256~1January-February~2000-49~Feature~Beyond the Call of Duty~~~~Escaping the trappings of Western medicine—if only for a few weeks each year—
thousands of doctors volunteer their services overseas with medical relief organizations. The work is difficult. Yet, most agree it’s immensely rewarding. Little, if no bureaucracy, politics or paperwork. Just the chance to practice
pure medicine.


Roaming the streets of Sobral, Brazil, a loudspeaker perched on its back, the truck makes its way around the coastal city, spreading the word about a group of U.S. volunteer surgeons coming to open a temporary clinic. Television and radio stations broadcast the reports over the airwaves. Local newspapers publish advertisements. Patients are recruited from all over the area—many travel hundreds of miles, sometimes by foot or horseback, to see plastic and reconstructive surgeon Dr. Jack Demos and his Pittsburgh-based Surgi-Corps International crew.


To parents of disfigured children, the surgeons are little-miracle workers, repairing a cleft lip in a matter of hours. To an adult with severe burn scarring, left untreated for years, the visiting team makes an unspoken wish come true. For a couple of weeks, from dawn until way past dusk, the physicians consult, operate and care.


Depending on where they go, Demos and his team—which might include a general surgeon, a urologist, an anesthesiologist and some assistants—usually consult with a couple hundred patients and operate on 50. The conditions the physicians attend to are rarely life-threatening. Now and then they’ll come across a patient with a serious infection, but the team usually corrects “horrible deformities” that would have been tended to earlier had the patients had access to care, Demos says.


Demos founded Surgi-Corps International in the mid-1990s with the intention of creating a “hometown” medical relief organization. With help from friends and a few overseas contacts, he pretty much runs the group himself. Demos organizes local fund-raisers, collects supplies and equipment from regional businesses, and takes his family with him on many of the trips. He even speaks about his medical relief efforts at Pittsburgh-area high schools and has invited several students to travel with him so they can witness for themselves how other people live.


“I’ve always been interested in going overseas and doing charitable work like this,” Demos says. It’s a passion that has gradually developed as he has become more successful and secure with his own career. Half of the surgeries Demos performs at Pittsburgh-area hospitals are cosmetic. “I make a good living here, so this is a way of saying ‘thank you,’” he says.


Surgi-Corps is a tiny enterprise compared with Interplast, a large humanitarian organization also specializing in reconstructive surgery. Demos has no desire to, and couldn’t possibly, compete with larger groups. He says more doctors should be chiseling away at the boulder that blocks individuals from accessing decent health care.


Demos’ success with Surgi-Corps leads him to conclude, “Anyone can do this if they make the proper arrangements.”


They’d just need a little initiative, lots of interest, and oh, yeah, some cash. Like many well-established physicians who volunteer overseas, Demos can afford to spend the time and money. Travel costs for Surgi-Corps volunteers range from $2,500 to $4,000 per person, depending on the destination and recreational activity that gets tacked on at the end. The destination never really matters, though, because no matter where Surgi-Corps goes, the goal remains the same: to provide services where none or few are available.


Altruism is well and good, but it’s not as if there’s nothing in these missions for Demos and other volunteers like him. They love this work. In fact, it enriches their lives like nothing else. “This is what medicine is all about,” Demos says.


DR. FEELGOOD


What a great escape it is for physicians to practice the best medicine they know and not have to worry about lawsuits, paperwork, health management organizations, time constraints and patients’ fees. Physicians are the primary volunteer source for medical relief agencies, but sometimes medical students are able to create their own opportunities. (See “Dreaming of Kenya,” p. 34.) Working as part of a medical relief project, these doctors are liberated and savoring every minute of it.


“I just feel the best when I’m there,” says Dr. Peter Egbert, an ophthalmologist at Stanford University who has been traveling to Ghana, West Africa, with Christian Eye Ministry (CEM) for the past 12 years. CEM is a program of a Michigan-based non-profit, non-denominational Christian relief organization called International Aid (IA), which was established in 1980.


“I’m using my talents to do what I want to do. The lifestyle is simple.
There’s no paperwork or politics,” he says.


Unlike Demos, Egbert began his medical relief volunteer work early on in his career, when Yale University School of Medicine required him to do a residency in Haiti in 1972. “I just thought it was fascinating and wonderful,” he says. This fascination continued years after that with trips to Afghanistan, China, Honduras and Saudi Arabia.


All of Egbert’s journeys required a measure of initiative on his part. He learned of an Afghanistan hospital in need of assistance by asking his colleagues about opportunities abroad. On another occasion, Egbert wrote to the Western Samoan government, in the South Pacific, to inquire whether they needed his skills. It took them three months to respond, but the answer was “yes.” So off he went. Other medical relief efforts were the result of finding listings in a resource book the American Academy of Ophthalmology publishes for physicians seeking to go overseas.


Egbert didn’t have to take action to begin his work with CEM, though. The ministry approached him. Dr. Frank Winter, who founded the program in 1983, asked for Egbert’s help, and it has been a beautiful partnership ever since, Egbert says.


Egbert enjoys giving his time and skills, and Ghanaians have access to a type of care that is rarely found in Africa. On average, Africa has one ophthalmologist per 1 million people. Volunteers like Egbert have allowed Ghana to enjoy better care.


The country has three CEM clinics, with 50 local staff spread among them. “The clinics came during a time of regrowth in the country,” Egbert says, referring to the late 1980s. About 20 eye specialists travel to Ghana each year. A typical two-week trip costs volunteers around $2,500. “Some go only once and never go back,” Egbert says. “Others return, like me.”


Dr. Milton B. Amayun, IA’s vice president for international programs and a public health physician, concludes that physicians like Egbert keep coming back because “they have a life-changing experience. They come back to [the United States] much more thankful for what they have.” And, Amayun explains, volunteers like Egbert are being exposed to an entirely new culture. “The [volunteers] are establishing relationships with people that they had never known before and are making long-term contacts.”


It usually takes Egbert three to four months to prepare for the journey, spending much of this time obtaining medical supplies and equipment from pharmaceutical and ophthalmology companies.


For each trip, Egbert and his wife stay one month in Ghana, living in a small cinder-block guesthouse. He works at each of the clinics, treating patients and performing surgery. CEM and its volunteers have worked hard to equip the clinics with the proper tools necessary to Egbert’s line of work—a luxury few medical relief workers experience. “We can offer quite good medical care,” he says.


And the work is steady—to say the least. “Patients are lined up in the morning and don’t go away until night,” Egbert says. “It’s impossible to turn people away.”


At the clinic, patients pay what they can afford. A typical Ghanaian family’s two-months’ salary is about $70. Requiring some form of payment is common in several areas of the medical relief world, especially where groups are trying to turn their clinics into independent facilities. “You have to have an economic base,” Egbert explains. Still, care is never denied. The emphasis on payment only exists as a way to strengthen a community’s reliance on their own health care.


PASSING THE TORCH


Along with treating patients, Egbert spends a lot of time training Ghanaian physicians to eventually take over the clinics’ practice.


“It usually takes two to three years to teach the physicians the specialty,” Egbert says. He has already seen the training begin to pay off. “One of our clinics is self-sustaining now, with only minimal support from Christian Eye Ministry.”


The transferring of skills is an important component to many medical relief organizations. It requires a longer commitment, however, and not all groups have the resources to do it.


Dr. Michael Rich, an internist pursuing a master’s degree in public health at Harvard University, spent six months with the 1999 Nobel Prize–winning Doctors Without Borders (DWB) specifically to train physicians in Karakalpakstan, an autonomous republic of Uzbekistan. It was his first medical relief mission.


“There’s a lot of illness [in Karakalpakstan],” Rich says. It’s an area that suffers from some severe environmental problems. The shrinking Aral Sea—called a “disaster zone” by the World Bank because of its polluted and evaporating waters—has contaminated the drinking water. When people drink from the area’s ground water, they’re consuming a liquid that has as much salt as a can of soup. As a result, there are a lot of sanitation problems, kidney diseases and hypertension, Rich says.


But one of the biggest threats to public health is tuberculosis (TB). “It’s at epidemic proportions,” says Rich. “TB is such a problem there, because with the lack of government resources, people were only given partial treatments.” And this made TB more resistant to drugs, making it incredibly difficult to fight, he says.


Rich, who had been in the Peace Corps before attending medical school, was the DWB physician in charge of training the volunteers. He did very little clinical work. “That can be disappointing for some people,” Rich says. “But, to me, I really liked the public-health aspects.”


Five DWB volunteers comprised Rich’s project team—a nurse, a trainer, a logistician, a lab technician and an epidemiologist. The team’s primary objective was to teach physicians how to recognize TB and treat it effectively. Team members also taught Karakalpakstan physicians about treatments for diarrheal diseases. Rich says the medical relief effort is aimed at giving Karakalpakstan physicians the knowledge and skills to take care of these illnesses on their own.


The republic had many TB hospitals, so project teams used their labs to conduct the training. This gave Rich the opportunity to tour the wards and witness what a lack of resources and space, combined with an epidemic, can do to a care facility.


“The hospitals are very crowded. There are eight or nine [patients] to a room,” Rich says. These packed facilities exceed Uzbekistan’s maximum occupancy codes, and the government fined many physicians for the conditions. “Ridiculous,” Rich says. The government was responsible for providing more space, and since none existed, “What were the doctors to do?”


The frustrations that came with these conditions didn’t stop Rich from enjoying the experience. “What I did in those six months—I had more impact on people than what I did in my years working in the U.S.,” he says.


WORKING FROM WITHIN


DWB isn’t the only organization focused on health and training that earned notable recognition last year. The African Medical and Research Foundation (AMREF) Inc., based in Nairobi, Kenya, won the 1999 $1 million Conrad N. Hilton Humanitarian Award.


AMREF specializes in bringing health education and medical care to some of the continent’s most vulnerable people. It is an example of an operation that began primarily as a voluntary medical relief group, called The Flying Doctors, and developed into a full-fledged organization focusing on health policy and education work as well.


In the 1950s, The Flying Doctors flew to remote African locations, performing reconstructive surgery and conducting health clinics. After some time, the founders recognized that “the solution really is in getting communities more informed and more involved in managing their own health care,” says John Batten, Ph.D., AMREF’s director general, who has been working in developing nations for more than 25 years.


Now with programs in more than 10 African countries, AMREF has broadened its work to include public policy debates, improving water and sanitation facilities, training indigenous health professionals, publishing health education manuals, conducting disease research—all the while continuing to provide health-care services to nomadic African populations. With such a heavy program load, Batten says, “We can always use directed, skilled volunteers.”


“The conflicts that are around, in the Third World in particular, are really a result of large numbers of very vulnerable people. And they’re vulnerable because they’re not informed. They’re sick. They’re not well educated and so on. So, we believe that it’s not just good health that we’re actually facilitating here. We’re providing a process that empowers people to be stronger actors in their own development,” Batten says. Pushing communities toward self-reliance is the only way to improve conditions, he adds. “The solution for Africa is to produce more skilled people at home.”


‘MACGYVERS’ IN THE BUSH


The rule of thumb for physicians volunteering overseas is to “bring all of the appropriate technology,” CEM’s Egbert says, emphasizing the word appropriate. “The Third World is littered with expensive equipment that no one knows how to repair,” he says.


Then there’s the added challenge of dealing with frequent power outages and bad plumbing. It might also be very hot and dusty or extremely cold and damp. All of these difficulties could make an impatient and inflexible person incredibly frustrated. But veteran relievers like Egbert aren’t phased. “I like [the challenge] actually,” he says. “It tests my wits.”


Encountering new forms of illnesses is another obstacle faced by U.S. physicians abroad. Demos and his Surgi-Corps crew frequently encounter diseases they’ve never seen before. “We try to figure out the best way to treat them,” he says. But in many cases, Demos admits, “You kind of fly by the seat of your pants.”


The ability to go head to head against a variety of challenges often leads a physician toward greater and faster skill development, AMREF’s Batten says. “[These doctors] are thrust into an environment where… there’s no other doctor around, and they have to deal with everything right off the bat.”


Batten’s colleague Dr. Pat Youri, a native Ghanaian who has been a physician for the past 27 years, agrees. “In Africa…because of the lack of laboratory and other support services, a doctor’s clinical acumen is relatively much more developed than many counterparts’ elsewhere who have access to supportive services,” he says. “Improvisation is the name of the game here.”


OFF THE BEATEN PATH


Dr. Heather Papowitz, an emergency physician, has volunteered her skills all over the world and now works at becoming a medical relief expert as part of Johns Hopkins University’s international health graduate program. She understands the need for creative thinking.


Papowitz’s craving for this work began in medical school with an international health elective in Belize, Central America. She did a rotation in a rural clinic. Armed with only her stethoscope and drugs like aspirin and penicillin, Papowitz had to rely on herself. “It was a relief, in some cases, because you didn’t have 100 drugs to choose from, and you could learn how to use basic treatments better.”


Papowitz says her experience “sparked me to think that there [were] other avenues out there for doctors.”


After completing medical school at Tulane University and a residency at Mt. Sinai Hospital in New York City, Papowitz dusted off her passport again. First she headed to a city hospital in Bangkok, Thailand. Next, she flew to India to volunteer in a rural clinic. Papowitz says that this experience led her to understand-
ing the connections between her patients’ illnesses and the environment in which they lived. But treating the same diseases over and over again—malaria, hepatitis, tuberculosis, leprosy—sometimes made her feel helpless. “They need educational and development programs, and that would take years,” she says.


CARING IN A CRISIS


Papowitz’s most life-changing experience came from a two-month stint with Doctors of the World (DOW) in the spring of 1999, when she cared for refugees at a camp in Senekos, Macedonia. “It just opened up my world,” she says.


DOW has been in the Balkans since 1992—vaccinating children against polio, combating the rising TB problem and promoting health education—so when the Kosovo crisis broke, they were one of the first organizations to arrive on the scene.


Not normally an emergency medicine relief agency, like DWB is, DOW quickly learned how to provide care in a crisis, Papowitz says.


And in the process, it became the “Cadillac of refugee camps,” says Dr. Drew Fuller, an emergency physician who also volunteered in the camp that spring and was a little wary, at first, of what he would encounter on his first medical relief operation. Plus, everything happened so fast.


“I only had a week to get things together,” Fuller says, “and [the trip] wasn’t confirmed [by DOW] until two days before I left.” Fuller’s first glimpse of where he would be spending the next month was surreal. “As we’re driving up to the camp, I look at the wire fence and the tent-city and think of the people trapped inside. It was strange. I asked myself, ‘Am I going to be able to handle what’s going to come at me?’” he says.


Surprisingly, even during this emergency situation, Fuller ended up playing the role of the village doctor and wishing he had more primary care experience. The problems Fuller treated were routine—colds, lacerations, upper respiratory tract infections, gastrointestinal ailments. He had a few special medical concerns to look for, like the spread of infectious diseases, but otherwise his work was back to the basics.


And the “basics” are what the 3,000 refugees needed. Forced out of their homes, separated from family and friends, they looked to these foreigners for strength and security.


Fuller made “tent calls” on the elderly and fragile in the predominantly Albanian camp population. He became close to several families. “They’re a very warm group of people,” he says, surprised at how well they were holding up during their time in the camp.


“I felt more like a physician than I had in a long time. You didn’t have all of these distractions that you have in Western medicine,” Fuller says.


Surgi-Corps’ Demos agrees. “Overseas medicine is pure medicine,” he says.



DEVELOPMENTS IN MEDICAL RELIEF


According to experts, attention to the mental and emotional health of a vulnerable population constitutes a new element in medical relief work. Treating psychosocial disorders is one challenge medical relief organizations must tackle in the 21st century, says IA’s Amayun, who, for the past 30 years, has worked all over the world.


When Amayun was in Cambodia in the late 1970s, mental health problems “were not an issue,” he says. But by the time the Bosnia crisis erupted in the early 1990s, psychosocial disorders “were like a gaping hole that wasn’t looked at properly by medical relief organizations.”


Now many organizations are focusing on how to address mental health issues and what sort of policies they’ll need to help these populations, Amayun says.


Developing practice protocols have become necessary as well—marking another change in the medical relief sector’s development, Amayun says. “Physicians can no longer go with their regular work styles.” They have to operate within specific ethical and practice guidelines developed by a consortium of organizations, he says.


And, as the number and size of organizations grow, the competition increases, says AMREF’s Batten.


“Ten years ago, [the competition] wasn’t that great. Organizations in Third World countries would work together,” Batten says. But today, many medical relief groups compete for such resources as grant and project funding. And, through their work, some organizations may actually be stealing resources from the very groups they are trying to help, he says. “They only work from the outside, occupying space that prevents local growth.”


Another change in the medical relief field is the growth of violent attacks on organizations and its volunteers. When Amayun began practicing medicine, medical relief groups maintained an existence of neutrality and were relatively safe in volatile environments. “Now, in Bosnia and other areas, [United Nations] workers and [non-governmental organizations] are targets of violence. Health workers are murdered in their homes,” he says.


Amayun has survived his fair share of dangers. “I have been the victim of a kidnapping attempt in the Sahara Desert,” he says, declining to go into the details.


Hazardous situations are common. Surgi-Corps’ Demos was accused of being a “military spy” when he was stopped by a military blockade while heading to a Nigerian airport to return home. He narrowly escaped arrest. “I thought I was going to die,” he says, still remembering the rifle pointed at his face.


DOW’s Papowitz realized she was in the middle of a war when she worked the night shift at the refugee camp. “I could see the missiles in the sky,” she says. Although Papowitz wasn’t exactly the specific target of an attack, she says the tension between the various political powers and the one she represented was still very alarming. “Macedonians hated NATO. It was never really comfortable.”


Politics can be dangerous. AMREF’s Youri says that when the organization’s workers provide health care to both sides of a warring nation, some governments accuse them of being rebel allies.


Bombs, military men and epidemics pose serious threats to medical relievers and their patients, but these dangers won’t keep the volunteer physicians away. Both Demos and CEM’s Egbert plan to do more volunteer work after retirement. “Yes, there are risks,” Demos says. “But does that mean we stay at home? Life is meant to be lived.”
~DREAMING OF KENYA


It is 1995 and the idea had been nagging medical student Benson S. Bonyo for years. A little voice in his head, whispering in his Luo tribal language, “Wadok Kenya. Wangaya dwaro jothieth.” It was telling him to “return to Kenya. Wangaya needs doctors.”


Wangaya is Bonyo’s home—a small farming village in Kenya located near Lake Victoria on the country’s southwestern border. The area is part of the Nyanza (the Swahili word for lake) province, one of the poorest and unhealthiest in the country. The nearest medical clinic is seven miles from his village. The closest hospital is a half-hour drive, or about a half-day’s walk, to the city of Kisumu.


When Bonyo was 8 years old and his baby sister was dying of dehydration, he wasn’t aware of either of these care facilities. The memory of her death and what doctors could have done to save her life—feed her intravenous fluids and antibiotics—troubles him to this day.


So in the late 1980s when Bonyo made his journey to the United States to pursue a career in medicine, his thoughts were of the 100 people in his village—all of whom he considers to be his extended family—and their needs. “This thing has always been in my mind,” he says.


The responsibility weighed heavily on his shoulders. So to make the task appear a little less daunting, he approached it all with a bit of jest.


“Let’s go to Kenya,” he jokingly said to three friends during the 10-minute class breaks at the Ohio University College of Osteopathic Medicine (OUCOM). And surprisingly his friends said, “That’s not a bad idea.”


Soon after that, classmates, some of them complete strangers, approached Bonyo in the halls. “I hear you’re planning a trip to Kenya,” they’d say.


“How did you find out about that?” he’d ask.


They would tell him of a friend who had told a friend who told a friend, and how they all thought it seemed like a great idea. Several months later, Bonyo found himself organizing a team of medical students and several physicians to head back to his homeland.


At first, says Bonyo, “It was horrible. I kept thinking, ‘What the hell have I gotten myself into?’” He was only a second-year medical student, with no idea what the team would be doing once they set foot in Africa. And everyone had already purchased their tickets to Kenya and committed their time. “I can’t [back out]. I’ve got to do it,” he remembers thinking.


With that resolve and only a few weeks remaining before the trip, Bonyo flew to his homeland to do some prep work.


First, he told his family (none of whom had ever been educated past the sixth grade or visited the United States…many of whom had never seen a white person…and all of whom had great hopes for Bonyo). “They didn’t know what to think,” he says, but they welcomed the visitors all the same.


Next, Bonyo went to Ahero, the local health clinic serving the rural Kisumu area and its thousands of patients. “We shall work with you any way you want,” clinic physicians and nurses told Bonyo. Then he traveled to two city hospitals, and people there said the same.


So the trip was set. Bonyo returned to Ohio with renewed confidence. A few weeks later, he led the 14-member team to Kenya.


“It was just amazing,” Bonyo says of the experience. “These people,” he says, referring to his fellow travelers, “were very prepared, very mature.”


The Kenya trip sparked something Bonyo had never imagined. “Kenya has now become an international medicine rotation [at OUCOM],” says Gary Snyder, OUCOM’s associate director of communication, who has traveled to Kenya twice.


The multidisciplinary program is now called S.H.A.R.E. (Students Health Assistance/Rural Experience) Kenya, and it sends medical students and professionals, along with an OUCOM-affiliated research team, to the country for three weeks every two years. Last November, 30 people participated in the program’s third trip to Kenya.


S.H.A.R.E. Kenya volunteers live in Kisumu and commute to city hospitals and the Ahero clinic. They bring donated supplies and equipment and allow the facilities to care for many more patients than the clinics would otherwise be able to handle on their own. Students receive credit for the program, and all participants pay their own travel and accommodation expenses.


A program such as this is essential to medical students, Snyder says, because “it pushes them out of the comfort zone and gives them an appreciation for access to care.” There is a connection, he says, between experiencing medicine in Kenya and practicing rural medicine in impoverished areas of the United States. “For poor folks in Appalachia…to drive 20 miles is a barrier to care,” Snyder says. Students see the lack of adequate care issues they witnessed in Kenya reflected in areas of Ohio and Appalachia and understand them better, he says. “Development of that perspective is important.”


As for Bonyo, he’s now a second-year family medicine resident at Akron City Hospital in Ohio and continues to travel with S.H.A.R.E. Kenya, hoping to one day open a hospital closer to his village. “I dream about that all of the time,” he says.


For more information about S.H.A.R.E. Kenya, contact Gary Snyder at OUCOM’s communication office at (740) 593-2199; e-mail gsnyder1@ohiou.edu; mailing address 323 TEB/The Ridges, Athens, OH, 45701. —R.S.


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


Using internist Dr. Michael Rich’s experience with Doctors Without Borders (DWB) as an example, here is an overview of how the medical relief matching process usually works. Unlike volunteers of smaller organizations, or those who travel independently, DWB and Doctors of the World medical relievers don’t pay anything for their trips, and they typically receive a monthly stipend (around $750).


If you’re interested in volunteering overseas once you’ve become a physician, you first need to contact the medical relief organization with which you wish to serve and fill out an application. Next you will undergo a strict screening process. If the agency selects you to volunteer, an orientation usually follows. Then it’s a waiting game for the perfect match to come along.


When a volunteer position opens up, DWB, for example, will call you with the details (location, date and time frame) and ask if you’re interested. If the answer is “yes,” then DWB will forward your application to that country’s DWB director. If the director thinks it’s a match, a DWB representative will contact you to finalize plans for your medical relief
mission. —R.S.


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IN PRINT



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~~~Rebecca Sernett is an associate editor of The New Physician.~Community and Public Health,International Health~
257~1January-February~2000-49~Feature~Safeguarding Your Future~A PRIMER ON LIFE AND DISABILITY INSURANCE.~Anthony J. Leahy~~Right now, as a busy, time-crunched medical student, you may not have even stopped to consider your need for life or disability insurance. But perhaps you should. Along with buying a home, paying for your education and saving for retirement, purchasing insurance is one of the most significant economic decisions you’ll make and here’s why.


THE LOWDOWN ON LIFE INSURANCE


Most people purchase life insurance to meet the future needs of a spouse, child or elderly parent. Some buy life insurance to build up cash reserves for the future when retirement or college tuition expenses loom.


To take out a life insurance policy, you need to be in reasonably good health. You may have difficulty getting coverage if you’re in poor health, or if you work in a high-risk occupation. But you may still be able to obtain insurance, though at a higher cost, even if your occupation or health condition makes you a less-than-perfect risk to insurers.


Insurance companies determine your risk level by reviewing personal information about you. Applications are reviewed for health factors (smoking, weight, heart disease, etc.), family history, occupation, gender, as well as a person’s financial situation.


Insurance should be part of an overall financial plan. It’s worth taking the time to assess your net worth, review your spending habits, determine how much you need to save for retirement and estimate how you’ll pay for your children’s education before you determine how much life insurance you need.


You should save about 5 percent to 15 percent of your gross income to meet financial needs over the long term.


Make sure your savings plan includes buying life insurance that’s equivalent to about five to eight times your current wages. So, if you earn $50,000 a year, you should have between $250,000 and $400,000 of coverage.


A well-drawn insurance plan looks at the assets you need to take care of your spouse, children and, in some cases, your parents. This amount may decrease over the years.


Ideally, your goal is to buy or adjust your amount of insurance to cover any shortfall between your family’s estimated income and expenses after your death. If we assume that the policy death benefit could be invested at 6 percent annually, the general rule of thumb is that you buy $100,000 in insurance for every $6,000 shortfall in annual income.


DO YOU REALLY NEED DISABILITY INSURANCE


As a physician-in-training, you’ve already committed considerable time, energy and money to building your career. In the not-too-distant future, working as a physician will provide you with an important source of income to maintain a certain standard of living. In a way, your ability to work is your most important financial asset.


No one wants to consider the possibility of becoming so sick or injured that they can’t work for a living. But if you were to become disabled, you would have several options to maintain your lifestyle. You could live off savings and investments. A liquidation of your assets also would be possible. Other options include getting a loan or obtaining eligibility for Social Security benefits. A final option could be relying on other family members or relatives as a source for financial help.


For most people, these alternatives are undesirable. Becoming dependent on others or relying on a final cash source could put you in an extremely uncomfortable, if not vulnerable position, especially if you have a long-term disability.


Disability income insurance helps you and your family cover the period of time when you’re disabled and unable to earn an income. This type of insurance can help provide a monthly benefit to replace your lost income while you’re ill or injured and unable to work.


So how do you decide how much insurance you need? Disability policies can be complex and difficult to compare. The key is finding a package that provides you with the greatest amount of financial protection for the most reasonable cost. Generally, there are three primary considerations you’ll want to take into account before choosing a policy.


Replacing your lost income. This is the most important function of disability coverage; and the most fundamental element of your protection plan is the definition of disability. It tells you under what conditions you’ll receive benefits to replace lost earnings.


A good policy should consider you disabled and eligible for your full monthly benefit if you are unable to work in your own occupation and choose not to work in another. Some of the better policies will even pay you a proportionate benefit while you’re working until you’re earning at least 85 percent of your former income.


Protecting your future insurability. Because your income will probably increase throughout your career, you’ll need additional disability protection. To purchase more coverage, however, you must be in good health—and that doesn’t always continue throughout your prime working years. A policy that provides future insurability benefits, allowing you to increase your coverage as income increases without providing medical information, can solve this problem.


Look for flexibility in choosing future insurability benefits. If you expect your income will grow gradually over time, then an indexing feature, which gradually increases the benefit in line with your rising income, will work best for you. On the other hand, if you expect rapid growth in income, you’ll want the flexibility to purchase additional amounts of coverage when your income increases occur.


Inflation protection. Inflation can have a devastating effect on the value of your monthly benefit if you’re disabled for a long period of time. Most policies offer an inflation protection or cost-of-living agreement that helps you maintain the purchasing power of your benefits throughout your disability.


When comparing inflation protection options, select a policy that provides “real” inflation protection—such as those that offer increases based on the Consumer Price Index, not an artificial percentage chosen by the insurance company. Choose increases calculated on a compounded, rather than simple, basis. Finally, make sure the inflation protection option doesn’t have a limit that caps increases in the benefit once your monthly benefit has doubled or tripled.


In the short term, yes, there are a lot of factors to weigh before purchasing life and disability insurance. But in the long run, the right policies will provide you and your family peace of mind.
~~~~Anthony J. Leahy is a manager with the Minnesota Life Insurance Company, which has provided AMSA members with group term life insurance for more than 30 years.
This column is sponsored by the Educational Finance Group, which offers the AMSA Advantage Educational Loan program.
~Medical Student Debt~
258~1January-February~2000-49~Feature~Student, Interrupted ~~CHRISTOPHER KLIMEK~~Getting into one medical school is difficult enough. Students forced by circumstance to
transfer and repeat the ordeal often face even tougher obstacles.


Alison Ambrose never wanted to split her education in medicine among two schools. Her two years at a mid-sized medical college in the Northeast had been happy ones, and she looked forward to completing her rotations at hospitals in the region. But when her fiancé found a good job in a city hundreds of miles away, Ambrose (not her real name) decided her commitment to her future husband outweighed any sense of obligation she felt to her medical school.


Her dean of students disagreed. The school she was trying to leave did not accept applications from transfer students, and they were no more eager to help someone find the exit. When Ambrose requested that her transcript and records be forwarded to another institution, her school demanded $500 for a service that most medical schools provide to students for free or at a nominal cost. Ambrose was stunned.


“I already paid $30,000 a year to go to school there,” she says. “I was at school on loans.” When Ambrose asked why the fee was so high, school officials were blunt: “They said, ‘We’re trying to deter students from doing this,’” Ambrose recalls. She protested, but ultimately chose to pay the fine rather than jeopardize her chances of admission at another school.


Fortunately, sympathetic professors stepped in and provided the recommendations Ambrose’s dean of students would not. After a four-week delay while she waited for her U.S. Medical Licensing Exam (USMLE) Step 1 scores to arrive, a school in the same Midwestern city as her future husband’s new workplace accepted Ambrose as a third-year student. She made friends quickly through her rotations, made up for her late start during her fourth-year vacation period, and yes, got married. Now in the midst of interviewing for residency, she has no regrets about her decision to transfer.


But Ambrose still fears the ire of her first school when she must again request transcripts or other documents, which is why she won’t allow the name of her old school to be published. And the number of students who transfer medical schools each year is small enough that to identify either her first school or the one she will graduate from in May would be to identify her.


Although Ambrose’s story may not be that of a typical transfer student in medical school, it isn’t an uncommon one, either. Several students contacted for this story refused to share their transfer experiences even under the protection of anonymity. Some cite the fear of reprisals from administrators at their former schools, while others simply say the experience was too personal, too painful or too wearying to talk about for publication.


These students are not alone in their reluctance to talk about transferring. The Association of American Medical Colleges (AAMC) says transfer admissions data are currently unavailable. But the organization’s Web site states that admissions officials should submit a form to the AAMC when they accept transfer students, and that the AAMC periodically distributes lists of all acceptances to medical school admissions officers around the country. Admissions officials at Brown University, Temple University and Baylor medical schools, among others, confirm that they regularly receive this list from the AAMC.


What is clear is that the number of medical students who transfer every year must be relatively small, given that no medical school contacted for this story reported granting more than 15 students “advanced standing” in any academic year, and most accepted fewer than five.


Most medical students who transfer appear to do so to remain close to a spouse or family member. In fact, most medical schools who consider transfers require applicants to show “hardship” or “a compelling reason” along with their transcript, recommendations and other materials.


As Audrey Uknis, assistant dean for admissions at the Temple University School of Medicine, puts it, “‘Hardship’ means we’ll entertain the transfer. Then we look at your grades and your scores.”


Nearly all schools that accept transfers share other requirements, too: The student must be in good standing at an accredited U.S. medical school. Most colleges allow students to transfer between years two and three only, although a handful of schools, such as Temple, permit transfers after the first year. Many allopathic schools won’t accept transfer applications from students at osteopathic schools. And if you’ve been dismissed from your school, well, don’t hold your breath until you’re accepted at another one.


Even if an applicant meets all requirements, acceptance with advanced standing is always contingent upon the number of spaces available, if any. Beth Bailey, director of admissions for the University of Virginia School of Medicine (UVa), says that while UVa does consider third-year transfers for admission, no spaces have been available since 1995. Prior to that, Bailey says, no more than two third-year slots have ever been available in any given year. And Patricia Fero, an admissions officer at the University of Washington School of Medicine, says Washington has accepted a total of two transfer students in the past 10 years.


Is it any surprise, then, that with these kinds of odds, transfer in medical school is not the path to an upgraded academic pedigree that an undergraduate transfer can be?


Rob Chisholm, a third-year student at the University of Texas Health Science Center at San Antonio (UT–San Antonio) who transferred there from Philadelphia’s MCP Hahnemann University puts it succinctly. “There’s the whole line of thought that if you transfer laterally, it’s possible,” he says. “But if you try to transfer up—if I would have tried to go to a Yale or a Harvard, that would probably have been impossible.”


Dr. Leighton Hill, senior associate dean for admissions at Baylor College of Medicine in Houston, which accepted approximately 15 percent of total applicants in 1999, confirms Chisholm’s suspicion. “One of the things we look at is whether [a transfer applicant] would have been admitted to our first-year class,” he says. And Temple’s Uknis says her school “almost never” considers a transfer applicant who wouldn’t have gotten in a year or two earlier.


While few schools appear to be as open in their efforts to discourage students from leaving as Ambrose’s, a random, unscientific poll of deans at medical colleges and universities around the country uncovers some who are eager to aid the process.


“We certainly don’t encourage transfers,” confirms Dr. Dennis Nadler, associate dean for undergraduate medical education at the State University of New York (SUNY) at Buffalo School of Medicine and Biomedical Sciences. “We believe that if someone has signed up to be educated with us, they’ve made a commitment, just as we’ve made a commitment to them.” But Nadler is no hard-liner, preferring to handle transfer requests on a case-by-case basis.


“We try to be human about it,” Nadler says. “We don’t write letters of recommendation for transfer. We don’t ever recommend that someone transfer.” But SUNY–Buffalo will verify a student’s good standing and forward a transcript without levying an additional charge, Nadler says. Like many other deans, he will usually accept marriage as a compelling reason to transfer, but not necessarily engagement.


“If you are in the Navy, there are times when for six to nine months out of the year, you’re on a ship someplace,” Nadler explains. “To us, just the idea of ‘I’m lonely’ does not constitute a compelling reason to transfer. [But] we won’t obstruct it.”


Dr. Peter J. Katsufrakis, associate dean for student affairs at the University of Southern California School of Medicine (USC), takes a more sympathetic view. Though he says he receives requests from students for his help leaving USC for another school less than once a year, he is always receptive.


“My practice has been to support the student,” Katsufrakis says. “I realize that when they come to me, they are usually in a difficult situation already.” He believes that administrators who take a purely dollars-and-cents view when a student asks for help applying to another school show a lack of sympathy unbecoming a good physician. “The loss of income to our school cannot compare with the pain of being separated from a spouse or missing the last six months of a parent’s life,” he says.


But he cautions that transferring for reasons less serious than these probably isn’t worth the cost, both monetary and emotional, to the student. “You’re giving up your social support network and immersing yourself in a new environment,” he says. “You don’t know anyone.” Along with the burdensome rotations every third-year student endures—and the difficulty of completing one’s academic program out of sequence because of the delay awaiting Step 1 scores, as Ambrose did—this added sense of isolation will be a cross too heavy for many students to bear, Katsufrakis warns.


Despite these difficulties, many students appear ready to take extravagant measures to transfer to be near a loved one. As the requirement for students to present a compelling reason for their transfer request has become commonplace, so has the potential for students to lie about it, says Kara Johnson, who works in the admissions office at USC. “I’m not saying it does happen, but I’m saying it can happen,” Johnson says. But she says USC’s admissions committee relies on the honor system when students present their reasons for transfer. “We expect them to tell us the truth,” Johnson says.


Johnson isn’t the only one wondering how many applicants are truthful about their motives. One third-year medical student among the 59 who tried unsuccessfully to transfer to USC this year had high hopes that she might finally be able to move in with her husband, a lawyer in Los Angeles. She was ranked “in the middle” of her class and scored “above average” on Step 1 of the USMLE. She is doubtful that all 11 of the transfer applicants USC accepted had more compelling reasons for seeking transfer than she did.


“It seemed fishy to me,” the third-year says. “I don’t know what their applicant pool was, but I can’t imagine that all of them had parents dying in Los Angeles.”


USC’s Katsufrakis responds that while compelling circumstances are the primary consideration when evaluating a transfer application, the school’s usual academic standards remain in place.


Nadler, meanwhile, recalls a case wherein a couple moved up their wedding date by more than a year after another New York medical school refused the groom-to-be’s request for transfer. The couple returned to the school’s admissions committee with their new marriage license in hand and asked them to reconsider. When an admissions officer called Nadler to discuss the case, Nadler gave his reluctant blessing, and the student was admitted.


Chisholm says that both marriage and a friendly relationship with the deans of both colleges were integral to his successful effort to enroll at UT–San Antonio in his second year.


“I had met all of the deans there from working [as the American Medical Student Association’s (AMSA) legislative affairs director for the 1997–98 academic year],” Chisholm says. “So I had face-to-face knowledge of all of the folks that I wanted to talk to about transferring, and they knew me as a person, so I think that helped. They also knew my wife. So they knew we weren’t trying to buck the system, or something weird like that. They knew that we were serious, and that I wanted to go to school down there.”


The fact that MCP Hahnemann declared bankruptcy during the year Chisholm left to work at AMSA’s national office in Reston, Virginia, made the decision to transfer even easier once he met his fiancée, then a third-year medical student at UT–San Antonio also on leave to work for AMSA. Because Chisholm knew well in advance that he intended to transfer—and because he had the uncommon luxury of a year off while he laid the groundwork for his transfer—he was able to conduct a subtle but persistent lobbying campaign on his own behalf, speaking frequently with the deans at both MCP Hahnemann and UT–San Antonio.


“It’s crucial to have a very strong relationship not [just] with the dean, but with the dean’s assistant,” Chisholm says, “because they’re always in the know.”


By pure chance, Chisholm also benefited from what he calls a “simpatico curriculum” among the two schools: Both MCP Hahnemann and UT–San Antonio teach immunology, traditionally a second-year course, in the first year. Even then, Chisholm had to wait for a second-year student at UT–San Antonio to drop out before he could enroll. He gambled and moved to Texas with his new wife, learning of his acceptance only “a week or two” before classes began.


Unlike Ambrose, Chisholm encountered no administrative resistance to his request. Indeed, Chisholm has nothing but praise for the way MCP Hahnemann officials dealt with him throughout the transfer process. He ascribes this fact to polite determination.


“You don’t go to them with questions. You say, ‘I need your help, and you need to help me,’” Chisholm says. “If you go there with an agenda and a plan, and you are very polite and serious about it, they will respond.”
~~~~Christopher Klimek is an associate editor of The New Physician.~Medical Education~
259~2March~2000-49~Feature~Panning for Positives~WHEN ARE SCREENING TESTS WORTH THE RISKS?~RICK STAHLHUT, M.D., M.S.~~Pyrite, also known as “fool’s gold,” is a very attractive rock. New World explorers sometimes loaded their ships with it, returning to Europe with false hopes and worthless cargo. If you toss your pan into any old stream, you’re more likely to find pyrite than real gold. But the experienced prospector knows that, expects that, and knows how to tell the difference.


There’s a lot of pyrite in medicine too. It’s the misleading test result—the one that threatens to send us down the wrong path. And like the prospector, we find it most often when we pan the streams where gold is especially rare. But if you know how to tell the difference, you won’t be fooled—or at least you’ll be properly suspicious when you find a bright, shiny rock.


You must understand such subtleties of testing to make sense of the screening debate surrounding breast and prostate cancer, HIV and illicit drug use. Unfortunately, this topic is often taught with equations that don’t give you an intuitive sense of what is going on in this most unintuitive of topics. So let’s skip the equations this time, briefly lay the groundwork, and then go directly to an example that I hope will make screening tests more clear.


Introduction to Testing. Physicians use medical tests to help classify their individual patients. If the test result is X, the patient is healthy. If the result is Y, the patient is diseased. To really understand testing, however, we need some altitude.


Looking down from 10,000 feet, we no longer have individual patients, but populations of patients, diseased and healthy. The ideal test would allow us to perfectly separate the diseased patients from the healthy ones. But tests aren’t perfect. The test results of the healthy people and the diseased people usually overlap (see Figure 1).


This means the “normal range” for a test is actually a compromise designed to balance the consequences of mislabeling healthy people as abnormal (“false positives”) with the consequences of missing people who really have the disease (“false negatives”). Incidentally, the other patients are either “true negative” (healthy and tested negative) or “true positive” (diseased and tested positive).


The ability of a test to separate the healthy and diseased groups is generally described by two somewhat confusing terms: “sensitivity” and “specificity.”


Sensitivity, or the True Positive Rate, describes the ability of the test to correctly classify the diseased population. If you have 100 diseased patients and the test sensitivity is .95, the test will be positive in 95 of them. The other five patients are “false negatives.”


Specificity, or the True Negative Rate, does the same for the healthy population. If you have 100 healthy patients, and the specificity is .97, the test will correctly classify 97 of them as normal. The other three will be “false positives.”


In Figure 1, notice how the sensitivity and specificity can be changed by moving the line that marks the edge of the “normal range.” Moving it left reduces the number of false negatives and will increase your sensitivity. But also notice that by doing this, you’ll increase the number of false positives and reduce your specificity. Moving it right reduces the number of false positives, but increases the false negatives. Whether it’s better to reduce false negatives or false positives depends upon the situation.


The discussion thus far has only focused on the characteristics of the test itself. Don’t forget that there are many other places where things can go wrong. The sample can be improperly drawn, labeled, transported, stored, processed or reported. Usually the system works, but mistakes can happen.


The Perils of Screening. Here’s an example of what could go wrong. A nervous Caucasian couple and their apparently healthy newborn arrive in your office and say, “Our best friends’ new baby was just diagnosed with cystic fibrosis [CF]. We understand you can do a cheap screening test to ensure our baby is OK. Would you please do it?”


You calmly explain that the baby seems fine. And since there is no family history of CF, their baby doesn’t need the test. The parents plead some more and convince you to order the test. The result comes back “positive.” What is the likelihood the baby actually has CF?


The prevalence of CF in the Caucasian population is 1 in 3,400. The CF screening test has a sensitivity of .85 and a specificity of .9985. You can plug these values into an equation, but you won’t really understand the answer when you’re done. So instead, let’s use Figure 2, the “2 x 2” table.


Pick a convenient number of newborns for this hypothetical experiment. How about 34,000? Plug that number into the lower right corner of the table. Then use the prevalence to fill in the bottom totals (divide 34,000 by 3,400). In your sample of 34,000 kids, 10 will have CF, and 33,990 are healthy.


Next, use the sensitivity to fill in the “Diseased” column. To find the number of diseased newborns testing positive (true positives) multiply the sensitivity by the total number of diseased in this example (.85 x 10). Subtract this figure from the total number of diseased patients (10 – 8.5 = 1.5). This number (1.5) represents the number of false negatives.


Use the specificity to complete the “Healthy” column. Put the number of healthy children who test negative for CF (.9985 x 33,990) in the true negative box. Subtract this figure from the total number of healthy children (33,990 – 33,939 = 51). This gives you the number of false positives (51). Total the rows.


Now you can answer the question: What is the likelihood that the baby really has CF? Or, in statistical language, what is the “predictive value of a positive test?” Simply look at the number of true positives (8.5) and divide that by the total number of positives (59.5). The likelihood is 14 percent.


To figure out what happened, look at the table. The low prevalence of CF in Caucasians caused the number of false positives (51) to greatly outnumber the true positives (8.5), even though the specificity was extremely high (.9985).


But suppose the situation was different. What if the newborn had a sibling with CF? The prevalence would be 25 percent instead of 1 in 3,400 (CF is autosomal recessive). Run the table again and you’ll find, if the screen is positive, the chances are better than 99 percent that the child has CF. Same test, different prevalence, different predictive value. Not intuitive, until you work through the 2 x 2s.


Usually, when a test is ordered by a physician, a positive result means something. That’s because an experienced physician doesn’t order a test without a good reason. The “good reason” ordinarily means that the patient is in a higher risk group. He may have symptoms of CF or a family history. The prevalence is higher in those selected patients, and the test works.


Calculating the Cost of Screening. When talking about a single newborn patient, the cost of screening is only the cost of the screening test. But how much does it cost to screen a population?


For this example, start with 3,400 newborns and screen them all at $4 each (total cost = $13,600). Now take the 5.85 newborns that test positive and give them the confirmatory test at $60 each ($351). That’s $13,951 per .85 CF patients found, or $16,413 per one CF patient found.


Next look at the cost (both financial and human) of not finding the patients early and decide whether it makes sense to do the screening. For CF perhaps it doesn’t, although it may make sense to screen the parents before the child is even conceived, but that’s a different story.


Take-Home Messages. There are several morals to this story. First, remember that the “normal range” for a test is a somewhat arbitrary compromise between creating false negatives and false positives. It is not etched in stone. If your patient and the test result don’t seem to make sense together, take some time to think. If the patient looks hyperthyroid, but the test is “high normal,” maybe the patient is a false negative.


Remember the old adage: Treat the patient, not the test.


Second, mass screening for rare conditions invariably results in many false positives. Be sure you and the patient understand the potential for false positives and what risks could be involved if you get a positive. Patients who screen positive for HIV may attempt suicide if they don’t understand the possibility that the test result could be in error. And there are other risks. Insurance companies may attempt to deny that individual coverage. Positive drug screens cause employment and legal problems. This doesn’t mean you shouldn’t do the test, but it certainly shows you need to take great care with the results.


Finally, remember that the cost of screening for rare conditions is not just the small individual cost to the patient, but also the much larger cost to society.


Panning for medical gold is sometimes a useful endeavor. The nuggets found could be valuable—or a risky, costly distraction. These issues will come up again and again as the medical community continues to work out what role screening plays in maintaining public health.


Next Time: Medical privacy—the struggle continues. As our data become computerized, the questions intensify. Who has access to our medical data? Under what circumstances? Do we have any control at all? What is the government doing about it? What can you do?
~Looking for new Web sites to point your browser to? Try these.




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FURTHER READING



—Rebecca Sernett
~~~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~
261~2March~2000-49~Feature~Time Has Come Today~~Nancy Hood~~Physician–leaders identify humanism, diversity and activism as themes that have emerged during medical
education’s past 50 years. But what does the future hold?


“My most shocking experience in medical school involved dealing with death. It began with my first patient who died. I was at the foot of her bed when she passed away. She had an extraordinarily happy look on her face. This was a very important moment for me—almost a transcendental experience.


“Two weeks later, another one of my patients died. Someone told me, ‘Mr. So-and-so just died—let’s go look at the boxcarring effect of the retinal veins.’ I literally ran down the stairs into this cubicle where this guy in his late 40s had just died, and I held back his eyelid and looked into his retina. I don’t recall seeing the boxcarring, but I recall thinking ‘What the hell am I doing?’ Here was a tragic situation—the patient was the head of the fire station and everyone knew him—and I was looking for boxcarring.”

—DR. ROGER BULGER


A KINDER, GENTLER PHYSICIAN


Although it could be an excerpt from the life of a medical student today, Dr. Roger Bulger’s experience occurred in the late 1950s. Throughout his training, Bulger—now president of the Washington, D.C.–based Association of Academic Health Centers—found himself having to continually readjust the balance between respect for patients and what he needed to learn as a student.


Today, medical education is still often criticized for training the humanism out of students. The grind and demands of medical school may eat away at one’s spirit, idealism and capacity for kindness. Additionally, a lack of curricular time for developing students’ humanistic qualities may contribute to their decline.


Mounting evidence indicates that medical schools are addressing these issues. However, the accounts of many former medical students (in other words, today’s physicians) suggest that educators have been slow to recognize the dehumanizing effects of medical training. When Dr. Barbara Ross-Lee, dean of the Ohio University College of Osteopathic Medicine, attended medical school in the early 1970s, she underestimated the challenges, both academic and emotional. “There were challenges to integrity, judgment, maturity, social perceptions and everything that makes up a part of your character,” she recalls. What she doesn’t remember is her school identifying these issues.


As dean, Ross-Lee hopes to move students away from persevering to actually enjoying the educational process and retaining and advancing their humanistic qualities. “Whether or not they get an A or B in biochemistry does not affect the type of physician they become,” she says. “The real issues are whether or not they have the personality and character necessary to be a good physician.” Ross-Lee believes that small-group interactions, self-directed learning and a lessening of the competitiveness of the admissions process will all contribute to training competent, humanistic physicians.


For Dr. Deborah Danoff, assistant vice president of the Division of Medical Education at the Association of American Medical Colleges (AAMC), the sheer volume of work and the intensity of medical school in the early 1970s were overwhelming. “Deciding on a balance between what I needed to do to be a doctor and to be a good person was an issue,” she says. Still, a certain transformation must happen during medical school that Danoff compares to the time between a baby’s birth and when it first speaks. “You go from an unformed person to someone who is capable of medicine,” she says. This should ideally be a positive conversion, not a rite of passage.


To their credit, schools today do have less lecture time, more elective time and varied teaching strategies compared to the medical schools of the 1950s. Allowing students to maintain lives outside of school contributes to training well-rounded, humanistic physicians.


In addition to minimizing the burden of medical school, educators can design courses to provide insight and training in the humanistic side of medicine. Even 50 years ago, however, the fast pace of scientific discoveries dictated the content of medical education. Bulger remembers being told on his first day of medical school, “The wonderful thing about medical school is that science progresses so fast that half of what we teach you will be disproved within three years of your graduation—the problem is that we don’t know which half!” The pressure to keep students up-to-date with current science and technology has increased exponentially since the 1950s. Often, little time, money or energy is left for developing the humanistic aspect of the curriculum.


How has medical education evolved in the last 50 years toward consciously training humanism into physicians? Dr. Jo Ivey Boufford, dean of the Robert Wagner Graduate School of Public Service, harbors doubts about students’ ability to sustain their idealism and basic humanity in the onslaught of science and medicine that schools deem necessary. “Students believe they have to unlearn the things that their grandmothers taught them in order to become a doctor,” she concludes.


Boufford thinks that today’s educators are at least struggling with the right issues—such as doctor–patient relationships and teaching outside the hospital. “These issues, however, were around in the 1970s,” Boufford notes. But they have “remained… demonstrations or models [that have not been] mainstreamed or sustained.”


What are the major stumbling blocks to improvements? According to Boufford, “People think American medical education is the best in the world, and they’re hesitant to change.”


However, some physicians think that medical educators are recognizing the trauma associated with medical school and are working to help students balance their educational commitment and their larger responsibility to themselves and their communities. The AAMC’s Medical School Objectives Project, for example, details how to train altruistic, knowledgeable, skillful and dutiful physicians. Among other topics, this project promotes the doctor–patient relationship, end-of-life care, spirituality and communication skills. Questions remain, however, over the exact competencies that make for humanistic physicians. Additionally, can these qualities be learned? Should they be admissions requirements? How can they be measured? Each answer results in many new inquiries.


•••


“Every day I was in medical school, I knew I was black and female because people let me know. People thought they were helping, but there were lowered expectations for women and minorities. When I was on a clerkship, I finally was able to pass a urinary catheter in a male. They had avoided giving me this task for a while because I was the only female. My supervising physician praised me to high heaven when he found out that I had done it. In reality, almost anyone could accomplish this task—other students did it on a daily basis. I learned to set my own standards because I couldn’t trust the external environment to give me honest clues about how I was doing.”

—DR. BARBARA ROSS-LEE



TWO STEPS FORWARD, THREE STEPS BACK


Issues of equality in medical education for women and minority students are not new. When Dr. Walter Shervington, president of the National Medical Association (NMA), entered the University of Maryland in 1959, the medical school had just graduated its first African American. There were only one or two African-American students in each class, and the hospital wards were segregated. Shervington recalls that his father—only the second African American to serve on the faculty at Johns Hopkins University—wasn’t allowed to admit his own patients for 25 years.


It wasn’t until 1969 that the American Medical Association (AMA) even began requiring medical schools to report minority data. At the time, African-American students comprised 1.5 percent of all medical students, excluding the traditionally black medical schools, Meharry Medical College and Howard University. An article that same year in the New England Journal of Medicine stated that the door to medical education for minorities “is carefully labeled ‘Disadvantaged Students,’ but it is open.”


Women in medicine have faced similar discrimination. Boufford remembers the first day of medical school when her class of 250 students was greeted with, “Gentlemen, welcome to the University of Michigan.” Since she was one of 25 women in the class, Boufford found the introduction inappropriate. “It wasn’t nasty,” she adds. “There was just no consideration.”


Certainly, in the last 50 years, medical student bodies have included more women. Today, some schools are composed of more than 50 percent women. However, women still hold far fewer faculty and administrative positions than men do. Women are more likely than men to report that the careers they were encouraged to pursue were affected by their gender. While recognizing the need for continued improvements, Boufford feels that schools have taken positive steps toward gender equality. “Some students today find some of the sagas from the 1970s pretty bazaar,” she says, referring to the welcome address given at her medical school.


Minority students haven’t fared as well as women in the last 50 years. Currently, underrepresented minorities make up about 9 percent of U.S. medical students. However, about 20 percent of the general population are underrepresented minorities, and a disproportionate number of minority populations are medically underserved. By the year 2020, one-third of the U.S. population will be underrepresented minorities. Minority students still believe that they must be twice as competent to be treated equally. And many minorities and women continue to report a lack of mentors as a barrier to professional development.


The diversity issue can be broken down into a discussion of numbers and a look at programs in the curriculum that address diversity. As an African American who grew up during segregation, Shervington says that medical education has come a great distance in minority education. However, he expresses concern over recent anti-affirmative action laws and practices. “Affirmative action has to do with trying to give a step-up for people who haven’t had opportunities for more than 200 years,” he explains. “It is an attempt to enrich our system by having everyone participate in it.”

Since medical schools actually choose future physicians, Ross-Lee feels strongly that the schools need to take a stand on diversity. “Medical schools have to take leadership from an ethical, moral and practice perspective,” she says. “Affirmative action is a process to reach an outcome. Nobody is looking at the outcome, they’re just objecting to the process.”


Ross-Lee maintains that women and minorities are crucial for successful medical schools because the subtleties of diversity cannot be taught in the classroom. Without diverse student bodies, all students suffer from a lack of exposure to diversity, and many populations are likely to remain medically underserved.


Shervington says that diversity issues must be addressed by society as a whole. Recent collaborations among the NMA, AMA, AAMC and student organizations are encouraging, but changing societal attitudes is more difficult. “Society at large doesn’t care,” Shervington says. “How does one change the attitude of society at large?”


Numbers, although easy to measure, will not guarantee the acceptance of diversity. “Issues for students of color are still pretty profound, including a lack of focus on the richness of their own culture and the lack of faculty of color,” Boufford says. “I’m afraid that numbers aren’t going to force change. People are going to have to make an effort to believe that these students have a lot to offer, and they’re not just students who need remediation.”


Achieving 50 percent women and 15 percent to 20 percent underrepresented minorities in medical school student bodies and faculty is only half of the battle. In order to create a medical education system where everyone feels comfortable sharing their own cultures and beliefs, some educators and students believe that diversity should extend beyond gender and race to include sexual orientation, physical ability, age, socioeconomic status and geographic environment.


Although admissions practices and curricula have improved the diversity of medical schools in the last 50 years, Ross-Lee feels “it’s better than it was, but it’s still not acceptable.” Curricular efforts are still largely elective, token, unevaluated and unintegrated. The numbers of underrepresented minorities have reached a plateau at best and are slipping at worst. And still many more questions remain unanswered.


•••


“I went to a small, Quaker, liberal arts college with lots of interactions. Students were expected to be self-motivated, and students and faculty questioned each other. At medical school, I was told to sit down, shut up, don’t ask questions and regurgitate what I was told. At the end of the first semester, I expected to give feedback to teachers because that’s what I had done in college. I circulated an evaluation form among my classmates. This was perceived as a radical act. It was suggested that this was not the way we do things.”

—DR. ROBERT GRAHAM


STAND AND DELIVER


Dr. Robert Graham, executive vice president of the American Academy of Family Physicians, remembers medical school in the mid-1960s as “rigid, boring and anti-intellectual.” However, he also recollects vividly being part of a generation of student activists. About his experience with circulating an evaluation form, Graham says, “This was both a start for me to try to change medical education, and it was also the beginning of students at my school becoming activists. This was starting all over the country.”


Dr. Fitzhugh Mullan, retired assistant U.S. surgeon general and currently a clinical professor of Pediatrics and Public Health at George Washington University, also became an activist in the mid-’60s while attending medical school. “The summer after my first year, I went to Mississippi as a medical civil rights worker. Seeing poverty, American racism, people who really did not have doctors and how positively they responded to someone who was interested in them and their medical care really made me want to be a doctor.”


Mullan says that schools today vary in how well they foster activism among their students. “Doctors and medical educators are not sociologists or saints. The frontiers of science receive much more attention than the frontiers of justice and equity,” he says.


Why should medical students and physicians be concerned with activism? Mullan maintains that their specialized education gives them a gift that should be shared with everyone. “They are the healers for the population as a whole,” he says. “There is some responsibility for them to develop skills to work with the entire population. The gap between the haves and the have-nots is probably larger than it has ever been.”


Participation in the National Health Service Corps (NHSC) is one way that Mullan lived his responsibility to the population as a whole. From direct participation and later directing the NHSC, Mullan concludes that joining the Corps is a way for physicians to put their shoulder to the wheel for a while.


Activism comes in many forms. Today’s medical students can get involved in shaping their school’s curricula for the future. Dr. Elizabeth Morrison, Director of Maternity Care Education at the University of California–Irvine, thinks that students can affect curricular change. At the local level, students can join student organizations such as the American Medical Student Association and curriculum committees at their schools. At the national level, students can become active in organizations such as the National Board of Medical Examiners. “Student representation is so important,” she explains. Committee members “don’t know what it is like to be a medical student the way current students do.” Morrison admits that students are not consulted as much as they should be, but maintains that students have the potential to make huge differences.


Ross-Lee also says that students are an underutilized resource in medical education reform. “Students don’t always appreciate this role, but their evaluations of the education process are important,” she states. Emphasizing again the need for students to enjoy medical school more, she adds, “We will be able to achieve true collaboration once students themselves start to look at the information as something they want.” These physicians recognize that medical student activism tends to wax and wane, but only students can ensure that there is more, not less, activism.


BEYOND FLEXNER


Changing medical education has been compared to relocating a cemetery. One person who actually accomplished the former feat was Abraham Flexner. Flexner was a layperson with a background in education who studied medical education around the turn of the last century, when it was desperately in need of reform and structure. Major changes initiated by the Medical Education in the United States and Canada, or the Flexner Report, in 1910 included: a four-year curriculum, two years of laboratory science, two years of clinical teaching in hospital and clinic settings, university affiliation, and the adoption of math and science entrance requirements. These changes are almost universally still in place today.


Interestingly, however, the Flexner Report also recommended the following: the integration of basic sciences and clinical training throughout the four years; the encouragement of active learning; the limited use of lectures and learning by memorization; learning by problem solving and critical thinking; and emphasizing that learning for physicians is a life-long endeavor.


When today’s physician–leaders are asked to list crucial turning points in medical education in the last 50 years, the Flexner Report is on several lists. “If I were Flexner and in favor of my model, I would be impressed with its durability,” Mullan says. “Today’s curriculum would not be totally unfamiliar to Flexner.”


Dr. Douglas Wood, president of the American Association of Colleges of Osteopathic Medicine, says, “I don’t think that medical education has changed substantively since the Flexner Report. The first three years have been modified, but we have seen very little change in the clinical years.” Why? Wood cites inertia as the culprit. “We’re doing OK,” he remarks. “We produce prestigious graduates, faculty are strained, even students sometimes object to change—they don’t like to be guinea pigs. There’s not a great reason to change.”


Wood identifies curriculum committees as having the potential to influence medical education, but not as they are currently comprised. “Individuals come with their own interests,” he says, referring to representatives from various departments who traditionally sit on curriculum committees. “Committees need to be made up of people who come because they are the best medical educators in the school and know something about medical education. Their mission should be to put student learning at the forefront.”


While Boufford sees incredible changes in the content of medical education, she does not think the process of medical education has changed much in the last 50 years either. “Changes are not mainstreamed,” Boufford says. “The issue of supporting teaching faculty and the role of faculty as teachers remains a problem for medical schools. Research used to be the priority. Now it’s clinical practice and research. The teacher is the odd person out.”


Likewise, Graham thinks that medical education did not reach its potential in the last 50 years. “There have been curricular chiropractic experiences,” he says. “But we’re just moving the pieces around.” Like Wood, he sees medical education as “comfortable” right now. “If you walk through an academic health science center, people are employed, faculty salaries are not decreasing, medical schools are not closing,” Graham adds. “There is no crisis yet.” Changes must come from the outside, according to Graham, and a drop in the application rate to medical schools may someday cause the crisis necessary to initiate this change.


LOOKING AHEAD:


The Next 50 Years -- What does the future hold for medical education? According to Dr. Jordan Cohen, president of the AAMC, “We need to move more toward establishing learning objectives, performance-based evaluations, and teaching and evaluating professional development.”


Boufford predicts an increased focus on aging, chronic diseases, mental health, cultural competency, communication skills and the doctor–patient relationship. Danoff realizes, “Health-care delivery is changing so fast that medical education will have to follow.” Among the issues she sees in the future are population health, medical technology, dealing with the uninsured, interdisciplinary team-based education, and the engagement of students in the political process to ensure that the environment exists for the healthiest nation possible.


Graham sees the Internet in the future of medical education. “Electronic information will be totally different from texts,” he predicts. “When this information is right, it will be of more value to students than the rigid text and will give students more information about patients who aren’t sick enough to be in the hospital.” Wood also anticipates an increase in technology used for instruction, including interactive computer-assisted teaching and virtual reality. “Particularly in surgery, virtual reality makes sense,” he explains. “You are literally allowed to practice and make mistakes.”


Bulger thinks that someday, medical students may be able to take their first two years of basic sciences via distance learning classes on the Internet, then transfer to a non-virtual medical school for the second two years. This format could increase access to medical school by controlling costs.


What do humanism, diversity, activism, Flexner and the physician–leaders’ predictions for the future of medical education all have in common? They all represent a combination of strengths and weaknesses in the current system of medical education. Medical educators, students and the public need to appreciate aspects of the status quo but must never tire of seizing opportunities to initiate improvements. As one who exemplifies that very strategy, Bulger concludes positively, “After 50 years of thinking about medical education, I wouldn’t change professions. If I were 25 years old today, I would be more interested than ever in entering the health professions.”
~~~~Nancy Hood is a former regional trustee of the American Medical Student Association.~Medical Education~
262~3April~2000-49~Feature~The AMSA Foundation’s Fifth Annual Primary Care Scorecard~~~~As we begin the 21st century, medical education faces a dilemma as well as an opportunity. The dilemma is not new. There’s a shortage of physicians entering or planning to enter generalist specialties. One probable reason behind this is the number of students who change their minds during medical school about pursuing primary care careers. The opportunity lies in what medical schools can do to encourage students to maintain their commitment to primary care specialties.


According to the Association of American Medical Colleges, in 1992, 14.6 percent of graduating students surveyed stated that they planned to pursue careers in one of the generalist specialties, but no school graduated 50 percent or more students with generalist intentions and only one school reached 40 percent. In 1995, 27.5 percent planned on pursuing careers in one of the generalist specialties, five schools graduated more than 50 percent and another 15 graduated more than 40 percent who favored generalist careers. In 1997, 39.6 percent
of fourth-year U.S. medical school students planned on entering generalist specialties.


Is it possible to identify what types of factors influence students to choose primary care as a specialty? More importantly, what influences students to switch from primary care to another specialty? Several surveys—including an informal one conducted as part of the American Medical Student Association’s (AMSA’s) Promoting, Reinforcing and Improving Medical Education (PRIME) project—reveal some of the major factors influencing students’ specialty choices.


Personal characteristics. Choosing a specialty is a personal decision based, in part, on an individual’s values and disposition. Recent studies suggest that medical student characteristics that are common among graduates entering generalist careers include initial specialty preference, geographic background, gender, age, ethnicity, economic and lifestyle factors, attitudes and personal values, service orientation and premedical academic performance. For example, older students, married students, women and those for whom high salaries are not as important are more likely to enter primary care, as are students who value a diverse patient population. Students who want to provide comprehensive care and develop personal relationships with their patients also tend to choose careers in primary care.


Monetary considerations. Studies have also found that income and monetary rewards are highly, but inversely, related to a generalist career choice. The debt incurred during medical training influences specialty decision. Currently, only 30 percent of graduating physicians enter lower-income primary care specialties, including family medicine, pediatrics and internal medicine. Having electives in primary care was another variable found to be associated strongly with students’ change of interest in primary care.


Time for family. Medical students entering primary care professions, especially in rural areas, are concerned about the effect personal and professional isolation will have on their spouses or families. Will there be work available for my spouse? What kind of education and opportunities will my children have? Moving away from extended family and friends can be an important consideration for some medical students.


However, many students view primary care specialties as less demanding of their personal time than other specialties with unpredictable hours, such as surgery and obstetrics–gynecology. These findings suggest there are ways to enhance medical school curricula so that more students pursue and enter primary care as their preferred specialty. The following suggestions may have an effect on the number of medical students who switch specialties.


Primary care electives. Increase the number and quality of primary care electives during third and fourth years. Does your school have a family medicine elective clerkship? Is the elective conducive to developing personal relationships with your patients? Is your preceptor also a personal mentor?


Loan repayment programs. Effectively disseminate information on programs in primary care that offer loan repayment in addition to salary, such as the National Health Service Corps. These programs can be an excellent way to experience the benefits of primary care with fewer concerns about financial considerations.


Mentoring. Create mentoring or precepting opportunities with community-based practitioners, beginning early in medical school and continuing as part of students’ clinical years.


Curriculum reform. Encourage innovative curriculum reform commitments that include a strong focus on primary care. Does your school have a service-learning track or spend time addressing issues in cultural competence? Are there opportunities to provide longitudinal care for patients?


The “AMSA Foundation’s Fifth Annual Primary Care Scorecard” focuses on one measurable aspect of medical education: the percentage of medical school graduates entering primary care residencies. Clearly, this is only one part of a larger effort to understand why so many students switch specialty choices between matriculation and graduation. The Primary Care Scorecard shows one end of the spectrum—specialty choice at graduation—and only by actively exploring what causes students to switch between matriculation and graduation can we affect future Primary Care Scorecards.


Meredith Burke Lawler is the AMSA Foundation’s PRIME project manager. Pam Supanwanid is a third-year medical student at Northwestern University in Chicago and a PRIME project intern. Additional assistance was provided by Lisa Old, PRIME project associate.


Percentage of 1999 Allopathic Medical School
Graduates Entering Primary Care Specialties































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































  Medical School %FP %IM %PEDS %IM/

PEDS		 %PC

1

 Univ of Illinois-Rockford 33.3 20.4 16.7 3.7 74.1
2 Morehouse school of medicine 27.6 24.1 13.8 3.4 68.9
3 albert einstein college of medicine 5.3 47.3 16.0 0.0 68.6
4 meharry medical college 25.9 24.7 12.3 4.9 67.8
5 SUNY-Stony brook 15.1 34.9 17.0 0.0 67.0
6 univ of washington 26.9 25.1 9.0 3.0 64.0 "Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US;
mso-bidi-language:AR-SA">†
7 mercer univ 25.5 25.5 10.9 1.8 63.7
8 univ of missouri-Kansas city 21.0 25.9 7.4 8.6 62.9
9 univ of california, los angeles 17.3 25.6 19.2 0.6 62.7"Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US;
mso-bidi-language:AR-SA">*
10 wright state univ 31.3 19.8 9.4 2.1 62.6
11 univ of rochester 5.1 35.4 15.2 6.1 61.8
11 univ of south carolina 20.6 20.6 19.1 1.5 61.8
13 east carolina univ 34.3 8.6 10.0 8.6 61.5
13 univ of minnesota medical school 28.1 22.4 8.8 2.2 61.5 "Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US;
mso-bidi-language:AR-SA">°
15 michigan state univ 24.5 17.9 11.3 7.5 61.2
15 univ of hawaii 24.1 20.4 11.1 5.6 61.2
17 univ of vermont 8.4 25.3 24.2 3.2 61.1
18 southern illinois univ 21.1 28.2 5.6 5.6 60.5
19 eastern virginia  medical school 20.8 20.8 16.8 2.0 60.4
20 univ of south dakota 32.0 16.0 10.0 2.0 60.0
21 univ of kansas 27.4 17.7 9.7 5.1 59.9
22 medical college of georgia 19.9 25.7 13.5 0.6 59.7
23 univ of nevada 32.7 15.4 7.7 3.8 59.6
24 univ of chicago pritzker 3.6 36.9 18.0 0.9 59.4
25 northeastern ohio univ 17.5 35.0 5.8 0.0 58.3
26 MCP hahnemann univ 17.8 25.0 15.3 0.0 58.1
27 univ of massachusetts 17.9 25.3 13.7 1.1 58.0
28 rush medical college 14.3 31.7 9.5 2.4 57.9
29 oregon health sciences univ 25.0 23.1 8.7 1.0 57.8
30 east tennessee state univ 14.8 27.9 14.8 0.0 57.5
30 univ of texas-San antonio 22.7 20.2 13.6 1.0 57.5
32 univ of nebraska 21.8 23.6 9.1 2.7 57.2
33 univ of kentucky 18.3 24.7 6.5 7.5 57.0
34 univ of connecticut 6.8 27.3 18.2 4.5 56.8
35. univ of virginia 17.8 22.5 15.5 0.8 56.6
36 univ of pittsburgh 12.1 25.0 16.4 2.9 56.4
37 univ of south alabama 15.3 20.3 15.3 5.1 56.0
38 medical college of ohio 15.5 24.0 10.1 6.2 55.8
39 univ of california, san diego 11.5 26.9 14.4 2.9 55.7
40 univ of florida 14.5 24.8 16.2 0.0 55.5
41 georgetown univ 6.8 33.5 12.4 2.5 55.2
42 west virginia univ 20.7 20.7 7.3 6.1 54.8
43 univ of new mexico 25.8 18.2 9.1 1.5 54.6
44 univ of southern california 15.2 29.7 9.5 0.0 54.4
45 northwestern univ 6.4 36.8 11.1 0.0 54.3
46 univ of cincinnati 12.4 21.2 16.1 4.4 54.1
47 univ of alabama 14.5 21.1 14.5 3.6 53.7
47 univ of iowa 27.8 15.4 9.9 0.6 53.7
49 wake forest univ 12.7 26.4 12.7 1.8 53.6
50 ohio state univ 20.7 18.1 11.9 2.6 53.3
52 new york medical college 6.8 29.2 15.1 2.1 53.2
53 univ of california, san francisco 11.4 26.9 13.4 1.3 53.0
54 harvard medical school 2.5 35.2 12.6 2.5 52.8
54 univ of arizona 19.1 14.6 169 2.2 52.8
56 saint louis univ 14.9 16.9 15.5 5.4 52.7
57 howard univ 4.0 34.3 13.1 1.0 52.4`
57 tufts univ 9.6 26.5 14.5 1.8 52.4
57 univ of missouri-Columbia 19.8 12.8 14.0 5.8 52.4
60 loma linda univ 17.3 25.6 7.1 1.9 51.9
60 loyola univ - stritch 13.5 25.6 9.8 3.0 51.9
62 brown univ 14.1 27.1 8.2 2.4 51.8
64 jefferson medical college 19.8 18.0 12.9 0.5 51.2
65 wayne state univ 17.2 25.0 6.6 2.0 50.8
66 univ of mississippi 15.1 24.7 8.6 2.2 50.6
67 emory univ 7.5 29.0 14.0 0.0 50.5
67 univ of illinois-Chicago 8.8 26.9 13.2 1.6 50.5
69 univ of maryland 10.1 22.3 15.8 2.2 50.4
70 temple univ 8.2 27.7 13.0 1.1 50.0
70 texas a & m univ 16.1 11.3 16.1 6.5 50.0
70 VCU medical college of virginia 16.3 18.1 12.5 3.1 50.0
73 albany medical college 13.6 18.9 15.9 1.5 49.9
74 SUNY-Buffalo 11.3 18.4 16.3 3.5 49.5
75 univ of california, irvine 15.3 21.2 12.9 0.0 49.4
76 weill medical colelge-Cornell 1.0 37.8 10.2 0.0 49.0
77 marshall univ 25.5 6.4 10.6 6.4 48.9
78 mt sinai school of medicine 2.4 30.7 15.7 0.0 48.8
79 univ of oklahoma 18.8 14.6 13.2 2.1 48.7
80 ponce school of medicine 6.3 28.1 12.5 1.6 48.5
81 new york univ 1.9 33.5 12.4 0.6 48.4
82 univ of california, davis 12.0 20.7 15.2 0.0 47.9
84 univ of wisconsin 17.6 14.0 14.0 2.2 47.8
85 univ of colorado 16.7 21.2 9.8 0.0 47.7
86 louisiana state univ - new orleans 11.9 21.9 8.8 5.0 47.6
86 medical univ of south carolina 16.7 14.2 15.0 1.7 47.6
88 univ of illinois-Peoria 12.3 15.8 12.3 7.0 47.4
88 univ of miami 11.5 19.9 14.1 1.9 47.4
88 washington univ 5.1 25.4 16.9 0.0 47.4
91 univ of michigan 14.2 19.5 8.9 4.7 47.3
92 texas tech univ 24.8 12.8 9.6 0.0 47.2
93 medical college of wisconsin 14.8 18.4 11.7 2.0 46.9
94 george washington univ 10.3 21.8 14.7 0.0 46.8
95 univ of texas-Galveston 21.2 15.6 8.0 1.9 46.7
96 UMDNJ-Robert wood johnson 7.4 26.4 10.8 20.6 46.6"Times New Roman";mso-ansi-language:EN-US;mso-fareast-language:EN-US;
mso-bidi-language:AR-SA">∞
97 univ of tennessee 12.7 22.4 6.1 4.8 46.0
98 columbia univ 0.7 31.7 13.1 0.0 45.5
99 univ of texas-Houston 15.3 14.3 10.2 5.6 45.4
100 finch univ/Chicago medical school 9.1 24.7 10.8 0.5 45.1
101 univ of north dakota 18.4 14.3 8.2 4.1 45.0
102 univ of north carolina-Chapel hill 10.4 18.7 14.2 1.5 44.8
102 vanderbilt univ 3.1 22.9 14.6 4.2 44.8
104 case western reserve univ 10.3 17.1 15.8 1.4 44.6
105 dartmouth medical school 17.5 12.7 14.3 0.0 44.5
106 johns hopkins univ 0.9 28.7 11.3 3.5 44.4
107 SUNY-Syracuse 12.9 23.8 6.1 1.4 44.2
108 uniformed services univ 16.8 16.1 11.2 0.0 44.1
109 univ of texas-Southwestern 6.2 31.1 6.2 0.5 44.0
110 boston univ 5.2 25.8 11.6 1.3 43.9
111 indiana univ 19.8 11.7 9.3 2.7 43.5
112 tulane univ 8.0 20.0 12.7 2.7 43.4
113 yale univ 2.2 26.1 13.0 1.1 42.4
114 SUNY-Brooklyn 2.7 23.2 15.1 1.1 42.1
115 pennsylvania state univ 13.3 16.2 11.4 1.0 41.9
115 UMDNJ-New jersey 5.2 22.1 9.9 4.7 41.9
117 baylor college of medicine 8.7 16.8 13.9 2.3 41.7
118 stanford univ 4.9 25.6 11.0 0.0 41.5
119 louisiana state univ-Shreveport 12.9 10.8 12.9 4.3 40.9
120 univ of louisville 13.3 12.5 8.6 6.3 40.7
121 univ of pennsylvania 2.2 22.5 13.8 1.4 39.9
122 univ of south florida 11.1 17.8 8.9 1.1 38.9
123 univ of illinois--Urbana-Champaign 16.0 8.0 8.0 4.0 36.0
124 duke univ 1.0 20.8 7.9 4.0 33.7
124 univ of puerto rico 8.0 18.6 6.2 0.9 33.7
126 mayo medical school 5.7 5.7 20.0 0.0 31.4

Unranked

- Universidad Central del Caribe -- no data submitted.




Percentage of 1998 Osteopathic Medical School
Graduates Entering Primary Care Specialties













































































































































































Medical School %FP %IM %PEDS %IM/

PEDS		 %PC

1

 chicago COM 88.4 5.3 2.1 0.0 95.8

2		 UMDNJ SOM 66.7 20.6 7.9 0.0 95.2

3		 michigan state univ COM 66.1 23.2 5.4 0.0 94.7

4		 univ of new england COM 85.5 5.5 1.8 0.0 92.8

5		 west virginia SOM 89.1 3.6 0.0 0.0 92.7

6		 kirksville COM 81.2 9.4 1.7 0.0 92.3

7		 philadelphia COM 76.6 11.0 4.6 0.0 92.2

8		 ohio univ COM 76.0 13.5 2.1 0.0 91.6

9		 univ of north texas COM 76.5 14.7 0.0 0.0 91.2

10		 univ of osteopathic medicine & Health serv 79.6 8.8 2.7 0.0 91.1

11		 new york COM 81.3 5.4 3.6 0.6 90.9

12		 NOVA southeastern univ COM 74.2 13.3 3.3 0.0 90.8

13		 lake erie COM 72.1 14.8 3.3 0.0 90.2

14		 univ of health science COM 70.8 9.2 4.2 0.0 84.2

15		 western univ COM 74.6 5.9 3.4 0.0 83.9

16		 oklahoma state univ COM 60.9 10.1 7.2 0.0 78.2


Unranked

- Arizona COM - First class graduates in May 2000.

- Pikeville College SOM - First class graduates in May 2001.

- Touro Univ COM - First class graduates in May 2001.



~The American Medical Student Association (AMSA) defines primary care as medical care delivery that encompasses the principles of comprehensive patient care, ongoing responsibility for the patient’s health, and overall coordination of the patient’s health-care needs, be they biological, psychological or social.


The allopathic medical schools provided figures for the 1999 graduating class. The rankings were determined by calculating the percentage of graduates from each school entering the four listed primary care residencies, then totaling these percentages and rounding to the nearest 10th of a percentage point (shown in the shaded column).


The American Osteopathic Association (AOA) provided figures for osteopathic medical schools for the 1998 graduating class. Each school’s ranking was calculated with the method described above. However, the AOA’s figures reflect only those graduates who reported or had chosen their residencies at the time the data were released.


The scorecard may include PGY-1 residents entering an internal medicine preliminary year who may go on to specialize in a non-primary care field, thus making the number of new physicians going into primary care specialties appear higher than actual.


AMSA is considering adding an additional category next year to reflect the numerous internal medicine/primary care residency statistics received. This year AMSA has included these Match
statistics under “internal medicine.” AMSA also received many suggestions to include obstetrics–gynecology (ob–gyn) as a separate primary care category. AMSA recognizes the important role of ob–gyn in primary care services, and while this year we did not include ob–gyn as a separate primary care specialty, we will consider doing so next year.


Any comments or suggestions to improve AMSA’s Primary Care Scorecard should be directed to Meredith Burke Lawler, at (703) 620-6600, ext. 256, or e-mail mblawler@www.amsa.org.


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


















































PC Primary Care
FP Family Practice

IM		 Internal Medicine
PEDS  Pediatrics
IM/Peds Combined internal medicine/pediatrics

COM		 College of Osteopathic Medicine
SOM  School of Osteopathic Medicine

†		 University of Washington includes students from WWAMI 

(Washington, Wyoming, Alaska, Montana and Idaho) schools

*		 University of California, Los Angeles, includes students from 

the Drew and Riverside campuses

°		 University of Minnesota includes students transferring from the Duluth campus

∞		 UMDNJ–Robert Wood Johnson figures are combined 

for the Camden and Piscataway/New Brunswick campuses
! Recently changed to Des Moines University Osteopathic 

Medical Center College of Osteopathic Medicine and Surgery

~~~~Career Development,Medical Education~
263~3April~2000-49~Letter from Afield~Bangkok’s Forgotten Children~~Dan Handel~~The problems of Klong Toey’s
poorest residents are largely ignored
by the local medical community.


Morning is peaceful in the portside district of Klong Toey, one of the most depressed regions of Bangkok. I wake up every day to the sounds and smells of people cooking breakfast. I pass shopkeepers and merchants preparing for the day’s business on my short walk to my office. It is still early, when the traffic is light and the smog absent, so I enjoy the fresh air as I prepare for another day at the Duang Prateep Foundation, a charity group dedicated to helping Thailand’s urban poor.


The residents of Klong Toey do not own their land; they have moved to the area in search of work at the nearby seafood factory or at the Port Authority of Thailand. The Port Authority owns the thousand acres of Klong Toey, and evicts people from time to time, though it uses only a quarter of the space.


I have taken a leave between my second and third year of medical school to spend seven months working as a public health officer here. One of my tasks has been to study the rate of height growth and weight gain in children in area kindergartens to check for malnourishment. Most of the children show no significant difference in height and weight compared to Thailand’s national standards, but this doesn’t mean they are healthy. The guidelines were devised 15 years ago, when Thailand’s economy and standard of living were very different than they are today. Now many malnourished children gain weight from a diet of junk food, making it harder for me to spot their poor nutrition.


I have also helped to identify an infestation of bed mites as the likely culprit in numerous appearances of a rash in children from an inland village, and I am conducting a survey to evaluate the general health of older Thais.


I prize these accomplishments, because each day brings me dozens of reminders of my many limitations. I only speak a little bit of Thai. With my blond hair and blue eyes, I am immediately recognizable as a farang, a foreigner.


Despite these obstacles, my work here is meaningful because the problems of Klong Toey’s poorest residents are largely ignored by the local medical community. I have seen volumes of research devoted to the health of higher-income Thais and Thais from rural regions, but almost none about the urban poor. This disparity is also evident in the distribution of physicians. Thai medical students serve an obligatory three years after graduation as payment for their free medical education, but they are seldom sent to practice medicine in the depressed regions of the cities.


Although violent crime is rare here, the presence of a major industrial seaport makes Klong Toey a natural gateway through which methamphetamines and heroin are smuggled and distributed throughout Thailand. Drug abuse seems to touch everyone here. Many mornings on my way to work, I see a boy of perhaps seven sniffing glue from a paper bag. I have seen other children throughout the community suffer permanent brain damage from the effects of inhalants. When I return home at night, a group of young men are often hanging around the courtyard next to my building injecting themselves with amphetamines. They are sometimes aggressive, and the sight of them usually causes me to take a detour back to my apartment.


Widespread IV drug use in Klong Toey contributes to a high occurrence of HIV. No one knows how much of the region’s population is infected, although the percentage is believed to be higher than that of Thailand overall, which is approximately 15 percent. The lack of easily available HIV testing is not viewed as a problem here, because there is no money to treat those infected. At the Mercy Home, an AIDS hospice around the corner from my office, an average of one patient dies every day. The 30 patients living at the Mercy Home at any given time are among the small number of HIV-positive people who receive AZT, but it is usually too late for these people by the time they are allowed to move into the home.


The foundation I work for runs a program that sends drug-addicted children to detox and then to live in drug-free environments in rural Thailand. I once asked the founder and secretary-general of the foundation why the children who had used IV drugs were not tested for HIV and Hepatitis B. She replied that even if the children tested positive for the disease, there was no money to treat them. Drug cocktails to combat HIV cost large sums of money even by American standards, which makes them unaffordable to all but the richest people in Thailand. The Thai government provides free health care to all its citizens, but only gives AZT to pregnant mothers to minimize the risk of transmission to their unborn. All these children would receive with these test results would be the knowledge that they have a disease that their health-care system is unwilling to treat.


Hearing impairment is another common malady among children in Klong Toey. Some lose their hearing from congenital rubella; others from the overuse of aminoglycosides as infants. Within the foundation, a school that provides free hearing aids and speech therapy to these children. While the students in this special school are lucky enough to have had their hearing impairments detected at a young age, many more Thai children go undiagnosed, missing the crucial years when they need their hearing to develop speech and social skills.


I recall the case of a young Cambodian girl who came to the foundation unable to speak Thai. A Bangkok police officer asked the foundation to take her in—even though she was not addicted to drugs—simply because she had no other place to go. The signs of abuse by the parents who had abandoned her were unmistakable. Cigarette burns covered her body, and her nose had been fractured so badly she appeared not to have a nose; just two nostrils that stuck out with below a flat surface between her eyes. We made a few calls, and found a surgeon who would do the reconstructive surgery for next to nothing. Several months later, I saw the girl again, her nose having reappeared as if by magic.


Before I came to Bangkok, I never realized how much a medical education empowers us to help others, not only with our own skills, but also with the association that we have with colleagues around the world.


This was the lesson of seven months in Klong Toey, Bangkok, geographically and culturally the opposite side of the world from my life in the United States—in a place where even “free” health care is out of the reach of many, and where an education in medicine is valuable currency in the economics of helping those in need.~~~~Dan Handel is a third-year student at Northwestern University Medical School in Chicago.~Community and Public Health,International Health~
264~3April~2000-49~Feature~Biomedical Research Warfare~~Leigh Fortson~~When Patrick Allen, Ph.D., was awarded a $1.2 million grant from the National Institutes of Health (NIH) to define the structure of the AIDS virus, he didn’t know that only 0.37 percent of biomedical research funds were given to black scientists.


Upon reflection, however, Allen found that the startlingly low percentage was consistent with his personal experiences. Throughout his undergraduate years at Springfield College in Massachusetts and his graduate studies at the University of California–Santa Cruz, and now as a postdoctoral fellow and research associate at the University of Colorado–Boulder, time and time again, Allen was and is the only black person in the lab.


At first, being the minority in an industry that’s traditionally dominated by white men didn’t faze him. But the news of so few black investigators being funded for scientific research did disturb him. Allen already knew about the higher-than-average incidence of heart disease, diabetes, high blood sugar and high blood cholesterol among black Americans. (See “Black Health Facts,” p. 26.) But when the numbers from the Centers for Disease Control and Prevention revealed that nearly 75 percent of all deaths from AIDS occur in black men; that black women have the disease at a rate that is 16 times that of white women; and that two-thirds of all children with HIV are black, Allen realized there was a health crisis in black America and that called for immediate action.


“I never dreamed this would be a concern of mine,” Allen says. “But when I think about so few blacks involved in AIDS research, and so many blacks who are affected by it, that polarity got me going.”


And Allen, 38, has been going strong around the country promoting a new health consciousness in the black community. “Black people are in bad health, and it’s not necessary. Health consciousness and caring about your body is not that difficult. And it’s not asking a lot,” says Allen, who launched the Black Biomedical Research Movement (BBRM), a non-profit organization set up through the University of Colorado. This is his attempt to encourage young black students to enter the field of biomedical research, while also forging a new mindset in minority communities to take responsibility for their own health and well-being.


It is bound to be a tough challenge, but Allen has faced down fierce opponents before. Born and raised in Jamaica, he always loved school because good grades got him the attention he liked—not only from family members—but from peers as well. A move to New York at age 13 changed everything. Being attentive in the classroom, finishing homework on time, and exemplary report cards cast him as the resident nerd. By high school, he figured out that the American way of attracting attention was through athletics.


Allen took up wrestling and excelled. By college, he was competing in national tournaments and eventually was invited to the 1984 Olympic trials. Fortuitously, a knee injury put an end to his wrestling career, so he turned to biology.


Allen credits his years as a serious wrestler for the discipline he now relies upon as a serious scientist.


“Science isn’t glamorous,” he says. “You have to be rigorous, you have to have discipline, you have to do things meticulously and sometimes nothing happens. Wrestling helped me learn those things.”


As one of relatively few black biomedical researchers wrestling with the AIDS virus, Allen splits his energy between exploring what inhibits the destructive properties of the virus (he was awarded a patent in 1997 for a discovery he made to that effect), and what contributes to the health crisis in black America. He sees a clear connection between the magnitude of the health crisis and the dearth of black scientists and biomedical researchers. In fact, he emphasizes, the crisis may be more about mistrust and fear than viruses, heart disease, or blood abnormalities.


“It’s beyond me how to forge a new consciousness,” he admits. “But just because it’s beyond you, doesn’t mean you can’t do something about it.”


Allen believes a cultural and historic mistrust of science and medicine must be overcome before African Americans can obviate the growing statistics that reflect the poor health of their race. To assist him in this crusade, he is enlisting the support of celebrities, athletes and musicians (including film director Spike Lee and Denver Bronco’s running back Terrell Davis) to contribute money, become spokespersons, or disseminate accurate information about the crisis through their work and their community outreach.


He is also pursuing support from traditional biomedical research funders. In 1999, the Office of AIDS Research at NIH became a benefactor of the BBRM. One of the institutes’ first gestures of support to the BBRM was to underwrite Allen’s participation in a reggae concert that he co-produced in Negril, Jamaica, in April 1999, which featured musicians who promoted awareness of how AIDS has infiltrated the black community. As an added bonus, the DuPont Corp. and the NAACP [National Association for the Advancement of Colored People], joined together to donate 10,000 condoms to the mostly college-aged music lovers on spring break who attended the concert.


While Allen is going straight to the masses with his message, he also has been negotiating with U.S. Surgeon General Dr. David Satcher and Secretary of Health and Human Services Donna Shalala about holding symposiums aimed at heightening awareness. Although collaborating with these political entities is a time-consuming process, Allen feels that their participation is critical to manifesting a past-due wake-up call for all Americans.


ONE OF TOO FEW FIGHTING THE PROBLEM


While he is one of few black biomedical researchers who’ve found the time and the resources to take on the challenge of improving black health, Allen certainly is not the only person attempting to counter these alarming trends.


Healthy People 2000 and 2010 are federal initiatives that also aim to improve minority health.


Emerging from the secretary of Health and Human Services office in 1990, the goals of Healthy People 2000 included reducing health disparities among minorities. The updated version of the program, Healthy People 2010, has the goal
of eliminating health disparities. Numerous calls to Healthy People 2000 for more details about the project were not returned.


Then there is the NIH’s Office
of Research on Minority Health (ORMH), the mission of which is to improve health among minorities.


“[ORMH realizes that] minority Americans are not fully benefiting from the advances made in biomedical research,” Allen says. Consequently, they have implemented an array of programs to “improve the health of minorities across their life span.”


Although he appreciates what’s being done in the context of these government-launched initiatives, Allen finds it hard to believe these goals will be met if the majority of black Americans aren’t aware that the problem exists, or how grave it is.


Without widespread public confidence in science and medicine, as well as simple knowledge of the initiatives, he says, it will be impossible to reach most of those goals.


Reclaiming the health of millions of Americans is as important as defeating other problems facing minorities such as escalating incarceration rates, infant mortality, teen pregnancy, drug abuse and poverty, Allen says. But before health becomes a priority, he believes African Americans must commit to themselves and to their community that they will participate in whatever it takes to be healthy.


“Today, [HIV is] predominately a black disease, and you have the black community and the church not owning up to the fact that it’s decimating our community,” he says.


Apriel Hodari, a graduate student in physics at the University of Maryland and a recipient of a National Science Foundation fellowship, agrees with Allen. She volunteered at the Children’s AIDS Network Designed for Interface Involvement in Virginia and was astounded that the overwhelming majority of people who came for service were black mothers and children. And yet, when she launched a program to recruit other volunteers, she was successful in signing up only two black women. All the rest were middle-aged white women.


“Generally, people don’t act like AIDS is an issue for black women,” she says. “So as a minority scientist, I really support what Dr. Allen is doing.”


So does Deborah Fontaine, African American Outreach program director of AIDS Atlanta. “We need to put a new face on AIDS. Most people think of someone gay, a prostitute or drug addict. They don’t think of a 53-year-old black woman, who has been monogamous with someone for 10 years, doesn’t practice safe sex once with someone else and acquires the disease. Nor do they think of a young black girl who gets it the very first time she has sex. When it comes to HIV, the black community is very judgmental and homophobic, and they simply don’t know what’s really going on because of a lack of education that’s culturally geared into the black community.”


Expanding the Black Researcher Population
Allen and other black researchers theorize that if more black researchers are conducting clinical trials for new drugs or procedures, then more minorities will be inclined to participate in the studies. And participation in those clinical trials, he emphasizes, is critical to the understanding and treatment of the health problems unique to African Americans.


A spokesperson at the Office of AIDS Research at the NIH who requested anonymity says that their agency has put “significant time and energy into increasing enrollment of minority representation in such tests.” In fact, she says the relative number of participants in most studies is comparable to the percentage of minorities who suffer from the diseases. “It’s something we’ve taken very seriously for a long time.”


And Clifton Poodry, director of the Minority Opportunities in Research Program at the NIH, says attempts to recruit young minority scientists have been in place for 20 years. Poodry’s office created programs that include providing funding for minority students to go into research-oriented institutions, improving research skills of faculty at minority-serving institutions, and developing infrastructures at minority research institutions.


“There are many success stories that come out of these programs, but the overall numbers of minority students entering a scientific or research-based career are the same as they were before. This worries us,” admits Poodry, who believes that the poor economics of so many minorities has a lot to do with why so few enter the field.


Allen disagrees.


“This lack of relationship between the black community and health consciousness is not something you can escape by becoming educated or wealthy, like you might be able to with crime or drugs. This is something that affects all black people,” he says. Taking it a step further, he continues:


“When I tell black people I’m a biomedical researcher, I hear them say, ‘You don’t see many brothers doing that. How’d you get into that?’”


He links those questions with the underlying mistrust that distracts young black students—regardless of their economic background—from pursuing medical research. Although he recognizes and appreciates that many of the black students who do study science gravitate to medical school, he believes it is equally as important to encourage students to choose a career in research.


“By their senior year, students hit this tradition of mistrust and get messages like, ‘Come on, you’re the only black. Why are you going into this?’ That’s when they choose medical school instead.”


Allen plans to use the BBRM to turn the tide concerning research. He has already secured a half-dozen commitments from prize-winning, heavily funded scientists to serve as mentors to talented, young black science students to be selected from existing science programs. One such program is The College Fund/UNCF–Merck Science Initiative, which steers black students toward research through internships with the pharmaceutical and research giant, Merck & Co.


Jerry Bryant, director of The College Fund/UNCF–Merck Initiative, applauds Allen’s efforts and shares his goal of drawing black science students away from the medical profession into research.


“[Students] know what getting an M.D. is,” says Bryant. “But they don’t know how to develop research in a novel area no one has ever studied before, and that’s kind of scary.” Allen and Bryant agree that exposing students to the unknown research environment will not only spark new interest in the field but understanding as well.


Allen believes that black and minority communities are disenfranchised from biomedical research, and the attitude that results from that is: “We’re suspicious—we’re afraid we’re going to be used as guinea pigs.”


This, Allen is well aware, has been the case in the past. Between 1932 and 1972, the so-called Tuskegee experiments denied black men with syphilis effective drug therapy. In 1997, President Clinton formally apologized for the wrongful experiments. In 1998, the Congressional Black Caucus declared a state of emergency in protest to them. That same year, President Clinton dedicated $156 million in honor of the crisis to research, prevention and treatment of HIV and AIDS in the African-American community.


With this history and with questionable research still being conducted, how can Allen confidently encourage people of color to engage in more clinical testing of new drugs?


He looks to the women’s movement for part of the answer.


“Women now trust science more than they did 20 years ago because they got involved in their own well-being. There are lots more women in science now. And there are seminars, classes, support groups, magazines and books written just for women and the issues unique to them because there was a need for them to come together and take responsibility for what was happening.


“In the same way, the more blacks that get into science and research, the more trust will be established, and then more positive changes can be accomplished. If you’re serious about minority health issues, then we need a campaign. We need to put this issue to the forefront and make sure it’s sustained over the next 20 years.”


Most people agree awareness and outreach are critical if profound change in the health of minorities is to occur. Poodry, for one, believes that Allen’s passion and commitment to improving the health of the black community is important and admirable. But, Poodry reluctantly admits that he’s afraid the energy Allen is spending on the movement to increase awareness is taking away from his research as a talented and promising scientist.


“There are so few minority scientists that can get competitive funding (such as the NIH grant). He shouldn’t have to be doing the outreach. It’s a shame that he feels he has to because no one else is.”


Allen’s response to this concern, which is echoed from other colleagues, is sadness.


“It hurts me to hear that. I love science, and I don’t want to disappoint my mentors and the people who believe in me,” he says. After a pause, he concludes with, “But how do you measure publishing two papers a year compared to starting a movement that could change the consciousness of people?”


This may indeed be the most difficult wrestling match of his life.~BLACK HEALTH FACTS