Olympia J. Snowe may be, for the moment, the most powerful woman in Washington. As the lone congressional Republican working to support President Obama's healthcare overhaul, no one will be more closely watched when the Senate Finance Committee votes next week on a bill aimed at curbing costs, improving coverage and making insurance more attainable for those without.
Some health insurers are using hardball tactics to pry patients from their sickbeds, which illustrates the colliding financial interests that pervade healthcare. It is a tug of war over where patients are treated, who decides how much care they receive and—fundamentally—which parts of the healthcare industry gain or lose when people become ill.
In light of a $24 million lawsuit filed by a doctor against Johns Hopkins Hospital in Baltimore claiming that he was unlawfully fired earlier this year, how can hospitals prepare for legal troubles?
Oscar Serrano, MD, a former surgical resident, says he was fired because he refused to lie on the ACGME Resident Survey, according to the Associated Press.
Serrano's lawsuit states the firing was unlawful because there's not enough evidence of poor performance as his evaluations only showed high marks, according to the Maryland Daily Record.
Unfortunately, lawsuits are unavoidable in graduate medical education (GME).
"Whether or not a person sues is outside of your control, but you can manage how you're going to deal with the lawsuit, take preventative measures, and anticipate certain problems," says Franklin Medio, GME consultant and former designated institutional official.
The best way to prepare for lawsuits is to ensure your policies, procedures, and documentation are in order. Competency-based evaluations and feedback are a key component to noticing red flags in resident performance. Evaluations should include objective and narrative components and should be viewed by relevant faculty.
"There should be documentation that the person had performance problems [and] they were counseled about those problems," Medio explains, adding that due process policies should be reviewed by hospital legal departments.
By the time you get to the point that you're firing a resident, he or she should not be hearing about problems for the first time. However because both faculty members and residents have little experience with giving—or asking for—feedback, performance problems are not always communicated effectively. Consider hosting educational sessions for faculty members that explain not only why feedback is important, but also how to make it effective. Similarly, they can teach residents how to request and receive feedback effectively.
Regarding the ACGME Resident Survey, programs can only go as far as helping residents comprehend the language used in the questions.
"You can make sure residents understand what certain words mean in their educational context, but nobody should be forcing residents to say certain things or lie," Medio says.
Additionally, site visitors question residents about problems identified on the survey or in anonymous complaints during a site visit to determine if they are real issues or just one resident's opinion or experience.
"The site visitors are pretty savvy about putting things into context," Medio says.
Julie McCoy is the associate editor for the Residency Department. For more residency information, visit www.residencymanager.com.
The good news about the physician shortage is that government leaders and academic experts finally agree that there is one.
For years, most policy makers and academics took the opposite view, arguing that the United States had too many physicians and that a limit should be put on the number of doctors being trained. Their arguments prevailed, and in 1997 Congress capped Medicare funding of physician graduate medical education. The number of physicians trained in the United States each year has been virtually frozen at about 24,000 since.
The pendulum has finally swung the other way, however, and the majority of experts now concede that there is a dearth of doctors, particularly in primary care. The Association of American Medical Colleges, for example, projects a deficit of 159,000 physicians by 2025. At least 15 medical specialty societies have released studies projecting shortages in their fields. The Lewin Group, a research company based in Washington, D.C., projects that universal coverage would drive the need for 35,000 additional physicians.
The Obama administration has clearly signaled that it understands more physicians will be needed in order to deliver on the promise of expanded access to healthcare.
To date, some action has been taken to increase physician supply. The Obama administration has earmarked $200 million in federal stimulus money to boost the ranks of the National Health Services Corps by 3,300 physicians and other clinicians. It also has reiterated the need to restructure physician reimbursement to more robustly reward primary care physicians for their role in managing care and implementing preventive services. There is also hope that new practice and reimbursement structures, like the medical home, will reignite medical student interest in primary care.
However, the surest way to make a real dent in the shortage is to lift the cap on Medicare funding of medical residency programs. Several bills have been introduced to Congress that would do so, including one submitted by Senator Bill Nelson (D-FL) and Congressman Joseph Crowley (D-NY) that would increase residency slots by 15%.
This would come at a cost of several billion dollars a year—not a significant part of Medicare's overall budget, but possibly prohibitive given current federal budget constraints. So far, none of the bills aimed at increasing physician supply appear to have gained traction, and it is far from clear whether or not residency programs will be expanded anytime soon.
What is clear is that the physician shortage would be considerably worse without the presence in this country of tens of thousands of international medical graduates (IMGs). Foreign-born graduates of international medical schools now comprise about 20% of all physicians in active patient care in the United States. In some specialties, such as cardiology, internal medicine, psychiatry, and nephrology, they comprise 30% or more of all active physicians.
About 6,000 IMGs complete residency training in the United States each year. Many of them remain here, often practicing in underserved areas to meet visa requirements. Others would like to stay but eventually practice elsewhere due to annual visa quotas and other immigration restrictions. These quotas and restrictions should be removed to ensure that any physician trained and qualified to practice medicine in the United States. has the option of doing so.
Unfortunately, this in itself will not solve the physician supply problem. It is time to consider opening U.S. medical practice to physicians who have trained elsewhere. Today, only physicians trained in Canada are permitted to obtain a medical license in the United States without completing a U.S.-based residency program. Canada's medical licensing exam and residency training programs are deemed to be equivalent to those in the United States. Physicians trained in every other country must complete a U.S.-based residency program to qualify for a medical license.
In the past, this policy has been a safeguard that has helped ensure a high standard of care. Today, however, there are thousands of highly-trained physicians from Europe, Asia, and elsewhere who, on a case-by-case basis, have the skills and commitment to contribute to the quality of care available in this country. In fact, a growing number of patients from the United States are traveling abroad to receive care from these doctors. This trend is likely to accelerate as the physician shortage makes access to doctors in the United States increasingly problematic.
It makes little sense to lose these patients or the care and innovation that select international medical graduates could provide. Can it be possible that only physicians trained in the United States and Canada have the skills to provide quality patient care? The time to seriously rethink this notion has arrived.
Carl Shusterman served as a trial attorney for the U.S. Immigration and Naturalization Service and is principal of the Los Angeles-based Law Offices of Carl Shusterman. He can be reached atcarl@shusterman.com.For information on how you can contribute to HealthLeaders Media online, please read ourEditorial Guidelines.
Some types of CME seem to be more effective than others and researchers are trying to understand why. Saul Weiner, MD, deputy director at Jesse Brown VA Medical Center and associate professor of medicine and pediatrics at the University of Illinois at Chicago, along with his colleagues, set out to explore this question.
They asked three CME providers presenting at a national Society of General Internal Medicine meeting to develop questions to assess what participants knew and felt about a particular subject before, immediately after, and nine months after a CME intervention. Participants were asked these questions immediately after the CME session and nine months later.
Participants in all three sessions demonstrated that they had gained knowledge immediately following the session.
Those who participated in a 90-minute session on research methods reported a modest gain in knowledge, whereas those who participated in an eight-hour research precourse experienced a large gain. A 90-minute clinical workshop produced a moderate gain in knowledge.
But participants in two of three sessions reported that they did not retain that knowledge after nine months.
"We don't know why there is variation, but with this small study, we can show that there is variation," says Weiner.
This article was adapted from one that originally appeared in the October 2009 issue of The Doctor's Office, a HealthLeaders Media publication.
Boston Medical Center will look at tightening enforcement of its conflict of interest policy, after determining that one physician violated the rules by earning thousands of dollars as a speaker this year for Eli Lilly & Co. BMC officials have reconvened the committee that oversees doctors' relationships with the pharmaceutical and medical device industry. The group will review "speakers bureau participation and control of presentation content and methods to monitor physician activities," according to a statement from the hospital.