America Abroad Media

Research ObjectiveTo inform how the measurement of community‐level social determinants of health (SDOH) at different levels of geography may affect the specification of the relationship between SDOH and hospital readmissions, as well as limitations and misclassifications that may occur at each level.Study DesignUsing a unique inpatient data set from New York State, including a subset of New York City residents and their geographic location geocoded to a block group, census tract, the NYC‐specific Neighborhood Tabulation Area (NTA), and Public Use Microdata Area (PUMA), we compare models predicting all‐cause unplanned hospital readmission rates within 30 days after inpatient discharge for three common conditions (acute myocardial infarction or AMI, heart failure or HF, and pneumonia or PN) using SDOH composite scores from variables collected at each geographic level with the baseline readmission model used by the Centers for Medicare & Medicaid Services (CMS). These models are compared on goodness of fit, statistical significance of the variables added to the baseline model, and the impact on hospitals treating high‐risk patients. SDOH data included geographic‐level variables for education, income, housing, English‐speaking, housing value, and employment.Population StudiedAll‐age and all‐payer residents of New York City that had an inpatient admission to a hospital in New York State for AMI (n = 17 994), HF (n = 53 998), or PN (n = 69 539) between January 1, 2013 and November 30, 2016.Principal FindingsCMS’s baseline readmission model performed worse than all four SDOH‐augmented models in goodness of fit. The added SDOH variables reached the highest levels of statistical significance in the model using the lowest level block group SDOH data, which also tended to have the highest levels of goodness of fit. Among all models, the model with a block group level SDOH composite showed the greatest measured performance improvement in readmission rate for those hospitals with the highest proportion of patients with SDOH high rates, compared to CMS’s current model.We also find that lower geographic levels, which have more numerous, smaller areas, have more widely distributed SDOH rates around the NYC average. As a result, when measuring SDOH at low geographic levels, more patients exhibited high‐risk levels for individual variables, compared to measuring at high geographic levels.ConclusionsNot only does including SDOH data improve model performance with statistically significant model variables and lead to changes in the distribution of hospital measurement, as compared to CMS’s readmission model, but smaller geographic composite variables tended to have even larger effects than those at larger geographies.Implications for Policy or PracticeThe absence of granular SDOH data means stakeholders face trade‐offs between precision and accessibility: While data at a higher geographic level might be less representative of the patient’s risk level, data at a more granular lever may be harder to obtain and measure accurately. This research suggests that SDOH data at more granular geographic levels provide better predictions of hospital readmission.

Medical educators should realize that the public's complaints about doctors--that they don't care enough about their patients, don't know enough to practice the best medicine, and don't do enough to maintain the public's trust--are exaggerations of the truth but highlight areas demanding improvement in the educational component of graduate medical education (GME). In addition to continuing to prepare residents for the demanding technical challenges they will face as physicians, those involved in GME need to (1) enrich significantly the educational content of residency programs; (2) promote the coordination, strengthening, and potential consolidation of the institutional responsibility for these programs; (3) reorder programs' priorities to make room for the added educational content, which means limiting service requirements to those necessary to meet prospectively defined educational goals; and (4) recognize the power of the hidden curriculum in communicating professional values, and thus modify significantly the way residents are treated. The author explains these recommendations in detail and notes a variety of ways that the Association of American Medical Colleges intends to help educators make these needed changes. He concludes by stating that a "time bomb" is ticking: many sectors of the public and many patients are becoming impatient with doctors. "Listening hard to their complaints and finding appropriate remedies is a must if we are going to ... answer our critics ... and continue to provide America with the world's best doctors."

Leadership in improving the education of doctors, while impressive, is not happening fast enough. While there are many obstacles, there is no time to waste in restructuring medical education to repair its present deficiencies, for otherwise outside forces could overwhelm today's education leaders with imperatives to make improvements on their own terms. The first step in addressing present shortcomings is to establish measurable objectives for the education of doctors that are aligned with the legitimate expectations of society and the enduring precepts of the medical profession. To provide guidance in establishing these objectives, the AAMC launched the Medical School Objectives Project (MSOP) two years ago. This project is now close to completing its initial phase, which is to define the knowledge, skills, attitudes, and values every medical student must demonstrate before graduating. Phase Two will be concerned with implementation (e.g., establishing assessment methods; improving faculty development; etc.). As for aligning the outcomes of medical education with the precepts of the profession, nothing is more important: if doctors do not have high standards of professionalism--altruism, respect, compassion, honesty, integrity, and others--medicine's very survival is threatened. Medical educators must insist that their graduates demonstrate these attributes, through more careful admission criteria, more attention to medical professionalism in the curriculum and in the evaluation of students, more community service for students, and improved role modeling by faculty. Leadership for the changes that are needed will not come from a once-in-a-lifetime leader of heroic proportions but from everyone within academic medicine leading the profession to its promising future through quality education.

Overall, the percentage of women attaining the ranks of associate professor and professor remains well below the percentage of men in those ranks. Few studies of women in academic medicine have been conducted that might guide the leaders of medical schools and specialty societies in addressing the reasons for this disparity. The Association of American Medical Colleges (AAMC) Faculty Roster System allows comparison of a cohort of faculty at any selected time following their first faculty appointments. This study examined men and women faculty who received their first appointments in the departments of radiology and internal medicine in 1976 and who were still active in 1986. Disparities between men and women in rank attained were apparent in both specialties but were greater in radiology than in internal medicine. Other variables examined include ethnic-racial self-description and teaching, research, patient care, and administrative responsibilities. The authors pose additional research questions requiring information that the Faculty Roster System is not designed to provide.