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Training Young Doctors: The Current Crisis

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Sometimes it seems that America has lost the capacity to address large social problems—infrastructure being a prime example. But look also at the continuing breakdown of the medical/healthcare system. Lara Goitein reviews a recent book in the NY Review of Books:

Let Me Heal: The Opportunity to Preserve Excellence in American Medicine
by Kenneth M. Ludmerer
Oxford University Press, 431 pp., $34.95

In the 1890s, Sir William Osler, now regarded as something of a demigod in American medicine, created at the Johns Hopkins Hospital a novel system for training physicians after graduation from medical school. It required young physicians to reside in the hospital full-time without pay, sometimes for years, to learn how to care for patients under the close supervision of senior physicians.

This was the first residency program. Despite the monastic existence, the long hours, and the rigid hierarchy, Osler’s residents apparently loved it. They felt exalted to be able to learn the practice of medicine under the tutelage of great physicians who based their teachings on science, inquiry, and argument, not tradition. And far from bridling at being at the bottom of the pyramid, they virtually worshiped their teachers, who in turn generally lavished great attention and affection on their charges. Osler’s innovation spread rapidly, and the residency system is still the essential feature of teaching hospitals throughout the country.

Residents are young doctors who have completed medical school and are learning their chosen specialty by caring for patients under the supervision of senior physicians, called attendings. Residents in their first year are called interns. As in Osler’s time, residents work long hours, although they no longer live in the hospital and are now paid a modest salary. The time this training takes varies—three years, for example, to complete a program in internal medicine. Following that, many go on to a few more years of training in subspecialties (for example cardiology, a subspecialty of internal medicine), and at this point they are called fellows.

Together residents and fellows, who now number about 120,000 across the country, are called house officers, and their training is termed graduate medical education (GME). The teaching hospitals where most of this takes place are often affiliated with medical schools, which in turn are often part of universities, and together they make up sometimes gigantic conglomerates, called academic medical centers.

Despite the fact that Osler’s idea lives on, there have been enormous changes over the years, and this is the subject of Kenneth Ludmerer’s meticulous new book, Let Me Heal. Ludmerer, a senior faculty physician and professor of the history of medicine at Washington University in St. Louis, sounds a warning. The Oslerian ideal of faculty and residents forming close relationships and thinking together about each patient is in trouble. Instead, residents, with little supervision, are struggling to keep up with staggering workloads, and have little time or energy left for learning. Attending physicians, for their part, are often too occupied with their own research and clinical practices—often in labs and offices outside of the hospital—to pay much attention to the house officers.

The implications for the public are profound. Nearly anyone admitted to a teaching hospital—and these are the most prestigious hospitals in the country—can expect to be cared for by residents and fellows. Whether house officers are well trained and, most important, whether they have the time to provide good care are crucial. Yet until Ludmerer’s book, there has been very little critical attention to these questions. It’s simply assumed that when you are admitted to a teaching hospital, you will get the best care possible. It’s odd that something this important would be regarded in such a Panglossian way.

Ludmerer refers to graduate medical education in the period between the world wars, following Osler, as the “educational era,” by which he means that the highest priority of teaching hospitals was education. Heads of departments were omnipresent on the wards, and knew the house officers intimately. A network of intense, often lifelong mentorships formed. Ludmerer gives a fascinating account of the propagation of talent; for example, William Halsted, the first chief of surgery at Johns Hopkins, had seventeen chief residents, eleven of whom subsequently established their own surgical residency programs at other institutions. Of their 166 chief residents, eighty-five became prominent faculty members at university medical schools. The influence of the giants of the era of education still reaches us through three, four, or five generations of disciples, and house officers quote Osler even today.

There was a strong moral dimension to this system. Ludmerer writes that “house officers learned that medicine is a calling, that altruism is central to being a true medical professional, and that the ideal practitioner placed the welfare of his patients above all else.” Commercialism was antithetical to teaching hospitals in the era of education. “Teaching hospitals regularly acknowledged that they served the public,” writes Ludmerer, “and they competed with each other to be the best, not the biggest or most profitable.”

Indeed, teaching hospitals deliberately limited their growth to maintain the ideal setting for teaching and research. Ludmerer offers the example of the prestigious Peter Bent Brigham Hospital in Boston (now named the Brigham and Women’s Hospital), which in its 1925 annual report declared that it had “more patients than it can satisfactorily handle…. The last thing it desires is to augment this by patients who otherwise will secure adequate professional service.” They also kept prices as low as possible, and delivered large amounts of charity care. With few exceptions, members of the faculty did not patent medical discoveries or accept gifts from industry, and regularly waived fees for poor patients.

To be sure, this golden age was not pure gold. These physicians were, on the whole, paternalistic toward patients; by today’s standards, many were elitist, sexist, and racist. But they were utterly devoted to what they were doing, and to one another, and put that commitment ahead of everything, including their own self-interest.

World War II brought great changes. In the postwar prosperity, the United States began to invest heavily in science and medicine, with rapid expansion of the National Institutes of Health (NIH), which in turn poured money into research at academic medical centers. In addition, the growth of health insurance led to more hospital admissions. In 1965, the creation of Medicare and Medicaid accelerated this growth enormously. According to Ludmerer, between 1965 and 1990, the number of full-time faculty in medical schools increased more than fourfold, NIH funding increased elevenfold, and revenues of academic medical centers from clinical treatment increased nearly two hundred–fold.

Initially, in the couple of decades following the war, the influx of money and the rapid growth simply gave momentum to the trajectory begun in the era of education. Reinforced by leaders who had trained during that era, the established traditions endured, and teaching hospitals for the most part defended their commitment to educational excellence and public service. However, the close-knit, personal character of graduate medical education began to unravel. By the late 1970s, academic medical centers began to take on the character of large businesses, both in their size and complexity, and in their focus on growth and maximizing revenue. Even if technically nonprofit, the benefits of expansion accrued to everyone who worked there, most particularly the executives and administrators. In 1980, Arnold Relman wrote a landmark article in The New England Journal of Medicine, warning of the emergence of a “medical-industrial complex.”

The growing commercialization of teaching hospitals was exacerbated by a change in the method of payment for hospital care. Health care costs were rising rapidly and unsustainably, and in the 1980s health insurers responded with what has been termed “the revolt of the payers.” Previously, most insurers had paid hospitals according to “fee-for-service,” in which payment was made for each consultation, test, treatment, or other service provided. But now Medicare and other insurers, in an effort to control costs, began to reimburse hospitals less liberally and by “prospective payment” methods, in which the hospital received a fixed payment for each patient’s admission according to the diagnosis. Whatever part of that payment was not spent was the hospital’s gain; if the hospital spent more, it was a loss. Hospitals now had a strong incentive to get patients in and out as fast as possible.

Quite suddenly, the torrent of clinical revenue that had so swollen academic medical centers slowed. Many hospitals did not survive in the new environment (the total number of US hospitals decreased by nearly 20 percent between 1980 and 2000). Those that stayed afloat did so by promoting high-revenue subspecialty and procedural care, for example heart catheterization and orthopedic and heart surgery, which were still lucratively rewarded. They also developed more extensive relationships with pharmaceutical and biotech companies and manufacturers of medical devices, which paid them for exclusive marketing rights to drugs or technologies developed by faculty, as well as access to both patients and faculty for research and marketing purposes.1. . .

Continue reading.

Written by LeisureGuy

24 May 2015 at 6:37 am

Healthcare advice from two health reporters

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Via Kevin Drum, this report in Vox by Julia Belluz and Sarah Kliff. The two offer 8 lessons learned from years of reporting on medicine and healthcare. To take just one example, consider this chart from the second lesson, “2) Ignore most news stories about new health studies”:

Medical_studies-05.0.0

By all means, read the entire article.

Written by LeisureGuy

20 May 2015 at 10:33 am

When state legislatures fail, people blame Obama

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Interesting article by Josh Marshall at TPM:

As the Charlotte Observer explains, Lang is a self-employed handyman who works as a contractor with banks and the federal government to maintain foreclosed properties. He was making a decent living, enough to be the sole breadwinner in the family. As the Observer puts it, Lang “he has never bought insurance. Instead, he says, he prided himself on paying his own medical bills.”

All seemed good until this February when a series of headaches led him to the doctor. Tests revealed that Lang had suffered a series of mini-strokes tied to diabetes. (It’s not clear to me from the piece whether Lang knew he had diabetes earlier or whether that was the diabetes diagnosis as well.) He now also has a partially detached retina and eye bleeding tied to his diabetes. The initial medical care for the mini-strokes ran to almost $10,000 and burned through his savings. And now he can’t work because of his eye issue and can’t afford the surgery that would save his eyesight and also allowing him to continue working.

That’s where we pick up the narrative from the Observer

That’s when he turned to the Affordable Care Act exchange. Lang learned two things: First, 2015 enrollment had closed earlier that month. And second, because his income has dried up, he earns too little to get a federal subsidy to buy a private policy.

Lang, a Republican, says he knew the act required him to get coverage but he chose not to do so. But he thought help would be available in an emergency. He and his wife blame President Obama and Congressional Democrats for passing a complex and flawed bill.

“(My husband) should be at the front of the line because he doesn’t work and because he has medical issues,” Mary Lang said last week. “We call it the Not Fair Health Care Act.”

Since Lang now has no income, he should be eligible for the ACA’s expanded Medicaid coverage, for which the federal government picks up tab. But Lang lives in Fort Mill, South Carolina. And South Carolina refused to accept Medicaid expansion. So he’s out of luck on that front too.

Just to recap: Lang broke the law by refusing to get health insurance coverage because he prided himself on being able to pay his bills out of pocket. But he got sick and actually had too little savings to cover even relatively small health care bills. By now open enrollment has closed. But he figured he’d be able to buy in if he got in a jam or wait till he got sick to buy coverage. Luckily the ACA’s Medicaid expansion covers him regardless. But the state of South Carolina refused to accept Medicaid expansion even though the federal government would pay for it. Lang is left in precisely the situation that would exist if the ACA had never been passed. So he blames Obama. . .

Continue reading.

Written by LeisureGuy

14 May 2015 at 10:08 am

Are the Republicans giving up on killing Obamacare?

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Here’s why they might:

blog_obamacare_gallup_republicans

That’s from a good post by Kevin Drum that indicates that at least some Republicans think that the Obamacare fight is over, and the general public won. Worth reading.

Written by LeisureGuy

18 April 2015 at 1:01 pm

Posted in GOP, Government, Healthcare

More good news on Obamacare

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Kevin Drum asks a good question: Why are Republicans so opposed to Medicare, now that it has been proven to work? Look at his post at Mother Jones:

During Obamacare’s initial open enrollment period, the uninsured rate dropped dramatically. Then it leveled out a bit when enrollment closed. So how are things going in its second year?

The latest Gallup numbers tell the story. During the first month of open enrollment, the uninsured rate dropped moderately, and then dropped sharply again during the first quarter of 2015. It’s now down to 11.9 percent:

blog_gallup_uninsured_2015_q1

This is great news, and confirms previous reports. As before, according to Gallup, the biggest drops have been among the young and those with low incomes. This represents millions of people who can now get decent medical care without fear of bankruptcy, and it’s being done at asurprisingly moderate cost. It’s just inconceivable to me why Republicans are so hellbent on ruining a program that’s showing such great results and such great promise for so many people.

Written by LeisureGuy

13 April 2015 at 5:46 pm

Posted in GOP, Government, Healthcare

Australia: If you don’t vaccinate your children, you don’t get government childcare benefits

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Australia has some good policies. One is the reasonably substantial fine levied on those who fail to vote—that should be implemented in the US. Another is this new policy (yet to be approved by Parliament), reported in Salon by Joanna Rothkopf:

On Sunday, Australian Prime Minister Tony Abbott announced a harsh new policy targeting anti-vaxxers: as of January 1, 2016, parents who opt out of vaccinating their children will be denied childcare-related government benefits. The measure, which could deprive families of up to $11,500 in government funds, still needs to be approved by Parliament before it can take effect.

“Parents who vaccinate their children should have confidence that they can take their children to childcare without the fear that their children will be at risk of contracting a serious or potentially life-threatening illness because of the conscientious objections of others,” Abbott said.

NPR’s Stuart Cohen reports that around 90 percent of Australian children are properly immunized, but almost 40,000 parents have claimed objections, which can be religious, medical, or even philosophical in nature.

The Sydney Morning Herald’s Stephanie Peatling reports:

Families claiming the end of year supplement for family tax benefits will also have to have their children vaccinated at all ages from the start of next year before receiving the payment…

People who have medical grounds for not vaccinating will continue to receive government payments.

But people with religious reasons will have their eligibility for government payments tightened.

They will only continue to receive childcare and family tax payments if they are affiliated with a religious group whose governing body has a formally registered objection approved by the federal government.

“The government is extremely concerned at the risk this poses to other young children and the broader community,” Abbott continued. “The choice made by families not to immunize their children is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments.”

Written by LeisureGuy

13 April 2015 at 2:00 pm

Therapy in another language via Skype

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Very interesting article in the NY Times by the therapist Anastasia Piatakhina Giré:

I have a psychotherapy practice in Madrid, but I often receive email requests for counseling from people in other parts of the world, since I also practice psychotherapy online, via Skype, in several languages: English, French, Italian and Russian. Alex’s email looked like spam, and I nearly deleted it. He wrote in an abrupt English, with neither a greeting nor a sign-off. When I read more closely, I saw that he was seeking therapy, though he didn’t say much else. In his brevity I sensed hesitation, a shade of doubt.

Some hide-and-seek is not unusual in the early phase of the therapy process. Asking for help involves a degree of exposure, which can trigger feelings of shame. For those who are wary about psychotherapy, the online format often appeals, as it avoids the physical, face-to-face confrontation of a classical consulting room and offers the option, or at least the illusion, of anonymity.

I wrote Alex back, asking if he might say a little more.

His second email was a bit longer, perhaps because he now trusted that behind my web page there was in fact a real person available to listen. He alluded to his “continuous work on overcoming my homosexuality.”

At this stage, I would usually invite a client to meet me via Skype to talk at greater length. But I was curious (I am only human): Where was Alex from? Something about his brisk, straightforward and slightly aggressive mode of address felt familiar to me, and I suspected he was Russian. But I am Russian, too. Why didn’t he avail himself of our common native language?

I wrote another email to Alex, listing the various languages in which I practiced therapy, and noting that Russian was my first language. It turned out that he was indeed Russian, and lived in a remote city many miles away from Moscow or St. Petersburg. At that point, we switched to speaking Russian. And we set up a time to talk via Skype.

At the beginning of our first Skype session, . . .

Continue reading.

Written by LeisureGuy

5 April 2015 at 9:20 am

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