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Editorials

Last 50 Editorials

(Click on title to be directed to posting, most recent listed first)

Medicare for All-Good Idea or Political Death?
What Will Happen with the Generic Drug Companies’ Lawsuit: Lessons from
   the Tobacco Settlement
The Implications of Increasing Physician Hospital Employment
More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
Disclosures for All 
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
   Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy 
Breaking the Guidelines for Better Care 
Worst Places to Practice Medicine 
Pain Scales and the Opioid Crisis 
In Defense of Eminence-Based Medicine 
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now 
Mitigating the “Life-Sucking” Power of the Electronic Health Record 
Has the VA Become a White Elephant? 
The Most Influential People in Healthcare 
Remembering the 100,000 Lives Campaign 
The Evil That Men Do-An Open Letter to President Obama 
Using the EMR for Better Patient Care 
State of the VA
Kaiser Plans to Open "New" Medical School 
CMS Penalizes 758 Hospitals For Safety Incidents 
Honoring Our Nation's Veterans 
Capture Market Share, Raise Prices 
Guns and Sleep 
Is It Time for a National Tort Reform? 
Time for the VA to Clean Up Its Act 
Eliminating Mistakes In Managing Coccidioidomycosis 
A Tale of Two News Reports 
The Hands of a Healer 
The Fabulous Fours! Annual Report from the Editor 
A Veterans Day Editorial: Change at the VA? 
A Failure of Oversight at the VA 
IOM Releases Report on Graduate Medical Education 
Mild Obstructive Sleep Apnea: Beyond the AHI 

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.

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Entries in medical education (3)

Thursday
Dec242015

Kaiser Plans to Open "New" Medical School 

The not-for-profit health maintenance organization (HMO) giant, Kaiser Permanente, announced plans to open a medical school in Southern California with the first class expected to enroll in the fall of 2019 (1). Kaiser is taking the unusual step of creating its own medical school instead of partnering with a university like recent deals made by North Shore-Long Island Jewish in New York and Beaumont Health in suburban Detroit. “We're not just launching another medical school,” Kaiser CEO Bernard Tyson said. “This is really a medical school in which we're bringing forward all the knowledge and wherewithal we've accumulated over the years as our physicians continue to innovate and drive population health and individual health.” Kaiser still has to work through the details of how the school will be funded and the amount of their investment. Kaiser's annual revenue was $56.4 billion last year, with an operating income of $2.2 billion (2).

Kaiser also announced that Dr. Christine Cassel would leave her role as CEO of the National Quality Forum to lead a team tasked with designing the school's teaching approach (1). Until 2013 Cassel was President and CEO of the American Board of Internal Medicine.

The Association of American Medical Colleges (AAMC) estimates a shortage of between 45,000 and 90,000 U.S. physicians by 2025 (3). “The opening of a new medical school will help address this shortage,” Dr. John Prescott, AAMC chief academic officer. However, Kaiser’s announcement is just the first step in building and operating a medical school, which must be accredited by the Liaison Committee on Medical Education, recognized by the U.S. Department of Education as the reliable authority for accrediting medical schools. “It’s a multistage process of moving from an idea to a fully accredited medical school,” Prescott said. “What Kaiser has done is announce its intentions. It’s years away from being a fully accredited school.”

Health care experts say opening its own medical school will provide a steady stream of physicians trained in the "Kaiser way" – a team approach of doctors, nurses, therapists and social workers working on behalf of patients (1). Prescott noted that the establishment of a school was a logical step forward for Kaiser (2).

Commercial interests are becoming increasingly involved in medical education. The University of Arizona's College of Medicine-Phoenix medical school was cited in June by the AAMC in four areas that needed to be addressed to avoid probation or loss of accreditation (4). Two of the four areas stemmed from uncertainties about Banner Health's alliance with the medical school after completing a $1 billion-plus acquisition of the two-hospital University of Arizona Health Network in Tucson.

The question is whether medical education will be independent from commercial interests. The physician should be first and foremost the patient’s advocate. However, the perception of many physicians is they are increasingly impaired in this role by the healthcare delivery systems in which they practice. A major concern is whether financial concerns of healthcare delivery systems might be the real motivation behind corporate interest in medical education. This conflict of interest should be a major concern to the AAMC and raises the important question of who will determine the medical education program in Kaiser's medical school-Kaiser or an independent medical school faculty?

Being a physician is a profession. Doctors should be trained to be doctors, not to be employees of healthcare delivery systems. The tone of the announcement is that Kaiser plans on training the latter.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Rubenfire A. Kaiser plans to take care model to the source: physician training. Modern Healthcare. December 17, 2015. Available at: http://www.modernhealthcare.com/article/20151217/NEWS/151219881?utm_source=modernhealthcare&utm_medium=email&utm_content=20151217-NEWS-151219881&utm_campaign=am (accessed 12/18/15).
  2. Terhune C. HMO giant Kaiser Permanente plans to open a medical school in Southern California. Los Angeles Times. December 17, 2015. Available at: http://www.latimes.com/business/la-fi-kaiser-school-of-medicine-20151217-story.html (accessed 12/18/15).
  3. Gordon LK. Managed care giant Kaiser to open medical school. Yahoo! Health. December 18, 2015. Available at: https://www.yahoo.com/health/managed-care-giant-kaiser-to-1323494699909174.html (accessed 12/18/15).
  4. Alltucker K. UA pursues medical-school fixes for accreditors. Arizona Republic. December 10, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/12/10/ua-pursues-medical-school-fixes-accreditors/77106640/ (accessed 12/18/15).

Cite as: Robbins RA. Kaiser plans to open "new" medical school. Southwest J Pulm Crit Care. 2015;11(6):275-6. doi: http://dx.doi.org/10.13175/swjpcc156-15 PDF 

Sunday
Jul242011

Changes in Medicine: Residency 

Reference as: Robbins RA. Changes in medicine: residency. Southwest J Pulm Crit Care 2011:3:8-10. (Click here for a PDF version)

The most important time in a physician’s educational development is residency, especially the first year. However, residency work and responsibility have come under the scrutiny of a host of agencies and bureaucracies, and therefore, is rapidly changing. Most important in the alphabet soup of regulatory agencies is the Accreditation Council for Graduate Medical Education (ACGME) which accredits residencies and ultimately makes the governing rules.

Resident work hours have received much attention and are clearly decreasing. However, the decline in work hours began in the 1970’s before the present political push to decrease work hours. The residency I entered in 1976 had every third night call during the first year resident’s 6-9 months on general medicine or wards. It had changed from every other night the year before. On wards, we normally were in the hospital for our 24 hours of call and followed this with a 10-12 hour day before going home and getting some well needed sleep. The third day was again a 10-12 hour day before repeating the cycle. This averages over 100 hours per week. There was one week of paid vacation and days off were rare. Both days off and vacations were expected to be done on electives.

First year residents were often poorly supervised despite a senior resident being on call with every 2 interns. Attending physicians were never in the hospital at night. I remember being told by a senior resident, that he was going to bed but I could call him if there was an emergency I could not handle-but he expected me to handle any emergency. I got the message not to call him.

The reduction in work hours was driven by residency directors trying to recruit sufficient residents to fill their slots. Residencies that required every other night call or had indigent level salaries were quickly becoming noncompetitive. By the time I left residency after 3 years, call had decreased to every fourth or fifth night and salaries had risen from about $10,000/year to $14,000/year for first year residents.

The reduction in work hours was brought to public attention and accelerated by the Libby Zion case of 1984 (1). The 18 year old Zion died from a complication of the monoamine oxidase inhibitor she had taken prior to hospitalization exacerbated by administration of meperidine and possibly by cocaine. When her father, Sidney Zion, a journalist/lawyer, learned that her doctors had been medical residents covering dozens of patients and receiving supervision only by phone, he became convinced his daughter's death was due to inadequate staffing at the New York teaching hospital where she died. Determined to ensure that others not fall victim to the same gaps that he blamed for his daughter's death, he crusaded to change resident work hours and supervision with frequent editorials and public appearances.

Over several years a sequence of events occurred to keep Zion’s death in the public eye: a grand jury was called to investigate Zion’s death; the New York State health commissioner appointed the Bell Committee to make recommendations regarding work hours; and a civil lawsuit against the doctors and hospitals was filed by Sidney Zion. All deemed the hospital negligent for leaving a first year resident alone in charge of 40 patients that night. The Bell Commission recommended that residents could work no more than 80 hours a week or more than 24 consecutive hours and senior physicians needed to be physically present in the hospital at all times and these recommendations were adopted by New York State.

The ACGME under political pressure to deal with resident work hours, appointed the Work Group on Resident Duty Hours and the Learning Environment in September 2001. The work group recommended new ACGME standards that were remarkably similar to those of the Bell Commission and these were adopted by the ACGME in 2003 (2).

The rationale behind the work hour reduction is that by working fewer hours and under greater supervision the care delivered by more rested and supervised residents will be better. A tragedy, in addition to Ms. Zion’s death, is that 27 years later we still do not know if this basic premise is true. Although the reduction in resident work hours and the in house presence of attending physicians has undoubtedly increased costs, the impact on length of stay and mortality remain largely unknown (3). The observational, retrospective research that has been done on the impact of resident hour reduction has been sufficiently flawed to make conclusions difficult (4-6). This is unfortunately part of a common trend in administrative medicine, i.e., to initiate changes based on political pressure and later attempt studies to justify the changes.

Concern has been voiced that reduction in work hours and autonomy due to increased supervision may compromise resident education (7). Although there would appear to be little evidence to date supporting this one way or another, I add my voice to those who raise this concern. Making independent decisions is vital to the maturation of residents to independent physicians. The present trend of reducing work hours and increasing supervision, may delay that learning experience to the first year or two of independent practice where correction and constructive criticism are unlikely to occur.

As work hours of residents decline, as medical knowledge expands, and as medical care becomes more complex our residencies will be hard pressed to train competent physicians. One approach is to lengthen the residencies to compensate for the reduced work hours (8). Adding another year or two of residency and/or fellowship is nothing more than extending the indentured servitude of residents to teaching hospitals. 3-6 years of post-graduate training is enough and extending the resident’s time may be more to provide adequate in house coverage than to improve the residents’ education.

I would recommend some carefully designed studies to investigate the impact of shorter work hours. The impact on mortality and length of stay should be examined along with the resident’s fund of knowledge. Perhaps armed with some sound data policy makers can make sound decisions regarding resident education, something we might call evidence-based medicine.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Lerner BH. A Case That Shook Medicine. The Washington Post, November 28, 2006. Available at http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html

2. Friedmann P, Williams WT Jr, Altschuler SM, et al. Report of the ACGME Work Group on Resident Duty Hours. 2002. Available at: http://www.acgme.org/DutyHours/wkgroupreport611.pdf

3. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360:2202-15.

4. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004;351:1838-48.

5. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:975-83.

6. Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH. Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298:984-92.

7. McCoy CP, Halvorsen AJ, Loftus CG, McDonald FS, Oxentenko AS. Effect of 16-hour duty periods on patient care and resident education. Mayo Clin Proc. 2011;86:192-6.

8. Larson EB, Fihn SD, Kirk LM, Levinson W, Loge RV, Reynolds E, Sandy L, Schroeder S, Wenger N, Williams M; Task Force on the Domain of General Internal Medicine. Society of General Internal Medicine (SGIM). The future of general internal medicine. Report and recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004;19:69-77.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.

Friday
Jul152011

Changes in Medicine: Medical School 

Reference as: Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7. (Click here for a PDF version)

I recently retired and have been encouraged to write about what has changed in medicine. However, the changes have been sufficiently extensive that one editorial would be too long. Therefore, this will be the first of several editorials examining medical school, residency, fellowship and practice.

The beginning of my own medical career was 1972 when I entered medical school, graduating in 1976. My reasons for choosing the specific school I entered were several: 1. A scholarship was provided that paid tuition; 2. It was a state school and otherwise relatively cheap; 3. The school would accept me after 3 years of college and without a college degree; 4. It was the medical school of my undergraduate school and I knew many of the entering students; and 5. I was told that it mattered less where you did your medical school training than where you did your residency. I saw no reason to delay admission to obtain a college degree and wanted to proceed with my medical education.

Most medical students in 1972 were like me, white and male. The most obvious change in the past 40 years has been the increasing number of women. My class of about 150 had only a few, maybe 5, women. The percentage of women graduates has gradually risen until in 2009-2010, women received 8,133 (48.3%) of the 16,838 MD’s awarded (1). However, the numbers of underrepresented minorities has not kept pace with the increasing percentage of women. The number of blacks graduating from medical school has modestly risen from about 700 in 1980 to a little over 1109 in 2008 with a rise in Hispanics from a few hundred in 1980 to 1183 in 2008. Yet those numbers still only represent 6.9% and 7.3% of medical school graduates, respectively, far below the 12% for blacks and over 15% for Hispanics of the general population (2,3).

Over 30 years of academic medicine I have not observed much change in the medical students’ abilities by the time I see them on a pulmonary or critical care rotation their senior year. The high numbers of applicants suggest that medical school acceptance is still difficult and the mean grade point average from college of an entering student is still well above 3.5. There has been little significant change in medical school education since the Flexner report in 1910 (4). Most medical schools still consist of 2 years of pre-clinical and 2 years of clinical education just like it did when I matriculated way back in 1972-6.  There have been the occasional novel educational programs in medical schools such as 3 year programs, a combined 6 year undergraduate and MD, or earlier clinical introduction, but most of these have fallen by the wayside. I’ve witnessed graduates from several of these programs and these medical education experiments do not seem to have adversely affected the medical students’ performance by the time I see them their senior year. I still find them bright, enthusiastic and articulate and ready to continue their journey to becoming doctors as house officers.

However, a major change which may be influencing medical training and career choice is the debt incurred by medical students. Although poverty was common in my class of 1976, large debt was rare. Now approximately 86 percent of U.S. medical students graduate with some debt, and of those, the average debt is almost $160,000 (6). Students at Doctor of Osteopathy (DO) schools appear to be particularly hard hit. In the US there are only 26 osteopathic schools compared to 133 allopathic medical schools that offer the MD degree. Yet, 6 of the top 10 medical schools that lead to the most medical student debt are osteopathic schools. Medical students graduating from those 6 schools averaged over $198,000 of indebtedness in 2009 (7). It has been claimed that this debt is a major influence on residency choice with fewer students going into residencies as primary care physicians because of their debt (7). However, medical student debt seems less likely to influence residency choice since most residencies pay about the same. Rather it seems that income potential after completing training may be having some influence. Primary care physicians often receive incomes half of some specialists (6).  Medical students realize this income differential and for some may be a major influence on choosing a specialty.

The concern that medical student indebtedness can influence the rest of their careers has been voiced by many and I echo this concern. This is especially true given that medical students face at least 3 years as a house officer, where salaries of about $50-60,000/year is insufficient to allow quickly paying off student loans. Although it seems unlikely that the high cost of some medical schools can be justified, I would not suggest Government cost regulation of medical school fees. My own experience with over 30 years of Government bureaucracy is that inevitably they will dictate medical curriculum based on politics, rather than science. Instead, I would propose a system of relieving medical student debt by allowing some students to obtain debt forgiveness by Government service. More on this in the later editorials in this series.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

  1. https://www.aamc.org/download/153708/data/charts1982to2011.pdf (accessed 7-10-11).
  2. http://www.scribd.com/doc/53281274/Minorities-and-Medical-Education-AAMC-Facts-and-Figures (accessed 7-10-11).
  3. Cammarata J. Minorities in Medicine: Still an Unmet Need. Medscape 2010 http://www.medscape.com/viewarticle/720541 (accessed 7-10-11).
  4. Flexner A. Medical Education in the United States and Canada, 1910. Available online at http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf (accessed 7-10-11).
  5. http://www.washington.edu/uaa/advising/downloads/gpamcat.pdf (accessed 7-10-11).
  6. Prep V. Weigh Medical Student Debt, Specialty Choice. US News and World Report.  2011. Available on line at http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2011/06/20/weigh-medical-student-debt-speciality-choice (accessed 7-10-11).
  7. Hopkins K. 10 Medical Schools That Lead to Most Debt: Some students are graduating with more than $200,000 in debt. US News and World Report. 2011. Available online at http://www.usnews.com/education/best-graduate-schools/articles/2011/04/14/10-medical-schools-that-lead-to-most-debt (accessed 7-10-11).
  8. Back PB, Kocher R. Why Medical School Should Be Free. New York Times. 2011. Available online at http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=2&ref=contributorshttp://www.nytimes.com/2011/05/29/opinion/29bach.html (accessed 7-10-11).

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.