Twenty-three new medical schools have either recently joined or are planning to join the 131 already in existence in the US. Six of them had been accredited as of mid-February. A shortage of places has led US students to enroll in medical schools abroad, and a shortage of graduates has led hospitals to hire foreign doctors.

The surge perhaps reflects a “perfect storm”—a confluence of surges in population growth, baby boomer needs, doctor retirements, and the number (40 million!) of Americans newly insured under health reform. Not to mention the $40,000 or so in annual fees locked up in each of those thousands of students currently unable to find a place in med school.

Many of the new schools claim to be focused on graduating primary care doctors to serve immigrant and disadvantaged communities, but some experts argue that these extra graduates will not make up for the number of retiring doctors and will not replenish the dwindling supply of primary care physicians, in part because many students will opt for high-paying specialization rather than (relatively) low-paying primary care. Others say that the mere availability of doctors fuels patient demand, and argue that nurse practitioners and physician assistants could substitute as primary care providers at a lower cost.

Even with the surge, the Association of American Medical Colleges (AAMC) still predicts a shortage of at least 125,000 physicians by 2025. A professor at the University of Pennsylvania School of Medicine suggests that additional changes to medical education are needed to increase physician supply.

Going Postmodern

The suggestion is being acted upon. Sarah Lovenheim wrote last November in the Washington Post about changes in medical schools that are trying to catch up with a “dramatically changing medical landscape.” The new landscape features holistic and alternative medicine, medical homes and patient-centered primary care, and new reimbursement rates and methods.

The examples Lovenheim cites include:

• Georgetown University, where dissection doesn’t begin until month four of med school and anatomy no longer exists as a distinct class. The traditional curriculum, organized around anatomy, physiology, pathology, and so on has been replaced by one organized around systems biology and a focus on organs rather than whole-body anatomy.

• Johns Hopkins University, which last year launched “the most significant revision of its medical school curriculum in 20 years.” Hopkins predicted “a number of drivers that made it clear to us that our curriculum was going to have to change to adapt to future societal developments.” Those drivers included the trend to patient-centered medicine and anticipation of health reform legislation. Its new curriculum (“Genes to Society”) teaches analysis of the genetic, environmental, and socioeconomic factors affecting the patient.

The Association of American Medical Colleges says that the schools are trying to “move medical education forward at least as fast as medical information and delivery changes,” in order to “train people not just for next year, but the next 20 and 30 years.”

iPhone 4 and Medical Apps

Well, medical information and delivery is changing real fast. For instance, a lot of attention in innovative healthcare in both the developed and the developing worlds is on the delivery of not just medical care but also medical education through smartphones and other wireless devices. Writing in HealthLeaders, Gienna Shaw gave these examples of mHealth (mobile health) apps available for the iPhone 4:

• A laparoscopic nephrectomy simulator that includes 3D animations and comprehension tests.
• iMurmur 2, which teaches medical students (or anyone else who cares to download the app) how to identify patient heart sounds.
• ImageVis3D, which lets the user manipulate 3-D images of CT and MRI scans and a wide range of scientific images.
• AnatomyLab, which simulates dissection using images of a real human cadaver.
• CancerTrials, a searchable database of experimental cancer therapies in clinical trials. The app maps relevant studies to the patient’s profile.
• MedAnywhere, which, according to its website, “provides constant and comprehensive medical care capability – from basic medical data access to full remote trauma treatment from a live surgeon, anytime and anywhere there is cellular service available.” Shaw notes that this app “will call users daily to remind them which medicine they’re due to take, the exact dosage they should take, and the exact time they should take it.” (It is not clear that the app is available as of August 2010, however.)

mHealth vs. Telehealth

A telemedicine network formed by an insurer (UnitedHealthcare) and a hospital system (Centura Health) was launched this June in Colorado. The Connected Care network of (initially) four rural clinics provides ear/nose/throat, cardiology, gastroenterology, neurosurgery, critical care/pulmonology, and pre- and post-surgery telemedicine consultations during an estimated 4,800 patient visits per year. Patients visiting one of the clinics are connected while there to a hospital specialist, over the telemedicine network

The clinics are equipped with videoconferencing systems, digital stethoscopes, and dermascopes. The Colorado Telehealth Network supplies the communication bandwidth and connectivity through its statewide fiber-optic network.

Meantime, the US Veterans Affairs Department (VA) is looking to mHealth delivered by cellphone and smartphone to improve the health outcomes of veterans, especially in rural areas a long way from a VA clinic or hospital. One prototype project under way is a mobile version of MyHealtheVet, the VA’s online personal health record, through which patients receive education and reminders and can order prescription refills.

An existing VA care coordination and home telehealth program involving achieved a 25 percent reduction in hospital lengths of stay and a 19 percent reduction in hospital admissions. The system links 43,000 chronically ill veterans with healthcare providers and care managers through videoconferencing, messaging, and biometric telemonitoring devices. Through the program, a single nurse can reach 150 patients remotely on a daily basis.

The US Army is also testing mHealth at five locations, to provide health tips, appointment reminders, and general announcements to patients with mild traumatic brain injury. Currently, the service is available to soldiers in five selected sites in Alabama, Florida, Illinois, Massachusetts and Virginia.

Boom in Telehealth Devices

So it is not surprising that there is a boom in telehealth devices. It has been estimated that by 2013, over two million telehealth devices such as digital blood-glucose meters and pulse oximeters will be sold annually in the US. A quarter of them (500,000) will be blood-pressure monitors (up from 50,000 in 2009) and 300,000 will be glucometers.

The devices will be offered with subscriptions to Internet-based services ranging from simple analysis of readings to sophisticated health management tools, and connections to personal health records (PHRs) such as Google Health and HealthVault.

This could prove to be a disruptive innovation to professional care providers.

Handheld Ultrasound

But disruption is preferable to demise. Businesses know they must innovate or die, none better than General Electric, whose CEO said his company’s FDA-approved handheld ultrasound machine, launched earlier this year, “could be the stethoscope of the 21st century.” The device’s images are good enough for it to be used in primary care to diagnose various conditions, in critical care to spot fluid on the heart and other symptoms, and in cardiology to monitor and measure lung function.

Nurses equipped with this sort of technology seem to us a no-brainer solution to the physician shortage issue, though the AMA will probably beg to differ. The fact is, nurse practitioners can perform many of the basic functions of primary care, at far less cost. Under health reform, they may get the chance. The American Association of Colleges of Nursing (AACN) believes the Patient Protection and Affordable Care Act will improve nursing education, research, and practice through provisions that:

• Increase and expand funding for nurse education and training
• Promote primary care, disease prevention, and wellness through:

– A mandatory Prevention and Public Health Fund
– More funding for the National Health Service Corps
– A Ready Reserve Corps created through the U.S. Public Health Service Commission Corps
– Funding for Nurse-Managed Health Centers, which provide services at a lower cost than other safety-net clinics, save millions of dollars annually through the preventative care they provide, and provide a clinical setting critical to nursing education
– A public health service science track
– Incentive payments for primary care services given by health professionals including nurse practitioners and clinical nurse specialists

• Provide healthcare professional help to guide patients and caregivers at risk for re-hospitalization, via a Community-Based Transitions Program (Sec. 3026)
• Establish a payment and delivery model for Nurse Practitioners and physicians who direct home-based primary care teams. (The regulation stipulates that nothing shall prevent an NP from participating in or leading a home-based primary care team) (Sec. 3024)
• Pays Certified Nurse-Midwives the same as a physician would be paid for covered services under Medicare

Virtual Doctors To Replace Real Ones?

Yes, the nurses’ day is coming… and going. An artificially-intelligent avatar able to understand speech, recognize pediatric conditions, and reason according to simple rules can make an initial diagnosis of a childhood ailment and its seriousness. A similar avatar serves as an executive’s personal assistant, responding to calls, consulting his calendar, deciding whether the executive can be interrupted, and even engaging the visitor in polite chit-chat: “Eric’s been in back-to-back meetings this afternoon. But he’s looking forward to seeing you.” And: “How about that Mariners game last night?”

These are prototype products of Microsoft’s research laboratory, which is contributing to the rapid progress in AI. For the rest of us mere mortals, evidence of that progress can be found in cellphones, iPhone apps, car navigation systems, and Web search services, where people increasingly simply speak to find something or somewhere, or get something done. Find a good Chinese restaurant nearby. Book me a table. Order something from the menu appropriate for my caloric needs and the blood sugar readings from my glucometer. Navigate me there.

According to New York Times reporters Steve Lohr and John Markoff, the number of American doctors using speech recognition software to record and transcribe accounts of patient visits and treatments has more than tripled in the past three years to 150,000, largely because the software is “unbelievably better than it was five years ago,” as one doctor told them, although he added that it is still far from perfect.

Give it another five years, and the doctor will be saying the same thing: the technology will be “unbelievably better” than it is today. Translation software being tested by the Defense Advanced Research Projects Agency is fast enough to keep up with some simple conversations, say Lohr and Markoff. Call center software can handle some calls without needing to bring a human (other than the caller, of course) into the conversation at all—unless, perhaps, they detect anger in the caller’s voice, in which case they will route the call to a manager. Voicesense speech analysis software can spot a dozen emotion indicators, including breathing, conversation pace, and tone.

The reporters point to a dire future for the estimated four million US call center workers and the 100,000 or so medical transcriptionists, already threatened by growing numbers of offshore call center workers and transcriptionists—whose own jobs are no less immune from the new technologies. Panasonic resolves one million more customer problems a year with 1.6 million fewer total calls than it did five years ago, and the cost of resolving a problem has declined by 50 percent.

Any “Basic work that can be automated is in the bull’s-eye of both technology and globalization, and the rise of artificial intelligence just magnifies that reality,” an MIT economist told them. On the other hand, he also told them that AI “will also spur innovation and create opportunities, both for individuals and entrepreneurial companies.”

Sure. But not nearly enough for everyone, we predict. The reporters themselves point out that the Microsoft projects are “only research initiatives, but they suggest where things are headed,” and that raises “concerns about the social impact of the technology.”

One such concern is that AI machines “could be used as tools to isolate corporations, government and the affluent from the rest of society. Instead of people listening to restive customers and citizens . . . it will be machines.” It may seem, to those of us who have had direct experience of being given the runaround by many an automated voice system, that there is no “could” about it: It is hard to find a phone number or an email for a warm body when you need customer service. At the same time, many of us—particularly the younger generation—have now been conditioned (programmed?) to respond to the machine like machines ourselves, and even to say “Thank you” to the machine before ending a call.

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The loss of jobs to machines is a much bigger social issue than the physician shortage, it seems to us. Yet our handling of the latter does not bode well for a solution to the former.

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