Category Archives: Science

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.

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.

Trying Something Different

 

linuxWe’re on a little trip, with a few changes from the norm. First, we’re using the train for transportation, which we’ve done several times, and after that, either walking or the Metro. Since it’s already a variation on my usual theme, I am not using my regular notebook computer, but instead a vintage 2008 hand-me-up netbook computer. Netbooks are generally about half the size (or less) of a standard laptop/notebook computer and have smaller memory and disk capability. While the modest hardware is designed to support a user who relies on the Internet instead of the computer itself, by using Linux as the operating system (OS) you can pack a lot of capability into a very small package.

Linux, in case you don’t know is an open-source operating system—meaning that developers can modify it to meet their needs, within certain parameters. More significantly, that also means that it is free. LINUX is a rewrite of UNIX, a very powerful—but very expensive commercial operating system. UNIX was written by computer nerds for computer nerds; LINUX, perhaps more so, since its development is shared among many developers. Many of the systems that you may connect with via the Internet probably operate using Linux, yet your Windows based computer is able to interact seamlessly.

This version of LINUX—Ubuntu—has a graphical user interface similar to Windows with similar functions; LibreOffice offers includes a word processor, spreadsheet, etc., all of which are also free. To utilize its most powerful features, however, you use the command line method—kind of like the old Microsoft DOS.

The reason I took this computer is to encourage me to learn more about the more powerful features of Linux by working with the command line. Linux seems to be popping up more often, especially among geek toys and systems. The Raspberry Pi microcomputer runs on Linux (although Microsoft made a Windows 10 version for it once it became so popular). However, Linux tends to be more robust, use less memory, and run faster in most cases.

In any case, so far, so good. Sunday’s blog was written on this machine, and so is today’s. We’ve been too busy having fun for me to devote myself to learning command line LINUX, but I’ve learned some. Having fun and learning all in the same day? Outstanding!

Lies, Damn Lies, and Statistics

The media try to help everyone avoid facts that might interfere with their willingness to accept, without question, the latest sound bite. Combine these efforts with an overall lack of critical thinking skills and a lack of understanding of mathematics among the population and it’s little wonder that we are in the position we are today. With the possible exception of big pharmaceutical companies, no one understands this better than politicians.

Take the debate swirling around firearms, for example. It is rife with anecdotal stories and inaccurate generalizations that lead you to the conclusion that murder most foul is rampant. However, according to a study by the Pew Research Center, gun deaths grew from 6.6 per 100,000 people in 1981 to a high of 7.0 per 100,000 in 1993, then dropped to 3.6 per 100,000 people in 2010. The Center for Disease Control and Prevention, on the other hand, reported 10.6 per 100,000 people in 2010, which then dropped to 3.5 per 100,000 people in 2013. Although each group gathers their data differently, the conclusion is the same—deaths due to firearms are lower than 35 years ago. Interestingly, they’re at about the same level as deaths due to automobile accidents.

Then there’s the brouhaha over photo identification in order to vote. The purpose, to prevent voter fraud seems reasonable, as does the statement that you need a photo ID card to get a library card, etc. However, is voter fraud really a problem, and if so, how much of one? Figures are difficult to find, but according to NBC in 2012, “A new nationwide analysis of 2,068 alleged election-fraud cases since 2000 shows that while fraud has occurred, the rate is infinitesimal, and in-person voter impersonation on Election Day, which prompted 37 state legislatures to enact or consider tough voter ID laws, is virtually non-existent.” That’s quite a crime wave—about 172 alleged cases throughout the country, every single year. I’m not certain what other crime occurs at a similar rate—attempts to steal the Statue of Liberty?

Then there’s the arguments between Pro-Choice and Pro-Life (arranged in alphabetical order). The emotional issue that always comes to the forefront is that it would be wrong to deny abortions to victims of rape or incest. Is that a significant group? Needless to say, accurate statistics are difficult to find, but the most frequent numbers buried in the fine print are either “one percent” or “less than two percent.”

I am not attempting to sway your opinion or your vote. I am merely demonstrating how so many issues are presented in a manner so as to elicit an emotional response rather than a rational one. As Jethro Tull sang, “I may make you feel, but I can’t make you think.”

Think back to school when your math teacher deducted points from a test because, even though you had the correct answer, you didn’t show your work. The media has mastered the technique of not showing its work (and some might claim it’s on purpose). In many cases the media loves to report a percent, but rarely do they share the denominator. The number upon which the statistics are based.

What is a 50 percent increase? If you start with 100,000 a 50 percent increase leads to 150,000. Of course, if you start with two, you can claim a fifty percent increase if you get to three.

As the political ad barrage season begins, ask yourself:

  • Is this a significant issue?
  • Is this an issue that can be resolved, or is it an emotional issue?
  • Are those making claims telling “the truth, the whole truth, and nothing but the truth?”

You may have to do a little research (Isn’t Google Wonderful?) to determine what the real facts are, but trust me—it’s worth it.

Content vs. Quantity

brown

 

There’s a famous quotation attributed to various people, but the supposed authoritative sources credit to Blaise Pascal:

I’m sorry I wrote you such a long letter; I didn’t have time to write a short one.

When I first started writing this blog I thought that my goal should be to write and post something every day. Of course, at the time, I had plenty of ideas—some worth sharing, some not. Good, bad, or indifferent, I posted them. Like the codfish, I laid 10,000 eggs hoping a few would hatch. Now, I try to limit myself to thoughts worth sharing. Iay—or may not—be succeeding.

I’m a science junkie. If it were 1955 or 1985 (or for that matter, 1895) I could have been Doc Brown in Back to the Future. The biggest difference is that he had a family fortune to support him while he experimented, while I’ve got a steady job (just as valuable, but less conducive to experimentation). Nevertheless, as kindred spirits, he in fiction and I in reality, we try to see what the next step might be. Which brings me to today’s issue.

Today there is a huge emphasis on STEM—science, technology, engineering, and math in the education biz, today—but there is no real commitment. It’s a lot of talk, but no real action. I’m not blaming the educators. God knows that I understand that there’s only so much you can do in guiding a teenager. However, among today’s teenagers, any interest in science is ridiculed. A student interested in STEM requires the commitment of the Maquis (that was the French Resistance in World War II); one must be willing to maintain a low—if not invisible—profile, only confide in a few trusted souls, and be willing to die a thousand deaths (of embarrassment) if discovered.

Kids today don’t realize that the person they call “nerd” today, will probably be called “boss” tomorrow.

In our effort to be politically correct and not impact anyone’s self-esteem we dare not put scientists, engineers, or mathematicians above athletes, gangstas, or “celebrities” who are famous for being famous. Personally, if I’m going to get my brain scrambled, I’d rather it happen in an experimental space craft rather than having repeated concussions playing football or via cocaine, meth, or whatever is the celebrity drug du jour.

Whatever happened to science fairs? High school science clubs? Achievement awards? When did it become shameful to be interested in science beyond the specific items included on the standardized test?

Think about it. To paraphrase Doc Brown, “Our future depends upon it.”

No Pretty Pictures

I often wish that my blogs would lend themselves to more pictures. I’m not a bad photographer, and some blogs are full of sunsets, beach scenes, Grand Lake up in the Rockies, or whatever. Mine—not so much.

I’ve been going through some physical therapy for some old injuries. The therapy has actually worked better than a variety of drugs that have been prescribed in the past. However, for it to work, I need to be consistent in my follow through. It struck me, that if there’s a common theme in life, that’s it.

How do you get to Carnegie Hall?

Practice! Practice! Practice!

It’s true of music, physical fitness, painting, even math or science. (Do YOU remember how to solve a quadratic equation? We all learned how in high school.)

Calvin Coolidge was not one of our more noteworthy presidents, being known as “Silent Cal.” However, he did leave us with a great thought:

Nothing in the world can take the place of Persistence. Talent will not; nothing is more common than unsuccessful men with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan ‘Press On’ has solved and always will solve the problems of the human race.

Calvin Coolidge
30th president of US (1872 – 1933)

Practice! Practice! Practice!