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

“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/

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.

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.

It’s a given that there are healthcare professionals out there with substance abuse problems. But, as we prepare to enter practice, many of us find it difficult to imagine that we’ll be working with affected individuals, or that we could become affected ourselves. Few professional programs ask students to consider what they would do if they suspected or knew that someone in their workplace was impaired. And, still fewer programs formally acquaint students with recovery resources.

No one really knows how widespread substance abuse is within the healthcare professions. With their livelihoods at stake, few people are going to admit to having a problem. Additionally, most health professionals are smart people who are relatively good at hiding their problems. A lecture given by Brian Fingerson, the president of the Kentucky Professionals Recovery Network, indicated that the figure is 12-16% for “pharmacists and some other healthcare professionals”¹.  Given that one out of every nine Americans over the age of twelve was found to have a problem with substance use or dependence in the 2007 National Survey on Drug Use and Health², the suggested range seems quite reasonable.

As healthcare professionals, we may be more likely to develop substance abuse problems than members of the general population due to high work-related stress, increased access to controlled substances, and our knowledge of drug effects. Those of us who do become addicted may be shielded from discovery by the trust of our patients and coworkers. Plus, we may work very hard to avoid discovery, fearing harsh professional, social, financial, and legal consequences.

By this point, it should be clear that you should expect to encounter impaired healthcare professionals during the course of your career. What is less clear is what role you will play in the situation and how you will feel about it.  When you aren’t sure about what is going on, it can be hard to take action. You may only suspect that a coworker is coming to work intoxicated. Maybe there are narcotics missing on a regular basis but you aren’t sure who is taking them. It is reasonable to have fears about accusing an innocent person. You may worry about losing rapport with your coworkers if your suspicions aren’t proven true. There are many other reasons that you may feel compelled not to act. Perhaps you are worried about feeling guilty about turning in a close friend, or taking a provider away from a family. Or, maybe you feel like it’s not your place to take action since others are already aware of the situation.

The bottom line is that an impaired colleague is a danger to both themselves and their patients and needs intervention. If you suspect that a coworker is impaired, you need to connect with someone who can investigate and assess the situation or refer you to resources to do so. This could be your employer, the state board, or a representative from a Professional Recovery Network (PRN) or Caduceus group. If you know that a coworker is impaired, they need to be relieved from duty immediately. But, in order to fully do the right thing, you should also make an effort to connect them the unique support, advocacy, treatment, and recovery resources available through a PRN program. It is may be best to shield yourself by giving the PRN their information and letting the program initiate contact. It is not necessary for the affected individual to know who made the referral.

With the advocacy and monitoring offered by PRN programs, many healthcare professionals are able to regain licensure and return to work while in recovery. These individuals are typically required to sign a contract with the PRN organization and are subject to practice restrictions such as not being allowed to work unsupervised or not being able to work more than a specified number of hours per week.³

While employers or partners must know whether or not a healthcare professional is in a PRN program, coworkers may not.³ They often choose not to identify themselves because they don’t want to deal with the stigma, have their work overly scrutinized, or be judged on a daily basis. If you do discover that a coworker is in a PRN program, I encourage you to be supportive. While there is potential for relapse, PRN programs are used because they work. One pharmacy PRN program coordinator at The Utah Conference on Alcoholism and Other Drug Abuses shared that the drug abuse rates in his state’s PRN program were lower than that of the general pharmacists population. So, with proper monitoring, it may be less risky to hire an individual in a PRN than it would be to hire the average applicant.

For students or professionals interested in learning more about substance abuse in the health professions, I recommend attending the University of Utah’s School on Alcoholism and Other Drug Dependencies, now in it’s 58^th year. This annual week-long event is designed to help students and professionals understand and cope with substance abuse and incorporates a mix of speakers, discussions, social events, and open meetings for recovering addicts and families. Exposure to and interaction with recovering health professionals is one of the most valuable aspects of the program. For students and professionals in recovery the school also offers a unique opportunity to connect with a supportive network of people who share similar experiences. The pharmacy section, which I attended this June, is the largest section of the group, with around 300 participants, mostly students. Other healthcare sections included physicians, dentistry, and nursing. Both college and continuing education credit and are available at a reasonable cost. For more information, please visit http://uuhsc.utah.edu/uas/

1) Fingerson, Brian. “Chemical Dependency Among Healthcare Professionals.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

2) http://www.drugabusestatistics.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch7

3) Quigley, Michael. “Issues in Relapse Prevention and Monitoring.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

Dr. David Sundwall was confirmed in January 2005 as Executive Director of the Utah State Department of Health. In this capacity he supervises a workforce of almost 1,000 employees and an annual budget of over $2.0 billion.  He currently serves as Immediate Past President of the Association of State and Territorial Health Officers (ASTHO), serves on the Executive Committee of ASTHO and is Chair of the ASTHO Government Relations Committee.

Dr. Sundwall has extensive experience in federal government and national health policy, including:

• Administrator, Health Resources and Services Administration (HRSA), Public Health Service, U.S. Department of Health and Human Services (HHS) and Assistant Surgeon General in the Commissioned Corps of the U.S. Public Health Service under Reagan administration (1986-1988).
• Director, Health and Human Resources Staff (Majority), U.S. Senate Labor and Human Resources Committee (1981-1986).

He currently has academic appointments at the Uniformed Services University of the Health Sciences, Bethesda, Maryland; Georgetown University School of Medicine, Washington, DC; and the University of Utah School of Medicine. He is board certified in internal medicine and family practice.  He is a volunteer primary care physician in a Utah public health clinic one-half day per week.

Dr. Sundwall recently took time out of his busy schedule to talk to the Student Doctor Network about health care policy.

David Sundwall, MD

What do you think are the greatest issues facing the U.S. healthcare system today?

“Cost” control, i.e. restraining the rate of growth of spending for health-care services.  This is not unique to the U.S., but is a global challenge in that our capacity and technology have outstripped our ability to pay for them.

The U.S. is the only industrialized/Western nation without single-payer health care.  Why do you think that is?

It is a historical fluke, in some respects, in that the passage of Medicare/Medicaid in 1965 was made possible by compromising to use existing private health insurance to administer the programs, even though paid for by federal (and federal/state ) taxes.  The general skepticism of “government” has long been a significant factor in the various health policies we have enacted, and avoided.

What concerns do you have with the single-payer model?

Few, but we all need to acknowledge that if we eventually embrace a “ single payer” system it will likely result in delays, inconvenience, and frustration with coverage policies that will be based on the “public good,” not necessarily the best new technologies.

What impacts would you anticipate to physician income and quality of life if a single payer model were to be implemented?

There will likely be a more fair, i.e. “narrower” distribution of compensation among physicians, regardless of specialty.  Primary care physicians would be paid more, sub-specialists less but still more.  I do not necessarily think income is closely related to quality of life, but most strive for high incomes and associate this with “success”.

What do you think the best solution is for the U.S.?

Eventually we will have a single payer system, not because it is necessarily “the best” but because it will be more fair, and enable restraint of spending.  It will be a difficult but necessary transition in that we are accustomed to getting what we perceive we need and want and when we want it.  This is simply too expensive to sustain, so we must acknowledge that “he who pays the piper gets to call the tune,” and to the extent we pay for health care with public funds the “government” could and should determine what services are covered and at what level.

The health reform bills currently under discussion in the House and Senate all require that every U.S. citizen carry health insurance (“individual mandate”) – do you think this is a necessary element of any solution?

Short of a “single payer” system, this is an essential component of health reform.  If it is not an entitlement, it should be required.

Proponents of nationalized health care often cite information that U.S. health care lags other industrialized countries, including the U.S. being 42^nd in life expectancy and 41^st in infant mortality.  How do you respond to such criticisms?

When you compare health status of Americans with health insurance coverage with other countries we compare favorably (better than most aggregate data from other countries).  This is pretty good evidence that having health insurance coverage is important to improve health.  However, there are other important factors that are not necessarily related to coverage, e.g. economic status, race, access, etc.

What are the incentives a for-profit health care model to focus on preventative medicine and keeping people healthy versus having them consume as much care and incur as much cost as possible?

Not many – though there is little hard evidence that “preventive” health services pay off over time.  We still don’t have consensus on what constitute best practices for preventive care and what will improve health status and reduce costs over time.

Critics claim that pharmaceutical and medical device companies make egregious profits.  Do you agree or disagree, and what reforms, if any, would you like to see in this area?

In a free market economy, I believe there should be opportunities for medical device and drug companies to compete and charge what the market will bear.  However, there may be justification for imposing regulatory restraints when “public” health insurance programs (financed with tax dollars) are purchasing such.

What solution would you propose address the criticism that overseas businesses have an advantage on costs because they don’t have to provide private health care?

I haven’t proposed a “solution,” but I believe our country’s ability to reduce health care expenditures will improve our ability to compete, whether it is accomplished by private or public-based health reforms.

What will be the impacts on physician income and quality of life of the proposed reforms?

See the answer I gave to the fourth question.  “Quality of life” and income are not necessarily related.  Physicians motivated primarily by income will be disappointed and possibly seek other ways to make a living. Those of us who value the rewards of patient care, service, and life-long learning of new biomedical science will still find being a doctor very rewarding.

Dr. Gary Flashner, MS, MD, ABFP is an emergency physician and Vice President of Medical Content for ExitCare, LLC.    He completed his undergraduate work at Muhlenberg College (Allentown, PA), Masters work at Penn State, medical school at Thomas Jefferson University, and residency in Family Medicine at Sacred Heart Hospital (Allentown, PA).    His 20 years of clinical practice and teaching endeavors (including 13 years of full-time work in hospital-based emergency medicine) were split between the eastern U.S. (Pennsylvania and Ohio) and California, including working at Yosemite National Park.

Dr. Flashner has been involved in medical informatics for 15 years with previous work that focused on the research and development of emergency department physician documentation systems and end-user screen design.    As an IBM Business Partner, he pursued a special interest in the use of computerized speech recognition as a data input method for physician charting, and he continues to provide guidance in the use of this technology.   After retiring from clinical practice, he worked for Eclipsys Corporation for four years.  That work included a focus on the development of their first software offering for hospital-based emergency departments.   At the beginning of 2009, Dr. Flashner accepted the position of VP of Medical Content at ExitCare with a focus on the research, development, and updating of patient education materials.

Dr. Flashner lives in Orange County, California.  He recently took the time to speak to the Student Doctor Network about his experiences.

Why did you choose to become a physician?

I recall declaring this as my “designated profession” from the time I was age 8.   During all of my pre-medical school years, the driving idea was “helping people”.

If you had it to do all over again, would you still become a physician? (Why or why not? What would you have done instead?)

With some hesitation, I would say “Yes”, if I had it to do all over again, I still would have pursued medicine as a career.   I experienced too many positives in the process of working with patients, families, etc.  Those positives included the challenges of the “detective work” of medicine, the joys of seeing improvement and/or control of numerous medical and surgical problems, helping to relieve pain (both physical and psychological), and the opportunity to truly “fix” problems that were fixable either by my own hands or through the referral to a subspecialist.

Tell us what it was like serving as the physician in Yosemite National Park.  What was unique about that environment?  What was it like to practice medicine there?

This was a very unique environment from a medical, social, and environmental point of view.    My family and I felt very lucky to be able to live and work in the one of the most beautiful places on the face of the earth.   We also felt very lucky to have our children spend their earliest years in that environment, and now that they are adults, the personal “connection” to Yosemite remains.   The local community was small, compact, tight knit, and retained many of the positive parts of “small town life”.

As a staff physician at the Yosemite Medical Clinic, I was joined by two other physicians (three during the summer months) and a staff focused on primary care services for the local community.   In doing so, we “knew everyone” in the local community – something that I found to be very enjoyable (although it also had its challenges!).   The community was also remote and isolated – the closest hospital and “urban” medical community was 85 miles west in a town of 50,000 people.   This presented challenges associated with medical “isolation” and the inability to conveniently discuss various aspects of patient care with colleagues.

The greatest challenges came mostly in the summer when the Park was jammed full of visitors.   The volume of patients coming to the Clinic for care predictably increased dramatically, and the Clinic functioned more as an emergency department than a primary care practice.   A significant volume of seriously injured multiple trauma patients were brought to the Clinic for initial stabilization, and there were numerous challenges associated with the logistics of transporting these patients to area trauma receiving facilities in Fresno or Modesto.   On site, we had to do everything ourselves with no backup from subspecialists – because there were no subspecialists.   There was no opportunity to call upon anesthesia, surgery, orthopedics, cardiology, ophthalmology, etc. to assist with problems that clearly required subspecialist/surgical intervention and critical care services.   The staff had to be very independent, creative, and resourceful.

What did you like most and least about being a physician and interacting with patients?

What I liked most:

• Collaboration on an intended goal of managing a problem, health maintenance, etc.
• Fixing a problem that can be fixed (broken bone, laceration, etc.).
• Providing reassurance.
• “Being there” during very difficult times.
• The adrenaline rush of a successful resuscitation.

What I liked least:

• Overly burdensome regulatory, malpractice, and insurance hassles.
• Unreasonable patient demands.
• Refusal to change destructive behaviors despite reasonable patient education.
• Anger in relation to undesirable outcomes out of the control of the medical staff.
• “Entitlement” mentality.

What made you decide to move from patient care into patient information systems?

In 1995, I was found to have a disc herniation in my neck.   That problem has progressed and worsened over the past 14 years, and I now have some problems with my hands that made me decide to work on a career change.   Being a computer nerd and having a passion for technology and information systems, this transition made sense.

Describe a typical day at work.

Currently, here’s what it looks like:

1. Email
2. Conference calls and frequent impromptu calls with our Document Manager
3. Organize the work/tasks for the day
4. Medical literature research, document revision, document review
5. Various other project work which may involve spreadsheets, databases, or both
6. Continued email throughout the day

What do you like most and least about what you are doing now?

What I like most:

• Excellent team of people in my work group.
• Work from home.
• Generally regular hours.
• Minimal work travel.
• Reasonable compensation for what I do.
• My work is valued, and I receive a lot of feedback supporting that.

What I like least:

• Occasional intense stretches of work 7 days a week as our company is undergoing rapid growth.
• Too much time sitting at a computer screen.

Are you satisfied with your income?

Yes.

If you took out educational loans, is/was paying them back a financial strain?

I did take out loans; but the total was relatively low ($25,000), and I was able to pay them off over seven years.  That was not a strain; however, that was also many years ago.

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?

Currently, I work 40-50 hours/week.   I sleep 8 hours a night.   I have 3 weeks vacation allotted per year.

Do you have a family and do you have enough time to spend with them?

“Yes” and “Yes”.

In your position now, knowing what you do – what would you say to yourself ten years ago?

“Keep doing what you are doing”.    Ten years ago, I had a pretty good idea that I would not be able to practice emergency medicine for too many more years because of the progressive orthopedic problems in my neck.   I was already pursuing endeavors in medical informatics, and I would have continued on the same path that I was already on.   Interestingly, 11 years ago, I originally met the founders of the company that I work for now, and that certainly reinforces the notion that I would keep doing what I was doing.

What information/advice do you wish you had known when you were an undergraduate? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided?)

I wish I had had some education as regards interview skills as well as help with organizational skills, time management, and being able to prioritize.

From your perspective, what is the biggest problem in health care today?

The biggest problem today is the way health care is prioritized within society and how it is paid for.

What other types of providers and/or technicians do you work with day-to-day?

Currently, I work with a Document Manager, two Medical Literacy Editors, a Cardiac Nurse, and our Foreign Language Coordinator.

What types of outreach/volunteer work do you do, if any? Any international work?

Nothing formal.   I make it a point to donate blood about four times a year.   I give financial support to a variety of medical organizations that include international relief funds (such as Doctors Without Borders and the International Medical Corps).

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?

For relaxation, nothing beats exercise, including walking on the beach and hiking in the mountains (Sierras and the Sawtooth Mountains in Idaho).    To achieve balance between work and life?    Try to monitor it as closely as you would monitor an unstable cardiac patient in the ER or ICU.   Re-assess, re-assess, re-assess.     Figure out a way to intervene when intervention is appropriate.    Work hard at learning how to say “No” – particularly as regards a variety of material gains and financial burdens.

What would you say to medical or other health professional students that want to mix a business career with health care?  What advice would you give them?

I would ask the student a lot of questions:  “Why do want to do this?    What are your goals in mixing business and medicine?”   I would need to know a whole lot more about what the student wants to do before I could provide any advice.

By Jessica Freedman, MD
President of MedEdits: Medical Admissions

Because the competition for admission to medical schools in the United States is extremely strong, many applicants consider attending medical school in the Caribbean. In fact, a great many bright and talented applicants are now opting to obtain their medical education in the Caribbean.

How can you decide what is the best choice for you? What must you consider in evaluating these schools? And will you be able to obtain a residency in the United States after you graduate? To help you decide if attending a Caribbean medical school is a good choice, this article provides a framework for evaluating these schools and the success of their graduates.

A Little Background

In the last four decades, the Caribbean has seen a steady increase in the number of medical schools on the islands as well as the size of their student bodies.  In the late 1970’s three Caribbean medical schools were established: American University of the Caribbean, originally located on the Island of Montserrat, Ross University on the Commonwealth of Dominica, and St. George’s University in Grenada.   Since their inception, these schools have educated many US citizens seeking a medical education outside the US,  and now about 60 medical schools in the Caribbean are listed in the Foundation for Advancement of International Medical Education and Research (FAIMERs) International Medical Education Directory (IMED).

The physicians who graduate from Caribbean medical schools play an increasingly important role in the US health care system by supplying residency programs with qualified applicants and helping to meet a well documented physician shortage, particularly in primary care medicine.  While accreditation, didactic studies (first and second years of medical school), and clinical rotations (third and fourth years of medical school) differ among institutions, requirements for graduate certification in the United States, as outlined by the Philadelphia based Educational Committee on Foreign Medical Graduates, are the same for all students graduating from all international schools, including the Caribbean.

Caribbean Medical School Accreditation

An article by van Zanten et al published in the June 2009 edition of Academic Medicine reviews some of the processes by which Caribbean medical schools undergo external quality assurance.  Accreditation for Caribbean medical schools is on several levels, including local Ministry of Health accreditation by some  individual Caribbean country’s government, regional accreditation by organizations such as The Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). The World Health Organization (WHO) does not accredit medical schools but maintains a list of schools that are recognized by local governments. In the United States,  The National Committee on Foreign Medical Education and Accreditation of the US Department of Education (NCFMEA) of the United States Department of Education determines whether the process conducted by an accrediting organization is comparable to the Liaison Committee on Medical Education (LCME) process of accreditation. This is a voluntary process so not all schools undergo this evaluation. If a school’s accreditation is deemed comparable to the LCME process, then that country can apply for US federal loans for those students. Currently, only 3 schools in the Caribbean are eligible for these loans.

California, Florida, New Jersey, and New York require individual school review and approval for Caribbean students to do rotations in that state.   In California, not only must the individual school be approved for clinical clerkships but the student’s clerkship and course work must be approved by the state medical board to obtain residency and subsequent physician licensure.  Any deficiencies in clinical training, as determined by the state, may need to be remediated to practice in California.  Many other states defer to California’s approval for the purpose of licensure because most do not have their own approval process. Also of note, New York has the largest number of international medical graduates in residency training and about one third of residency programs in the US are located in the state of New York.

It is important to know which organizations have accredited any school you consider attending.  Knowing if the state in which you intend to practice recognizes your school is also important.  Caribbean medical schools proudly display these accreditations on their websites so if an accreditation is missing, be wary.

Quality of Medical Education in the Caribbean

Another recent study by van Zanten and Boulet published in Academic Medicine examines the quality of medical education in the Caribbean. The report finds tremendous variability in both the quality of undergraduate medical education and in students’ performance. The only way to evaluate the education Caribbean medical students received was to examine students’ scores on the United States Licensing Exam (USMLE) Step 1, which is taken after the second year of medical school. Investigators calculated the average USMLE Step 1 first time pass rate for each country in the Caribbean. In evaluating this data they also took into account that some islands have more than one medical school.  The countries with the highest percentage of students passing the (USMLE) Step 1 on the first attempt were Grenada (84.4 %) and Dominica (69.7%). Countries with the lowest pass rates were Saint Lucia (19.4%) and Antigua/Barbuda (22.9%).

Preclinical Years

Students typically spend the first four to five semesters of medical school in the Caribbean completing basic science courses before taking USMLE Step I.  Basic science curriculums in the Caribbean are similar to US curriculums.  Some schools offer a fifth semester, either in the Caribbean or in the US, to help students prepare for the USMLE Step 1 and transition to their clinical semesters.

Living in the Caribbean can present many challenges for those who have never lived outside the United States. For many students, it will be their first time away from the United States for a prolonged period of time. Many of the luxuries found in large US cities, such as restaurants, movie theaters, shopping malls, and commercial gyms, are not available on the islands, and friends, family, and religious support groups are thousands of miles away. On the plus side, many students form strong relationships with classmates and also enjoy learning about the history and culture of the local West Indian population. Former students also have fond memories of celebrating yearly holidays such as Carnival, the colorful, festive, and historical event celebrated annually throughout the Caribbean.

After successfully passing the USMLE Step 1, students proceed to their clinical rotations, which usually are outside of the Caribbean.  When evaluating schools, it is important to ask what percentage of students who initially enroll in each class actually take and pass the USMLE Step 1 and successfully proceed to clinical rotations.

Clinical Years

Core clinical rotations and third and fourth year curriculum in Caribbean schools resemble those of US medical schools. Caribbean schools that offer clinical training in the US have strict guidelines about the location and quality of students’ clinical training.  All core rotations and subinternships must be completed in hospitals with which the Caribbean medical school has an active, written affiliation agreement and which have appropriate clinical faculty members. Rotations must be approved by the Accreditation Council for Graduate Medical Education  (ACGME). In addition, it is preferable that hospitals have approved residency training programs (or their British equivalents) in the specialties through which students rotate.  Students also take both parts of USMLE Step 2 (clinical knowledge and clinical skills) after the third year.

Hospitals in which electives are taken should also have approved postgraduate programs in those specialties.  For example, it is best to do an anesthesia elective at a hospital that has an anesthesiology residency. Regardless of school affiliation, however, individual hospitals still reserve the right to screen individual students for elective clerkship acceptance. Some individual hospitals and departments do not accept international rotating students, which can limit the away electives in which students can participate. From a competitive perspective, it is always preferable to participate in clinical rotations located in hospitals that not only have ACGME accredited residency programs but are academic teaching hospitals rather than community hospitals.

If I Go To a Caribbean Medical School, Can I Get a Residency?

Graduates of Caribbean medical schools have tremendous success in obtaining residency positions, even in competitive specialties. It helps to attend a well-established Caribbean school, perform well on the USMLE Steps 1 and 2, and obtain strong letters of recommendations. (See my previous articles: Getting Into Residency Part 1 and Part 2 for more information.) Before applying for the residency match and early in medical school, students should strategically plan their clinical clerkships in the US, ideally arranging rotations in the settings where they prefer to match.  In recent years, Caribbean students with strong academic and clinical performances have been able to obtain competitive residency positions at an increasing rate.  However, the largest number of students pursue less competitive specialties, such as internal medicine or family practice.  Some students are also able to ”prematch” into residency positions outside of the National Resident Matching Program (NRMP).

When evaluating the success of a Caribbean medical school’s graduates, it is important to find out specifically where and in what specialties students match. Also determine what percentage of fourth year students match into categorical programs. This information may not be easy to obtain. While schools typically publish their match results, it is unclear if these lists are truly comprehensive.

After residency, Caribbean medical students, along with their domestic colleagues, will obtain board certification and must meet specific requirements for state licensure. The quality of one’s residency training usually carries more weight than the medical school attended, so obtaining the best possible residency and even fellowship can help Caribbean students overcome some of the bias foreign students face when competing for competitive attending positions.

Educational Commission for Foreign Medical Graduate (ECFMG) Certification and Graduate Medical Education Programs

To be eligible for ACGME accredited residency programs in the United States, and for licensure in many states, students who graduate from a Caribbean medical school must obtain an ECFMG certificate. Eligibility for this certificate includes graduating from a medical school listed in FAIMERs online International Medical Education Directory (IMED) and passing the USMLE Steps 1 and 2 (both clinical knowledge and clinical skills).  For more details, see the ECFMG website at www.ecfmg.org.

Questions to Ask

School History

• When was the school established?
• What percentage of students are US citizens?
• By whom is the school run and what are the credentials of the academic faculty?
• Has the school had any recent changes in leadership? Are any leadership changes expected?

Caribbean Medical School Accreditation

• By whom is the school accredited and is the school accredited by the states of California, Florida, New Jersey, and New York?  Is the school listed in FAIMER’s IMED?

Admissions, Medical Education and Curriculum

• The quality of your medical education begins with the advice you receive prior to attending a Caribbean medical school. Is your premed advisor well versed in the pros and cons of attending medical school in the Caribbean?
• If interviews are required, by whom are they conducted – alumni, administrative staff, faculty and/or current students?
• What are the mean overall and BCPM (biology, chemistry, physics and math) GPAs and MCATS of accepted students? Are MCATs required to submit an application?
• Does the school have more than one matriculating class annually and are admissions rolling? Unlike most US schools, Caribbean medical schools typically have two to three first year classes that begin at different times during the academic year.
• What is the average size of each entering class? Does the size vary depending on the start date?
• How many students enroll in each first year class? What percentage of students who enter as first year students start third year rotations as scheduled?  What percentage of first year students match into categorical residencies in the United States during their fourth year? What percentage of first year students graduate? (Understand that graduating does not necessarily mean matching, so both of these questions must be answered.)

Financial Concerns and Living Conditions

• Do most students fund their education using outside loans or scholarships? Are these loans backed by the US government or are they private loans? Does the school offer financial guidance to help students choose the best loans and make responsible financial decisions?
• Where do students live and what are the housing conditions? Does the school provide housing?

Clinical Studies

• Where do students do their clinical training? Can students choose where they do core rotations? Are the rotations ACGME accredited? Do students work alongside US medical students?
• Are students allowed to do elective rotations? How many? Can students do away electives at nonaffiliated hospitals? Does the administration or faculty help students obtain away electives?

Residency Match and Professional Guidance

• Does the school provide guidance to help with the match process? Do students have an assigned advisor to help them?
• Where and in what specialties did students in the most recent graduating classes match for residency, and what percentage of fourth year students matched into categorical residencies?
• What percentage of students do not match annually? What percentage of students must enter the “scramble”? For students who enter the scramble, does the school provide assistance to find an unfilled residency spot?

Alumni and Student Support

• Where do alumni practice geographically, in what specialty and in what type of practice (community or academic)?
• Will the school provide contact information for alumni and current students with whom to speak?

Medical School in the Caribbean

Going to medical school in the Caribbean can be a good option as long as you do your research and make an educated choice. The medical education you will receive in the Caribbean varies tremendously, and the success you will have after graduation depends on many factors. Attending a top Caribbean medical school is a great option for some students but, just as for US medical students, once in school you must “do the right thing” to secure an excellent residency, (See my article Getting Into Residency Part 1 and Part 2.) I have had several Caribbean medical student clients earn residencies in competitive specialties, including anesthesia, emergency medicine, and internal medicine so, yes, it can be done!

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).

The author would like to thank Marta van Zanten for clarifying parts of this article.

References

1) van Zanten M, Boulet J R. Medical education in the Caribbean: variability in medical school programs and performance of students. Academic Medicine. 2008;83: s33-s36.

2) van Zanen M, Parkins LM, Karle H, et al.  Accreditation of undergraduate medical education in the Caribbean: report on the Caribbean accreditation authority for education in medicine and other health professions. Academic Medicine. 2009;84: 771-775.