Impact on HYPERLINK “Alternative medicine - Wikipedia” \o “Alternative medicine” alternative medicine
When Flexner researched his report, “modern” medicine faced vigorous competition from several quarters, including HYPERLINK “Doctor of Osteopathic Medicine - Wikipedia” \o “Osteopathic medicine” osteopathic medicine, HYPERLINK “Eclectic medicine - Wikipedia” \o “Eclectic medicine” eclectic medicine, HYPERLINK “http://en.wikipedia.org/w/index.php?title=Physiomedicalism&action=edit&redlink=1” \o “Physiomedicalism (page does not exist)” physiomedicalism, HYPERLINK “Naturopathy - Wikipedia” \o “Naturopathy” naturopathy and HYPERLINK “Homeopathy - Wikipedia” \o “Homeopathy” homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than HYPERLINK “Biomedicine - Wikipedia” \o “Biomedicine” biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.
Impact on HYPERLINK “Osteopathic medicine in the United States - Wikipedia” \o “Osteopathic medicine in the United States” osteopathic medicine
Although almost all the alternative medical schools listed in Flexner’s report were closed, the HYPERLINK “American Osteopathic Association - Wikipedia” \o “American Osteopathic Association” American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner’s recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of osteopathic and " HYPERLINK “Allopathic medicine - Wikipedia” \o “Allopathic” allopathic" medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.
References
HYPERLINK “Flexner Report - Wikipedia” \l “cite_ref-0#cite_ref-0” \o “” ^ HYPERLINK “http://www.unmc.edu/Community/ruralmeded/flexner.htm” \o “http://www.unmc.edu/Community/ruralmeded/flexner.htm” UNMC’s Flexner’s Impact on American Medicine
Beck, Andrew H., 2004, " HYPERLINK “http://jama.ama-assn.org/cgi/content/full/291/17/2139” \o “http://jama.ama-assn.org/cgi/content/full/291/17/2139” The Flexner Report and the Standardization of American Medical Education", Student JAMA 291: 2139–40.
Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press. HYPERLINK “Book sources - Wikipedia” ISBN 0801871247.
Flexner, A., 1910. HYPERLINK “http://www.carnegiefoundation.org/elibrary/docs/flexner_report.pdf” \o “http://www.carnegiefoundation.org/elibrary/docs/flexner_report.pdf” Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
HYPERLINK “Norman Gevitz - Wikipedia” \o “Norman Gevitz” Gevitz, Norman, and Grant, U. S., 2004. The D.O.s (2nd ed.). Baltimore: The Johns Hopkins University Press. HYPERLINK “Book sources - Wikipedia” ISBN 0-8018-7834-9.
Goodman, John C., and Gerald L. Musgrave, 1992. " HYPERLINK “http://www.ncpa.org/w/w67.html” \o “http://www.ncpa.org/w/w67.html” How The Cost-Plus System Evolved". Patient Power. Washington, D.C.: Cato Institute,
W67.
Kessel, Reuben, 1958. HYPERLINK “http://www.jstor.org/pss/724881” \o “http://www.jstor.org/pss/724881” “Price Discrimination in Medicine”, Journal of Law and Economics 1 (Oct., 1958): 20–53.
Starr, Paul, 1982. HYPERLINK “The Social Transformation of American Medicine - Wikipedia” \o “The Social Transformation of American Medicine” The Social Transformation of American Medicine. Basic Books. HYPERLINK “Book sources - Wikipedia” ISBN 0465079350.
Steinreich, Dale, HYPERLINK “June 10 - Wikipedia” \o “June 10” 10 June HYPERLINK “2004 - Wikipedia” \o “2004” 2004. " HYPERLINK “http://www.mises.org/story/1547” \o “http://www.mises.org/story/1547” 100 Years of Medical Robbery".
Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education. Univ. of Wisconsin Press. HYPERLINK “Book sources - Wikipedia” ISBN 0299117502, HYPERLINK “Book sources - Wikipedia” ISBN 0299117545.
HYPERLINK “http://www.washingtonpost.com/wp-dyn/content/article/2008/10/05/AR2008100502173_pf.html” http://www.washingtonpost.com/wp-dyn/content/article/2008/10/05/AR2008100502173_pf.html
‘We Are at a Saturation Point’ judges India’s health care system as underfunded and understaffed.
RESEARCH REPORTS, ISSUE BRIEFS, CASE STUDIES
Health Affairs
24) HYPERLINK “Account Suspended” The Geography of Graduate Medical Education: Imbalances Signal Need for New Distribution Policies from Health Affairs by Fitzhugh Mullan (et al)
We analyzed Medicare cost reports from teaching hospitals and found large state-level differences in the number of Medicare-sponsored residents per 100,000 population (1.63 in Montana versus 77.13 in New York), total Medicare GME payments ($1.64 million in Wyoming versus $2 billion in New York), payments per person ($1.94 in Montana versus $103.63 in New York), and average payments per resident ($63,811 in Louisiana versus $155,135 in Connecticut). Ways to address imbalances include revising Medicare’s GME funding formulas and protecting states that receive less Medicare GME support in case funding is decreased and making them a priority if it is increased
25) HYPERLINK “Account Suspended” Building a Health Care Workforce for the Future: More Physicians, Professional Reforms, and Technology Advances from Health Affairs by Atul Grover and Ldia M. Niecko-Najjum
Traditionally, projections of US health care demand have been based upon a combination of existing trends in usage and idealized or expected delivery system changes. For example, 1990s health care demand projections were based upon an expectation that delivery models. Realistic workforce planning must take into account the fact that expanded access to health care, a growing and aging population, increased comorbidity, and longer life expectancy will all increase the use of health care services per capita over the next few decades-at a time when the number of physicians per capita will begin to drop.
26) HYPERLINK “Account Suspended” Reforming Health Professions Education Will Require Culture Change and Closer Ties Between Classroom and Practice from Health Affairs by George E. Thibault
The size, composition, distribution, and skills of the health care workforce will determine the success of health care reform in the United States. Whatever the size of the workforce that will be required in the future to meet society’s needs, how health professionals are educated merits additional attention. Reform of health professions education is needed in the following six critical areas: interprofessional education, new models for clinical education, new content to complement the biological sciences, new educational models based on competency, new educational technologies, and faculty development for teaching and educational innovation.
HYPERLINK “http://www.census.gov/population/www/projections/usinterimproj/usproj2000-2050.xls” http://www.census.gov/population/www/projections/usinterimproj/usproj2000-2050.xls
Legislation Would Regulate Nurse-To-Patient Ratios In Hospitals.
On its “Floor Action” blog, HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2013041801ahla&r=5739032-a741&l=04b-069&t=c” The Hill (4/18/2013, Kasperowicz) reports that, on Tuesday, Sen. Barbara Boxer (D-CA) “proposed legislation that would require hospitals to maintain a minimum nurse-to-patient ratio at all times, and allow the government to audit and penalize hospitals that fail to comply with this rule.” Boxer’s bill “is meant to help address the nation’s shortage of nurses, and would also ensure patients get the care they need while in the hospital.” The measure “would apply to hospitals across the country that participate in Medicare and Medicaid, and is similar to bills that failed to advance in the last few Congresses.”
Sebelius Announces Initiative To Train Advanced Practice Nurses.
The HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2012073101ahla&r=5739032-edfe&l=017-4bb&t=c” Durham (NC) Herald Sun (7/31/2012, Offen) reports Health and Human Services Secretary Kathleen Sebelius “announced Monday at the Duke School of Nursing a four-year, $200 million project designed to dramatically increase the number of advanced practice nurses providing primary care, particularly in under-served areas.” Duke and four other hospitals in the US selected for the project “will double the number of advanced practice nurses it trains, with 216 additional students enrolled by 2016.” The Herald Sun quotes Sebelius as saying, “We are putting more advanced practice nurses on the front lines of our health care system and further strengthening and growing our primary care workforce,” adding that the project “will help achieve the goals of the Affordable Care Act by increasing access, cutting costs and ensuring high quality medical care by significantly expanding the number of nurses with advanced degrees who can deliver primary care.”
The HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2012073101ahla&r=5739032-edfe&l=018-715&t=c” AP (7/31) reports Sebelius “also met with nurse practitioners to talk about investing in the nursing workforce through additional training and support provided by the law.” Payments to the hospitals, which will be spread over four years and provided under the Affordable Care Act, “will be determined by the number of additional nurses the hospitals are credited with training.”
The HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2012073101ahla&r=5739032-edfe&l=019-7a4&t=c” Raleigh (NC) News & Observer (7/31, Bonner) reports, “One of the requirements for Duke and the other hospitals is to have half the clinical training for students occur in non-hospital settings.”
Meanwhile, the HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2012073101ahla&r=5739032-edfe&l=01a-997&t=c” Houston Chronicle (7/31, Kever) reports, “Rick Gilfillan, director of the Center for Medicare and Medicaid Innovation, said each hospital will be reimbursed for the costs associated with training the nurses, rather than being given a set amount of money.” Texas’ shortage of healthcare providers “is expected to grow worse as more people gain health insurance when the main provisions of the Affordable Care Act take effect in 2014,” but “advanced practice nurses could absorb some of the burden by providing primary care.”
California Senate Approves Bill Expanding Role Of Nurse Practitioners.
The HYPERLINK “California considers expanding role for nurse practitioners” Los Angeles Times (5/29/2013 , McGreevy) reports that the California state Senate Tuesday approved a bill which “would allow nurse practitioners to independently perform more medical functions now within the domain of physicians.” The measure, intended to address “an expected shortage of doctors” in the state, “would allow nurse practitioners to have stand-alone practices to provide primary healthcare services independent of physicians including certification of disability claims, prescription of drugs and approving many treatments.”
State Medical Licensure Requirements Pose Barriers For Volunteer Physicians.
HYPERLINK “http://mailview.bulletinhealthcare.com/mailview.aspx?m=2012091701ahla&r=5739032-8c1d&l=03d-7f7&t=c” American Medical News (9/17/2012, Krupa) reports on the debate over medical licensing. Physicians must typically complete complex licensing applications for each state, which “makes it difficult for physicians to practice in multiple states if they want to volunteer to help victims of disasters or if they work for a growing number of health systems extending across state lines.” Additionally, the article notes that “the expansion of telemedicine also has fueled the debate for physicians seeking to use technology to bridge geographic barriers to care.” Later, the article mentions that “the American Medical Association supports standardization of licensure requirements, greater reciprocity among states and reduced licensing burdens on physicians.”
HYPERLINK “Bloomberg - Are you a robot?” Bloomberg - Are you a robot?
Health Care A Looming U.S. Doctor Shortage By HYPERLINK “Bloomberg - Are you a robot?” Alex Wayne on September 27, 2012. When the Affordable Care Act’s insurance mandate takes effect in 2014, some 30 million newly covered patients—people generally treated in emergency rooms now—will be shopping for doctors. That’s a problem because the U.S. has 15,230 fewer primary-care physicians than it needs, according to the U.S. Department of Health and Human Services.
Yet teaching hospitals aren’t rushing to fill the void. The federal government foots most of the bill for residency programs—and Congress has capped enrollment at about 85,000 students for the last 15 years. “We’re actually already later than we should be in addressing the issue,” says Tom Price, a Republican congressman from Georgia who’s also an orthopedic surgeon.
Medical schools are pressing lawmakers to pass legislation introduced in August that would add 3,000 residencies a year through 2017. The cost to taxpayers: about $9 billion. “It is an expense that is necessary,” says Allyson Schwartz (D-Pa.), a co-sponsor of the bill. Deficit-watching Republicans say the government should quit funding the program.
Medicare pays for more than 75 percent of doctor residencies. Atul Grover, chief public policy officer for the Washington-based Association of American Medical Colleges, says teaching hospitals pick up the tab for about 10,000 positions annually, at a cost of $145,000 per resident. One way to lessen the burden on taxpayers would be to collect fees or taxes from insurers, Price says. That would amount to a “cost shift,” says Robert Laszewski, an insurance industry consultant in Alexandria, Va. Insurers “pass all premium taxes, state and federal, on to the customer,” he says.
The administration says taxpayers are already subsidizing doctor training too heavily. The government spent $9.5 billion on the program in 2009, the most recent year available. That was $3.5 billion more than what it actually cost for residencies, according to the Medicare Payment Advisory Commission, which monitors the spending.
But Washington isn’t accounting for all the indirect costs associated with training, says Mike Rossi, who oversees government reimbursements at the University of Pennsylvania Health System. Of the $120 million Medicare paid last year to support 855 Penn residents, $96 million went toward direct expenses such as salaries; the remaining money was necessary to cover “clinical inefficiencies,” Rossi says, such as having residents perform multiple tests on a patient so they can get practice.
If funding issues aren’t resolved, Grover’s organization predicts the doctor shortage, including specialists, will climb to 130,000 by 2025. That may mean less preventive care and fewer hoped-for cost savings. Says Grover: “We’re going to have to find ways to see more patients with fewer physicians.”
The bottom line: The U.S. is short on primary care doctors, just as 30 million people are about to acquire health insurance under Obamacare.
HYPERLINK “Nightly News with Lester Holt: The Latest News Stories Every Night - NBC News | NBC News” Nightly News with Lester Holt: The Latest News Stories Every Night - NBC News | NBC News
It’s a national health care crisis. There just aren’t enough doctors in our country. The shortage has hit rural America especially hard, but there may be some solutions. NBC’s chief medical editor Dr. Nancy Snyderman reports.
Chiara Sottile writes
Tucked among the cornfields, windmills and water towers of Littlefield, in west Texas, Dr. Isabel Molina treats one patient after the next at Lamb Healthcare Center.
Littlefield is a small, dusty town of about 6,500 people, but Molina’s two-doctor practice draws from a much larger area. She and her partner serve a total population of about 15,000, she estimates. To keep up with her patient load, Molina regularly works 13-hour days without stopping to eat.
“I usually eat breakfast over charts. I usually eat lunch over charts while I call patients back and take care of my dictations,” says Molina, 38. “I do love what I do, but it is getting a lot harder to do this.”
Molina is just one of thousands of primary care doctors nationwide working in an area designated as having too few health professions to meet the needs of the population.
The Association of American Medical Colleges (AAMC) estimates that there is a shortage of up to 20,000 physicians and that the deficit will grow to 100,000 physicians in the next decade. An aging population - and an aging population of physicians themselves - will make matters worse as health needs become more severe and as doctors retire without enough new ones to replace them. And, millions more Americans will rely on our existing physicians when the Affordable Care Act fully kicks in next year.
“We are very concerned that we’re going to hand insurance cards to 30 million people and we won’t have the doctors to treat them,” says Dr. Atul Grover, the chief public policy officer at the AAMC.
West Texas is one pocket of the country where entire counties lack even a single health care provider. The dire need inspired an innovative program at Texas Tech University Health Sciences Center in Lubbock, Texas.
“We felt at Texas Tech that it was very important to help solve the primary care crisis as best we could and one of the ways of doing that was to try to make sure we get enough students into primary care and into family medicine,” says Dr. Steven Berk, the dean of the School of Medicine at Texas Tech University Health Sciences Center.
From that concern, the Family Medicine Accelerated Track (FMAT) was born at Texas Tech. The program teaches the competencies of four years of medical school in only three years and offers a scholarship to all students in their first year.
Keeley Ewing-Bramblett is a third-year medical student at Texas Tech who grew up in the rural, one-physician town of Post, Texas, and saw firsthand how overloaded the town’s only doctor was.
“I really just want to go back to a place where I know I’m going to be making an impact and where I’m going to get to see kind of the fruits of that impact,” says Ewing-Bramblett, 24. She signed up for the FMAT program the day she heard about it, and hasn’t looked back.
"When they offered an accelerated track where I could get out and be doing what I love essentially a year sooner and also for half the amount of debt that would have otherwise been incurred, for me it was kind of a no-brainer,” recalls Ewing-Bramblett.
To curb the physician shortage, medical schools across the country have boosted their enrollment by 16.6 percent since 2000. Five-thousand more students are expected to graduate per year by 2019, according to the AAMC.
But just graduating more students won’t reverse the physician shortage.
There has been a bottleneck to getting more young doctors into residency programs: the stage in medical training that follows graduation from medical school and takes place under the supervision of licensed physicians. The number of federally funded residencies has been frozen since 1997 when Congress passed the Balanced Budget Act.
“A lot of the benefit of increasing those class sizes and building those new medical schools - a lot of those benefits won’t be realized unless there’s additional residency positions,” admits Berk.
Of almost 22,000 U.S. medical school graduates who wanted to be “matched” to a residency position this year, 1,600 applicants did not find one, according to the National Resident Matching Program that places residents.
That’s one more reason why lawmakers are stepping in. Congressman Aaron Schock (R-IL) and Congresswoman Allyson Schwartz (D-PA) introduced the “Training Tomorrow’s Doctors Today Act” in March that would create 15,000 new Graduate Medical Education slots over the next five years.
In an interview, Schock stressed that, “We know that a crisis is coming where there are more and more Americans who need doctors that are going to go without if we don’t get them trained and in the field.”
Even if the bill passes - no easy task in an era of squeezed budgets - there is no guarantee that new doctors will practice in the areas where they are needed most.
“Physicians cluster in urban centers where they can work with each other efficiently and leave the rural areas and some other areas underserved in the process,” explained Dr. Richard “Buz” Cooper, director of the New York Institute of Technology’s Center for the Future of the Healthcare Workforce.
Back in Littlefield, Molina bounds from one appointment to the next. “When you’re this short-staffed, it becomes something that is at the cost of everything else. Missing things with my kid, missing things with my family,” she admits.
As she leaves one exam room, files the necessary stack of papers and steps into another room to asses a patient, , she smiles all the while. “Once I actually have help, I think then I’ll be able to relax and see what a real life feels like again.”
Dr. Michael Johns, a professor in the Schools of Medicine and Public Health at Emory University, says it will take wider reform to get doctors the help they need. “Just having more doctors is not going to fix this.” he says. “For one, we need a team-based approach that will get nurses, and other members of the healthcare team more involved with more responsibility.”
And, while the Family Medicine Accelerated Track will graduate more family care doctors, it does nothing to increase the number of specialty physicians nationwide.
“What everyone is missing is that a little over half of the shortage is in specialty medicine,” argues Johns. “The battle shouldn’t be about having a 30-to-70 ratio of specialists to primary care doctors, it should be about how we have a shortage of both.”
The slow pace of reform is frustrating for medical students like Ewing-Bramblett who chose primary care medicine because her mother suffers from chronic illness and a primary care physician made an outstanding difference in her care.
“It hurts me on a few levels,” said Ewing-Bramblett. “There’s just no way that you can establish the type of relationship with your patients that’s going to really foster their care like I experienced with my mom. There’s no way you can do that in the 10 minutes that you have to see each patient.”
For now, all she can think to do is hold on to her determined spirit. She knows what to expect: the long hours, waiting rooms packed with patients, even personal sacrifices.
“There’s really no question about where I want to go,” she says. “I’m going to be making a difference in at least one small community.”