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.

Repetition is the key to learning

Cramming for Monday's exam, I happened to think about this classic clip from Sesame Street. I can't believe it's on YouTube. There are probably only a handful of people in our class who are old enough to remember it....

SOM in the news

This article mentions the controversy surrounding faculty and administrative salaries at the SOM, there is a very interesting detail about Dr. Babitz in there that we should all be made aware of...

GOP abuzz over U. salaries

Senate leader says he'll probe executive compensation

By Sheena McFarland
The Salt Lake Tribune

Article Last Updated: 12/23/2007 01:39:57 AM MST

When House Republicans gathered in a daylong closed-door caucus Monday on Utah's Capitol Hill, they didn't confine their discussions to the tax cut proposal that hogged headlines.
They also spent part of the meeting talking about the generous salary increases of top University of Utah administrators, said Rep. Kory Holdaway, R-Taylorsville.
Holdaway, co-chairman of the budget committee over higher education, said he was "taken aback" by hefty salary increases for administrators reported by The Salt Lake Tribune.
He wasn't alone.
"There's definitely some questions being asked. People are scratching their heads wondering what's going on," Holdaway said.
The university's top 12 administrators saw an average jump of 37 percent in compensation during the past five years, compared with a 7 percent bump for the school's faculty. Meanwhile, student tuition during the period climbed 45 percent.
Drawing particular attention was the $735,000 salary and $193,000 annual retirement fund payment for Lorris Betz, senior vice president for health sciences. Betz's compensation increased 88 percent in the past five years.

..... Read More

Diagnosis Wenckebach

Three weeks ago I would have had no idea what they're singing about in this spoof. Clever Canadians.

Disgusting...

Here's an article to read (or, rather, skim over) at 1:30 AM, instead of studying the mechanics of cardiac muscle: 20 Under 25: The Top-Earning Young Superstars

i have one word: disgusting.

does lebron james really need to get paid $15 million per year for running back and forth on a court? he's only 22 year old! don't get me wrong, i love to watch basketball, but at a price of $15 million per year for 1 athlete? i'm sorry, but that's ridiculous.

though tiger is not under 25, i want to vent about him anyway. get this: tiger woods earns $100 m from just endorsements. that is not right when you consider that through his 5 year nike contract, mr. woods earns US$55,000 a day, while a thai worker producing nike clothing would have to work for 14,000 days, or 38 years to receive this same amount. yessirree, nike spends the equivalent of 14,000 workers' daily salaries to pay tiger woods for just one day. another translation: a worker would have to work for 26.5 million days, or 72,000 years to receive what tiger woods gets during his five year contract with nike. don't believe me? here are my sources:
Clean Clothes Campaign
Work Conditions

or how about tyra banks' $6 m for wearing skimpy underwear and strutting down a runway and posing for the camera (Forbes)?

go here for an interesting time in comparing salaries --> Salary Timer
it's rather disturbing.

was there ever a time in history when there existed no disparity between different social classes? i think not. i'm a believer in social justice and equality, but i also believe that it is fair for someone to earn a higher salary if he/she has gone through years of schooling and training to practice medicine, to perform research and find treatment options/cures for diseases, to manage large firms, to safely fly a plane, to teach, fix cars/other machinery, or to develop advanced and efficient technology, as compared to someone who needs little training to answer phone calls, to fold clothing, to sell cars, or to flip burgers. no offense. i hope i don't appear to be an elitist, but i think that my reasoning is justified. one additional thought that i have is this: there sure as hell is no justification in my mind for a movie star, an athlete, a model, or a singer to be earning about 1,500 times the amount that an average person in the U.S. would earn. seriously, go to that salary timer and make the comparison.

i don't know the answer to making the poor richer, or on the other end, making the rich poorer, but there are ways that we can lessen the economic gap between societal classes... yes, a CEO may make a 6-figure income that is rightfully deserved, but we can cut down on his/her $50,000 annual bonus, the trips to paradise destinations, the $100 course meals, among many other benefits (i learned of these benefits on 20/20 or dateline episode once). physicians need not go to $100 course dinners thrice times a week, paid for by pharmaceutical companies, or receive expensive gifts...

of course, we can factor in individual habits of saving and spending when looking at any societal class. can you say money management and budgeting? even if two people earned similar incomes, one who saves, invests, budgets, and spends wisely would live comfortably, while the other who spends frivolously and rarely saves or invests will find himself strapped for cash in the long run.

bah. what an unfair world. all these stars who are earning millions upon billions need to spend one month in a third world country. the people paying for these stars' salaries might benefit from doing the same. maybe then will they learn the value of a dollar.

but who am i to be talking? i know i have contributed to this appalling trend of paying stars the big bucks. yes, i have purchased tickets to go to sporting events. yes, i've been to concerts and the movies. yes, i've bought cd's and dvd's, watched tyra's shows, gone shopping, etc.

damn. we're all screwed.

i conclude that we all need to re-evaluate our values... perhaps i have said too much..

thanks pete, for being contagious and putting me on my soapbox today.

good night.

Just for fun

Any resemblance to real members of our class is entirely coincidental.