Watching the Food Channel, I learned long ago how to crush garlic: Place a clove under the flat of a carving knife and confidently bang down hard with your closed fist. That was when the Food Channel paraded a covey of working cooks. Serenely seigneurial, they told us what to do and showed us how to do it. Those coaches have been traded in for teams that compete for prizes, exciting and entertaining, but leaving viewers like me no wiser in ways of the kitchen.
On the TV morning news once a week or so, Marian and I see the weekend listing of the most popular movies rated by how much money they have brought in. But popularity of itself does not tell us what the movie is about. As in so many other parts of life, winning the race seems to be the point of the lists..
In our Darwinian society, competition serves a purpose, but one that shaves down differences that may still serve useful purposes.. There was a time when Yale College, for example, cherished its differences from the college to the north. Proud of its prowess in the humanities, Yale leaders cared little that the institution in Cambridge better served budding scientists. Today, however, one reads that Yale College will compete for science and math students, to beat out not only Harvard but also MIT. One wonders why.
The University of Connecticut Medical School (UConn to us Nutmeggers) was founded in 1961 to supply practicing clinicians for the cities and towns of the state. That was a prudent decision back when Yale Medical School was growing stronger in research: a state of around 3 million people did not really need two research institutions. But somehow over the years – and I have no information other than from newspapers and gossip – officials at UConn have turned to the status prizes that research wins.
In part, this increasing competition may come from the triumph of protocol over outcome. How you do something trumps what you do. Medical schools have to fulfill certain criteria to maintain the approval of national examining boards. Changing some hoary approaches is very difficult, and so new ideas languish. To be sure, setting national standards does away with favoritism, cronyism, and prejudice: the medical schools of the 21st-century are far more open than those of the mid- 20th-century, but need they all compete for the same kind of “excellence?”
What could be wrong with a medical school that proudly affirms its mission to train first-class clinicians, leaving to others the training of “lab docs.” There are many questions for their faculty to answer, among them-for example- whether nurse practitioners function as well in primary care as graduate physicians. Important clinical questions of “evidence-based “ medicine can be explored with the same sense of righteousness as studying the twists and turns of the genome.
I am aware of the wide-spread conviction that “Physicians are scientists.” Whether they need to be trained as scientists is a different question. I used to light a cigar, though I could not make a match. Clinicians could forego the foreign language of organic chemistry and structural biology to become as acquainted with the character of their patients as with the structure of their molecules.
The question about UConn may be moot, now that Quinnipiac University in Hamden CT, like 18 or so other educational institutions, proposes to build its own medical school to train practitioners, but presumably in 20 years, their support for “basic” research will turn far stronger than that for clinical practitioners.
It is sad that few in the medical hierarchy praise training medical practitioners as loudly as unravelling the skeins of the genome.
Howard Spiro, M.D.
Sunday, March 7, 2010
Tuesday, February 23, 2010
Surge of new medical schools may not be the best way to turn out more primary care doctors
A recent article in the NYTimes described a "surge" in new medical schools and how it would increase the increasing demand for primary care physicians (“Expecting a Surge in U.S. Medical Schools” Page 1,Feb. 15). In response several letters from high-ranking medical educators were published a week later (“New Schools, to Train New Doctors”. Letters, Feb. 22.)
Surprisingly, none of the correspondents mentioned that there might be other ways besides opening new medical schools to train more primary care doctors. Before going to medical school, all doctors spend at least two college years studying subjects like organic chemistry, physics , calculus, and biochemistry. For primary care doctors, however, these subjects are of little use once they are in practice. By tailoring primary care doctors’ studies to what they actually use in practice, their training period could be shortened by at least two years. Not only would this allow more students into primary care programs and produce more primary care doctors quicker, but it would also reduce their student loan debt.
It is amazing that none of the correspondents thought of this.
Surprisingly, none of the correspondents mentioned that there might be other ways besides opening new medical schools to train more primary care doctors. Before going to medical school, all doctors spend at least two college years studying subjects like organic chemistry, physics , calculus, and biochemistry. For primary care doctors, however, these subjects are of little use once they are in practice. By tailoring primary care doctors’ studies to what they actually use in practice, their training period could be shortened by at least two years. Not only would this allow more students into primary care programs and produce more primary care doctors quicker, but it would also reduce their student loan debt.
It is amazing that none of the correspondents thought of this.
Sunday, February 21, 2010
antidote for primary care shortage
Combining premed and medical school into a six year program was recently mentioned in American Medical News by AMA president J.James Rohack, MD (“100 years after Flexner, AMA is still a force in med ed”,amednews, Feb. 8)
For those choosing a primary care specialty , such ‘early-entry’ would be beneficial. Clearly, for most primary care doctors, the time spent in the basic sciences is excessive and would be better spent learning clinical skills. Primary care doctors have little need for the in-depth knowledge they are expected to assimilate from their basic science courses.
The importance of the sciences is unquestioned. But how intense does the experience with them have to be for primary care doctors? Surely, organic chemistry, physics, biochemistry, calculus, biology of vertebrates, for example could be toned down to their special needs.
Further, many students who would make good general practitioners are stymied by the basic sciences and don’t go on to medical school. The acute shortage of primary care doctors, in part, is caused by this inappropriate screening process.
Early-entry that combines college and med school into six years is a good idea. It may be the antidote to the primary care shortage.
Edward J. Volpintesta MD
For those choosing a primary care specialty , such ‘early-entry’ would be beneficial. Clearly, for most primary care doctors, the time spent in the basic sciences is excessive and would be better spent learning clinical skills. Primary care doctors have little need for the in-depth knowledge they are expected to assimilate from their basic science courses.
The importance of the sciences is unquestioned. But how intense does the experience with them have to be for primary care doctors? Surely, organic chemistry, physics, biochemistry, calculus, biology of vertebrates, for example could be toned down to their special needs.
Further, many students who would make good general practitioners are stymied by the basic sciences and don’t go on to medical school. The acute shortage of primary care doctors, in part, is caused by this inappropriate screening process.
Early-entry that combines college and med school into six years is a good idea. It may be the antidote to the primary care shortage.
Edward J. Volpintesta MD
Saturday, February 20, 2010
Response to Dr. Pauline Chen's "Do You Have the 'Right Stuff' to Be a Doctor"?
Dr. Pauline Chen broached a serious subject in “Do You Have the ‘Right Stuff' to Be a Doctor” in the Jan. 15 issue of the New York Times.
For almost a hundred years American medical schools have focused mainly on medical research. To be admitted to medical school, a student has to demonstrate a high aptitude for science. That is the reason why they turn out physicians who contribute greatly to the advance of medical science.
But, as Dr. Chen pointed out, are students who might not have strong aptitudes for science, but who have personal qualities that would make them good practitioners being overlooked by the screening process? Should personal qualities like openness, conscientiousness, extraversion, and agreeableness also be taken into account as well?
This question is not a new one. It was suggested that the answer lies with whether medical schools want to turn out great researchers or great practitioners. I don’t think however that this is an either/or situation. Since both kinds of doctors are needed why not decide what percentage of each will satisfy society’s needs; and adjust the medical school admission rate accordingly?
However medical educators decide to handle this problem, the predominance of the sciences in medical school will make the transformation difficult.
The shortage of primary care doctors is the most obvious example of how medical schools have created a lop-sided physician workforce. By over-concentrating on students’ scientific aptitudes, they have created a medical culture that rewards medical specialization to a much greater degree than primary care.
The result is an unbalanced, over expensive, work force that under serves many of society’s basic medical needs. The lack of primary care providers is one of the central issues of the health care debate. It most likely will be solved, in part, by recruiting suitably trained nurses to provide some primary care services independently.
For almost a hundred years American medical schools have focused mainly on medical research. To be admitted to medical school, a student has to demonstrate a high aptitude for science. That is the reason why they turn out physicians who contribute greatly to the advance of medical science.
But, as Dr. Chen pointed out, are students who might not have strong aptitudes for science, but who have personal qualities that would make them good practitioners being overlooked by the screening process? Should personal qualities like openness, conscientiousness, extraversion, and agreeableness also be taken into account as well?
This question is not a new one. It was suggested that the answer lies with whether medical schools want to turn out great researchers or great practitioners. I don’t think however that this is an either/or situation. Since both kinds of doctors are needed why not decide what percentage of each will satisfy society’s needs; and adjust the medical school admission rate accordingly?
However medical educators decide to handle this problem, the predominance of the sciences in medical school will make the transformation difficult.
The shortage of primary care doctors is the most obvious example of how medical schools have created a lop-sided physician workforce. By over-concentrating on students’ scientific aptitudes, they have created a medical culture that rewards medical specialization to a much greater degree than primary care.
The result is an unbalanced, over expensive, work force that under serves many of society’s basic medical needs. The lack of primary care providers is one of the central issues of the health care debate. It most likely will be solved, in part, by recruiting suitably trained nurses to provide some primary care services independently.
Wednesday, February 10, 2010
"Doctors for America" a good idea
I read in the Winter issue of Yale Medicine an encouraging article titled “Doctors for America”. Started by Yale alumni, the group, Doctors for America, promotes health care reform and encourages physicians to get engaged in the debate and to speak out.
The article mentioned two issue of particular importance: (1)increasing the reimbursements for primary care physicians (2) eliminating the defects of the malpractice system.
It is widely known that most medical students are turned off by primary care. But merely paying these physicians more for their services is not the whole answer. Their training should be more in touch with what the “real world” requires of them. In my pre-med years I knew several students who would have made excellent general practitioners but who because of average grades in organic chemistry or biochemistry lost out on their dreams of becoming physicians. They went on to become biology teachers, chiropractors, optometrists, and business executives. Others attended foreign medical schools.
The point is that making the basic science courses less intensive for those interested in primary care would attract more into the specialty. This sounds heretical, but most primary care doctors have no need for the organic chemistry and physics and biochemistry, that they endured as rights of passage.
Regarding malpractice reform, the biggest problem is that it allows unpreventable bad outcomes to be misconstrued as malpractice. Because malpractice suits can seriously harm physicians’ reputations and their livelihoods, many doctors order tests and consultations that are not necessary to ward them off. Appropriately called, “defensive medicine” this practice has become common. Not only does it raise the cost of health care immensely but it exposes patients to risky procedures and medications.
The flaws of the malpractice system have deformed the doctor-patient relationship.Some physicians threatened by the fear of lawsuits, or having had the bitter experience of having undergone litigation, have come see patients as potential lawsuits. Some even refuse to take on complicated cases for fear of downstream litigation.
Clearly, better ways of dealing with medical liability are needed. Patients and doctors can be fairly treated with alternative methods. Some that have been proposed include placing limits on non-economic damages. Another is a workers' compensation system such as that used in Scandinavia;it eliminates the adversarialism of a trial and because disputes are resolved fairly but without destroying physicians’ reputations, physicians are not as ready to practice defensive medicine.
The health care debate is filled with uncertainty. But one thing is certain. Doctors must make their presence felt.
The article mentioned two issue of particular importance: (1)increasing the reimbursements for primary care physicians (2) eliminating the defects of the malpractice system.
It is widely known that most medical students are turned off by primary care. But merely paying these physicians more for their services is not the whole answer. Their training should be more in touch with what the “real world” requires of them. In my pre-med years I knew several students who would have made excellent general practitioners but who because of average grades in organic chemistry or biochemistry lost out on their dreams of becoming physicians. They went on to become biology teachers, chiropractors, optometrists, and business executives. Others attended foreign medical schools.
The point is that making the basic science courses less intensive for those interested in primary care would attract more into the specialty. This sounds heretical, but most primary care doctors have no need for the organic chemistry and physics and biochemistry, that they endured as rights of passage.
Regarding malpractice reform, the biggest problem is that it allows unpreventable bad outcomes to be misconstrued as malpractice. Because malpractice suits can seriously harm physicians’ reputations and their livelihoods, many doctors order tests and consultations that are not necessary to ward them off. Appropriately called, “defensive medicine” this practice has become common. Not only does it raise the cost of health care immensely but it exposes patients to risky procedures and medications.
The flaws of the malpractice system have deformed the doctor-patient relationship.Some physicians threatened by the fear of lawsuits, or having had the bitter experience of having undergone litigation, have come see patients as potential lawsuits. Some even refuse to take on complicated cases for fear of downstream litigation.
Clearly, better ways of dealing with medical liability are needed. Patients and doctors can be fairly treated with alternative methods. Some that have been proposed include placing limits on non-economic damages. Another is a workers' compensation system such as that used in Scandinavia;it eliminates the adversarialism of a trial and because disputes are resolved fairly but without destroying physicians’ reputations, physicians are not as ready to practice defensive medicine.
The health care debate is filled with uncertainty. But one thing is certain. Doctors must make their presence felt.
Sunday, February 7, 2010
Eliminating insurers' antitrust exemptions
In a Feb. 4 editorial “Making health insurance less competitive” the Washington Times mentioned that eliminating insurers’ limited antitrust exemptions will make them less competitive. The argument is that insurers need to compare mortality and care data to operate, which sounds right, but, it has flaws that speak against it. Disease is not so easily or thoroughly identified by statistics as insurers believe. The statistics they gather and compare may approximate, but can never truly reflect the different social and economic factors reported in their statistics.
If insurers didn’t share information they would be compelled to gather and act on their own mortality and care data. That would make them more competitive, not less so. Broad statistical data bases can be misleading; and can dehumanize medical practice by minimizing the uniqueness of individuals’ diseases. Patients may have the same disease as far as its name goes, but the disease itself and its progression are influenced by social and economic factors, and even the geographical areas in which the patients live. Such non-statistical information is important and can seriously skew the date that insurers deal with.
But, apart from this, there is, an even more fundamental issue, at play. Namely, that as long as insurance companies have to generate profits for shareholders, patients’ premiums will be higher and their coverage will be lower, than, ideally, they could be.
Clearly, shareholders and patients competing against one another is a poor foundation to build a health insurance system on, regardless of whether insurers have more, or less, or even no competition at all.
If insurers didn’t share information they would be compelled to gather and act on their own mortality and care data. That would make them more competitive, not less so. Broad statistical data bases can be misleading; and can dehumanize medical practice by minimizing the uniqueness of individuals’ diseases. Patients may have the same disease as far as its name goes, but the disease itself and its progression are influenced by social and economic factors, and even the geographical areas in which the patients live. Such non-statistical information is important and can seriously skew the date that insurers deal with.
But, apart from this, there is, an even more fundamental issue, at play. Namely, that as long as insurance companies have to generate profits for shareholders, patients’ premiums will be higher and their coverage will be lower, than, ideally, they could be.
Clearly, shareholders and patients competing against one another is a poor foundation to build a health insurance system on, regardless of whether insurers have more, or less, or even no competition at all.
Wednesday, December 30, 2009
The anguish of litigation
December 30, 2009
New York Times
To the Editor,
Re “A Patient Dies and Then the Anguish of Litigation” by Joan Savitsky, M.D. (December 29, 23009): I applaud Dr. Joan Savitsky for having the courage to share her experience of being sued for medical malpractice. For physicians, the shame and estrangement associated with a medical malpractice suit is similar to that felt by Hester Prynne in Nathaniel Hawthorne’s Scarlet Letter. She was forced to wear a large A as a sign of shame for having committed adultery.
Doctors who are sued aren’t forced to wear a scarlet M for malpractice but their sense of shame and anger is overwhelming. The threat of a malpractice suit is so intimidating to physicians that they frequently order many unnecessary tests and consultations in order to ward them off. This is called “defensive medicine”. It is one of the biggest reasons why health care is so expensive.
Clearly, the time has come to find new ways to handle medical malpractice. New methods are needed that treat injured patients fairly, but do not subject doctors to the tribulations that Dr. Savitsky experienced.
New York Times
To the Editor,
Re “A Patient Dies and Then the Anguish of Litigation” by Joan Savitsky, M.D. (December 29, 23009): I applaud Dr. Joan Savitsky for having the courage to share her experience of being sued for medical malpractice. For physicians, the shame and estrangement associated with a medical malpractice suit is similar to that felt by Hester Prynne in Nathaniel Hawthorne’s Scarlet Letter. She was forced to wear a large A as a sign of shame for having committed adultery.
Doctors who are sued aren’t forced to wear a scarlet M for malpractice but their sense of shame and anger is overwhelming. The threat of a malpractice suit is so intimidating to physicians that they frequently order many unnecessary tests and consultations in order to ward them off. This is called “defensive medicine”. It is one of the biggest reasons why health care is so expensive.
Clearly, the time has come to find new ways to handle medical malpractice. New methods are needed that treat injured patients fairly, but do not subject doctors to the tribulations that Dr. Savitsky experienced.
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