Tag Archives: medical education

A Fix for the Doc Shortage Is Right Under Our Nose

by Karan Chhabra

Yesterday Catherine Rampell wrote up an often-overlooked aspect to the doctor shortage debate:

Thousands of foreign-trained immigrant physicians are living in the United States with lifesaving skills that are going unused because they stumbled over one of the many hurdles in the path toward becoming a licensed doctor here.

The United States already faces a shortage of physicians in many parts of the country, especially in specialties where foreign-trained physicians are most likely to practice, like primary care…

The new health care law only modestly increases the supply of homegrown primary care doctors, not nearly enough to account for the shortfall, and even that tiny bump is still a few years away because it takes so long to train new doctors. Immigrant advocates and some economists point out that the medical labor force could grow much faster if the country tapped the underused skills of the foreign-trained physicians who are already here but are not allowed to practice.

It’s a great article, one that you should read in full if you’re skeptical about the magnitude of the issue. And the international medical graduate (IMG) issue as a whole is essential to understanding what our “doctor shortage” is and how to fix it.

First things first: the whole notion of a doctor shortage might seem implausible to many of us. Yes, it can take time to get a checkup with the PCP, but in many metropolitan areas there are actually plenty of doctors (even in primary care). It turns out the doctor shortage is primarily an issue of geography: it’s not so much how many doctors we have, as where they set up shop. Many proposals to increase the doctor supply ignore this fact, and drive more doctors to well-stocked urban areas. Why? The same reasons anyone would rather live next to an art museum than a ball-of-twine museum—desirable metropolitan areas are, well, more desirable. But according to the AMA, IMGs disproportionately practice in those areas underserved by domestic graduates:

Fully 25% of physicians practicing in the U.S. and 27% of residents and fellows are IMGs. These physicians overwhelmingly are the men and women who provide care in underserved and rural areas and to populations that might not otherwise have access to health care. Our numbers tell us that IMGs tend to practice in areas that have a ratio of fewer than 120 physicians for every 100,000 people and a high percentage of elderly and minority patients. We need them. Badly.

Second, the international docs in this article are not all back in their home countries, chomping at the bit to come stateside. They’re right here in the US, under our noses, languishing in technical roles that waste the immense training they acquired abroad. In other words, the “brain drain” critics invoke has already happened—they’ve already left their home countries—but under the status quo, their medical training is helping no one. By letting them practice in the US, where they have already relocated (for one reason or another), at least their skills are going to use somewhere.

So what’s stopping them from practice? As Rampell points out, there’s a slew of hurdles, but one outweighs all the rest:

The process usually starts with an application to a private nonprofit organization that verifies medical school transcripts and diplomas. Among other requirements, foreign doctors must prove they speak English; pass three separate steps of the United States Medical Licensing Examination; get American recommendation letters, usually obtained after volunteering or working in a hospital, clinic or research organization; and be permanent residents or receive a work visa (which often requires them to return to their home country after their training).

The biggest challenge is that an immigrant physician must win one of the coveted slots in America’s medical residency system, the step that seems to be the tightest bottleneck.

The biggest irony is, this is the same exact bottleneck preventing domestic med students from addressing our doctor shortage. Six percent of American grads still don’t make it into residency programs. Despite that, American med schools are popping up left and right; overall enrollment is set to increase 30% by 2016. But without more residency spots, we’re most likely going to have more wasted medical degrees—both American and international. Most alarming of all is that President Obama has actually tried to decrease residency funding further—by 7-10% over the next decade (since residencies are funded primarily through Medicare)t. There are immigration and credentialing hurdles to IMG practice that are far beyond my expertise, but protecting the residency spots we have is a no-brainer.

Finally, there is no good reason to believe IMGs are worse doctors. The ones who make it to the US are the best of the best in their home countries, and research shows they may even outperform those with American degrees clinically—mortality rates for heart failure and heart attacks were actually better in the patients of IMGs. I’d also point out our rich, diverse population of immigrant patients. If you believe we need more black and Hispanic doctors because they provide more culturally competent care to black and Hispanic patients, I challenge you to argue the same isn’t true for patients who are Chinese or Russian or Brazilian. The doctors are here. Let them do their job.

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Karan is a Rutgers-Robert Wood Johnson Medical School student 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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Today’s the Last Day to Make Sure Family Docs Learn about Contraception

by Karan Chhabra

I was pretty alarmed to read news today that training in contraception may be made optional for family medicine doctors-in-training:

The proposed new rules, they say, drop existing requirements that family medicine residents be required to undergo training in contraception and counseling women with unintended pregnancies.

Essentially, the board that oversees residency training (required for doctors to become board-certified) concluded that its educational standards needed more flexibility, and identified contraception education as one of those areas where it could lay off a little bit. Religiously-affiliated medical centers appear most likely to take advantage of this flexibility. But let’s be clear: this is a proposed change, not yet final, and it’s about training–not about whether reproductive health services can be provided. It’s also possible that trainees could learn a good deal about contraception through FOAM. So the sky isn’t falling, but I have serious misgivings about the precedent this sets.

A few months ago I offered my thoughts on the birth control debate as a whole:

The national conversation on birth control should look a lot more like ours on aspirin. When we talk about aspirin, we talk about about whether it’s right for you. When we talk about birth control, we get one-size-fits-all generalizations, political chaos, and name-calling. Something is wrong. These are individual, medical questions that demand individual, medical answers. Ethics have a place in medicine; faceless bickering and moralism do not.

I wrote those thoughts amid the debate on insurance coverage for contraception–a question that boils down to whether members of an employer-sponosred insurance plan ought to cross-subsidize people’s birth control expenses. In short, it’s thorny. Today’s question is different: should primary care doctors-in-training be required to learn how to provide services related to reproductive health? Should they be qualified to answer those individual, medical questions? To that, my answer is yes.

Family doctors are patients’ first line of trusted healthcare. In many parts of the country, they’re patients only line; not everyone can go to an ob/gyn for routine concerns like birth control. But we already have evidence that family doctors’ understanding of the research on birth control is inconsistent. Why make it worse? More importantly, though, what makes it okay to privilege certain types of medicine over others? Why is family planning any less a part of primary care than say, heart disease? If in fact it is, why can’t religiously-affiliated programs apply the same segregative logic to patients suffering from addiction or contemplating suicide, just because they disagree with it?

Medical education is about preparation. We go through medical school, residency, and all the rest to make sure that we can handle whatever our patients ask of us (within, of course, one’s specialty). Medical education should not be about judgment, about right or wrong, or about politics. It was one thing when the nation asked whether religiously-affiliated employers should pay for birth control. I believe it’s quite another thing when we ask whether our primary care doctors need to know about it. When authorities accept willful ignorance because of concerns that are at their core political, they attack the heart of a profession built on nonjudgmental service, and the patients who rely on it.

Today, April 25, is the last day for comment on this proposal. If you have something to say, do so in this form (courtesy of Reproductive Health Watch) and email it to familymedicine@acgme.org.

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Karan is a first-year 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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Med School Flipped, Turned Upside-Down

by Karan Chhabra

Dr. Chris Nickson recently asked, if a Martian landed on Earth and looked at how we do medical education, what would she think?

Could it really be true that so many dedicated, brilliant people with the same objectives could be doing exactly the same thing at the same time without sharing their resources? … That they could put so much work put into teaching sessions that so few actually attend? The Martian would think to herself, why don’t these educators find a way to share resources? Why don’t they make video and audio recordings so that learners can review them when it suits their hectic schedules and learn asynchronously… Perhaps students could even do all the didactic stuff before the teaching session even begins, then learn actively through discussion and simulation in a flipped classroom?

Nickson makes a powerful set of arguments in favor of “FOAM“—free, open-access meducation. It’s as simple as it sounds: you’ve probably heard of Khan Academy‘s great work “flipping the classroom” so that rote learning takes place at home, and classroom time is saved for collaborative problem-solving and application—FOAM extends that model to med school.

What would we go to class for? Be creative. I know one of my most helpful small-group experiences was reading EKGs with a practicing cardiologist. We could do the same with radiographs, with pathology slides, with metabolic panels. I also know that there’s no substitute for cadaver dissection, shadowing physicians, and practicing clinical skills–so we’d still be showing up for those valuable experiences. Finally, in this post at least, I’m only thinking about FOAMing the preclinical curriculum; the following two years on the wards can’t be replaced by online videos. (Got more ideas? Leave them in the comments.)

I won’t rehash the arguments in favor of asynchronous learning per se—read Nickson’s post or this NEJM article for more. Or go to a med school lecture hall and count the heads in there; you’ll see that asynchronous learning is already happening (9 a.m. starts + videorecorded lectures = asynchrony by default). I’m more interested in what would happen if we took this idea to its fullest potential. And I can think of several huge wins we’d gain, but only if we really flip it all the way:

Win #1: Standardized quality. We’ve all been there—you’re in class with a lecturer who doesn’t want to be there, and to be honest, you don’t want to either. Some teachers will always be more effective than others. Why does every school have to reinvent the wheel for every single course? By giving every student the best of the best lectures, we’d be able to learn better, and hopefully care for patients better. Not to mention that this is already happening–many students rely on sources like Pathoma (even paying out of pocket) for highly effective teaching they may be lacking in class.

Win #2: Individualized goals. What if we took “flipped” education as a way to go deeper in what you’re more interested in? In the first and second years of med school, most people don’t have their specialties decided, but many have an inkling. Becoming familiar with each is an important part of the first two years, but becoming an expert in all is impossible. We all have to choose one, but the preclinical years are decidedly one-size-fits-all. With more flexibility, students interested in surgery could go deeper into surgical approaches and anatomy. Students interested in primary care could learn about behavioral change and prevention. And this isn’t inconsistent with Win #2, standardizing quality–everyone gets the best of the best, but they get a chance to focus more on what speaks to them.

Win #3: Saving time. Dr. Ezekiel Emanuel thinks we could shave 30% off the length of medical training; preclinical training is a good place to start. Three US schools are already rolling out ways to get an MD in three years instead of four by streamlining preclinical education. And if you’ve got the drive to cram twenty months of preclinical education into twelve, why shouldn’t you? Like everyone else, you’ll still have licensing exams and clinical rotations to test your mastery–but if you can learn what you need in half the time, you should be allowed to try (but don’t say I didn’t warn you).

Win #4: That money thing. With time spent in med school comes money. A huge draw of the new three-year tracks is the amount they’d save students in tuition and other expenses–at least $60,000 a head. The amount is nothing minor, but it could mean more for our entire healthcare system–since many students cite debt as the reason they choose lucrative specialties, shortening training and cutting debt could make it easier for students to choose primary care. And if schools spent less time and money reinventing the wheel for each course, instead sharing what they’ve already developed, I have to believe it’d take something out of their expenses. (I poked around for numbers to quantify the cost of developing lectures, but unfortunately it doesn’t seem like schools are investigating this. Go figure.)

Seductive as they may be, there are a few powerful forces keeping these wins from taking root. One is the culture of academia as a whole, in which professors must teach in order to be “productive” scholars–even if they don’t want to, or if they’re not the best at it. If they don’t, it’d be harder for them to ascend the academic ranks. But I’d argue that if their interests are in research, they should be rewarded for doing research instead of lecturing unwillingly at our expense. Educational efficacy should trump dated scholarly norms. The accreditation standards for US schools don’t even include in-person lecturing: all the more reason to experiment a little.

Now, I’m not trying to suggest that putting a few lectures online will cure all that ails medical education. But I am asking for us to, at least hypothetically, reimagine preclinical training from the ground up. The resources are all out there, but schools need to acknowledge rather than resist them. Doing so could create more time for us to learn the art of medicine—doctorish things like patient interaction, diagnostic reasoning, and exam skills—while freeing us to learn the science of medicine the way we do best.

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Karan is a first-year 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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Helping Your Doctor Help You (Part II of II)

by Karan Chhabra

Ubel critical_decisions_cover

This is the second in a two-part interview with Dr. Peter Ubel, a physician, behavioral scientist, and author of the book Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices TogetherMissed Part I? It’s right here

KARAN: You referred to patient education earlier, not just in terms of treatment information but also the types of questions to be asking. But what about the former? Our generation is definitely comfortable using technology to look up health information, and we get a ton of information through news, magazines, and the general media. But not all of it’s good. So how do you recommend people sift through the good and bad information out there, when they’re trying to inform themselves before a visit to the doctor.

DR. UBEL: Of course, the education system should help people learn how to objectively look at things and help them when things go over their heads.

But the other thing I’d say is, print out and bring in the stuff that you see online, show it to your doctor, and let them tell you what’s right or wrong about it. Then they’ll know what you care about more than they did before, which is really valuable. Your doctor shouldn’t be threatened when you bring these materials in; they should be happy that you’re helping focus the visit on the topics you care about. If you’ve got misconceptions that are affecting the way you’re behaving, like what pills you’re taking or not taking, the doctor should be happy to have a chance to address those misconceptions.

So: print it out; bring it in.

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Helping Your Doctor Help You (Part I of II)

by Karan Chhabra

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Dr. Peter Ubel is a physician and behavioral scientist at Duke, as well as an author and personal mentor/hero. I recently read his latest book, Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together, and recommend it highly to anyone interested in making the right medical decisions—either as a patient or a practitioner. I spent a lot of time with the topic when I wrote my Honors thesis, but Dr. Ubel‘s book beats everything else I’ve read at dissecting the psychological and historical quirks that make decision-making such a complicated issue. In addition, it offers a lot of concrete advice on how to do the decision-making dance better.

Dr. Ubel and I had this interview to elaborate on how his book applies to the Millennial generation and our unique medical needs. Because the conversation was so chock-full of decision-making goodness, we had to split it up into two parts—the second half can be found here.

KARAN: Though I hope our readers all read your book, for those who haven’t just yet, I want to start with an example that touches on the issues it discusses. I recently got a bad ankle sprain. The following week, I went to a local orthopedic surgeon for it. He was a very old-school doctor; before even talking about treatment options at all, he was getting his stuff out to give me a cortisone shot for my ankle. I was still trying to give him my history and symptoms and I had to stop to ask what he was doing. It was a little scary; I had no desire to get a shot, and from whatever little I know, I think cortisone might’ve even hurt more than it helped. But I’m obviously not residency-trained in orthopedic surgery, so I didn’t feel right questioning his opinion. So while I have seen how the patient autonomy movement has affected the way doctors are ethically trained, which you discuss in your book, I still think there are a lot of doctors who fit the old mold. As a patient, especially a young and inexperienced patient, it’s difficult sometimes to know how to respond.

DR. UBEL: I don’t think this is an old/young issue. If anything, people tend to think their older patients are more deferential than the younger ones. Most people in their 20s are more into the “consumer” mindset than older people who grew up in the “doctor knows best” era. But when you are young, the age difference between you and the doctor is bigger, so that could make it harder to be assertive when interacting with your doctor. But patients ought to feel they can assert themselves because, even for mundane issues, any time there’s more than one way to go about it, the patient deserves to know what their alternatives are and to be a partner in the decision. So what happened to you is not the best possible medical care. Whether the doctor made the right choice, that’s one thing. But if he didn’t say “One thing we could do is this, but you should know, there are other alternative. For example, if you don’t want to get a shot, we could just give it time, etc.” If the physician didn’t speak to you that way, that’s a problem.

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