Medical School Rationing

Fixing Healthcare – Part 2 — Doctors

I’ve known many intelligent, talented, committed young people who aspired to become doctors, but couldn’t get into medical school. Some were resigned to their fate and used their degree in biochemistry to become medical technologists; others made arrangements to attend medical school outside the United States—primarily in the Caribbean. In one case, in order to study at a school in the Caribbean, the aspiring medical student’s parents sold virtually everything to finance her education. She’s nearly complete with her rotations back here at US hospitals and plans on serving rural or tribal underserved areas.

While we don’t have enough graduates of United States medical schools, we grant 85,000 special visas to foreign medical graduates every year because it’s a “critical shortage.” Today, roughly one quarter of all practicing physicians are foreign medical graduates. I’ve worked with many, and while their initial desire is to return home, after about six months the sports car and the arm-candy significant other appears. When I ask if their plans have changed, I’ve been told, “If I return home, I will be paid in chickens and melons. If I stay here, I will be paid in dollars. I like dollars better than chickens and melons.”

So, we import thousands of non-American doctors every year even though we have many Americans who want to study medicine but are turned away.

A decade or so ago, when more students wanted to study law, the educational industry had no difficulty in adding seats—even if they had to build new schools. Why won’t (not can’t) we do the same for medical schools?

Some claim there wouldn’t be enough residency opportunities if we graduated more doctors from US schools, yet foreign medical graduates can and do get residency positions at US hospitals. In any other industry, this might be viewed as restraint of trade.

I suggest that the goal of US medical schools should be to increase their capacity so that by 2030 ALL US residency openings can be filled with US citizens who graduated from US medical schools.

Next, I would change the entry criteria to include the following:

  1. Accepting students with a commitment to actually practice medicine; better yet a commitment to practice whatever type of medicine is in short supply, wherever needed, for at least three years. After that, every accommodation should be made to place that individual in a residency or fellowship of their choosing for which they have the talent, without a decrease in salary.
  2. While academic achievement is important, the ability to work as a team is critical. History is full of brilliant people who didn’t succeed because they could not work with others, and medicine is now a team sport—whether the person with MD or DO after their name likes it or not, they are teammates with the nurses, technologists, therapists, etc. No one is a superstar.
  3. Children of doctors or other elites should have to prove themselves more—not less—than other medical school candidates. They’ve grown up exposed to the field, often in an environment of privilege, so they should demonstrate their desire to serve, not their pedigree.

In short, we need more doctors, but our current method of selecting them is less than optimal.

Fixing Healthcare in America

First in a series

To correct healthcare and get costs under control, we must first acknowledge, then change the healthcare industry’s unique and outrageously dysfunctional business model.

  1. Physicians and other practitioners who decide which resources will be used in a hospital are often neither the direct provider, the one who pays, nor the beneficiary of the service. Basic economic rules, therefore do not apply. Medical tests, which are intended to provide information that will in some way impact the patient’s course of treatment, don’t. Many test and other procedures are ordered even when the outcome of the test will in no way affect the treatment of the patient or its results.
  2. Medical products and services are priced without any rationale. Often, prices are set artificially high in order to allow large discounts to insurance companies. This means that patients without insurance can be charged list price; eighty dollars for an aspirin or $100 for a BandAid®. Hospitals, which were once a ministry, stewardship, or public service have changed their priority to the bottom line. Some hospitals now own and operate their own collection agencies augmented by a small army of lawyers to guarantee that they collect what they have billed. This is why it is not uncommon for a small-town hospital to have millions of dollars in the bank—and still retain their not-for-profit status.
  3. And the insurance companies that get those big discounts? The hospital needs a staff of trained bureaucrats to generate the paperwork that is sent to the insurance company in order to receive payment. Payments may not be received for several months (for the MBAs out there—remember the first rule of finance—a bird [dollar] in the hand is worth two in the bush [accounts receivable]). When payment does arrive, administrative staff must reconcile the payments and file additional paperwork as necessary. All this adds to the hospital’s costs without adding any value. The insurance companies, on the other hand, are usually quite profitable, even after spending a lot of money on lobbyists. But just like Don Corleone said, “It’s nothing personal, it’s strictly business.”

So, what do we do?

First, it would be valuable to have the physicians evaluate how tests really affect the outcome for their patients and develop appropriate protocols. Malcolm Gladwell relates an excellent example in his book, Blink. The cardiology staff at Cook County Hospital was able to reduce tests while simultaneously improving patient outcomes.

[Gladwell, Malcolm (2005). Blink: The Power of Thinking Without Thinking. New York: Little, Brown.  ISBN 0-316-17232-4 (Especially the chapter on Cook County Hospital Cardiologists)]

Second, revise medical pricing so that it reflects reality—and that must include adequate margin to offset costs for necessary but expensive services. Emergency rooms are expensive to operate while an intensive care unit for patients suffering from burns is actually cost prohibitive. However, hospitals have an obligation to the community to provide necessary services—either directly or by affiliation—to the community. The community, in turn, must ensure the hospital is resourced to provide a wide range of services. If hospital prices reflected cost plus a reasonable margin to offset other costs, and everyone paid the same price—patient or insurance company, it might lead to more rational decisions—outcomes first, but economics as a consideration. If Grandpa—God love him—is a 96-year-old heavy smoker with high cholesterol and other morbidity factors who was hospitalized because of a stroke, a battery of tests that will not affect his quality of life or his longevity are not appropriate, and the insurer should not be expected to provide carte blanche payments. However, if the prices are realistic, the family may decide that they would be willing to pay for those additional procedures on their own.

Third, emphasize cooperation over competition. Is there any other business, other than hospitals, that would allow someone to work in their facility AND directly compete with it? Radiologists have their competing imaging centers, surgeons may have their private surgery centers, etc. Should specialty practitioners be entitled to benefit from the hospital’s patients and compete with the hospital for those same patients? It should be the practitioners’ choice—one or the other, but not both.

Two excellent resources for these issues are:

Brill, Steven (2015), America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. New York. Random House. ISBN 978-0812996951

Rosenthal, Dr. Elisabeth (2017). An American Sickness, New York: Penguin Press. ISBN 9781594206757

If you want to fix American healthcare, pass this along to your friends, neighbors, doctor, etc. I’ll get a lot of hate mail, but we need to have the discussion.

More to follow.

Lime Green?

In my poor, struggling student days, I drove a 1972 lime green Ford Pinto. In fairness, it was actually a fairly reliable car, although when it had a problem, it was an all-night effort to fix. Living in Ohio, with all the salt on the roads, it needed to have the body patched every spring and most autumns. It had so much fiberglass and Bondo that I believed that I could have driven it through a metal detector with nary a peep from the security machine.

Did I mention it was lime green?

Needless to say, I have neither owned nor wanted a lime green car ever since.

Tonight, on my way home from work I saw a Lamborghini. I saw a $450,000 Lamborghini. I saw a $450,000 lime green Lamborghini.

Naturally, I mentioned this to my wife who found it surprising that Lamborghini would offer one of their four-wheel works of art in lime green.

But then we realized, that if you can afford a Lamborghini, you can pretty much have whatever you want.

If I buy a suit, I buy it off the rack and have it altered. Wealthy people have tailors who hand-make their suits. It’s likely that they get their cars the same way.

“Ah, yes. I want grey glove leather seats and oak interior trim—the light oak, mind you, not the dark. The most powerful engine, of course, and now, let’s see, do I want a four, five, six, or seven speed transmission? I think five will be enough—I’ll already be pulled over by every cop that sees me, just so they can get a look at the car and the bloke that owns it, so no sense in going even faster.

“I’ll need full satellite navigation and satellite stereo for the radio—that doesn’t fade in tunnels—with storage for at least a thousand, no, make that ten thousand songs—all in full fidelity. The passenger’s visor will need a lighted mirror; my dates need to make sure their makeup is just perfect.

“Make sure that there are plenty of cup holders, although if anyone spills anything, they’re going to pay for the detailer to make a house call.

“I’ll need all weather tires, of course, tinted glass, and . . . .I’m forgetting something. What am I forgetting?

“Oh, I know, the colour (please notice the British spelling). I want my Lamborghini painted the lime green colour they used for Ford Pintos in the early 1970s.

“As usual, money’s no object, but I’ll use my friends at the club as my customer satisfaction survey—which will be widely distributed.

“Well, I’m off. Good day.”

Dress Code

I see where American Airlines was turning passengers away for violating their dress code. Apparently, one or more teenage girls were wearing leggings, which was not up to company standards in the opinion of the highly-trained, fashion-savvy, senior-executive-level gate agents.

I do remember when airline flight involved men wearing suits and women dresses, complete with white gloves. Of course, back then, airlines treated customers like guests and even provided an actual meal—no grabbing a dried up old sandwich in the terminal and an overpriced bottle of water—the meals were served on plates, with coffee cups and saucers. Gate agents were courteous. Although quite over-the-top, flight attendants (stewardesses—a man couldn’t get a job as a flight attendant) were required to meet certain levels of attractiveness in terms of weight, makeup, and the latest fashionable uniform.

May I suggest a compromise? The airlines can start by losing the “passengers are like cattle” attitude and start being a little nicer; stop trying to cram 16 extra passengers onto each aircraft by designing seats that mimic medieval torture devices. Next, they can stop gouging us for checking bags to the tune of billions of dollars per year. Maybe then we can talk and compromise on the dress code for the airline passenger. It would probably be best if we chatted over the free meal and coffee (in cup and saucer) during the flight.

Getting Old, or Something

John Scalzi, In Old Man’s War, talks about getting older, and dealing with disease and other physical frailties. It was something like, “It’s not one thing after another, it’s everything all at once.”

Inside—and this sounds weird—I feel timeless. I feel like the same me as I was when I was walked to school on the first day of kindergarten. Of course, there were some stages in my life that I intentionally ignore, but it was the same me, even then.

The bad news is that I cannot do as many things, or do them as long as I used to. I certainly keep shorter hours (sorry, 8:00 PM, time for bed—but then again, my alarm goes off at 5:00 AM). However, what I do these days is grounded in a better understanding of life, the world, and the will of God. Diplomats, politicians, salesmen, attorneys, et al, say things that are their job, not what they mean—at least in some cases. I tend to ignore that noise and focus on those things that rise above it. No matter what people say or do, I believe that God’s will predominates, even if we do not immediately see it. In other words, everything is going to ultimately be all right.

The “everything all at once” isn’t all bad. It includes the ability to see the big picture, rather than the sound bites, the trends, or whatever. That’s the benefit of getting older.

Positions

No, not that.

There’s a great Monty Python bit in which the suitor is talking to his intended wife’s father. The abbreviated version would go something like this.

Graham Chapman: “Do you have a position?”

Michael Palin: (Snort) “I cleans public lavatories.”

Graham Chapman: “And is there a potential for promotion?”

Michael Palin: “Yeah–after five years they gives me a brush.”

We spend the first quarter of our life preparing to take on a position. The next two quarters of our lives, we define ourselves by our positions. Finally, we learn that our position is what we do, not who we are.

Jackson Browne (with, perhaps some help from his neighbor Don Henley) may have said it best in “Running on Empty”:

Gotta do what you can just to keep your love alive
Trying not to confuse it with what you do to survive

We are who we are and we do what we do–don’t confuse them.

 

Returning to the Mother Country

Although we Americans are great friends with the British, there is that 800-pound gorilla in the room. We sort of, kind of, in a way cut our ties with the British Empire back in the 18th century, and reinforced the decision in the early 19th. Oh sure, we’ve been relatively friendly since the early 20th century, but we still bloody split up years ago!

How many divorced couples maintain an interest in what their ex is up to? Not many, and most who do, do so for all the wrong reasons. It’s fine to keep things civil on behalf of the children, but I’m talking about a genuine affection for the exes latest efforts. It doesn’t—or at least shouldn’t happen.

So why do I have a preference for BBC television programmes over most American programs? I’m not talking about an innocent fling with Monty Python’s Flying Circus in my younger, more foolish years—that’s to be forgiven, and perhaps even expected. I’m talking regular perusing of Netflix with full intent of finding a British programme of interest. I do hope the English don’t find our television offerings intriguing; I know the New Zealanders did back in the late 1980’s, but back then it was 5 million people and 60 million sheep—and long before Peter Jackson filmed the Tolkien stories there.

At least I can excuse my preference for BBC News over anything on the air or internet over here. That provides some comfort.

Good Heavens! I just realized that I’ve taken to drinking tea at breakfast!