Putting a comment on blast ...

“Life is best enjoyed when time periods are evenly divided between labor, sleep, and recreation...all people should spend one-third of their time in recreation which is rebuilding, voluntary activity, never idleness.”

~Brigham Young

I received this comment from p3/4md. It is a bit of a rant, but speaks directly to many of my frustrations with some of the medical students that I encounter.

'I know he's only eleven months, but we think he might be a genius.'

Being a third year med student, almost done with my core clerkships, I'd like to comment on this from our perspective, and then, from my perspective.

First: Medical students are quick learners to do what is most efficient. We always have our eye on the end game. In college, it was medical school, in medical school, it is residency.

Let's just forget about the first two years of medical school in this talk, because quite frankly, in my opinion, it has little to do with how the students will act, clinically.

These statements are true. Like many things we do, it is about end game. What I try to stress to my residents is that they are not training to be residents. End game is becoming a physician. in our case an orthopaedic surgeon. Practice like it.

Residency is based primarily on your step I/II scores and your grades, most probably, your clinical grades.

In our Surgery clerkship for instance, our grade is basically derived 50% from shelf exam score, and 50% by your ward attending/resident.

We as med students know that if we show up on time, and blend in with our peers, we're going to get 80-85% for our clerkship grade. If our resident/attending likes us, and we're actually halfway competant and helpful, we'll get a grade of 85%-90%. If we're lucky, and the attending is nice, we'll get a grade in the 90's.

If we bust our behinds, work hard, and become advocates for our patients, we're still going to ride that luck factor to get a grade above 90% (which is honors.) I've had attendings/residents praise me, say they've learned more from me than they thought they taught me, and still give me an 87.5. Tell me, what do you expect of me to do well? I've had residents and attendings put down "the best medical student I have ever had" etc. etc. in the their comments, and still give me a 95%, why not a 100%? If I performed above expectations, and was the best you have ever seen, doesn't that logically warrant a grade of 100%?

Granted, I know no one is perfect, and some can be more stringent than others, but seriously, give me a break. I've had (in college and other areas,) people say "I don't believe in giving 100's, no one is perfect." Well, by that same logic, if no one is perfect, and 100% can never be achieved, why have the score there to begin with??? In that case, should it not be assumed that 100% is "just less than perfect" ??

Anyway, enough with that rant :) The point is, in order to do really well in our clerkships, the effort required can be overwhelming. The extra effort required to get into the 90's for our grade is tremendous, and many times, regardless of how well you perform, there's still a significant chance that you won't get an exceptional grade.

We all know this. We've all been there. We know that attending "He's a jerk.. it's not worth it".

In the face of studying for a shelf exam or the myriad of ungraded pass/fail papers that you have us write, I am intelligent, I can balance my time.

Why do I do this? Well, I know that if I do well on the shelf, the 5-10% of the clinical grade that may be impossible to receive, will be easily superceded. Enough said.

So why should I bust my hump.. when I can study more, and make up for it on exam, and then some.

I think this is what really frustrates me. It is one of the reasons that I posted previously about grade inflation. When I look at a resident and a student, I don't look at hours spent in the hospital or the kiss @$$ stuff. Most of us can see through the false smiles. What I look for is someone who is worried about doing the next right thing for both patient and team.

Consider the following (and this isn't me being arrogant or whatever.. this is just how it is):

Unfortunately (or fortunately, depending on how you look at it) my parents instilled a good work ethic in this young doctor. I care.. I really do. I work hard, examining patients, talking to them, building rapport, etc. I showed up 30 minutes before everyone else to preround on my patients, even though no one would ever hear my morning report. Yes, I can hear murmurs that residents can't pick up. Yes, I can put in IV's faster/more efficiently than my interns. Yes, when a patient is desat'ing, I have the ABG kit in my hand, and am feeling for a radial pulse before my resident says "we need an ABG." Yes, I've out diagnosed my resident and my attending. Yes, I paid attention, I read alot, and I understood. If i'm thrown in an ICU/SICU, I can navigate my way around, manage patients, and be confident. No, I know I'm not an attending, I know my limitations, but I also know that they're far beyond that of my peers.

Do I think that's because I am smarter, or better than my peers? No. It's because I know I worked harder to know this. And I damn well have the right to be proud of it. :)

Why did I learn this stuff? Because I think that doctors should graduate and know how to save people's lives. To be useful, and not just know a bunch of facts.

So I bust my hump, etc. And I am proud of myself..But then, I look at a peer of mine:

She shows up late, and does the bare minimum. It's a big month if she actually talks/puts her hands on a patient. She's "going into optho... why should she care?" She leaves early.. and studies while the attending is speaking.

No attending/resident is going to bad mouth her.. they're all too nice. They'll say something benign in her evaluation, and give her a grade of ~85. Then, she'll do well on the shelf.. and get honors.

Her transcript says honors
My transcript says honors.

To the residency world,.. we are equal.

I know more, I worked significantly harder.. but in the end, what difference did it make for the "end game?"

Yes, ideally, we all should be looking for the benefit for the patient.. and should learn to be the best that we can be.. Well, I say fiddle sticks to that.

The most important patient in this scenario is yourself. Who is going to sacrifice in a selfless way before themselves. Yes, there are a few.. but that is certainly not the majority.

So we are in a constant battle. And the grade is king, it truly is.

Although grade is king, you should always do what is right. End game is being a physician.

So, after a year of dealing with this junk.. yes, I now sometimes I find myself debating if I should put that extra effort in. I do it anyway, because I think it is the right thing to do. I feel obligated. I know I am not well accompanied in this thinking.

Most of us learn to just "get by".. and this is evident by the strength of the interns. Most of the interns I've encountered are babbling fools. Why? Because they "just got by" in medical school. It creates a vicious cycle. It sets the stage for residency.

In the wake of the recent match.. I feel bad for the folks who have to decide on these candidates. They all have honors.. they all did well. How do they judge work ethic and good clinical skills? It's almost impossible.

*sigh* what is ahead in the future..

-p3/4md

p3/4md, I love this comment because I can feel your frustration with the system and the abuses of the system by your peers. The hardest thing for a residency selection committee to do is find people who have good work ethic and clinical skill. It is one of the reasons so many programs take people who rotated with them. Hang in there young padawan.

“The self-confidence of the warrior is not the self-confidence of the average man. The average man seeks certainty in the eyes of the onlooker and calls that self-confidence. The warrior seeks impeccability in his own eyes and calls that humbleness. The average man is hooked to his fellow men, while the warrior is hooked only to infinity.”

~Carlos Castaneda

Regardless of how many times I do it 20 miles is still a long frickin run ...

"The range of what we think and do is limited by what we fail to notice. And because we fail to notice that we fail to notice, there is little we can do to change until we notice how failing to notice shapes our thoughts and deeds."

~R. D. Laing

About 5 years ago, I started running. On a dare, I ran a 1/2 marathon. I needed to be challenged. For someone who had never been a runner, the 13.1 mile distance seemed like an unsurmountable distance. After the race, I realized that it wasn't as difficult as I had expected. It didn't require a lot of training. Like many amateur runners, I quickly made the leap from 1/2 marathon to marathon. I read the books and got training plans. I talked to marathoners. The truth is that the marathon is not just running a 1/2 marathon twice. Most will tell you it is much more; the marathon begins after the 20th mile.

Marathon training can be painful. In the beginning, it's fun. Most of the runs are rather short. The average training plan is about 3-4 months. If you run regularly, the first few weeks are just a continuation of what you have been doing previously. The challenges come when the middle distance run is greater than 8 miles and your long run is greater that 16 miles. Training runs that use to be 30-60 minutes become 1 1/2 - 2 1/2 hrs. Injuries begin to pile up. Your body aches. You ask yourself on a number of occasions the question, why? For me the answer is, because it is there. It is a challenge. I will defeat the 26.1 mile monster. The training is a necessary evil. The long runs of 18-22 miles on a Sunday must be done to prepare me for the marathon day. If I don't prepare, I won't be ready and I will fail.

In one of the early posts, I wrote about how I felt residents and medical students today are soft. Maybe that was a little harsh; they are more like the new, the proud, and the privileged. Some who read this thought I was speaking to the hot button issue of the 80 hour work week. My opinions don't have anything to do with the hours spent in the hospital. It has nothing to do with them wanting to have a life, i.e. not being in the hospital all the time. It has more to do with how they view their chosen career. When you are training, you can't do it part time. Medicine is not a DELL computer where you choose only your favorite components. You can't come into a specialty without having at least a basic knowledge. These basic components become the building blocks for future learning and professional growth.

When I look at my residents and the young medical students, there is an inherent lack of drive to learn their craft. It is no longer a priority. Like many of my generation, Gen X, and even more so in the Mellinial generation, there is a undercurrent of entitlement. It is their right to be taught this information and to do these procedures. They are not here for so called "scut." Heaven forbid we talk about patient care and continuity of care. We are in the era of teams and patient hand offs. No one is responsible for a patient. Patients are handed from one person to another like a hot potato. The residents are well rested but who is actually responsible for the patient. Who is taking ownership? Ah yes, it is the attending's responsibility. So, now if I am going to do everything, why should I teach? And if the attendings and mid level providers are going to be doing a majority of the patient care, are we training 1/2 a physician? Are we training physicians who can pass a test but can't treat a patient?

Regardless of the rules and regulations placed on training, patients still expect you to be a physician. When a patient asks you a question, you can't answer "I missed that lecture because I was over hours." No matter how low the hour restrictions go, physicians in training will still need to gain the experience. They must put in the time to train.

Medicine is mountain, regardless of your specialty. The amount of information that you need to understand is increasing. In todays medicine, the number of known diseases, medications, diagnostic testing, and procedures, are probably double of what they were 20 years ago. The business end of medicine is more complicated. Medical practices have adjusted because of medical legal issues. The style of medicine practiced is affected by both private insurance and CMS. There are regulating agencies, like JCAHO, that make suggestions hospitals have to follow. Then there is the possibility of P4P. You must be a physician, business man, politician, and lawyer. To say we teach them all well would be the understatement of the century.

Like the marathon, medicine requires endurance training. It can be fun, but for the most part it is painful. For clinical medicine, you simply have to get the clinical experience. Book learning helps but experience solidifies the information and places the written word into perspective. Regardless of how smart you are, you still have to put in time outside of the hospital to read. The reading must be not only on clinical and basic science, but also on the business, and health policy, ect. You must train yourself to prepare for the end game, you medical career and practice. Everyday is a school day and contrary to popular belief, your learning and educating does not end at 80 hours; just like my run doesn't stop at 20 miles.

“Never mistake knowledge for wisdom. One helps you make a living; the other helps you make a life.”

~Sandra Carey

There'll be no shelter here ...

"They who have put out the people's eyes, reproach them of their blindness."
~ John Milton

...
I need to watch things die
From a good safe distance
Vicariously, I
Live while the whole world dies
You all feel the same so
Why can't we just admit it?
...

Vicarious
TOOL

I remember when it began. At the time, it was a novel thought. I don't know if MTV knew it at the time, but The Real World was ground breaking. It opened a whole new genre, entertaining through others' fortunes or misfortunes. For Generation Y, this has always been a part of their lives. Caricatured lives placed in the open for all to see. Computers and the Internet have perpetuated our desire to create worlds for make believe lives. Avatars are created; caricatures of our inner selves. Social networking sites explode. We don't call any more, just text. In this make believe world, we can live our fantasy lives and project our opinions in a forum with little anxiety, fear, or regulation. For those who felt they had something worth being heard, they took to blogging.

When I began blogging, I wasn't sure what to expect. What I found was that it was a wonderful community of people with different opinions on any number of topics. For many of the anonymous posters, it is a world where their voices could be heard. Like the wild west, it is an unstructured platform where opinions can be made, discussed, and debated without fear of repercussion. This community has its own set of rules. For many of the medical students and residents, it is their venue. They grew up here. From Myspace to Facebook to Twitter, their lives and ideas have been free form on the Internet. In this brave new world, I am a learner.

...
Hospitals not profit full
The market bull's got pockets full
To advertise some hip disguise
View the world from American eyes
Tha poor adore keep feeding for more
Tha thin line between entertainment and war
fix the need, develop the taste
Buy their products or get laid to waste
Coca-Cola was back in our veins in Saigon
And Rambo too, we got a dope pair of Nikes on
Godzilla pure m@#*&fu%@n' filler
Get your eyes off the real killer

Cinema, simulated life, ill drama
Fourth reich culture, Americana
Chained to the dream they got you searchin for
Tha thin line between entertainment and war
...

There'll Be No Shelter Here
~Rage Against The Machine

In terms of technology and popular information, the medical community is generally behind the times. Caught up in our world of IV's and Ambu bags, we lose perspective on the real world. We teach the youth of America, yet we have no perspective on what is important in their world. Our eyes open only when topics are discussed in the media or cause a direct effect on us (the medical community). We are naive on many issues and undereducated outside of our world.

Change and the unknown create fear. Blogging and social networking is an uncontrolled medium. A venue where opinions can be voiced anonymously open forum. The paranoid mind says this medium will be used to slander the institution or organization and must be regulated. Although universities claim to welcome differences, there are policies that prevent true open discussion of all opposing views. In the Ivory Towers of academic medicine, popular ideas flourish. We feign tolerance. Unpopular thoughts are discounted and discarded. Hierarchy and politics rule. In this atmosphere, subordinates believe they lack the power to question. In an open forum, would I voice my opinions to a superior? As a subordinate, where is my platform?

Born with insight and a raised fist
A witness to the slit wrist, thats with
As we move into 92
Still in a room without a view
Ya got to know
Ya got to know
That when I say go, go, go
Amp up and amplify
Defy
I'm a brother with a furious mind
Action must be taken
We don't need the key
Well break in

Something must be done
About vengeance, a badge and a gun
cause I'll rip the mike, rip the stage, rip the system
I was born to rage against 'em

Fist in ya face, in the place
And I'll drop the style clearly
Know your enemy...know your enemy!

Yeah!

Hey yo, and d!$k with this...uggh!
Word is born
Fight the war, f@!k the norm
Now I got no patience
So sick of complacence
With the d the e the f the I the a the n the c the e
Mind of a revolutionary
So clear the lane
The finger to the land of the chains
What? the land of the free?
Whoever told you that is your enemy?
...

Know You Enemy
~Rage Against The Machine

Are we too nice?

“High achievement always takes place in the framework of high expectation.”

~Charles F. Kettering

When I went through all of our applications, it was hard to separate one application from another. The white pages and black lettering blended together after the about 15th application. For a majority of the applications, all I had was a name, school, and their basic statistics.

John Doe

• Medical School: State University of X or X University
  
• USMLE step 1: 235
• Clinical Rotations: 1/2 clinical honors
• Orthopaedic Rotations: honors
  
• LOR's: good to excellent with some stating he is in the top 10% of students rotating this year
• Personal Statement: "... Since I injured my knee playing football, I have always wanted to be an orthopaedic surgeon. ... I have played sports all of my life ..."

I can't count the number of times that I have read this type or similar application. The names of the applicants are sometimes interchangeable. What aspect of their application tells me that this is going to be a stud or a dud? I have received a number of emails and have read plenty of forums that ask the same question, "what do I need to get into orthopaedics?" If I could tell you the exact recipe, I would, but I don't think there is one. In truth, we all know the recipe, good grades, good scores, good rotations, and a little luck. I think what is more important is the special ingredient or special sauce you bring to make you different.

Many applicants get caught up in the numbers of the game. Time and time again the question is asked, "what score do I need to get into orthopaedics" or "what grades do I need" or "how much research do I need"? I can give numbers of the typical solid application, as I have listed some above, but does that guarantee a spot? Not so much. The quoted figures on scores, grades, research, and AOA are just guidelines, not a guarantee. Every year there are applicants with strong numbers that don't get into a residency. So, why didn't they match? Typically, when I have reviewed these non-match applicants, the reason was either glaringly obvious (USMLE score 205, bad letters, failing a subject in medical school) and on other occasions, it was not. When there was no glaring flaw, the applicant looks like every other applicant. There is nothing in their application that makes him/her stand out.

I have asked myself why is it that that most of the applicants so similar. Is it because they have all used performance enhancing drugs to make them all academic superstars? All jokes aside, I think it may have more to do with the way we grade. I blame it on kids soccer, where everyone gets to play and in the and they all get a trophy. Many parents display their honor role student sticker on the rear window of their SUV. All the children are A and B students. Many go to a 4 year university and expect the same. They argue for a better grade and petition for grade changes when it doesn't meet their expectations. The professors that grade on a true Bell Curve are not liked or considered "hard" because they give out fewer A's and B's. Over the past 10 years, I have noticed this trend and I have wondered if we (educators) are too kind in our evaluations?

With a student's application, we receive a copy of the grade distribution for that medical school. When comparing applicants from one school to another, there are definite differences in grading philosophies. I don't know if this is a problem with the grading set up or that we are "too nice." In my experience of clinical grading, unless the student does something drastically wrong (like never show up or cursing out a patient), the student will at least receive a pass. The question is who receives the highly coveted Honors. Each School varies in their grading system. The grades can range from pass/fail only to honors/pass/fail to honors/high pass/fail to honors/high pass/marginal pass/fail and the always popular A/B/C/D/F (with +/-). What puzzles me about all of these systems is that the average tends to be a B or high pass. There are schools with greater that 50% honors in some subjects. You may say, well are these the "lesser schools"? Not so fast young patawan. In my limited research (okay not really research but observation), it is more common for the "very competitive schools" to have more of a top heavy grade distribution and the "less competitive schools" to have a more even grade distribution. It is not uncommon for a school to have grading distribution (in the clinical years) with greater than 50% honors and less that 30% passes. How does this allow for us to assess these applicants? If you score only gives out 20% honors and you received a high pass, should you be penalized? On the other hand, if you went to a school that gave greater that 50% honors, should you be given bonus?

With competitive specialties' concentrating on USMLE scores, students have been crushing this test. The USMLE is one of the only tools we have to compare applicants from different schools and areas of the country. Because the USMLE "powers that be" don't want the test to be used in the manner we use it, they do not provide us with the distribution of scores. In the old days, the mean was in the low 200's (205 when I took it) with a standard deviation of 20. Today, the mean is in the mid 210's. Therefore, a score in the 90's of 225 is equivalent to a score of about 235 in today's scoring (I am guessing). Most of the applicants I have reviewed have an average of a 230 (just a guess, again no true data). Again, when trying to create separation like Randy Moss from a corner back, it doesn't happen. The applicant's are all bunched together like 6 year old children playing soccer.

You may say, "then look at the letters of recommendation (LORs)." This is less helpful than the grading. Most folks have the prerequisite letter from their program chair that says he or she is a supernova or has star like qualities. There are usually 1-2 letters from surgeons that are not known by most interviewers and 1 from a well known surgeon. Although the letters are helpful when pointing out top end and lower end, they to not create the needed separation to differentiate one applicant from another. There have been occasions where I have read the same recommendation on 2 or 3 applicants from the same physician. Although we think we know the code words, I think we kid ourselves at thinking we can read into another's recommendation like it is Morse Code. Usually the true meaning is missed, except when comments are blatant like, "we recommended that he look into other specialties ... "

What is the answer? I have recently begun to reevaluate my own grading system. How is my grading? Am I too nice? The answer is yes. I believe that many of us don't want to be the bad guy. Who wants to be the professor who fails most of his/her students? I don't think that there are many who would answer yes. I believe we do need to re-center. In the clinical setting, the average grade should be a pass. The excellent grades should be give to those who truly stand out for the rest of the students. As an educators, we must communicate our expectations are and explain what passing grade means. Is this a student problem, I would propose it is not. It is a educator problem. We have evaluate honestly. No more just checking the 4 out of 5 box. If they have met expectations, then they should get a pass. You may read this and think I am arguing for more strict grading, but I am not. I think that our grading should be fair. Lumping the average around above average is not fair to those who are truly above average.

“Success is simple. Do what's right, the right way, at the right time.”

~Arnold H. Glasgow

I guess surgical training is smililar all over the world ...

“Cruelty is fed, not weakened, by tears”

~Publilius Syrus

Bongi stopped by my site, so I thought I would check out his site (thanks for stopping by). It rocks (probably be cause we use the same blue theme). I ran across an interesting post called Tears. It reminds me of old school surgical training. I feel that this style of training or belittling has no role in medical training today. Just my opinion.

“Cruelty is, perhaps, the worst kid of sin. Intellectual cruelty is certainly the worst kind of cruelty.”
~G. K. Chesterton

How do we educate residents with todays restrictions .... (part III)

“It is a miracle that curiosity survives formal education.”

~Albert Einstein

So the next question is how do we, educators, teach our audience, the learners, our craft with in the restrictions of different governing bodies, while appropriately meeting the specific needs of the current generation?

As we look at the need of the current generation, we can see that there is an emphasis on the individual yet they want to be mentored. They are in touch with the newest technology and may require different ways of communicating. You may be required to give them instant feedback. Heck, we have cell phone and the text messaging. I want to know now. Why didn't you pick you your phone? I think we, educators, must keep in mind that everyone’s time is important. The learners do not need to learn all of the information in one sitting. People learn and think best when well rested and fed. This progression to a kinder gentler medical training is a change in philosophy. It will make less bitter people.

The learners, on the other hand, must understand that they will be required to be active participants in their own education. Because less will be learned directly from the educator, the learner must be facile with the other learning media. Learners must seek out knowledge. There is not enough time to do passive learning; the learner must seek out the opportunities to gain clinical skill. This is something in the past that was provided by shear volume; now, it must be sought out and learn through alternative means. Unlike many things that can be learned by reading, those who are in clinical specialties must learn from patients. Patients and their diseases do not always follow the rules. The more patients you see, the better understanding of the possible variations in presentation. This can not be learned by computer simulation or by reading in a text book. There is no algorithm will incorporate every clinical scenario. So, the patients must be seen and evaluated. With all of the new technology, one of the key skill set of the physician is slowly being lost, the physical examination.

There are some significant changes coming in the future that will effect resident education. Many current residents and medical students harp on the 80 work week and the low pay. There are the arguments that say that the hospitals and universities get 100+ thousand dollars for each resident and the resident should get more money or have to work less hours. I say, be careful what you wish for. Let's go into some basic changes that will effect resident education directly and indirectly.

NEED TO INCREASE PHYSICIAN NUMBER

Although there are some that believe that,

There has been a systematic attempt to limit the number of spots in medical schools. With a limited supply of training institutions, there was insufficient supply to meet demand.

There have been some significant changes over the past few years to actually increase the number of physicians. Here is a little history.

In 1992, the Council on Graduate Medical Education (COGME) issued a series of reports expressing concern with potential surpluses of physicians and recommending an increase in the percent of physicians trained and practicing as generalists. These concerns led the Council to develop a recommendation that 110 percent of the number of U.S. medical graduates in 1993 should enter residency training each year (or about 19,750 physicians) and that half of these physicians should be generalists. This recommendation became known as the “110/50-50” goal for the physician workforce in the U.S.

Recently put out in the COGME's 16th report, they assessed the future supply, demand, and need for physicians in the United States (U.S.) through 2020 for both generalist and non-generalist physicians will exceed what we are currently producing.

Summarizing some of their findings:

1. Under current production and practice patterns, the supply of practicing physicians in the U.S. is expected to rise from 781,200 full-time equivalent (FTE) physicians3 in 2000 to 971,800 in 2020, a 24 percent incease.

2. At the same time, for a number of reasons and under a number of scenarios and models, the demand for physicians is likely to grow even more rapidly over this period than the supply.

3. The need for services, reflecting primarily the use of services under universal insurance and increased utilization review processes, is also expected to increase over the period.

4. The models and alternative scenarios used to make the predictions included a number of factors that could have a major impact on supply, demand, and need and, consequently, on a potential gap in the physician supply. Many of these factors are likely to add to the shortage of physicians.
> Changing lifestyles for the newest generation of physicians, with the possibility that new physicians will work fewer hours than their predecessors;
>Continuation of the rate of increase in the use of physician services by those over 45, which has been increasing for the past 20 years, and increased use of services by the baby-boom generation compared to prior generations
> Expected increases in the Nation’s wealth that would contribute to continued increases in the use of medical services.

Other factors could also lead to larger shortages and are not included in the baseline projections or alternative scenarios. These include the following:

> A potential increase in non-patient care activities by physicians, including research and administrative activities;
> A potential change in practice patterns for physicians over 50, including a reduction in hours worked before retirement and earlier retirement patterns;
> Possible increases in departures from practice due to liability concerns of physicians;
> Decreases in hours worked by physicians in training;
> Possible decreases in immigration of graduates of foreign medical schools;
> Possible increases in the number of physicians limiting the number of patients on their panel (sometimes referred to as “boutique medicine”);
> Advances in genetic testing that could lead to increases in the use of services as individuals learn they are at risk for certain illnesses or conditions; and
> Additional medical advances likely to keep individuals with chronic illnesses alive longer without curing their illnesses.

THE MEDICAL SCHOOL RESPONSE

In response to the findings of COGME, medical schools have started the process of increasing the class sizes to help with predicted future needs. This is in contrast to the past where there was a decrease in both medical school classes, as well as a push towards the primary care specialties. With the current findings, there will be a need across the board. There is less of a push for those primary specialties. In June of 2006, AAMC came out with a Statement on the Physician Workforce. They recommended:

1. Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 level over the next decade. This expansion should be accomplished by increased enrollment in existing schools as well as by establishing new medical schools.

2. The aggregate number of graduate medical education (GME) positions should be expanded to accommodate the additional graduates from accredited medical schools.

3. The AAMC should assist medical schools with expanding enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

4. The AAMC should continue to advocate for and promote efforts to increase enrollment and graduation of racial and ethnic minorities from medical school; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

5. The AAMC should examine options for development of: (1) a formal, voluntary process for assessing medical schools outside the U.S.; and (2) a mechanism for overseeing the clinical training experiences in the U.S. of medical students enrolled in foreign medical education programs.

6. The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the U.S.

7. National Health Service Corps (NHSC) awards should be increased by at least 1,500 per year to help meet the need for physicians caring for under-served populations and to help address rising mdical student indebtedness.

8. Studies of the relationship between physician preparation (i.e., medical education and residency training) and the quality and outcomes of care should be conducted and supported by public and private funding.

RESIDENCY FUNDING

Residents are mostly funded by Centers for Medicare and Medicaid Services (CMS) and this is for taking care of Medicare patients. That funding is split into 2 parts: DGME and IME. The DGME (Direct Graduate Medical Education payment) is the direct cost of the resident (salary, benefits, malpractice, etc). The IME (Indirect Medical Education) is the indirect cost of medical education (teaching, supplies, cost of personnel for each residency and GME, and the increased cost of training institutions because of trainees). The dollar amounts vary based on an algorithm, but the gist is that the DGME is about ~$70-90,000 and the IME is ~$30,000. In the near future, like next year, the IME is being decrease by about 1/2. Another change that will affect residencies is that if a resident goes to a course for education, the government will not pay for those days, unless they were vacation days. If a resident is in an outpatient setting, unless approved by CMS, the hospital or facility will have to cover the residents salary for that given time. Every hour of a resident’s day has to be accounted for and reported to the government. If there is a question, that time will have to be covered by the institution. Many would have you believe that the hospital make a mint of of the residents. They get money from the government and then they are able to bill for facility fees and attendings bill for their work. There are actually some articles that are coming out to dispute this.

Along with the CMS guidelines the numbers of medical graduates will be increasing but the residency "cap" has not. Therefore the number of residencies paid for by CMS will not change. There have been some policies to change this, but they are not currently in place. Hospitals have responded to the lack of governmental GME funding by funding residency positions themselves.

Why do I say be careful what you wish for? I can see in the future requiring tuition for residency. When the government pulls most or all of the funding, this may be happening.

TIME

Time is going to be an issue. With many of the newer generation wanting a "life", they are going to spent less time learning in the hospital. We have run into this problem with trying to fit in a curriculum that is considered a necessity by the RRC. When do you find time to have didactics? In today’s world, the didactics must be taught between the hours of 630 am and 6pm, Monday through Friday, no weekends, no holidays. This makes things tough in the surgical specialties. Yes, we can hire PA's and NP's to cover floor work; and yes, the attendings can start the cases by themselves (I actually prefer this because I get to operate). The problem is that this is education time too. In the surgical specialties, noon conferences don't work. That means it must be at the beginning or the end of the day.

Hospitals are being crushed by decreases in reimbursements so they are pushing to get more done with less. More cases are done in less time. Start the cases early and on time so that they can get more done before the end of the day shift. They don't want to pay overtime. Many hospitals want to push the OR time back to 7am. Hospitals administrators know that residents slow down many attending surgeons and would rather not have them operate to decrease OR time. So how are we going to prevent monetary problems from effecting the education of our needed practitioners?

WHAT'S THE ANSWER?

In the end, this question I wanted to solve has only brought more questions. I will continue to reevaluate my on education styles. I hope to keep this generations eyes open. I want them to look not only at how they are affected, but at how their choices and actions affect those who will follow them. As an educator, my ultimate goal is to put out a good product (physician/surgeon) in the end. The means of doing that may vary but hopefully the outcomes will be the same.

"In youth we learn; in age we understand.”

~Mari Von Ebner-Eschenbach

The beatings will continue until the morale improves ...

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

~John Quincy Adams

As I have written previously, and it is confirmed in one of the forums on the Student Doctor Forums, medical students these days are soft. I say this half in jest, but it does have some truth; otherwise, it would not make so many upset. From “my perspective” medical students and sometimes residents are not here to learn. They feel that we, the attendings, are making things to give them busy work. We are just giving you more paperwork to fill out, another dictation to do, or another patient to see. There is no medical relevance to anything you are asked to do, no education to be had. Everything must have some teaching value otherwise it is a waste of their time. They would rather study for the shelf exam which definitely correlates more with patient care that actual patient care.

This past week we have a medical student on service who is here to learn. She is a fourth year and this is her last rotation. She could cruse the rest of the way. That’s what most others do. “I am on month away from being a doctor, I have matched, why should I work so hard?” Hey, I am not knocking that mentality, it’s “senioritis.” We have all had it. What make her rotation interesting is she actually wants to learn. HOLY SHIT BATMAN, a medical student who want to learn about what we are doing. Yeah, we get the orthowanabes but they don’t count. Usually, those not going into ortho are really here to just have another elective. We are a surgical elective and we don’t require much of them. But, she actually wants to learn. Hmm, go figure. Isn’t this why we went to medical school or may be it was to be rich?

Why would this surprise me? Well, it is the interest. It makes me want to spend the extra time teaching. The extra time explaining why we do this or that. It makes me think. It reminds me why I am in academics. Sometimes all the other factors that many medical students and residents don’t see and these things can get you down. To have all the pressures of the powers that be and the top have uninterested residents and medical students as well will just frustrate you. (uurgh)

From the attending side, you are being pulled at multiple levels. From the upper level, administration of the hospital wants you to operate more and bring in more “business.” Residents want you to let them run free to operate and make decisions, as well as, get home at a reasonable hour; they don’t want to spend too many hours in the hospital, “we do want a life.” There are patient obligations. Patients call the office wanting to be seen right away for their acute intoeing consult. Other physicians want you to be available for consults so alleviate their fears of an acute case of “I can’t diagnose the cause of your pain” syndrome. Your partners want you to see more patients and operate more so that there will be more revenue for the practice as a whole. And if you are in a big university, the head of the university and/or medical school may have an interest in what you do. This makes your ultimate goal of patient care a little difficult at times. How can you dedicate your life to the education of the future medical providers without being disenchanted?

It is when a young physician reminds you how interesting medicine is and what good we can do for patients. You are reminded about the differences you make in patients life everyday. This may be an idealistic view but reminds me of why I am here. I want people to aspire to be better, to understand disease processes, and find cures. I want to change the world. Ok, that was a bit much, but I do want to make a difference. So, the way I chose to do it is by one patient, one medical student, and one resident at a time. I will continue to try to spread the little knowledge I have with the hope that someday they will do the same.

"Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, 'I will try again tomorrow'."

~Mary Anne Radmacher