Hope and Skepticism about the New MCAT

by Karan Chhabra and Allan Joseph

The MCAT (better known as every pre-med’s recurring nightmare) just went live with some pretty big changes intended to better prepare premedical students for the healthcare system of tomorrow. We’ve got a guest post over at Dan Diamond’s Forbes blog examining and reacting to the changes. A small excerpt:

That’s why we applaud the AAMC for resisting this bias and placing social science, psychology, and the humanities on the same plane as pure science — where they belong. The new MCAT sends a new signal to aspiring docs: they need this knowledge just as much as they need hard science, and the medical community now demands they have it…

But unless admissions committees firmly commit to selecting “broader” applicants in all aspects of their applications, the newest version of the MCAT will fail in the same way its ancestor did.

This is something we’ve thought a lot about, but we’re really interested in hearing your thoughts — take a read and let us know your thoughts on Twitter (see below) or in the comments.

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Karan is a medical student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives. Follow him on Twitter @KRChhabra.

Allan is a third-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.

The CO-OP program, 5 years later

by Allan Joseph

Most PM readers can remember the heated debate over the public option that took place half a decade ago (!) during the ACA’s drafting — and are well aware that there is no public option in the law. What many don’t remember, however, is what was put into the law instead of the public option — the Consumer Operated and Oriented Plan program, or the CO-OPs.

I’ve been working with Dr. Eli Adashi, the former medical-school dean here at Brown, for some time now looking into the CO-OP program, which is a fascinating, under-studied provision of the law. We published a Viewpoint in JAMA that went online this week (ungated) that summarizes the CO-OP program and looks towards its future. Go take a look!

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Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

What are tomorrow’s policy problems?

by Allan Joseph

In a few weeks, my institution is hosting the AMA’s Northeast-region meeting for medical students who are interested in policy and advocacy, among other topics. I’ve been asked to give a presentation on the policy problems of the future, and ways for the attendees to prepare for those problems and to help shape their solutions.

I thought I’d take an informal poll to help guide my talk. So what do you see as the biggest healthcare policy problem of the next 1 year, 5 years, 10 years, and/or 25 years? What can medical students do to prepare for them, and how should physicians shape the solutions?

Send me your answers to any or all of those questions via email, on Twitter, or in the comments below.

Thanks!

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Allan Joseph is a second-year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPH. You can follow him on Twitter @allanmjoseph.

Has med school changed for the better?

by Karan Chhabra

 

Every third-year has heard it.

…When I was in your position, I was taking 24-hour calls every other night. If my resident was there, I was there….

We’re regaled about the glory days, without shelf exams, without phlebotomists, and—by god—without those work-hour restrictions. The days when medical students wouldn’t dare ask their residents for help, or residents their chiefs, or chiefs their attendings, and so on. I hear a bit of romance: the heroism of providing total patient care, exactly when the patient needed it, unfettered by handoffs or outside interference. I envy the skill required to practice medicine almost-literally in one’s sleep.

As the veteran doc continues his (yes, usually his) soliloquy, he may admit that it wasn’t the safest model for patients, or the most humane for trainees. He may today be a better doctor for it, but he’s a bit ambivalent about whether it should remain exactly the same today. Presumably he wasn’t alone, because since the good ol’ days, the third year of medical school has morphed into something barely recognizable.

Now, rather than arriving before our residents and leaving after, our time is “protected” in many ways. We have lecture days devoid of patient care, service-learning commitments, and other activities designed to expand our learning beyond the hospital’s four walls. We have shelf exams demanding a much broader scope of knowledge than a typical day on the floor. Occasionally we’re granted a bit of time to study for said exams. Sometimes, we even have weekends.

This is progress, in many ways. Teachers with the right training are supervising patient care. We’re gaining exposure to ambulatory care, where the bulk of American medicine takes place. We’re acquiring the research skills to practice up-to-date medicine as it evolves, rather than learning from sheer repetition. We’re learning how to communicate humanistically and practice ethically. And, in fits and starts, each generation is learning a bit more about how the many pieces of the healthcare system fit together.

But I wonder how much has also been lost. Residents’ duties have gone from the bedside to the computer, where information flows in and orders stream out. We can “round” on vitals and labs at the nurses’ station without ever laying eyes (let alone hands) on the patient. Nurses, phlebotomists, and other members of the workforce have taken over so much of what we formerly called “patient care”—which in turn has evolved from a tactile task to a cognitive one. It’s no surprise that medical students’ experience has followed suit. By the end of a clerkship, we can rattle off pathology, pharmacology, and differential diagnoses till even the attendings fall asleep—but heaven forbid we’re asked to start a difficult IV. I worry I’ll end up in a new generation of well-read, friendly, ethical, system-conscious doctors who’ve learned the textbook but forgotten the patient.

As a student, the times when I’ve lacked longitudinal patient contact have been the most taxing. The hours spent chasing labs and consults or “rounding” at the nurses’ station are the ones that leave me wondering what medicine has become. And I have to ask if the apparent epidemic of physician burnout is really about too little human contact rather than too many hours on the floors. Some have decided that rather than returning to patient care, we should be learning on simulators instead. But to me, that would represent the pendulum swinging even farther away from those we must eventually serve. Lest the establishment forget, we will someday be treating patients rather than machines and multiple-choice problems. Will we be ready?

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Karan is a third-year student at Rutgers Robert Wood Johnson Medical School and Duke graduate who previously worked in strategic research for hospital executives.

Follow him on Twitter @KRChhabra or subscribe to the blog.

How my PCP alerted me to the potential for abuse in telehealth

by Tom Liu

I recently called my primary care physician (PCP) for the first time in years to get my immunization records, and encountered a strange message saying he was not currently seeing patients. My mom had apparently encountered the same message weeks ago. “Maybe he retired,” she suggested.

I did a quick google search of my PCP’s name to find an alternate contact number, and instead found a shocking article from the local newspaper. Apparently my PCP has been indicted for falsifying tax returns and participating in an online pharmacy organization that provided prescription drugs without an in-person physician examination.

Remote Prescribing: Lucrative, Pervasive, and Very Illegal

I did a quick search online and confirmed that the practice of offering prescription drugs through a “cyber doctor” prescription, relying only on a questionnaire is indeed very illegal.

It is also very pervasive. The National Association of Boards of Pharmacy (NABP) reviewed 10,700 websites selling prescription drugs and found that 97% of them were “Not Recommended”. Of these, 88% do not require a valid prescription and 60% issue prescriptions per online consultation or questionnaire only.

What struck me was how this appeared to be a case where the market came together to produce a “triple win” for profit-seeking internet pharmacies, shady physicians (such as my own), and a subset of patients willing to pay a premium to access drugs (most commonly weight loss drugs, erectile dysfunction drugs, and commonly-abused antidepressants and painkillers).

According to one analysis, one such website offering prescriptions from its own doctors listed prices for fluoxetine (brand name Prozac) and alprazolam (brand name Xanax) that were roughly 400% to 1800% higher than prices from a more traditional Internet pharmacy not offering prescriptions. The fact that such “remote prescription” websites remain in business despite the huge price differential suggests that they are attracting patients willing to pay that premium to avoid seeing their regular doctor. And as for where that money is going—well, my doctor was alleged to have received roughly $2.5 million over six years.

Similar Incentives Could Exist for Telehealth Writ Large

Given the clear business case driving abuse in this model of “remote prescribing”, I wondered about the risks of overuse and abuse in the rapidly burgeoning field of telehealth more broadly. After all, one of the promises of telehealth is its ability to make the delivery of services more convenient for both patients and providers. A physician could vastly expand the number of patients he/she sees without leaving the office—which has been identified as a potent way to alleviate the physician shortage problem.

But that would only hold true if the proliferation of telehealth does not generate additional, potentially unnecessary demand. And substantial evidence points to the presence of physician-induced demand under a fee-for-service system. Currently, Medicare pays for a limited set of telehealth services under the same fee-for-service payment model used for in-person visits. Within Medicaid, while select states are experimenting with bundled or capitated payments that include telehealth, others are retaining their fee-for-service model.

In a testimony before the House Energy and Commerce Committee last month, Dr. Ateev Mehrotra, an expert on telehealth, noted, “To reduce health care costs, telehealth options must replace in-person visits.” I’m not convinced this is the case—especially when there is a clear financial incentive to provide more care.

“The very advantage of telehealth, its ability to make care convenient, is also potentially its Achilles’ heel. Telehealth may be ‘too convenient.’” — Ateev Mehrotra

In some cases, fee-for-service payments for telehealth may result in outright fraud, as my physician may have done. In others, it may simply encourage providers to err on the side of providing more care given uncertainties in a practice environment. In fact, a study led by Dr. Mehrotra found that PCPs were more likely to prescribe antibiotics during e-visits than in-person visits.

As various constituencies continue to debate the best approach for paying for telehealth, it is imperative for us to better understand how the incentives and convenience of telehealth interact to affect overall utilization. Blindly carrying our existing fee-for-service system into the new world of telehealth options may produce some unintended consequences.

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Tom is a healthcare researcher with experience in public health and blindness prevention. Follow him on Twitter at  @tliu14 or check out his blog.

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