Posts Tagged ‘Journal of the American Medical Association’

Medical School Enrollment on the Rise

Tuesday, November 1st, 2011

More young Americans are deciding to become physicians during a tough jobs market, even though they tend not to choose the high-demand primary care.  American medical schools were pleased when they received a record number of applications in 2011.  Applicants increased by 1,178, or 2.8 percent, according to the Association of American Medical Colleges (AAMC).  Fully 43,919 men and women applied to U.S. medical schools this year, including 32,654 first-time applicants, according to the Washington, D.C.-based AAMC.  First-year enrollment increased by three percent to 19,230, a rise of 18,665 when compared with 2010.

A vital highlight is the larger number of African-American applicants, following a 0.2 percent decline in 2010.  Those numbers grew by 4.7 percent to 3,640 in 2011, while enrollees rose by 1.9 percent to 1,375.  The number of Hispanic/Latino applicants also grew by 5.7 percent to 3,459, with enrollment rising by 6.1 percent to 1,633.  Asians comprised 22.7 percent of the total applicant pool; applicants who identified themselves as white made up 62.3 percent of the total.

Meanwhile, first-time female applicants grew 3.3 percent to 15,953, while female enrollment increased by 3.2 percent to 9,037.  The number of first-time male applicants increased by 1.9 percent for a total of 16,698 applications with 10,193 enrollees, a 2.9 percent increase when compared with 2010.  AAMC said medical schools attract well-qualified applicants, noting their academic profiles included an average grade-point average of 3.5 and an MCAT score of 29.

“We are very pleased that medicine continues to be an attractive career choice at a time when our healthcare system faces many challenges, including a growing need for doctors coupled with a serious physician shortage in the near future,” said Darrell G. Kirch, M.D., AAMC president and CEO.  “At the same time the number of applicants is on the rise, we also are encouraged that the pool of medical school applicants and enrollees continues to be more diverse.  This diversity will be important as these new doctors go out into communities across the country to meet the health care needs of all Americans.

“U.S. medical schools have been responding to the nation’s health challenges by finding ways not only to select the right individuals for medicine, but also to educate and train more doctors for the future.  However, to increase the nation’s supply of physicians, the number of residency training positions at teaching hospitals must also increase to accommodate the growth in the number of students in U.S. medical schools.  We are very concerned that proposals to decrease federal support of graduate medical education will exacerbate the physician shortage, which is expected to reach 90,000 by 2020,” Kirch said.

Wait a minute!  The Council on Physician and Nurse Supply disagrees, noting that the U.S. will be short 200,000 physicians by 2020. “According to recent data, physician demand seems to be a real crisis,” said Onyx M.D. CEO and Chairman Robert Moghim, M.D.  “Not only is the overall physician shortage a major problem but certain specialties will be hit harder than others, especially primary-care specialists.”

In fact, the AMA announced that the number of primary-care physicians (PCPs) could decrease by 35,000 to 40,000 by 2025.  Apparently PCPs are becoming increasingly frustrated in many areas of their practice.  “Dealing with third-party payers, governmental red tape, slowness in receiving reimbursement and increased time spent with non-clinical paperwork seems to be driving this discontent,” said Monty McKentry, VP of Client Services & Recruitment at Onyx M.D.  He notes that, “These factors may be the cause of the newly reported data from the Journal of the American Medical Association that only two percent of current medical students intend to go into primary care.”

To make this situation even worse, there is a growing concern that one new physician entering the work force may not equal the productivity of a retiring physician.  This can be attributed to a cultural shift to a better work-life balance, shorter working hours and increased demand for more part-time work.  With the anticipated shortage in primary-care physicians, demand will increase for short-term coverage or locum tenens (a place-holder).  “We anticipate a wide variety of new opportunities as primary care physicians look for other alternatives such as locum tenens, Moghim said.”

Finally, Kirch highlighted programs that provide scholarships and loan forgiveness in exchange for working as general practitioners in the nation’s underserved areas.  According to Kirch, more funding is needed for these programs, and payments to primary-care physicians for services should be increased.

Why Aren’t Physicians Paid For Talking To Their Patients?

Tuesday, July 5th, 2011

One possible reason that more physicians do not choose family practice as their specialty could be the fact that an essential part of the job is spent talking with patients – an activity that pays less than does performing procedures.   According to a recent study published by the Journal of the American Medical Association, just two percent of medical students plan a career in general internal medicine, pediatrics or ob/gyn.

Writing on the KevinMD.com website, Jennifer Adaeze Anyaegbunam says that “Family doctors spend more time talking to patients than performing procedures, but these doctors don’t get paid much to chat.  According to Dr. Sameer Badlani, a professor at the University of Chicago School of Medicine, when physicians are paid on a fee-for-service basis, specialists have the opportunity to make four to five times as much as a family physician.  Given the increasing debt of medical students, it is no surprise that the overwhelming majority choose to specialize.  In order to increase the supply of primary-care providers and meet the anticipated demand, family physicians need to be reimbursed more for their services.  Congress is looking into legislation that includes provisions for loan forgiveness and increased Medicare/Medicaid payments to primary-care providers.  Additionally, there have been talks of expanding the National Health Service Corps, program that utilizes scholarships and loan repayment to recruit primary care professionals to work in underserved areas.”

Primary-care physicians spend more time talking to patients and helping them avoid health crises to cope with chronic and incurable diseases than they spend performing tests and procedures. These doctors ask relevant questions, about health and life circumstances, and listen carefully to their patients.  These are physicians who know their patients and the circumstances and beliefs that can make health problems worse or hamper effective treatment.  The problem is that reimbursements are dictated by Medicare and other insurers.  As a result, physicians are not compensated well for taking the time to talk to patients.  They are primarily paid for procedures – such as blood tests and surgery — and for the number of patients they see.  Most spend long hours doing paperwork and negotiating treatment options with insurers.  The payments they receive have not increased along with increases in the costs of running a modern medical practice.  To earn a reasonable income of $150,000 a year, many primary-care doctors squeeze more and more patients into the workday.  “If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.  In a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other conditions that required medical attention.  “There just isn’t the time to address them all,” Thomashow said.

Dr. Alan J. Stein, an infectious disease specialist in private practice in Brooklyn who treats many patients with HIV, described his practice as “heavily cognitive.  I spend a lot of time talking to patients — listening to them, examining them, interpreting tests and figuring out what’s wrong,” he said.  “I don’t do procedures in the office.  Over the last 10 or 15 years, the income of procedure-based physicians like cardiologists has increased significantly, whereas for those in primary care it has remained the same.”

Despite this, many physicians are reluctant to talk to their patients via e-mail.  Suzanne Kreuziger, a Milwaukee registered nurse, said.  “It makes sense to me to have the words laid out, to be able to re-read, to go back to it at a convenient time,  If I were able to ask my physician questions this way, it would make my own health care much easier.”  Her experience is shared by the majority of Americans: They want the convenience of e-mail for non-urgent medical issues, but fewer than 33 percent of doctors use e-mail to communicate with patients, according to surveys.

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project.  “The health care industry seems to be lagging behind other industries.”  Physicians have good reasons for avoiding e-mail exchanges with their patients.  Some are concerned that it will increase their workload.  Others worry about hackers compromising patient privacy.

Breast Cancer Surgery Doesn’t Always Require Lymph Node Removal

Wednesday, February 23rd, 2011

Many women with early breast cancer don’t always to have their lymph nodes removed, as is often recommended. The federally funded study, involving nearly 900 women who were treated at 115 sites across the country, found that those who kept their lymph nodes were no less likely to survive five years after the surgery than those who did not, the researchers reported in the Journal of the American Medical Association.  Breast cancer is diagnosed in about 200,000 women each year in the United States, with the cancer reaching the lymph nodes in about 33 percent of the cases.

The study’s finding turns a century of standard medical practice on its head.  According to Dr. Armando E. Giuliano, the lead author and chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, CA, approximately two-thirds of these women will match the study criteria and one-third will not. For that one-third — about 10 percent of breast cancer patients overall — node removal might be needed.  An additional five percent of all patients have “distant” disease at the time of diagnosis, meaning the cancer has already spread to organs or bones.  In the remaining two percent of cases, the stage of the disease at diagnosis is not known. There is still a risk of lymphedema even after only a few nodes are taken for biopsy, but the risk is significantly reduced than when multiple nodes are removed.

Dr. Monica Morrow, an author of the study and chief of the breast service at Memorial Sloan-Kettering Cancer Center in New York said that “Genetic breast cancer doesn’t influence how we treat the nodes.  Due to the increased risk of second breast cancers, many of these women chose mastectomy.  Women with mastectomy require axillary dissection if the nodes are involved.”

“Removing all of the lymph nodes under the arm is, first of all, for many women a second trip to the operating room” said Dr. Elisa Port, Mount Sinai Medical Center’s chief of breast surgery.  “And secondly, there’s a lot of side effects associated with removing all of the lymph nodes under the arm.  There’s a higher risk of developing what we call lymphedema, which is swelling of the arm.  There is some numbness on the inner part of the arm that you can get from cutting through the little nerves that run near the lymph nodes, and some women even have mobility issues.  So sparing them this bigger surgery is certainly significant for a large number of women.”

Professor Robert Mansel, professor of surgery at University of Wales College of Medicine, Cardiff, an expert in breast cancer research, said the study is very controversial with a lot of practice “based on feelings, not data.” Mansel currently favors lymph node removal, believing the research on leaving them intact is so far inconclusive.   He urged caution about the study, pointing to “lots of warning signs,” such as failure to include as many women in the study as they would have liked – meaning the trial was “under powered”.  When faced with the prospect of lymph nodes not being removed, many patients chose not to enter the trial, he said.  He also pointed to the study’s five-year follow-up, which he believes is too short.  “Breast cancer, if nothing else, is a long-term disease, which makes this study only half way to being reliable.”

Mt. Sinai’s Dr. Port acknowledges that not all breast surgeons will agree with the new study.  “But there is no question that for many people the results that you don’t have to remove cancer are very counterintuitive and go against the sensibility of what we, as surgeons, have been ingrained to do, which is remove cancer.  And the more cancer you can remove, the better.  Doctors are supposed to do what they know to be the safest thing, and many of us erred on the side of caution, which is to take out those lymph nodes to make sure we weren’t missing anything.”