Sunday, March 1, 2015

Residency (GME) Positions: Addressing the Nation's Healthcare Needs

I’ll start this post with full disclosure: I am a medical educator, and have spent a good portion of my professional life educating trainees (residents) to prepare for independent practice.  My specialty is combined internal medicine-pediatrics, or “Med-Peds” for short, and my personal clinical practice is primary care for the underserved.

I have been very interested in what the future health care environment will look like, and thus follow updates from agencies that comment on the future of health care, as well as the supply of physicians and other health care providers.

There are some facts about which very few disagree, and there are others where interpretations are very different.  We do know that many new medical schools have opened up within the past few years, and also that many existing medical schools have increased matriculation. 

From this, it would seem as if the supply of physicians to care for future generations is being addressed.  But remember that, to be a physician practicing independently, one must graduate medical school, and also complete residency training.  It is this part, the percentage of residency training positions, which has NOT increased as much as the medical school matriculation.  The actual number of positions has increased, but not at the same rate as medical school graduates (see Figure 1).  In short, the “bottleneck” for US students to become practicing physicians is indeed US residency positions, known as GME, or graduate medical education.  The National Residency Match Program (NRMP) does state that there are enough GME positions for all US graduates, but there are other graduates (from international medical schools) applying for these same positions.

This was a busy week for such projections.  The AAMC came out with a roadmap earlier this week describing plans for how to address this situation.  The Commonwealth Fund, however, delivered another interpretation of the situation, stating that the current healthcare situation can handle the influx of new patients as a result of the Affordable Care Act.  This follows on the heels of the IOM report last year addressing the GME issue and recommending no additional funding for new residency positions, among other things. 

So who is correct?  I admit my biases on this topic, in that a) I am an educator, and attend the AAMC meetings, and b) I practice in a state where even the Commonwealth Fund writes that there are fewer primary care docs.  For the record, our Med-Peds residency program is the largest one in the country, and has been for at least 20 years.  About 40-45% of our graduates choose primary care as their ultimate specialty, higher than either hospital medicine or further fellowship subspecialty training.  This percentage of graduates choosing primary care was higher in the 1990s.

I’m curious what readers of this blog think about the situation.  Is there a doctor shortage, and is there a shortage of primary care physicians?  Will patients be able to get access to health care given the influx of new patients into the health care system?  What else should be done besides the roadmap outlined by the AAMC?


Thanks for reading; I’m curious to hear differing opinions.

Saturday, February 21, 2015

Storytelling, Narrative Medicine and the Digital Age

Narrative medicine and reflective exercises have been a very important tool in the education of medical professionals.  With social media's integration into the fabric of society, it is important for today's trainees to understand the implications of public storytelling on one's professional persona.  This recent editorial and article on the topic in the journal Academic Medicine this month describe the divide between digital natives and digital immigrants, and how each might have different viewpoints of how storytelling is disseminated.

And then here is another recent piece in the Atlantic about the topic, in which the author reflects on her writing about a patient experience and whether it should or should not be published.

I don’t claim to have any of the answers for this myself.  What is the correct approach to disseminating storytelling or narratives about patient encounters?  Do others learn from it or not?  Some pioneers are addressing this situation directly.  Dr. Bryan Vartabedian, who has spoken at our institution about the public physician, has just announced a MOOC related to Medicine in the Digital Age.

What I do know is that medical schools really MUST teach this material to students and trainees.  It is our obligation to the future of the profession to understand digital literacy and the impact of our storytelling on patients, each other and ourselves, given how easy it is to push out blogs into the public space.


Thanks for reading.

Thursday, January 29, 2015

Enhancing Social Media within Medicine

So Twitter recently announced that it now has a video feature (up to 30 seconds).  See this post.

I wonder how we can use such an opportunity in medicine and medical education,  Will short snippets or "nuggets" of information now be sent via Twitter from one doctor to another?  Interesting to see what will come of this.  The hope would be that health care professionals would use it for dissemination of information that IS allowed in the public space, and not to violate privacy laws.

For those interested in learning more about social media within medicine, here is a nice review from JMIR on the topic, published within the last year.  The enhancement of such services is a great example of how innovation in technology has the potential to improve communication and education.

Wednesday, December 24, 2014

Reflections in Medicine and Medical Education 2014


2014 has been a tumultuous year, especially in medicine.  Frustrations with electronic health record systems, the Ebola virus, reactions to the Ebola virus, response to the new MOC requirements, burnout, and many others all contributed to the complexities that exist in medicine.  In medical education, questions like "what do the milestones really mean?" are common thoughts emanating from educators.  I'm not even touching Entrustable Professional Activities either!

Our school also passed a new conflict of interest policy.  I was privileged to lead this effort in 2014, and, despite unanimous approval of the policy in less than a year, I continue to get more questions "what about my situation?  Is that ok?"

In short, it is a tough time to be in medicine, no doubt.  Increased fear of being sued, decreased reimbursement, more regulatory requirements, and the uncertainty of exactly where medicine is going make for challenging times.

So how do people cope with this?  

Some choose to go "nose to the grindstone" and work harder.
Some decide to "call it quits" and leave medicine.
Some opt to "fight back", through advocacy in the form of blogs saying "enough is enough".
Some take a step back and say "at least I have a job and job security".
Some are put off by the "it's a job" phrasing, opting for "it's a profession, and unfortunately it is slowly eroding".

I know that resiliency is a helpful trait to handle all the changes, but still, I don't have all the answers.  I strongly believe that in the end, what I do matters, to learners, to patients, and to future learners and patients.  What trainees do matters.  What doctors and other healthcare professionals do matters.

That, coupled with blessings of continued good health, allows me a little peace in a hectic world moving at a frenetic pace.  Just try to search for your own similar peace.

Happy Holidays to All!

Alex

Friday, November 28, 2014

Conflict of Interest: Managing Scandal

I have had the privilege of chairing the Industry Relations Conflict of Interest Committee at the Indiana University School of Medicine, the medical school where I work, over the past year.  I have learned a lot about interactions of academic physicians with industry, and have certainly heard differing opinions on the topic.  Our policies were recently approved (unanimously, I might add!) by all of the pertinent committees, and already, many faculty have had comments and questions about specifics of the policy.

One common theme that we have also heard is that “regulatory agencies and administrative bodies” have hurt the field of medicine.  I certainly understand the additional burdens of what it takes to practice medicine, and how those burdens can actually damage the patient-physician relationship.  However, when one looks at why conflict of interest policies are put in place, one needn’t look very far to see why it is necessary.

Here is a prime example.  The Journal of Patient Safety had to deal with this recent example with its own editor.  Dr. Charles Denham, the [now] former editor of the journal, failed to disclose his own financial conflicts of interest with organizations which paid him.  This impacted recommendations he made with respect to clinical guidelines that center around optimizing patient safety.

What is interesting to me is that sometimes, how one handles a scandal can be as important as the scandal itself.  Covering it up, hiding it, or trying to sweep it under the rug are all examples of ways that don’t work.  It is amazing that it is this same sense of “doing the right thing” that parents try to teach their children.  What impressed me in this example is how the journal chose to address this.  The journal has opted to tighten its own policies and processes around conflict of interest, for authors, editors and others who make decisions about articles within the journal.  They even published an article describing what they plan to do. 


For anyone wondering how to handle a scandal, THIS is how to handle a scandal.  Admit the wrongdoing, describe what steps need to be taken for the better, and, simply, apologize.  As written in this NPR piece, “airing the dirty laundry”, while painful, is a necessary step.  

I applaud Dr. Albert Wu, Dr. David Bates and the journal editors for demonstrating the right way to manage this situation.  I think this is a great learning experience for the patient safety movement, for editors, and for all physicians who interact with industry.  Conflicts of interest are complex, but it all comes back to the fact that there is a public trust that must be put front and center.  If we violate that trust, then we have done a disservice to the profession, to ourselves, and, most importantly, to our patients.

Wednesday, November 19, 2014

Randomized Controlled Trials, Social Media and "Intention to Tweet"

I have to hand it to cardiologists: for years they have created the most innovative and fun names for trials that are conducted.  As a generalist, I still remember the DIG trial from way back when, or the RALES trial, sometimes referencing names of trials when discussed medications for common conditions such as heart failure.  As therapy evolves, we get a PARADIGM-HF shift, some might say!

Today, I was sent a tweet about a fascinating trial, the “Intention to Tweet” trial (hats off again to our cardiology colleagues: TNOTY (Trial Name of the Year).  This trial was a randomized trial of social media to see the impact of social media on views of articles within one journal, Circulation.  In the intervention group, they tweeted out links to half of the articles, and a link to the Facebook page.  In the control group, no tweets were sent.  Kudos to Lee Aase for a wonderful review of what was done in the study, and what it might mean for the future. 

Essentially, what the authors found was that there was no difference in clicks between the articles which had tweets sent/Facebook page links, and those which did not.  Some might refer to this as a “negative trial”.  I think that, in medicine, we need to see results of “negative trials” that show something was ineffective or not better than “usual care”, just like we need to see results that demonstrate a positive effect of an intervention.

But here is the clincher for this: I have seen several tweets from physicians and other scientists who are meaningful users of social media who are questioning the results or the design of the trial.  Some might interpret this as a “defeat” for social media.  

Looking on the Altmetrics page for this particular article, however, paints a different picture.  Recall that this article was announced and sent out TODAY (11/19/14) as an early release article.  The Altmetrics description for this article puts it at the 92nd percentile of all articles within this Circulation journal.  It is in the 94th percentile for all articles of a similar age.  94th percentile!  That is pretty awesome!  Compared with other articles of a similar age in this journal Circulation, it ranks 2nd, in the 85th percentile.  Again, this article came out TODAY.

So here is the kicker.  This article on social media, based on these Altmetrics data, has “gone viral” on social media (at least compared with other articles from this same journal), and is ranked quite favorably in one metric used to gauge social media impact (that metric being “Altmetrics”).  I think that suggests exactly the opposite of what the conclusion did (meaning that dissemination of THIS ARTICLE via social media made it quite a favorable article), which could be interpreted as "social media does have an impact on readership of journal articles.  See this screenshot from Altmetrics from 10:30 pm EST on 11/19/14.



I applaud the authors for developing such a trial and Circulation for having social media editors in the first place.  Those of us who “believe” in the power of social media to teach, to learn and to advocate appreciate the scientific principles which went into creating this trial.  I do agree with one sentence in the conclusion that “further research is necessary to understand and quantify the ways in which social media can increase the impact of research”.  

This article is a wonderful first step towards understanding these concepts, and provides a meaningful way to understand how to consider the impact.  As a social media editor for a journal myself (JCEHP), I plan to reference this article and use it in descriptions of how social media can impact journals, and ultimately, patient health and outcomes.

Friday, November 7, 2014

Medical Education: What Matters

So I've been in Chicago for the past few days at the inaugural Association of American Medical Colleges (AAMC) Medical Education meeting and the Society for Academic CME (SACME) meeting.  What a showcase of incredible learning opportunities!  Here are just a few of my take home thoughts and reflections from the past few days.

1. Healthcare in the U.S. has real problems, and medical education can really contribute to fixing this. We need to start calling ourselves healthcare learning systems. Medical education matters!

2. Getting one's message out to others (whether in the form of an abstract for a future presentation, or in a manuscript for a peer-reviewed publication) means that one has to be mindful of words.  Words matter!

3. Technology can be used to improve communication and healthcare, but we must be careful that technology in and of itself is not a solution.  People matter!

4. Seeing old friends and meeting new people create a wonderful community of learners, and together we can tackle problems better as a group than as individuals. Connections matter!


I still have another day of learning here, and lots more people to meet!  Thank you to the organizers for a wonderful meeting!

[for the record, I wrote and posted this piece while on the "L" headed to the meeting]