Vol. 143 March 1, 2016 What’s In A Name?

March 1, 2016

Hub thumbnail 2015

 

Few Americans recognize the contributions of IMGs (international medical graduates), or more broadly all foreign-born physicians, to U.S. healthcare.

 

Physicians born anytime in the 1930s – 1950s are more likely to have the surname Smith, but starting in the 1960s the U.S. saw an uptick in diversity, and in both the 1970s and 1980s, Patel topped this list as the most common last name among all physicians. Patel is now officially the last name most frequently preceded by “Dr.”

Rank 1930‑39 1940‑49 1950‑59 1960‑69 1970‑79 1980‑89
1 Smith Smith Smith Lee Patel Patel
2 Lee Lee Johnson Smith Lee Shah
3 Miller Miller Miller Johnson Kim Lee
4 Johnson Johnson Brown Patel Smith Smith
5 Kim Patel Williams Kim Nguyen Nguyen

This trend is likely to continue. Since the 1980s, the number of Asian American med school graduates has increased from almost none to making up approximately a fifth of all graduates . According to the 2014 census, foreign-born doctors now make up approximately 25 percent of all physicians practicing in the U.S.

Current medical student enrollment statistics reflect a similar mix.
Of 86,746 medical students in U.S. medical schools in 2015:

46,108 were men       (53%)
40,634 were women  (47%)
All: 54% white
.      20% Asian
.      8% multiple ethnicity
.      6% African-American/Black
      5% Hispanic
Only 2% of U.S medical students are “Non-U.S. Citizen or Non-Permanent Resident”

These figures confirm that most of the 25% practicing physicians that are “foreign-born” have come to the U.S. after non-U.S. medical school graduation for residency training and have stayed to practice. Foreign born physicians require a J-1 visa from the U.S. government to participate in our residency training programs. In 2011 65% of physicians with a J1 visa (foreign-born) were practicing primary care (internal medicine, pediatrics, and family medicine) compared to 28% of U.S. medical graduates.

The AMA has estimated that once the Obamacare “access to care” elements are fully implemented and as our older age demographic increases we will be about 90,000 physicians short of those needed to maintain optimal physician/population ratios. Much of that “physician shortage” will be in primary care. Interestingly the two most popular specialities for IMGs are Anesthesia and Psychiatry. One specialty does not require a lot of talking to patients. They are asleep most of the time. The other requires nothing but talking! Of course, the highest percentage of IMGs (20%) are from English-speaking India.


Vol. 100 November 1, 2013 Paranoia and Other Scary Bits

November 1, 2013

Cheney cartoon

“Just because you’re paranoid doesn’t mean they aren’t out to get you.”
– Joseph Heller, Catch 22

Even the powerful can get paranoid
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. (1) We knew that his DC residency was pixellated in the Google satellite view. We wondered if he was on the NASA phone surveillance list, but then we remembered that he ordered that.

Sometimes “They” are right
Surveys of over a million people nationwide revealed that Northeast people were described as “irritable, impulsive, and quarrelsome”. Ever drive in Boston? Midwest and Deep South people were considered “conventional, friendly, sociable, compliant, and emotionally stable”, while the West weighed in as “creative and relaxed, reserved, and perhaps somewhat distant.” Well, California IS distant from Boston and New York. (2)

“Whenever physicians are talking about quality, they are talking about money”
From 2005 to 2010 the urology practices that owned a new radiation technology (IMRT) for treatment of prostatic cancer used IMRT twice as much as urologists who did not own the machine so had to refer patients to others for IMRT. Treatment of prostatic cancer with IMRT cost about $31,000 as compared to about $16,000 for surgery or implantation of radioactive seeds. (3)

“I can’t find a primary care physician!”
In 2006 the Association of American Medical Colleges (AAMC), fearing a future doctor shortage, recommended a 30% increase in medical school slots. That goal may be reached by 2016. BUT, there has been no federal support for increased residency training slots. The AAMC states that there is currently a 15,000 shortage of residency training slots. Medicare funding of Graduate Medical Education (GME) is the major support of residency training, and it was reduced by $11 billion during the ACA debates. It is unlikely to be restored during the 2014 budget debates.  “Physician shortages may become more apparent as the ACA’s coverage expansion takes hold.” (4)

“Not another new flu?!”
Chinese health officials announced in March that a “novel” influenza A virus (H7N9) had infected 132 people and that 37 of them had died. BUT, there has been no evidence of human-to-human transmission and very few of the 20,000 Chinese with flu-like illness actually showed infection with H7N9.  A new element in the tracking of the virus was the recognition of huge spikes in tweets containing the word “H7N9” in both Chinese and English. “Digital Disease Surveillance” is the new term.

Why does a state refuse federal money via Obamacare to subsidize its Medicaid program ?
The New England Journal of Medicine says there are 33 such states, and John Stewart says there are 26. These states are declining to set up health insurance marketplaces (“exchanges”) under Obamacare (ACA) and have acquiesced to the federal government to do so. As a result these states will NOT receive the ACA federal subsidy (up to 100%) of their Medicaid costs for the next three years. John Stewart’s incredulous search for a common denominator of why these states would “bite off their nose to spite their face” came up with only one, a Republican governor and/or a Republican-controlled legislature. (5)

“Umpires are always ruling against my team!”
A study of a million pitches in or near the strike zone, but not swung on, revealed that umpires are less likely to call close ones against batters who are catchers. Presumably due to the rapport that the two develop over long hours of being in close proximity.  Also, the strike zone for the next pitch when the count is no balls and two strikes is apparently 26% smaller than the strike zone when the count is 3 balls and no strikes.(6)

There is no free lunch…or free drugs.
Coupons for free prescription drugs were available in 2011 for nearly 400 brand-name drugs or about 11% of all brand-name prescriptions. 75% of the coupons were for drugs treating chronic conditions (those needing six months or more of treatment), and 58% of those brand-name drugs had lower-cost alternative drugs available. By the time the brand-name coupons expire or run out, the pharmaceutical companies seem to hope that the patient has developed a loyalty for it or resists a change to a lower cost equivalent because of its perceived effectiveness.(7)

“I could be killed by lightning playing golf in the rain.”
Who would think otherwise with all those golfers out there swinging metal golf clubs under big antenna-like umbrellas in the rain? It turns out that anglers, campers, and boaters account for more of the 152 fatal lightning strikes over the past seven years than golfers.  About half of the anglers and boaters were struck while seeking safety. The others were clueless and presumably victims of a “bolt from the blue.”

Fear of terrorism
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”…”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.” (8)

“Will my baby’s flat head harm the brain?”
The American Academy of Pediatrics 1992 recommendation to reduce sudden infant death (SIDS) by having the infant sleep on his/her back has worked. The incidence of SIDS has dropped by 50%, but referrals to subspecialty clinics for plagiocephaly (flat head) have increased.  In a recent study of four Canadian communities 47% of 440 infants had observable plagiocephaly (a flat side of the head). Most were mild and needed no treatment, but the mothers probably stayed worried until time and normal activity rounded things out. (9)

References:
1. Boston Globe, 10/26/2013, report from interview on “60 Minutes”
2. Boston Globe, 10/27/13, report from Journal of Personality and Social Psychology
3. NEJM, 369;17,  October 24, 2013
4. NEJM, 369;4,  July 25, 2013
5. NEJM, 369;13, September 26, 2013
6. Boston Globe, 7/122/13, report from “Social Pressure at the Plate: Inequality, Aversion, Status, and Mere Exposure”
7. NEJM 369;13,  September 26, 2013
8. The New Yorker, May 20, 2013, p. 36
9. Pediatrics 2013 Aug; 132:298


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