The Pull to the Countryside

Drawing Physicians to Rural America with the AHA

This October 1st opened enrollment of the Affordable Health Care Act (ACA), which is the most sweeping social change for Americans since the Social Security Act Roosevelt signed in in 1935. The AMA has praised this event as historic. And with the government taking a stronger control in healthcare, there will be a guiding hand.

One only need look at the news headlines and the Health Provider Shortage Areas (HPSAs) to understand that rural Americans face greater health risks than urban Americans. Only 10% of American physicians practice in rural areas, whereas rural regions compose 25% of the American population.

The ACA offers coverage to millions of otherwise uninsured Americans. Particularly, the change affects 60 million who live in rural areas of the United States. Presently, one out of every five uninsured Americans lives in a rural area, compared to one in six for the population at large. And because of lower income among rural residents compared to urban residents, there will be an even greater need for doctors to an area that has historically suffered a doctor shortage.

With 32 million Americans harnessing new access to healthcare, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase by 2019.

But despite the need for physicians in rural areas, the incentives have remained low. Physicians in rural areas perform tasks that would be performed by specialists in more urban areas. Call schedules remain a burden in rural areas, with a one in two or one in three call ratio. Educational resources are not available in rural areas to the degree they are in urban areas. Typically, even local physicians who want to practice in rural areas where they grew up must go out-of state to urban centers for residency, which has resulted in less interest among physicians to practice in rural hometowns.

How will the ACA bring physicians to rural areas?

Initiatives of the ACA to increase physician distribution to rural areas:

Increases competition among insurance providers, allowing the Health Insurance Marketplace to lower costs.

Authorizes funding for additional medical residency training programs through the Health Resources and Services Administration (HRSA) and the ACA’s own Prevention and Public Health Fund. Training would preferentially encourage primary care and general surgery. In general, the ACA will offer incentives to physicians for more necessary specializations. Presently, the ratio of primary care physicians is one-third, to two-thirds specialists. In a report completed this by the Congressional Research Service (CRS), this ratio is not in proportion to the health needs of patients.

Allocates money to increase the primary care workforce by training more doctors.

Requires that Medicare-funded residency training slots be redistributed from hospitals that are not using them or that have closed, to hospitals seeking to train additional residents.

Allocates a greater amount of money for scholarships and loans for all health professionals. It relieves the basic need for physicians by training an increased number of physician assistants and nurses.

Expands the number of general staff who work in rural health centers.

Increases the number of nurse-managed clinics at nursing schools where nurses in training treat rural patients.

Offers a 10 percent bonus, through 2015 for primary care doctors who offer services to Medicare patients.

Subsidizes loan repayment or offers education grants to professionals trained in undersupplied specialties such as pediatrics, mental health, geriatrics, behavior health, and general surgery, in exchange for serving in under-serviced areas.

Plans to increase physician productivity.

Encourages increased efficiency and coordination among all personnel in medical homes, clinics, and hospitals, as well as other care organizations.

Reduces isolation among physicians by offering access between rural centers and colleagues, and by increasing further continuing educational opportunities to rural physicians.

Establishes a National Health Care Workforce Commission to develop economic incentives and grants and contracts for physicians, encouraging greater support of primary care training and greater distribution to rural areas. This includes distributing Residency slots to rural areas. It also encourages physician training in community-based settings to offset the greater orientation toward specialty care in hospital-based residency training. This may be the most important aspect of the new law, as it creates a regulatory commission which will continue to promulgate rules and regulations to improve delivery of healthcare services.

For more information, read the Federal Office of Rural Health Policy report, “Office of Rural Health Policy Rural Guide to Health Professions Funding“. And for an in-depth definition of “rural”, visit the USDA Website page defining this term.

As the medical illustrator and editorial artist for Med Monthly, our publisher asked me to illustrate Med Monthly’s November 2013 cover. The Affordable Healthcare Act, with its shift in perspective towards rural America, brought me to wonder what are we looking to? What do we want from this initiative? Health insurance itself is not much more than 100 years old, in the U.S. But if we can accomplish this great aim to offer healthcare more equally to all Americans, urban or rural, we’ll be a fairer place to live, and a little bit closer to our ideals.

For the full article, visit MedMonthly Magazine HERE.

Laura Maaske

Can the AHA Draw Doctors the the Countryside? Illustrated by Laura Maaske; © 2013 Laura Maaske - Medimagery LLC
Can the AHA Draw Doctors the the Countryside? Illustrated by Laura Maaske; © 2013 Laura Maaske – Medimagery LLC

Laura Maaske, B.Sc., M.Sc.BMC, Writer & Illustrator

November 5, 2013

Medimagery Medical Illustration & Design

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Flipping the Medical School Classroom

The high-tech future of medical education

Was your medical training all you had hoped it to be? Did you learn as much as you expected or knew you could? Was learning effective, efficient, and fun? Technology is changing the practice of medicine. But it is also changing the way medical students learn, expectations of their potential, and the way they want to be learning.

A Changing World

AMA outlines a need for change in medical education

Medical education cannot remain the same, given the changing world. According to James L. Madara AMA EVP and CEO, there is gap between what students are learning, and the everyday reality of practicing as a physician[1]. In fact, the AMA is taking suggestions as models for this change, and has funded a number of schools to begin to reform standards in medical education.

To instigate practical change, he American Medical Association is granting $11 million in the course of five years to a list of winning medical schools that will explore teaching innovations. These schools must come up with better offerings for individual learning styles, methods to assess core competencies, improving patient outcomes and safety, and better efficiencies health care financing.

Grant recipients for this initiative, named Accelerating Change in Medical Education, include,

  • Indiana University School of Medicine
  • Mayo Medical School
  • NYU School of Medicine
  • Oregon Health & Science University School of Medicine
  • Penn State University College of Medicine
  • The Brody School of Medicine at East Carolina University
  • The Warren Alpert Medical School of Brown University
  • University of California – Davis School of Medicine
  • University of California – San Francisco School of Medicine
  • University of Michigan Medical School
  • Vanderbilt University School of Medicine

To read a summary of the proposal offered by each school, visit the AMA Grant Projects Webpage[2].

What Endures in Education?

Plato was right

We all know better than to say because a learning strategy is new, it is better. So how do we judge? Educators create exhaustive studies to answer this question. And their insights offer us a few points of focus as we look through the filter of new technology to see how education might be improved. Reading and collecting ideas about education, through my own effort to create good ebooks for students, I have gathered a list of keys to good education:

  1. Individualized learning. This seems like a new idea. But formal education is new in human history. Before the Egyptians introduced formal education, 3000-5000 BCE[3], people learned person-to-person. So all education was individualized. Formal education offered efficiency. But more recently, educators are making the effort to allow students options to learning, so that their individual needs and preferences might be addressed. In studies of medical students preferred learning styles, it was found that students prefer that instruction to be offered in all avaiable formats (visual, audio, reading/writing, and kinisthetic) rather than one or another[4].
  2. Socratic method. Perhaps the greatest innovation in education came from Socrates. The Socratic method is way of teaching so that the student systematically explores a question. Through active thinking, the student finds answers.
  3. The lecture. Plato did not believe the written word was the best form of transmitting knowledge, and he suggested the oral tradition as the best way to learn[5][6]. Certainly his students would have had to take notes in order to have any record of all as to what was taught. Socrates, as well, felt that the implementation of written texts would weaken the mental faculties of students, who would no longer be inclined to commit ideas to memory[7]. The word itself, “lecture” is a 14th Century Latin word, which means, “to read” from a text. But this is not what students need today, and the traditional 45 minute lecture has been shown to be too long for a student’s attention span. 20 minutes works best for adults[8]. It must be modified to be effective. And it is typical for most people, that their minds wander during a lecture[9].
  4. The textbook. Although the Greeks used texts for learning. And while Gutenberg printed a few Latin books on his presses. The use of textbooks in formal education did not begin until the 19th Century[10].
  5. Repetition. Repetition as a key to learning dates back to the earliest forms of edcuation. However, it takes on a new possibility in the classroom. More recently, as students are using the computer and “flip the classroom” lectures as a way to review lecture materials, students find it extremely easy to review the materials that they find challenging. It has even reduced the need for students to ask professors questions outside class.This has been shown to be one of the most exciting innovations with technology, and it has freed time for professors to use in class to engage in less lecture-based and more Socratic forms of interaction with students.
  6. Practical Immersion. Apprenticeship is the traditional and enduring environment for hands-on learning. Many professions require internship. While many of these skills cannot be replicated in the digital environment, still many can be with simulated three-dimensional “worlds”.
  7. Interactive design. This really follows fromt the Socratic Method, as an ideal which enourages students to think and solve problems as a way of gaining deeper knowledge and understanding. Interactive, active rather than passive engagemnt with information, is best form of learning that can be offered to students.
  8. Fun, engagement, and interest. Traditionally, these goals were considered a luxury or frivolity in education. But more recently, educators are offering these aims as objectives in learning. As we all know, when we enjoy our work, when we become absorbed and engaged, and whatever helps us to focus our efforts, will make learning possible. Global learning, offered int he digital age, offers not just interactivity, but the possibility for great and interesting educators who are fantastic at teaching to reach extremely wide audiences and experience world recognition in a way teachers and professors rarely have before.
  9. Tests or markers of knowledge. Controversial as tests may be as a tool to measure knowledge, they are nonetheless an eduring method for self- and outside-assessment. With technology, increasingly it is becoming possible to test student remorely. This brings education closer to a one-world classroom.
We’re working on apps, here at Medimagery. This is a layered hand app to reveal layers of anatomy with the touch of a finger.

Keeping education goals in mind

What do we want our new doctors to be capable of?

Among the suggestions for using technology to make education better, medical schools offer these goals to keep in mind:

  1. Possess strong foundation of science with ability to use scientific method to seek new knowledge, and to critically evaluate medical literature
  2. Know the human body: cell and organ structure and function, system function and integration
  3. Understand molecular, genetic, biochemical, and cellular processes as they relate to human body
  4. Know determinants of human health and disease: personal, social, or environmental impacts; apply principles of pharmacology and therapeutics
  5. Safely perform routine diagnostic and therapeutic procedures
  6. Interpret routine laboratory results, clinical tests, and image scans related to common conditions and illnesses
  7. Skillfully perform physical and psychiatric examinations
  8. Formulate appropriate management strategies for patients, suitable to that patient’s needs and values
  9. Curiosity and passion to address future needs of society from a health perspective
  10.  Learn in a self-directed way with lifelong commitment to learning
  11.  Capacity to collaborate well and communicate clearly
  12.  Capacity for reflective practice, to recognize one’s own limitations, to improve one’s own performance
  13.  Exercise sound clinical reasoning and decision-making skills; to perform critical evaluations of healthcare situation and systems
  14.  Professionalism and leadership skills
  15.  Capacity to interpret and apply evidence, to interpret clinical information
  16.  Creativity: to produce new discoveries, to assimilate new information, and to apply this information to patient care
  17.  High ethical standards; Recognize, anticipate and navigate ethical dilemmas in medical care.
  18.  Empathy towards others and understanding of others’ needs; advocate for the interests of their patients.
  19.  Ability to gather the necessary information from patient history, to understand socioeconomic and cultural impacts, to accurately write a patient history, and then to correctly interpret this information
  20. Understand and utilize the healthcare in context as a larger system

So what changes are taking place now?

New possibilities emerge as a result of technology

“Born-digital” textbooks and learning materials are those which have been originally created in a digital format. They offer a full range of necessary features to make learning all the objectives of the course possible. These include interactive features to test principles and formulas being described, video clips to augment learning, and an audio track of the book text.

Schools are still in an embryonic stage, to be taking full advantage of technology that is offered today. In a survey of 940 bookstores, run by the Follett Higher Education Group, roighly 2% of tge textbooks sold at college bookstores are in a born-digital format[11].

Among schools making the transition, Stanford School of Medicine is taking a lead. Its goals are to reinvigorate the classroom by offering online lectures in short segments. These lectures are offered my many instructors and specialists in the field, as needed. This allows textbooks to pull from primart sources for knowledge. Short lectures are followed up with quizzes.

The classroom time then is freed up. It becomes a place for discussions rather than lectures. Students take more initiative in asking questions so learning can be individuized. Time traditionally spent in lecture is now spent in real-world application, problem-solving, case studies, and team-based endevors.

The new paradigm offers a growing possibility for academic superstars. Stanford Medical School relies on input from Salman Khan[12], famous for his engaging style in teaching subjects from math to art history, to help faculty make their presentations more interesting and engaging. Khan says, “I have a self-paced lecture to be seen at home… and what used to be homework, I now have students doing in the classroom.”

But medical schools cannot accomplish this alone. Textbook publishers play an enormous part in offering content. Innovative digital textbook company Kno has introduced, “Kno Me.” It’s a personalized dashboard which allows students to mark their performance, time commitment, and engagement with materials, in mastering content.

Textbook publishing giant, McGraw Hill, recently announced a plan that offers a place for textbooks in the changing medical classroom. This Spring it has begun to offer a textbook suite with “adaptive learning technology”, which means it collects data on individual student comprehension (knowledge, skill, and confidence). It uses this data to create algorithms for customized study. The program also offers “before-the-course” materials to help students warm-up before difficult classes. It includes photo-realistic virtual labs to make preparation for labs more effective. The book “talks” to students, offering instructions and suggestions on the most effective way to read, based on the student’s needs and performance. This textbook is not groundbreaking, but it is a good step forward.

The new changes put students in the powerful position to make critical suggestions, and of demanding that their educational content be effective. New materials should be available easily to all devices, probably Web-based. Content should be updated frequently and as soon as facts change. The books should be as interactive in teaching concepts and in testing them, encouraging critical thinking skills in the time-proven Socratic style.

Instructors should have greater impact as well, trusting that the material is peer-reviewed and authoritative. Instructors will have the freedom to choose which chapters and segments of material to be included in a course. Both students and faculty will be able to make use of the analytical capabilities of Smartbooks as a method of assessing their effectiveness in student learning.

[1] AMA pledges millions to jump-start innovation in medical education, By Kevin B. O’Reilly. Jan. 28, 2013

[2] Proposals offered by each school can be viewed at

[3] Formal education introduced by Egyptians.

[4] Heidi L. Lujan and Stephen E. DiCarlo. First-year medical students prefer multiple learning styles. 10 October 2005.

[5] Plato advising the oral tradition as the best:

[6] Plato’s Seventh Letter advising the oral tradition over written for passing significant knowledge, 360 BCE.

[7] Socrates discourages written text as detrimental to learning.

[8] Joan Middendorf and Alan Kalish. The Change-up in Lectures. 1995.

[9] Rick Nauert. Short Lectures, Frequent Quizzes Maximize Online Learning. April 8, 2013.

[10] Textbooks become standardized in formal education.

[11] Jeffrey R. Young. The Object Formerly Known as the Textbook. January 27, 2013.



– See my full original article in Med Monthly Magazine at:!

Laura Maaske, July 2013 • Medimagery Medical Illustration & Design
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You Imagine: Exploring Medical Apps

Written by Laura Maaske on January 31, 2013 in Research & Technology – No comments

It is now within reach of a physician who has a need to be met, to seek a small developer and developer and request that an app of his or her own be developed. So, for this final part in my “You Imagine” series, I want to ask what makes a good and effective health app on any mobile device.

With over 17,000 health and medical apps available in iTunes, and with an average price at around $2.00, iTunes “Health” and “Medical” categories are two of the fastest growing sectors of app development. There are health games that offer, for example, quizzes to assess calorie content of various foods. There are GPS apps, order tracking apps, weight management apps, pedometers, diabetes regulating apps, and calorie counting apps, just to name a few. These apps might be associated with push notifications that offer users reminders to take meds or other health interactions.

According to Float Mobile Research, almost 80% of Americans want to use mobile apps to assist in their health decisions, and 40% of physicians believe that the mobile apps can reduce their patients’ need for office visits[1]. But which ones do people enjoy, which ones do people learn something from, which ones do people keep, and which ones effectively achieve their goals?

1. I like this app

Apps should be sociable, personal, engaging, interesting, and fun

To like an app, even for adults, it must be fun, personal, or interesting. Its visual appeal must grab our interest from the beginning, and not disappoint. A health app can not be overly complicated to use, and it must meet our expectations seamlessly as we begin to click and navigate through it. Because we are social creatures and find greater meaning in our personal ties, a health app must also connect us to friends, family, and our physician and health care providers. Certainly, it might also venture to introduce us to others who share our health concerns and our same health circumstances.

Pricewaterhouse Coopers Managing Director, Christopher Wasden, speaking at the Healthcare Information and Management Systems Society’s annual conference 2012, offered suggested that interoperability, or networking, is a great area of opportunity in the health app playing field. This potential has been slow to implement because, as my own clients express, there is concern about patient privacy. As security protocols are being addressed for electronic medical records (EMRs), and as the FDA regulations become clear to developers, patient privacy will be maintained while allowing patients to share personal data with exactly those they intend to.

Wasden’s suggestion that social networking is a key point to one of the most exciting capabilities of mobile devices. For people who own smartphones and tablets, social media and texting are preferred ways of passing information because they are personal. The tendency we have to check our devices and to check-in means that physician offices might reach their patients most effectively by tapping into this preference.

Mayo Clinic cancer patient educator Sarah Christensen, whose newsletter “Living with Cancer” has over 60,000 subscribers, has learned from the experience of bringing resources to patients via iPad that social media is the key to reaching her patients[2]. She says this recognition of the social nature of the search for health and wellbeing, is the key to reaching people, and it breaks people from the limits of geography.

Some of the apps making great effort to offer an interesting and socially integrated experience include Runtastic (, which manages exercise routines and aims to make it fun.

2. I’ve learned from this app

Apps should be intelligent and supportive of our learning needs, offering compiled health behaviors and even offering marketing informatics.

Certainly, apps can offer medical information in layer upon layer of complexity. But this alone is not always strong enough or useful enough insight; nor motivating for all. We want an app to be intelligent, to adjust to our behaviors and to offer something new from the outside world. Apps should be smart enough to suggest and make health suggestions that are unique and specific to our needs, strengths, weaknesses, and to our unique pattern of health choices.

Apps should work with the lifestyle and needs of both the doctor and the patient. iPads and iPhones prove their usefulness in a variety of new ways by the innate hardware features that complement such engaging software capabilities: functions like recording, light, and camera capabilities; or by offering the option to record specific data through devices such as attached stethoscopes, lenses, to be used for recording data. Using an iPad to record data, heart sounds, and integrate resources is a powerful step in the direction. Dr. Ariel Soffer is a South Florida cardiologist who developed an app allowing patients to take a photo of their veins and send the photo to for feedback[3]. It’s a simple idea, but powerful, time saving, and it efficiently integrates the healthcare system without violating strict patient privacy laws.

The app should be flexible and allow for different learning styles. People differ in which method of presentation reaches them best.[4] It might offer information in different formats: visual, text, and audio, for example. It might offer linear approach for some, and a linked approach for those who like to choose their own path towards knowledge[5].

3. I’ve kept this app

Apps should be integrated to the health care system, and integrated into our lives so that we return to them again and again.

In Tom Myers’ review article, What makes an effective Health App[6], he says, “A good indicator of usefulness of an application are retention figures. That is how long does the app stay on the users device.”

This is quite a demand for an app. Even for my kids, the best shelf life for any single game has been months. And there have been a few games, as well that have remained on the iPad for a year now, which are only opened once a month. I would suggest that an app that is retained longest is not necessarily achieving its goals any more than one which is held onto for a couple of months. My children throw away a game when they have mastered it. And this is a good sign that they have moved on to something of a greater or different challenge.

I would suggest that, specifically, apps with short term goals, such as those teaching anatomy or physical therapy exercises would not need a long retention cycle. But those intended to be incorporated into a patient’s long-term health care plan should be capable to collect data of different types, or to access wide knowledge. But app retention would not be the sole factor to consider in determining the usefulness of a health app.

Larklife ( is one example of an app that is well incorporated into the user’s lifestyle. Lark offers daytime and night-time wristbands to monitor patients sleeping and waking activity. It logs this data into the mobile device.

4. This app changed me

Apps should have goals, directed for outcomes. They should change a behavior or health outcome the user desires changed, and by be implemented into the healthcare plan.

Any health app should be designed with a goal in mind. Often this goal is some health outcome. Alain Labrique, director of the Johns Hopkins Global Health Initiative, and many before him in the field of interactivity research, suggests that apps are more effective when they engage the users in a responsive way. Some send reminders to keep patients, particularly with those whose medical conditions need monitoring, on their medical or prescription regimens. This goes beyond simply social connectedness as discussed above.

Labrique believes apps that are designed well to engage and offer reminders can tip bad behaviors in favor of good choices, and that sharing information with one’s health care provider, or with others who experience the same health issues, is a more effective approach to keep a patient’s health on track. The simple reminders and tracking of choices can help people to be aware and to take control in a more active way. Labrique believes these apps increase a person’s tendency to think about their health, and that this is an advantage over the fairly infrequent reminders that health care providers offer during doctor visits.[7]

Christopher Wasden also suggests that apps be designed with a target in mind for changed behavior: to be focused on some particular outcome. Wasden’s fifth key to success for a mobile app is that it be socially integrated. Good behaviors require friends for support. And finally, Wasden suggests that a good app is fun and engaging: visually dynamic and interesting to use.

Some apps specifically might be working on these types of changes. Few have been tested for outcomes. One example of a tested mobile health effort involved a study of 204 participants aiming to improve their diet. Participants used mobile devices with remote coaches. As a result of these mobile health interventions, participants were doing better at the end of the study: eating more vegetables and fruits, engaging in less sedentary leisure activities, and decreasing their fat intake.[8]

This understanding of effectiveness will be the next place to be moving, in the exploration of mobile devices and the implementation of health apps into our everyday lives. One app making great strides in this endeavor include, RunKeeper, which offers rigorous personal training, heart graphs, location tracking to monitor exercise patterns, and goal-setting strategies. Keas, Retrofit, Beeminder, and Lift are other apps which focus on goal-setting. These are all robust apps and time will tell which strategies work best.

It is a continued marvel for those of us who grew up in a world where even clunky computers were a novelty, that we can hold so much power in the palm of our hands. But our expectations for these devices soar beyond our imaginations. We want these tools to be fun, interesting, engaging, incorporated fully into our health care plan, socially connected to other people and to our physician, and most of all, effective in the intended function for each app. Maybe we would even like an app to change our lives!

Continue reading “You Imagine: Exploring Medical Apps”