Would free medical schools increase primary care?

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An op-ed by Peter B. Bach and Robert Kocher in the NY Times March 28, 2011, “Why medical school should be free”, makes a strong argument for just that. They acknowledge that this might seem unreasonable given the fact that physicians, regardless of specialty, make so much more that the average American; indeed are “all but 2 of the 15 highest paid professions”. This data is from the Bureau of Labor Statistics, published just a week earlier. An article by Harry Bradford in the Huffington Post, “America’s 10 best paying professions: Bureau of Labor Statistics”, that indicates that 9 of those top 10 are physicians, surgeons and dentists, with CEOs the only non-medical profession cracking the group, and that at #9, ahead of psychiatrists (#10) but just behind family and general practitioners (#8). The actual numbers from BLS may be suspect; while $174K for FPs may be close to correct, there is no where I know of, one could hire an anesthesiologist for anything close to as little as $220K (or radiologist or orthopedist or surgeon).

So why shouldn’t students pay to get into such lucrative professions? After all, other schools, professional and non-professional, cost money; this is true whether the degree is in law, business, engineering and accounting, which all pay relatively well, or  music, art, teaching and social work, which pay much more poorly. What is special about physicians that should make them be able to go to school for free, as do, say, firefighters and police? Bach and Kocher argue that the high cost of medical education, with students currently averaging over $150,000 in debt and rising, contributes significantly to both the shortage of primary care physicians that this country desperately needs and will continue to need in increasing numbers, and the cost of health care, with physicians entering the specialties that make lots of money by doing lots of highly-reimbursed procedures, many of which may not be medically necessary. As discussed in the recent blog piece Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center (May 30, 2011), the shortage of primary care doctors is projected to significantly increase as a result of the aging of the population, the influx of formerly uninsured people through ACA, and the fact that students are entering primary care at a rate too low (just over 20%) to even replace the already-too-low percent of the physician workforce that is now primary care (just over 30%), not to mention raise it to the necessary 40%-50%. By making medical school free, and thus eliminating this debt burden, students who were interested in primary care would have far less disincentive to entering the field – and earn very good livings, as what is currently the 8^th most highly paid profession.

Going beyond this, Bach and Kocher suggest a creative method of financing the estimated $2.5 billion that this would cost (based on average current medical school tuition): charging for post-graduate (residency) training in non-primary care specialties. Medical school graduation (unlike most other schools, including graduate schools) does not prepare one to be a doctor; rather it prepares the student to be trained in a medical specialty (residency). Residents are not charged tuition, but are instead paid as workers (although it is often considered an educational “stipend”; labor law decisions have varied from state to state). Under this proposal, students entering primary care residencies would continue to receive the stipend, while those entering other specialties (in which they could expect to make a great deal more money) would actually pay (they suggest $50,000 a year, in current $) that would be put into a pool to cover the cost of medical school tuition. The actual process of collecting this money and transferring it to the medical schools, as well as controls on methods of gaming the system (for one, they note, medical schools raising the tuition as students no longer have to pay it themselves) would have to be fairly complex. Nonetheless, this is a great idea; if medical school and residency together are the educational requirement for practicing medicine, then the basic education would be free to the student while entry into higher-income specialties would require additional years of, essentially, tuition. There would be no restrictions imposed upon student choice, but the financial incentives would significantly switch from the “voodoo” workforce policy Dr. Phillips identifies (see May 30, 2011 blog) to one that is aligned with desired outcomes.

A particularly attractive aspect of this proposal is that it would not further add to the debt burden of lower-income students seeking to become primary care physicians; in the May 30, 2011 blog I quote E. Grey Dimond, founding dean of the University of Missouri-Kansas City Medical School (now the highest-tuition school in the US) saying “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” Under the system proposed by Bach and Kocher, those farm kids – and kids from underserved urban areas – would have a chance to gain a medical education and return to serve their communities.

The other ostensible benefit, decreasing medical costs, is not likely to come from this policy alone, however. Indeed, those students entering those more highly paid specialties would wish to maintain their incomes at high levels to justify the additional cost of their education. If there indeed are many procedures being done which are not medically indicated, and there is evidence that there are (see, for example, Rita F. Redberg’s Op-Ed piece in the NY Times “Squandering Medicare’s money”, May 25, 2011), the way to reduce them is to place further restrictions on them and decrease the amount that they are reimbursed by Medicare and other payers. This would further decrease the financial incentive to choose these specialties instead of primary care.

An alternative, however, is to continue to pursue – and exacerbate – “voodoo” workforce policy. The AMA’s “RUC”, described in Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, which is only willing to consider increased payments for primary care if the entire pie is increased thus permitting other specialists to not make any less, is a great example of how to do this. Another is the policy of “balanced benefits” contained in two bills, the Medicare Patient Empowerment Acts, introduced in the House by Rep. Tom Price and Senate by Sen. Lisa Murkowski, and strongly endorsed by the AMA, and described in detail by Dr. Don McCanne’s “Quote of the Day” on May 27, 2011.Hidden by the high-sounding names, this bill would destroy Medicare as it currently exists, and replace it with a de jure, as well as de facto, two-class system of health care. Under the current Medicare law, physicians who accept Medicare have to accept the amount Medicare pays for a given service, plus the amount that Medicare determines to be patient responsibility, as payment in full.  Under these new bills, Medicare patients could see physicians who do not now accept Medicare, use their Medicare benefits to pay the what it pays, and then pay out of pocket the difference between that and the doctor’s charge. Essentially, this would turn all but high-income Medicare beneficiaries into the equivalent of Medicaid recipients.

It is a vile proposal, which would harm most Medicare patients and pad the incomes of physicians. It is more than embarrassing that it has been so strongly endorsed by the AMA and many other physician groups, who are clearly in the business of increasing the income of their members rather than benefiting patients. Dr. McCanne notes that the American Academy of Family Physicians and the American College of Physicians (internists) are conspicuously absent from the group of endorsers. For that he, and I, and the members of these organizations, are grateful. The AMA and the other endorsers of the Price and Murkowski bills deserve the strongest condemnation from Medicare beneficiaries, their families, and the American people.

"Top Doctors": Who are they -- and who are they not necessarily?

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I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads (www.topdoctors.com) where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?

Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.

Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).

Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.

If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.

So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.

They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.

I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.

So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!
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Rankings of Medical Schools: Do they tell us anything?

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Often it appears that Americans are obsessed by “rankings”. I am not talking about which is the best: car, TV, stereo, video game, and all the other consumer products we buy, and which are evaluated and often ranked by various organizations such as Consumers’ Union, based upon explicitly stated criteria. I am talking about the more subtle and subjective of rankings of various organizations and providers of services, particularly universities. More specifically, I will address the rankings of schools of medicine, and most specifically use as examples those in primary care and family medicine.

The US News and World Report rankings of colleges, and graduate schools in a wide variety of areas, including medicine, are the most well-known and “respected” (in the sense of “paid attention to”[1]) of the national rankers. The question is, what do the rankings mean? How are they derived? What do they reflect about the “product” being evaluated? Are they using criteria that are accurately assessing what I am looking for in a school? Are these down-to-earth, utilitarian, “Consumers Report”-type evaluations or are they more James Bond-like brand-name dropping[2]? Of course, if what I am looking for in a school is indeed cachet -- its status, fame and brand-name recognition -- then there is no difference. If, however, I am looking for outcomes – what is the success of that school in educating people in the area in which I wish to be educated, it is important to look at the criteria being used and the degree to which they accurately predict outcomes.

In general, most educators do not feel that US News rankings accurately reflect what they purport to be ranking – quality of the school in a particular area. These criticisms probably are more vocal from those who believe that they are ranked lower than they should be, but even those ranked highly will usually acknowledge, sotto voce, that they are not completely accurate – although they are pleased to be ranked highly. Recently, probably in response to ongoing criticism from the higher education community, US News has begun to publish the criteria that they use for ranking, the weight that they give to each criterion, and the method that they use to gather the information. This helps us to assess the validity of those criteria. (Validity is a concept that is used in research to evaluate the quality of a tool being used – how well does it actually measure what it is that I am using it to measure?).[3]

Medical schools are comprehensively ranked by US News in Research and in Primary Care. For Research the criteria include “peer assessment” (by other Deans, Chairs and Residency Directors), selectivity (how high were the pre-admission grades and scores on the Medical College Admissions Test of its students, percent of applicants accepted – low is ‘good’), faculty:student ratio, # and $ amount of research grants. For Primary Care, peer assessment and selectivity are again considered but rather than measuring research grants, they look at the total number (#) and percentage (%) of graduates entering primary care residency training. In addition, US News reports top-ranked schools in a variety of program areas (AIDS, Family Medicine, Geriatrics, Internal Medicine, Pediatrics, Rural Health, Women’s Health); in these areas the rankings are done entirely by peer assessment.

The Peer Assessment counts for about 40% of the weight of the rankings for primary care (and 100% for the program areas listed above). Deans of medical schools, department chairs in the “primary care” specialties, and directors of residencies in those primary care specialties are asked to list the top schools, in their opinion. These are then cumulated and weighted. Selectivity accounts for about 15%, faculty:student ratio another 15%, and is the same as measured for Research. The final 30% consists of the schools self-report of the % of students graduating who enter the primary care specialties, defined by US News as family medicine, general internal medicine, and general pediatrics. Let us deconstruct those three sets of criteria.

Percent of students actually entering the primary care specialties might seem to be the most objective, outcome-based criterion, and thus the most important. However, there are some problems in the data. What is, for example, the definition of entering a “general internal medicine” residency? Virtually all schools count everyone entering an internal medicine residency because, after all, the first 3 years, the residency they matched in, is indeed general medicine. The problem, of course, is that after completing that residency a percentage of graduates will enter medicine sub-specialty training (to become cardiologist, gastroenterologists, endocrinologists, etc.) and not practice primary care. And, as detailed in previous entries (“A Quality Health System Needs More Primary Care Physicians” December 11, 2008, Ten Biggest Myths Regarding Primary Care in the Future” by Dr. Robert Bowman January 15, 2009, “More Primary Care Doctors or Just More Doctors? April 3, 2009, and others) in recent years the percent entering subspecialty fellowships on completing their residencies has been increasing so much that the number of students entering internal medicine residencies who actually become primary care/general internists is becoming vanishingly small.[4] [5] So measuring those entering internal medicine residencies dramatically overstates the actual production of primary care doctors. But at least everyone does it.

Arguably, the most sensitive indicator is entry into family medicine; the reason is that virtually all family medicine residents become primary care doctors, so when the number of students entering family medicine is up, it means that interest in primary care is up, and it is likely that the percent of students entering internal medicine who will become general internists is also up. When, as now, the number entering family medicine is down, so is the number of internists entering general internal medicine.4,5

Peer assessment may be good, but it also has flaws. These include: people’s memories are dated (they may remember that a place was good and so assume it still is), they may assume that a place that is good in many things is good in everything (e.g., Harvard gets votes for great family medicine, even though there is no family medicine at Harvard!), and the ratings (especially from deans and chairs) may reflect the prominence of the faculty in primary care rather than the school’s success in producing primary care physicians. This is not to minimize the latter; “Best” primary care school does not equal “most students entering primary care”; it also includes the scholarship and prominence of the faculty on the national and international stage. Finally, because the chairs and residency directors surveyed are from all three specialties, the degree to which one or more is particularly strong or weak (or perceived as particularly strong or weak) can color the assessment.

Selectivity is an ironic criterion. The simple fact is that the more selective a school is the lower the primary care production. This is explained in many of the previous posts; in brief, students from medical families in upper class suburbs who had great schools and thus the likelihood of the highest grades are the least likely to enter primary care, while those from rural and inner-city backgrounds, as well as those from minority and lower income backgrounds are more likely to. High faculty:student ratio sounds good, but probably doesn’t matter to students unless they are teaching. In fact, schools with higher faculty:student ratios don’t usually have more teachers; the additional faculty are either doing research (good for the research criterion, less obviously so for primary care) or providing clinical care in a variety of settings that have little or nothing to do with educating students.

So what is the correlation between high US News primary care rankings and entry of students into primary care? I have only the data on family medicine, but given, as above, that this is the most sensitive indicator of primary care, it is probably worth using. Here it is:

Of the US News’ “Top 50” schools in Primary Care:

· -Only 10 were among the top 15 in either percent or total number of students entering family medicine.
· -Fully half (26) of these “Top 50” primary care schools were below the national average of 8.2% of students entering family medicine. Thirteen had 5 of fewer students entering family medicine, and 7 had 2, 1, or 0!

Conversely, only 6 of the top 15 schools in percent of students entering family medicine, and only 9 of the top 16 (4 way tie for 13) schools ranked by number of students entering FM, made US News’ “Top 50” for primary care.

What about US News’ “Top 10” for Family Medicine (remember, these are ranked only by “peer assessment”)?

Only 3 of these medical schools were in the top 15 for students entering FM by percent, and 3 by total number of students entering FM residencies. Two schools were both, so a total of 4 of US News’ “Top 10” medical schools for family medicine were in the top 15 in either category. And of these 4, the highest rank for percent of students was #11, and for total number, the highest rank was #4.

Among that group of “Top 10 Family Medicine” schools, 3 (30%) were below the national average for percent of students entering FM, and 3 of them were quite low: 7 students (4.1%); 6 students (4%); and 2 students (2.2%)!

Again, conversely, only 3 of the top 15 schools by number of students, and only 4 of the top 15 by percent of students, entering family medicine residencies made US News’ Family Medicine top 10.

So how valuable are these rankings? The answer is: it depends. If you want high status, they are “it”. If you want a school that is actually successful at producing graduates who enter primary care, don’t count on them.

[1] Also as in “you’re not respecting me – but you will now that I’m pointing this gun at you!”
[2] I presume there is some newer name-brand dropper, but Ian Fleming was the master at one time.
[3] Not always so obvious; I could ask people if they smoke, but the answers might have limited validity if people don’t tell the truth. A blood test for a nicotine breakdown product might, e.g., be a more valid test.
[4] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[5] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64