Self-regulated learning and performance in medical school

We are always worrying about medical student performance. Measures of performance, including grades and standardized test scores, are monitored and discussed regularly. After sitting on an academic performance committee for several years, I have noticed that some students that struggle are a surprise to the faculty. Oh sure, there are some students who have lower pre-matriculant variables (undergraduate science GPA, MCAT, performance in upper level science courses) prior to starting medical school. In those students we might expect a lower performance in medical school. But there are regularly, students who did well during undergraduate studies, they have MCAT scores that are fine, and they are coming before the academic committee because of poor performance-usually failing a course or multiple courses.  Why does this happen?

Educational researchers in the Netherlands (ErasmusUniversity Medical Centre) and the Centre for Research and Innovation in Medical Education) have tried to tackle this question. (1) Their research question was: what is the relationship between motivation, learning strategies, participation, and performance in medical school. They are interested in the concept of self-regulated learning (SRL) which can be thought of as a learner that uses meta-cognition, motivation, and behavioral proactivity to improve their own learning. Several things that can be seen in self-regulated learners (and I would say in high-performing medical students): they monitor their progress towards their own goals; they are interested in learning for the sake of learning; and they develop and utilize effective learning behaviors.

This study was done in a medical school in Rotterdam, the Netherlands which has a six-year medical curriculum. First year students in 2008 and 2009 were included in the study. There were 303 students in 2008 (32% male) and 369 students in 2009 (37% male). Students were given a questionnaire that was about their study techniques and were given immediate feedback and recommendations for ways to improve. An 81 item survey with six motivation subscales and nine strategies subscales was given to measure their Self-regulated Learning. The survey used a Likert scale (1=not at all true of me to 7=very true of me). The questions were things like “understanding the subject matter of this course is very important to me” and “I ask myself questions to make sure I understand the material I have been studying for this course” and “I make sure I keep up with the weekly readings and assignments for this course.” Students also rated their attendance in lecture, clinical skills training, and assignments

The authors found that Participation (lecture attendance, completing study assignments, and skill training attendance) was positively associated with Year 1 Performance and improvements in the mean GPA. Deep learning strategies were negatively associated with Year 1 performance. So students who utilized deep learning strategies more frequently as their study method, had more difficulty in the preclinical (Year 1) curriculum.

So why does participation affect performance? Is it just because people that go to lecture are able to learn things and get explanations that are not in the available written information? Or is it because of the repetition of the material? They have heard it more times- a concept known as distributed practice (study effort is distributed over several study sessions). Or is it differential repetition? Material is presented in lecture, on-line modules, tutorials, small groups, skills training, and independent study which gives more opportunity to absorb and integrate the information into a structured knowledge base.

Is it just because people that go to lecture are more in tune with the material covered and how it will be tested? Since they go to lecture, they know what is going to be on the test based on the cues and clues from the faculty. This is an area that needs more research. We want students to utilize deep learning strategies because information that is learned this way are more likely to retain that information. We don’t want students that do better on the test just because they show up, unless showing up leads to deeper learning and retention of information.

References

(1) Stegers-Jager KM, Cohen-Schotanus J, Themmen APN. Motivation, learning strategies, participation and medical school performance. Medical Education 2012: 46: 678–688.

Physician burnout: is there anything that we can do?

A recent post by Pauline Chen, MD on the New York Times Wellblogspeaks about the nation-wide epidemic of physician burnout. She quotes a recent study published in the Archives of Internal Medicine by Shanafelt, et al (2) that measured the symptoms of burnout using a validated survey instrument (Maslach Burnout Inventory) (3). There were huge differences based on the specialty of the physicians. The highest rates of burnout were found in doctors at the front line of access to medical care: emergency medicine (OR 3.18), general internal medicine (OR 1.64), and family medicine (OR 1.41). These differences remained even after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school.  When compared to a probability-based sample of working adults in the US, physicians had a higher risk for emotional exhaustion (32.1% v. 23.5%), depersonalization (19.4% v. 15.0%), and overall burnout (37.9% v. 27.8%). Overall, 45.8% of physicians had at least one symptom of burnout.

Wow! That is scary! These are practicing physicians who are working themselves to a state of emotional and physical exhaustion. When physicians feel like this they are more likely to make mistakes and medical errors. So, bringing this back to medical education, is there evidence about burnout in learners? Well, a recent article in AcademicMedicine by Dyrbye, et al (4) addressed this question. The authors found that positive mental health had a protective effect on burnout.

In this study, 4,400 medical students from seven medical schools (Mayo College of Medicine; Uniformed Services University of the HealthSciences; University of Alabama School of Medicine; University of California,San Diego; University of Chicago Pritzker School of Medicine; University ofMinnesota Medical School; University of Washington School of Medicine) were surveyed. The students’ mental health was measured using a validated instrument that measures emotional, psychological, and social well-being. The symptoms of burnout were measured using the same Maslach Burnout Inventory that was used in the practicing physician survey.

What the authors found was not surprising: medical students also had high levels of burnout. 42.1% of the students had high scores in emotional exhaustion, 52.5% had a positive depression screen, and 17.4% reported suicidal ideation. When they asked about mental health, interestingly, most students were doing well. 53.1% were flourishing and 42.5% were moderately healthy, while only 4.3% were languishing. Students that were described as languishing reported a low frequency (“never” or “once or twice” in the past month) on more than one of the emotional well-being items and a low frequency on at least six of the signs of positive functioning.

48.2% of students who were languishing reported suicidal thoughts in the past 12 months compared to 25.1% who were moderately mentally healthy (p< 0.001). The scary part was that those who were flourishing still had a 9% rate of suicidal ideation. Students who were languishing were more likely to cheat, more likely to display other dishonest behaviors, less likely to endorse altruistic beliefs, and less likely to care for medically underserved patients.

This is scary stuff! It suggests that a lower, more negative mental attitude in a medical student is correlated with not only their personal feelings about themselves (ie: suicidal ideation) but also how they act within the professional environment (dishonesty and cheating). It may be that if we could identify those students who are languishing, we could intervene to help them improve their mental health. Interventions could impact their professional behavior and quite possibly their performance in the academic realm of medical school. The question is: what are those interventions? More research will be needed to figure out what can be done and what works best.

References

(1) Chen PW. The Widespread Problem of Doctor Burnout.  New YorkTimes.  August 23, 2012
(2) Shanafelt TD, Boone S, Tan L, et al.  Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.  Arch Intern Med. Published online August 20, 2012.
(3) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996.
(4) Dyrbye LN, Harper W, Moutier C, et al.  A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout. Academic Medicine  2012;87(8):1024-1031.

Career outcomes of graduates who initially failed Step 1

I know that I have been gone for a while. Sorry about that...

I saw a really interesting article in Advances in Health Sciences Education (1) this month.  The authors decided to study the career outcomes of graduates of six Midwestern medical schools who had initially failed USMLE Step 1. In this retrospective study, the authors sought to determine the academic and professional career outcomes of medical school graduates who failed Step 1 on the first attempt. They took a cohort of students who graduated from the Ohio State University College of Medicine, Michigan State University College of Human Medicine , Washington University School of Medicine, SouthernIllinois University School of Medicine, University ofIowa Roy J. and Lucille A. Carver College of Medicine, and the University of Michigan School of Medicine. In this cohort of 2,003 graduates from 1997-2002 were 50 (2.5%) students who initially failed Step 1 and these students were compared to the 1,953 students who passed Step 1 on the first attempt.

There were several interesting findings in this study. The authors used information from the MSQ (Medical Student Questionnaire), the GQ (Graduate Questionnaire), the AMA Physician Masterfile, ABMS Board certification, and the AAMC Faculty Roster System. Data was gathered from all six schools and merged into a single database. Some of this data has issues, for example the MSQ and the GQ both rely on student self-report. The AMA Masterfile may mis-categorize some doctors and the cohort only includes students who made it to graduation and for whom they had complete data available (about 43% of the total graduates). But with that being said, this is a pretty good study with a large cohort of graduates.

So, what did they find?  As you would guess, passing USMLE Step 1 on the first attempt has major repercussions for medical students. Most students (94%) pass the test, but not all. Students who fail Step 1 are less likely to pass Step 2 and less likely to ultimately graduate from medical school. (2) But this group of students had all graduated so are they still impacted? There is not a lot of evidence that medical school test performance is correlated to residency clinical performance, but Program Directors still put too much emphasis on Step 1. In fact, a national survey of Program Directors (3) found that 84% would seldom or never interview a student who had failed Step 1 even if they eventually passed Step 1.

In this study, those who failed were more likely to be women, minorities, and older. In fact, there were significant differences between these groups. When compared to men who graduated, women were 3.2 times more likely to have failed Step 1 on the first attempt (p < 0.001). African Americans were 13.4 times more likely to fail when compared to whites (p < 0.0001), and Latinos were 7.4 times more likely (p < 0.0001) to fail when compared to whites. They are more likely to end up in primary care residencies, to be older, and to come from families of lower income.

This data obviously has huge implications. Every medical school has a few failures on Step 1 and should be concerned about the implications. Are we willing to tolerate this difference in the relative risk of failing a nationally standardized high stakes examination? There may be pre-matriculate variables that explain some of the differences, but there also may be ways to identify and intervene in high-risk students’ academic career in ways that can decrease their risk of failure.

Take a look at the programs that are in place at the University of Texas Medical Branch in Galveston and Southern Illinois University. They have been successful in helping students that were identified as at-risk students. Unfortunately, but many schools would rather try to decrease the number of at-risk students that they admit.

The method that is often used is to try to admit students with higher MCAT scores and higher undergraduate GPAs. The problem with this strategy is that in doing this the school will also increase the number of rich, white, male students who come from urban backgrounds. This leads to a student body that is less diverse. That is something that our schools should not tolerate.

References

(1) McDougle L, et al.  Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt. Adv in Health Sci Edu.  7 April 2012 (Online First).

(2) Biskobing DM, et al. Study of selected outcomes of medical students who fail USMLE Step 1. Medical Education Online  2006;11(11):1–7.

(3) National Resident Matching Program, Data Release and Research Committee. Results of the 2008 NRMP Program Director Survey. Washington, DC: National Resident Matching Program. 2008

Impact of medical school tuition

In my blog, How much should medical school cost?, I wrote about an innovative proposal by Peter Bach and Robert Kocher to make medical school free. Dr. Bach is the director of the Center for Health Policy and Outcomes at Sloan-Kettering Cancer Center. Dr. Kocher is a special assistant to President Obama on health care and economic policy. Their proposal has gotten a lot of press. It seems that many people have an opinion about the cost of medical education. Dr Joshua Freeman wrote in his blog, Medicine and Social Justice Would free medical schools increase primary care?.  Dr Kenny Lin, in his blog the Common Sense Family Doctor wrote Strengthening the primary care pipeline.  Dr Pauline Chen wrote in the New Times Health blog about The Hidden Cost of Medical Student Debt. 

I was thinking about another aspect of the cost of medical school.  It is something that I have not heard people talking about. Most of the negative aspects that have been talked about are related to the negatives to the student and the impact on their future career choices. There is also some (important) talk about the societal negative of less students choosing primary care and family medicine.

But what about students who never graduate from medical school?  Medical schools try very hard to keep students in school because of the big investment in that individual student. If you get into medical school in the US, your chances of graduating are extremely high. Something like 96 percent.¹  But what happens if you don't graduate? At most schools, the student would be on the hook for the cost of their education.  Wow!  Saddling a medical school graduate with $150,000 in debt is bad, but we say--they are going to be doctors, they can afford it. But if a student leaves school or is dismissed from medical school for academic reasons, they are still going to have that debt of $150,000.

It is a big deal. When the faculty are talking about the academic performance of a medical student, they should not have to worry about the financial ramifications of their decision. But, honestly, how can they not consider the implications. They are essentially condemning someone to financial ruin by saddling them with a debt that rivals that of a new home. And state schools are relatively cheap. If they are at a private medical school or one of the osteopathic schools, their debt may be as much as $300,000. 

The faculty on a dismissal committee are given an unenviable task. They are acutely aware of their responsibility to the public and society. They do not want to graduate a student who is not qualified to be a physician. By the time a student gets to this point they have been on the dean's office radar for a long time. These students have generally failed several courses or national standardized examinations, they have been through a lot of remediation, and there has been an enormous effort to salvage their medical career. The faculty have invested a lot of time and effort into the student. The faculty really care about the students. The school has invested a lot of money in them. A position in the medical school class can never be regained, so if a student is dismissed that spot is gone forever. The faculty feel that they have failed when a student is dismissed. The financial ramifications just make it worse.

So, I would like medical schools to consider a no-fault system.  If a student is dismissed from medical school, their tuition and fees are refunded to them. Let's take the financial part completely out of the discussion.  This will be better for the students and for the faculty. An potential effect of this policy, would be to encourage schools to take a chance on more at-risk students.  Some of these students might be from disadvantaged backgrounds, some might be underrepresented minorities, and some might be from rural areas. These students are less likely to apply to medical school and even when they apply, less likely to graduate.¹ Disadvantaged students may choose to not even try medical school because of the financial consequences of failure. A no-fault system would eliminate those consequences.

What do you think?

References

1) Garrison G, Mikesell C, Matthew D. Medical School Graduation and Attrition Rates [https://www.aamc.org/download/102346/data/aibvol7no2.pdf]. Analysis in Brief AAMC.  2007. Vol 7 Number 2.

Research in medical education

I had a crazy thought the other day,  why don't we do more research in medical schools. I know you're saying that there is a ton of research going on in the modern medical school.  But I bet if you are reading this you don't care that much about most of the research that is going on. Sure, there is plenty of basic science research. For instance, my good friend and co-conspirator/ co- director of our first medical school module is the famous Joe Fontes. He is in the Department of Biochemistry and he has two RO1s from the NIH.  Pretty impressive!  We also do some clinical research. One of my partners has an RO1 from the NIH to study colon cancer screening in minority populations.

But I am talking about research on and about the educational process. How much of what we do on a daily basis is evidence based?  I don't mean the knowledge content that is being delivered but the way that the information is delivered.  Is a lecture better than a small group?  Is an experienced lecturer better than one who is young and inexperienced?  Is a preceptor visit a better way to learn about professional behavior than lecturers. Are preceptorship visits better for teaching clinical skills or faculty physicians or trained patients?

These are all important questions. Why don't we know the answers to them?  

You might say that we know the answer to some of those questions. I would say that we probably know part of the answer to some but we don't know the whole answer to any of them. But does that matter? I think it does. We talk all the time about how we think evidence-based medicine is important but do we apply the same standard to the education of our students? I don't think so. I am not even sure that we could all agree on the definition of "better".

But don't you think we should have an evidence-based standard for educational practice just like we have for clinical practice?  This is what I propose. We need a medical school that is totally based on the best available educational research. Wait a minute, that won't work, will it?  We already know that there is not enough evidence for most of what we do. So, if we can't do it now maybe we could in the future. But how can we get there? Here is the radical part. We need to experiment on our students. (a big gasp was heard!)

The funny part is that I think we already do this. But right now we are not getting their permission.  Every time that we use an unproven educational method in our teaching, we are experimenting on them. We just don't get their consent.  I propose that we start asking for consent and randomize them to the standard educational method or to a well thought out intervention that is based on sound educational theory. This will require us to have a good grounding in educational theory which most physicians don't. And it will require an acknowlegement by us that our methods may not be right. We might need to change.

If I was a med student, I would be excited by this. Our students in Salina (see my blog about Salina) were told at the beginning that they would be the innovators, not guinea pigs. It was and is exciting to them. They were excited to be the first to prove that a medical school could be run in a small town in rural Kansas.  I think that the same would be true on other campuses with other methods. Let's be innovators.  

What do you think?

Empathy

A recent study Rosenthal, et al (1) in the journal Academic Medicine, studied the Jefferson Empathy Scale in medical students at the Robert Wood Johnson Medical School . This study was born out of a committee that included medical students, residents, and faculty. Their purpose was to design a curricular intervention that could be done in the third year of medical school that would help to preserve empathy throughout the year. 

The purpose of the study was "to evaluate JSPE-MS scores of two consecutive medical school classes in order to assess the impact of an empathy-preserving curricular innovation". At RWJ Med school they believed that there is a decrease in empathy across the third year of medical school. Anecdotally, I think that most medical educators know this to be true.

Wiggleton and colleagues (2) found moral distress, burnout, and depression in third year students. In this study, the authors described 50 potentially distressing situations which medical students might encounter in clinical rotations. Situations included: a patient had very advanced disease because they faced barriers to accessing care; a member of the team was disrespectful to someone below them in team ranking; optimal care was not provided as a result of alcoholism, drug use or homelessness; and our team provided care that only prolonged a patient's suffering. Over half of these situations had been experienced at least once. 35% of the situations caused mild to moderate distress.  

Diseker and Michielutte (3) found that empathy decreased before and after clinical experiences in the third year. The author's administered the Hogan empathy scale to all medical students. They found the empathy scale to be negatively correlated to MCAT scores. (see my previous blog about the MCAT). And they found that there was a significant decline in the empathy score from the beginning of medical school to the end.

Hojat and colleagues (4) found empathy significantly declined across the third year of medical school. They found that empathy did not really change that much in the first and second year, but the decline during the third year persisted until graduation. Interestingly, 27% of the students did not have any decline in empathy.

So, in this study the authors designed a curricular intervention that was given in the clinical year. Their intervention was six interactive sessions that were given during each of the required third-year clerkships. The sessions were one hour long and included time for debriefing on intense experiences, reflective essays/blogs,  and discussions of role models, patient care, morally distressing events, and the students' reactions.

This intervention seems fairly simple and similar to a longitudinal experience that our school has in the third year of medical school. The authors were able to document a lack of change in empathy across the third year. There was no statistically significant change in pretest/posttest empathy scores (pre = 115.4, post = 113.9, p =.135). One interesting fact was that student who entered family medicine, internal medicine and pediatrics had significantly higher empathy scores than those entering other specialties such as surgery, urology, otolaryngology, and anesthesiology.

Hopefully, there will be more interventions designed to help our students during the third year. It is hard. They are vulnerable and are often treated like crap. Dr. Steven Kanter (5) in his opening editorial in the March issue of Academic Medicine, reminds us that we need to think with our head as well as our heart to provide the best patient care. If we damage our students they will no longer have the ability to think with their heart, to care for their patients.  OK, I will get off the soap box for a while.

REFERENCES

(1) Rosenthal S, et al Humanism at Heart: Preserving Empathy in Third-Year Medical Students. Acad Med 2011;86(3):350-358.

(2) Wiggleton C, et al. Medical students' experiences of moral distress. Acad Med 2010; 85:111-117.

(3) Diseker RA, Michielutte R. An analysis of empathy in medical students before and following clinical experiences. J Med Educ. 1981;56:1004–1010.

(4) Hojat M, et al. The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84:1182–1191.

(5) Kanter S. Think With Your Head and With Your Heart. Acad Med  2011;86(3):273.

Professional dress: does it matter any more?

Sorry, I have been absent for a couple of weeks.

We started a new class of students off on their medical journey last month. The first year students arrive on campus bright-eyed and bushy tailed as it were. At our school most are fresh out of college. They have spent the last four or five years as Biology or Chemistry majors. They went to class or maybe they didn't. Most college courses don't have attendance requirements. They are generally allowed to dress however they want, this time of year shorts, flip flops and ball caps are the norm.

In 2005, there was a big flap (or should I say flip/flap) when the national championship women's Lacrosse team from Northwestern University was invited to the White House to meet President George Bush.  The scandal began when several people noticed that a picture taken of the ladies showed four of the nine players in the front row wearing flip flops.  Now these ladies were dressed up in skirts and nice clothes. After all they were meeting the President, but dressing up apparently did not include changing shoes.

 

So here we are with another class of new medical students. I am the co-director of the first module so I am sitting there in class most every day. The students are polite, they almost always address me as Dr Delzell, and so far I have not seen any rude behavior in class. But at least half the class is wearing flip flops. T-shirts are the norm. Many extolling their undergraduate school or their fraternity/sorority. Many of the guys wear ball caps. 

Now don't get me wrong, I like to dress casual. As soon as I get home from work I put on shorts and a t-shirt. I love to wear flip flops. I would love to have a job at a medical school that is located on the beach so I could wear casual Hawaiian-style shirts and flip flops every day.  But I don't.  And neither do our students. 

I know that there are some schools that require professional dress whenever the students are on campus. Dr. David Steele, Senior Associate Dean for Medical Education at the Paul L Foster Texas Tech School of Medicine in El Paso has told me that at their new medical school the faculty decided to require students to dress professionally every day. Even during the basic science lectures. And last year, we were invited to be visiting professors at the Yerevan State Medical University in Yerevan Armenia. We visited the campus and toured one of their large lecture halls that would hold about 600 first year medical students. It had hard wooden benches and no air conditioning and the students were required to dress up (suit and tie for the men) each day for lecture.

I don't know if it makes a difference. We talk all the time about how Millennials-Generation Y is different from past generations. I am sure that in the sixties when the hippies started their first day of medical school, they were wearing bell bottoms and tie-dye shirts. I am sure the professors were concerned about the lack of professionalism that those students displayed.  This is to some extent a generational issue that is seen every year. But where is the line?  When is it a generational issue-where the younger generation have a different set of internal rules and values that guide them in different ways than a previous generation? And when is it a maturation issue-where you need to learn behavior from those that are your teachers and mentors?

New Salina med school campus unique in U.S.

The following is an excerpt (posted with permission) of an article by Dave Ranney from the Kansas Health Institute News Service that was originally posted on July 5, 2011 on the KHI website. Dave Ranney graciously gave permission for this reposting.

SALINA — Next month (actually tomorrow), the University of Kansas School of Medicine will open a four-year, fully accredited school – officials prefer to call it a campus – next door to the Salina Regional Health Center.

“This will be the smallest medical school campus in the country and Salina will be the smallest city in the country - outside of a few major suburbs - to have a medical school campus,” said Dr. Heidi Chumley, senior associate dean for medical education at KU Medical Center.

The first class will have eight students, seven of whom are from Kansas.  KU Medical Center officials said they plan to add eight students a year at the campus in each of the next four years.

More primary-care docs

“The goal is to develop more primary care doctors for rural Kansas,” Chumley said. “We’re shooting for 75 percent (of the new school’s eventual graduates) choosing primary care, and 75 percent rural.” Much of the new school’s curriculum will be tied to the classroom offerings at the KU Medical Center’s campuses in Kansas City and Wichita. “We completely redid our curriculum about six years ago. It’s very computerized now,” said KU Medical Center Executive Vice Chancellor Dr. Barbara Atkinson. “All the lectures are podcasts. They’re all going to be teleconferenced (in Salina), though some will be generated on-site.”

The cost of remodeling the three-story building has been picked up by Salina Regional Health Center. And the hospital’s foundation and several private donors are covering many of the operational costs and scholarship offers. “So far, we’ve not asked the state for any money for this because we understand the financial situation the state is in,” Atkinson said. “But we have asked donors to support it and they’ve been very, very generous. Incredibly generous.” Salina-area benefactors, she said, hope to raise $2.5 million over the next four years. They’ve already raised $1.5 million with $1 million coming from the Salina hospital.

Salina Regional Health Center has hosted a residency program for KU Medical School graduates for about 30 years.  Most of its residents went on to start or join rural practices.

Model for other states

“What the University of Kansas is doing, I think, will be a template for having a positive impact on the number of medical practitioners in rural communities,” said Brock Slabach, senior vice president at the National Rural Health Association. “Other universities will be watching because, really, for a major medical school to commit itself to meeting rural-community needs like this is truly novel. It shouldn’t be, but it is.”

Slabach said he’s long been baffled by the fact that medical school officials in many rural states’ fail to see the connection between their states' shortages of health care providers and their students leaving for big cities in other states. “I wouldn’t include Kansas in that group,” he said. Last year, a national survey of how well medical schools were fulfilling their “social mission to train doctors…” ranked KU School of Medicine fifth in the nation. The school was ranked eighth for its percentage of graduates (44 percent) practicing in underserved areas.

Earlier this year, a Kansas Department of Health and Environment survey found that 51 of the state’s 105 counties had less than one physician per 2,695 residents and were considered medically underserved.

Looming retirements

“The shortage of health care professionals has been a critical issue for a long time,” said Dr. William Cathcart-Rake, director at the KU-Salina campus. “It’s not new, but what is new is that now we have a number of physicians who are nearing retirement age, and a good number of them are practicing in the rural communities.” Generating enough new doctors to replace those who are retiring – especially in rural areas - will be difficult, he said. “We have to do something,” Cathcart-Rake said. “We can’t keep doing what we’ve always done. It’s not enough.”

The Salina campus, he said, will be geared toward allowing students from small towns to complete their studies and residencies in a small-town environment. “There is evidence that shows that if someone is trained in a rural area they are more likely to stay in a rural area,” he said. “So the idea is that from day one we’ll be training our students in in non-metropolitan settings and exposing them to all the good and the bad that comes with life in rural Kansas. After that, we’ll hope for the best.”

Cathcart-Rake, who grew up in small town in Orange County, Calif. (“…back when there was still a small town in Orange County”), has been practicing medicine in Salina for 32 years. “The perception is that if you go to a small town you’ll work yourself to death, you’ll never get a vacation and you won’t get to spend time with your family,” he said. “The way to get around that is to be with a group of physicians so you can cover for each other so you don’t have to do everything for yourself.

Going where no medical school has gone before....

On the front page of the Saturday (July 23, 2011) New York Times, an article by A.G. Sulzberger proclaimed Small-Town Doctors Made in a Small Kansas Town.  This week, the University of Kansas School of Medicine is opening a new campus in Salina, Kansas.  Salina will be the smallest town in the US to host a four-year medical campus. The stated purpose of the new campus is produce primary care doctors that will practice in rural Kansas. Dr. Heidi Chumley, the KU Senior Associate Dean for Medical Education and Associate Vice Chancellor for Educational Resources and Interprofessional Education, is leading KU's development of this campus with strong support from Chancellor Bernadette Gray-Little and EVC / Executive Dean Barbara Atkinson. The fact that this article ran on the front page of the NY Times is a testament to the uniqueness of this new campus. The LCME reviewers of the Salina program thought that it was "an interesting model" that "could be a stimulus for other schools".

As you might expect, the program has generated a lot of interest:

Dave Ranney from the Kansas Health Institute had a nice article on the KHI web site on July 5, 2011, New Salina med school campus unique in U.S. I will be reposting an excerpted version of this article in the next few days.

Elana Gordon of KCUR, the University of Missouri-KC NPR affiliate, did a nice article about the new campus, Tiny School to Create Tiny Town Docs. This ten-minute interview with Dr. Chumley ran on the air and a podcast is posted at this link.

Roger Cornish, from KWCH 12 Eyewitness News (a Wichita CBS affiliate), has a great interview with Kayla Johnson and several of the other new first year medical students at the Salina campus. You can watch the video of the interview titled, Classes begin at K-U Med / Salina.

Lily Wu from KAKE (another Wichita TV station) did an interview of the students and staff at the new campus, Medical Students Interested in Serving Small Towns.

I am sure that there will be more press on this over the next few days and weeks. Congratulations to Dr. Chumley and the University of Kansas for this historic endeavor.

Follow up

I wanted to follow up on some issues that I have blogged about recently.

On February 4, 2011, in my post Why do we put so much import on the MCAT , I wrote about the value of the admissions test for medical school. The Medical College Admissions Test is one of several screening mechanisms used by medical schools to determine who should be allowed to pursue medical training. A recent editorial (1) in the New England Journal of Medicine by Joshua Tompkins (Science Journalist and Medical Student at the USC Keck School of Medicine) discussed the expense of MCAT and Board prep courses. According to Mr. Tompkins, medical students are taken advantage of by a "multi-million-dollar industry in commercial exam-preparation assistance". These (for-profit) companies play on student's fears--fears of failing, of not getting a high enough score to get into their residency of choice, their fear of not matching in any residency.  The problem is that there is little to no evidence that these board prep courses actually do anything to affect a student's score on the MCAT  or USMLE step 1.  A systematic review of commercial test preparation (2) found that "current research lacks control and rigor" and the evidence to support these courses was weak or non-existent. According to Mr. Tompkins, pre-clinical medical students "focus on obscure minutiae and rare conditions" and "spend less time studying the common diseases they will face during clerkships, residency, and practice".

And while we are talking about medical school admissions. In another recent blog, Personality traits that predict success in medical school , I wrote about using personality profiles to chose which students should be in medical school. An article in the July 10, 2011 New York Times by Gardiner Harris, New for Aspiring Doctors, the People Skills Test reports on the use of a specific type of medical interview that is being implemented at Virginia Tech Carilion School of Medicine in Roanoke, VA. The Dean at Virginia Tech Carilion is a family doctor named Dr. Cynda Johnson. She happens to also be a former resident and faculty member from the University of Kansas. Virginia Tech Carilion (and several other schools) are using the multiple mini interview or MMI to screen potential medical students. The test is administered to students as part of their medical school interview and is designed to "assess how well candidates think on their feet and how willing they are to work in teams". According to Dean Johnson, "if people do poorly on the MMI, they will not be offered positions" in the medical school class.  The MMI is also a pretty good predictor of performance in the preclinical years of medical school. (3)

Way to go Virginia Tech. This is definitely a step in the right direction.

References:

(1) Tompkins J.  Money for Nothing? The Problem of the Board-Exam Coaching Industry. NEJM 2011; 365 (2): 104-105.

(2) McGaghie WC, Downing SM, Kubilius R. What is the impact of commercial test preparation courses on medical examination performance?  Teach Learn Med 2004; 16 (2): 202-11.

(3) Eva KW, et al.  The ability of the multiple mini-interview to predict preclerkship performance in medical school. Acad Med  2004; 79 (10 Suppl): S40-2.

A new blog: A Journey to Family Medicine

I would like to introduce you to one of my students. Brooke is a brand new fourth year medical student. I have known Brooke since the first month of medical school. She was assigned to my PBL (problem-based learning) group. This means that she and nine of her classmates were going to be meeting with me every month or so to work our way through a clinical case. Every basic science module has PBL cases. There are multiple purposes for these PBL groups: to learn about clinical medicine, applying basic science concepts to a patient case, to learn about the professional aspects of medicine, and to foster and promote interactions with medical school facutlty members. We get to do all of that and more.

The PBL groups are definitely one of my favorite parts about being a teaching faculty member. Our students come into school with such high expectations and aspirations. They are not cynical or jaded (yet). They have a lot of different motivations for medicine but generally have one thing in common--they want to help people. Usually, by the end of two years, I know these students pretty well. I learn about their families. It is great getting to know them individually as people, not just as students. I don't try to talk them into going into primary care, but they do get two years of listening to my opinions (for what that is worth).

So Brooke was in the last Family Medicine clerkship this year. By the time, I saw her, she had already taken Internal Medicine, Surgery, Geriatrics, Neurology, Psychiatry, Pediatrics, and OB/GYN. The students at the end of the year are an interesting group. Clinically, they are very accomplished. But often they are stressed. They are trying to decide what residency program they should try to get into. They are tired after a year of long clinical rotations. And, honestly, they are often a little cynical about the educational process and medicine. There is data that says that students' empathy and emotional intelligence falls throughout the third year.

But Brooke was excited. She could not wait to come to Family Medicine. She told me the first week that she had been thinking about it for a long time and had decided that Family Medicine was the specialty that she was going to choose. She is smart. She could do anything that she wanted to do. She is confident and poised. She is a class leader. Not formally, but informally. The other students on the rotation looked to her for leadership which she provided quietly without any fanfare. And she decided that she wanted to be a family doctor. I must tell you, that is one of the greatest thrills!

So, I asked her if she would write about her experience. She is going to blog from now until Match day and maybe beyond. She is going to write about her life and being a medical student. She is going to write about the process of applying to residency, interviewing, and the Match. I hope that if you work with medical students you will tell them about her blog. The name is: A Journey to Family Medicine.

How much should medical school cost?

It does not seem that many people care very much about the cost of medical education in the US. But we should be concerned. Did you know that the average debt for a medical student on graduation from a state funded medical school is about $150,000. To put that into perspective, the average cost of a four bedroom house in suburban Kansas City, where I live, is $225,517 not much difference.(1)

Many people will see that and say,"who cares, doctors are rich". I can't argue with that fact, doctors are rich. Physician salaries are in the top 5 percent of all jobs in the US. A recent blog from Dr Joshua Freeman described the top 10 paying jobs in America. Physicians held 9 of the spots. There are many ways to fund medical school, including loans, repayment plans, and my personal favorite-having a rich dad. I remember the first day of my medical school experience and one of the women in my class asked a question during the financial aid lecture. "Can you send the bill to my daddy?" Repayment programs can be very effective. Here in Kansas, we have one of the oldest and best. Students that commit to practice in an underserved county (that is most of Kansas), choose a primary care specialty such as family medicine, internal medicine or pediatrics, and maintain their academic standing are given a full tuition scholarship and a monthly stipend. Over its 50 year history the Kansas Medical Student Loan program has placed hundreds of students in communities across Kansas.

So back to why should we care about this? Well, as I discussed in a previous blog, Production of Primary Care Doctors, [ student debt is one of the primary deterrents to students choosing primary care specialties such as family medicine. The equation is fairly straight forward. More student debt leads less students choosing family medicine residency training (and other primary care specialties). Less students in family medicine residencies means less primary care physicians in practice. The data at this point is pretty clear. If there are less family doctors per capita in a county in the US, that county is less healthy. The citizens die more frequently, they are hospitalized more often, and over all they are less healthy.

Wow, all of that because medical school costs a lot? No, not all but enough that a recent Op-Ed in the NYTimes should be given some serious thought. Drs Bach and Kocher proposed that medical school tuition should be free. Then how would we pay for it? Their idea is a good one. Tax the students that want to choose specialty practices. Basically, the idea is that medical school is free if you choose to practice in a primary care field like family medicine or general pediatrics. If you decide that you want to be a dermatologist or a radiologist or another specialty then you have to pay for your training.

That may seem unfair to the students that want to go into dermatology, but remember the state and national government (and we the people) have a huge investment in medical education and the health care field. $1,400 for every car you buy from General Motors is for health costs, medicaid accounts for 1/3 of the budgets in most states, and even private medical school receive millions of dollars from the federal government to support biomedical research. And we don't need more dermatologists. We do need a strong and vibrant primary care infrastructure. The beauty of this idea is that it could be changed as the physician practice population changes. If we need more anesthesiologists then we make the payback less. If we need more general surgeons, then we make the pay back less to do general surgery. If we need less plastic surgeons then we just raise the payback more. How much? How ever much you need. Would a student choose to do orthopedic surgery if medical school was going to cost them a million dollars? How about 2 million? You get the idea?

Will this ever happen? Unlikely, but we can hope...

References
(1) http://money.cnn.com/pf/features/lists/hpci_data/index.html

The new (and improved?) MCAT

Some of you may have heard about the proposed revisions to the Medical College Admissions Test. What do you think about the changes?

The AAMC released the preliminary report from their MR5 advisory committee. This task force was appointed in 2008 with broad representation from medical school deans and administration, basic science and clinical faculty, premed advisors, and included a resident and a student. This group, chaired by Steven Gabbe, MD (Senior VP for Health Sciences THE Ohio State University) was given the task of making recommendations for changes and revisions to the MCAT "that are likely to increase the exam’s value to medical school admissions committees and examinees".(1) The last time that the MCAT was significantly revised was in 1991.

The MR5 Committee got feedback from faculty at medical schools, deans and administrators, resident physicians, and medical students.  In spite of this, some of the changes have gotten significant criticism. They have made fourteen recommendations, including an increased emphasis on Behavioral and Social Sciences Principles and Critical Analysis and Reasoning Skills. (2) 

As I wrote about in a previous blog, Why do we put so much import on the MCAT? , the MCAT has major problems when used as a decision point for medical school.  The MCAT may even be a negative predictor for some important characteristics of physician behavior, such as verbal fluency, breadth of interests, and the ability to communicate. (3) 

So, it seems that changes to the test would be welcomed. I don't know. Honestly, my major problem is not the composition of the test so much as the way that the test is used by medical schools across the country.  The MCAT is the primary determinant for students' admission to medical school, often overshadowing other important factors such as communication skills, altruistic intentions, and a service orientation.

I was surprised by some of the comments on the AAFP's website . These were comments that were posted by readers after an announcement about the MR5 recommendations. Some physicians seem to feel that the changes that are recommended by the MR5 committee will make students less qualified for entry into medical school. "I was always better at Chemistry and science than in fuzzy subjects that didn't require logical thinking" and "Medicine is a scientific profession which requires the high-caliber minds who can think scientifically and objectively". And then there was my favorite, "Is this another attempt at the academia trying to brainwash students?"

I think much of this concern comes from a misunderstanding of the value of the test. It also may have something to do with changes in medical education and the practice of medicine that many physicians are not ready to embrace.  Medical school needs to do a better job of preparing students for practice in environments that are team-based and collaborative, and use information at the point of care.  The days of a physician who acts and practices alone and in a vacuum are gone. We need students who can work with nurses, pharmacists, physical therapists, social workers, and lay patient educators. (4)  The days of a physician who knows everything about everything that they do are gone. There is too much information.  We need students who can access information at the point of care and interface with electronic resources at the same time as they interact with a patient.

So, what should be in the MCAT. I would like MCAT to test some of the important aspects that are beyond the science. Science is not that hard to teach. Make the science portion pass / fail. If you meet this level, we think you can pass USMLE Step 1.  But many other important topics are harder to teach. Why can't the MCAT have more emphasis on ethics?  It could have more questions about health policy and the politics of medicine.  I would love to see a personality profile measure built into the test. What about service and altruism. What about team work? Are there measures of how collaborative people are in team situations? Now some people will say a test can be scammed for those kind measures. I am sure that is true, but with the numbers of people taking the MCAT and the amount of resources that are available, I bet a valid and reliable test could be constructed that would measure more than just knowledge.

References:
(1)  https://www.aamc.org/initiatives/mr5/
(2)  https://www.aamc.org/download/182662/data/mr5_preliminary_recommendations.pdf
(3)  Gough HG. Some Predictive Implications of Premedical Scientific Competence and Preferences. J Med Educ  1978; 53: 291-300.
(4)  http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html

Production of primary care doctors

COGME has just released their 20th report, Advancing Primary Care. Unless you are a real geek like me, you probably don't know what COGME stands for. COGME is the Council on Graduate Medical Education. COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. The legislation calls for COGME to advise and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS), the Senate Committee on Health, Education, Labor and Pensions, and the House of Representatives Committee on Commerce. The Health Professions Education Partnerships Act of 1998 reauthorized the Council through September 30, 2002. Since then, the Council has been extended through successive annual appropriations governing the Department of Health and Human Services.(1)

Now, there is some history here.  In January 1994, COGME released its Fourth report, Improving Access to Health Care Through Physician Workforce Reform. In that report the authors took the position that the physician workforce was not meeting the needs of the US healthcare system and the public need. The report concluded that we needed more generalist physicians.  Their recommendation was that 50% of all graduates should enter practice as a generalist physician (Family Medicine, General Internal Medicine, and General Pediatrics). Their goal was to attain this by 2000. As we know that did not happen. In fact, it went the other direction.

But interestingly in their Sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000-2020 (2005), COGME reversed themselves and said that market forces should determine the proportion of students in an in specific specialty. The exact recommendation was: The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target.  Wow, what an amazing mistake that was.  Since that time, the proportion of students choosing family medicine and primary care in general has continued a downward trend. In 2008, the total proportion was down to 32%.  Clearly market forces are not working.

Dr Jerry Kruse, Chair of Family & Community medicine at Southern Illinois University who I wrote about in a recent blog was Chair of one of the writing groups for the COGME report.  According to Dr. Kruse, market forces didn't work because there is not a traditional supply and demand market in the US healthcare system. What we have is really a supply and supply market.  We have a virtually unlimited amount of care that can be delivered (whether it should be is a different discussion) and a funding pot that rewards doctors, hospitals, DME companies, etc for doing more (See Dr. Lin's post at the Common Sense Family Doctor). The rewards are financial and huge. So, the market is designed to reward doctors financially in specialties that do more technical and procedural things. (A more detailed discussion of this can be found in a recent post by Matthews and McGinty on the Wall Street Journal Health blog.) These are specialties such as, Radiology, Orthopaedic Surgery, Anesthesiology, and Dermatology. The "ROAD", as some medical students have taken to calling it.

Medical students are not stupid. They figured out that the financial rewards of practicing in the higher paid specialties were extraordinary. The median lifetime income gap between a student choosing primary care versus a specialty is 3.5 million dollars.(2) Currently, US primary care doctors earn about 55 percent of what specialists earn on average. When primary care doctors' salaries dropped as a proportion of specialists' salaries, interest in family medicine and other primary care areas also drop. The key number seems to be around 70 percent. If the income of primary care doctors as a proportion of the income of specialty physicians goes up then student interest goes up as well. The Altarum Institute estimates that increasing primary care income to 80 percent of specialty income would double medical student interest in primary care. This would increase the percentage of students choosing primary care to about 40 percent.(3) 

Canada had the same problem. From 1998 to 2004, they had a 25% drop in students choosing family medicine and it worried the Canadian health ministry.(4)  In a country that has universal coverage, it is vital that the primary care base is adequate. In Canada, they understand and believe that they need a specific number of family doctors in order to be able to take care of the populace. To address this national crisis (their words not mine) they invested in student interest by building up and supporting medical school family medicine interest groups (FMIG).  And they raised the salary of family physicians. They did not make family medicine and specialist salaries the same, but they raised the proportion to 87%.  By 2006, the median income of Canadian family physicians was $212,000 per year compared to the median annual specialty income of $245,000.(4)  That was enough. Interest started going back up. Medical students choosing family medicine has increased by 27 percent each year since 2004.

Why can't we do that in the US? There are so many reasons that I don't think I could even begin to cover them all but let me hit some of the highlights. We don't have a national universal coverage system.  Doctors are mostly self-employed or work for large healthcare organizations (like hospitals). The government does not directly decide how much doctors are paid.  (For more on this, read Dr. Freeman's post Outing the RUC: Medicare reimbursement and Primary Care) 

The most important reason is probably that we don't see this as a national crisis.  Most people think that we have the best healthcare system in the world. Unfortunately, the data does not support that. We have a mediocre healthcare system compared to the rest of the world by any measure. The primary care base is the key to the system. We need to and should adopt the COGME recommendations. If we don't have enough primary care doctors (translate=enough students choosing family medicine), the US population will be less healthy. There is no question. Our population will be less healthy, people will die prematurely, and it will cost more.(5)

References
(1) http://www.cogme.gov/whois.htm
(2) Wilder V, Dodoo MS, Phillips RL Jr, Teevan B, Bazemore AW, Petterson SM, Xierali I. Income disparities shape medical student specialty choice. Am Fam Physician. 2010 Sep 15;82(6):601
(3) Altarum Institute. (2009). Updates to BHPR phy­sician supply and requirements models. Presenta­tion to COGME, p. 15. Rockville, MD, from COGME 20th report
(4) Canadian Institute for Health Information. (2007, December 13). Physicians in Canada: Average Gross Fee-For-Service Payments, 2005-2006. Re­trieved May 11, 2010, from http://secure.cihi.ca/ cihiweb/products/FTE_APP_2005_Eng_final.pdf
(5) Phillips RL Jr, Bazemore AW.  Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010 May;29(5):806-10

Using interviews to select medical students

This is the fourth in a series of posts about entry of students into medical school. In the last post, I blogged about personality traits that may be better suited to being a medical student. Unfortunately, most schools in the US do not use personality profiles as a screen for incoming medical students.

At most schools, the closest that we come to this is the admissions interview. Many believe that a 30 minute interview is a good way to weed out bad apples. I am not sure that this is true. Just on the surface, it seems like an experienced interviewer may be able to identify highly dysfunctional people. By dysfunctional, I mean traits that would be obviously detrimental to their function as a physician. These obvious dysfunctional traits are things like: students who have difficulty talking to others, students who have flaws in their ethical approach to life, and students who have problems with their reasons for entering medical school. But what does the literature say?

Powis, et al (1) used a case-control design to study students who were admitted to medical school but did not graduate. They retrospectively analyzed 56 paired cases and controls. The cases were students who had left medical school due to failure or withdrawal, while the controls were students who had completed medical school. The controls were all students who had excelled in the their academic performance. The students who left medical school had all been rated lower at their admission interview. Effect sizes were statistically significant in the Overall rating (ES=2.17), self-confidence (ES=2.59), perseverance (ES=2.98), and tolerance of ambiguity (ES=1.04).

The Powis study used a objective and structured interview and they compared the students who left or were dismissed from medical school to those who received Honors in medical school. It is not clear that the admission interview would distinguish between failing students and anyone who would not fail. Admission interviewers have widely variable reliability. Powis found the inter-rater reliability varied from .23 to .63 for seven different qualities assessed by two faculty members. Other studies have found that reliability data is better for interview programs that use a structured interview process (.82 to .84) while with unstructured interviews the reliability is .61 to .75. (2)

So, reliability is not great, but seems to be better with more structure. Part of what provides structure is giving interviewers training and giving them types of questions to ask. But (and this is a big but)...I think that the interviewer has to be experienced as an interviewer. They have to be able to sort through the information presented by the student. They have to be willing to ask probing questions and be willing to make the student uncomfortable. Questions about ethical grounding or hypotheticals about decision-making are difficult. Interviewers can be blinded by other characteristics. Like MCAT scores．

For instance, I have heard interviewers say, well they didn't interview very well but they have great MCATs, so they will do fine. I am not kidding, I really heard a faculty member say that. And they were being serious! I know that is not supported by the data, but you still hear it a lot. The interviewer has to be experienced enough to ask tough questions. Not just, "tell me about your fraternity activities in college" but hard questions about ethics, hypotheticals, and dilemmas. They have to ask about motivation, why do they want to come to medical school. They have to get beyond the pat and prepared responses that students practice during their mock interviews and really push the student to get at internal motivations and thought processes.

And what about medical students? In my experience the medical students that we ask to interview are pretty good at sniffing out the bull. But their problem is that they feel so happy to actually be in medical school and almost finished (our interviewers are fourth year students) that they tend to be a little easy on the score sheets. Gutowski and colleagues,(3) looked at current medical student interviewers. They found that when compared to faculty interviewers, students wrote more about applicants' motivation, personality, communication skills, and interests. Student wrote more in the overall evaluation sections (p<0.001) and gave more examples on the motivation section (p<0.0011) and communication skills section (p<0.0035).

So, I guess the bottom line is that there is no easy way to figure out who are the right students to admit to medical school. We should push for multi-dimensional models that minimize the MCAT and utilize personality characteristics. We should ask the admissions committee (and the dean) to define what they think are the qualities and characteristics of the students that should matriculate to our medical school. And maybe most importantly the admissions committee should be held responsible for the results of their work.

References
(1) Powis DA, Neame FLB, Bristow T, Murphy LB. The Objective Structured Interview for Medical Student Selection. BMJ. 1988;296:765-768.
(2) Albanese M, et al. Assessing Personal Qualities in Medical School Admissions. Acad Med 2003;78:313–321.
(3) Gutowski CJ, et al. Current medical student interviewers add data to the evaluation of medical school applicants. Medical Education Online 2010;15:5245.

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