Tuesday, October 25, 2011

Things we don't know about residency

New York Medical Students,
Let’s discuss the most important thing to any medical student: having a job once you get out of medical school. Namely, I want to talk about residencies. We’re New York medical students, the cream of the crop (or so we tell ourselves)! Residency is something we’re concerned about, but we’re still pretty confident it will turn out well for us. I thought it was somewhat of a “given” that hard work and the New York State aura would carry me into a residency someplace; I think many people feel this way. It’s why I want to take a few minutes to simply discuss some of the things no one tells you about medical school. These will be things everyone seems to get wrong in casual discussion of residencies. Some of them will worry you: good. It won’t all be doom and gloom, but frankly, if you’re not concerned about residencies by the end of this I can only assume you’ve stroked out and lost the capability for concern.

One of the first incorrect thoughts about residency is that residency is a sure thing, a “given” for any American graduate who can pass the boards. Recently, the New England Journal of Medicine released a report on the future of residencies. For those who want to read it, here is a link: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr1107519. The basic conclusion of the report is that there are currently three likely growth patterns that residencies will take in the future and all three show that in the next few years we will RUN OUT of residencies. I will repeat this: the report shows that, even with the most optimistic projections, the number of United States trained MD and DO graduates will outnumber the total residency spots of all American graduate medical education accrediting agencies. The most optimistic projections seem to suggest the tipping point will be the year 2020; more pessimistic projections based on current debate in the US congress suggest 2015 may be the tipping point. This means that unless there is dramatic change in congress to secure more spots we may very well have students in United States medical schools right now that will NOT have a job when they graduate. Recently the president of the Greater New York Hospital Association was asked what his take home message to students of NY would be. His response was that we should be marching in Washington and Albany en masse with sandwich boards around our necks because very soon jobs will not be there for us and right now almost no one understands nor cares about our problem with this, plain and simple. What is a medical graduate in the US without a residency? Given the debt I’m in right now, I don’t even want to think about that.

Yet somehow this problem is not caused by an absolute lack of residencies, or a residency freeze, which is the second common misconception. It seems pretty much everyone has heard, to some extent, about the balanced budget act of 1997 (BBA-1997). If you haven’t then a simple explanation is this: residencies are overwhelmingly funded by a cut of Medicare’s budget. In 1997, in an attempt to reign in Medicare’s cost, the federal government put a freeze on the expansion of any residency program. This freeze is one of the most misunderstood concepts in medicine as many people seem to believe it capped the number of residencies in an absolute sense, which it did not. The BBA-1997, along with its amendments in 1999 and 2000, prevented any existing program from expanding its residency programs indefinitely. What it did not do is prevent any new programs from opening, and over 100 new programs open in the ACGME every single year. The one issue with this is that the program, generally, only gets one chance to be evaluated for new residencies so they must carefully plan out when they throw their hat into the residency ring. To show an example of this growth: there were 8403 ACGME programs in 2006 and 8967 in 2011. Additionally almost 1,700 residency positions open each year (103,106 positions in 2006, 111,586 in 2011) in the ACGME, and 200-250 additional spots in the AOA open every year. Unfortunately the “nearly 2000” figure is over all years of residency training, the actual number of new first year spots is less than 500 per year. 

So why, if residencies are expanding by around 500 combined spots per year, are we about to run out of residencies? Simply put, we are building medical schools at an unprecedented rate. In the past five years 15 medical schools have opened in the US and 12 more will open in the next 2 years. Among those numbers are two new medical schools in New York, Touro and Hofstra. There are many simple reasons for this massive expansion. One of the simple reasons is that running a medical school is usually a profitable endeavor, despite medical education in the US being primarily non-profit. Perhaps a more pertinent reason is that many people feel that American students should be taking American residencies and should be trained in America. Much of the inertia behind all the new schools being built is to provide sufficient schooling to allow all qualified students to stay within the country for medical education. The issue is that this medical patriotism comes at a time when congress is contemplating cutting Graduate Medical Education (GME) funding as a way to say they “cut Medicare” without harming any patient coverage. It also is happening far too quickly for the system to react to, and the massive influx of students that has already began pouring in with the graduating class of 2011 will only continue to rise precipitously as each new school has its first graduating class.

The last misconception is that it’s a lost cause and we, as students, don’t have the time or power to stop anything. It’s not a lost cause. There is so much more to be done. There is so much already in motion. I want to draw your attention, at the very end of this, to a bill currently on the floor of the Senate. This is the link: http://thomas.loc.gov/cgi-bin/query/z?c112:S.1627:#. This bill seeks to do the seemingly impossible and ask for the 1997 cap to be lifted so that 3,000 additional spots can be added each year until a proper number of residency positions are attained. The bill is co-authored by NY’s own Chuck Schumer. In addition MSSNY recently penned a “kitchen sink” letter where they listed out every major demand of the medical society. In a lead position among those demands were the need to expand GME in any local or national way feasible to both protect current NY students and graduates and to strengthen the number and strength of funding of programs for future all future graduates. Medical students, ones you’ve elected, are in the MSSNY-MSS trying constantly to make sure students are represented in every debate in New York and that the student bodies stay educated on the issues at hand.

There is a lot we still don’t know about the future of graduate medical education in the United States and New York itself. One thing is for certain, if we as students sit aside idly and simply say “we are too busy for this” we will have no say and our needs will be ignored as they cost the system money. The fact that our very educational system is on the brink of non-sustainability and an occupational bottleneck will not register in anyone’s mind unless we actually begin a conversation within our schools, within our communities, in the state and on the national level. Until students put down the books, albeit very briefly, and make our voices heard, the chances of having a catastrophe on our hands rises every week. You’ve worked so hard to get this far, what have you done to secure your future lately?

Wednesday, August 24, 2011

Terms ever med student should know

Some of us like debating. Something about the challenge of presenting a point so persuasive that you can change people’s minds on a subject. Often it’s the ability to look at something from a novel new angle which is the best way to win over someone to your viewpoint. Perhaps the most vital strategy, for obvious reasons, is speaking the same language everyone else is using. I speak English and Spanish, but much more the former than the latter. I could definitely understand the debate in Spanish and I could respond on some level, but being eloquent is an entirely different matter.

This comparison to Spanish carries over to medical lingo. Most of us have no idea what all the terms thrown around rapidly really mean. We hear things like CMS, SGR, and Tort reform and have no clue what they really mean. While fully explaining the nuances of all these things can, and likely would, take thousands of lines of text, a few sentence summary will suffice. Below you’ll find a crash course summary of some of the important terms every medical student should know, for no other reason than you will hear them and they will directly affect your medical career. Some might be simple, but this list is about making sure we all know the basics to understand this material, if you want to be an expert in it, do a Google search.

Centers for Medicare & Medicaid Services (CMS): A section of the federal government that basically oversees Medicare, Medicaid, and all other state and national health insurance initiatives. They are the oversight for HIPAA as well. Important to students as residency payments and availability comes from the decisions CMS makes each year after monitoring the residency environment each year. They are the source of your money for residency.

Graduate Medical Education (GME): A term for both the period of time one is a resident and the amount of money set aside in Medicare for paying residents. GME has been capped since 1997. GME can come from other sources than Medicare (e.g. Veterans Affairs funds make up 9% of total US GME) , but it is overwhelmingly directly from Medicare.

Balanced Budget Act of 1997: A law that cut $112 billion from Medicare, including $44 billion directly from payments for services. It also put a cap on the amount of funded residencies Medicare would support. That cap has not increased since 1997, though creative accounting and money reallocation has allowed for at least a 7.6% increase in residency spots since then. New residency programs must gain funding by: diverting funding from another residency to the new one, utilize a loophole (e.g. a small number of new residencies are allowed in rural areas each year), or find independent funding.

Sustainable Growth Rate (SGR): A program put into effect after the Balanced Budget Act of 1997 which limits how much physicians are allowed to spend per Medicare patient, regardless of illness. While the SGR does not limit spending on an individual patient basis, it measures the amount of money spent by Medicare per patient in the year and punishes or rewards doctors based on what percent of GDP it is. Physicians have rarely ever functioned under the proposed yearly spending limit and it has only been through deal cutting that payments cuts that accrue each year are never enforced. Recently the government decided to enforce the cuts, a 21% cut in all physician payments. This cut was delayed until 2012 (when it will be at least 23%). SGR is currently one of the most strongly opposed policies by the AMA, as they feel the entire system is flawed and will only lead to a choice between pay cuts or under-treating patients.

Tort Reform: Also known as malpractice reform. Tort law is involved with wrongs done against individuals which break no contract or existing criminal law. The relevant portion of tort law is medical malpractice, which generally falls into the category of negligence. It is believed that the constant risk of being sued leads to a drain on the system where physicians perform extra tests they do not feel are necessary, both protecting them from liability and charging the patient for things they likely didn’t need done. Similarly malpractice insurance is a huge drain on physicians (OBGYN malpractice cost for basic coverage go as high as $142,000 per year, with NY being among the most expensive states). Physicians argue limiting potential winnings and/or the ability to file frivolous lawsuits would lessen the need for “defensive medicine” and make medicine more cost efficient. Lawyers argue any limitation on winnings or ease of filing will deprive those truly injured from getting their compensation.

New York Medical Liability Reform: The budget office of NY, which contains no medical personnel, identified medical malpractice reform as one of the key ways to balance the NY State budget in 2011. Their plan would cut as much as 25% off of malpractice insurance costs, put a cap on the maximum “pain and suffering” award (only a portion of the total award), create a fund specifically for newborns with birth injuries,  and put safeguards up to prevent frivolous lawsuits. These changes were expected to cut huge amounts of cost from the budget as much of the cost of malpractice is a state burden through the public hospitals being sued and performing “defensive medicine.” The budget bill met strong opposition from the Trial Lawyer Association and the medical liability reform portions were eventually cut from the bill before it passed.

NYC Health and Hospitals Corporation (HHC): A “public benefit corporation” that is run as a private company, but primarily state funded (similar to how power companies work). HHC is the single largest hospital system in America. It operates 11 hospitals, 4 nursing homes, 6 diagnostic centers, and over 80 medical offices in New York City. It also runs MetroPlus, the New York City branch of Medicaid. HHC has been in the news recently for its difficulty keeping profitability, a serious issue for a state-funded organization that is likely to leech money rather than ever fold. HHC was also in the news a few years back for a $100 million deal with St. George’s Medical School in the Caribbean where it sold clerkship spots, some of which were occupied by New York-trained students, to the highest bidder. Although the broker of the deal within the HHC board stepped down after admitting to breaching ethics to broker the deal, the HHC continued with the deal anyway for financial reasons.

International Medical Graduate (IMG): A student trained overseas that comes to America to practice. Frequently divided in conversation between FMG and US-IMG. Foreign Medical Graduate (FMG) is a term that is technically interchangeable with IMG, but is generally used to convey that the student is foreign-born as well as foreign-trained. This terminology generally is never applied to Canadians or Americans who trained in Canada, as they are treated as US trained physicians in most casual senses. US-IMG is a term used when one wishes to specifically refer to American citizens who travel to a different country to earn their medical degree before returning to the US for residency. The large majority of US-IMGs attend one of the 17 "offshore american" schools in the Caribbean.

Thursday, August 18, 2011

Medcest - An Epidemic of Dating

You’re a first year medical student. Eight hours a day you sit in your seat listening to the various doctors trying to teach you about autonomic nervous system ganglia. Sometimes its physicians with receding hairlines and boring stories of rare “zebras,” and sometimes it’s PhD’s with esoteric and insanely specific special interests. You can’t decide which one is worse, so you try to focus on something more interesting. Your thoughts go to the date out at the local bar you have planned with the attractive blonde in the fourth row of the lecture hall on the left (They’re always more attractive in the fourth row on the left, just a rule of medical school).  You’re thinking about your chances to turn this low key trip to MacLaren’s pub might turn into something legendary, maybe even the first sparks of a relationship. You’re not thinking about that question on how to treat organophosphate toxicity, the one which will show up on the test for sure. By the way, the answer is atropine sulfate and pralidoxime (2-PAM). You can thank me later.

Now you’re a third year medical student. You finally managed to scrape together enough time to spend some personal time with your significant other this month. Surgery has made you firebomb nearly your entire social life, except for your partner. You are excited to meet them back at MacLaren’s where you had that first low-key hang out that lead to what seemed like a bulletproof relationship. So many people have told you what a gamble relationship in the same school can be. One person even made a joke about it being better to open a restaurant since those only have a 50% failure rate. But what do they know? You think this to yourself the whole time you’re at the bar: while you’re having the unexpected argument with your partner, while they are yelling at you that you no longer give them the time that you used to, while they say that you’ve both changed too much, while they walk out of your life. Of course, they didn’t really walk out of your life. You’ll see them tomorrow at the surgery suite while you finish the second month of your rotation. You’ll also see them for the next two months after that for internal medicine. The school’s policy on changing rotation sites is pretty strict about not being able to rotate at different sites even if you don’t really want to spend every waking hour at the hospital working in the same service as your ex.
There is an underreported epidemic in medical school of students on a highly risky practice called “dating.” And I’m not here to tell you to give up on your dreams of finding Mr. Right in your class, nor Ms. Right Now at a histology microscope. But just like your RA hopefully warned you in undergrad, you don’t necessarily want to have relationships of any kind in situations where you’ll see the person every day if you break up. They called it “floorcest” back then and it was the principle that you remain solely platonic with everyone on the same dorm floor as you, so there is no friction if things go sour. I guess the logical conclusion is to extend the principle to anyone in your lecture hall in the pre-clinical years, and your specific rotations in clinical years. We’ll call it “medcest” so it retains that cringe-inducing ring to it.
There are all sorts of emotional pleas for why people will do this, I’ll let amorous anatomy partners defend themselves; I’m going to focus on why you should perhaps think twice about it. It goes far beyond the simple ‘you’ll see them every day’ argument that was used in undergrad. Most people feel that medical schools would be qualified as “doctorate education”, which is very hard to argue against given the name of the degree you earn. I argue that medical school is instead an ‘occupational school’ of the highest educational caliber. If you view medical school as training you directly for an occupation, which it certainly is, you can begin to realize that any bridge you burn is a potential lost opportunity in the future. The people you learn with now are some of the best resources for helping you accomplish the true team art of medicine. Even if you don’t go on to work with these people at all, study resources, connections in other cities, references, and research assistance are all so vital throughout medical school and practice that it is nothing short of a sin to lose those resources over anything.
Furthermore medical school is insanely insular and there are no secrets among anyone. If you think no one knows, you’re wrong. If you think no one cares, you’re the talk of the class and you’re wrong. The students who choose not to partake in medcest all find your little foray into it much more entertaining than the most common lab finding in Chronic Granulomatous Disease. Even if this person doesn’t know you from a hole in a wall, eventually word will get around just because human nature is to marvel at stuff like this and, in some shameful corner of their being, hope that if it becomes a train wreck breakup they get to see it. Everyone hears the gossip and eventually will choose sides. I once had a doctor make an inside joke to a group of students, none of which talk to her, about the students’ mutual friend not being able to throw a proper punch and earning himself a bar room fracture. When the school doctors know the status of your 5th metacarpal and who the proper people to joke about it with are, you can be sure that everyone knows about, and has an opinion on, your relationship no matter how open or secret you are about it.  What happens if you break up with your significant other over a ‘miscommunication’ or other, often inflammatory, situation? Not only will you have angered your previous flame, you will have the story of your actions and/or misdeeds run the rounds through the whole school. Forget losing out on opportunities with one person and burning bridges, you’re potentially napalming the whole countryside now.
There is also a small chance that you may become a bit of a repeat offender. If you somehow escape from one in-school relationship relatively unscathed you may be tempted to simply move onto the next opportunity. This is a poor idea. I know plenty of people, myself included, that liked a particular “type” of person and would keep dating within one large social circle where people had that “type” in common. That didn’t work out well for anyone in undergrad. I feel like this goes without saying that serial dating in medical school is, perhaps, even worse and exponentially raises the odds of a bad outcome. The only thing worse than having the other 100 people in your class know all about your personal life and potentially judge you, is let them keep that judgment ammunition to shoot holes in your next attempt at medcest. There are reputation factors: where dating around your class may earn you titles that are less than complimentary. Simply put, if I have to enumerate out all of the reasons why serially dating people within your own class is a terrible idea, perhaps it would be more entertaining to simply let you try it and find out first hand.
Of course, love is a force you can’t resist; or so I’m told by the RnB music industry. If you truly fall head over heels for the girl who chews her highlighter in that sexy way in row 7 seat 2, or the guy in the library who wrote you a love sonnet about the wheal and flare reaction, who am I to stop you? Your friends, they should be the ones to stop you. If you friends fail in their duties to convince you to avoid this huge gamble, and my warnings on the risks don’t stop you from trying, then I wish you the best of luck. Relationships can be a beautiful thing, and I have seen one or two nice ones come out of the medical school chaos. I have simply seen many more train wrecks and horror stories. I just want to do my part to bring awareness to the under-reported epidemic of medcest.

Friday, August 5, 2011

Medical Advocacy and Star Wars

I’m not afraid to admit that the Star Wars trilogy, the original trilogy, was my favorite three movies when I was young. As a younger boy I didn’t understand one of the key moments of the first movie, though, and it always bothered me. I didn’t understand why Obi-Wan Kenobi would turn off his light saber and let Darth Vader strike him down. For those unaware of the movie plot, I’ll make the scene very simple. Obi-Wan Kenobi represents everything good in the world and Darth Vader represents everything bad. They had fought before and, to put it lightly, Obi-Wan demolished Vader in a previous battle. Yet when it comes time to have a real battle, and perhaps destroy Vader for good, Obi-Wan simply puts his weapon away, admits defeat, and lets Vader kill him.

To a 7 year old boy who wandered around in an oversized hoodie, hitting things with a cardboard paper towel tube, and generally trying to be like Kenobi, this moment was somewhat traumatizing. For a long time I believed that Kenobi held all the power and simply gave up because he thought he erroneously thought the fight was too hard to overcome. He put his lightsaber away because he didn’t believe in himself and he died rather than fight. I want to now acknowledge all the Star Wars fans frothing at the mouth; yes, I later realized he stopped fighting because in defeat he became both an immortal in the force and a martyr to drive Luke to his own heroics, but that doesn’t change how important my initial misunderstanding was.

When I talk to people about advocacy, especially at the student level, all I hear is defeatism. I can see them all pulling an Obi-Wan on me and simply saying that nothing they can do matters so they might as well just let the ‘inevitable’ happen and continue on with their lives without any resistance. When I hear someone tell me that ‘they can’t change anything’ or that ‘they need to focus totally on their studies’ I want to shake them and explain how crazy they sound to me.

On the former, experience has shown me that when debates become entrenched it tends to become ‘physicians’ versus another monolithic, entity without any face or soul as far as the common person cares. Today its doctors and trial lawyers, yesterday it was doctors and insurance companies, tomorrow its doctors and the IRS. I actually think doctors can win that last one. But I digress, when the debate becomes stale politicians, and other political movers and shakers, seek out the fresh faces that aren’t sworn to party lines. Students are seen as a fresh and innocent source of opinions. Generally speaking, we truly want what is best for the health of the whole society, and have shown willingness to make sacrifices in our future in order to create a health society that we feel is more “enlightened.” Students who speak up become central in the debate, our comments get the presidents to respond, the politicians to meet us in person, and the debate to shift dramatically. All we need is the courage to not give up before the fight even begins.

When I hear that a student wishes to focus more on education than advocacy I have a bit more understanding. Don’t get me wrong, I still believe they are being penny wise and pound foolish, but they are making an intelligent decision in their immediate future. Despite this, no amount of great grades will change that the health landscape, where we will almost all end up, is rapidly turning against physicians as the advocates for physicians often cannot match up to the vocal defenders of other vested interests. We study to be great physicians, but it would take so little time to act on behalf of the profession we hope to become so that organizations outside of the hospitals don’t recreate the world inside of it before we even get there. Sometimes just physicians suffer; sometimes decisions are made that hurt physicians and patients. The former is bad, the latter is a national tragedy that keeps happening over and over; all while students study diligently, completely oblivious to the detriment these changes will have on them.

I’ll give you a theoretical example from my own school. In late March and early April I was contacting every single school in NY to try to organize a united front to support a suggested NY State budget that would include many pro-physician changes along with a few compromises.  One of the greatest changes was an indemnity fund that, among other things, would lead to an estimated 25% cut in the malpractice insurance costs for obstetricians. In my home institution we were studying OB/GYN right as the debate on the medical-related portions of the budget was raging. A student I approached to take a few seconds of her time to sign a form letter for me, or write her own letter if she felt so compelled, rebuffed me coldly and refused to sign. Her reasoning for not signing was that she wanted to be an obstetrician and couldn’t do anything for me this close to test time, as she had time to read nothing else but her textbooks for the next 3 days and had to have a perfect score on her OB/GYN exam. I tried to explain the irony of not wanting to support current and future obstetricians because she was too busy studying to become one, but she had already tuned me out. Her lightsaber was down and she had accepted her defeat, whether she consciously knew it or not.

Recently the medical students of New York State participated in a study on their opinions on advocacy, among other issues. The study showed 68% of students want to be more involved with advocacy and legislative issues involving medicine, and 78% felt that their actions could have a positive impact on patients and colleagues. Despite the apparent willingness to participate, the study also showed that only 21% of students have ever participated in any way in such issues.  I can’t help but look at those numbers and assume there is a disconnect between what we students feel like we can and should be doing, and what we are willing to do when actually faced with the opportunity. The sense that we’re under qualified, the fear of time commitment, and the idea that we’re facing insurmountable odds are all fallacies that we tell ourselves when acting just isn’t what we want to do today. If I am going to do one thing in my term as your Chair of the Legislative Awareness Committee for MSSNY, it’s that I’m going to make sure every time a student thinks “someone should stop that” or “I don’t like that,” I’ll be there to give them the tools to make sure their opinion is well-informed, heard by those in power, and valued. No student should ever feel hesitant to broadcast their ideas publicly on these matters.

Now that I’m older I see there was another lesson Obi-Wan, and all of Star Wars, was trying to teach when he let a singular force strike him down. No one person can do it alone. This was true when Obi-Wan realized he was more powerful as a ghostly mentor to Luke than as a human warrior. This is true when you look at the entire trilogy. When it was time for Luke, the hero, to save the day in the first movie he fails. He misses time and time again when he tries to win by himself because there is too much pressure on him the enemies to line up a good shot. It’s not until Han Solo comes to his aid and Obi-Wan encourages him to trust in himself that he saves the day. This is even true in the other movies. Who defeats the bad guys? Not the hero acting alone. Luke loses. It’s Darth Vader, realizing what is being forced on Luke (death in this case) is reprehensible and joins forces to stop the Evil. Out in space there is another battle where you expect some major character to be the one to blow up the New Death Star. Who does blow up the Death Star? Lando Calrissian, a relatively small but very memorable supporting character, is the guy who saves the day in the end. For those who don’t know, Lando is basically the epitome of a medical student. He is charismatic, brave, intelligent, and fatally flawed by complacency. Lando chooses early in the trilogy to aid the villains rather than rock the boat and try to resist. He only becomes a hero once the protagonists convince him that it is possible to make a difference and change the universe.

So, maybe we can be a bit more like Lando Calrissian and Obi-Wan and realize that we can effect massive change if we support each other, rather than acting alone or simply submitting to a future we do not approve of without a fight. In the mean time, I’m going to watch the Star Wars trilogy again; and yes, I’ll be on my couch dressed up as Obi-Wan Kenobi, cardboard tube and all.