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The growing number of medical schools


For Kaiser Health News

The  announcement by Kaiser Permanente that it plans to open its own medical school in Southern California has attracted a lot of attention in the healthcare community.

But Kaiser is actually at the trailing edge of a medical-school expansion that has been unmatched since the 1960s and 1970s, say medical education experts. (Kaiser Health News is not affiliated with Kaiser Permanente.) In the past decade alone, according to the Association of American Medical Colleges, 20 new medical schools have opened or been approved.

That’s no coincidence. In 2006, the AAMC called for a 30 percent increase in medical-school graduates by 2015 to meet a growing demand, both through expanded class sizes and newly created medical schools.

“We’re on track to meet that 30 percent increase in the next three or four years,” said Atul Grover, AAMC’s chief public-policy officer. “Enrollment is already up 25 percent since 2002.”

Many of the new schools focus on producing more primary-care physicians — those specializing in pediatrics, family medicine or general internal medicine. In fact, Kaiser Permanente already has a partnership with the University of California at Davis in the northern part of the state on a fast-track training program for primary care.

But Kaiser leaders say their new school (projected to enroll its first class in 2019) is about more than just primary care.

“We need to prepare physicians for the way healthcare is delivered in the future,” said  Edward Ellison, M.D., executive medical director for the Southern California Permanente Medical Group. He said students need to learn not just medicine, but about integrated systems of care and how to work in a much different medical environment. “Our advantage is we can start from scratch,” he said.

Another advantage is the HMO’s deep pockets.

“They’ve got huge resources,” said George Thibault, president of the Josiah Macy Jr. Foundation, which focuses on medical education. “This is a grand experiment, but if anybody can do it, Kaiser can.”

Kaiser Permanente is far from the first healthcare provider to launch its own medical school — the Mayo Clinic has had one since 1972 and is about to expand that school from its home base in Minnesota to its satellite campuses in Arizona and Florida.

Thibault said health-provider systems are already heavily involved in the new medical schools, often as partners with degree-granting universities, “which itself is a new trend.” For example, on Long Island, the North Shore-LIJ Health System co-launched a medical school with Hofstra University in 2011.

One big question is whether all these new schools will eventually produce more students than there are residency positions, which are necessary to complete the training. The federal government, which funds the majority of those residencies through the Medicare program, capped the number of residencies it would fund in the 1997 Balanced Budget Act.

Currently there are about 27,000 residency slots available each year, which are filled by students who have earned M.D. or D.O. degrees (doctors of osteopathy) in the U.S., as well as foreign medical-school graduates and U.S. citizens who have graduated from medical schools overseas.

Between the new M.D.-granting schools and a rapid expansion of osteopathic medical schools, AAMC’s Grover said, demand will soon outstrip supply. Residency slots “are growing at about 1 percent per year,” he said (mostly funded by health systems themselves since Medicare will not), “while undergraduate medical education is growing about 3 percent per year.”

But Edward Salsberg of George Washington University, who has spent a career documenting health workforce trends, said any potential conflict is still a long way off.

“When you start with an excess of 7,000 slots” of residencies over graduating U.S. medical students, “it takes a very long time” to consume that excess, he said. By the year 2024, he and others concluded in a recent article in the New England Journal of Medicine, there will still be 4,500 more slots than graduates.

“So yes, U.S. medical students will have a slightly more limited range of specialties to choose from,” said Salsberg, “but still plenty of room.”

There are also questions about whether there even is a physcian shortage that all these new schools are aiming to alleviate.

Grover, whose organization has led the call for more physicians, said the anticipated shortage of primary-care physicians might not be as acute as originally thought. That’s because the U.S. is producing dramatically more nurse practitioners and physician assistants, who also provide primary care.

That’s probably a good thing, at least in supply terms, said Thibault of the Macy Foundation. Because it turns out that many students graduating from new primary-care-focused school’s programs are in fact opting to become specialists instead.

“The career choices in the new schools look remarkably similar to career choices of more traditional schools,” he said. The graduating medical students “are responding to the same set of signals and stimuli” about prestige, income and lifestyle.

Increasing the number of physicians who know veterans’ issues



“Memorial Day, Boston,” by Henry Sandham.


For Kaiser Health News

Most former servicemen and women (and their families) get their healthcare at civilian facilities, where only rarely do health professionals ask patients if they or close relatives have a military background. But not only do veterans suffer from a disproportionate share of ailments such as post-traumatic stress disorder and brain injury, many who were in combat zones may also have been exposed to hazards such as the defoliant Agent Orange in Vietnam, or huge burn pits in Iraq and Afghanistan that produced toxic fumes.

Recognizing the potential for missing important health issues, a small group of medical professionals banded together to ensure that in the future doctors will at least be aware of the possible medical problems of former military members, who now number about 14 million. Going forward, the exam every medical student and new physician must take to get a license will include questions about military medicine. That, in turn will force medical schools to teach it.

Brian Baird, a former Democratic member of Congress from Washington and a licensed clinical psychologist, has helped spearhead the change, which is being publicized as the country prepares for Veterans Day this Wednesday. He said he was inspired by some of his own patients who returned from duty in need of help.

“We don’t even ask, ‘Have you or a loved one been deployed overseas,’” he said in an interview. “And I thought, what a terrible oversight.”

Baird set out to talk to every medical organization he could find. Several responded, or were working on a similar project at the same time, including the White House’s “Joining Forces” initiative.

Baird found an eager partner in Steven Haist, a physician and vice president at the National Board of Medical Examiners, which develops and runs the U.S. Medical Licensing Exam.

Haist has spent nearly four years organizing the effort and bringing in specialists from the Department of Veterans Affairs and every branch of the military to develop and write the questions. Military medicine will be included in all three of the exam’s “steps,” which students take at different points in medical school and after they complete the early phases of post-graduate training.

“In some respects, I think it could have been done a lot sooner,” said Haist, given many of the well-recognized issues affecting returning troops from Vietnam and the first Gulf War. But he said he hopes that ensuring that physicians know about potential problems “will improve the health care that is received by returning deployed servicemen and women and their families.”

Karen Sanders, M.D., who helps oversee academic training for the VA, and who got the project funded, says she’s confident the change will make things happen. “If you change the exams, schools and curricula will follow,” she said. “We hope this will drive schools to offer courses” in medical conditions experienced by members of the military. A surveyconducted by the Association of American Medical Colleges found that as of 2012, only about half the schools had such courses.

Other medical organizations have also acted to better integrate the health problems stemming from military duty into non-military health care. Both the American Medical Association and American Academy of Nursing are actively encouraging providers to ask patients about their or a family member’s military service.

But encouraging is not enough, say Howard and Jean Somers. Their son, Daniel, committed suicide in 2013 after being unable to receive treatment for mental-health issues upon returning from Iraq. They have been working to improve the care at the VA and bring more attention to returning troops’ health problems ever since.

“How do you make it a requirement without making it part of the licensing or re-licensing,” said Howard Somers, a retired urologist.

They called putting questions on the licensing exam “fantastic,” but stressed that something similar needs to be done to educate doctors who have completed their training and initial licensing.

In order to maintain his medical license, said Howard Somers, “I had to take an online course in pain management. That would be another way to address this, to get medical societies to make this a requirement.”

Former Congressman Baird agrees. “I’ve asked a lot of physicians about it, and many of them said, ‘You know I’ve had courses in things I will never see in my practice. But there’s a pretty darn good chance I’m going to see somebody who’s been deployed.’”

But getting military service training to be a required part of continuing education for doctors is a daunting task. “You’d have to deal (separately) with every state medical board,” says the VA’s Sanders.

There is also a parallel effort to put questions about military service not just on intake forms that patients fill out but also in the electronic medical records that are filled in by health care providers.

Epic, a spokeswoman for Epic, the dominant software developer in the market, said that the company’s standard record does include questions about military service, but they don’t show up unless the customer  — a hospital or doctor’s office – requests that.  “Pediatrics, for example, will not turn it on,” she said.

But Baird insists that the question should be included on every single electronic medical record, including those for children: “The classic case would be a child struggling in school, who can’t sleep.” A doctor might prescribe medication, he said, “but never stops to ask if anybody in the (child’s) family has been deployed.”

Baird recognizes that while the adoption of the test questions marks a milestone, there is still a long way to go. “My goal is nothing less than making this a permanent  aspect of our medical education and our health care system,” he said. “It’s rather shocking that it hasn’t been done actually.”

CMS ratings said to lack key socio-economic data


The groups says that Medicare’s five-star scale that rates the quality of care doesn’t offer a complete picture because it fails to reflect these distinct  factors.

One way to address the problem, the groups say, is for CMS to add  income-related information into its ranking calculations. The star-rating system currently uses patient-satisfaction data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to determine the scores.

Beth Feldpush, senior vice president for policy and advocacy for America’s Essential Hospitals, told CMS that research warns  that larger hospitals, teaching hospitals and hospitals serving many low-income patients could well receive lower star ratings even though they provide quality care to the most vulnerable populations. She also complains  the system  oversimplifies complex and individualized choices that patients must make about their health.

She urged the agency to use  measures endorsed by the National Quality Forum that clearly  account for these socio-economic and demographic factors.


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