It has been WAY too long and for too many reasons (conferences, travel, a hurricane flooding out 4 East Coast guests) we haven’t got together but #THCBGang is back.
At 1pm PT – 4pm ET tomorrow September 30, joining Matthew Holt (@boltyboy) will be fierce patient activist Casey Quinlan (@MightyCasey); THCB regular writer Kim Bellard (@kimbbellard); ; medical historian Mike Magee (@drmikemagee); and board-certified patient advocate Grace Cordovano (@GraceCordovano).
Come here what we have to opine on the latest in health and more!
The Wall Street Journalreported that the American Dental Association (ADA) opposes expanding Medicare to include dental benefits. My reaction was, well, of course they do.
They apparently don’t care that at least half, and perhaps as many as two thirds, of seniors lack dental insurance, or that one in five seniors are missing all their teeth. The ADA prefers a plan for low income Medicare beneficiaries only, although state Medicaid programs were already supposed to be that, with widely varying results between the states.
The ADA is following blindly in the AMA’s opposition to enactment of Medicare, ignoring how fruitful Medicare has turned out to be for physicians’ incomes. It’s all about the money, of course; the ADA thinks dentists can get more money from private insurance, or directly from patients, than they would from Medicare, and they’re probably right.
As is typical for our healthcare system, good design is no match for interfering with the incomes of the people/organizations providing the care.
By the same token, I suspect that the real opposition to “Medicare for All” is not from health insurers but from healthcare providers. Health insurers, a least the larger ones, have done quite nicely with Medicare Advantage, and would probably welcome moving members from those balkanized, largely self-funded employer plans to Medicare Advantage plans.
No, the bloodbath in Medicare for All would be the loss in revenue of health care professionals/organizations missing out on those lucrative private pay rates. As Upton Sinclair once observed, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” Or, as Guido tells Joel in Risky Business, “never, ever, fuck with another man’s livelihood.”
Very little about our healthcare system has been consciously designed. It’s a patchwork of efforts – legislative/regulatory initiatives, tax provisions, entrepreneurial choices, independent design decisions — and many unintended consequences. We should be less surprised at how poorly they all fit together than that some of them fit at all. Find someone who is happy with our current healthcare system and I bet that person is either making lots of money from it, or not receiving any services from it.
You could design a worse system, but it wouldn’t be easy.
Fast Companyrecently featured 32 design experts sharing their thoughts about the most important issues facing designers today. Most of the issues were not related to healthcare, at least not directly, but I want to highlight a few of the quotes and suggest how they might apply to the design mess healthcare is in.
I’ll start with Robert Wong, vice president, Google Creative Labs:
Too often, design optimizes for solving the immediate problems at hand or immediate user needs and wants. It is more important than ever to slow down, zoom out, look at things from all different perspectives, and consider the long-term and broad societal impact of anything we make. Good design makes our lives better. Great design makes the world better.
In healthcare, we’re usually trying to solve for an immediate crisis, one that has finally gotten so bad that we’re forced to take action. We did it with the pandemic, with some triumphs and many failures (e.g., vaccines: triumph; vaccine cards/tracking: failure). Now Congress is trying to rush through major changes in Medicare in record time, with no time taken to “slow down, zoom out,” much less to “consider the long-term and broad societal impact.”
I get the “never waste a crisis” mentality, and the hyper-partisanship that causes Democrats to try to seize the Congressional advantage they currently have, but we’ll be lucky if we get, in Mr. Wong’s words, good design, much less great design that will make the world better.
Ma Yansong, founder, MAD Architects, pointed out: “Design over-complies on commerce, making people consume unnecessary things. If design is to lead the future, it should focus more on the important, necessary things, not making the unnecessary look better.” Similarly, Albert Shum, corporate vice president of design, Microsoft, believes: “If we can design conspicuous consumption, we can design sustainable consumption with the levers we have to shift behaviors.”
Healthcare has way too much conspicuous consumption—some driven by patients, some done to patients – and it is way too hard for even professionals to distinguish between the necessary and the unnecessary. We need to stop making the “unnecessary look better” – do we really need that test, that pill, that procedure, that stay — and start designing for “sustainable consumption.”
Céline Semaan, founder, Slow Factory, said: “Waste is a design flaw.” I love that adage. Imagine what a healthcare system that treated waste, in all its forms, as a design flaw might look like!
Meanwhile, Don Norman, founding director emeritus, Design Lab, UCSD said: “Design must change from being unintentionally destructive to being intentionally constructive.” Too often, our design decisions in healthcare have been unintentionally destructive. For example, Andrew Ibrahim, surgeon and chief medical officer, HOK Healthcare, pointed out:
At every level of design—user design, product design, process design, space design, policy design, neighborhood design—it has become more and more clear how our design decisions can mitigate or exacerbate disparities.
The disparities in healthcare — whether they are all those seniors without teeth, all those people of color having worse health, all the women suffering from third-world maternal health, or all those low-income people lacking access to care or adequate financial support when they do receive it – are outcomes of design designs. Admittedly, not always intentional decisions, but design decisions nonetheless. We haven’t thought through the consequences — or haven’t cared enough about them.
So back to the original question: should dental – or hearing, or vision – be included in an expanded Medicare? It’s the wrong question. The real question is, why does our healthcare system believe that medical, dental, vision, and hearing are all separate in the first place? They’re each important to our health, and each has impacts on the other. Good design would start from there, not from simply layering on new benefits. Great design would factor in all of the social determinants of health.
I don’t know what “great design” for healthcare look like. I’m no longer confident that we can even achieve good design. But I’m pretty sure that continuing to play Jenga with our current system will inevitably cause it to crash.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.
Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?
The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.
Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.
Primary care here is wasting time in many ways:
When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.
When we are forced to act as if we only see our patients once – ever, instead of over several visits year in and year out. We can’t see you quickly for your sore throat or UTI, because a visit without the required screenings hurts our quality ratings. Having non-physicians do the screening (the point I am making above) is not necessarily the solution because my medical assistant can’t keep me humming and at the same time do all the screening duties on even patients with the simplest of clinical problems.
When we keep thinking that the only time and place for us to interact with our patients is in the office visit. All other “businesses” are figuring out how to engage their “customers” via emails, podcasts, events and so on. Very few medical practices are doing the same. We typically only make money when patients are seen in the office, but if we could have staff interact with patients in whichever way is most appropriate between visits, the time patients spend in the office would be shorter and more effective and clinic productivity would improve – as would quality. Right now, so many of our visits are a real scramble to get through.
When we use the telephone in such inefficient ways. In an era when people generally have their personal cell phone on them, we act as if we are calling them at the phone booth on the corner of their block. They leave a message saying “please call me back”. You do and they don’t answer. You leave a message saying “please call me back”, and so it goes. A personal cell phone is as private these days as an email or a secure patient portal. I think we can leave general messages with patient permission – your tests came back normal, please double up on your new prescription and come back in two weeks, things like that.
When our administrators are too preoccupied with well-meaning but stilted and bureaucratic top-down mandates. Just like providers often can’t be as helpful as they would like to their patients because of our mandates, there is little room for innovation on the administrative side because of the regulatory burden.
We have become a terribly rigid and stuffy “industry” during my 40 years as a physician. We are not like a flea market or Saville Row (London’s bespoke tailor street) like yesterday’s private practice. We are like the postal service or the US immigration service. There will be disruptions if we don’t start moving with the times, and with our patients. They will move away from us whenever they can, to Concierge Medicine, Direct Primary Care, freestanding clinics, varyingly alternative practices or even non-medical caregivers, leaving only the most utterly sick and complex patients with us. Is that what the Fed, Medicare, Medicaid and the insurance companies want for us? And is that what is best for most patients?
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
It’s Telehealth Awareness Week! Today on Health in 2 Point 00, we cover Pager raising $70 million, bringing their total to $132.6 million. German-based company Ovivia gets $80 million, bringing their total to $127 million. Meru Health raises $38 million, and NOCD raises $33 million. —Matthew Holt
It’s been quite a while since Jess & I did a Health in 2 Point 00 and that one was buried in our Policies|Techies|VCs conference in the first week of September. But, as John Malkovich says, We’re back…
Commure gets $500m and maybe one day we’ll know what it does, Spring Health adds to the mental health funding party, UniteUs buys competitor NowPow; Nomad banks $63m for its nurse hiring service, and Xealth adds $24m, even though I’m not sure it’s more than a feature! – Matthew Holt
Not all who wander are lost: Nomad Health lands a $63M Series D round after a year of 5X revenue growth for their tech-driven healthcare staffing marketplace that helps hospitals hire nurses on-demand. This round, led by Adams Street Partners with participation from all existing investors, brings the company’s total fundraising up to $113M. Co-founder & CEO Alexi Nazem stops by to tell us how the startup is not only planning to expand its focus from nurses to other types of healthcare providers but how the process of doing so will transform Nomad from an on-demand staffing agency to “‘THE’ workforce management platform for healthcare.”
Alexi puts it this way: “In healthcare, the product is CARE. And, who is the product team? It’s the doctors, the nurses, the allied health professionals…and the fact that there’s no intentional management of this group of people who steward $1.5 trillion dollars of cost in the US every year is beyond unbelievable.”
The problem is twofold. First, there’s the way temporary staffing is currently being handled: by 2,500 different staffing agencies that take a fragmented, predominantly people-powered approach to sourcing, vetting, and hiring candidates. The cost is high to a health system looking to shore up their nursing staff, and the experience for job-seeking nurses is very opaque, with information being revealed about a job only after a significant investment of time within the application process. If the match falls apart, all the people involved in the process are left to try again.
This leads to the second issue – that, big picture, the status-quo way of temporary staffing is leaving behind a LOT of valuable data. Data about the clinician that is useful to the management of their career, and data about the workforce that would prove valuable to a hospital looking to better manage its care delivery resources.
We journey into the details behind Nomad’s business model, which is cutting costs for hospitals while also increasing pay for the 150,000+ clinicians on its platform. AND, while we’re there, we also find out how they expect their on-demand staffing approach to playing out in the booming virtual care space.
If you, like me, continue to think that TikTok is mostly about dumb stunts (case in point: vandalizing school property in the devious licks challenge; case in point: risking lives and limbs in the milk crate challenge), or, more charitably, as an unexpected platform for social activism (case in point: spamming the Texas abortion reporting site), you probably also missed that TikTok thinks it could take on LinkedIn.
Welcome to #TikTokresumes. Welcome to the Gen Z workplace. If healthcare is having a hard time adapting to Gen Z patients – and it is — then dealing with Gen Z workers is even harder.
TikTok actually announced the program in early July, but, as a baby boomer, I did not get the memo. It was a pilot program, only active from July 7 to July 31, and only for a select number of employers, which included Chipotle and Target. The announcement stated:
TikTok believes there’s an opportunity to bring more value to people’s experience with TikTok by enhancing the utility of the platform as a channel for recruitment. Short, creative videos, combined with TikTok’s easy-to-use, built-in creation tools have organically created new ways to discover talented candidates and career opportunities.
Interested job-seekers were “encouraged to creatively and authentically showcase their skillsets and experiences.” Nick Tran, TikTok’s Global Head of Marketing, noted: “#CareerTok is already a thriving subculture on the platform and we can’t wait to see how the community embraces TikTok Resumes and helps to reimagine recruiting and job discovery.”
Marissa Andrada, chief diversity, inclusion and people officer at Chipotle, told SHRM: “Given the current hiring climate and our strong growth trajectory, it’s essential to find new platforms to directly engage in meaningful career conversations with Gen Z. TikTok has been ingrained into Chipotle’s DNA for some time, and now we’re evolving our presence to help bring in top talent to our restaurants.”
Chris Russell, managing director of RecTech Media, also told SHRM: “Video is eating the world. It has become so pervasive in our lives that the next generation of job seekers has no qualms about showcasing themselves in a 30-second clip.”
The New York Timesobserved: “In modern job searches, tidy one-page résumés are increasingly going the way of the fax machine.” Karyn Spencer, global chief marketing officer at Whalar, added: “Hiring people or sourcing candidates through video just feels like a natural evolution of where we are in a society. We’re all communicating more and more through video and photos, yet so many résumés our hiring team receives feel like 1985.”
Farhan Thawar, vice president of engineering for Shopify, which was one of the pilot TikTok resume companies, believes: “We have this thing where if you can’t explain a technical topic to a 5-year-old, then you probably don’t understand the topic. So having a medium like TikTok is perfect.”
Try explaining why COVID vaccines are safe.
The Wall Street Journal is also watching the trend: “Video résumés are fast becoming the new cover letter for a certain breed of young creatives…For some brands, soliciting video résumés on social media is a way to meet more young, diverse job candidates.”
As it turns out, even Gen Zers have misgivings about the idea. A survey by Tallo found them fairly evenly split:
The survey did find, though, that extroverts liked the idea more (65%) than introverts (40%), which probably shouldn’t be surprising. There was widespread agreement (72%) that a video resume would be more effective for demonstrating creativity/personality, with traditional resumes better for professional summary, experience, and hard skills.
A bigger concern, though, was the possibility of bias:
The very element that gives video resumes their potential also presents the biggest problems. Video inescapably highlights the person behind the skills and achievements. As recruiters form their first opinions about a candidate, they will be confronted with the information they do not usually see until much later in the process, including whether they belong to protected classes because of their race, disability, or gender.
Lest you think this is not important to your organization, that Gen Z’s needs don’t really matter, Morten Peterson, CEO of Worksome, writing in Fast Company, calls Gen Z the “new disruptors,” pointing out: “The overwhelming majority of today’s graduate pool come from Generation Z and will do so for the next decade at least.” If companies don’t adapt to their needs, he warns, “10 years down the line they will find they have been left behind by competitors far more open to change.”
And they vote with their feet. Research from Amdocs found they, along with Millennials, are much more likely than Baby Boomers or even Gen X to have considered leaving their job within the last year:
Every industry is having a hard time recruiting and keeping workers these days, and healthcare is no exception. Between normal burnout, pandemic-related burnout, vaccine mandates, and the lure of jobs that offer more opportunity for remote work, most healthcare organizations are struggling to have enough staff. When the current Baby Boomer doctors, nurses, technicians, and aides retire, there better be Gen Z replacements ready to step in.
Some healthcare organizations are already starting to use TikTok for marketing, others are trying to combat misinformation, but most healthcare organizations are probably not just behind the curve when it comes to recruiting workers using TikTok; they may not have yet realized there is a curve. If, as NYT said, one-page resumes are going the way of the fax machine, well, in healthcare those fax machines haven’t gone very far.
RecTech Media’s Mr. Russell said it: “video is eating the world.” Healthcare’s world too.
TikTok resumes may not take off. Tallo’s survey found it low on the list of sites Gen Zers felt comfortable posting a resume on (perhaps not coincidentally, Tallo’s site was rated the highest, followed by LinkedIn). Video resumes more generally may not become the norm. Those bias concerns with video resumes are real and must be appropriately considered.
But Gen Zers are different, and healthcare organizations, like other organizations, better be thinking about how to best recruit them.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.
On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.
In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).
Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.
The authorization for the colonoscopy referral does require my clinical judgement: My patient may not be medically stable for their routine colonoscopy because of a recent heart attack, or they may have already had a diagnostic colonoscopy at another hospital because of a GI bleed, or they may now have a terminal illness that makes screening for colon cancer moot.
But, please – when we can land robots on Mars – give me an easier way to say “yes” or “no” in my multimillion dollar system!
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
If you’re involved in medical education or residency selection, you know we’ve got problems.
And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake of the decision to report USMLE Step 1 scores as pass/fail, the Coalition for Physician Accountability convened a special committee to take on the undergraduate-to-graduate medical education transition. That committee – called the UME-to-GME Review Committee or UGRC – completed their work and released their final recommendations yesterday.
This isn’t the first time I’ve covered the UGRC’s work: back in April, I tallied up the winners and losers from their preliminary recommendations.
And if you haven’t read that post, you should. Many of my original criticisms still stand (e.g, on the lack of medical student representation, or the structural configuration that effectively gave corporate members veto power), but here I’m gonna try to turn over new ground as we break down the final recommendations, Winners & Losers style.
The UGRC recommendations run 276 pages, with 5 appendices and 34 specific recommendations across 9 thematic areas. It’s a dense and often repetitive document, and the UGRC had the discourtesy to release it in the midst of a busy week when I didn’t anticipate having to plow through such a thing. But this is the public service I provide to you, dear readers.
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WINNER: COMMITTEES AND FURTHER STUDY.
All told, the UGRC recommendations aren’t bad.
Some – like Recommendation #11 below – are toothless but hard to disagree with, and many of the recommendations that are more specific don’t go as far as I’d like.
Hard to disagree with anything in Recommendation #11… but also hard to believe that asserting any of it is going to change anything. (To me, the most interesting part of this recommendation was the typing style shown in the clipart.)
But most of the recommendations are good, and almost all are thoughtful and offer the promise of improvement… someday, at some indefinite point in the future (after futher study and additional consideration by more special committees, of course).
There are a few immediately actionable recommendations (such as the proposal for exclusively virtual interviews for the 2021-2022 season) which are unlikely to generate much controversy. And there are a handful of others that ought to inspire more debate.
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Recommendation #18 calls for reporting the results of both the USMLE and COMLEX-USA on the same normalized scale.
WINNER: OSTEOPATHIC MEDICAL STUDENTS.
Currently, around three quarters of osteopathic medical students take both the USMLE and COMLEX-USA. In almost all states, either one is sufficient for licensure – but residency program directors strongly prefer the USMLE.
The de facto requirement for DO students to take two licensing exams is expensive and wasteful, and I’m on record as opposing it. If program directors could assess relative exam performance at a glance – through use of a single normalized score – many fewer DOs would feel compelled to take the USMLE.
(It’s worth pointing out, however, that the National Board of Osteopathic Medical Examiners (NBOME) doesn’t need the UGRC in order to make COMLEX-USA and USMLE scores more easily comparable: all they’d have to do is replace their ‘distinctive’ 200-800 score range with the 300 point scale more familiar to most program directors.)
Approximate percentile conversions for the COMLEX-USA Level 1 and Step 1 examinations.
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LOSER: MDS AND IMGS.
The problem with treating COMLEX-USA and USMLE scores the same is that not everyone can take either exam. Although DO students are allowed to sit for the USMLE, MDs and international medical graduates (IMGs) are not eligible to register for COMLEX-USA.
Put another way, a DO student who is unhappy with his/her COMLEX-USA score might choose to take the USMLE to try to improve it – but an MD or IMG gets only one shot.
But that’s not the only bad news for MDs and IMGs.
Although there is wide individual variation, DO examinees overall score ~20 percentile pointslower on the USMLE than they do on COMLEX-USA.
This mirrors pre-existing differences in standardized test performance between DO and MD medical students: the average MD student scores around the 81st percentile for MCAT performance, while the average osteopathic matriculant scores around the 58th.
For students matriculating to an MD school, the average MCAT is around 511; for osteopathic matriculants, it’s 504.
In other words, to achieve the normalized score that will appear on ERAS, DO students taking COMLEX-USA compete against a somewhat less-accomplished group of standardized test takers than MDs and IMGs taking the USMLE.
(This potential source of unfairness could, of course, be rectified by allowing MDs and IMGs the option of taking COMLEX-USA.)
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WINNER: THE NATIONAL BOARD OF OSTEOPATHIC MEDICAL EXAMINERS.
Recently, the NBOME has faced increasing questions about whether maintaining a ‘separate but equal’ licensing exam for DOs does more harm than good. I’ve argued – in direct response to a letter from the CEO of the NBOME himself – that all physicians should just take the USMLE, and that the NBOME should limit their exams to assessing specifically osteopathic competencies. Obviously, this kind of thinking presents an existential threat to the NBOME.
But if Recommendation #18 succeeds in establishing the COMLEX-USA as being equivalent to the USMLE for residency selection, the NBOME’s existence is all but assured – and they’ll find themselves in the enviable business position of selling exams to the rapidly-growing captive audience of osteopathic medical students for years to come. (You may therefore be unsurprised to learn that the NBOME’s CEO was a member of the specific UGRC workgroup that advanced this recommendation.)
While perusing the references for Recommendation #18, I was a bit surprised to see a link to an old Sheriff of Sodium post mixed among the references to authoritative academic journals.
Let’s just say this citation reflected a very selective reading of my bibliography as it relates to the NBOME… but I appreciated the credit nonetheless.
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LOSER: THE UNMATCHED.
The preliminary report from the UGRC included 42 recommendations; the final report, just 34. Among the specific recommendations left on the cutting room floor was the old #19, which called for studying the unmatched.
Recommendation #19 from the UGRC preliminary report called for a committee to study unmatched applicants.
Sure, the final report still notes the need to “explore the growing number of unmatched physicians in the context of a national physician shortage” in recommendation #2, but you can’t escape the feeling that unmatched doctors are de-emphasized in the final report. (Other preliminary recommendations that seem de-emphasized include the previously enthusiastic support for an early result acceptance program, which follows a letter from the NRMP noting that they would not pursue such a program this year.)
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WINNER: STUDENT LOAN LENDERS.
For many students, transitioning to residency is a period of serious financial stress. The student loans that were disbursed in August are long gone… but the first paycheck of residency may not come till mid-July or even the first of August.
To address this important issue, the UGRC brings us Recommendation #33, which calls for funding these predictable expenses “through equitable low interest student loans.”
Which, I guess, is one way to do it.
Of course, another way would be for programs to subsidize this transition. You know, insofar as residents are revenue generators for the hospital well beyond the value that they are compensated. (n.b., if anyone tries to use selective accounting to argue otherwise, simply ask them why some keen-eyed hospital administrator hasn’t cut the residency program if it’s such a money loser.)
Nope, says the UGRC. “These costs should not be incurred by GME programs,” going as far as to make a specific enjoinder against even offering sign-on bonuses.
Why go there? If a program chose to help with moving expenses or give a small signing bonus – possibly because they realized that doing so was a more effective way of recruiting under-represented minority applicants than giving them a lanyard or can koozy with the hospital logo – why stop them?
(The only reason I can think of is that if some programs started doing this, others might feel compelled to do it, too. Better for everyone to link arms, hold the line, and make less affluent residents take on more loans.)
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Every year, students interview at more programs and submit longer rank lists – even though overall match rates are unchanged.
WINNER: INTERVIEW CAPS.
Recommendation #24 calls for limiting the number of interviews that an individual applicant can accept.
When 12% of residency applicants consume half of all interview spots in specialties like internal medicine and general surgery, this is low hanging fruit.
(My only criticism is that the proposal for specialty-specific limitations on interviews is unnecessarily complicated in a world when many applicants apply to multiple specialties – and may also have the unintended consequence of encouraging some well-qualified-but-nervous applicants to double apply.)
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When programs aren’t transparent about their filters, applicants pay the price.
WINNER: TRANSPARENCY.
Recommendation #6 calls for a verified database of programs that will include “aggregate characteristics of individuals who previously applied to, interviewed at, were ranked by, and matched for each GME program.”
If this is implemented – and I have doubts it can be practically accomplished while maintaining the confidentiality of residents in the program – it would be a big victory for applicants, who may spend thousands of dollars applying to programs who never even read their application.
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WINNER: DOXIMITY RESIDENCY RANKINGS.
Transparency about what kinds of applicants match at each program doesn’t just help applicants – it will be a data gold mine for Doximity Residency Navigator or any other company that purports to produce an ordinal list of residency programs by their quality.
Whatever data get included in the UGMC’s “interactive database” will be scraped by bots and used to judge the quality of the program (as if all residency programs were engaged in a direct competition amongst each other for a single goal). Look for more foolish metric-chasing to follow as programs try to make their reported data look good lest the rankings find them unworthy.
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WINNER: CHEAP INTERN LABOR.
In my original post, I pointed out the somewhat head-scratching preliminary recommendation calling upon the Centers for Medicare and Medicaid Services (CMS) to change the way that they fund residency positions (so that a resident could change specialties and repeat his or her internship without exhausting the CMS subsidy that the program receives). Gotta say, I was disappointed to see this recommendation persist in the final report (now at #3).
I get it: some residents realize only during their internship that they’ve made a horrible mistake with their career choice and need a mulligan.
But to the extent that this problem occurs, does it reflect a failure of GME funding – or a failure of the medical school to provide adequate exposure to that specialty before someone spends a year of 80-hour workweeks doing something that they don’t want to do?
What’s most perplexing is assertion that this move will “lead to improved resident well-being and positive effects on the physician workforce.” Buddy, lemme just stop you right there – no one’s well-being is going to be improved by doing an unnecessary internship. Seems more like a way to turn career uncertainty into extra cheap intern labor.
Instead of “Try this internship! If you don’t like it, you can choose another one next year!” we should instead push medical schools to prevent this problem by abbreviating the preclinical curriculum, pushing core clerkships earlier, and giving students more opportunity to explore careers before application season rolls around.
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LOSER: CHECKED-OUT FOURTH YEARS.
We’ve all kinda come to an agreement that the fourth year of medical school doesn’t pack same kind of educational calories as the first three years. For better or worse, fourth year has become a mixture of application season and rest/recovery before residency. Though there are exceptions, most students don’t receive educational value commensurate with the tuition they pay.
But Recommendation #30 calls for “meaningful assessment” after the Medical School Performance Evaluation (MSPE) is submitted in September, so that a individualized learning plan can be submitted to the student’s residency program prior to the start of residency.
That’s fine, as far as it goes – but it was the description of what that assessment might be that really made the hair on the back of my neck stand on end:
This assessment might occur in the authentic workplace and based on direct observation or might be accomplished as an Objective Structured Clinical Skills Exam using simulation.
If this were a WWE pay per view event, the announcers would be shouting, “Wait!!! It can’t be!! That’s the NBME’s music!!!” as the new, rejuvenated Step 2 CS exam strides into the arena through a cloud of fog. Maybe I’m being paranoid… but I just can’t believe Step 2 CS is gone for good, despite carefully-worded assertions to the contrary.
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Want to be convinced that we need application caps? Give me 45 minutes of your time.
WINNER: APPLICATION CAPS.
I mocked the preliminary recommendations for repeatedly and correctly noting that Application Fever is the root of much of what ails the UME-GME transition – but failing to acknowledge the most logical solution. But now, in response to feedback received during the period of public comment, I am pleased to report that the final recommendations now includes the words “application caps.”
I’m telling you, momentum is building for application caps. Go right ahead and hop on the bandwagon. Plenty of room on board.
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WINNER: INNOVATION.
Recommendation #23 calls for more innovation, which is hardly controversial or noteworthy. But what’s interesting is that the committee actually recommends some parameters for success.
Appendix C notes that goals could include a 20% reduction in applications submitted per position (i.e., from 132 to 102, or back to 2010 levels), or that we should stabilize the fraction of applicants who match outside their top three ranks (a fraction that has been steadily rising each year). And innovation should be allowed so long as the Match has matching rates of +/- 2% from 2020 Match rates (when they were 94% for US seniors, 91% for DOs, and 61% for IMGs).
And maybe this is what I find most encouraging about the otherwise-tepid UGRC recommendations. It does feel like there is some momentum building for real, practical change. More and more people are recognizing the problems and starting to think, at least, about ways of doing things other than how they’ve always been done, and we’re starting to set some parameters for how those changes might occur. These recommendations won’t get us where we want to go – but they build upon and keep those conversations going, and have to be considered a step in the right direction.
(Hey, I’m a glass-half-full kind of guy.)
Dr. Carmody is a pediatric nephrologist and medical educator at Eastern Virginia Medical School.This article originally appeared on The Sheriff of Sodium here.
Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.
Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.
The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.
An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.
He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.
I ordered a pulmonary consult and tonight I was thinking to myself: “Does the vagus nerve sometimes get compromised by hilar masses or adenopathy?”
My first search hit was a 2014 article about a previously unknown association between gastroparesis and pulmonary adenocarcinoma. It has been associated with upper gastrointestinal cancers since 1983 and also with small cell lung cancers and pancreatic cancer.
So my compromised vagus theory may or may not be relevant, but the general link with malignancy was news for me.
As so often in medicine, one diagnosis leads to another.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
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