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Tougher times ahead for physicians trained abroad?


It may be getting harder for physicians trained abroad to get good jobs in U.S. healthcare because of a big increase in the number of graduates of American medical schools.

In the past few decades, physicians trained abroad have usually had little trouble finding residency positions that can’t be filled by U.S. graduates.

But  since 2002, 16 new allopathic and 15 new osteopathic medical schools have opened in the United States, and many existing schools have expanded class sizes. By one estimate, U.S. medical school enrollment will rise almost 50 percent in the next few years.

Cost-consciousness shakes up medical education


This Washington Post article discusses how the cost-consciousness revolution in U.S. healthcare “is starting to shake up one of the most conservative parts of medicine: Its antiquated model for training doctors.”

“Once paid {only} a la carte for the procedures and services they perform, physicians are beginning to be reimbursed for keeping their patients healthy. Doctors trained in the science of medicine, the diagnosis and treatment of the sick person in front of them, are increasingly responsible for helping to keep their patients out of the hospital.

“Those changes have been rippling through the health-care system for years in an attempt to address rising costs but were powerfully accelerated by the Affordable Care Act. That has left medical schools scrambling to catch up.”

Among the signs of change:

“Penn State is making its first-year students patient navigators. The University of Texas at Austin is building a medical school from scratch, with an explicit focus on areas beyond the doctor-patient interaction, such as health-care delivery and population health. The AMA {American Medical Association} is worried enough about the problem that it has been giving out millions of dollars to prod new kinds of teaching, in the hope that doctors’ training can adapt as quickly as the system they will soon join.”

Seniors tell med students what they want


By SUSAN JAFFE, for Kaiser Health News


When doctors told Robert Madison that his wife had dementia, they didn’t explain very much. His successful career as an architect hardly prepared him for what came next.

“A week before she passed away her behavior was different, and I was angry because I thought she was deliberately not doing things,” Madison, now 92, told a group of nearly 200 students at Case Western Reserve School of Medicine here. “You are knowledgeable in treating patients, but I’m the patient, too, and if someone had said she can’t control anything, I would have been better able to understand what was taking place.”

Belle Likover recounted for the students how she insisted when her husband was dying of lymphoma that doctors in the hospital not make decisions without involving his oncologist. “When someone is in the hospital, they need an advocate with them at all times,” said Likover, who turns 96 next month. “But to expect that from families when they are in crisis is expecting too much. The medical profession has to address that.”

Madison and Likover were among six people all over the age of 90 invited to talk to the second-year medical students this month. The annual panel discussion, called “Life Over 90,” is aimed at nudging students toward choosing geriatric medicine, the primary-care field that focuses on the elderly. It is among the lowest-paid specialties, and geriatricians must contend with complex cases that are time consuming and are often not reimbursed adequately by Medicare or private insurance. And their patients can have diseases that can only be managed but never cured.

Students often are attracted to more lucrative specialties such as orthopedics or cardiology, said Jeremy Hill, who was in the audience. One undeniable factor is money: the 35-year-old North Carolina native may owe as much as $300,000 when he graduates, enough – he is quick to point out – to buy “a nice-sized house.”

Yet Hill is one of the few Case students who say they are leaning toward choosing geriatrics.

The American Geriatrics Society estimates that the nation will require about 30,000 geriatricians by 2030 to serve the 30 percent of Americans over age 65 with the most complicated medical problems. Yet there are about 7,000 geriatricians currently practicing. To meet the needs, the society estimates medical schools would have to train at least 1,500 geriatricians annually between now and 2030, or five times as many as last year.

The low number of geriatricians is not surprising considering that their average salary was $184,000 in 2010, almost three times lower than what radiologists earned, the American Geriatrics Society has reported.

Elizabeth O’Toole, a geriatrician and med school professor who arranged the panel discussion, acknowledged in her introduction that most students were interested in other specialties. Yet she warned them not to overlook the needs and outlooks of older patients.

“No matter what you’ll be doing, you are going to be working with these folks,” she said. More than 400,000 people 80 years old and older receive knee replacements last year, 35 percent of men over 80 and 19 percent of women have coronary heart disease and the most common medical procedure among people over 65 is cataract surgery. Successful outcomes depend on the patient’s cooperation and that, she said, requires “an understanding of who the patient is.”

Students who braced themselves for a solemn litany of medical problems from the panel were in for a surprise. It wasn’t just what the visitors said that made an impression, but how they said it.

The group offered the students advice, telling the doctors-to-be to look at their patients instead of typing notes into a computer, take more time with older patients and answer their questions.

“Having to see so many patients a day is tragic,” said Simon Ostrach, 92, a professor emeritus of engineering at Case, who recalled being rushed through an appointment with an orthopedic surgeon who did little for “excruciating pain” after his hip replacement.

When it was her turn, Likover pushed back her chair, stood up and had no need for the microphone she was offered.

“Getting old is a question of being able to adapt to your changing life situation, having a little less energy, not being quite as healthy as were you were before,” said Likover, a retired social worker. Four years ago, she was hospitalized twice for congestive heart failure until she learned how to manage the disease through diet. She also has an occasional irregular heart beat and only recently began walking with a cane. She swims at least three times a week, serves on several committees addressing seniors’ issues, and has been a Jon Stewart fan because “getting a laugh every day is very, very helpful.”

“I have lived a very good and hopefully useful life and death does not concern me. It is going to happen,” she told the students. “And I think that kind of outlook, not worrying about every little ache and pain makes a big difference and a very happy life.”

“That’s a perfect segue to my story,” said Ostrach. “I attribute my longevity to smoking, drinking and overeating,” he told the students. And doctors who tried to reform him “are all long dead and gone.” He was an athlete in college, wrestling and playing tennis, “but as I got past 60, I found that listening to opera, smoking good cigars and having a little cognac was much more pleasant.” All in moderation, he added.

Efforts to introduce relatively healthy older adults to medical students can “reduce the sense of futility and show [the students] that there are real people with real lives who can benefit from quality health care,” said Chris Langston, program director at the John A. Hartford Foundation, which focuses on aging and health who has been analyzing the trend for the past several years.

But Jeremy Hill and the roughly two dozen members of Case’s “geriatric interest group” are the exception. For them, the challenge of a complicated patient — “figuring out the puzzle” as one student put it — is what makes geriatric medicine worthwhile, even when a cure is out of reach.

“I have such respect and admiration for this population, and if I could somehow give them one extra good day they would not have had otherwise,” said Hill, who then paused for a moment, “I would be privileged to work with them.”

After the session, Hill went up to Ostrach, who had said he’s been lonely since his wife died. After chatting for a few minutes, he told Ostrach, “If you’d like to have lunch sometime, please call me,” and handed him a scrap of paper with his phone number.

Medical schools elevating communication, teamwork skills


By JULIE ROVNER, for Kaiser Health News


Medicine has changed a lot in the past 100 years. But medical training has not.

Until now.  Spurred on by the need to train a different type of doctor, medical schools around the country are tearing up the textbooks and starting from scratch.

Most medical schools still operate under a model pioneered in the early 1900s by an educator named Abraham Flexner.

“Flexner did a lot of great things,” said Raj Mangrulkar, associate dean for medical student education at the University of Michigan Medical School. “But we’ve learned a lot and now we’re absolutely ready for a new model.”

And Michigan is one of many schools in the midst of a major overhaul of its curriculum.

For example, in a windowless classroom, a small group of second year students are hard at work. They’re not studying anatomy or biochemistry or any of the traditional sciences. They’re polishing their communications skills.

In the first exercise, students paired off and negotiated the price of a used BMW. Now they’re trying to settle on who should get credit for an imaginary medical journal article.

“I was thinking, kind of given our background and approach, that I would be senior author. How does that sound to you?” asks Jesse Burk-Rafel.

It may seem like an odd way for medical students to be spending their class time. But Erin McKean, the surgeon teaching the class, says it’s a serious topic for students who’ll have to communicate life and death matters during their careers.

“I was not taught this in medical school myself,” says McKean. But she says today communication is more important than ever. “We haven’t taught people how to be specific about working in teams, how to communicate with peers and colleagues and how to communicate to the general public about what’s going on in healthcare and medicine,” she says.

It’s just one of many such changes. And it’s dramatically different from the traditional way medicine has been taught. Flexner’s model is known as “two plus two.” Students spend their first two years in the classroom memorizing facts and their last two shadowing other doctors in hospitals and clinics. Mangrulkar says when the curriculum was instituted it was a huge change from the way doctors were taught in the 19th Century.

“Literacy was optional, and you didn’t always learn in the clinical setting,” he says. Shortly after Flexner published his landmark review of the state of medical education, dozens of the nation’s medical schools closed or merged.

But today, says Mangrulkar, the two-plus-two model doesn’t work. For one thing, there’s too much medical science for anyone to learn in two years – and most information can be quickly accessed from a smartphone or tablet. At the same time, medicine is constantly in flux. What Michigan and many other schools are trying to do instead is prepare doctors for the inevitable changes they’ll see over their practice lives.

“We shouldn’t even try to predict what that system’s going to be like,” he says. “Which means we need to give students the tools to be adaptable, to be resilient, to problem solve, push through some things, accept some things, but change other things.”

One big change at many schools is a new focus on learning not just how to treat patients, but about how the entire health system works.

Susan Skochelak is a vice president with the American Medical Association, in charge of an AMA effort that is funding changes to medical school programs at 11 schools around the country. She says the new focus has had an added benefit: Faculty members are learning right along with the students about some of the absurdities in the system as it is today.

Only because they have to guide students through the system do they discover, for instance, that some hospitals schedule patients for tests like MRIs around the clock. “And one of my patients had to come and get their MRI at 3 am. How do they do that? They have kids! ” she says faculty members have told her.

Sometimes it’s not doctors who are the best teachers about how the system works.

Doctors tend to focus on patient care, since that’s what they know, she says, but when it is time to learn about the system as a whole, it can be more fruitful to hook students up with the clinic managers.

Another major change is making sure the next generation of doctors is ready to work as part of a team, rather than as unquestioned leaders.

In another classroom at the University of California-San Francisco, several groups of students are practicing teamwork by working together to solve a genetics problem.

Joe Derisi, who heads the biochemistry and biophysics department at UCSF, is more guiding than teaching, as he gently suggests a student’s tactic is veering off course: “I would argue that it may not be as useful as you think, but I’m obliging.”

Onur Yenigun, one of the students in the class, says that working with his peers is good preparation .

“When I’m in small group I realize that I can’t know everything. I won’t know everything,” he says. “And to be able to rely on my classmates to fill in the blanks is really important.”

The medical schools that are part of the AMA project are already sharing what they’ve learned with each other. Now plans are in the works to begin to share some of the more successful changes with other medical schools around the country.

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