Medicine’s privilege gap

Have doctors become increasingly removed from the everyday struggles of their patients, especially patients who occupy the lower rungs of the socioeconomic ladder?

A letter to the editor in the July issue of Academic Medicine raises some thought-provoking questions about a “privilege gap” that’s opening up in medicine.

It starts at the very beginning, with the selection process into medical school, writes Dr. Farzon Nahvi, an emergency medicine resident at New York University’s Bellevue Hospital:

Data from the Association of American Medical Colleges show that over 60% of medical students come from families in the top quintile of household income, with only 20% coming from families who earned in the bottom three quintiles. Similarly, the median family income of American medical students is over $100,000. In other words, the average medical student comes from the upper 15% of America.

This is anything but reflective of the patient population, Dr. Nahvi goes on to explain: “They are all of America: rich, poor and in between.”

And it has an impact, he maintains:

The unfortunate consequence of this is that patients sometimes struggle to be understood by well-meaning but, ultimately, privileged doctors who sometimes cannot relate to patients of other backgrounds.

Being privileged does not necessarily make a physician incapable of understanding the daily lives of his or her patients, of course. And many physicians resent (often rightfully so) the stereotypes that portray them as money-grubbing, golf-playing, Beamer-driving plutocrats who consider themselves above the masses.

Yet the statistics cited by Dr. Nahvi don’t lie. And they’re a problem for a society in which the health gap between the well off and the not so well off has been extensively documented. As Dr. Nahvi points out, how can doctors be aware of the issues their low-income patients face – unable to afford prescription drugs, for instance, or unable to take time off work to get to the pharmacy – when “it often doesn’t occur to the more privileged that such issues even exist”?

If medicine in the U.S. is becoming a bastion of privilege, it’s probably because it increasingly takes privilege to survive the rigors and costs of becoming a doctor.

The cost of a medical education is a significant burden for aspiring doctors; a report from the Association of American Medical Colleges puts the median amount of medical school debt at $170,000 for the Class of 2012 (and this doesn’t include any debt students may have accumulated from their preceding four years of college).

Then there’s the protracted training time to consider: four years of undergraduate education, four years of medical school and, at a minimum, three years of residency before doctors actually start earning real money. Once they’ve arrived, they can start acquiring the trappings of an upper-middle-class lifestyle – but this is small comfort to the bright young high-schooler from a low-income family who dreams of being a doctor but lacks the financial wherewithal to even get a foot in the door.

One could also argue that the medical school admission process itself tends to favor students with the “right” kind of background, i.e. those who already possess strong socioeconomic advantages.

So what’s the solution? Dr. Nahvi writes:

The stopgap fix is to better train all students to deal with all types of patients. A true long-term solution, however, is to steer more representative slices of America – individuals from all income levels – into medicine. There are many ideas for how to do this, from special recruitment strategies to arrangements for financial aid. Fundamentally though, for change to occur, admission committees need to recognize the importance of getting more middle- and low-income students into our medical education system.

Doing so won’t be easy, because it’s not just about money. Many other ingredients come into play: a solid grade school and high school education, parents and teachers who encourage careers in medicine and hold aspiring students to high expectations, and even local role models who can show young people that someone like them can successfully become a doctor.

There doesn’t seem to be much public discussion about how to narrow the privilege gap in medicine. Since part of the solution likely will lie at the community level, maybe this needs to change.

Blowing the whistle on bad doctors

I admit to some hesitation in using the term “bad” doctors in the title of this post. Physicians can fall short in many ways, often for reasons that are purely human and forgivable. It doesn’t necessarily mean they’re incompetent or that they are somehow bad for their patients.

Medicine is like any other profession, though. Sometimes a doctor is too impaired to safely take care of patients. In these circumstances, colleagues need to be willing to intervene, not only for the sake of maintaining professional standards but also to protect the public. But judging from a newly published study in the Journal of the American Medical Association, doctors are often very reluctant to blow the whistle.

The authors of the study surveyed 1,891 doctors and found a noticeable gap between what they professed to believe about dealing with impaired colleagues and what they actually did about it. The physicians who participated in the survey represented a variety of specialties, from family practice and pediatrics to surgery, anesthesiology and psychiatry. The majority, 64 percent, said they “agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.”

Seventeen percent personally knew of a colleague who shouldn’t be practicing medicine. In more than two-thirds of these cases, the physicians in the survey said they reported it to the appropriate authority. But this still left close to 30 percent who did nothing. Reasons for failing to take action included a belief that someone else was taking care of it, a belief that nothing would be done about it, and fear of retribution.

These findings are actually not too surprising. It has long been known within inside circles that physicians tend to be reluctant to report a colleague. There’s a lot more under the surface than the arrogance of protecting one’s own, however. Medical Economics magazine explored some of the issues after conducting its own ethics study back in 2002, and found that many factors come into play.

There’s the question of how to deal appropriately and compassionately with addiction or physical or mental illness. Should a physician have his or her license yanked because of an addiction, or should the doctor first be urged to seek treatment? Does a mental health disorder automatically mean someone is unfit to practice medicine? If physicians believe they’ll be punished for having a disease or disability, might it not result in a reluctance to seek help and end up driving these problems underground?

A more challenging issue is when a physician has poor skills or chronically exhibits poor judgment or lapses in ethics. Clinical incompetence can be hard to discern, the article notes:

If you assist someone at surgery or some other highly visible activity, you may be in a position to evaluate his competence. But how do you know whether what someone does in his office meets the standard of care, especially if he’s in a different specialty?

Some outcomes information is becoming available in areas like cardiac surgery. But most doctors don’t use that data in deciding on a referral; in fact, they rarely even check publicly available information on sanctions by state medical boards. So their knowledge of whether a consultant is competent comes mainly from patient feedback, hunches, and hearsay.

Truth to tell, it can also be extraordinarily difficult to rat out one of your own – particularly if you don’t have proof or even if you simply empathize with the colleague whose office is next door to yours. Many physicians, says Medical Economics, might wonder how they would feel if the tables were turned:

Craig Wax can testify to that. When he got out of family practice residency two years ago, he would have been inclined to report any physician he suspected of being impaired. But since then, with both group and solo practice under his belt, he’s decided it would be better to approach an impaired physician privately.

“I’d be afraid of ruining the other doctor’s reputation. I’d also be concerned about earning a reputation as a whistle-blower, he says. “Other doctors may think I’m overreacting and say, ‘Oh, it’s just Charley. He’s always done that, and he’s always managed it. It’s silly to report him.’”

In the Medical Economics survey, 4 percent of the respondents said they would do nothing if they became aware of a colleague whose performance was impaired by drugs, alcohol or a physical or mental illness. Thirty-one percent said they would talk to their colleague privately and 65 percent said they would report the physician to the appropriate authorities.

Ideally, there would be systems in place to monitor physician performance so problems are detected sooner and addressed more quickly. But these can be inadequate or dysfunctional; indeed, they can end up being a case of the fox guarding the henhouse, as Dr. Robert Wachter points out in his incisive analysis of a scandal earlier this year involving a Baltimore cardiologist who placed more than 500 unnecessary stents in patients.

Where was the peer review? Dr. Wachter wonders. And did hospital politics allow the cardiologist a free pass, as long as he kept generating revenue?

Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.

Left unsaid in all of this is what patients are supposed to do if they suspect their doctor is impaired or incompetent, or is engaging in unethical behavior. Is there any reason to think patients don’t face some of the same issues about reporting someone? Patients might fear being wrong, or that the authorities will do nothing about their complaint. They might also fear being labeled a troublemaker, or possibly even dismissed from someone’s practice for registering concern about the physician’s competence.

That fact that most of the physicians in the JAMA survey – more than 80 percent – didn’t personally know of an impaired colleague suggests the majority of doctors are indeed competent. The gaps in the profession’s ability to police and regulate itself are troubling, however. It’s not reasonable to think the public is better equipped to be the enforcers, and turning the responsibility over to government opens up a whole new, and probably undesirable, can of worms. If the medical profession wants to do better, it needs to confront these issues itself.

Desperately seeking orthopedists

The Willmar medical community has racked up some recent successes in bringing new doctors on board. They’re still struggling, however, to find more orthopedic surgeons – a specialty that continues to have high local demand but is short on supply.

It has been a source of ongoing disappointment and frustration, for the community as well as for ACMC and Rice Memorial Hospital. It’s not that the medical group and the hospital aren’t trying hard enough; they are. Unfortunately they’re up against a set of national trends that don’t work in their favor.

A workforce study by the American Academy of Orthopaedic Surgeons sheds some light on some of the things that have been happening within the profession. The study is a few years old; the data were collected three years ago during a survey of 24,000 orthopedic surgeons who are members of the academy. There’s no reason to think, however, that the picture has changed dramatically since 2006, and indeed the survey results help illuminate why it has become increasingly challenging for rural communities such as Willmar to recruit orthopedic surgeons.

One of the most significant trends: Since 2000 or thereabouts, orthopedic surgeons – especially younger surgeons – have become more likely to specialize. Only about one in four now practices general orthopedic surgery. Almost 40 percent are specialists, and 32 percent combine general orthopedic surgery with specialty surgery. Among those who are specialists, about 20 percent focus solely on hand surgery, and 18 percent specialize only in surgery on the spine.

Obviously there’s a need in rural Minnesota for orthopedists who can do hand and spine surgery. But for orthopedic surgeons whose practice is highly specialized, there probably isn’t enough patient volume in a rural area to financially sustain this type of service, hence they tend to be more concentrated in urban and suburban areas. Meanwhile, rural communities find themselves competing for a smaller supply of orthopedic surgeons who are generalists or who specialize in more than one procedure.

Another finding from the survey: Orthopedic surgeons overwhelmingly prefer to practice in single-specialty groups. Eighty-one percent of the surgeons in the survey were in private practice, and 60 percent of these were orthopedics-only group practices. Only 9 percent are in multi-specialty groups such as Willmar’s ACMC. It’s not clear why this is so, but it’s what the numbers are telling us.

The survey also found the orthopedic surgery workforce is getting older. Orthopedic surgeons under age 40 accounted for fewer than 15 percent of orthopods who were actively practicing in 2005-06.

A particularly interesting finding from the survey is a trend toward early retirement. The study notes:

There is a small, but significant, group of orthopaedic surgeons retiring from active practice earlier than the expected retirement age of 65 in the U.S. The reasons for this retirement are unknown without further study.

The survey queried orthopedic surgeons about their retirement plans and found that nearly 8 percent expected to fully retire within the next two years.

Essentially what we have is a workforce of orthopedic surgeons who are getting older, getting closer toward retirement, and being replaced by younger surgeons who are increasingly likely to specialize (although the AAOS report notes that the trend towards specialization appears to be stabilizing).

What does it mean for the local community? Orthopedic surgeons are out there, but given the overall issues with the workforce supply, the recruitment challenges are unlikely to ease any time soon. For many years Willmar enjoyed a strong, thriving orthopedic surgery program that had been built up by ACMC and Rice Hospital; in fact it was somewhat unusual among rural Minnesota communities. Patients and the community perhaps grew to expect this level of services would always be available, and we’re now having to adjust to the fact that it’s not. As orthopedic surgeons retire or move on, they’re becoming harder to replace. Although local providers know there’s a need and although they’re working on it, progress is unfortunately far slower than they’d like.

The whole situation underscores why the physician supply and the ability of local entities to recruit doctors is so important, and why it should matter to the rest of us. Without the physicians – and, we’d add, without other qualified personnel such as nurses and technologists – the service simply can’t exist.

Illustration courtesy of Fotosearch

Class of 2013

First-year students entering the University of Minnesota Medical School will undergo a rite of passage Friday at the annual white coat ceremony. It’ll be held at Northrop Auditorium on the university campus, followed by a reception for the students, their families and friends.

What’s the significance of the white coat? Until the late 1800s, physicians wore black, which was considered formal dress suitable for the seriousness of the doctor-patient encounter. But as science invaded medicine and the role of germs in transmitting disease became more clearly understood, white came to symbolize cleanliness and medical authority. (As it turns out, white coats aren’t so clean after all, and some medical organizations have decided to ban them – but that’s another story altogether.)

There’s an interesting account here that explains the meaning of the white coat ceremony:

… Students beginning their studies in medical school see their education and role as future physicians as aspiring to be worthy of the long white coat. Medical school must give students the scientific and clinical tools to become doctors. Just as importantly, the white coat symbolizes the other critical part of students’ medical education, a standard of professionalism and caring and emblem of the trust they must earn from patients.

A few tidbits about the U of M’s medical class of 2013: There are 170 students. Seventy-two percent of them are from Minnesota. There are six international students, one each from Canada, Mauritius, Nigeria, Vietnam and Zimbabwe.

Slightly more than half the class, 54.1 percent, are male; 45.9 percent are female. Their average undergraduate GPA is 3.74.

They have four long, hard years ahead of them. Let’s wish them well.

Linkworthy 1.0

A sample of some of the more thought-provoking and/or interesting stories, essays and whatnot that I’ve encountered recently on the Web:

- The Minnesota Medical Association recently posted the latest issue online of its monthly magazine, Minnesota Medicine, and as always, it’s full of good stories. Start your reading with "Civic Duty," which profiles the community involvement of several small-town Minnesota doctors. One of the featured physicians is Dr. Richard Horecka, a family practice doctor at Affiliated Community Medical Center in Benson who also is active in local economic development.

Also check out the cover story, "Role Reversal." Four doctors describe their own experience with injury and illness, what it was like to be the patient instead of the doctor, and how it changed their perspective in caring for their own patients.

- On the New Old Age blog at the New York Times, there’s a fascinating discussion about the silence that often surrounds end-of-life issues. The title sums it up: "At the End of Life, Denial Comes at a Price."

- If you need money, how about becoming a clinical test subject? MinnPost explores this phenomenon in "In hard times, lure of guinea pigging grows." 

- Most Americans believe everyone should have some form of health coverage. But are there enough doctors to handle the increase in patients if there’s universal coverage? Dr. Marc Siegel sounds the alarm in an opinion piece for the Wall Street Journal, "When Doctors Opt Out." Although he is primarily addressing Medicare, his thoughts could equally apply to rural Minnesota, where the supply of doctors is steadily shrinking.

- Real doctors can’t stand "House" but they like "Scrubs" and the recently departed "ER." MedPage Today reports on a survey it conducted and the impact of TV shows on real-life relationships between doctors and patients. Surprisingly, some of the respondents thought the TV medical dramas were sometimes helpful in encouraging patients to seek needed care and in portraying the human side of the medical profession.