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Medical Education, Medical Schools

Does medical school debt cause students to choose more lucrative specialties?

Last week, we re-published a Wing of Zock post on medical school debt. Over on that same blog, Julie Fresne, director of student financial services for the Association of American Medical Colleges (AAMC), takes issue with one of the original writer’s points: that concern over medical school debt affects students’ decision about specialties. Fresne writes:

While many claim that debt leads medical students to choose more lucrative specialties, AAMC research indicates that debt does not play a determining role in specialty choice for most students. The report, “Physician Education Debt and the Cost to Attend Medical School,” includes a section outlining evidence on the “minor role of debt in specialty choice.” Studies show that specialty choice is a complex and personal decision involving many factors. Some students with high debt do in fact choose primary care and AAMC data suggests that there is no systematic bias away from primary care specialties by graduates with higher debt levels…

Previously: It’s time for innovation in how we pay for medical school, 8 reasons medical school debt won’t control my life and Will debt forgiveness program remedy doctor shortage?

Medical Education, Medical Schools

It’s time for innovation in how we pay for medical school

handstiedThere is a tremendous amount of handwringing among students, workforce researchers, and medical school deans about the record amount of debt that medical students incur – more than $175,000, according to the Association of American Medical Colleges. This has unintended consequences, including student selection of more lucrative specialties and placing medical education beyond the reach of low-income and minority students. The average household income for a matriculating medical student is more than $110,000 per year. We must get serious about reducing this debt. A talented medical workforce is a national priority.

[Louis Sullivan, MD,] authored an op-ed piece published in the Washington Post on June 9, 2014, “The Outrageous Cost of Working in Medicine.” In the piece, Sullivan discusses this challenge from both diversity and equity perspectives. He wrote, “You shouldn’t have to come from a wealthy family (or be willing to tolerate a lifetime burden of debt or the deferral of buying a home and starting a family) to go into health care.” Yet 60 percent of medical students hail from families with incomes in the top 20 percent of the nation. Meanwhile only 3 percent come from families with incomes in the lowest 20 percent.

National policymakers believe that, because professionals with medical degrees have high earning potential, they should therefore be in a position to repay loans in excess of $250,000 to $300,000. It simply hasn’t worked out that way for many talented young people who have turned away from the health professions altogether. The “gentrification of health care” serves no one well.

(In this post, I’m not talking about financing graduate medical education – GME – which is funded by Medicare, Medicaid, and academic institutions. In March 2001, Joe Newhouse, PhD, and Gail Wilensky, PhD, published an article in Health Affairs on GME asserting that it does not meet the economist’s definition of “public good:” benefits that are equally available to everyone that cannot exclude consumers from consumption. In the same issue, Uwe Reinhardt, PhD, and Adepeju Gbadebo, MD, pointed out that if GME is indeed a public good, society must also be willing to pay reasonable costs. In return, the leaders of academic medicine must inform society what each component of their social mission really costs, and be willing to be held more formally accountable for their use of the resources.)

What options exist to decrease undergraduate medical school debt?

Decrease medical school tuition and increase efficiencies. Tuition is actually a small part of most medical schools’ revenue. Most revenue comes from clinical services, transfers from teaching hospitals, and research funding. Although less than 5 percent of total revenue at most schools, tuition payments are still significant enough that their loss would impair the institutions’ ability to sustain their missions. There is significant variation in medical school tuition between and among public and private institutions. We could analyze the costs of education to determine if efficiencies can be realized using shared core faculty, distance learning, and MOOCs (massive open online courses) “to inform society what each component of their social mission really costs, and be willing to be held more formally accountable for the use of resources,” per Reinhardt and Gbadebo.

Make medical school free and government-funded. Peter Bach, MD, and Bob Kocher, MD, propose that medical school should be free. In their May 28, 2011, New York Times editorial, they advocated a new way of paying for medical training to address the looming shortage of primary care doctors and to better match the costs of specialty training to the income it delivers. They proposed that the government pay medical school tuition and then defray the costs of $2.5 billion per year by charging doctors for specialty training. This is not the first proposal to recommend making primary care training more accessible. The National Health Service Corps helps doctors repay their loans in exchange for a commitment to work in an underserved area, but few doctors sign up.

Make medical school more affordable for students committed to public service. The Wall Street Journal on April 22, 2014, published an analysis of federal student loan debt forgiveness programs, which increased nearly 40 percent in the past six months. One program, “Pay As You Go,” requires borrowers to pay 10 percent a year of their discretionary income – annual income above 150 percent of the poverty level – in monthly installments. Under the plan, the unpaid balances for those working in the public sector or for nonprofits are then forgiven after 10 years. At least 1.3 million Americans are enrolled in the program.

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Events, Medical Education, Medical Schools, Stanford News

Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine

Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine

Dr. Abraham Verghese, MD, MACP a speech at the Stanford University School of Medicine Convocation on Saturday, June 14, 2014. ( Norbert von der Groeben/ Stanford School of Medicine )

More now from Saturday’s commencement ceremony, courtesy of my colleague Tracie White, who recounts the sentiments of the day in a medical school news story. During the event, White reports, graduates reflected on their years of hard work, thanked their loved ones and faculty members for their support, and took their first steps as doctors.

During his opening remarks, School of Medicine Dean Lloyd Minor, MD, told the new doctors, “Have the courage to follow unmarked paths… Listen to your patients. They are trying to tell you the diagnosis… Above all else, listen to your heart.” He was soon followed by Stanford physician and best-selling author Abraham Verghese, MD, who delivered the keynote speech and urged graduates to look to the time-honored role of the physician-patient connection and learn from this relationship. As White wrote:

[Verghese] began his remarks with words of warning, noting that soon-to-be-published research shows that medical students spend as much as five to six hours per day in front of the computer during their clerkships.

“That just astonishes me and worries me, and you are not doing it by choice, but because that has become the nature of our work,” he said. “You will need courage and determination to push back when things detrimental to your time and your care of the patient are being thrust at you. Electronic medical records don’t take care of patients: You and our amazing colleagues in nursing and the other health-care professions care for patients.

“People take care of other people,” he said to loud and long applause from the audience.

Both heritage and rituals, like the ritual of commencement, play an important role in the career of a physician, he said.

“You are also participating in a timeless ritual… when you get to examine a patient. You are in a ceremonial white gown. They are in a ceremonial paper gown. You stand there not as yourself, but as the doctor. As part of that ritual they will allow you the privilege of touching their body, something that in any other walk of life would be considered assault…

“The ritual properly performed earns you a bond with the patient… The ritual is timeless, and it matters.”

More photos from the day can be found in this gallery, published earlier on Scope, and on the medical school’s Flickr page.

Previously: Stanford Medicine honors its newest graduates, Congratulations to the Class of 2013!, Stanford medical school alum fulfills lifelong dream to participate in commencement ceremony and In commencement address and Atul Gawande calls for innovation around “entire packages of care”
Photo by Norbert von der Groeben

Medical Education, Medical Schools, Stanford News

Medical students take time to thank their patients

Medical students take time to thank their patients

thank you tree - smallWith their heavy academic workloads and the constant demand to keep up with the ever-growing body of medical literature, one might question whether medical students have time to learn and absorb the importance of developing the human connection vital to the doctor-patient relationship. Here’s something that provides strong evidence that they do: A group of fourth-year medical students here started a project to thank patients for being their most important teachers.

In today’s Inside Stanford Medicine, I write about the project, which featured 35 anonymous thank-you cards from medical students arranged into a display for the recent Medicine and the Muse Symposium. Some cards touch on life and death issues, some focus on the importance of hands-on medical training, and others express simple appreciation of the human bond. Reading over these heartfelt letters, it’s clear that the students recognize that the patient-doctor connection is key to their medical education. Here’s a sampling:

I will always remember that you asked me for an ice-cold Slurpee from 7-Eleven in broken words when you finally gained consciousness and spoke to me. I will never forget your gentle but firm nod expressing that you wouldn’t want artificial feedings prolonging your life… Taking care of patients like you and helping them in times of need makes medicine worthwhile… You taught me how to be a good physician and I will always remember you.”

Thank you to the patient with vasculitis and related short gut syndrome for sharing your physical pain as well as worried for the future with me. Thank you to the former physician with mental health concerns for teaching me humility. Thank you also to your families for teaching me about the impact of illness on your lives as well.

Thank you for reminding me why I chose to do medicine. For showing me that we can improve medical care further. For you and future patients.

Previously: Medical students and author Khaled Hosseini share their muse with Stanford community and Reality Check: When it stopped feeling like just another day in medical school
Photo by Jia Luo

Events, Medical Education, Medical Schools, Stanford News

Stanford’s senior associate dean of medical education talks admissions, career paths

Stanford's senior associate dean of medical education talks admissions, career paths

Okay, so you want to go to med school. Let’s talk! Last month at Med School 101, Charles Prober, MD, senior associate dean of medical education, got serious with a group of aspiring medical professionals who all happen to be high-school students. (The annual event brought 140 teens from 10 local high schools to try on the role of med student for a day.)

In his session recorded in the video above, Prober discussed the wide range of possibilities a person with an MD can pursue, including patient care, research and education. He also described the many factors the School of Medicine‘s admissions team considers when selecting candidates – 7,500 applied for 90 spots last year – and described how MCAT scores are only part of the equation. “We look for the distance traveled,” Prober said. And that distance can include non-medical interests: “We want to attract people into medicine who love history, English and computer science” as well as medicine, he explained.

Previously: High schoolers share thoughts from Stanford’s Med School 101, At Med School 101, teens learn that it’s “so cool to be a doctor” and A quick primer on getting into medical school

Events, Medical Education, Medical Schools, Stanford News, Technology

Using technology and more to reimagine medical education

Using technology and more to reimagine medical education

Over on The Health Care Blog, Michael Painter, MD, JD, shares his thoughts from a recent meeting at Stanford’s medical school inviting medical education leaders to debate big questions in their field. Painter, a senior program officer at the Robert Wood Johnson Foundation, explained that meeting participants discussed ways that educators can use technology and other tools “to help create a durable culture of health for all.”

From the post:

In 2013 we extended a $312,000 grant to Stanford Medical School that will support work by five medical schools, Stanford, Duke, University of Washington, UCSF and University of Michigan, as they create a consensus knowledge map of the critical things medical students should learn.

Why a knowledge map? The simple answer: because there isn’t one, and we need one if we’re going to build massive core online medical education content.

Why change now? There’s building pressure on fortress academia: pressure to push health care toward high value, pressure for health care to center itself on the patient rather than the professional, and pressure from technology, specifically the ability to move previously closely held knowledge of the expert more efficiently to the learner.

Here’s where this mapping effort also starts to get interesting. It wouldn’t be that surprising if these education leaders ticked through all the reasons why change is too hard—why it can’t or won’t happen. Instead something marvelous is happening: they’re challenging each other to examine the time they spend with their students—asking if they ignite the kind of passion in their learners that others ignited in them.

An even more hopeful sign—these leaders want to connect the teaching of new healers—from the beginning—with the key partner: the patient. Their early reimagining is fixed on patient and story.

Previously: A closer look at using the “flipped classroom” model at the School of MedicineCombining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Stanford professors propose re-imagining medical education with “lecture-less” classes

Medical Education, Medical Schools

Using digital resources to redefine the medical education model

iPad_032514Today on MedCrunch, Stanford medical school alumna Stesha Doku, MD, examines how digital resources can enhance the traditional medical school curriculum to ” help health-care professionals succeed in their goals to deliver quality care.” Highlighting online learning sites such as PodMedics, which offers medical and surgical video tutorials, Doku writes:

What we gain from the growth of such applications and more general sites such as Khan Academy is that the physical classroom is becoming less relevant. It’s not so much a question of the classroom being not enough, but rather if the classroom is the correct place to deliver our learning materials in the first place. If so, are we delivering distilled and most importantly relevant information?

While we value those who are ‘smart’ in medicine, we must make more effort to value those who can translate their knowledge into improving outcomes and progressing our field. This may mean spending less time on acquiring knowledge that has no application. This may also require spending more time practicing application.

As reported previously on Scope, the School of Medicine is developing the Stanford Medicine Interactive Learning Initiatives, which utilizes the “flipped classroom” model to make better use of the fixed amount of educational time available to train doctors.

Previously: Social learning in a medical photo-sharing app for doctors, A closer look at using the “flipped classroom” model at the School of Medicine, Combining online learning and the Socratic method to reinvent medical school courses, Using the “flipped classroom” model to re-imagine medical education and Rethinking the “sage on stage” model in medical education
Photo by Stanford Ed Tech

Medical Education, Medical Schools, Stanford News

At Match Day 2014, Stanford med students take first steps as residents

At Match Day 2014, Stanford med students take first steps as residents

MatchDay14-

Last Friday, small envelopes containing big news were handed out at the Li Ka Shing Center for Learning and Knowledge. During Match Day 2014, med students at Stanford and around the country learned where they would be paired to begin residency, and thus the next phase of their lives and careers. My colleague Tracie White was on the scene when Stanford students opened their letters. She reports:

The 81 students matched in 19 different disciplines in a total of 15 different states. California topped that list with 17 percent of all the graduating students.

Seventy percent of the 81 students matched with their first choice and 90 percent with one of their top three choices. At the top of the list for medical specialties was internal medicine, with 19 students. Pediatrics came in second, with nine students.”It was a long, painful process,” said Kevin Chi, his shaking hands holding the letter that told him he had matched in pediatrics at Stanford, his first choice. He hugged fellow student Tania Rezai, who had matched to a family medicine residency in Santa Rosa.

Kira and Erick Westbroeks, pictured above with their baby, will be moving to Baltimore; Erick Westbroek matched in neurosurgery at Johns Hopkins.

Previously: Matching into family medicineImage of the Week: Match Day 2013My parents don’t think I’m smart enough for family medicine: One medical student’s storyMatch Day 2012 decides medical students’ next steps and A match made in heaven? Medical students await their fate
Photo of the Westbroeks by Norbert von der Groeben

Medical Education, Medical Schools, Stanford News

Match Day 2014: Good luck, medical students!

matchday13-1-031513Medical students at Stanford, and thousands more around the United States, will gather this morning at 9 AM Pacific time for the annual Match Day celebration. Students will join family, friends and faculty members as they nervously clutch white envelopes, which indicate where they’ve been “matched” for their residencies and play an important role in shaping their futures. We wish students at Stanford and around the country the best of luck!

Match Day, for those not familiar, is the annual event where students learn where they’ll spend the next four to seven years of their lives completing residencies. To determine the post-graduation assignments, the nonprofit organization National Resident Matching Program uses a computer algorithm that aligns the choices of the applicants with those of the residency program.

This morning, my colleague Tracie White will be joining students on the Stanford campus to capture the ceremony and excitement. Watch for her story later on Scope.

Previously: Matching into family medicine, Image of the Week: Match Day 2013My parents don’t think I’m smart enough for family medicine: One medical student’s story, Match Day 2012 decides medical students’ next steps and A match made in heaven? Medical students await their fate
Photo by Norbert von der Groeben

Medical Education, Medical Schools, SMS Unplugged

Top 10 reasons I’m glad to be in medical school

Top 10 reasons I’m glad to be in medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Stanford School of Medicine class of 2013 before the Dean's Welcome Reception and Stethoscope Ceremony on Friday, August 23, 2013.  ( Norbert von der Groeben/Stanford School of Medicine )A friend of mine e-mailed me this blog entry awhile ago. Titled “10 things you need to give up to become a doctor,” the piece describes “your free weekends,” “your desire to change the world,” and eight other similarly positive items as areas of life that medical students need to sacrifice on their path to becoming a doctor.

As I read through this entry, my mood grew increasingly dismal. By opting to go to medical school, had I really committed myself to a lifetime that, according to the author, would be devoid of creativity, good health, big dreams, and more? I refused to believe that was true.

So, instead of dwelling on aspects of my life that may or may not be compromised on my path to becoming a physician, I want to highlight parts of my life that have been enriched by my medical school experience thus far. Here we go: The top ten reasons (organized loosely by importance) that I’m glad to be in medical school:

10. Four extra years of free two-day shipping via Amazon Student
I’ve ordered everything from tuning forks to trash bins – and I look forward to my future purchases being delivered via drones. Thanks, Amazon!

9. Daily dose of cheaper-than-Starbucks caffeine
For everyone paying $2.95 for a latte at Starbucks, be jealous! Stanford medical students get $2.70 lattes (+ an extra 25 cents off if you bring your own mug) at the Med Café every day.

8. 24/7 gym access
The 4th floor of Li Ka Shing is strictly for medical/bioscience students only and houses study rooms, a lounge, and a gym. Not that I ever have the urge to work out at 4 AM, but if I wanted to, I could!

7. Having friends come to me when they’re sick and feeling like I can diagnose them
Friend: “I’m feeling a little sick.”
Me: “I CAN HELP.”
(Five minutes later)
Me: “Actually, come see me again in like 4 years.”

6. Sleeping in scrubs like it’s no big deal
Because, really, they’re the most comfortable pieces of clothing I own.

5. Living life on pass/fail
It feels like this is the first time in my life where I’ve been given the freedom to learn at my own pace, in my own style. There are very few assignments in medical school, and as such, we can take the material presented to us and decide for ourselves how to master it. I can’t describe how incredibly refreshing this approach is.

4. Being on a text-message basis with role model physicians
Following my first patient encounter, one of my advisors texted me, saying: “You are a skilled, empathetic interviewer. I greatly enjoyed working together yesterday and look forward to more experiences.” Needless to say, my advisor’s thoughtful, compassionate words completely made my day.

3. Full-length white coats
At Stanford, medical students receive white coats that are just as long (i.e. up to our knees) as coats worn by MDs in the clinic – a constant reminder that there are no hierarchies: We are part of a single medical team, with the shared goal of caring for someone in need.

2. Being surrounded by inspired, motivated classmates
From founding non-profit organizations to creating World Health Organization reports to winning international awards for their research, my classmates are among the most accomplished, friendly, and down-to-earth individuals I have ever met.

1. Finding meaning every day of my life
Whether it’s through a patient visit, an anatomy lecture, a morning at pediatrics rounds, or a standardized patient encounter, I’m reminded every day that what I’m learning is directly linked to caring for others.

Hamsika Chandrasekar is a first-year medical student at Stanford’s medical school, with an interest in medical education and pediatrics.

Photo by Norbert von der Groeben

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