By Glenn Laffel, MD, PhD
Senior Vice President, Clinical Affairs
Practice Fusion

Not too long ago, it seemed safe and reasonable to define health information technology (HIT) narrowly as the management of health information and its secure exchange between patients, providers, and insurers.[1]

For many, the definition effectively compartmentalized HIT. It was for someone else, not me.

That began to change when quality initiatives started forcing physicians to deal with performance data and patients began showing up with reprints of journal articles they hadn’t read themselves.

But nothing could have prepared physicians to handle the flood of HIT that inundates them today, a flood that threatens to sweep away established codes of professional conduct and disrupt the very processes by which care is rendered and doctors communicate with patients.

Consider these examples:

1) Dr. Jain, a medical intern[2] receives a friend request on Facebook from Erica Baxter. As a medical student, Jain helped deliver Baxter’s baby. Is Baxter simply a grateful patient interested in sharing news about her child, or does she have other motives? Jain clicks “confirm,” granting Baxter access to his network of friends, his personal photographs and blog, and the scrawls of others on his wall.

2) Dr. Margolis, a middle-aged pulmonologist, receives 120 emails per day. The assortment reflects her busy life. There’s one from her child who needs a lift at 6:30. Her dentist has an opening for her prophylaxis, and her secretary just added a patient to her afternoon schedule.

And then there are emails from her patients, some of which require immediate attention.

Problem is, Dr. Margolis can’t read all her emails. She has a thousand unread messages in her inbox. She worries that some contain time-sensitive information from patients.

3) Dr. Tapscott, nearing the end of his career in family practice, is convinced by office personnel to adopt an electronic health record (EHR).

But the implementation goes poorly. He can’t get the hang of it and believes it puts a barrier between himself and his patients. Five months and $20,000 later, he ditches the system.

Physicians have faced emerging ethical challenges before. Their struggle to develop professional identities is as old as the profession itself. And this isn’t the first time they’ve have had to incorporate new innovations, but the HIT Deluge multiplies these challenges several fold, and creates myriad new ones, many of which remain vexing even to deep thinkers in the field.

The Impact of EHRs on Medical Education

EHRs are a prime example of this. They have begun an inevitable march into the lives of all physicians, stimulated by the American Recovery and Reinvestment Act, which allocated $21 billion to encourage “meaningful use” of such systems[3].

The Fed’s largesse is based on the premise that EHRs will improve quality and reduce the costs of care, but the move will impact the health care system in other ways as well. One such area is medical education.

What kind of impact can we expect? In some ways, EHRs appear to enhance medical education, but in others, the impact appears to be negative.

Benefits
Two studies suggest that EHRs improve documentation[4] by medical students. In the first, Morrow and Dobbie found that first-year students who used an EHR to document a history recorded more features of pain [5]than those using paper charts.

In another survey of third-year students, Rouf and Chumley showed that 72% reported asking more history questions when prompted by an EHR.

These authors also assert that EHRs make it easier for faculty to give feedback to students[6], track the procedures they perform and store records of interesting cases for future use.

Beyond this, EHR speeds access to the medical literature which should facilitate learning and encourage students to rely on medical evidence.

Risks
EHRs have some negative impact as well, particularly relating to the learning environment and patient-physician communication.

EHRs can disrupt the learning environment by creating shortcuts that threaten the time-honored process by which trainees synthesize patient’s symptoms, signs, and lab results into a coherent story and present them to senior clinicians for feedback and discussion.

One example of this is the process by which trainees copy and paste chart notes and other information created by others, and send them to supervisors for feedback. This discourages critical thinking by the trainee[7].

The potential negative impact of EHRs on physician-patient communication is particularly acute for medical students who are just finding their voices as professionals. Inserting a terminal into the middle of a student’s session with a patient adds complexity to the interaction, might reduce eye contact and stilt the conversation, and prevent her from seeing how her words and body language affect her patients.

Tweaking Medical Education to Leverage EHR Benefits

As these issues show, the quality-improving, cost-reducing benefits of EHRs can only be realized by aligning multiple systems and user-based factors. Educators can begin the alignment in three ways:

Begin EHR Education Early
The process should begin in Year 1. Non-science oriented courses like “Introduction to the Patient,” present ideal opportunities to introduce the medium.

If students master EHR skills before their clinical rotations, they can focus the latter time on traditional learning exercises, such as clinical reasoning, diagnosis and so on.

What to Teach
Students should be taught how to use basic EHR functions like order entry, lab look-up, messaging and charting. This exposure should occur away from patients so students can focus on the EHR itself.

They should also be exposed to the nuances of physician–patient communication in the presence of an EHR. Specific communication techniques include:

-        adjusting the spacing between patient, physician and computer so the patient can see what the physician is doing on the computer,

-        encouraging the physician to walk-through data on the screen with patients,

-        spending no more than 30 seconds at a time typing into the computer,

-        making eye contact with the patient; assessing the patient’s emotional status and understanding of the information provided

Don’t Forget Faculty
Most medical school faculty have received no EHR training, yet until they become facile, they can’t be good role models for students. This topic is beyond the scope of this article.

Social Media: Disruptive Force in Medicine

In medicine, social media including Facebook, Twitter, YouTube, blogs and virtual physician communities has grown explosively.

Enterprising providers have deployed sophisticated social media strategies to extend their brand around the world. The Mayo Clinic, for example, maintains several blogs[8], a Facebook fan page[9] (which has 8,800 fans), a library of YouTube videos and a Twitter stream[10] (7,120 followers)[11].

Many physicians also leverage social media to help patients access support networks, a heretofore difficult undertaking for homebound or geographically isolated patients, or those with rare diseases.[12]

But social media also creates challenges for physicians.

In some ways, the challenges are most acute for the youngest physicians, who grew up with Facebook. Unlike their counterparts, they are familiar with social media, but some have become ensnared by it.

Thousands of young physicians have created personal social histories and exposed them on Facebook. Their challenge is to manage this archive while forging identities as professionals.

A study by Thompson and colleagues the University of Florida sheds light on the challenge. They found that of the 44% of students at the UF Medical School who maintained Facebook profiles, only 37% made their entries private. More than half shared information regarding their sexual orientation, while 58% shared their relationship status and half shared political opinions.

A closer inspection of the profiles of 10 randomly-selected medical students revealed that 7 included photos showing them drinking alcohol. Five of these implied excessive drinking. Three students had joined groups that were flagrantly sexist (“Physicians looking for trophy wives in training”) or racially charged (“I should have gone to a blacker college”).[13]

The boundary-blurring effects of social media extend in every direction since medical students, nurses, housestaff, fellows and faculty are linked[14], and the chain is only as strong as its weakest link.

What has been done to mitigate risks associated with social media?

Many have issued warnings. “Caution is recommended,” wrote Jules Dienstag in an email to Harvard medical students. The Dean for Medical Education explained that when “using social networking sites such as Facebook…items that represent unprofessional behavior that are posted by you reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended consequences.”

Similarly, Drexel University College of Medicine warned students that information on social-networking sites can impact decision making regarding their applications to residency programs[15].

Warnings like these are analogous to a “Dangerous Rip-Currents” sign at the beach. By the time people read it, they have arrived in wet suits, having driven an hour to get there.

Some believe the challenges posed by social media are large enough to warrant promulgation of guidelines for its use in health care, modeled after AMIA’s “Guidelines for the Use of Electronic Mail with Patients” which were published just as providers began relying on that medium.[16]

Such an approach begs questions like who has the authority to issue such guidelines, or whether they could impact behavior without an associated means for enforcement. And since no one believes that social media utilization in healthcare should be regulated, the alternative is to modify medical school curricula and beef-up CME.

With social media, the genie is out of the bottle.

Innovations That Make a Difference

Even though EHRs and social media have had a large impact on medicine, it does not necessarily follow that medical education should be modified to account for them.

After all, thousands of technologies have disseminated into the mainstream; medicine accommodates them organically.

To some extent, this is happening with social media. In the Florida study of Facebook utilization for example[17], 64% of medical students were found to have fully public Facebook accounts, whereas only 12% of residents did.

It’s also true that finding space to teach HIT in a packed medical school curriculum means subtracting time from something else.

Still, we argue that the HIT Deluge presents unprecedented challenges to patient-physician communication and while blurring social boundaries in ways that generate ethical challenges and legal risks that cannot be ignored.

Medical schools including Harvard, Stanford, Vanderbilt and UCSF approach the conundrum by offering elective courses in HIT, often in conjunction with other graduate schools.

HST.921, “Information Technology in the Health Care System of the Future,”[18] is an example. The course is open to all graduate students at Harvard and MIT, including those at Harvard Medical School.

In it, students learn how HIT improves health care quality and provides new options for patient education and self-care.

Florida State University College of Medicine, one of the nation’s newest medical schools, has taken a more aggressive approach. Bypassing the above-mentioned incremental approach, its  Internet-age curriculum has HIT woven into its fabric.

FSU students receive laptops upon arrival. Their textbooks are on line. During orientation and first semester, they learn to access library resources on line and gain exposure to decision support tools.

In the second semester, they receive PDAs and learn how to carry out literature reviews and manage bibliographies on line.

In their fourth semester, FSU students learn to use SOAPware, a laptop-supportable EHR. During their third year, they use SOAPWare during supervised patient encounters and receive feedback from supervising physicians.

And what about all the physicians who graduated medical school years ago and have had no HIT education whatsoever? That’s where Russ Cucina, an associate medical director of IT at UCSF plays a vital role. Cucina, you see, teaches a CME class called, “Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs to Know.”

We hear it’s filling up fast.

[2] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[3] http://www.ehrbloggers.com/2009/07/meaningful-use-take-ii.html

[4] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[5] http://www.stfm.org/fmhub/fm2008/July/Heidi462.pdf

[6] http://www.biomedcentral.com/bmcmededuc/

[7] http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000069

[8] http://www.mayoclinic.org/blogs/index.html

[9] http://www.facebook.com/pages/Mayo-Clinic/7673082516

[10] http://twitter.com/mayoclinic

[11] http://www.informationweek.com/news/healthcare/patient/showArticle.jhtml?articleID=219200127

[12] http://www.nytimes.com/2009/06/11/health/11chen.html?_r=1

[13] http://news.ufl.edu/2008/07/10/facebook/

[14] http://content.nejm.org/cgi/content/full/361/7/649?ijkey=Tarf0DE9052Gc&keytype=ref&siteid=nejm

[15] ibid

[16] http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9452989

[17] http://news.ufl.edu/2008/07/10/facebook/

[18] http://www.hst921.org/home/

Glenn Laffel is Senior Vice President of Clinical Affairs for Practice Fusion.  Practice Fusion addresses the complexities and critical needs of today’s healthcare environment by providing a free, web-based Electronic Health Record (EHR) application to physicians.

Excerpted from

The rancor over how to reform America’s healthcare system rages on, as millions of uninsured and underinsured people struggle to find affordable medical care. Meanwhile, volunteer health professionals from across the country, like those at the Greater Milwaukee Free Clinic, do their best to put a bandage on a serious national wound.

Author Stephen J. Busalacchi highlights the work of internist George Schneider, MD, of Milwaukee, in his oral history, White Coat Wisdom: Extraordinary doctors talk about what they do, how they got there and why medicine is so much more than a job.

In this excerpt from the chapter titled, Sick, Huddled Masses, Dr. Schneider reveals that the vast majority of patients he sees at his free clinic twice per week are working people who can’t afford health insurance.

Visiting the Greater Milwaukee Free Clinic is like walking back in time. It’s as if it was preserved from the 1970s, even though this space had been a private practice doctor’s office until the early 1990s. The carpet is drab, the chairs are worn and the other furnishings are a mish-mash of donated stuff that fills the gap. Even the clock on the wall has a pharmaceutical company name emblazoned on it, as do other free supplies.

The office has “crappy file cabinets,” according to Dr. George Schneider, the medical director, but he’s grateful for them and all of the other donations, because they allow him to help people who are not getting medical care.

When you’re sick and have nowhere to go, you probably don’t give a damn about these frivolous details. Patients come here in droves twice a week to receive care from the dozens of physicians, nurses and others who volunteer their services.

Although the doors don’t open until five, Dr. Schneider says it’s not unusual to have somebody waiting at three. By the time the clinic opens, a crowd is huddled in front of the building.

Schneider, who founded the free clinic with his wife, Kathleen, in 1995, sees its popularity as a bellwether for the failings in our current health care system.

Dr. George Schneider, Medical Director, Milwaukee Free Clinic

Dr. Schneider:  Growing up, the idea of doing something charitable was something that went on in our family. My mother was from Northern Wisconsin, from a small farm in a small town, and it seemed to me there were always people coming to the house and staying for a while, who were moving from northern Wisconsin to the city. They heard about her. They stopped in, maybe had a meal. Maybe spent a few nights. I remember my mother giving things away.

“Here are some clothes. Here are some pots and pans and plates and pencils, to help get you started.”

My father was a garbage man who worked for the city of Milwaukee, but he also had an interest in real estate and had multiple duplexes in town. Some of his tenants were not always very timely in paying their rent, but he let them stay, as much as he could. He did not evict anybody. There was always that background in our house about doing things for people who were kind of down on their luck. The free clinic maybe was a natural evolution of that.

Last year, we saw about 1,930 patients. The volume has probably increased by about 25% a year over the last several years. Volume has increased over the past several years, compared to the first seven years of the clinic.

Does that worry you?

Yeah, it’s a concern because the very existence of free clinics is a reflection on the whole health care system. The system is breaking, and it’s broken in some areas. So yeah, it’s nice to say your numbers are going up, but not at the free clinic.

One of our original goals when we started back ten years ago was for the clinic to go out of business, but it doesn’t look like that’s going to happen anytime soon. We see more immigrants who come to the clinic. We see more working people whose employers are making them pay more of the premium and the cost is prohibitive. It’s basically, a question of fairness and justness.

The current model based on employment isn’t working. In my practice, I see people whose deductibles are going up. The employers are paying less and less their share of the premium, and so more of my patients are raising issues of cost and testing and primary care services, especially drugs.

Covering the uninsured is an issue society has to deal with. That number keeps rising every year, and society and politicians sort of dance around the issue and nobody really does anything. The uninsured, that’s not really a group of people anybody is looking to take care of and get their support and vote.

Single payer is really the way to go. Whether that’s national health or some other model, I don’t know. I don’t have enough knowledge to answer that question. I feel the current system with private insurance companies—that’s a very expensive system. The overhead is high. Their overhead runs anywhere from 15 to 20 percent. Medicare runs with three or four percent overhead. You could cover all the uninsured on savings from administrative costs.

Will it happen?

I think, slowly. The system is crashing, slowly, but inevitably. More and more people are complaining about it, everything from the uninsured poor to those who are working, who have insurance. The deductibles are higher, and the co-pays are higher.

The clinic’s open two nights per week. When we first started, we had one physician working. But because of the volume increase over the past two years, I’ve gone there pretty much two nights per week to work along with the regular physician of the night, and probably working three to three and a half hours a night.

The doors don’t open until five, but lots of times there’s somebody sitting out there at three. We have twenty chairs in the waiting room and they’re usually all filled. We start seeing patients around six and we leave when we’re done. An early night, we might get out by eight-thirty. Some nights we’re there until ten or eleven.

Who are these people who come to the free clinic?

The typical patient we see reflects my practice—an adult with hypertension, diabetes, smoking, bronchitis, or arthritis. It’s really the working poor. Our mission statement says that we see low-income, working, uninsured people—people who fall through the cracks, those that don’t have health insurance, but they make a little more money and they don’t quality for other programs.

We see a lot of people who work part-time jobs, who maybe earn $15,000 a year and live on that. Some of them work multiple part-time jobs. Some have full-time jobs, but they can’t afford the insurance that’s offered, or maybe insurance just isn’t offered.

Benefits aren’t provided for those who work for a temp agency. We see people who—and this is a situation we’ve become more aware of recently—who qualify for disability, and get on social security and disability, so that raises their income, which in turn, disqualifies them from participation in government programs because their income went up. We do see more and more people chronically unemployed, chronically not working.

I saw this patient who had lost his job and noticed some swelling in his abdomen. He went to another physician, and was told, based on the examination, that, “You have cancer. You’re going to be dead in two months.”  So this guy was just going downhill from already being down and depressed. We asked a few questions. Where were you? Who said this? He was a little vague, so we ordered the $800 x-ray.

He didn’t seem that ill, just very depressed. He was kind of getting ready to die. We did a CT scan of his abdomen, and there was nothing wrong with him. There was nothing wrong with him, so we told him that, gave him the good news. It kind of turned his life around. He was ready to cash in his chips and die. He never came back to the clinic, so I assume he went out and got a job.

How much satisfaction do you derive from this?

It’s a great feeling to see somebody who comes in who’s not feeling well, who’s not doing well, who is sick—and you’re able, with just an examination and some testing and interpretation of the results, to cheer them up, and get them feeling better. Yeah, it’s very satisfying. You get a real high from that.

They’re grateful, but we’ve noticed an attitude develop over the past few years, kind of an entitlement mentality. You give somebody something and they want more. That’s very discouraging for volunteers, and being at the free clinic it gives us a little freedom to say, “No, we don’t have it. That’s all you get.” Some people we’ve kind of told, “We don’t want you to come back here anymore. Go someplace else.” We might be free, but we’re not stupid. That’s just a small minority, but it only takes one a night to ruin the whole night for everybody.

We’ve fired patients from the clinic just because we don’t want one bad apple to ruin it for everybody else. The volunteers see that, and it typically happens with a new volunteer, and it’s easy to say, “I don’t need this. I’m not coming back here. These people are abusive. I could be doing other things.”

Is the demand going to keep increasing?

I think so, until something is done. In the United States, we have a wonderful health care system, but we don’t have a fair health care system. The resources aren’t going to the people that need them. You see the people who need it the most, but can’t get it because they don’t have insurance. It’s a fairness issue more than anything.

Stephen J. Busalacchi is author of White Coat Wisdom: Extraordinary doctors talk about what they do, how they got there and why medicine is so much more than a job www.whitecoatwisdom.com ©2009 Apollo’s Voice, LLC

For most residency applicants, the arrival of November marks the beginning of the interview season. This often brings back memories of the medical school admission interview, with the ubiquitous “Why do you want to be a doctor?” question.

Four years later, you find yourself in a similar situation – this time, hoping to land a position in the specialty and residency program of your choice. “Why do you want to be a doctor?” is now replaced with “Why do you want to go into [this specialty]?” and “Why are you interested in our residency program?” While the questions will differ to some extent, you may be experiencing the same gamut of emotions – uncertainty, nervousness, and perhaps even fear.

Given the highly evaluative nature of the interview process and its importance in the residency selection process, this anxiety is well-placed. Over the years, many surveys of program directors have inquired about the importance of the interview. Recently, the National Resident Match Program surveyed 1,840 program directors representing the nineteen largest specialties to determine the factors used for ranking applicants.¹ Ranked number one, even higher than clerkship grades and USMLE scores, was the residency interview. A number of previous studies substantiate this finding. In one study done at the Children’s Hospital of Pennsylvania, interview scores were found to be the most important tool for the ranking of applicants.² In a survey of family medicine and obstetrics/gynecology residency program directors, the residency interview was found to be most valuable in the ranking of applicants.³ Program directors of internal medicine residency programs have also rated the interview as most useful for ranking decisions, with 96% of respondents reporting the interview to be highly or moderately useful.⁴

While receiving an interview invitation is an honor, simply being interviewed does not guarantee a place on a program’s rank list. In a study of emergency medicine residency programs, with data obtained from 3,800 individual interviews, a total of 14% of interviews resulted in unranked applicants.⁵ In another study, one third of applicants were actually ranked less favorably following the interview.⁶ Dr. Reilly, former program director of the University of Texas medical school at Houston psychiatry residency program, states that a “good interview can save someone with the less than perfect application. A bad interview cannot always be salvaged by a paper record.”⁷ The conclusion here is that the interview is critical to your chances of a successful outcome.

Recognizing the importance of the interview, we have devoted four chapters and nearly fifty rules to the interview process in our book, The Successful Match: 200 Rules to Succeed in the Residency Match. In this column, we discuss three of the most important rules for interview success.

Dig deep

The primary goal of an interview is to impress upon the decision-makers that your unique qualifications are exactly what they seek.  Many decision-makers refer to this as “fit.” Will your strengths and aspirations help the program achieve its own goals? Are your proven qualities the type necessary to achieve success as a resident in their program? In order to convey this message, you need to know yourself, and you need to know the program, and you need to be able to convey this knowledge during the interview.

Conveying this message starts with demonstrating a strong and sincere interest in this particular residency program. One of the easiest ways to impress an interviewer is to arrive well prepared, having thoroughly researched the residency program. Start with the program’s website. What is the program’s philosophy? Is the program known to produce academicians? Is it recognized for its contributions to community service? Is research an area of key emphasis in the department? What is the program looking for in a resident?  With this knowledge in hand, you will be better prepared to demonstrate to the program that you are precisely the type of individual they seek. Equally important, the information that you gain will help you decide if this is a program where you would like to train.

While most applicants will review the program’s website, too often the research begins and ends there. We recommend that you dig deeper. Perform an internet search to learn more about the program, its faculty, the hospital, and the city. Well before your interview, contact graduates of your medical school who are residents or faculty at the program. Locate physicians in your area who trained at that program. These individuals can provide valuable information about the program, which you, in turn, can refer to during the interview. For example, “Dr. Ran, the chairman at my medical school, was recently a visiting professor in your department. In speaking with him, I learned about how your program really pioneered human simulation training as a teaching tool. I’ve been looking forward to learning more about that during this interview.” Candidates who make the effort to take these steps can convincingly demonstrate that they are truly interested in the program.

Many applicants do an excellent job in researching a program in advance. Unfortunately, many don’t know how to, or don’t feel comfortable, demonstrating this knowledge. They may end up making no reference to the specific information that they have read or learned about the program, or they may ask the type of basic questions that could have been asked by any other applicant.  The end result is a generic interview, and a lost opportunity to demonstrate your strong interest in the program.

First impressions can make or break you

Multiple studies have shown that creating a favorable first impression is critical to interview success.  In one study done by Thomas Dougherty, chair of business and economics at the University of Missouri, a favorable first impression led to an easier and more successful interview. Interviewers who are more favorably impressed by interviewees during the first few minutes went on to treat those applicants more positively. They spoke with a more positive vocal style, engaged in more active recruiting of the applicant, and asked less questions.⁸ Although this study was in another field, medical faculty interviewers are not unlike those in other fields. The impressions they form of you through your first interactions will play a pivotal role in your interview success, or lack thereof.

The obvious measures in managing first impressions remain critical. One should arrive early and be well-dressed and impeccably groomed. The ability to maintain appropriate eye contact and shake hands properly are little discussed in medicine, yet are no less important. One article in the Lancet found a strong correlation “between a firm handshake – as evidenced by strength, vigor, duration, completeness of grip, and eye contact – and a good first impression.”⁹ It is important to be able to walk into a room and project self-confidence through your body language, facial expressions, and tone. In addition, the ability to engage in small talk is more important than many applicants realize. Dr. Jamie Collings, program director of the emergency residency program at Northwestern University, states that “whether the topic is the weather, current events, or sports, you’re expected to participate.”¹⁰ She encourages applicants to get “up to date on current events, see a movie, read a non-medical book, and read the paper regularly.”

Dr. Ziegelstein, associate program director of the internal medicine residency at Johns Hopkins Bayview Medical Center, states that “individuals who interview and judge others for a living (e.g., program directors) often form very strong first impressions. Typically, those individuals are flexible and those impressions are changeable, but those first impressions are nevertheless important.”¹¹ In our experience helping applicants prepare for interviews, we know that applicants spend considerable time preparing for anticipated questions. Unfortunately, most applicants then give little or no thought to the factors involved in a favorable first impression. Preparing for the subjective factors involved in first impressions is just as important as preparing for the typical interview questions. If you’re uncomfortable with small talk, practice with others. Mock interviews with friends, colleagues, and mentors may highlight weaknesses, and are an important tool in interview preparation. Make sure you’ve received honest feedback on your interview performance.

Stand out from the rest of the crowd

You are competing with, perhaps, hundreds of other applicants. It is critical that you ask yourself “What is it that sets me apart from the other candidates?” Through our own experiences interviewing applicants, and through discussions we have had with other faculty interviewers, we know that few applicants make a concerted effort to stand out from the rest of the pack. We agree with Dr. Krogh, former faculty member of the department of family practice and community medicine at the University of Minnesota, who reminds applicants that “programs interview hundreds of applicants, many of whom are compatible with the program. Make yourself noticeable enough. How you do it is up to you but many unfortunately do not even try to do it.”¹²

We understand that you may not consider yourself unique. In fact, parts of your background and qualifications are likely to be similar to other applicants – good grades, solid USMLE score, and good medical school. Is there anything truly unique about this package? Not on the face of it. But there can be. Many applicants have remarkable accomplishments, but fail to recognize or discuss them. Others have unique strengths or particularly strong qualities that they fail to emphasize in their application materials and interview.

Did you have a fantastic overseas international health experience during medical school? Were you involved in cutting edge research? Do you have a special or unusual talent? Have you gone out of your way on clinical rotations to emphasize patient education and the provision of patient educational materials? Do you have an aptitude for teaching, and have you demonstrated that through your activities in medical school? Were you the founder of your medical school’s pathology club or the president of AMSA? If so, the interview represents a wonderful opportunity to highlight these accomplishments.

We’ve spoken to applicants who brainstorm, and don’t feel as though they can discuss anything remarkable or unique about themselves. While that’s hardly ever the case, you can still utilize additional ways to stand out. Impress your interviewers with your level of preparation. Showcase your strong communication skills. Answer each question by taking it one step further than most applicants. For example, applicants often answer the question “What are your strengths?” with a short list of qualities. “My strengths include my attention to detail, interpersonal skills, and ability to persevere.” Most applicants stop there. The few that continue with an example that highlights their strengths succeed in leaving a memorable impression. “My ability to persevere has been central to my success. The pathology interest club that I wanted to set up at my medical school was initially applauded, but my cofounder and I hit many obstacles. Even though I started during first year, the club didn’t come into existence until my third year, and it was my perseverance that kept me going and dealing with all the roadblocks.”

Asking insightful questions is yet another way to distinguish yourself. These can highlight your individual qualities, as well as your interest in the individual program. Dr. Ksiazek, program director of the Pritzker School of Medicine ophthalmology program at the University of Chicago, states that “You do not want to blend into a sea of other applicants by asking the same old questions.”¹³ As interviewers, we’ve all heard the typical “What do you consider to be the weaknesses of the program?” Contrast that with: “In medical school, I have had several international health experiences which I have found very fulfilling. That’s why I was particularly excited to learn about the global health track your residency offers in Kenya. What kind of impact has the global health track had on residents in your program?”

And finally…

As you approach your interviews, focus on how far you’ve come.  By offering you an interview, the program has essentially informed you that you are a competitive candidate. Given that programs routinely receive hundreds or even thousands of applications, an interview invitation is a real honor. Programs only extend these invitations to candidates who are being seriously considered for a residency position. Having come so far, it is essential now that you devote the effort, time, and preparation necessary to sell yourself effectively and convincingly to programs.

References

¹Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.  Accessed on October 26, 2009.

²SwansonWS, Harris MC, Master C, Gallagher PR, Maruo AE, Ludwig S. The impact of the interview in pediatric residency selection. Amb Pediatr 2005; 5 (4): 216-220.

³Taylor CA, Weinstein L, Mayhew HE. The process of resident selection: a view from the residency director’s desk. Obstet Gynecol 1995; 85 (2): 299-303.

⁴Adams LJ, Brandenburg S, Blake M. Factors influencing internal medicine program directors decisions about applicants. Acad Med 2000; 75: 542-543.

⁵Martin-Lee L, Park H, Overton DT. Does interview date affect match list position in the emergency medicine national residency matching program match? Acad Emerg Med 2000; 7 (9): 1022-1026.

⁶Gong H, Parker NH, Agar FA, Shank C. Influence of the interview on ranking in the residency selection process. Med Educ 1984; 18 (5): 366-369.

⁷Reilly E. Career counseling: psychiatry. Available at www.uth.tmc.edu/med/administration/student/ms4/2003CCC.htm.  Accessed October 22, 2008.

⁸Dougherty TW, Turban DB, Callender JC. Confirming first impressions in the employment interview: A field study of interviewer behavior. Journal of Applied Psychology 1994; 79: 659-665.

⁹Larkin M. Getting a grip on handshakes. Lancet 2000; 356: 227.

¹⁰Available at www.saem.org/…/0/…/MSS_CollingsTheInterview2009SAEM.doc.  Accessed on October 22, 2009.

¹¹Ziegelstein RC. “Rocking the match”: applying and getting into residency. J Natl Med Assoc. 2007; 99: 994-999.

¹²Krogh C, Vorheis C, Abbott G. The residency interview: advice from the interviewer. The New Physician 1984; 8.

¹³Ksiazek S, Taylor TL. Pritzker residency process guide: ophthalmology. Available at http://pritzker.uchicago.edu/current/students/ResidencyProcessGuide.pdf.  Accessed on October 22, 2009.

“Is there a doctor in the house?” is a Hollywood cliche.  But when it comes to the houses of the United States Congress, the answer is always “Yes.”  Physicians have served in every Congress from the first in 1789 through the current 111th Congress.(1)

Currently, there are 16 physicians who serve as members of Congress (1), 14 in the House of Representatives and two in the Senate (2). With health care reform a pressing issue currently facing the United States, several additional physicians are seeking election to Congress this year in races across the country (3).

Dr. Ami Bera

The Student Doctor Network recently spoke with physician candidate Ami Bera about what health care professionals bring as candidates, and what life is like on the campaign trail for a physician.

Dr. Ami Bera is a Clinical Professor of Medicine and former Associate Dean of Admissions at the UC Davis School of Medicine. He also served as former Chief Medical Officer for Sacramento County, CA where he directed SacAdvantage, a program providing access to care for 200,000 uninsured.

Tell me about the office that you seeking.

I am running for the Democratic nomination for the 3rd U.S. Congressional District in California. The seat is currently held by Republican Congressman Dan Lungren, who has served eight terms and is a former California attorney general. There are three candidates running in the Democratic primary so far: myself, Elk Grove City Councilman Gary Davis and Sacramento Municipal Utility District Director Bill Slaton.

What motivated you to enter the race?

Honestly, it was never a stated goal for me to run for elected office. But after I stepped down from my position as Associate Dean of Admissions at UC Davis, I found myself looking for a way to serve. In the past I have done service behind the podium and have been disappointed by the follow-up on important issues by our elected officials. I realized that I have a desire to change the political conversations we have been having: to move away from doing what is best for one’s polling and promotion to advancing some of the great work on issues that is done by those behind the scenes and at non-profits.

What steps did you take before entering the race?

The idea of entering this race first occurred to me last October. I decided that I would explore the idea instead of focusing on “why shouldn’t I do this.” I started by speaking with some friends who are in the state legislature. They told me I had a great resume on healthcare, and that my experience growing up in an immigrant family would make me a compelling candidate. But they encouraged me to run for city council first and to work my way up the political escalator.

I had no desire to be a career politician and when looking at the race from an intellectual perspective it seemed like the time was right for me to enter. This district is now 40% Republican and 38% Democratic. The demographics have shifted with an increase in minority voters and migration from the Bay Area. With approval ratings for elected officials at record lows and the focus on healthcare, this is the perfect election to run as a non-career politician and a physician. It is a potentially winnable race, an opportunity for me to change our political conversations, and to fix healthcare.

What is your day-to-day life like as a candidate?

After filing in April, the first phase in a campaign was to establish legitimacy. A sad reality of the U.S. political system is that legitimacy is measured by fundraising ability. Generally a day starts around 5:30 am with email and internet communication. I meet with people for coffee and lunch. It is essential to build relationships with potential donors. Also, we have focused on getting people engaged with the campaign and on collecting small donations of $5-$20.

This next quarter ends September 30 and we are still focused on fundraising. I am going to Washington, D.C. to meet with Democratic leaders and to build a buzz about the race.

We have been able to focus more on voter outreach through townhalls and house parties. In the evening I usually attend multiple events. I am working as hard as I did during residency and I do miss having some quiet evenings at home to relax. But I love what I am doing.

What do you love about being a candidate?

When I first started in the race I had to see if I enjoyed being a candidate. I very quickly found that I love it. Being a candidate and talking with voters is a lot like what we are trained to do as physicians. I listen to other people sharing their suffering, ask questions, listen, and reflect back to them. As a physician I am trained to engage with people in tough subjects and this has been an asset as a candidate, especially when discussing controversial topics that can inspire passionate responses in voters.

What have been the most rewarding and challenging aspects of the campaign so far?

It has been very rewarding to put my ideas out there and to see them resonate with people. I try to present my ideas in an authentic way and I want to understand where people in the community are coming from. I have found that by doing this communities have really let me into their lives. This has been a very humbling experience.

The greatest challenge with campaigning is that it involves a lot of talking about myself. I know I have a healthy ego, but I always want it to be less about myself and more about the voters. So I try to find a balance by focusing on my values, telling my story, and presenting the stories of other people I meet. It has been hard because I am not a “sound bite” guy. How do you focus on a topic as complex as healthcare reform in a sound bite? But I have focused on stories and hope that they will stick better than sound bites.

How has being a candidate affected your work as a physician and educator at UC Davis?

I took a leave of absence from UC Davis at the end of June to focus on the race. The medical school has been supportive but as an apolitical organization, they cannot overtly support me.

The students are mostly aware that I am running. I would love to get the students more engaged in the race because I think it is a unique opportunity. But I am very conscious not to push myself on them. I will be teaching periodically, but am largely removing myself from the medical school’s daily activities.

How have your wife and daughter responded to your candidacy?

When I first verbalized my idea to run this past December and January, Janine, my wife, was in disbelief. But after she realized I was serious, she raised questions about how it would impact our family. Would we have to move to Washington, D.C.? To split time between two locations? She did not embrace it at first, but as she has seen it unfold she is in it with me to win. Janine is my best asset and I expect that as we get busier she will represent the campaign at events.

My daughter just started 7th grade, so she does not fully grasp the implications of my candidacy yet. As we get further along we will have lots to talk about and some big decisions to make if I win. In the end I am most concerned about being authentic and running as hard as I can. If I do that and I lose, it is okay. But I am not willing to compromise my self, my values, or my family to win.

Have you always had an interest in politics?

Most of the people in my life who have known me well are not surprised that I am running. I have always been engaged in politics, mostly focused on the politics of change and how to move forward on issues that I care about. My mom would say that I was a pain as a child, always questioning and exploring new ways of doing things. I was very fortunate to grow up in a family that allowed exploration and offered safety and support whenever I fell down.

How have the positions that you have held in the past helped to prepare you for elected office?

My experiences as a physician have given me perspective on all aspects of healthcare delivery. My life has unfolded unexpectedly and I have taken opportunities as they have presented themselves. As chief resident I realized I was interested in working on systems issues. After residency I spent four years in practice at the county medical clinic and as the medical director of care management for the five hospital Mercy system. This experience allowed me to focus on systems issues and way to increase efficiency in care delivery.

I then served as the Chief Medical Officer for Sacramento County and worked on ways to increase coverage for the uninsured. I was then offered the opportunity to look at how we train the next generation of physicians by serving as the Associate Dean of Admissions at the UC Davis School of Medicine. While I never planned to set up these experiences, they have built upon each other and given me a very unique perspective on healthcare.

Tell me more about the program you started to increase coverage for the uninsured.

Using two million dollars from the county and one million from the federal government, we created a program called SacAdvantage that targeted low wage workers and small businesses with two to fifty employees that had not previously offered health insurance. It was built on the employer-based model of care and provided a subsidy from the county to make it affordable for small businesses to cover their employees.

The main problem I see with it now is that it still ties coverage to employers and people could lose coverage if they moved to another state or changed jobs. I now favor offering all Americans a compassionate baseline of health care that is not tied to employers. Additional coverage could then be provided by employers or purchased by individuals.

What do you see health professionals being able to bring to elected office?

All of the training that we have will help us in politics. What makes a good doctor—having compassion, good listening ability, the ability to make hard decisions quickly, and leadership skills—are all essential in politics. As physicians we have a particular ability to articulate the story of healthcare in this country. If voters ask me about “death panels” at a townhall I can tell them about what happens in the ICU regarding end-of-life issues. I find it embarrassing how silent physicians are given that we are held in high esteem by many. As a group physicians need to step up to the plate on healthcare.

If health professional students have interests in politics what do you advise they do to pursue a career in this realm?

I think it is most important for students to discover their passions and what is most important to them. Too often students look decades into the future and try to plan out every step of their career. But it is better to focus on the present than to try to be calculating. Look at what you are passionate about today and work on issues within your sphere of influence, for example resident work hours. It takes courage to address these issues and the skills you build will help if you choose to run for office later. You will learn by doing.

It is also important to know your strengths and weaknesses. Embrace your flaws and your ignorance. That way you will know when to delegate tasks and to let others with greater knowledge take over for you.

How can health professionals with limited time get involved in politics?

I would advise that they find a local organization that does work on an issue that they really care about. Focus on finding one project that can be done to really make an impact. The skills that one builds working at the local level are the same ones that are used in elected office. In politics there is just a bigger stage.

References

1. “Doctors on Hill seek voice in reform debate”, June 15, 2009, AMEDNEWS.com, http://www.ama-assn.org/amednews/200…5/gvl20615.htm

2. http://www.ama-assn.org/amednews/200…3/gvsa0223.htm

3. http://www.beraforcongress.com/, http://www.trivediforcongress.com/, http://www.jayfleitman.com/,  http://wargotzforussenate.org/

Dr. William James

By Samir P. Desai, M.D., and Rajani Katta, M.D.
Authors of The Successful Match: 200 Rules to Succeed in the Residency Match and
250 Biggest Mistakes 3rd Year Medical Students Make And How To Avoid Them

As the Paul Gross Professor and Vice Chair of the Department of Dermatology at the University of Pennsylvania, Dr. William James directs the dermatology residency program at the University of Pennsylvania, which recently was found to be the highest ranked academic dermatology department in the United States.¹

He is widely regarded as an outstanding clinician, teacher, and researcher, having received numerous honors and awards. He has published over 200 peer-reviewed publications, served as the editor-in-chief emeritus of the emedicine dermatology section, and been on a variety of national committees.  We recently had the opportunity to speak with him about the dermatology residency selection process.

In a recent survey of dermatology residency program directors, 87% of programs cited a letter of recommendation from the department chair as an important factor in selecting applicants to interview.²  How can students interact and work with the chair in such a way that the chair is able to write a productive and meaningful letter?

First of all, the Chair is certainly a great person to be able to work with and get a letter from. In many circumstances, though, that’s not going to be the person who is most involved with students, especially depending on the size of the program. Your letter doesn’t necessarily need to be from the Chair. It could be from one of the academic dermatologists in the program, either the Program Director or one of the faculty members.

It should be from someone with whom you’ve worked and who knows you in some meaningful way. That would usually mean at least working in a clinic with the letter-writer. Specifically, not just observing in clinic but actually interacting with patients and discussing diseases. It may involve rounding with the inpatient team and presenting patients in follow-up. It could be writing or participating in a project, such as a clinical project or a case report. There should be some meaningful interaction. There needs to be information about how the applicant works, what kind of ideas they have, and how they interact with patients and the team. That really is the key: being able to get to know your letter-writer long enough so that they can take examples and then detail how an applicant would be a good person to have in the residency program. For the people reading the letters, they’re going to be looking for some meaningful pieces of information that is based on personal observation.

Audition electives have been found to be very important in the dermatology residency selection process.³ What sets apart students who shine during these rotations from those that are average?

First of all, enthusiasm. There are students, believe it or not, who show up and look a little bored. I think enthusiasm for the work and the subject is very important. The way students interact with others is certainly a key. You can have all the brains in the world, but if you can’t get along with people, that doesn’t say much for your ability to work on a team or work with patients. Sometimes students can be a little too aggressive in their interactions, probably because they’re trying to either come across as enthusiastic or they’re trying to show off their smarts. There is a fine line regarding what is appropriate for the level of training. At the same time, I think faculty members do take into account that students are trying to make a good impression, so I think there is some leeway there.

Hopefully, there will be opportunities to demonstrate their knowledge base or get involved with a project. If you find that the dermatologists are getting excited about a case and saying “I haven’t seen this before” or “I don’t really know what is a good treatment for this condition; let’s go look it up”, this would a great opportunity for the student to follow up by reporting ”This is a case that I learned something from; I looked it up, I thought about it, and I’d like to pursue it a little further.”  

Dr. Miller, who is Vice Chair of Clinical and Educational Affairs in the department of dermatology at Penn State College of Medicine, has encouraged applicants to make their personal statement unique.⁴ Too often, he has read statements where an applicant writes about “being a visual person” or is drawn to the specialty because of the “ability to do procedures.” Having read thousands of statements, what advice can you offer for the dermatology applicant seeking to create a unique statement?

I think the main point is that this can’t be a recitation of what’s already in other parts of the application. I’ll get to the positive side, but one of the main things that bothers me with personal statements is reading about that first I did this, and then I did that, and I wrote this paper, and I did this research, and I published it in this journal, and I did this volunteer work. It’s all in the CV already and the whole statement becomes “I, I, I.”

But while the personal statement is just that – personal – if it’s all going to be about delineating accomplishments that are covered in other places, then that simply isn’t helpful. What is helpful is to draw a picture of yourself that can’t be obtained from anywhere else in the application. It should be personal – this is who you are, this is what makes you excited, these are your special interests. Sometimes it may be outside of medicine, sometimes it may be a volunteer experience that is expanded upon, or it could be a personal connection that stimulated the applicant to want to do something more, such as a specific part of Dermatology down the line. You might express your future goal, as that is something that wouldn’t be revealed in other parts of the application.  

It certainly has to be sincere. If everyone just says at the end of their statement “I want to be an academic dermatologist” and there’s nothing else in the application that tells a reason for this, it’s not believable. It would help if you can describe your personal background and bring in information about your life that isn’t available in other places, and then transfer that into a future plan.

Overall, your statement has got to be personal, sincere, and bring out information not available in other places.

Students recognize the importance of research in the dermatology residency selection process and hope to participate and, perhaps, become published in the field.  Although there are over 100 dermatology residency programs in the United States, some programs are more prolific than others in terms of scholarly activity. For example, between 2001 and 2004, your program produced 318 publications, placing it among the top dermatology programs in the country.¹ What recommendations do you have for students who wish to do research but are either at schools lacking a dermatology residency program or for those whose dermatology department focus is largely clinical?

I would expand the idea of research. If a student doesn’t have any background in laboratory-based basic science research, then they could work in a lab to see what it’s like. However, most of the time people that don’t have that type of background, and don’t have advanced degrees, are not going to end up in that situation.

Most of the time, students are going to be looking for more of a clinical-based project. Protocol-based projects and clinical research do require a fair amount of time in order to get things off the ground and move through the process. For the person that you’re describing, they could get involved with a review article, a case report, or a small case series. Other possibilities could be a review of charts or a review of pathologic specimens. With that type of background, these are the types of projects that such a student would be both capable of and interested in, and would make the most sense for their background.

There is a growing shortage of academic dermatologists with fewer residents pursuing a career in academics.⁵ Years ago, your program developed the unique Dermatology Fellowship for Academic Clinician-Teachers, with the goal being “to develop future leaders in dermatology who will attain positions such as residency program directors, professors in clinician-educator tracts, and departmental chairman.”⁶ As a lifelong academician, what are some misconceptions that students have about academic dermatology?

Students are, of course, being taught in an academic setting, and depending upon the people they’re exposed to, some may tend to see the bright side of things, while others will focus on a less attractive side. There are pluses for academic Dermatology and pluses for private practice, but there are also negatives for both. If someone is more negative they may assume that “since this is what academic medicine is about, private practice must be better.” However, they don’t have the knowledge base about what actually goes on in private practice, and they don’t know the negative aspects.  In other words, they think it’s greener on the other side of the fence, but they don’t really look on that other side to see what’s there.

I think that some of the misconceptions are that academicians don’t make such a good living – but I don’t really know any academic dermatologists that are living out of their car.  I think we make a better living than 99% of the citizenship in the United States, so I think that that’s underappreciated. 

I sometimes hear things like “there’s too much politics in academics” and I can’t say I don’t understand, but personally I think it’s an overstatement. In my opinion, it’s all about interactions with others, and if you have good interaction skills, then you’ll do fine.

Certainly there are concerns about independence and the size of organizations, or what some people might call bureaucracy. I think that you have to be able to operate in a larger setting. If you are someone who is an entrepreneur and wants to be in charge all the time, then you probably aren’t built to go into academics.  But if you are more able to accept some bureaucracy, then certainly in exchange for that you get a lot of infrastructure. You have a lot of the business side of medicine that you don’t have to deal with, and in return you can concentrate on patients.  In private practice, you’re responsible for hiring and firing, balancing the books, and complying with the regulatory requirements. Private practitioners are small business operators and good business sense is necessary.

You have to be self-aware of what kind of arena your personality would best operate in, and in the end that’s something you are going to have to figure out for yourself.

Dermatology residency programs routinely receive hundreds of applications for just a few positions. As the years have passed, the academic credentials of applicants have become more impressive. In the 2007 Match, 47% of U.S. seniors who matched were members of AOA and the mean USMLE Step 1 score was 238.⁷ While strong credentials are certainly important to secure interviews, it is the interview that ultimately makes the difference. What advice can you offer students as they prepare for interviews? 

One of the things I find is that people tend to want to downplay what they have done. If it’s done out of modesty, that’s fine, but I think there are people that have a pretty darn good record, and unfortunately they say things like “Well, my boards could have been better, but you know I had this happen in my personal life.” Basically, they’re apologizing. They may have gotten 80% honors grades and yet they’re apologizing for this one rotation that they didn’t honor, and trying to come up with a reason or excuse. That’s just not a good way to approach an interview.

The way to approach an interview is to be self-confident and to accentuate the positives. They’re clearly there, because if you’re interviewing for a program, you must have a lot of positives. We don’t just interview anybody. You’ve got a good record, so you want to go in and be self-confident about that. You want to look good, and you want to come in sharp and enthusiastic. 

You should also treat everybody well. Some applicants will bow down before the Chair and then are rude to the residency program coordinator. That’s just not a good practice. I also think there’s something to be said for a practice interview if you’re nervous.

Ultimately, you want to be honest and open during your interview.

In 2007, out of 407 U.S. seniors applying to dermatology, 158 failed to match (39% of U.S. senior applicants).⁷ Applicants who fail to match often wish to reapply the following year. What can these applicants do to strengthen their application?

There are certainly a number of dermatology fellowships out there. It’s been documented that applicants who complete these fellowships have a higher match rate the second time around. I think that’s probably because you get to know the director well, and since they know how you work and how you produce results, they can write you a better letter of recommendation. I’ve also seen some individuals plan to do degree-producing programs, such as a Masters of Public Health, or a program with a focus in biostatistics or epidemiology.

There are certain objective measures that can’t be changed. You can’t change the Dean’s letter, you can’t change your board scores, and you can’t be AOA the second time around. However, you can publish and get new letters of recommendation. These are ways to strengthen your application.

Some applicants who fail to match pursue a pre-residency dermatology fellowship. In a recent survey of fellowship directors, it was learned that 92% of past fellows (176/190) were able to match successfully following completion of the fellowship.⁸  How can applicants make the most of these fellowships?

Most of these fellowships are directed by individuals that are fairly well-known in their specialty. A letter of recommendation from a faculty member that spent months, or sometimes a year, with an applicant is a very valuable resource. That’s going to be more information than the prior application, and the letter writer is able to be very rich in their detail about what supports the positive things that they say about the applicant. We look very closely at that.

Many fellowships are directed by some very productive members of our specialty. If the director is known for publishing, putting abstracts in meetings, and making headway in addressing different questions, then it’s expected that the applicant will have participated in those results.

There may be interview questions such as “why do you think you didn’t match?” There are certainly applicants who don’t match who have fantastic records, and for some reason they just didn’t make it. There may be cases where you cannot say that’s the reason I didn’t get in. But if there were an item or items that weren’t so good, then you have to plan to address those. You can’t change those items, but another way to address prior performance is to demonstrate in a more current job that you can do the work, and you can do it well.

References

¹Wu JJ, Ramirez CC, Alonso CA, Berman B, Tyring SK. Ranking the dermatology programs based on measurements of academic achievement. Dermatol Online J 2007; 13(3): 3.

²Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.   Accessed June 12, 2009.

³Clarke JT, Miller JJ, Sceppa J, Goldsmith LA, Long E. Success in the dermatology resident match in 2003: perceptions and importance of home institutions and away rotations. Arch Dermatol 2006; 142(7): 930-2.

⁴Miller J, Miller OF 3^rd, Freedberg I. Dear dermatology applicant. Arch Dermatol 2004; 140(7): 884.

⁵Resneck, J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol 2004; 50: 50-4.

⁶Available at the University of Pennsylvania Department of Dermatology website (http://www.uphs.upenn.edu/dermatol/education/clinician-educator.html).  Accessed on June 12, 2009.

⁷Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 National Resident Matching Program main residency match (2^nd edition). Available at http://www.nrmp.org/data/chartingoutcomes2007.pdf.  Accessed June 12, 2009.

⁸Wasong SH, Miller JJ, Zaenglein AL. Does a predermatology fellowship increase the chance to match in dermatology? J Am Acad Dermatol 2008; 59(3): 535-6.

Treating a pediatric patient at a mission clinic in Albania (courtesy Joel Mundall)

“In Africa, we wash and re-use the gloves,” said one of our resident physicians who was doing clinic procedures with me.

When he graduates from our Family Medicine Residency Program at Loma Linda University, he is planning to work in the mission field in Africa where he spent time as a medical student. We had been discussing principles of “universal precautions” and discussing the use of medical gloves.

I looked at him as he was wistfully staring at the boxes of gloves that line the exam rooms in our Family Medicine clinic at Loma Linda University in California. Gloves that are ubiquitous here in the United States are so precious in the mission field. I remembered seeing mission photos, from our doctors who went to Africa and Papua New Guinea, showing gloves drying on clotheslines ready to be re-used. All day, I thought about medical gloves and the hands that wear them, the hands that are extensions of the doctors we are training to care for patients in the United States and around the world.

At Loma Linda University School of Medicine, students are encouraged to take elective rotations at mission hospitals and clinics around the world. The program, called Students for International Mission Service (SIMS) exemplifies the university’s commitment to global service. It empowers students to become compassionate, socially responsible health professionals and helps to promote the health of global communities. SIMS offers students opportunities to do mission work of various lengths. There are weekend interdisciplinary trips to mission clinics in Mexico and longer trips to various other countries. Students can also participate in an International Service Learning program (I-Serve) in which they do a month long observational or hands on clinical experience at a mission hospital. There is funding available through the Dean’s office to help defray travel costs. The students are usually housed at the mission site.

Mother with newborn at clinic in Nigeria (courtesy Joel Mundall)

Resident physicians at Loma Linda University (LLU) are also encouraged to do a mission elective either domestically or overseas. Some of our residents have recently returned from mission work in Malawi, Mexico and Nepal.

When resident physicians (at our institution or other institutions) plan an elective rotation, they must consider if their salary, malpractice insurance and benefits such as health insurance will carry over during their elective. At LLU, residents can choose from the “big book” of approved mission clinics around the world which will allow their salary and benefits to be uninterrupted.

Resident physicians and other health professionals often face the dilemma that they want to enter mission service but they are concerned about how to pay their student loans. For non–medical students who wish to serve in the mission field, they can apply for the Global Service Scholarship Program (administered by the Loma Linda University Global Health Institute in conjunction with SIMS) and they can get their student loan indebtedness amortized while they volunteer in an international setting.

At Loma Linda University Family Medicine Residency Program, several of our residents have chosen to participate in the Deferred Mission Appointment (DMA) Program. This program enables medical or dental students to work in overseas mission service with financial stability. During medical school they receive a stipend to cover room and board. After graduation they are placed in one of the Seventh–day Adventist Church’s many health care organizations world wide. In the DMA program, they receive a salary and competitive benefits such as health insurance, licensure fees, one month furlough (vacation time) plus continuing medical education time each year, and a percentage of their student loan indebtedness is amortized each year they serve in the mission field.

“The DMA program was an obvious choice because it makes it possible to work internationally without any delays after residency for repaying my loans,” said Dr. Joel Mundall. “Without this program, if I were to try to work for a little while to repay my loans before going, I would be at risk for never leaving this country or going where God wants me to be.”

The mission hospital in Nepal (courtesy Aaron Sartin)

Most of our residents will serve a six year term in the mission field and they may choose to stay on afterwards. At their mission site, they staff medical clinics or possibly a hospital and train indigenous people to provide health care services. This program is administered by the World headquarters of the Seventh-day Adventist Church in Silver Spring, Maryland.

As Dr. Aaron Sartin, a third-year resident in the DMA program explained: “A large barrier to doing mission service after residency is the enormous medical school debt, which grows exponentially after years of in-school and residency deferments. That barrier is removed with this program as the medical school debt is amortized over a six year mission term overseas. At the time I signed up for the program it seemed like seven years was so far away and would seemingly never arrive. Now in my third year and last year of residency in Family Medicine this reality is less than a year away.”

Although our residents in the DMA program may be placed around the world, most of them will be heading to Asia or Africa. They can request their first choice but they will not know until they complete their residency where they will be going.

“Recently, my wife and I returned from a three week mission elective to Nepal where we witnessed first hand the poverty and great need (physical, emotional and spiritual) as well as the beauty of the people,” continued Dr. Sartin. “We were awakened as never before to how blessed we are in the United States and reminded of our responsibility to use these gifts to be a blessing to others, both here and abroad. Where will we end up? That remains to be seen but as a Christian physician I am confident that God will direct us to the right mission field.”

As I put on my gloves for the next procedure, I couldn’t help but wonder where the skills I was teaching my residents would be used to provide health care around the world.

For more information, access http://www.llu.edu.

Jessica Freedman, MD

By Jessica Freedman, MD
President of MedEdits

Your son or daughter wants to get into medical school. Of course, you want to help, but how? Many parents, including those who are physicians themselves, are overwhelmed by the medical school application process. They want to guide their young adult children but also want to allow their “kids” to work independently and don’t want to do too much hand holding.

So, what do you, as parents, need to know about the medical school admissions process to help your premedical student to succeed? This article reviews some basic material to help parents and their children make wise choices that will help them to gain acceptance to medical school.

Know the facts, but try not to add more pressure to the cooker

It is important for parents to know what is required of their children to gain admission to medical school. This means knowing the premedical prerequisites and the activities in which students should be involved. But it also means understanding how to help without adding more stress.

Achieving this balance often depends on the relationship between parent and child. It is essential, however, that parents understand that their children are young adults who will someday soon be required to make independent (and very important) decisions. Since a career in medicine requires maturity and independent thought and decision making, parents should encourage these qualities while remaining involved in their children’s lives.

Consider carefully what college to attend

Many premedical parents ask me where their child should attend college. The most common question is: “Should my child attend a prestigious college where ‘As’ are more difficult to earn or go to a college or university that is considered less prestigious but where high grades may be easier to earn?” The answer to this question is not easy.

What is most important with regard to medical school admissions is academics. A high GPA (3.9) and a strong MCAT score (above 30 with a good distribution) are the most important factors for an application to be considered for review by an admissions committee. I have seen people who went to outstanding colleges but earned 3.3s or so who had difficulty gaining admission to medical school. Thus, students with similar MCAT scores but with higher GPAs from less prestigious undergraduate colleges may receive more interviews (and thus more acceptances) than the student who went to a top ranked college but had a lower GPA.

Help your child choose best major and courses for them

The emphasis in medical school admissions now is diversity. So, beyond the basic premedical prerequisites, students should major in what interests them most. Majoring in something other than biology or chemistry would be looked upon favorably by admissions committee members. It is always wise, however, to take upper level science classes regardless of the student’s major to demonstrate academic excellence in the sciences. I also suggest that all premedical students take biochemistry and, if possible, statistics; Medical schools like to see these courses on transcripts.

Think about the activities in which your premedical student should participate

Just as with their courses, students should become involved in activities that motivate and interest them. While everyone knows that medical schools “like to see” research, community service, and teaching, first and foremost, all applicants must have clinical and shadowing experiences. Also important is that students do not become involved in extracurricular activities at the expense of their academic success and that they do not accumulate a list of activities just for the sake of doing so. In-depth involvement is preferred over a long list of superficial activities and will likely lead to stronger letters of reference.

Put together a good “team” to help your son/daughter gain admission to medical school

This team should consist of professors, mentors, extracurricular leaders and premedical advisors. Remember that you cannot be everything to your child and that having other people to provide support and guidance throughout this process is helpful. I find that many “kids” like to have other objective authority figures to help advise them.

Think seriously about some time away from formal academics

Many applicants now take a year away from formal academics before going to medical school and apply during the spring of the senior year rather than the spring of junior year.  Some parents are uncomfortable with this idea, but it can be difficult for students to get “all of their ducks in a row” in time to submit a successful application at the end of their junior year of college. Applying in the senior year also allows applicants to have an extra year of grades on their transcript, which can be important for many applicants whose grade point average (GPA) tends to trend upward from the freshman to senior year. I find that some applicants who are not successful the first time they apply often fail because they and their parents did not understand how much work and organization is required for a successful medical school application.

Understand that the medical school application process is long!

As parents, it is important to understand that the process of applying to medical school requires a tremendous amount of endurance and perseverance. Many parents of my clients who are physicians lament: “It wasn’t this complicated when I applied!” Indeed, as medical school admissions have become more competitive, the process has become more laborious and expensive.

The application season officially begins when the student starts thinking about composing and submitting his or her primary application in June. But, students must also take all required courses and the MCAT and request letters of reference and transcripts in addition to composing an excellent application. Then, after the primary application is submitted, students must fill out secondary application essays for many schools and go on interviews. Some applicants may not know what school they will attend until they “get off a waitlist” in August. Thus, the application season may last for more than a full year.

Medical school applicants tend to be a highly motivated group who hold themselves to high standards. Sometimes, in an effort to make sure their kids stay on track, parents ask questions constantly, do GPA calculations, plan curriculums and seek out summer activities that will bolster their child’s application. There is a fine line between helping and hovering, and I find that this added pressure can sometimes backfire.  The premedical race requires agility and careful judgment, and parents play an important role in helping premedical students to reach the finish line.

Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).

Dr. Al Berg

by William Burnett

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding that science is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health. 

Dr. Conrad Fischer

Despite the growing number of scientific advances over recent years, the ability of doctors to cure or deal with diseases that were fatal not ten years ago, and heightened recognition by patients for those in the medical profession, a study conducted by Dr. Conrad Fischer suggested that many in the medical field were highly dissatisfied with their careers. Armed with these alarming results, Dr. Fischer set out to let everyone know that now is an exciting era in medical history and, quite possibly, the best time to be in medicine. The result is his book, Routine Miracles.

Dr. Conrad Fischer, author of Routine Miracles, is an infectious diseases specialist and a prolific teacher of medicine; he has published twelve books for the medical community. He is also an influential medical advocate. He was instrumental in the construction and passage of legislation that led to the near eradication of pediatric AIDS in the United States. He was formerly the Associate Chief of Medicine for Educational and Academic Activities at SUNY Downstate School of Medicine. He has been Chairman of Medicine for Kaplan Medical since 1999, and has held Residency Program Director positions at both Maimonides Medical Center and Flushing Hospital in New York City. He lives in New York City with his two boys.

Dr. Fischer recently sat down to talk to the Student Doctor Network about his research.

Please explain a little about your research for Routine Miracles and what surprised you the most?

There is an enormous disconnect between patients who feel the “miraculous” nature of what they receive in terms of treatments and a near-numb “routineness” of flat emotionality from doctors.  I can’t help but feel the root of the problem stems from our own medical school faculty and senior physicians poisoning the minds of medical students.  In our own research data it shows that 80% of medical students feel that medicine was better 25 years ago and that the public does not trust them. They identify senior physicians and faculty as the source of this impression. So, our best role models for a life of practicing medicine, and pursuing a life of investigation turn out to be the most damaging influence of all.

Why is this the best time to be practicing medicine and why is it the worst time?

Treatment is the best it has ever been by far.  We now have brain operated artificial limbs, hearing restoration, cancer cures, corneal transplants in four minutes, and cures that seemed like science fiction a few years ago.  It is hard to write good science fiction because the facts catch up so fast. Paradoxically, a recent study showed that more than 90% of primary care doctors are dissatisfied.  There is an unprecedented level of demoralization at a time when we can heal people in so many amazing new ways.  The worst news is that our freshest and newest members, students, interns and residents firmly believe medicine was better before and we are devolving as a profession.  They are not motivated to follow a life of investigation that will give us the next generation of scientific and medical breakthroughs.

You work with students every week. How are they different from you and your colleagues 20 years ago?

Students and especially residents are less cynical, less sarcastic and more professional than they were 20 years ago.  This is because of the mandatory decrease in resident work hours. You couldn’t possibly expect the same energy and compassion when you were up for 36 hours straight.  Now residents rest a little and you are kinder, warmer, and not burnt out and cynical.  Most MDs do not see this.  They look down on new students telling them it was better before.

Students on the other hand seem more concerned with personal economic issues.  They think the sky is falling in medicine, so they should find a nice high paying subspecialty to hide in.  There is virtually NO drive to consider careers of investigation that might lead to new cures.  So, you have nicer and kinder people taking care of patients, but who rarely question how they might find a cure.  In 20 years I predict the rate of medical advancement will be dramatically diminished.

In your opinion what three things need to happen quickly to help fix our healthcare system?

1. Universal coverage
2. Doubling of the research budget at National Institutes of Health
3. Decrease or supplement the cost of Medical education so that students choose a future that is not based on income potential or concerns about paying off student loans.

Why are you such a fervent advocate of universal health insurance coverage for all U.S. citizens?  How do you respond to arguments against—and fears surrounding—implementing a system of socialized medicine?

First off, universal coverage is just the right thing to do. I think the concern about financing is ludicrous. We did not worry about financing when the military budget went from 350 billion to 750 billion, which is considerably in excess of the amount needed for healthcare reform.

“Socialized medicine” is a scary word to frighten ignorant people. We have Medicare as a government run system as the largest insurer in the country. We have the veteran’s hospitals as the largest system in the country and it all works well.

Doctors are scared for their paychecks. Other people are, frankly, just unconcerned with people who will be sick if they think they have to pay for it.

If we are to live in a Great Civilization, we MUST take care of all our citizens, Period.

Routine Miracles

As you stress in Routine Miracles, young doctors are frequently weighed down by hundreds of thousands of dollars in student loan debt.  What would you change about how we finance medical school education?

I would subsidize the medical schools to lower tuition and I would add trading a year of tuition for every year you spend in a lab during research. We do it for the military, why not for research?

It only costs about $2.4 billion a year for EVERY student in the country.  That is about what we paid for ‘cash for clunkers’ car program.

What is your relationship with insurance companies like?

This is the only thing that 95% of MDs and students agree on – it is HORRIBLE!  If I had to deal with insurance companies full time, I would drop out of medicine.  I also find it unconscionable that while facilities are closing because of budget gaps, the CEO of Aetna insurance is getting a 32 million dollar salary.

What do you hope people will take away from reading Routine Miracles?

Unless we take better care of the emotional well being of our best and brightest students and trainees, in terms of seeing the grandeur of finding new cures and treatment, the amazing advancement in medicine will screech to a near stop.   There is action to take here. It is about fixing the disconnect between breakthroughs and the complete lack of excitement and engagement of the “Best and Brightest” new doctors.  Routine Miracles is about how, in an age of extraordinary advances, we need to get our students into the lab and in a life of investigation and discovery.  If we don’t do this now, the future will be a lot less bright.

Charles Q. North, MD, MS

Students may not be aware of the variety of opportunities available within the Indian Health Service (IHS).

To learn more about IHS and the volunteer, scholarship, and employment opportunities available, the Student Doctor Network recently spoke with Dr. Charles North, retired Chief Medical Clinical Officer for Indian Health Services.

Charles North attended medical school at the University of Pittsburgh and completed his residency at the University of Minnesota.  Currently, he serves as Professor of Family and Community Medicine at the University of New Mexico School of Medicine.

Would you explain what the Indian Health Service is?

Gladly. The Indian Health Service (www.ihs.gov) is an agency within the United States Department of Health and Human Services (HHS). Since IHS is designated as an agency or “Operating Division” within HHS, it is a parallel organization to the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA) and several others.

The IHS was created in 1955 when Congress transferred responsibility for health of American Indians and Alaskan Natives from the Bureau of Indian Affairs to the federal department that preceded HHS. The IHS is the principal federal health care provider and health advocate for Indian people.

The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

The goal is to ensure that comprehensive, culturally acceptable, personal and public health services are available and accessible to all American Indian and Alaska Native people.

The foundation of the Indian Health Service is to uphold the Federal Government’s obligation to promote healthy Indian people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. It is charged with providing direct medical care in the broadest sense, elevating their health status to highest level possible.

Congress passed the Indian Self-Determination and Education Assistance Act in 1975 to provide Tribes the option of assuming from the IHS the administration and operation of health services and programs in their communities, or to remain within the IHS-administered direct health system.

The IHS has around 15,000 employees and Tribes probably employ about an equal number of tribal employees. Over 70% are Indian or Alaska Natives. There are about 1,000 physician positions in the system, about half of whom are primary care physicians.  As of July 2009, 21% of the physician positions were vacant.

There are 35 states that have significant Indian populations and/or reservations, mostly in the western United States and Alaska. About half of the health care for Indians and Alaska native populations is administered by the tribes and reservations themselves and half by the “feds” (i.e., directly by the federal IHS).

The Indian Health Service might be an appropriate career path for certain health professional students. Is this mainly a program for students who are from Native American Indian communities, or is it open to any qualified health professional?

The IHS’ first priority is indeed to the Native students themselves. We have a scholarship program for Native students and Indian preference for all federal positions.

But there is a shortage of qualified Native students, with not enough people in training to meet the projected need of the rapidly growing population. Even though there has been a steady increase in numbers, we do not expect that Native students will be able to meet the human resource needs of either the IHS or tribal programs in the foreseeable future.

What type of background do you look for in the IHS and whom do you think would find this an appealing career?

The most successful students are those oriented towards working with service to underserved populations, who enjoy cross-cultural and “transcultural” experiences, who have a special appreciation for an American Indian or Alaskan Native community or who want to work with indigenous people.

If you have a background working in the Peace Corps, or AmeriCorps or have done missionary work, you may be attracted to the populations and communities that the IHS serves.

Say you are a college student interested in pre-med or in one of the health professions.  How would you get information about eligibility for the scholarship programs?

There is a national IHS office in Rockville, Maryland that helps anyone interested in scholarships. However, the criteria for scholarships are quite rigorous. Most of these opportunities would be for enrolled members of tribes. If you are in this category, ones’ tribal administration or the Rockville office can guide you through the application processes.

The Native Health Initiative funds summer health and justice internships. The IHS does provide some opportunities nationally in the Commissioned Officer Student Training and Extern Program (COSTEP) that lead to early commissioning in the United States Public Health Service (USPHS) Officer Corps and provide exposure to health professionals in federal agencies, including the Indian Health Service Commissioned Officer Corps.

Are there experiences for baccalaureate students on Indian reservations and other places?

Several reservations and tribal clinics have developed programs, such as the “health and justice” initiatives mentioned above. An interested person should contact a local site. There may be a volunteer program that would suit your interests and background. I am aware that anthropology majors, linguistics majors – even persons interested in law enforcement – have found things to do on some reservations. Undoubtedly, an experience of this kind early in one’s education might reinforce an early interest in this kind of service.

I would expect that there are more opportunities for students who are already enrolled in health professions schools?

Yes, such students have several options. The summer COSTEP program mentioned above requires that one signs up for the commissioned corps. We get a lot of students. Most of the interest is from pharmacy and engineering programs, but other health professionals are eligible.

Many of the schools in the 35 states with federally recognized Tribes have relationships with IHS and Tribal sites. Some programs in Alaska will pay room and board and airfare to get students to remote Alaskan communities.

Other programs will cover transportation and room and board for fourth year medical school elective rotations. You should check with your school and see if there are options for you to work in Indian Health facilities.

In Albuquerque, the IHS has a formal affiliation with the University of New Mexico. One of its Tribal sites takes students from all over the country. The Navajo, Tucson and Phoenix IHS Areas in the Southwestern United States also take students from throughout the nation.

Oklahoma has many local affiliations, so there are many opportunities there. The Northern Plains, Montana, Minnesota, North Carolina and Washington State regions all have some active and dynamic relationships. Check with your school.

How did you personally decide on a career in the Indian Health Service?

I was interested in service to needy populations even when before I was a medical student at the University of Pittsburgh. After taking a senior year elective in preventive medicine on the Navajo reservation, I entered a residency at the University of Minnesota and took an “outstate” (rural) rotation in Cass Lake, Minnesota, home of the Leech Lake Ojibway.

At that time, having a residency rotation at a remote Indian Health Service site was considered so different an experience that my University of Minnesota department chair and several professors flew up to Cass Lake to see it.

If you are a student or resident and want to do something like this, check with your school. Most likely you have faculty that are IHS veterans. The school may work something out with you.

Are there particular lifestyle interests that you find make a good match?

Generally, people who like to live in rural areas may find this is a good fit. Those people who love riding horses, rodeos, backpacking into “frontier” areas, mountain biking, long distance running, skiing, fishing, hunting, and so on often find the rural and frontier IHS settings attractive.

But for those who are oriented to urban life, you could live in a city and work at an Indian Health urban or rural site.  It is a fact that over 50% of the Indian population lives in urban areas. Urban Indian programs exist in some of the largest cities in the US. For some specialties, the only positions that exist are at the urban sites.

Beside the scholarship program for Indian students, do you have “loan repayment for service” programs?

The IHS has a loan repayment program, similar to the federal Health Resources and Services Administration (HRSA) National Health Service Corps program for community health centers. It has been funded at a lower level than the need, but it is quite possible that there may well be more money allocated to this program in the future.

It currently is set at $20,000 a year covering all the health professions, not just physicians. Because of the financial resources of some of the tribal sites, such as the Navajo, there are supplemental funds for loan repayment. One should check with local sites.

In the IHS, to date, loan repayment has been used mainly for retention, rather than recruitment. Stay tuned on on loan repayment, as this may be augmented in this era where health care reform is a legislative priority.

There are a number of IHS Indian health Health centers sites that get HRSA “Section 330” funding – a principal program for funding community health centers. They may be eligible for HRSA loan repayment program for either an urban Indian or Tribal site.

Not every person who went through the University of Pittsburgh medical school chose careers in the Indian Health Service. How did you get interested in this field?

I grew up in Seattle and observed that Native people there had both lower health status and lower socioeconomic status. I was interested in civil rights and social justice. I met Native students in in college and found we had many interests in common.

When I went to medical school in Pittsburgh, they had an elective on the Navajo reservation rotation for fourth year medical students. I went to a preceptorship at Fort Defiance, Arizona, where I worked in the hospital, clinic, and community health program and did some epidemiological research.

Personally, I love the Southwest, and liked working with tribal people, feeling that I was responding to a tremendous demand for health services. I found that the IHS healthcare services were extremely well organized into a rational system, unlike most of the rest of the country.

The IHS integrates public health and primary health care in such a way that one could make a difference quickly in meeting healthcare needs. I found this system of community oriented primary care very satisfying compared to private practice. Then I did a third year residency rotation in Minnesota and found that the system there was very similar and comfortable for me.

I loved the IHS system that existed in both Fort Defiance and Cass Lake. The population needs far exceed our ability to meet them, but I felt that I was fighting the right battle, that the organization’s core values were congruent with my core values. So after residency that is all I wanted to do.

I went to the Hopi Reservation in Keams Canyon, Arizona and served as a family physician, director of community health services and eventually became the chief executive officer of the health system there.

The integration of public health and medicine in team programs made great sense . The health care team is much better developed in Indian health.