of anything other than providing more funding for the system, you’re likely to be toast in short order. And don’t even think about promoting “two-tier” health care! Governments at the federal and provincial level have risen and fallen based on the health care issue; it’s a major component of provincial government spending, and many Canadians view medicare as a component of national identity.

Government involvement in Canadian health care began in earnest in 1944, when the government in the province of Saskatchewan introduced a system to provide free health care to the elderly and retirees. This was followed shortly in 1947 by a public hospital insurance plan featuring a $5/person/year premium. In 1959 the socialist government of Tommy Douglas (considered one of the “fathers of medicare“) announced the first universal public health insurance program in Canada. Needless to say, Saskatchewanian (Saskatchewanite? Saskatchewanish?) physicians were wildly opposed, even going on strike for a few weeks in 1962.

A decade later, the ideals that drove the new program in Saskatchewan came to fruition on the national stage, as medicare was introduced in the remaining Canadian provinces beginning in 1967. This was not done in one fell swoop. The constitution in Canada has established health care as the domain of the provinces. The federal government rolled out medicare across the country not by fiat, but by offering matching funds (now block grants) to provincial health plans that met certain legislative criteria; this has given the federal government an important role in both financing and “regulating” provincial health care plans, though in recent years the federal share of health financing has fallen as low as 15-20%, with the rest paid by the provinces. In this sense, the structure of Canadian health care financing more closely resembles that of US Medicaid than of US Medicare. It should also be noted that both the earlier and current iterations of provincial health plans covered mostly to exclusively hospital and physician services: no home care, drugs, devices, etc.

Federal Legal Framework

By the mid-1970s, the last Canadian province had signed on to medicare and the program was not due for another major shake-up until 1984, the year the Canada Health Act was passed. The CHA is still the current governing framework for public health care in Canada. It re-affirmed the five basic criteria and two conditions for federal funding, but unlike the previous federal legislation, the CHA more clearly authorized the federal government to withhold transfer payments as a penalty for provincial transgressions.

The CHA imposes 5 basic eligibility criteria for provincial plans to receive federal support.

1. Public administration: each province’s health plan must be administered by a publicly-accountable, non-profit entity. In practice, this is usually a government agency or arm’s-length government-owned insurer.
2. Comprehensiveness: all “medically necessary” services must be covered, though provinces get surprisingly wide latitude in defining what is medically necessary.
3. Universality: all residents of a province must have access to public insurance on the same terms and conditions. In other words, all insured must be equal, and all are equally insured. The Act defines “insured persons” in such a way that treatment sought under worker’s compensation or auto insurance regimes escapes some of the dictates of the Act. In addition, provinces are allowed to impose minimum residency length requirements (e.g. 6 months in Ontario) before residents are eligible for coverage; in some provinces, this even applies to Canadians moving from other provinces.
4. Portability: provincial plans must reimburse insured persons for medical services used during temporary absences from the province, at least at the rate specified in the provincial plan’s fee schedule.
5. Accessibility: access to coverage must be uniform and barrier-free. There can be no discrimination or disparate treatment based on age, income, health, etc. On the provider side, provinces are required to have a clear and transparent fee schedule, with providers being “reasonably” compensated.

In addition, the CHA imposes two more specific conditions on funding that cut more closely towards health care delivery, as opposed to the five conditions that govern financing.

1. Balance-billing (or “extra-billing” as it’s sometimes called in Canada) is banned. Physicians and hospitals are not allowed to charge provincially-insured persons for provincially-covered services in addition to the province’s payment for the service. This is similar to US Medicare’s ban on balance-billing.
2. Provinces are not allowed to impose “user charges” for insured services. This became an issue recently as the government of Quebec toyed with the idea of introducing modest co-pays for some services for some insured. Not allowed.

The result is a “system” that’s not just one system. Each province (and possibly each territory?) has its own provincial health insurance plan that is run subject to the constraints of the Canada Health Act. The federal government administers health plans for members of the armed forces, the RCMP, and First Nations living on reservations. Worker’s compensation and auto liability insurance also play small roles.

The provincial plans are the major players, and are what most people in Canada and the US think of when they discuss the “Canadian health care system.” Though the criteria laid down by the CHA result in the appearance of national uniformity (and to be fair, a good deal of actual uniformity) in how health care is financed, administered, and delivered in Canada, there is a good deal of meaningful variation between provinces.

The Private Sector

One important dimension of variation is the role of the private sector in delivering and insuring services that are covered by provincial plans.  As of 2005 (I haven’t looked more recently, but am unaware of major changes since them):

• Four provinces (QC, AB, BC, PEI) allowed physicians and other covered providers to set their own fees for providing covered services without billing the province. However, these provinces did not allow any reimbursement of patients or providers for covered services not billed to the province. In addition, these provinces banned private insurance coverage of any service covered under the provincial plan, even if delivered in the private setting.

  In 2005, a physician and his patient sued the Quebec government, arguing that the ban on private insurance coverage of privately-delivered publicly-covered medical services violated the Canadian Charter of Rights and Freedoms and the Quebec Charter of Rights and Freedoms, especially given long waiting times for treatment in the public system. The case made its way to the Supreme Court of Canada, which ruled that the prohibition violated the Quebec Charter of Rights and Freedoms. Given that the decision was grounded in QC provincial law, it had only limited direct impact in the other three provinces.

• Three provinces (ON, NS, MB) forced providers going outside the public payment system to charge at the public fee schedule. They also banned private insurance coverage of privately-delivered care that was also covered by the provincial plan, though two of these provinces (ON, MB) reimburse patients for out-of-pocket expenses paid to private providers.
• Three provinces (SK, NB, Nfld) allowed unfettered private delivery and private insurance for services covered by the provincial health plans. Newfoundland would reimburse patients for out-of-pocket expenditures to private providers up to the provincial fee schedule, whereas SK and NB provided no reimbursement for private expenditures.

   

• Private diagnostic clinics were beginning to emerge in three provinces (QC, ON, AB) in response to a pervasive lack of timely access to diagnostic imaging services. Though these clinics operated outside the public system, Ontario and Alberta actually contracted with some of them to provide services to public patients. For those with the means, however, payment could secure an earlier appointment for imaging, shortening the amount of time waiting for a diagnosis, and where applicable allowing earlier entry into a queue for treatment.

A National Single-Payer?

One of the features of health care in Canada that is often overlooked by proponents of single-payer in the United States is that Canada as a whole does not have a “single payer,” which means it’s hard to make sweeping generalizations about details. Covered services, the quality and quantity of care provided, and physician/provider payment vary across provinces. Not earth-shatteringly so, but enough to introduce a small modicum of inter-provincial competition for physicians, and “competition” in services and benefits mediated through political pressure (e.g. “Patients in BC can get this drug, why won’t you pay for it here in Nova Scotia!”). Given the perennial importance of medicare as a political issue, the importance of popular pressure to increase funding and expand services should not be trivialized.

It’s also worth pointing out that about 30% of Canadian health care spending is individuals’ out-of-pocket payments for things like drugs, home health, hospital amenities, and other non-covered services. This is 2-3 times the fraction of health care spending in the US that comes directly out of individuals’ pockets in exchange for services received.

Unions, Public Employees, and Hospitals

Contrary to what I’m told is common belief in the US, most Canadian physicians are not government employees. Though some provinces hire doctors for what I surmise are analogues to Community Health Centers, the vast majority of physicians are independent contractors paid on a fee-for-service basis according to the provincial fee schedule. In Ontario, some family physicians practicing in so-called “Family Health Teams” are capitated, and some emergency physicians are paid by the hour. An interesting wrinkle is that some provinces have hard caps on how much a physician can earn in any year; obviously this creates disincentives to working so hard / so much that the cap would be reached in a year. (It’s not just hypothetical: I have a few physician friends in Canada who have made great strides in their golf game as a result of this cap).

Hospitals, on the other hand, are closer to highly-regulated public utilities. In Ontario, most hospitals are non-government or arms-length, non-profit entities. Most of their money comes from a “global budget” (i.e. “this is your budget for the year”), though there have been experiments with US Medicare-like prospective payment systems for certain conditions. Patients also pay per-diem fees for non-covered amenities (e.g. private inpatient rooms, phone and TV service as inpatients). Provinces (or regional health authorities, or whichever provincially-created entity is in charge in a given province) have at least some control over hospitals’ capital spending. In Ontario, regional health authorities determine what sorts of specialty services and facilities are available at which hospitals within their purview. Hospitals are allowed to engage in public fundraising for capital campaigns; I’m not sure how this interacts with provincial controls on capital spending.

Physician licensing and governance is a point of special interest to me. There is the usual plethora of physician groups, specialty societies, etc., similar to what is found in the US. However, given the effective monopsony power of provincial governments in the market for physicians’ services, provincial medical associations have emerged whose main function is to represent physicians in fee schedule negotiations with government. Canadian physicians seem to have more input into provincial fee schedules than American physicians do into Medicare fee schedules. Whereas American physicians set the relative weights of various services in the Medicare fee schedule (and only indirectly lobbying for changes in the monetary conversion factor), Canadian physician organizations typically negotiate for dollars directly with government.

The Ontario Medical Association is one of these organizations. Unlike groups such as the American Medical Association, their orientation (and their website!) is very physician-centric. In addition to negotiating the terms of the provincial fee schedule, the OMA also sets maximum rates that physicians can charge for certain non-covered services (phone consultations, insurance forms, etc.).

Physician licensure and discipline is also done at arm’s-length from government. Unlike in the US, where medical licenses and disciplinary action are typically the domain of state government medical board, most (if not all) Canadian provinces have allowed the medical profession to remain somewhat self-regulating. For instance, the College of Physicians and Surgeons of Ontario is the licensing and disciplinary body for physicians in Ontario. Its governing body is composed of 16 physicians elected by their peers, 3 physicians selected from Ontario’s 6 medical school faculties, and 13-15 members appointed by government. Also of note is the fact that many provinces, including Ontario, condition licensure on the Canadian equivalent of specialty board certification. The opposite conditionality holds in the US.

By the Numbers

It would be foolish to try to replicate this series of three posts at the Healthcare Economist, where Jason Shafrin does a wonderful job of collecting the major summary statistics for infant mortality, life expectancy, access to care measures, and physicians per capita.

Next Time

In an upcoming post, I’ll discuss common American medical student perceptions of Canadian health care (as exemplified by the post at The Differential mentioned at the outset, and with some telling anecdotes from March’s AMSA conference), along with the always-hot topic of waitlists for treatment.

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?

AAFP Doubles Down on Government Trough, SGR

Few physicians are fans of the Sustainable Growth Rate: the formula by which Medicare is (supposed) to make adjustments to physician payment each year. Primary care physicians would be especially hard hit by the massive payment cuts that the formula calls for. So far, these cuts have been staved off for months at a time over the course of the last few years, resulting in a cycle of impending doom followed by temporary relief as the can is kicked yet further down the road.

The Wall Street Journal’s Health Blog had this to say on physician organizations’ proposals to Congress for longer-term solutions to the SGR mess:

 American Medical Association: Repeal the SGR, then “implement a five-year period of stable Medicare physician payments that keep pace with the growth in medical practice costs.” During that period, pilot “a new generation of payment models” (medical homes, for example), then transition to those that improve quality, care coordination and costs. The AMA also wants Medicare to permit balance billing — physicians charging Medicare beneficiaries for an amount above and beyond what the government program covers.

American Academy of Family Physicians: After SGR repeal, there would be a five-year transition to the patient-centered medical home. Primary-care physicians would receive a higher reimbursement rate than other specialties, and primary-care incentives included in the health-care overhaul law would be increased and extended.

American College of Surgeons: After SGR repeal, set a “realistic budget baseline” for future payment increases, ” which should “fairly reflect the costs of providing quality health care and are sufficient to preserve the patient-physician relationship and ensure patients have continued access to the physician of their choice.” During a five-year transition to different payment models,  reimbursement growth would vary by service.

To my surprise, it’s the AMA that’s on to a nugget of something good: allow balance billing. Not a perfect solution, but it could be a major step towards something sustainable in the long run.

Somewhat less surprising is the willingness of the AAFP to double-down on the model that’s already failed them for so many years. It’s unfortunate. If primary care is going to be attractive to people like my classmates and me, the pay will have to be better, and the job will have to be better. Living an even more bureaucratic work experience and making a living that continues to be at Congress’s mercy aren’t on any medical student’s wish list.

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: Rent-Seeking, Ignorance, and Close Calls

Today was “Advocacy Day” at the 2011 AMSA Convention. Three hundred medical students descended on the Hill to push AMSA’s talking points on various pieces of legislation. There’s a Sparta joke in there somewhere.

We started off with a talk from Dr. Atul Grover, the “Chief Advocacy Officer” for the Association of American Medical Colleges (AAMC). His description of the AAMC’s recent lobbying efforts were a stark reminder that regardless of what one might think of the cause, there is something very, very ugly about rent-seeking… and medical schools do lots of it.

“Highlights” from Dr. Grover:

• “Democrats go out and buy banned books and read them individually. Republicans form censorship committees, read them as a group, and then maybe burn them.” I know the Republicans probably don’t feel any great affinity for the AAMC, but even this strikes me as a bit much from the guy whose job it is to make nice with them.
• In the coming weeks, over 100 AAMC member schools and hospitals will commit to a major patient safety and quality initiative, including curricular changes at medical schools, and universal usage of pre-operative checklists and central line checklists in ICUs. You heard it here first!
• The AAMC is also planning an initiative on inter-professional collaboration together with schools of nursing, osteopathy, and pharmacy [no word on the quacks naturopaths]. While the education-oriented professional organizations are on board, there has been some resistance from other professional organizations representing these groups. And people wonder why medicine never seems to speak with a coherent voice.

From there, we moved to “issue training.” Foolishly/fortuitously, I was assigned to lobby for “Health Care For All.” Lucky AMSA… not only did they not have to pay the~300 white-coat-clad medical students to go out and parrot their talking points for them, we actually paid them conference fees! Yet parrots we were expected to be. The sheets with talking points were passed around, and the presentation about the pending legislation we were to discuss with our Senators and Representatives was given.

Of course, when the medical student audience has little knowledge of the policy issues, it’s easy for them to be told what to think, that they might do AMSA’s bidding.

The presentation was an exercise in entertaining ignorance… an appraisal shared even by the liberal (but informed) students sitting near me. Frighteningly, the presentation was given by AMSA’s senior people on advocacy/policy issues. To wit:

• They uncritically parroted the controversial assertion that lack of insurance is responsible for tens of thousands of excess deaths per year.
• They still cling to the absurd notion that more than 2/3 of bankruptcies are caused by inadequate health insurance.
• They believe that “single-payer” = “universal coverage,” and that all OECD countries except the US have single-payer health systems.

The lobbying itself was interesting. Myself and a partner from the same part of the country met with legislative aides for our Senator and Representative. For the first, we made a good faith effort to parrot the AMSA line (hey, why not?). After seeing the futility of a conversation in which we both disagreed not only with what the aide was saying but with what we were saying, we changed our tune ever-so-slightly for the second. It was fun.

My belief that AMSA is an organization that shouldn’t be taken seriously by policymakers is growing more and more…

Live from AMSA 2011…

The American Medical Students’ Association (AMSA) is one of the many professional (or in this case, pre-professional) organizations that represents various slices of the medical community. Of these, they are by far the biggest embarrassment to the medical community that I have encountered. Not just because they take positions with which I wildly disagree — that would be entirely acceptable. Rather, because they base their support for their policy positions on nothing more substantive than vague generalities and pleasant-sounding buzzwords and phrases.

Of course, this means that when the SUMS AMSA chapter sent out a call for students interested in attending AMSA’s 2011 annual conference in Washington DC, I pounced.

So here I am, braving the (acute) rainy weather and the (chronic) oppressive sterility of DC and its suburbs to bring you, my loyal readers, the latest and greatest updates from what is already promising to be a most entertaining boondoggle.

A sampling of macro-level AMSA Follies that pre-date the conference:

• AMSA believes strongly in left-wing solutions to healthcare, and are particular fans of single-payer. Nothing wrong with that, disagree though I might. Of course, that their senior advocacy and policy staff regularly confuse “single-payer” and “universal coverage” could lead one to believe that they don’t have the intellectual backing for the talk they’re talking. Most of their stated rationale consists of the usual empty mom-and-apple-pie rhetoric that one expects from a campaigning politician, not a group that expects to be taken seriously on the policy issues.
• AMSA is a big pusher of the pharm-free movement, releasing an annual scorecard comparing medical schools’ policies on physician-pharm conflicts of interest. There are many polemical t-shirts on sale to this effect.In my view (and in that of many others), they’ve gone way too far… almost to the point of McCarthyism. Of course, this hasn’t stopped their conference from taking sponsorship money and selling booths to all manner of medical informatics companies, medical device companies, medical publishers, medical test prep companies, and of course… government.
• AMSA is a big believer in “woo” (aka quackery of all stripes). Not only do they sponsor summer courses in such delightful nonsense as “therapeutic touch” (“reiki”), but they also invite the quacks into their conference. The Association of Accredited Naturopathic Medical Colleges has a booth here, and various naturopathic “schools” from across North America have sent students.

This group claims to represent the future doctors of America. What scares me is that they actually might.

Stick around for the weekend for more AMSA Follies, and be sure to see what I’m up to on Twitter (@nwsblog), or by following the #amsaconv2011 hashtag. The connectivity here is spotty, but I hope to provide commentary in as real-time-as-possible on the weekend’s shenanigans.

This is one window into the world of medical organizations you won’t want to miss.

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.