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