Diary of an AMA-MSS Chair 2005

Now that's teaching.

2007-02-28T03:51:45Z

Since many students are not able to travel to DC for the always-fabulous AMA-MSS lobby day (or the AMSA conference, which is also fabulous, although focused on quite different issues), my state holds our own Pennsylvania lobby day. I just asked my clerkship director for time off to go to said lobby day. His response was not "Yeah, whatever, go make it up with weekend call." It was "We try to encourage this sort of thing. Have a good time." That, right there, gives me a lot of hope for the future of academic medicine and the profession in general.

It sort of makes me wonder if organized medicine shouldn't be trying to recognize academics who contribute, either through positive attitude or active involvement, to building the future leadership base of our profession and training future physicians in advocacy skills. I know the AMA has been trying to actively reach out to the academic sector, especially with initiatives like ITME. Maybe we should start by recognizing those who have already seen the light.

Random idea: medical coupons

2007-02-02T14:48:29Z

As I've told many of you individually, I have now finished my PhD and returned to third year. My first rotation is in what we call "community medicine", which basically sends the student around to various homeless and underserved clinics in the Pittsburgh area. I'm loving it -- it's a great way to connect the theoretical health policy work I did as MSS Chair to the real world.

I was talking with one of our clinic docs a day or two ago in a brief break between patients, and of course we briefly touched on the merits of single-payer vs. market-based approaches. (Well, OK, he did almost all of the talking. I'm not stupid enough to express an opinion to an attending.) He did get me thinking about the whole "billing complexity" problem -- the fact that most practices/institutions need to keep around two or more staffers just to sort out what the various insurers will pay.

It ocurred to me yesterday in the shower that there may be a relatively simple solution to this. Most people who'll read this are already familiar with the voucher concept as applied to health insurance. What if we took that a step further? What if health insurers just issued their patients "coupon books" that could be taken to any physician, and which basically said "Perform anything within the following range of CPT codes on this patient, document it, and send it in with this coupon and we'll pay you the coupon face value." No more need to collect co-pays, hassle patients after the fact, or anything like that -- you know what you're getting when the patient walks in the door. Heck, you might not even need to be part of a network.

It's obvious how this would work for simple things like primary care office visits. Surgeries and other specialty care are trickier, since they'd presumably require some kind of HMO-like pre-authorization. Still, it seems like it'd be viable, at least from my day or two of thinking about it. Can anyone see any barriers I've missed, or does anyone know of an insurer that's already tried something like this?

CBO Study of Medicare changes

2006-12-09T14:23:13Z

Continuing the "things you should read" series, here's a CBO report on changing Medicare to be more like a defined-contribution plan. The interesting thing is the key detail of the proposal under discussion -- it would NOT abolish current fee-for-service Medicare! Instead, the idea is to give every Medicare patient a chunk o' money and have the current Medicare program compete head-to-head with private insurance programs.

I find this interesting because it reminds me of what we currently do with student loans, which IMHO has worked quite well. The competition between direct and indirect lending has kept both sides more honest and forced them to focus on delivering the best benefits they can to the borrower.

It's a tricky question, because there'd be a lot of behavioral changes on the part of both patients and insurance companies in response to something like this. Still, we are going to have to overhaul the Medicare system in the very near future, and at least according to CBO's analyses, the premium support idea could generate some Federal savings without raising beneficiary premiums too much.

Article worth reading

2006-12-08T13:11:17Z

From Academic Medicine, an article about the general professional education of the physician (i.e., "What the heck is med school for, anyway?") that is a good read for those of us who think about med-ed reform.

Musings about communication

2006-11-16T00:10:14Z

Many interesting things happened at the Interim Meeting in Las Vegas, some of which were photographically documented and will be forthcoming. We made further progress on medical education reform (including another good Initiative to Transform Medical Education), and there's lots of good news about policy and health system change that I'll let the current GC communicate. For myself, I'm currently reviewing my notes from the Committee on Long-Range Planning session, where my job was to interview members about communication. It's a topic I've been thinking about a lot; frustration with our communications was one of the reasons I ran for Chair back in 2004. I was able to make a few changes, but big issues remain. We don't have current contact information for most of our members. When we do have contact info, requests for members' input (e.g. surveys, leadership applications, and action alerts) receive single-digit response rates.

There seem to be two fundamental problems here. One is that the sheer magnitude of the AMA as an organization is causing mental shutdown. We work on so many things than when we try to tell the average student about them, he/she is unable to process the information and responds by ignoring everything. The other is that fundamentally, the people we are trying to reach do not believe that they care about what's in the emails. We repeatedly heard that students find it bothersome to express their opinions via survey or form, not just to the AMA, but to the myriad other groups inside and outside the medical school.

It seems to me that the leaders of medical organizations (including most of the readers of this journal) have basically two choices, when faced with this dilemma. On one hand, we can (justifiably) state that our classmates are being stupid and short-sighted by ignoring the world around them, and we can continue to seek ways to make them care. This is hard, but might be easier than the second option: to find a way to deliver everything through human-to-human contact and lunchtime talks, which are the only things that seem to work. (There is also a third option, namely, use what we know to make sure that we're taken care of, then leave our colleagues to manage on their own. It's not pretty.)

So, which should we do? We know that any student is capable of comprehending the basics of health policy and health economics -- it's no more complex a body of knowledge than human physiology. We're all perfectly capable of surving a "drink from the firehose" environment, because that's how we make it into and out of med school and residency. The only difference is that we all care about physiology, because it's on the USMLE. Should we try to put health policy onto the Boards as well, in order to force it to be taught? Try to make more academics believe in the value of organizations beyond their specialty societies? Or do we give up entirely on changing the culture of medicine, and focus on training an army of peer-to-peer advocates to do focused interventions and awaken the advocate within each of their classmates?

The Joy of Medicare

2006-11-03T03:42:41Z

As usual, I'm reading through the book for the AMA House of Delegates, and getting a good education in practical health economics. There's several good reports, including Higher Education Act reauthorization, new AMA policy to protect the poor from negative effects of HSAs, and improvements to the AMA Plan for the uninsured that would solidify what we're going to do for patients with predictable high costs (i.e., severe chronic health problems). These are all good things, and it makes me happy that the AMA leaders are paying attention to them (especially those last two). Today, though, I wanted to highlight something a bit different: Council on Medical Service Report 3, which is about how we pay for post-operative care when someone has a surgery, and specifically, how the Medicare rules work.

This is best explained by an example. Let us say that Joe Medicare is from a small town in rural Pennsylvania and requires a surgery that is complex, but can be done on an outpatient basis. He travels to Pittsburgh to have the procedure performed by Dr. Alice, a world-renowned surgeon who has the latest equipment. Dr. Alice gets paid by Medicare, and her payment is meant to cover pre-operative testing, the surgery, and post-operative care. Since it's an outpatient surgery, Joe then travels back to his hometown. A day or two later, he's feeling a lot worse, so he goes to his local emergency department, where he is seen by Dr. Bob. Dr. Bob takes care of Joe and maybe even admits him to the hospital for a day or two of care by Dr. Carl.

So, having cared for Joe, Drs. Bob and Carl can get paid by Medicare for services provided, right? Wrong. Dr. Alice was already paid for all of Joe's post-operative care, which is considered to be everything short of another trip to the OR. If Bob and Carl want to be paid, they and their staff have to call up Alice and her staff, get them to agree to share the post-operative portion of the Medicare fee, make sure everybody's billing system knows what is going on, and then submit the claims properly to Medicare using "CPT modifier 55". This requires a written agreement between all the physicians. If they do all this, Bob and Carl will split 10% of the fee that Alice was paid, which was not necessarily calculated based on the intensity of care that Joe required. Now, to test your understanding, which of the following is likely to happen?

In practice, choice C might be prevented due to Medicare's prohibition of "balance billing"; I'm not going to pretend that I understand all of this completely. But let us pause and reflect for a moment. Some of my colleagues, including the frequent commentors on this journal, would like to extend Medicare and other Federal programs to be the principal health coverage for the American people, on the grounds that it will reduce administrative costs and provide a more just allocation of health care dollars. This, right here, is an example of that simplified and efficient health care system. If you don't see any problem with bad incentives and inappropriate resource allocation in the example above, I have some first-rate investment opportunities for your consideration.

Admittedly, private payers aren't much better, since they tend to adopt the Medicare rules for stuff like this. On the other hand, it's a lot easier for a private insurer to change its rules when those rules are being stupid, since it doesn't have to go through the Federal Register/public comment period process. Nevertheless, this struck me as a glaring example of how complex and generally broken the current Medicare process is, and I felt it should be shared. Read the report if you'd like to see what we're going to try to do about it; it's mostly a matter of trying to facilitate communication and pre-surgery agreements.

Interesting survey

2006-10-04T14:36:35Z

From a researcher at the Cambridge Health Alliance, a survey about physicians/trainees knowledge of the Geneva Conventions and the "doctors' draft".

You should take this survey. Not necessarily because it's good research -- I personally find a slight bias in the way the questions are asked, enough that it reminds me of the "push polls" that one does in a political campaign to spread negative information about the opposition. You should take the survey because it'll teach you about both the Geneva Conventions and the thing that'll make them important to you: the Health Care Personnel Delivery System, more commonly known as the "doctors' draft". My good friend turnberryknkn has been banging the drum about this for years, trying to make students and physicians aware of exactly how easy it would be for a large number of us to be scooped up and shipped overseas on a few weeks' notice. That's not necessarily a bad thing, but it's important to know that it could happen.

ITME Thoughts

2006-09-27T00:52:46Z

While I'm fresh back from the Initiative to Transform Medical Education meeting, I thought I'd jot down a few impressions. There will, at some point, be a formal report. In the meantime, feel free to ask questions or highlight areas that deserve further clarification.

The meeting was different in tone from the first time around. The first time, while not quite a "gripe session", was mainly focused on problems. This one was focused on solutions. As such, it was a much more structured process, with multiple rounds of small-group solution development and large-group reportback. We went through three rounds: identifying specific strategies for change, finding the promoters and barriers of those proposed changes, and then identifying entitities who would be agents for that change or opponents of it.
It was also a much bigger meeting -- I don't have the precise count, but it felt about twice as big. We had more stakeholders from more domains of medical education, which is good. (It also led to some productive side conversations about licensing exams, but that's a topic for Ben Galper to discuss more.)
I may be a bit biased due to my small group assignments, but one major theme running throughout the two days was the idea of re-connecting physicians and trainees to service and altruism. We repeatedly discussed how the "hidden curriculum" ends up pounding the humanism out of students and residents, and even came up with some strategies to fix it. I'm not going to talk about those here, because it'd be unfair to jump the gun on the synthesized report, but I'll say that I think most of you will like them. I'll also say that implementing them all will take a LOT of work and would change the face of many of the institutions we take for granted (LCME, ACGME, Step exams, CME requirements, etc.).
There was one interesting trend. Throughout the meeting, people kept coming up with solutions that were focused primarily on changing the premed requirements and the content of four years of med school, with minimal focus on residency and CME. They were dragged back onto course by the meeting leaders and other participants, but I was surprised by how many people hoped that they could just fix everything by changing the applicant pool. One of my student colleagues expressed some cynicism at this and felt it was largely due to Deans and other academic types not wanting to accept blame for the problems. I take a different view. My suspicion is that they focused their attention on the areas we can control. We can control premed requirements and the curriculum, especially in the first two years, but after that, a physician's education is largely in the hands of an army of heterogenous attendings. Who wouldn't be a bit discouraged at trying to change that?
That segues nicely into another point: the meeting had great optimism and good strategies, but there was also a strong thread of pessimism and discouragement. I suspect that, now that we were finally crafting solutions, some of the folks in the room started to realize precisely how enormous a task we are taking on. This is clearly surmountable, but it's going to take people like you and me. We're going to need to keep injecting hope (and a certain amount of naivete) into the process to keep it going once the inertia of the system starts to fight against change.
There was talk of using the participants group to start sharing around key articles (either opinion pieces or peer-reviewed research) that would help us brainstorm more specifics of the solutions. Should that happen, I'm sure I'll be sharing the articles with you.
Overall, I'm pleased. It wasn't the blue-sky high energy of the first working group meeting, but it moved things forward, and I heard a lot of conversations between fairly powerful people, sketching out how they might implement some of the proposed changes. That, to me, is an encouraging sign. Even though we still need to find substantial resources and figure out how to navigate rocky terrain, people recognize that this can be done, and they believe that this initiative can be a vehicle to do it.

There were also two items I found interesting that didn't make it through the early rounds of solution-development, so I'll share them with you here:

Provide better exit options from medicine. There was talk about how we as a profession ought to identify and remove toxic and incompetent people. The counter-argument was that most physician trainees have invested substantial personal resources by the time we identify a problem, and it would be a grotesque injustice to simply turn them out on their ear. A senior colleage from another organization suggested that what we need is a mechanism to buy people out of the profession. Essentially, all the medical education stakeholders pay into a fund, and when someone is identified as simply not being able to make it as a physician, the fund pays off their loans and gets them career and life counseling to move them into a more suitable career.
Merge the accreditation entities. The word of the meeting was probably "silo". We repeatedly talked about how individual specialties, departments, attendings, etc. all operate in their own semi-autonomous worlds with no mechanisms to make sure everyone's working towards a common goal. To me, if we're going to fix that aspect of medical education, it ought to begin by looking at the way we accredit our learning system. The LCME, ACGME, and ACCME all accredit different aspects, are governed by different mixes of people, and implement their own internal change processes with minimal to no coordination with the rest of the education system. I am reminded of the work hours debate -- we were unable to get LCME to adopt the ACGME work hour standards by reference, because it was not safe to have an LCME standard tied to the arbitrary actions of an external group. Just breaking down that barrier would go a long way towards really unifying all of medical education around a common mission.

What would you change?

2006-09-08T17:31:21Z

In about two weeks, I'll head to Chicago for the next meeting of the AMA Initiative to Transform Medical Education. Once again, they will break stakeholders into small groups and we'll discuss the medical training system. Last time, we identified problems. This time, we are to find solutions. Specifically, according to the briefing materials, we are asked to find solutions to eleven basic problems:

So, I ask: what would you change? What specific things would you do to address each of these?

An unreasonable proposal

2006-08-30T12:05:31Z

A small thought, while I try to get around to this oft-promised series of entries about leadership and the AMA. (It's outlined; completing the series is competing for time with "finish thesis", "clean out junk from apartment" and "deal with residual AMA duties".)

In my and others' writings about the problem of debt, we often note that some schools are able to raise enough philanthropic dollars to be practically tuition-free, while others are still struggling for scholarships. We see similar trends at the college level, where the Ivies have enough money to give substantial need-based grants, but many smaller institutions do not. This is particularly unfortunate because a scholarship that sends one person to Harvard might send three to a state school. (The price differential isn't quite as big in med school, but if you factor in cost of living, you could definitely support two PennState students with the cost of one Tufts student.)

Here, then, is the crazy idea: have wealthier schools partner with less-wealthy cheaper schools to maximize the effectiveness of scholarship dollars. For instance, use some of Mayo's money to support students for whom there's no room in the Mayo class, but who were accepted at the University of Minnesota. It is, as noted, a crazy idea. The most immediate barrier is that it's very hard to fundraise for. It would require alumni of one school to be comfortable subsidizing students elsewhere. The trend in med ed philanthropy is just the opposite; our AMA-MSS study of available scholarships (not online, but available on request) showed an overabundance of small funds earmarked for students from specific counties, ethnicities, specialties, etc. Doing what I'm suggesting would require physicians to think of ourselves as a single community, not divided by where we went to school or how we practice. It'd also require medical schools to work together instead of trying to cut each others' throats (an understandable desire as NIH dollars become scarce). Sadly, both of those are pipe dreams for the foreseeable future.

Citizens' Health Care Working Group

2006-08-02T13:41:26Z

The Citizens' Health Care Working Group is a government-sponsored effort to make suggestions for reforming the US health care system. They've released an interim set of recommendations for how to restructure health care in America, and they are seeking public comment. Everyone who cares about the future of our health system is strongly encouraged to go and submit comments. Whether or not this particular initiative pans out, their findings will be public and will be used by others seeking to enact reforms.

Personally, I think their recommendations are fairly sound. If you look at the comments to date, you'll see that people from multiple ideological perspectives are unhappy, which is generally a good sign that a group has found middle ground. More generally, what they're talking about is finding ways to rebuild our safety net and promote solid preventive care without attempting the impossible task of providing everyone all the care they might wish to consume. They're trying to get America to realize what we sorely need to -- that every health system design involves trade-offs, and that we need to decide as a nation what we are willing to give up and what we really want to get. I continue to believe that anyone who says that everyone can get everything for free is ignoring some fundamental economic and physical realities, but we could certainly be more effective with the dollars we spend now.

In the dark corners of the Internet...

2006-07-12T11:47:28Z

Came across this yesterday during random Googling and had to share. Some of you are perhaps familiar with Wikipedia, an online user-authored encyclopedia that appears to have reached sufficiently reliability that it's approaching Britannica quality. Of course, one problem with an online encyclopedia is that people with less-than-evidence-based points of view are free to attempt to use it to propagate those views, often under the "mention the controversy" argument.

I was pleasantly surpised to find out that the AMA HOD's own Dr. Stu Gitlow is among those fighting for accuracy, in this case about alcoholism and its status as a treatable medical disorder. Some of you have perhaps met Dr. Gitlow, as he's frequently seen during Reference Committees testifying in favor of MSS-authored resolutions on public health measures.

This concludes your interesting tidbit for the day. I swear I'm going to get around to those deep thoughts on leadership Real Soon Now. I've written notes for them, at least.

Things that are good and happy

2006-06-23T02:10:11Z

Another for the "ways the AMA is continually improving" checklist: our new President used his first eVoice column of the year to talk about the uninsured. Not tort reform or Medicare payments, but the uninsured. That is, to me, a sign that we have good leadership in place for the year ahead.

Victory is mine!

2006-06-22T02:14:38Z

As you may have heard, Congress finally repealed the single-holder rule. You have one week to shop around before student loan rates rise on July 1st. Go find yourself a good consolidation package (I recommend Graduate Leverage, but I have a conflict of interest there), then come back here.

What you should know is that the AMA has been one of the organizations advocating repeal of this rule for years. Why has the AMA been doing this? Because we have a medical student section, and because that medical student section convened a group in 2003 that we colloquially called the "Debtbusters". You can find its final report here, and you might note that the very first recommendation, on page 35, is repeal of the single-holder rule. We spent the 2003 Interim Meeting getting this report passed through the AMA House of Delegates (forgoing our opportunity to enjoy the Hawaiian beaches directly outside), and that shaped AMA advocacy priorities in DC.

The point? Your loans will be cheaper to repay, because students have a voice through the AMA. It took longer than I expected, but the system can work!

The Revolution Will Not Be Televised

2006-06-13T19:40:29Z

Very good speech by outgoing AMA President J. Edward Hill, calling for us as physicians to get our patients together and start a revolution in health care.

Photos!

2006-06-04T22:28:47Z

In preparation for Annual, have cleaned out my camera, so you get photosets of this spring's travels.

March National Advocacy Conference (may have already posted this one)
March AMSA Convention
May AMA-MSS Region VII

Come and see the progress inherent in the system!

2006-05-23T14:10:41Z

Reviewing piles and piles of material in preparation for the Annual Meeting, and came across Council on Medical Education Report 5, on students' clinical duty hours. Check out Table 1 on page 2, where the number of schools with policies restricting students' work hours is slowly increasing. That right there is a direct result of a resolution originally introduced by medical students and wrangled into policy by former MSS leaders.

As I often say, this system is never as fast or as easy as I'd like it to be, but it does tend to work in the long run.

Quick thoughts on MLR

2006-05-10T12:07:56Z

As I'm sure most of my readers know by now, the US Senate voted on medical liability reform yet again on Monday, and yet again, it failed. I wasn't going to write about this, but I was at the AMA-MSS Region VII Meeting this past weekend, and one of that meeting's events bothered me. We had planned to go out into the community and serve uninsured patients. Nothing major, just health screenings and education, but it'd have made a difference. The week before the meeting, the partnering community organization talked to their lawyers, realized the liability risk was more than they could assume, and backed out. It's just one more example of how badly the current "lawsuit model" of medical justice is hurting patients.

Of course, the astute among you might ask "Why would you expect this vote to go any different than the last two or three the Senate has held?" Here's one reason: we changed the bill. When we sent med students up to Capitol Hill to lobby in March, some Senators claimed that they weren't supporting liability reform because it would apply to drug and device manufacturers as well as physicians, and they didn't want to give Big Pharma a free ride. It so happens that Monday's bill didn't cover anyone except physicians and hospitals. Guess what? The exact same people voted against it who voted against it last time. If you were one of the people who joined us in March, you might want to see how your Senator voted.

Ramblings on physician organizing

2006-04-03T12:00:12Z

I'm writing this on my way back to Pittsburgh from the AMSA convention and the National Physicians Alliance kickoff meeting. It was an interesting conference, at least in part because much of the message sounded familiar from AMA meetings: health care is in need of serious reform, and physicians must organize to become the agents of reform. The main difference was in the preferred solution to problems.

At the same time, there was a repeated expression of frustration that so many physicians are primarily motivated to organize around economic issues. I was a little disturbed to hear people characterizing this as somehow being contrary to patients' interests. It's not, no more than resident work hour reform was against a rigorous medical education. A physician who can't get paid, or who spends all her salary on liability insurance, is a physician who will be forced to leave. No amount of love for one's patients is able to counter the basic fact: the practice has to have enough money to pay the staff and the expenses. Is it pure selflessness? Nope. But the notion that "good for business" and "good for patients" are mutually exclusive is incredibly short-sighted and harmful.

Beyond that, there's another reason why medical organizations should put significant resources into the "pocketbook" issues. You may have heard of Maslow's hierarchy of needs. It's got a lot of imperfections as a model of human behavior, but it's a decent heuristic for purposes of this entry. There are a few people in this world who will ignore the well-being of themselves, their family members, and their children in order to serve their patients. These are good people, but they are not the norm, and they shouldn't be. Most physicians, like most human beings, need to feel that their livelihood and ability to provide for their dependents is secure before they can start worrying about the big-picture problems. We've seen this in internal AMA surveys of both members and non-members -- most physicians do want to do something about the inequities in our system, but first they need us to help them into a stable situation where they'll have the resources to take on that fight. In other words, if we are able to get rid of some of the stressors on students, residents, and practicing physicians, we'll be more able to "unmask" their natural caring instincts and mobilize our profession for positive social change.

One thing during the NPA conference gave me a lot of hope: in conversations and in overhearings, I repeatedly heard people talk about changing the AMA and all of organized medicine from within. That, to my mind, is exactly the right attitude. Not every AMA policy is exactly where I want it to be, and our advocacy balance isn't weighted exactly the way I (and other members of this year's Governing Council) think it should be, but that's inherent in any organization that has to represent all of medicine. Overall, the AMA's still doing good work. On the other hand, if we had some more talented physician-leaders who were committed to revitalizing and transforming organized medicine for this new century, things could rapidly tilt more in our preferred direction. GLMA's been really good at figuring this out and acting on it, which is why (in my opinion) they've been such a visible and effective force for good this past year or two. So, here's hoping that we're going to see some of the NPA founders at AMA or state society meetings in the near future!

Region IV rocks

2006-01-16T13:07:53Z

Went down to the Region IV meeting this weekend. Wow. These guys have their act together in a way I've never seen -- a completely integrated programming, transportation, and dining/social experience. It included a tour of the Shands medical center's new proton beam setup, complete with three-story welded gantries that rotate around a patient to deliver high-precision radiation therapy. Total nerdgasm. Plus, I got a chance to sit with Ben for a bit and talk about plans for next year.

The thing I really want to highlight, though, is the diversity. The ethnic and social background mix I'm seeing at this meeting is better than anything at any other AMA meeting I've been to. It's good to see even a part of our organization actively reaching out to underrepresented minorities, and hopefully the rest of us can learn from their example!

New photos!

Aforementioned Region IV meeting.
Initiative to Transform Medical Education.

Letters of recommendation

2006-01-06T03:05:18Z

I've just finished reading the latest in my series of Very Thick Books of applications, this one the apps for the AMA Foundation Leadership Awards. These are the awards that fund students and residents to travel to the National Advocacy Conference and our student/resident Lobby Day. Doing this has reminded me of one very important thing that I now share with all of you who may someday apply for an AMA position or for anything else:

BEFORE YOU HAVE SOMEONE WRITE YOU A RECOMMENDATION LETTER, MAKE SURE THEY'LL WRITE A GOOD ONE!

I see this over and over again in applications I read -- students go to their Deans and ask for a letter of recommendation for some AMA position. The Dean sends us something -- namely, they send us the Medical Student Performance Evaluation letter. I've read at least three just this time around that didn't even bother to fine-tune -- they actually concluded with "[pronoun] would be an asset to any residency program." There's some great ones in there too, including some from directors of free clinics and even one from a patient, but I shouldn't be seeing any instances of "I taught this person in one med school course, sie was an excellent student and by the way sie answered questions in class, I came to appreciate hir intellect and enthusiasm."

At least one person is probably not going to get an award because their letter didn't highlight unique strengths that aren't obvious from the rest of the form. Don't let this be you -- make sure your Dean (or whomever else) knows you well, and if he/she doesn't, then get someone else to write! (Or, in the worst case, write your own letter and ask him/her to use it as a base. You'd be surprised how often that works.)

OK, rant over. Doing some stuff with agenda for next GC meeting; might tell you a bit about that process in a future entry, just so you know how the sausages are made.

Things that aren't in the official description...

2005-12-20T18:27:07Z

One of the unofficial Chair's duties is to serve on an advisory board for Graduate Leverage, a company started by some Harvard MBAs to market consolidation loans to graduate/professional students. They try to keep us up to date on legislation affecting loans (with, occasionally, a bit of political handicapping from yours truly), tell us about new products they're developing, seek our advice on how to better serve the students we represent, and so on. It's not *much* work, probably averages out to about an hour a month, but it's another random bit of unpaid labor, and I've always wondered if I should feel exploited that I'm giving useful information to a for-profit company.

I guess they recognize this, because today's mail included a little gift basket of cheese, crackers, smoked salmon, chocolate, and cookies. Not something I was expecting, but I'm definitely not complaining. It did make me wonder if this is something that gives me a conflict of interest, hence the blog entry to disclose it. Then again, nobody comes to me for student loan advice anyway...

Initiative to Transform Medical Education

2005-12-09T04:55:21Z

Last night, I returned from the first large-group meeting of the AMA's Initiative to Transform Medical Education. We got together deans, program directors, staff from accrediting/licensing bodies, Federal agency staff (including two former AMSA presidents), students, residents, AMA leadership, and representatives from health-focused foundations. The goal was to sit down and figure out what's good in meded, what's bad, and what our ideal vision of the medical education of tomorrow should be. Basically, if you've heard of the Flexner Report: doing it again, but in the context of today's multi-regulatory system.

This was probably the single most exciting meeting I've been to during my five years with the AMA. It's been a long time since I went to a meeting where everyone at dinner and lunch was talking about work (and wanted to do so), but that's what we had here. I deliberately tried to move around, sit with strangers, and generally hear lots of viewpoints. Everyone seemed to be overflowing with things they wanted to talk about and try to fix, and to me, that's a very good sign.

I can't really judge what the consensus was at the end of the day; I didn't hear even a tenth of the conversations, and I can't read minds. What I can do is tell you what I personally took away, and what's kicking around in my head about where I see our system going. For me, the critical point is this: physicians of my generation and the next are going to face a system that will shift under their feet on almost a daily basis. Scientific and technological knowledge are growing exponentially, geographical barriers are getting leakier (both through migration and networking), patients and society demand better outcomes, and the current education and health systems are not prepared to handle this speed of change. Physicians are not trained to be the kind of flexible, team-based "lifelong learners" that they'll need to be.

Given all of that, just bolting some health policy classes onto the first year ain't gonna cut it. Here's my argument, version 1.1:med school should produce MBAs with ethics and basic clinical knowledge. Now, that is deliberately exaggerated, but it gets the point across. If you look at the good business schools, they produce graduates who don't necessarily have a whole lot of factual knowledge, but who understand how to organize a team, analyze a system/process, develop rapport even with "difficult" people, and do multiple-scenario planning to be prepared for future surprises. Replace the accounting with clinical knowledge and instill true ethics and professionalism, and you'd have a good primary care doc.

Will he/she know the precise mechanisms of action of every drug in the armory, or the precise effects of five cytochrome SNPs? No. But he/she will be way more equipped to see through slick drug reps, negotiate a contract, manage a patient through the maze of a health care non-system, advocate for and understand universal coverage, and rapidly locate info on those SNPs if it becomes important. I postulate that this is a far more flexible and useful toolkit for the doc of the 21st century, and I'll put my money where my keyboard is: that's the same skillset I'm trying to learn for myself, even though it means being a less-good scientist. (On the other hand, I'll also bet those same skills will help if I'm ever given my own lab.)

I could continue, but I think that lays out the skeleton of the argument. Thoughts or gut responses? (According to my profs, it's the same number of neurons for either...)

Also, coming soon to a blog near you, musings on trust. Over the past year, there are many people who I've come to trust despite previously seeing them as adversaries and as uninterested in the greater good of patients and students. There's some good lessons there for the MSS as a whole, when I get a chance to write them.

Interim Photos

2005-12-01T01:03:24Z

Photos from the 2005 Interim Meeting are here, including many fine shots of your MSS leaders riding the mechanical bull at Gilley's.

Working on updating and overhauling MSS website, managing various tensions in MSS leadership (always seems to occur around holiday season...), starting to review the first of the reports due in June 2006, and in general trying to keep things on track. Next week, it's back over to Chicago for the first meeting of the Initiative to Transform Medical Education!

Brief interlude: student loans

2005-10-28T15:45:09Z

While our #1 priority this year is the uninsured, we haven't forgotten about making medical education affordable. If you'd like a quick rundown of what's been going on in DC and what our AMA's been doing, the Board of Trustees just released a nice summary report.