May 7, 2012
For decades, the attempts at health care reform have aimed to increase access. The United States is one of the few industrialized nations in the world that does not provide universal health care to its citizens. And repeatedly, those who oppose it have been forced to argue that access isn't the problem some make it out to be. Why?
The emergency department, they say. After all, it is a commonly held belief that no one can be denied care there. So -- in essence -- everyone can get free health care if they need it. We have a universal system after all.
That, of course, is not true.
It's not even close. Let's start with the idea that emergency rooms must provide you care.
What's important to remember is that you can't be refused emergency care. That's because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that any hospital that takes Medicare or Medicaid must check you for emergent conditions and treat them if they exist. Since nearly every hospital in the country takes federal funds from one of these programs, nearly all hospitals are subject to EMTALA.
But "emergency medical condition" has a pretty narrow definition. It includes active labor for women and acute conditions that would cause death, serious bodily organ harm or serious bodily function impairment if they were not treated right away.
If politicians are meaning to say that women have universal access to delivery care, then I suppose there's an element of truth to that. But there's no guarantee of prenatal care in the emergency department. If they are saying that we have universal access if we're acutely having a heart attack, then I suppose there's truth to that as well. But there's no such access for lipid panels, stress tests or prescriptions for cholesterol medications that might help you avoid the heart attack in the first place. If you're acutely obstructed by massively advanced colon cancer, it's likely you can get emergency surgery to end the blockage. But your cancer is likely too far advanced to cure at that point. Moreover, you're not going to get chemotherapy in the emergency department nor could you have gotten the colonoscopy that might have detected the cancer far earlier.
You can't get preventive care in the emergency department. You can't get screened for a host of disorders. You can't get treatment for your depression there or really for any chronic mental disorders. You can't get help with your child's autism, ADHD or developmental delay. And even if you could, it wouldn't be free.
April 3, 2012
Major changes are coming to the nation’s medical residency programs. The Accreditation Council for Graduate Medical Education (ACGME), the nonprofit organization that evaluates and accredits more than 9,000 medical residency programs in the United States, has announced it will transform how these programs will be accredited in the years ahead.
As described in an article published in the March 15 issue of The New England Journal of Medicine (Nasca TJ et al. 2012;366:1051-1056), the ACGME’s next accreditation system (NAS) for graduate medical education is centered on six domains of clinical competency, developed in concert with the American Board of Medical Specialties. In an interview, the article’s lead author, Thomas J. Nasca, MD, chief executive officer of the ACGME in Chicago, characterized these domains as “patient care and technical skills; medical knowledge; professionalism; interpersonal communication; systems-based practices; and practice-based learning and improvement.” Dr. Nasca stated that the NAS “is the culmination of a decade’s worth of work building consensus around the competencies.”
The difference between the past accreditation system and the NAS, said Dr. Nasca, is that the new system will evaluate educational outcomes rather than just processes, and the core or essential educational outcomes will be standardized for each specialty. To distinguish between a process standard and an outcome standard, Dr. Nasca gave the following example: “There must be simulation training in induction of anesthesia” is a process standard; “The resident demonstrates effective incorporation of knowledge and skill in the administration of anesthesia” is an outcome standard.
In July 2013, seven of the 26 ACGME-accredited core specialties will implement the NAS. The seven specialties are emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology and urology. In July 2014, the remaining specialties will apply the NAS.
Dr. Nasca detailed some of the projected benefits of the NAS. Residents will be reassured that all programs teach and evaluate the same desired outcomes, with a “more targeted evaluation of performance, and more effective formative feedback—a focus on what is essential.” The program directors will get a less intrusive ACGME, with decreased administrative burden, giving them time for more mentoring and direct education. The public will be the “ultimate beneficiary,” because it will get better-trained physicians.
“It’s not just an educational exercise,” said Dr. Nasca. “We will reassure the public of the completeness of the training and that each graduate has demonstrated the core skills required in their chosen specialty, prior to entering clinical practice in the profession.”
According to Christine Stencel, spokesperson at the Institute of Medicine (IOM), the National Academies, Washington, D.C., “The new accreditation system is consistent with recommendations of the IOM’s 2003 report Health Professions Education: A Bridge to Quality.”
When asked about the IOM’s view of the NAS, Ms. Stencel pointed to a study of the governance and financing of graduate medical education that the IOM will begin conducting in June 2012. “The committee for that study will likely take up aspects of the ACGME accreditation reported by Dr. Nasca in The New England Journal of Medicine. IOM cannot prognosticate on what this related new study will conclude and recommend and therefore must withhold any judgments.”
A comprehensive article about the ACGME’s NAS will appear in the May issue of Gastroenterology & Endoscopy News.