Rags to Riches thru [Medical] Education?

Or … Riches to Rags for Docs and the ACA?

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American society prides itself on being a meritocracy, particularly with the fruition of the ‘American Dream’ being achieved by individuals from all types of backgrounds; like doctors, Financial Advisors [FAs] and all medical professionals.

Success

Success today typically involves some form of higher education, to expand intellectual capacity and to hone a skill-set.

However, the highest quality education is not the most easily accessible. And so, this infographic takes a look at how the elite tend to fare well, and how the disadvantaged aren’t provided the same opportunities.

Source: www.onlineschools.org

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HISTORY: Medical Education and Practice in the USA

Domestic Medical SCHOOL Education

Robert James Cimasi

Todd A. Zigrang

Health Capital Consultants - Healthcare Valuation

U.S. medical education began in the late eighteenth century as an apprenticeship program in which physicians taught their trade to a few pupils, a pedagogical learning style which relied heavily upon the capacity, skills, and knowledge of the individual physician.[1] However, as learning newly discovered information and utilizing new technologies became more necessary to the industry’s practice, many physicians found the apprenticeship system no longer adequate as a manner of educating the next generation of physicians.[2] As a result, the conventional concept of medical education that originated in the U.S. in the 1750s was manifested through informal courses and demonstrations by private individuals or for-profit institutions. Those individuals who were not satisfied with a typical U.S. medical education, consisting of two identical 16-week lecture terms, might venture to Europe for a more formalized and detailed manner of learning.[3]

One of these students who studied in Europe was William Shippen, who began teaching an informal course on midwifery when he returned to the American colonies in 1762.[4] He later addressed the limitations of what might be taught in one informal course when he began teaching a lecture series on anatomy to help educate those who wished to be a physician, but could not travel abroad. John Morgan, a classmate of Shippen, noticed the potential of his friend’s endeavor and proposed the idea to create a professorship for the practice of medicine to the board of trustees of the College of Philadelphia.[5] Just across town, Thomas Bond, who conceived the idea of, and successfully established, the Pennsylvania Hospital with Benjamin Franklin, recognized the value to allowing medical students to participate in bedside training.[6] When Bond agreed to a partnership with the College of Philadelphia, the University of Pennsylvania became home to America’s first medical school.[7]

In 1893, Johns Hopkins University also made history by housing the first medical school that was able to operate out of a university-owned hospital.[8] The medical school not only encouraged clinical research to be performed by every member of their faculty, but the program also included a clinical research clerkship for every student during their rotation.[9] This program quickly became the model to which schools aspired and set the foundation for national medical education by connecting science and medical research with clinical medicine.[10]

With these early examples of medical schools, America’s field of medical education and clinical medicine made monumental strides. However, the societal pressures, caused by the U.S.’s population growth and demand for educated physicians,[11] did not allow many other universities to build on Johns Hopkins’ or the University of Pennsylvania’s foundation model, and led to the development of medical schools that had their own unique set of entrance and graduation requirements. While some focused entirely on medicine, other schools (termed Studia Generalia) also incorporated law, theology, and philosophy in their curricula.[12] In an attempt to both understand and make uniform the field of medical education, the American Medical Association (AMA) founded the Council on Medical Education (CME) in 1904.[13] The CME created minimum national educational standards for training physicians, and subsequently found that many schools did not meet these established standards.[14] However, the CME did not share the ratings of any of these medical schools “outside the medical fraternity.”[15]

In 1910, the AMA commissioned the Carnegie Foundation for Advancement of Teaching to conduct a study of medical education and schools.[16] Abraham Flexner conducted the inquiry and detailed his findings in what became known as The Flexner Report.[17] In his review of the U.S. medical education system, Flexner found that many of the proprietary medical schools met the AMA’s educational goals, but an imbalance existed between the pursuit of science and medical education.[18]  Professors were focused solely on student throughput, and did not ensure a high level of medical training that reflected the developments in the medical industry.[19] As aptly noted by Dr. John Roberts in his book entitled The Doctor’s Duty to the State, “[m]any of you remember the struggle to wrest from medical teachers the power to create medical practitioners with almost no real knowledge of medicine. The medical schools of that day were, in many instances, conducted merely as money-makers for the professors.”[20] As the AMA gained more influence over the provision of healthcare in the U.S., the value and power of medical education also gained recognition. Notably, teaching hospitals had the power to influence the development of their disciplines through their research initiatives, the quality of care they provided, and their ability to operate as an economy of scale, allowing them to dictate the evolution of medical education.[21]

Since the establishment of the first medical school in the U.S., medical education has been the foundation for shaping standards of care in the practice of medicine and defining medical errors as deviations from the norms of clinical care.[22] When Thomas Bond helped establish the University of Pennsylvania medical school, he envisioned a normal day where the physician:

…meets his pupils at stated times in the Hospital, and when a case presents adapted to his purpose, he asks all those Questions which lead to a certain knowledge of the Disease and parts affected; and if the Disease baffles the power of Art and the Patient falls a Sacrifice to it, he then brings his Knowledge to the Test, and fixes Honour [sic] or discredit on his Reputation by exposing all the Morbid parts to View, and Demonstrates by what means it produced Death, and if perchance he finds something unexpected, which Betrays an Error in Judgement [sic], he like a great and good man immediately acknowledges the mistake, and, for the benefit of survivors, points out other methods by which it might have been more happily treated.[23]

Originally, students were to study and learn from medical errors and adverse events through medical education as a means of improving the quality of care. However, it is difficult to effectively implement any significant advancement learned through the research and investigation of prior errors in a timely and cost-effective manner. Additionally, physician supply shortages have only increased the amount of patients that a physician must see daily, while simultaneously decreasing the amount of time they can spend with each patient. Although medical education continues to be one of the central underpinnings to the development of the medical industry, outside pressures that shape the clinical practice of physicians continue to limit physician effectiveness in providing quality care to patients.[24]

While improving the quality and rigor of medical education has been a constant focus throughout the history of U.S. medical education, the challenges of replicating it on a scale that produces enough qualified physicians to meet the growing demands of the U.S. population, with constantly changing technologies, has consistently been a central issue. Notably, in the 13 years preceding 1980, the ratio of actively practicing physicians to patients increased by 50%.[25] This increased physician-to-patient ratio led to concerns over quality of care and cost-effectiveness, which in turn caused the creation of a government committee to evaluate physician manpower allocation and distribution. The Graduate Medical Education National Advisory Committee (GMENAC) was first chartered in April 1976, and later extended through September 1980.[26] Its purpose was to “analyze the distribution among specialties of physicians and medical students and to evaluate alternative approaches to ensure an appropriate balance,”as well as to“encourage bodies controlling the number, types, and geographic location of graduate training positions to provide leadership in achieving the recommended balance.”[27] GMENAC produced seven volumes of recommendations regarding physician manpower supply,[28]  through the development of several models by which to determine the projected number of physicians that would be needed in the future by different subspecialties to achieve “a better balance of physicians.”[29] Ignoring critics of the report, U.S. medical schools adjusted their enrollment numbers in response to the GMENAC’s recommendations, causing a significant decrease in the supply of new physicians going into the 21st century.

***

History of Conventional Medicine - 24 Hour Translation ...

[1]       “Healthcare Valuation: The Four Pillars of Healthcare Value,” Volume 1, Robert James Cimasi, MHA, ASA, FRRICS, MCBA, CVA, CM&AA, John Wiley & Sons, Hoboken, NJ: 2014, p. 22-23.RR

[2]       “Before There Was Flexner,” American Medical Student Association, 2014,

         http://www.amsa.org/AMSA/Homepage/MemberCenter/Premeds/edRx/Before.aspx (Accessed 1/7/15).

[3]       “Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care,” By Kenneth M. Ludmerer, New York, NY:

          Oxford University Press, 1999, p. 4.

[4]       “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-5.

[5]       “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-5.

[6]       “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-5.

[7]       “Before There Was Flexner,” American Medical Student Association, 2014,

         http://www.amsa.org/AMSA/Homepage/MemberCenter/Premeds/edRx/Before.aspx (Accessed 1/7/15).

[8]       “Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care,” By Kenneth M. Ludmerer, New York, NY:

          Oxford University Press, 1999, p. 18-19.

[9]       “Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care,” By Kenneth M. Ludmerer, New York, NY:

          Oxford University Press, 1999, p. 18-19.

[10]     “Science and Social Work:  A Critical Appraisal,” By Stuart A. Kirk, and William James Reid, New York, NY: Columbia University Press, 2002, Chapter 1, p. 2-3.

[11]     “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

          Publications, Inc., p. 6-7.

[12]     “Western Medicine: An Illustrated History,” By Irvine Loudon, New York, NY: Oxford University Press, 1997, p. 58.

[13]     “Western Medicine: An Illustrated History,” By Irvine Loudon, New York, NY: Oxford University Press, 1997, p. 58.

[14]     “Western Medicine: An Illustrated History,” By Irvine Loudon, New York, NY: Oxford University Press, 1997, p. 58.

[15]     “Western Medicine: An Illustrated History,” By Irvine Loudon, New York, NY: Oxford University Press, 1997, p. 58.

[16]     “U.S. Health Policy and Politics: A Documentary History,” By Kevin Hillstrom, Thousand Oaks, CA: CQ Press, 2012, p. 141.

[17]     “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-19.

[18]     “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-19.

[19]     “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 3-19.

[20]     “The Doctor’s Duty to the State: Essays on The Public Relations of Physicians,” By John B. Roberts, AM, MD, Chicago, IL: American Medical Association Press, 1908, p. 23.

[21]     “Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care,” By Kenneth M. Ludmerer, New York, NY:

          Oxford University Press, 1999, p. 19.

[22]     “Science and Social Work:  A Critical Appraisal,” By Stuart A. Kirk, and William James Reid, New York: Columbia University Press, 2002, Chapter 1, p. 2-3.

[23]     “Dr. Thomas Bond’s Essay on the Utility of Clinical Lectures,” By Carl Bridenbaugh, Journal of the History of Medicine (Winter 1947), p. 14; “The Flexner Report on Medical Education in the United States and Canada in 1910,” By Abraham Flexner, Bethesda, MD: Science and Health

         Publications, Inc., p. 4.

[24]     “Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care,” By Kenneth M. Ludmerer, New York, NY:

          Oxford University Press, 1999, p. xxi.

[25]     “How many doctors are enough?” By J.E. Harris, Health Affairs, Vol. 5, No. 4 (1986), p.74.

[26]   “Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services – Volume VII,” Graduate Medical Education National Advisory Committee, Washington, DC: U.S. Government Printing Office, 1981, p. 5, 16.

[27]     “Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services – Volume VII,” Graduate Medical Education National Advisory Committee, Washington, DC: U.S. Government Printing Office, 1981, p. 73.

[28]     “Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services – Volume VII,” Graduate Medical Education National Advisory Committee, Washington, DC: U.S. Government Printing Office, 1981, p. 5-6.

[29]     “GMENAC: Its Manpower Forecasting Framework,” By D.R. McNutt, American Journal of Public Health, Vol. 71, No. 10 (October 1981), p. 1119.

[30]     “Crossing the Quality Chasm: A New Health System for the 21st Century,” Institute of Medicine, National Academy of Sciences, 2001, front matter.

[31]     “Overview of Medical Errors and Adverse Events,” By Maité Garrouste-Orgeas, et al., Annals of Intensive Care, Vol. 2, No. 2 (2012), p. 6.

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Understanding the Modern Challenges of Student Doctors

An Evolving Educational Model

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By Cyndi Laurenti

laurenticy@gmail.com

Medical education could be driving potential doctors away and damaging those who do go on to practice with long hours, high debt, inconsistent training, and lack of emotional support. Research indicates the current structure of residency programs produces resident physicians who are stressed, sleep-deprived, and prone to medical errors.

Medical Residents

Medical school graduates who’ve begun their on-the-job training are called residents varying in length from three to seven years, depending on the specializations doctors pursue. Most programs utilize experienced physicians called preceptors to teach the new doctors how to practice their particular branches of medicine. Another common practice is to pair second- or third-year residents with one or more first-year residents, so the senior students take on some of the teaching and supervision roles.

Duties

Residents admit patients to the hospital, obtain medical histories, perform examinations, and administer treatments or do procedures under the guidance of the senior resident or preceptor.

The hours in a residency program are long. Despite recommendations from the Institutes of Medicine intended to decrease long shifts and work hours, 80-hour weeks are common in residency programs and 30-hour shifts with five-hour sleep periods are the norm. Moreover, those 80-hour work weeks represent the average over a four-week period, so a resident might actually work considerably longer in a single week.

Work Shifts

Rotating shifts, in which residents work at different times of the day or night, are also common. Sleep deprivation is the norm: a 2004 survey of over 3,000 residents reported 66 percent slept less than six hours a night, and 20 percent slept less than five. Of even more concern, those who slept less than five hours a night reported they had used alcohol, resorted to stimulants to stay awake, had serious accidents or injuries, had conflicts with other professional staff, or made serious medical errors.

Financial Stress

Many residents also face financial or family stressors as well. Debt is common in medical school: the New England Journal of Medicine reports one fourth of graduating residents have debt exceeding $200,000. Some residents use their limited free time to moonlight for additional income as the average medical resident salary is about $45,000 per year.

Age

Medical residents are often in their late twenties or early thirties, a time when many people look to starting families. The lack of income may drive them to work extra hours in an already crowded schedule, which prevents them from spending time with children or a spouse, if indeed they manage to have either. Research from as far back as 1986 indicated over 40 percent of medical residents experience problems with their spouses during residency. Respondents often feel the working conditions of residency contribute to family problems, which in turn affect their hospital work as a result. On a positive note, researchers have found stress can be moderated by family relationships and social contact, and recommended social support systems be fostered in residency programs.

Stress

Emotional stress related to patient care is another aspect of the issues with residency. Over 70 percent of residents in one study reported hospital activities such as cardiopulmonary resuscitation were extremely stressful and the lack of a debriefing session afterward increased the impact of that stress, particularly when the resident felt the resuscitation was inappropriate.

Recipe for Disaster?

The combination of stress and sleep deprivation is a recipe for disaster. A study at HarvardUniversityfound residents who worked extended shifts or long hours were involved in 300 percent more fatal errors than when they did not work excessive hours. These same physicians reported they were likely to fall asleep during surgery, patient examinations, hospital rounds or lectures, and that their medical errors induced guilt, anger, humiliation, and decreased compassion for the patients they treated.

To add to these stresses, as recently as October 2011 almost half of graduate physicians in one survey reported they had been harassed, intimidated or discriminated against while residents. These behaviors took the form of verbal abuse and being assigned extra work as punishment. The sources of inappropriate behavior were primarily specialty physicians, but specialty residents, hospital nurses, and patients also participated in the harassment.

The Changing Paradigm

Some residency programs have made changes to improve the quality of life for residents. These include strategies such as decreasing patient load, senior residents supervising a single resident instead of two or more, and decreasing hand-offs, the transfer of patients from one group of residents to another. Other recommendations include debriefing sessions for stressful situations such as cardiopulmonary resuscitation, ethics committees to which residents can take complicated problems, and increased emotional support.

I.O.M

Other possible strategies include a decreased shift length, or simply adherence to the Institutes of Medicine’s guidelines for residency training programs. Social networks for residents’ spouses and families would provide a forum to air concerns and obtain emotional support from those in similar circumstances.

Additional efforts to relieve medical student debt would also make a considerable positive impact. A program currently exists in theUnited Statesfor physicians to obtain loan forgiveness: the National Health Service Corps pays off medical student debt if the physician practices full-time at a NHSC-approved site, usually a federally-qualified health center, rural or Indian Health service clinics, or prison. If a physician serves full-time for six or more years, the entire debt may be repaid by the NHSC.

Assessment

Most residency programs in other parts of the world are similar to those in theUnited States, although there may be different laws that affect work hours or salaries. There is clear evidence that overstressed and sleep-deprived residents are more likely to make serious or even fatal medical errors and lose their sense of compassion for patients. The current residency system is expensive, emotionally stressful, and puts the lives of patients at risk. America (and likely other nations as well) would benefit from making even more changes in residency programs to provide adequate time for sleep, family or social interaction, and emotional support for fledgling doctors.

About the Author

While she figures out her next career move, Cyndi Laurenti works as an online writer and editor. Her primary interests are education, technology, and how to combine them. She enjoys the trees and beaches of thePacific Northwest, and looking things up on other people’s iPhones.

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Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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