Category Archives: People

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.

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?

Disaster Communications

This past weekend, amateur (ham) radio operators in the Western Hemisphere participated in an annual emergency exercise called Field Day. In the event of a disaster, regular communications is often disrupted. Not only can cellular equipment be damaged, but the system can be overloaded by increased usage; in some cases, cellular communications can be limited to essential personnel ONLY by FEMA.
Most home telephones (for those who still have them) are not independent circuits, but are part of the house’s internet/cable television system. If power is lost, anyone with a wireless telephone won’t be able to use it.
Handling short range communications via amateur radio is relatively easy. Field Day is to practice as to how long range communications can be ensured without relying on existing systems. Our local club set up seven radio stations at a local park; antennas designed for the various operating frequencies were strung from trees, with the highest being at least 60 feet off the ground. The radios—along with computers, and the all-important coffee maker—were powered by solar cells or generators.
The actual communications portion of Field Day began at 2:00 PM on Saturday and continued around the clock. During that time, over 700 other stations were contacted; most were other stations set up for the drill, but there were amateur operators from around the world that made contact with us as well.
Most of us hope never to have a fire, but we have smoke alarms, fire extinguishers, and fire insurance. The few of us that do have a fire are relieved to have the additional protection. The same holds true for amateur radio’s role in communications. It’s not needed every day, but when it is needed, it can be a life saver.
The best part? Hams often arrive with their own equipment and provide the service at for free. THAT is the reason it’s called the Amateur Radio Service; hams cannot be paid for the services they provide.

Elites

While we often talk about elites, we tend not to use that term. Elites are the people in any society who enjoy special privileges.

For a long time, elites were entitled to such status as a birthright, the most obvious example being royalty. If your father was King, it must be God’s will, and therefore the son must be qualified as well. Personally I don’t think God gets involved in politics, but you never know.

John Adams predicted that even though our constitution prohibited titles of royalty there would still be an elite class. He figured that those with educations would prosper, ensuring that their offspring would be afforded education and any wealth that the family had amassed, although in many cases the younger elites ended up with an education and the family debt. Nevertheless, they enjoyed the status.

The American dream is that we’re a meritocracy—anyone can achieve through ability and hard work, and sometimes this works. In fact, there have been periods in our history, such as the 1950s, when this was common, Nevertheless, it is not guaranteed.

Today, many of the elites once again obtain their status by birthright. There are many young men and women as, if not more talented, than the children of Tom Hanks, Will Smith, or the Barrymore family. However, it is the children of the elites who seem to land the acting roles. Is Eddie Van Halen’s son better than the band’s original bassist? Cheap Trick sold many albums with Bun E. Carlos as their drummer, but Rick Nielsen—the guitarist now has his son filling that spot.  Julian Lennon didn’t have to work his way up from playing wedding and bar mitzvah gigs. How many Fords have been senior executives at their namesake auto company?

Do we as a society get our best value from this practice?