Who wants to live forever?!?!

On a recent flight across the United States, a familiar song played on my iPod, Queen’s Who Wants to Live Forever.  While the song clearly asks a question about mortality and immortality, that question has two derivations.  The two questions are:

1.       Who wants to win the prize of immortality?

2.       Why would anyone want to live forever?

Some further context may help.  The song was written and performed by Queen for the movie Highlander.  The movie follows Connor MacLeod who was born in 1518 in Glenfinnan near the shores of Loch Shiel.  He is one of Earth’s immortals who fight for the ultimate prize of omniscience.  The person who wins the prize must behead all of the other immortals on the planet.  As each immortal succumbs, the victor gains the strength of the fallen.  That sounds pretty simple, thus, who wants the prize?  Who wants to live forever?

The problem is that Connor does not always like being immortal.  In the movie’s opening scene he is almost killed in battle by another immortal in a Scottish clan skirmish.  Just as he is to be beheaded his clansmen stop the rival – the Kurgan.  Connor, who will surely die, is taken back to Glenfinnan, but inexplicably lives.  It is now his clan that wants him dead figuring that he must be possessed by the devil.  He is eventually banished from the village.  After this he meets a woman, Heather, who becomes his wife.  He cannot have children, he’s immortal, and this is a lifelong sorrow for he and Heather.  Worse, Heather grows old over the years and he does not.  She eventually dies in his arms.  He learns that immortals should have transient bonds.  So, why would anyone really want to live forever?

OK, now you are asking what this has to do with OGME.  Well, there was a recent article in the Wall Street Journal entitled "Why Doctors Die Differently."  The article reported on the differences between physician’s end of life decisions versus those of the general public.  There were some striking differences.  Who wants to live forever?  Physicians were more likely to choose conservative and palliative management when faced with low cure or survival rates.  The question posed is whether physicians unique perspective, they clearly have both knowledge and experience dealing with end of life issues and watching other people die, changes their view of the question.  To the general public, the prize is immortality.  The medical community – doctors, nurses, researchers, pharmaceutical companies – has been in search of this prize since the beginning of time.  Clearly that resonates with the public – why else would they be willing to pay so much for so little?

Some may say that medicine hasn’t furthered the immortality notion.  Think for a second though about Queen’s voice Freddie Mercury.  Freddie died far too young of AIDS.  All one has to do is watch a Queen concert on YouTube and they will see one of the most alive people ever known.  Freddie could command entire stadiums across two continents (as he did at Live Aid).  Listening to him sing Who Wants to Live Forever and another poignant song, The Show Must Go On, make me wonder what his view of certain death must have been.  He contracted HIV in the late 1980s and died in the early 1990s.  Everyone who got HIV at that time died of AIDS or an AIDS associated illness.  We all know, Magic Johnson knows quite well, that that doesn’t happen now, at least in the “developed” world.  HIV is only one death sentence that has been pardoned.  There are many more each year.

They lesson for physicians, physicians in training and physicians that train physicians is that the end of life is many times as important as life itself.  It is also important to share the lessons of our previous patients with our current patients.  It seems clear that physicians head those lessons when they make their own decisions regarding death and dying.  We need to ask patient both:

1.       Do you want us to do everything to make you better?

2.       Are you sure that you would like to suffer more?

The answers are a matter of perspective…

Everything flows...nothing stands still...the final installment

I know that you have all been on the edge of your seat for part 3, so without further adieu, here it is, the last facet, organizational flows…

·         The AODME is in the midst of a strategic planning process.  This has entailed using proven methodology to flesh out our goals and aspirations as an organization.  The board held a planning retreat in July (in conjunction with the AOA House of Delegates) and there were surveys of membership before and after this retreat.  One large move is the decision to focus on excellence in Clinical Osteopathic Medical Education.  This includes the undergraduate, graduate and continuing medical education spheres, with an emphasis on OGME.

·         As many of you know, the AODME has purchased management services from the AOA since 2003.  This contract has been automatically renewable on a yearly basis.  The AODME shares a close working, teamwork relationship with the AOA and recently had Susan Sevensma, DO appointed as the liaison from the AOA Board to the AODME Board.  This is a first for both organizations.

·         Finally, the AODME underwent a by-laws change in December of 2011.  This change culminated four years of discussion on the topic, through three annual meetings, multiple surveys and drafts of the changes.  The by-laws were ratified by a 90% positive vote of two thirds of the members.  This was not small accomplishment for a small and diverse organization.  The changes brought the AODME in line with the current structure of OGME, including the realization that most DMEs commune as OPTIs.

Everything flows…nothing stands still.  The AODME and OGME are certainly proof of this.

Everything flows...nothing stands still...Part 2

To continue on from yesterday’s beginning financial flows in OGME are the next topic.

·         Last week Bloomberg Government released a study that discussed the impact of several cuts in payment from Medicare for Graduate Medical Education.  The bottom line is that both the Simpson-Bowles Commission’s proposed $60 billion cut over 10 years and President Obama’s ~ $10 billion over 9 years would have a significant impact.  One of the most interesting findings – a particularly ominous one for OGME and the osteopathic profession – is the notion that the cuts would disproportionately impact primary care.  This is because Medicare pays hospitals for medical education and primary care is not done in hospitals.  As hospitals look to recoup the lost revenue, it holds that they may wish to have more service for the trainees.  Trainees that provide service to hospitals are specialty trainees, not primary care trainees.

·         The second financial concern on the minds of osteopathic directors of medical education (DMEs) is the now enacted fee change for OGME programs.  This was enacted by the Executive Committee of the AOA Board in early December.  Some might remember that there was a great deal of concern surrounding this policy amongst DMEs last Spring.  blOGME commented on the topic in the inaugural post and again here and here.  I’m sure that we can expect more comment in Louisville in April.

·         The final financial concern on the DME mind is the stability of hospitals where OGME takes place.  There has been no shortage of hospital consolidations, bankruptcies and closures over the last ten plus months.  Again, OGME may be disproportionally impacted in this arena as more community hospitals are targeted.  We have seen hospitals in New York, Michigan and Pennsylvania mentioned.  What impact lasting consequences this has on OGME remain to be seen.

The goal is to have more tomorrow.

For some additional reading, see several worthwhile blog posts on primary care’s future and funding.

Everything flows...nothing stands still

I had the honor to represent the AODME this past week at the AOA’s Midyear Board of Trustees meeting.  On Friday, I delivered a brief review of issues and happenings in OGME and the AODME.  I will share them with you here, in a somewhat expanded outline form.  Over the next few months, I hope to expand on several of the topics.

I have noted the Greek philosopher Heraclitus previously.  He is the one who noted that nothing endures but change.   In the same breath, he also noted that “everything flows” and that “nothing stands still.”  This latter two points probably sum up well Graduate Medical Education in the United States and OGME in particular.

Recent flow can be highlighted in three areas:  operational/accreditation, financial and structural.

Operational/accreditation

·         The “new” AOA program standards in many specialties and new crosswalks have been in play for several months now.  Early feedback from programs, OPTIs and the November PTRC meeting were generally positive.  More change is coming in this area in the form of institutional accreditation.  This is new to AOA programs and the devil will be in the details of implementation.

·         The AOA match has come and gone.  While the match statistics are interesting (and pontification on their meaning is an annual early February topic much like Punxsutawny Phil’s shadow), “matching” for osteopathic programs is a 5 part process – AOA match, scramble, wait, NRMP match and finally another scramble.  The wait until the final process is delayed this year by SOAP – not what you wash one washes their hands with – by the Supplemental Offer and Acceptance Program of the NRMP.  The structured scramble.  The uncertainty for OGME is that unmatched DO students are bound to SOAP prior to scrambling “back” to OGME programs.  The impact remains to be seen, but many osteopathic DMEs and program directors are rightfully concerned.

·         The final area of uncertainty comes from the proposed ACGME rule that would require AGCME training as a prerequisite for further ACGME training.  ** I purposefully linked to a Google search for "ACGME proposed rule" here so you can see the reaction yourself. **  blOGME has previously highlighted the details.  It seems clear that the proposed rule will have some impact on current students given anecdotal reports from the field.  The AOA and the ACGME are meeting on the topic of collaboration.  I am honored to be part of those deliberations.  If readers have not yet viewed ACGME CEO Tom Nasca’s piece in the New England Journal of Medicine on the Next Accreditation System (NAS) they should do so ASAP.

That is probably enough to keep one busy for now.  I will follow-up on the other two topics in the coming week.