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Tag: Medical Education

Letting AI Physicians Into the Guild

BY KIM BELLARD

Let’s be honest: we’re going to have AI physicians.  

Now, that prediction comes with a few caveats. It’s not going to be this year, and maybe not even in this decade. We may not call them “physicians,” but, rather, may think of them as a new category entirely. AI will almost certainly first follow its current path of become assistive technology, for human clinicians and even patients.  We’re going to continue to struggle to fit them into existing regulatory boxes, like clinical decision support software or medical devices, until those boxes prove to be the wrong shape and size for how AI capabilities develop.

But, even given all that, we are going to end up with AI physicians.  They’re going to be capable of listening to patients’ symptoms, of evaluating patient history and clinical indicators, and of both determining likely diagnosis and suggested treatments.  With their robot underlings, or other smart devices, they’ll even be capable of performing many/most of those treatments. 

We’re going to wonder how we ever got along without them. 

Many people claim to not be ready for this. The Pew Research Center recently found that 60% of Americans would be uncomfortable if their physician even relied on AI for their care, and were  more worried that health care professionals would adopt AI technologies too fast rather than too slow.  

Still, though, two-thirds of the respondents already admit that they’d want AI to be used in their skin cancer screening, and one has to believe that as more people understand the kinds of things AI is already assisting with, much less the things it will soon help with, the more open they’ll be.    

People claim to value the patient-physician relationship, but what we really want is to be healthy.  AI will be able to help us with that.

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Dear Patient, If You Have to Treat a Cold, Know This:

BY HANS DUVEFELT

Americans hate being sick. There are too many cold medicines out there to remember by name. But there are really only a handful of different drug classes to consider.

In order to choose any one of them, be clear about what you want to accomplish. It’s actually very simple.

1) Make my cold go away faster: Zink, echinacea, visualization/manifesting, sauna, prayer (may be mostly placebo effect ).

2) Stop my nose from running (including post nasal drip): You’ll want the crud to leave your body as soon as possible, so turning off the drain pipe that your nose has become can increase the risk of stagnant mucous in your sinuses becoming secondarily infected. But intermittent use of a decongestant (pills like pseudoephedrine, diphenhydramine or nasal sprays like Afrin) can help you look healthier than you are for an important Zoom meeting.

3) Make my nose run and relieve the pressure in my sinuses: Lots of fluids, room humidifier/vaporizer, shower steam, nasal steroid spray, guaifenesin (Mucinex) or even nasal lavage (Nettipot), but I personally have reservations about that one.

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What’s Up, Docs

BY KIM BELLARD

Here’s how I’ll know when we’re serious about reforming the U.S. healthcare system: we’ll no longer have both M.D.s and D.O.s.

Now, I’m not saying that this change alone will bring about a new and better healthcare system; I’m just saying that until such change, our healthcare system will remain too rooted in the past, not focused enough on the science, and – most importantly – not really about patients’ best interests.

Let me make it clear from the outset that I have no dog in this hunt.  I’ve had physicians who have been M.D.s and others who have been D.O.s, and I have no indication that there have been any differences in the care due to those training differences. That’s sort of the point: if there are no meaningful differences, why have both?  

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Imaging a Different Future

By KIM BELLARD

Two articles have me thinking this week.  One sets up the problem healthcare has (although healthcare is not explicitly mentioned), while the other illustrates it.  They share being about how we view the future.  

The two articles are Ezra Klein’s Can Democrats See What’s Coming? in The New York Times Opinion pages and Derek Thompson’s Why Does America Make It So Hard to Be a Doctor? in The Atlantic. Both are well worth a read.  

Mr. Klein struck a nerve for me by asking why, when it comes to social insurance programs, Democrats seem so insistent on replicating what has been done before, especially in Western Europe.  He asks: “But what about building here that which does not already exist there?”  He worries “that the Biden administration’s supply-side agenda is stuck in the past and not yet imagining the future.”

Those are exactly the right questions we should be asking about healthcare.

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Recommendations From the Coalition for Physician Accountability’s UME-to-GME Review Committee: Winners & Losers Edition

By BRYAN CARMODY

If you’re involved in medical education or residency selection, you know we’ve got problems.

And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake of the decision to report USMLE Step 1 scores as pass/fail, the Coalition for Physician Accountability convened a special committee to take on the undergraduate-to-graduate medical education transition. That committee – called the UME-to-GME Review Committee or UGRC – completed their work and released their final recommendations yesterday.

This isn’t the first time I’ve covered the UGRC’s work: back in April, I tallied up the winners and losers from their preliminary recommendations.

And if you haven’t read that post, you should. Many of my original criticisms still stand (e.g, on the lack of medical student representation, or the structural configuration that effectively gave corporate members veto power), but here I’m gonna try to turn over new ground as we break down the final recommendations, Winners & Losers style.

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Medical Education Must Adapt to Support the Broadening Role of Physicians

By SYLVIE STACY, MD, MPH

As a physician and writer on the topic of medical careers, I’ve noticed extensive interest in nonclinical career options for physicians. These include jobs in health care administration, management consulting, pharmaceuticals, health care financing, and medical writing, to name a few. This anecdotal evidence is supported by survey data. Of over 17,000 physicians surveyed in the 2016 Survey of America’s Physicians: Practice Patterns and Perspectives, 13.5% indicated that they planned to seek a nonclinical job within the subsequent one to three years, which was an increase from less than 10% in a similar survey fielded in 2012.

The causes of this mounting interest in nonclinical work have not been adequately investigated. Speculated reasons tend to be related to burnout, such as increasing demands placed on physicians in clinical practice, loss of autonomy, barriers created by insurance companies, and administrative burdens. However, attributing interest in nonclinical careers to burnout is misguided and unjustified.

Physicians are needed now – more than ever – to take on nonclinical roles in a variety of industries, sectors, and organizational types. By assuming that physicians interested in such roles are simply burned out and by focusing efforts on trying to retain them in clinical practice, we miss an opportunity promote the medical profession and improve the public’s health.

Supporting medical students and physicians in learning about and pursuing nonclinical career options can assist them in being prepared for their job responsibilities and more effectively using their medical training and experience to assist various types of organizations in carrying out missions as they relate to health and health care.   

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USMLE Step 1 During COVID-19: A Fog of Uncertainty

Marcus Wiggins
Puneet Kaur
Pranav Puri

By PRANAV PURI, PUNEET KAUR, and MARCUS WIGGINS, MBA

As current medical students, the ongoing COVID-19 pandemic represents the most significant healthcare crisis of our lifetimes. COVID-19 has upended nearly every element of healthcare in the United States, including medical education. The pandemic has exposed shortcomings in healthcare delivery ranging from the care of nursing home residents to the lack of interoperable health data. However, the pandemic has also exposed shortcomings in the residency match process.

Consider the United States Medical Licensing Examination (USMLE) Step 1. A 2018 survey of residency program directors cited USMLE Step 1 scores as the most important factor in selecting candidates to interview. Moreover, program directors frequently apply numerical Step 1 score cutoffs to screen applicants for interviews. As such, there are marked variations in mean Step 1 scores across clinical specialties. For example, in 2018, US medical graduates who matched into neurosurgery had a mean Step 1 scores of 245, while those matching into neurology had a mean Step 1 score of 231.

One would assume that, at a minimum, Step 1 scores are a standardized, objective measure to statistically distinguish applicants. Unfortunately, this does not hold true. In its score interpretation guidelines, the National Board of Medical Examiners (NBME) provides Step 1’s standard error of difference (SED) as an index to determine whether the difference between two scores is statistically meaningful.  The NBME reports a SED of 8 for Step 1. Assuming Step 1 scores are normally distributed, the 95% confidence interval of a Step 1 score can thus be estimated as the score plus or minus 1.96 times the standard error (Figure 1). For example, consider Student A who is interested in pursuing neurosurgery and scores 231. The 95% confidence interval of this score would span from 215 to 247. Now consider Student B who is also interested in neurosurgery and scores 245. The 95% interval of this score would span from 229 to 261. The confidence intervals of these two scores clearly overlap, and therefore, there is no statistically significant difference between Student A and Student B’s exam performance. If these exam scores represented the results of a clinical trial, we would describe the results as null and dismiss the difference in scores as mere chance.

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The Step 1 Score Reporting Change – A Step in the Right Direction for IMGs?

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By TALAL HILAL, MD

The United States Medical Licensing Examination (USMLE) Step 1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), has been the exam that people love to hate. For many years, blogs, Twitter feeds, and opinion pieces have been accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit score and instead report a pass/fail score. This animosity towards the Step 1 exam originates from the reality that medical schools have increasingly focused their curriculum on teaching what the Step 1 wants you to learn – medical trivia that almost always has no bearing on how to approach a clinical problem.

This “Step 1 Madness” is unhealthy. The reasons for its existence are many: residency and fellowship programs allow it to exist by idolizing higher scores, some believe it is a metric that can predict future quality of care, board pass rates, etc. And some are naïve enough to think that what is tested on the Step 1 is actually useful medical knowledge! It may be due to a combination of the above that the Step 1 has found itself in such a peculiar spot. However, the emphasis on the Step 1 score means that medical students’ fate is being determined by a single test. Nobody wants their fate to be so unmalleable.

Those who were writing vehemently against a 3-digit score rejoiced when the FSMB/NBME announced on February 12 that the Step 1 will finally become a pass/fail test as early as January 2022!

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Applying Smarter, Part 1: Breaking Down the AAMC’s Apply Smart Campaign

By BRYAN CARMODY, MD

“YOUR LIKELIHOOD OF SECURING RESIDENCY TRAINING DEPENDS ON MANY FACTORS – INCLUDING THE NUMBER OF RESIDENCY PROGRAMS YOU APPLY TO.”

So begins the introduction to Apply Smart: Data to Consider When Applying to Residency – a informational campaign from the Association of American Medical Colleges (AAMC) designed to help medical students “anchor [their] initial thinking about the optimal number of applications.”

In the era of Application Fever – where the mean number of applications submitted by graduating U.S. medical students is now up to 60 – some data-driven guidance on how many applications to submit would be welcome, right?

Right?

And yet, the more I review the AAMC’s Apply Smart campaign, the more I think that it provides little useful data – and the information it does provide is likely to encourage students to submit even more applications.

This topic will be covered in two parts. In the first, I’ll explore the Apply Smart analyses and air my grievances against their logic and data presentation. In the second, I’ll suggest what the AAMC should do to provide more useful information to students.

Introduction to Apply Smart

The AAMC unveiled Apply Smart for Residency several years ago. The website includes lots of information for students, but the piece de resistance are the analyses and graphics that relate the number of applications submitted to the likelihood of successfully entering a residency program.

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What’s on USMLE Step 1?

By BRYAN CARMODY

Recently, I was on The Accad and Koka Report to share my opinions on USMLE Step 1 scoring policy. (If you’re interested, you can listen to the episode on the show website or iTunes.)

Most of the topics we discussed were ones I’ve already dissected on this site. But there was an interesting moment in the show, right around the 37:30 mark, that raises an important point that is worthy of further analysis.

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ANISH: There’s also the fact that nobody is twisting the arms of program directors to use [USMLE Step 1] scores, correct? Even in an era when you had clinical grades reported, there’s still seems to be value that PDs attach to these scores. . . There’s no regulatory agency that’s forcing PDs to do that. So if PDs want to use, you know, a number on a test to determine who should best make up their class, why are you against that?

BRYAN: I’m not necessarily against that if you make that as a reasoned decision. I would challenge a few things about it, though. I guess the first question is, what do you think is on USMLE Step 1 that is meaningful?

ANISH: Well – um – yeah…

BRYAN: What do you think is on that test that makes it a meaningful metric?

ANISH: I – I don’t- I don’t think that – I don’t know that memorizing… I don’t even remember what was on the USMLE. Was the Krebs Cycle on the USMLE Step 1?

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I highlight this snippet not to pick on Anish – who was a gracious host, and despite our back-and-forth on Twitter, we actually agreed much more than we disagreed. And as a practicing clinician who is 15 years removed from the exam, I’m not surprised in the least that he doesn’t recall exactly what was on the test.

I highlight this exchange because it illuminates one of the central truths in the #USMLEPassFail debate, and that is this:

Physicians who took Step 1 more than 5 years ago honestly don’t have a clue about what is tested on the exam.

That’s not because the content has changed. It’s because the memories of minutiae fade over time, leaving behind the false memory of a test that was more useful than it really was.

I’m speaking from experience here.

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