Category Archives: Culture

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.

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.

 

Everybody panic! It might snow!

Buffalo, NY 2014 (Courtesy PBS)

Southeast Virginia’s TV meteorologists are in a full-blown tizzy because (gasp!) it looks like it’s going to snow. This is not necessarily bad, because TV meteorologists love to be in a tizzy over any weather event—but if you lived as boring a life as they do, wouldn’t you? The only other excoitement they get is standing outside in a storm on a live broadcast telling everyone else not to go outside.

Our neighboring states average the following annual snowfall:

West Virginia 62″

Delaware and Maryland 20.2″

North Carolina (due south of us) 7.6″

Virginia as a state averages 10.3″ per year, but the southeast (Norfolk, Virginia Beach, Hampton, Chesapeake, etc.) averages a paltry 5.8 inches, although eighty years ago, in January 1936, there was a record snowfall of 20 inches. Wow!

So, wish your television weatherman a happy blizzard, but leave quickly or risk having it all explained in great detail to you.

Undocumented Features

explo

Former Washing Machine Photo Daily Mail

Among software types there’s an old joke that programs never have bugs—merely undocumented features.

Hardware I catching up:

  • Airbags that spontaneously deploy and throw shrapnel at the car’s occupants,
  • Cars that adjust the engine to run one way during emission testing and another for regular driving,
  • Smartphones that burst into flames,
  • AND, my personal favorite—washing machines that explode

People today don’t realize how good they have it. When I was a kid, you had to do all these kinds of things the hard way—by hand. It was tough. If you wanted to blow up the washing machine, first you had to stuff the tub with a $#!+load of firecrackers with the fuses connected. There was always enough moisture left inside the washing machine so that half of them would get soggy. Still, once you lit the fuse, you had to run like hell to get out of the way. If the fuse fizzled out, you never knew how long to wait to go back and try to relight it without accidently blowing yourself up. We worked for results, and when we blew up a washing machine, we were proud!

Today, people just expect these things to happen all by themselves.

Inspiration from the Movies

Indiana Jones and the Last Crusade

Indiana Jones and the Last Crusade

I love movies, although I no longer have the time to devote to watching as many of them as I’d like. In a few years, when I retire, I hope to correct that problem.

Movies aim to elicit feelings, not thoughts, but sometimes feelings actually lead to critical thoughts. Take, for example, the Indiana Jones movies; while “The Search for the Lost Ark” was wonderful, the “Last Crusade” was important. It touched on some lessons that we don’t teach in schools, but are critical nevertheless.

Indian Jones, a fictional archeologist from the time when archaeologists were more “pot hunters” than scientists, seeks the Holy Grail—the cup Jesus drank from at His last meal. To reach the grail, he must pass three challenges:

  • The Breath of God – “Only the penitent man will pass.”
  • The Word of God – “Only in the footsteps of God will he proceed.”
  • The Path of God – “Only in the leap from the lion’s head will he prove his worth.”

    (http://indianajones.wikia.com/wiki/Temple_of_the_Sun)

What can we learn?

“Only the penitent man will pass.”—None of us are perfect, and we must be sorry for how we’ve hurt one another.

“Only in the footsteps of God will he proceed.”—God has given us direction through so many means, all of which come down to, “Love God above all things, and love your neighbor as yourself.”

“Only in the leap from the lion’s head will he prove his worth.”—It takes faith to live, grow, and do good in this world. Logic alone is not enough; logic applies only to this world, while faith touches the next.

God, in his infinite wisdom, touches us through scripture, religious communities, and even the movies. But then, since He is God, why wouldn’t He?

The Decision and the Declaration

Today, on July 4th, we celebrate the Independence Day, when the Declaration of Independence was approved by the Continental Congress in 1776.

However, history is more interesting than just the event and the date.

On June 7, 1776, the senior Virginia member of Congress, Richard Henry Lee introduced a resolution stating:

Resolved, That these United Colonies are, and of right ought to be, free and independent States, that they are absolved from all allegiance to the British Crown, and that all political connection between them and the State of Great Britain is, and ought to be, totally dissolved.”

Congress adopted the Virginia motion on July 2, 1776, thereby refuting our status as a colony; this is why John Adams believed that we would celebrate our independence on July second, the date of the decision.

The Declaration of Independence was approved two days later, on July 4, 1776.

While the Declaration of Independence is a masterpiece, and I recommend that everyone read it today, it was not the decision, but merely the explanation to the world as to why the decision had been made. Although we have seen many portrayals of all the Founding Fathers assembled together in Independence Hall to sign the document on the fourth of July, most, but not all, signed on August second; one signer, who was not a member of the congress until later in the year, signed in November.

As is often the case, history is more complex, and far more interesting than the snapshot presented in civics class.

* Thanks, once again to Wikipedia. If you use it, kick in a donation—even a dollar helps.