The way American doctors are trained needs to be overhauled, an expert panel recommended Tuesday, saying the current $15 billion system is failing to produce the medical workforce the nation needs.
"We recognize we are recommending substantial change," says health economist and former Medicare Administrator Gail Wilensky, co-chairwoman of the nonpartisan Institute of Medicine panel that produced the report. "We think it's key to justifying the continued use of public funds."
The federal government provides more than $11 billion a year in payments to support the training of doctors who have graduated medical school, mostly through the Medicare program. Most of that goes to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly another $4 billion annually.
"The scale of government support for this phase of physician education is unlike that given to any other profession in the nation," said the report, which was funded by a dozen foundations with the support of a bipartisan group of members of Congress.
Even though the system has operated this way for decades, there is little data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century, the panel found.
Despite a growing public investment in graduate medical education, there are persistent problems. They include uneven geographic distribution of physicians, too many specialists and not enough primary care providers, and a lack of cultural diversity in the physician workforce, the report found.
Not only that, the authors note, "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice and lack sufficient training and experience in care coordination, team-based care and quality improvement."
The committee proposes a sweeping overhaul of the entire financing program for graduate medical education, with the goal of shifting the program "to a performance-based system," rather than one that merely funnels money to any facility with an accredited training program.
The current Medicare medical education payment system would be phased out over 10 years. At the end of the phase-out, policymakers would reassess whether Medicare should continue to subsidize doctor training at all, and if so, to what extent.
The panel calls for spending the same overall amount from Medicare over the next decade, adjusted for inflation. But it would be distributed much differently, with a declining share providing direct subsidies to teaching programs. An increasing share would go instead to a "GME transformation fund" that would finance new ways to provide and pay for training, and to fund training positions "in priority disciplines and geographic areas."
The funds would still be distributed through the Medicare program, but a new "GME Policy Council" would be created under the office of the Secretary of Health and Human Services to oversee workforce issues and commission research on how well the federal dollars are being spent. The committee recommended that states impose similar requirements for Medicaid training funds.
Major teaching hospitals in the Northeast would be most immediately affected, since they account for a disproportionate amount of Medicare medical education funding and number of doctors-in-training. The panel called for an end to the current system of payments that favor those hospitals. Instead it said that Medicare should make a flat "per resident" payment to training sponsors based on the national per-resident amount, adjusted for location.
It's time to close the open checkbook for teaching hospitals, the panel said.
"The statutes governing Medicare's GME financing were developed at a time when hospitals were the central - if not exclusive - site for physician training," the report said. But by doing that, "the Medicare payment system discourages physician training outside the hospital, in clinical settings where most health care is delivered."
Members stopped short, however, of recommending that Medicare stop funding graduate medical education altogether, at least for the near future.
The rapid evolution of the health care sector, said Wilensky, "was an important rationale for potentially using the leverage provided by government funding to try to train the health-care workforce we needed for a 21st century delivery system."
But the panel also did not recommend lifting the current cap on the number of residencies that Medicare supports. That cap was imposed in the 1997 Balanced Budget Act.
"Increasing the number of physicians per se is not likely to solve important workforce issues," Wilensky said, "particularly with regard to specialty distribution or geography."
All of the changes proposed in the report would have to be made by Congress, because government support for graduate medical education is written into Medicare and other laws. The politics, however, are unclear because the changes would produce winners and losers among programs training interns and residents.
After the fact that it's a blatant and ridiculous fraud, the first thing you might notice about The Bachelor(ette) franchise is its prim, Victorian attitudes about sex. For a show that encourages 14-person dates and the temporary negotiation of a lifestyle that could be best described as G-rated swinging, the whole shebang is awfully precious when it comes to the fact that sometimes, some of these people have sex with each other.
The having of sex generally makes its official arrival in the narrative each season at the point where the Bachelor or Bachelorette (let's say Bacheloron) has three Strivers left to choose from. These are the ones who go on "overnight dates." At an overnight date — and the more you hear this explained, the more creepy and clinical it will sound — the couple opens a sealed note from host/procurer Chris Harrison, who instructs them that they may spend the night in separate rooms or together in the "fantasy suite." The fantasy suite is not filmed, meaning that it does give couples the chance to spend at least a little bit of time alone before they decide to get married (!), but the unspoken purpose of the fantasy suite is, unambiguously, that you can have sex in it before the final decisions get made.
It's always been clear that some Bachelorons are comfortable having sex with three people within a few days and others are not. Not everybody Does It. Not even everybody who goes to the fantasy suite Does It. Some people probably Do Stuff That Is Not It, or that is Not It Exactly. Generally, the show connotes the suggestion that sex at least may have been had by showing you the door to the suite closing on the couple. Generally — although I can blissfully admit I have not seen every episode of every season — this is not something they talk about directly after the fact. They do not say "the sex was great," even though you can tell sometimes that it was. They do not say "the sex was disappointing," even though you can tell sometimes that it was.
Instead, there is a sort of strange agreement that although everything else, including engagements and breakups, is entirely public, you have a right to secrecy when it comes to who did what with who. We will follow a sad person into a limo to cry and collapse, but whether you kept your underwear on is for you to take to the grave.
That's what made Monday night's finale and post-show live update so surprising.
Generally, the way a Bachelorette season works is that each of the final two men has a private moment with the Bachelorette in which they propose to her, and she says yes or no. The analog in a Bachelor season is that each woman goes to find out whether he's going to propose or not. (If you have noticed that you commit a final act of either acquiescence or decisiveness depending on whether you are a boy or a girl, you win $20,000 in imaginary Bachelor Bucks in the Spot The Freakazoid Gender Politics Up In Here Sweepstakes.)
This year, however — and she was not the first to do this — Bachelorette Andi decided that since she already knew she wanted to marry giant-toothed former baseball player Josh, she would spare Wisconsin native Nick the trouble of picking out a ring and putting on a suit. So she went to see him and told him that it wasn't him, he was not the guy, and she would be giving her final rose (...never mind) to Josh.
Nick, who had been feeling pretty confident, looked devastated. He kept struggling like he was trying to say something to Andi, and as I watched him squirm and seemingly bite his tongue, I came up with a stone-cold guess regarding what his deal was.
Finally, after way too much pointless dumpsplaining on Andi's part, she left. She went off to see Josh, they got engaged, they kissed with such lip-smacking ferocity that it sounded like somebody was climbing the Empire State Building with suction cups on his hands and feet, and it was over.
Buuuuuuut it wasn't, quite, because there's always the hour they call After The Final Rose, presumably because Brand Extension and Just Leave It On This Channel And Rest Your Fingers, Baby seemed tacky. During that hour, we typically get to catch up with the couple to see whether they're still together (sometimes they're not) and happy (sometimes they're not), but we also check in with the runner-up to see whether he or she has recovered (sometimes s/he has not). This time, there was lots of buildup about the fact that Nick had tried to get Andi to meet with him in person earlier to ... maybe explain the breakup more? ... and she'd declined. So Nick had given Chris Harrison a letter to hand to her, which was written on notebook paper, because apparently he wrote it during homeroom. This would be Nick's big chance to confront Andi.
For a brief moment, it seemed like Nick was going to think better of all this confrontation. Rather than demanding answers, he thanked her for opening him up to the idea that he could feel love. She encouraged him to stick with that idea.
It was not to be. Nick had more to say. Many of those at home hoped he would not say it, whatever it was. STOP, NICK, we thought. STOP WHILE YOU CAN STILL STOP.
"Knowing how in love with you I was, if you weren't in love with me, I'm just not sure why, like, why you made love with me."
[Please note that as I rewatched the clip to add that quote, my shoulders involuntarily hunched up to my ears.]
Andi bristled at this, saying that seemed "below the belt" and like something that should be private, which is both kind of crazy and perfectly logical. In a way, they're less far apart here than they seem: Nick thinks he's arguing an old-fashioned view in which sex means something, at least when one person has declared himself to be in love, so one doesn't play with someone else's feelings by engaging in it when to do so might be misleading. Andi thinks she's arguing an old-fashioned view in which one does not kiss and tell, particularly about a relationship that's over, particularly during something that is mostly supposed to be a happy celebration of a new relationship. They both would claim that they're arguing simple sexual ethics — simple good bedroom manners.
The problem is that this is not a simple situation. This is a situation massively complicated by the fact that — oh, right — it took place within a completely artificial environment in which people have already waived all kinds of expectations they would normally have when it comes to sexual ethics. Andi has already agreed to reveal far more about her romantic and sexual life than she would if she weren't doing all this on television. Nick has already agreed that he will participate in a contest in which there will be, at the end, a loser — someone in precisely his position, who is in love and is essentially strung along until the very end and then dumped. She's already waived, up to a point, "what's private is private," and he's already waived, up to a point, "don't mislead me."
But because sex has always lived in such a bizarre part of Bachelor World, both used for titillation and withheld from view as part of a respectful pantomime of romance, it affects the dynamic in unexpected ways. It was hard to avoid the feeling that while Nick might have been justified in feeling icky about having had sex with her when he didn't realize she intended to dump him, bringing it up on live television was more about embarrassing her; otherwise, why break the unwritten rule that what happens in the fantasy suite is only vaguely alluded to outside the fantasy suite?
Part of the weird appeal of this show, admittedly, is its tendency to stumble, entirely unwittingly, entirely without sophistication, into actual brambles involving sex and gender. Little conversations about who would move to be with whom, little exchanges with parents, little turns of phrase (Josh's repeated use of the expression "make her my wife" made me feel like I was watching a 1950s western) — it's all so fake, and yet it blunders into these wee little bursts of honesty.
The irony of the entire thing was that the bursting of this particular bubble, the abrupt abandonment of the unwritten rules about fantasy suite nondisclosure, might have seemed like an intrusion of modern vulgarity on the surface. But what Nick introduced was actually an extremely traditional cultural idea within our sense of how men and women relate to each other: the spurned partner who regrets having had sex when it turns out the feelings weren't reciprocated.
What's different is that in the traditional version of this narrative, this comes from the woman. Maybe Nick was trying to embarrass or shame her, maybe he was trying to make her uncomfortable. But if this had been the other way around — a woman complaining that a guy shouldn't have had sex with her if he didn't love her — there'd be no assumption that the revelation of sex itself was supposed to reflect poorly on him. It would be about false pretenses only.
It's almost impossible to imagine a man who chose to be the Bachelor setting his jaw and saying what Andi did about how revealing that they'd had sex was hitting below the belt. That's not because Andi is necessarily wrong or that her reaction is necessarily female; it's because within popular entertainment, there's almost no such thing as casting aspersions on men for the sex they're having, particularly within the confines of an arrangement like this, where everyone is on board voluntarily.
It's just ... strange. It's all strange. It's a prim undertaking with lots of bikini shots. It's an 8:00 p.m. show that sends people off to what might as well be called the Sex Lounge. It throws all kinds of stereotypes and nonsense into a blender and produces a simulacrum of traditional courtship with ten people at once.
And it almost never gets anybody married.
Summertime bodes well for reggae music. The genre's biggest crossover moves — from Sean Paul to I Wayne — have been made during the balmier months, when Americans relax enough to stretch the geographical limits of our soundtracks. This year's case in point: Chronixx, Jamaica's current it-artist, steadily making strides on international shores. The 21-year-old Rastafarian singer — his sweet, sincere tunes and old-school-yet-not-overly-nostalgic sound are welcome antidotes to an irony-laden culture — released his debut EP, performed on Jimmy Fallon's show and, this weekend, took the stage before a filled-to-capacity crowd for a free concert at Central Park SummerStage. That venue holds 5,500 people and an estimated 2,000 more stayed outside the gates, listening. It was a LargeUp event with New York's iconic Rice and Peas sound system DJing throughout. Backstage, Chronixx reasoned with Baz Dreisinger about music-making, Rasta and the state of reggae.
BAZ DREISINGER: What a show! The crowd hit capacity almost right after the gates opened. Even Mick Jagger came out. What does it mean to you to be at SummerStage — one of few current reggae artists to perform at this venue in recent years?
CHRONIXX: Central Park was definitely, officially one of my most exciting shows ever. New York City is home to a lot of Jamaicans and Caribbean people — I think there are more Jamaicans here than in Jamaica. It's home. So it feels like getting accepted at home.
And performing on Jimmy Fallon — again as one of few reggae artists to ever do so?
It was wonderful, but frightening, because I knew that everyone in Jamaica was watching, and if you mess up, you mess up in front of your whole family. My mother was watching, my grandmother was watching — it was scary. But other than that, it's just music — it's living. The stage becomes insignificant, the setting becomes insignificant, and you fall in love with the music and get in that state of relaxation and from there, the interaction and performance come to be.
How did it, literally, come to be — that Fallon performance?
Jimmy Fallon came to Jamaica and was staying at Goldeneye [the boutique hotel owned by Island Records founder Chris Blackwell]. He was on vacation, and he heard my music and liked it. So it was that simple: on vacation in Jamaica, hear some reggae, like the reggae — and here I am.
After the Fallon performance you posted something on your Facebook page about not having to water down one's Rasta identity in order to achieve crossover success. Explain what you meant.
Rasta is our platform, that's where we stand. And if you remove that platform, you're not standing on anything. As a Rasta, as a Jamaican youth, that is my culture, that is who I am. So regardless of the music, the instrumentation, which show I am at — I'm going to be a Jamaican Rasta. When you look at the music charts, there's reggae there but you don't see nothing about Rastafari — and that doesn't matter to me. There are a lot of youths out there who want to hear what I have to say as a Rasta, and I can't brush those billions of youths under the carpet, just for a mainstream audience.
Is a mainstream audience something you think about? Current reggae has a kind of boom-and-bust history with American audiences: moments of great crossover success, but little lasting presence.
That's because for us, as Jamaican youth with our morals, we are only willing to go a certain distance to please the mainstream. For me, unless people respect my morals and my culture, I can't go too far. The industry doesn't respect our culture; they try to give it a pop image. That's what the celebrity thing is in America: You're talented and then they refine it to suit everybody. You can reach to a level but then you're asked to do and be things that are not acceptable. Dem say America is the land of the free, but except for the Rastaman — the respect is not there. I think that's it with the mainstream thing: Celebrity life can't work for a person like me; as Rasta you deal with the earth, you deal with farming, with meditation, health — and a celebrity life doesn't facilitate any of those.
So how do you plan to navigate that celebrity world, considering?
My plan is just to live and do what I can, until I can't do it anymore.
Last time Jamaican music was seriously on America's radar it was dancehall: Sean Paul, Elephant Man, back in the early 2000s. Do you think roots reggae, your music, is more marketable?
Americans are marketing geniuses. They can market fridge to Eskimo people. Dem can market anything. You ever hear some song that's number one in America and you're like — this? So they can market dancehall, roots — whatever.
Your album Dread & Terrible is independently released. What made you go that route?
Just how a woman say she want to remain single for a while, you know, and see whaa gwaan? That's why. You get signed too young and you get signed for less than your potential. It's actually my EP, but everyone called it an album, which it's not. It's a project that captured a vibe I was feeling, not a full album.
You're identified — along with other young artists like Protoje and Jesse Royal — as part of Jamaica's "new roots movement," which blends old-school roots music with a kind of new-age hipster aesthetic. Does this label annoy you?
Not at all. We are a movement, with a lot of youths — a whole heap o we shouting at the same time, very loud and very vibrant.
Your father was a reggae artist named Chronicle, so you practically grew up in the studio. How old were you when you first started making music?
From ever since.
Who are you listening to these days?
Enya. Her vocal abilities, her elasticity, ability to replicate strings and percussions — amazing.
Your song "Smile Jamaica" is the perfect replacement for Bob Marley's "One Love" in all the tourism ads. Would you be up for having that song used in those ads featuring happy tourists?
That song is for the people and if it will ultimately benefit the people of Jamaica, by all means.
What is your songwriting process like? How do you make music?
It can come from a memory, a color, a feeling. From there, it becomes a word or a phrase or a sound. I meditate a lot with my thoughts. I spend half an hour every day just thinking, and that's really how I make music. Melodies for me are more like a mechanical thing — you know what kind of melodies will drive certain feelings — that's the technical part. When you meditate so much, the songs are already there, so you go in the studio it flows.
See, I'm not a perfectionist with music. I like it raw; I don't like to polish it too much. If so God give it to me I'm not going to use my human brain to replace heavenly things with human things. A lot of things that don't make sense to our brains make sense to our souls. So the grammar not right — the grammar is not correct. Some of the "ares" could be taken out; some of the "is" could be "are"; you didn't pronounce the "t" properly — but it's feelings. When you think, you don't think in complete sentences. And when you feel, you don't feel in perfect grammar.
Most sports novels are about the aspiration to excel physically: to run faster, stretch out one's arms farther. The really cool thing about Ride Around Shining, a debut novel by Chris Leslie-Hynan, is that it doesn't stick to that familiar rulebook. Even though it's set in the world of pro basketball, our narrator here is not the guy who aspires to be a great player; rather, he's the guy who aspires to be a great suck-up to the great player.
Jess, as our narrator is called, is a white-bread grad student, finishing his "second useless degree." One day, he hears that a player for the Portland Trail Blazers, named Calyph West, is looking for a chauffeur and Jess lands the job. Thus, begins Jess' life of eager servitude, driving Calyph around in his "entry level" Jag, waiting on the party guests who swarm into Calyph's McMansion on weekends, and even helping Calyph to dress, choosing from his array of beautiful suits, in pearl gray, honey butter and pinstripe silver.
If your literary allusion antennae have begun twitching, you've read your Fitzgerald. This novel about nouveau-riche excess, social class and hero worship references The Great Gatsby on practically every page, beginning with Jess's retrospective Nick Carroway-like narration, as well as that premise of a white chauffeur driving around his rich black passenger — that's a scene that mirrors the famous "Queensboro Bridge" passage in Gatsby.
But, Gatsby isn't the only Great Book that Leslie-Hynan cites: there's a bit of Othello lurking in a subplot about the scheming Jess' crush on Calyph's white wife, Antonia. And, in Jess's tall tales about his own background and the wily way he sets in motion an accident — via ice sculpture — to sideline Calyph early in the novel, the Ripley stories by suspense master Patricia Highsmith spring to mind.
Sometimes, all this breathless literary sampling overwhelms Leslie-Hynan's own voice and plot, giving his story a contrived final Jeopardy! question feel. But in its calmer, more assured moments, Ride Around Shining lays claim to being an interesting novel on its own terms, offering some fresh takes on those big American topics of race, class, manhood and meritocracy.
Race, in particular, enters into even the most casual of interactions between Jess and his employer, Calyph, who sometimes seem to be developing a genuine friendship. "Other times," Jess tells us, "I felt just as sure we weren't really friends at all, that he was having me on ... [M]aybe he'd just grown accustomed to the queer allegiances of white boys tired of their own skin ..."
The most compelling moments here are the crowded party scenes where Jess finds himself the lone non-basketball player and usually the only white guy — "Chalk," as he's called — in the room. Occasionally, he's allowed into the conversations, but the black players are always quick to let him know when he's misstepped.
During a conversation at a house party, the question of who's on the inside and who's on the outside — not only at the party, but in America — becomes especially tangled. Jess spots one of those arcade games outfitted with plastic rifles, so he asks his host, an old basketball player nicknamed "the Pharaoh," if he hunts.
The Pharaoh snorts: "Who am I, Colin Powell?"
Jess tells us that: "I was about to banish myself to silence ... when [the Pharaoh] shook his head a little wistfully and continued.
"I'd like to shoot a elk," he said. "Make me feel part of somethin' ... "
"Make you feel part [Re]publican," [says another player].
"Imagine that ..." Pharaoh said, laughing huskily. "Half a dozen brothers go up to Montana, lookin' right, showin' dignity, shootin' at some elk. Why don't that happen?"
"I'm just sayin', we shouldn't shut ourselves out. This America."
That's a rousing affirmation of American possibility, but because Ride Around Shining is so cleverly retracing Gatsby's doomed route, we readers are clued in that there's a limit to what even the most high-flying basketball player here is going to achieve. Ride Around Shining is an often provocative read: it wouldn't be my first round-draft pick, but it's got game.