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Challenges related to the globalisation of medical education

The new global medical education system, marked by its growing size and complexity, has led to greater concerns about quality assurance of individual graduates and their educational programs.

Assuring a quality medical education varies considerably from country to country, as do training standards. Traditionally there have been two ways to assure quality, assessment of the individual practitioner (e.g., licensure examinations) and accreditation of a school or educational program.

The globalisation of the medical workforce and evidence that suggests that foreign medical graduates perform more poorly on standardized exams than graduates from local schools is leading to an interest in more uniform ways to conduct each quality assurance process.

You can find below what the M3 Global Research community answered to this question.

By registering with M3 Global Research you will receive the Monthly Pulse directly to your inbox and you will be able to give your opinion about relevant healthcare related issue and compare your thoughts with your colleagues around the World.

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Talking to… Dr. Aaron Milstone

Aaron Milstone

Dr. Aaron Milstone is a pulmonologist in Franklin, Tennessee and has been in practice for more than 20 years, 15 of them as an Associate Professor in Medicine at the Vanderbilt University Medical Center. In this interview to the M3 blog, the doctor shares the novelties in the treatment of COPD and asthma, his main areas of interest, and his opinions on e-cigarettes and home-test for sleep disorders.

Data from the United Network for Organ Sharing shows a 3% increase in organ donation in the US since 2016, and a 27% increase over the last ten years. What’s your opinion on new techniques which are helping to facilitate that?

I was at Vanderbilt University Medical Center in Nashville, Tennessee, where I directed a lung transplant program for 15 years, so obviously was involved in a great deal of critical research into transplantation. In terms of lung transplants, there are many aspects contributing to the increase in organ donation, including educating the public, and expanding the donor pool to include older patients, and the preservative solution used has improved so an organ can last longer outside the donor body than ever before.

Another one of your areas of expertise is the management of COPD. What are the hottest news in this field?

Yes, my main areas of interest are COPD and asthma. I have a large clinical research program conducting phase 3 and 4 studies in both asthma and COPD. COPD is a real hot topic now as we get ready to have biologic options for patients with the condition. COPD is an enormous problem in the US, especially in the South-East of the US where smoking rates are particularly high – the highest in the US. Just in my own state of Tennessee, the incidence is very high compared to the US in general. In turn COPD rates are very high here as well. My opinion is that we are in the era of Columbus in terms of COPD treatment.

By that I mean that historically we’ve used inhalers, but now we have drugs with new mechanisms of action and new delivery systems. Now a fixed dose, triple drug therapy has come to the US market, within the last year, and there are also multiple LABA/LAMA combinations and many more therapies to come. Triple drug therapy is going to have a significant impact – patients can now use a single device rather than three inhalers, so adherence improves.

Historically we’ve relied on patients to tell us whether they’re taking their medications, but now we’re doing a lot of research looking at new ways to improve compliance, and many of those involve smart electronic devices and smart phones. In the future, your inhaler will be able to report how frequently it’s been utilized, whether the correct dose has been administered and, most importantly, give feedback to the HCP. There’s lots and lots of knowledge on the horizon that will revolutionize the use of inhalers at minimal cost to the patient and HCP.

We’re also doing a lot of work with biologic therapy. Recently one of the larger drug companies published data on biologics and exacerbations of COPD. The impressive feature of biologics is that they have the ability to improve lung function but also may have the potential to reduce flare ups. So, I think there’s going to be a change worldwide in how we treat COPD and asthma in the near future. There are currently four different biologics treatments already on the market for asthma, and many more in the pipeline, and I’d expect to see biologics treatments for COPD coming soon. It’s an exciting and unique time to be in pulmonary medicine. I believe that soon there are going to have to be niche sub-specialists who are very familiar with immunology and biologic drug classes.

Data on smoking in the US shows that the percentage of people smoking has declined from almost 21% in 2005 to 15.5% in 2015, but cigarette smoking is still the leading cause of preventable deaths in the country. In other countries there have been initiatives to reduce smoking via taxation etc, how do you think the US should approach this?

The data in the US is very similar – there is a linear correlation between smoking tobacco and higher taxation. The states that have the highest taxation on tobacco tend to be in the east. The states that have the lowest taxation tend to be in the south-east, and there is a very clear correlation between taxation and prevalence. Taxation on tobacco products can be very effective at keeping prevalence down.

Another strong approach that I’m an advocate for is improved pharmacologic coverage by insurers. Unfortunately, most insurance companies do not cover the cost of smoking cessation products such as nicotine replacement patches. I think that insurance companies should be lobbied to cover the cost of treatments for smoking cessation. At the moment if a patient can’t afford nicotine replacement patches or other treatments they have a much lower likelihood of stopping smoking. Some insurance companies now are giving discounts on premiums to patients enrolled in tobacco cessation courses or if the patient makes a ‘valiant attempt’ at cessation, and I think that’s a really good way to increase quit-rates. I think that counselling combined with pharmacologies is the best approach.

I do agree that the Australian approach to taxation is helpful, but I also think that you need to look at secondary intervention in terms of helping people to quit and giving them affordable ways to quit. This has been a real focus for me as I live in the South, and Tennessee has one of the lowest rates of taxation, and hence is a state with very high tobacco use prevalence. The reality is that I see so many complications of tobacco in terms of stroke, myocardial infarction, and lung cancer, that this area of medicine is very important to me.

The UK has reached a record low in terms of smoking rate, with over a million people reporting using e-cigarettes, which can be somewhat controversial. What are you take on them?

I think the main problem with e-cigarettes is that the long-term health effects of these cigarettes remain unknown. There’s a multi-center study looking at the long-term impact of their consumption, and until the effects are known I strongly advocate against using them to quit smoking. Yes, there are less carcinogens, but many still include high levels of nicotine. The way I see it, is that you’re just switching out one addiction (ie. cigarettes), for another (ie. e-cigarette). I believe that when we see long term data we may find that e-cigarettes are no safer than regular cigarettes, but we don’t know that at this time.

Regarding sleep disorders, another area of concern in Pulmonology, what’s your evaluation on the recent practice of home tests for the diagnosis of sleep disorders?

Definitely a hot topic. Any physician, such as a primary care physician, for example, can now order a home sleep test for a patient. However, I think the patient really loses out on some of the analysis and expertise when they’re not seeing someone who is board-certified in sleep medicine. The reason I say that is that many of the home sleep tests lack data on aspects like leg movement, so you may not be able to make a diagnosis of periodic limb movement disorder with a home sleep test.

In addition, there’s a very crude analysis of REM and non-REM.  So, many times the home sleep study may not be adequate for a diagnosis of, for instance, narcolepsy or idiopathic hypersomnia. At the end of the day, home sleep tests are best when the health care provider is looking specifically for sleep apnoea. However, a home study can lack sensitivity for patients with mild sleep apnoea. Unfortunately, if you haven’t seen a board-certified physician for the analysis you may not have been fully assessed for other diagnoses like idiopathic hypersomnia, and most importantly, may not get the degree of follow-up after starting CPAP if you have been diagnosed using a home sleep study.

That being said, home studies are a trend that’s not going away. Physicians have to be very selective about who gets a home sleep study. The health care provider has to be purely thinking about sleep apnoea and ensure that the patient is safe to be assessed in the home environment. If someone has significant heart or lung disease or underlying seizure disorder, those patients should all be assessed in a monitored sleep lab setting. Also, if you do a home study you want to make sure adequate follow-up is in place when the patient initiates therapy with positive pressure (ie CPAP or BPAP).

How will technology impact medical practice?

Original research by M3 Global Research was featured in City AM and Business Reporter this week. Our findings on how physicians think technology will impact medical practice was included in Anna Delaney’s article ‘What healthtech can learn from fintech’.

With healthcare being touted as one of the tech trends to watch over 2018, the text is built on the idea that technology in healthcare might soon have the same impact it has had in consumer’s banking behaviour.

Delaney highlights that, according to the survey conducted by M3 Global Research earlier this year, 26% of UK doctors see that investment in self-diagnosis technology will have the most impact on patients over the next five years. And she goes on to ask: will this make people increasingly independent from their doctors?

The article doesn’t fail to mention the importance of developing trust, and suggests that having trained and accredited physicians involved is key.

Click here to read the full text.

Talking to… Dr. Lawrence Feldman

Dr. Feldman, a dermatologist specialising in the treatment of melanoma, practising for 30 years in the US, spoke to the M3 blog about prevention, new treatment developments and the changes in patients’ approaches to the condition.

M3 Global Research is about to launch a large patient outcome study about melanoma. If you are a dermatologist or an oncologist and are interested in participating, please contact blog@eu.m3.com. If you are not a member of our panel and are interested in participating, you can register for this study here.

What do you think about new developments such as optical biopsy, or tests that look at gene expression patterns and allow physicians to see if stages 1 and 2 are likely to spread, new types of immunotherapy and targeted therapies etc?

The field has definitely changed dramatically, more so than any other field as we have gone from a situation where there was really no therapy that was effective, to now seeing therapies that can induce prolonged remission and even overall survival rates. As far as the gene expression profile, it is a huge advance, perhaps even replacing biopsy in the future. And with optical biopsy and dermatoscope use, the clinical diagnosis of melanoma has gotten much better.

How long ago would you say was the breakthrough?

I would say it began about five years ago. It’s really when things started to change, I guess with the introduction of Zelboraf (vemurafenib) – that was the big turning point.

How do you personally keep updated with news in melanoma treatment?

I would say conferences, congresses, symposiums, journal articles, Tumor Board. We have a Tumor Board at the hospital on a pretty regular basis, so all these things help us to keep up to date.

From your experience, how is the level of treatment in the US compared to other countries?

I think the level in the United States is high, I’d say it’s quite advanced. We definitively have access to many of the newer therapies.

And how is access to treatment for patients? Do most insurances cover melanoma treatment now?

If you are following NCCN (National Comprehensive Cancer Network) guidelines, access is very good. It is harder to get access off-label.

What’s the part played by prevention in skin cancer?

I would say it’s the key. Prevention is better than treatment. So, especially if it’s about avoiding sunburn early on, that would be probably the most critical thing.

During the past 30 years have you noticed changes in patients’ attitudes and empowerment? Are patients more aware of conditions such as melanoma and therefore pay more attention to their own bodies, coming to you with questions?

I think people are more aware of it. Even younger people are more aware of the sun causing it, and even tanning salons, that are ‘a big thing’ in the United States and also a big campaign that has got more publicity recently.

How important is early detection for the treatment of melanoma?

It’s key. We talk about 3 things: prevention, early detection, and treatment. Prevention is the most important, so you don’t have the problem at all; early detection is vital because if you catch the melanoma before it’s reached a certain depth, then you don’t really need any other therapy; and then early treatment, for patients that are less fortunate.