Sunday, August 26, 2018

Free tuition in medical school is only one step toward producing the doctors America needs

The NYU School of Medicine shook the world of medical education recently by announcing that tuition would be free. The NY Times article about it says that ‘Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.’ Certainly, it is easy to understand that a $55,000 per year tuition bill is going to be way beyond the ability of most medical students and their families to pay, and that a total indebtedness that is often over $250,000 may well affect the specialty choice of medical school graduates. While physicians in any specialty make far more than the average American, compound interest makes the payments a lot more than $25,000 a year for 10 years; often more, indeed, than that average American income (think about the payments on a $250,000 home loan, which usually has a lower interest rate). This may tip the balance between choosing betwee, say, family medicine or anesthesiology, when the latter choice can be expected to result in an additional $7 million in lifetime income.

The other, presumably obvious, impact of free tuition could be the ability of the school’s admissions committee to take more students from lower income families than they currently do. Note “lower income” is not necessarily the same as “low income”, as 80% of medical students now come from the top 20% of income. And, yet, they still have a lot of trouble paying for school, tuition plus the Times’ estimated $29,000 a year in living expenses (in NYC). It is not necessarily true that ability to pay is a significant criterion in the admissions decisions of medical schools, but rather that there are confounders. A big one is that being from a high-income family is associated with having the higher grades and test scores that are so valued by medical school admissions committees (probably especially those, like NYU, that are very interested in producing MD/PhDs and other laboratory researchers). Free tuition, however, might mean that those students from lower-income families who do gain admission will be under less financial pressure to take paying jobs while in school (a really bad idea when trying to succeed in medical school). In addition, those students who have started their own families or whose families of origin have counted on them helping to support them, would have one big less thing to worry about.

We definitely need more family physicians and other primary care doctors than we are producing now (and NYU has produced one of, if not the, lowest number family physicians of all US medical schools). We also need far more students from lower-income and underrepresented minority and rural backgrounds. The reason is not just for ethical or moral, or making up for past practices. It is directly about providing quality healthcare to all the American people, because physicians are most likely to practice in settings like those in which they grew up and feel most comfortable. Thus, students from upper-middle and upper income, primarily white (and Asian) suburbs are most likely to practice in those settings – which are precisely those least in need of more doctors. Students from rural or low-income or minority communities are much more likely to practice in such communities, and these are the places most in need of more doctors. Of course, the correlation is far from 100%, but the trend is overwhelming. Thus, to the extent that free tuition can increase either of these goals, it would be a great thing.

So what is the problem? Well, it is far from certain that free tuition will lead to these desirable outcomes. This point is made by family physician (and NYU medical school graduate) Kenny Lin, MD, in his Common Sense Family Doctor blog. Although Dr. Lin’s 2001 class had only four graduates entering family medicine, it was a larger number than any class since. He points to the fact that NYU has never had a Department of Family Medicine (one of the few such schools, almost all of which are “elite” private and on the East Coast). He also notes that in terms of producing other primary care doctors (general internists and general pediatricians), NYU has also done very poorly.

More important, Dr. Lin cites a study published in the JAMA Network by Grischkan, George, Chaiyachati, et al., that demonstrates that students entering family medicine (one of the lowest paying medical specialties) have a higher average debt load than those entering fields such as radiology, dermatology, and ophthalmology. He writes
These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

This is a very important point. Dr. Lin, focused on the critical issue of producing more family physicians and primary care doctors, believes that eliminating tuition and thus taking students from more diverse backgrounds “will likely have a small, but measurable, positive effect on primary care.” He urges that NYU and other schools increase their “pipeline” programs to help students from less advantaged background gain the skills that they need to be both admitted to and successful in medical school. I agree, but I would go beyond that.

Medical schools should train the doctors America needs. This means fewer subspecialists, and more primary care doctors. This means a smaller percentage of doctors practicing in the suburbs of big cities, and a larger percentage practicing in rural areas and underserved inner-city communities. This is not going to happen if we keep taking the same students we currently do, no matter how nice they are, no matter how high their grades are, and no matter how much they are like (or often are) the children of the faculty of the medical school. If you don’t think this is important, a recent paper from the National Bureau of Economic Research by Alsan, Garrick, and Graziani titled “Does Diversity Matter for Health? Experimental Evidence from Oakland” (reported in the Times article “The Secret to Keeping Black Men Healthy? Maybe Black Doctors”) demonstrates that it does: a significantly higher percentage of black men received important tests, took medicines, and made lifestyle changes when advised to by a black doctor rather than a white or Asian one. Importantly, this comes from more than a knee-jerk reaction to the race of the physician; it has a lot to do with how they were treated. While the ‘white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that referred to medical recommendations…black doctors often left more personal notes, like “needs food, shelter, clothing, job’. This goes beyond race, and suggests that both our overall medical curriculum focuses too much on the disease and not the person, and further that minority physicians may be more likely to realize that it is a person who needs to be treated, and identify the social determinants of health.

Indeed, Elisabeth Rosenthal, the editor of Kaiser Health News, argues in an Op-Ed in the Times that medical school should be free only for those who make a firm commitment to entering specialties and practicing in areas that have real need:
…if a student chooses to become an ear, nose and throat surgeon in suburban New York or a private cardiologist in Miami, fine. He or she can pay back what has been borrowed. But if that doctor chooses to deliver babies in rural Oklahoma or practice pediatrics on the South Side of Chicago, then he or she should get to keep every penny of salary.

I agree, and believe that to make this likely, medical schools, both private “elite” schools like NYU, and certainly state-supported schools, need to take a much higher percentage of students from the lower half of the family income scale, from rural areas and from groups that have been historically underrepresented in medicine. And not just a few more, not just a pilot program with 2% or 5% or 10% of the class. These programs must be far more extensive. The entire class should be composed either these groups of students or of students who, while perhaps from wealthier, whiter, more suburban backgrounds, have demonstrated an extended commitment to service to others. Extended, like the Peace Corps, or Teach for America, or VISTA, or working abroad for years in service programs, not a car wash fundraiser one Saturday.

Some, and sadly this may include many in the administration of medical schools, particularly “elite” ones, will say this can result in the exclusion of the “best” applicants. It may, in fact, lead to the exclusion of some of those with the highest grades, and may even require additional work on the part of the faculty to help students with less rigorous academic preparation. Or, perhaps, elimination of much of the nonsense memorize-detail coursework of the pre-clinical curriculum. But while “best” can mean many things, if the definition is not “most likely to make a positive difference in the health of all the American people” it needs to change, and soon.

Free tuition, at NYU, or other private schools, or state-sponsored schools, may be a terrific idea, and one that should be widely imitated. But it is only one part of an overall strategy, including changes in the selection of applicants, the curriculum of the schools, and the reimbursement of primary care, to significantly change the kinds of doctors that are produced so that they meet our nation’s needs.

Sunday, August 19, 2018

Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some

The American Academy of Family Physicians (AAFP) has added five new recommendations to its Choosing Wisely campaign. I have discussed “Choosing Wisely” before (‘“Eggs Benedict” and “Choosing Wisely”: Often the best thing to do is nothing’, April 14, 2012), but will briefly review it. First introduced by the American Board of Internal Medicine Foundation (ABIM-F), the program calls for each specialty society to list at least five things that are done by members of that specialty but either should not be done at all or should only be done in far more restricted circumstances that they currently are.

The five new recommendations by the AAFP bring their total to 20; this is good, because many other specialty societies have never expanded upon their original five. And for some of those groups, even those original five were kind of tentative, almost like “well, this test or procedure is not good, so you probably shouldn’t use it too much”.  One reason Family Medicine has more is because the field is so broad and its practitioners care for problems in all areas, but I fear that another reason is the reticence of some specialty societies to make negative recommendations about things that their members make a lot of money from doing, even if they are not medically indicated. As I noted in ‘Medical interventions we shouldn’t be getting: issues of cost, health, and equity’ (December 12, 2015) regarding imaging for uncomplicated back pain:
…some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients.
The radiologists, who perform the MRIs and CTs, also did not recommend against this procedure.

The radiologist societies also recommend screening for lung cancer with low-dose CT scans in smokers and former smokers, and in fact, to date, none of the specialty societies are recommending against it. There is some evidence that this (not inexpensive) test may be able to detect lung cancer early in many people, sometimes while it still can be effectively treated, but even this is not certain. Rita L. Redberg, MD, in an editorial in JAMA Network “Failing Grade for Shared Decision Making for Lung Cancer Screening”, notes that while (payment by Medicare for) the test was approved on the basis of one positive study, three subsequent studies have not shown the benefit. In addition, it is not without risk of harm. The harms come not only from radiation exposure, but from complications of the biopsies needed to follow up on positive tests. And, also noted by Redberg, 98% of positive tests are “false positives”, where the patient does not have cancer. Some of this high percentage of false positives comes from testing the wrong people (“screening creep”, where a test that has been shown to be of benefit in a limited population is incorrectly assumed to also be of benefit to a wider group). the US Preventive Services Task Force (USPSTF) recommends that the screening only be done on the patients for whom it is indicated (!!), and only after the doctors engage in “shared decision making” (SDM) with their patients by helping them understand both the potential risks as well as benefits to the test, and what their individual probability of each is.

Apparently, doctors do not do this, as demonstrated by the research article that Redberg’s editorial accompanies, “Evaluating Shared Decision Making for Lung Cancer Screening” by Brenner, Malo, Margolis, et al. Taping and analyzing recordings of doctors recommending this test to their patients, they found no evidence of the physicians presenting the important information and engaging in SDM. It was a small sample (this is difficult and time-consuming work), but as Redberg points out there is no reason to imagine that overall practice is significantly different. While this study specifically looks at low-dose CT screening for lung cancer, and finds that SDM doesn’t happen often, this is a concern for many other tests and interventions that are often done when they are not indicated, and rarely have the risk/benefit presented to people so that they can participate in SDM.

One example of such a test is the use of screening pelvic examinations (the part where the provider puts her hands in and feels around, not the Pap smear part) in non-pregnant women. One of the AAFP’s new “Choosing Wisely” recommendations (#16) appropriately comes out against it: “Don’t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline-appropriate screening for cervical cancer”.  This is because the most basic characteristic of a screening test (essentially, any test – whether a physical exam or lab or x-ray – done in asymptomatic people) is that there has to be a disease that the test can, with some reasonable rate of accuracy, screen for. There is no condition that can be screened for by a pelvic examination (including ovarian cancer, which has been cited, and is always too advanced to successfully treat by the time it can be felt). I have been teaching students and residents to not do “screening” pelvic examinations in asymptomatic non-pregnant women for decades.

For similar reasons, previous AAFP “Choosing Wisely” recommendations, had already recommended (#5) against doing Pap smears in women in whom it is not indicated (those who are under 21 or have had removal of their cervix for non-cancer disease), and in women over 65 who have had negative prior Paps and are not at high risk for cervical cancer (#9), and not requiring either Paps or pelvic exams for prescribing oral contraception (#15). In addition to not doing a screening test when there is no disease to screen for (pelvic exams), they should also not be done when the risk is very low and lead to excessive false positive tests. This seems like a lot of “don’t dos” in the same general area of women’s screening, but it is warranted not only because family physicians do a lot of such screening, but, more embarrassingly, because many OB/Gyn specialists both continue to do them and to teach students and residents to do so. Indeed, not doing screening pelvic examinations is distinctly not one of the 10 “Choosing Wisely” recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yes, OB/Gyns do make some of their living doing such procedures (as do family doctors), but frankly it is a small percent compared to doing surgical procedures. Sometimes tests and procedures continue to be done even when they are not indicated (or potentially harmful) because of tradition. Or because of publicity campaigns run by disease-specific advocacy groups, especially for various types of cancer, that sow fear rather than truth.

But when such tests and procedures continue to be done, even in part, because those who perform them, the doctors and hospitals and laboratories and device makers, make money doing them rather than for medical benefit, it is reprehensible. And, even more, it saps funds from other important health-related care, particularly for those people who have the least money and are least likely to be insured. We do not have a unitary national health system in which money not needed in one area can be easily transferred to spending on necessary care for other people or conditions, but we need to get there.

It is unacceptable for people to get tests and procedures that are dangerous and of no benefit regardless of funding. It is similarly wrong for even relatively benign tests and procedures that are not medically indicated to be done because those performing them make money. But it is worst that many people do not get even basic, indicated, beneficial care while money is being wasted, or worse, on these other procedures.

The terribly flawed attitude of treating healthcare as a business was illustrated by a comment from Charles Bouchard, senior director of theology and ethics at The Catholic Health Association, in a NY Times article that found fewer than 3% (all in Washington State, which legally requires it) of Catholic hospital websites “contained an easily found list of services not offered for religious reasons.” He said '“I think that any business is not going to lead off with what they don’t do. They are always going to talk about what they do do. And that goes for contractors and car salesmen. They are not going to start off by saying, ‘We don’t sell this model,’ or ‘We don’t do this kind of work.’”

That’s the problem. Selling things people do not need to them if they have money (and not offering things there is no profit in so doing) is a common way to run a business. It is no way to run healthcare.

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