290~6September~1999-48~Feature~Going Global~~Dana James~~Preparing for an international health elective requires a lot of hard work and resourcefulness. But this doesn’t stop more and more medical students—realizing the experiences’ benefits—from seeking them out anyway.


For spring break 1996, Gina Wilson-Ramirez and Steve Pergam, second-year students at the College of Medicine at the University of Nebraska Medical Center (UNMC), were counting latrines and measuring children in Nicaragua with a group of their fellow classmates. It may not seem like the most glamorous of spring breaks, but it was a trip that took two years to plan. Wilson-Ramirez, with a background in public health and Latin American studies and experience with human rights work in El Salvador, was intent on pursuing her passion for international health in medical school. Pergam, a native Omahan, wanted to go places and make a difference. But when they entered medical school, they found an unreceptive administration and classmates who weren’t bit by the same “bug.” Undeterred by the lack of support, Wilson-Ramirez and Pergam connected with a clinic in an underserved area of Nicaragua that is sponsored by an Omaha-area church and Rotary Club. Paying for the trip themselves, they spent their first spring break doing a health-needs assessment and administering vaccinations to members of the community.


But the pair had long-term plans. “We thought that if we could get it off the ground,” Pergam says, “then we could get more people involved.” And after that first year, they began giving talks and slide shows to promote the experience to other students. A group of about 10 signed on. Over the course of the next year, the students took orientation sessions and Spanish classes organized by Pergam and Wilson-Ramirez and raised $20,000 to fund the trip. “It was an amazing experience,” Wilson-Ramirez says. The two students have since moved on to residency programs in New Mexico, but through the leadership of Sara Pirtle, of the Office of International Studies and Programs at the University of Nebraska Medical Center, students from around the country still stream to that clinic today.


Caroline Stuck, deputy director of the Office of International Affairs at the University of North Carolina at Chapel Hill (UNC) School of Medicine, recalls the advice a New York physician gave to a medical student worried about pursuing an international health opportunity without the blessing of the administration: “My view has been—run until apprehended.”


And students are running with it. A growing number of them seek out health experiences around the world, usually in the form of clinical elective rotations or public-health and community-based research projects. And while some structure is developing within medical education to support these opportunities, medical students still have to do a majority of the legwork themselves.


— c —


No national studies have been done in the last five years on the level of participation of U.S. medical students in international health. The most recent numbers, from 1992, showed that about 16 percent participated annually in international electives. The same study, published in Family Medicine, found that between 1990 and 1993, the number of international health courses offered at U.S. medical schools increased by 35 percent, and the number of students participating in these courses increased by 58 percent.


Even without hard data, most insiders believe the upward trend continues. Dr. Molly Martin, recent graduate of the Medical College of Wisconsin, says she saw student participation double each year. And as a former coordinator of the American Medical Student Association’s (AMSA) International Health Action Group (IHAG)—which has since become the Global Health Action Standing Committee, or GHASC— she fielded several calls a day from medical students wanting to go abroad.


A number of factors contribute to rising student interest and involvement. For one, many medical students are taking notice of their changing demographics. Wilson-Ramirez and Pergam, in the process of building their case for a funded trip to Nicaragua, learned that Lexington, Nebraska, a community of 10,000 people, has the largest population of a certain indigenous Guatemalan tribe outside of Guatemala. “As people start to understand how culturally diverse cities are becoming, they realize that exposure to international populations is really important,” says Panjaporn Pam Supanwanid, a third-year student at Northwestern University Medical School and current GHASC coordinator. “In the past, this probably wasn’t emphasized.”


The Internet also helps students discover what opportunities are available. There has always been a wealth of information that students haven’t known how to tap. “[The Internet] changes things in a big way,” says Dr. Fern Hauck, associate professor and director of research of the department of family medicine at Loyola University Chicago Stritch School of Medicine. “The Web is tremendously powerful.” Students can access Web sites that offer comprehensive listings of international opportunities. And they can join listserves, which provide forums for networking with students and faculty from around the country. A pediatric resident in Maine, Dr. Tod Sweeney, set up a fourth-year elective in Ireland entirely via the Internet. He didn’t actually speak to his supervising physician, whom he found by keyword searching “Ireland” and “physicians,” until he arrived in Ireland. For months, they had communicated only by e-mail.


Martin points to another, less tangible reason for the trend. She couples the increased involvement in international health with the push for primary care training. “The whole population of medical students is changing,” Martin says. “More focus and emphasis on primary care means more people come to school with an interest in service.”


Finally, students are realizing the personal and professional benefits of doing international health. In fact, most students who go abroad agree that they get more out of the experience than they are able to give back to the community where they work. “I don’t think there’s one student who doesn’t have something happen that actually affects the way they practice medicine forevermore,” says Dr. John Walden, director of the department of family and community health at Marshall University.


— c —


Despite the surge of student participation in international health, relatively few established offices exist at medical schools. UNC, Harvard and Cornell universities, for example, have formalized international health centers. Typically, these centers fund fourth-year electives in developing countries, and students receive credit and a grade for the experience. To help prepare them, schools provide the students with faculty advisers and orientation sessions. Some also fund summer research and public-health projects for rising second-years.


But such programs are the exception. “So many times I have students from such-and-such school call me,” Stuck says. “They tell me they’ve gone to their student affairs [office] and gotten nothing.”


That students leave deans’ offices without funding, contacts or advice comes as no surprise to some seasoned students and faculty. Wilson-Ramirez and Pergam worked from January until June—preparing and presenting a proposal, sending explanatory e-mails, making follow-up phone calls—to try to drum up administration support for their trip. “We didn’t get a good response,” Wilson-Ramirez says.


Some deans’ offices hesitate to approve an international experience if they know little or nothing about the quality of experience and supervision the student will receive. “They’re worried about opening a Pandora’s box,” Hauck says. But it’s not just a question of whether their students are simply lying on the beach all day. A host of safety and liability concerns accompany travel in developing countries. “It’s not just a great adventure anymore…. Medical schools are very vulnerable,” The best safeguard against mishaps, says Joan May, assistant dean of financial aid at the Weill Medical College of Cornell University, is to properly prepare students for their trips—which busy deans may decide they don’t have the time to do.


Also, some administrations are not convinced of the necessity of international experiences, in large part because there’s no concrete evidence available showing the benefits. The international health community has failed to conduct methodical, comprehensive studies of students who have gone abroad to determine their attitudes and plans following the experience. (However, the International Health Medical Education Consortium, a national organization of faculty and medical schools, is now working on one.)


At many medical schools, the driving forces behind incorporating international health into training are highly motivated medical students. Northwestern University fourth-year student Becky Liddicoat, unhappy that her school didn’t sponsor international opportunities and inspired by the efforts of Wilson-Ramirez and Pergam, got proactive. Rather than ask her administration to support international experiences because it’s the altruistic thing to do, Liddicoat says, “I wanted to show them that it’s in their own best interest.” So she researched what percent of patients at Northwestern Hospital were Spanish-speaking. Armed with this type of evidence and a detailed proposal of how the program could work, she approached her dean. That was two years ago. Today, Northwestern funds the international electives of four rising second-year students and four fourth-year students. “Our dean was very interested in doing it, but no one had put together a good proposal for it before,” she says.


On the national level, AMSA’s GHASC is active in creating a number of international opportunities. Every year, members organize study tours, where a group of students travel to a developing country for about two weeks to learn about the local health-care systems and the communities’ needs. Students also will be organizing AMSA’s SALUD program, which offers the combination of language training and community-health experience.


“I want to emphasize to students that if you don’t have anything at your school, form something on your own,” Hauck says.


Such an undertaking may sound overwhelming, but there’s a strong student community willing to help. The GHASC, for example, is a useful source for advice and contacts. “We have so many passionate people involved who really care about global health,” Supanwanid says. The standing committee, which was formed when IHAG and the Occupational and Environmental Health Interest Group merged last March, has an up-to-date Web page, a popular listserve and a bimonthly electronic newsletter. The Web page, located at www.amsa.org/sc/global.html, is packed with links to comprehensive lists of international programs, clinical elective sites, international-oriented U.S. residency programs and international health reading materials.


Playing perhaps the most crucial role in supporting student efforts are faculty members who have a personal interest in international health. Hauck, for example, went to Israel as a medical student in the ’70s. After that, it was on to England, Africa, St. Lucia and Thailand. Her commitment to international health has not wavered over the years. Now she spends several hours a week advising students who want to pursue international health experiences. She also sends e-mails to the entire student body informing them of international health opportunities. “I just kind of naturally assume the role without the title or recognition,” she says. “I do it because I believe in it.”


According to the experts, faculty gems like Hauck can be unearthed at nearly every medical school in the country. When May surveyed faculty at Cornell who had worked abroad, she received responses from more than 100 who said they would be happy to help students. Another good resource are foreign-born faculty who likely still have colleague contacts in their home countries.


Until about nine years ago, advising students on international health experiences was something faculty members did on their own. That was until a group of them who kept running into each other at international health conferences decided to form the International Health Medical Education Consortium (IHMEC) in 1991. The consortium was founded to “help faculty help students to have a quality international experience,” says Stuck, IHMEC’s executive officer. Today IHMEC, with 300 members representing more than 65 medical schools in the United States and Canada, is an information hub: It publishes resource books on such topics as international health electives and language courses, creates international health curricula, hosts annual meetings and maintains an active listserve. “IHMEC is an extremely important connection for faculty,” Hauck says. Earlier this year, an IHMEC member sent two students to Nepal for an elective. Before the students arrived, Hauck learned their site sponsor had been deported for political reasons. Hauck immediately got on the IHMEC listserve to solicit ideas and advice from her colleagues and quickly received 20 responses. By the time the students’ plane touched down, a new location and supervisor were already in place.


— c —


How an international experience rates depends greatly on how well the student prepares before he or she goes. “It’s so important that they’ve done as much planning and gained as much advance knowledge as possible,” Hauck says. This can be a daunting task if students aren’t pointed to the right resources and people. Fortunately, some faculty and students—who collectively have logged millions of miles around the world—eagerly offer advice.


Start early. You need to get the ball rolling early for a number of reasons. Some sites are highly competitive and slots fill fast. Hauck says they have to turn students away every year for the two-month elective rotation in St. Lucia. Also, details such as getting vaccinations, obtaining a visa, raising money, and solidifying plans with your host site will require considerable time. Hauck says if you’re doing a fourth-year elective rotation you should begin preparing during third year. IHMEC recommends even longer. In its manual, Preparing for International Health Electives, IHMEC says the timeline for planning an international health elective starts two years prior to the departure date.


Focus your search. So many organizations, sites and volunteer opportunities exist, Martin says, that students don’t know where to begin. To narrow the field, first decide on a country and ask your faculty if they—or their colleagues—have connections there. “Ask everyone you come across,” Stuck says. “You’d be amazed how many have knowledge.” Directories and Web sites also are great resources. Martin recommends AMSA’s International Health Electives for Medical Students, 7th Edition; the Global Health Directory from the Global Health Council; the International Healthcare Opportunities Clearinghouse, a search engine created at the University of Massachusetts; and IHMEC’s Web site. (See “Resources,” p. 16.)


But location isn’t everything. “You also have to decide what you can do,” Stuck says. Many of the elective rotations you’ll find are geared toward third- and fourth-year students who have had training to see patients. First- and second-years may have to dig a little more to find structured experiences. For preclinical students, Martin recommends programs that integrate language training with exposure to local health-care delivery, or suggests they consider doing a public-health project. Liddicoat contrasts her public-health experience in Pakistan—where she established a study looking at living conditions, gathered data and trained people to conduct interviews—with her summer in Zaire at a mission hospital. “I was in a tertiary care setting [in Zaire],” Liddicoat says. “There wasn’t a lot for me to do there, and it wasn’t as good an experience.”


Go with an established program. It may seem adventurous to strike out on your own, but it also can prove foolhardy. One student, for example, decided she was going to do an abortion-counseling project in Brazil. “[Abortion] is against the law in Brazil,” says Dr. Audrey Bernfield, director of enrichment programs at Harvard Medical School. “That would have been a disaster waiting to happen.” To avoid potential fiascoes, Bernfield recommends that you get involved with a group or person who has experience with a location.


Following in the footsteps of others allows you to learn from their successes and failures. Long-standing programs also are more likely to have a structure in place to ensure the student has a high-quality experience. Finally, the rotating student will benefit from the credibility built by the program’s sustained involvement in the community.


Dr. Jeffrey Heck, IHMEC president and director of the residency training program at the University of Cincinnati Mercy/Franciscan Hospital, has been sending residents and students to the same clinic in Honduras for eight years. In addition to working in the clinic, these physicians-in-training have created a waste-management system, started a water conservation project and built a high school. The local people affectionately call the neighborhood where the clinic is Barrios de Cincinnati, and the nearby river Rio de Cincinnati. “It’s not a very pretty river, but it’s a compliment,” Heck says.


Do a “research” project. Most schools that give funding, credit and a grade for international health experiences require their students to do a research project, which can range from describing a component of the health-care system to looking at treatments for a common disease to doing a community assessment of health needs. “We call it ‘research,’ but it’s a very broad definition,” Bernfield says. Doing a project helps you use your time more effectively once you arrive, Hauck says. “At the site, there are so many different problems and there’s so much to see and learn,” she says. “Having definitive goals in mind gives you some direction.” Again, it’s about finding focus.


Be a creative fund-raiser. AMSA estimates that a six-week international health elective runs students about $2,500—a prohibitive price for many. Luckily, sources of financial assistance are available to help defray part or all of these costs. Now it just takes some creativity and hard work on your part to tap them.


Start with your own school. The group at Nebraska sold T-shirts and held raffles at lunch time, solicited donations from individual departments, faculty and alumni, and even created a medical Spanish class that they charged students to take (a Spanish professor they knew agreed to teach the course for free). Another medical student paid her way to Kenya by holding a series of information sessions for faculty and fellow students. She served food and explained what she intended to do. For each person who donated $20 or more, she sent a personal postcard from Kenya. From the 10 sessions, she raised nearly $1,000. Shetal Shah, a fourth-year medical student at Cornell, got an advance from his school’s alumni magazine in exchange for writing an article about his international experience.


Another idea, from the Creative Funding for International Health Electives handbook, prepared by Pirtle of the UNMC, in collaboration with AMSA and IHMEC, is to contact your alumni association, which may allocate money for a specific international project. The College of Medicine at the UNMC, for example, received a grant from its alumni association to fund an international elective in Belize for three years. Students receive room and board and half of their airfare for the one-month elective.


Outside your school, you can apply for fellowships awarded by humanitarian, service or religious groups, such as the Medical Assistance Program International and the Rotary Foundation. These programs usually have some specific eligibility requirements but are very generous in their support. Students also have been able to obtain funding from local organizations, corporations and churches.


Creative Funding for International Health Electives provides a list and description of many traditional, non-traditional and university funding sources. You can access the handbook on AMSA’s Web site. If you’d like a printed copy for $5,
e-mail Pirtle at sep@unomaha.edu or the AMSA Resource Center (AMSARC) at amsarc@www.amsa. org.


Read up on the country and culture. “You need to go with a sense of respect for the area where you’re working,” Bernfield says, which means familiarizing yourself with the country’s culture, issues and problems. “It sounds like an obvious thing,” Hauck says, “but it’s amazing how many students don’t do that because they’re running from one final to another and don’t have time.”


— c —


This may seem like a lot of work for a six- or eight-week rotation, but it’s an experience that keeps on giving well after it’s over. And it’s not only the students who benefit in the long run. Most educators and advisers are noticing that the students who work abroad tend to go to underserved areas back in the United States. Wilson-Ramirez and Pergam say that the classmates who went to Nicaragua all wanted to be placed in rural sites for their third-year family medicine rotations. “There weren’t even enough spots for them,” Wilson-Ramirez says.


Martin explores this trend in a new manual, Bringing International Health Home: A Guide to Applying International Health Principles to Underserved Communities at Home (soon to be available through AMSARC). In the introduction, she writes: “Not enough institutions can see the benefits international electives give to students and physicians…. [W]hat requires more emphasis is that these electives teach participants to be better thinkers, to understand more about the world and the people in it, and to feel the strength and confidence to improve their own communities when they return home.”
~American Medical Student Association’s Global Health Action Standing Committee
www.amsa.org/sc/global.html


Global Health Council
www.globalhealthcouncil.org


International Federation of Medical Students’ Association www.ifmsa.org


International Health Medical Education Consortium
www.unmc.edu/Community/ihmec/


University of Massachusetts’ International Healthcare Opportunities Clearinghouse
library.ummed.edu/ihoc/
~~~Dana James is a former editor of The New Physician.~International Health,Medical Education~
291~6September~1999-48~Feature~Raison D’Etre~WHY SHOULD YOU CARE ABOUT COMPUTERS.~RICK STAHLHUT, M.D., M.S.~~Why should humanistic, Patch-Adams-loving medical students and physicians care about computers in health care? After all, aren’t computers just part of the managed-care–based dehumanization of medicine we see happening all around us? Could technology possibly help our patients enough that we should bring this silicon spawn of the Devil into our inner sanctum?


Why should technology-savvy students and physicians care about human–computer issues? Shouldn’t “InfoMed” simply devote its pages to reviewing the latest cyberbox to hit the medical scene?


It has been two years since the “InfoMed” column began in The New Physician, and I’m sensing it’s time to reiterate its purpose and my rationale for writing what I do.


In general, “InfoMed” strives to show how health care can be more humane when we learn to use computers appropriately. Likewise, technology alone is insufficient for success. Finally, systems are most useful if you’re ready to “practice different.”


Humane care through computing. A 1997 study in The Lancet found 17.7 percent of patients admitted to the ICU or surgical floor of a particular United States teaching hospital suffered a “serious adverse event”—i.e., a human error that hurt or killed the patient. A 1991 Journal of the American Medical Association study revealed that 31 percent of internal medicine residents (of the 45 percent who responded to the survey) thought their worst error killed someone.


Not very humane. But human error is common in medicine, partly because we expect physicians and nurses to be machines. We put them in chaotic, time-pressured situations and then expect them to function without mistakes. Sorry folks—people can’t do that without help.


Computers can help. Computer-based reminder systems, for example, have been shown in the outpatient setting to cut the rate of certain kinds of physician-errors by 50 percent. That’s not because the physicians didn’t know the right thing to do. It was simply because they forgot. A relevant, patient-specific reminder, at the appropriate time, would have been all they needed to get it right.


But that doesn’t mean computers should be “the doctors.” It means human and computer capabilities are complementary. Humans provide the diagnostic and therapeutic decision-making skills, as well as the humanitarian qualities the patient needs. Computers help provide a safety net, make it easier to practice prevention, or practice evidence-based medicine, or look at populations of patients—all things, the experts say, medical school should be teaching you these days.


People can certainly misuse computers to create an inhumane situation for patients and doctors alike. But properly applied, this technology is essential for giving our patients the care they deserve—a valued goal for even the most
techno-abhorrent physician.


Technology is not enough. But don’t get hung up on the technology. Yes, I know it’s fun for some of you to have the latest gadgets with the most megahertz. But technology, by itself, won’t get the job done. A high percentage of clinical computer systems fail to win the support of their users. Why?


First, technophiles often try to insert technology where no real problem exists. A faculty member once told me he wanted to force all his medical students to use computers for patient histories and physical exams. When I asked what student problem he was trying to solve, he waved his hands a bit and gave several inadequate answers. Ultimately, I realized he was merely trying to make the rotation look futuristic in hopes of attracting good residency candidates. Ironically, he would have alienated students unless the project was redirected at real student needs.


Second, sometimes clinical people aren’t interested in technology because they don’t perceive the real problem that needs to be solved. For example, despite its documentation in literature, human error is an invisible, unappreciated problem to many practitioners. If you want them to use a computer system to decrease error, you may need to convince them that the human error problem really exists in the first place.


Third, many systems are not usable in real life. This lack of usability can occur for a number of reasons: The technology takes too much time to learn or use, does not fit into workflow, or causes errors. These types of failures are extremely common, due to the time-pressured, mobile nature of medical practice. For example, when a Michigan hospital installed terminals in patients’ rooms to allow personnel to enter vital signs at the bedside, the system failed within days of installation because of an unacceptably long login process.


In short, technology can only be successful if: 1) it solves a real problem; 2) the users agree it is an important problem; and 3) it is organized in a way that the users can apply to real life. It would be nice if they could afford it, too.


Be careful about privacy. This same technology that promises to improve health care can also destroy lives if improperly designed or administered. In late 1996, a member of the Tampa Health Department created a list of every HIV-positive person in the county and mailed it to the Tampa Tribune (fortunately, the Tribune didn’t print it). Appalling, but this is the great risk of large medical databases. The solution, in part, is to limit the size of our systems and have strong security and privacy policies. And if we can’t get that right, then maybe the most sensitive patient data should simply never be entered into an easily searchable database.


Practice different. Don’t practice medicine like it has always been practiced. Innovate! Look at the problems we have been ignoring and see what you can do about them. For instance, we know patients are crashing from drug interactions. Use software to screen your patients. Don’t have time? Show your nurse.


Primary care docs—keep your sickest patients out of the hospital. Review their names, diagnoses and meds on your computer once a month. Anything new in the literature? Are they on the meds you thought they were? Maybe even call them on the phone for a quick check-in. Yes, there is time for that—hire a physician’s assistant to see the earaches in your practice. Focus that expensive brain of yours on the difficult problems everyone else might otherwise ignore. Imagine how thrilled your patients will be to know you are thinking about them. Imagine the money you’ll save the health-care system (and yourself) by keeping them healthier. Not sure you’ll make enough money? Trust me—you’ll be fine. For more information on how to innovate and practice different, stop by my Web site, web.net-link. net/~stahlhut/, and select “Escape the Rat Race.”


Wrap-up. So, in essence, that’s what “InfoMed” is all about. Since September 1997, every two months or so, I describe a health-care problem that needs your attention and suggest technologies that can help. Or, I describe a common information technology and show you how well it fits into the real world. Ultimately, I’m hoping that you’ll find a way to take these ideas with you into a clinical world that desperately needs your help and transformation.


Next time on “InfoMed.” Although promised last time, this time for sure—it’s “expert systems.” When can they help? When can they hurt? How would you know the difference? Stay tuned.
~CAUGHT IN THE WEB


This month’s Web sites aren’t exactly specific to Dr. Stahlhut’s column, but enjoy them anyway.


JAMA Editor Lives On
www.medscape.com • Dr. George D. Lundberg, former editor of JAMA, has launched an online-only journal called Medscape General Medicine, found on Medscape’s Web site. Dr. Lundberg told The Washington Post that he hopes this online pub will someday rival JAMA. You be the judge.


BioMedNet Beagle
www.biomednet.com/hmsbeagle • With daily biology, medicine and biotech news updates,
featured laboratories (including a live “LabCam”) and a dash of humor, HMS Beagle clearly stands out among the many online journals. Plus, who can resist that beagle?


Health On the Net
www.hon.ch • An international initiative, Health on the Net promotes the use of the Internet and related technologies in the fields of health and medicine. The Web site features hardy medical search engines, including MedHunt and HON Code of Conduct. Serious surfers only.


Healthanswers.com
www.healthanswers.com • Not just for the
average consumer, Healthanswers.com gears itself toward, well, someone like you. Drug databases, health news, a heart-rate calculator…. You can even search for meningocele repair. Try it.


For Pa. and Elsewhere
www.physiciansnews.com • With medical and health policy news specific to southeastern and western Pennsylvania, Physician’s News Digest offers more than just the local spin. Check out their medicine and law section.
—Rebecca Sernett

-----------------------

FURTHER READING


“A Human-Centered Approach to Medical Informatics for Medical Students, Residents, and the Practicing Clinician” (Academic Medicine 1997; 72:881–7), by R.W. Stahlhut, et al. If you’d like more detail about this approach to understanding the use and misuse of technology in medicine, this article’s for you.


“Education as part of the health care solution. Strategies from the Pew Health Professions Commission”( JAMA 1992; 268:1146–8), by E.H. O’Neil. This article describes what the experts think you should be getting in medical school, including training in lifelong learning, community health and health-care process improvement.


“To Err Is Human: Human error in medicine is common, inevitable—and manageable,” by R.W. Stahlhut. (The New Physician 1997; 8:13–14) This column provides more detail on the human error problem.
~~~New Physician contributing editor Rick Stahlhut is a medical informatics writer and consultant. Contact him with questions or suggestions for column topics at stahlhut@net-link.net, or check out his Web site, at web.net-link.net/~stahlhut/.
~Learning Tools and Technology~
292~6September~1999-48~Feature~Masters of Their Domain~~Janice Rosenberg~~In the maze of managed care and burgeoning group practices, more medical students and physicians are seeking to take control of their careers with M.B.A. degrees.


Marcia J. Coleman crunched plenty of numbers in 1997 as she took courses in finance, marketing, economics, statistics—all the usual classes any budding Bill Gates would take to earn the prized three-letter, proper-name suffix M.B.A. (Master of Business Administration).


Normal stuff. The difference was she wasn’t out to build an empire, and she already owned a rather nice suffix. It showed on each form she filled out at the University of Tennessee College of Business—Marcia J. Coleman, M.D.


The ob–gyn specialist is one of a growing group of medical students and practitioners seeking complementary graduate degrees to boost their power and marketability in today’s changing medical environment. In a world of HMOs, expanding group practices and complicated care, a keen business acumen has become key.


Examples abound. Dr. Teresa Maria DeLuca, a resident in psychiatry at Thomas Jefferson University, grew frustrated by government rules and regulations that limited patients’ access to psychiatric care. So she expanded her career beyond one-on-one interaction with patients. In 1996, DeLuca became not only chief resident at Thomas Jefferson, but a candidate for an M.B.A. at Drexel University as well.


After 20 years in practice, Dr. Woodruff J. English, an internist and infectious disease specialist in Portland, Oregon, decided he wanted to tap into a larger knowledge base than was available through standard continuing medical education. He received a master’s degree in medical management from Tulane University in 1998. He now works as a hospitalist, caring for patients and serving as a manager and leader in his hospital’s health-care system.


“There is a trend today toward getting post-medical [Master of Public Health] and M.B.A. degrees,” says Dr. Arthur Lazarus, vice president and corporate medical director for behavioral health at Humana Inc., in Louisville, Kentucky. “Because fewer physicians are interested in basic research and more are interested in being able to manage their own practices or in working within the managed-care or insurance industries, these are more desired degrees than the Ph.D. of yesteryear.”


FROM THE GROUP UP


It’s a new generation of physicians, those who did not practice in the so-called “golden era,” who are driving the trend for added skills that will help them impact the future of medicine, says Thomas Gilliam, director of the M.B.A. program in medical group management at the University of St. Thomas in Minneapolis. Doctors over age 50 see their patients, work within the system and look forward to retirement. Younger physicians, in the profession for the long haul, accept the idea that medicine is also a business.


The evidence, they say, is everywhere: Solo practices have consolidated into group practices with 10 or more physicians and revenues exceeding $10 million. The growth of managed-care organizations has left many physicians feeling as though they’ve lost control over the practice and delivery of medical care. As a result, many are viewing business education as a route to positions of authority in HMO and insurance corporations, where their clinical knowledge would balance the business focus of non-physician managers.


“Several years ago I looked around the country and saw lots of HMOs and physician practice organizations forming, all run by lawyers and M.B.A.s,” says Dr. Richard Janeway, professor of medicine and management at Wake Forest University (WFU) School of Medicine. The Winston–Salem, North Carolina, campus is one of 16 medical schools in the country with a combined M.D./M.B.A. option.


Each year, three or four medical students apply for WFU’s five-year program. They spend one year and a summer at the Babcock Graduate School of Management, then enter medical school, earning management degree credits for medical school courses such as statistics and population health studies.


Both the University of Chicago and Northwestern University’s medical schools sandwich business studies between the usual four-year physician training. Northwestern students apply to the Kellogg Graduate School of Management during their third year and spend their fourth year studying business. The fifth year mixes clinical electives with management courses.


At Chicago, dual-degree students finish two years of medical school, spend four quarters taking 14 M.B.A. courses, then return to medical school for the two clinical years. The business degree is not granted until the M.D. is complete.


To keep in touch with medicine, University of Chicago medical student Julie Pearlman arranged to spend one day a week working in clinics during her business sojourn. “Whatever field of medicine you go into—academic or private—medicine today is very much a business,” she says. “I’ll be more effective in what I do with an understanding of business.”


For students who don’t want to add extra years to their studies and are willing to undertake intense course loads, there is Texas Tech University Health Sciences Center. The four-year program is one of only two in the country (the other is Tufts University School of Medicine) that do not require additional years of study. Texas Tech students spend the summer prior to medical school and the summer after the first year taking heavy doses of M.B.A. course work. They also take business courses each semester of their first two medical years and each semester of their fourth year.


Although the architecture of each program differs, all of the combined-degree curricula demand that participants juggle two mind-sets at once—a reality observers and students alike say helps them prepare for the career challenges that lie ahead.


“The more physicians who understand the larger system, the better off we’re all going to be,” says Dr. David Nash, M.B.A., associate dean of Jefferson Medical College. “Our own professional arrogance has been our own worst enemy. Had more physicians paid attention to the [changes in the medical system], we wouldn’t be in the muck and mire we are today.”


Despite the battles with decreasing autonomy physicians face, not everyone thinks the med school years are the time to be studying business. Lazarus and others suggest students first finish medical school, complete an accredited residency, become board certified and practice for at least five years before starting an M.B.A. program.


“If you’re just out of medical school with an M.B.A., you won’t be seen by older physicians as a leader, because you have no experience and haven’t lived through the changes in medicine,” says Mary Frances Lyons, vice president and partner at Witt Kieffer, a national health-care consulting firm specializing in executive search. “Before you go for [an M.B.A.], accept some responsibility for management matters where you’re practicing. Sit on a committee or task force. Know what you’re going to do with the degree before you get it. Otherwise, having an M.B.A. shows only that you can study and take a test.”


OLDER AND WISER


For established doctors who have tested the medical-career waters, getting brainy about business has in many ways become a necessity.


But even for practicing physicians who may have held leadership or committee positions during their careers, the thought of signing on at a standard graduate school of business is daunting. For those who have had no accounting, economics, tax or investment courses, in-class competition with accountants and other experienced business types threatens to be fierce. Courses that are not necessarily focused on health-care issues are likely to seem irrelevant. And still for others, the idea of taking time out of a thriving practice to play the role of student once more seems an impossible hurdle.


In 1991, the University of South Florida (USF) introduced a remedy for those concerns. It became the first school to offer a distance-learning business degree for practicing physicians. Doctors enrolled in the 21-month M.B.A. Program for Physicians travel to Tampa six times for two-week sessions. Between sessions, students use the Internet for research and exchange e-mail with faculty. In-state doctors pay $33,000 and out-of-state $47,000 for the privilege. So far, nearly 250 have graduated.


“These physicians are often the farsighted ones who want to be leaders and aren’t afraid of being market driven,” USF program director Susan Stevens says.


The USF program and the M.B.A.-for-M.D.s echo it spawned are largely high-wired acts. Laptop computers, online courses and the Internet are integral to their operations. If you can juggle technology and keep your battery supply energized, alums say, the balancing act is worthwhile.


Business learning is placed in a health-care context, said one student–physician, so “physicians don’t have to be converting widgets to patients all day long.”


Most of these hybrid programs also are characterized by brief and infrequent on-campus sessions in addition to the online courses they require, which adds frequent flier miles but allows docs to keep up with their patients. At the University of Wisconsin (UW), mid-career physicians spend seven to 10 days on campus in four separate semesters, each time taking four intensive courses. Back home, students receive assignments on the program’s Web page, interact with professors through e-mail, and participate in weekly evening teleconferences.


“The idea is to allow doctors to fit this into their careers,” says Mark Covaleski, a UW professor of health-care financial management. “People who took the course 10 years ago are now in prestigious upper-level positions in administrative leadership and management.”


For some doctor-turned-M.B.A. recipients, the climb happens sooner. Coleman, the ob–gyn who chose to further her studies at the inaugural University of Tennessee (UT) program in 1997, was juggling both clinical and management responsibilities at an HMO before heading back to school. Now, she is an assistant vice president at Wyeth-Ayerst Pharmaceuticals near Philadelphia. Coleman says the course work at the yearlong Physicians Executive M.B.A. program in Knoxville was anything but irrelevant to her new post.


Although online detractors complain that Internet courses (they make up half the learning at UT) can’t replace the give-and-take that occurs within a classroom’s walls, Coleman says she never skipped a beat. “The Internet technology was phenomenal. It was like being there in person. And I began using the information almost immediately. I feel really good that I did it.”


M.B.A. ACTION FANTASTIC?


Good reasons for acquiring an M.B.A. abound, but are physicians signing up for business courses with eyes wide open? Jefferson Medical College’s Nash is not so sure. He cautions that an M.B.A. is not “a ticket to salvation” from managed care.


As with any graduate studies, an M.B.A. should not be pursued lightly, Nash and other experts warn. Although it seems common sensical, those in-the-know say an M.B.A. is not the answer for physicians who are tired of clinical practice, embittered, frustrated and simply looking to do something different. Experts also say that being fed up is not the heartiest excuse to drop $40,000 or more on further education. Nor is an M.B.A. the solution for physicians who discover they do not like clinical work and view medical school as a mistake.


Dr. John M. Eisenberg, M.B.A., administrator for the federal government’s Agency for Health Care Policy and Research, advises physicians considering M.B.A.s to ask themselves two questions: Am I interested enough to take the courses? Do I really want to take a year or two out of my life to take them?


“Getting an M.B.A. is not the only way to become a clinical manager,” Eisenberg says. “There are many good leaders without business courses, and lots with business courses who are lousy managers.”


POMP AND CIRCUMSTANCES


Many who have successfully completed dual degrees say their careers have changed for the better. Before getting his degree, Dr. Tom Hirsch was spending 80 percent of his time in clinical practice and 20 percent as co-medical director of an HMO in Madison, Wisconsin. His management work, consisting primarily of solving personnel problems, was stressful and provided no opportunities for personal growth.


After receiving a Master of Science in Administrative Medicine from UW in June 1998, Hirsch became one of the decision-makers at Madison’s Dean Medical Center. The switch has allowed him greater flexibility. He practices rheumatology two days a week, spends two days as medical director of the large, multispecialty group and uses the fifth day to catch up.


For Dr. Jim Kuo, the five-year M.D./M.B.A. program he completed at the University of Pennsylvania and Wharton School of Business in 1991 was enough to convince him to skip residency training and go directly into the world of business. With a focus on medical technology, he has managed venture capital funds worth millions of dollars, founded and run a biopharmaceutical company and completed major licensing deals for pharmaceutical giant Pfizer Inc. Now he serves as vice president and head of business development at a genomics company, Myriad Genetics Inc., in Salt Lake City.


Although M.B.A.s are often thought of as automatic salary boosts, Dr. Len Wilkerson didn’t leave 16 years of family medicine in Kissimmee, Florida, to earn big bucks. After Wilkerson got an M.B.A/M.P.H. from USF, he took a job as a medical director at Cigna Healthcare of Tennessee in Memphis—and took a pay cut of $30,000. Wilkerson says the decision was worth it.


“I think there ought to be doctors who jump the fence, change the system…and work to change the behavior of doctors who aren’t exactly honest with the system,” he says.


But not every mid-career physician who obtains an M.B.A. will find satisfaction in a new career. “There’s no question that employment of physicians on the delivery side of health care in managerial positions has gone up dramatically,” says Dr. Janet Porter, interim president of the Association of University Programs in Health Administration in Washington, D.C.


But, she adds, dual-degree docs should keep in mind that, except in a few rare cases, the industry suffers from a lack of jobs that allow physician M.B.A.s to manage two or three days a week and still practice on the other days.


How will this new breed of doctors manage their alter egos? It’s a difficult question for those who wish to chart medicine’s future both from behind their desks and inside their hearts.


“The more time I spend in the business school, the more I miss medical school,” says University of Chicago medical student Pearlman. “But I saw this as the chance of a lifetime.”
~M.P.H. BALANCED


While many physicians are earning M.B.A.s to become better managers, those seeking a population-based perspective on health care are adding a Master of Public Health (M.P.H.) to their credentials.


The Association of American Medical Colleges lists 37 schools that offer combined M.D./M.P.H. programs.


“The changing health-care marketplace is the single biggest factor influencing students to get an M.P.H.,” says Dr. Stephen R. Smith, associate dean for medical education at Brown University. “It seems the degree is particularly useful for careers in academic medicine,” Smith says. In a recent study of Brown’s M.D./M.P.H. graduates, 83 percent of those who had completed a residency were holding medical school faculty appointments, he says.


Dr. Rowland Chang, a professor of preventive medicine, medicine, and physical medicine and rehabilitation at Northwestern University Medical School, agrees. “If you want to be an academic physician engaged in non-laboratory-based research, this is a good degree to have.”


Chang credits the era of managed care with an increase in the popularity of the M.P.H. “Managed-care organizations that take responsibility for the health of their subscribers are beginning to look at the health status and satisfaction of their clients in aggregate,” Chang says. “So there’s a lot of opportunity [for doctors] at the interface of medicine and public health.”


Students at Northwestern attend M.P.H. classes in the evening and finish their M.D./M.P.H. in four years. Tufts University and Brown University medical schools also offer four-year combined degrees.


Minority students who want to work in underserved areas are among those who find M.P.H. degrees beneficial, says Audrey Bernfield, director of enrichment programs at Harvard Medical School.


And mid-career doctors also can receive M.P.H. degrees from a wide variety of schools around the country. Those who receive M.B.A.s from the University of South Florida (USF) can earn an M.P.H. using credits given for some M.B.A. courses and an additional six to nine months of public-health classes.


“Not many schools have all three programs available,” says USF program director Susan Stevens. “But a lot of doctors asked for it, and we just graduated our first class of about 20.”


Since 1984, physicians wishing to become board certified in preventive medicine have been required to obtain an M.P.H., including four core courses, according to Constance Hyland, administrator at the American Board of Preventive Medicine in Schiller Park, Illinois. Practitioners can specialize in general preventive medicine or one of three subspecialties: occupational medicine, public health or aerospace medicine. Many residency programs have established connections with schools of public health to provide the necessary courses.


The Medical College of Wisconsin offers an off-campus M.P.H. to physicians in preventive medicine fields. Students admitted to the program must attend one on-campus orientation session where they meet faculty, staff and other students and are introduced to the practical aspects of course requirements and computer log-on procedures. Course content is delivered through a combination of printed materials and materials accessible on the World Wide Web. — J.R.


------------------------


RESOURCES


PROGRAMS
American College of Physician Executives
www.acpe.org


M.B.A. for Physician Executives Program at Kennesaw State University
www.coles.kennesaw.edu/grad/index.htm


Texas Tech University
www.ttuhsc.edu/pages/som/mdmba.htm


University of South Florida
M.B.A. for Physicians
www.coba.usf.edu


----------------------

PUBLICATIONS


A Decade’s Experience at Tufts With a
Four-Year Combined Curriculum in
Medicine and Public Health
Markley H. Boyer, M.D., D.Phil., M.P.H.
Academic Medicine, Vol. 72, No. 4/April 1997.


M.D./M.B.A.: Physicians on the New Frontier of Medical Management
Edited by Arthur Lazarus, M.D., M.B.A.
American College of Physician Executives, 1998.


The Physician’s Essential M.B.A.: What Every Physician Leader Needs to Know
Michael J. Stahl and Peter J. Dean
Aspen Publishers, Inc., 1999.
~~~Janice Rosenberg is a Chicago-based freelance writer.~Career Development,Medical Education~
293~6September~1999-48~Feature~Socially Responsible Investing~IS YOUR MONEY TIED UP IN BIG TOBACCO?~RICHARD W. TORGERSON~~If you are a mutual fund investor, chances are some of your money is invested in Big Tobacco. Among the varied companies trading stocks on Wall Street, tobacco companies are the only ones whose products are deadly even when consumers use them properly and in moderation. The World Health Organization estimates 3 million deaths due to tobacco consumption per year. More and more investors are realizing that there simply is no way to ethically profit from tobacco consumption. In several opinion surveys, the vast majority of the investing public opposes the idea of their own money being tied up in tobacco.


Problem is, most of the larger mutual funds have investments in tobacco companies. Further, any of the Standard & Poor’s 500 (S&P500) “index funds” automatically include holdings in the largest tobacco companies by virtue of the fact that they are a part of that index. This means that millions of Americans are unknowing investors in tobacco, even though they’re personally opposed.


Why is this an important concern? When you invest in a stock, you participate in the advancement of the company’s value, if even to a small degree. The more buyers of a stock there are, the higher the stock price will go. With a high stock price, a company is better able to obtain equity financing for their business operations and use their stock to “buy out” other companies. Even a slight increase in the stock price caused by your purchase puts dollars in the pockets of company executives.


In 1996, the American Medical Association (AMA) called on all investors to divest from the more than 1,400 mutual funds containing tobacco stocks and bonds. In addition, the AMA asked mutual fund companies to sign a tobacco-free investment pledge. Three years later, very few funds have signed the pledge, and nine of the 15 largest mutual funds still contain tobacco stocks.


So what can you do to find out if your money is tied up in the tobacco industry? Start with the list of tobacco companies targeted by the AMA (see “The AMA’s Dirty Dozen,” below). While it’s a fairly simple matter to check your portfolio against this list if you’re a stock investor, mutual fund investors need to dig deeper. Check your fund’s latest annual or semiannual report. In these reports are listings of every holding of your fund, at least as of the date the report is prepared. That’s just a first step, though. If you want to ensure that your fund manager doesn’t buy shares of Philip Morris, for example, check your fund’s prospectus to see if an explicit ban on buying tobacco stocks is listed. If not, then you are subject to the fund manager’s whim.


You also may not want to limit your concern to just the AMA’s “Dirty Dozen.” There’s an entire infrastructure of companies catering to the tobacco industry, including paper manufacturers, packaging firms, ad agencies and distributors that profit from addicting people to nicotine. While most tobacco-free fund managers stop short of boycotting individual vendors that sell cigarettes—such as national grocery or convenience stores—a number of these vendors are getting pressure from shareholder activists.


People who own shares of a company literally own a piece of that company. That gives them the right to vote on and introduce proposals at the company’s annual meeting. Increasingly, anti-tobacco activists are exercising their rights by pressuring management to divest in Big Tobacco.


In recent years, some successes have been tallied. Kimberly Clark, the makers of Kleenex, once had significant operations supplying papers and other supplies to the tobacco industry. In 1995, three weeks after shareholders voted to drop that business, the company sold all of its tobacco-related operations. Similarly, in 1996, 3M Media—a major outdoor advertising chain—was pressured by shareholder activists to stop accepting cigarette ads.


To lend your voice to the shareholder activism movement, check the Interfaith Center for Corporate Responsibility Web site (see “On the ’Net,” p. 42), which lists shareholder activist activities on a wide variety of issues. If you own shares of stock in any of the affected companies, you can then ask your financial adviser how to vote your shares at the next annual meeting.


As a medical student, you also may want to look into your school’s portfolio and encourage the administration to divest their tobacco stocks. You also can try pressuring your mutual fund company to vote in favor of anti-tobacco shareholder proposals. If you’re unsuccessful in that effort, switch to one or more of the several dozen funds that have explicit anti-tobacco stances. But before changing any of your investments, check with your financial adviser first. The changes you make should be consistent with your own personal financial and tax situation.


Cleaning your portfolio out of tobacco-related investments could be healthy for your long-term bottom line. Although many on Wall Street cling to tobacco stocks as high-performers that generate loads of profit over time, that’s beginning to change. Two tobacco-free stock indexes—the Domini Social Index and the Citizens Index—both have outperformed the S&P500 significantly in the 1990s, proving that you can earn excellent competitive returns without relying on tobacco stocks.


Increasing economic dangers combined with pressure brought by socially responsible investors has created a growing exodus of institutional investors out of tobacco. As of 1998, more than $440 billion of institutional assets were made tobacco-free portfolios. Along with the AMA, insurance companies like Aetna and Allstate, government pension funds in states like Florida, Massachusetts and Maryland, universities like Johns Hopkins, Harvard and Haverford have joined religious and non-profit institutions nationwide to boycott tobacco stocks. The withdrawal of that market support may be worsening an overall bearish trend in tobacco stock prices. And while past performance is not always indicative of future results, this is a trend that’s unlikely to stop anytime soon.
~The AMA’s Dirty Dozen


  1. Brooke Group, Ltd. (BGL)

  2. Culbro Corp. (CUC)

  3. DiMon, Inc. (DMN)

  4. Loews Corp. (LTR)

  5. Mafco Consolidated Group (MFO)

  6. Philip Morris (MO)

  7. RJR Nabisco Holdings (RN)

  8. Sara Lee Corp. (SLE)

  9. Schweitzer–Maudit International (SWM)

  10. Standard Commercial Corp. (STW)

  11. UST, Inc. (UST)

  12. Universal Corp. (UVV)



SOURCE: AMERICAN MEDICAL ASSOCIATION

--------------------


ON THE 'NET




~~~Richard W. Torgerson is a registered principal with Progressive Asset Management Securities. He can be reached at RTorgerson@aol.com or by phone at (410) 655-9588. Securities offered by Financial West Group, Inc., Member NASD, SIPC.
This column is sponsored by the Educational Finance Group, which offers the AMSA Advantage Educational Loan program.~Medical Student Debt~
294~6September~1999-48~Feature~Changing Practices, Saving Lives~~Laura Milani~~Part of being a good physician is learning how to care for your gay and lesbian patients


Many lesbian patients do not receive Pap smears because their physicians assume that since they don’t have sex with men, the tests are unnecessary—a belief research disputes. Some gay and lesbian patients have been denied treatment at a physician’s office because of a doctor’s homophobia. Medical schools have been known to educate future doctors about homosexuality in the same terms as bestiality.


When a gay or lesbian patient enters your office, what do you do? Do you even bother to ask your patients about their sexual orientation? Don’t think it matters? A new report by the National Academy of Sciences’ Institute of Medicine (IOM) challenges the medical profession’s general attitude that ignorance about a patient’s sexual orientation is bliss. In terms of a patient’s health, ignorance is never bliss.


IOM’s study, “Lesbian Health: Current Assessment and Directions for the Future,” which was released earlier this year, looks at the greater context of lesbian patients’ lives and goes on to identify risk factors they face for diseases like breast cancer. This focus in itself is unusual, for prior to the report’s release, most studies involving gay and lesbian patients conducted by mainstream medical organizations centered around HIV/AIDS, says Dr. Kathy Oriel, an assistant professor of family medicine at the University of Wisconsin Medical School.


The IOM report found fear of discrimination seems to keep lesbians from seeking routine medical care, the stress of homophobia can negatively impact health, and questions about sexual orientation should be included on national health studies.


“[The IOM study] is really monumental because it comes from such a prestigious, powerful medical organization,” says Oriel, who is president of the San Francisco–based Gay and Lesbian Medical Association (GLMA), which has been pushing such issues for years. “It lends credence to the whole issue of sexual orientation in the health-care setting,” she says.


But despite the report, Oriel and other gay and lesbian health advocates say, such issues remain at best a footnote in medical education and clinical practice.


An oft-cited 1992 Academic Medicine study discovered that only an average of three hours and 27 seconds was dedicated to homosexuality-related health issues in the curriculum at U.S. medical schools—a figure observers say likely has not increased much since then.


What concerns gay and lesbian health advocates more than the length of time spent studying these issues is the narrow context in which they are taught.


“The teaching that goes on still largely is confined to human sexuality classes,” says Dr. Mark Townsend, assistant professor of psychiatry at Louisiana State University (LSU) Medical Center in New Orleans, who is one of the authors of the 1992 survey. “And we don’t know which schools still are talking about it in the same breath as [psycho-sexual disorders] and bestiality, because when I graduated from medical school in 1988, that’s the way homosexuality issues were taught.”


Before the University of Washington created its award-winning course “Health Issues of Sexual Minorities”—which addresses medical, public health and medical–legal issues specific to the gay community and gained approval for credit toward graduation in the 1996–97 academic year—such issues were addressed “sporadically or not at all,” third-year medical student Oren Traub says.


IN THE CLASSROOM AND BEYOND


Issues surrounding homosexuality should be addressed both within the classroom and during clinical rotations, says Dr. James Lock, an assistant professor of psychiatry at Stanford University School of Medicine, who recently authored “Strategies for Reducing Homophobia During Medical Training” in the Journal of the Gay and Lesbian Medical Association (JGLMA).


Some of the most obvious areas where relevant issues come up include obstetrics and gynecology, Lock says. A recent study by researchers at San Francisco’s Lyon– Martin Women’s Health Services and the University of California determined that lesbians have a higher body mass index, fewer pregnancies and more breast biopsies—three previously identified risk factors for breast cancer.


Lock also points to pediatrics and adolescent medicine—where suicide rates for lesbian and gay youth are at least three times that of their heterosexual peers—and psychiatry, where the psychological impact of homophobia can be explored. He says less obvious but equally important areas include endocrinology and genetics—where assessment and treatment of patients who have conditions such as Turner’s and Klinefelter’s syndromes are complicated by questions about sexual orientation.


Although advocates’ previous efforts to address the situation focused on creating a comprehensive curriculum on gay and lesbian health issues, Townsend says, the thrust now is to identify and train physicians with core competencies, such as taking a sensitive sexual history.


“We’re working toward things like, how do you identify the [gay or lesbian] patient, and how do you, with the knowledge we have already, screen for things like suicidality, cigarette smoking and recreational drug use, which in the gay male community is a scourge right now,” Townsend says.


Such physician–patient skills are not gay-specific but rather apply to any cultural subgroup. “We really are, with no apologies, lifting what has already been developed [in medical education] for other minority populations,” he says.


Lock agrees. “As with other cultural groups, if you don’t know the right questions to ask, if you can’t develop sympathies for the various problems they’re facing in their lives, it’s going to be very difficult to be a good physician, to be trusted sufficiently to even have your recommendations followed [by your homosexual patients],” he says.


For homosexual patients and their doctors, this trend is essential to improving the physician–patient relationship and the patient’s health. It represents an attempt to eradicate the negativity and exclusion homosexual patients often encounter when visiting the doctor’s office. “It begins when you walk into a doctor’s office, and you’re handed a clipboard with the intake form and it says, ‘Are you married, single, widowed or divorced?’” Dr. Jocelyn White, an internist at Legacy Good Samaritan Hospital in Portland, Oregon, and co-editor of the JGLMA, says. “How do you answer that if you’ve been in a relationship with your partner for 19 years? And then how do you know whether your doctor is going to be comfortable with your sharing information about being a lesbian?”


A 1990 survey found 72 percent of lesbians had experienced ostracism, rough treatment, derogatory comments and disrespect toward their partners by their medical practitioners. In a 1994 survey of GLMA members, 88 percent of the 711 respondents said physician–colleagues had belittled their gay or lesbian patients in public.


More than half of the GLMA respondents reported seeing care denied or delivered in a substandard manner to gay or lesbian patients because of their sexual orientation. And while 98 percent said patients should inform their doctors about their sexual orientation, 64 percent said doing so might jeopardize their care.


Lock notes that subtle and overt cases of gay and lesbian patients being “dismissed” by physicians remain a big problem. A California woman recently filed an anti-discrimination suit against a primary care physician in Mission Viejo for one such alleged incident. During the woman’s first checkup, which included a gynecological exam, the doctor asked what form of birth control she used. After she told him she didn’t need any since she is a lesbian, he told her he didn’t want her as a patient because he didn’t approve of her “lifestyle” and gave her names of two other doctors who might see her.


STUDENT EFFORTS


Students have been making great strides in trying to change the medical and education communities’ often destructive attitudes and practices.


The American Medical Student Association (AMSA) Foundation is tackling gay and lesbian health issues in the context of culturally competent care. The Promoting, Reinforcing and Improving Medical Education (PRIME) project that the AMSA Foundation developed under contract with the U.S. Public Health Service’s Bureau of Health Professions Division of Medicine will include a training module to be piloted at three medical schools in fall 2000.


“This hopefully will give physicians the training, skills and knowledge base they need to effectively treat patients who are different from them—either visibly or invisibly different,” says Henry Ng, a third-year medical student at Michigan State University College of Human Medicine and student co-director of PRIME.


Some medical schools stand out in their attempts to train physicians who will feel at ease treating gay and lesbian patients and their unique health issues. Often, these efforts are or were student-initiated.


Students were the force behind the 1992 booklet A Community of Equals: A Resource Guide to the Gay and Lesbian Community, which is distributed by Temple University’s Office of Student Affairs.


The University of Washington School of Medicine’s “Health Issues of Sexual Minorities” course—which this spring received top honors from AMSA and GLMA in the groups’ first Lesbian, Gay, Bisexual and Transgendered Health Achievement Award—was student-initiated. A new chapter of AMSA’s Lesbian, Gay and Bisexual People in Medicine (LGBPM) at Case Western Reserve University School of Medicine snagged second place for its work to help modify the school’s patient-interview exercises to include sexual-history scenarios. Members also are working to include more gay and lesbian health issues in the school’s new “Millennium Curriculum” to be implemented next year. This includes moving sexuality issues out of the curriculum’s psychiatry portion and including more mandatory exposure to clinical management of gay and lesbian patients.


INCLUDING PERSONAL CONTACT


Because lack of personal contact with gays and lesbians is strongly linked with negative attitudes, Lock says the most effective lessons are those that directly involve individuals.


At MCP Hahnemann University School of Medicine, first-year students attend a discussion with lesbians, gays and bisexuals as part of their human sexuality curriculum.


Oregon Health Sciences University School of Medicine takes a similar approach. In the spring of their second year, students attend a two-hour class on health-care issues related to sexual orientation that is proctored by lesbian and gay physicians.


Case Western Reserve’s LGBPM chapter hosts a popular series in which a gay or lesbian physician or health worker leads a round-table discussion about how their sexual identity has affected their careers.


At Stanford University School of Medicine, gay and lesbian students organize a lunch-time series of lecture/discussions on homosexuality and medicine that the dean’s office sponsors by way of providing pizza.


Getting to know peers who are gay is an effective way of reducing homophobia, Lock suggests, but he adds that this is tricky because many gay and lesbian students keep their orientation a secret.


“There’s good reason for medical students to be anxious [about coming out],” Lock says, “because there’s thinking out there that they aren’t [going to make] good doctors. [They are] extraordinarily dependent on making a good impression and not having people think anything bad about them in order to get those residency [recommendation] letters. So in a climate where they feel like anything could be counted against them, like their sexual orientation, it makes it very difficult to come out.”


A 1996 study of family practice resident applicants and training directors by Oriel and colleagues found that one-quarter of training directors “might rank” or would “certainly rank” an applicant known to be gay lower than a heterosexual applicant. Twenty percent said gay residents would not easily “fit in.”


In a 1996 survey of LGBPM members by LSU researchers, 62 percent of respondents reported being exposed to anti-gay remarks from a classroom instructor, while 42 percent reported that clinical faculty had uttered offending statements.


Trying to teach future physicians how to provide culturally sensitive care has limited impact in such environments, Townsend says.


“What the attendings and residents don’t say, or the indirect things they say, is often as important as what they do say,” he says. “So tacitly endorsing making fun of someone’s race or ethnicity or class or sexual orientation often speaks volumes to what is really valued in the curriculum.”


But Townsend’s LSU colleague Dr. Mollie Wallick, a professor of psychiatry, says it also works the other way around.


“When a respected staff person says positive things about an openly gay individual or chastises someone for making disparaging remarks, that has a profound effect on the students’ responses to a similar situation in the future,” Wallick says.


“So there are small steps,” she says, “that can have a big impact on eliminating homophobia within medical education.”


Ultimately, Lock says, the task of sensitizing doctors to the specific needs of gay patients boils down to one global principle:


“It really is just a matter of keeping physicians aware that not all people are exactly alike in how you approach them.”
ents.~~~~~LGBTPM~
295~7October~1999-48~Feature~Hospitalists: Just a Flash in the (Bed) Pan?~~Rebecca Sernett~~Only time will tell the fate of this relatively new group of physicians, but most experts say hospitalists are already making their mark in medical history.


Fresh out of his internal medicine residency in Gainesville, Florida, Dr. John Nelson found himself in a common situation. He had the medical training, but where was he going to put it to good use? Several of his friends went to work in the ER—a career Nelson found unattractive; too many children in trauma. A private practice wasn’t exactly what he wanted either, at least not for now. And, before he could debate it much longer, an intriguing opportunity presented itself.


A colleague invited him to join a new practice where physicians spend all of their time in the hospital taking care of other doctors’ patients. This sounded promising. Liking the hospital and feeling his training suited him well for this role, he signed up.


“The hospitalist opportunity seemed to offer the best of two worlds,” Nelson says, using the term for his profession that is commonplace now but unheard of back then. He figured he’d work there for a few years or so and then move on. For four years, there were two physicians: the first doctor and himself. But it didn’t take long before the buzz got around, and more and more primary care physicians sought their help.


That was in 1988—eight years before Drs. Robert M. Wachter and Lee Goldman coined the term “hospitalist” in The New England Journal of Medicine (NEJM)—and Nelson has no plans of abandoning his inpatient work. The Gainesville practice now has seven full-time hospitalists and one part time, and Nelson is one of the leaders of the hospitalist movement. As co-president of the National Association of Inpatient Physicians (NAIP), he is frequently invited to speak about the hospitalist model (see “Types of Hospital Care,” p. 24) and how organizations can institute their own programs.


And despite its incredible pace, Nelson is the first to say the evolution “shouldn’t be a race.”


“I’m on no mission to have hospitalists’ practice replace private care,” Nelson says.


Ever since Wachter and his colleague came up with the term in their 1996 article, the hospitalist movement has spread like wildfire. Now chief of hospitalist-based medical service at Moffitt–Long Hospital and associate chairman of the department of medicine at the University of California, San Francisco (UCSF), Wachter can’t remember if he used the term first, or if he heard someone else use it and included it in the article. But he can remember this: “What happened after [the article] was accepted was remarkable to me.”


Soon after the piece appeared in the NEJM, physicians around the country telephoned him, saying he described their work perfectly. These were physicians who before this had no specific group of doctors with whom to associate themselves. This included the two current co-presidents of the NAIP—Nelson and Dr. Winthrop Whitcomb. Lacking a network of inpatient physicians, these individuals were, more or less, working in isolation. Then, here comes this article in a well-respected journal that not only describes their inpatient work, but also gives them a name—hospitalist. Snap. Crackle. Pop. Next comes the NAIP.


Perhaps it hasn’t been as simple as that, but Wachter admits, “It has been far easier than I thought it would be.”


His article did more than help unify a unique group of physicians—it also lit a fire under the hospitalist model, and the fire still burns.


As hospitalists began to regularly write and lecture about their profession, some physicians, particularly in primary care, became suspicious. What does the hospitalist model say about the role of the traditional family doctor? What does it mean for patients? A frequently used illustration is this: If hospitalists were a new drug, and it came out with as few studies and research as hospitalists did, would we be using it?


The way some physicians (now considered hospitalists) have been silently practicing medicine for years suddenly has become something akin to that unexpected jalapeño in your sub sandwich—either you love it, hate it, or decide to get used to it. Physicians on both sides of the fence say that perhaps it’s best to get used to it, or at least wait until the fire burns down and see what remains.


“I think the hospitalist movement is here to stay,” Dr. Hal Sox, immediate past president of the American College of Physicians– American Society of Internal Medicine (ACP–ASIM), says. “It meets some important needs, and they give high-quality care for patients.”


But what exactly is a hospitalist?


THE HOSPITALIST


Current definitions call physicians hospitalists if they spend 25 percent or more of their time as physicians of record for patients admitted or transferred to the hospital by primary doctors. (Primary care physicians spend an average of 12 percent of their time treating inpatients.) Some hospitalists also take charge of patients who are admitted through the emergency room and have no primary care physician. Many European countries practice medicine this way, but it is relatively new to the history of medicine in the United States.


Each hospitalist model is unique to the community it serves. Nelson, for example, typically works a 35- to 70-hour week in the hospital for 21 consecutive days. Physicians at his practice rotate their services between two hospitals, doing as much as they can to provide continuity.


Hospitalists often are valued for bringing efficiency, leadership and a continual presence to the hospital environment. They are known as “acute generalists”—physicians who use their general medicine skills in severe situations, requiring a specific acumen suited to the hospital. Inpatient physicians also have more invested in the hospital and tend to be more apt to initiate hospital quality-of-care improvements.


NAIP’s Whitcomb, director of inpatient medicine service at Mercy Hospital in Springfield, Massachusetts, leads a practice of eight inpatient physicians. He says when the service was introduced at his community hospital, the results were immediately visible. With a hospitalist always on duty at night, patients received immediate care from an expert when needed, Whitcomb says. They didn’t have to wait for a response from their primary physician. The same was true for daily and end-of-life care. General communication with patients’ families improved, and Whitcomb says the inpatient physicians raised the bar
for non-hospitalists who practice in the hospital.


“It’s because we’re here,” he says.


There is another side to the story, though, one that is often found across town. Hospitalists introduce an opportunity for physicians to improve the quality of care in their office practices—something, Whitcomb says, that isn’t often mentioned.


Primary care physicians who use hospitalists should have more time to focus on preventive medicine, screening, treatment of chronic conditions, management of complex patients and office efficiency, he says.


Dr. Lanny Copeland, board chair and immediate past president of the American Academy of Family Physicians (AAFP), reminds doctors who use hospitalists that “they can do a better job in the office setting if they don’t have to be a slave to the hospital.” The physicians he knows who choose to work with hospitalists tell him they’re interested in improving their quality of life—which, consequently, helps their patients.


HOT MARKET


The market for hospitalists is booming—just take a look at the employment classifieds in the back of popular medical journals. And, you guessed it…. The reason for the growth of this type of physician is complex.


Wachter believes the growth is a rational response to the medical profession’s changing environment. He predicts that in five to 10 years, the number of practicing hospitalists could reach 19,000 (similar to the current number of cardiologists)—at which point the job market will be saturated. This won’t really affect the number of primary care physicians, he says, because the ratio of primary care physicians to hospitalists is 8-to-1, on average. Currently, NAIP’s paid membership approaches 1,000, and it estimates there are approximately 4,000 practicing hospitalists.


Internal medicine residents across the nation are envisioning a hospitalist career on the horizon. Dr. Tye Young, an intern at the University of Tennessee College of Medicine–Chattanooga Unit, hopes to tap into this explosion when he finishes interning in three years. Young—who has a background in osteopathy, finance and hospital administration—thinks a hospitalist career would work well uniting his experiences and stabilizing his personal life. He is married and has a young daughter, so balancing work and family is a top priority. “Part of the appeal to me is a defined work schedule,” he says.


But while others see the hospitalist boom as a rational development and a suitable career choice, Copeland calls it a symptom of an unstable health-care system—a popular view among some primary care physicians. Still, others say it began well before the development of HMOs.


Initially, the hospitalist role was born of physicians’ needs—as in Nelson’s case. Nelson suspects the movement might have its roots in pediatricians with office practices who had only one patient in the hospital and found it convenient to share the commute and inpatient services.


Today, many hospitalist programs are initiated for the same reason, except now there is another coal to throw in the fire. As a result of their efficiency, hospitalist models have proved to be effective at cost-cutting. In march managed-care companies.


The attempts of managed-care companies in states like Florida and Texas to institute mandatory handoffs has turned hospitalists into a hot-button issue. Mandatory handoffs usually mean primary care physicians are forced to turn over the care of their hospitalized patients to inpatient physicians. This, Nelson says, speaking for hospitalists across the country, “taints us.”


Primary care physicians who work with Prudential HealthCare in Florida, for example, were sent letters in mid-February explaining that in a month, they had to send all of their inpatients to a designated hospitalist and would be forbidden from inpatient care. Enraged, the physicians appealed to national organizations like the AAFP and ACP–ASIM, whose leaders wrote letters to Prudential HealthCare, saying that this is no way to practice good medicine. Their collective efforts, along with resistance from a local hospital, succeeded. The company backed off.


Similar events took place in Texas, but the Texas Medical Association, the Texas Academy of Family Physicians (TAFP) and the Texas Society of Internal Medicine went further with their opposition to the mandates. They took action to support state legislation that prohibits the mandatory use of hospitalists. But, TAFP reports, the legislation failed to get out of Texas’ House of Calendars committee.


“One of the problems with this,” Nelson says about managed-care companies and NAIP’s own efforts to stop such edicts, “is that the casual observer is led to the conclusion that [hospitalists are an] offspring of the HMOs…or agents of the HMOs.”


Nelson says this couldn’t be further from the truth. He says it is imperative for physicians themselves to be interested in the hospitalist model. Whitcomb agrees. “It’s bad for hospitalists individually and collectively, if all of the participants aren’t actively invested in this system.” Proper communication is key to the hospitalist model. It helps ensure patients’ care won’t become fragmented from one physician to the next.


“One of the main aspects of primary care is the whole aspect of continuity,” says Dr. Paul Jung, third-year internal medicine resident at Case Western Reserve University’s MetroHealth Medical Center. He worries about adding a new person to the loop. “Communication between doctors is not always what you’d expect it to be,” he says.


Hospitalist systems have a variety of procedures—voice mail, fax, e-mail, message centers, face-to-face visits—geared to keeping the hospitalist and primary care physician well-informed. Experts say possessing excellent communication skills is necessary to become a successful hospitalist (see “Hospitalist Training,” p. 24).


But because hospitalization is often a stressful, complicated and emotional time in a patient’s life, both hospitalists and primary care physicians worry when a patient sees too many new faces. Most hospitalist systems have guidelines to keep the number of hospitalists the inpatient sees down to one and at most two.


Although many physicians concede that some patients switch their primary care physicians as often as once every year, most agree that maintaining some sort of continuity during a patient’s hospital stay is desirable. It’s a responsibility that equally rests on the shoulders of both doctors. “It behooves the primary care physician to inform the hospitalist,” Copeland says.


The AAFP has published tips for family physicians who work with hospitalists that reflect the idea of mutual responsibility. Guidelines include having the primary physicians tell their patients about their confidence in the hospitalists and suggest physicians and new hospitalists call on the inpatients together.


Part of the problem with mandatory handoffs is that the initial layer of trust between a patient’s primary physician and hospitalist crumbles, leaving cracks in the relationship. In these cases, physicians—offended at having to hand their patients over—might be less likely to fully communicate.


But don’t worry, says Wachter, who leads a hospitalist training program at UCSF and is working on the first hospitalist textbook. Mandatory handoffs won’t be a common model for hospitalist systems, he says. “That’s just not going to happen. It would be different if a group of primary care physicians themselves mandated that their group would be giving up their inpatient care services,” he says. But as for the long-standing threat, Wachter says he sees pressure from managed-care companies dying down.


“It’s hopeful thinking,” ACP– ASIM’s Sox says of Wachter’s prediction, “and it’s hopeful thinking that I engage in as well.” He concedes “[managed-care companies] seem to be backing off,” but that the threat remains during these times of “desperate finances.” Sox, the Joseph M. Huber professor and chair of the department of medicine at Dartmouth Medical School and Dartmouth– Hitchcock Medical Center, says more companies might be tempted to institute mandates.


In 1998, the ACP–ASIM entered a three-year affiliation with the NAIP—the college’s first affiliation in its combined 84-year history. In exchange for approval rights for NAIP’s bylaws, policy statements and some activities, the ACP–ASIM gives the NAIP financial support. The college’s official policy is to support hospitalist programs only if they are voluntary.


“The ACP–ASIM leadership felt it was important for the goals of hospitalists to be aligned with internists,” Sox says. “It has worked extremely well so far. They keep us informed, and it has been very important to us in our efforts to prevent mandatory handoffs.”


BROADER PICTURE


Beyond the managed-care concerns, however, are the bigger implications hospitalists have on medicine and medical education.


Physicians who like to think
of themselves as “specialists in breadth”—caring for patients from the “womb to tomb” or “cradle to grave”—worry that the use of hospitalists, even in voluntary systems, might limit their freedom to practice the medicine they were trained to do. It means a surrendering of their privileges and an abandonment of their patients. To them, the traditional doctor disappears. These fears grow even more dramatic when hospitalists talk of developing their own specialty.


“There is no longer any doubt that [the hospitalist model] will become the dominant way of practicing medicine,” Wachter says. “I think a specialty is inevitable.” He says the market will decide when it will happen. But, there are some hoops hospitalists would need to jump through first, and they’re in no rush. These include proving hospitalists have a distinct and unique body of knowledge, that they generate new research and information and that they can create a specialty exam specific to their job.


Others have their doubts about creating a new specialty.


“I’d like to have proof of my skills in the hospital,” Nelson says, and mentions that it would also be nice to have something that declares he’s “not just an HMO stooge.” But he’s not sure a specialty is needed.


One of the possible risks of doing so is that physicians lacking this specific credential could be denied from practicing inpatient care.


Most primary care physicians recognize this. “I don’t see the benefits of creating another specialty,” says Dr. Elizabeth Morrison, director of maternity care education and assistant clinical professor at the University of California, Irvine, department of family medicine. Morrison, who has worked alongside hospitalists in the past, says she fears that if the movement grows too quickly, “residency programs would divide into outpatient and inpatient [training].” Hence, physicians desiring to go into primary care would be locked out of the hospital.


Copeland envisions similar threats to traditional medicine. “There would be some real concerns in regards to the training of primary care physicians,” he says. “They need to know how the disease evolves, how to do follow-up…. If the hospitalist movement does catch on, [hospitalists] won’t be everywhere, so there is a need for [primary care] physicians to have those inpatient care skills.”


Part of what makes primary care physicians so anxious is that “[the hospitalist controversy] is an emotional issue…. It is very passionate,” Copeland says. “It shows the aspect of family physicians being close to our patients…. I still like my hospital privileges.”


But, according to Whitcomb and other hospitalists, these apprehensions may be unwarranted. “I’m not as worried about the outpatient doctor getting pushed out,” he says, citing specialty exams for cardiology and critical care that don’t withhold access to physicians lacking these credentials. There are some real needs for a hospitalist specialty, he says, and these include providing a sustainable career track and maintaining a standard of practice.


FURTHER EVALUATION


Many groups—associations, researchers, academics, physicians—are eager to put the hospitalist model to the test.


The NAIP and its members regularly study the model and its effects on patients, physicians, cost and care. For example, Dr. Steve Pantilat, assistant clinical professor of medicine at UCSF, co-presented the results of a hospitalist continuity-of-care study at the Society of General Internal Medicine’s (SGIM) annual meeting in May.


Around 1,400 California family physicians were surveyed about their communication with hospitalists. UCSF researchers reported that, overall, 63 percent of the family physicians said hospitalists were “a good idea,” and 59 percent were satisfied with the communication. These results and other factors led researchers to conclude that improvements still need to be made. One improvement would be to increase the contact between the hospitalized patient and primary physician.


Family physicians also are interested in evaluating hospitalists. The AAFP has plans to use part of a $7.72-million family medicine research grant to study hospitalists and cost of care. As a beginning step, a hospitalist task force—which the AAFP created in 1997—has already queried the association’s 88,000 members on their feelings about the issue.


The family physicians, family practice residents and medical students who make up the association were split down the middle. According to the results, half of the membership welcomes the hospitalists’ extra help, in part to have a better lifestyle. The family physicians’ office practices are busier, and they’re seeing sicker and sicker patients. They recognize the efficiency a hospitalist program can offer.


The membership’s other half feels, according to Copeland, “[that] this really goes against the idea that to be a consummate physician, you take care of patients in the hospital.”


Because no opinion outweighed the other, the task force resolved neither to support nor oppose hospitalists. Instead, it would just sit back and wait.


“Hospitalists are an ongoing aspect of medicine, and we need to just watch and see how it shakes out,” Copeland says.
~HOSPITALIST TRAINING


Leading hospitalists say training in general internal medicine suits their work well, but there are areas that require further attention:




TYPES OF HOSPITAL CARE


The hospitalist model is catered to the specific community it serves. Here are four general types of hospital care:




RESOURCES ONLINE


www.naiponline.org—NAIP’s home page.

www.hospitalist.net—Contains a wealth of information for and about hospitalists, including a “Hospitalist Casebook.”

www.aafp.org—Search AAFP’s publications for hospitalist studies and results on its hospitalist task force.

www.sgim.org—Use SGIM’s Web site to browse abstracts of recent hospitalist studies presented at its annual meeting.

medicine.ucsf.edu/programs/hospitalists/
fellowships/index.shtml—Details UCSF’s hospitalist fellowship programs.


PRINT


“The Hospitalist Movement in the United States,” Robert M. Wachter, David R. Goldmann, eds. Annals of Internal Medicine, Vol. 13, No. 4 (Part II).
~~~Rebecca Sernett is an associate editor of The New Physician.~Career Development,Practice of Medicine~
296~7October~1999-48~On the Wards~Dating Game~A REBEL YELL TO ALL SUBMISSIVE THIRD-YEARS.~SHETAL SHAH~~On the last day of my rotation, I, the humble medical student, made a controversial and potentially life-altering medical decision. Gingerly walking to the newborn nursery, I asked the attractive, tomboyish pediatric intern to dinner. Surprisingly, she said, “Yes.” Well, sort of….


As I learned, there is no faster way to become the most popular male third-year medical student than to ask someone higher in the chain-of-command on a date. The life of the single, male third-year is often a monastic one. Isolated from first- and second-years by laborious rotations, his waking moments otherwise spent reading or complaining to friends via cyberspace, he is condemned to the bowels of the library. My date, then, became symbolic for us all—a reminder to the lonely souls that fourth year, with its abundant vacation time and easier clerkships, may actually arrive and bring with it a life outside the hospital.


Until I asked the intern to dinner, we had exchanged exactly 23 words with each other. Six of them included “How ya’ doing?” twice. But in a way, I had known her for eight weeks. Her name often surfaced during the underground, smoke-filled-room discussions of third year. Jon was in love with her. Heather thought her rude and arrogant. I contemplated asking her out.


After four weeks of furtively glancing her way in the darkened, slide-show light of noon conferences and inquiring as to her eligibility, the clerkship ended and, with it, my status on the pediatric ward. After the No. 2 pencils of the end-of-rotation exam had been collected, I approached the nursery as cautiously as one tests a pan to see if it’s hot. My heart raced and body considered vasovagality. Remember your first junior high school dance, with the boys massed on one side of the gym and the girls huddled on the other? If you recall the vertigo, fever and muscle weakness you felt as the music began and how the sides hesitantly met and asked one another to dance for the first time, then you know how I approached the seventh-floor hallway.


The feelings were instinctive, hard-wired in an evolutionary past. Nervousness comes from uncertainty; and the risk involved is not only a possible rejection, but rejection of hurricane severity. How much of my ego she would leave intact added another level of danger. I remember her exact words regarding another suitor: “If he were the last man on earth, I’d clone a dead man before going out with him.”


Many reasons existed—beyond the hospital politics and awkward rumors—to simply refrain from asking her to dinner. As an intern, her life was one of constant preoccupation, but mine was one of medically indentured servitude. Considering my meager 23 years of age, she may have thought me too neonatal to dine with. Would she risk eating with a medical inferior—especially one she didn’t know well? Gamblers would bet I had a greater chance of being appointed chief of neurosurgery.


Clearly this was not an optimistic situation. But I asked her anyway, and the action had less to do with her than with a common unspoken problem students face. Third year is punctuated with a series of mini-crises, including everything from “can’t find the X-ray” to forgetting one of Ranson’s criteria. But, often neglected are the larger internal conflicts—the submission and constant derision, the restraint of personalities to fit in with the service team, the feigning of enthusiasm in psychiatry clerkship—all performed thespian-style to fuel the greater theme of the year: avoidance. Conflict, the student knows, creates an uncomfortable situation, one where ignorance might be suspected and unearthed by the attending…a cardinal mistake.


What results is a compromised spirit—a personality deranged and hesitant to so many superiors for so long in the quest for knowledge that a mild self-loathing develops. A friend on the general-surgery service said it best: “The more time I spend on rotations, the more I split into two people. The quiet, timid one in the hospital, and the real me outside of it. And I am beginning not to like the person inside the hospital that much.”


We all suffered from the same affliction. Prior to my third-year withdrawal, I fancied myself a daredevil with an aggressive grasp on life. There was a fervor, idealism and voraciousness in my approach to life and learning. These are the characteristics that get you into medical school. The students chosen for prestigious schools are those who make their voices heard.


But now, at certain times, I hoped not to be called on. I spent my time calling up X-rays, drawing bloods and asking questions that are never really answered and fumbling for answers to questions I’m asked. But here on the medical floor, deviation from my assigned role is rewarded with a poor evaluation. And to the third-year student, such black marks carefully constructed on academic records could haunt you for the rest of your life.


In asking the beguiling pediatric intern to dinner, I made a forthright attempt to claim some of my personality back. In this one act, I tried to step closer to the courageous person I had been for 23 years and befriend the part of me that spent so much time in the hospital. I would achieve this goal in grandiose fashion. I would risk my reputation in an entire department for the reward of a single date and an uncertain romantic future.


Dressed in a lucky tie, I moved toward the nursery. As I closed my eyes to settle my racing heart, she approached. With the cries of neonatal infants behind me and the traffic of postpartum mothers in front, I asked her to dinner.


Her initial response was “yes,” and I left the seventh floor thinking I had plans for next Thursday night. I bragged to a classmate and word spread. For several hours I experienced pure ecstasy. My roommates toasted me in the kitchen, and a classmate saluted me in the post office. This was a celebratory event.


But two hours later, it all ended. A supervising resident phoned to say the pediatric intern requests I don’t call, because the situation is regrettable. She had used my third-year mentality against me, knowing it’d be academic suicide to criticize a supervising resident prior to the submission of evaluations.


Muted, I thanked the supervising resident and hung up the telephone.


A good student is one who examines his experiences so he can apply what he has learned. And it’s hard to extract only one lesson from my “date.” There was a moral victory in standing up to fear and actually being myself, though it gained me nothing but the ire of a medical superior and material for jokes from classmates. The pediatric intern never faced me in rejection—proving knowledge, but not maturity, comes with an M.D. degree.


In the end, my old habit of being the submissive third-year overwhelmed me, leaving me more humble and less vital than when I started. My adviser, a pediatrician himself, maintains restraint will make me a better doctor. But I doubt it’ll make me a better man.
~~~~Shetal Shah survived his frustrating third year and is now a fourth-year medical student at Weill Medical College of Cornell University.
~Student Life and Well-Being~
297~7October~1999-48~Perspectives~Wake-up Call~MEDICAL STUDENT TRAGEDIES WON'T STOP UNTIL WE ACKNOWLEDGE THEM.~JERALD WINAKUR, M.D.~~When a medical student at the University of Texas Health Science Center jumped off the 10th-floor observation deck of a local hospital, there were few lines in the paper about it. I remember the murmurings among my colleagues at the time: The student must have been “disturbed”; he must have had “other issues.” Certainly, his suicide had nothing to do with his chosen profession. My chosen profession.


I had been out of medical school for 21 years. At 46, I had—and still have—one of the busiest internal medicine practices in our city. Yet, despite half a lifetime of distance and professional success, once again I was reminded of my old medical school friend, Jake Summer.*


I can still picture Jake on our first day of medical school, both of us in our short white coats. The pockets of those coats, which would soon bulge with stethoscopes, reflex hammers, flashlights, index cards and assorted “peripheral brains,” were empty then. All we had was our enthusiasm, our idealism. Jake’s dominant feature were the bushy, comical eyebrows that almost hid his sensitive brown eyes. In our group, he was the even-tempered one, the one who never panicked before the exam, the one we looked up to.


But there was a sadness about him even then. I knew his mom suffered from multiple sclerosis and recently had been institutionalized. She died not long after. He rarely mentioned it, but I am sure her chronic illness is one reason he went into medicine. We all had our reasons. Mine was watching my grandmother die a lingering death from pancreatic cancer. But we had too much to learn if we were to succeed, and there was no time to get bogged down in these “other issues.”


The popular solution to dealing with the strain was to ignore it until the unthinkable occurred. In his recent book, The Tennis Partner, Dr. Abraham Verghese, professor of medicine at Texas Tech University School of Medicine in El Paso, reminds us that every year, two full medical school graduating classes—200 young doctors—are needed to replace the physicians who kill themselves in this country.


My friend Jake has been gone a long time. I didn’t go to his funeral. I have never even been to his grave. We were interning in different cities during Thanksgiving in 1974 when he told his girlfriend he was spending the holidays with his family and told his family he would be with his girlfriend. Then he took an overdose of sleeping pills.


He was gone from my life in an instant, like so many overdosed patients I had tried to save during my ER internship rotations. I was still in the middle of that hellish year and still had two more years to go after that. When was I supposed to mourn? Just take a deep breath and move on. That’s what all the Iron Men did, after all. That’s what all of our academic mentors did. No, we didn’t need a formal medical school course in self-denial. We learned by example.


Even now, 25 years after I took the Hippocratic oath, the Texas medical student’s death causes me to believe an intense lack of compassion still lives on in medical education. And I am more than sad; I am angry.


I am angry at the pharmacology professor who grabbed a white rabbit by the ears and tried unsuccessfully several times to dispatch it with blows to the back of the head with a baseball bat. We listened to it scream and shriek, until the professor had finally finished it off, until we could have a heart–lung prep to work on. She belittled us for not wishing to kill our own rabbits in this same manner. My group decided we would all just watch the experiment with the one she killed and leave the others alone.


“Too soft,” she said. “You’ll never make it in medicine.”


I am angry at the assistant professor who, during my surgical rotation, sent students into the clinic to “pan for gold,” as he put it, to find cases upon which the housestaff could operate. I remember how he patted me on the back when I presented the woman whose breast lump I had discovered. “Nice find,” he said, congratulating me in front of her.


I am angry at the professor of medicine, a major figure in cancer research, who, as my attending during my internship year, belittled my presentation of a case after I had been up all night with eight other admissions and no time to prepare. “You’re presenting this case like a second-year student!” he screamed, red-faced, in front of the whole group.


I am angry at the ungodly, inexcusable hours we all worked. So tired we were, so exhausted. And during all of these years through medical school, through internship, through residency, we were taught this lesson: You do not matter, your health does not matter, your family does not matter. You may—if it does not get in the way of your ability to be objective—have compassion for your patient. But there is no time, no need for you to have any for yourself. You are a physician, after all.


Jake and I never talked about being brainwashed during our medical school years. We didn’t have enough insight, enough perspective to realize what was happening to us. Now he is gone, and I miss him. Worse, I miss the self I lost along the way and am only now trying to unearth from the morass of these early experiences.


I remember going back for the fifth reunion of my residency class—hardly any of us attended—and voicing my disappointment that there was no training given to us about how to take care of ourselves…about how I thought this was a failure of our training program. Everyone looked uneasy, but no one said another word about it. The silence of my old mentors disappointed me, and I never went back for another reunion.


What to do about the anger? What to do to make compassion a critical part of medicine for those who will practice it? Oh, it is easy to give lip service to the solutions that already exist: conducting special classes, offering empathic mentors for medical students, reducing internship and residency hours, spreading the word about professional help for practicing physicians, such as the Talbot–Marsh Clinic in Atlanta or the Society for Professional Well-Being in Durham, North Carolina. Any number of these organizations operate across the country to help doctors suffering from burnout. But it is too easy to say to a colleague, “Why not check out this or that program?” and let it go at that. In the end, no mere suggestion to seek help will be enough to undo the damage that has already been done to so many of us, that is being done right now in so many medical schools and teaching hospitals across the country.


How many of us feel a deep unease, a fear that oblivion’s hand is on our shoulder, when we learn that one of our colleagues—even someone we might not know very well—is ill, had bypass surgery, or has just been diagnosed with cancer or AIDS, or has a “little problem?” How many of us, when we hear that it is one of our own behind that door onto which a scrawled, “No Visitors” sign is taped, tip-toe by on our rounds day after day?


I say it is time to go in anyway. It is time to open doors. It is time Hippocrates ceases to glare and begins to look benevolently upon his own. And it begins with each of us.
~To the Medical Student Who Jumped From the Roof of the Hospital


I know that place well,

watched too many

sunsets in between

the despair of learning it all:

the bony articulations,

the long path

the blood takes to make its way

all the way down....



the sky was so brilliant then—

cascades of pink and red: endless.

where else could one find

such a spectacle?



the iron bars across the view

were to keep the psychos

from heaving themselves off:

who else would do such a thing?



First do no harm Hippocrates said

to those who chose to follow

his path.



but I have

always been on my own—

the nights on the wards

merging into the next day and the next….


I watched the lights of the city ignite,

then fade until the sky

bled morning....



maybe once I thought:

I knew it all…

an arrogant illusion

that soaks into the skin

like formaldehyde....



at the bedside, in the end

there is only one’s self to blame…

Hippocrates always looks away

when another pair of lids is closed.



all those nights: I sought solace

in the risings of the moon,

the constellations——

they ran together like

the seasons, away like the years—



and I must admit

there were those times

I looked for ways

to scale those bars myself—



though for me they were too formidable,

and instead I finished rounds,

round and round

and round always trying to grasp

a handhold on what I knew,

what I didn’t know,



searching

tomes heavier than newborns

for answers I have yet to find….



yet at times

found myself hated

for being on that pedestal,

for not being God or

worse

hated by my own self unless

I could always be right

and I never could….



like me you were never taught

those center-of-gravity lessons

and landed feet first

in the doctors’ parking lot——

splintering

your tibias, fibulas

ramming

your femurs through your pelvis

rending

your femoral arteries

slicing

your aorta....



when you left early

Hippocrates glared at the

crimson horizon.

I stared down still awaiting

the dawn.

~~~Jerald Winakur is a freelance writer and an internist and geriatrician in a San Antonio, Texas, private practice.~Ethics,Student Life and Well-Being~
298~7October~1999-48~Feature~This Time, the Primary Color Is Green~~Tammie Smith~~Four black medical colleges’ stories tell a modern painful truth: Mission alone no longer guarantees survival.


They are, depending on how you look at it, either the likeliest or unlikeliest of health-care partners in the highly competitive and fluctuating health-care landscape of Nashville, Tennessee. The one partner, Meharry Medical College School of Medicine—a black medical college in financial turmoil for much of its 123-year existence and one that found its bottom line undercut even more by the state’s massive Medicaid overhaul a few years ago. The other, Vanderbilt University School of Medicine—the white, wealthy medical school that has been the city’s darling for much of its existence, but which in recent years also found itself facing serious threats to its ability to stay competitive.


Last January, the two institutions announced they had formed an alliance. They will share laboratories, libraries and faculty, among other things. Vanderbilt will also manage city-owned Metropolitan Nashville General Hospital, which has been Meharry’s main teaching hospital since 1998. This sort of strategic partnership is not unique to the national health scene; but, it is worth noting here that the two institutions are such opposites.


Of the 125 accredited allopathic medical schools in the United States, only three others besides Meharry are focused on training African-American doctors—Charles R. Drew University of Medicine and Science in Los Angeles, Howard University College of Medicine in Washington, D.C., and the Morehouse School of Medicine in Atlanta.


Collectively, these four schools play a much smaller role in the training of black doctors than black medical schools did a century ago when segregation and racism shut blacks out of white medical schools. In 1997, only about 14 percent of the 1,158 black medical school graduates earned degrees from the four schools. Each year, the four schools collectively graduate about 230 new medical doctors, about three-fourths of them African Americans.


Compounding the plight of black medical schools is the obvious. In a country where such social theorists as Harvard University’s Cornel West write that race still matters, it is reasonable to expect that black institutions experience more difficulties.


That said—and despite all the griping over the market’s failure to consider the special teaching and research missions of medical schools, arguments used to justify government subsidies and higher patient charges—administrators at these schools have come face-to-face with reality. These days the primary color is green, as in dollars. The schools need to adapt, adjust, or get out of the way.


MISSION VS. MONEY


“In the past, we had deep problems but could look for a bailout,’’ says John E. Maupin Jr., Meharry’s president. “[But] the bar has been raised for all institutions. You cannot survive anymore just because you have a special mission.”


You hear the same at Howard University. “We’ll either be thriving, or we won’t be here,’’ says Dr. Victor F. Scott, a gastroenterologist and president of the medical school’s faculty practice plan. “[Managed care] is not going to take its foot off the neck of hospitals and providers. Anything they can do to reduce payments to providers is fair game.”


Scott says one needs an action plan. “In five years, what happens depends on what we do now. If we get in alignment with the university, reduce duplicated activities such as payroll, if the university is more successful at bringing physicians into compliance, if we get to negotiate contracts as a team, if we develop more successful community skills, attract more patients, market well, make appropriate alliances for our benefit—if we do all of these things, we will thrive.”


Where black medical colleges are five years from now may also depend on how good they are at singing their own praises. One thing in their favor: demographics. Minority populations, particularly Latinos/Hispanics, are growing. Study after study points to more disease in minority groups and less care available to them—a health-care market niche ready and waiting.


Why aren’t black veterans getting high-tech cardiac procedures? Why do young black women get breast cancer less often but die from it at higher rates than whites? What can be done to reduce alarming rates of diabetes in Native Americans? Black medical schools have always focused on nurturing a crop of doctors who desire to eradicate health-care disparities. With some ingenious planning, this approach can still be the ace in their pocket.


Take Charles R. Drew University of Medicine and Science, for example: “African-American doctors are four to five times more likely to serve African-American patients. Mexican-American doctors are much more likely to serve Mexican-American patients,’’ says Dr. Theodore Miller, associate dean for Drew’s medical student affairs.


Located in South Central Los Angeles, Drew has a predominantly Mexican-American student body. This reflects the area’s transition from being a community that used to be more than 90 percent black, to now being only about 40 percent black with Mexican Americans as the prevailing population.


Dr. James L. Kyle II is chief medical officer at Drew and director of clinical business development. He is responsible for investigating ways to bring in more dollars from patient care. “As I see it, there are several products we can bring to the medical marketplace,’’ Kyle says. “Clinical services—investigative research by pursuing clinical trials for pharmaceutical firms; and consultative—taking advantage of the expertise of faculty, for government, social service agencies and developing countries. When I arrived here [three years ago], none of these had been conceptualized.’’ Even so, he says this wouldn’t have mattered. “We’ve had no resources to build enterprise.’’


Academically, Drew is in a unique position. Its undergraduate medical program is linked with the University of California, Los Angeles (UCLA), School of Medicine, where Drew medical students do their first two years of medical training.


“Students have access to the basic science program [at UCLA],’’ explains Dr. Roy Wilson, former dean of the medical school. “They have a lot of resources. So from a functional standpoint, we could not come close to duplicating what is provided.”


Financially, the school is tied to county-owned Martin Luther King Jr. Hospital—a massive structure across the street from the college where Drew residents train. Together, the college and hospital form King-Drew Medical Center. In the arrangement with the hospital, the county pays 75 percent of physicians’ salaries, while Drew pays the rest with some of that coming from county dollars. This puts the school in a peculiar position.


“We are building a university on the back of a faculty that does not belong to us,’’ Kyle says. “It’s formidable. The Bible basically says, ‘Can any man serve two masters?’ It makes it a big problem when the university portion of compensation is the smallest portion.”


Drew’s attempt to gain more control over faculty was derailed in May 1999, when county doctors voted to unionize. Drew had just renegotiated its contract with the county when it happened, Kyle says. The plan had been to transition within the next five years to an arrangement whereby, instead of individually contracting with Drew physicians, the county would have an umbrella contract with Drew to provide health services at the hospital. Such an arrangement would have given Drew more say-so over faculty time.


“The county would be considered the primary client, but there could be other clients as long as we performed in accordance with the purchase services agreement,’’ Kyle says. “Now, we have to deal with a small but powerful physicians’ union. There is a proposition here in California, in Los Angeles County, which precludes the outsourcing of county personnel unless it’s proven to be more cost-effective. So the lawyers for Los Angeles County believed that the clinical model of the contract would be challenged in a lawsuit. Therefore, the opportunity to do that has been withdrawn.’’


But they have not given up yet. “We are hoping this will change, and the political will of the board of supervisors will see better. We think this contract is so unique for all three medical schools in Los Angeles County that it should be exempted,’’ Kyle says.


THINKING OUTSIDE THE BOX


But there are other efforts Drew can attempt, Kyle says. One idea: a physician network including doctors in the community—as many as 1,000 of them, not just those on the Drew faculty. In exchange for their services, the doctors would have better bargaining power with managed-care companies. This network would require a little start-up funding, though. Such an endeavor could cost as much as $10- to $12 million to get it off the ground.
\

“We lack the bricks and mortar of having our own buildings in which health care can be provided. So if we wanted to get started immediately, we would have to go out and lease space,’’ Kyle says. Plus, he says, figure in the management costs.


On the other hand, a more promising idea includes taking advantage of Drew’s unique faculty.


“What we are trying to do is focus on what we do best,” Kyle says. “Ninety percent of our faculty are specialists in a market where specialists are hard to come by. We believe we can harness those resources of our specialty doctors and pick up one or two specialty consultation offices and market our physicians to local IPAs [independent practice associations] and HMOs that are trying to service this community.


“We’re looking at creating small niche markets in that overall market. One thing we are looking at is dialysis. We are in a community that has a high incidence of end-stage renal failure. We believe we should be in a renal failure. We believe we should be in a joint venture with one of the major dialysis companies and have our own dialysis unit on our campus. We are also looking at wound care, so our surgeons can be involved in management of non-healing wounds.” They also are investigating ways to create niches elsewhere in pediatric specialty care to serve local managed-care groups. Drew physicians have already formed an eye institute to specialize in cutting-edge eye care.


“We are acquiring land and raising funds and hope to break ground in 18 to 24 months,’’ Kyle says.


In Nashville, Meharry engages in creative enterprising as well. Maupin, a Meharry dental school graduate with a master’s degree in business administration, has been president of the school since 1994. When he first arrived, he found the school a heartbeat away from closing its doors. In the five years since, Maupin has orchestrated a turnaround no longer requiring resuscitation at every turn.


One breath of life has been the partnership with Vanderbilt, which has the potential to help Meharry attract faculty and students, and help both schools lure federal research dollars. What is not known is whether it will fill the Metro-Nashville General Hospital’s beds—something Meharry needs for its residency programs. Meharry also needs those patients, once discharged, to continue seeing its doctors. In the mid-1990s, the college shut its teaching facility, Hubbard Hospital, for lack of patients. Just before it closed, state records show Hubbard’s 207 staffed beds reported an average daily census of 59 patients—a 29 percent occupancy rate, the lowest in the city. The empty hospital drained the college’s bank accounts and was a leading factor to the college losing accreditation of its obstetrics–gynecology residency.


In hopes of keeping a stream of patients, Meharry works at developing an integrated health network. This means partnering with community health clinics that would feed patients into Metro-Nashville General Hospital. To establish this, Meharry will receive a $4-million annual, five-year renewable grant through the Office of Minority Health (OMH).


“The project is based on the merger between Nashville General and Hubbard Hospital,’’ says Mimi Chafin, OMH public health analyst.


There are several stages to the plan. The first is to implement the merger plan, then develop a management information system linking the hospital and ambulatory sites. After this, they will begin providing managed-care services to the underserved population and evaluate its effectiveness. The final stage is to plan and provide managed-care curriculum development. The grant will support the cost of the faculty involved in providing the care.


Why Meharry? The president’s earlier assertion that the school can’t survive on special missions alone is not entirely true.


“[The grant is] a result of historic commitment on [OMH’s] side to support Meharry and its endeavors,’’ Chafin says. “We previously, in 1990 and ’91, had a memorandum of understanding, which was established to say the same thing. [It said] that we recognize that you are a resource for the nation, and we will support you and do whatever we can through our programs to support you.”


SURVIVING THE EXODUS


Go north to Washington, D.C., and officials at Howard University College of Medicine also seek survival strategies.


“There are three universities [with medical schools] in this city and not room for three,’’ Howard’s Scott says. “There are at least a dozen community hospitals around here. Next to us is Washington Hospital Center. Not far from them is Providence Hospital, which is never empty. There are two institutions within two miles of us. It’s difficult to compete.”


And he means difficult. The nation’s capital’s market forces have everyone quivering, says Tom W. Chapman, senior associate vice president at The George Washington University Medical Center. This runs especially true for the medical schools. In June, Georgetown University Hospital announced losses of $75 million. What’s causing all of this?


“For one, managed-care restrictions are costing [the hospitals] patients,’’ Chapman says. “Also, the population is dwindling in D.C. The city is losing 10,000 people a year. It’s significant and persistent and will not go away.’’ He says suburban hospitals also heighten competition by developing expertise in such lucrative high-tech areas as coronary care and heart transplants—this used to be how academic medical centers set themselves apart.


Howard, like the three others, is trying to reverse the exodus. A few years ago, it spruced up the hospital emergency department. Walking though the facility, one would find it difficult to tell they’re not in one of those suburban hospitals with valet parking.


“We are the biggest and best in emergency care,’’ Scott says. “They don’t bypass us like they used to.” Howard University Hospital operates in the black, he says—a confirmation of its success.


“We are doing quite well, actually. I can’t say that for the other teaching hospitals in the district. One was bought by another large company. The other is in discussions. I think the reasons we are OK is because we have sort of been in a defensive posture financially for so long,’’ Scott says.


Of the four black medical colleges, Howard is the only one that has a cancer center and a transplant program. Scott says he can see the university building on that specialized base. “Whereas there may be too many subspecialists in the overall medical community, the number of subspecialists who are African American is still far below the population percentage. We feel that we serve a particular purpose in keeping our subspecialty programs open.’’


In terms of clinical operations, Howard, like the other schools, moved to a performance-based compensation for its physician faculty. Last July, the university came close to putting the final touches on changes to the faculty practice plan.


“In the past, we had a universal approach to it where all the money was in one pot,” Scott says. “We’ve [now] gone to a departmental kind of budgeting system, so that a department has to function within its own productivity. If they want to bring somebody else on new in their department, for instance, they have to find that practice site, patient load or revenue to support that particular faculty member.” Physician faculty will still negotiate separately for the clinical and academic portions of their salaries, he says.


As the youngest and smallest of the four black medical schools, Morehouse School of Medicine has given itself a great challenge. It wants to double the size of its first-year medical school class from 35 to 70. At the school’s helm sits Dr. Louis Sullivan, former health and human services secretary during George Bush’s presidency. Under Sullivan’s leadership, Morehouse recently completed a hugely successful fund-raising campaign. Still, like the other schools, it has to think in terms of patients and dollars and how to get more of each.


“We are trying to keep our head above water like everybody else,’’ says Dr. Wm. Lynn Weaver, professor and chairman of the school’s surgery department. “We are trying to increase outpatient base by expanding out of the hospital that has been our primary affiliation.’’


Grady Memorial Hospital, a 953-bed structure, has been the school’s traditional training partner. But earlier this year, Morehouse added a 369-bed hospital to its training pool—South Fulton Medical Center. The new affiliation was not totally unexpected. The school had attempted to link with South Fulton several years before, but had failed when hospital medical staff rejected the offer.


“[The staff] didn’t want any affiliation with any medical school. They felt somewhat threatened. Everybody is fighting for the same patients,’’ Weaver says.


What has changed since then? South Fulton has a new hospital administration and a new appreciation of partnerships.


“What do they get out of it? They get what they hope would be more patients in the hospital by adding more physicians to the staff,’’ Weavers says. “They also hope to raise the quality of the medical care. It has been proven that in any hospital with residents, medical care goes up. [And] they receive graduate medical education dollars.’’


For Morehouse, South Fulton offers another site to send their residents. And it also provides access to a population more likely to have health insurance. This is important in bringing in more dollars. Grady Memorial is a hospital for the poor. Some of its patients may be on Medicaid, but many are uninsured or underinsured.


“[In] my department, we get 20 percent on the dollar for all the care we do there,’’ Weaver says. “The school enables me to continue a viable teaching program.’’ For how long can that go on? Weaver is unsure.


“My residents can take care of patients as well as the faculty. They can pass the boards. They can do good on the exams. But if my department is not profitable, then that’s the standard I am being held up to more and more. Profits vs. performance.… It’s getting really ugly. It’s a shame.’’


In Washington, D.C., the OMH is about to start the second phase of a project that tries to alleviate some of this ugliness.


“The intent of the [project’s] first part was to identify key issues, such as endowments, how to diversify programs and critical relationships of the schools,’’ says OMH deputy director Tuei Doong. Other areas focused on were financial performance, revenue augmentation, and development of strong organizational structures and governance.


In this next phase, “The idea is to come up with some strategic actions for these schools that would help them fulfill their mission in this environment of managed care,’’ Doong says. “The goal is to really identify how the schools can continue to address what they call the public policy need for well-trained providers and researchers who are committed to addressing health-care needs of minorities.”


The project—“Managed Care: Strategic Plan to Train and Produce Research and Physician-Trained Clinicians”—will be completed in January 2000. It is important for the future of the four institutions and the medical students they serve.


In the end, what will make the difference for the black medical colleges, their students and patients will be their ability to align mission and money, to reach a comfortable place so that neither is pursued at the expense of the other. When this is accomplished, the schools can stop talking about survival and begin looking at success.~A LITTLE HISTORY


At the turn of the century, African Americans interested in becoming physicians had a choice of almost a dozen black medical schools scattered in the southern and middle-Atlantic states.
There was Leonard Medical School at Shaw University in North Carolina. In Kentucky, there was Louisville National Medical College. Others were in Tennessee, Maryland, New Orleans, Pennsylvania and Washington, D.C. Many of these schools were created by religious philanthropies, while others were for-profit ventures.
“The number of black physicians in the United States increased markedly between 1890 and 1920 as medical schools devoted to educating blacks opened their doors,’’ writes medical historian Todd L. Savitt, a professor at East Carolina University, in the Bulletin of the History of Medicine. “Most graduates remained in the South, where they had grown up and learned medicine (there were no black medical schools in the North), but as the rest of the black population began to migrate North in the early decades of the 20th century, so did black physicians.”


Of the dozen or so black medical schools that existed in the early part of the century, only two survived the massive overhaul of medical education around 1910, which was sparked by Abraham Flexner’s report, “Medical Education in the United States and Canada.” (See “Spotlight,” The New Physician, May–June 1999.)


By 1923, only Meharry’s and Howard’s medical departments survived Flexner’s criticism. Experts argue that the dramatic effects are still being felt today.
Decades after Flexner, with the numbers of blacks entering medicine still leaving much to be desired, two additional black medical schools were born—Morehouse School of Medicine in Atlanta and Charles R. Drew University of Medicine and Science in Los Angeles.


Drew literally rose out of the ashes of the 1965 Watts riots—one of the most violent outbreaks of the 1960s which occurred in the Watts area of Los Angeles. A commission appointed to study the cause of the riots concluded that numerous social needs were unmet in the largely black and Hispanic communities. One of those needs was basic health care. Drew began as a two-year postgraduate medical school in 1966. In 1978, the plan for the Drew–UCLA undergraduate medical education program was approved. Three years later, students enrolled, and in 1985, a charter class of 15 students graduated with medical degrees.
Morehouse College, a well-respected men’s college, established a medical department in 1975 as a two-year program. In 1981, the medical department became an independent school of medicine, accepting both men and women. The first class of medical doctors received degrees in 1985.


Around the time these schools were forming, headway was being made to desegregate medical education. Affirmative action victories were opening doors to institutions traditionally closed to African Americans. From 1968 to 1984, the number of blacks entering medical schools quadrupled, from 278 to more than 1,100—with most enrolling at typically all-white institutions. —T.S.


-----------------------


RESOURCES


Charles R. Drew University of Medicine and Science - Established in 1966

1731 East 120 St.

Los Angeles, CA 90059

Admissions: (323) 563-4800

President: Dr. Charles K. Francis

Interim dean: Dr. Thomas Yoshikawa

Web page: www.cdrewu.edu



Howard University College of Medicine

Established in 1868

520 W Street, N.W.

Washington, DC 20059

General information: (202) 806-6270

Dean: Dr. Floyd J. Malveaux

Web page: www.med.howard.edu




Meharry Medical College School of Medicine

Established in 1876

1005 D.B. Todd Blvd.

Nashville, TN 37208-3599

Dean’s office: (615) 327-6204

President: Dr. John Maupin Jr.

Dean: Dr. A. Cherrie Epps

Web page: www.mmc.edu




Morehouse School of Medicine

Established early 1970s

720 Westview Drive, S.W.

Atlanta, GA 30310-1495

Administration: (404) 752-1551

Admissions: (404) 752-1650

President: Dr. Louis W. Sullivan

Associate dean for student affairs: Dr. Angela Walker Franklin

Web page: www.msm.edu
~~~Tammie Smith is a freelance writer based in Nashville, Tennessee. This article is based on her 1997 Kaiser Media Fellowship project.~Diversity in Medicine,Minority Affairs~
299~7October~1999-48~Feature~Animal Labs~IS THERE A MIDDLE GROUND?~Nancy Hood~~“When we first walked into the lab, all the students were kind of quiet and subdued,” says Emily Burns, second-year student at the University of Colorado School of Medicine (UCSM). “You see these dogs that are really cute—they’re all different. Just like Buffy next door. Tied to the tables, spread-eagle, on their backs with their legs tied down.


“Their heads are way back. It’s kind of a jolt when you first walk in. Most people took their time and did what they needed to do to start getting comfortable. I acknowledged that the dogs were there and then didn’t deal with it until I had to.


“Periodically, you have to check to see if [the dogs] have enough anesthesia and check some reflex. Sometimes they twitch. This doesn’t necessarily mean that they need more anesthesia, but sometimes it does. The breathing is marked—the rib cages are prominent when they are on their backs. They’re breathing slow and deep. That’s about the only way you know they’re living. Three dogs in each room. I tried to pet them and stuff while I was working with them—rub their feet or something just to let them know I appreciated them. There was a faint dog odor, and the blood had a smell when we started cutting.


“After the first lab, students could practice sutures on a dog. In some of the later labs, we put catheters in and an endotracheal tube. It was kind of gory. The procedures required for the labs were not extremely invasive, though. After the last lab, we were encouraged to open the chest wall, and we saw the heart beating and felt it. I almost passed out and had to leave, but it was actually pretty amazing to see a live heart and lungs.”


Many students enter medical school knowing animal labs are a required component of their educational experience. For some, like Daniel Waggoner, third-year medical student at the University of South Alabama (USA), these labs become a valuable learning tool. “It was a tremendous experience. Upfront, I would have preferred another option, but after completing the dog lab, I would choose it again because [we] actually got to do things. Going through the lab really changed my ideas.”


For others, the idea of a dog lab is so disturbing that they choose to opt out and may even initiate efforts to end their existence.


This is true for Stephanie Ganz, second-year student at New York Medical College: “I and about 15 other students were not happy about doing the lab, so we put together a survey,” she says. Their findings revealed that some students felt uneasy about the labs. Ganz and some of her classmates hope the results will help convince their physiology department to at least offer an animal lab alternative to students.


FINDING A MIDDLE GROUND


Almost all schools with animal labs allow students the option of not participating. In some, students have to write about their objections, meet with a professor and research the answers to the labs as if they had participated.


Third-year USA medical student Monica Williams-Murphy wanted out and found her school to be responsive. She had long conversations with her professor about her religious conflicts. “I struggled with whether I wanted to take part or not, and I decided to go with my heart,” she says.


But refusing the lab may not be an attractive option for all students. “As far as testing and grading are concerned, [these are] the other major reason[s] why students choose to do the labs,” says Carey Lee Cuprisin, second-year student at UCSM, who opted out of the dog lab. “Most students feel that unless they participate in the lab exercises, they won’t be able to do well on the lab final.”


Pressure from their peers may also discourage students from forgoing the animal lab. Adam Dimitrov, third-year student at the University of Miami School of Medicine, did not participate in the lab. “Many students who did take the lab felt that those who didn’t were showing cowardice of some sort and lacked the emotional withdrawal that they felt was needed to survive in the medical field,” he says.


So, is there a middle ground? Are there alternatives?


Technology continues to improve the interactive, real-life nature of computer programs used in place of or in addition to live animal labs, but other, more creative alternatives are becoming popular. These usually involve re-examining why medical education really needs the lab.


Several years ago, Harvard Medical School redesigned their curriculum, searching for the best way to achieve their objectives. “The decision was made that all the exercises and everything we taught would be based on human physiology, as opposed to mammalian physiology,” course director Dr. Bruce Zetter says. “There was a simultaneous effort to make the courses more medically relevant, so as much of the curriculum as possible was moved to the actual hospital.” Harvard medical students played a role in this reform.


As a result of the curriculum change, Harvard’s physiology course no longer includes an animal lab. First-year students experience hands-on labs using themselves as subjects for echocardiograms and stress tests. They also shadow a cardiac anesthesiologist to learn physiology from an actual surgery.


Most experts estimate that less than 50 percent of U.S. medical schools use animal labs—this is down from an estimated 73 percent in 1992. And they predict a continued decrease in the numbers. Dr. Richard Simmonds, vice-president elect for the American Association for Laboratory Animal Science and director of laboratory animal medicine at the University and Community College System of Nevada, says that “because of all the political pressures, you’re going to see less and less [animal labs]. Eventually they will all be gone.”


Dr. James T. Stull, chair of the department of physiology at the University of Texas Southwestern Medical Center at Dallas, says financial pressures led to lab closings about five years ago at his medical school. It was costing around $20,000 per year to run the labs. Computers, laser discs and small-group discussions replaced them.


However, going against the trend, Duke University School of Medicine reintroduced an animal lab about five years ago. “Hands-on experiences were perceived as a real need,” says Nels Anderson, associate professor of cell biology at Duke. “We wanted to bring the experimental side of physiology back to the traditional curriculum. Also, for some students, the animal lab is a very powerful way to come to grips with their discipline.” Duke incorporates computer programs and other laboratories as part of its physiology courses as well.


IT'S A LIVING THING


Students and professors alike cite the “hands-on” aspect of animal labs as being crucial to medical education.


Third-year University of Miami School of Medicine student Christopher M. Estes says, “Not only did I gain a firmer understanding of several basic principles of cardiovascular physiology, but I [also] had a hands-on experience with life and death.”



Dr. Neal D. Barnard, president of Physicians Committee for Responsible Medicine (PCRM), disagrees with this hands-on claim. “Most labs have to do with demonstrating the regulation of the cardiovascular system,” he says. “These systems are not very complicated. The dog lab is just to reinforce the concepts.”


Practicing procedures is another common reason for maintaining animal labs. “Students intubate and put in arterial and venous lines. [They] often have no appreciation for the fact that arteries and veins actually bleed,” says Dr. Joseph N. Benoit, a professor in the department of physiology at USA. “I would much prefer my physician to have learned how to put in an arterial line in the laboratory setting than on me.”


Barnard argues against this, saying,“What you learn in a dog lab with regard to procedures is almost nothing. Repetition is necessary to learn anything. Doing something once in medical school years before you are in clinical practice is irrelevant.”


Interestingly, the goals of learning how to be compassionate and appreciating responsibility for a patient’s life have been used by both sides. “Compassion is such a fragile commodity that we should use every opportunity that we have to instill it,” Barnard says. A PCRM-published point-counterpoint on medical school animal labs states, “Shouldn’t a student’s first clinical experience be life-affirming? Dealing with patients involves much more than just physiology, pharmacology and surgery; it involves counseling, listening to their needs and, above all, helping instead of harming them.”


WHY DOGS


“The reflexes in the dog are most like those of humans,” Benoit says. “We use human laryngoscopes, and the size and texture of [the dogs’] vessels are similar to humans.’” An Association of American Medical Colleges 1994 study found that 70 percent of schools with animal labs use dogs. Other animals frequently used include pigs and rabbits.


Many dogs are obtained from pounds. According to some professors, these dogs would have been euthanized anyway, and all precautions are taken to keep the dogs pain-free during the experiments. Plus, they say, they follow strict guidelines on how to treat research animals.


Not everyone agrees with such justifications. “Dogs best for labs are also the most likely to be adopted,” Barnard says. He and other animal-lab opponents contest that animals suffer, especially during the transportation and housing process preceding the actual lab.


Some state laws prohibit the use of community pound animals for research or teaching, requiring schools to obtain the dogs from purpose-bred dealers or from pounds in other states. Such laws frustrate many professors. “If we could use animals from nearby pounds, the transportation process would be much less stressful for the dogs,” Simmonds says. “Also, it would seem to me that it is more unethical to raise dogs for the purpose of animal labs. We ought to be using more pound dogs, but political pressures are making it difficult to do so.” Using animals from a local pound also would greatly reduce the cost of dog labs, he says.


In the end, however, there seems to be no easy answer to whether a medical school should use an animal lab.


Students learn best in different ways. “We will never have the data to prove who is right,” Simmonds says. “The issue is what teachers think is the best way to teach.”
~~~~Nancy Hood is a second-year medical student at the Ohio State University in Columbus, Ohio.~Ethics,Medical Research~
300~8November~1999-48~Feature~Silicon Savants~~Rick Stahlhut, M.D., M.S.~~“Yeah, I’ve got a case,” says Mike, an internal medicine faculty member. “The patient was a 70-year-old man complaining of chest pain and shortness of breath.” I enter this into the computer. Thirty seconds later, we’re reviewing a list of diagnoses. It is Morning Report time. A room full of internal medicine residents, faculty and students watch the projected computer screen as I demo “DXplain”—the venerable diagnostic tool from Massachusetts General Hospital.


Mike reviews DXplain’s list and says, “That might have helped.” He points to diagnosis No. 7: dissecting aortic aneurysm. “This could have inspired them to check for it, and then we would have had a correct diagnosis.” As it turned out, Mike’s residents incorrectly diagnosed the patient as having pulmonary embolism (PE)—a blood clot blocking the pulmonary arteries—so they anticoagulated the patient. Of course, when the aorta is tearing apart, you want plenty of coagulation. PE was a particularly unfortunate misdiagnosis.


DXplain might have helped this patient survive, merely by reminding the physicians of a rare disorder they had otherwise failed to consider. To understand this better, let’s begin by looking at the medical diagnostic process itself.


How diagnosis works...or doesn’t. First, the physician gets the patient’s chief complaint and history of present illness. Next, the physician forms a tentative diagnosis list based upon what they remember and what “looks right,” and then begins chasing data to help refine that list—initially with questions, then exam findings, and, sometimes, diagnostic studies. Eventually, the physician “makes the diagnosis” and begins treatment, if appropriate. This point is attained when the top diagnosis reaches a particular level of certainty, or when there are no other reasonable tests to be performed, or when time runs out (as in an emergency). After treatment begins, the patient’s response to treatment (or no treatment) is used to confirm or refute the working diagnosis. If the patient gets better, the physician was “correct.” If not, they try again.


Cognitive psychologists have learned some of the ways a diagnosis can go wrong. Our brains have two main decision rules (or “heuristics”) that help us create the differential diagnosis list and rank it. One is the “availability” heuristic: “The easier it comes to mind, the more likely it is right.” So, when I say, “chest pain,” you probably think “heart attack.” It usually works because availability is a quick-and-dirty substitute for disease prevalence—the more often you see a disease, the more available it is in your head. Availability fails when we are inexperienced, or when a recent traumatic experience causes us to remember something too strongly. For example, Mike’s residents may have readily diagnosed PE in the patient mentioned earlier because they recently misdiagnosed a patient that really did have PE.


The other built-in heuristic is called “representativeness.” The more something looks like a classic case of X, the more we think the diagnosis is X. Like the availability heuristic, it’s fast and it works pretty well. When representativeness fails, it’s often because we think we’re seeing a classic presentation of something rare, when it’s really an unusual presentation of something common.


There are other problems in diagnosis as well. We tend to focus on positive findings more than negative ones. We tend to seek information to confirm our beliefs, rather than refute them. And we hold onto our original ideas too strongly when new information comes in.


Although people have been trying to build medical diagnosis systems for more than two decades, we still know remarkably little about the frequency and root causes of general diagnosis failure and the severity of the resulting damage. Does a typical family practitioner make a major error once a year or once an hour? How often is the patient harmed? Is the error caused because the practitioner doesn’t think of the diagnostic possibility? Or is it because they fail to take into account the prevalence of the condition by focusing on the representativeness of the presentation instead? Could it be a simple case of lack of knowledge?


Can computers help us?


Do they compute? Do we have hard evidence that computer diagnostic systems make us better?


For such “general” diagnostic tools as DXplain, the answer is “not really.” Without solid answers to the questions above, it is difficult to know how much a general diagnostic assistant like DXplain can help.


A good beginning, however, is presented in a 1994 New England Journal of Medicine article, in which several well-known systems were evaluated for raw accuracy. They gave the systems a series of patient cases and compared their results to those of a panel of experts. The accompanying editorial gave the “expert” systems a “C–”. Still, the study didn’t directly ask, “When generalists use these systems, do they arrive at the correct diagnosis more rapidly, less expensively or with less errors?” But, the article did contain a tantalizing clue: Each system suggested an additional two diagnoses per case that the experts thought were important, but had not made the panel’s original differential diagnosis list. (Just like Mike and the dissecting aneurysm.) If the systems can help a group of experts, perhaps they can help a solo practitioner, too.


In terms of “specific” tools—yes, some of them do make us better.


For example, a recent study by H.P. Selker and others in the Annals of Internal Medicine looked at 10,689 patients admitted to the emergency department with symptoms consistent with cardiac ischemia. Of these, 673 patients were ultimately determined to have “stable angina,” meaning, “yes, ischemic heart pain, but no significant change and no heart damage.” In a perfect world, none of these patients would have been admitted to the hospital. But in this multi-center study, 85 percent of them were, with 22 percent also going to the coronary care unit (CCU). A computer assistant, which was tested in this study, helped physicians reduce these unnecessary and expensive admissions from 85 percent to 79 percent and CCU admissions from 22 percent to 16 percent.


Another specific tool helps physicians and cytotechnologists reduce error in interpreting Pap smears. By manual methods alone, 12 percent of diseased patients are missed, largely due to the difficulty of noticing small groups of abnormal cells during a low power scan of the slide. A digital screening assistant, PAPNET, has been shown to decrease false negatives significantly in a recent meta-analysis from 12 percent to 8 percent.


Ready for Prime Time? As the data above suggests, some systems are ready to go. For many others, the jury is still out. Ultimately, a significant diagnostic tool should be subject to the same scrutiny as any other intervention, because they get right in the middle of a crucial part of medicine—the diagnostic process. Well-designed systems can make us better, but poorly-designed systems can have side effects that may be worse than the disease—one reason why the FDA has considered regulating them as medical devices.


The idea that a machine might help with diagnosis is disturbing to many physicians. They pride themselves on this most interesting and magical cognitive process, and see computer-assisted diagnosis as a threat. But medicine has constantly striven to extend physician abilities through the stethoscope, radiograph and lab tests. Like these tools, computers help us to reduce error and provide the best possible care. Within their wiring and microchips rests the potential to make us better diagnosticians. But computers can never replace the human touch our patients need within the Western World’s medical machine.


Next Time on InfoMed. Y2K-willing, I’ll discuss “test interpretation” in the next column. Tired of being befuddled by “sensitivity,” “specificity,” “false negatives” and the like? I promise you’ll get it this time. And, believe it or not, it really is important.

A Last Note on Y2K. It would be informatics-malpractice if I didn’t take this, my last chance before the New Year, to remind you about the year 2000 computing problem. History has shown that large computer projects usually get done late, so follow the advice of the American Red Cross and at least cover the basics. If nothing happens, that’s great. Good luck in ’00!
~CAUGHT IN THE WEB


Crying out for more information about expert systems or Y2K help? Visit these sites Dr. Stahlhut has found for us:


—Rebecca Sernett


FURTHER READING


“Performance of four computer-based diagnostic systems” (NEJM 1994; 330.25: 1792-6.), by E.S. Berner, et al. Evaluates several general diagnostic systems like DXplain, and finds that, although they aren’t particularly good at getting the diagnosis, they could improve the differential diagnosis list of even a panel of human experts.


“Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review” (JAMA 1998; 280.15: 1339-46), by D.L. Hunt, et al. Looks at the quality of available research on decision support systems in general (not just diagnostic systems). They find that these systems “can enhance clinical performance for drug dosing, preventive care and other aspects of medical care, but not convincingly for diagnosis.”


“Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia” (Annals of Internal Medicine 1998; 129.11: 845-55), by H.P. Selker, et al. Offers a fairly convincing demonstration that a computer-based tool can help emergency physicians triage patients with possible heart attack more accurately and less expensively.


“Assessment of automated primary screening on PAPNET of cervical smears in the PRISMATIC trial” (Lancet 1999; 353.9162: 1381-5). Read this study, and you’ll have a pretty good idea what is happening on the PAPNET front.
~~~New Physician contributing editor Rick Stahlhut is a medical informatics writer and consultant. Contact him with questions or suggestions for column topics at stahlhut@net-link.net, or check out his Web site, at web.net-link.net/~stahlhut/.~Learning Tools and Technology~
301~8November~1999-48~Feature~Military Medicine: Being All that You Can Be?~~Howard Bell ~~The military offers medical students an attractive package in exchange for a few years of service. But life in uniform isn’t for everyone.


Would you rather owe a sack of money to Mr. Got Rocks at First National or four years of your life to Uncle Sam? For medical students on military scholarships, graduating debt free is worth doing the time. Thirty percent of Health Professions Scholarship Program (HPSP) students go the distance and become career military docs. Even most who jump ship after payback say it was a fair trade.


What can you expect when you sign up for a Health Professions Scholarship? Ensign Mike Reiter spent a few weeks at Pensacola Naval Air Station completing the Navy’s “knife and fork” class. “You learn how to salute and how to handle yourself,” says the 22-year-old second-year medical student at Rush Medical College in Chicago. He has the use of a 9mm Beretta down pat, too.


For 10 hours a day, Reiter learns about military strategy, military leadership and Navy core values. And he will complete an aerospace medicine sampler, where he job-shadows a flight surgeon—a doctor who takes care of pilots who fly high-performance aircraft.


Back in Chicago, Reiter does not wear a uniform or do anything Navy-like, even though he is a commissioned officer, as are all HPSP students. You can’t tell him apart from any other medical student—except that every month the Navy sends him a check for $900 to pay his living expenses. Reiter will never pay a penny of tuition. His books and supplies are compliments of the Navy, too. “I like the idea of coming out of medical school debt free,” he says.


Nor could you pick Caela Miller out of a crowd as she walks to second-year classes at the State University of New York at Stony Brook. After graduating from Yale with a biochemistry degree, the 22-year-old got a Health Professions Scholarship—good for any branch of the military—and is now a second lieutenant in the Army. Like most HPSP students, she does two 45-day active-duty tours during medical school. Other than that, she’s just a medical student. “It was cool,” she says of the Officer Basic Training Course in San Antonio. “We learned how to wear a uniform, shoot a gun and rappel. It wasn’t like boot camp at all.”


Second Lt. Robyn Ratcliff echoes that sentiment. “There’s almost no military training. You sign some papers and make some promises.” Ratcliffe, a third-year medical student at the Medical College of Ohio in Toledo, got her three-year scholarship through the Air Force and completed her one-month orientation training in Alabama. “I loved it,” she says. “It’s not the physical challenge people are afraid it might be.”


Although there are a lot of little rules and requirements you have to endure, medical students have it easy, Reiter says. When his drill instructor told him his hair was a tad long, there was no bellowing or bulging neck veins. “You’re not gonna be doing pushups in the mud,” he says.


Reiter, Ratcliff and Miller must apply for residency at a military hospital, which doesn’t have to be their first choice. There may not be a slot for them anyway, in which case, they complete a civilian residency. After residency, they give Uncle Sam three to four years of active duty. “The commitment part is the biggest turnoff for a lot of people,” Ratcliff says. “They’d rather be committed to debt than to the military. I just look at it as three more years of training beyond residency.”


Besides money, the military offers more hands-on training than many civilian medical students get, says Col. David Ellis, M.D., M.P.H., deputy commander for clinical services at Womack Army Medical Center, in Ft. Bragg, North Carolina. “Before I was even an intern, I had done 60 deliveries, he says. Some civilian residents don’t graduate with that much experience.” Otherwise, Ellis says military internships and residencies must comply with the same standards as civilian programs.


Last summer, 2nd Lt. Miller did research, shadowed a surgeon, learned to suture and assisted in an operation during her active-duty rotation at West Point. She got paid for it, to boot. “I doubt I’d get that kind of experience in civilian medicine,” she says. “I certainly wouldn’t be paid for it.”


The military is a good place to go through “the clinical seasoning process,” says Dr. Daniel Kopp, an Army physician for 32 years who now practices family medicine in Waynesville, Missouri. “Most young doctors come out of residency a little too cocky. Reality soon whittles them down to size. It can be more comfortable to go through the seasoning process as part of a team that supports each other, lives, plays and practices together and shares the same goals and mission.”


SALARIES AND BENEFITS


Of course, if money is your mantra, you won’t be happy in the military. Military physicians are paid less than their civilian counterparts. Residents are the exception. They get paid $48,000 to $54,000, compared to about $35,000 for civilian residents.


But the gap between civilian and military pay narrows the longer you stay in, especially for primary care docs. Lt. Col. Gordon Miller, M.D., chief of primary care at Keller Army Hospital in West Point, New York, is a family practitioner with 15 years experience. He earns $120,000 per year including housing and living allowances. That’s near the median $132,000 for civilian family practice docs, according to the Medical Group Management salary survey, but it’s still lagging. An orthopedic surgeon at 15 years makes about the same. But on the upside, military physicians don’t pay malpractice insurance or overhead, which can gobble 50 percent to 60 percent of your gross revenue.


Military retirement benefits also are good. You could, if you wanted, retire in your late 40s at 50 percent of base pay—up to 75 percent if you stay in for 30 years. Many, like Kopp, then use their “golden years” to practice civilian medicine.


Ellis left the Army for a civilian solo practice, but re-enlisted partly for the retirement benefits. “I calculated I’d have to sock away $1,300 a month in an 8-percent account to equal my military pension. That’s hard to do, especially when you’re just getting started. I could gross more in private practice, but that’s offset by the [private practices’] longer work hours and overhead, which keep creeping up.”


A DAY IN THE LIFE


Physicians who’ve practiced on both sides of the fence agree the hours are the same or longer in civilian practice. Military physicians get 30 days of paid leave every year—comparable to what salaried docs in large group practices get, but tough to pull off in a small group or solo practice. “I’d take military hours hands down,” says Lt. Col. Greg Belcher, M.D., a medical flight commander at Travis Air Force Base in California. Belcher practiced civilian medicine in San Antonio. “I spent a lot more hours working weekends when I was a civilian.”


Ellis agrees. His day begins at 7:30 or 8 a.m. and ends by 5:30 p.m. He’s on call three to four nights each month. While stationed at Fort Sill, Oklahoma, it was every 12th night. At West Point, Miller says he takes call every fifth weekend. While based in the Azores, Air Force Maj. Erick Stone, M.D., pulled call every fourth or fifth night because the patient/physician ratio was high. It’s less frequent at Travis, where he is now.


Military physicians treat the same birth-to-death mix of patients civilian docs treat. “It’s no different,” Kopp says. “All ages, same pathologies. But because military families share a common culture, you often connect the diagnostic dots quicker.”


Many military physicians based stateside start their day treating active-duty walk-ins for an hour, then scheduled patients the rest of the day. While based in Italy, flight surgeon Stone flew with his patients. “Each aircraft and each mission has its own physical and mental stressors,” he says. “You play, eat and fly with the pilots.”


The military experience often is more rewarding for young physicians who are given more responsibility in the military than they are in civilian medicine, Miller says. During his first three years as an army doc, he was a clinic commander in Germany. Later, as a primary care consultant, he coordinated staffing for 29 clinics. He has also practiced hospital-based medicine. “You’re put in charge of a lot of assets and resources. You quickly develop confidence in your abilities that will serve you well no matter which career path you take,” he says.


PACK YOUR BAGS


But the life of the military doctor is a nomadic one. Plan on moving every three to four years. Moving and deployment—not pay or practice conditions—are the biggest reasons physicians leave the military, Ellis says. “It’s a real show-stopper for a lot of folks.”


Adds Kopp, “The most frustrated military docs were those who grew up with roots and didn’t like the moving.”


On the other hand, travel and variety are what keep Stone in the Air Force. “I’ve seen the world and immersed myself in other cultures,” he says. “My two daughters speak fluent Italian. They’re loving the adventure. I’ve flown the best high-performance aircraft in the world. Let’s face it—they’re fun. I’m not tied down to my practice or burdened with overhead.”


Let’s not forget, though, that with the military service comes the possibility of serving in the middle of a war. Military physicians in all branches are routinely deployed to combat zones. The good news: Deployments often last only a few weeks to a few months. The bad news: Chances for deployment have increased since the 1980s because of the Kosovos, Bosnias, Somalias and Desert Storms around the world.


“The average military physician can expect to be deployed once or twice in a 20-year career,” says Col. Kenneth Franklin, M.D., who spent a few months in Desert Storm, patching the wounded in a field of unexploded cluster bombs. Franklin is now deputy commander for clinical services at West Point’s Keller Army Hospital.


Some military docs escape deployment. Kopp was never deployed during his 32-year career. “It’s feasible a military physician could serve their entire career and not see combat,” he says.


GREENER CIVILIAN GRASS?


Physicians who’ve trod the turf on both sides say civilian and military medicine both have their weeds. Kopp might still be in the military if he had known how political civilian medicine can get. Still, he likes having less regulation and supervision as a civilian physician. And, medical technology in the military is a bit behind civilian medicine, Kopp has observed. Plus, military formularies can be more restrictive. “We sometimes had to send patients off-base for prescriptions,” he says.


But military medicine may be your best bet if you want a career that combines teaching and research with patient care. Belcher found this to be true. Specializing in infectious diseases, Belcher didn’t plan to stay in the Air Force, but he just couldn’t find a civilian job where he could do all three. “I’ve looked three or four times in the last eight years,” he says. “I’m not impressed with what’s out there.”


For many, the world of military medicine is too attractive to pass up. After three years of solo family practice in northeast Texas, Ellis had a tough time leaving civilian life. “But my family and I missed the Army and its opportunities for academic medicine. I couldn’t find a civilian opportunity that appealed to me.”


No studies have compared the quality of civilian and military medicine. Joint Commission on Accreditation of Healthcare Organizations’ survey scores over the past 10 years have been three to four points higher for military hospitals than civilian hospitals—96 for military compared to 92 for civilian in 1997, according to statistics compiled by the Army Medical Department. More than 95 percent of military hospital physicians are board certified, compared to 82 percent in civilian hospitals. Eighty percent of military hospital registered nurses have Bachelor of Science in Nursing degrees, compared to 34 percent in civilian hospitals.


Franklin has served on three physician credentialing committees that recruit civilian specialists for temporary military duty. “A lot of civilian physicians complain about how much more careful we are,” he says.


That’s a carefulness that Kopp and others say makes for better medicine. “Civilian medicine seems to emphasize the bottom line,” Kopp says. “Military medicine is practiced for quality, not money. In the military, we constantly did chart reviews and analyzed outcomes. In civilian medicine, the word ‘quality’ gets used a lot, but actions speak louder than words. So far, I’m underwhelmed by how civilian doctors treat patients.”


Ellis took military care for granted, until he practiced civilian medicine. “Civilian medicine is good,” he says, “but the military has better quality-assurance structures.” Ellis speculates the military’s predilection for controlling things works in its favor when it comes to quality assurance.


Kopp agrees. “The military may enjoy advantages,” he says. “It’s easier to implement quality improvement in a tightly structured environment.” But, civilian physicians practice with greater autonomy, he says.


Franklin takes a philosophical look at the differences. “Military medicine is as close to pure medicine as you can get,” he says, referring to its strong emphasis on patient care. “A patient’s ability to pay has zero to do with how we treat them. It simplifies and purifies the doctor/patient relationship. We’re not worrying about coding or insurance reimbursements. Care is free to all active-duty soldiers and their families. That appeals to me.”
~IS IT RIGHT FOR YOU?


Military medicine may appeal to you. Or it may not. One thing’s for sure: Decisions you make now will shape the rest of your life. Before you sign on the dotted line, do some reconnaissance.




ASK THEM:




ASK YOURSELF:




If you answered no, you and military medicine might make a good match.


-----------------------


UNIFORMED SERVICES UNIVERSITY WINS BUDGET BATTLES


The Uniformed Services University of the Health Sciences (USUHS) has always been a favorite target for budget-cutting legislators. But the nation’s only federal military school seems to survive every attack. USUHS is run by the Department of Defense in Bethesda, Maryland. It graduates 165 medical students each year, nearly all of whom become career military docs. Congress created it in 1972 to fill a need for more physicians in the military.


But five years ago, USUHS was on the defensive [see The New Physician, July–August 1994]. The House of Representatives considered closing the medical school on several occasions. The Clinton administration targeted the university as a waste of post-Cold War defense dollars, and Vice President Al Gore recommended the school be closed. Others said keep it open but focus more on training physicians for the Public Health Service, which includes the National Health Service Corps and the Indian Health Service.


Presently, USUHS is in no imminent danger of attack. In fact, it’s stronger than ever, according to Dr. Val Hemming, dean of the USUHS medical school. “We have survived all the political folderol,” he says and points to Program Budget Decision #711R, which was signed by the Secretary of Defense in 1997. Among other things, it states that it is the will of Congress to keep the university open, reiterating the government’s commitment.


But #711R does not innoculate USUHS from challenges. The latest came last January, when Senate Armed Services Committee Chair Russell Feingold
(D-Wisc.) introduced legislation to terminate USUHS. Civilian schools, he asserted, train enough docs to supply the military—and they do it cheaper, too. But, the Senate never gave the bill serious consideration, and it has no companion bill in the House.


As for congressional efforts to boost the university’s public-health emphasis, the opposite has happened. The university graduated its last class of Public Health Service students this year.


Like Health Professions Scholarship Program (HPSP) students, USUHS students get free tuition, books and supplies, plus housing and living allowances, compliments of Uncle Sam. In addition, they receive active-duty pay of $32,500 per year, free medical care and access to military commissaries. “These are fairly comfortable medical students,” Hemming says.


Students complete all rotations and residencies at military hospitals, whereas many HPSP students resort to doing a civilian residency. After residency, USUHS grads owe the military seven years of active-duty service. HPSP students owe three to four years. Eighty percent of USUHS grads stick around after completing their seven-year payback. Only about 25 percent to 30 percent of HPSP grads stick around after their three- to four-year commitment.


During medical school, most HPSP students have relatively little exposure to military life. Most complete only one or two 45-day active-duty tours, which can be deferred or canceled if the student can show it interferes with studies.


It was once thought USUHS grads would comprise 10 percent of all military physicians, but the number is closer to 20 percent, Hemming says. “If trends continue,” he says, “in another 10 to 20 years, one-fourth to one-third of all military physicians will be Uniformed Services grads.”


USUHS will always be under the microscope, Hemming concedes, as politicians look for ways to save money. “But right now,” he says, “we’re healthier than ever.” —H.B.


------------------------


WHISTLE-BLOWER BLUES


Your career may at some point be at the mercy of bad people—so ambitious, they will do anything to advance their careers—even sacrifice the quality of patient care they allow you to provide. It happens in civilian medicine, and it happens in the
military.


But in the military, it may be harder to escape.


Civilian and military physicians have been punished for blowing the whistle on poor care. But civilian whistle-blowers won’t have their credentials confiscated and be confined to a mental hospital, as was Dr. Stephen Whitlock Smith.


Lt. Col. Smith, who has been an Army physician for 17 years, got his start as a Health Professions Scholarship Program (HPSP) student at George Washington University. He stayed in the Army because he liked the Army. He never observed any problems until about four years ago, while stationed in Germany. Budgetary shortfalls pressured high-ranking military physicians to order subordinates to provide substandard care. Smith had the moxie to report the Army’s assistant surgeon general for reckless endangerment of patients. He formally accused some of his superiors of cronyism, suppressing records of adverse outcomes and wrongful death. “Sharks have risen to the top,” Smith says. “As a medical student, I would worry that these people could affect my career.”


Smith isn’t the only one who faced psychological and financial torment. Anyone who speaks up in any branch of the military can look forward to facing false legal and malpractice charges, and getting passed over for promotions, says Dr. Craig Michael Uhl, a former Naval physician and HPSP student from the University of Chicago–Pritzker School of Medicine. Uhl describes his first several years of active duty as “stellar.” But when he was set up to be the fall guy in an understaffing situation, he complained. “I got booted from my job into a dead-end job because I did the right thing for my patients,” he says.


His superior officer wouldn’t help, Uhl says, because her boss was being considered for the next Navy surgeon general position and didn’t want to make waves. Charges against Uhl were mysteriously dropped shortly before he left the Navy, but only after he’d spent thousands of dollars on legal fees. “Many good doctors’ careers are destroyed while the mediocre and politically adept remain high in the food chain,” he says. “Prospective HPSP students should think carefully before they sign.” —H.B.



LEADING SECRET LIVES


Shawn Fultz couldn’t live with the lies anymore. He’d been dating someone. They had to speak in code because phones were monitored at Andrews Air Force Base, where he was completing a pathology rotation. So much as holding hands would be grounds for dishonorable discharge.


In February 1997, when Fultz told the Air Force he was gay, he was a fourth-year medical student on a Health Professions Scholarship at the University of Pittsburgh. “The military was the only way I could afford medical school,” Fultz says. “When I got the scholarship, I hadn’t even come out to myself.” Before he told the Air Force, he had to tell his parents—the considerate thing to do and also legally prudent. It helps the Air Force confirm it’s for real, not just a ploy to take the scholarship money and run without serving the military time.


Gays and lesbians are not welcome in the military. Simply stating you are gay or lesbian is grounds for immediate discharge. After Fultz notified the Air Force by letter, they cut off his monthly scholarship payments and assigned an Air Force investigator to determine if he was pretending to be gay to get out of his four-year active-duty payback. “They wanted me to prove I was gay and answer a bunch of questions about my personal life,” Fultz says. “I refused on the advice of my attorney, who said the questions violate the military’s own ‘Don’t ask—Don’t tell’ policy. My answers might have been grounds for dishonorable discharge.”


According to the Clinton administration’s 1994 “Don’t ask—Don’t tell” policy, gays and lesbians can serve in the military as long as they don’t publicly discuss their sexual orientation. In return, the military is barred from asking anyone about their sexual orientation. The policy was supposed to make it easier for gays and lesbians to serve in the military, but Pentagon figures show gay and lesbian troops are being discharged at a far greater rate than before the policy took effect.


In return for his candor, the Air Force sent Fultz a letter: Pay us back the $79,000 in scholarship money, plus 3.2-percent interest. After battling 15 months of letters and attorney fees, Fultz agreed to pay back the scholarship, even though most students in his situation do not. “I couldn’t make residency plans,” he says. “Until the matter was resolved, they could still require me to complete my residency at the Air Force hospital where I matched. The Air Force claimed this was my way of getting out of a match I wasn’t happy with.”


Fultz asked the Air Force if he could postpone paying until he has finished residency and could afford to do so. He’s still waiting for an answer. Meanwhile, he has not repaid a penny of the $79,000 and is in his third year of an internal medicine residency at the University of Pittsburgh. The Air Force turned Fultz’s case over to a collection agency, which has since added on a $20,000 penalty. Fultz did, however, receive his honorable discharge in May 1999. —H.B.


-----------------------


RESOURCES


U.S. Navy: (800) USA-NAVY

Order a free video about life as a Navy physician: www.navyjobs.com/professional/phys/html/index.html.


U.S. Army: (800) USA-ARMY

Learn about scholarships, loan repayments and career opportunities in the Army Medical Corps: www.goarmy. com/med/amch.htm.


U.S. Air Force: (800) 423-USAF

Read about jobs, lifestyle and benefits for Air Force doctors: hp.airforce.com.


Military Medical Student Association

Chat with military medical students and get a taste of what it’s all about at the Uniformed Services University: www.usuhs.mil/mmsa/mmsa.html.


Physicians Online

Anyone with a DEA number can join for free and get access to candid discussions about military medicine experiences: www.pol.net.


Alternative Views

Dr. Stephen Whitlock Smith—an Army physician for 17 years—accuses top Army doctors of ordering subordinate physicians to provide substandard care. Click on “additional information” and read all about it: www.stephenwhitlocksmith.com.
~~~Howard Bell is a medical writer in Onalaska, Wisconsin.~Career Development,Military/VA Medicine~
302~8November~1999-48~Feature~A Natural High~~Elizabeth A. McNichol~~From tiny Woodburn, Indiana, to Washington, D.C., Food and Drug Administration Commissioner Dr. Jane E. Henney never faced a hurdle she couldn’t leap.


She was homecoming queen. If you know any facts about Jane E. Henney, this is probably not one of them. It’s not that it’s a great secret, a diamond of a tidbit unearthed from the past. Just four words notable for their simplicity. One of the nation’s most accomplished women doctors, with a résumé as ongoing as her Midwestern roots, once stood before her peers at Manchester College in Indiana wrapped in the swath of the traditional female popularity contest. A tiara of tradition.


It is, quite probably, a disservice to old-school feminists to begin a story about the rise of the first woman commissioner of the Food and Drug Administration (FDA) in this way. A crown, some flowers, the idea of a man presenting you on his arm while leading you down a path—too much style, not enough substance. But this is not a narrative about fitting a mold, or not fitting a mold. It’s about a woman who grew with her small-town values, who worked hard, loved fairness but not politics and dreamed big even when dreaming seemed impossible.


Doc Niswander saw the dreaming in action—in fleeting, riotous, exuberant action—one day in 1968. He peered out the window of his house near the Manchester campus where he taught anatomy and physiology, and there was quite a sight: Janie Henney, smile stretching and legs flying, beating a path like Achilles to his door with a golden ticket in her hand.


“She had just pulled it out of her mailbox,” Doc says. “It was her letter of acceptance to medical school.”


Tradition, it is safe to say, faded to the background of Henney’s life that day, replaced with a little something the rare folks among us embrace. It’s called Passion, with a capital “P.”


A LEADER FROM THE START


Now Henney sits as comfortably as a teenager in jeans on the couch of her office—only with decidedly more grace—swinging one leg vertically in front of the coffee table. She is a tall, thin woman of 52, her hair pulled back in a bun, her forehead creased with only the kind of wrinkles that seem to speak more of unending youth than of old age. Since she won a hard-fought nomination to the top FDA post 13 months ago by dazzling the Senate Labor and Human Relations Committee with her thorough intellect, Henney, an oncologist by specialty, has kept a quiet profile, rarely speaking to the press. She prefers to be less a mouthpiece of the FDA than a doer.


Though her friends call her a pioneer, she seems more like a woman with unfinished business to take care of in public health—business that began with the Student American Medical Association (SAMA), the precursor to the American Medical Student Association (AMSA). Henney first stepped into the public-health arena while a student at the Indiana University School of Medicine, where she became a leader in her SAMA chapter. She never looked back.


“At that point in time, medical students really didn’t have many opportunities early on to get clinical experience outside the tertiary care center,” she recalls. “So what we did was place students for the summer, particularly between their freshman and sophomore years, in smaller communities. We teamed them up with local physicians, who not only let them get involved in what they did in their practice every day, but also involved them in all the other ways a physician is called upon to be a leader in the communities in which they serve.”


The Medical Education Community Orientation [MECO] initiative had humble enough beginnings in Middle America. It began with a small grant from the Sears Foundation, but grew to become SAMA/ AMSA’s historically largest community health program. Thanks in part to an article Henney wrote for the Journal of the Indiana State Medical Association in November 1971, the program garnered enough attention in the region that Henney and her cohorts obtained a full grant to take it national.


“The real success of the program, I think, came when those grants ran out,” she says, “and many of the states had become so enamored with the program that it started to institutionalize either at the medical school or within the state legislature. They wanted to keep the program going. So even though AMSA’s involvement was still a presence, it had ownership at a far different level. Being from a small town, MECO was something I was just naturally drawn to. It was enormously fulfilling.”


In addition to the leadership skills AMSA honed in Henney, who in later years served as president of the AMSA Foundation, she got a little something more out of the experience than simple knowledge.


“I had the opportunity, and the very rich opportunity, to meet medical students from all over the country, people I never would have met if I had gone through the typical grind of going to school, going to clinic, meeting the students who were in my own classes and no others,” she says. “I would say that the friendships I developed in that medical student association are as strong as some of the friendships I developed in college or medical school. And I still retain them.”


In fact, Henney will celebrate her 20th wedding anniversary next June with one of those friendships: her husband, Dr. Robert Graham, former executive vice president of the American Academy of Family Physicians.


EMBRACING ENORMITY


Upright. Professional. These are the words most often used to describe her. That, and beautiful. “She never dated much in college,” Niswander says in disbelief. “She was very devoted to her work.” These days, Henney devotes herself to the agency. It’s a tremendous amount of responsibility, greater perhaps than the general public realizes. But responsibility is as central and binding to Henney’s very core as is the air she breathes. Always has been.


“The way we learn from problems that are unsolvable, the way we can turn something hopeless into something possible—she thrives on that,” says friend Jo Young Switzer, vice president of academic affairs at Manchester and a former classmate.


“Actually,” Henney confirms, “that’s part of the enjoyment of the job, the enormity of it. I really love complexity. I enjoy working with people. So making complex things work and working with strong and dedicated people on behalf of others—it’s a dream.”


Indeed, wherever she has been, be it as the vice president for health sciences for the University of New Mexico School of Medicine, the interim dean/vice chancellor for the University of Kansas School of Medicine, or the deputy director of the National Cancer Institute, Henney has been a problem-solver.


One of the greatest quagmires the FDA regularly encounters is finding the budget to reign over its vast jurisdiction, which includes everything from pharmaceuticals to artificial sweeteners. During her last go-around at the FDA, when she was the deputy commissioner for operations from 1992–94, Henney was instrumental in revitalizing the agency’s drug and biologics review system through the Drug User Fee Act of 1992. Henney calls the law “proof certain that when the agency is provided with adequate resources, it is up to the challenges it is given.” By infusing the review system with funds from fees paid by drug companies whose products were waiting for approval, the FDA sped up the process of getting life-saving medicines to doctors and the public.


But opinions are plentiful, and even a tool as seemingly useful as the user-fee program battled criticism as Henney traveled through the FDA head confirmation process. One conservative think-tank observer, Henry I. Miller, wrote in The Wall Street Journal: “Dr. Henney is a quintessential Clinton choice: a true believer in arrogant, intrusive, damn- the-expenses government regulation. While she was the deputy commissioner, the regulatory burden on drug companies grew….”


But Henney proves what those close to her contend: that she will steadfastly, if graciously, stick to her guns.


“It’s not like any of our decisions are easy,” she says. “But are they important? Do you feel like you’re making a difference? That’s the thrill of any job. Do some people think you’re wrong at everything you do? Yes. Do some people think you’re a great heroine? Yes. But you have to set your own internal satisfaction and your own comfort with your decision-making. Otherwise, this job could drive you crazy.”


One decision Henney wishes the FDA had been able to avoid were a rash of drug and product recalls over the past year—and five drugs since 1997.


“What we found in a nutshell was that the speed of the review really had not been the problem,” she says, punctuating each word with an arm outstretched toward her interviewer. “The problem most often was that once they got into the marketplace, they were used in larger settings than ever would be used in a study setting, or they were used in ways that were never contemplated by the indications that were on the label.


“And no matter what we did as an agency in terms of how to inform individuals or health professionals of how to use these products, they continued to be used in a way where the risk started to outweigh the benefit. And so we were forced to the final endgame of not just putting out more information on a label or in educational materials, but in actually having to say, ‘We can’t have this. It’s gotta be recalled.’”


For Henney, it’s an endgame to be abhorred, to be prevented in any way possible. Everything, she says, has some sort of risk, because once her agency gives a product the nod, it goes into the open marketplace, where physicians and patients handle their own risk management.


“The challenge that we will present medical students at the FDA in coming years is also a great opportunity,” she says. “The onslaught of new products is going to be even greater. One of the first orders of business, then, for future physicians is to reach a comfort level and a knowledge level with those products that they are going to use on behalf of their patients. That means making sure they are well used and appropriately prescribed, and that they well inform their patients about those products. That is the key.”


Her comments, those of a federal agency head—those of policy and implementation and efficacy and all those other ’tions and ’acies—are rather freshly interrupted by the sort of wishful, hopeful, I-believe-we-can-do-this smiles not often seen in bureaucracy. Perhaps this is because she fancies herself less of a bureaucrat than a peoplecrat. Folks with passion will do such things, as if to remind the rest of us that there is a human face behind everything we do. And yet, it’s true, she and the agency she heads do command 25 cents of every dollar your loan money spends, 25 cents of every dollar your mother spends, one quarter of the contents of the pockets of everyone you treat or will treat.


So shouldn’t she be as well known as Alan Greenspan? Shouldn’t we be watching her briefcase for marketplace indicators?


Henney gives a laugh that comes from her toes. “Well, there are pluses and minuses to that happening,” she says in an ironic, throaty voice. Then, with a graceful, state-dinner tone: “I have had the privilege, ever since I started my career, of working for very public institutions. Dealing with the public arena is something I’m accustomed to. The impact of the FDA, however, is very different, because the FDA really does impact every single individual in this country every single day.


“I don’t think it’s important that ‘Jane Henney’ be on the lips of every single American, or that her name be known, but that people have an appreciation for what this organization does on behalf of the public health.”


That’s quite a departure from the very public face her predecessor at the FDA, Dr. David Kessler, brought to the vanilla-bean-inspired office in Rockville, Maryland. Kessler, who left in 1997 to head the Yale University School of Medicine, thrust the role of FDA commissioner into the political spotlight with his efforts to commandeer nicotine product regulation as an agency duty. Criticism of Kessler’s publicity-minded agenda frequently ruffled feathers on Capitol Hill and elsewhere.


“Our budget suffered terribly over the last five years with David in charge,” says Linda Suydam, a senior associate commissioner at the FDA and chief of staff for the Office of Tobacco and Public Affairs. “People on the Hill were very upset with him. Dr. Henney is more open, more contemplative. They are two very different people. She loves to make organizations run efficiently; he was not much for structure.


“There are advantages and disadvantages to being high-profile. You can galvanize the public to certain issues, but you can also galvanize opponents,” Suydam says.


Therein lies one of Henney’s largest challenges as commissioner. The politics. Industry wants quick reviews of products for more revenue. Physicians want quick reviews of drugs for better patient results. Congress wants whatever the little old lady in Peoria wants, which is a little of both. And the FDA’s job is to want everything everyone else wants, as safely as humanly possible. Pressure? Nah.


“There’s always a balancing of forces and interests that go on when you’re dealing with a regulatory agency of any type,” she says. “But I find that if we make our decisions here at the FDA and make sure they are firmly grounded in science, we stand on firmer ground. We make decisions that are in the interest of public health. Sometimes that’s as disruptive and unpopular to consumers as it is to industry, but if we’re not in a place where we can defend a decision based on scientific evidence, then we very quickly lose a position of strength.”


She has—if not the in-your-face, “fight authority” chutzpah of a Mellencamp muse—the Midwestern, three-stoplight, Little-Pink-House security of her mind and its contents. If Jane Henney’s FDA is political, and it surely must be if reachable by an exit off the Washington Beltway, it is so only by peripheral coincidence. That, say friends, is why she will be remembered as the “most qualified FDA commissioner in history” and a woman with very few enemies.


“She brings integrity to whatever she does,” Switzer says. “You know that whatever she’s associated with is going to be fair and sensitive to the needs of all groups of people. She’s not buffeted by fads or trends. She brings a lot of small-town with her wherever she goes.”


‘WELL, WHY NOT?’


It is a timeless refrain, of course, in stories like these. Small-town values. Small-town wisdom. Small-town dreams....


“I can remember going to the doctor in my small town, Dr. Mosier,” says Henney with a wistful smile, “and being fascinated by what went on in a physician’s office. It was the kind of office that still had all of those amber pill bottles on the wall, and he was the quintessential sort of Norman Rockwell physician. He took care of everybody. When you went to the doctor, you dragged your dolls, you took your dogs...and he just sort of paid attention to it all. He was just a wonderful and revered person in the community.”


Henney drew her strength from the people she knew in tiny Woodburn, Indiana, population 512. A friend of the family died of breast cancer, a woman whom Henney calls “a town heroine.” She was drawn to the woman’s courage; it taught her much of inspiration. And then there was her mother, who Henney refers to as “Rosie, the Riveter.”


“My mother so desired to go to college, to have a career, but she truly was living in a time when that wasn’t possible. She became a secretary, but she wanted a college education—probably so bad she could taste it. But she came from a family with nine children and lived on a farm. There wasn’t enough money. So from the time we could even think we were hearing something, she rammed into her kids: ‘Education, Education!’ It was a very strong value.”


So strong, in fact, that Henney was on track to become a schoolteacher at Manchester College.


“Really, when I was growing up, there were three paths you could take as a woman. You could become a nurse, you could be a schoolteacher or you could be a secretary. Even to be a social worker, an occupational therapist, a travel agent….


I mean, those occupations, for a person from a small town, just didn’t exist, let alone thinking about entering one of the professions like law, medicine, business. It’s not what women were expected to do, even if they thought about it.”


But while she took English and social-science classes, Henney was also taking her fair share of life-science courses—and loving them, and wondering….


And so one day she walked into Emerson “Doc” Niswander’s office and laid it out on the table for him. She was thinking about it. She was thinking about what she really wanted to do, and she was thinking that, well...it wasn’t teaching. It was doctoring.


What was his response to this bold young woman hoping to become one of 12 women enrolled in Indiana University’s medical school class of 250? “Well,” Niswander told her, “why not?”


“And I couldn’t come up with any ideas as to why not,” Henney remembers now with wonder in her voice. “I knew I was doing as well in my classes as the premeds were. I knew I wanted to. So I’d figure out a way.”


For his efforts, Doc, now 85 and retired from teaching, received a golden ticket of his own: to Washington, D.C., last January to see his star pupil sworn in as the first female FDA commissioner in history. And to hear her acknowledge in her speech his three simple words to her so many years ago, right there in front of the president of the United States.


“At the time,” Niswander recalls from Henney’s student years, “none of us thought about her being a leader in the public-health world. But she didn’t either. Her main aim was just to get into medical school.”


My, how things change.


“I think it’s always significant when an individual breaks a barrier, and it’s a real honor to know I’m the first female to be FDA commissioner. But,” Henney says with a sly smile, “I guess I take more pleasure in knowing that I won’t be the last.”


Like Dr. Mosier, she has become a revered person in the small towns where she got her start, whether it’s Woodburn or Manchester.


Jo Young Switzer lived on the same hall as Henney at Manchester, where Henney now serves on the board of trustees. Switzer says that whenever Henney is in town, students are anxious to hear what she has to say—and Henney is anxious to share her wisdom. She recalls that, at the height of her nomination process, Henney came to Manchester and spent 90 minutes chatting casually with 40 students from all fields of study, explaining what gave her the skills to make the shift from practicing to administrating to leading. All the classes she took, she said, including those education courses that would have put her in front of a classroom instead of an examining room, gave her the breadth of knowledge to climb to her position today.


“She hooked it right to their own experience,” Switzer says.


Recently, Henney was in town for a board meeting, and she was met with a great surprise. Out of the 1,100 students at the college, 600 of them had convened to sign an enormous card for her. Switzer recalls that one student had written these oh-so-reverent words: “You’re just too awesome!”


“I said, ‘She would never talk like that,’” Switzer says, tickled at the very thought. “She’s much more formal. But I suspect that this was a young woman who might aspire to follow in Jane’s footsteps one day.”


Riotous, exuberant, Achilles-like footsteps, no doubt. And with a crown fit for a commish.
~FACTS BOX


Jane E. Henney, M.D.

BORN: March 26, 1947, in Woodburn, Indiana

SPECIALTIES: Oncology, internal medicine

EDUCATION: M.D., Indiana University School of Medicine, 1973; B.S., Manchester College, North Manchester, Indiana, 1969



FAMILY: Married to Robert Graham, M.D., former executive vice president of the American Academy of Family Physicians



PROFESSIONAL:



~~~Elizabeth McNichol is a former associate editor of The New Physician.~Women in Medicine~
303~8November~1999-48~Feature~A Virtual Diagnosis~WILL TELEMEDICINE BECOME AN EVERYDAY PRACTICE?~Aleksandra Syska ~~Have you ever imagined how it would be to prescribe medications via the Internet? What about examining a hospitalized patient while you’re sitting by the light of your desk lamp at home or reading a patient’s X-rays from 5,000 miles away? Or, what about signing test results to a deaf patient during a televideo conference? No, it’s not the next generation of “Star Trek.” It’s telemedicine, and doctors and medical specialists around the world practice it. Experts say telemedicine is the gateway to “new and improved” health care. They point to it being a quicker and faster way of exchanging medical information. How is this all possible? Is it really worth it? Read on.


TELEMEDICINE


Broadly defined, telemedicine is the transfer of electronic data—including high resolution images, sounds, live video and patient records—from one location to another. It consists of connecting patients with medical experts by using electronic diagnostic tools and modern telecommunication. In the most extreme cases, telemedicine can save a sailor at sea who is in need of an emergency operation, for example. Closer to home, rural patients are finding that telemedicine can improve access to quality medical care that’s not readily found in more isolated communities. This may all be accomplished with a variety of technology including, but not limited to, an ordinary telephone call, the Internet and satellites.


While the explosion of telemedicine interest over the past five years makes it seem as if the concept is relatively new, the National Aeronautics and Space Administration (NASA) has been exploring telemedicine since the early 1960s by monitoring the health of humans in space. Physicians, hospitals and medical schools began studying telemedicine uses in 1964, primarily for medical education. Today, radiologists use teleradiology to interpret emergency CAT scans at all hours of the night.


HOW DOES IT WORK?


Telemedicine can involve several methods of consultation: store-and-forward, interactive and televideo conferencing, facsimile equipment and even, under some definitions, ordinary telephone calls.


In the store-and-forward method, patient information is acquired from the patient site, stored in a computer system as a mail message and sent to the specialist site for consultation. Based on the presented information, the specialist can make an evaluation or recommendation and send the message back to the patient site, where the primary physician and patient can review it together. These messages may contain such information as lab results, X-rays, text messages, scanned documents, audio recordings and diagnostic images captured by electronic devices.


The interactive method is where both the patient and specialist sites are able to consult “face-to-face” via televideo conferencing and the store-and-forward method. They may use such medical equipment as endoscopes and electronic stethoscopes to aid in diagnosis. Doctors using this method say that the virtual “face-to-face” conversation between the physician, patient and specialist allows the specialist to immediately assess the patient’s condition and be available for future needs.


WHY IS IT USED?


Telemedicine is frequently used in correctional institutions, home and rural health-care settings, emergencies and research. Reasons for its use vary from maintaining public safety to providing the only available care.


Telemedicine offers inmates in some prisons access to specialized health care online, which eliminates risky repeated trips outside. East Carolina University School of Medicine, for example, has been performing telemedical consultations to Central Prison, the largest maximum-security prison in North Carolina, since 1992. When Central Prison’s full-time physicians need to consult a specialist, they do so online. Its use of telemedicine keeps dangerous criminals confined while providing them with specialized care. This reduces the possibility of escape. It also allows the prison physician to have direct contact with the outside medical community—a benefit not available to them before.


Telemedicine has also been valuable in giving patients in rural areas access to advanced techniques more available in larger cities. “I think [telemedicine] is a good idea for rural patients where there is a physician shortage and a quick assessment needs to be done,” says Jyoti Rau, a second-year medical student at New York Medical College.


Typically, rural health-care emergency services transmit images to larger medical centers for evaluation by appropriate medical specialists. The University of South Alabama (USA) College of Medicine and BellSouth BusinessSM teamed up in the summer months to work on getting telemedicine to rural areas. The Southwest Alabama Rural Telehealth Network (SARTN)—an 18-month, $3 million project–—is the area’s first comprehensive telehealth network. It uses cutting-edge technologies to link medically underserved rural communities in Mobile and Washington counties to the regional health-care resources and specialists in the university’s health system.


“We’ve felt for a long time that it is important to extend medical care to patients wherever they may be,” says Dr. J. Raymond Fletcher, medical director of USA’s telemedicine services.


Each rural site is equipped with video cameras, computers, electronic stethoscopes and other examination devices enabling university specialists to examine patients “virtually.” They may also formulate treatment plans which, in many cases, can be followed by a visit to the patient’s own physician. SARTN participants say that this technology will alleviate costly and time-consuming trips to specialists in Mobile. USA uses the network to bring specialists in several medical specialties to a service area where many live below the poverty level. SARTN incorporates rural residency programs for medical students, distance learning for area medical professionals, patient education and counseling, and community education programs.


A health policy consulting group, the Office of Rural Health Policy and Abt Associates recently conducted a survey of all 2,472 rural hospitals in the United States and found that 353 use some form of telemedicine. These hospitals reported notable improvements in dermatology, cardiology and neurology; however, annual telemedical operating expenses are about $60 million, half of which is for teleradiology.


Radiologists are frequent telemedicine users. “The benefits are in costs and time savings for the physicians and hospitals,” radiologist Dr. Allen Powell says. “Because of telemedicine, we are able to send direct digital images of X-rays at all times of the day without having to pay a visit to the office. We’re able to look at X-rays done in the emergency room in the middle of the night without leaving our houses. The ER doctors have the advantage of accessing specialists 24 hours a day.”


Home care services find similar benefits as well. Alacare Home Health Services Inc., a Medicare Home Health Agency serving North Alabama, recently implemented a project examining how telemedicine can be used with homebound patients to improve total patient care.


“The biggest obstacle is the physician’s willingness to embrace new technologies and methods,” says John G. Beard, Alacare’s chief executive officer. “We expect that it will take some time before a large percentage of our physicians choose to make extensive use of this tool.”


Telemedicine often provides the only available care in emergency situations. In one case, a surgeon at the New England Medical Center was able to coach a boat captain at sea through a delicate ear operation on his suffering wife. This operation used link satellite voice communication and computer faxes. Emergency evacuation from a ship at sea to treat such a case could cost more than $50,000. Because of instances like these, major cruise lines have begun adding comparatively inexpensive telemedical equipment to their shipboard hospitals.


Several case studies and projects are being performed to test the work of telemedicine. The Everest Extreme ExpeditionTM 1999 (E399), which was first piloted in 1998, researched the uses of telemedicine last May in an attempt to enhance the quality of medical care in space exploration. A team of 15 health-science members traveled to the rooftop of the world—Mount Everest—in a six-week expedition to research the human body’s adaptation to high altitude, high stress and low-oxygen conditions. (See photo on p. 25.) Building on last year’s data and observations, E399 mapped how the human circulatory system redistributes blood flow to allow more oxygenated blood to the brain. Advanced technologies such as digital microscopes and portable bio-pack/personal status monitors and locator devices were tested for the first time to track the team’s vital signs. The coming decade will see adaptations of similar devices in rural areas and home care delivery.


RISKS TO CARE


Additional research is needed to fully evaluate the quality of telemedicine’s patient–physician relationship and the legal issues involved. Because of this and how telemedicine challenges traditional health care, physicians and physicians-to-be are putting it under their microscopes.


“[Telemedicine] is no substitution for the real presence of a physician in the office to take a history and examine the patient,” Rau says. “It dehumanizes the experience of the physician–patient interaction. When a patient feels that the doctor is just an image on the screen rather than a person who cares about them and their health, it distances the patient from the physician. It is frustrating enough that in the era of managed care, we are forced to spend less time with patients.”


In terms of the physical exam, the physician may be a lifesaving factor. The exam is an inexpensive way to identify patients needing expensive tests. It forces doctors to touch their patients, thereby creating a physical bond that many feel to be a crucial element in the art of healing—an art that telemedicine lacks.


“[The physical exam] is the only time that we have an opportunity to literally touch our patients. To relinquish it would be a mistake. If you have available technology as an alternative, you’re going to rust at the bedside. We now have an entire generation or generations of teachers and physicians who may not be very comfortable with that bedside part,” says Dr. Salvatore Mangione, a pulmonary specialist, in a recent New York Times article.


Are patients and physicians accepting telemedicine? Overall, many physicians, like their patients, have accepted telemedicine into their daily routine. At the same time, physicians learning to accept it have some practical concerns related to the inability to touch or see their patient in a “face-to-face” setting. In many cases, the physician’s ability to touch a patient is essential for a correct diagnosis. The key question is whether the patient and the physician at the remote site can adequately describe tactile sensation to the specialist.


According to recent studies, patients have been shown to accept the medical care provided to them over the telemedical network and have seemed to respond positively to “being on TV.” Patients have said they feel as if they have received “special care.” However, the effects of telemedicine on quality of care have not yet been fully studied and reported. Patients’ acceptance of telemedicine may change dramatically if studies prove that quality of care is diminished in any way by the use of this treatment.


Telemedicine also awaits more examination of its legal repercussions. Physicians, some say, are at greater risks of making mistakes, leaving the door open to malpractice suits. Another issue is where a claim should be filed when a patient resides in New York and her physician is in Utah. If there were a conflict among state laws relative to the rights of the patient and the physicians involved, which law would apply? Some say it’s the one in the patient’s state. Often it is up to a judge to decide. Other potential liability issues are in the area of international telemedicine, where there could be a conflict of laws between countries. Physicians practicing telemedicine across international borders or across state lines are advised to contact their professional liability carriers to determine any possible coverage limitations.


WHAT'S NEXT?


It has been said that telemedicine will be a success when the hype calms and the technology used is seen as an everyday practice. Only more frequent use and studies can determine what the future holds for telemedicine.
~RESOURCES


CHECK OUT THESE TITLES ON TELEMEDICINE:




ONLINE TELEMEDICINE LINKS




To learn more about the E399 project, log on to: www.everestextreme99.org
—A.S.
~~~Aleksandra Syska, a freshman at St. Bonaventure University, was the publishing assistant for The New Physician.~Community and Public Health,Health Disparities~
304~9December~1999-48~Feature~The Financial Health of Medical Schools~~Christine Wiebe~~IN THE WAKE OF LAST YEAR’S BANKRUPTCY SCARE AT MCP HAHNEMANN, SOME MEDICAL SCHOOLS ARE RADICALLY CHANGING THE WAY THEY MANAGE THEIR FUNDING AND EXPENSES. THE DAYS OF “SHELL GAMES”—MOVING MONEY FROM ONE AREA TO ANOTHER AS NEEDED—ARE COMING TO AN END.
NOW MANY SCHOOLS ARE TURNING TO SOMETHING CALLED MBM TO HELP RECONCILE THEIR BOOKS. BUT WHY, AS A MEDICAL STUDENT, SHOULD YOU CARE?


What would you say if a broker asked you to invest $10,000 in a business without telling you anything about it? What if he refused to give you a routine accounting of your investment, insisting you did not need to know the details of the business?


Hardly anyone would make such a deal. And yet, medical students invest that much and more each year in a venture they know little about. In fact, some medical schools are very secretive about their finances, hiding information from the very students who are helping fund them.


What may surprise you is just how risky some of those investments might be. For years, insiders have whispered about the financial instability of certain schools. Accreditors have cited concerns about funding in some schools’ reports. Local newspapers have revealed financial troubles at teaching hospitals across the country, but who has time to read newspapers during medical school?


Of course, many medical students have heard by now about MCP Hahnemann, the medical school that went bankrupt last year—an event that sent shock waves through the medical education community and exposed the financial vulnerability of the “enterprise,” as insiders like to call the national medical education network. Now everyone is wondering, could it happen here?


“That was sort of a wake-up call that some of the techniques that medical centers were using to survive might not be the best techniques,” says Dr. Donald E. Wilson, dean of the University of Maryland School of Medicine.


As scrutiny of medical education financing increased, however, it became apparent that even those closest to the problems were uncertain about their true financial status. Many schools have used accounting procedures that intermingle funding for education, research and clinical programs. Expenses for each of these “missions” also have been intertwined, making it extremely difficult to follow a money trail.


But growing financial pressures are forcing schools to get their books in order. Income from patient care that was used to subsidize medical education is getting squeezed by managed care. Funding from government sources is drying up. Schools no longer have a free flow of money that they can shift from one area to another as needed—what some administrators describe as a shell game.


Now, some medical schools are radically changing the way they manage their funding and expenses. As with any revolution, these changes promise to turn some people and practices upside down. But the goal is to shore up the financial foundation of medical education in this country.


Better accounting methods may even make it possible for the first time to assess whether medical schools are financially sound.


Hidden Problems - In general, studies about the financial health of medical schools have produced good reports. The problem is that generalizations do not tell the whole story.


Each year, for instance, the Journal of the American Medical Association (JAMA) publishes a report on medical school funding. The latest report analyzing data for the 1997–98 school year showed that the medical education “enterprise” was continuing to grow, albeit at a slower rate than in previous years, says Robert F. Jones, Ph.D., associate vice president of the Association of American Medical Colleges (AAMC). Such information tends to reassure medical schools that things are basically OK.


“The other story is that there’s a fair degree of variability,” Jones adds. In fact, the JAMA report actually masks the fact that some schools have “severe issues,” he says.


Tracking medical school finances has always been difficult. “It’s not clear sometimes just looking at revenues and expenses,” Jones says.


Some schools rely primarily on the income faculty generate through patient care, for instance, while others may actually subsidize that activity. Some schools receive generous funding for medical research, while others lose money by allowing faculty to conduct research that is not funded. Some schools are generating interest on their endowments—or private gifts—while others are whittling away their “nest egg” to cover losses at affiliated teaching hospitals.


“The relative health of schools depends to a great extent on the kind of configuration they have,” Wilson says.


Perhaps the only safe generalization to make about medical schools’ financial health at this point is that they all are suffering.


“Any medical school that says it’s not having financial difficulties has its head in the sand,” Wilson says.


Other medical leaders agree. “I think it’s fair to say that no place is immune from financial pressures at this time,” says Dr. Carol Aschenbrener, a former CEO of an academic health center who now works as a consultant.


Actually, financial struggles are not new, particularly at teaching hospitals, although they have been largely kept quiet, Wilson says. “No one wants to talk about it because that would scare away students.”


Recently, however, newspapers and even institutions themselves have begun pulling away the veil of secrecy. Georgetown Medical Center in Washington, D.C., for example, announced it had lost $62 million in the fiscal year ending June 1998. Renowned teaching hospital Massachusetts General in Boston reported losses of $4.8 million in the first quarter of this year. Brigham and Women’s Hospital there reported a $3.5 million loss during the same time period.


Those are just some of the better known academic medical centers. Others are similarly smarting from funding cuts due to managed-care strategies and government program changes. And when teaching hospitals are hurt, the pain extends to medical schools.


“If the partner that you need is losing so much money, it’s only a matter of time until you suffer,” says the AAMC’s Jones.


Harvard Medical School, for example, recently announced it would spend $20 million over the next five years from endowment funds to subsidize education programs at affiliated teaching hospitals. Such strategies, while helpful in the short run, are not final solutions, Jones says. “They can only go so long before the university’s endowment is dried up.”


Other medical schools are severing ties with teaching hospitals, hoping that each will fare better on their own. Georgetown University, for example, recently transferred its struggling medical center and physician practices to a regional hospital network, called MedStar Health, while retaining the medical school’s academic and research programs.


“We, like everyone else, depended on cross-subsidies to pay for medical education,” says Dr. Carolyn Robinowitz, Georgetown’s dean for academic affairs. At some point, however, clinical services became a drain on the network. Research funds have been increasing, she says, “but it’s not enough to carry the day.”


Balancing the Books - Basically, schools only have two options as they try to strengthen their financial positions, says consultant Aschenbrener: Find new sources of revenue or cut costs. The first will be extremely difficult to achieve in the current budget-shrinking atmosphere. The latter most likely will be accomplished either by reducing the number of people medical schools are paying, reducing the amount they are paid, or both, she says.


Although the thought of cutting positions or salaries likely will elicit gasps from faculty across the country, Aschenbrener says such a move would only return schools to a more historically appropriate composition. About three decades ago, she says, medical schools had more students than faculty, as one might expect. In the intervening years, however, that ratio flipped as schools acquired more physicians to generate more practice income.


“Now that’s being attacked,” Aschenbrener says.


As schools begin examining their financial status more closely, they will have to consider where and how to make appropriate “adjustments.” That is where a new accounting strategy comes in.


“There’s this cultural revolution going on in the way medical schools are being managed,” says the AAMC’s Jones. The new methodology is called MBM, which stands for mission-based management. Although that might sound like bureaucratic mumbo-jumbo, it actually means what it says.


“MBM is a way to get organized so decisions can be made that preserve and strengthen your missions,” explains Dwight Monson, a consultant with the CSC Healthcare Group who has been working with medical school leaders to implement the new strategy.


“These physicians are extremely bright people, but they haven’t been exposed to management techniques,” Monson says. MBM gives them the tools to separate each of their medical school’s “missions” and to clarify the money flow for each.


Put simply, it allows schools to specify who and what is involved in teaching, research or clinical services.


“Heretofore there’s been no way to keep those monies separate and to say, ‘Here’s what we’d like their use to be,’” Monson says.


Administrators and faculty at Creighton University School of Medicine in Omaha implemented MBM last year after deciding they needed a clearer picture of the school’s operations and finances.


“We asked ourselves, are we focusing on the core missions that we generally espouse?” recalls Stanette Kennebrew, M.B.A., J.D., associate dean for administration and finance. “Do we know how each mission is faring on its own? Are faculty burdened by too many tasks? And do we know how much that costs, any of it?


“And the answer was, ‘No,’” Kennebrew says with a laugh.


School officials decided to take on the cost of revamping its management system by participating in a pilot project sponsored by the AAMC and assisted by CSC consultants. In the face of shrinking clinical revenues, many of the faculty saw the need for changes, Kennebrew says. “Things you used to take for granted are now gone.”


Faculty helped develop productivity measures to determine how much time each professor was spending on teaching, research and patient care. These measures were weighted to reflect the intensity of each activity, Kennebrew says. Teams then tracked revenue sources that were meant to be used for each of the school’s three “missions” and compared the inflow with the outflow.


What they found surprised everyone.


“Education was fine,” Kennebrew reports. In fact, there was a surplus for funding education programs, whereas research projects were operating with a deficit.


“Nobody thought that was going to be the result,” Kennebrew says.


Once faculty could see that unfunded research was a problem, they accepted the need for new rules about engaging in such projects. Now, they must bring a rationale for any unfunded research project before a school committee, rather than simply expecting to be given time to pursue pet projects. “It’s no longer a ‘deal,’ it’s actually a decision,” Kennebrew says.


Other changes are likely but will be implemented slowly, a promise given to the faculty to ensure their support, Kennebrew says.


“Of course, if somebody is asleep at the wheel, it’s going to show that there is no ‘revenue stream’ for their activity,” Kennebrew says. Rather than using such information punitively, however, administrators hope to shift faculty behavior—such as requiring more publications or more time in the classroom—to more accurately reflect their funding sources, she says.


In fact, schools may actually choose to use funding from one area to subsidize another in order to promote their priorities, says consultant Monson. “You just have to live within your overall financial constraints.” And, you need to be conscious of those choices, he says.


For example, one school Monson worked with was able to make some management changes that brought in greater revenues. At the same time, certain programs that had been identified as priorities remained unfunded.


“Somebody has to step back and say, ‘Did we build the mission the way we aspired to?’ If not, you have to make some tough decisions,” Monson says.


Thus, MBM promises to end the “shell game” that medical schools have—perhaps unintentionally—been running, says Maryland dean Wilson. “If you look at all the pieces of the mission, you can’t disguise how you’re using your time,” he says.


Of course, shining light into the dark corners will not be welcomed by everyone. “Increased accountability is not something that folks necessarily want to be involved in,” says Wilson, whose school has used MBM procedures for two years. “Looking at individual productivity creates tensions,” he says.


At Creighton, faculty participated in the MBM “revolution” because they knew the school was having financial difficulties, Kennebrew says, whereas other faculty may not have reached that point yet. “Some have not felt personally the problems that may be in their system,” she says.


Creighton administrators assured the faculty that they would have input in any changes along the way, which eased many fears, Kennebrew says. “If there’s no trust in the system, then the faculty are not going to be excited about [any changes] because they think [the changes will] be used against them.”


Some experts, however, question whether separating revenues and costs by “mission” is really possible.


“I think that’s hopeless,” says Mark Pauly, Ph.D., professor of health-care systems at the University of Pennsylvania’s Wharton School.


“Medical education has chosen to use a model in which you need to be part of the delivery system,” Pauly says. “When you are taking medical students with you on rounds, are you providing education or patient care?” he asks. “The way medical education is currently run, trained students and treated patients are sort of a joint product.”


MBM consultant Monson admits that some measures may not be perfect, but argues that an attending making rounds with students can be measured against a practitioner making rounds without students, to isolate the educational cost.


Furthermore, Monson asserts, MBM strategies can be extremely useful even if not perfectly accurate. “You have to ask, ‘Are we trying to come up with a perfect management system, or are we trying to come up with a set of tools that give people informed judgment?’” he says.


“At Creighton, being able to understand the budget for the first time has had an amazing impact,” Kennebrew says. “The fact that people can look at the whole set of financial statements has added more trust into the system,” she says. Faculty no longer suspect that the dean has a “secret pot of money” to fund pet projects, for instance, because nothing is hidden anymore, she says. “That by itself has been instructive.”


But the most likely motivator for schools to join the “revolution” will probably be financial necessity.


“It’s human nature that we don’t like to make changes unless there’s an immediate threat or some great opportunity,” Aschenbrener says. “You can’t get people to go through the discomfort of the change unless they’re convinced that it will be better than the status quo.” Unfortunately, some medical schools still have not gotten that message, she says. “Many medical schools think ‘it won’t happen here,’” she says, or they expect to be rescued if trouble does strike.


“I think we have a lot of evidence that some magic rescue is not in the offing,” Aschenbrener warns.


A Silver Lining?


The good news for medical students is that all this financial pressure on schools may actually serve to reinvent the training system in a way that benefits the trainees.


“Having a successful business allows us to make it a successful research vehicle and a successful teaching vehicle,” says Maryland dean Wilson.


Others agree. “One positive effect for students is that faculty will get more credit for teaching,” says the AAMC’s Jones. “It’s going to help promote the teaching function of faculty.”


Currently, faculty is caught on a treadmill to produce more patient revenues, sometimes at the expense of teaching and research. “In MBM there’s a more explicit reckoning of their time,” Jones says. “It’s really intended to preserve the academic mission, to ensure that that sort of subtle erosion of research and teaching time doesn’t take place.”


Of course, simply accounting for time and revenues doesn’t increase the overall budget or necessarily relieve financial pressures, Jones adds. But it clarifies the issues for medical schools so they know what they need to address.


At Maryland, the new management techniques have enabled administrators to balance the budget, although Wilson is still wary. “The success is evanescent,” he says, pointing out that financial pressures are expected to grow in the coming years. Without relief from further government cuts that are now scheduled, “I think it will be very difficult for medical schools to continue the level of research and education that they’re involved in today,” Wilson says.


Will medical schools go out of business? “I don’t think so,” Wilson says. “The issue is, will the product that they turn out still be there? You can always turn out doctors, but what about the quality?”


AAMC leader Jones admits he predicted incorrectly five years ago that a dozen schools would close by now, so he is more reticent about making such predictions now. “There are other forces that resist schools going out of business,” he says, citing political and social powers that support medical schools.


“I don’t see schools going out of business,” Jones says, “but there could be changes in the way they do business.” All will certainly have to employ cost control measures, he says, which could affect faculty salaries. More changes could include regional collaborations with other medical schools, for instance, to eliminate duplications and achieve cost savings.


Although cost-cutting often is associated with the loss of services and programs, experts insist that this financial revolution could actually result in a better medical education system if schools approach the changes appropriately.


At Georgetown, for example, the new “partnership” with MedStar will not only free the medical school of financial pressures in the hospital market, it will also offer a greater array of clinical experiences through the broader hospital network.


“I think the students will benefit,” says Georgetown’s Robinowitz. Although faculty still are “jittery” about how the changes will affect them, many are intent on preserving the school’s academic mission, she says. Some, for instance, have taken early retirement and are now teaching without pay.


“There seems to be a commitment to the students that goes beyond whether there’s money,” Robinowitz says.


Georgetown has “felt the pain” of financial pressures sooner than most schools, Robinowitz adds, but others should be prepared for the trend to reach them. Education officials hope schools will take the opportunity to strengthen and improve their academic programs.


“One of the things that might happen is a return by some schools to an earlier model, where the size of the faculty is significantly smaller but they spend more time engaged with students,” suggests consultant Aschenbrener. “That could be appealing to both students and faculty.”
~TAKING A PERSONAL INTEREST IN YOUR SCHOOL'S FINANCES


What can medical students do to ensure their medical school is financially sound?


Not much, experts say.


Ideally, premedical students should weigh a school’s fiscal status before making a selection. “You want to not pick a school that’s going to close,” concedes Robert F. Jones, associate vice president of the Association of American Medical Colleges. But except for cases where financial troubles are well known, such an assessment is very difficult to make, he says.


“The ability to predict the vulnerability of a school is based on so many things that the prediction would not be very good,” he admits. Even accreditors who conduct financial reviews were unable to foresee the troubles that forced Allegheny University of the Health Sciences’ medical school into bankruptcy last year, he says.


Jones and other medical educators believe students should concentrate on their studies rather than spend a lot of time evaluating schools’ finances, particularly because all medical schools nationwide are experiencing financial challenges.


“If they find out the place is a little shaky, what are they going to do?” asks Dr. Carol Aschenbrener, a medical education consultant. “It’s not as if there are places to run to anymore.” Furthermore, students at accredited medical schools can take solace in the fact they are assured a complete medical education even if their school has to close, Jones says. “The [medical education] community wouldn’t allow those students to be left by the wayside,” he says.


Not everyone agrees that students should be so trusting, however.


“There has to be a lot more student activism,” says John Po, a fourth-year student at the rescued Allegheny institution, now called MCP Hahnemann University School of Medicine. Former Allegheny leaders have been accused of lavish and improper spending practices, and Po is convinced that students should demand full disclosure of their school’s finances. “Every student should know what the financial situation at their school is,” he says.


Schools ask for plenty of information about applicants’ financial status when a student applies for financial aid, Po points out. “There should be an equal burden to demonstrate financial solvency” on the school’s part, he says.


Experts say students can look at certain areas to get a general feel for a school’s financial standing:


Relationships with teaching hospitals. Academic medical centers across the country are struggling financially, and those problems are reverberating at medical schools. The Allegheny school, for instance, was dragged down by the financial troubles of its parent health-care system, says Mark Pauly, Ph.D., professor of health-care systems at the University of Pennsylvania Wharton School in Philadelphia. “The take-home message is that the health of any medical school is inextricably intertwined with the larger academic medical center,” he says. Students should be concerned if the teaching hospitals affiliated with their medical school are losing money, which often is reported in local newspapers.


Revenue sources. Schools are funded by a variety of sources, including income from faculty medical practices, endowments, research grants, tuition and state funding.


“We all think that income from services to patients is the most volatile,” says Pauly. In the past, patient care was a cash cow for medical schools, he says. “Now, in the era of managed care, it’s quite the reverse.” Students should be wary if they see that faculty practice income makes up a large piece of their school’s revenue pie.


“If you look to the future, the place that relies more on patient income is going to be a riskier proposition,” Pauly says.


Financial plans. Given that experts agree all medical schools face tough financial times, it makes sense that they should have a plan to address those problems, and not all do.


“Some places are already making hard decisions,” says Aschenbrener. “Some still are just tinkering at the edges.” Premedical students should choose schools that are proactive about developing new fiscal strategies, because those without such plans may not have a very bright future.


”The longer they wait,” Aschenbrener says, “the worse off they are.”


Open channels. Schools that keep information from students and are unwilling to disclose their financial situations may have something to hide, warns Shaka Walker, a fourth-year student at Georgetown University School of Medicine, and a member of the Liaison Committee on Medical Education (LCME), the accreditation agency for U.S. and Canadian
allopathic medical schools.


Premedical students who hear rumors or news reports about a school’s financial troubles should raise those concerns during interviews with the school, Walker says. If they are not satisfied with the answers they receive, they should look for information from outside sources.


One source is a school’s LCME accreditation report, which includes a self-analysis of institutional finances. Some schools are very forthcoming about such information.


Georgetown leaders, for example, share routine audit reports with faculty and students, says Dr. Carolyn Robinowitz, dean for academic affairs. “The Allegheny experience has gotten us to do a very extensive review of expenses,” she says. Sharing that information helps boost confidence in the system. “We may be losing money, but we’re not squandering money.”


Although many students and educators agree that awareness of a school’s financial status is important, they urge students not to become overly preoccupied with such concerns.


“You kind of have to have faith in the people running your medical center,” Walker says. —C.W.
~~~~Medical Education~
305~9December~1999-48~Letter from Afield~Givers of Compassion~Reaching out to the Nicaraguan/Honduran border.~DAN HANDEL AND PRIYA JOSEPH~~For many of us, what we had been working for didn’t seem real until we stepped off the plane in Managua. At that moment, the numerous raffles, the volumes of letters sent to solicit money and supplies, and the endless phone calls and e-mails seemed worthwhile, whereas before we had just been working toward what had felt like an abstract goal: to provide desperately needed medical care to the people of two impoverished Nicaraguan villages.


We had started in the fall of 1998 as a group of 19 second-year medical students. Our number dwindled to 11 by the time we left. One member was unable to go at the last minute after being diagnosed with mononucleosis. Two weeks before our departure, we learned we needed a licensed physician to accompany us so we could distribute the large amount of drugs that we were bringing. By a stroke of luck (and the persistent paging of almost every internal medicine resident at our local hospital), we were able to convince a third-year internal medicine resident and his fiancée, an occupational therapist, to join our endeavor.


Our plan was to disperse in two groups. The first group would travel north to a town on the Nicaraguan/ Honduran border called Ocotal. There we would provide medical relief to victims of Hurricane Mitch, which had ravaged the area the previous fall. The second group was to remain in Managua to conduct vaccinations in the asientamientos, or squatter villages, where the poorest part of the population lived.


On reaching Managua, we found that eight boxes of medical supplies had not arrived. Since half of the group was to leave for Ocotal the next morning, we had no choice but to go without the supplies and adjust our treatment options accordingly.


MANAGUA


On our first day at the clinic, we went through an extensive history of the health problems plaguing Managua. The one member of our group fluent in Spanish was off at the American embassy for the morning registering our passports, so the rest of us struggled to understand the words of the Nicaraguan social worker who was to serve as director of our temporary clinic.


The social worker explained that in Nicaragua, the mountainous terrain causes water to flow down toward the ocean, flooding poorly irrigated areas. Drainage canals constructed to alleviate these problems became convenient sites to dump refuse. When the rains come, the canals become clogged with trash and overflow into the surrounding land. This polluted water then makes its way back to the villages—exacerbating the health problems of the villagers.


We spent the evening of our first day in Nicaragua practicing intramuscular vaccinations on each other to minimize the trauma we were going to inflict the following day. As we walked down the long dirt road the next morning, we were first struck by the image of large canals riddled with trash. Exposed power lines were strewn everywhere, because villagers spliced the lines from one location to another as new shacks popped up. As we made our way to the clinic site, the social worker went from home to home telling people where we were going to be. Given the number of unnamed dirt roads involved in our journey to the clinic, we were later amazed when seemingly all of the villagers found their way.


We proceeded to set up shop at the dead end of one of the roads as people arrived, decked out in their Sunday-best. We eventually got an assembly line of sorts in motion as we all became more comfortable in our roles. We learned that you had to hold a child’s hands and arms so that they would not try to pull the vaccination needle out (as one successfully did). One infant “voiced” his objections by passing gas in response to his shot—much to the chagrin of the injector and the amusement of bystanders. By the end of the day, we had seen around 160 people.


Over the next two days, we went to other asientamientos to set up our traveling clinic. By the end of the week, we had provided a variety of vaccines, vitamin A tablets, albendazole, and fluoride treatment to almost 600 people.


The conditions we saw were disheartening. Children commonly had teeth that were rotted out or had been completely worn down. Children who were naturally brunette-haired were brought to us either completely blond or with blond streaks—a typical sign of malnutrition called the “flag sign” as seen in kwashiorkor (protein-calorie malnutrition). Nearly all women of childbearing age seemed either to be pregnant or a recent mother. Women who we thought were in their 30s were barely 20 years old. Their surroundings had aged them.


OCOTAL


During the truck ride to Ocotal, we saw and heard tales of Hurricane Mitch’s destruction. Located six hours north of Managua on the Nicaraguan/Honduran border, Ocotal was one of the towns most severely damaged by the storm. We were told that many of the roads we rode on were newly built to replace the cement bridges the hurricane had halved and washed away. Single walls of houses provided the only evidence that families had once lived in the areas through which we traveled. From what we heard of how these places used to be, the destruction was as though entire communities had been erased into the waters. At times during the journey, the seven of us just sat in silence, letting the scenery tell its own story.


Our residence for the next three days was Casa Materna, a community home for women in their last month of pregnancy. These women cooked, cleaned and maintained the home in return for an ambulance ride to the hospital at the time of their delivery. We took the night to settle in, ration our supplies for the next three days of work, and make a logistical plan for our clinic the next morning. We decided that the three who did not speak Spanish fluently were to organize and run the pharmacy while the other four worked with the patients.


The next day, we quickly realized that our plan needed drastic revisions. The old schoolhouse in which we had set up clinic was full of patients waiting to be seen. Spanish dictionaries were exchanged, and soon, all of us were obtaining histories, conducting physical exams and formulating diagnoses. For each patient, we would report our findings to the resident, who would then authorize us to give the appropriate medications.


Most of the patients we saw were women and children (the men were at work) who typically complained of fevers, headaches, gastric reflux, arthritis and back pain. The children often had fungal and parasitic infections. Urinary tract infections and sexually transmitted diseases such as trichomonas vaginitis, chlamydia and bacterial vaginitis were also common. For these infections, we based our treatment choices solely on the histories, as we were unequipped to conduct Pap smears and run lab tests.


In many cases we were unable to offer meaningful assistance. This was true for the men who walked into the clinic with all the classic signs of congestive heart failure, a young boy with a barrel chest from years of untreated asthma, and a woman whose left side had been paralyzed by a stroke. There were also cases of clear medical malpractice: a baby with Down syndrome whose mother had been told otherwise; a boy with a misaligned shoulder joint that had healed improperly after a fracture; a young girl who came to us with an infected wound following drainage of a cranial cyst. In these situations, we were left with no means of treatment or rehabilitation. All that we could provide was compassion.


This compassion, above all else, was the essence of our connection with these people. We could see it in the children’s smiles when we gave them toothbrushes and in the mothers’ faces when we listened to their children’s lungs. These patients were eager to be touched, to have someone give importance to the daily fevers and pains that they accepted as a part of life. It was frustrating to realize how much of our medicine was simply a luxury for them. The bottles of aspirin, vitamins, cough syrup, antacids and antibiotics were bound to run empty in a few weeks, and their coughs and fevers would most likely return. All that would remain of our services were the memories and the care, spoken and shared.


As we flew home, we marveled at the sight of the active Mount Motumbo. It was symbolic of the situation of these people: volatile and unpredictable. Our hope is that the people we served gained as much from us as we did from them. The people of Managua and Ocotal gave us a perspective that cannot be taught in the classroom.
~~~~Dan Handel and Priya Joseph are third-year medical students at Northwestern University Medical School in Chicago.~Community and Public Health,International Health~
306~9December~1999-48~Feature~On Shaky Ground~~Christine Wiebe~~ONE YEAR AFTER THE ALLEGHENY SAGA, MEDICAL STUDENTS AND EDUCATORS ARE STILL WONDERING, HOW UNIQUE WAS THAT FINANCIAL CRISIS, AND COULD IT HAPPEN AT OTHER MEDICAL SCHOOLS?


Even before the bottom fell out, John Po had suspicions that something was not right at his new medical school. “My Mom even asked, ‘Are you sure that’s a real university?’” he recalls, referring to when the school notified him it was changing its name before he enrolled in 1996.


Po felt it was an affront to the community that the new school owners had changed the name to Allegheny University of the Health Sciences, reflecting its place in the larger Allegheny empire. But like most new medical students, he was just glad to get in.


In fact, the Allegheny affiliation held great promise at the time. Leaders of the non-profit hospital chain that stretched from Pittsburgh to Philadelphia had pledged to make it one of the premier health-care networks in the country. It had acquired the Medical College of Pennsylvania (MCP) in 1988 and then took over Hahnemann University’s medical school in 1993 to further that goal. The new, combined Allegheny medical school brought together top-notch researchers and academicians, and the hospital network provided broad clinical opportunities for trainees.


The expanding enterprise seemed to have an endless supply of resources.


“The first year was opulent,” recalls Po, who is now a fourth-year student. “Money was flying around, and there were lots of freebies.” A corporate jet shuttled some professors from Pittsburgh—Allegheny’s headquarters—to the Philadelphia campus, he says.


During Po’s second year, the Allegheny network continued to grow with the acquisition of more hospitals. “Everybody felt really good about it,” he says, except for skeptics, like him, who worried that the organization was growing too fast.


Then came a hint that not all was well. In October 1997, the hospital chain axed 1,200 hospital workers as it responded to market pressures hitting hospitals all across the country. Stories appeared in local newspapers questioning the network’s financial stability. At the medical school, the general consensus was that everything would be OK, Po says. But some, like Po, still worried.


By July 1998, Allegheny filed for bankruptcy.


“Nobody knew until the bombshell hit,” Po says.


The parent company, called Allegheny Health, Education and Research Foundation (AHERF), admitted it owed $1.5 billion. The Chapter 11 bankruptcy filing covered the foundation, its hospitals and physician practices, and the university, which included schools of medicine, health professions, nursing and public health.


And the troubles didn’t end there. Suddenly, the 1,100 Allegheny medical students faced the prospect of losing their school. Administrators assured them they would be placed at other medical schools if Allegheny had to close. But that was little comfort to students with partners or families who might have to be uprooted.


“We felt like pawns,” Po says. Students were warned to clear out their lockers in case the school was padlocked, he says. Professors began scrambling to salvage their careers. “It’s certainly not conducive to good learning when professors are trying to figure out what to do with their futures,” Po says.


Meanwhile, the financially troubled hospitals in the Allegheny network were reeling from bad publicity and fallout over unpaid bills to supply vendors. Occupancy levels plummeted, which severely restricted learning opportunities for third- and fourth-year students.


“At one point, [the hospital] had fewer than 80 patients,” recalls Stephen Kelly, a fourth-year student. “Students were basically on rotations going to the library all day.”


Some medical teams were assigned to only one or two patients, Kelly says.


In addition, supplies became limited. Students were forced to scrounge for paper just to complete progress notes, Kelly says.


In the fall of 1998, a rescue plan was announced. Tenet Healthcare Corp., a national hospital chain, agreed to buy the bankrupt hospitals and signed an agreement with Drexel University to manage the schools so students could continue their training.


But the process has drained some of the school’s resources. School officials admit that research funding has dropped. Many of the school’s most prominent researchers have abandoned ship, and even some of the most loyal faculty have moved over to the University of Pennsylvania.


Despite strong leadership from Drexel, the future of the medical school still seems somewhat nebulous. Repeated requests for interviews with school leaders went unfulfilled. The institution’s Web site still lists leaders who are no longer at the school. Many prominent faculty members’ office phones have been disconnected with no forwarding message.


Some of the student body is in similar disarray. Third- and fourth-year students are sent to Pittsburgh hospitals for some of their clinical experiences, about 70 to 90 at any one time. They receive free, furnished housing and some meals while they are there. But the result, Kelly says, is that medical school classes lack cohesiveness. As for their educational experience, some students fear they have suffered.


“We’ve learned hard lessons that aren’t usually part of a medical education,” Kelly says, “but we’ve lost out on lectures and other experiences.” This past summer, he did a remedial rotation in orthopedics to bridge gaps in his training and to establish a relationship with the supervisor in anticipation of residency interviews.


Some fourth-year students are worried about how they will fare in residency interviews and are trying to make up for missed training experiences, Kelly says. “Especially the people who are going for competitive residencies, it really hurts them.”


How unique was the Allegheny crisis, and how likely is it to strike at any other medical school? Allegheny leaders have been accused of bad and perhaps even fraudulent business practices. AHERF’s CEO was receiving more than $1 million in compensation, almost three times as much as his counterpart at Penn’s medical system. Allegheny leaders have admitted to withdrawing at least $50 million from endowments and other restricted funds during the year before declaring bankruptcy. Their actions have prompted lawsuits as well as state and federal investigations.


“But a key element to their downfall was the health-care environment that everyone’s experiencing,” says Robert F. Jones, Ph.D., associate vice president of the Association of American Medical Colleges. Government and private insurers’ attempts to control hospital costs have put academic medical centers everywhere at risk, he says, and that has dire consequences for medical schools as well.


In fact, the Allegheny saga is not that different from the financial struggles unfolding at many other medical schools, says Gerald Soslau, Ph.D., professor of biochemistry at MCP Hahnemann University School of Medicine (the restored school’s name). The only difference, he says, is that Allegheny administrators were getting “exorbitant salaries” and employing risky financial practices.


“When you have mismanagement and procedures that are somewhat shady at best, layered on top of an already bad situation, it’s going to crumble,” Soslau says. Fortunately, he adds, Drexel has “dramatically corrected” many of the school’s problems. “They have a very strong management style that is more academic,” he says. “Obviously, they have to be astute about business practices, too.”


One controversial move was reducing the faculty size, which inevitably involved retaining and firing some of the “wrong people,” Soslau says. However, administrators are diligent about trying to minimize that problem and to retain and recruit top-notch people, he says.


“The current administration is really making great strides at stabilizing and reversing poor policies,” Soslau says. “It looks like things are moving in the right direction.”


One goal is to bring clinical practice income up to a “break-even” point, Soslau says. The other primary goal is to assure consistency in students’ education. In order to achieve both goals, which sometimes compete with each other, the school had to take a hard look at each faculty member’s contribution.


“Schools can ill afford to pay the salary of even one individual who is not necessary,” Soslau says. Faculty who do draw salaries must truly participate in the educational process, he adds.


That kind of scrutiny is expected to spread to other schools as well.


“I think we all agree that faculty size will shrink,” says Dr. Harris Clearfield, a gastroenterologist and president of the medical school faculty last year. “It’s going to change the face of academic medicine,” he predicts. Some academic medical systems have grown fat and probably need to be cut, he says, whereas others may be devastated by imposed reductions.


“The question is, as you cut down on your size, whether the educational mission is compromised,” Clearfield says. Research, for instance, may be one of the biggest casualties of funding cuts.


Clearfield declined to talk about the situation at MCP Hahnemann, weary of media scrutiny. Like the Allegheny signs that were torn down at the schools and hospitals, he and others prefer to close the book on that chapter of history.


But Clearfield gave Drexel good marks thus far. “I think they’ve handled their educational goals pretty well,” he says.


Fourth-year student Kelly, however, dismisses the “don’t worry, be happy” attitude that he says many faculty and even students are taking this year. He still worries about whether he will have received adequate clinical experiences by the time he finishes medical school.


That concern apparently is shared by outside medical leaders who are watching the school closely. The Liaison Committee on Medical Education (LCME) awarded the medical program full accreditation in the spring of 1998, only to be called back to the school after the bankruptcy filing.


During the second visit, the survey team found the clinical faculty strength “problematic,” according to its report, but added that “it may be sufficient to conduct the clinical experiences required in the undergraduate education program.”


The team also disclosed that members had received conflicting reports about the availability of clinical experiences, particularly in pediatrics and ob–gyn. One student had not participated in any deliveries during a month-long rotation in ob–gyn. Another reported having no hands-on obstetrical experience through half of a clerkship.


Other concerns, such as difficulties in scheduling lectures because of departing clinical faculty, are mentioned in the report. The LCME decided the school still was in “substantial compliance” with accreditation standards. However, the committee continues to visit and review reports on the school.


In its report, the survey team urged the LCME to continue assessing the availability of clinical resources and posed some probing questions about the newly reorganized medical school: “Can the clinical faculty in their new practice entities succeed in the competitive Philadelphia health-care market to the degree necessary to become truly self-sufficient?” the survey team asked. “If they do succeed, will the efforts required to achieve success be at the expense of the commitment and resources necessary to maintain the current quality of the third- and fourth-year medical student teaching programs?”


As medical leaders ponder those big questions—for MCP Hahnemann as well as for other medical schools—students at the restructured Philadelphia institution contemplate more immediate issues. Those range from upcoming residency interviews to simple “quality of life” problems, such as learning a new e-mail system, finding alternatives to a closed bookstore, and accommodating reduced operating hours for the school shuttle buses.


“Those are just little things,” Po says, “but they’re things we didn’t expect when we entered medical school.” He tries not to dwell on such matters, he says, but he can’t help feeling resentful.


“No medical student should have to go through what we went through,” Po says.
~~~~~~
307~9December~1999-48~On the Wards~‘Awaiting Medivac’~MEDICAL MANAGEMENT WOULD POSTPONE DEATH FOR A FEW HOURS AT BEST.~AUDREY YOUNG, M.D.~~Bethel, a quiet town on the remote western edge of Alaska, is the hub for roughly 50 Eskimo villages. There are no roads in the region, so villagers travel primarily by small aircraft. Nearly all of the area’s 20,000 inhabitants are Yupik Eskimos, a people known for peaceful, spare living.


After my first year of medical school, I went to Bethel to work in a chronically understaffed Emergency Room (ER) at the local Indian Health Service hospital. Most nights, a big-time trauma case was called in over the radio scanner in the triage room. When calls came in, an attending physician instructed village health aides on how to manage and prepare patients for transport via Medivac, the hospital’s airplane rescue service.


I soon discovered that violence was common in the isolated region. The suicide rate far exceeded the national average. Stories of teenagers shooting one another surfaced once every few weeks. Reports of the violence came almost instantaneously across the scanner in the ER.


One night, close to midnight, a call about a 23-year-old man from Aniak, a village 100 miles up the Kuskokwim River, came in. The young man had shot himself in the left ear with a .22-gauge handgun, and the bullet had exited above his right eyebrow. I pictured the quick breaths popping from his mouth and the clots of blood in his hair.


“Patient is agitated…pupils are 2 millimeters on the left and 3 millimeters on the right, blood pressure 85 over 64,” the health aide reported. “IV is in, fluids going. He’s gotten his tetanus. Awaiting Medivac.”


That evening, clouds hung low against the ground in long stretches up the river, as was typical in the region, and the primitive airport in Aniak was fogged in. To complicate matters, the village runway was nothing more than a gravel patch on a bit of level ground. When aircraft were preparing to land after dark, local villagers would have to use their truck headlights to illuminate the landing site.


“Awaiting Medivac,” the health aide called in again.


A pilot wearing a blue jumpsuit came into the triage room, which was simply a large closet with a desk and three shelves of textbooks. “This is Medivac. We can’t land in Aniak with the weather this way.”


“Left pupil 2 millimeters, right pupil 4 millimeters,” the voice crackled back. “Blood pressure 80 over 50. Heart rate 132.”


“What fluids are you running?” asked the ER attending.


“Lactated Ringer’s, about 200 cc’s in.”


“Squeeze the bag as hard as you can, and then hang a second bag,” she instructed.


The pilot came in again and reported that the National Guard would not fly into the region.


“He’s going to die anyway,” the attending said softly.


One by one, each of the private carriers in Bethel refused to fly into Aniak, insisting the weather was too treacherous to land without radar guidance. Eventually the patient’s family hired a private air company to fly in and transport the patient to an Anchorage hospital.


Later I learned that the case was simple, medically speaking. The gunshot wound involved both sides of the patient’s brain, known as a biventricular injury. Bleeding would eventually force his brainstem into the spinal canal and kill him. Medical management would postpone death for a few hours at best.


Standing in the cramped triage room, I thought about the village of sleepy men climbing into their trucks, turning their engines over and pointing their vehicles toward the runway. With idling motors and heat blasting, they would sit huddled in jackets, waiting to save a man who was going to die whether he was in Aniak, Bethel or Anchorage.


I thought about the fixed-wing airplane lifting off in Anchorage into the dull, dark sky. The restless man wrapped in bloody blankets, lying under fluorescent lights. A mother and a father standing among thick clouds in an endless night that would claim their son.


I knew exactly what would take place in Anchorage. The doctors and nurses would run a code when the patient’s heart gave out. Someone in scrubs would crunch down on his chest, trying to get the sluggish organ to beat again. Then someone would slide a plastic tube into his windpipe and force fresh air into his lungs. The floor would be slippery with saline, plastic wrappers and syringes. The man would die with a clump of people bent over his failed body.


The medics in Anchorage would respond automatically, as I had seen the Bethel doctors do. The resuscitation would be swift, incisive and thrilling, as I saw again and again. When the patient’s heart gave out, he would be left alone in the room with a sheet thrown over his body, waiting for the mortician to take him away.


In the end, they would talk of the things they had done during the resuscitation—whether the atropine and shocks and compressions had been too much or too little. They would not talk about the family or even utter the patient’s name.


I was learning to be a doctor with my own private outrage.
~~~~Audrey Young is an internal medicine resident at the University of Washington.~Community and Public Health,Health Disparities~
308~9December~1999-48~Feature~Seal of Approval~~Christine Wiebe~~EVERY SEVEN YEARS, U.S. AND CANADIAN ALLOPATHIC MEDICAL SCHOOLS UNDERGO AN ACCREDITATION REVIEW BY THE LIAISON COMMITTEE ON MEDICAL EDUCATION, BETTER KNOWN AS THE LCME. THE REVIEW COVERS EVERYTHING FROM THE CURRICULUM TO PHYSICAL FACILITIES TO STUDENT SERVICES. BUT WHAT IS THE LCME’S ROLE IN GUARANTEEING A SCHOOL’S FISCAL HEALTH?


The letters “LCME” are branded on so many things at a medical school, yet most students and even some faculty don’t know what they mean. Like the Good Housekeeping seal of approval, these letters—which stand for the Liaison Committee on Medical Education—signify that a medical program with LCME accreditation has met certain standards.


Accreditation is an ongoing process that produces numerous volumes of reports each year and demands many hours from volunteer surveyors and school officials. In fact, the most common complaint about the LCME is that the task of proving a school’s worthiness every seven years is an onerous one.


“It takes an enormous amount of time to put all this together,” says Dr. Richard Wheeler, associate dean for student and academic affairs at the University of Arkansas College of Medicine. His school recently completed a nearly two-year review, receiving full reaccreditation in April.


Beyond the reams of paper generated by this process is the hope that continuous self-study by the schools, and oversight by this select committee, will produce a better medical education system. And although accreditation may sound like a dry, almost perfunctory procedure, it is in fact an intense and even controversial process that increasingly is drawing more students into the fray.


Medical students have participated on the LCME for about two decades, but they were only granted voting status two years ago after demonstrating their value as participants, according to other committee members. Other students at programs undergoing review also have the opportunity to express their opinions about the merits and challenges at their schools. Recently, at Stanford University School of Medicine, for instance, students were instrumental in highlighting inadequate facilities there, prompting the LCME to issue stern demands for improvements. In fact, the school narrowly avoided being placed on probation because of the deficiencies cited by the survey team.


Accreditation review covers many aspects of a medical program, from the curriculum to physical facilities to student services. School finances have always been part of the review as well, and that area is drawing even closer scrutiny in light of the financial problems some schools and affiliated teaching hospitals have experienced.


“It’s a difficult time for academic medical centers across the country,” says LCME Secretary Dr. Harry Jonas. The committee basically asks whether this institution has the resources to provide an adequate medical education. With further government funding cuts expected in the coming years, Jonas explains, the committee is preparing to deal with a growing number of negative answers to that question.


“Financial problems are going to become more evident,” Jonas predicts. As in all areas that the committee reviews, the LCME hopes to find problems while they still can be fixed. That requires a certain amount of openness on schools’ parts to admit their weaknesses, something school officials are not always eager to do.


“I don’t think any of us want to wave that around like a flag,” admits Arkansas’s Wheeler. He adds, however, that almost all school reviews do find some flaws. “I don’t think there’s ever been a report that didn’t have some challenges,” he says. The point of identifying problems in accreditation reports, however, is to guide schools in making improvements.


“We don’t call a press conference,” Wheeler says, “but we want to make sure that everyone who’s in a position to positively change things sees what the LCME says.” Schools have different approaches to how they handle accreditation reports, however. At Stanford, for example, many faculty were surprised to learn a year after their school was reaccredited that the LCME had been just one vote away from putting the school on probation.


Dr. Kenneth Melmon, Stanford’s associate dean for postgraduate medical education, revealed the findings at a faculty meeting, urging the school to remedy the deficiencies. The LCME report had cited a lack of bathrooms and air conditioning in the medical school library, along with other facility problems.


“They spotted some very serious flaws,” Melmon says. In fact, some of the same problems had been noted in earlier LCME reviews in 1983 and 1991. This time, however, the administration has promised to resolve the problems.


“That promise never would have been as well developed if the students hadn’t believed the LCME study was excellent,” Melmon says. In fact, students signed a petition calling for the facilities to be upgraded. “It’s the student response to the LCME that made the LCME more of an important issue,” he says.


Although he and other medical leaders at Stanford are still waiting for significant improvements, Melmon says he believes the threat of losing their accreditation will force changes. The LCME has asked the school to provide a progress report next year, and Melmon hopes they continue to apply pressure.


The Stanford example demonstrates the LCME’s interest in student concerns, says Jason Schneider, a fourth-year medical student at New York University School of Medicine, and a member of the LCME. “To me that shows sensitivity to something that only students are going to care about,” he says, referring to the “comfort issues” at the library. It also demonstrates the important role students can play in the accreditation process, he says. “It’s a very powerful way to effect change.”


Student members of the LCME also have been instrumental in adding new accreditation standards, Schneider says, such as requiring procedures to discourage student harassment and abuse. Additional guidelines undergoing final review this year will require clinical experiences in end-of-life care and an understanding among students and faculty of the different approaches to the medical system by people of diverse cultures. The guidelines will also recommend that schools have programs to promote the mental well-being of students and facilitate their adjustment to medical school.


In addition to direct student participation on the LCME, all medical students have the opportunity to get involved in their individual school’s “self-study.” Schools vary in how much they encourage student involvement, but all are required to have some input on the reports they provide to the accreditation committee.


“The LCME takes very seriously student input in terms of how they view their educational experience,” says committee member Dr. J. James Rohack, associate medical director for the Scott and White Health Plan in Temple, Texas. Although committee members don’t want to hear complaints about students’ grades, for example, they are eager for suggestions to improve schools. In fact, he believes students are obligated to report problems in the interest of making the school better for succeeding classes.


Unfortunately, many students are either unaware of the opportunity for giving input or are dissuaded from getting involved, says Shaka Walker, a fourth-year medical student at Georgetown University School of Medicine and a member of the LCME.


“The reality is that you’re not often going to find students who have the time or the empowerment to take that on,” Walker says. He agrees, however, that LCME members are keenly interested in students’ views, “probably to the dismay of some administrators,” he says with a laugh. At some schools, officials may not feel that students have enough expertise to get involved in particularly complex issues such as financing.


“But they’re also the consumers, and they have a right to know,” Walker says.


At Georgetown, students are included on many school committees and are given many opportunities to be involved in school reviews, Walker says. As a member of the LCME, he intends to make it a priority to look for adequate student input on all schools’ reports.


Other committee members are equally committed to listening for students’ voices, and they are aware that some students may feel compelled to hide problems out of loyalty or fear of retribution.


“I think the survey teams can tell if students are trying to ‘save’ their school by presenting overly optimistic reports,” says LCME member Dr. Nancy Nelson, associate dean for student affairs at the University of Colorado School of Medicine. “We also can tell if the student report was written by someone other than students.”


During site visits, Nelson has always felt she was getting the “straight scoop” from students, she says, and she has never heard of any backlash against students who speak out. In fact, she encourages students to approach school officials if they feel they are not given enough opportunity for input, even when the school is not undergoing accreditation review. According to Nelson, LCME members place a high value on established channels for such input.


“The student voice is very strong and very important,” Nelson says. “I think many students may not know that.”


In fact, students and faculty should view the LCME as their ally rather than as an adversary, committee members say. “The LCME is an agent of change,” says Jonas. “Our job is not to be the nation’s policemen. We don’t go to schools to say, ‘We got you!’”


The committee understands the stresses of an accreditation review because it must submit to the process itself in order to be reauthorized by the U.S. Department of Education every five years, Jonas says. “We have to go through a very rigorous process ourselves.”


The LCME must be sanctioned by the federal government so that students in the programs it accredits can qualify for federal financial aid, for instance, and so that schools can receive federal funds. Federal approval also imposes certain requirements on the LCME. For example, the LCME must require schools to correct any deficiencies cited by the committee within a “reasonable” time, Jonas says. Some observers wonder whether this makes the committee reluctant to identify problems as much as they should. The problems at Stanford, for instance, had been obvious for almost two decades. And in another case, the medical program at Allegheny University for the Health Sciences in Philadelphia had received full accreditation just months before its parent company, Allegheny Health, Education and Research Foundation, filed for bankruptcy and nearly brought down the medical school.


The financial status of medical schools probably needs to be more closely scrutinized, says Stannette Kennebrew, M.B.A., J.D., associate dean for administration and finance at Creighton University School of Medicine. Schools are beginning to realize they need more sophisticated data collection and financial management, she says. “But when you look at for-profit systems like Wal-Mart, we’re way behind,” she says. “We just don’t have the systems in place.”


Although most educators agree that schools need to take a harder look at their finances, some argue that the LCME cannot be expected to guarantee a school’s fiscal health.


“I think they do ask for sufficient information to get a general idea of our financial information,” Wheeler says. “I would hate to see them suddenly turn into an auditing agency.”


LCME members agree, however, that they probably will pay even closer attention to financial issues from now on. “Most schools are financially stable, but there are some that the LCME keeps its eye on,” says student member Schneider.


What happened at Allegheny’s medical school simply demonstrates the LCME’s “inability to predict the future,” Schneider says. At this point, he adds, the committee is watching the restructured school, MCP Hahnemann University, very closely.


Although committee members are careful not to discuss individual schools, LCME’s Jonas says he is confident that the group “played the role that they’re required to play by law” when evaluating that troubled school. “I think the track record would show we made lots of visits to MCP Hahnemann. And we continue to monitor that situation very closely,” he says.


In addition, the LCME has asked Jonas to make special visits to at least three other schools this past year due to heightened concerns, says committee member Rohack. He declined to name the schools, but pointed out that the Association of American Medical Colleges (AAMC) provides resources for schools to address problems they might encounter. In fact, the AAMC began developing new accounting and management strategies for medical schools in response to concerns highlighted by the LCME about school finances nearly 10 years ago, Rohack says.


In general, committee members feel they are working together with schools to continuously improve medical education, Rohack says. “Schools have their hearts in the right place,” he says. “But sometimes you have to hit a mule in the head with a two-by-four to get its attention.”


Schools may not always be thrilled to get whacked, although some actually welcome the outside intervention to force needed changes. Stanford faculty were well aware of deficiencies at the school, says Dr. Lewis Wexler, who headed the school’s accreditation review. But the LCME report served as a “wake-up call,” he says, which he hopes will finally bring about the needed improvements.


Sometimes LCME findings can even help schools get additional funding they need, says Arkansas’s Wheeler. When the committee found his school’s anatomy lab inadequate, for instance, it gave the school leverage to secure new funds from the state legislature.


Students should feel good about being at a school that has undergone this careful review process and is authorized to bear the LCME stamp of approval, Jonas says.


“The LCME is the reason you’re at a U.S. school and not at another one in the world,” Jonas says.~The LCME at a Glance


The LCME (which stands for Liaison Committee on Medical Education) is the accrediting body for medical education programs in the United States and Canada. The LCME accredits only allopathic medical schools; osteopathic medical schools are accredited by the American Osteopathic Association. Each of the 125 U.S. and 16 Canadian allopathic medical schools accredited by the LCME must submit to a comprehensive review every seven years, which includes a site visit. In addition, schools must produce annual and interim reports when directed by the LCME.


All this information is evaluated at quarterly meetings of the 17-member accrediting committee, composed of volunteers who rotate through
designated positions. Two slots are held for medical students, appointed by the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC), the two associations that sponsor the committee. The AMA and the AAMC each appoint six professional members as well, such as medical school deans. The last three positions are held by two public representatives, such as practitioners and a representative of the Committee on Accreditation of Canadian Medical Schools.


Accreditation benefits. Medical schools must be accredited by the LCME to receive federal grants. Medical students must be at an accredited school to qualify for federal student loans, to take the U.S. Medical Licensing Examination (USMLE), or to enter residencies approved for medical licensure in most states.


Filing complaints. Students can file a complaint about a medical school with the LCME secretary’s office. Each year, the secretary’s office rotates between the AMA and the AAMC. This year, it is based at the AMA. Comments or complaints can be directed to Secretary Dr. Harry Jonas at (312) 464-4657, 515 N. State St., Chicago, IL 60610. E-mail harry_jonas@ama-assn.org; fax (312) 464-5830.


For detailed information about the grounds and procedure for filing a complaint, you can order a copy of the LCME’s Rules of Procedure and see
appendix E. Copies are available from the AMA’s LCME office, or the AAMC’s office, located at 2450 N St., N.W., Washington, DC 20037; phone (202) 828-0596.


Accreditation schedule. To obtain a free copy of The Directory of Accredited Medical Education Programs, which lists the academic year of the next full survey for each U.S. and Canadian medical school, contact either LCME office. To inquire
about upcoming accreditation surveys contact those offices directly as well.


Student involvement. The LCME sends
materials to schools a year before a school’s next scheduled full accreditation survey. These materials include instructions for completing a database, guidebooks for an institutional self-study with student involvement, and preparation of the survey report.


Another packet of information is sent about three months before the survey, including an outline of responsibilities of the dean’s office and a suggested schedule for the visit. A list of the team members who will be visiting the school, including contact information, is included.


To order a free copy of The Role of Students in the Accreditation of U.S. Medical Education Programs, contact the LCME.


For more information, contact the LCME’s student members: Steven Schneider at schnei01@med.nyu.edu, or Shaka Walker at
walker@medlib.georgetown.edu, or visit www.lcme.org, the LCME’s Web site. —C.W.
~~~Christine Wiebe is a New Physician contributing editor and the author of a recently released book on paying for medical school, The Right Price: How to Finance a Medical Education and Feel Good About It (Sage Publications). ~Medical Education~