Category Archives: patient-centered medicine

Moving GME Forward

by Allan Joseph

David Goodman and Russell Robertson have a thought-provoking paper in the latest edition of Health Affairs (which is filled with great stuff) proposing a new system for graduate medical education (GME), which is the catch-all term for internships, residencies, and fellowships physicians complete as part of their training. Here’s the key part of the abstract: 

This article … proposes a new funding mechanism coupled to a competitive peer-review process. The result would be to reward GME programs that are aligned with publicly set priorities for specialty numbers and training content. New teaching organizations and residency programs would compete on an equal footing with existing ones. Over a decade, all current programs would undergo peer review, with low review scores leading to partial, but meaningful, decreases in funding. This process would incentivize incremental and continual change in GME and would provide a mechanism for funding innovative training through special requests for proposals.

The current GME system is mostly based on Medicare and pays hospitals both for the teaching costs of GME and to compensate teaching hospitals for their overall lower efficiency and sicker patient population. There aren’t a whole lot of restrictions beyond accreditation on residency programs; since a 1997 limit on the number of federally-funded positions at each hospitals, residencies have basically stayed the same — including in their specialty distributions and teaching models. As the health system evolves in its needs — most notably, towards chronic care and away from the acute, hospital-based care that dominates medical education — GME is stagnating.

The proposal suggests converting some, but not all, of GME funding into a competitive review process, somewhat similar to how researchers win grants from the NIH. It wouldn’t immediately disrupt an important source of funding for teaching hospitals, who simply couldn’t function without sufficient numbers of residents. However, by allocating a noticeable portion (perhaps 20-30%) of GME funding based on desired characteristics (the authors identify teaching quality, community service, graduates’ practice locations, and curricular goals as examples) could incentivize residency and fellowship programs to innovate in ways that benefit the larger system. Ideally, this would allow for spillover effects beyond the reviewed funding as hospitals innovate throughout their training programs.

Would the proposal work? It sure looks like it, at least in some form. The central problem is figuring out how to incentivize GME to fit the future needs of the system while allowing room for the incentives to change based on changing needs, all while preventing massive upheaval in the current system. The Goodman-Robertson proposal does all three, putting enough at stake to incentivize change and innovation without making hospitals worry too much about losing all of their residents. In addition, since the reviewing body can change the selection criteria as needed, the proposal would allow the selection process to evolve as the long-term needs of the system change.

There are only a couple problems. Chief among them is the natural change-averseness of healthcare financing, but since that really has nothing to do with the proposal, we’ll just set it aside for the moment. Political opposition to the proposal will cluster in a few spots, though the authors have taken great care to keep their proposal flexible. The most central flashpoint will be the body actually conducting the competitive review: what gives it the authority to steer the healthcare system and set criteria for major funding decisions? There’s something to be said for the concerns over what would amount to a mild version of central planning in the physician workforce. While the proposal is also intended to incentivize new GME programs, if the criteria aren’t set properly, it’ll be nigh impossible for new and totally innovative programs to win any awards, especially with reviewers likely taken from status-quo institutions. Finally, the uncertainty over residency slots for programs under review could affect their ability to properly participate in the match process, though timing the process would probably mitigate that issue.

But really, the political process is going to be difficult regardless, and the proposal at least tries to give innovation a leg up. Those issues pale in comparison to the benefit of moving GME towards a system in which the incentives for individual programs actually line up with those of the system at large. There’s not a lot in healthcare you can say that about — but why don’t we start with GME and see where that takes us?

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Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Hold on a second: On the harms of residency work-hour restrictions

by Allan Joseph

Let’s start here: I’m only a first-year medical student. I don’t claim to have inside knowledge into how residency works. But when I saw this widely-shared New Yorker article by cardiologist Lisa Rosenbaum decrying restrictions on resident work-hours, I was struck by how many in the medical field took Dr. Rosenbaum’s argument at face value. I think she makes some valid points, but I worry that in blaming new regulations for every problem, the medical profession misses a critical opportunity to examine its own weaknesses.

Take the article’s opening anecdote, about a mistake made by “Resident B,” who had taken responsibility for a colon-cancer patient from “Resident A.” Dr. Rosenbaum attributes the error to the fact that Resident A was forced to leave the hospital due to work restrictions — but as we see in the article’s own words, the error came from somewhere different (emphasis added):

So when [Resident B] arrived, [Resident A] handed her a fresh list, which now included an instruction to pull the abdominal drain. 

A few hours later, [Resident B] entered the patient’s room, saw the kidney drain coming from the patient’s back, and assumed it was the one to pull.  

This error was absolutely preventable within the context of the work-hour restrictions. Sure, Resident A wouldn’t have made the mistake if he had been there, but Resident B had to make a faulty assumption to make that error. That’s not the regulations’ fault — it’s due to a problem in coordinating care. The patient was going to be in the hospital for several days, perhaps even weeks. Unless you wanted Resident A to be in the hospital for the duration of the patient’s care, the handoff was going to happen somewhere. And if that’s the case, the handoff had to be better.

I’m not saying that work-hour restrictions don’t contribute to poor handoffs. They almost certainly do. But they can’t be the only cause. The American healthcare system is rife with care-coordination problems, due in no small part to physicians’ historical role as “their own bosses” and resulting distrust of administrative solutions. It doesn’t help that paperwork issues with nascent electronic-health-record (EHR) systems add roadblocks to effective coordination, but again, that doesn’t mean we need to get rid of restrictions, it means we need to get better EHR systems.

There are issues with the work restrictions that do need to be addressed. For the physician-in-training, residency is supposed to be learning experience: see as many cases as you can and learn from each and every one of them. Work-hour limitations do reduce your caseload over a typical three- or four-year residency program, but perhaps physicians could improve their training through longer residency programs. Morning rounds should be a sacred time, and there should be enough flexibility in the system to allow residents to complete proper handoffs. But none of those issues require a wholesale repeal of the regulations. They simply require improvement of that which exists. If patients really are more comfortable with rested physicians, and we can improve the system to the point that education and care are at least as good as they were before, then why shouldn’t we put patients’ wishes first?

There are always solutions to the problems brought about by changes like new regulations, new EHR systems, and new reimbursement systems. But instead of looking to move forward and lead a new generation of innovation, physicians tend to look backwards and bemoan the loss of what once was. Rather than training in an environment that sees and addresses the flaws in the practice of medicine, a new generation of physicians is training in a culture that would simply rather blame new regulations and cruel administrators for all of its issues. We can analyze work hour restrictions’ effects on clinical and educational outcomes, but we can’t use them as a scapegoat for all that ails academic medicine.

Our profession is not perfect, and neither are residency work restrictions. But instead of blaming external factors for all of our problems, why can’t we improve the regulations and our own care? We’d produce better physicians in the process — and that’s an outcome we can all agree on.

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Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

Friday News Dump: Wonkbites

by Karan Chhabra

Health news doesn’t stop for oppressive heat, Memorial Day Weekend, or the French Open, and neither will Wonkbites:

  1. Look Ma, No Bankruptcy: Obamacare’s under-26 coverage provision has cut the amount of uninsured young adults showing up at emergency departments, according to a new study in the New England Journal of Medicine. One of the ACA’s most popular provisions, it allows adults to stay on their parents’ insurance plans until they’re 26. To put some numbers around it, in 2011, this meant an increase of $147 million in emergency department costs that were covered by insurance.
  2. Party poopersClostridium difficile (“C. diff”) is a life-threatening infection that can happen to any patient when antibiotics wipe out the normal bugs in their gut. You might’ve heard that fecal transplants are being used experimentally to cure them. What you might not know is that those poop swaps have shown a higher success rate than vancomycin (the heavy-duty antibiotic currently used for C. diff), and that nonetheless the FDA is introducing regulations to make them much more difficult for doctors to provide. The FDA cites safety and quality control as its concerns—but doctors are refusing to provide the procedure and delaying potentially lifesaving care in the process.
  3. Is there magic to the map? Wonks have had a lively debate on a study aiming to debunk research that, according to Jordan Rau, has “influenced a generation of health policy thinking.” The new research attacks a premise advanced by the Dartmouth Institute for Health Policy and Clinical Practice—specifically that arbitrary geographic variation explains much of our healthcare cost burden. Instead, this new work says that Dartmouth’s geographic cost variations were driven primarily by those regions’ underlying health status.
  4. Have it your way—and pay more? A recent study, according to many, has shown that shared decision-making increases healthcare costs. I have to interject with a few reactions:
    1) If you read the methodology, you’d find out what it actually says is that patients who responded to a survey saying they prefer more of a role in their healthcare turned out to have higher lifetime healthcare costs. Cause-and-effect could run the opposite way—those who’ve dealt more with the healthcare system end up preferring more of an active role.
    2) If someone used a stronger methodology to demonstrate that shared decision-making cost more, I’d still support it. Healthcare should provide what patients and families want, not what providers want—and if that costs more, so be it.
    3) That said, conventional wisdom is that more healthcare is better. If more patient-centered care means more healthcare, perhaps the medical establishment and media need to do a better job of showing that more is sometimes better, but not always.
  5. The more you know: Righty? You’re more likely to use your cell phone on your right ear. Lefty? The opposite. Why? Science.

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Karan is a student at Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

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Building a Better Doctor

by Allan Joseph

As medicine changes faster and faster, the medical community keeps talking about reforming the way we train physicians. Medical schools across the nation are revamping their curricula, and now, driven in part by an upcoming change in the MCAT, the focus is shifting to the prospective physician’s undergraduate years: the premedical education.

Perhaps the highest-profile call for reform is this editorial in the New England Journal of Medicine from Dr. David Muller of the Mount Sinai School of Medicine. Dr. Muller lays out the case for “premed reform” quite nicely, and I won’t go over that again, though it’s certainly worth reading in full. Yet if we want to create the “21st century physician” (here’s a good, recent look at what that looks like), I think Dr. Muller and other premed-reform advocates aren’t going far enough. If we really want to create the physician of the future, we have to look beyond undergraduate classrooms and laboratories — we need to do more.

One thing that surprised me about my recent trip through the medical-school admissions process* was this: You don’t need a whole lot of prior knowledge to succeed in medical school. Sure, taking that extra advanced biochemistry class as a college senior might make for a slightly easier weekend of studying a year down the road. But the fact is that with a fairly basic level of scientific knowledge (the MCAT’s chemistry, physics and biology sections aren’t much beyond an Advanced Placement high school course), most premedical students could learn the sort of “book knowledge” physicians need in medical school. The things that will truly set good physicians of the future apart, however, take much longer than a couple years of classwork and rotations — they form over a lifetime. And those skills — “soft skills” like empathy, problem-solving, project management, and communication — don’t often develop in the undergraduate classroom.

Yet we still expect premedical students to get them in the classroom. If we keep expecting them to do that, we’ll still struggle to create the right kinds of physicians. So let’s broaden our focus and encourage premeds to put down a textbook every once in a while — and maybe even get them to think they don’t have to spend their free time doing research, either.

Two specific pieces of the premedical experience come to mind:

1. Extracurricular experience. Every premed knows a full resume is a good one when it comes to medical school applications. But rarely do schools take a hard look at what those experiences actually helped students developed, perhaps beyond time management. Medical schools should begin to evaluate students based on the skills they developed and demonstrated in their extracurricular activities. For example, students who don’t hold leadership titles in student clubs often have to learn how to communicate, work in a team, improvise, and balance multiple demands. Those students don’t always get the name recognition, but in a healthcare system moving towards team-based care, they’re incredibly valuable. It’s certainly difficult for medical schools to figure that out, but perhaps more targeted application questions about experiences that helped developed target skills could supplant questions that simply require lists of experiences and responsibilities.

2. Interview Day. They’re certainly some of the most stressful days a premedical student will face, but the surprising part is, the evidence says that traditional interviews don’t do a great job at selecting the best students — perhaps they filter out the very worst communicators at most. That’s why schools around the country are moving to new interview formats: group interviews, blinded “Multiple Mini Interviews,” and others. No interview method is perfect, but interviews based on group problem-solving like those at Northwestern or ethical scenarios like those at Duke are a good start. They allow medical schools to directly observe the qualities they want. More schools should move towards these innovative models, which allow students with the necessary soft skills to succeed.

These are only two suggestions of ways to improve the premedical experience, but they’re effective because they change the incentives premedical students face. If there’s a tangible reward to developing problem-solving skills as an undergraduate, premeds will do it. If there isn’t, they won’t. Certainly this alone isn’t going to solve our problems — we still need to change our curricula and, in the long run, push for a sea change in the premedical culture — but they’re a start. And medical schools can start looking for them now, because the longer they wait to really start looking for the physician of the 21st century, the more the 21st century goes by.

*If only to combat the perception that I might be whining about the system because it spat me out, it may be worth noting that I’m very happy with how the process went and am making a final decision in the next two weeks. In addition, I haven’t mentioned any schools I applied to in this post. 

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Allan Joseph is a senior at the University of Notre Dame studying economics and pre-medical studies. You can follow him on Twitter @allanmjoseph.

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Medication Adherence Shouldn’t Be A Blame Game

by Karan Chhabra

We don’t have miracle drugs. But to many, statins come awful close. They lower cholesterol levels, slash mortality rates in people with heart disease, and we’re learning more about how they can even prevent cancer in healthy people. They’re cheap, too, and some of the most-prescribed pills out there. Like any other drug, they come with side effects, of which doctors and patients taking statins are well aware: muscle pain tops the list, but there’s also a risk of liver damage and potentially even developing diabetes. But research published last week shows that the problem is bigger than we think: we thought only 5-10% of patients came down with side effects [1], but this study says it’s actually more like 17%—almost double. About 60% of those patients suffering side effects stopped taking statins, at least temporarily, as a result.

This is important information for clinicians, patients, and policymakers. A lively discussion is still underway on whether we should be giving statins to healthy patients who don’t currently have heart disease, and these new data should enter that discussion. Patients, too, deserve an accurate picture of what they’re getting themselves into.

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