The hottest medical school in the country right now is the New York University School of Medicine thanks to the gift of a generous benefactor that promises to make medical school free for all current and future medical students. The news was met with elation from the medical community of physicians that groans frequently about student debt loads routinely north of $200,000 upon matriculation. Not surprisingly, the technocrat class of public health experts and economists did not share in the jubilation. The smarter-than-the-rest-of-us empiricists are, after all, trained to think in terms of social justice and net benefits to society. The needs of medical students are far down the list of priorities when forming this social justice utopia.
Contemporary arguments for social justice in some form or the other trace their roots to the philosopher John Rawls and his 1971 magnum opus – “A Theory of Justice”. In words that would infuse liberal thought for a generation, Rawls laid out a blueprint for a just society by proposing a thought experiment called “the original position”. This was a hypothetical scenario where a group of people are asked to form the rules of a society which they will then occupy. The catch is that the people making the decision do so behind a ‘veil of ignorance’ not knowing the disadvantages conferred by any number of attributes (age, sex, gender, intelligence, beauty, etc. ) they may be reincarnated with. Rawls posited that under conditions in which there was a possibility of being born as a disadvantaged member of society, social and economic inequalities would be arranged to be of greatest benefit to the least advantaged members of society.
At first glance, it would seem that the objections to tuition-free medical school rest on a social justice framework that does not seem to comport with gifts to the soon-to-be-wealthy. After all, the $200,000 investment for medical school pales in comparison to the lifetime earnings of the average physician who is assured at least a six-figure income in seeming perpetuity. But it is not entirely clear that one has to even combat Rawlsian ideals to rebut the social justice do-gooders with strong opinions on how other people should spend their money. A Rawlsian framework never intended that everyone in society would be able to achieve the same outcome regardless of starting position. Rawls actually went out of his way to argue that inequalities were justified in society as long as the operating rules served to raise the position of those worst off in society. A rising tide should lift all boats – the rich may become richer, as long as the poor become richer as well.
The competition to get into medical school is fierce. The Association of American Medical Colleges just announced that this year, nearly 50,000 students applied for just over 20,000 positions at the nation’s 141 MD-granting schools – a record. But medical schools do not have a monopoly on selectivity. The average student applies to approximately 15 schools, and many are accepted by more than one. Students attempting to sort out where to apply and which admission offer to accept face a big challenge, and they often look for guidance to medical school rankings.
Among the organizations that rank medical schools, perhaps the best-known is US News and World Report (USNWR). It ranks the nation’s most prestigious schools using the assessments of deans and chairs (20%), assessments by residency program directors (20%), research activity (grant dollars received, 30%), student selectivity (difficulty of gaining admission, 20%), and faculty resources (10%). Based on these methods, the top three schools are Harvard, Stanford, and Johns Hopkins.
Rankings seem important, but do they tell applicants what they really need to know? I recently sat down with a group of a dozen fourth-year medical students who represent a broad range of undergraduate backgrounds and medical specialty interests. I posed this question: How important are medical school rankings, and are there any other factors you wish you had paid more attention to when you chose which school to attend?
Each year, over 20,000 US students begin medical school. They routinely pay $50,000 or more per year for the privilege, and the average medical student graduates with a debt of over $170,000. That’s a lot of money. But for some who pursue careers in medicine, the financial cost has been considerably greater. Melissa Chen, 35, a final-year radiology resident at the University of Texas San Antonio, calculates that her choice of a medical career has cost her over $2.6 million in lost wages, benefits, and added educational costs. And yet in her mind, the sacrifice has definitely been worth it.
The corpse, laid out on a gurney and covered with a white sheet, was wheeled onto the stage by two women in long, white lab coats. A middle aged man with a bow tie welcomed us, the incoming class of the spring semester, to Uppsala University and the Biomedicine Center, where we would spend the next two years in “pre-clinicals”, until we knew enough to start our three and a half clinical years at the Academy Hospital.
The Biomedicine Center was almost brand new, a glass and concrete labyrinth with a large sculpture depicting Watson and Crick’s DNA molecule by the front entrance. The vast complex lay near S-1, the Uppsala military regiment. The brick buildings diagonally across the street were very familiar to me as the place where I had met the biggest failure in all my twenty years only months before.
As I sat in the large lecture hall with the corpse on the stage, I glanced over at L., my buddy from the Swedish military’s elite division, the Interpreter School, where we had also sat next to each other on the first day, when the Captain in charge told us:
“Soldiers, you may all have been the smartest kids in your school, but it’s different here. Most of you won’t make it, and will be culled over the next two months. The Interpreter School accepts eighty recruits and graduates twenty to twenty-five. If you don’t have what it takes, don’t waste our time or yours!”
L. and I had both thought that learning Russian would be a neat way to spend our compulsory year and a half in the military, but just barely more than a month after that harsh introduction, we were both on our way back to our respective home towns to figure out what to do until we would be able to start medical school. Our military service was put on hold until we could return as medics.
The man with the bow tie went on to introduce our guest professor, on loan from the University of Bavaria. As we all knew, the Germans have been the greatest anatomists since the last century, and all of us had already been to the University book store to purchase Haeffel’s “Topografishe Anatomie”, which would be our constant companion for the next five months.
Someone has been listening to me. Or rather, to me and a growing number of voices that are questioning the requirements for admission to medical school. I have argued in a past blog that you won’t get more good primary care doctors, who practice a lot of humanities in addition to the science, if the only people you admit to medical school are scientists. Two medical schools and the American Association of Medical Colleges are beginning to agree.
Pauline Chen gives a good overview of what’s happening in this area here. Essentially, Boston University and the medical school at Mt. Sinai have made pretty radical efforts to apply either more than the traditional evaluation points to their admissions process, or different ones altogether. Mt. Sinai, in particular, has an extraordinary an early-acceptance program for college sophomores and juniors in which they can get into medical school without the MCATs, and without a few of the standard pre-med science and math requirements. In return, the accepted students have to continue to major in an humanities-related field and maintain an adequate GPA. They also have to undergo intensive science enrichment courses prior to matriculation. BU hasn’t gone quite that far, but they have included many more “holistic” data points into their admissions decisions, a process that is extremely labor intensive for the schools’ admissions staff.
Both schools have great ideas that are showing some promising results. I see a couple potential problems:
1. Mt. Sinai seems to be sort of cramming in all the old science requirements in off-hours, allowing students to pursue wider studies in college. I would rather see a larger decrease in the science and math requirements. Basic chemistry and biology are probably necessary, but no one has ever explained to me why you need physics. Or calculus. You don’t need most of this stuff in medical school. All you need in medical school is the ability to put your head down and push through the memorization. You don’t need math, you just need patience. The thing is, the only way to get rid of the math and science is to get rid of the MCAT, because believe you me you can’t get through that behemoth with an english major. Then, even if you do that, you eventually run into Step 1, the first of the three-part exam you take in medical school to pass medical school. The Mt Sinai kids might need more “enrichment” courses to get through that. If those hoops are eliminated, you might find some great doctors underneath those mountainous requirements.
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.
Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.
The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care . This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.
How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings.That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation.But the crisis in our primary care pipeline goes far beyond the money.
Have you ever wondered about what goes on behind the scenes—how new drugs are magically produced and brought forth? We’ll continue to take the mystery out of clinical research and drug development and to provide background information so that both patients and physicians can make more informed decisions about whether they wish to participate in clinical trials or not.
To develop a medicine, from the time of discovery of the chemical until it reaches your drug store, takes an average of 12-15 years and the participation of thousands of volunteers in the process of clinical trials (Fig 1).
Very few people participate in clinical trials—it is even less than 5% for patients with cancer—due to lack of awareness or knowledge about the process. We’ll go into detail about how drugs are developed in later posts.
An inadequate number of volunteers is one of the major bottlenecks in drug development, delaying the product’s release and usefulness to the public. Of course, many people may suffer or even die during this wait, if they have an illness that is not yet otherwise treatable. So if you want new medicines, learn about—and decide if you wish to participate in—the process. I have, as a volunteer subject, researcher, and advocate.Continue reading…
First-year medical school enrollment in 2016–2017 is projected to reach 21,376. This projection represents a 29.6% increase above first-year enrollment in 2002–2003 and comes close to reaching the 30% targeted increase by 2015 the AAMC called for in 2006.
Of the projected 2002–2016 growth, 58% will be at the 125 medical schools that were accredited as of 2002. New schools since 2002 will experience 25% of the growth, and the balance (17%) will come from schools that are currently in LCME applicant- or candidate-school standing.
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.