It looks at:
By JULIE ROVNER
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.
The Mayo Clinic has developed a science of physician burnout.
One of Mayo’s (perhaps surprising to some) findings is that younger and older physicians suffer less burnout than mid-career ones. The young ones have not become tied to older, fee-for-service forms of practice and many older ones have started to cut back hours and have the pleasant prospect of retirement coming soon.
The middle ones, however, must deal with the stress of changing to fee-for-value systems and dealing with workplaces that have become more regulated, bureaucratic and bottom-line focused, with an expanded menu of metrics to measure their performance.
It’s clear that increasing administrative, financial and other pressures are probably putting more pressure on doctors of all ages than ever before. They need all the help they can get to deal with it.
Reuters reports on a study that found that “Women in surgical training programs who feel that those around them endorse negative stereotypes about female doctors have poorer psychological health than others who do not feel a ‘stereotype threat.”’
However, “Not all women perceived a stereotype threat. And such perceptions did not affect the mental health of young women in non-surgical specialties, the researchers found.”
“Perceiving that others have a negative stereotype about you ‘is a general phenomenon that affects all sorts of people and circumstances, including white men doing athletic activities and ethnic minorities in academic achievement,’ said lead author Arghavan Salles, M.D., of Washington University, in St. Louis.”
“Stereotype threat is present in all fields, but the negative consequences appear to be less in other specialties than in surgery,” Dr. Salles told Reuters.
“The culture of medicine as a whole, particularly the training environment, should take stereotype threat into account,” Liselotte N. Dyrbye, M.D., of the Mayo Clinic, told Reuters. She wasn’t part of the new study. She added that having more women in leadership positions as role models for female medical students would help.
Panoramic view of Salt Lake City.
As this very important New York Times article says: “Most businesses know the cost of everything that goes into producing what they sell — essential information for setting prices. Medicine is different. Hospitals know what they are paid by insurers, but it bears little relationship to their costs.”
But now, thanks to a project led by Vivian Lee, M.D., “the hospital is getting answers, information that is not only saving money but also improving care. The effort is attracting the attention of institutions from Harvard to the Mayo Clinic. The secretary of health and human services, Sylvia Mathews Burwell, visited last month to see the results”
While the costs of other medical centers in the Salt Lake City area have increased an average of 2.9 percent a year over the past few years, the University of Utah’s have declined by 0.5 percent a year. “We have bent the cost curve,” Dr. Lee told The Times.
The paper says that the “linchpin of this effort at the University of Utah Health Care is a computer program — still a work in progress — with 200 million rows of costs for items like drugs, medical devices, a doctor’s time in the operating room and each member of the staff’s time. The software also tracks such outcomes as days in the hospital and readmissions. A pulldown menu compares each doctor’s costs and outcomes with others’ in the department ”
The big culprits:
Fee-For-Service System Corrupts Medical Practice.
Growing Costs To Consumers Affect Doctors.
Electronic Health Records Can Thwart Physician Performance.
But Dr. Pearl points to some organizations, such as the Mayo Clinic, Kaiser Permanente and Geisenger Clinic, that have overcome many of American healthcare’s problems and improved the lives of patients and physicians as a result.
As a Wall Street Journal article notes: “Managing those people’s health care is often difficult. Integrated health systems, such as Kaiser Permanente and Mayo Clinic, aim to ensure that treatment for one condition doesn’t interfere with care the patient is receiving for other diseases. Often, however, the responsibility of coordinating treatments falls on the patients themselves.”
Trying to avoid serious complications from taking different medications and dealing with the fact that too often physicians of a patient with multiple chronic illnesses don’t talk with each other about the patient’s case are among the biggest challenges.
Maybe it will help that the U.S. Department of Health and Human Services (HHS) has issued a curriculum for training healthcare professionals and others in caring for patients with multiple chronic conditions.
HHS has taken other steps to help patients with multiple chronic conditions. The Centers for Medicare and Medicaid Services, a HHS agency, now reimburse providers for time spent coordinating chronically ill patients’ care outside of regular office visits.
Obviously, many experts hope that electronic health records will increasingly help physicians keep track of their chronically ill patients.
One recommendation is that patients create their own medical records by, for example, keeping updated lists of medicines that they are taking and bringing them to all visits to physicians.
See article below, too:
MedPage Today, citing a research article in the BMJ, reported “Symptom checker software appropriately triaged emergent patient cases 80% of the time, but that accuracy fell off for non-emergent care (55%) and self care (34%) scenarios in a standardized test….”
xxx
This is part of a reporting relationship with Kaiser Health News and National Public Radio.
There’s a warning out today for those who go online or to apps to figure out why they have an upset tummy or nagging cough or occasional chest pain. Symptom checkers, those tools that ask for information and suggest a diagnosis, are accurate only about half of the time.
The finding is from a Harvard Medical School study that reviewed 23 sites, such as WebMD, the Mayo Clinic and DocResponse. One third listed the correct diagnosis as the first option for patients. Half the sites had the right diagnosis among their top three results, and 58 percent listed it in their top 20 suggestions.
Dr. Ateev Mehrotra, one of the study’s authors, urges patients to be cautious when using these tools.
“These sites are not a replacement for going to the doctor and getting a full evaluation and diagnosis,” he says. “They are simply providing some information on what might be going on with you.”
About a third of U.S. adults use the sites, although not necessarily in place of going to the doctor.
Some of the diagnostic questions are also used by nurse triage phone services and,
Mehrotra says, these online tools are about as accurate as the call-in lines offered by many insurers and physician groups. “[They are] better than just a random Internet search,” he said.
Researchers entered the symptoms of 45 patients from vignettes used to train medical students. The Mayo Clinic’s first online diagnosis was right only 17 percent of the time, but had the correct diagnosis on a list of 20 in 76 percent of cases. Dr. John Wilkinson, who works on Mayo’s symptom checker, says the tool directs patients to medical research and prepares them to talk to their doctor.
“We’re always trying to improve but if most of the time the correct diagnosis is included in the list of possibilities, that’s all we’re attempting to do,” he says.
The diagnosis accuracy rate for physicians is 85 to 90 percent. But Jason Maude, who runs a high performing tool called Isabel, says he does not want a Web versus doctor showdown.
“The whole point is not to set the patient against the doctor or replace the doctor, but to make the patient much better informed and to ask the doctor much better questions, and then together they should do a much better job,” he says.
Isabel ranked well in the study, showing the correct answer more than 40 percent of the time in the first diagnosis and 84 percent in the top 20 answers. Those high results, Maude says, may be because the site lets patients type in their own description of symptoms. They might describe a “tummy ache” or “stomach cramps” rather than the more clinical choice of “abdominal pain” used by many online symptom checker tools. And Isabel asks just two or three questions before patients describe their problem, as compared to sites that ask patients to click through 20 questions — steps Maude said may discourage use.
Clarifying how and why patients use these tools is critical, say the study’s authors. They could reduce unnecessary office visits or inform patients as they talk with their doctors. But for some, the tools may encourage people to seek unnecessary care.
Mehrotra says patients used symptom checkers more than 100 million times last year, a fact that may stun some physicians.
“While most doctors know patients are going to the Internet to search for medical advice, in terms of these symptom checkers, I’ve been surprised that few of my colleagues even knew they existed,” he says.
David L. Brown, M.D., an anesthesiologist and a leading expert on pain management, has joined Cambridge Management Group (cmg625.com) as a senior adviser. He survived his own prolonged life-threatening illness related to military-acquired hepatitis C, which gave him a particularly deep understanding of the needs of patients and their families facing end-of-life decisions. The experience led Dr. Brown, an Air Force veteran, to found Curadux — a firm dedicated to pioneering a revolutionary decision-support model for those facing advanced illness.
Dr. Brown’s research has focused on acute pain relief in post-surgical patients, as well as relief of pain related to pancreatic cancer. He and colleagues are investigating a novel cannabinoid-2 compound (MDA-7) that shows promise for Alzheimer’s disease symptom management and relief of neuropathic pain.
He recently retired academically and clinically from the Cleveland Clinic, where he was professor and chairman of the Anesthesiology Institute.
Previously, he led the departments of anesthesiology at the University of Texas’s M.D. Anderson Cancer Center; the University of Iowa Hospital and Clinics, and the Virginia Mason Medical Center, as well as serving as professor of anesthesiology at the Mayo Clinic.
Dr. Brown is past president of the American Society of Regional Anesthesia and Pain Medicine; past editor-in-chief of the journal Regional Anesthesia and Pain Medicine; past president of the Association of University Anesthesiologists, and past chairman of the Accreditation Council for Graduate Medical Education’s (ACGME) Residency Review Committee for Anesthesiology. He was also a member of the ACGME board.
He has been a director of the American Board of Anesthesiology and chairman of the Foundation for Anesthesia Education and Research.
Dr. Brown received his medical degree in 1978 as a member of Alpha Omega Alpha, the medical honor society, at the University of Minnesota, after undergraduate work at Iowa State University and the University of South Dakota. In 1982 he completed his anesthesiology residency at Wilford Hall U.S. Air Force Medical Center, in San Antonio. Before that, he was a flight surgeon in the USAF for the 319th Bombardment Wing.
