Archive for the ‘Medical Education’ Category

Training medical students through international electives   Leave a comment

A number of recent academic studies have shown that global health experiences are becoming more essential in the eyes of medical trainees. One particular study suggested that the vast majority of current surgical residents are interested in global health experiences. Our research group at Emory has further shown that medical students are likely considering global health offerings when students evaluate residency programs. The reality for residency programs today is that failing to offer opportunities in global health may be harming their ability to recruit the best applicants for their program. However, medical schools and residency programs alike have had difficulty overcoming the logistical difficulties while also maintaining the quality of medical education provided during such experiences.

Medishare_ultrasound

Drs. Jahnavi Srinivasan and Viraj Master demonstrate point-of-care ultrasound techniques to medical students Lee Hugar and Pete Creighton during Emory Medishare’s surgical camp in Hinche, Haiti.

For the last five years, I have worked intimately with a small group of faculty and students at Emory University School of Medicine to design a for-credit international surgery elective that attempts to demonstrate the feasibility of such a training experience for medical student. A long-form retrospective piece on the effort and how it has evolved to meet the needs of multiple stakeholders has just been published in the Bulletin of the American College of Surgeons. The key takeaway from our group’s experience is that the common criticisms of these short-term trips fail to wholly encompass the range of benefits being provided. If one assesses solely the educational value or exclusively the burden disease effect for the patient population, a perspective that incorporates the cumulative benefit of these programs is lost.

As I have started the transition from medical student to general surgery residency, it has become increasingly important for me to find a way to communicate our message to the next generation of medical students. At Emory, I have no doubt that an exceptional class of rising senior medical students with global health experiences will have no problem continuing to build on the model there. But what can be done for other medical schools that don’t have such a program or have not operationalized it in a manner that can continue across multiple years? After considerable thought and planning, we have released an early version of a website, www.MedStudentTrips.org, that will serve as a repository of public clinical manuals, planning documents, and advice for those looking to replicate the Emory Medishare model at their own school. In passing on such knowledge, I hope to catalyze such efforts at other institutions in the future.

For information on Emory Medishare, the student-faculty medical humanitarian collaborative discussed in this article at http://www.emorymedishare.org.

For those looking to design such a program at their own medical institution, Emory Medishare has posted many of its public resources at http://www.MedStudentTrips.org.

 

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Dermatology’s two-tier patient classification and its implications for effecting change in the medical profession   Leave a comment

A few years ago, the New York Times reported a strange scheduling phenomenon encountered by patients at dermatology clinics in southern California. The article cited a study in the Journal of the American Academy of Dermatology that examined scheduling wait times in a number of American cities. If a patient were looking for a chemical peel or Botox® injection, clinics could routinely schedule the patient for later the same week. In contrast, if a patient had a concerning mole or eczema that had not responded to routine treatment, it would often take a month to get an appointment. Interviews with industry experts at the time suggested that many dermatology practices were effectively running two separate practices split along patients needing medical versus cosmetic dermatological consultations. “Medical dermatology” is a category within the specialty that addresses dermatological disease (e.g., skin cancer, acne, eczema, psoriasis). “Cosmetic dermatology” refers to dermatologic needs to improve one’s appearance but are not the result of any derangement within the body. Common problems in cosmetic dermatology include wrinkle-reduction, altering skin pigmentation, and removing age spots.

An important aspect of this distinction between the two major categories of dermatologic needs is the grossly different financial impact of each. Cosmetic dermatology is almost never reimbursed by medical insurance while medical dermatology is usually required by law to be included in insurance coverage. This difference effectively creates two classes of patients in a typical dermatology practice. The medical dermatology patients pay a nominal co-pay and then a physician could spend weeks trying to capture a relatively small amount of additional revenue from the patient’s insurance company. In contrast, cosmetic dermatology patients are paying in full at the time of their visit at a price that can theoretically be as high as the local market will bear. The New York Times article noted that a dermatologist could double his or her annual income by focusing more of their practice on cosmetic procedures. The reported scheduling behavior suggests that many dermatology practices attempt to capture a greater share of cosmetic dermatology while potentially limiting the volume of medical dermatology because of these financial incentives.

While the reader’s knee-jerk reaction may be that government regulation be used to “force” dermatologists to more equitably accept both types of patients, I would suggest that the current situation highlights an opportune moment for professional activism of a kind rarely seen in medicine. The ultimate obstacle to scheduling a medical dermatology appointment is a limited supply of appointment slots in certain localities. Ironically, this long-time shortage of medical dermatology care notwithstanding, clinical training in dermatology is one of the most competitive specialties in medicine within which to receive a training position. In theory, if enough dermatologists were trained and sent to practice in an area this shortage would solve itself. However, increasing the number of dermatologists being trained would likely create a disproportionate amount of cosmetic dermatology practices. This disproportionate desire from graduates to practice cosmetic dermatology limits the profession’s desire to expand the number of trainees each year. One potential solution is for a formal distinction in training to be made from cosmetic and medical dermatology. Doing so would not be easy and would likely require a combined effort from accreditation bodies to require the trainees in dermatology only be trained in either subspecialty, and it would also require cooperative state medical boards to prohibit one group practicing the other’s trade. Given the different financial incentives of each subspecialty, a likely result of such a change would be that cosmetic dermatology would continue to be the highly-competitive, highly-compensated field that dermatology largely resembles today while medical dermatology would be a more academically-focused, less competitive, moderately-compensated field that it should be.

The real take away from this discussion is not determining whether the greater dermatology community ever makes such a radical step to fix a distorting externality of the profession. The ultimate point here is that the medical profession, its accrediting bodies, and training institutions ultimately have many of the tools to improve healthcare delivery and training in the U.S. today. Historically, our profession has been relatively passive which encourages external actors (e.g., governments, industry) to shape how we provide care to patients. While engaging outside influencers is important, medical providers are often best suited to recognize and adapt to problems that arise in the practice of medicine. It is up to medical providers then to embrace their role as change-makers.

What to do about the worldwide healthcare workforce shortage?   Leave a comment

A community health worker registering patients at a rural health fair

A community health worker is seen here registering patients at a rural health fair outside Thomonde, Haiti. Community health workers are critical at serving "last mile" healthcare needs and are typically deeply embedded in communities.

It is widely acknowledged that the developing world is in the midst of a healthcare personnel crisis. Even the citizens of middle-income countries that have begun to reap the rewards of increasing standards of living and the emergence of disposable incomes are finding that local health systems lack the healthcare personnel to provide adequate care. The World Health Organization estimates that  57 countries lack the health care personnel needed to reach health-related Millennium Development Goals. Even small increases in the ratio of healthcare workers to the general population correlate with substantial declines in maternal, infant, and child mortality.

Unfortunately, progress is not being made fast enough, and the primary problem is lack of infrastructure. The consulting firm McKinsey & Co. has modeled current workforce education capabilities and estimates that $33 billion and 300 new medical schools would be needed in sub-Saharan Africa alone to meet the continent’s workforce needs. Radical changes to the existing system of healthcare workforce education are needed if health systems are to meet the demands of a world in need of accessible and quality healthcare.

The current paradigm of health workforce education across much of the world involves a massive financial and social investment into the education of highly-skilled, upper-tier medical professionals that typically requires 5-10 years of higher education. However, in a number of developing countries, substantial healthcare services have been provided with less highly trained mid-level providers.

Pharmacist providing medicine and counseling

Having trained pharmacists available at dispensaries ensures that patients receiving proper counseling on the use of medications.

Changing the workforce shortage starts with changing the paradigm. New models of healthcare workforce education need to be tried that move away from the high-cost, state-run institutions currently being used. One alternative would be to begin offering private, market-based programs that provide a more flexible path to licensure as mid-level providers. These programs could use a modified version of distance education — already popular in the developing world — and take advantage to the expanding technical capabilities of mobile networks in these communities.

The biggest obstacle to experimenting with new workforce education strategies is the regulatory environment. Many governments in the developing world still find it difficult to license mid-level providers given their unusual place in the medical hierarchy and these governments’ lack of experience with such providers. Additionally, these novel education schemes would need to be accredited as well.

Given these regulatory hurdles, a “bottom-up” approach of market creation is unlikely to work for new education models. Hence, the workforce shortage issue is ultimately a policy problem. If one is able to leverage government policymakers, these new models of medical workforce training represent a great opportunity for addressing the biggest, least recognized problem affecting global health today.

Interested in learning more? See this proposal I previously prepared on how such market-based education solutions could be implemented given the risky regulatory environment.