By Jaan Sidorov, MD

I remember when one of my patients with coronary artery disease suggested that he be given a course of an antibiotic to lower his future risk of a heart attack. The patient had done his homework, quoting literature that pointed to a possible infectious link to atherosclerosis. He also was aware of the theory that aspirin’s benefit had less to do with blood thinning than reducing underlying inflammation.

Fast forward to the Feb 2-8 Economist that has an editorial pointing out that U.S. legal expertise may not require the completion of three years of law school. Why not, it asks, cut the requirement back to two years or, even better, skip the school requirement entirely and license anyone who can pass the bar exam?

And then there’s the Feb. 11 Wall Street Journal, where “Notable and Quotable” refers to the “BA Bubble.” Charles Murray argues that a looming oversupply of college graduates may portend a decline in the employment value of a liberal education. Work careers may consist of serving as ”apprentices” and “journeymen” before becoming ”craftsmen.”

All of which makes me wonder if the vaunted Doctor of Medicine degree may be vulnerable.

Why should physician education be immune from a perfect storm of over-priced graduate education, “alternative” web-enabled learning with on-the-job-training? The declining value of the formal credential may be less about the university degree and more about competency, turbocharged by flexible licensing and a discerning consumer.

Non-physician health care professionals are arguing that their expertise is enough to enable them to deliver babies, administer anesthesia, prescribe drugs and perform surgery. My traditionalist colleagues argue that patient safety is at stake and that lay persons may not be able to discern all of the possible risks, benefits and alternatives. When things go occasionally wrong in the delivery suit, operating room or with a drug, they say a credentialed and experienced doc can make the difference between life and death.

Continue reading “The Rise of the Non-Physician Expert”

By Peter Ubel, MD

If Americans judged the quality of hospital care the way Newsweek judges high schools, we would soon be inundated with “charter hospitals” that only treat healthy patients.

As reported in The New York Times, thirty-seven of Newsweek’s top 50 high schools have selective admission standards, thereby enrolling the cream of the eighth grade crop. That means that when these high scoring eighth graders reach eleventh grade, they’ll be high scoring eleventh graders, helping the school move up the Newsweek rankings. These selective admission schools simply have to avoid screwing up their talented students.

That’s no way to determine how good a school is. The measure of a good education should be to assess how well students did in that school compared to how they would have been predicted to do if they had gone to other schools.

Imagine two liver transplant programs, one whose patients experience 90% survival in the year following their transplant and the other whose patients experience only a 75% survival rate. Based on that information, the former hospital looks like the place to go when your liver fails. But aren’t you curious about the kind of patients that receive care in these two hospitals? Wouldn’t you want to know whether that first hospital was padding its statistics by selectively transplanting relatively healthy patients?

Continue reading “Getting Quality Right: Exercise Due Caution When Grading Hospitals, Schools and Doctors”

By Peter Pronovost, MD

Nearly a year ago, one of my blog posts bemoaned a gap in our training of future physicians—a lack of training in the skills needed to lead projects in patient safety and quality improvement.

I wrote the post after speaking to a group of medical students who were energized about this area of work. Yet, as I reflected on the talk:

“I had to confront the sad reality that most of them will graduate ill-prepared to lead the improvements of quality and safety our health care system needs. They no doubt will know chemistry, biology and physiology, but they may not know about human factors, implementation science or performance measurement—the language of quality improvement. They will know orthopedics and genetics but they won’t know teamwork and systems engineering. They likely know about German scientist Rudolph Virchow, the father of cell theory, yet they do not know John Kotter, the father of change theory whose model for leading change is highly effective and widely used.”

So how can medical students, residents and fellows make quality improvement and patient safety a focus of their clinical careers? On Nov. 10, the Armstrong Institute and the American College of Medical Quality will be hosting the National Workshop on Quality for Medical Education—affordable and open to anyone—that focuses on how medical students, residents and fellows can integrate safety and quality into their clinical careers. What career paths exist? What tools and skills are needed to carry out this work, and where do you get them? What kinds of quality and safety projects are residents and students taking on?

Continue reading “Training Future Physicians in Safety and Quality”

By David Whelan

There’s a larger question here about why the scholarly world allows itself to be judged by secretive Scandinavian committees sitting on endowments funded by money made selling explosives. But let’s put anti-Nobel polemics aside.

The announcement today that Alvin Roth and Lloyd Shapley won this year’s award in economics came with the explanation that they had devised systems for matching buyers and sellers that led to more rational outcomes than existing markets.

Shapley, a contemporary of “A Beautiful Mind’s” John Nash, introduced an elegant theory 50 years ago to explain the (relative) stability of marriage pairings despite the fact that individuals have complicated preferences when choosing a mate. Shapley’s idea is that the person you end up with is the best match given everyone else’s preferences.

You might prefer someone else more than your current mate, but that person has you lower on her list, and so on. Imagine Larry. If he could Larry would have definitely married Elizabeth Taylor. But she was taken so now Larry is happy with his actual wife. (To sum it up in a way that would make an economist cringe.)

Alvin Roth built on that early theory. He designed actual markets that used the matching principle, also known as the deferred acceptance algorithm, as a guiding principle. The most famous example of a Roth market is the Residency Match.

Medical residency is a job that lasts three to seven years, depending on the program, and follows graduation from medical school. It is required for a doctor to complete a residency in order to be licensed to practice.

In the “old days” medical students would apply to hospitals and rank their preferences in a way that was visible to those institutions. A hospital would first review those applicants who had indicated them as the first choice. If spots remained to fill, a hospital would then look at those who had picked it second, and so on. You can quickly see how this system punished people who shot high and missed. They would end up at one of their last choices because the best places would fill up quickly.

Continue reading “Alvin Roth Receives Economics Nobel For Flawed Residency Match System”

By Kent Bottles, MD

1. You Will Have to Move a Lot

I went to medical school in Cleveland and did myj pathology residency in San Francisco at UCSF.  I was on the medical school faculty at UCSF, Iowa, Allegheny University of the Health Sciences, and Michigan State.

Since leaving academic medicine, I have worked at a bio-tech start up in Cambridge, an educational and research institute in Grand Rapids, a $2 billion integrated delivery system in Iowa, and an evidence-based medicine consortium in Minneapolis.

In my experience physician executive positions do not always last a long time because the environment changes, my career aspirations changed, and getting the job done sometimes means alienating enough people to get in the way of long job tenure.

2. You Will Have to Reinvent Yourself Over and Over Again

My main professional roles have included: medical school pathology course master, surgical pathologist, division head, vice chair of academic department, chair of academic department, medical director of managed care, corporate operations officer of ambulatory care, special assistant to the president of a big ten university for managed care, search consultant, chief knowledge officer of a genomics bio-tech start up, president and ceo of an educational consortium, chief medical officer of a delivery system, president and ceo of an evidence based medicine institute, and health policy professor at a school of population health.

Continue reading “Eight Things I Keep Wishing Med School Had Taught Me About Business”

By Marion Nestle

Yesterday, New York City Mayor Michael Bloomberg announced a ban on sales of sugary drinks larger than 16 ounces in restaurants, delis, sports arenas, and movie theaters.

The reactions have been ferocious, and not only from the soda industry, which placed an ad in the Times (see below).

The New York Times also weighed in with an editorial arguing that the mayor has now gone too far and should be sticking to educational strategies.

Alas.  If only educational strategies worked.  But they do not.

We know this from what it took to discourage people from smoking cigarettes.  We also know this from research on eating behavior.  This shows that it doesn’t take much to get people to eat too much.

Just barrage us with advertising, put food within arm’s reach, make food available 24/7, make it cheap, and serve it in enormous portions.

Faced with this kind of food environment, education doesn’t stand a chance.

That’s the point the Mayor’s proposal is trying to address, however clumsily.  After all, a 16-ounce soda is two servings.

Sugary drinks—especially large ones—make sense as a target for a portion size intervention.

Continue reading “Mayor Bloomberg’s Soda Ban Proposal Hits the Wall”

By Ilana Yurkiewicz

What does it take to get into medical school today?

High MCAT scores. Pre-requisites galore, coupled with a stellar GPA. Research experience. Clinical experience. Volunteering.

It has become a series of check-boxes, many going through the process gripe. Worse, it’s an exercise in conformity.

Last week at TEDMED, Dr. Jacob Scott shone the spotlight on this system as a root cause of the lack of creativity among people going into medicine.

“You can’t take any risks, or you won’t get in [to medical school] – you won’t get into the club,” he told the audience. But, he continued, that means weeding out creativity. Future doctors are being trained to “memorize certainty,” rather than think imaginatively.

Having gone through the admissions process recently, I could relate to many of Dr. Scott’s sentiments. It’s true: preparing to get into medical school does little to encourage risk-taking. Admission criteria are rigid. And you know if you don’t do what they ask, there is no shortage of others who will.

Want to become a doctor? You can’t slip up, or you’ll fall behind. You can’t rock the boat, or you won’t get admitted.

This critique is not unique to medical education. Scott’s talk reminded me of a speech by former Yale English professor William Deresiewicz to the 2009 plebe class of the United States Military Academy at West Point. Skeptical of modern benchmarks of success, Deresiewicz told the young cadets:

“It’s an endless series of hoops that you have to jump through [to get into college], starting from way back… What I saw around me were great kids who had been trained to be world-class hoop jumpers. Any goal you set them, they could achieve. Any test you gave them, they could pass with flying colors…. I had no doubt that they would continue to jump through hoops and ace tests and go on to Harvard Business School, or Michigan Law School, or Johns Hopkins Medical School, or Goldman Sachs, or McKinsey consulting, or whatever. And this approach would indeed take them far in life.”

Continue reading “Is Medical School Admission Squashing Creativity?”

By Paul Levy

Every day, a 727 jetliner crashes and kills all the people on board.

Not really. But every day in America, the same number of people in American hospitals lose their lives because of preventable errors.  They don’t die from their disease.  They are killed because of hospital acquired infections, medication errors, procedural errors, or other problems that reflect the poor design of how work is done and care is delivered.

Imagine what we as a society would do if three 727s crashed three days in a row.  We would shut down the airports and totally revamp our way of delivering passengers.   But, the 100,000 people a year killed in hospitals are essentially ignored, and hospitals remain one of the major public health hazards in our country.

There are a lot of reasons for this, but I’d like to suggest that one reason is a terrible burden that is put upon doctors during their training and throughout their careers.  They are told that they cannot and should not make mistakes.  It is hard to imagine another profession in which people are told they cannot make mistakes.  Indeed, in most professions, you are taught to recognize and acknowledge your mistakes and learn from them.  The best run corporations actually make a science of studying their mistakes.  They even go further and study what we usually call near-misses (but perhaps  should be called “near-hits.” ) Near-misses are very valuable in the learning process because they often indicate underlying systemic problems in how work is done.

If you are trained to be perfect, it is very hard to improve.

Continue reading “How to Get Better at Harming People Less”

By Mark Schuster, MD

Dr. Mark Schuster is the William Berenberg Professor of Pediatrics at Harvard Medical School and Chief of General Pediatrics at Children’s Hospital Boston. This essay is based on a speech he gave the featured speaker at the Children’s Hospital Boston GLBT & Friends Celebration in June, 2010.

The first time I stood before a large audience to speak was when I was 13 years old. It was at my Bar Mitzvah. I walked up to the podium, looked out over the sea of faces, and thought to myself, I am a homosexual standing in front of all of these people. And I wondered what would happen if I told them.

That was in 1972, and even mentioning the word homosexual, unless paired with an expletive or derogatory adjective, would have been unacceptable at my synagogue. It would have been unacceptable in my home, my school, or any place I knew. I could not have conceived of telling my doctor. I assumed that I would never say out loud that I am a homosexual. The idea that I would someday be able to stand in an auditorium, stand anywhere, just a few miles from where I live with my husband, our two sons, and our dog, with everything but the white picket fence, was not something I could imagine.

Today I stand on a different stage. The Children’s Hospital Boston GLBT and Friends group asked me to share my story as part of its celebration day. How I got here, what I learned along the way, especially at Children’s, and how the world changed — these are what I will talk about.

A decade after I considered turning my Bar Mitzvah into a public confessional, I entered medical school at Harvard. Some students had started a gay group the year before. They had scoped out the territory, searched for role models, and come up nearly empty. In a creaky old closet, tucked way in the back, they found a world-renowned senior physician at Children’s. He advised against starting the group, offering that it was much better to be secretive about being gay so that no one would bother you. I’ve heard that same advice many times from men and women from earlier generations who had fewer options in their day.

Continue reading “On Being Gay In Medicine”

By Victor R. Fuchs

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care.  His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.”  He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist.  Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care.  Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes.

I expressed similar concerns in 1974 in my book Who Shall Live?, but at that time I rejected the claim that the problems of medical care had reached crisis proportion.  In 2011, however, I agree with those who say the need for comprehensive reform must be marked URGENT.  The high and rapidly rising cost of health care threaten the financial credibility of the federal and state governments.  The former finances much of its share of health care by borrowing from abroad; the states fund health care by cutting support of education, maintenance of infrastructure, and other essential functions.  These are stop-gap measures; neither borrowing from abroad nor cutting essential functions are long-run solutions.  The private sector is equally distressed.  Surging health insurance premiums have captured most of the productivity gains of the past thirty years, leaving most workers with stagnant wages.  Not only is there a pressing need for changes in organization and delivery, but Ezekiel Emanuel and I, in our proposal for universal vouchers funded by a dedicated value-added tax, argue that such changes must be accompanied by comprehensive reform of the financing of medical care (Brookings paper).

But that’s not what I want to talk to you about today.  My subject is the urgent need to change the structure of medical education.  It seems to me that such change is necessary, and perhaps inevitable, given the revolution in medicine over the past half century, and given the changes in organization and delivery of care that lie on the horizon.

Continue reading “Rethinking Medical Education”