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!