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Pennsylvania Med Student Reflections – 2017 AMA-MSS Hot Topics

The Pennsylvania Medical Society sent medical students to the AMA-MSS meeting this June in Chicago. Here are their reflections on the top issues that came out of the meeting:

 

Making the Case To Regulate Air Ambulance Reimbursements

Elisa Giusto, Philadelphia College of Osteopathic Medicine

As a rising fourth year medical student and delegate from the Philadelphia College of Osteopathic Medicine, I was honored to attend the Annual AMA-MSS House of Delegates meeting.

I was also primary author of a successfully adopted resolution entitled "Air Ambulance Regulations and Reimbursements" which I would like to discuss more in detail now as I plan to also submit it to the Pennsylvania House of Delegates.

Although the current state of our national health care system might be in flux, one fact is clear: air ambulances are life-altering in more ways than one. Although air ambulance companies undoubtedly save lives, especially in largely rural and critical situations, there is major cause for concern.

When patients are in need of an air ambulance, the main priority is getting them care as soon as possible, not checking if it is an in-network provider. However, that little detail makes a huge difference when it comes to a potential $50,000 price tag.

There are several issues that must be overcome to come up with a solution to this problem ranging from proper triage to adequate reimbursement.

The American College of Surgeons has published field triage guidelines, yet 59 percent of patients transported by air ambulance had minor injuries, as defined by an Injury Severity Score of less than 15. In addition, The Airline Deregulation Act of 1978 prohibits states from regulating the price, route, or service of an air carrier, including air ambulances, for the purposes of increasing competition, reducing rates, and improving airline passenger service.

Yet, Air Methods, the nation's largest air ambulance operator, has seen an increase in their average bill of $17,262 in 2009 to $50,199 in 2016, which is far more than the actual cost for a flight of only $10,199.

Air Methods has also resorted to hundreds of lawsuits against individuals throughout the country seeking salary garnishment and other forms of debt collection. A major hurdle in this situation is that Medicare only reimburses 59 percent of air ambulance costs, adding an average of $15,984 to the cost of self-pay or privately insured patients.

Furthermore, laws from Wyoming seeking to cap air ambulance fees and North Dakota forcing air ambulance companies to become participating providers by joining major insurance company networks have been struck down in federal courts.

It is difficult to say if there will be any progress regarding this issue in the near future, but I am glad to have attended the Annual AMA-MSS House of Delegates meeting to at least keep in mind that the less glamorous business aspects of medicine may actually have the most dramatic impacts on our future patients' lives, and remember that it is our responsibility to use this time as medical students to learn about all factors in medicine in order to give our patients the best possible health care.

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AMA-MSS Theme: Social Reform and Battling Injustice

Ludwig Koeneke, Sidney Kimmel Medical College at Thomas Jefferson University

In November 2016, our country elected conservative businessman Donald Trump to serve as our country's next president. Although many from the liberal camp may consider his election as a loss for Democrats and left-leaning thinkers, it served as a catalyst for a collective consciousness in our country.

Previously, Americans saw themselves as rugged individuals who either made it or did not. Success was measured as the fruit of one's labors and failures was entirely the fault of the individual. This Regan-era style thinking has been shed by the millennial generation and in its place, a more social-minded perspective resides.

This was clearly evident at the 2017 annual AMA-MSS meeting, where multiple resolutions getting passed that would never have received the light of day in previous years.

Perhaps the most striking piece of legislation that was passed was Resolution 12, National Healthcare Finance Reform: Single Payer Healthcare. It was a resolution that demanded that the AMA-MSS change its position on health care policy from a multimodal healthcare system to a single payer system. The most impressive aspect to this meeting was that this resolution, with clear socialist undertones and motivations, passed with flying colors on the floor and with minimal resistance.

Another example was that this year the AMA-MSS voted in favor of a resolution designed to take a stance against poverty and poverty-level income. Once again, this resolution passed and with little to no resistance.

The AMA-MSS has now adopted the stance that poverty is a negative determinant of health and that we support any legislation that will help alleviate poverty in this country.

The overall theme of this year's annual AMA-MSS meeting was centered around social reform and battling injustice. As future physicians, we have the option to adopt a legacy-based medical system that was never truly thought out from the ground up, or replace it with a well-thought-out system that benefits all Americans.

Judging by the atmosphere of this year's meeting, I believe my future colleagues opt for the latter of the two.

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Why Schools Should Administer Clinical Skills Assessments to Med Students

Michael A Loesche, PhD, University of Pennsylvania, Perelman School of Medicine

Council of Medical Education Report 9: Feasibility and Appropriateness of Transferring Jurisdiction over Required Clinical Skills Examinations to LCME-Accredited and COCA-Accredited Medical Schools

It was exactly one year ago, during the 2016 AMA annual meeting, that the House of Delegates (HOD) voted to call for an end to nationally administered clinical skills assessments for medical students, in favor of school administered examinations.

This year the Council of Medical Education issued their report on the matter and determined that this ask was unfeasible and recommended rescinding our policy on the matter (D-295.988). Your Pennsylvania Delegation opposed this report, along with many other groups including the Medical Student Section, Resident and Fellow Section, and the Young Physician Section to name a few. To fully understand the topic, I think it is pertinent to know the history of the exam and its impact on students.

The USMLE implemented Step 2 Clinical Skills (CS) in 2004, however, it is not entirely clear why this was done. There was not an uptick in in physician incompetence, there were no outcries from the public, there was no big court case that changed the landscape of medicine. The stance often repeated by USMLE is that it fulfills the public's expectation of clinical competence, but is that really true?

Certainly another examination appears superficially to enhance the clinical competence of medical students, but we are an evidence-based profession — where is the data? The truth is the data is scarcely made available to external researchers and even the publications authored by the USMLE report "admittedly weak" correlations between exam scores and future performance of residents.

These correlations are so weak, you would need to compare the lowest quartile to the highest to see any meaningful effect. In fact the vast majority of state licensure boards do not require Step 2 CS outright, but they do require Step 3 — the issue here being that the USMLE does not allow you to sit for Step 3 unless you have passed Step 2 CS.

The USMLE often touts the high levels standardization they offer in their examination centers. To my knowledge, they have never reported on their inter-grader reliability (a metric used to assess the agreement between two graders), but other studies have suggested this number is in the range of 0.8, or 80 percent correlation.

This is not trivial and in fact considered to be fairly good in the world of subjective examinations, however, this still means there is considerable variance. How many students have had their future derailed because of this statistical noise? This seems all the more cruel when you recall that the test fails to predict resident performance, regardless of the reliability of that grade.

Another explanation for the implementation of this exam came to me from a former board member of the USMLE: litigation. Before the USMLE implemented Step 2 CS, they offered the English Competency for Foreign Medical Graduates (ECFMG) examination, which was meant to ensure that foreign medical graduates (FMGs) would be able to effectively integrate into American hospitals.

A class action lawsuit was being threatened against the USMLE for treating FMGs differently from domestic students, which amounted to discrimination. Accordingly, the USMLE decided that the ECFMG exam should not be done away with, rather it should be expanded to all medical students. We live in an era of defensive medicine, but do we want this to spill over to the education of our students as well?

Finally, many have accused the USMLE of balancing their budget on the backs of medical students. This is always the hardest claim to prove, but because the USMLE is a non-profit, you can take a look at their taxes. You may be surprised to find out that the USMLE brings in $14.5 million more in revenue than it does in expenses.

Their CEO makes over a million dollars. To my knowledge going back to 2003, the NBME which owns the USMLE has never reported any operating losses (I'm not an accountant though). On the other hand, salary expenses increased roughly 10 percent in 2014 (the most recent taxes available), much more than the roughly 0.2 percent rise nationwide. Not a difficult feat to accomplish when you consider the effective monopoly this institution has to determine both the supply and demand.

The USMLE Step 2 CS exam currently costs $1,275 and is offered in six cities in the country. This means the majority of students need to not only pay for the exam, but travel and hotel accommodations.

Consider that most students are paying for this with their student loans, in fact one study estimated that students spend an aggregate of over $36 million per year for this examination. In the same study, the authors suggested that the cost of identifying one student who would fail the exam twice to be over a million dollars.

This is assuming the test actually provides accurate assessments of students' abilities, which as I alluded to earlier they do not. This also assumes that Step 1, Step 2 CK, and school assessments have also failed to find this so-called "double failure." If Step 2 CS is really the only thing stopping our schools from unleashing unfit students on patients, our medical schools are in a much worse condition than we thought.

The major problem with the report authored by the Council of Medical Education was that it starts with the assumption that the USMLE has created an effective assessment of clinical skills. They rely on the expertise of the USMLE to inform their opinions on the feasibility of schools implementing similar examinations. The report claims that most schools would need to invest nearly $4 million to perform the examination appropriately.

This estimate is unreasonable as 91 percent of medical schools already offer in-school assessments and as I have discussed there is no need to match the USMLE's standardization, as even this controlled environment fails to accurately assess students' abilities.

It is hard to reach for a bar that doesn't exist. Because of this, the Council of Medical Education concluded that the AMA ought to rescind its own policy on the issue.

Fortunately, a near unanimous ground swell of opposition to the report was heard at the reference committee and the Council of Medical Education offered an amendment to keep current policy and continue to study the matter. Your PAMED delegation, always an advocate of students, was critical to this effort and for that we, the students, are thankful.

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Investments in Energy: Putting Ethical Responsibility Over Fiscal Responsibility

Gillian Naro, Penn State Hershey College of Medicine

My heart was pounding in my chest as I stood up in front of hundreds of my medical student peers to give testimony for a resolution for the first time. I have never been a part of an organization that used parliamentary procedure as the American Medical Association (AMA) uses to lead the Medical Student Section (MSS) deliberative body.

I fumbled on my phrasing of requests to the governing council. My peers, however, were supportive and I continued to explain to the AMA-MSS why resolution 33, "AMA Policy on Investing in The Fossil Fuel Industry," should be adopted.

A group of medical students across AMA regions contributed the construction of this resolution asking the AMA to divest in any affiliated corporations and organizations that generate the majority of their income from the fossil fuel industry. As medical students, the authors recognized the importance of considering a patient's health as a determinant of not only pathogen exposure or genetics, but also the quality of environment.

This is why it is essential that the AMA lead by example by publically signaling their position on the environmental impact on health through divestment.

In addition to being an author on this resolution, I also felt compelled to give testimony in support of resolution 33. Despite my nerves and shaky voice, I tried to relay how important it is that the AMA puts ethical responsibility over fiscal responsibility. This is not the first time the AMA has faced a divestment decision.

In 1981, the AMA set this precedence by selling tobacco stocks. After the scientific and public recognition of the devastating effects tobacco smoke has on the body had become widely known and accepted, the AMA used their divestment actions as a rhetorical statement on the ethical responsibility of physician and medical groups to be leaders in public health.

The AMA and Intergovernmental Panel on Climate Change has concluded that the burning of fossil fuels are both the driver of climate change as well as a direct threat to human health. Furthermore, the AMA also favors employment of ecologically responsible environmental practices and education. For this reason, we asked the AMA to seek sustainable investments when fiscally possible.

I stepped away from the microphone after asking my peers to adopt this resolution. The Governing Council Speaker called the vote. I was thrilled to hear a resounding chant of "aye." The resolution passed the AMA-MSS and will now be presented for vote and deliberation at the AMA House of Delegates.

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Who Should Interpret When Caring For Patients With Limited English Proficiency

Perry Patton, University of Pittsburgh School of Medicine

A resolution proposed by an AMA-MSS Region 6 member dealt with the use of interpreters in the care of patients with limited English proficiency.

Current AMA policy supports the use of the patient's family or friends in interpreting for patients in a medical setting, in part out of respect for the autonomy of the patient and their family. The resolution proposed that the AMA encourage the use of interpreters when available instead of family members or friends, but this resolution was initially not recommended for adoption by the AMA-MSS reference committee on the grounds that it reduced patient autonomy.

Though we're taught to hold patient autonomy perhaps above all else, the resolution's author and many other delegates in attendance gave convincing testimony raising patient safety as a primary concern in ceding the role of interpreter to a patient's family.

These family-members-as-interpreters may have limited understanding of the medical information they're translating, and without a professional translator present, the health care provider present would have no way of assessing what information is actually being transmitted to their patient.

Additional concerns arose in using family interpreters in situations where the interests of the patient and their family member diverge. A family member could choose to purposefully withhold information about treatment options they disliked, or could deliver wrong diagnoses in order to spare the patient bad news.

Though the vast majority of family members interpreting have the best interest of the patient in mind, the room for error or misinformation is quite high. The resolution's author drew on his experience as a clinic translator in drafting the proposed policy; he understood firsthand how important and sensitive the role of translator is in a medical setting.

The passage of this resolution at the 2017 annual meeting is a prime example of the ways that student involvement in the AMA can help shape its policy for the better.

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Single Payer Health System

Aleesha Shaik, Drexel University College of Medicine

Seven hundred people, three incredible days, and one windy city later – it is safe to say that AMA-MSS Annual 2017 was a success.

It is always a surreal experience to attend one of these conferences, the passion of hundreds of medical students tangible in the air as we discuss policy. But this one in particular seemed to produce a more energized crowd than usual. With the uncertainty of the American health care system fresh on everyone's minds as a result of current deliberations in the House and the Senate, students from around the country came together to stand up for their patients.

In a strong statement against the health care plans being discussed on Capitol Hill, a resolution was proposed and supported by all seven regions in favor of a national single payer system. The MSS reiterated that affordable and equitable universal health care is a core tenet of the AMA's values.

Whereas we spend more money on our health care system than any other country in the world and still struggle with disparities in access for various racial and socioeconomic groups, there is significant evidence countries using the single payer system have fewer such issues. Not only would such a system ensure more equitable care, but it has been shown to decrease the burden on the economy by eliminating many administrative costs within the insurance industry and other costs for hospitals and physicians.

The resolution also clarified that this position does not preclude our support or search for alternative solutions.

Our health care system isn't going to become a single payer system overnight and is likely to face resistance within the current political sphere; however, it is crucial that we begin to lay the groundwork for the future and make our stance clear. As future politicians work to devise a system that works, our well-respected positions should serve as a compass for optimal patient care.

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Returning Home With New Ideas

Jordan Spencer, Lake Erie College of Osteopathic Medicine

Yet again I have had the privilege to attend the MSS HOD, and have come home on fire ready to take on the world. I recognize that it is not cheap for PAMED to send us as students to these events but rest assured this is an investment in the future of Pennsylvania well spent.

After returning from my first conference, I was so full of ideas that I ended up writing over 20 pages in articles/essays from subjects varying from leadership, to partisanship in policy making, none of which ever came to fruition as a publication, however that was not the point. Rather it was my way of putting on paper my excitement, thoughts and ideas, to hold onto for future moments.

At the end of this most recent HOD I have come home convinced that I need to pursue some sort of graduate education, that will better prepare me to help move the wheels of policy in the future (MBA, MPH, MPA, Etc.), and have begun brainstorming ways I can squeeze it into my career path between school, residency, loans, and life. I want to be able to contribute as much as possible to organized medicine and help others see the vision that I have been privy to experience.

These short weekends are arguably some of the greatest learning moments of my medical school career. Your investment in the future is creating a legion of excited young future physicians who are ready to stand arm in arm with you in the future of policy and diplomacy.

We have the energy and the fire to be your workhorses. Lead us and guide us and continue to share with us your experience as you already have; we will gladly help you take on the medical landscape of our great commonwealth.

As an aside, I am a transplant to Pennsylvania and I have discovered myself proud to tell others where I am from during these meetings. And this year it was exhilarating to see the Pennsylvania delegates take up just under two whole rows of the meeting at large and close to half of the region.

Also, I am proud to claim I am now a true western Pennsylvanian as over the weekend I caught myself saying "this needs fixed" a proud moment indeed.

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Investments in Energy: Putting Ethical Responsibility Over Fiscal Responsibility

Doug Wells, Geisinger Commonwealth School of Medicine

One of the most interesting resolutions discussed during our Region 6 AMA-MSS meeting reads as follows: The AMA should (1) recognize the negative effects that greenhouse gas emissions have on human health; (2) urge the federal government to reduce and control the emission of greenhouse gases; (3) consider divesture of its investments in energy companies whose primary business relies upon fossil fuels; (4) explore investment opportunities in renewable energy solutions. While Resolves 1 and 2 are already addressed by existing AMA policy, Resolves 3 and 4 are newer ideas that have not yet been addressed.

It is widely recognized that fossils fuels are a major contributor to the adverse global climate changes that our Earth is currently undergoing. These climate changes have a largely negative impact on human health in two main ways:

  1. first, by creating unpredictable conditions that will produce health problems which disproportionately impact the public health of vulnerable populations;
  2. and second, by increasing the severity of the adverse health effects that are already impacted by climate or weather factors.

Although there are various reasons to support fossil fuels that were discussed during our meeting, such as their importance in the plastics industry which the medical field heavily relies on, the unprecedented negative impact that they are placing on society's health gives the AMA sufficient motive to take a stance against fossil fuels by divesting "its investments in energy companies whose primary business relies" upon them.

If there is a divesture of funds, it only makes sense for the AMA to invest in other energy sectors, such as renewable energy sources. Not only does it make sense, but it also makes a more significant impact on our society's health.

If the AMA chooses to only divest in energy companies whose primary business relies upon fossil fuels, it is likely that the impact on the $5 trillion fossil fuel industry would be minimal. However, if the AMA can contribute to renewable energy sources, it will help them grow to the point where hopefully one day, there will no longer be a significant need for fossil fuels.

Less fossil fuels will yield significant health benefits by decreasing the previously mentioned negative effects that fossil fuels have on climate change. Thus, it seems clear that the AMA should look to divest in energy companies whose primary business relies upon fossil fuels, while exploring other investment opportunities in renewable energy solutions.

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Addressing Asian-American Health Disparities

Sasha Jia, Temple University. Lewis Katz School of Medicine

After becoming a board member at the AMA chapter of my medical school, Temple University School of Medicine, I was excited by the opportunity to join a massive network of medical students and doctors.  With all the unpredictable changes occurring at the White House, it’s a more important time than ever for doctors to present a united front and engage in shaping health care policy. Knowing that AMA is able to influence decisions in D.C., I was eager to partake in the House of Delegates meeting in Chicago and become involved in the Medical Student Section.

As a first-time delegate going to the HOD meeting, I was overwhelmed by the daunting agenda and resolutions presented. I decided to focus on understanding my responsibilities as a PAMED delegate and focus on region VI resolutions. Being brand new, I looked forward to meeting other PAMED delegates at the introductory sessions and learning more about my role. It was reassuring to hear from other students that the seemingly complex voting system is indeed digestible with time and experience. I discussed with my Temple team the Region 6 resolutions outlined in the Reference Committee Report. Although all the resolutions highlighted were interesting, one in particular that caught my eye was focused on Asian-American health disparities.

As a first-generation immigrant from China, I witnessed first-hand the physical and emotional barriers Asian-Americans face in obtaining culturally-appropriate care. I was pleasantly surprised at the opportunity to speak on a topic that I can personally attest to. During the Region 6 Policy Meeting, this particular resolution faced a surprising amount of debate. Opinions in the room ranged from not understanding the purpose of the resolution to the idea that the wording should be more inclusive of all races and ethnicities. Although I was hesitant, I voiced my opinion to the group and felt the rush of adrenaline in having my words heard.

At the general assembly meeting, I tried my best to cast informed votes and participate; however, most of the resolutions were unfamiliar to me. Nonetheless, I felt motivated to draft relevant resolutions with my teammates and other Region 6 members and have the opportunity to present our platform at the next HOD meeting.

 

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