Archive for November, 2010

Your First Patient

Wednesday, November 10th, 2010

We know from Mary Roach’s oddly cheerful book, Stiff, that human cadavers play an unseen but important role in everything from bullet testing to automobile safety. Of course, cadavers are also central to medical education. Learning anatomy by dissecting an anonymous body is a rite of passage for future doctors.

It’s also an expensive ritual. As medical imaging technology improves, some medical schools are seeking to replace live dissection with computer simulation. One school in Indiana is going in the opposite direction. They are integrating dissection into the entire curriculum by making the cadaver a doctor’s first patient.

As reported in the Chronicle of Higher Education, students at Indiana University Northwest meet relatives of the deceased to gain a fuller picture of how the person lived, not just how she died. The students learn a more holistic approach to medicine, applying the lessons of their histology class to the tissues they examined.

For their part, the family members gain insight into their family’s health history. The husband of one donor plans to attend the graduation of the students who dissected his wife. This approach models not only good pedagogy, but also good clinical practice.

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?

Setting a Good Example

Monday, November 8th, 2010

The 2010 meeting of the Association of American Medical Colleges concludes this week in Washington, DC. The association's president, Darrell Kirch, MD, called on the members present to prepare themselves for the future of academic medicine.

One of the reforms he called for stood out because it called for changes in how faculty members behave not how institutions operate. When it comes to designing a sustainable system of health care, the example should begin with physicians and medical school faculty. Unfortunately, this is not always the case, as Kirch notes:

  • Data indicate that, despite our knowledge and experience, our faculty and staff members are not always wise consumers of heath care. We often do not receive basic preventive services or good continuity of care, and too often we overuse tests and procedures despite the best medical evidence.

The same innovative health care delivery systems that we deploy in our communities can be aimed at our own faculty and staff. Academic medical centers are employers, too, and shoulder costs related to workers' health. By modeling good health practices, we can not only set an example for patients but also assert leadership in the uncertain future of health care.

Online Privacy

Friday, November 5th, 2010

Within a week of signing up for Facebook, one doctor I know received a friend request from a name he didn't recognize. Then, it dawned on him, the potential "friend" was one of his patients. Most professors can share a similar story of friend requests from students and the thinking that goes into the decision to accept. Do I want to remain accessible and open up new channels of communication with trainees? Or do I want to maintain a private life online?

One way to tackle this dilemma is to realize that the whole notion of privacy on the Internet is antiquated. Even when you think you are erecting walls to protect your personal data, new technologies are poking holes in those protections. For example:

  • Do you ever log on to a social media site from Starbucks? Most wireless connections do not encrypt all the information you send to your account. A new browser extension, Firesheep, collects log ins from those around you and lets you impersonate them online.
  • You may think your personal information is safe when you reject a friend request on Facebook. A new feature, however, makes it harder to reject a request outright. The first option is to accept a request or "not now." Clicking "not now" removes the request from the screen, but still allows the person to see parts of your profile unless you hit a second button to reject them outright.
  • Facebook does make it possible to control information through privacy settings. But to do so requires checking 170 different options in 50 separate categories. Increasingly, the default position is to allow more access to your data. This graph nicely illustrates how much of your information is automatically revealed if you don't take proactive steps.
  • So you think you'll outsmart Facebook by keeping a barebones profile just so you can have access to your friends' postings. Even with no data to go on, Facebook can triangulate information about you using your friends' profiles and target you with specific ads.

So, it may be a false choice whether to accept the patient's or student's request as a friend. They and others can still find out about you on-line. One option is to join a privacy-centered social media site like Diaspora. More realistically, just assume that everything you post will be visible, and surf accordingly.

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.

Diversifying the Faculty

Wednesday, November 3rd, 2010

The statistics are revealing:

  • Of 130,000 medical faculty in the U.S. only 1/3 are women
  • 4% are Hispanic
  • 8% of clinical department chairpersons are women

Linda Pololi, a former professor of medicine and now senior scientist at Brandeis's Women's Studies Research Center, conducted interviews with women and minority faculty to find out why academic medicine has not been hospitable to them. She summarized her findings in a recent article from the Chronicle for Higher Education.

Her subjects described a system at odds with the altruistic values that motivated them to pursue academic medicine. They found the work environments competitive, individualistic, and profit-driven. Moreover, women and minority faculty members suffered from unconscious bias.

Faced with such a structural problem, Pololi discourages separate diversity initiatives. Rather, she calls for a change in culture that values all members' contributions.

Lightbulb Moments

Tuesday, November 2nd, 2010

We tend to think of scientists hatching a paradigm-shifting idea while hunched over a lab bench. Even the language we use to describe these insights convey lonely genius: an epiphany, a lightbulb, a eureka moment. A new book by technology writer Steven Johnson, Where Good Ideas Come From dispels that image.

Taking examples from commerce, science, and the arts, Johnson shows how ideas with lasting impact emerge from social networks. He cites the work of psychologist Kevin Dunbar. In his research, molecular biologists achieved their greatest discoveries not through experiments, but at lab meetings. In sharing mistakes and posing theories with colleagues, they stimulated new discoveries.

It's become fashionable to decry meetings, but great ideas emerge from the human interaction that goes on in groups.

Breaking Ground

Monday, November 1st, 2010

Last week, the Boston University School of Medicine broke ground on a new student residence on Albany Street, near the Crosstown Building. Mayor Menino was on hand alongside university leaders and student representatives. Not only was this an encouraging project for the economic development of Boston, but also it portends assistance to defray the high cost of medical education

Tuition, fees, and health insurance at BU's School of Medicine run $51,134 for the current academic year. Only 4 other medical schools in the country charge more according to data collected by the Association of American Medical Colleges. Of course, the median for all private medical colleges is a not-too-cheap $47,408.

By building its own low-rent apartments, BU can  help mitigate the high cost of tuition in a relatively high-cost city. This benefits more than just the institution. A recent study of primary care doctors suggests that easing medical students' debt can help increase the number of physicians who practice in underserved areas.