By BRYAN CARMODY, MD
“YOUR LIKELIHOOD OF SECURING RESIDENCY TRAINING DEPENDS ON MANY FACTORS – INCLUDING THE NUMBER OF RESIDENCY PROGRAMS YOU APPLY TO.”
So begins the introduction to Apply Smart: Data to Consider When Applying to Residency – a informational campaign from the Association of American Medical Colleges (AAMC) designed to help medical students “anchor [their] initial thinking about the optimal number of applications.”
In the era of Application Fever – where the mean number of applications submitted by graduating U.S. medical students is now up to 60 – some data-driven guidance on how many applications to submit would be welcome, right?
And yet, the more I review the AAMC’s Apply Smart campaign, the more I think that it provides little useful data – and the information it does provide is likely to encourage students to submit even more applications.
This topic will be covered in two parts. In the first, I’ll explore the Apply Smart analyses and air my grievances against their logic and data presentation. In the second, I’ll suggest what the AAMC should do to provide more useful information to students.
Introduction to Apply Smart
The AAMC unveiled Apply Smart for Residency several years ago. The website includes lots of information for students, but the piece de resistance are the analyses and graphics that relate the number of applications submitted to the likelihood of successfully entering a residency program.
By HANS DUVEFELT, MD
I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant relative risk reduction but not a big absolute one; the Number Needed to Treat is about 70, so 69 out of 70 patients would take it in vain for the heart failure indication. The NNT for cardiovascular death is around 38 over a three year period – over a hundred patient years for one patient saved). There are already other diabetes drugs that can reduce cardiovascular risk and I see cardiologists prescribing them for non-diabetics.
It’s a bit of a head scratcher and it makes me think of the recently re-emerged interest in the notion of a “Polypill” with several ingredients that together reduce heat attack risk. The tested Polypill formulations are all very inexpensive, which is a big part of their attraction. Jardiance, on the other hand, costs about $400 per month.
The “rep” asked whether this medication would be something I’d be likely to discuss with my diabetic patients.
“Well, you know I’ve only got fifteen minutes…” dampened his expectations. But I told him about the Polypill studies. I think patients are still not ready to make the distinction between on the one hand medications that treat a more or less quantifiable problem like blood sugar levels, blood pressure or the much less straightforward lipid levels and on the other hand ones that only change statistical outcomes. Most of my patients have trouble wrapping their head around taking a $400 a month pill that doesn’t make them feel better or score a whole lot better on their lab test but only changes the odds of something most people think will never happen to them anyway.
By LISE ALSCHULER, ND, FABNO
I am a naturopathic doctor, and because I operate outside of insurance-based medicine, I have, what most healthcare providers would consider, lots of time with my patients. My typical first patient appointment is 90 minutes long and my follow-up visits are 30 minutes long.
What, you may ask, do I do with all this time? I get to know my patients by listening to their stories, their concerns and their hopes. We delve into their health concerns, we review their medical records, and we explore lifestyle-based strategies to optimize their healing and wellbeing.
In short, I listen and apply what I know in partnership with each patient with the goal of empowering them towards greater wellness. Over and over, I hear from my patients how unusual this is. They speak about the 5-minute visits with their doctors that feel rushed and disconnected. They express frustration and dismay about being a diagnosis, not a person, when seeing their healthcare providers.
A recent survey conducted by the New York Times found that two-thirds of Americans support some form of change to the current healthcare system and favor moving towards greater insurance coverage for all. My experience for almost 25 years leads me to conclude that underlying this vision of healthcare is a deep-seated desire for patients to be cared for and listened to.
By HANS DUVEFELT, MD
In medicine, contrary to common belief, it is not usually enough to know the diagnosis and its best treatment or procedure. Guidelines, checklists and protocols only go so far when you are treating real people with diverse constitutions for multiple problems under a variety of circumstances.
The more you know about unusual presentations of common diseases, the more likely you are to make the correct diagnosis, I think everyone would agree. Also, the more you know about the rare diseases that can look like the common one you think you’re seeing in front if you, rather than having just a memorized list of rule-outs, the better you are at deciding how much extra testing is practical and cost effective in each situation.
Not everyone with high blood pressure needs to be tested in detail for pheochromocytoma, renal artery stenosis, coarctation of the aorta, Cushing’s syndrome, hyperaldosteronism, hyperparathyroidism or thyroiditis. But you need to know enough about all of these things to have them in mind, automatically and naturally, when you see someone with high blood pressure.
Just having a lifeless list in your pocket or your EMR, void of vivid details and depth of understanding, puts you at risk of being a burned-out, shallow healthcare worker someday replaced by apps or artificial intelligence.
By HANS DUVEFELT, MD
So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.
It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.
When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.
What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.
By BRYAN CARMODY
Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.)
Most of the topics we discussed were ones I’ve already dissected on this site. But there was an interesting moment in the show, right around the 37:30 mark, that raises an important point that is worthy of further analysis.
ANISH: There’s also the fact that nobody is twisting the arms of program directors to use [USMLE Step 1] scores, correct? Even in an era when you had clinical grades reported, there’s still seems to be value that PDs attach to these scores. . . There’s no regulatory agency that’s forcing PDs to do that. So if PDs want to use, you know, a number on a test to determine who should best make up their class, why are you against that?
BRYAN: I’m not necessarily against that if you make that as a reasoned decision. I would challenge a few things about it, though. I guess the first question is, what do you think is on USMLE Step 1 that is meaningful?
ANISH: Well – um – yeah…
BRYAN: What do you think is on that test that makes it a meaningful metric?
ANISH: I – I don’t- I don’t think that – I don’t know that memorizing… I don’t even remember what was on the USMLE. Was the Krebs Cycle on the USMLE Step 1?
I highlight this snippet not to pick on Anish – who was a gracious host, and despite our back-and-forth on Twitter, we actually agreed much more than we disagreed. And as a practicing clinician who is 15 years removed from the exam, I’m not surprised in the least that he doesn’t recall exactly what was on the test.
I highlight this exchange because it illuminates one of the central truths in the #USMLEPassFail debate, and that is this:
Physicians who took Step 1 more than 5 years ago honestly don’t have a clue about what is tested on the exam.
That’s not because the content has changed. It’s because the memories of minutiae fade over time, leaving behind the false memory of a test that was more useful than it really was.
I’m speaking from experience here.
By HANS DUVEFELT, MD
We knew that the most powerful way to provide substance abuse treatment is in a group setting. Group members can offer support to each other and call out each other’s self deceptions and public excuses, oftentimes more effectively than the clinicians. They share stories and insights, car rides and job leads, and they form a community that stays connected between sessions.
Participants with more experience and life skills may say things in group that we clinicians might hesitate saying, like “Now you’re whining” and “Time to put on your big boy pants”. They can become role models by being further along in their recovery and by at the same time revealing their own fear or respect for the threat of relapse.
What has also happened in our clinic, entirely unplanned, was that after an informational meeting where we explained the group model and had a national expert physician speak about opioid recovery, several parents raised their hand and said there should be a group for families, too.
We listened and within a few months we started such a group and now, a year and a half into it, the group is co-led by a few of our patients, who naturally had become leaders of the patient group earlier.
By HAYWARD ZWERLING, MD
I recently saw a patient who received a bill for an outpatient procedure for $333. The Medicare allowable reimbursement for the procedure was $180. I have seen other medical bills where the healthcare provider was charging patients more than 10 times the amount they expected to receive from Medicare or any insurance company.
one of my patients had an unexpected medical complication which necessitated a
visit to an emergency room. He received a huge bill for the services provided.
When I subsequently saw him in my office (for poorly controlled diabetes) he
told me he could not attend future office visits because he had so many
outstanding medical bills and he could not risk incurring any additional
medical expenses. While I offered to see him at no cost, he declined, stating
the financial risk was too high.
patient is required to pay the entire medical bill if they
- no insurance
- poor quality insurance
- a bureaucratic “referral problem”
- an out-of-network provider, which means they have no contractural relationship with the healthcare provider/institution, as might result from an emergency room visit or an unexpected hospitalization.
physicians and other healthcare providers usually do not know what they are
going to get paid for any given service as they contract with many insurance
companies, each of which has a different contracted payment rate. Healthcare
providers and institutions typically set their fee schedule at a multiple of
what they expect to get paid from the most lucrative payer so as to ensure they
capture all the potential revenue. In the process, they create an economically
irrational fee schedule which is neither reflective of a competitive
marketplace nor reflective of the actual cost of the services provided.
By SAI BALA, JD
United States medical education system is heralded as one among the top in the
world for medical training. Given the strict standards of education, multiple
licensing boards, and continuous oversight by governing bodies, getting a placement
to train in the US is extremely competitive. In 2017 alone, nearly 7000+ non-US citizens
(commonly referred to as “foreign medical graduates”) applied to compete with 24,000+
US citizens for American residency spots to pursue specialty training. The
reasons for this competitiveness are simple. The vast majority of medical institutions
in the US boast a comprehensive curriculum that entails basic sciences,
clinical principles, practical and hands-on didactics, and enriched exposure to
the clinical aspects of patient care. This training produces astute clinicians
that are capable of resolving the most complex diagnoses while providing comprehensive
it is high time to recognize that being a shrewd clinician is no longer a
sufficient product for the demands of the healthcare market today. That is to
say, the scope of medicine today for a physician has gone far beyond resolving
complex medical problems, but demands a higher understanding of multidisciplinary
skillsets, most important of which are finance and legal theory. In these
aspects, the US medical education system direly underprepares physicians, and
thus, requires a thorough reevaluation.
art of medicine, as much as it was originally developed to be purely about the
betterment of patient health, has become yet another siloed service industry.
Simply put, patients are customers, and physicians are increasingly held
accountable for the financial metrics and revenue their work produces. Compensation
models are increasingly favoring productivity based payment methods, such
as the relative value unit (RVU) system, and are moving away from the
traditional, salaried physician. This has resulted in increased pressure on
physicians to become more efficient with their workload and patient docket,
while managing the often turbulent and contradictory interests of insurance,
patients, and hospital administration.
By SAURABH JHA, MD
Despite an area under the ROC curve of 1, Cassandra’s
prophesies were never believed. She neither hedged nor relied on retrospective
data – her predictions, such as the Trojan war, were prospectively validated. In
medicine, a new type of Cassandra has emerged –
one who speaks in probabilistic tongue, forked unevenly between the
probability of being right and the possibility of being wrong. One who, by conceding
that she may be categorically wrong, is technically never wrong. We call these
new Minervas “predictions.” The Owl of Minerva flies above its denominator.
Deep learning (DL) promises to transform the prediction
industry from a stepping stone for academic promotion and tenure to something
vaguely useful for clinicians at the patient’s bedside. Economists studying AI believe that AI is revolutionary,
revolutionary like the steam engine and the internet, because it better predicts.
Recently published in Nature, a sophisticated DL algorithm was able to predict acute kidney injury (AKI), continuously, in hospitalized patients by extracting data from their electronic health records (EHRs). The algorithm interrogated nearly million EHRS of patients in Veteran Affairs hospitals. As intriguing as their methodology is, it’s less interesting than their results. For every correct prediction of AKI, there were two false positives. The false alarms would have made Cassandra blush, but they’re not bad for prognostic medicine. The DL- generated ROC curve stands head and shoulders above the diagonal representing randomness.
The researchers used a technique called “ablation analysis.”
I have no idea how that works but it sounds clever. Let me make a humble
prophesy of my own – if unleashed at the bedside the AKI-specific, DL-augmented
Cassandra could unleash havoc of a scale one struggles to comprehend.
Leaving aside that the accuracy of algorithms trained
retrospectively falls in the real world – as doctors know, there’s a difference
between book knowledge and practical knowledge – the major problem is the
effect availability of information has on decision making. Prediction is
fundamentally information. Information changes us.