Medical Student Burnout

This NY Times article is written by Pauline W. Chen, MD, Harvard College grad and author of Final Exam: A Surgeon's Reflections on Mortality. It's a stark reminder perhaps to think hard and weigh your options before embarking on the medical path. But even if you pursue medicine for all the right reasons and with enthusiasm, medical school is just a very, very challenging experience for most students.

The medical culture is not one that can be characterized as actively encouraging students to admit vulnerability and ask for help. But it's so important to do so.

Cuts in Funding for Cambridge Health Alliance

With all the budget problems for the federal and state governments (mostly notably California), it may not be a surprise that there are anticipated deep funding cuts coming for the Cambridge Health Alliance. This healthcare network runs many of Boston's community health clinics in underserved communities.

Presidential Health Plans

Newsweek has a quick Q&A session with a Harvard health policy professor about the healthcare plans proposed by Obama and McCain, drawing some lessons from Massachusetts.  Might be a good primer for those headed out on medical school interviews.

Got Insurance?

Why the candidates' plans might not deliver on universal health coverage

Mary Carmichael

NEWSWEEK

From the magazine issue dated Oct 6, 2008

Barack Obama and John McCain have put forth radical—and radically different—proposals to change the way Americans do, or don't, get health insurance. Is it really possible to make sure everyone's covered? Are the candidates even trying for that? And what lessons can we learn from Massachusetts, which has embarked on its own experiment with universal health care? NEWSWEEK's Mary Carmichael spoke with Katherine Swartz, a professor of health policy and economics at Harvard who studies insurance and recently published an in-depth analysis of the McCain plan:

CARMICHAEL: McCain wants to take away the tax break workers get on health insurance at their jobs, and instead give people who buy their own insurance $2,500 in tax credits. Families would get $5,000. What do you make of this idea?

SWARTZ: The positive part is that it would reduce favoritism in the tax system. If you're unemployed, or if you're with a small employer who doesn't provide health insurance, you don't get any special treatment [taxwise] on insurance now. The bad part is that the tax credit could make it harder for low-income people to get insured. In the current system, a lot of low-income people with jobs are getting insurance they could never afford on their own.

The credit is supposed to help.

But you have to purchase health insurance to get the tax credit, and low-income people still may not be able to do that. For a family, insurance premiums in the nongroup markets are typically above $700 a month, and that's with a deductible of at least $5,000. We're talking $8,400 a year in premium payments, but the tax credit is only for $5,000. You still have to pay $3,400, plus the deductible, before the insurance covers medical expenses. Also, the type of coverage on the individual market typically does not cover as many services as group policies. If you buy your own policy, when you get sick, you are going to pay more out of pocket.

Can you explain McCain's plan to help out people with previously existing conditions by expanding "high-risk pools"? 

We've had state-sponsored high-risk pools for several decades, but they cover fewer than 200,000 people. They were set up so insurance companies could essentially cede people who they predicted would have very high health-care costs. At one point McCain said he would subsidize high-risk pools with between $7 billion and $10 billion a year. That would cover maybe 3 million people, which is not much of a dent in the 47 million people without insurance now.

How many people would be insured under McCain's proposals, compared to today?

My colleagues and I have predicted that around 21 million people in the first year would lose access to health insurance because their employers would stop offering it. About 21 million higher-income people would take the tax credits and buy their own insurance. So it would be a wash in the first year. We worry that within five years, more employers would stop offering insurance, and we'd end up with more people uninsured than there are now.

Now let's look at Obama's plan. What exactly is an insurance exchange?

The one he's proposing looks a lot like the Health Connector we have in Massachusetts. It acts as a clearinghouse where people can buy insurance policies that are essentially given the Good Housekeeping Seal of Approval by the state. In the Obama plan, there's a minimum set of benefits every plan has to offer, and if your income is below some threshold yet to be specified, you would get a subsidy. Small businesses could also use this exchange to provide health insurance. This has worked very well in Massachusetts.

And his national health plan?

It's basically one more choice offered in the exchange. It sets a floor for what kinds of services the other plans would have to offer. Here's where we have to start thinking about the total cost. If the national plan is quite generous in terms of services covered, the proposal's cost will be more than the campaign is estimating.

In Massachusetts, costs have already gotten out of control.

Costs are higher than expected, but that's partly because the original projections underestimated the number of uninsured people who were eligible for subsidies. It's also partly because health-care costs are rising—and that's the case everywhere.

Obama would also require insurers to cover people with pre-existing conditions. Wouldn ' t insurers raise premiums?

Yes, premiums may be higher. I think people need to consider the alternative—if patients are closed off from coverage, they still go to the ER, and we all pay for that.

Does the Obama plan actually provide universal coverage?

No. It requires that children be covered, but there's no mandate for other individuals. Some adults would continue to be uninsured—roughly 6 percent of the nonelderly, compared with 17 percent now, so many more people would have insurance than do now.

Obama's plan is very ambitious. How on earth can we pay for it?

Given the federal deficit, that's a problem for both plans. McCain's plan is not cheap either. I think it will be hard for either candidate to do much in the next few years.

Plan to defer or apply later?

I've met with quite a few students recently considering the timing of their med school applications. For those who know they want to take some time off, the question is whether to apply now and plan to defer enrollment or apply later and plan to enter med school for that application year.

Quite a few advisors and admissions deans have been weighing in on the topic. I thought I'd share one perspective from a med school admissions dean. Some of the text has been modified to remove identifying information.

I would just like to clarify some points from a medical school perspective.

First and foremost, applicants can only request deferral if they have been accepted to medical school, that is, if they already hold a place in an entering class. There is no "deferral policy" from AMCAS, so each medical school decides whether:

1. it grants deferrals (and many do not);
2. it has deadlines to apply for deferral;
3. it places conditions for the deferrals (ie. one year, two, indefinite, etc or only granted for certain reasons);
4. whether the deferral is binding or not.

It gets slightly more complicated because of point #4 and the fact that AMCAS requires all deferred applicants to reapply, for there is no other way to enter them in the matriculation year's data base. The reapplication, though, is more or less a bureaucratic procedure and if the medical school has a "binding" deferral policy, there is not even an application fee involved. A binding policy means that the applicant can only "reapply" to the one school that granted him/her the deferral. If the deferral is not binding, then AMCAS charges the fee because, in principle, the applicant can reapply in the open market while still holding a place at one school.

I know, it is kind of complicated. Hopefully I was able to explain things more or less clearly. We typically defer between 5-8 applicants each year, almost automatically upon receiving a request. This is because, in general, the request is for work/study/fellowship related activities. From our perspective Rhodes, Fulbrights and other prestigious fellowships or awards get our automatic deferral. We do have a binding policy so the deferred applicants don't pay the AMCAS fee and are automatically entered as "Accepted" in the reapplication year data base.

When applicants approach me to ask whether they should apply one particular year but with the intention of deferring, my advice is to say, "don't do it."

Lee Ann and I agree with this final assessment. We do recommend that students not apply to medical school until they are ready to attend, given the restrictions on deferral and the advantages of having an extra year for the medical schools to review (i.e. more life experience, more coursework, etc.). In addition, if an applicant is accepted off a wait list, he or she will not be able to defer. On the other hand, if applicants are fortunate to receive a great opportunity, or decide after application that they need a break, they may apply for and be granted a deferral.

We're of course available to discuss your particular situation.

Sophie, M.D.

Public Health Dentistry

In thinking about global health, students don't often consider the various avenues outside of becoming a medical doctor. Dentistry is one of those options. Here's what a graduate from the Harvard School of Dental Medicine said when I asked, "What have you found to be the best resources for exploring public and global health options in dentistry?"

As for different avenues for public health dentistry, both domestic and international, there are several. Often, students who are part of a particular religious group (e.g.- Alpha Omega, CMDA = Christian Medical and Dental Association), and/or social organizations (e.g.- YMCA), can find opportunities to serve through pre-established partnerships. Within each dental school, there are usually a couple faculty who are involved in public service, whether it be in nearby communities or abroad. It is important to note that although there is a need for international healthcare providers, medical and dental healthcare needs in our immediate domestic and U.S. communities are very real as well.

My best advice for those students who are interested in pursuing public health dentistry would be to directly contact the Public Oral Health Policy and Epidemiology Department at their respective dental schools. Generally, it is there that they can find a wealth of undiscovered information regarding on-going service projects, and/or collaborate with faculty to pursue new projects and ideas.

For those who are interested, a helpful resource may be the International Volunteer Organizations Guide. And for those Harvard students out there interested in dentistry, we're hoping to announce a program for you soon. Stay tuned.

"Traffic rules" for accepted students to med school

Lee Ann and I have been getting a number of questions from concerned students who have been accepted to med school this year. Upon acceptance, med schools ask students to respond to their acceptance offer, typically within two weeks of acceptance. It's important to realize that accepting this offer means holding a spot at that school and does not mean a binding commitment to attend.

Per the traffic rules from the AAMC, accepted students may hold multiple acceptance offers until May 15, at which point they will need to choose one school and withdraw from the remainder of their offers. They are not required though to withdraw from schools where they have been waitlisted. Of course, if a student has already made a decision not to attend prior to May 15, they should withdraw to be fair to other applicants in the pool.

If you have questions about this, please let Lee Ann or me know!

Med school applicant trends and data

Recently, I was at a meeting for Boston-area health professions advisors, and a couple folks from the AAMC (Association of American Medical Colleges) were discussing med school applicant data. I don't think any of this should necessarily inform an individual student's decision-making around medicine but it is interesting nonetheless.

What pleasantly surprised me is the data on re-applicants (meaning students who apply but are not admitted the first time). Of those applicants who applied only once, 48% were admitted (this is the national average; Harvard's was 93% last year). Of those who applied twice (meaning those who were denied the first time through), 39% were admitted. To me, these are encouraging numbers (when noting the marginal difference in rates between first- and second-time applicants). Total re-applicants are a fairly small group but it seems that many of these students succeed in the end.

Having said this, when making decisions around whether to apply now, apply later, or reapply, it's really important to talk through these individual circumstances. The important point to make about re-applicants' success is that it is not due merely to having submitted an additonal application; rather, it's because these students significantly improved the weaknesses in their original application. I often (as I know Lee Ann does as well) encourage premeds to plan to apply to medical school just once, to take this approach. This means addressing the significant weaknesses before applying, not using the application process as a gauge of competitiveness. Applying to "see how it goes" is usually not the best strategy.

There are practical reasons for this--time, money, psychological burden, etc.--but I do think that upon applying again, re-applicants are scrutinized in a different way. They are expected to have significantly updated their applications. This is all to say, plan to apply once. But for re-applicants who are ultimately qualified and for whom medicine is good career, a healthy number succeed in the end.

But on to other things...

Right now, we're experiencing a peak in applications. The total number will be around 42,000 in 2008. Historically, this comes after a dip in 1988, a peak in 1996, and another dip in 2002 (dot com bubble?). And by 2015, the AAMC projects that the number of applications from women will exceed those of men.

For more information on Harvard data for medical school, OCS publishes a data report which is available for viewing in the 1st floor library. And if you have photos or pictures that would be good for this blog, please send them my way! Not enough mixed media on this thing.

Global health resources and panelists' nuggets of wisdom

The panelists at both the undergrad and "gap year" discussions during the Global Health Expo last week had a lot of good advice and resources to share. These programs affirmed to me the value of the Harvard community, the wealth of expertise and wisdom that exists among you all.

The panelists at the gap year discussion recommended several good web resources, including globalhealth.org, the listserv on the American Medical Student Association's (AMSA) global health site, and the directory of non-profit orgs from idealist.org. The challenges in global health are large and complex, and there are not clear-cut linear paths to exploring the field (or fields since it encompasses so many). As a result, learning to do informational interviews is such a good practice to get into. There are a ton of Harvard alumni who are happy to talk with you about what they do. Follow your curiosity and reach out to them via Crimson Compass. It's easier to conceptualize something like a job or organization when it's personalized.

One of the take-homes for me from the undergrad panel was to find a community here where you can discuss these issues. And, from the gap year panel, a take-home was to begin to develop your own framework for thinking about global health in order to know what questions to ask and to be able to critically evaluate the work of NGOs.

Below are the remainder of my take-homes (as interpreted by me). It's a fairly quick and dirty list. But first, the earth:

Undergrad panel (4 seniors)

• find an intellectual community or peer group and discuss issues
• equip yourself to speak the language of global/public health
• learn how what you can do now at Harvard connects to larger, longer-term goals
  go for big questions; technical expertise by itself is easy
• seek broader contextualization of issues
• distinguish between an organization’s ethos (e.g. social justice) and actual product
• get involved with a good organization; be okay with putting yourself at their service
• pick courses based on people and ideas primarily
• orgs are often reticent to involve undergrads; know what you’re getting yourself into
• it’s okay to struggle with whether or not a future in medicine is the best option--this is common!
• find mentors and see how they did it
• it’s an important geopolitical moment for global health…go for it!

Gap Year Panel (1 MBA, 1 PhD, 2 MD/PhDs)

• investigate specific organizations
• think about particular skill you would like to develop; what do I want to learn in the 1-2 years off?
• distinguish between an NGO’s mission statement and actual impact
• seek out mentorship and don’t just jump at any opportunity; some oversight will make the experience more fulfilling and less disorienting
• time off is time well spent--you will inevitably gain something from it; even learning to take care of yourself and pay your own bills is worthwhile.
• ask about the size of the organization (e.g. World Bank or community setting?)
• ask about where you’ll be living (e.g. among international crew or local people?)
• gap year can provide context to what you’re doing, what you want from your work
  experience, in any form, can be formative; don’t underestimate this
• learn a language perhaps
• use the gap year to explore whether you really need an MD
• make sure you know who the org is accountable to
• be wary of orgs that ask for money or sound too good to be true
• when you arrive, be sensitive to culture; observe and be friendly but don’t state solutions
  honestly evaluate whether you’re really ready for grad school
• do informational interviewing in the field (e.g. Crimson Compass, professors, etc.); word of mouth is valuable

Enjoy the long weekend!

Funding for global health experiences

So much that I'd like to write about after the Global Health Expo last Thursday and Friday. (There have been some great freshman programs recently too but those'll have to wait.) Since what's most pressing for students right now is the fellowships process, I wanted to share information about several specific funds that would apply to global health work.

Here are the particular ones mentioned at the gap year panel last Friday. This isn't an exhaustive list. Many others can be found in the supplement to the Harvard Guide to Grants and Harvard's international funding database. An alternative way to find OCS-administered fellowships is by looking at the calendar of deadlines.

• Roux (all returning undergrads; overseas; summer; March 20 deadline)
• Boothe (juniors & seniors;U.S. or overseas; summer; February 20 deadline)
• Pforzheimer (juniors & seniors; US or overseas; summer or post-grad; March 7 deadline)
• Richardson (graduating seniors; US or overseas; post-grad; March 12 deadline)
• International Centers, e.g. DRCLAS (undergrads; overseas; summer; February 26 deadline for common application)
• Other public service fellowships or international fellowships

Keep in mind that fellowships and funding can be found everywhere, including at other centers on campus. Get out there and poke around. And keep in mind that something like the Roux is for an overseas project specifically around global health issues but other funds may apply to the same project. Make sure you read the criteria carefully.

Much more nuggets to share about the Global Health Expo but will need to do that later. By the way, 317 students attended the fair at OCS on Friday afternoon. Wow!

Next time...take-home points from both undergrad and gap year panels

It's fellowships time

Many students are in the process of applying or thinking about applying for funding for their summer opportunities. I wanted to share some of my quick thoughts.

• "Fellowship": There's nothing special about the word. All it means is a type of grant--financial support provided to an individual for some specific experience. I'll admit that I didn't understand the concept of a fellowship until after college! Don't get intimidated by the word.
  
  
• Gobs of Money?: Yes, it's true that Harvard offers a ton of financial support to students to do interesting things with their summers. But it doesn't mean getting that support is easy. The difficult thing with fellowships or internships at Harvard and elsewhere is the sheer number and variety of them. Each has their own criteria and restrictions whether it be by class year, time period, industry or field, area of the world, nature of the opportunity, etc. Case in point: Even as someone who served on the selection committee for one of the Radcliffe fellowships last year, I can't recall exactly what the criteria were for that fellowship (although I certainly knew them at the time!).
  


• Where to look?: Finding an appropriate fellowship requires time. Browse the OCS fellowships office website; you'll find the Harvard Supplement for their guide to grants online. Monitor your listservs and keep your ears open. Some fellowship and internship programs, like Weissman and CPIC, are well-publicized, others not as much. And if you have specific questions, drop by the Fellowships office on the 3rd floor of OCS. Paul and Adonica have open walk-ins during the day and can either answer questions on the spot or arrange to meet with you later. So long as you have some sense of what kind of opportunity you're interested in, they should help give you a sense of the fellowships landscape.
  


• When to apply?: It's intersession and time to relax so I don't like talking about deadlines but do keep in mind that many fellowship deadlines are in February (and some at the end of January).
  


• Shapes and sizes: While a fellowship basically means funding, they come in different flavors. For instance, for one fellowship, you may be asked to apply with an internship that you intend to set up on your own in mind (e.g. Weissman). For another, you may be asked to explain your interests in your application, and the organization will then find an internship or opportunity that suits you (e.g. many of Harvard's international centers such as the Davis Center for Russian and Eurasian Studies). And the most structured programs offer the opportunity and the funding together (e.g. IOP Director's Internships in which internships are already set up). All fellowships will require that you have a sense of what you'd like to do but it's not true that you necessarily need to know every last detail.
  


• How to further explore?: First things first, think about what you'd ideally like to do. I often recommend that students look at what other students have done to see the range of possibilities out there. So if you know you're interested in going abroad, check out the (newly online) Weissman reports, wonderful write-ups by previous fellows that describe their experiences. If you know the general field you'd like to pursue, reach out to faculty, departments, and academic centers to see what they know. If you know the area of the world you'd like to be in, reach out to Harvard's international centers. When I asked these orgs at the Summer Opportunities fair if they'd be willing to meet with students to discuss their interests, I don't think there was anyone who refused. Folks want to help you! And talk to your fellow classmates whether that means individually or via a student group. In many ways, you guys are your own best resources.

Good luck! If there's something you'd like me to clarify or expand on, let me know. Happy intersession.

The "traditional" professions

Really interesting article in the NY Times about medicine and law, the two "most elite of the traditional professions." Lots of evidence of burnout and dissatisfaction in both perhaps due to a culture shift in how we think about work, more demanding hours and work conditions, and the allure and perception of competing options like investment banking. The article puts notions of prestige and money right out there in the open, and is brutally honest about what some doctors think about the work they chose.