Archive for March, 2024

Our health care system is upside down in many ways. One of them is the adminstrative burden of Electronic Health Records. Another is the cost of medical school.

Wednesday, March 20th, 2024

From 2003 through 2020, I was a Founding Director of Commonwealth Care Alliance, a non-profit Massachusetts HMO serving dual-eligible beneficiaries.¹ From 2017 until my retirement at the end of 2020, I was Chair of the Board.

In 2006, we were excited to enter the world of electronic health records, EHRs. Doing so was expensive, but we believed the new technology would allow us to make a giant leap forward in serving our members. Little did we know that the uncharted territory we were about to enter would also resemble a minefield the deeper in we got.

Every health care organization in Massachusetts, as well as the federal government, encouraged every health care provider to make the move to EHRs. This meant that for-profit businesses soon emerged to build bigger and bigger EHR systems, which they could then sell to the nation’s health care community. And so it went.

Eighteen years later, the administration of EHRs is one of the reasons America is losing physicians, especially Primary Care Physicians, PCPs. On average, physicians spend 9.2 hours a week filling in documentation for electronic health records, forcing many of them to stretch workdays into the evenings. This phenomenon is so common that it’s frequently called “pajama time” as doctors continue working on charts after putting their kids to bed. A 2022 JAMA Internal Medicine study estimated, “Assuming a 5-day work week and 47-week work year, US physicians spent 125 million hours documenting outside office hours in 2019.”

And when was the last time you saw your PCP (if you have one; a quarter of the nation doesn’t) without a laptop in hand, into which he or she would stare while entering information throughout your appointment? The one-on-one time is often more with the laptop than the patient. Entries into that laptop have to be precise, because everything is tied to billing. The researchers in the cited study reported, “84.7% of surveyed physicians agreed that documentation solely for billing purposes not only added to their administrative burdens, but was also perceived as onerous.”

Time spent documenting is often time not spent with a patient. The average time a patient spends sitting in a waiting room (20 minutes) now exceeds the average length of a primary care appointment (10 to 15 minutes). Long wait times, general inconvenience, and quick-like-a-bunny appointments drive down patient satisfaction and discourage some people from seeing doctors altogether.

It also weighs heavily on doctors and discourages many from remaining in the profession they worked so hard and paid so much to enter. Moreover, it discourages many young people from entering it in the first place, so much so that the number of America’s primary care physicians has been declining since 2015.

The cost of medical school

Another reason for the steady decline in the number of PCPs is the cost of medical school. It’s expensive.

The annual cost of the average four-year medical school is now more than $58,000.  For a public medical school the cost is nearly $53,000; it’s about $65,000 for a private institution. Elite schools, like ones in the Ivy League, are all around $75,000 per year. The most expensive medical school in the nation for in-state residents is Hackensack Meridien School of Medicine, at $80,203 per year. For out-of-state residents, the University of Washington School of Medicine is the most expensive school at a whopping annual cost of $96,489.

As you can imagine, upon graduation, newly minted physicians  are deep in debt from undergraduate and medical school loans.

According to the Education Data Initiative, medical school graduates owe a median average of $215,100 in total educational debt, undergraduate debt included, when they enter the profession.²  The average physician ultimately pays $135,000 – $440,000 for an educational loan—plus interest. At current interest rates (6.54% as of September, 2023), a $200,000 loan can double over ten years.

Medical school costs in the U.S. are orders of magnitude higher than the costs in European medical schools. For example:

  • France: At about $633 per year, medical school is nearly free;
  • Germany: Medical school is free;
  • Switzerland: The cost is $912 per semester;
  • Spain: Public medical schools charge $3,505 per year (however, private, elite schools are much more, averaging $27,376; still, this is not even half elite school costs in the U.S.); and,
  • United Kingdom: The cost in $9,250 per year, but after year five, there is no cost.

All of which is why physicians in America, both PCPs and specialists, are paid nearly double their peers in the most developed countries in Europe. They owe so much in debt, they have to be.

On top of this seemingly ridiculous paradox is the fact that total health care costs in America are, and have been for many years, nearly double the average for the other 38 developed countries in the OECD.

Despite this, life expectancy in America, at 76.4 years, is lower than two-thirds of all the countries in the OECD, including all of the ones cited above. Yes, uninformed Americans denigrate the UK’s National Health System, but, at 80.4 years, that nation’s citizens manage to live four years longer than we do.

What can be done to right our foundering health care ship?

Perhaps not much. The highly consolidated health care system in the U.S. is so deeply rooted with so many vested interests, doing anything other than nibbling around the edges seems herculean. But that doesn’t mean we shouldn’t try.

For a start, we could make going to medical school easier and cheaper.

We could take a hard look at NYU’s Grossman School of Medicine, which, since 1841, has been nationally recognized for the excellence of its degree program. More important for this discussion—tuition is free. As the school puts it:

We are proud to offer every student enrolled in our MD degree program Full-Tuition Scholarships as part of our tuition-free initiative. We believe providing tuition-free education will lead to better patient care and will benefit society as a whole by turning the best and brightest future physicians into leaders with the potential to transform healthcare.

If a medical school in the heart of New York City can provide free tuition, do you believe it possible for others to do the same?

Well, two others are now. As of August 2024, tuition will be free for all students attending Albert Einstein College of Medicine, also in New York, thanks to a $1 billion donation from Ruth L. Gottesman, chair of the school’s board of trustees — the largest gift ever to a medical school.

And students at the Uniformed Services University’s (USU’s) F. Edward Hébert School of Medicine not only attain a medical degree for free but are paid during their studies.

Those pursuing an MD degree from USU enter the institution as commissioned officers of the Army, Navy, Air Force, or Commissioned Corps of the U.S. Public Health Service. As such, they receive a graduate student stipend while enrolled. They also get other benefits, including free medical care, a housing allowance, and paid time off.

Students at USU receive over $70,000 annually through base pay and other allowances, according to USU. That is in addition to not paying tuition while enrolled.

In return, the program requires a seven-year commitment to active military duty. Time spent in graduate medical education, such as in a residency, does not count toward the required commitment.

These three schools are demonstrating in three different ways that succeeding in medical school does not have to entail being lashed to a long-term, onerous financial anchor.

New physicians from these schools will still have to face the documentation burden that awaits them, but at least they will be spared the added burden of coughing up more than $2,400 per month for ten years to repay loans they did not have to secure.

I am certainly not such a fool as to think that free tuition at  Grossman, Einstein, and USU will cause a radical shift in how we produce the doctors we so dearly need. But it’s a start.

And if we can get beyond three, we may have the beginning of a Movement.


¹ People eligible for both Medicare and Medicaid. Known as “Duals,” these are the sickest of the sick and the poorest of the poor. They make up ~5% of the population, but consume nearly 40% of all health care dollars. Helping them to become healthy also lowers costs, a real win-win.

² In 1978, the average medical school debt in the U.S., adjusted for inflation, was $53,648 (Actual debt in 1978 dollars was $13,500).

Russia is using our abandonment of Ukraine to commit cultural genocide

Tuesday, March 12th, 2024

On 24 February 2022, the day that began Vladimir Putin’s invasion of Ukraine, Russian armored vehicles and soldiers crossed over the southern border from Crimea, the region captured in another invasion eight years earlier. The new invasion force rolled into Henichesk, a sleepy settlement of some 20,000 souls in southern Ukraine.

When they arrived, the Russian invaders encountered not the cheering, open-armed, welcoming people they’d been promised. Instead, they saw Ukrainians who in addition to being unimpressed with the arrival of their “liberators,” were also  downright hostile, although hostile only in a verbal sense, as most of the townspeople were on the other side of 60.

On that day, one older woman, looking every bit the mild-mannered grandmother, asked an enemy soldier, in an exchange filmed on a phone, “What the fuck are you doing here? You’re occupiers! You’re fascists! You came to my land uninvited.” She then tried to hand him a packet of seeds. “These are sunflowers seeds. You should put them in your pockets so that they will grow on Ukrainian land after you die. From this moment you are cursed!”

Two months later, the occupiers introduced a familiar figure to the townspeople. Dressed in a three-piece suit, and sporting his familiar goatee and moustache, Vladimir Lenin stood tall on his new pedestal. The Russians had erected his statue outside the town’s main council building. They flew Russian and Soviet flags from the roof. Just in time for Lenin’s 152nd birthday.

Well, things have gone steadily downhill from there in Ukraine.

As we find ourselves in the third year of this war, Ukrainians continue to do their best to expel Putin’s invaders, all with ever dwindling ammunition and weapons, thanks to Republicans in our Congress. Although probably quite the understatement, Ukraine’s Defense Ministry reports that, thus far, the nation has seen more than 31,000 of its soldiers killed in the conflict, as well as nearly 11,000 innocent civilians. It also claims its forces have killed more than 414,000 Russian soldiers since the start of the war, Putin’s cannon fodder. More than likely, these figures are inaccurate on both ends. I write  from the experience of dealing with “body counts” during the Vietnam War.¹

Humanity isn’t all the Russians have destroyed in Ukraine. Russian missiles and drones (many of them Iranian), as well as airplanes, have wiped out vast swaths of Ukraine’s infrastructure, which, as I and others have written, will require a Marshall-like Plan to rebuild.

However, there is one thing that’s gone unnoticed until now, and it is reminiscent of German actions during World War II — Russia’s looting of museums and destruction of its churches.

James Brooke, writing for the Berkshire Eagle,² reports this is occurring on a mammoth scale. In response, Ukraine has assembled its own team of Monuments Men working to catalog and repatriate stolen art. This new unit of Ukraine’s Territorial Defense Force is also gathering evidence to prosecute Russian military looters and vandals, if they can ever find them.

As Brooke writes:

It will be a big job. In the biggest cultural destruction Europe has seen since 1945, the United Nations Educational, Scientific and Cultural Organization’s latest tally pegs the two-year toll at damage to 343 sites — 127 churches, 151 historic buildings, 31 museums, 19 monuments, 14 libraries and one archive. Ukraine’s Culture Ministry says 1,189 cultural objects have been damaged or destroyed.

Brooke believes there is more going on here than stealing valuable art and busting up churches. He reports that Kyiv’s Maidan Museum Director Ihor Poshyvailo said recently in a Zoom call with American historians, “This is also the heritage war. It’s a war against our memory, historical memory. Against our identity. Against our culture. And, of course, against our future.”

Mystetskyi Arsenal cultural center director Olesia Ostrovska-Liuta added, “This Russian war in Ukraine is very tightly connected to culture. The basic assumption which lies beneath this assault is that Ukraine should not exist as a separate phenomenon with its own political agency. Any Ukrainian otherness from Russia should be erased. It is genocidal in its attempt and in its action … culture is in the very core of this war.”

During three years of horror in Ukraine, we have seen the deliberate bombing of Ukrainian hospitals, schools, and apartment buildings; corpses strewn in streets and stuffed into mass graves in Bucha; the veiled threat to resort to nuclear war if the West keeps supporting Ukraine; the Hermann Göring-like theft³ of the country’s magnificent cultural treasures. After seeing all that, how can we casually walk away?

But that is what we appear to be doing. That is what the world sees.

Congressional Republicans, falling all over themselves to do whatever Donald Trump demands, no matter how unpatriotic, are helping Putin and his Russian thugs to defeat Ukraine.

They are also helping to destroy its soul.


¹ I was once ordered by my Commanding Officer to get into a Light Observational Helicopter to go look for what someone in another chopper had reported “might” be the body of a North Vietnamese soldier. That “body” turned out to be a big tree branch; that’s how desperate we were to add to the body count.

² The Berkshire Eagle is a Pulitzer Prize-winning newspaper in Pittsfield, Massachusetts.

³ Smithsonian reports Nazi military leader Hermann Göring amassed his own personal collection of art stolen from museums and private homes. His collection totaled more than 1,000 items, valued at $200 million in 1945, most of it stolen from France. The art was hidden at various locations in Berchtesgaden, Germany, in the Bavarian Alps until discovered by the Monuments Men. The recovered artwork was then collected at Unterstein before transport to the Central Collecting Points at Munich and Wiesbaden.