What’s healthcare’s sideways threat?

It’s the “sideways threats” that bite companies, he said. “If you think of Kodak and Fuji, competing in film for 100 years, but then ultimately it turns out to be Instagram.”

– Reed Hastings, CEO of Netflix, interviewed in the NYT.

If medicine is anticipating disruption from AI, everyone is wary of private equity and consolidation, and physicians are frustrated and scared about losing their market dominance to midlevel providers, what are the sideways threats for healthcare?

Or is it still all of those things, just to those stakeholder groups that don’t see them coming?

I for one don’t think clinical fields have fully appreciated the narrow gap between what it takes to fully replace radiology with what it takes to completely and fundamentally change just about everything else.

Review: Doctor’s Orders (Hierarchies in Medicine)

Sociologist Tania M. Jenkins compares and contrasts two geographically similar academic and community internal medicine residencies in her book, Doctor’s Orders, which discusses hierarchy in medicine. Her overall thrust:

Amidst a widespread and pervasive emphasis on individual merit in medicine, I found that largely structural advantages and disadvantages, often dating back to childhood differences in social class, are frequently misidentified as differences in individual achievement and motivation among medical graduates, helping USMDs float to the top of the status hierarchy while pushing non-USMDs toward the bottom.

Jenkins lumps everything other than US allopathic grads together as non-USMDs (DO, Caribbean MD, US citizen IMGs, and non-US IMGs)

Hierarchies in status, defined as collective understandings of social worth or prestige, such as those between USMDs and non-USMDs, remain highly informal, as do the processes for climbing the ranks. In fact, as I will argue, it is precisely this informality and the accompanying belief that anyone can become part of the elite with enough work and dedication that allow such status distinctions to persist.

This is part of the pervasive myth of Step 1 as the great equalizer for non-USMDs. The idea that if you absolutely destroyed Step 1 you could go far. Anecdotes abound, because yes, an IMG has absolutely needed to do well on Step 1 in order to successfully match. But, but, these successful IMGs are using Step 1 largely to compete with other IMGs. Many of the dozens of programs they apply to aren’t really considering their applications. The AAMC, which runs ERAS, is happy to take applicants’ money to apply to ever more programs while providing program directors with the tools they need to filter out those very same apps.

It’s the perception of true meritocracy, but insofar as we use standard metrics like exam scores, we use them largely within bins/tiers and not equally across all-comers.

These findings also remind us that artifacts of standardization, like Board exams and program accreditation, should not be confused with indicators of equality in medical education.

No big secret there. In many cases, they also probably shouldn’t be used as indicators of quality either, but that’s a different story.

But I think the most interesting thing about the book is that it focuses on physicians exclusively and ignores the real substantive hierarchal change happening in medicine today, which is rapid rise and expansion of midlevel providers. Take, for example, her brief discussion of the sociological history of modern medicine dating back to Eliot Freidson’s Professional Dominance in 1970:

Freidson, the primary proponent of professional dominance, maintained that as long as doctors held sole control over their gatekeeping functions (such as deciding who could become a doctor and who should be admitted to a hospital), they would continue to exert dominance over paramedical professionals and patients—despite incursions from nonmedical sources.In response, scholars criticized Freidson for being out of touch with the massive macrosocietal changes happening in the healthcare system and instead proposed their own theories of professional decline. One of the more serious challenges to Freidson’s professional dominance theory came from the proletarianization thesis. Proponents heavily criticized Freidson’s contention that the medical profession was impervious to the considerable socioeconomic changes happening around it. These scholars contended that increasing bureaucratization (especially the shift from self-employment to hospital employment) was creating a proletarianized profession, with formerly self-employed practitioners becoming constrained by bureaucratic controls within hospitals.

They predicted that, as medical practice became increasingly bureaucratized and specialized, physicians would become mere salaried employees, lose control over the terms and conditions of their professional work, and thereby become proletarianized. In turn, Freidson strongly criticized proletarianization theorists for overstating physicians’ loss of independence. He rejected the notion that simply by joining a bureaucratic organization like a hospital, “[doctors] become mere cogs in a machine of production.” He pointed to other professionals, like engineers and professors, who have long worked in bureaucratic organizations without having their knowledge and skill “expropriated” by nonprofessional superiors, and he noted that even with increased government and organizational control, physicians look nothing like typical alienated blue- or white-collar workers. While there is no doubt that some aspects of proletarianization have materialized (for example, Medicare, rather than physicians, largely dictates reimbursement rates for specific diagnostic codes), for the most part Freidson remains correct that doctors continue to control the processes of entry and the content of their professional work, suggesting that the professional decline forecast by so many sociologists in the 1980s has not come to pass.

I find this conclusion fascinating because I think it’s largely incorrect (or at the least, incomplete). And I suspect most physicians would agree.

Many doctors do (or at least certainly believe they do) function as cogs in the machine, working within a bureaucracy in which they typically have minimal input, where they control little about the day to day logistics of their jobs, and for which their main leverage for change (if any) is to quit. The process is overall gathering momentum.

While doctors may have maintained control over their fiefdom, they’ve instead been sidestepped by the large healthcare organizations that employ them and increasingly by the legislators who have historically protected them. So that strict control has become increasingly irrelevant and the inflexibility of the residency system even more damaging when organizations willingly and knowingly and sometimes preferentially choose to replace physicians with non-physicians providers as a cost-savings and/or profit-generating measure.

This part of the narrative is supremely complex (book-length to be sure), but physicians have some blame here by not producing sufficient numbers of doctors in the right critical fields to meet demand. Nature abhors a vacuum. We’ve also somehow tried to simultaneously maintain that only doctors can do the vast majority of clinical medical tasks while also training and using physician extenders to do many similar tasks nearly autonomously when it’s convenient for the bottom line. We shouldn’t be surprised that the boundaries get blurred when there is big money at stake and time to compound.

Which brings me to this last point:

The free-standing internship was eventually abolished in 1975, making a multiyear residency required for all medical graduates.

In a world where non-physicians providers increasingly have full practice authority fresh out of school, I think there’s a compelling argument for bringing back the internship-is-enough-to-meaningfully practice. While there are still standalone transitional and preliminary years, it’s not really a pathway to respected independent practice. A medical doctorate should count for something other than just a prerequisite to multiyear residency training. It’s increasingly naive and unsustainable to pretend that a doctor can only learn new aspects of medicine within a residency, or even that a residency is the best way to learn all relevant skills. For better or worse, the marketplace is proving otherwise.

When physicians burn out of their chosen calling, they typically leave clinical medicine altogether. I think one of the big factors at play that we rarely talk about is that the combination of residency and the board certification racket locks many doctors into a narrow specialization (or subspecialization) from which there is no escape.

There are lots of doctors who can’t get a residency or who want to change professions that essentially barred from meaningful clinical work, and that’s an incredible waste.


The Power of Pausing

Solitude on its own won’t give us knowledge and compassion—it depends how we use that time with ourselves. But it gives us the opportunity to listen to ourselves, to hear the ideas, inspiration, feelings, and reactions that arise, and hopefully to approach what arises with kindness and compassion even when the thoughts that come up are painful or unflattering.

Moments of pause are especially powerful when combined with gratitude and feelings of love. I had a medical school professor who struggled with the demands of being a mother, doctor, teacher, researcher, and administrator. Finding time to meditate or go on a retreat was a near impossibility for her, but whenever she washed her hands before seeing a patient, she would let the warm water run over her hands for a few extra seconds and think of something she was grateful for—the opportunity to be a part of the patient’s healing, the health of her family, the joy of teaching a student earlier that morning. She was one of the first people to teach me that the power of gratitude can be delivered in the smallest of moments . . . and those moments have the power to change how we see ourselves and the people around us.

If we ever forget the power of pausing, we need only remember the lesson of our heart. The heart operates in two phases: systole where it pumps blood to the vital organs and diastole where it relaxes. Most people think that systole is where the action is and the more time in systole the better. But diastole – the relaxation phase – is where the coronary blood vessels fill and supply life sustaining oxygen to the heart muscle itself. Pausing, it turns out, is what sustains the heart.

From former Surgeon General Dr. Vivek H. Murthy’s lovely book, Together: The Healing Power of Human Connection in a Sometimes Lonely World.

When the pandemic first exploded earlier this year, I naively hoped that it would be a unifying enemy that would help us transcend our differences. That didn’t happen here at least. I think some fortunate people were able to pause, but pausing–like many things–is easier with privilege. When I look at the depressing state of community and political discourse, I think Murthy has it exactly right:

The great challenge facing us today is how to build a people-centered life and a people-centered world. So many of the front-page issues we face are made worse by—and in some cases originate from—disconnection. Many of these challenges are the manifestation of a deeper individual and collective loneliness that has brewed for too long in too many. In the face of such pain, few healing forces are as powerful as genuine, loving relationships.

Recalls and Exam Security

Out of all the reasons organizations like (but not limited to) the ABR have used as an excuse to shy away from remote content or historically relied on commercial testing centers, I strongly suspect exam security is the only one that actually matters.

While an individual not cheating on the exam is important for exam integrity, that type of exam security is a relatively straightforward n=1 problem. The real exam security that matters is the security of intellectual property. Nevermind that all these medical organizations use questions largely written and initially vetted by volunteers, losing hundreds of proprietary questions in one fell swoop to some industrious malcontent is the real fear.

The recent utter failure of the American Board of Surgery’s virtual testing also makes the point: once people have seen a significant fraction of the questions for a high stakes exam, it’s back to the drawing board. A doomed effort to administer an exam remotely sets an organization back by months, at the least.

That’s because recalls—people sharing memorized exam content—are a big deal. In fact, news about the universal use of recalled study questions for the radiology oral boards back in 2012 was the driving force behind the creation of the MCQ-only Core and Certifying exams, administered only on-site in bespoke testing centers created by the ABR itself in Chicago and Tuscon that sit gathering dust for most of the year.

While recalls are against organizational policy (and thus certainly something an individual should not do), the focus on recalls as a destabilizing force for the fairness of exams is…lame. Literally every important high-stakes exam including the SAT, MCAT, USMLE, and the various board exams have engendered a massive test prep industry around offering nearly the same thing: questions written–sometimes by the same people!–to exactly simulate those very same exams. Many, including most of the USMLE prep products, use software that even completely mimics the test software down to the pixel.

But I want to posit a fundamental misunderstanding:

A Really Meaningful Modern Test Shouldn’t Rely on Hiding its Content

Imagine a radiology exam had a question demonstrating a benign hepatic hemangioma on CT or MRI. Imagine a second-order question asking about management (nothing). If that information were put into a series of recalls, it would be meaningless. Every radiology resident should get the question correct because it is relevant to radiology practice and unavoidable during normal training. And if the exam, like the USMLE licensing exams or the various specialty board exams, purports to be a measure of minimal competency for safe independent practice, then all the questions should be relevant to daily practice.

If someone has mastered all of the relevant “recalls,” then they would presumably be ready to practice radiology. It’s okay if the fraction of answered questions is high if we expect the questions to reflect things we really want everyone to know. Mastering all of this exam content is exactly what we want trainees to do!

Recalls only matter in two situations:

  1. If exams need to include questions designed to differentiate high-level performance, separating the best from the average. In this setting, questions that should be really challenging become easy, throwing off the balance of exam difficulty. It’s precisely because the designers want to give you brainbusters that the element of surprise is key. But in a world where high-quality informational content is at your fingertips, this component of mastery is increasingly irrelevant. The things we really want people to know quickly, like how to manage a true emergency like a code or how to drop a line, are never satisfactorily going to be assessed with a multiple-choice question. That’s what a real-life training program is for. Performance on an MCQ test is typically only good at predicting future performance on other MCQ tests.
  2. Questions that really really test critical thinking. In this setting, the examinee shortcuts the thought process and arrives directly at the answer, defeating the purpose of the question. While the MCAT contains a fair number of reasoning questions along these lines, this is rarely the case in real life for medical licensing and board exams.

Every question bank for every major test is composed of glorified recalls. Pretending otherwise is silly. If all questions contained important material and the ability to answer them reflected meaningful knowledge and competence, then someone able to memorize the plethora of recalled questions would be exactly what you’d want: qualified.

A brief interview (about my Free 120 explanations)

I did a brief interview with the folks at Elite Medical Prep ages ago that went live today. I can’t believe I’ve been writing up explanations for the NBME practice materials for so long, but, well, I guess I have.

On a related note, if you’re in the market for personalized 1-on-1 tutoring, they’re a good group of folks. Tell them I sent you and they’ll give you $50 off when you purchase 5 hours or more.