Free Tuition for Medical Students?

Always a trailblazer, The Mayo Clinic’s Medical School has had a generous scholarship program for the past 20 years that enables about 60 percent of its students to attend school tuition-free. The 50 students who started at Mayo last summer each received $25,000 to use towards tuition of $29,200. Students also are eligible to receive an additional $2,000 to $5,000 a year based on need, said David Dahlen, director of student financial aid at Mayo, based in Rochester, Minn.

Now, a few other schools are experimenting with much-needed financial relief for medical students. Most notably, the University of Central Florida’s brand new med school is offering four-year scholarships for tuition, fees and living expenses for every member of first-year class.  Students have until December to apply; already, the school has received 2,996 applications for its charter class of 40.

The Wall Street Journal reports that the $7 million needed to fund the charter class came from individuals and private philanthropies. There was no single donor who did most of the work; the two largest gifts were each a bit over $300,000. Perhaps other medical schools could follow this model.

The bad news is that this first class is the only one that will receive such a sweet deal. There will be some scholarships for students in subsequent classes, but essentially the University of Central Florida is using the financial packages to attract a top entering class, hoping that this will set the pace for the school’s future.

Mayo, of course, doesn’t need to offer financial enticements to draw the best students. It is simply part of the school’s “philosophy that your qualifications, motivation and commitment to service–rather than finances–should guide your decision to apply to medical school.” 

Now, the Cleveland Clinic has set out to follow Mayo’s example. The
32 students entering the Cleveland Clinic Lerner College of Medicine at
Case Western Reserve University later this year will pay no tuition.
The Cleveland Clinic will use its endowment and revenue from hospital
operations to cover the $43,500 tuition bill to Case, which is
affiliated with the clinic. And more scholarship aid will be given to
current students.

The Clinic’s goal is to free students from the feeling that they
have to choose high-paying specialties to pay off the debt, rather than
going into academic and research oriented medicine, toward which the
Clinic program is geared.

Finally, Harvard University has announced that it will reduce the
cost of a four-year medical education by as much as $50,000 for
families with an income of $120,000 or less. In the past, a student’s
family had to pay about $12,500 annually toward the tuition, fees, and
living expenses that make up the $65,000 cost of a year at Harvard
Medical School, before the student became eligible for $24,500 a year
in subsidized federal and institutional loans.

“Harvard’s initiative comes at a time of widespread concern among
physician leaders that the rising cost of medical school discourages
lower-income students from pursuing medical careers,” the American
Medical Association reported, “and sways some medical graduates to pick high-income specialties.”

Of course, when it comes to financing medical school education, the
U.S. remains an outlier. Most developed countries view medical
education as a social good, and governments fund all or a significant
part of the cost. Nevertheless, these changes suggest that medical
schools are becoming aware of the need to attract a broader swathe of
students. Today, 60 percent of all medical students come from the
wealthiest one-fifth of all U.S. families. Another 20 percent come from
families lucky enough to be on the fourth step of a five step ladder.
According to the NEJM,
a recent national survey of under-represented students reveals that the
cost of attending medical school was the number-one reason they did not
apply.

23 thoughts on “Free Tuition for Medical Students?

  1. I have to say this is definitely a step in the wrong direction.
    It is hard enough to get ebnchmarking data on how much medical schools spend to educate students in the first place. Proposals which focus on finding new sources of funding for medical education (to lower the cost to the student) are a little like rearranging deck chairs on the Titanic.
    Why not focus on how to make medical education cheaper in the first place?
    Instead of finding more money to fund something which is fundamentally too expensive, why not allow the introduction of competitive alternative models to the current US medical school model
    since you and I both went thru medical school, we both know the first 2 years of can probably be learned from a CD or video link off the web at <1/10th the cost of educating a current medical student. Only once clinical bedside teaching occurs would one need to have more labor intensive 1 on 1 education. And right now, there is no abillity for students to competitively prive this education out do to the extereme monopoly medical schools have on medical education.
    Again, the solution is not new sources of funding, the solution is to improve medical educational productivity.

  2. Red Baron-
    Tuition covers only about 10% of the cost of educating med students.
    So the relationship between tuition and cost of education is a loose one.
    Quite possibly there are ways to reduce the cost of educating students– though the cost of the medical technology is a major, unavoidable part of the expense. .
    Having students do the first two years on line does not seem an acceptable solution.
    As a former university professor I can say that attempts to teach anything more substative than, say, the first two years of grammar of a foreign languge, online are dommed to fail.
    When the subject is complex, you need the back and forth of students asking questions, professors asking questions, and students having access to professors to ask questions after class.
    Bottom line: teaching is a labor-intensive profession–like nursing. Trying down-size the number of teachers needed is like trying to down-size nurses in a hospital. YOu need the one-to-one contact.
    Also, med students need to learn to work collaboratively. Study groups provide a good first experience in collaboration.
    We already have too many physicians who think of themselves as Lone Rangers. We don’t need doctors who spent the first two years of their education staring at a screen.

  3. Dr. Rick–
    Thanks for the information.
    It also gives me some hope that this is the beginning of a trend.
    This is something that he next administration should look at.

  4. Dr. Rick–
    Thanks for the information.
    It also gives me some hope that this is the beginning of a trend.
    This is something that he next administration should look at.

  5. “Tuition covers only about 10% of the cost of educating med students.”
    I cannot think of a better way to validate what I am saying.
    “Having students do the first two years on line does not seem an acceptable solution”.
    And you are so sure about the truth of this statement you believe we should ration AICDs to people before we attempt other models of medical educational deliver/ Other ways to improve educational productivity?
    Remember, even if 90% of medical students need to continue to be educated the current way and only 10% of them are capable of learning from a computer, the financial benefits to society would be so massive from that 10% that some might view preventing such a program as immoral.
    Further, my point regarding ‘online’ medical education is really to point out that there are a great many ways we can educate people to perform the tasks and skills currently performed by traditional physicians without actually having to fully fund-produce physicians the way were currently do in the firstplace.
    While the most obvious has already started in the wider use of Mid-levels (NPs and PAs). We can do much more than this.
    MLPs never go to medical school; their time period between high school graduation and first employment is certainly shorter than most physicians (though this is mostly because they don’t attend residencies, PA programs are still often 4 years).
    Most diagnostic radiology does not need to be done by certficed radiologists. yet sadly we have not ssen much wider use of MLPs in reading (say) xrays, CTs, MRIs, etc… (like lab techs read pap smears under the supervison of pathologists today), there is no reeason they could not… Kaiser has already done studies showing that for simple long bone x-ray films, radiologists do not add any clinical diagnostic accuracy to a process in which they are not used– yet still we/Kaiser uses them for med mal reasons.
    In fact, when I think on it, the other day my wife twisted her ankle and it locked in flexed position. Xrays at the orthopedists office were negative so he ordered an MRI (heaven only knows why since we all knew she needed an operation?). Anyway, the MRI was read as neagative by BOTH the radiologist and my wofe’s orthopedist. When my wife (a stay at home mom), curious to know what an MRI looked like (having NEVER seen an MRI in her life), asked to look at it, she noticed the osteochondral fragment within 60 seconds; addendum reports to the inital negative dictated readings noted a bone fragement on ‘re-review’.
    Washington DC once had suture techs (they were used by GW), but the DC medical societies abolished positions. Experts felt they were ‘dangerous’…
    And you and I both know whether we truly need cardiologists to perform most PTCAs (in fact, I have seen MLPs performing them in come centers).
    Look at neurosurgery: not too long ago most neurosurgical services in most teaching hospitals in the US after 7pm were run by 3rd or 4th year residents. Most of the craniotomies done at night were performed by 3rd and 4th year resident and the outcomes were just fine. Then one day the certification bodies came by and decided that level 4 trauma centers needed ‘in-house’ neurosurgical attendings. And almost overnight neurosurgical shortages popped up all over the coutnry… so while outcomes for >90% of the things that the 3rd and 4th year residents managed did not immprove (did anyone ask if we really needed 7 years of trainng for a simple burr hole?), now nerosurgery for trauma is in short supply everywhere.
    I noticed the other day that GIs have passed laws preventing MLPs from performing colonoscopies, etc…
    The list goes on and on and on.
    So while I certainly agree with you that many of our biggest problems in healthcare in the US center around medical school/training and certification, MORE FUNDING for a totally dysfunctional system is certainly not the solution.
    On last example: there is perhpas no better example of the lack of connectio between certification and competency than Silicon Valley where PhDs are rather much rarer than they once were.
    Yet still this loss of ‘certification’ has not changed the rate innovation, complexity or performance of the computers silicon valley produces one bit.
    And Japan has proven the issue is not technology. It is how we utilize the technology.

  6. the free medical school will just create debt free specialists.
    that assumes that those new schools will be able to get their graduates into residencies.
    otherwise they will claim foul as they are pursuing alternative careers instead of entering primary care.

  7. at my medical school, the first two years could have been videotaped 30 years ago and displayed on a projector for all the interaction that occurred.
    i find it interesting that maggie (not an attack, please don’t perceive it as one) offers her anecdotal experience as a university professor to support her position. however if a physician offers their experience on a matter, that comment is met with arguments of data supporting maggie’s position. data likely created by people who are not physicians potentially filled with inaccuracies which can be interpreted in many ways but supposedly more convincing than anecdotal experience. unless you happen to believe your experiences, and that data to the contrary reflect bad data/contrived conclusions, or a minority experience.
    anyhoo, cheers.

  8. Anon said “the free medical school will just create debt free specialists”.
    I couldn’t agree more.
    The real issue with medical education has always been just what Maggie alluded to: “Tuition covers only about 10% of the cost of educating med students.”
    If tuition is $45-$50,000/year and the ‘real cost’ is 10 times that, run the numbers yourself for 4 years at a 5% interest rate to get a sense of just how much ‘real’ money society actually spends to producing physicians.
    And this is just the cost to society after 4 years. Medical students repay society once they become interns. But in truth, interns are not worth that much to society so again the interest on this large social cost grows (albeit at a slower rate) until it slowly starts to shrink in year 2+ after graduation (really depends on how you run the numbers on intern social ‘pay back’– a combo of intern productivity, how many hours an intern works at low pay, how low the wages are and how long the intern-residency training lasts).
    FYI– it is one of the main reasons we tolerate as a society such long and onerous specialty training programs at lowpay and long hours- we (the collective) are trying to recoop some of the tremendous investment we made in these people.
    Of course medical schools have been trying to game the system forever by creating endowements to permanently codify their outrageous cost structures forever-And who complains when they do? Once thess endowements are formed, they appear to offer ‘free education’, so certainly medical students won’t complain and we all absolutely certainly know that the med school faculty won’t complain.
    And everyone else is simply too confused to understand just how much money society tied up in an unproductive system.
    At least Maggie is playing on the right field when she mentions medical education as one of the main reasons for the high cost of healthcare in this country (many western countries really). Sadly, she continues to play for the wrong team.

  9. Red Baron & Anonymous–
    It seems to me that we are talking past each other about two separate problems.
    You say that we spend way too much on medical education–which may well be true.
    I’d be very interested in more information about how other developed countries train their medical students–whether they manage to train them using fewer resources. (I’m willing to believe that is the case, but would like to see numbers and learn more about how they save costs.)
    I’m talking about a separate problem: the fact that the high cost of medical school for the U.S. student means that the students who apply come from a very small slice of upper-class and upper-middle class mainly white families.
    We need doctors who understand the cultures of the whole population including working class and poor white families as well as African Americans and Latinos.
    Not long ago a study came out showing that when African-Americans go to an ER they are much less likely to get adequate pain-killers. This may have to do with how they describe their pain, how nurses and doctors perceive them, etc. But clearly there’s a problem.
    And any very bright kid who wants to become a doctor should have a chance to compete for a place in medical school, whether or not his family is well off.
    This is no reason why medical schools could not simultaneously cut waste in their system of training.
    Presumably their have been studies of how to make medical education less expensive?
    Are their schools that do things differently? (I think of Mayo which has a culture which is quite different from most medical centers.)
    And from talking to medical students at some schools, I know that interaction with teachers is very important–at least at some schools.
    There have been studies, going back to the early 60s trying to show that very large numbers of bright children can be taught by one teacher, on closed-circuit TV.
    (I know because I was one of the kids.) The experiments failed..
    So I continue to be skeptical about training doctors online.

  10. At a recent hearing in Congress about whether wealthy universities should be required to spend a higher percentage of their endowments each year, the Amherst representative was quoted as saying that the all in cost to educate an undergraduate at his university is approximately $80,000 per year. Since Amherst is a highly selective school with well regarded and, presumably, well paid professors teaching comparatively small classes, it’s hard for me to understand how it can cost $500,000 per year to educate a doctor. Perhaps one of the experts out there can provide some insight into just where all this money goes and what it pays for. Or is it just a lot of creative accounting used by academic medical centers and teaching hospitals to maximize education payments from Medicare?

  11. Barry, you hit the nail on the head! (well, not if you are validating the congressional spending mandate)
    In fact that nail’s head is an enormous money black hole if you look at it—which most of the American education establishment would prefer us not to examine. If you think there is big cost difference between an ‘elite’ undergraduate education like Amherst @ $80,000 year and a medical school education @ $500,000/year (6.25), just think how big the difference is between a medical education and a community college at only $4000/year (125… A 20 fold difference!) http://articles.latimes.com/2004/mar/07/local/me-grad7. I am not so sure the content or quality is all that different between introductory American histories or introductory college chemistry between the two institutions (though they would like us to think they exist). I am the first to say there is a big difference between Amherst and a community college, but the coursework content and classroom teaching (at least in the first two years) is probably not one of them– education has become intimately intertwined with social status, prestige, etc… Which in general I could care less about except when people want to subsidize prestige at the cost of rationing healthcare to people who might otherwise afford it.
    What is clear to many of us is in the medical administrative world is training and licensure (what I call the “certification assures competency model”) are among the biggest reasons healthcare is so expensive in the first place. And while I recognize this has probably always been true (we did tried to regulate stethoscopes) and will probably further always be true (unless someone can think of a better model), it does not mean we shouldn’t look at what we are doing from time to time to see if there might be a better way to build the mousetrap… we must always remember that the “certification assures competency model” can also work against the interests of the collective periodically.
    And right now, we are letting fear drive the system. We may have a good model in traditional medical education, but we also know we cannot do everything with the resources we have– rationing is simply a necessity. We have not yet had a national dialogue on rationing, but you policy wonks have them all the time. Since you know we must ration, perhaps looking at system training productivity before we cut back on actual care might also be worth considering?
    Our current system was created in a time very different from today– few people went to school and there was far less technology to help ‘less trained’ medical practitioner make medical diagnoses. But today most Americans do go to school and technology is pretty darn good at helping ‘less trained’ practitioners make a decision (which is why my wife can read an MRI having never seen one in her life). We can super specialize people from the very beginning (like training art students to read CTs or MRIs and NEVER go to medical school).
    It is clear that in today’s world, much medicine does not require a physician as we traditionally define them anymore. And similarly, SOME of the way we ‘produce’ or train traditional physicians (since they are clearly still necessary) MIGHT not need to be done the way we traditional do it (at least not for ALL traditional physicians).
    Looking for alternate models from other countries is interesting, but unnecessary. Their system is not our system. So if we don’t find them: “so what”! If other countries don’t want to use MRI scanners because the think them ‘too expensive’, that is their choice. But if we like them (and I personally I like MRIs, I like nuclear stress thallium mibi, I like AICDs, I like pacemakers, I like etc… (as long as they are used ‘appropriately’). Might we still use these technologies heavily but not use traditional physicians to read/insert/install/deploy the majority of these technologies?
    It seems to me it’s our country, we can provide care however we want. Doing it differently is not necessarily ‘bad’. Harming patients is bad. Worsening outcomes is bad. Using someone cheaper to produce than a physician at a similar outcome is not necessarily bad at all (at least in the Red Baron scale of moral sins).
    And this is where the problem with the certification-licensing comes in. It’s against the law to even try alternate models!
    For though major universities like Duke and U. Colorado originally develop alternate models to the modern physician (Dr Eugene Stead at Duke developed the physician assistant model and Loretta Ford and Henry Silver developed the nurse practitioner program at the University of Colorado in (oddly enough) the same year- 1965; something I am sure is not a coincidence), major universities have not improved these variants anywhere near the level private industry would like to see them as it is clear these mid-levels are a threat to many university subspecialty interests.
    And since the only way new healthcare practice models seem to develop is under the ‘guidance’ of a major university—it has become the proverbial fox guarding the henhouse.
    And Maggie, you are correct:
    1.They are different
    2.Studies on online education shows it is a clear failure in the earlier years
    More power to you if you want to fight for greater socioeconomic equality (though I think it is an entirely different issue than cheaper healthcare and sometimes you need to choose which you want). My issue is when you suggest solutions to socioeconomic inequities in medicine that also require people accept healthcare rationing (which oddly enough, I agree we need but for different reasons). The moral cost-benefit of such agenda seems spurious.
    If you are pushing for more diversity in medicine, it seems a better way is to:
    1.Focus on lowering the barriers to entry into medicine in the first place (improving educational productivity would most definitely meet this criteria)
    2.Make a better argument as to why it is in your readers financial interest to do this (and I’ll even help you on this below)
    Diversity amongst physicians actually makes economic sense to “the collective” for the simple reason that end of life issues are clearly the most expensive issues in the entire healthcare system (remember I once mentioned that healthcare spending follows fractals (i.e. non-linear or non-Gaussian patterns) and you thought I was… ????). At least in the private community, the data suggests that since people are really not all that different, other cultures/poorer socioeconomic groups will absolutely accept less “futile” care at the end of life IF (and this is the key) and ONLY IF the issues are presented to them in ways that are personally meaningful/relevant. It is clear (at least amongst my own physicians and MLPs) that when a black or Hispanic provider speaks with a family of similar ethnicity (or poorer socioeconomic status but similar ethnicity), he/she will be more capable of connecting with that family than say a white/wealthy physician— didn’t you ever wonder why Miami spend so much more money than Minnesota?)… And you didn’t even need to call the white physicians racist/denying minorities dilaudid SOBs to reach that conclusion.
    As for online education, again, after the age of 21, there is a lot of data showing it can work (not for everyone, but for many). This is why the Universty of Phoenix has become so successful. And IF a 22 year old tries online medical school for 2 tears at $4000/year and fails the exams (remember, medical students need to pass exams after their 2nd year in order to continue), that is really not all that expensive to society (as opposed to having a traditional medical school fail after the 2nd year). If you want to add a 2nd year ‘bedside manner’ test to the current testing schedule as well (as a further screen against people who look at computers all day), still failing ‘non-passers’ would be cheaper than what we currently do (125 to 1 is a VERY big difference to overcome).

  12. Barry and Red Baron:
    The cost of educating a medical student cannot be separated from the cost of running an academic medical center (i.e. inpaitent and outpatient hospital)
    In order to train, students need to be in a hospital setting (inpatient and outpatient) surrounded by patients suffering from a wide variety of diseases.
    This why academic medical centers are normally located in cities–where there will be enough patients suffering from different diseases–both common and rare–for students to get the experience they need.
    In theory, of course, students could train on “simulated human bodies” on computer screens.
    But there is general agreement that medicine is already too mechanistic. Actually meeting the human being, and being subjected to the surprises that unique human bodies present us with is part of the training.
    As a general surgeon once said to me–when you cut into a body, you’re never entirely certain what you’ll find. Human antaomy does not always follow the blueprints in the textbooks.
    Also we know that the body and mind are not easily separated. Even if you’re a subspecialst, you need to have an understanding of the whole patient.
    So, assuming you want stuents to train on real people, you need a large hospital in an urban setting.
    Given the history of U.S. cities this means that you are going to be in a community with a large number of imporverished patients–many uninsured, others on Medicaid which will pay the hospital significantly less than it costs to treat these patients.
    Studies show that academic medical centers do significantly more “charity care” than other hospitals.
    Academic medical centers also provide the “social goods” that many hospitals don’t provide: burn units, trauma units, ERs, detox units, psychiatric facilities, etc. etc.
    These are not lucrative “lines” of services but again, students need to train on burn patients, they need to do a rotation in an ER, etc. And the community needs someone to provide these servcies.
    All of this is part of hte cost of medical education.
    Add to that the cost of the cutting edge technology and labs that academic medical centers need.
    Not every hospital in the U.S. needs to have the latest equipment– Technology from 5 or 10 years ago–or even older–is often fine.
    But if you are training students who will be going out in the field in 5 to 8 years–and practicing for another 35 years–you don’t want to train them on 15-year-old technology. Clearly they should be learning to use the latest technology–as long as it is the most effective.
    In addition, academic medical centers are also the centers for the nation’s medical reserach. (When the professors who teach med students aren’t teaching, they do reserach.)
    In order to pursue that research they need cutting edge equ9pment and labs.
    Some of that is financed by grants from the private sector, but only if the research is likely to lead to a profit in the realtively near future.
    Academic medical centers also are the only place where patients suffering from rare diseases can get help. So they need the equipment and the staff to
    treat those patients.
    Finally, we have too many hospital beds in the U.S.–particularly in citites. Inpatient stays are much shorter than they used to be. So while academic medical centers can easily keep a good share of their beds full with poor patients, they are having a hard time competing to keep the rest of their beds filled with insured patients–the patients they need to help pay for the uninsured patients..
    I’ve done some resarch, and it’s impossible to break out the cost of medical education in the classroom and medical education in the hospital, out-patient satellites, etc. It’s all one ball of wax.
    Finally, Red Baron seems to suggest that a med student might decide, at the beginning of his education, that he wants to be a radiologist and just focus on learning on to read diagnostic tests.
    But it’s essential that med students have an opportunity to sample the full range of medical specialities through “rotations”.
    How else would anyone find out that they have what is needed to work with burn patients who are in severe pain? Or that they are drawn to the challenge of working in a pediatric intensive care unit? Or in an ER? Or with the elderly in a geriatric unit? Or as a palliative care specialist?
    We desperately need doctors in these areas, but few would know that this is what they want to do unless they try it.

  13. Maggie, your response is just plane wrong on so many levels… though I agree that getting benchmark data on medical education is INCREDIBLY hard to find (and believe me, I have tried)…
    Again to help you out, though I do not have any links at my fingertips, since you seem to have ‘connections’ I suggest that if you are truly interested in medical education benchmarking data, you try asking the NHS. I know they are a little further along this process than we are here in the states because I once saw benchmarking data years ago when I studied for a few months at St. Bart’s and Greater Ormond street in London.
    Alas I did not keep the data (I was a medical student at the time and did not realize how unusual it was to be given such data) and have since been unable to find its equivalent… Although, I do know that a number of subspecialties training program lengths have been shortened in recent years (a colleague of mine who recently immigrated to Maryland benefited
    from this whist doing his vascular surgery fellowship in Scotland) and I know (at least he told me) that the shorting came out of UK benchmarking studies of residency training length.
    Perhaps this is a starting point?
    FYI- when you say “The cost of educating a medical student cannot be separated from the cost of running an academic medical center”
    My response is-B.S.
    As a number counter for a rather large medical practice (and we have residents at one facility though no students), I am suprised you are not embarassed to give this answer.
    Statisticians have the ability to tell the effect of cigarettes vs. TV on IQ but still these same statisticians who work for a medical school cannot seperate basic issues like this?
    You have totally drunk the Kool aide
    they are selling you?
    Arn’t these the same statisticians with whom you agree when we need to avoid building new hospitals?
    Arn’t they the same ones who tell us that community institutions need to send them subspecialty patients because their institutions can show ‘subtle statistical’ improvements in the quality and cost of care when tertiary centers treat these same patients over when community hospitals treat these patients?
    All your other arguments are interesting, and may be true, but since we DO NOT have the ability to seperate these issues out (gee I wonder why???), how will we ever know????
    You would not tolerate this BS from those of us in the ‘private world’. why do you continue to tolerate it from academics?
    As for whether students ‘sample’ all specialites before the decide on a caree… I really hope they do get a ‘big picture’ before they decide. But if they do not, I don’t really care.
    IF sampling the full range of specialities means I need to ration care to someone’s (my own)mother. That is a chose I will accept gladly.
    We have to chose priorities in life. Although it sound a little melodramatic, I chose to protect the living.

  14. And Maggie, apart from letting the academic institutions obfuscate you with their standard argument: “we can’t give you data for X because it is so intimately intertwined with Y” you are also letting them manipulate you with that old emotional “indigent and complex care” rider. Does it make you feel better knowing this is the reason you left empty handed when you asked for the data? Would you tolerate such a response from ‘fee for service’ physicians?
    But even more importantly, you are also letting the academic institution re-frame the terms of this discussion which was one of the major points I was warning you about in the first place.
    I suggest you and your readers try the following experiment: next time either you or your readers look at a radiology report, look to see if something similar to the following has been written:
    “Hypodense nodule in left hepatic lobe. Differential diagnosis includes (and you will be given a small list of things). Recommend follow up ultrasound. CLINICAL CORRELATION IS ADVISED”.
    “lucency metacarpal head, possible fracture, CLINICAL CORRELATION IS ADVISED”
    Translated: ‘the radiologist looked at a picture and told you they saw a dark spot and are calling it dark or they saw a white spot and are calling it white’.
    Since the radiologists themselves seem to be telling us all day long that they do not read studies with clinical information when they return what they believe to be a meaningful interpretation (at least MOST OF THE TIME… which is no foul since they are not clinically involved in the patient’s care), why not listen to them?
    And again I say ‘most of the time’ because every now and then of course the radiologists do ask for more information—just like pathologists do on the occasional pap smear they are asked to over read by their techs.
    But you and I both know that MOST of the time what a radiologist does can be done by a simple technician (who you could have recruited and trained from an art school to read JUST a particular type of study- say JUST a chest XRAY or JUST a head CT… and these art students probably would love the supplemental career income since most art students seem fairly poor), so let it be done by a simple technician.
    And this is not a simple academic discussion either (remember how I keep reminding you that non-linear fractal issues keep cropping up in medical economics???):
    The number of images radiologists are reading annually is exploding exponentially in recent years with the advent of CT and MRI. Whereas a single chest x-ray study might be 2 films to read, a single CT or MRI study can literally be hundreds of images for a radiologist to read. The net effect is that a radiologist can read far FEWER individual CT or MRI studies per hour than they can read chest x-ray or V/Q studies per hour. But as the age and complexity of medical care is increasing, and people are surviving cardiovascular diseases more which means they are now getting cancers a few years later… sadly we are all going to die of something one day), the need for advanced studies is increasing at a time when the actual number of films being per study read itself is growing exponentially.
    And to add further insult to injury, as technology itself improves (like the recent switchover from 16 detector CT scanners to 64 multidetector CT scanners allowing slices at closer than 1mm intervals vs. the more standard 5mm slice), we can now use these new technologies for novel indications in a way we could not even a few years ago (like looking at plaques in coronary blood vessels, etc…). Of course this means a 5 fold increase in the number of films required for a single study in for an indication that didn’t even exist a few years ago.
    … And I don’t mean to particularly pick on radiologists (though they are easy targets), I simply use theirs as an example. Issues like this are cropping up everywhere in medicine.
    But again, back to my original point, one thing I do know that academic institutions should absolutely NOT be allowed to control is this debate. I certainly value their input (even if it sometimes sounds like I do not), but it is just one voice among many.
    Don’t drink the Kool Aid Maggie

  15. Also medical students don’t really touch patients in their first two years– or have you forgotton?

  16. Red Baron,
    You are sorely mistaken regarding MLPs. Healthcare is not a free market. Doctors dont and wont compete against MLPs for services. More providers, whether they are doctors or associates degrees MLPs only drive UP costs, they NEVER drive them down.
    Compare the costs of a hospital staffed with a lot of MLPs compared with hospitals that have few MLPs. You’ll find that its the total number of providers that dictates cost, NOT the makeup of MLP s vs doctors.
    NYC has more MLPs per capita than any other healthcare sector in the country, yet they also have the HIGHEST per capita healthcare costs. Why hasnt the high concentration of MLPs in NYC driven down costs?
    Answer: because healthcare is not a free market and doctors dont compete against each other or against MLPs, they just increase the total spending as they scavenge for more patients.

  17. “Also medical students don’t really touch patients in their first two years– or have you forgotton?”
    thats not true. A quick survey of the 10 nearest medical schools in my region shows that all of them start some kind of clinical training in year one.

  18. Since Red Baron and his wife claim to be expert radiologists, I’d like to propose a little challenge.
    Each of the scans below has a diagnosis that was based SOLELY on the presentation of the MRI.
    Lets check your performance against the read of the radiologist. You can report your answers on this thread.
    #1: http://i491.photobucket.com/albums/rr271/platon205/mri027a1.jpg
    #2:
    http://i491.photobucket.com/albums/rr271/platon205/mri026b2.jpg
    #3:
    http://i491.photobucket.com/albums/rr271/platon205/mri025b2.jpg
    #4:
    http://i491.photobucket.com/albums/rr271/platon205/mri020a.gif

  19. Joe, you make a few good points:
    1. The US healthcare is not a ‘free market’ system.
    My response: I was not saying it was nor was I saying that it should be.
    2. MLPs do not solve total system cost issues because we do not have a ‘free market system’.
    My response: you are confusing two different issues:
    A. How much is the TOTAL amount that a system can spend?
    and
    B. How do we spend that money within the system?
    I was not suggesting mlps be used to solve a total system cost issue as I realize MLPs cannot solve a total system cost issue. The only thing that can solve a total system cost issues IS RATIONING. And FYI to remind you there are 2 ways we can ration:
    A. Demand led rationing—which is the basically free market rationing (“I can’t afford this so I won’t buy it (demand it)”)
    or
    B. Supply led rationing—which is basically a classic government control over how much is spent paraphrased “that is all you are going to get no matter what”.
    I was suggesting we use mlps (and newer yet to be developed careers which are ‘mlp’ like) in a ways different than today to solve issues around HOW we spend the money we spend within our healthcare system. So to give you an example, IF the total amount available to spend in a system is 10, and IF a technician costs 1 and an MLP costs 2 and a doctor costs 5: we can get 10 technicians for a price of 10, or we can get 5 mlps for a price of 10 or we can get 2 for a price of 10 (in fact we can get ANY permutation of them that total a price of 10).
    The reason I suggest we use mlps and even ‘newer’ careers yet to be developed is that IF a person (whether a doctor OR an MLP) can only see 2 patients (or read 5 studies) an hour. Then we can see 20 patients an hour/read 50 studies an hour in a 10 tech system, or we can see can see 10 patients and hour/read 25 studies an hour in a 5 mlp system OR we can see 4 patients an hour/read 10 studies an hour in a 2 doctor system (again, all systems only spend 10).
    (FYI– I do realize there are productivity differences between physicians and mlps- I am only making a simplified point)
    3. You corrected me that medical students in fact do have clinical rotations in their first two years.
    My response- “You are correct, but it does not change my basic point at all”.
    Medical education is simply WAY too much and can be done much cheaper—the numbers just don’t add up. Here is a link for the LSU medical school curriculum in the first 2 years http://www.medschool.lsuhsc.edu/student_affairs/curriculum.aspx. Notice 21% of the first year’s 873 hours are clinical. If you run the numbers with the following assumptions (and I have), they just don’t add up no matter how much you slice it: internists and family physicians cost between $100-$150/hour (after benefits/med mall/payroll taxes), emergency physicians cost between $150-200/hour (same) and anatomists (surgeons) cost $200-250/hour (same), assume a 50% overhead cost of buildings and admin (what most public school districts in the US pay), there is still no possible way you can get anywhere close to even $300,000 (and that even assumes clinical teaching with a 1:1 student: teacher ratio (unrealistic… my memory of didactics were with ratios on the order of 1:4 to 1:6) and that the teacher IS NOT billing the patient for their clinical evaluation as they are seeing the patient alongside the medical students (also very unrealistic). Run the numbers yourself, I did several times.
    4. I cannot read theses MRIs and CTs so therefore we need radiologists to read them.
    My response— this is not the proper comparison at all (and I think you know it). I can’t read pap smears, yet we still let techs read them. Why does my not being able to read a CT or MRI like you mean a tech cannot also be taught to read them? The comparison you need to make is between a TRAINED techs, (say pulled from art school and SPECIFICALLY TRAINED TO READ ONLY MRIs OF THE BRAIN for (say) 3 years). Then compare the sensitivity and specificity of these techs to radiologists. And IF the tech’s reading rates are worse, you then need to compute what each additional life saved would have additionally cost IF a radiologist had read the study and not a tech (using the cost of raining a tech vs. the cost of training a radiologist). And then you need to compare the amount spent per year of life saved on this difference vs. ever other way we could have spent money in our healthcare system.
    That is the ONLY valid comparison… And FYI, I would be willing to personally bet money that IF the study was done (and I know your specialty would do everything in its power to prevent it from ever happening) it would validate the use of alternatives to radiologists.
    It is certainly worth a try.

  20. Why pay a tech in the USA 50k to read MRIs when you can pay an Indian radiologist overseas 20k to read it?
    Thats already happening, in fact MGH sends about 40% of its reads overseas to be read electronically.
    Radiology is readily outsourceable and its happening en masse. Its a far better solution than training a new cadre of techs, all of whom would be billing insurance/Medicare at inflated USA cost of living indices.

  21. usain,
    If it was only as you say.
    Remember, to read films in the US, you need to be a licensed US radiologist, which is something that is controlled at the state level with medical licensing.
    This really means these Indian radiologists need to complete a US residency in radiology and have a US medical license in the state they are reading films.
    Indian degrees-training programs are not accepted as “good enough” by state licensing boards.
    These radiologists are really just US doctors living abroad and are really NOT all that much cheaper. To the extent they are it is becasue 1. they are willing to earn slightly less to be near their families and 2. the time difference allows these radiologists to read films during their daytime which would be our nighttime and therefore you do not need to pay premium salaries for keeping people awake all night.
    And FYI- while these kinds of programs are OK for us, they are terrible for India… really just another example of the taxpayors of another country subsidizing American citizens.
    Most of these physicians were given subsidized education by the Indian government which becomes a ‘brain drain’ to America.

  22. am amedical student in africa who is seeking for tuition to sponsor me to complete my course.i hve seen that the organisation has sponsored many medical students.
    thanx