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Tag: Education

Is Medical School Admission Squashing Creativity?

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.”

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How to Get Better at Harming People Less

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.

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On Being Gay In Medicine

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.

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Rethinking Medical Education

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.

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Health Alert: Health and Education

I believe I am one the few commentators on the Internet who routinely compares the fields of health and education (see previous posts here and here). The reason: lessons from one field are often applicable to the other.

The parallels are obvious: In both fields (1) we have systematically suppressed normal market forces; (2) the entity that pays the bill is usually separate from the beneficiaries of the spending; (3) providers of the services see the payers, not the beneficiaries, as their real customers and often shape their practice to satisfy the payers’ demands — even if the beneficiaries are made worse off; (4) even though the providers and the payers are in a constant tug-of-war over what is to be paid for and how much, the beneficiaries are almost never part of these discussions; and (5) there is rampant inefficiency on a scale not found in other markets.

Long before there was a Dartmouth Atlas for health care, education researchers found large differences in per pupil spending (more than three to one among large school districts, e.g.) that were unrelated to differences in results. In fact, study after study has found no correlation between education spending and education results. (See Linda Gorman’s summary at Econlog.)

Internationally, the parallels continue. Just as the United States is said to spend more than any other country and produce worse outcomes in health care, the same claim is now made for education.Continue reading…

A Culture of Fear and Intimidation: Reforming Medical Education

Even as we set out to reform U.S. health care, we continue to train medical students as if they were going to work in the old, broken system. Today, everything about medical education needs to be re-thought, from how we select students for admission to med schools to what we teach them about how to provide safe, patient-centered care.

A shocking new report from the  Lucien Institute at the National Patient Safety Foundation reveals how today’s medical schools fail their students as it lifts the curtain on a culture of  “abuse, shame and blame”  that undermines professional morale, inhibits teamwork– and ultimately puts patient safety at risk.   (Thanks to Dr. Diane Meier for calling attention to this report on Twitter.)

“Achieving  safety in the work environment requires much more than implementing new rules and procedures,” the report observes. “It requires developing and sustaining  cultures of safety that engender trust and embrace reporting , transparency, and disciplined practices. It also requires anatmosphere of respect among the health care disciplines  and a fundamental ability of all practitioners to work together in teams.”

The white paper, entitled “Unmet Needs: Teaching Physicians to Provide Safe Patient Care”  was prepared by an  “Expert Roundtable on Reforming Medical Education” that included a broad array of medical education leaders, students, patients, representatives from key organizations, experts from related fields, and members of the Institute. The Roundtable met in extended in-depth sessions in Boston in October 2008 and June 2009 before reaching a consensus regarding the current state of medical education—and  what medical education should ideally become.

The Roundtable participants acknowledge that med school students frequently are abused and demeaned and that this behavior is widespread. Each year, the Association of American Medical Colleges conducts a survey of medical students asking questions such as have you been “publicly belittled or humiliated?”  From 2004 to 2008, 12.7%  to 16.7%  of students answered “yes,” with “female respondents reporting higher rates” of abuse. Most often, students were humiliated by clinical faculty and residents (66% and 67%, respectively), followed by smaller but significant percentages of nurses and patients.

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The State of the Union – And the Economy: Why We Need Health Care Reform Now

According to the headlines, 10 percent of Americans are unemployed. The truth is that closer to 17 percent of the population cannot find full-time work; this number includes workers who have become discouraged and have given up looking for work as well as those who have settled for part-time jobs because they cannot find the full-time employment that they need.

The situation is not going to change anytime soon. As Princeton economist Paul Krugman recently warned: “We are facing mass unemployment — unemployment that will blight the lives of millions of Americans for years to come.”

“Even if industrial production picks up, unemployment will continue to lag,” observed Goldman Sachs’ Abby Cohen, speaking at Barron’s Roundtable about a week ago. “The problem is far more than cyclical.” (You may remember Cohen as a bull during much of the ‘Nineties boom. By temperament, she is hardly a doomster, but when she looks at today’s economy, she is very concerned.)

Cohen is saying jobs are not going to suddenly appear with the next business cycle. Current levels of unemployment reflect deep structural problems that go back at least two decades.

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Impact of EHRs on Medical Education

By GLENN LAFFEL

Glenn

Author’s Note: This the second of a 5-part series whose purpose it is to make the case for implementing a widespread, systematic approach to HIT education in medical schools and continuing medical education programs for physicians. A previous post reviewed challenges posed by the HIT Deluge.

Countries around the world are racing to digitize patient medical records. In the US for example, the American Recovery and Reinvestment Act allocated $21 billion to an incentive program designed to encourage the “meaningful use” of such systems.

The Federal government’s largesse is based on the premise that EHRs will improve the quality of care and reduce its costs, but the move will impact the health care system in many other ways as well. One area sure to be impacted is the education and training process for new physicians.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but there are as many or more instances in which the impact appears to be negative. Thankfully, careful planning can mitigate most of the collateral damage, a topic to be covered in this series’ next installment. For now, we’ll settle for a review of the good, the bad and the ugly.

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