Medical Education on the Brink: 62 years of Front-Line Observations and Opinions

From an harshly worded editorial published in the Texas Heart Institute Journal by Herbert L Fred, MD, MACP this month entitled "Medical Education on the Brink: 62 Years of Front-line Observations and Opinions*:"

"Over the sixty-two years that this report covers, medical education has moved its focus from the patient to the laboratory and now the doctor.  As a result, we currently have a training system that is doctor-centered, technology-driven. computer-dependent, algorithm-loving, and Internet-based.  And thanks in large part to the ACGME, we are exchanging sleep-deprived, competent healers for a growing number of "wide-awake technicians."  Many of these limited-work-hour trained individuals cannot take an adequate history, perform a reliable physical examination, create a sound management plan, or communicate effectively.  Therefore, they don't deserve the image of competence that their training certificates convey.

So it all boils down to this: The kind of health care that American medicine is capable of providing and the kind the American people actually receive are worlds apart.  Consequently, those of us in medical education have a major obligation and responsibility to close that gap."

Dr. Fred offers the following solutions:

"First, we must abolish the ACGME mandate on work hour limits.  When discussing the mandate with program directors in medicine and surgery around the country, I hear nothin but dissappointment, dissatisfaction, and disgust - my sentiments exactly.  Therefore, given its previously listed drawbacks, coupled with its unproven benefits to patient outcomes despite 9 years of intense evaluation, the time has come for program directors to unite and overthrow the mandate.  Getting rid of it, however, will be difficult and will require strong professional leadership and solid support from the public, which at present favors the limited hours.

In place of the existing mandate, we could (and should) revert to the unlimited work-hour system that has served all disciplines well for 100 years.  Or we could select program directors from each specialty to devise a work-hour system best suited for and limited to their particular discipline.  Either move would be a great step in the right direction, because the existing mandate is our biggest obstacle to producing competent physicians."

I think Dr. Fred has hit the nail on the head, but while he beautifully articulates what more senior physicians have observed over the past ten to twenty years, I think that unless there are rewards to physicians for their long hours from family, there will be very little going back to the days of old.  Doctors of tomorrow have accepted lower wages in exchage for a more balanced life-style.  Since payments to physicians are not likely to increase in the years ahead thanks to health care reform, I see no incentive for younger doctors to accept longer residency work hours any longer, even if program directors demand them.

It IS sad to see the deterioration the skills Dr. Fred mentions in our younger doctors.  But I find the younger doctors who have completed training are still eager to learn.  Educators of today should stop expecting doctors of tomorrow to learn everything in their three or four years of residency training with "unlimited hours."  The availability of information online is incredible and I would suggest that medical educators would better serve doctors of tomorrow by teaching (and showing) them how to continuously think critically about their patients and published studies.  Even more important they should learn an even more important skill: to learn how NOT to say "I don't know" but rather "I don't know but I'll look it up."   Sure we should turn from computers and lean more on our patients as educators- after all they still are, and will continue to be - our very best teachers.  But if we use computers as a useful tool rather than a crutch, our patients and students will be better for it in the long run.

-Wes

Reference:

Fred, Herbert L. "Medical Education on the Brink: 62 years of Front-Line Observations and Opinions." Texas Heart Institute Journal Vol 39, No. 3, June 2012, pp 322-329. (Contents here).

*I regret that the publication is not yet online and because of copyright restrictions, I hesitate to publish the entire work here.

Nay Fellow Way?

It was to be a routine pacemaker.

The parties assembled. The room prepped. IV started. Chest scrubbed. Antibiotics given. His nervous eyes raised when he saw me before the procedure, relieved at the sight of at least one familiar face.

"Are you ready?" I asked.

"Yes," he replied, "I think so."

"Any last minute questions?"

"I don't think so," he said.

"Great! Then let's get this over with..." I turned to the lab staff and signaled them to proceed.

"Oh, doc! I forgot. Can I speak with you a second? Ya know, privately?"

"Sure," I said returning gurney-side. I drew the curtain.

He leaned forward and whispered: "Doc, no fellow, right?"

I stopped and contemplated the question, then acquiesced. "Would you mind if I use one as my scrub tech, but I'll be the primary operator?" I asked.

"Yeah, that would be okay - as long as you're the primary operator."

* * *

This little exchange got me thinking: what would I want? Honestly, I'd probably want an attending physician working on me, too. After all, it makes sense, right? Get the most experienced hands and all.

But there are good reasons to have a fellow involved with your surgery, if the opportunity presents itself:

• We need to keep training. None of us will be doctors forever, and now more than ever with tons of people entering the health care marketplace there is a need to have well-trained doctors in place to meet the need ahead. You can read all you want about how to do a procedure, but until you've done one yourself on a living, breathing individual, you have no concept of the complexities involved. Starting slow in a closely supervised, supportive setting, makes for some very technically-savvy doctors of tomorrow.


• They improve your surgical technique. The better I can teach someone to do what I do, it seems the easier it is for me to do it, too. Throughout our careers as doctors, we work hard to solidify our competency "brand" amongst our patients and peers. Particularly for specialists: screw up a case or two and your "brand" is quickly tarnished. This is especially important as we train fellows - none of us wants to tarnish our "brand" when trainees work with us either. Therefore, you better bet that bottom dollar we'll be supervising those fellows closely.


• Fellows keep you sharp. Oh sure, they often ask mundane questions but occasionally they ask remarkably astute questions, too. When this happens, they make us think and as a result, we all get smarter.


• They're another set of eyes and hands.It never hurts to have another set of eyes contribute their interpretation to a tough case nor an extra set of hands for that extra retractor. Ever.


• They slow you down. There is no question that teaching someone else takes more time than doing a procedure yourself. This definitely has its downside. But time spent now might pay large dividends in the future when that same doctor has to work on you someday. Also, spending a bit more time can have it's upsides - especially if you really don't want to have dinner with your mother-in-law.


• More often than not, fellows are extra-careful. By their very inexperience and their desire to excel in training, I have found most fellows I work with especially conscientious when they dealing with patient and their procedures.

So the next time you have surgery and are introduced to a training fellow in medicine, consider letting a fellow help out on your procedure.

It might just be the best thing you ever did.

-Wes

Fellowship Graduation

Dr. Wes with Colleagues and Friends
Cardiology Fellowship Graduation,
National Naval Medical Center, Bethesda, MD
1993

I'm not sure there's ever a time in medical training where one is so happy to get on with their careers as the day you complete your fellowship training. For a few very intense years, a special bond forms between you and those who work beside you - you've seen tough cases, sad cases, spectacular cases, together.

Fellowship was a chance to focus on the science and art of a very narrow segment of medicine. In my case, it was cardiology and (later) cardiac electrophysiology. I was glad I was able to retrieve the picture above, taken just before I completed by cardiology fellowship training. I wonder where all those magnificent people are now, and marvel at the young faces, the tennis shoes, the film canisters above the image intensifiers that are now obsolete, replaced by fancier digital acquisition systems.

It was with some poignancy that I saw another graduating class in hail the efforts of the graduating cardiac electrophysiology fellows on Friday.

There they are, surrounded by friends, staff members, family members, and a whole host of support personnel (nurses, technicians, education administration, etc.) They are, for now, at the peak of their game - as ready as they can possibly be for working independently (we hope). They look back. Remember all the good times and bad. They get gifts to wish them well. They get signed momentos. Joy - pure, nervous joy.

And that's the paradox of such moments when we part ways, isn't it? We leave our friends and closest colleagues to head off on our own and make a mark. What lies ahead, we haven't a clue...

...because despite all the hours and effort, that's when the learning really starts.

-Wes

Fellowships and Visas

I saw this updated webpage this morning from Dartmouth Hitchcock Medical Center on how to apply to their EP fellowship program. It contains this statement at the end:

Special note for foreign national physicians: You must have a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) to be eligible for application to a GME-accredited clinical training program. We accept applicants with J1 visas. We will assist H1-b visa applicants with their paperwork but are not able to absorb any of the cost involved with their transfer.

Why do foreign applicants get a "Special note?"

For those not familiar, J-1 visas require the applicant to return to their country of orgin for two years before being eligible to return to the US. There are exemptions to this requirement to return to their country that can be granted, including a "No Objection Statement" from their government or the "Conrad Program." The Conrad Program is a waiver issued for a foreign medical graduate who has an offer of full-time employment at a health care facility in a designated health care professional shortage area or at a health care facility which serves patients from such a designated area.

H1-b visas are a 6- to 10-year visa permitting employers to temporarily employ foreign workers in specialty occupations, like medicine.

Each year, scores of applicants apply for these cherished specialty and subspecialty fellowship spots. Subspecialty medicine is already an incredibly competitive venture owing to the pyramid structure already inherent to programs with limited fellowship training positions.

But there is another aspect to selecting fellows that few (if any) programs will openly admit: they don't want to train their competition.

It is well-known that following their training, many fellows tend to prefer to stay at or near their training hospital - often because it is simply easier (and less expensive) to stay locally to work if possible. Many hospital programs know this - especially ones in upper-crust communities with more than one competing hospital system. As such, there is a bias toward hiring foreign-trained fellows in fellowship programs because programs don't have to worry about oversaturating their market. This, then, skews competition for fellowship programs toward accepting foreign applicants in lieu of US-born applicants.

Others will argue that no such bias exists - that application processes are careful to cull only the best and brightest. After all, they are "equal opportunity employers" that promise "...to provide equal opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, sex, age, sexual orientation, national origin, disability, handicap, veteran or other legally protected status." Still others will say, "get over it," it's an international market for health care providers now.

No one can deny that there are benefits to cultural exchange that occurs when non-US physicians enter programs and that there are benefits to other countries when these doctors do return. But could medical schools inadvertantly be turning their backs on US-born medical students who have paid nearly $300,000 for their medical education just so they can avoid local competition and discrimination claims? Might there be a better way to offer health care to underserved areas in the US and abroad besides hiring foreign physicians for fellowship?

With the increased pressure to shrink subspecialty medicine in favor of primary care with health care reform, perhaps it is time we re-visit the J-1 visa issue for our US medical schools and fellowship programs. Maybe we should require all of our new graduates to work for two years in underserved areas before settling in their chosen community.

Then again, better to keep it politically correct and not discuss these issues, right?

-Wes

For Cardiology Fellows: One Tough Job Market

The e-mails from fellows are coming from far and wide.

Faced with the uncertainty over health care reform, the slumping economy, and the looming pay cuts to cardiologists, cardiology fellows are seeing one of the most challenging job markets in years. As a result, the number of e-mails we've received from fellows probing for potential job openings has accelerated to unprecedented levels.

For those who fear health care reform, fear not.

Before any bill has made it to the Congressional floor, certain aspects of health care reform are already here.

-Wes

Goodbye Northwestern. Hello University of Chicago

Today's the day I magically lose my appointment at Northwestern University and transition to the University of Chicago's Pritzker School of Medicine. As of 1 July 2009, NorthShore University HealthSystem changes it's medical school affiliation, so I changed the "About Me" section on my sidebar.

For patients and collegues alike, I really don't expect much change, except for the logos worn by the medical students and residents.

But as we change affiliations, I'd like to thank all the residents from Northwestern with whom I have had the pleasure to work with and learn from over the years. I wish you all the best as you transition to the real world.

Now, Univeristy of Chicago, it's your turn.... (heh, heh).

-Wes

What Matters When Choosing A Fellowship Program

It was an unusual week of Intensive Care Unit activity. There was atrial fibrillation, atrial flutter, cardiogenic shock, cor pulmonale and even an occasional atrial tachycardia thrown in for good measure. And while the patient issues were grave, the residents I saw seemed to take it all in stride, for they had just matched in their fellowship positions. Life was good. They were at the top of their game. They had survived Round 1.

“So where are you going?” I asked. And they proceeded to tell me, appearing genuinely excited about their upcoming adventures. Hematology/oncology. Dermatology. Pulmonary medicine. Some programs here in Chicago, some far away, but still, they were enthusiastic. It was nice to see.

I watched as they typed their notes – much faster than I could ever imagine. They stopped briefly to answer a text message on their cell phone, then continued. Streaking fingers on keyboards, multi-tasking, opening new windows to search a reference, facile at looking up who was covering infectious disease today by perusing the on-line call schedule. “The operators taught me,” she said. “They got upset I was bothering them for the information all the time.”

And so it went.

Watching this, I couldn’t help but ask: “What would you guys ever do without an electronic record, I mean, have any of you ever entered a paper-based order?”

“Oh, yeah. I’ve done it. But I don’t think I could ever go back. Oh, God, no!”

“Really? What if the computer goes down? Doesn’t it ever worry you that things might grind to a halt? What about new residents who have never seen a paper chart?”

“Oh-my-God! They’d have no clue! I heard Suzie matched at Georgetown, and they still have paper-based records – I mean – I feel so sorry for her. She won’t have a clue. I’d never go to a program with paper records any more. It would suck.”

And so, in my carefully-conduced ICU research on three current-day residents accustomed to dot-phrases and instant everything, I’d say the electronic medical record industry is secure.

-Wes

Cardiology Fellow Made $250,000 While Moonlighting

Um, it might not be legal:

Court records show Tiano worked at the clinic between 2005 and 2007 while working as a cardiology fellow at Marshall. Tiano earned $250,000 between August 2005 and September 2007, according to the affidavit.

Tiano's medical license was placed on three years' probation in December 2008, according to the state Board of Medicine.

Tiano was reprimanded by the board in connection with "prescribing, dispensing or administering a prescription drug other than in good faith and in a therapeutic manner in accordance with accepted medical standards, and failing to practice medicine acceptably," according to the order placing his medical license on probation.

-Wes

Interesting Factoids Overheard at the ACC Meeting

Overhead at the ACC Meeting today in Chicago:

There are 174 active cardiology training programs in the United States.
Ten programs do not participate in the National Resident Matching Program (NRMP).
Of the 164 remaining programs, there were about 1200 applicants to fill 699 training positions for Cardiovascular Disease. 6 positions went unfilled.
Approximately 40% of applicants were from non-US medical schools.

Ref: The NRMP's stats - informative, but their stats did not mention the total number of applicants who applied for the 699 positions.

* * *

Although there are about 4000 doctors who call themselves "electrophysiologists" in the US, only about 1700 carry valid board certification from the American Board of Internal Medicine in Cardiac Electrophysiology.

* * *

Just thought you'd like to know...

-Wes

Conquering Heart Disease is Multifaceted

An interesting question comes to mind when reading this study from the New England Journal of Medicine about how far we've come in twenty years treating heart disease: If we're doing such a good job with all of our public health initiatives and evidence-based treatment strategies, then why do we need more cardiologists? Why are we experiencing such a dearth of general cardiologists now and in the foreseeable future?

I think there's a lot of merit in this statement:

The looming critical shortage of cardiologists is due to a confluence of factors. The number of U.S. medical school graduates matching in internal medicine residencies has declined dramatically over the last 20 years. Fewer cardiologists are being trained today than a decade ago. An estimated 10% of cardiologists will retire in the coming decade. The baby boomers are reaching the age when cardiovascular disease rates climb sharply. The average patient load in cardiovascular medicine is declining, and maintaining those lower patient loads requires a greater number of physicians, Dr. Williams continued.

The road to cardiology requires a path through internal medicine, and where internal medicine training goes, so go budding cardiologists.

But I do not think this is the only reason the general cardiologists' numbers are declining.

I am aware of many, many residents who have completed their internal medicine residencies and are eager to enter cardiology fellowships but are unable to "match" in any cardiology fellowship position. I have seen graduating residents submit 50 to 70 letters to programs across the country without a single interview granted. This is where the REAL pruning of potential cardiology trainees occurs.

Fellowships are expensive for hospitals and academic programs. Funding sources have become limited as the squeeze to pare expenses continues in healthcare. So fellowship positions are often one of the first things reduced as a cost-cutting measure. Fellowships have historically also been partially funded by industry grants at times, but as the closer scrutiny of industry perks to medicine increase, these funds are more difficult for training programs to acquire. Competition for fellowship slots, then, becomes keen.

The training programs themselves are sometimes to blame. Some programs freely recognize that there may be some danger to "training their competition." Most trainees often like the city they're training in, so they look to stay nearby, making competition for patients near the training center higher if the new cardiologists chooses to practice outside the training center's immediate patient catchment area. Rural locations have fewer patients to treat, so geography may also limit the spread of cardiologists to more rural areas.

Training the new cardiologist also requires commitment from the academic faculty. As pay-for-performance initiatives drive productivity interests and are coupled with declining Medicare and insurer reimbursements, academician-teachers are being driven to become clinical revenue producers with less time to teach. It is hard to have a training program if there is no incentive to teach. Where's the Medicare reimbursement for this?

So if you want more cardiologists, not only must we make more fellowship positions, but we must also figure out how to compensate the folks doing the teaching so they're not penalized for doing so.

-Wes