Who should we take in medical school? What should be the criteria? Who will be a good doctor?

There are many serious inequities in our society, and they tend to build upon one another. People with more advantages have more opportunities to do well themselves, and those with fewer have less. Those advantages (or, conversely, disadvantages) include wealth, white race, male  gender, suburban or urban (but not poor areas) location, and education. All these feed one another. For example, coming from a well-to-do family and being white dramatically increase the odds of success in a chosen field. Even if there were no discrimination against people based on race and color (and this is a long way from being true), there is still the fact that people of color are grossly over-represented in low-income communities and families. This is a clear example of structural racism, so that effective discrimination based on class disproportionately falls on people of color.

An important manifestation of this exists in healthcare, and in particular the production of healthcare professionals (but also in other professional fields). In medicine specifically, we have a physician workforce that does not reflect the population of the US in terms of class (or family income), race, gender (although this is the area in which the greatest progress has been and continues to be made), geographic location (rural vs. urban), and specialty choice. Our doctors overwhelmingly are from upper-middle-class backgrounds, are white, are from suburban (or well-to-do urban) communities, and largely male. They practice in urban and suburban areas in even greater proportion than they come from them, in part because they also practice in specialties and subspecialties that cannot survive in smaller communities, rather than in family medicine and other primary care specialties that are in shortage. This exacerbates the other inequities by making healthcare something that is less accessible to many Americans based on geography (where are the doctors located?) and culture, as well as because of cost, the absence of a universal affordable healthcare system being an almost uniquely American phenomenon.

Not having a medical workforce that looks like America, or practicing in the areas and specialties where there is most need, goes beyond the admissions process to medical school. It is impacted by the curriculum (both formal and informal, or “hidden”) in medical school, by role models and mentors, and very much by the potential income from practice. The systemic characteristics of society greatly influence who is considered a “good” candidate for medical school, and even who applies. These are considerations addressed in a recent blog post on LinkedIn®, a professional networking site, by Dr. Heidi Chumley, dean of the Ross University School of Medicine (RUSM). Dr. Chumley focuses on the challenges faced by students from backgrounds underrepresented in medicine (URiM), and in particular on the emphasis on performance on the Medical College Admission Test (MCAT) for deciding who gets into medical school, since URiM students perform less well on that test. She notes that what seems like a small difference in scores makes a significant difference in admission: “There remains an unexplained gap in average MCAT scores between White (503.1), Black (494.9), and LatinX (497.1) test-takers. This gap matters as 29% of applicants with a score of 502-505 are accepted compared to 10% with a score of 494-49.”

Dr. Chumley also address two other critical points. First, that the lower MCAT scores are likely tied to many of the social and educational disadvantages faced by URiM students, thus reflecting, and compounding, the other factors that these students have to overcome. Second, that efforts implemented by many medical schools (and endorsed by the Association of American Medical Colleges, AAMC) to have a more “holistic” admissions process mostly changes the selection of which high-scoring students are admitted. Yes, it is great that students who have a social conscience and have done volunteer work in the US and abroad are selected over those who are selfish and not so involved, but this rubric, as she points out, ignores the fact that many lower-income (and URiM) students need to work at paying jobs to support themselves (and often their families), and devalues such employment in comparison to the voluntarism that is more accessible to those from privileged backgrounds.

Added to this is the financial component of the cost of medical school itself, which, in the US and in the US (and Canadian) serving Caribbean medical schools (of which Ross is one of the largest and most prominent), is staggering. Students typically graduate from medical schools with debt loads of $250,000 or more. In addition to being outrageous to start with, add the fact that compound and accrued interest makes the total to be repaid much higher, and this encourages students to choose higher-paid specialties even when that is not where the greatest need is (you may make, over a lifetime, $7M more practicing as, say, an anesthesiologist compared to a primary care doctor) or even where the student’s personal interest lies.

Dr. Chumley describes some of the efforts to increase access for URiM students at RUSM, and they are indeed impressive. They include “pipeline” relationships with HBCUs (Historically Black Colleges and Universities) and HSIs (Hispanic-Serving Institutions) and  re-thinking what criteria for admission are essential, valuing the life experience (including work experience) of applicants and putting less emphasis on the absolute score students get on the MCATs. As she points out, the MCAT predicts performance on similar multiple-choice tests of knowledge including most “pre-clinical” tests in medical school, and the licensing exam, the USMLE (particularly Part I, which covers basic science). It definitely does not predict performance as a good or excellent clinician. Also, while there are significant differences in the first-time pass rates on USMLE in those who score “over-500” (> 95%) and “just under 500” (> 80%) groups on the MCAT, the medical school curriculum should be addressing those differences.

The two points I would like to emphasize are the criteria for who is likely to become a good doctor (and thus should preferentially be admitted to medical school) and the enormous cost burden on medical students that obviously falls hardest on those with the least wealth. As I have said before (The high cost of medical education: Who should be trained to become doctors?, Dec 10, 2019; Free tuition in medical school is only one step toward producing the doctors America needs, Aug 26, 2018), those who should be given the opportunity to become doctors (ie., be admitted to medical school) should be those most likely to make a positive difference in the health of our population. This includes a sense of community over self, a willingness to serve where needed, and interest in (preferably commitment to) practicing the specialties most in need in the areas most in need of them. Since URiM doctors are more likely to practice with patients from similar backgrounds (and those patients are often more comfortable seeing them), and a comparable correlation exists with those from rural backgrounds, these characteristics should be very important criteria. As should coming from a family with lower than average wealth and income, which requires addressing the second point. Higher income does correlate with better education and higher MCAT scores, and maybe higher scores on basic science tests in medical school (which are very like undergraduate science tests) and USMLE Part I scores, but not (and almost inversely) with practicing the specialties most needed and caring for the people most in need. So this should at best be a neutral, not positive, criterion.

And the money is a big one. You can admit a student from a low-income family who will be a great doctor, but they should not have to go into absolutely crushing debt and certainly not to enter the highest-income specialties to pay it off. This can partially be addressed by medical schools offering scholarships and states and localities offering loan-repayment programs, but it would be most effective if the federal government could subsidize the cost to make it far lower, and in conjunction with requirements that schools (state or private, stateside or Caribbean) to produce the physicians America needs.

Of course, as well, and even more important for all our people, to have a free or very low cost universal health system.

 

Disclosure: Dr. Chumley and I have known each other for many years and previously worked together.

A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care

People in the US are worried about a lot of things, but apparently the top one is whether, and how, they are going to be able to pay unexpected medical bills. The chart below, based on an August, 2018 survey, is provided by Drew Altman, President of the Kaiser Family Foundation, in the September 24 Axios. Indeed, concern about medically-related costs come in not only as #1, but as #2 (health insurance deductible), #4 (prescription drugs), and #6 (monthly health insurance premium), making up 4 of the top 8 concerns, all of them ahead of “rent or mortgage” (#7) and “food” (#8). All 8 of these concerns are upsetting; it is outrageous that over one-third (37%) of Americans are very or somewhat worried about being able to afford food, or 41% rent or mortgage. But a twice as many people, two-thirds, 67%, are very or somewhat worried about being able to afford unexpected medical bills, and over half (53%) about their health insurance deductibles.

 Of course, those who are worried are not evenly distributed among all Americans. They are not the suburban men who are turning more toward Trump, as they sit on the golf course by their $500,000 homes. They are certainly not the people in power in Washington, whether in the administration like Jared Kushner, who pays no income tax, or his father-in-law, President Trump, who has not released his tax returns, or the senators and even congressmen who make policy, or the members of the Supreme Court.

They certainly do include the poor, including many who are members of minority groups; those who, even in the best of circumstances are barely hanging in there – or often are not. These are the folks for whom paying for housing and food is an all-consuming concern, who do not know where their next meal may be coming from. For them, extraordinary medical bills are not even something that they can spend time worrying about, although they would certainly not be able to afford them.

Those worried, however, also include the large percentage of Americans (see the numbers) who are not poor, but are not all that far from it, people who are not that many paychecks from homelessness (a good measure of real risk). These are people who do not qualify for Medicaid (especially in the states that have not expanded it under the ACA), do not yet qualify for Medicare (and even many of those who do), and who often have health insurance either through their employers or through the ACA marketplaces. The employer health plans, overall, are cutting back on benefits, increasing employee contributions (#6), requiring higher deductibles (#2), and even instituting lifetime caps on benefits as well as excluding many times of illnesses. Fortunately for these people, the ACA has important requirements that help protect them: that people with “pre-existing” conditions be eligible for health insurance (without that, many folks with chronic disease would not be covered), and that there be “community rating”, which means insurance companies can’t charge individuals with particular conditions many times more than they charge others (without which most folks wouldn’t be able to afford the premiums).

It is also true that the current administration and Congress have been trying very hard to limit, when they cannot repeal, these very protections that provide a minimum safety net for most Americans. They are also keeping up a drumbeat about the “cost” of programs such as Medicaid (it’s just poor people, after all, except it is also your elderly parents and grandparents in nursing homes, and this is the bulk of the cost), Medicare (a bit of a “third rail” in politics, but which lots of Republicans keep bringing up as needing to have its benefits cut), and even Social Security, the program that keeps many, many American seniors from being in real poverty even as it continues them in near-poverty. The fear of losing insurance because of having a pre-existing condition is, scarily described by Kurt Eichenwald in a NY Times Op-Ed on October 16, 2018.

The fear of #1, “unexpected medical expenses” is, I assume, primarily about getting sick when you weren’t planning on it. Most folks are not hoping to get sick, but for some the exposure is particularly great because part of the way they handle #6, monthly health insurance premiums, and #2, high deductibles, is not be either uninsured or poorly insured. The latter is particularly common, both in many employer plans and even in ACA individual plans. Indeed, while they call it something different (“free choice” and “granting Americans the freedom to buy health care across state lines”[1]), the administration and Congress are actively encouraging high-deductible, low-coverage policies. This makes premiums seem affordable (or more affordable), but is a disaster when someone gets sick (back to #1).

In addition, limited networks are a quicksand trap for many people, who try to carefully go to doctors and hospitals that are in their networks, only to find themselves faced with huge bills from emergency room physicians, specialists, surgical assistants, and lab and imaging services that are not. This is truly a kind of “gotcha”, a quicksand trap. It is unbelievable; or maybe it is too believable. What may be more unbelievable, to many Americans, is that in most other developed countries health care systems are designed to serve people’s health, not trick and bait-and-switch for the purpose of corporate profit.

Medicare, as currently structured, is not a panacea; 31% of US seniors go without health care because of cost. But it is much better than nothing, and could be really good if it was better funded, and for-profit insurers were not skimming the “cream” (the least sick) into Medicare Advantage plans (which have much higher overhead/administrative costs than traditional Medicare).

Sadly, the issue of whether Americans should have adequate and affordable health care has become highly partisan. This is in some part because at least a portion of the Democratic Party has moved to positions in support of health care as a right, and a universal health insurance system (such as Medicare for all). But it is much more because the Republican Party has moved into complete opposition to any plan to expand health coverage to more Americans (e.g., Medicaid expansion, ACA) and is actively and aggressively moving to cut funding for ACA, for CHIP, for Medicaid, and even for Medicare (“we can’t afford it” is the stated reason, although it really means “we can’t afford it while giving multi-trillion-dollar tax cuts to corporations and the wealthiest”).

Sadder is the fact that many of those most affected, many of those with the greatest worries about health costs, whether unexpected illness, high deductibles, high prescription drug costs, high premiums, are reliable Republican voters. The Associated Press published a piece describing how the Democrats are focusing on health care for the midterm elections, citing the senate race in my state, Arizona. It describes how the Republican candidate, Martha McSally (currently my congressperson) tries to talk with business executives about the tax cuts but is regularly interrupted with questions about health care:

‘They are asking about Democratic ads saying McSally, currently a congresswoman, supported legislation removing the requirement that insurers cover people with pre-existing medical conditions.

"It's a lie," McSally said quickly, accustomed to having to interrupt a discussion of the tax cut to parry attacks on health care. But she had voted for a wide-ranging bill that would have, among other things, undermined protections for people with pre-existing conditions and drastically changed and shrunk Medicaid.’

Actually, then, it is she who is lying. Hopefully she, and other GOP legislators, will pay a price because people vote for those who are actually trying to solve their health care problems, regardless of party. We can hope that more and more Americans will, at least on this important issue, stop voting against their own interests.

I hope.

[1] This is actually the phrase used in the “survey” – completely non-scientific and filled with leading or directive questions – that Trump sends out to his supporters.

Status Syndrome: an important determinant of health

This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.

In a recent blog (Keeping immigrants and all of us healthy is a social task), May 19, 2013), my good friend Josh Freeman wrote about the social determinants of health. When I commented that arguably the most important determinant was missing from his list he suggested that I write this book review blog as his guest. While I had long ago read quite a few papers on the topic of social determinants of health and health disparities that addressed the material that Josh covered in his blog, for me it was an eye-opening experience to read a book a few years ago by Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our Health and Longevity[1]. I found Professor Marmot’s explanations to provide a unifying idea that resonated with me.

Everyone knows that wealthier people are on average healthier than poorer people. However, it doesn’t follow that wealthier countries, including the United State (US), are necessarily healthier than poorer countries. For example, three countries that I am rather familiar with, Chile, Costa Rica, and Cuba, have life expectancies and other population health statistics that are as good or better than ours despite huge differences in average wealth.

Professor Marmot’s thesis is that, after a minimal threshold, it is not so much absolute differences in material means that makes wealthier people healthier, but rather their perceptions of their social status within their reference group. To quote him,

“The remarkable finding is that among all of these people [i.e. the groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome.”

Professor Marmot is a British physician and epidemiologist from University College, London. His book carefully presents the evidence that it is the psychological experience of how much control you believe you have and your opportunities for full participation in society that is at the heart of social determinants of health.  He presents evidence from many countries and comparisons between them, and evidence related to individuals within different types of social hierarchies, and finally ends with evidence that countries with less inequality are healthier than those with more.

One example that he discusses in detail is that British office workers at the bottom of the office hierarchy have a higher risk of heart attacks than senior managers at the top, while just a generation ago popular wisdom was that highly successful “type A” personality people in stressful jobs were more prone to coronary artery disease.

Before reading his book I had seen some documentaries on primates that suggested that lower status animals had poorer health and reproductive outcomes and shorter lives on average compared with high status animals that was relatively unrelated to sufficient access to resources such as food. In addition I lived for a number of years in Chile as a young adult; my middle class income by Chilean standards was dire poverty by US standards. I was an American expatriate, a status  that was highly regarded in Chile, and also during some of those years I was a medical student. Despite the fact that I was really poor by US standards I was happy and healthy and my children also seemed as happy and healthy as US kids. After returning to the US I read some papers that included data to show that the generation of newly arrived Hispanic immigrants enjoy relatively good health outcomes, which deteriorate in subsequent generations despite the fact that the families have acquired more material wealth in absolute terms. No good explanations were included for the findings in those papers. After reading The Status Syndrome it made sense to me. The initial immigrants were probably using their country of origin as the social reference and subsequent generations had a US social frame of reference. I concluded that minority groups in this country have health disparities in large part due to the experiences of inequality and discrimination relatively more than due to absolute access to material means or even specific services - including health services.

In the latter part of his book Professor Marmot demonstrates that the countries with the best health statistics in the world are those that are both relatively wealthy and more equal. Examples of such countries are Sweden and Japan. On the other hand, countries at the other end of the spectrum present a reaffirming contrast. He spends the latter part of the book arguing for a political agenda in favor of reduction in social inequality.

If you haven’t figured it out by now, I highly recommend this book. It will transform how you think about the social determinants of health.

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[1] Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health and Longevity. Owl Books. Henry Holt and Company. New York. 2004.