Michael Walls, DO, MPH, is the current national president of the American Medical Student Association (AMSA). With 30,000 members worldwide, AMSA's ongoing initiatives include advocacy for providing equitable lowering drug prices, equitable access to healthcare for all, understanding how environmental and social determinants of health impact health, and the timely and paramount issue of reproductive rights. In this episode of SoundPractice, Dr. Walls discusses the medical education scorecard initiative, which fills gaps that often exist in medical school training and the question what should medical school training look like in future?
This transcript of their discussion has been edited for clarity and length.
Mike Sacopulos: My guest today is Michael Walls. Dr. Walls is a physician based in Connecticut. More importantly, he is the president of the American Medical Student Association. Dr. Walls, welcome to SoundPractice.
Dr. Michael Walls: Hi, so good to be here. It's nice to meet you.
Sacopulos: I'm interested in knowing more about the American Medical Student Association. Can you tell me about the history of AMSA?
Walls: AMSA was originally founded in 1950. We were the student section of the AMA, the American Medical Association. And over the first 15 or so years as the student section of the AMA, we had eventually sort of broke off for philosophical differences from the organization and changed our name. I believe in around 1968, at which point we used to be SAMA, the Student American Medical Association, and that switch to AMSA, American Medical Student Association. When we did that, AMA created the new current student section. But since then, AMSA has been very involved, both politically and within medical education. Some of the big things that we've worked on is advocating on Capitol Hill for things like the Family Practice Act of 1970. We were one of the organizations that worked with the match NRMP to change the match algorithm to favor medical students.
We also did things like working on residency work hours, limiting those to 80 hours a week, which is still a lot, but is better than the no restrictions from before. Things like Earth Day. We've been involved politically since the early 50s. And then we've had really incredible alumni come out of the organization; one you had on this show recently was Dr. Jay Bhatt, who was our president, I believe 2007, Dr. Leanna Wen, who was a former health director for Maryland, president of Planned Parenthood. Those are some of our more notable alumni who were both AMSA presidents. We've had a long history of getting involved with advocacy and trying to not just advocate for ourselves as future physicians, but for patients and trying to make sure that our patients are having equitable access to healthcare. And of course, that's always an ongoing battle, but something that we've been dedicated to for a long time.
Sacopulos: Excellent. Well, you certainly have some big shoes to fill Dr. Walls. What are the criteria for membership? Do you accept international students? What about post-grads, residents? Fellows?
Walls: Really anyone within the whole spectrum from pre-med to full-fledged attending physician, we have spots for. Most of our work is geared directly towards our domestic medical students, but we do have a fair number of international medical students, primarily in the Caribbean, but I have a few friends within AMSA who have gone to school in Poland and a couple from, I believe, Iran. We do have both international and domestic medical students. We have a very large engaged pre-medical sort of branch; most of them join as a way to get involved and learn more about how to get into medical school. But then we also have a few other sort of fringe benefits, where if you're a family member of a medical student, you can join primarily in a supporting role. We have membership for our residents, our former AMSA alumni, we call them OATs, Old AMSA Types, we have a lot of ways that we're trying to engage our OATs. One of our board members is our graduate trustee who's in charge of bringing all our alumni back in and helping to mentor some of our younger members.
Sacopulos: Well, in preparing to speak with you today, I reviewed the American Medical Student Association's website. You have an impressive organization. How is AMSA funded?
Walls: We're primarily funded from our membership dues. We get a fair amount of donations from alumni, from other organizations. We have a grant from an anonymous donor that funds our Reproductive Health Project. We've been doing a lot of work in that respect, which was good timing, we're hopefully about to enter our fourth year of the grant. And the timing for that was unfortunately rather perfect, but we primarily function based off our membership dues, which allows us to do most of our things from our annual convention every year, we already had it this year, next year will be in June, but primarily from membership dues and some partnerships with other organizations.
Sacopulos: I'm interested about some of the current initiatives of your organization. Can you tell us about some things that are going on?
Walls: Some of our biggest projects right now is, like I just mentioned, the Reproductive Health Project. This has been one of the more impressive projects I've seen come out of AMSA, at least since I've been involved for the last almost nine years. But with that, we're really interested in connecting medical students and pre-medical students with policymakers around abortion, abortion providers themselves, patient advocates. It's been our biggest project.
We just last night had an interview with Lizz Winsted, who is the co-creator of the Daily Show and currently running the “Abortion Access Front.” She's a comedian, so it was talking about a very serious issue, but in a very candid way. We're really trying to focus on that front, on educating medical students on how to advocate for their patients and really just what abortion is and why we consider it to be integral to just health in general.
But outside of that, we also have put a big emphasis on medical education reform, especially since COVID, medical education has changed pretty drastically into one of our big projects - our medical education scorecard, where we're surveying medical students to figure out what parts of their education are important. And then determining how well their schools are doing that with the idea behind it to be, if we can show schools, “Hey, you're kind of lacking in your student wellness programs” or anything like that we can show them like, “Hey, this is an area for you to improve” and then potentially provide them with resources and point them to schools that are doing it better.
And then, we have eight action committees and five campaigns that cover, they cover essentially pretty much everything you can think of in medicine. So, we have our Global Health Team, Community and Public Health, Environmental Health, Wellness and Student Life, Med Students for Gun Safety, Health Care for All. So, we have initiatives for all those things, building in phone banking, writing letters to the editor, and working with local members to help facilitate the advocacy and build leadership skills.
Sacopulos: Give me some idea of the size of your organization. How many members do you have?
Walls: We're somewhere around 20,000 to 30,000 members, and that's a combination of medical students, pre-medical students, and international.
Sacopulos: Congratulations. That doesn't happen by accident. Well done.
Walls: It does not.
Sacopulos: So, we at the American Association for Physician Leadership are obviously firm believers in the importance of physician leadership. Why is medical student involvement in leadership and advocacy important to AMSA?
Walls: I think that's really the integral question to why AMSA exists in the first place. I think just because of our status as medical students and as future physicians, we're seen as leaders in society. I think just the fact of the nature of who we are and the path that we've chosen that, it's almost expected of us. I think in older generations there has not been the same approach of the importance of advocacy, at least not on the scale, I think it is now. But I think no one I've talked to disagrees that our healthcare system is broken, our education system is failing, and not just for patients, but also for providers. And so, with medical student advocacy, I think there's so many different areas that we can improve from a medical student or from an education perspective.
We learn a lot about how to pass Step 1 or Level 1, which you take after the second year of medical school, but we don't talk all that much about the things that really impact our patient. One of the things that's come out in the last probably 20 or so years is, your zip code determines more than your genetic code in terms of your health. And medical education has not really changed to adapt that until just recently. When I was there, we had one student-led lecture on some of the structural competencies and how things like white supremacy can negatively impact our Black patients. Now, our school has a whole course where they spend several lectures throughout each semester. They have standardized patients where you can sort of practice on someone who's there to critique you. We have transgender standardized patients. I know all of that came from people in my class and from the years before and after me. Through their advocacy it was able to change the curriculum that way. And so, I think that highlights why it's so important for medical students to get involved in advocacy.
And then in terms of the larger political realm, I think things like, at least at the time of recording this, the inevitable overturn of Roe V. Wade has a very significant impact on even myself as I'll be applying into emergency medicine. And just the fact that, a lot of these states are going to be restricting abortion, even if I don't perform abortions myself, it definitely changes how I would approach a patient who is having a miscarriage and what medications I can give them. One of the medications we used to treat is Miso, and I, depending on the state, may not be able to prescribe that for someone who is having a miscarriage because of some of the laws.
It really impacts myself and other medical students as we're applying to residency on where we can safely practice without fear of being personally prosecuted. I think, on a personal note, that's how it impacts medical students. And then we see it every day in our patients. I was practicing in a hospital that was a large population of migrant farm workers, generally low health literacy, something like 70% of our patients were monolingual Spanish speakers. There's this sheer volume of people I saw with just uncontrolled diabetes who came in on DKA, diabetic ketoacidosis, or having amputations because of their uncontrolled diabetes, is hard to watch as a medical student, and highlights how important it is that medical students get involved.
Sacopulos: There are many student organizations out there, why AMSA?
Walls: That's a great question. We work with a lot of the other medical student organizations on various issues. I think where AMSA is unique is, from an advocacy perspective, we're not focused on one particular issue. We have groups that we work with, like the Med Students for Choice who work on reproductive health and abortion access, Med Student Pride Alliance focuses on transgender health and LGBTQ health. With AMSA, we're just the American Medical Student Association, we can focus on all these issues. We have all our action committees and campaigns, which really allows us to be mobile and work with individual chapters on whatever issue interests them. So, if one chapter, say in Oklahoma after the Tulsa shooting, was really interested in getting involved with Med Students for Gun Safety, we have avenues to do that.
We can really adapt to the political realm at the time. Because we've been around for so long and because of the number of members we have, we have full-time staff that helps us with some of the behind-the-scenes things, helping us keep track of our budget, helping make sure our programming runs smoothly. It allows our national leaders, who we have more or less 70, to really focus on engaging members and creating the content that really engages our medical students. And then for myself, I graduated from medical school and I'm taking a year off to do AMSA full-time before residency, which really allows me to build relationships with other organizations. We've been working with the White House, Office of the Surgeon General. We really get to build those relationships and make sure that the medical student voice is heard. Which all the other medical student organizations do as well, but just because of the nature and how AMSA is structured, we're able to sort of do that full time, which certainly helps. And then from our education perspective, we have lots of opportunities for medical students to sort of fill in the gaps of medical education. We have our Scholars programs which focus on everything from general advocacy to Health Care for All to transgender health, health disparities, and learning, like I had talked about at my school, we didn't have a whole lot in terms of the structural competencies, but by joining AMSA I can take these scholars programs to fill in those gaps on my own. And of course, now hopefully the people from my school wouldn't need that.
Sacopulos: Tell me a little bit more about the Scholars program, what's involved and how does it work?
Walls: Twice a year, every fall semester and then every spring semester, we'll have a number of these Scholars programs that meet for usually an hour, once or twice a month, depending on the program and hear from experts. And these are all medical student run, so we have two or three medical students who run the program, not necessarily delivering all the content, because obviously we're also still learning, but coordinating and finding the speakers to come talk; so our transgender health Scholars programs will bring in experts in estrogen and hormone therapy to teach medical students how to treat those patients. And I think with that in particular, that really struck me when I was talking to our transgender Scholars program was particularly with estrogen with the risk of that is, it increases the risk of stroke. And so, with some people you're like, “oh, maybe not the best idea to prescribe them estrogen,” but then when you also think about, “okay, well it increases the risk of stroke by 2 to 3%, but then it decreases the risk of suicide by like 30 to 40%.” It's really not as dangerous as it makes it seem. That's one of the areas where we can really improve the education of medical students. Our Scholars programs are, personally, one of my favorite ways for medical students to sort of fill in those gaps.
Sacopulos: Dr. Walls, you and your colleagues at AMSA are really the future of the medical profession, what change do you see the next generation of physicians making to the way medicine is practiced?
Walls: Honestly, I think it's going to be quite drastic over the next couple of decades as my generation finishes residency and starts to get more involved with leadership. I think we're already seeing it in education with students taking the initiative to say, we're not learning how to treat our patients, we're learning how to treat diseases. And this has been something that I think has been in the works for a while, and I think over the last few years, we've really seen that shift where medical students are taking in a vested interest in what they're learning and helping to change the curriculum themselves. I've talked to countless medical students, both in AMSA and in other organizations, when they're working on their clinical rotations.
In the EMR, we have GFR based on African Americans. There was one study, probably 50 years ago, that the GFR for African American patients was somehow different and that's caused a lot of worsening outcomes for our Black patients in terms of needing kidney transplants and getting on treatment for that. Medical students have already worked with their hospitals, worked with the CMOs to have those removed from the EMR in general, so that it doesn't negatively impact our African American patients. And I think that's just part of it; even when I was going through medical school, couple classmates and I were talking about, if we had our own medical school what we will do differently and how we would restructure that.
I think as we get into education, as we get it more involved in politics, I hope that we'll see a big change in both how we deliver from a systemic perspective, as well as how we deliver it on an individual perspective. And I'm hoping with that increased focus on the social determinants of health, increasing diversity in medicine, that will start to close the gap between the health disparities affecting people of color compared to non-Hispanic white patients who do much better in almost every regard.
Sacopulos: I think you've anticipated kind of where I was headed here doctor. And certainly, medicine's dynamic and evolving quickly. When you compare that to higher education, which is more geologic in its evolutionary speed, what specifically do you think needs to be changed in the medical education curriculum? I know you're talking about having your own medical school, give me some specific things that you would do differently. I'm very interested in this.
Walls: I had an Excel sheet, but I'm not even sure I still have that on my computer of what I would do. I was just at a conference hearing from a PA who was teaching at a PA school of how they did it, that I believe was at Duke, was a really impressive way of approaching it, where they had a whole class that was just dedicated to addressing health disparities. And so, as they were going through renal, they talked about things like the GFR for Black patients and the negative impacts of that. We're getting away from the term cultural competency, and I believe the best phrase is cultural humility and understanding how to treat various patients. They had an entire course dedicated to that. And how you think about, as you're going through your pulmonary lecture, how other factors outside of cystic fibrosis and asthma, but what environmental factors impact that. Just thinking about the fact that your patient just moved to the area, and they might be in a house that has asbestos, even something as simple as asking the extra questions.
I think really what has been missing in medical education and still in medicine for most providers is, our social history tends to be, “do you smoke? Do you drink? Any recreational drugs?” And sometimes, “are you working?” And I think that's an area that, if I had my own medical school, I would expand significantly to think about all the other factors, and not just, “are you working?” but, “what kind of job?” or, “are you lifting anything?” And really trying to expand thinking about what other factors might contribute to a disease, including things like whether or not they're able to afford medication and things of that nature.
There have been a lot of studies that, unfortunately, empathy decreases year to year within medical school. So, your first-year medical students are very empathetic, but by the time they graduate that's dropped off fairly significantly. And I think a big part of that is, wellness in medical school is not great. I think it's improving. Most schools at this point have therapists and things to help their medical students suffering from mental health disorders, but the structure of the medical school itself, because it's so rigorous is really not conducive to good mental health practices. I think there are certainly ways to improve that a lot, thinking about when you're taking tests and providing opportunities for students, where it's not, “every test is super high stress, and if you fail it, then you're done for the year” type of thing. The things that keep all the medical students up at night.
I think those are two of the biggest things I would change is, working to not decrease the empathy, bringing in real patients and hearing from them, because I think the first two years of medical school you don't get much of that. I'm learning all about heart transplants, but I don't see a patient with a heart transplant. It creates this disconnect, we're learning about the diseases and not how to treat a patient. I think bringing in patients and hearing their stories early is really important too.
Sacopulos: I'm interested to know where you see AMSA going in the next year to two years. What issues will you be focusing on? What does the future look like?
Walls: The biggest one, of course, is reproductive health because of the work we've been doing there with our reproductive health grant and our Reproductive Health Project, that's our biggest priority. And we've been working with a number of different groups and working with a couple people in the White House to really find ways to increase abortion access because, beyond just having an effect on our patients, it has an effect on how medicine is practiced in general. And so reproductive health is absolutely going to be one of our biggest ticking points.
I talked about the medical education scorecard, and I think working with organizations on mental health and medical education reform and how we can ensure that our medical students and future physicians are really learning how to treat their patients. Healthcare burnout is at an all-time high and it's even higher for medical students and residents, and so really focusing on mental health is a big one.
I think the next biggest thing is with access to healthcare and lowering drug prices. We've been working with lowering drug prices now for a while. And I think that's one of those areas where we think we can really make a big impact on. We tried working on allowing Medicare to negotiate drug prices when with Build Back Better. Unfortunately, that one didn't pass, but we're still optimistic that we can make a big difference there. And then another big topic, that has not gotten enough attention politically was one of the provisions that Built Back Better, was the ATA subsidies which are set to expire on December 31st. On January 1st, if Congress hasn't done anything by then, our most vulnerable patients are going to see fairly significant increases in their healthcare premiums, which could trigger the death spiral and see a lot of people dropping health insurance because they can't afford it or switching to worse insurance plans where they effectively don't have health insurance.
I think those are our biggest issues. Of course, I’m also going to continue working in gun violence prevention, keep working on environmental health and how climate change impacts health. So, we're not going to forget about everything else, of course, but those are our big priorities for the year.
Sacopulos: Dr. Michael Walls, keep up the good work, sir. Thank you for your time today.