One of the things that used to make physicians different from other providers is the ability to prescribe drugs. This is not true anymore, but the majority of prescriptions are stil written by doctors. Prescribing practices of physicians vary widely across different populations and specialties. If a doctor takes medicare patients, his prescribing patterns are part of the mountains of data medicare collects about it’s patients. In 2003 the government passed an expansion of medicare called Part D. This program pays for prescription drugs. 35 million people have medicare Part D.
Propublica, the non-profit investigative reporting organization, says there’s a problem with medicare part D. It’s not that it was a bad idea, or that it costs too much. The intention was good and it has cost less than it was expected to. The problem seems to be that doctors are prescribing too many dangerous or inappropriate drugs to patients, mostly the elderly. Propublica looked at Medicare’s data and found 70 physicians with outlying prescribing records, including abnormally high prescriptions per day, or high numbers of prescriptions for sedatives, narcotics, and antipsychotics. The article says that the Center for Medicare Services, or CMS, is not monitoring doctors closely enough.
Now, I don’t know how many doctors prescribe to patients who have Medicare Part D, but I bet it’s a much larger number than 70. Propublica pulled out some of the most egregious examples to illustrate their point. There are doubtless some charlatan physicians out there and some unscrupulous ones, but not many. Let’s forget the doctors who prescribe for cash or to game the system. Everybody else might be trying to do the right thing in a misguided way. For example, Propublica cites one physician who prescribes too many antipsychotics for demented patients. The thing about dementia is that it causes people to do things that are dangerous to themselves. In some cases the drugs can help decrease the disordered thinking that leads to dangerous behavior. The best thing for a demented patient is to have someone who cares about them watching them or very near them all the time, to prevent harm. This doesn’t happen of course. A bunch of demented people get put in a big ward with one or two nurses. If no one can watch them, the solution is to medicate them. A nursing home medical director may be doing the best he can in a bad situation.
Other doctors prescribe too many narcotics. There are multiple reasons for this, some having to do with patient population or specialty, others having to do with path of least resistance, yet others having to do with patient and family demands. And yes, some doctors would rather just prescribe something to get you out of their office than try to deal with what’s really wrong with you.
Physicians prescribe things that aren’t approved by the FDA for specific uses. For example, Haldol, an antipsychotic, has well-known anti-nausea properties. I don’t believe it is FDA approved for this use. Propofol, a powerful sedative, also has anti-nausea properties not approved by the FDA. Decadron, a steroid, also has anti-nausea properties. Sometimes it’s voodoo, sometimes it’s placebo, sometimes it might actually work. When someone is really sick, you might try all of them. Most of the time the doctor is making an effort to help.
Are there unscrupulous or dangerous physicians out there? Absolutely. Should those physicians be stopped. Absolutely. The problem is that you have to scrutinize everyone all the time to find these 70 guys. It becomes kind of like Homeland Security guys at the airport; everybody has to take their shoes off cuz one guy had a bright idea. How many terrorists has that system caught? More regulation is not the answer. If you make more rules, you burden the honest folks while the dishonest ones will find a way to work around them. Let’s look at WHY this is happening. Do demented people need more supervision? Do doctors need more time to evaluate pain? Do medical schools need to teach pharmacology better? Do residency programs need to evaluate young physicians in their pharma usage?
There will always be bad actors. Let’s not punish everyone else for their behavior.
OK, moving away from controversial topics for a bit. I am going to post a section of my “book” (in my imagination it’s a book) in which I talk about the development of Harvard Medical School. I do so because changes are afoot in American medical education and it is interesting to see how major reforms occurred in the past. It’s a little rough, so don’t decide not to read the “book” (in my imagination it’s a book, as I’ve said) if you hate this chapter.
Freeman Allen graduated from Harvard Medical School (HMS) in 1899. The medical school had grown exponentially in the 50 years prior to Freeman’s graduation. The first person who had an idea for a medical school was John Warren, John Collin’s father. Because of the revolutionary war, the apprentice system for training doctors broke down, the doctors having joined the army or fled. Unable to go abroad to study, men were becoming doctors with essentially no training at all. Warren organized some lectures and demonstrations at the hospital (presumably the Continental General Established Hospital, at which he was superintending surgeon). He had tried to bring in a couple of other doctors to form a faculty, but they suspected Warren of trying to gain a pecuniary advantage, and refused. Warren’s lectures were open only to members of his own staff and certain med students he trusted, as dissection was illegal. The newly formed Boston Medical Society eventually decided to sponsor these lectures. In 1782 Harvard’s president Joseph Willard considered establishing a medical professorship and Warren was asked to outline a course of study that would supplement the apprentice system. In 1782 the medical school was created with three professors: Warren to teach anatomy and surgery, Dr. Benjamin Waterhouse to teach theory and practice, and Dr. Aaron Dexter to teach chemistry and materia medica.
By 1814 there were four medical schools in the US: University of Pennsylvania, Harvard, one in Baltimore, and one in Hanover, New Hampshire. Students were required to do two courses of lectures, two years of apprenticeship, a third unspecified year, then pass oral examinations in medicine, Latin, and experimental philosophy, and submit a dissertation. In 1849 Harvard medical school consisted of eight doctors and around 150 students. The school was located in a building on Mason street but was soon to relocate to a new building on North Grove Street on land donated by Dr. George Parkman, whose father had been present at the first successful anesthetic and who was to be found murdered in the chemistry lab in December of 1849. There was no requirement that students have an undergraduate degree. There were no pre-admission exams and essentially no entrance requirements. J. Mason Warren, son of the Warren who performed the first operation under anesthesia, never had more than 2 years at college. The requirement that medical students had to have an undergraduate degree was initially suggested in 1887. A degree wasn’t actually required yet when Freeman matriculated, and wouldn’t be until 1901.
Around 1850 lectures in medicine were given starting in November of every year and were four months long. The medical school of 1850 was really a school of medicine in it’s clinical aspect, but the alliance of science and medicine was neither acknowledged nor taught. The original purpose of medical schools, after all, was to supplement the existing apprenticeship system, not create a new entity. Lecture time was considered “extra”, hence the limit of four months. For hands-on clinical training the MGH charter provided that students from either the Massachusetts Medical College (as HMS was then known) or physicians’ private students could be admitted by ticket to see the practice of the hospital. Examinations for a medical degree were given twice a year at which three faculty were all that were required to be present, usually the faculty that taught the subject and who were paid for the classes by the students they were examining. They were oral exams and were informal and short. J. Collins Warren, a member of the prominent Warren family of surgeons, took one of his oral exams bouncing along in a buggy with his examiner Richard Hodges. Candidates to take the MD exam had to be 21 years old, have attended two “full courses of lectures” (four months each) at the college and have studied for three years with a physician (an increase of one clinical year since 1814). Candidates still had to show knowledge of “Latin and experimental philosophy”. If you did those things and passed the exam, you were a doctor. This is why young men of means went to Europe to study medicine, where the standards of admission of and of learning were much higher.
In 1869 Harvard acquired a new president, Charles William Eliot. The medical school had 13 faculty members. Eliot was to shake up those 13 men and the future of medical education. He advocated for changes in medical education including a progressive three year course including lectures, labs and hospital training, abolition of fees to individual professors, entrance requirements, and written examinations. The old guard, helmed by Dr. Bigelow, opposed all these changes but the young doctors who had recently gone through the system advocated strongly for reforms. Bigelow’s faction was eventually defeated, and quality of students and graduates began to rise soon after. The school outgrew the North Grove Street location and J. Collins Warren was secretary of the comittee charged with raising money for another new building for the medical school on Boylston street at the corner of Exeter street, in the newly-created Back Bay. This new building was opened in 1883.
At the time Allen graduated from the medical school in 1899 HMS had as many as 100 teachers and faculty and 710 students attending medical lectures. The duration of medical school was now the 4 years that has been standard ever since. In Allen’s first year of medical school he took Medical Chemistry along with two hours of lab every week. The Sears family had donated money to the school for new laboratory space, called Sears Laboratories. Some of the labs he took were likely located at MGH or the Boston City Hospital, where new lab facilities were making Boston a center for the study of pathology. In fact, laboratory or practical learning was beginning to take the place of extended lectures. He took Applied Physiology or Physiological Chemistry as it was re-named. He studied 16 of the most common surgical procedures in the form of “exercises” as well as a Surgical Landmarks course. Later in the year he repeated these surgical procedures under the supervision of an assistant. He had to complete 24 hours of such practice. He also had to care for and report on at least four cases of clinical medicine. Anatomy was taught over the first two years. In his fourth year he had the option of electives like histology, infectious diseases, embryology, and Clinical Microscopy. If he took any anesthesia course at all it would have been as part of a month-long surgical clerkship in his third year.
Thanks Kermit. Thanks a lot. The abortion debate lives to rage another day. Unless you’ve been on Jupiter you’ve probably heard that this guy named Kermit Gosnell, an “abortion doctor”, has been convicted of murder on multiple counts, including the murder of babies. Now, while I am pro-choice, I think Gosnell was a charlatan, and if he’s guilty of all the things they’ve accused him of (now don’t sniff, the courts have been known to be wrong) words cannot express my disgust. The problem I have with Gosnell is that he has fueled the fire of the wrong debate. Each side of the abortion debate is going to use this to their advantage, with the edge probably going to the pro-lifers. But the real issue is: why did those women find it necessary to go to him?
The media has said that Dr. Gosnell was serving a largely poor community. We don’t know many more details about the patient population. West Philadelphia is a largely black and latino community with a high crime rate. One street corner is listed as 8th of the 10 top street corners for drug dealing in Philadelphia. All this is true despite the presence of the University of Pennsylvania. The women that went to Gosnell likely were desperate and had nowhere else to go. The Affordable Care Act hasn’t reached west philly. Actually, it sounds like basic health care hasn’t reached that area. I don’t know if Gosnell was the only OBGyn in the area or the only one performing abortions. The media can call something an “abortion clinic” when it could be a Gyn clinic that provides abortion as part of it’s services. But if he was the only game in town, that’s a problem. The absence of basic services for women like birth control (and yes, birth control is a basic service) and the availability of a clean health care facility is something we talk about in third world countries, not here.
The people in washington, who’s wives have excellent health care, can argue until the world ends about whether abortion is right or wrong. Gosnell’s patients either knew or felt they had no other choice. If they had had access to birth control and basic gynecological education they wouldn’t have been there. If they had jobs and health insurance they wouldn’t have been there. If they didn’t live in a culture of violence and drugs they wouldn’t have been there. If they had access to a solid education they wouldn’t have been there. If they were fortunate enough to be born or live elsewhere, they wouldn’t have been there. If they had CHOICES, they wouldn’t have been there.
While I would never defend what Gosnell did, he may have felt he was doing a good service for this patients. Maybe a woman was raped by her father and he wouldn’t let her come to a clinic until she was too far along. Maybe a 13 year old girl got pregnant and was afraid to tell her parents until it was too obvious to hide. Maybe this 13-year-old saw her 13-year-old friends with their babies and decided it she couldn’t do it. Maybe she was being raised by her grandmother who was 80 and wouldn’t be able to care for a newborn. Maybe she didn’t know how to contact adoption agencies, or even know where to find one. Maybe Gosnell saw the world into which children were being born and decided to “help”.
This conviction should not spark a debate about abortion. It should spark a debate about why we are failing our disadvantaged women.
The blogosphere is packed with ideas. That’s one of the features that makes it fun and stimulating to be a part of. Most of us just write our ideas to ourselves and our two readers (three if you include the cat) and count ourselves fortunate to be part of the conversation. Within the last couple of months my attention has been called to a new forum for ideas: TED. TED stands for Technology, Entertainment, and Design. It’s motto is “Ideas Worth Spreading”. It started out as a conference that brought innovators in the three focus fields together. It has morphed into something much broader. The TED forum now includes TEDMED, for medical issues, TEDWoman, TEDGlobal and so on. The organization also fosters new talent with it’s sponsorship of awards and fellowships.
You can’t just sign up to go to one of the TED conferences. Or rather, you can, but you’ll have to pony up $4,000-$7,000. But on TED.com you can access thousands of 20-minute “TEDTalks”, short speeches from leaders in various fields whose talks were originally given at one of the conferences but can be viewed for free on the TED site. These talks are universally fantastic. For example, PBS aired a TEDTalk segment on education, the first televised TEDTalk as far as I know. Rita Pierson talked about teaching as making a connection between people. Ramsey Musallam talked about teachers as cultivators of curiosity. Angela Duckworth talked about how to cultivate passion and perseverance for very long-term goals, a characteristic she calls “grit”. Bill Gates talked about money, of course. Geoffrey Canada talked about educational innovation. Pearl Arredondo, whose father was a gang member, talked about schools as safe havens. And Sir Ken Robinson (I LOVE him, why have I never heard of this guy???) wondered why alternative education is called “alternative”. You can google any of these folks and find they are all leaders in the field of education, not always famous but always considering something interesting.
I have only one, well two, concerns about TED. One, it’ so frigging expensive. Two, like the blogosphere, TED is all talk. That’s it’s point. I will be interested to see if the talking translates over time into doing. In this world of social media and a never-ending quest for more information, there’s a lot of talk. Talk is fun, interesting, stimulating, cheap. Doing is hard, frustrating, and expensive. Doing requires grit.
Yesterday at the faculty meeting of the, well, faculty, we learned that the first year residents in anesthesia will now have to take AND PASS a written exam at the end of their first year. They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way. Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year. You didn’t have to pass it or get a certain grade; it was sort of a reality check, to see how you were doing. I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test. It might be a solution in search of a problem, I have no idea.
Here’s the thing. Testing freaks residents out. They have been taking high-stakes tests their whole entire lives. In high school they had to get As and score a 1400 on the SAT. In college they still had to get As, but also had to ace the MCAT. In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t. Results of those had bearing on what residency you got into. The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test. Residents are masters of this. There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online. Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.
Cramming for a test is not learning. Let me make that perfectly clear. You forget it the minute you walk out of the exam room. Learning facts and passing multiple choice exams is not learning. It is not necessary to UNDERSTAND a subject to do well on it on tests. Prime example: me in calculus. I had no idea what I was doing or what it meant but I knew if I memorized how to run the steps I could always get the answer right. It was hilarious in a really sad way that I didn’t appreciate at the time. Med students and residents are not lazy learners. Given the right incentive they want to understand the material. But they also know two very important facts: 1. Most of the facts are not necessary to clinical functioning. A lot of the questions asked are about things you never actually use in practice. Everybody knows the dweeb who aces the exam but is completely hopeless in the clinic. Conversely you can have a great clinician who somehow managed to make it this far without knowing the partition coefficient of Sevoflurane. 2. The most important thing is always what the people in power think of you. The system is rigged so that passing the exams substitutes for more in depth and complicated evaluations. A great exam result is likely to get you off the hook for practical failings.
This new test will likely result in all first year anesthesia residents freaking out. They will haul around review books, new ones that have generated a lot of money for the people who write those things. They will look sidelong at their friends to see who is studying more than who or who knows more esoteric facts. They will stay up late and yawn in the OR. Study groups will form. Marriages will falter. Children will go unfed. And once the exam is over, nothing will have changed. Their skills will be the same. They will have been learning facts in place of learning how to give anesthesia. Awesome.
Someone has been listening to me. Or rather, to me and a growing number of voices that are questioning the requirements for admission to medical school. I have argued in a past blog that you won’t get more good primary care doctors, who practice a lot of humanities in addition to the science, if the only people you admit to medical school are scientists. Two medical schools and the American Association of Medical Colleges are beginning to agree.
Pauline Chen gives a good overview of what’s happening in this area here: http://well.blogs.nytimes.com/2013/05/02/the-changing-face-of-medical-school-admissions/?ref=health. Essentially, Boston University and the medical school at Mt. Sinai have made pretty radical efforts to apply either more than the traditional evaluation points to their admissions process, or different ones altogether. Mt. Sinai, in particular, has an extraordinary an early-acceptance program for college sophomores and juniors in which they can get into medical school without the MCATs, and without a few of the standard pre-med science and math requirements. In return, the accepted students have to continue to major in an humanities-related field and maintain an adequate GPA. They also have to undergo intensive science enrichment courses prior to matriculation. BU hasn’t gone quite that far, but they have included many more “holistic” data points into their admissions decisions, a process that is extremely labor intensive for the schools’ admissions staff.
Both schools have great ideas that are showing some promising results. I see a couple potential problems:
1. Mt. Sinai seems to be sort of cramming in all the old science requirements in off-hours, allowing students to pursue wider studies in college. I would rather see a larger decrease in the science and math requirements. Basic chemistry and biology are probably necessary, but no one has ever explained to me why you need physics. Or calculus. You don’t need most of this stuff in medical school. All you need in medical school is the ability to put your head down and push through the memorization. You don’t need math, you just need patience. The thing is, the only way to get rid of the math and science is to get rid of the MCAT, because believe you me you can’t get through that behemoth with an english major. Then, even if you do that, you eventually run into Step 1, the first of the three-part exam you take in medical school to pass medical school. The Mt Sinai kids might need more “enrichment” courses to get through that. If those hoops are eliminated, you might find some great doctors underneath those mountainous requirements.
2. Asking sophomores to commit to medical school means you’re asking 19 and 20 year olds to decide what they want to be when they grow up. I couldn’t even decide what to wear on any given day when I was 19. The path of medical school and residency is so long and so arduous that it’s a tough commitment to make at any age, let alone 2 years out of high school. Kids should be having fun and learning a wide range of great new things in college, and even after. It’s the perfect time in their lives to do this. The best thing would be to at least consider the application of ANY college student who wants to apply, even if he doesn’t have the science and math. You’d be more likely to end up with an happy, well-rounded individual.
My proposals aren’t going to come true, of course. We hold onto the doctor-scientist identity very strongly. But these schools and the AAMC are making a start and I bet they’re making some great doctors too.