“Free Tuition” Isn’t a Primary Care Pipeline

This week, there were two types of discussions on my social media feeds: non-medical friends fascinated by New York University’s announcement of free tuition for all its medical students, and medical friends frustrated that their own schools weren’t so generous (gee, thanks, Vanderbilt!)

To be clear, it’s an impressive and laudable feat to cover tuition—at present, around $55,000 per year—for about 450 students in perpetuity. By the Association of American Medical Colleges’ numbers, 75% of the Class of 2017 graduated with education debt; on average, over $190,000 per student, between eight years of undergraduate and medical studies. NYU raised $600 million in donations to ensure that its graduates don’t have such financial considerations hanging over their early-career decisions.

NYU’s stated rationale here is twofold: to reduce the cost barriers that would prevent some students from pursuing careers in medicine, and to encourage students to choose less-lucrative specialties like primary care. “I don’t want people moving away from what they’re passionate about because of their fear of the money,” said Rafael Rivera, NYU’s Associate Dean for Admissions and Financial Aid.

I think those are pressing problems for medical education, and I applaud NYU for putting forth a bold, ambitious solution. I just don’t think it’s the best fix for either issue.

Free tuition is a definite game-changer for students from less-affluent backgrounds that otherwise might not have been able to afford medical education. As a society, we need these people to become doctors. They’re more likely to return to the communities and populations they’re from to practice. Moreover, seeing as there’s a wealth of literature on the implicit biases that shape our care of women, minorities, and socioeconomically disadvantaged patients, medicine could certainly benefit from the added diversity of represented backgrounds and viewpoints among its ranks.

That being said, NYU students will still have to take on $27-29,000 per year in costs of living and other expenses, which may continue to deter some of those cost-prohibited prospective physicians.

It’s also not clear how this improves access over less costly initiatives, like Columbia’s $250 million plan to eliminate medical student loans. From my own medical school experiences, many of my classmates (though certainly not all) came from well-off backgrounds. I’d estimate at least 30% were themselves children of doctors, myself included. Can’t a university like NYU find a better use for the extra $350 million its plan will take over Columbia’s than to give aid to some students like me who, ultimately, would likely be able to become doctors and attain well-off lifestyles without it? Its education or social work students, for whom a six-figure income at their ten-year reunion is less assured, probably have some ideas.

Free tuition is a start to medical education’s access problem. A real solution, though, needs to consider the myriad ways low-income students are shut out from medicine—like limited early exposure, fewer test-prep resources, and less resume-building opportunities, to name a few—and act broadly to make a substantial impact.

If free tuition is a suboptimal solution for improving access, it’s even worse for solving the shortage of primary care physicians.

A $220,000 four-year tuition relief makes primary care specialties more feasible for altruistic students who are deterred from lower-paying fields by the prospect of loan repayments. It doesn’t, by any measure, make such careers more financially attractive in the U.S.’ current payment structure, in which doctors are paid for doing things, and paid even more for invasive or interventional things than for time spent talking to people or thinking through complex diagnoses.

According to Doximity, the average Manhattan general pediatrician makes $181,000; for family physicians and internists, it’s $205,000 and $207,000, respectively. When an NYU medical student chooses primary care, they choose to forgo the salary of an orthopedic surgeon ($458,000), radiologist ($384,000), or cardiologist ($391,000) out of an intellectual interest or sense of social duty in preventive care or population health management. Against a lifetime of thirty to forty years’ worth of accumulated earnings, the cost of a medical degree—even considering the interest on loans a student might otherwise take—is a drop in the bucket.

Don’t get me wrong: primary care is muchmuch more important than the salary comparison suggests. It’s just not any better a financial decision with a free medical education than without it.

To add an even more cynical perspective, as NYU’s application pool undoubtedly draws even more competitive, talented applicants, it wouldn’t be surprising to see its match list tip even more toward selective specialties like derm., IR, ortho., or ENT.

So, if medical schools really want to cultivate primary care doctors, they can introduce tracks for primary care-specific training and exposure, like the ones at Duke and Johns Hopkins. They can offer accelerated training programs for primary care, as Mercer and Texas Tech do. If they go the scholarship route, like NYU, they can borrow from UC Riverside‘s playbook: it covers tuition, but only if the students stay and practice in underserved Inland Southern California.

What NYU and its donors have done is an incredible gift for its future graduates, one which will surely have an impact on its students’ bank accounts—not to mention, its upcoming years’ U.S. News rankings. It’s every bit as generous and impressive as it seems. It’s not, though, the moonshot strategy for improving access to medical education or promoting careers in primary care that some, like The Atlantic, NPR, or Fox News, suggest.

P.S.: If you’re from NYU Med and reading this, I’m totally not related to any other Utrankars you might see an application from in the next few years.

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Why professional societies are worth it

As someone who’s all too familiar with the ‘student loan life,’ there are few things I’d recommend as essential buys besides UWorld, ramen noodles, and Keurig cups. One that’s often overlooked by medical students, though, is membership in the professional society for your future specialty.

Cue the collective groan. I know, and I get it: why pay an annual subscription fee to join a club, add a line on your CV, and pay your respects to “the guild?” At first, I felt similarly skeptical. As a digital native, I was confident that I didn’t need my professional society. I had a blog. I had a Twitter account and LinkedIn profile. I could advocate for myself, and network for myself.

Since then, as I’ve furthered my interest in anesthesiology and advanced my involvement in the specialty, I’ve come to see the value that a $10 American Society of Anesthesiologists (ASA) student membership provides. Here, I’ve outlined a few of the high-yield benefits of the ASA Medical Student Component—and, I should add, even if you’re not a gas-passer in the making, these same benefits likely extend to the society for whichever specialty’s caught your heart.

Know what’s happening in the field, and where it’s headed. Through the ASA, I receive a complimentary print subscription to Anesthesiology, its peer-reviewed journal; the ASA Monitor, its monthly magazine; and ASAP, the weekly email newsletter. As an outsider looking in, these publications provide an introduction the ‘hot topics’ in anesthesia research and practice and an overview of educational content that’s likely to be useful on your anesthesia rotation (and not to mention, future training). Not all of it applies to learners, so feel free to gloss over the articles on practice management or billing code jargonology, but you’ll pick up enough to show attendings that you’ve done your homework, and to show interviewers that you know what you’re getting into.

Learn, do, and network at the Annual Meeting—for freeThe ASA and other specialty societies know that their students are their future, and they invest in our growth (and theirs!) by waiving students’ registration fees for the ANESTHESIOLOGY Annual Meeting. This conference is a ‘must-do’ for the future anesthesiologist, without question. It’s an opportunity to learn what’s new in anesthesia through presentations and panel discussions, practice procedures in hands-on skills workshops, and network with residency programs (and future employers!) And again, it’s all for free—which, right behind “go home” and “do you want to do this procedure?” are a medical student’s favorite words.

Support the people who are fighting for your future. In medical school, it’s sometimes easy to be complacent about advocacy, policy, and the landscape of physician practice; after all, life after residency seems so far away that we’re rarely looking beyond the next shelf exam. Even if you’re not looking ahead to the future, your professional society is. That’s why, in the last year, the ASA has been looking out for anesthesiologists and their patients and advocating for physician-led anesthesia care—and for evidence of that, look no further than the Safe VA Care initiative. And these are challenges facing every specialty: family medicine, internal medicine, pediatrics, psychiatry, radiology, you name it. Even if you view your membership as solely an investment in the safety of patients and the relevance of your future profession, it’s well worth it. And of course, if you want to go the extra mile, there are advocacy opportunities and leadership positions available.

When you think about what it costs to become a physician today—medical school tuition, supplies for clinical rotations, test prep resources, residency application and interview travel fees, and much more—a $10 annual membership to the American Society of Anesthesiologists (or your specialty’s professional society), with all it affords, is easily the right decision. If it does present a financial challenge for you, don’t worry; your medical school’s student affairs office, your school’s anesthesiology department, or your state’s anesthesiology society can likely lend a hand. Whatever the case, don’t overlook the chance to tap into this valuable resource and the education, professional development, and advocacy advantages that come with it.

Bottom line: prospective members, join the ASA, or your professional society, ASAp (#badpuns, I’ll admit). For current members: what additional benefits or perks have you gotten from your involvement in your professional societies? Leave a comment to weigh in!

Disclaimer: I am a medical student member of the American Society of Anesthesiologists and a member of the ASA Medical Student Component Governing Council. This blog post is not on behalf of the ASA, nor has it been authorized or supported by the ASA (or any other organization) in any capacity; it represents my views, and my own advice for my fellow future anesthesiologists, alone. [In short, I speak for myself, because I’m fairly certain nobody wants me to speak for them anyway!]

When Breath Becomes Air

As I write this, I’m wiping away the tears in my eyes stirred by Dr. Paul Kalanithi’s When Breath Becomes Air. Richly reflective and powerfully evocative, it’s the touching narrative of a doctor’s attempts to confront death—as a student of literature, as a neurosurgeon, and as a patient—and, through the lens of terminal illness, examine how dying gives meaning to living.

With When Breath Becomes Air, Dr. Kalanithi allows us to, in his words, “Get into these shoes, walk a bit, and say, ‘So that’s what it looks like from here … sooner or later I’ll be back here in my own shoes.'” It’s a walk that resonates particularly strongly for me as a fledgling physician.

As he reflects on his medical training, Dr. Kalanithi looks back with the perspectives of both patient and provider to offer valuable insights on what it means to be a physician: someone who translates statistics and survival curves into a patient-oriented language of values, identities, and capabilities; someone who is relentless in the pursuit of operative excellence, but understands that a surgeon is more than an expert technician; someone who aspires to perfection, but ultimately accepts his fallibility.

For any avid reader of medical non-fiction, these reflections will sound familiar, the stuff of Better and Being Mortal. And yet, When Breath Becomes Air feels different, because it explores medicine’s virtues, values, and flaws from the perspective of a patient, someone who is both an insider and outsider to medicine. As Dr. Kalanithi writes, “As a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know.” His perspectives on what makes a good doctor are informed by an intimate understanding of what patients feel, what patients think, and what patients want that most of us, as providers, can only infer and intuit from our interactions with illness in the third person.

At its heart, When Breath Becomes Air is about more than how we ought to provide care; it’s a contemplation of how we ought to live. The life of a physician-in-training often feels like a life of anticipation, of potential, of surviving the present to reach the rewards of the future. We spend a third of our lives studying, sacrificing sleep, accumulating loans, and watching our friends build lives that are less exhaustive and more lucrative, all of which we accept for the eventual promise of a career that offers an unparalleled balance of intellectual engagement, moral fulfillment, and socioeconomic comfort.

I ask myself, then: if faced with a terminal illness tomorrow, would I feel that I’d achieved anything more in 23 years besides a pursuit of a life still yet to come? For Dr. Kalanithi, the prospect of dying gives the present an immensely deeper significance, a more imminent urgency. As I read his detailed recollection of his last day as a physician, a heartfelt recall of each interaction, each sensation, each incision, I felt uncomfortably reminded of what I’ve seen and done over the last week, and how it felt so unremarkably routine. I’d been present, but I hadn’t been truly present.

Reading When Breath Becomes Air, I felt called to attention, awoken from autopilot to embrace the quiet miracles and subtle wonders that transpire around us each day in the hospital. If we practiced medicine each day as if it were our last, what might that look like? What could it do for our connections with patients, for our interactions with our colleagues, for our thirst for meaning and fulfillment in our daily lives? This, I think, is Dr. Kalanithi’s strongest parting advice for us. And as cliche as “live as each day is the last” sounds, that we so rarely do it makes it advice worth hearing.

When Breath Becomes Air is an easy read that raises difficult questions, a short book that invites lengthy pauses for thought. Whether you’re in medicine or not, you’ll invariably someday find yourself pondering the matter of mortality and the meaning it imparts to the closing days of life—and therefore, you’ll invariably find this book to be both moving and meaningful.

Thanks, Dr. Kalanithi.

Well, Here Goes Nothing

It’s finally here.

After 13 years of K-12 schools, four years of college, and one year of pre-clinical medicine, I’m finally doing the unthinkable: stepping beyond the classroom, trading chalkboards for charts, swapping study guides for stethoscopes, and putting 18 years of learning into application at the bedside.

Well, sort of–there’s still grand rounds, morning report, and core didactics. And I’m far from done with textbooks or tests. But it’s hands-on, and it’s dynamic, and it’s the closest I’ve ever felt to actually doing anything tangible, applicable, or useful, so I’ll seize the opportunity for a little ‘hooray!’

Just one thing: I’m scared to death–tense, timid, terrified, and (D) all of the above.

In the days to come, I anticipate carefully budgeting my umms, uhhs, and I don’t knows. I expect to know all the right answers–that is, about five minutes after the question’s been asked and the resident’s moved on. I plan to stockpile the responses that are valid for almost any question; I’m told ‘cytokines’ and ‘idiopathic’ are reasonably reliable. The unshakable conviction that I’m only here because of an admissions office clerical error is back, right on cue from this time last year.

Here’s the wild part, though: even though all that’s true, and sleeping in is about to mean 8:00am, and a two-day weekend is about to be a vaguely fond memory of days past, I’m still really, really amped for this.

These next few months, there’s no telling what might happen. I might get to introduce a life into this world. I might get to reboot a heart that’s stopped beating. I might get to offer someone a word of comfort in their waning days. Even the most simple of things sound like opportunities–I might draw upon 19 years of lessons and lectures to decipher what’s making someone feel crummy, then find a way to make them feel less crummy.

It’s going to be petrifying, but profound. Terrifying, but terrific. Wild, but wonderful.

As I embark on this next chapter, then, these are my promises to myself. In the months to come, I hope to revisit these promises, to measure my personal growth against them, and to hold onto them as my compass, my ‘true north,’ of moral and intellectual character.

Start humble; stay humble. This one’s easy, especially when you don’t have the expertise or credibility to be anything but humble. As I grow in this clinical life, though, I hope to retain what it feels like to not have the answers, to speak from a place of low hierarchy. and minimal confidence.

Remember that everyone’s an educator. Even while learning to think like a doctor and do as doctors do, I hope to bear in mind that there are many things to be even better learned from my other colleagues and collaborators: from nursing, compassion and advocacy; from social work, resourcefulness and relationship-building; from environmental services, perseverance and ‘can-do’ willingness.

Seize every moment like it’s once-in-a-lifetime. This year, I’ll rotate through 100 specialties, and 99 of them won’t be my future profession. In other words, for anything I do this year, it could be the first day of the rest of my life, or the last time I ever deliver a baby or close a surgical incision. I’ll inevitably be tempted many times this year to skip a learning opportunity or cursorily participate in an educational experience–”I’m never going to need this skill.” When that happens, I hope to catch myself, to cherish everything as potentially unique, and to stay open to the moments that might unexpectedly captivate me.

Resist a reductionist view of the patient. Toward the end of first year, I knew I was overdue for a summer break when I’d catch myself tuning out of the ‘irrelevant’ parts of the patient narrative, feeling impatient with the details that weren’t pertinent to a diagnosis. As the medical student, I have the gift of being ‘non-essential’; my histories and physicals are, most likely, just educational exercises. In that context, I hope to remember that it may occasionally be more impactful to defer the review of systems to allow a patient space to reflect. I hope to remember that there’s more to patient care than a detailed differential.

Exist beyond medicineFor better or worse, medicine isn’t my all-consuming identity, my sole purpose. I’d like to think I exist beyond the hospital, in the form of values, leisurely pursuits, and relationships. Naturally, this won’t be the year I chase my dreams of seeing the world, or the year I take a step back to focus on my relationship. The hours of clerkships and the drive to study more, to know more, to perform better will be demanding, and these will come first. I hope, for my sake and for the sake of those dear to me, that this medical apprenticeship doesn’t become everything–the only thing–that I’m about.

So there it is–the manifesto of who I am now, and who I hope to become (or not become) by the conclusion of this whirlwind of a year. Preachy? A bit. Sappy? Definitely. Over-ambitious and doe-eyed? Sure, probably. Still, I know the odds are against me, and chances are high that I’ll end this year more jaded, more skeptical, and less empathetic. And maybe, just maybe, if I set my goals to an aspirational degree of virtue, goodness, and empathy .. then I’ll land somewhere in the middle, and fare just okay.

Well, here goes nothing.

On ‘Leadership’ in Medicine

In medicine, there are many buzzwords that are thrown around so frequently and loosely as to lose meaning or purpose. I’m looking at you, ‘patient-centered.’ And you, ‘disruptive innovation.’

Now that it’s August–the season of medical school orientations and white coat ceremonies–there’s another that, as if on cue, is making the rounds: leadership. This time of year, medical students are treated to speech after speech by deans who wax poetic about the physician-leader.

“We brought you here not to be 9-to-5 employees, but leaders in medicine.”

“We’re not just in the business of training doctors; we’re developing leaders.”

At the time, I was a fresh-faced, doe-eyed disciple in my first days of a lifetime in medicine, and I hung onto every word of the sermon–enchanted, captivated, inspired.

In the coming months, though, that inspiration turned to curious inquisition. Inquisition turned over to weary skepticism. One year in, I’ve started to deconstruct and critically evaluate the ambiguous aspiration that is ‘physician-leadership,’ a process that’s led me to these questions.

What’s a physician-leader? A year ago, we were challenged to be more than “9-to-5 employees”–to go beyond the ‘ordinary’ work of doctoring and patient care to advance the frontiers in scholarship, administration, and healthcare delivery.

Since then, though, I’ve seen some sparks of inspiration among the seemingly mundane that reveal a broader sense of leadership. There’s the country family doctor who, as a lone knight, stewards the health and wellness of an entire community. There’s the intensivist who speaks up to oppose medically futile care and guide patients to ‘a good death.’ Does one have to be an Ezekiel Emanuel or an Atul Gawande to be a physician-leader, or can we find and appreciate glimmers of leadership in the day-to-day labors of being ‘just a doctor?’

What’s it mean to train physician-leaders? As orientation became an ever-faint blip in the rear-view mirror, so became the relevance of leadership and transformative thinking in our day-to-day coursework. If we were being trained as physician-leaders, how was our training any different from that of physician not-leaders? I think we learned anatomy the same way. Same for physical diagnosis and pathology, too. A year in, I’m not sure how exactly one trains as a physician-leader, as opposed to a not-leader.

To train physician-leaders is an admirable aspiration, but it would be a little more admirable if there were a little more substance to it.

What’s with the love of leaders? As the old adage goes, if everyone’s special, then nobody really is. Likewise, if everyone’s a leader and trained from the start to think only as a leader, is there anyone left to be led? Students are selected into medical school by leading in the classroom, leading in activities and organizations, and leading in the community. When students who have only ever led arrive at medical school and are instructed to lead, does it compromise the profession’s ability to form hierarchies or collaborate?

I wonder if medical schools ought to teach, along with leadership, the principles of good followership–active listening, influencing from below, knowing when (and how) to challenge a leader. Perhaps then, we’d see stronger cohesion and collegiality, both within our profession and among the health professions.

Don’t get me wrong, now–the importance of effective leadership in medicine by physicians, for physicians is hard to overstate, especially at a time when doctors are facing increasing pressures from changing practice models, shifting payment structures, and growing information technology demands. For now, though, leadership as it’s preached and praised in medical education is a notion without clarity, an ambition without substance.

Speeches and sermons at orientations and white coat ceremonies are good. If we want to do better, though, maybe we should recognize and teach the brand of leadership that happens not only at the highest levels, but in “9-to-5 medicine.” Maybe we should actually think critically about what it means to train physician-leaders as a functional practice, rather than a buzzword not reflected in the curriculum. And maybe, just maybe, we should understand that there are limits and complements to a singular emphasis on leadership that are worth instilling, too.

The eStudent: Nothing About Me, Without Me?

I recently had the wonderful privilege of being accepted to present at a conference on medical education. I’m excited; this is a first for me!

It also came with a less-than-wonderful ‘first’: the privilege of paying a hefty conference registration fee.

Now, I can appreciate that organizing a conference is an expensive endeavor. Venues cost. Staffers cost. Esteemed keynote speakers cost. I get that.

What I don’t get is how a conference on medical education can accurately reflect interests and engage stakeholders in medical education by pricing out the main recipients of medical education: students.

Sure enough, looking over this conference’s speakers list, students are scarce. Plenty of deans, administrators, clinician-educators, and research scholars, though. It’s a conference about learners, but without learners.

To be fair, this isn’t a new phenomenon. Last year, I was elated to see the AAMC webcast its Medical Education conference. With great interest, I watched. I learned. I chimed in via Twitter when the dialogue called for (more often, presumed) a student’s perception or perspective.

And then I rolled my eyes when the post-conference survey, to the question, “Which of the following describes your role?” failed to include the option, “Student.” That moment spoke volumes, and it said everything about the student’s role in educational innovation and curricular design.

This is the essence of the problem. As students, there has to be a bigger role for us in medical education than taking post-intervention comprehension assessments or filling out satisfaction surveys. There has to be, to draw upon clinical analogies, a shared decision making model that invites students’ values, goals, and habits throughout the design process. Medical education without student engagement makes about as much sense as patient care without patient involvement.

To give credit where it’s due, I’m lucky to attend an institution where the student voice is present from the inception of an educational design process. But my experiences on the national scale imply these are outliers, not norms, and that’s a fundamental flaw.

ePatients, as advocates for access to their clinical records and active involvement in their own care, have in recent years coined the moving message, “Nothing about me, without me.”

That’s the attitude we need in medical education. That’s what we have to aspire to, and advocate for. To be eStudents: learners who don’t just participate in and function within an educational ecosystem, but actively shape it.

On Rounds | 4.26.2015

It’s the weekend after end of block exams, which means it’s time to dig through the 742 links in my Pocket queue. That also means it’s time for another edition of “On Rounds,” bringing you my favorite reads of the week.

On the new MCAT | Forbes
There’s a lot to like about the new Medical College Admission Test; with new content in psychology and sociology, MCAT 2015 acknowledges that there’s more to doctoring than biochemical pathways and physics equations. But are multiple-choice tests the best way to identify humanistic, socially aware aspiring doctors? What more we can do to foster diversity and holistic thinking among medical trainees? Allan Joseph and Karan Chhabra break down the good, the bad, and the path forward.

On quack science and journalistic ethicsVox
When it comes to pseudoscientists and their cults of personality, what’s a better-knowing journalist (or healthcare provider) to do? Speak out, and validate a quack? Or stay silent, and let faulty information rule the airwaves? Julia Belluz is on point with this one, and her insights and advice here ought to be required reading for every journalist, scientist, and clinician with a social media account.

On medical schools as laboratories of health transformationForbes
Esther Dyson once remarked that change in medicine happens one retirement at a time. She’s dead right. If we want our healthcare system to pivot from expensive care and late-stage interventions to systems-based practice, preventive care, and population health, the transition begins with how we train future doctors to think. At UT-Austin, the new Dell Medical School is bringing a ‘re-boot’ to a 100-year old model of medical education. David Shaywitz breaks down their educational approach, and what it could mean for medical schools nationwide.

On the value (or maybe not?) of health apps New York Times
There are two kinds of people. On one hand are those who own wearables and use health applications: the young, the affluent, the health-conscious. On the other hand are those who might often benefit from digital health but can rarely afford it: chronic disease patients, the elderly, and those with limited access to care. Today, the consumer market for health apps and devices is larger than ever. How do we connect tech fads to health outcomes? How do we balance rapid innovation with health equity? This NYT article doesn’t offer all the answers, but it raises many of the right questions.

On restoring the ‘joy of medicine’Medstro
When it comes to physician lifestyle, we keep hearing the same stuff: provider burnout is at a high; satisfaction is at a low; most doctors today wouldn’t recommend the profession to their children. We know all that; now, what are we going to do about it? Medstro and Geneia’s “Joy of Medicine Challenge” invites your ideas to restore joy to the practice of medicine, and they’re offering $1,000 for your thoughts. Instead of talking about how our healthcare system is broken, let’s ideate on how to fix it.