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.

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: By Reader Demand

I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”

Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).

AMSA Follies: Primary Care and Health Policy

A pair of physician-researchers from an AAFP-funded research institute spoke about integrating a career in medicine with a career in policy research. That was interesting to me as a medical student, but of general policy interest was their take on the future of primary care:

• They were surprisingly genial about specialists, and avoided playing the blame and recrimination game. This was welcoming and refreshing. Medicine is divided enough as it is.
• They count Nurse Practitioners and Physician Assistants as primary care providers. I would think that this undermines their cause slightly (“hey, if non-physicians can do the job…”), but I’m sure they have their reasons.
• I overheard one of the speakers talking to a student in the hallway after the main presentation. I caught a bit of their discussion about Qliance. They were both of the opinion that that sort of market-based, patient-centred model will be important to revitalizing primary care. The AAFP speaker was trying to cram the Qliance model into the “ACO” box, but hey… no one’s perfect. It’s great to see some of the professional societies recognize the need to get off the government-dependence gravy train before it derails completely.

Also of note was the following… special moment: one of the students in the audience objected strenuously to the speakers’ use of “industrial,” “corporate” terms like — wait for it! — “supply,” “demand,” “surplus.” He wanted to know how the sky would keep from falling so long as we keep referencing “that paradigm.”

Oy.

AMSA Follies: Entrepreneurialism/Market Solutions *and* Social Justice?

Dr. Gloria Wilder, one of the “thought leaders” for this year’s AMSA convention, was introduced to us as someone who believes in “market solutions to social justice problems.” The program mentioned something about her being a fan of entrepreneurialism. Needless to say, I skipped out on the AAMC’s Chief Academic Officer to see what Dr. Wilder had on offer.

Turns out that it wasn’t quite what I was expecting. Silly me, expecting any sort of heterodoxy at an AMSA convention (besides the token non-liberal on one side of tomorrow’s policy debate).

I really wished that Dr. Wilder would have talked more about her business, Core Health and Wellness Centers. Aside from a throwaway mention of its $1 million+ profitability this year (treating mostly poor patients, at that!), and her lack of contempt for the wealthy, the talk was centered mostly on traditionally liberal conceptions of social justice (e.g. how the minimum wage ought to be higher, about how some have the temerity to claim that Medicaid might be associated with worse outcomes than uninsurance, how one might not want an all-mighty public sector union in Wisconsin, etc.).

Which is fine. Those are not unreasonable positions to hold, wrong though I may find them. What’s clear, however, is that Dr. Wilder does believe in an entrepreneurial manner of achieving the social justice goals that she advocates for. There was no mention of needing more grants, no mention of needing to beg government for more. At the end of the talk, she chided us not to be “robots” in “corporate (e.g. academic, government, managed care)” settings and instead to practice the sort of compassionate, patient-centred care we learn in medical school. That is an entrepreneurial vision. Unfortunately, when basic market principles and the idea of entrepreneurial are either foreign or anathema to many medical students here (see my Twitter feed for one egregious example), I would have been excited for her to take a stronger stand in favour of the market and entrepreneurial forces that she merely alluded to.

Unlike the conception of social justice that she shares with the majority here, those values (markets, entrepreneurialism) are in sore need of a strong defense at this conference. I can only do so much from the Internet!

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.

From plain film to 3D: radiologists as superstars?

Like other enthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services.  The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures.  By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.

Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?

Now, the WSJ article helps to explain exactly how this situation has come about.  The “market” for physicians’ services is one in which nominal and relative prices are set from above.  They’ve been set in such a way that the “ROAD to happiness” starts with Radiology.  (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)

This lends itself to an interesting thought experiment.  Would diagnostic radiologists fare this well under a market system?  I think they would, and here’s why:  I think that radiologists are medicine’s superstars, at least in an economic sense.

The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician).  It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet).  The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it.  Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.

This strikes me as at least superficially similar to some aspects of diagnostic radiology.  The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately).  And we as a society have decided that we want the best:  that is to say, we want our scans read by radiologists.

What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties.  That it may take less time to read a scan doesn’t lessen the value added by having the scan read.  The worth of the information to the patient is independent of the time it takes to derive it (within limits).

So, would radiologists still be on the ROAD in a market-based system of payment?  The case in favour looks pretty good.  Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts.  Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?

This is why we can’t have nice things anymore

For someone like me — young, healthy (knock on wood), and with no need for frequent contact with the health care system — a primary care physician is a nice thing to have.  I can go to my family physician for medical school checkups, vaccines, minor acute illnesses… but honestly, if I were to wind up “medically homeless” it wouldn’t be the end of the world.

For someone older or in poorer health, maybe with a chronic medical condition or two, a primary care physician is much more than “a nice thing to have.”  Chronic condition management, specialty consult management, generally looking after all the patient’s medical problems… that can wind up being the difference between well-managed illness on the one hand and an expensive trip to the emergency room on the other.

As I’m sure you’ve heard, there’s a growing consensus that the US does not have enough primary care physicians.  Why not?  There are a lot of potential answers to that question floating around out there, some of which are probably correct at least in part.  Opinion tends to coalesce around the following explanations:

• Primary care physicians tend to earn less than other physicians
• Primary care physicians’ lifestyles are not as enviable as those of some other physicians
• Primary care practice is perceived as being relatively more exposed to the hassles and red tape of third-party payers
• Medical students aren’t sufficiently exposed to primary care/good primary care role models and/or medical students encounter too much disrespect for primary care from faculty in other specialties.
• There aren’t enough primary care residency positions relative to specialty residency/fellowship positions.

I can believe all of these to varying degrees, though I’d hazard that the first two (to me, the third is a subset of the second) on the list are the main causes right now.  The last one doesn’t strike me as all that persuasive.  Residency slots have to be filled by international medical graduates, or simply stay unfilled, because not enough US medical students want to go into those fields.  Increasing the number of training positions in primary care won’t solve anything without an increase in medical student willingness to fill these slots.  The problem is clearly medical student demand, not training position supply.

Many of the proposals to “fix” primary care have rightly focused on the most plausible causes for the shortage.  Some professional organizations would hope to narrow the pay disparity by either cutting specialist pay, tweaking the Medicare pay formula to better compensate “Evaluation and Management” service codes, or simply by going back to Congress and begging for more money (sense a theme here?).  Others believe the solution lies in expanding retainer practice, which would have the added bonus of improving pay and lifestyle/regulatory hassle issues.  There are some who think that the “Patient-Centred Medical Home” and “Accountable Care Organization” will save primary care (or not).

Others would take more roundabout routes to creating more PCPs.  Instead of (or perhaps, in fairness, in addition to) changing the nature of the job to make it more desirable, they would take steps to essentially hoodwink medical students into choosing primary care as a field.  Some people think that Nurse Practitioners and Physician Assistants can and will step in to fill the void left by medical students (while “can” may be questionably questionable, the “will” is an even more uncertain proposition).

Yet others have jumped the shark entirely.  Via John Goodman some time ago, and KevinMD more recently is a summary of an AMA expert report on the real reason more students aren’t going into primary care:  it seems that we’re too nerdy, insufficiently altruistic, and (*gasp!*) bad at advocacy and community organizing.  Too much problem-solving acumen, not enough passion for social justice!

Because clearly, primary care has nothing to do with problem solving.

The links above point out the many, many flaws in this line of reasoning.  There are two big ones that come to my mind, however.

The first is the issue of “social justice.”  It’s a nice phrase, and an amorphous concept.  I’m in favour of social justice, and for certain methods of achieving it.  Ask a typical left-liberal what they think of my conception of social justice and my preferred means of advancing it, and you’ll likely provoke a good deal of rage, sputtering, and denunciation.  It’s one of those terms that’s thrown around a lot without being defined.  That said, it’s really only one segment of the political spectrum that has a high affinity for that phrase… when you see the AMA using it, you can be pretty sure what it is they’re referring to.  According to them, medical school admissions should be based on a political orthodoxy because, well… apparently it will produce more primary care physicians.

This isn’t even the biggest problem with the proposal.  Remember how I mentioned earlier that one of the reasons students aren’t going into primary care fields is because of pervasive disrespect for them in the medical academy?  The lack of role models and exposure?  The constant denigration by medical and surgical specialists?  The idea that someone is “only” a primary care physician?

How does the implication that primary care work doesn’t require problem-solving skills do anything other than contribute to these sorts of perceptions?  The very idea amounts to a proclamation that primary care is “lesser” medicine!  “Primary care physicians aren’t real doctors… I mean… the important skillset for them is community organizing for social justice!”

While this report may have its heart in the right place, I’m sure that medical students will be smart enough to read between the lines and see that it’s merely confirming the prejudice that they’re seeing in all other areas of their training.

This is the medical academy’s solution to save primary care.  And that… that is why we can’t have nice things.

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.