More interest in primary care, but are med schools ready?

Interesting story from the American Medical Association’s news wire today about the growing number of medical students who are opting to pursue careers in family medicine. Students matched with family medicine residencies are up 14%this year from 2008, the writer reports (based on information from the national residency matching program).

But the story also points out that some of the nation’s most revered medical schools might not be ready to train new family medicine practitioners. Johns Hopkins, Columbia, Yale, and Harvard have no family medicine departments, although some do offer concentrations in primary care and general medicine.

And why does any of this matter? Well, the Affordable Care Act and our nation’s changing health care needs are demanding more of an emphasis on preventative care (as opposed to treating a problem once it gets bad, and often more expensively), not only as a way to bring down costs but also because it’s just better for patients. But we’ve got what many experts call a shortage of primary care doctors now, and we’re not turning new primary care doctors out fast enough to fill the projected gap (some say that gap will be tens of thousands in just a couple of decades). So it looks like medical schools have a big role to play if we’re going to build the health care workforce we need for the future.

Can Future Docs afford to go into primary care?

Researchers writing in Academic Medicine, the journal of the Association of American Medical Colleges, think so. Or rather, after crunching the numbers – medical school debt load to potential income and expenses – they think medical students who decide to go into primary care as a specialty will be able to pay off their school debt on a primary care doctor’s salary.

But…

That’s for graduates with “median levels” of debt, they say – which is about $160,000 after four years of medical school. The study’s authors write that, out of all the graduates in 2011, 23% of those who went to private medical school left with $250,000 or more in debt. With that kind of debt load, the researchers found it economically unrealistic that a primary care doctor could pay off her loan in 10 years and have enough to live on, especially if she lives in an expensive region of the country. Rather, she might have to enroll in a loan forgiveness program, or extend the repayment period.

Why does this matter? Because there are calls for more primary care doctors coming from, it seems, everywhere these days. Better primary care – meaning annual check ups, a doctor who knows you and follows your health for a while, preventative care, help navigating the world of specialists and more complex health care if you need it – is being billed as the best way to improve our collective health as well as reduce health care costs. That’s opposed to waiting until a chronic condition, for example, sends you to the emergency room because you didn’t see a doctor regularly who could have helped you manage that chronic condition in a way that was better for your health and your bottom line.

But primary care hasn’t been as attractive a specialty for doctors because it’s just not as well paid as other specialties. And with so much debt to pay off after medical school, the thinking has been that doctors will choose a high paying specialty to help pay it off. Still, the data doesn’t necessarily bear that assumption out.

What Future Docs I meet tell me is that they really want to find the specialty that interests them most, that makes them happiest. And many seem to be considering specialties they think are in need right now, regardless of the pay.
They might be interested to know, however, that someone has finally done the math – a pretty extensive economic analysis – to learn whether their idealism can really pay off. Their conclusion in a nutshell:

Our economic modeling of a physician’s household income and expenses across a range of medical school borrowing levels in high- and moderate-cost living areas shows that physicians in all specialties, including primary care, can repay the current median level of education debt. At the most extreme borrowing levels, even for physicians in comparatively lower income primary care specialties, options exist to mitigate the economic impact of education debt repayment.

Future Docs 4: Thinking specialties, gaining real experiences

We’re checking in on our Future Docs Sarah and Peter, whom we’re following all year to learn more about becoming a doctor in today’s changing health care landscape. They’re half way through their second year of medical school now, and they’re already grappling with career decisions and the realities of a hospital’s sickest patients.

Transcript
Sarah Rapoport is a second year student at Brown University’s medical school. She’s 24, a New Yorker, and already an accomplished scientist. When we last checked in with her, she was waiting for her cardiology exam results and had just started doing shifts in an emergency department. She did great. Now, she’s thinking about her future.

“It’s constantly a conversation in the back of my head,” she says.

And the conversation—about what area of medicine she should specialize in—goes something like this:

“If I meet a doctor, I want to know how they chose that specialty, how they knew that was the right decision for them, why do they love it? I really want to find something that I will love every day of my life.”

Rapoport will spend the rest of her two and a half years in medical school at Brown University gaining clinical experience in a wide range of specialties. But she’ll have to choose one when she begins her residency training after graduation. If she picks something like general surgery, she can still specialize even further later on. But Rapoport says she’s already looking for clues to help her decide.

“Someone once told me to just pay attention to what you enjoy. And I think there’s a lot of wisdom in that, that you can be surprised by what makes you happy.”

Before last year, Rapoport says she never would have thought that radiology would interest her.

“But last year when we had our anatomy class, whenever we would dissect a certain part of the body we would also learn how to read the CT and X-ray images that correlated. I loved the CTs and the x-rays. I thought they were so beautiful.”

The artist in her appreciated those images. But the scientist in her loved the unit on cardiology – the physics of the heart pumping blood. Still, what interests her in the classroom might look a lot different when it comes to hands on experience with patients with real medical problems. But sometimes, it’s not so different. Part of Rapoport’s schedule this year includes shadowing a doctor at Rhode Island Hospital. And twice in the past month, she says she’s seen patients who seemed to walk right out of her textbooks.

“There was a man who had come in in DKA, which is diabetic ketoacidosis, so someone who is a diabetic but somehow for whatever reason, their glucose is through the roof. Usually glucose is supposed to be no more than 125. And this patient came into the hospital with a glucose reading of 570 something.”

Rapoport says it was thrilling to recall the classic DKA symptoms she’d studied in class—a fruity odor on the breath, blood sugar through the roof, frequent urination—and observe each one in this patient. Thrilling but tough to watch a patient suffer. On another shift a man with jaundiced skin and a bulging belly showed up on her unit. She recognized the signs of end-stage cirrhosis of the liver.

“I’d heard of everything he was telling me. But in terms of hearing it from someone who personally was experiencing it and struggles with what all of these symptoms are, that was new.”

She’ll never forget him. It was also one of the first times she encountered a patient whose disease was so severe there wasn’t much doctors could do. She knows there’s no way to be fully trained for those kinds of situations, but she can practice other skills…like putting in stitches, or sutures. All she needs is a fruit bowl.

“The bananas I sutured probably wouldn’t pass the test of my putting them in the fruit bowl and someone not realizing that they had been sewn back together. But maybe that’s something to aspire to.”

This is the busy café on Brown medical school’s first floor where I met another Future Doc, Peter Kaminski, who you might remember. He’s also a second year student at Brown, the one who listens to lectures at double speed on his computer. Kaminski has been exploring his own interests. He says he’s pretty clear that he wants to specialize in some kind of pediatric medicine. And he’ll have lots of opportunities to gain experience in that field over the next two years. But he says he hasn’t gotten as much exposure to something else he loves: health care policy. Namely, the nation’s changing—and, he says, broken—health care system. So he and a few fellow students launched a lecture and discussion series to fill in some of the gaps.

“What me and this team of medical students have done our best to do is try to line up a variety of speakers from the area and also just nationally to talk about topics as diverse as Medicare, Medicaid, the development of community health centers, private health insurance, and things like the Affordable Care Act.”

Kaminski says turnout has been so high they’ve moved to a bigger lecture hall. And he says that signals how closely his peers are following the implementation of the Affordable Care Act—legislation that’s reshaping the national health care landscape.

“I think they don’t just have their eye on it. I think they’re intent on being the creators of change. I mean we recognize that things are going to change one way or another, whether we want them to or not. But with that comes tremendous opportunity to reshape things in a way that has tremendous benefit, not only to patients, providing direct care, but family members, and also to providers as well. It’s hard work taking care of a population when the system’s really not functioning the way it should. And if we can provide better health care more affordably and in an easier fashion, that makes our lives easier too,” says Kaminski.

So, he runs this lecture series, plus another extracurricular project he helped launch that pairs undergraduates with senior citizens in the community who need a health care advocate. And he still manages to have fun.

“I’ve been learning tango for the past two months.”

That’s right. Tango lessons.

“When I was in high school I was very into singing and sailing. And my friends used to joke about me becoming a wandering troubadour at some point.”

So perhaps he’ll be a wandering troubadour who also happens to practice medicine, shape health care policy, and advocate for vulnerable patients. But will all these extracurricular activities look good on his transcript—and help him get into a good residency program?

“Maybe they might help me. Maybe some residency directors will look at them and just think I’m very good at distracting myself. But to be honest I’m not really doing it for anybody other than myself or my sense of the fact that I live in this community, I want to be an asset to this community, and if I can provide some beneficial service then I’m going to do that.”

Future Docs Peter Kaminski and Sarah Rapoport are wrapping up the first half of their second year of medical school. They’ve learned the basics of nearly every kind of physical exam. How to interview patients about what’s wrong. How the body’s major systems function and what happens when they’re not working right. They’re just beginning to call on all of this new knowledge on the hospital ward. But next semester, they’ll have to put it to a much scarier test: the first major licensing exam of their careers.

Duty hours: still up for debate?

Medical residents still work loooong hours, longer than most of us will ever work in a single week at a paying job: 80+ hours. But that’s down from much longer work-weeks, a mandate from the Accreditation Council on Graduate Medical Education (ACGME) after complaints that long hours were contributing to woozy residents, too sleepy to make the best decisions for their patients.

But in a recent New England Journal of Medicine article, NEJM editorial fellows Lisa Rosenbaum, M.D., and Daniela Lamas, M.D. argue that the ACGME may have implemented those new duty hour rules too hastily. Where, they ask, is the careful weighing of the evidence and examining of options that doctor-scientists hold so dear?

The ACGME acknowledges that the need to create a uniform standard has forced the development of rules that cater to the lowest common denominator, rather than allowing each specialty to mold an environment that suits its trainees’ learning needs and ambitions. “Standards are standards, and we tried to be flexible,” says Ingrid Philibert, ACGME senior vice president, “but my sense is we’ve created a rigid monster without flexibility.”

So what exactly should the ACGME go back to the drawing board on? Rosenbaum and Lamas say it’s the bigger picture that needs examining.

Both short-term and long-term outcomes should be considered. For instance, when assessing work hours, do we look at safety within the confines of a 16-hour shift, or can we examine the effects of a bad handoff 6 months after the fact? Equally critical, how do we understand what will happen 5 years down the road, when today’s trainee is suddenly facing 100-hour workweeks because that’s what it takes to get the work done?

Residents I’ve spoken to seem to have mixed feelings about the new duty hour rules, too (new, in that they were just revised last year and are taking effect now). They want to learn everything they need to in order to take the best care of patients, and some say that just takes a varying amount of time. I’d love to hear what others think.

Future Docs 3: The changing face of residency

Anne Kuritzky, 3rd yr resident, begins morning rounds.

After medical school, most doctors go through a kind of on-the-job training called residency. Residency programs have been around for a while, but some recent changes in those programs are impacting not only how residents practice but how patients receive care. So in the next Future Docs story, we take a look at residency from two angles. First, we meet third year general surgery resident Anne Kuritzky, who takes us on morning rounds on the surgical intensive care unit. Then, I join our Morning Edition host Elisabeth Harrison in the studio to talk about the showdown ahead on Capitol Hill over residency program funding and the changing needs driving residency specialization.

Transcript:
Residents still spend several years learning their specialties on the job from more experienced doctors. And they still get nervous their first night on duty.

“Oh my gosh, I was terrified!”

Meet Anne Kuritzky, a third-year resident in general surgery at Rhode Island Hospital. She’s remembering her first shift, her first year as a resident.

“I was there by myself overnight, which, now, wouldn’t be, in the new rules you can’t do that,” Kuritzky explains.

The new rules Kuritzky’s talking about say you can’t be there by yourself anymore. They’re established by the organization that accredits residency programs.

“That first night, when it got to be like 6 pm, and everyone else was like, ‘Alright, we’re going home.” And I mean, like, there are people at home you call if you have problems and stuff. But, it’s a little bit like, ‘OK. Now we’re getting into this. Now we’re going to do this.’”

Morning rounds team on the SICU

And she got through it. With this simple goal in mind.

“You just want to make sure that you make it to the next day and so do all the patients. And you feel like, if that happens, you’ve won,” says Kuritzky.

Of course, there’s much more to it than that. As a general surgery resident, Kuritzky has been busy learning how to do everything from remove a gallbladder to how to care for patients after an operation—with more supervision. This morning, she’s about to begin morning rounds on the surgical intensive care unit.

“I’m here kind of starting my 24-hour shift…”

…Yep. A 24 hour shift. It sounds long – and it is. But, in fact, the number of hours residents can work has shrunk. Rules about duty hours were revised just last year because of concerns about residents not getting enough sleep. Now, they can only work 80 hours a week, on average. And some experts worry even that’s not enough to learn what you need to know. Which you learn, in part, by doing this:

“And so what we do is with my attending, and then we have a nurse practitioner and then also a critical care fellow,” Kuritzky explains, “we’ll go around as a group and we’ll talk about every patient in kind of a systems-based fashion and figure out what their plan is for the day.”

Translation: they’ll gather outside each patient’s room to talk about not only the surgery he’s recovering from, but how every system in his body is working. There’s something new about these morning rounds, too. That group Kuritzky mentions is a multi-disciplinary team, including a pharmacist and a nurse. The idea is to share information and make better decisions about a patient’s care. Just a couple of decades ago, a resident and her attending physician might not even know the names of the nurses on their ward, let alone ask them to join in. On this shift, Kuritzky kicks things off by presenting the patient to the others.

Patient rooms on the SICU ward

“OK,” Kuritzky says, “so first up, we have a 78 year old male.”

Attending physician Shea Gregg, Kuritzky, and the rest of the group circle up around a computer on wheels, just out of earshot of the patient. Because this conversation is for the doctors. The patient is an older gentleman recovering from some abdominal surgery. He’s resting in an arm chair just inside his room.

“Ok, pulmonary?” Gregg asks.

Gregg challenges Kuritzky to consider other possibilities, checks her understanding.

After they wrap up the presentation, it’s time to talk to the patient. Dr. Gregg leads.

“You feel better today? You look better,” Gregg says.

He was feeling a bit better, actually. And Kuritzky will be watching over him through the night. But in the meantime, there are seven more patients waiting to be seen. Orders to be written. Paperwork to complete. And it’s time to move on.

Attending physician Shea Gregg checks the patient’s scans.

Next up: Morning rounds and the changing face of residency

Anne Kuritzky presenting a patient to her attending on morning rounds in the SICU.

Coming up next in Future Docs, meet third-year surgical resident Anne Kuritzky. This Thursday on Morning Edition on Rhode Island Public Radio, join Anne on her morning surgical rounds, and then join me right after for a brief discussion about what’s changing for residency programs and how that affects patients and doctors.

Here’s a preview: just a couple of years ago, Anne was an intern – a first year resident. Back then, she was allowed to be the only doctor on duty, on the floor, overnight. Today, that isn’t allowed any more. Also, the number of hours she can work were recently limited to 80 a week (still sounds like a lot, right?). And morning rounds aren’t just for attending physicians and residents anymore; they’re multidisciplinary. That means a pharmacist might be discussing your plan of care with the attending, too – a sight you might not have seen on the wards just 10 years ago.

 

And next up, we’ll check in with second-year medical students Sarah Rapop0rt and Peter Kaminski. They’ve just wrapped up a section on the human reproductive system (yes, there were jokes), and now they’re looking ahead to a holiday season that includes hitting the books as much as the cranberry sauce.

Brown med school dean steps down

Ed Wing, dean of medicine and biology at The Warren Alpert Medical School of Brown University, will be stepping down at the end of this academic year. He’ll return to Brown after a sabbatical to continue teaching, researching, and writing. Meanwhile, the university will launch a national search for his replacement.

Ed Wing, stepping down as dean. Photo courtesy Brown University.

Under Wing’s nearly five-year tenure, the school increased its enrollment and welcomed its largest medical school class ever this. The school moved into its new home in the Jewelry District. And it made strides in deepening its international and public health curriculum. From the 2008 press release announcing his appointment, here’s what he was responsible for during that time:

Brown’s Division of Biology and Medicine is the center of Rhode Island’s biomedical research and medical education enterprise. With an annual budget of $129 million, 769 campus- and hospital-based faculty, and more than 1,200 community-based faculty, the division oversees 660 undergraduate students and more than 1,000 medical residents, fellows, graduate students, postdoctoral students and medical students. The division is composed of The Warren Alpert Medical School, the Program in Biology, and the Program in Public Health.

So, Wing’s replacement is important to more than just Brown med students – our “future docs,” – but also to the many residents, faculty, patients, and more who will be under his or her leadership.