medical education news

Big Changes Ahead in Medical Education

The U.S. should be prepared for massive changes in the next few years in the way physicians are trained, experts said here Thursday.

Change will have to start with inter professional education, George Thibault, MD, president of the Josiah Macy Jr. Foundation in New York, said at an event sponsored by Health Affairs to promote its theme issue on medical education. “We know all health professionals are going to work together in formal and informal teams, yet we educate them separately and then are surprised when they don’t work together well.” Instead, professionals should be educated together so they are prepared to work together as teams, he said.

In addition, a new model of clinical education is needed, Thibault continued. “The [current] model is very fragmented and still too hospital-based to take care of a population with chronic illnesses who are largely outside the hospital. The model needs to be more longitudinal and community-based.”

Then there is the content of the curriculum. “Since [the Flexner report], biological sciences have been the basis for medical education,” he noted. “We need to add social sciences, systems management, economics, and medical professionalism.”

Thibault also suggested that medical schools move away from time-based education and toward education based on development of competencies, “so learners move through as they are ready to move through. We cannot continue to have a locked-up approach determined by everybody doing the same thing or determined by just time and place. This can lead to a more efficient system … and to professionals who are specifically prepared for the careers they’re going to take on.”

Several speakers lamented the lack of medical students willing to go into primary care. “Part of that is the culture of medical school — what’s conveyed to students plays a major role,” said Uwe Reinhardt of Princeton University in New Jersey.

“You come home and you say, ‘I’m a pediatrician,’ or you say you’re like Sanjay Gupta — a neurosurgeon. What gets you the date?” he said.

Although people often point to medical education debt as a barrier to pursuing the lesser-paid primary care specialties rather than the more well-paid specialties, Reinhardt disagreed that it’s a major problem. “Look at medical school indebtedness — on average it’s about $220,000,” he said. “I always tell physicians who bellyache, ‘you know that guy who just opened a restaurant — what do you think they pay on a mortgage?’ It’s probably close to your [loan], and somehow they make do.”

“Debt is a nuisance, but not prohibitive,” he added, noting that the Association of American Medical Colleges is trumpeting record medical school enrollment despite students’ debt problems.

For the primary care situation to change, “we need accountability,” said David Goodman, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire and a co-principal investigator of the Dartmouth Atlas of Health Care. “The best way is with public guidance leading to peer review that leads to public funding,” with priorities that are set annually. “That might [include] increase in primary care [residency] funding — putting a thumb on the scale allows being a priority.”

Goodman proposed a scheme in which each year, 10% of physician training programs would need to reapply for their funding. Programs that are reapplying would be competing with other established programs as well as new residency programs. Applications would be peer-reviewed, and successful applicants would get an interim review to make sure they were on track.

Under such a system — which would mean that each program would be reviewed once per decade — meritorious training programs would be able to expand, while weaker programs would lose 10% to 15% of their funding. And because the awards would be made every year, it would give the system “the ability to change priorities with each succeeding year, over time,” he said. “Sure, we’ll make mistakes, but they’ll be smaller mistakes.”

Audience members also heard from Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.)who are co-sponsoring the “Training Tomorrow’s Doctors Today Act,” a bill that would increase the number of graduate medical education (GME) slots by 15,000 over a 5-year period. “This is an issue that’s uniting [Republicans and Democrats] on Capitol Hill,” Shock said.

Both Schock and Schwartz also expressed support for legislation that would repeal and then replace Medicare’s much-maligned sustainable growth rate (SGR) formula for physician reimbursement. Schock noted that one reason the House Energy and Commerce Committee was able to get unanimous support among its committee members for its SGR repeal proposal, which would cost an estimated $179 billion, was that “they didn’t say how they’re going to pay for it.”

Rep. Dave Camp (R-Mich.), chair of the House Ways and Means Committee — which is charged with coming up with ways to pay for legislation such as an SGR fix — has been briefing committee members on possible “pay-fors,” said Schock, who is a member of the committee. “So stay tuned” to see what happens, he added.

Schwartz said she hopes that GME reform may eventually be included in an SGR fix bill should one be passed. “When we do something about the SGR, there might be a moment when we could slip this [GME] legislation into our discussion,” she said.

Source: Med Page today

 

Medical student study: sickly schools, healthy results

Medical student study

Students with the same entry grades perform better at medical school if they hail from poor-performing schools.

This is one of the conclusions of a study of nearly 5,000 students from 12 UK medical schools published last week in the journal BMC Medicine.

The research, titled The UKCAT-12 Study, finds that the average A-level scores of students’ schools is the only piece of contextual data with significant power to predict performance in medical school.

The finding complements a study by the Higher Education Funding Council for England in 2003, which came up with a similar result for UK universities in general, and the early findings of a follow-up, expected to be published next year.

The UKCAT-12 Study, authored by Chris McManus, professor of psychology and medical education at University College London, and colleagues from UCL and Birkbeck, University of London, says the reason for the phenomenon may be that high-performing schools give pupils’ work “extra polish”that is not available when they leave. Another possibility is the “big fish, little pond effect”, so students from lesser academic environments have higher ambitions.

“That the effect found by [Hefce] is now found in medical students suggests that there is a strong argument for using the contextual measure of average A-level attainment at a secondary school in making admission decisions,” the authors say.

The paper also lends support to the widespread use in medical school admissions of the UK Clinical Aptitude Test (UKCAT), which tests numerical, verbal and abstract reasoning, decision-making and situational judgement. It was introduced in 2006 to help distinguish between high-achieving applicants.

Based on their analysis of students who took the test between 2006 and 2008, the authors conclude that A-level grades remain the strongest predictors of medical school success. But used in conjunction with A-level and GCSE results, the UKCAT offers a small but significant boost to predictability, particularly for mature students, who often have “unusual combinations of academic qualifications”, and female students, who tend to outperform males at medical school but get worse UKCAT scores.

The paper also notes evidence that the test has widened participation and concludes that its use in admissions is “in many ways more justifiable than the use of Ucas personal statements, which…are open to criticism for difficulty in scoring consistently, are subject to a range of influences, including social opportunity, and have not been shown to predict success in medical school”.

Source: Times Higher Education

20 %of Nations Medical Education Funds Go to NY

 

New York state received 20 percent of all Medicare’s graduate medical education (GME) funding while 29 states, including places struggling with a severe shortage of physicians, got less than 1 percent, according to a report published today by researchers at the George Washington (GW) University School of Public Health and Health Services (SPHHS).

New York suffers from no lack of physicians yet in 2010 the state received $2 billion in federal GME funding according to the study, which appears in the November issue of Health Affairs. At the same time, the researchers found that many states struggling with severe physician shortages received a fraction of that funding: For example, Florida received one tenth the GME funding ($268 million) and Mississippi, the state with the lowest ratio of doctors to patients in the country, received just $22 million in these federal payments.

“Such imbalances play out across the country and can affect access to health care,” said lead author Fitzhugh Mullan, MD, the Murdock Head Professor of Medicine and Health Policy, a joint position at SPHHS and the GW School of Medicine and Health Sciences. “Due to the rigid formula that governs the GME system, a disproportionate share of this federal investment in the physician workforce goes to certain states mostly in the Northeast. Unless the GME payment system is reformed, the skewed payments will continue to promote an imbalance in physician availability across the country.”

Other authors of the study include Candice Chen, MD, MPH, assistant professor of health policy and pediatrics and Erika Steinmetz, MBA, senior research scientist at the SPHHS Department of Health Policy.

The study adds to the evidence suggesting that the current system of allocating graduate medical education or GME money is based on an inflexible and outdated method, one that contributes to large imbalances in payments and a growing shortfall of physicians in some areas of the country. Since its start, the Medicare GME program has paid teaching hospitals to provide residency training for young physicians. In 2010, those teaching facilities received $10 billion in GME payments, an amount that represents the nation’s single largest public investment in the health workforce.

To find out how that $10 billion was distributed, the researchers analyzed the 2010 Medicare cost reports that list federal GME payments to teaching hospitals all over the country. The team found a disproportionate amount of Medicare GME dollars flowing to Northeastern states such as New York, Massachusetts and Rhode Island. In fact, the study shows that in these three states Medicare supports twice as many medical residents per person as the national average. And New York alone has more residents than 31 other states combined.

“Teaching hospitals in the Northeastern United States have a long history of large residency training programs, which capture a large share of GME funding,” Mullan said. “But these states also have the highest physician-to-population ratios. They are not doctor shortage states.”

While some residents move elsewhere after training, the majority of newly minted physicians set up a practice near where they were trained. Therefore, it is important that states with rural and growing populations receive appropriate support for starting and maintaining residency programs, Mullan said.

 

The study shows that many other parts of the country lose out when it comes to Medicare GME funding. Many Southern and Western states — which already face shortfalls in their physician workforce — such as Montana, Idaho, Arkansas, Wyoming, Florida and even California do not do well in terms of Medicare GME funding under the current system, according to the authors.

The researchers also found:

Large state-level differences in the number of Medicare-funded medical residents even when the density of the population is taken into account. For example, New York again is at the top of all the states with 77 Medicare-funded medical residents per 100,000 people while California has 19, Florida 14, and Arkansas has just 3.

Medicare GME payments have not kept pace with factors such as rapidly growing populations in Southern and Western United States. For example, Florida, Texas and California have rapidly growing populations yet they received substantially less GME funding in 2010.

Medicare’s current GME formula pays very different amounts to train medical residents depending on the state. For example, the federal government pays Louisiana $64,000 per year to train each medical resident but gives Connecticut $155,000 for the same job

 

  • The findings from this paper document a substantial imbalance in GME payments, one that has been frozen in place since 1997 when Congress passed a law that capped the number of residency positions at each hospital. Under the 1997 law, teaching hospitals can train any number of physicians but Medicare pays for the training only up to the allocated cap, the authors point out.
  • The end result of the cap and other inflexible attributes of the current GME system is a system that gives teaching hospitals in certain states with large numbers of practicing physicians big incentives to train more residents while shortchanging many smaller and rural states.

Ways to fix the problem include revisiting the GME payment formula and devising one that distributes GME funding so as to stimulate the growth of residency training in parts of the country that are chronically underserved or are growing rapidly. In addition, the authors say the GME funding system needs an oversight body that would look now and in the future at the distribution of GME dollars and make decisions about the best places to steer funding so that the federal government is making the wisest investment in the physician workforce.

 

Source: Science Daily

Medical education is still worth the cost

 

In 2000, the soaring dot.com industry crashed. Seven years later, the housing boom ended abruptly. With tuition rates swelling, could the medical education market be the next bubble to burst?

Probably not, concludes a paper published Oct. 30 in the New England Journal of Medicine and co-authored by Cornell health economist Sean Nicholson, since such a collapse would occur only if doctors’ incomes dropped sharply and before medical schools could act to rein in costs. However, for veterinarians, optometrists, pharmacists, dentists and certain types of newly minted M.D.s, the prognosis is not so encouraging.

The article, “A Medical Education Bubble Market?,” is co-authored by David A. Asch, M.D. ’84, professor of medicine at the University of Pennsylvania, and Marko Vujicic of the American Dental Association.

A bubble market occurs when a good becomes overvalued because buyers are willing to pay higher prices in hopes of selling it for a greater payoff. The bubble deflates when the asset suddenly returns to a more reasonable intrinsic value, leaving buyers from the peak of the boom with something worth far less than what they paid.

In U.S. health care, medical education costs have risen sharply in recent decades, but medical school slots remain competitive in part because applicants believe their lucrative future wages justify taking on significant debt. But the economics have become much less favorable in the past 15 years, the authors found, based on debt-to-income ratio – the average debt of a graduating student compared to the average annual income of a newly employed physician in that field.

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“Debt-to-income ratios reflect what students must borrow rather than what they must pay and, given whatever other assets they may have, how much into the hole they have to go,” the authors write. “Thus, these ratios may better reflect how students actually feel about buying education.”

Family physicians and psychiatrists are the worst off their first year out of school: In 2010, their debt equaled about 85 percent and 80 percent of their yearly income, respectively. That’s roughly double the ratio new doctors in those same fields faced in 1996. Doctors in specialized fields fared much better: Orthopedists, cardiologists and radiologists held a debt-to-income ratio under 35 percent – only a slight rise from 1996 levels.

But the picture is far more troubling for other doctors. The ratio for new veterinarians climbed above 160 percent in 2010, with optometrists (130 percent), pharmacists (110 percent) and dentists (95 percent) not far behind. In fact, veterinary medicine may already be in a bubble market, the authors argue.

As long as physician salaries remain high enough to justify their debt burden, medical education should avoid a similar fate. But, the authors warn, “there are strong signs that we can’t or won’t … keep paying doctors a lot of money.”

The Affordable Care Act is funded largely by reduced Medicare payments to hospitals, part of a growing demand to cut U.S. health care costs. Doctors’ incomes, though sluggish, have been spared so far but could be targeted soon as more savings are sought.

“The main point we are trying to make is the connection between what we as a society are spending on physician services and how much medical schools can charge for tuition,” said Nicholson, professor of policy analysis and management in the College of Human Ecology. “If we are serious about reducing health care spending, then that means we also need to cut the cost of creating new doctors if we want to continue to attract the most promising applicants into the profession.”

The study was funded, in part, by the American Dental Association.

Source; Cornell Chronicle

Officials ink deal to create medical school in Las Vegas

Nevada’s university leaders have signed a partnership agreement to begin establishing a new M.D.-granting medical school in Southern Nevada.

The agreement, or memorandum of understanding, outlines a vision for UNLV and the University of Nevada School of Medicine at UNR to work together to create a four-year medical school at UNLV that would mint medical doctors.

The UNLV medical school would open under the University of Nevada medical school’s accreditation, but will eventually become its own independently operated, separately accredited and financially-sustainable medical school.

Nevada System of Higher Education Chancellor Dan Klaich, UNR President Marc Johnson, University of Nevada School of Medicine Dean Tom Schwenk and UNLV President Neal Smatresk signed the agreement on Wednesday. Nevada regents are expected to vote on the agreement at their December board meeting.

“Increasing the medical education and health care options for Nevadans has always been a top priority for the Nevada System of Higher Education,” Klaich said in a statement. “I’m proud of the collaboration between our two universities and their efforts to bring these long-discussed plans from the drawing board to reality.”

Earlier this year, Nevada’s higher education leaders — led by Regent Mark Doubrava — directed UNLV and UNR to begin developing plans for a UNLV medical school while continuing to develop the medical school at UNR. UNLV’s faculty senate and graduate student government also supported plans for an on-campus medical school.

Currently, UNR operates the University of Nevada School of Medicine; students complete their core classes in Reno and can complete their clinical training in Reno and at University Medical Center in Las Vegas.

Proponents of a UNLV medical school have long argued that the current model for medical education in Nevada has not served Southern Nevada, by solving its shortage of physicians. Las Vegas is the largest metropolitan area in the United States without an allopathic medical school.

Over the years, Nevada’s higher education leaders have proposed different ways to expand the current medical school’s footprint in Southern Nevada by purchasing a Las Vegas home for the medical dean and kicking around the idea for a $220 million academic medical center at UNLV.

Ultimately, regents decided upon creating a separate medical school for Southern Nevada that could educate high-quality physicians, spur new medical businesses and make Las Vegas a mecca for medical tourism.

“We’ve known for a long time that it is imperative that we build the health care capacity of Southern Nevada,” UNLV’s Smatresk said in a statement. “This collaborative agreement is a substantial step forward and offers a path that effectively utilizes the resources of two great institutions to address our critical needs in health care.”

The signed partnership agreement between UNR and UNLV would not only kickstart a second medical school in Nevada but help the two universities attract federal funding for medical research that would benefit northern, southern and rural communities.

“The ultimate goal is to best apply our resources and steward the investment placed in our organizations to result in improved medical care, health care services and quality of life for Nevadans,” UNR’s Johnson said in a statement.

Developing a Southern Nevada medical school will require a collaborative partnership not only between UNR and UNLV, but also among UMC, Las Vegas hospitals and the medical community. All parties must coordinate designing, financing and building a medical facility that will house clinical research and medical science training.

Building a Southern Nevada medical school will require “substantial incremental funding” from state and private sources, according to the partnership agreement. The construction cost for the UNLV medical school is expected to cost about $80 million.

The agreement calls for funding to be maintained to the UNR medical school and for more funding to create fellowships and residencies to keep physician interns in Nevada, where they are more likely to settle down and open a local practice.

“The quality of life and economic development of the state are dependent on our ability to educate more medical students, train more residents and fellows in more specialties and subspecialties, and improve the quality of care through clinical research,” Schwenk said in a statement. “This agreement is a huge step forward in accomplishing those goals.”

Earlier this year, UNLV’s Lincy Institute commissioned Tripp Umbach, a top national health care consulting firm, to conduct an economic impact study for a Southern Nevada medical school.

Tripp Umbach estimated that a UNLV School of Medicine could have a $1.9 billion total economic impact to Nevada, including the creation of 5,353 jobs and and $94 million in tax revenue by 2030. That represents six times the current economic impact of the UNR medical school, at $285 million.

The firm also recommended that UNLV medical school begin in 2016 with an initial class of 60 medical students, and grow to an incoming class of 120 students by 2030. To support its new medical school graduates and to retain them in-state, Tripp Umbach also advised that Las Vegas must create a minimum of 240 new residency positions.

In the coming months, higher education leaders will discuss the Tripp Umbach recommendations and set a timetable for the construction, programming, financing and accreditation of a UNLV medical school.

Source: Las vegas Sun

 

Is Medical Education in a Bubble Market?

The costs of medical education must be reduced as part of efforts to rein in health care costs more generally, according to a Perspective published online this week in the New England Journal of Medicine. The currently high costs of medical education – which at some schools rise above $60,000 per year – are sustainable only if physician salaries remain high, which the authors, led by a physician from the Perelman School of Medicine at the University of Pennsylvania, say is less likely because of efforts to reduce health care costs.

 

Noting that students leave medical school with debt that often exceeds $150,000, the authors argue: “If we want to keep health care costs down and still have access to well-qualified physicians, we need to keep the cost of creating those physicians down by changing the way that physicians are trained. From college through licensure and credentialing, our annual physician-production costs are high, and they are made higher by the long time we devote to training.”

 

“People wonder whether we are in a bubble market in medical education,” says lead author David A. Asch, MD, MBA, Professor of Medicine and Director of the Center for Health Care Innovation at Penn Medicine.  In bubble markets, such as the recent US housing market and the dotcom bubble of 2000, prices rise based on speculation rather than intrinsic value, as people buy houses or stocks with the hope of reselling them to those with even more optimistic views of their valuation. When clearer thinking returns, those who haven’t sold are left having overpaid, holding an asset they cannot unload.  “In the case of medical education, students buy their education from medical schools and resell that education in the form of services to patients.  Medical education can remain expensive only so long as there are patients, insurers, and employers who are willing to pay high prices for health care. But if prices for physician services decline, then the cost of medical education will have to decline too, or people won’t be willing to pay for medical school in the first place,” Asch says.

 

The authors warn that high debt-to-income ratios drive students away from less financially rewarding fields.  “Debt-to-income ratios reveal how much a student has to go into the hole financially for education compared to what a graduating student might earn,” says Asch.  “For example, it costs approximately the same to become an orthopedist, psychiatrist, or primary care physician, but orthopedists earn much more.”

 

That might suggest that there is already a medical education bubble for psychiatry and primary care, but as bad as the debt-to-income ratios might be for those fields, they are even worse for some other fields outside of medicine.  The authors note that veterinary medicine is closer to a bubble market situation, which could burst when potential students recognize that the high costs of becoming a veterinarian aren’t matched by high income later.

 

Source: Penn News

Enrollment in MD, DO Schools Hits New Highs

Medical school applications and enrollment reached record highs this year as organized medicine’s cries for more funding for residency slots continued with little response from Congress.

The number of first-year medical students exceeded 20,000 for the first time in 2013, reaching 20,055, the Association of American Medical Colleges (AAMC) said Thursday in its annual report on medical school enrollment and applications.

Meanwhile, first-year student enrollment at osteopathic medical colleges increased 11.1% in 2013, to 6,449, according to the American Association of Colleges of Osteopathic Medicine (AACOM).

The two organizations increased their pleas for Congress to provide more money for graduate medical education and funding residency training slots to handle the newly minted doctors.

“We think, that as much as we see gridlock in Washington, that is something that we need to attend to sooner rather than later,”Atul Grover, MD, PhD, chief public policy officer at AAMC, said during a congressional briefing Thursday.

First-time medical school enrollment jumped 2.8% this year and is up 21.6% since 2002, according to the AAMC. The group attributed the increase to four medical schools opening their doors this year and an additional 14 increasing their class sizes by more than 10%.

Total medical school applications are up 6.1% to 48,014, this year while first-time applicants have grown 5.8%, the AAMC said. First-time female applicants increased 6.9%, after remaining flat in 2012. Hispanics attendance at medical schools increased 5.5%.

Furthermore, total enrollment at osteopathic medical schools increased to 4.9% over 2012, growing to more than 22,000 students. New osteopathic medical schools opened in the last year in Alabama, North Carolina, and Indiana.

“Because large numbers of new osteopathic physicians become primary care physicians, often in rural and underserved areas, it is evident that the osteopathic medical profession will help the nation alleviate a primary care physician crisis,” Stephen Shannon, DO, MPH, AACOM president and chief executive, said in a statement. “And colleges of osteopathic medicine are expanding and increasing to meet this demand.”

But the increase in enrollment will mean little in the fight to ease the nation’s physician shortage unless teaching hospitals have a greater ability to train physicians, the AAMC and AACOM said. The AAMC projects a shortage of more than 90,000 doctors by 2020.

“Unless Congress lifts the 16-year-old cap on federal support for residency training, we will still face a shortfall of physicians across dozens of specialties,” AAMC President and Chief Executive Darrell Kirch, MD, said in a release. “Students are doing their part by applying to medical school in record numbers. Medical schools are doing their part by expanding enrollment. Now Congress needs to do its part and act without delay to expand residency training to ensure that everyone who needs a doctor has access to one.”

The Balanced Budget Act of 1997 limited the number of residencies Medicare would support. But seeing the pending shortage of physicians coming, the AAMC pleaded with its members in 2006 to increase its enrollment, which was mostly flat between 1980 and 2006.

While medical schools have complied, the number of residency training positions has remained the same. Nearly 1,000 graduates initially were unmatched last year, a number that was eventually whittled down to 520.

“We should probably be training another 4,000 doctors per year,” Grover said.

With 26,504 medical students starting in 2013 between osteopathic and allopathic medical schools, only 26,392 first-year residency slots existed in 2013, Grover said.

“We hear from our educators and our teaching hospitals the way that clinical revenues have been compressed, they don’t have the resources for additional positions anymore,” he added.

Legislation is pending in both chambers — H.R. 1201 and S. 577 — that would increase the number of residency slots Medicare would support by 15,000 over 5 years. The legislation would cost about $9 billion over 10 years, Grover said.

It costs about $145,000 a year to train a physician, but Medicare supports only about $3.2 billion annually of the roughly $15 billion it takes to train physicians nationwide.

Source: Med Page today