Posts Tagged ‘medical education’

Taxing Residents

Tuesday, November 9th, 2010

The Supreme Court heard arguments yesterday in a case with both financial and philosophical repercussions for medical schools. Employers and employees must pay a portion of their salaries to the federal government for Social Security and Medicare. Students working for the university while studying are exempt from the taxes.

In 2005, the U.S. Treasury Department ruled that medical residents do not qualify for the exemption, which was intended to support students working part-time. Medical residents work full-time and then some, so the government reasoned that they should be treated as employees and subject to the tax. At stake is $700 million in additional revenue.

The Mayo Foundation and the University of Minnesota appealed the decision, winning a round in court, but then a federal appeals court overturned the ruling. In appealing the case to the  Supreme Court, the petitioners received friend of the court briefs from a consortium of academic medical centers including Boston Medical Center.  They argue that residents are indeed students in that they attend classes, receive training, and learn about patient care.

The Supreme Court did not seem to indicate its thinking. The debate reminds me of the conflict between universities and doctoral students over unionization. In the end, many graduate students made the case that they were both students and employees and won the right to unionize. Medical residents already belong to unions, so how does that complicate the question of whether they are students or employees?

Medical Marshall Plan

Thursday, November 4th, 2010

Two days after many candidates running on belt-tightening platforms won election seems like an awkward time to endorse a plan to increase government spending. Still, a call to arms by T. Samuel Shomaker, Dean of Medicine at Texas A & M, warrants consideration.

Dr. Shomaker likens the state of medical education to Europe after World War II. The Marshall Plan cost the United States $13 billion in the short-term but earned it lasting, prosperous allies. Something similar could be done with medical students. He proposes that the federal government pay the first two years of medical school tuition in exchange for a postgraduate year providing primary care in an underserved area.

Upon completion of the year, doctors could earn forgiveness for their remaining medical school debt by staying on in the position or matching with a primary care residency. They may choose a specialty residency, but then the last two years of medical school tuition loans will be theirs to pay back.

Former Labor Secretary Robert Reich has made a similar proposal for undergraduate education. Making tuition free may sound radical, but it promises to lower barriers to entry for many students while also producing more of the educated citizens we need.

Med Ed Reform

Wednesday, September 22nd, 2010

This week in Washington, DC the Association of American Medical Colleges and the American Medical Association are hosting a conference on the state of medical education. Coming 100 years after the publication of the Flexner Report, the conference also coincides with several proposals to reform how medical faculty teach.

Several panelists have critiqued the standard model of medical education, which relies on prolonged exposure to a predetermined content. They favor quality over quantity and more flexible models of learning. Speakers have also suggested placing more emphasis on outcomes. This would require more rigorous assessment of teaching and careful attention to what kinds of jobs graduates take.

So far the talk about reform has stayed mostly at the level of talk. The focus on flexibility and quality is not controversial, but implementing them may be. As long as faculty get rewarded for teaching the way they always have, little change will reach medical students.

Attracting PCPs

Monday, August 30th, 2010

The number of primary care physicians in the United States is already too low to meet the demand. With the implementation of  reforms to bring health care access to millions more, the shortage of PCPs will become even more acute.

Time Magazine reported on this looming problem last week. Experts estimate that we will be short 30,000 primary care doctors by 2015. With fewer than 7% of current medical students interested in practicing general internal medicine or family medicine, the problem will only escalate.

Like other media that report on the problem, Time blames the rise in debt that medical students accrue. Even though the average primary care physician can expect to make almost $200,000 a year, that is less than half what a cardiologist can earn and a small part of the $500,000 in loans that a student might have to repay.

Money is no doubt a consideration for medical students choosing a specialty.  I doubt many applicants for dermatology residency slots chose to pursue medical studies because of a passion to treat skin diseases. Rather, dermatology offers a higher pay with more control over schedules. For younger generations, practicing medicine should not be incompatible with building a life.

MCAT Optional?

Thursday, July 29th, 2010

McGill University in Montreal will no longer require Canadian applicants to its medical school to take the MCAT. The admissions committee hopes the move will increase the number of Francophone students in its program. Applicants from outside Canada will still be required to submit MCAT scores.

Although McGill has no objection to standardized testing (and indeed tried to arrange for a translated test), the move fits into a trend of test-optional undergraduate institutions. Bates College eliminated the SAT for applicants 25 years ago and has seen no drop in student quality. By some measures, applicants are more qualified.

With the push for learner-centered medical education and the empathetic physicians, it seems contradictory that medical schools would still rely heavily on a multiple-choice test for admissions decisions.

Residency Plagiarism

Tuesday, July 20th, 2010

Ever since the Internet became the predominant source of information for students, new concerns about plagiarism have arisen. Certainly academic dishonesty existed before, but now a sneaky student does not even have to take the time to copy purloined passages by hand. It’s just a cut and a paste away.

The New York Times reported on this trend recently. Now the Annals of Internal Medicine have published a study called “Plagiarism in Residency Application Essays.” The authors analyzed application essays for the five largest residency programs at Brigham and Women’s Hospital using the Turnitin application. They found that 5% of the essays registered as plagiarized.

In general, international students and students with lesser qualifications were more likely to plagiarize, but the study found instances of top students plagiarizing, too. I tend to think that part of the blame lies with the assignment. A personal narrative is such a vague prompt. Applicants don’t intend to be dishonest, but they have little guidance for what kind of essay is appropriate. In this case, it seems safe to borrow from a supposedly trusted source. This is not to excuse their actions, but it does suggest that the application process could be tailored to elicit more original responses.

A Century After Flexner

Monday, July 12th, 2010

Abraham Flexner was not a physician, but his report, Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching changed the way medical students learned. It professionalized training and standardized teaching practices.

One hundred years later, the Carnegie Foundation has released another report. Educating Physicians: A Call for Reform of Medical School and Residency calls anew for a close look at medical training. Since Flexner’s original recommendations, the field of health care has changed dramatically, though the way new M.D.s are taught has not.

The authors found several weaknesses in the current system:

  • Inflexible, excessively long training
  • Overly focused on inpatient clinical experience
  • Poor connections between formal knowledge and experiential learning
  • Inadequate opportunities to work with patients over time

At Boston University, a group of medical educators has formed a journal club to respond to the critiques in the new report. The state of graduate medical education has improved since 1910, but the centennial provides a symbolic opportunity to update the curriculum.

Foreign Medical Schools

Wednesday, June 30th, 2010

The Government Accountability Office released a report this week on the role of federal student loans in supporting foreign medical schools. Like the recent Congressional hearings on for-profit undergraduate education, foreign medical schools claim billions of dollars in federal aid from students with little evidence about return on the investment.

One of the GAO’s findings, as reported in Inside Higher Ed is that 97% of U.S. medical school graduates pass the Step 1 licensure exam on the first try, but only 64% of foreign medical school graduates do. If foreign medical schools, some of the largest of which are for-profit, receive taxpayer money, then they should produce competent doctors.

At the same time, foreign medical schools help meet the need for physicians in this country. And no doubt many of their graduates are outstanding doctors. The larger issue may be the high cost of medical education at home and abroad, which requires students to go deeply in debt to pursue their dreams.