.
How much of the practice of medicine is “science”? How much science, as in “how many science courses” should be required of students applying to medical school? How much science must be taught to students once they are in medical school? To what degree does this require the memorization of mountains of facts as opposed to learning to and practicing the scientific approach to thinking and problem solving and analyzing data? What about other material that might help in being an effective physician…the social sciences of psychology, anthropology, sociology, or the broader content of a “liberal” education such as literature, history, philosophy, foreign languages? Is there a place for these in medicine? Is there a need for these in medicine? If there is, what is the best way to ensure that students acquire the knowledge, both temporally (prerequisites or in medical school) and pedagogically?
These questions are important to medical educators, and to students planning to apply to medical school, as well as “pre-med” advisors in colleges. Most medical school faculty are physicians or “basic scientists” (physiologist, biochemists, anatomists, pharmacologists, neuroscientist and those straddling the disciplines or creating new ones). There are usually a few social scientists, especially epidemiologists and psychologists, based in departments of preventive medicine, community medicine, and public health, and psychiatry. There are also likely to be a small number of people with degrees in education (largely in the office of medical education), and in humanities (frequently involved in teaching ethics, the branch of humanities most commonly taught in medical school). In general, the basic science faculty believe that the material they teach is crucial to the creation of competent physicians, while clinicians range from agreement (perhaps less passionate) to a belief that they don’t use or remember much of the biological sciences that they had to learn, and the main thing students need to do is to get through it, pass “Part I” (of the US Medical Licensing Examination, USMLE, which emphasizes basic science and is usually taken after the first two years of medical school), and get on to the “important stuff”, their clinical education and training.
Occasionally, the faculty even engage in in-depth discussion and analysis of how the material is taught; whether intensive study of sciences in the first two years of medical school tested by recall of facts on examinations is the best way to learn – and retain so that it can be used years later in clinical work – the content. Many, if not most, schools, have gone to some form of “integrated” curriculum in the first two years, most often based on organ systems, teaching the aspects of each of the basic sciences relevant to that system, mixed in with clinical perspectives, epidemiology, ethics, and social determinants of health. Most have decreased the number of hours of lecture and increased small-group learning, including Problem-Based Learning (PBL) in which groups of students review a patient case, with a facilitator, with the goal of learning how to approach thinking about a patient and their problems and how to work with not only their disease but with them, in all of complexities of life that they face. Some schools, such as the new Paul L. Foster Texas Tech medical school at El Paso, spent over a year with educators, clinicians, and basic scientists poring over every piece of the curriculum and how it would be delivered and reinforced, before admitting their first class.
I have often written about who does, or should, get into medical school, particularly in the context of predicting specialty choice for primary care (e.g., Medical Student Selection, December 14, 2008; Are we training physicians to be empathic? Apparently not., September 12 2009). A recent article in Academic Medicine, “Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program”[1] by David Muller and Nathan Kase, looked at the performance of students who were taken in a special program that did not have science requirements with that of “traditionally prepared” students. Their conclusion is that “Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.” Of course, there were some differences; they performed a little worse (statistically significantly, but still well) on the USMLE Part I. They performed better on their psychiatry clinical clerkship, and not significantly better or worse on their other clerkships. The success of the students in this program (“HuMed”) was great enough that more students who were not science (or “pre-med”) majors were accepted by Mt. Sinai outside the program; nationally, 18% of students matriculating in medical school in 2009 were humanities and social science majors while at Mt. Sinai it was 25% without HuMed students and 43% counting them. There are a lot of caveats: the HuMed program offered (voluntary) pre-matriculation introductions to organic and biochemistry, and the HuMed students were all very high performers in their areas of college study. Perhaps it means that if you are a very smart – and skilled, for being a successful student is a skill – student you can make it in medical school even without lots of premedical science, but if you are not, the science helps.
This article does not answer this question, but it did receive significant national coverage. The New York Times article by Anemona Hartocollis on July 29, 2010, “Getting into med school without hard science”, generated many blog comments and letters. One, by a Mills College professor of chemistry and physics, David Keeports, notes that “Many people have great personalities, but medicine is a science. A person who has avoided fundamental scientific and mathematical knowledge and the scientific approach to problem solving isn’t the person I want to see when I have a medical problem.” Well, he is a physical science professor, and maybe not representative of the entire population, most of whom really value the ability of a doctor to successfully communicate with him. More important, however, is his comment, that “I see no place in medical school for anyone who hasn’t demonstrated an ability to easily learn, assimilate and analyze technical information.” I agree with that completely; I have frequently written about the need to understand the scientific approach and thought process. I believe that the most important of these is epidemiology (listed above as a social science). It is critical that physicians are able to understand and interpret the data coming from scientific studies, and be able to explain it effectively to their patients. This is, however, different from being required to memorize huge numbers of facts that you will forget soon after the exam, and not miss later.
Because the amount of scientific information continues to increase, and because much of it renders what we used to “know” incorrect, medical school faculties should be able to identify what pieces of factual information a student really needs to know to become a doctor and to be able to think scientifically, identify how to effectively teach it and measure learning, and tie that to the skills that a practicing physician will need. The concept of “competency based education”, rather than an education devoted to learning and regurgitating content, has been around for a long time. One of the best publications on competency-based medical education was published by the World Health Organization (WHO) in 1978, and examine such education from an international perspective. Competency-Based Curriculum Development in Medical Education. An Introduction. Public Health Papers No. 68., by WC McGaghie, GE Miller, AW Sajid and TV Telder provides guidelines for effective teaching and learning in medicine that are as valuable, and as needed, today as they were more than 30 years ago when it was written. They argue against teaching a course (say, in the first year of medical school) and expecting that the material learned will be remembered and usable in future years. They note that only a small portion of what is learned in a course is remembered only a few years later if it is not used. I would add that the material that is remembered is less likely to be that which the student will need in the future than that which was so counter-intuitive that it took many hours of rote memorization. They argue for a curriculum that teaches relevant material, and effective ways of thinking, in the context in which it will be used, and teaching and measuring competency rather than memory.
Too much of medical education is driven by inertia and vested interest, e.g., these are the kind of students we’ve always taken, this is the material we’ve always taught, this is the way we’ve always taught it, this is the way we’ve always measured it, and (surprise!) the kind of students we’ve always taken are those who do best on the tests that we give which measure retention of what we’ve taught the way we taught it. Rather, we should start from the other end: what kinds of doctors do we want and need, what set of skills and knowledge do we want them to have? Then we need to figure out what characteristics of incoming students (personality, knowledge, and life experience) are most likely to make them become those kind of doctors (input variables), and what content and educational methods will me most effective in helping them to learn the skills they will need (process variables). This makes a lot of sense, but it can challenge existing models of who teaches, how they are reimbursed, and who gets in to school.
Maybe models such as those of Mt. Sinai and Paul L. Foster schools of medicine will help lead the way. But we all need all medical schools to move into the modern era, of identifying societal needs, what their graduates need to look like to meet those needs, and measuring the degree to which these outcomes are achieved.
[1] Muller D, Kase N, “Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program”, Acad Med Aug 2010;85(8):1378-83.
.
Showing posts with label Norcini. Show all posts
Showing posts with label Norcini. Show all posts
Thursday, August 26, 2010
Saturday, August 14, 2010
Primary Care, IMGs, and the Health of the People
.
For several years now, there has been a great deal of discussion about increasing the number of physicians in the US through increasing the number of students in US medical schools. The Association of American Medical Colleges (AAMC) has called for a very large increase, and it is in fact happening, both through the creation of new medical schools and the expansion of class size in existing schools. AAMC has also called for the expansion of post-graduate specialty training (residency) positions because medical school graduates have to do residencies before they become practicing physicians. What specialties those new positions are will thus determine the makeup of our physician workforce. If we need more primary care physicians we will need both more primary care residency positions and a greater interest on the part of medical students in entering those residencies, which I have discussed previously (Primary care specialty choice: student characteristics , July 12, 2010; Primary Care and Residency Expansion, January 7, 2010).
To recapitulate, increasing the probability that students will choose primary care requires using criteria actually associated with primary care choice, which are both demographic and based on the individual’s previous activities, mainly in volunteer service. The risk of relying on intention as expressed in an essay or interview is made clear in a recent letter to the editor in Family Medicine from the new Commonwealth Medical College in Pennsylvania. An “overwhelming majority” of the students who were accepted to the school had expressed, in their essays and interviews, a very high level of interest in primary care, and had “consistently cited a predilection for small towns,” high priorities for the school. By the time of matriculation, that is when they started school, that only 23% had any interest in any of the primary care specialties, including OB-Gyn!
If US medical schools graduate more students without comparable residency expansion, the probable outcome would be the displacement of graduates of foreign medical schools by graduates of US medical schools. This might, intuitively, sound like a good thing, given the question of whether graduates of foreign medical schools provide care of the same quality that US graduates do. This concern can be more than xenophobia; in the US accrediting bodies, the Liaison Committee for Medical Education (LCME) for allopathic medical schools and the Accreditation Council for Graduate Medical Education (ACGME) for allopathic residencies, along with the American Osteopathic Association (AOA) for osteopathic schools and residencies, provide very rigorous standards enforced by regular re-accreditation. Internationally, the thousands of schools are, in most countries, less standardized; not only may there be dramatic differences in medical education between countries but among medical schools within countries.
It is in this context that Norcini et. al. published “Evaluating the quality of care provided by graduates of international medical schools” in Health Affairs, August, 2010 (29[8]:1462-68), to significant national coverage; the article in the New York Times by Denise Grady on August 3, 2010 is called “Foreign born doctors give equal care in the US”, which seems to give us the answer. They do. That is not only reassuring, but could be raise the question “Why, then, increase the number of US medical graduates if the international graduates who come fill unfilled residency spots are just as good?” Well, for one thing there is the very important issue of “brain drain”; physicians from other countries, often underdeveloped countries with great physician shortages of their own, come to train in the US. Ostensibly, for most of them on training visas, the idea is that they will go back to their own countries with the new skills that they have acquired in the US and benefit their own people. In reality, most of them want to, and usually do, find a way to stay in the US. From an individual point of view – the ability of an individual to seek a better life for his/her family, or at least a higher income – it is consistent with the history of the US. From a societal point of view, however, this leaves their home countries with marked shortages of doctors; there are more Ghanaian trained physicians in the US and UK than in Ghana[1]. And, to the extent, which is often the case, that the medical education was paid for by the government and people of the country of origin, not the individual, it can be particularly inappropriate.
Another question is “is it true? That is, do Norcini and colleagues actually demonstrate that “foreign born doctors give equal care in the US”? The population that they studies was doctors in Pennsylvania, a big state with a lot of variety (rural/urban, rich/poor). They looked at physicians who were US-born graduates of US medical schools (USMGs), and compared them to both foreign-born graduates of foreign medical schools (IMGs) and to US-born graduates of foreign medical schools (USIMGs), most from those schools in the Caribbean, which I have previously discussed (Who will care for the underserved? The role of off-shore medical schools, June 2, 2010). They measured the “quality of care” by measuring length of stay and mortality rate of patients hospitalized for acute myocardial infarction (heart attack, MI) and congestive heart failure. They also looked at the outcomes by specialty (cardiologist, general internist, family physician). The results showed that the percentage of in-hospital deaths for these diagnoses were lower for IMGs than for USMGs, and for USMGs lower than USIMGs. These differences were small but statistically significant. For length of stay, USMGs were lower than either, and IMGs were lower than USIMGs. How much to make of these differences since there were other variables: longer time since medical school graduation, being rural vs. urban, and not being a cardiologist resulted in longer stays; interestingly being a cardiologist resulted in higher mortality.
One can think of all kinds of possible explanations, including unmeasured differences in severity of illness, and the authors, in their Discussion, identify several. The most obvious is that they looked at only two parameters (death and length of stay) in two diseases in hospitalized patients. The authors acknowledge this, although they point out that these are very common diagnoses. They virtually ignore that measuring care in the hospital is only one dimension of care, most of which takes place in the outpatient setting, and run the risk (although they do not explicitly say this) of implying that if a doctor can deliver quality care in the hospital, when people are sicker, they obviously can do it in the “simpler” outpatient setting. This is an egregious fallacy, most obviously (see "Uncomplicated" Primary Care?, October 8, 2009) because in the hospital doctors have far more control, while for outpatients they are at best advisors to their patients. The authors did a credible job given the difficulty of measuring what they want to measure – quality of care delivered by physicians – but the validity of the results suffer from another fallacy , that what is measured is what is easy/possible to measure, not necessarily what you are interested in (see Defining "Streetlight" Research, February 26, 2009). Still, it is good work.
The real problem is in identifying the cause(s), speculating on what they might be and then taking this to the next level, raising problems that might exist if the speculations on cause on correct. IMGs might perform well because they are “top performers” in their countries, and have often had prior post-graduate training in their own countries prior to coming to the US and entering residency; much of this is hospital-based. The authors worry about the pool of USIMGs, noting that “Part of this performance difference may be due to variability in the quality of the medical schools that U.S.-citizen international graduates attend, but to some degree, it may also reflect their ability. It will be important to monitor this possibility, since the pool of U.S. applicants to international schools is a potential source of students for U.S. medical schools as they expand.” There is very likely a difference in the training and education of US students at many off-shore medical schools, although, like other foreign schools, they vary a great deal. The danger is in identifying “ability”.
The most important health problem in the US is that some people do not have access, for financial or geographic reasons most commonly. Thus a study like the current one, which looks only at patients who have received hospital care for their diagnoses, are looking at a somewhat skewed sample, and can miss the total impact on population health that comes from including those people not counted because they got no care at all.
Students who get into US allopathic medical schools have higher grades and test scores than the ones who don’t. While many students choose osteopathic schools because of their interest in osteopathy, a large number choose them because they didn’t get into allopathic schools; on average their grades and standardized test scores are lower. Those who do not get into either school may choose offshore schools. Are they less able? Does lower, but still good, performance on standardized tests make a candidate less able? The data that exist show poor correlation between MCAT scores and grades and clinical performance. Moreover, are the students who attend Caribbean medical schools representative of those who do not get into US schools, and might get in if more students are accepted? Not entirely, since on average they come from even higher socioeconomic status than the already high US medical students.
Many outstanding students, measured in many ways, are not accepted in medical schools in the US every year (Medical Student Selection, December 14, 2008). Taking more students (by virtue of larger classes or more schools) may lower the mean MCAT score, but is not, in itself, likely to decrease the clinical performance of graduates. Indeed, if those new students are more likely, because of their backgrounds and/or values, to care for populations that are currently underserved, rural and urban, they will increase the health status of the American people.
[1]Hagopian A, et. al., “The flight of physicians from West Africa: Views of African physicians and implications for policy”, Social Science & Medicine, Volume 61, Issue 8, October 2005, Pages 1750-1760.
.
For several years now, there has been a great deal of discussion about increasing the number of physicians in the US through increasing the number of students in US medical schools. The Association of American Medical Colleges (AAMC) has called for a very large increase, and it is in fact happening, both through the creation of new medical schools and the expansion of class size in existing schools. AAMC has also called for the expansion of post-graduate specialty training (residency) positions because medical school graduates have to do residencies before they become practicing physicians. What specialties those new positions are will thus determine the makeup of our physician workforce. If we need more primary care physicians we will need both more primary care residency positions and a greater interest on the part of medical students in entering those residencies, which I have discussed previously (Primary care specialty choice: student characteristics , July 12, 2010; Primary Care and Residency Expansion, January 7, 2010).
To recapitulate, increasing the probability that students will choose primary care requires using criteria actually associated with primary care choice, which are both demographic and based on the individual’s previous activities, mainly in volunteer service. The risk of relying on intention as expressed in an essay or interview is made clear in a recent letter to the editor in Family Medicine from the new Commonwealth Medical College in Pennsylvania. An “overwhelming majority” of the students who were accepted to the school had expressed, in their essays and interviews, a very high level of interest in primary care, and had “consistently cited a predilection for small towns,” high priorities for the school. By the time of matriculation, that is when they started school, that only 23% had any interest in any of the primary care specialties, including OB-Gyn!
If US medical schools graduate more students without comparable residency expansion, the probable outcome would be the displacement of graduates of foreign medical schools by graduates of US medical schools. This might, intuitively, sound like a good thing, given the question of whether graduates of foreign medical schools provide care of the same quality that US graduates do. This concern can be more than xenophobia; in the US accrediting bodies, the Liaison Committee for Medical Education (LCME) for allopathic medical schools and the Accreditation Council for Graduate Medical Education (ACGME) for allopathic residencies, along with the American Osteopathic Association (AOA) for osteopathic schools and residencies, provide very rigorous standards enforced by regular re-accreditation. Internationally, the thousands of schools are, in most countries, less standardized; not only may there be dramatic differences in medical education between countries but among medical schools within countries.
It is in this context that Norcini et. al. published “Evaluating the quality of care provided by graduates of international medical schools” in Health Affairs, August, 2010 (29[8]:1462-68), to significant national coverage; the article in the New York Times by Denise Grady on August 3, 2010 is called “Foreign born doctors give equal care in the US”, which seems to give us the answer. They do. That is not only reassuring, but could be raise the question “Why, then, increase the number of US medical graduates if the international graduates who come fill unfilled residency spots are just as good?” Well, for one thing there is the very important issue of “brain drain”; physicians from other countries, often underdeveloped countries with great physician shortages of their own, come to train in the US. Ostensibly, for most of them on training visas, the idea is that they will go back to their own countries with the new skills that they have acquired in the US and benefit their own people. In reality, most of them want to, and usually do, find a way to stay in the US. From an individual point of view – the ability of an individual to seek a better life for his/her family, or at least a higher income – it is consistent with the history of the US. From a societal point of view, however, this leaves their home countries with marked shortages of doctors; there are more Ghanaian trained physicians in the US and UK than in Ghana[1]. And, to the extent, which is often the case, that the medical education was paid for by the government and people of the country of origin, not the individual, it can be particularly inappropriate.
Another question is “is it true? That is, do Norcini and colleagues actually demonstrate that “foreign born doctors give equal care in the US”? The population that they studies was doctors in Pennsylvania, a big state with a lot of variety (rural/urban, rich/poor). They looked at physicians who were US-born graduates of US medical schools (USMGs), and compared them to both foreign-born graduates of foreign medical schools (IMGs) and to US-born graduates of foreign medical schools (USIMGs), most from those schools in the Caribbean, which I have previously discussed (Who will care for the underserved? The role of off-shore medical schools, June 2, 2010). They measured the “quality of care” by measuring length of stay and mortality rate of patients hospitalized for acute myocardial infarction (heart attack, MI) and congestive heart failure. They also looked at the outcomes by specialty (cardiologist, general internist, family physician). The results showed that the percentage of in-hospital deaths for these diagnoses were lower for IMGs than for USMGs, and for USMGs lower than USIMGs. These differences were small but statistically significant. For length of stay, USMGs were lower than either, and IMGs were lower than USIMGs. How much to make of these differences since there were other variables: longer time since medical school graduation, being rural vs. urban, and not being a cardiologist resulted in longer stays; interestingly being a cardiologist resulted in higher mortality.
One can think of all kinds of possible explanations, including unmeasured differences in severity of illness, and the authors, in their Discussion, identify several. The most obvious is that they looked at only two parameters (death and length of stay) in two diseases in hospitalized patients. The authors acknowledge this, although they point out that these are very common diagnoses. They virtually ignore that measuring care in the hospital is only one dimension of care, most of which takes place in the outpatient setting, and run the risk (although they do not explicitly say this) of implying that if a doctor can deliver quality care in the hospital, when people are sicker, they obviously can do it in the “simpler” outpatient setting. This is an egregious fallacy, most obviously (see "Uncomplicated" Primary Care?, October 8, 2009) because in the hospital doctors have far more control, while for outpatients they are at best advisors to their patients. The authors did a credible job given the difficulty of measuring what they want to measure – quality of care delivered by physicians – but the validity of the results suffer from another fallacy , that what is measured is what is easy/possible to measure, not necessarily what you are interested in (see Defining "Streetlight" Research, February 26, 2009). Still, it is good work.
The real problem is in identifying the cause(s), speculating on what they might be and then taking this to the next level, raising problems that might exist if the speculations on cause on correct. IMGs might perform well because they are “top performers” in their countries, and have often had prior post-graduate training in their own countries prior to coming to the US and entering residency; much of this is hospital-based. The authors worry about the pool of USIMGs, noting that “Part of this performance difference may be due to variability in the quality of the medical schools that U.S.-citizen international graduates attend, but to some degree, it may also reflect their ability. It will be important to monitor this possibility, since the pool of U.S. applicants to international schools is a potential source of students for U.S. medical schools as they expand.” There is very likely a difference in the training and education of US students at many off-shore medical schools, although, like other foreign schools, they vary a great deal. The danger is in identifying “ability”.
The most important health problem in the US is that some people do not have access, for financial or geographic reasons most commonly. Thus a study like the current one, which looks only at patients who have received hospital care for their diagnoses, are looking at a somewhat skewed sample, and can miss the total impact on population health that comes from including those people not counted because they got no care at all.
Students who get into US allopathic medical schools have higher grades and test scores than the ones who don’t. While many students choose osteopathic schools because of their interest in osteopathy, a large number choose them because they didn’t get into allopathic schools; on average their grades and standardized test scores are lower. Those who do not get into either school may choose offshore schools. Are they less able? Does lower, but still good, performance on standardized tests make a candidate less able? The data that exist show poor correlation between MCAT scores and grades and clinical performance. Moreover, are the students who attend Caribbean medical schools representative of those who do not get into US schools, and might get in if more students are accepted? Not entirely, since on average they come from even higher socioeconomic status than the already high US medical students.
Many outstanding students, measured in many ways, are not accepted in medical schools in the US every year (Medical Student Selection, December 14, 2008). Taking more students (by virtue of larger classes or more schools) may lower the mean MCAT score, but is not, in itself, likely to decrease the clinical performance of graduates. Indeed, if those new students are more likely, because of their backgrounds and/or values, to care for populations that are currently underserved, rural and urban, they will increase the health status of the American people.
[1]Hagopian A, et. al., “The flight of physicians from West Africa: Views of African physicians and implications for policy”, Social Science & Medicine, Volume 61, Issue 8, October 2005, Pages 1750-1760.
.
Subscribe to:
Comments (Atom)