Adam Gaffney’s recent Boston Review article, “What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.
Dr. Gaffney is president of Physicians for a National Health Program, and a co-chair of the Working Group on Single-Payer Program Design, which developed the “Physicians’ Proposal for Single-Payer Health Care Reform.”
A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.
Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care. Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”
That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.
As Gaffney recounts, a young Reinhardt at age 19 relocated to Canada just in time to witness the birth of their National Health Care System. He travels next to New Haven to receive his PhD in Economics from Yale, and then settles into a long and distinguished career at Princeton.
In Priced Out, Gaffney finds an evolved Reinhardt, one who acknowledges that the problem is not simply opaque pricing (“It’s the prices stupid.“), and certainly not over-utilization of services as Atul Gawande popularly promoted, but rather the wasteful and rigged privatized system awash in ill-gained profits.
As Gaffney reports, “Reinhardt describes in Priced Out, hospitals and other providers have met insurers’ bloat through profound administrative distention of their own.” And “a cosmic law is that every dollar in expenditures is somebody’s income…(creating) fundamentally a political problem, not a technical one.”
For the solution, Gaffney turns to Canadian Robert Evans rather than Reinhardt, who “described in 1991 the special sauce of cost containment…universalism in conjunction with simple source funding.” In summary, Gaffney writes, “The way we pay for health care has produced a curious but deadly mix of deprivation and excess. There is no great mystery behind it. It’s the financing, stupid.”
As Code Blue’s tracking of the
medical history however reveals, this declaration is incomplete without two
important additions. The complexity Americans struggle with today was
intentional, and the MIC would have been unable to execute their opaque, profit
sharing conspiracy without the reinforcement of all sectors (including many
patient support groups) reinforced by an integrated career ladder for academic
medicine with overflowing and hidden conflicts of interest.
My own mentor, Columbia health economist Eli Ginzberg, cautioned in his 1990 book, The Medical Triangle, “The competitive market is an opponent, not an ally of cost containment.” Eight years earlier, Reinhardt’s Princeton colleague, sociologist Paul Starr, in The Social Transformation of American Medicine, commenting on similar risks with an air of hopefulness, wrote: “A trend is not necessarily fate.”
But my own research, tracking the
evolution of the collusive Medical-Industrial Complex over the three quarters
of a century following World War II and into the present, suggests that Starr’s
fears expressed in 1982 of “private
plans controlled by conglomerates whose interests will be determined by the
rate of returns on investments” was well founded.
How and why American medicine arrived at
this point is now clear. Instead of embracing a thoughtful approach to
strategic health planning following WWII, our nation encouraged a free
enterprise and entrepreneurial attack on disease, even as our military built
out rational national health systems for Germany and Japan. Along the way,
major health sectors—including the medical profession, hospitals, insurers, and
pharmaceuticals—infiltrated government bodies, weakening regulatory controls as
they pursued self-interest and profitability ahead of the interests of American
patients, families, and communities.
Cross-sector leaders like myself helped
the various MIC sectors populate and socialize one another’s territories, at
times competing, and at other times colluding in the pursuit of career
advancement, deregulation, and federal funding. The new information age helped
spawn complex insurance and delivery systems focused on mining and monetizing
proprietary patient databases. These required expanding nonclinical workforces
and encouraged the opaque gaming of the system and diversion of profits. More
and more money flowed in to an ever-increasing number of derivative
organizations, many flirting at the edges of criminality, that figured out how
to gain entry into the increasingly complex pharmaceutical, insurance,
hospital, patient care, electronic medical record, medical education, and
scientific research supply chains.
As we entered the new millennium, players within the various MIC sectors discovered common political ground with the help of their overlapping lobbyists in Washington and statehouses across the land. But articles like Gaffney’s and books like Code Blue have increasingly exposed these opaque and collusive networks, making it clear that MIC complexity is intentional and conspiratorial, and must be opposed.
The majority of Americans now agree that
universal health coverage is a central underpinning of a civilized society,
essential to creating a stable government, an empathetic culture, and
productive healthy citizens. Implementing such a program requires careful and
thoughtful governmental planning and execution with integration of a wide range
of other social services. It must be budgeted with careful prioritization, but
it is certainly doable.
As Dr. Gaffney suggests, the required corrective action now is far more comprehensive and centers on the 800-pound gorilla we must subdue to truly free ourselves from the MIC syndicate’s stranglehold: our perverse, profit-driven, and incredibly wasteful health insurance system. Could the transformation we need be as simple as removing the age restrictions on Medicare and Medicaid, proposed by some on the left, thereby letting every citizen in on the benefits enjoyed by seniors and the needy during the past half century? Certainly that is one option worth discussing.
But to embrace true reform, we must follow
the money and follow the data, and build on progress already made. Clearly the
time has come for the US to join the rest of the industrialized world and
consolidate health insurance into a standardized single-payer/multi-plan system
that provides a secure package of basic benefits for all. The first step should
be establishing minimum standards and a centralized control system, which would
trigger a cascading series of changes leading to more detailed answers to the
question “How do we make America healthy?”
In the Declaration of Independence, our
nation’s founders proclaimed that equality was self-evident. Nearly 250 years
later, what has become equally self-evident is that there is no equality
without reasonable access to health care, and that universal insurance coverage
is the only system that truly can provide access that is reasonable. Rather
than resisting this approach once seen as “un-American,” our citizens are
beginning to see single-payer/multi-plan universal access to affordable and
effective care as the essential next step to ensuring what should be every
American’s birthright—life, liberty, and the pursuit of happiness.
Magee MD is a Medical Historian and Health Economist at the Presidents’ College
at the University of Hartford. He is the author of Code
Blue: Inside the Medical Industrial Complex (Grove Atlantic/2019). (www.mikemagee.org)
The post Charting The Economic History of US Health Reform appeared first on The Health Care Blog.
As recent events in northeastern Syria make clear, the number of displaced people in the world is rising — as are their health needs.
In 2018 I went with a team of other doctors to a Syrian refugee camp in Lebanon. At one stop, a woman offered us homemade bread as we examined her husband, although the couple had very little money and not enough food for themselves. As we ate the bread, she asked if we could leave them extra medications since they didn’t know when the next humanitarian mission would come through their camp.
Her request was reasonable in the situation – indeed, many other refugee families we treated asked us the same thing. Their host countries’ healthcare systems are simply not equipped to handle their needs. Lebanon alone has almost 1.5 million refugees, an increase of 1/4 of their population.
But expecting vulnerable and displaced people to hoard needed medicine is neither sustainable nor humane. Instead, we must make it part of the social contract for healthcare corporations to use some of their massive wealth to help reduce disparities in global access to healthcare. Pharmaceutical companies and the retail industry have already created efficient models healthcare corporations could follow.
Currently, many nongovernmental organizations raise money to send volunteers to refugee camps and other areas with dramatic unmet need. Often these volunteers ask their hospitals to help by donating equipment. Sometimes healthcare companies will also donate equipment or medications, but the path to achieve these contributions is neither easy nor guaranteed.
On both my trips to Lebanon, the healthcare providers on our team cobbled together bags of medications, pacemakers and other equipment we needed to do our work there. Most of the equipment came from our local hospitals, with a smaller percentage coming from the medical companies.
Yet most healthcare companies have mission statements that describe increasing health and wellness. For example, a highly respected company, Johnson & Johnson, writes in their Credo, “We must help people be healthier by supporting better access and care in more places around the world.”
I propose that these healthcare companies send their own representatives to refugee camps around the world to see firsthand what their lifesaving products could do. The price would be small for them, compared to the cost to NGOs operating on a shoestring budget, or volunteers paying out of their own pockets. The logistics would be easier for them as well. Many of these companies already operate in countries that host refugees.
Once on the ground, representatives could work with NGOs that know the local landscape to donate medications. A model for this action is the pharmaceutical companies that make HIV medications. Many African countries have a very large population with HIV, and patients are not able to pay for medications as they do in more affluent countries. In these regions, pharmaceutical companies often sell the medications to local governments or NGOs at a substantially lower price than they do in the United States, for example. Certainly in Africa, pharmaceutical companies are not motivated purely by profit.
Another model for philanthropy comes from the retail industry. For example, the sock company Bombas advertises that for every pair of socks sold, it donates one pair. This sell-one-give-one model could be applied to the pharmaceutical or medical device industry as well.
Donating medical supplies would have tax benefits for the companies. In addition, providing supplies directly from the source would eliminate waste and inefficiency in the system. Currently, a hospital purchases a device from a company and then donates that device to an NGO. But it’s much cheaper for the company to donate the device directly because the cost of the device is cheaper to the manufacturer than to the consumer.
A downstream benefit would be that if the refugees had more access to medications, they would be healthier and less of a burden to the local healthcare systems, which are already incapable of handling the additional patient volume. Additionally, by using fewer local resources, animosity towards refugees for taking away resources could be diminished.
In the camps, local citizens and the West at large often see the “poor, dirty refugee.” But most of the refugees are proud, honorable citizens that had to flee due to no fault of their own and would love to go back to their lives if given the opportunity. That is sadly not possible. Seeing them hoard medications because they don’t know if our visit will be the last group they see for six months or three years is not only heartbreaking, but immoral in the face of the resources that are already available to healthcare corporations.
Some will argue that “charity begins at home” — there will always be needs that go unaddressed. However, we should not be paralyzed to inaction because other places and people also need our assistance. We start somewhere and make a difference in one life, one camp, one city or one country.
When I was visiting the couple in Lebanon who offered us the bread, I kept thinking of the children’s story about an impoverished village and an individual who began to make a meal out of a stone. Soon, others offered vegetables and meat. In time, they made this stone soup into a real soup, capable of feeding the entire village. Likewise, the occasional visit from a foreign doctor with a little medicine and cobbled-together equipment cannot do much for the millions of suffering refugees; however, with the help of NGOs and medical companies, small acts can be magnified and scaled to sustain our global village.
Dr. Krishnan is a cardiologist and Associate Professor at Rush University Medical Center in Chicago, as well as a Public Voices Fellow at Rush University.
The post What a Sock Business Can Teach Health Care Companies appeared first on The Health Care Blog.
Healthcare providers are
moving forward with their digital initiatives, pursuing intranet development, implementing e-prescribing software, and deploying
EHR systems and patient portals to enhance patient care, maximize staff
efficiency, and improve the bottom line.
However, while medical professionals
are largely enthusiastic about digital healthcare solutions, the disparity
between the rate of clinical support and patient utilization of some of this
software, patient portals in particular, is enormous. Even though patient
self-service solutions have become ubiquitous in medical facilities nation-wide,
over 62% of US hospitals report that their patient portal systems are used by less than a quarter of all patients.
Patients still don’t see
enough value in patient portals, voicing concerns over the steep learning curve,
lack of training, anxiety regarding data security and confidentiality, and
other issues. Addressing these challenges is critical to encouraging patient
buy-in and getting more patients involved in their health.
Since most medical
facilities in the country already have patient portals in place, the next step
to overcome barriers to their adoption is to expand these systems to deliver
features that will get more patients involved.
A Friendly User Interface
A clunky and inconsistent
user interface is a major stumbling block that makes it impossible for many
patients to make it past the sign-up screen. Even if patients feel motivated to
use a self-service portal, when they crash upon a counterintuitive UI, their initial
enthusiasm quickly gives way to frustration and resignation.
with a patient portal can discourage patients from any further attempts to use it
in the future. For that reason, one of the first improvements to consider for any
existing patient self-service system should be UX optimization. A skilled frontend development team can enhance the design and navigation of any
patient portal to create a seamless user experience and keep patients involved.
An Effective Mobile App Combo
market penetration in the U.S. exceeds 70%. The general shift toward mobile devices also
impacts healthcare consumers, as they are increasingly engaging with their
health using mobile tools.
To address this trend, nation-wide
healthcare services suppliers such as UnitedHealthcare support patients with
custom mobile patient portal solutions that make it possible for the users to
take care of their health on the go. Smaller medical providers are also catching
up, leveraging out-of-the-box apps and extending them to deliver patient
self-service capabilities on mobile devices.
registration forms ease the registration workflow by offering a simple and
time-efficient way for patients to fill out their details and consents before
the first appointment.
By reducing patient wait
time in medical facilities and enabling end-to-end secure control over the
submitted data, digital forms are a simple method of encouraging patient
communication. Online forms also benefit healthcare services suppliers by alleviating
the front-desk burden, minimizing the likelihood of clinical errors,
streamlining patient flow, and delivering a holistic view of a patient and their
Many available patient
portals already support online registration; others can be easily extended with
custom functionality or integrated with one of the available off-the-shelf
While most patient portal
solutions by default support integration with core EHR systems, by extending an
open API, they can also connect to other third-party digital solutions and
medical IoT devices, such as step counters, glucose monitors, or sleep
Considering the growing use
of wearables by US consumers that’s more than tripled since 2014, open APIs
become an instrumental feature of any patient portal.
When patients couple their
portal profiles with e-health wearable devices, they can automatically upload
and sync all their health data to gain a detailed insight into their health and
well-being over time.
Thanks to real-time
information flow between various tracking devices and health systems, physicians
can regularly and easily review patient vitals to make informed diagnostic and
Top patient portal
solutions, like those of Nextech, MyChart, or Athena, embed secure messaging to
offer an alternative to face-to-face medical appointments through asynchronous,
direct communication with physicians.
This type of interaction
can be of particular advantage to patients with chronic illnesses or mobility
issues, and those living in remote areas. Because of the highly-sensitive
nature of the data processed through patient portal systems and regulatory
compliance requirements imposed on healthcare providers (HIPAA, to start with),
all patient-doctor communication must be properly secured with data encryption.
According to a report by TransUnion, 62% of patients say that knowing their healthcare expenses in advance impacts the likelihood of their pursuing care, while 68% of healthcare consumers fail to pay off their medical bill balances fully.
To resolve these concerns,
comprehensive patient self-service solutions such as Experian Health feature a
payment management component that supports a wide range of payment options,
providing patients with greater transparency when it comes to managing health finances.
These features include e-payments,
billing queries, insurance support, payment history and retrieval, and more. By
extending these features, healthcare organizations can not only augment patient
engagement and increase patient portal utilization but also monitor and manage
patient collections to boost recovery rates.
Toward a More Convenient Access to Healthcare
make persistent efforts toward patient-centric, value-based care. Introducing
and enhancing patient portal solutions makes this task easier, allowing medical
providers to promote proactive patient self-care and spur meaningful patient interactions.
Empowering patients with a sense of authority and responsibility for their health with patient portals creates opportunities for better patient engagement, which in turn drives better treatment outcomes. On top of that, fostering patient activation through self-service patient software enables providers to become eligible for MIPS and other incentive programs and further refine the quality of their healthcare services.
Sandra Lupanova is SharePoint and Office 365 Evangelist at Iflexion, a software development and IT consulting company headquartered in Denver.
The post 6 Core Patient Portal Features to Get More Patients on Board appeared first on The Health Care Blog.
The Cure for healthcare isn’t Medicare for All, it’s establishing organizations with complete responsibility for the total care, costs, quality and outcomes for a person.
Discussions of Medicare for All substitute structure for substance. They engender a debate about the trappings of care delivery, administration, and cost, but don’t address the fundamental issue, which is how to provide genuinely better care for people of all ages and economic circumstances.
The premise of Medicare for All is that a single payer will provide better and more cost effective care. But what is really needed is single entity accountability. Whether there are one or many, whether they are public or private, is not as important as that one organization and its people become responsible for the total health and care of an individual and the costs associated with that care. With incentives for doing it well, and penalties for doing it poorly. And an ease of transition for people to move from an entity that doesn’t serve them well to one that does, to maintain the benefits of competition and varied approaches based on differing conditions.
Focusing on Medicare for All promulgate a systemic flaw baked into our health insurance and provider systems. High costs and lower quality can’t just be fixed by a single payer negotiating lower drug prices, nor would providing fewer services mean better care at lower costs. The core problem is exemplified by the invidious arbitrary split in public health insurance between Medicaid and Medicare, with each providing different services spread out among many providers, none of whom have sole responsibility for the complete health of the person.
BetterCare for All need not be a win-lose proposition, of Medicare for All or nothing. The feasibility near term of a one payer system is low, whereas the feasibility of building on existing systems and frameworks to create single system accountability is much higher.
Single accountability addresses the structural flaws in the US health system, which have positioned the US to have the highest costs for healthcare in the world while ranking 11th (last place among developed nations) in the quality of care, with all the negative quality of life implications that implies.
Whether it’s Medicare, a form of Medicaid, or private insurance, unless a single entity oversees the care of a person across the so-called care continuum — home, office, hospital, facility — and the levels of reimbursement and pay are adjusted by the quality of care and outcomes of that person, the systemic problem of high costs with poor outcomes, and lack of access, will remain in place.
Health care provision is often well described as being in silos, or buckets. For example, when an enrollee in a Medicaid program has to go to a hospital, the Medicaid plan’s responsibility, oversight, even patient information, stops. Similarly, while many Medicare recipients could benefit from services in the home, Medicare doesn’t cover most of them. The same individual is arbitrarily — one should say absurdly — carved up into different components for care services. The results from this lack of coordination are severe. Estimates of excess costs stemming from lack of coordination range from $45 billion annually on up.
Our fractured system embeds structural conflicts among the major parties, to the detriment of the patient. Insurers are called payers, which sums up their primary function and the limit of their mandate, which has little to do with actual care quality. Under fee-for-service models, their incentive is to limit services provided and the costs of those services. Recently a branch of UnitedHealth Group, a huge payer, that administers treatment and addiction services for insurance plans was found to have violated its fiduciary duty under federal law by using overly restrictive guidelines and adopting financial incentives intended to restrict access to care, reflecting the perverse incentives of what should be a system promoting care, not limiting it.
Fee-for-service providers, on the other hand, want to maximize services to generate revenues, and make up in volume for the discounts they have to offer to obtain payer clients. Hence the frequent accusations of in effect churning tests and procedures, inflating costs well beyond what are necessary.
Under so-called alternative payment models, such as value-based payments, the payer shifts the burden of total cost to a provider, giving them a single, capitated rate for the set of services they provide. That of course encourages minimizing services and their related costs, with adverse impact on patients. Hospitals and large plans in turn attempt to slough off their obligations under value payment models by shifting the burden of performance to practitioners or agencies.
That structure causes a lack of alignment between who could institute improvements, such as the introduction of new technologies, and who might benefit from their use. A home care agency might be best suited to provide better technology to gain and use information about the patient in the home, but they do not benefit financially from better outcomes and so have no incentive to bear the costs of the technology.
In a recent briefing on meeting cost reduction goals for NY State’s Value-Based Payment program by its Dept. of Health, healthcare plans were specifically told to only address Medicaid payments, and not Medicare. Why? Because states pay for Medicaid, but the feds pay for Medicare. i.e., when it comes to Medicare management, the state doesn’t care! Yet the high costs and quality imperfections of our system reside as much in Medicare as Medicaid.
Medicare for All also posits an increasingly central role for hospitals in the care infrastructure. But hospitals are not well-suited to be the organizations that provide comprehensive care management. Hospital cultures, skills, staffs, training, are all built around taking care of people in the hospital. And while hospital executives might howl in protest, the simple fact is that hospitals are ill-equipped to deal with people outside their four walls, to be purveyors, or even monitors, of home and community based services. They have historically evinced little interest in doing so, and even now, with various incentive and penalties in place to try to force them to look to care in the community, they don’t do it at all or very well.
Integrated health systems, such as Kaiser, are better situated to do so. Within those systems hospitals focus on being better hospitals, nested within an administrative superstructure that manages care — and equally importantly costs — across all stages of a person’s care life. Establishing such networks or comparable managed care organizations would do more and more quickly than trying to shoehorn hospitals into a central care management role they can’t fulfill.
A recent study from the University of Colorado Anschutz Medical Campus found that
60% of home health workers say they lack adequate patient information from hospitals to inform care, often leaving patients unprepared for treatment. Another study found that 94% of patients had at least one medication discrepancy when comparing referring provider and home health care medication lists. These problems persist, and won’t be solved by trying to change hospitals’ “personalities.”
The nation funded tens of billions of dollars to underwrite electronic health records in the abstract belief that improving the storage and access to care information would in turn have a salutary effect on care quality. Only the disparate EHRs installed in hospitals and provider systems don’t talk to each other, nor do they include effective gathering and use of information about patients where they spend most of their time, in the home or other non-clinical settings beyond the scope of EHR data collection.
Attempts to fix these issues are perforce piecemeal, since they simply mirror dealing with the different spokes of care one at a time rather than building a central hub of care management and responsibility. Various programs that try to connect some of the dots between Medicaid and Medicare still leave large gaps in between, as have those which seek to reduce avoidable hospital readmissions that cost an estimated over $30 billion a year, year after year.
Enormous strides and cost savings while improving quality can be obtained by more inclusion of information from and services in the home, where people spend the bulk of their time and where many health problems originate. Discerning these problems in a timely fashion can prevent deterioration, provide lower cost treatment options, and enable people to remain where they most want to be.
But the orientation of hospitals and providers has been to ignore the home in favor of the more costly and burdensome options of hospital, emergency room, office, and nursing home. Study after study indicates the enormous costs from poor coordination among many providers; a single entity tasked with managing the entire care of the individual, including their home, is the best solution to getting universal coverage at an affordable price.
In my former position as Director of New York City’s Energy Office, we instituted energy conservation programs with measures from swapping lightbulbs to upgrading insulation and HVAC systems which paid for themselves in 1–2 years. But there is no concept of payback in healthcare. What organizations hear is, “we have to pay for something now,” without doing the math as to the benefits over time such investment can yield, operating within an infrastructure that doesn’t incentivize them to make such calculations.
Our health care system suffers from the artificial separations of services to people — Medicare and Medicaid, between payers and providers, the isolation of home and community services from institutional ones. The cure lies in connecting these elements with strong bonds under the management of a single entity charged and familiar with the total life of the person we call a patient, but who is far more than that.
Robert M. Herzog has been an entrepreneur and consultant in technology, media, finance, and healthcare, most recently as founder and CEO of eCaring, Inc. This post originally appeared on Medium here.
The post BetterCare for All appeared first on The Health Care Blog.
What’s next for digital health’s premier IPO, Livongo? Executive Chairman Glen Tullman says “the best day of going public is the day you go public,” but there’s got to be more to it than that right?! We get inquisitive about acquisitions, keeping the market happy, and how his applied health signals company is blurring the lines between tech and healthcare. Is Livongo a tech company or a healthcare company? What does that AI-plus-AI really add up to?
Filmed at the HIMSS Health 2.0 Conference in Santa Clara, CA in September 2019.
The post Livongo’s Post-IPO Plans? | Glen Tullman, Livongo appeared first on The Health Care Blog.
It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.
This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.
We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life
Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.
In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.
I think that is a factor mostly when someone is looking for sophisticated specialty interventions, often one-time-only, like “where’s the best place to go for high risk cardiac surgery”.
When looking for primary care, people still tend to ask, “who’s a good doctor”, rather than “which is the better primary care group, Uptown Medical Associates or Statewide Primary Care”.
How do you as a clinician in today’s restless and mobile society earn trust and build therapeutic relationships in fifteen minute visits with several visible and invisible intruders in the room – the computer and the insurance company, for starters.
I have previously reflected on how to prepare yourself for beginning a clinical encounter. My ABCs are Attention, Behavior and Connection.
But where do you go from there, how do you continue, grow and nurture a therapeutic relationship over time in the kind of environment most of us work within?
Here are a few lessons I have learned myself:
1) Listen and respond. How many times do we hear that patients don’t get to speak for even a minute before we interrupt them? If you hear something that immediately requires clarification, do what you would do in a social situation. Say that what the other person just said is important or interesting, reflect back what you think you understood and then be careful not to give them too many yes or no options, but invite them to continue their story. Imagine that you’re meeting an interesting person at a dinner party, not leading a legal interrogation.
2) Set an agenda. Almost every time I ignore this little rule, I get burned. Patients may not reveal their real concern when making an appointment and their priorities may have changers since then. Going all-in with what you think is their main issue and saving “do you have any other concerns” until the end of the visit is a recipe for disaster. That agenda-setting may need to be addressed right away or after hearing a little about the main concern. If you don’t ask what people need from you, how can you ever hope to fill your role as their provider?
3) Budget time. Don’t act frustrated about the reality that time is at a premium, and don’t declare that you have too little of it until you know how serious or urgent your patient’s concern is. The person with a seemingly trivial concern may need you to help them with the biggest or worst problem of their life, so invest your time and attention on listening and understanding early on in the visit. By acting unhurried at first, you are more likely to create an atmosphere of trust and caring; once you know your patient’s concern and their diagnosis or differential diagnosis, if they feel heard, you can move more quickly to wrap up the visit if you need to.
4) Manage the perception of time. If I am running late, I often enter the exam room and demonstrably sit down, take a deep breath and relax my posture as if I am finally arriving at the most important appointment I have all day. That slowing down gesture helps me to undo my patient’s fear that I’m going to be rushing them along. If they think I’m not going to meet their needs, their memory of the visit will likely be just that, even if I do a pretty good job technically for them.
5) Don’t be a hero. My 2018 post “Be the Guide, Not the Hero” points out the fact that everyone is on heir own journey in life and we are at best guides in our patients’ pursuits. If we try to be the hero in their stories, we create unhealthy, dependent relationships that often lead to patient disappointment or even resentment. As guides instead of heroes, we also remind ourselves that we are not the ultimate experts on what is best for our patients. Since our patients are the heroes of their own stories, they must ultimately decide which piece of advice from which guide they will choose to follow.
6) Be true to yourself. On the one hand, I believe we must adapt our demeanor to the situation – reassuring, motivating, inquisitive or sometimes decisive – but we must stay within the range of our real selves. I can be jovial only to a point or I will seem and feel like I am pretending, for example. People can usually sense falsehood a mile away.
7) Balance disclosure. We can not build therapeutic relationships as only technicians; we must engage as real people and you can’t be real without showing emotion, genuine interest, engagement and a good amount of humility. We have to be careful to show that we are fallible like everybody else but also that we ultimately have our act together. Nobody wants a self absorbed, overconfident guide, but nobody wants a weak and insecure one either. If we say we never had tough choices to make or regrets we carry with us, how can we expect patients to allow us to be close enough to build trust?
I tell people things they could relate to that I don’t think would come back to haunt me. I tell them how many miles I have on my car, but not how much money I spent on repairs. I tell them about my life lessons from being a Boy Scout or going through basic training in the Swedish army, the antics of the beagles I’ve had in my life or the way my one-time vegetarian diet made me put on weight. I tell them I was homesick at my first scout camp, but I don’t talk about things that could distance patients from me; not that I am a golfer or a sailor, but pictures and magazines of such things will alienate as many patients as it might build relationship with. My Arabian horses didn’t cost much money, they were adopted from a horse rescue and simply needed a home. Our relationship with animals, I believe, is more likely to show that we have the capacity for relationship building with humans, too.
8) Build continuity. From one visit to the next, find a thread to follow. For some patients, it is their chronic disease, for others their family or their hobby. Reconnecting about what you talked about last time is a powerful and quick way to reestablish the fact that you know each other and that you care about your patient. It brings you straight into a space where you are ready to do the work you do. Even if you have to pull up their last visit in the EMR (maybe even looking at the screen together), that quick reconnection that begins every visit helps make you seem better prepared; maybe you don’t remember the details of the last visit but you do remember your patient very well.
9) Solicit participation. When it’s time to formulate a treatment plan, don’t be too quick to lay it out as if there is only one way to do things.
10) Plan when and how to reconnect. “Followup PRN” isn’t usually the best way to conclude a visit in your mind or the EMR. Friends don’t usually leave each other saying “I’ll see you around”, that’s more for casual acquaintances. It’s important to agree on what to do after the test results come in, when the antibiotic runs out, if the rash doesn’t go away or when to meet up if everything is going well. Not making such plans devalues the relationship and makes you look as if you don’t care about your patient.
Everything on this list is about how we interact with the people we engage with frequently or infrequently. We must always look beyond the diagnosis and the Chief Complaint (which should be Chief Concern – where did “complaint” come from?). Remember Osler:
The good physician treats the disease; the great physician treats the patient who has the disease.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
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Today on THCB Spotlight, Matthew catches up with Kuldeep Rajput, the founder and CEO of Biofourmis. Biofourmis uses biomarkers and sensors for health management, in pursuit of this dream of predicting disease before it happens so we can improve and health outcomes. The key question here is, how do you take a known pharmacotherapy and combine that with a digital solution so that it can synergistically act on patients to drive meaningful outcomes?
Biofourmis announced this week that they are acquiring Biovotion, as well as a commercialization deal with Novartis. Why did a device-agnostic platform decide to acquire a biosensor company? For the contract with Novartis for a major rollout of their heart failure platform across Asia—what are they trying to accomplish?
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Today is Health in 2 Point 00’s 100th Episode and we are reporting from Frontiers Health in Berlin! Jess and I talk about Google & Ascension’s deal to move all of their information and data onto Google Cloud, however, they are currently facing backlash over data privacy issues and are being investigated by HHS’ Office for Civil Rights. Apple released some new research on EKGs, carrying out a clinical trial on 400,000 people, I didn’t think their results were that interesting, but their ability to reach that many people for a clinical trial was impressive and may open up new doors in research for recruiting participants using Apple products. At Frontiers Health, Noom, a nutrition startup focusing on managing chronic care conditions, announced that they are looking to do $235M in revenue by this year, which is big news considering Livongo (which IPOed this year) did $165M in revenue. We also take a moment of silence for Bernard J Tyson, CEO of Kaiser Permanente, who was an active leader for equity in health care and a leading black executive for the community. Rest in Peace – Matthew Holt
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Forced absence from gun violence has created a literal and metaphorical void in schools across our country that may impact students and staff for decades to come. The students are referred to as “Parkland kids,” “Sandy Hook students,” or “Columbine survivors.” These labels are sadly reflective of a new reality for American schools, as students, teachers, and staff no longer feel safe. America’s students feel vulnerable as the facade of schools as a safe place is no longer true. The Center for American Progress recent report revealed that 57% of teenagers now fear a school shooting.
Often, perpetrators of gun violence leave a trail of “red flags” for years, as they are troubled youths. This was the case in the Parkland shooting. Tragically, multiple agencies failed to respond to the signs the troubled young man was leaving, including specifically writing online that he aspired and planned to be a school shooter.
In the aftermath of the Parkland, Florida tragedy, parents and school districts turned to security experts demanding a plan of action. Sadly, the information provided was substandard and lacked evidence to support the strategies as efficacious. Lives weigh in the balance and there is no more tolerance for guessing.
Research is needed to guide the creation of evidence-based frameworks for school communities to address prevention as well as protection. Threat assessment teams are a strategy to assess for potential threats, but more importantly is that an intrinsic safety network is woven into the fabric of the educational system. Exposing the root cause of the contagion of violence impacting our youth is key.
School communities are looking for guidance, answers, and action to address the explosion of school-related violence, including mass shootings. We are grappling with questions of safety from mental health service availability, system strategies to best protect students and staff, and determining the root cause of this burgeoning public health crisis. There is an agenda to toughen up America’s schools by arming teachers and adding additional resource officers in a knee jerk effort to protect students, but do not prevent further events. These purposed reactive strategies lack scientific support.
To date, little to no data has been collected about the long-term impact of exposure to gun violence. We count the number of events, weapons used, number killed and injured, but we do not measure the outcomes of the collateral damage to the students, staff, parents, and society in general. Americans are living in the liminal space of these violent events, waiting for the next one, which is the new sad reality. America is teetering between what was once safe and the realization that American students are now more vulnerable than ever. America is in the unchartered territory of gun violence, America’s schools are minefields. We must not look away from the fallout, instead we must study the direct trauma and the vicarious trauma of societal association, as all America is affected, especially our vulnerable children.
Children carry trauma in their genes, as stress of this magnitude can have life-long health impact. Exposure to adverse childhood experiences leads to toxic stress that changes our biology and impacts long-term health outcomes well into adulthood . Not all children who experience developmental trauma are impacted in the same way. We must examine these long-range health implications for those exposed to a life-threatening event such as a school shooting, as well as what makes them thrive.
Resilience, or the ability to bounce back, is a learned skill that facilitates the ability to emotionally circumvent present circumstances. Gun violence research will inform prevention strategies that may facilitate resilience in children, but until an evidence-informed pathway for prevention is in place, we are simply reacting out of fear. We must act responsibly with our strategies to mitigate this public health crisis of gun violence. The dearth of research in all aspects of gun violence and the lack of an evidence-based framework for prevention has added to the intensity of the public health epidemic in which we find ourselves, and until this supportive science is in place, America’s students will continue to suffer.
The numbers are astounding, as 26,000 children and teens have been killed in gun violence between 1999 and 2016 (Ingraham, 2018). There are 26,000 desks that sit empty in schools across this country from deaths due to gun violence, forced absences. A void that students feel. Students have not forgotten their friends, and nor must we, as they are America’s fallen students. This number is rising and an emerging public health crisis is unfolding before our eyes and we must have courage of conviction to stop this through research-informed preventative strategies.
WHERE WE NEED MORE RESEARCH
School communities need evidence-based preventative safety strategies that focus on psychological and physical safety initiatives.
Research is needed to understand short and long-term impact of exposure to gun violence and its potential effect on long-range health outcomes in students.
Parsons, C., Thompson, M., Weigend Vargas, E. and Rocco, G. (2018). America’s Youth Under Fire – Center for American Progress. [online] Center for American Progress. Available at: https://www.americanprogress.org/issues/guns-crime/reports/2018/05/04/450343/americas-youth-fire/ [Accessed 6 Sep. 2018].
National Scientific Council on the Developing Child (2010). Early Experiences Can Alter Gene Expression and Affect Long-Term Development: Working Paper No. 10. http://www.developingchild.net
The National Child Traumatic Stress Network. (2018). Effects. [online] Available at:https://www.nctsn.org/what-is-child-trauma/trauma-types/early-childhood-trauma/effects [Accessed 30 Sep. 2018].
Ingraham, C. (2018). More than 26,000 Children and Teens Have Been Killed in Gun Violence Since 1999. [online] Washington Post. Available at: https://www.washingtonpost.com/news/wonk/wp/2018/03/23/more-than-26000-children-and-teens-have-been-killed-in-gun-violence-since-1999/?noredirect=on&utm_term=.6cc2298493c0 [Accessed 6 Sep. 2018].
Robin Cogan, MEd RN NCSN is a nationally certified school nurse in the Camden City School District and a part-time lecturer and Clinical Coordinator at Rutgers-Camden School of Nursing. This post originally appeared on Affirm here.
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“YOUR LIKELIHOOD OF SECURING RESIDENCY TRAINING DEPENDS ON MANY FACTORS – INCLUDING THE NUMBER OF RESIDENCY PROGRAMS YOU APPLY TO.”
So begins the introduction to Apply Smart: Data to Consider When Applying to Residency – a informational campaign from the Association of American Medical Colleges (AAMC) designed to help medical students “anchor [their] initial thinking about the optimal number of applications.”
In the era of Application Fever – where the mean number of applications submitted by graduating U.S. medical students is now up to 60 – some data-driven guidance on how many applications to submit would be welcome, right?
And yet, the more I review the AAMC’s Apply Smart campaign, the more I think that it provides little useful data – and the information it does provide is likely to encourage students to submit even more applications.
This topic will be covered in two parts. In the first, I’ll explore the Apply Smart analyses and air my grievances against their logic and data presentation. In the second, I’ll suggest what the AAMC should do to provide more useful information to students.
Introduction to Apply Smart
The AAMC unveiled Apply Smart for Residency several years ago. The website includes lots of information for students, but the piece de resistance are the analyses and graphics that relate the number of applications submitted to the likelihood of successfully entering a residency program.
The first thing we need to do is get oriented to these figures.
The Apply Smart graphics all take a similar form, so for sake of example, let’s examine the one for U.S. medical graduates who applied to residency programs in internal medicine.
APPLY SMART: INTERNAL MEDICINE
The x-axis shows the number of applications submitted by students applying for residency positions. Pretty straightforward.
The y-axis is labeled “Probability of Entering a Residency Program.” It corresponds to the percentage of applicants who successfully entered a residency program in internal medicine. Everyone who enters an internal medicine residency program gets counted, regardless of whether they entered through the Match or the SOAP.
The curves show the probability of entering a residency program in that specialty for the group of candidates who applied to x number of programs.
The curves were created using spline regression. By tracing each curve, we can see how that probability of residency entry changes with the number of applications submitted by different groups of candidates.
The graphic for internal medicine (and most other specialties) has three curves. Each corresponds to a group of applicants with a particular range of USMLE Step 1 scores (bottom, middle, or upper tertile).
THE “POINT OF DIMINISHING RETURNS”
Each curve has a point labeled as the point of diminishing returns – the point at which the relationship between the number of applications submitted and the probability of entering a residency program changes. (This was calculated as the first knot in the spline regression.)
Up to the point of diminishing returns, the group of applicants who submit x+1 applications have a higher probability of entering an internal medicine residency program when compared to those who submit just x applications. After the point of diminishing returns, the probability of entering residency program stops increasing with each additional application.
WHAT ARE WE SUPPOSED TO CONCLUDE FROM THE APPLY SMART GRAPHICS?
Here’s what we’re supposed to take away from these graphics. Let’s use the emergency medicine graphic as an example.
APPLY SMART: EMERGENCY MEDICINE
Suppose I want to apply in emergency medicine, and I have an ‘average’ USMLE Step 1 score (middle tertile, 221-237). That would put me on the gray curve in the chart above, and would place my point of diminishing returns at 23 applications (with a confidence interval of 22-25).
Bear in mind, the mean number of applications submitted by U.S. MD graduate applying in EM in 2018-2019 was 51. But according to the AAMC, applying to more than 23 programs will not significantly increase my probability of entering an EM residency program – so why waste my time and money?
At first glance, this sounds great. Maybe if all applicants used the Apply Smart graphics, they’d stop applying to so many programs, and we’d finally break Application Fever? Right?
I mean, why not?
My issues with Apply Smart
I’ve got a few.
I’ll begin with more philosophical issues before highlighting the major methodological flaw that is likely to prevent the Apply Smart campaign from doing anything other than stimulating students to submit even more applications.
PROBLEM #1 – PERPETUATION OF MISINFORMATION
The official video for Apply Smart states:
You’ve probably heard that residency slots aren’t growing at the same rate as graduating medical students – so an already complex and competitive situation has become, well, even more complex and competitive.
Here’s the problem. It’s not true.
Here’s what is true. There are more residency applicants than there are PGY-1 residency positions. (That’s been the case since 1992.)
What is not true is the disparity between applicants and available positions is widening.
SCREENSHOT FROM THE OFFICIAL APPLY SMART VIDEO, IN WHICH A MEDICAL STUDENT WITH A HANGDOG FACIAL EXPRESSION PONDERS THE WIDENING DISPARITY BETWEEN MEDICAL SCHOOL GRADUATES AND RESIDENCY POSITIONS. (CHEER UP, BRO! IT’S NOT TRUE!)
The number of medical graduates is increasing – but so are PGY-1 residency spots. So the best way to look the disparity between the two is by calculating the number of available positions per applicant.
Since 1996, that ratio has been relatively stable around 0.8 positions per Match applicant (range: 0.75-0.86). In fact, there has been an improving trend over the last 5 years or so, as you can see from the graphic below (taken from the 2019 NRMP Match Results & Data report).
Notice that, for U.S. allopathic seniors, there is a substantial (and increasing!) surplus of residency positions. In fact, in 2019, there were 1.70 residency positions available for every graduating American M.D. – which is the highest it’s been in over 40 years.
Match rates are improving, too. (Not for U.S. seniors – because they’ve had a Match rate of 92-95% since 1982. It’s kind of hard to go up from there.) But if you look at the overall match rate – including all applicant types – it’s increased from 71% in 2008-2009 to 80% in 2019.
Obviously, these statistics do not fit the common narrative that the residency job market is tightening. Application Fever is not driven by a major change in the competitiveness of the residency selection marketplace. (As I’ve discussed before, the perception of increased competition occurs because not all programs are equally desirable to applicants, and applicants realize that ‘overapplying’ to programs provides a relative advantage against their peers in securing a desired commodity.)
So I take issue with the AAMC framing their campaign with this kind of misinformation. Claiming that residency positions aren’t growing at the same rate as applicants is neither fact-based nor helpful if your goal is to encourage candidates to submit a rational number of applications.
PROBLEM #2 – CORRELATION DOES NOT EQUAL CAUSATION
The Apply Smart data are observational. The AAMC did not create these curves by randomizing applicants to apply to x number of programs, and then measuring their match rate. They just observed what happened in the real world.
Thing is, students do not apply to a certain number of residency programs at random. Whether a student applies to 5 programs or 105, there are reasons for it. Students who choose to apply to more programs likely differ systematically from those who choose to apply to fewer in myriad ways that impact their attractiveness to program directors.
In fact, some of the Apply Smart graphics show an interesting pattern for students applying to the largest number of programs. Take, for instance, this one, for students applying in anesthesiology.
APPLY SMART: ANESTHESIOLOGY
Look at the yellow curve – the one for applicants with USMLE Step 1 scores >/= 237. Notice how it bends downward on the right-hand side of the graphic? In fact, it looks like it would fall significantly below the curve for applicants with lower USMLE scores if the x-axis were extended, doesn’t it?
Would these students have had more success in the match if they’d only applied to fewer programs? I doubt it. There’s something else going on there. More likely, relatively weaker students choose – very reasonably – to apply to more programs to maximize their chance of matching. Stronger candidates just as reasonably choose to apply to fewer.
Simply put, we cannot use the Apply Smart data to conclude that a student can increase his likelihood of successfully entering a residency program by applying to more programs, or that another student will have the same probability of success if she applies to fewer. Observational data just do not support that kind of conclusion. Instead, we can only conclude that the type of candidate who applies to x programs has a certain probability of entering a residency program in that discipline.
PROBLEM #3 – BIAS
And now it’s time to discuss the biggest problem with Apply Smart – the probabilities are all biased.
To show you how, let’s start by examining the Apply Smart graphic for my field: pediatrics.
I love pediatrics. It’s a great field, and I’d recommend it highly. But as residencies go, it’s not exactly a competitive one. There a lot of very good residency programs, and each one takes a lot of residents. Sure, if you’re hell-bent on matching at one of the so-called “top programs”, then pediatrics is as competitive as anything else. But outside of that, a capable U.S. medical graduate shouldn’t have trouble finding a good match.
So look at the Apply Smart graphic closely, and explain to me what is going on on the left side of the chart.
YIKES! LOOK AT THOSE LOW PROBABILITIES FOR STUDENTS WHO APPLY TO <10 PROGRAMS!
According to this, U.S. allopathic medical graduates who apply to 5 pediatric residency programs have only a 40% chance of successfully entering a residency program. Ouch! Why didn’t someone tell them to apply to more programs?
Of course, something about this doesn’t add up.
Intuitively, we might expect that the applicants who apply to the fewest programs would enjoy the highest success rates. Given the high cost of going unmatched, you’d think that a student would apply to only 2 programs if she were certain that she’d get into one of them, right?
Remember, also, that under the ERAS fee schedule, applying to 10 programs costs exactly the same amount as applying to 1.
So who are these people who are applying to <5 programs and accepting a 20-40% success rate for residency entry?
I’ll tell you who. People who don’t really care if they match in pediatrics or not.
See, even though the y-axis is labeled “Probability of Entering a Residency Program,” the analyses are specialty-specific. That is, a candidate who applied in pediatrics but matched in another specialty is considered as not having entered a residency program.
The problem is, many students apply in more than one specialty. Check out the ERAS Cross Specialty Applicant Data below.
IN 2018, AT LEAST ONE U.S. MEDICAL STUDENT APPLIED TO EVERY SINGLE COMBINATION OF SPECIALTIES LISTED ON THIS TABLE.
Maybe there are 410 students who honestly couldn’t decide between their love for anesthesiology and and their passion for pediatrics, and 332 students who were completely torn between a career as a pediatrician and one as a general surgeon. Or maybe, just maybe, most of these candidates are applying to pediatrics as a backup.
And because most of these candidates are well-qualified, and will end up matching in their preferred specialty, they only submit a handful of applications in their backup specialty.
So that’s why the Apply Smart analyses all look the way they do, with an increasing probability of residency entry up to the ‘point of diminishing returns.’ It’s because the data are biased by backup applications.
(In fact, I have a hunch that if the AAMC removed the backup specialty applications and instead ran the analysis using only applicants in their preferred specialty, there would be no “point of diminishing returns.” Think about it: if you had your heart set on being a general surgeon, but you only applied to one surgery program, you’d have to be pretty darn sure you were going to match there, right?)
PROBLEM #4 – MORE BIAS
Including backup applicants doesn’t just bias the determination of the ‘point of diminishing returns’ – it biases the rest of the analysis as well.
To demonstrate how, let’s take a look at the graphic for diagnostic radiology.
APPLY SMART: DIAGNOSTIC RADIOLOGY
Imagine you’re a would-be radiologist with Step 1 scores in the upper tertile, and you want to figure out how many applications you should submit.
So you look at the yellow line in the graphic above, see that the point of diminishing returns is at 20 applications. (Not bad, when you remember that the average U.S. medical student applying in diagnostic radiology submitted 49 applications in 2019.)
But wait. What’s that dashed line extending to the left from the point of diminishing returns? What does that mean?
Oh. Wait a second.
According to Apply Smart, that little dashed line means that even candidates with the highest tertile of USMLE scores have only around a 65% chance of successfully entering a diagnostic residency program when they apply at their point of diminishing returns.
Is diagnostic radiology really that competitive?
No. It isn’t.
In reality, the Match rate for U.S. seniors in 2019 was 89%. (And bear in mind, that’s the Match rate for all comers, not just those in the top third of Step 1 scores.)
Again, this is due to the failure of Apply Smart to exclude candidates who are applying to backup specialties. The net effect is that the asymptote of the probability curves falls below the actual Match rate for every specialty.
FOR EVERY SPECIALTY, THE MAXIMUM PROBABILITY OF RESIDENCY ENTRY ACCORDING TO APPLY SMART IS SIGNIFICANTLY LOWER THAN THE ACTUAL MATCH RATE.
The psychology here is powerful.
Not long ago, on a slow day in clinic, I showed the Apply Smart graphics to a few medical students, and asked them what they took away from the graphics.
One student – a young woman who wanted to be an anesthesiologist – looked at the graphic for that specialty and identified her point of diminishing returns as 18 applications. She smiled and looked relieved – her advisor had suggested that she apply to 30-35 programs.
DON’T BELIEVE YOUR EYES. IN REALITY, 96% OF U.S. MD APPLICANTS SUCCESSFULLY MATCHED IN ANESTHESIOLOGY IN 2018.
And then, without any prompting, she noticed that submitting 18 applications was seemingly associated with only a 70% chance of getting into an anesthesia program.
Her face clouded with worry.
I asked how many programs she thought she’d apply to. “Probably 30 or 35,” she said.
WHAT IS THE LIKELY EFFECT OF APPLY SMART?
The AAMC is quick to point out that, for almost all specialties, the number of applications submitted by the average student is greater than the point of diminishing returns. Therefore, the Apply Smart data should result in medical students submitting fewer applications.
I doubt it.
For the reasons I mentioned above, I question how many students who overapply will apply to fewer programs in response to the Apply Smart graphics. (Try convincing a student with $200,000+ in student loans to apply to fewer programs – when doing so appears to confer only a 60-70% probability of matching in their dream specialty. It’s gonna be a tough sell.).
But for a moment, let’s assume that the AAMC is right, and that all the students who are overapplying choose to decrease their applications to their point of diminishing returns.
In that case, the mean number of applications submitted by students would fall. But would it program directors receive fewer applications overall?
Maybe. It depends whether the Apply Smart data encourages other applicants to apply to more programs.
See, for students applying to fewer programs, the interpretation of Apply Smart graphic is unambiguous: you should apply up to your ‘point of diminishing returns’ in order to increase your probability of entering a residency program.
However, if the candidates on the left side of the graph apply to more programs at the same time that candidates on the right side apply to fewer, then the changes offset each other, and program directors will remain just as buried in applications as they are now.
To predict the effect on overall applications, we’d need to know the actual distribution of applications submitted. Then could estimate how many students apply below their point of diminishing returns, and how many apply above it.
The AAMC doesn’t provide this information. But some other studies do.
Here, for instance, is the distribution of applications submitted by current internal medicine residents.
FROM: ANGUS SV, ET AL. AM J MED 2018; 131(4): 447-452. PUBMED
Notice that the number of applications submitted is not a normal distribution. It’s skewed to the right, with a relatively small number of applicants submitting a large number of applications.
Other specialties likely have similar distributions. And because we’re dealing with right-tailed distributions, where the mean is greater than the median, encouraging applicants to increase their applications up to the ‘point of diminishing returns’ will significantly increase the overall number of applications that are submitted.
Check out these data for general surgery, one of the few specialties in which the median number of applications is publicly available:
FROM: JOSHI ART, ET AL. J SURG EDUC 2019. PUBMED
(In light of this, I’ll leave it to you to surmise why the AAMC only reports the mean number of applications that students submit for most specialties, and not the median or interquartile range or other more informative statistics.)
THE BOTTOM LINE
Apply Smart is not going to fix Application Fever. At best, the analyses are biased and largely uninformative. At worst, they’re actually engineered to stimulate an overall increase in applications.
We can do better… and in Part 2, I’ll explain how.
Dr. Carmody is a pediatric nephrologist and medical educator at Eastern Virginia Medical School.This article originally appeared on The Sheriff of Sodium here.
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