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  • Congress: Take Action To Protect Stafford Loans

    Elizabeth Wiley, MD, JD, MPH
    National President, American Medical Student Association


    More than 86 percent of physicians-in-training rely on student loans to pay for medical school. If Congress does not take action by July 1, subsidized Stafford loans for graduate and professional students will be discontinued and undergraduate subsidized Stafford loan interest rates will double, increasing from 3.4 percent to 6.8 percent. This limits education and career choices for physicians-in-training, who already have an average debt of more than $160,000 at graduation. Beyond the pocketbook, critical issues in American health care such as access to care, diversity and cultural competency in the workforce, and health disparities are all affected by the debt burden carried by today's physicians-in-training. AMSA believes that the debt burden may contribute to the measurable decline in students entering primary care fields in favor of more lucrative specialties.

    Some members of Congress have introduced legislation to cut the Prevention and Public Health Fund rather than close corporate loopholes in order to prevent an increase in undergraduate Stafford loan interest rates. Investments in prevention and public health not only improve the lives of our citizens but are also cost-effective. This funding for cancer screening, immunizations and health education is essential for a healthy nation and a health care system that prevents illness rather than solely treats disease. The American Medical Student Association calls on Congress to take action to protect Stafford loans and the Prevention & Public Health Fund. Protecting corporations at the expense of students or prevention is unacceptable.

    Take Action Now!

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  • Medical Education Reform

    Aliye Runyan
    University of Miami Miller SOM 
    Medical Education chair
    education.chair@amsa.org

    It was refreshing to hear Marty Nemko’s perspective on medical education reform in the Washington Post article published recently as these are precisely the types of changes AMSA strives for, nationally and locally. Medical education, standardized by the LCME and varying little throughout medical schools across the country, has also changed little since Abraham Flexner wrote his seminal report in 1910.

    The national AAMC conference in 2010 examined this very issue; titled “Shaping Physicians of the Future: A Century after the Flexner Report”, most of the meeting was dedicated to examining how medical education needs to move forward to best benefit the doctors and patients of our current and future generations. It is true, medicine and medical education remains entrenched in tradition, and while this helps institutional memory and provides structure to becoming a medical professional, it also makes innovation in teaching difficult to accept. The practice of medicine is extremely different than it was 100 years ago – more identified diseases, an upsurge of technology, the influence of business in medicine, the use of social media, the globalization of healthcare. 

    The tradition of “old school” medical education – basic science, reading and regurgitating information (where the infamous medical school = drinking from a firehose analogy comes from), and learning the practice of medicine as one individual competing against his/her peers – is very outdated. 

    Physicians practice in a collaborative and multi-faceted world – and medical students often enter residency ill-equipped to handle social issues, end of life care dilemmas, advocating for their patients who have lack of access to care, and navigating the stacks of paperwork required for each hospital and clinic visit. Recognizing this, many schools have moved to problem-based learning alongside lectures, introducing students to patient care early in their preclinical years, and some, such as Baylor and Duke, have moved to cutting down the second year of classwork so students can get into the hospital setting more quickly. While these are progressive moves, a more substantial push to comprehensive medical education reform is necessary, as Nemko points out. Reform should encompass the spectrum of training: from admission requirements (more balanced, liberal arts focused prereqs and patient advocacy/ethics focused admission interviews) to medical school graduation requirements (social medicine, advocacy, communication skills). 
     
    One of my favorite lines from the article is ”A medical education that inculcates a measure of humility would help physicians understand the field’s current limitations, be more honest with patients and more motivated to contribute their clinical findings to the still adolescent field of medicine.” Too often, physicians and physicians in training become short sighted to the big picture of medical practice and their role in it. In fact, we have the power in our hands to change our field – from the bottom up, from the top down – it takes courage and creativity, yes, but more and more it will become absolutely necessary, in order to keep up with the progress of medical science.

    Feel free to contact your Med Ed team with any questions and ideas!

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  • No-cost birth control! New HHS guidelines on women's preventive health

    By Kathy Wollner
    Women's Policy Coordinator, AMSA Gender & Sexuality Committee


    This week, buried under chatter about raising the debt ceiling, was some pretty great news for women’s health care. The U.S. Department of Health and Human Services (HHS) announced new guidelines that all FDA-approved contraception options must be covered by all new health insurance plans*** without cost-sharing. These guidelines are based on the Institute of Medicine (IOM) recommendations issued this July and will go into effect August 1, 2012.

    This means women will be able to get whatever mode of birth control is right for them - oral contraceptive pills, patches, rings, injectables, IUDs - without having to pay co-pays or contribute into their deductibles.

    This is huge in assuring that women will no longer be burdened with additional costs when seeking family planning. We know that giving women access to contraception allows them to prevent unintended pregnancies and space their children in a way that’s healthy for both moms and babies. When women have access, they and their partners are able to plan their families in the way that’s best for them. Removing barriers based on cost is a big step in the right direction toward ameliorating health disparities based on income and access.

    But wait, there’s more!

    Other services to be covered by new health insurance plans without co-pay include well woman visits, HIV testing and counseling, STD counseling (testing is covered under existing guidelines for women under 24 and those at high risk), HPV testing for women over 30, domestic violence screening and counseling, and breastfeeding support, supplies, and counseling.

    The Obama Administration’s support of evidence-based medicine and commitment to investing in preventive health care will in the end have a major impact on women’s health. No woman should be unable to access these basic health services due to cost. I am beyond excited for myself, my sisters, my friends, and my future patients that we can stop making health care decisions based on what’s covered by insurance and start making them based on what’s best for our health and well-being. Hooray!


    *** What exactly does “new health insurance plans” mean? Good question. It essentially means that it won’t go into effect for everyone right away. While many employers stick with the same coverage year to year, there’s pretty much always a re-negotiation of the terms of the plan in some way, which will make it “new.” It’s unclear at this point (to the people who know more than me who I posed this question to and thus to me as well) what this means for individual plans, but in the case of group plans, these new guidelines should catch up to most plans sooner rather than later.

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  • HHS Requires Free Birth Control for Women

    This week the Department of Health and Human Services (HHS) announced new guidelines requiring health insurers to cover certain women’s preventative services, including birth control, HPV screenings, breastfeeding support and STD counseling.

    The guidelines are based on the recommendations issued by the Institute of Medicine in July. According to HHS Secretary Kathleen Sebelius, the decision is a part of the Affordable Care Act's move toward prevention. "These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need."

    Many groups oppose the guidelines, citing that many people have moral and religious convictions against contraception. President Obama issued an amendment allowing religious groups who offer insurance coverage to employees the right to choose whether to cover contraception.

    "Covering birth control without co-pays is one of the most important steps we can take to prevent unintended pregnancy and keep women and children healthy," said Cecile Richards, president of Planned Parenthood Federation of America.

    Supporters believe that covering contraception will helps the government save money by decreasing the number of unintended pregnancies, which accounted for 51 percent of publicly funded births in 2006. By reducing the numbers of unintended pregnancies, the move could save more than $11 billion in medical costs.

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  • Preserving Funding to Medicaid and Medicare

    By Colin McCluney
    AMSA Education & Advocacy Fellow

    Last week, I had the pleasure of representing AMSA, along with other national leaders, at meetings at the White House and the Capitol to emphasize the importance of preserving funding to Medicaid and Medicare. While key entitlement programs are on the chopping block, we want the voice of physicians-in-training to be heard. AMSA joined with 14 other physician organizations in signing a coalition letter to oppose cuts to Medicaid and Medicare; this letter was hand-delivered to leadership from both parties in the House and the Senate. In addition to expressing our opposition to any reduction in benefits or coverage from Medicaid and Medicare, we emphasized our support for innovation in health care administration to reduce costs.

    Medicare has long been one of the most popular governmental programs, covering over 45,000,000 individuals, and has thus been largely protected from significant cuts. Medicaid, on the other hand, is less well-regarded and is frequently targeted as an opportunity for cuts. Why is this? Perhaps it’s due in part to the unglamorous perception that Medicaid is for poor people, a segment of the population that is hard to mobilize politically, frequently forgotten about and easy to demonize (think about the notion of lazy welfare cheats for example). On top of that, some groups and individuals have claimed that people are better off being uninsured than having Medicaid. Take all these things together and you can see how easy it could be to cut elements of the program. As you might have intuited though, these assertions aren’t true. While Medicaid does cover eligible individuals at certain poverty thresholds, it is worth noting that Medicaid covers some 30,000,000 children nationwide and provides payment for about a third of all births. Most exciting, though, are the recent findings to come out of a randomized controlled trial of Medicaid in Oregon. The origins and methodology have been extensively reviewed elsewhere but the key results were that individuals with Medicaid received more preventive care (for example, mammograms), had fewer financial problems (for example, borrowing money to pay debt or having bills end up in collections), reported having a regular doctor, and were much more likely to rate their own health as “excellent” or “good” (rather than “fair” or “poor”). While objective data on quantitative health outcomes won’t be available for another year or more, it is clear that Medicaid has already had a substantial positive impact on those individuals lucky enough to have been enrolled. This study – the first on the effects of health insurance since the landmark Rand study – shows clearly the value of Medicaid in improving the health and well-being of some of the most vulnerable Americans.

    The budget negotiations will rumble on and Medicaid & Medicare will continue to be targets for cuts. Even after this round of discussions is finished, it is clear that there will be more battles to come. We see, however, that these programs are essential and effective in helping provide access to necessary medical care for a significant portion of the population, and we will continue to fight to support Medicare and Medicaid, to oppose cuts, to ensure & expand coverage, and to reduce waste.

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  • Good Communication is Critical

    In the New York Times this weekend, Gardiner Harris writes, “New for Aspiring Doctors, the People Skills Test,” which describes the M.M.I. – the multiple mini interview. This new process tests medical school applicants on their social skills and is being used by at least eight medical schools in the nation. Unlike all of the other exams students are expected to take, the M.M.I. does not have right or wrong answers. It tests for proper communication skills, which will be critical in the hospital and patient care setting down the line.

    It is very important that physicians be able to communication effectively and compassionately with their patients. However, this article brings up some interesting questions. Should an applicant – whose grades and test scores are perfect - be declined acceptance to medical school because they lack the proper social skills? Can these communication skills be taught? With a pending physician shortage, is the nation really in a place to turn away future physicians?

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  • New Medical School Model

    Yesterday, National Public Radio ran a story called, "New Medical School Model: Adopt A Family To Treat." They mention that after decades without a single new school, five new medical schools have opened since 2009, and 10 more are being accredited. They credit this response to the growing doctor shortage.

    In particular, the story focuses on Florida International University's College of Medicine in Miami. This new school has instituted a new approach to education - community-based medical curriculum. Each medical student is assigned to a local family in order to "improve the health of the family and the quality of life in the neighborhood."

    The school says they want to produce more primary care physicians.

    Two solutions that AMSA has proposed for the shortage of primary care physicians includes (1) erecting new medical schools that focus exclusively on primary care as a part of the infrastructural improvements that are a component of the incoming administration’s economic development plan, and (2) reward those schools that already focus on training primary care providers by increasing funding for the primary care-related research being conducted at such institutions making it commensurate with that awarded for more specialized research occurring at other institutions that demonstrate less focus on primary care.

    Listen to the entire NPR story here. Comment here and let us know what you think of this new curriculum. 

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  • Comparative Effectiveness Research and Cost-Effectiveness Analysis... What's the Difference?

    by Ken Williams
    Graduate Special Student
    The Johns Hopkins University Bloomberg School of Public Health

    Lately, I have had a lot of people ask me about the difference (if there is one) between comparative effectiveness research (CER) and cost-effectiveness analysis (CEA), so I thought that I would take this opportunity to provide a very brief introduction to the subject.

    The American Recovery and Reinvestment Act (ARRA) created the Federal Coordinating Council for Comparative Effectiveness Research (Federal Council), which is charged with coordinating the research and guiding the allocation of the money invested in CER by ARRA. In all, $1.1 billion USD has been earmarked for CER with $300 million going to the Department of Health and Human Service’s (HHS) Agency for Healthcare Research and Quality, $400 million for the National Institutes of Health, and $400 million for the Secretary of HHS. With this amount of money on the line, CER has become a very hot topic here inside the beltway.

    While there are many definitions of CER out there, the Federal Council, in a report to the President and Congress, provides the following, which serves as an overall guiding definition for the entire federal government:

    Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.
    • To provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub­ groups.
    • Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies.
    • This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

    That is, CER takes evidence-based data about different interventions and seeks to determine the benefits and harms of each as compared to each other.

    One of the most important things to notice about the list is that it does not ever mention cost. This is where most of the confusion sets in. In the US, the official CER guidelines, as presented by the Federal Council, do not take cost into consideration as a factor. This is not the case universally, however, as other countries, sub-national governments, and organizations do list CEA as an important component to CER.

    As compared to CER, cost-effectiveness analysis (CEA) is entirely focused on the costs of medical and public health interventions. Specifically, CEA will calculate the cost per some measurable improvement (or decline) such as quality-adjusted life years or disability-adjusted life years or the like. While CEA is not included as part of the official US CER guidelines, it is still important to note that CEA can provide valuable supplemental information for decision makers.

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  • Health is a Human Right

    by Ken Williams
    Graduate Special Student
    The Johns Hopkins University Bloomberg School of Public Health

    “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
    -Universal Declaration of Human Rights, Article 25

    On December 10, 1948, the General Assembly of the United Nations adopted and proclaimed the Universal Declaration of Human Rights. Every year on the anniversary of this date, I am reminded just how important it is that we continue our work towards improving the health of our nation and the world. The more than sixty thousand physicians-in-training that make up the membership of AMSA have committed ourselves to the task of ensuring a future where every person in this country has access to health care without regard to age, sex, gender, social class, nationality, ethnicity, sexual identity, or any other artificial barrier to the health and well-being to which every human being has a right.

    AMSA has dedicated itself to the strategic priority of ensuring quality, affordable, health care for all. We see our mission as being actively engaged in the social, moral and ethical obligations of the profession of medicine. With the work we did helping to pass the Patient Protection and Affordable Care Act (ACA), we have worked to move our nation one step closer to this goal. We still have many more miles to go, though.

    In the post-ACA world, we now must redouble our efforts to ensure that not only are coverage gaps reduced and that every citizen has access to quality, affordable, innovative health care, but also that the system itself is sustainable well into the future. As the Universal Declaration of Human Rights proclaims, everyone has the right to health and medical care; our task is to ensure that we can provide it.

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  • Should Residents Be Considered Students or Employees?

    On Monday, the U.S. Supreme Court heard oral arguments for the case Mayo Foundation v. United States, 09-837. They are deciding whether residents should be considered students or employees. At issue is an 8th Circuit Court of Appeals decision upholding an IRS rule that deems resident physicians as ineligible for a "student exemption" to the Social Security and Medicare systems (FICA) tax because they work full-time.

    Mayo Clinic officials want the court to overturn a federal appeals court ruling and restore the student exemption for medical residents. The Obama administration said that Social Security taxes for medical residents can be as much as $700 million a year.

    Last month, AMSA and the Committee of Interns and Residents/SEIU Healthcare filed a friend of the court brief with the Supreme Court. 

    More than 100,000 resident physicians - doctors who have graduated medical school and received their M.D. or D.O. degree -- are working in teaching hospitals across the country as they acquire the on-the-job training required for certification in their medical specialty (for example, pediatrics or surgery). Resident physicians are known for their extremely long work hours, including 80 hour work weeks and on-call shifts of 24-30 consecutive hours, and for the round-the-clock services they provide to patients in more than 1,000 U.S. teaching hospitals.

    The FICA student exemption has historically been granted to colleges and universities who employ undergraduates part-time to work in on-campus jobs -- for example, the university library or computer lab. In an attempt to improve their financial bottom line, some teaching hospitals have sought and won FICA tax refunds for themselves and also for resident physicians they employ because the wording of the rule was vague. In 2005, the IRS clarified its rule to explicitly exclude those working 40 hours or more a week.

    In Mayo Foundation v United States of America, both the Mayo Foundation and the University of Minnesota dispute the IRS rule, claiming that all hospital employers and resident physicians should be exempt from paying into the Social Security and Medicare systems.

    AMSA joined CIR in filing the amicus brief because "it is important to define the work of resident physicians," said Elizabeth Wiley, JD, MPH, AMSA Legislative Co-Director. "Residents are underpaid for all the hours they work and the often irreplaceable services they provide. To compare what we do as students to the work and responsibility of residents - well, it just defies truth and logic."

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