A big tuition hike at the U?

http://www.sltrib.com/ci_8620810

Proposed Medicaid rule could cut U. graduate doc-training funds

By Lisa Rosetta
and Brian Maffly
The Salt Lake Tribune

Graduate medical education in Utah may take a one-two punch.

The Centers for Medicare and Medicaid Service, CMS, is proposing a rule that would say money spent training doctors would no longer be reimbursed by Medicaid. In Utah, that would mean $19.3 million that helps fund residency programs at teaching hospitals could disappear.

The University of Utah School of Medicine alone could lose $12 million - at the same time it is bracing for an $11 million loss in revenue from another rule change limiting public hospital reimbursements.

"We are in an absolute worst possible situation," said dean David Bjorkman.

Spreading the $11 million hit among the school's 408 medical students would raise tuition by $27,000, putting Utah's tab on par with the costliest schools in the nation, the dean noted.

"That's not right for the state and it's not right for medical education to price so many people out," Bjorkman said.

Critics say the CMS proposal is an abrupt reversal for a federal agency that has for decades covered graduate medical education as a cost of providing hospital services and patient care.

And it comes at a time when Utah, like the rest of the country, is struggling to train enough physicians to keep pace with a growing population's health care needs.

Barbara Viskochil, director of University Health Care's Department of Medicare and Medicaid Services, wrote to CMS last summer and urged it to rescind the proposed rule.

"Educating future physicians and other health care professionals has never been more important, given the numerous studies predicting a physician shortage in the near future," she wrote.

David Squire, executive director of the Utah Medical Education Council, said the state only trains 20 percent of its physician workforce - a number that could shrink with the impending cuts.

"We will be disproportionately hurt in this state," he said. "If these cuts take place today, there is going to be a pipeline delay. We'll immediately hire that many less interns and residents."

Primary Children's Medical Center could lose about $3 million, hurting its ability to offer residency slots, said Bill Barnes, director of government relations. Losing even one resident would be big blow to the state, which is "way under-supplied with pediatricians," he said.

The hospital, which offers 52 residencies, would "try to find money elsewhere to cover it," Barnes said. "It just would make it a lot more difficult to try and manage it."

lrosetta@sltrib.com
bmaffly@sltrib.com

Are physical exam skills obsolete?

An excerpt from Intern: A Doctor's Initiation by Sandeep Jauhar (2008):

In the fall I rotated through the geriatrics ward. One of the attending physicians was an irritating woman whose idea of the Socratic method was pimping you with really vague questions, then acting like she had already thought of whatever answers you gave and that you were only telling her what she already knew. The other attending was a throwback to "the days of the giants," when pneumococcal pneumonia was diagnosed by injecting sputum into mice and antibiotics for urinary tract infections were tested on agar plates. One morning, one of my interns presented a case to him of an elderly man who had been hospitalized with fever and a cough producing green sputum. "He has pneumonia," she proclaimed confidently. "Take a look at this chest X-ray." She pulled up a digital image on a computer screen showing a distinct pneumonic streak. The senior physician waved it off. "First tell me about your lung exam," he said.

It was a common scenario on the wards: young doctor ignoring physical examination to the chagrin of an older and wiser counterpart. At one time, keen observation and the judicious laying on of hands were virtually the only diagnostic tools available to a doctor. Now, on the wards, they seemed almost obsolete. Technology -- ultrafast CAT scans, nuclear imaging studies, and the like -- ruled the day, permitting diagnosis at a distance. Some doctors didn't even carry a stethoscope.

There was a growing disconnect between the older and younger generations of physicians on this issue. While residents were apt to regard physical examination as an arcane curiosity, like an old aunt you've been told to respect, a few physicians proselytized on its behalf, claiming for it a power it probably no longer has. These anachronisms wanted to hear about whispered pectoriloquy or some such esoteric finding of the lung exam before letting you describe the results of a chest X-ray. Our apathy seemed to fuel their fervor, increasing their fear that exam skills would atrophy and die.

"Medical students don't know how to listen for breath sounds," our attending complained. "It's not that they're bad students; it's just that no one is teaching them. When I was a resident, you had to know physical diagnosis because we didn't have any other tools. CAT scans were just coming out. You had to cut someone open to figure out what was wrong with them."

One morning I shared one of my favorite medical stories with my team. We had just finished examining an elderly woman with a cardiac rhythm disturbance when I mentioned that Karel Wenckebach, a Dutch physician at the turn of the twentieth century, discovered the arrhythmia later named after him by timing a patient's arterial and venous pulsations. Wenckebach's discovery preceded the advent of the EKG and still stands as one of the most astute clinical observations in the history of medicine. Isn't it amazing, I asked my team, what doctors were once able to do?

"Today we'd get an EKG," an intern shrugged. "It's more accurate anyway."

"Who has the time to stare at a patient's neck?" another said. "They'd think you were crazy!"

It is true that teaching hospitals are busier than ever, and residents probably have less time to spend examining patients. And it is true that physical examination is often inaccurate. But these facts only partly explain its apparent demise.

The major reason for it, I have come to believe, is that doctors today are uncomfortable with uncertainty. If a physical exam can diagnose a slipped spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the major culprit, I think, is fear of subjective observation. Doctors today shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible. If postmodernism teaches that there are many truths, or perhaps no truths at all, postmodern medicine teaches quite the opposite: that there is an objective truth that will explain a patient's symptoms, discoverable provided we look for it with the right tools.

See the Feb 25 issue of AMNews for another excerpt and an interview with the author.