Example Portfolio Letter – Student #3Dear Portfolio Reviewers,.docx

Example Portfolio Letter – Student #3
Dear Portfolio Reviewers,
I would begin with something along the lines of “writing and
I have always had a troubled relationship” or “I’ve never been
much of a writer,” but, unless this is the first portfolio letter
you’re reading, you’ve probably seen that opening more times
than you can count. In any case, describing my relationship
with writing as troubled would be oversimplifying the issue.
Let’s start by going back to assignment 1, where I reflected
on the variability of my writing proficiency depending on the
type of writing. In the context of open-ended creative writing, I
can honestly say that I love writing. I love being able to tell a
story and entertain people. Unfortunately, I’ve yet to find that
beauty in less open-ended writings. That’s not to say I hate
non-creative writing, just that I don’t love it. For example, last
summer I wrote a paper about a small research study I’d
performed with little trouble. The result wasn’t a piece of art,
but it was accurate, honest, and easy to follow. In reflecting on
that paper at the beginning of the quarter, I couldn’t figure out
why I’d done so well on it.
Over the course of the quarter, however, I’ve come to realize
the connection between that structured academic paper and
freeform creative writing assignments: organization. Neither
type of paper required much planning. Most of the creative
writing papers I’ve written are narratives, which typically
progress chronologically. Thus, as long as each of my ideas
connected to the next, I was able to write a well-organized
story. Similarly, the academic paper I wrote had a very well
defined structure. Our professor gave us an outline of all the
sections our papers should contain, so I followed his guidelines
and the result was a well-organized paper. After making that
connection, I realized that my main problem with most papers is
developing a structure, and have focused on that throughout the

quarter.
I chose to include assignment 2 because I feel that it
demonstrates my organizational progress, particularly when
juxtaposed with assignment 4. The second assignment had a
relatively open ended prompt, but because I chose a handbook
for my genre I was able to develop a clear structure using
headings and subheadings. This approach allowed me to
organize my thoughts and communicate them to my reader. My
second reason for including assignment 2 was its difficult
topic. I decided to write about the issue of bad teaching,
targeting high school teachers as my audience. While I have
many ideas regarding what makes a teacher good or bad,
addressing teachers directly posed the challenge of giving
advice without causing offense. For example, upon first
considering bad teaching I thought of a particularly bad high
school experience and planned to include it in my paper.
However, after the first draft I realized that it would be better to
keep my paper positive (no one wants to read about all the
things they’re doing wrong), so I changed it to a short anecdote
from one of my favorite classes. I also added many sentence-
level revisions to maintain a positive and relatable tone.
Even if assignment 4 hadn’t been required for the portfolio,
I would have included it. The topic is one I find interesting and
had already thought about beforehand, so I was able to focus on
organizing my analysis. I think this paper shows my progress in
that regard. I organized assignment 2 with headings and
subheadings, but by assignment 4 I could produce a similarly
well-organized paper without an obvious outline. In addition to
showing what I learned this quarter in terms of organization, it
also integrates other concepts from the course, such as genres
and writing for an audience. Most of my revision was at the
sentence level, as my tone and word choice were at times too
informal.
While I will definitely need to keep thinking about my
papers’ structures in future writing, UWP 1 has significantly
improved my ability to organize a paper, which will certainly

help me in future writing. Furthermore, it has given me a better
understanding of writing for a specific audience and genre,
which will help me ensure that the style and tone of my writing
is appropriate.
Thank you for your time, and I hope you enjoy reading my
papers.
Sincerely,
Student #3
The Experts: What Should Be
Done to Fix the Predicted U.S.
Doctor Shortage?
June 20, 2013 1:29 p.m. ET
What, if anything, should be done to alleviate the predicted
doctor shortage in the U.S.?
The Wall Street Journal put this question to The Experts, an
exclusive group of industry,
academic and other thought leaders who engage in in-depth
online discussions of topics
from the print Report. This question relates to a recent article
that debated whether
residency programs should be expanded to produce more
doctors and formed the basis of
a discussion in The Experts stream on Wednesday, June 19.

CARL WIENS
The Experts will discuss topics raised in this month's Big
Issues: Health Care Report and
other Wall Street Journal Reports. Find the health care Experts
stream, recent interactive
videos and other exciting online content at
WSJ.com/HealthReport.
Also be sure to watch Murali Doraiswamy of Duke University
Medical Center, Dr.
Loren Cordain of "The Paleo Diet," vegan cookbook author Isa
Chandra
Moskowitz and T. Colin Campbell of Cornell University as they
discuss the positives and
negatives of a vegan diet in an interactive video chat that aired
on Monday, June 17, at 3
p.m. Eastern.
http://www.wsj.com/articles/SB10001424127887323393804578
555741780608174
Kathleen Potempa: Let Nurses Provide Primary Care
I hope that many readers are now aware of the Institute of
Medicine's 2010 report that
identifies nurses as a key component to addressing the health-

care needs of the nation,
especially the need for primary-care providers. Subsequent
reports continue to support
this idea, especially as the Affordable Care Act moves through
its various stages of
implementation.
Nurses, in particular advanced practice registered nurses
(APRNs), are efficient at
providing primary care—from both cost and patient experience
perspectives. They
receive extensive education and training that is carefully
regulated through national
standards for curriculum and certification examinations. APRNs
must prove their
proficiency through national boards, similar to how most
medical specialties are
regulated. APRNs practicing at the full extent of their education
and training make
health-care systems more efficient at providing quality care,
allowing all members of the
team to focus on their specialties.
That said, one concrete step we can take toward improving
access to care is to encourage

state legislatures to update rules of practice for APRNs—the
largest group of which are
nurse practitioners (NPs). As the National Association of
Governors concluded in 2012,
"Most studies showed that NP-provided care is comparable to
physician-provided care on
several process and outcome measures." Moreover, the studies
suggest that NPs may
provide improved access to care. Currently, 19 states and the
District of Columbia allow
APRNs to practice to the full scope of their training, and such
legislation is being
considered in several more states. Meanwhile, the remainder of
the country struggles
against practice barriers that are inefficient and restrict critical
access to care.
Kathleen Potempa (@kathleenpotempa) is the dean of the
University of Michigan School
of Nursing.
George Halvorson: Relieve Doctors of Their Student-Loan
Debts
We definitely need more primary-care doctors in the U.S. One
of the major reasons for

the current shortage of primary school doctors is the level of
medical-school debt that
doctors incur on their way to getting their licenses. The
smartest thing we could do to get
more doctors into primary care might be to forgive medical-
school debt for any and all
doctors who practice primary care for five to 10 years. That
program would actually pay
for itself in three years.
How could it pay for itself?
It would pay for itself because the average primary-care doctor
now makes about
$150,000 a year and incurs roughly $200,000 in debt. The
specialty doctors incur slightly
more in debt, but they make over $250,000 a year in income.
That is $100,000 a year in
additional pure salary cost for each doctor.
So if we keep more doctors at the primary-care reimbursement
level instead of having
them bill for their care at specialty fee levels, we would
actually save $100,000 per
doctor, per year. Forever.

So forgiving $200,000 in debt one time for each doctor actually
saves millions of dollars
in fees per doctor, and that-debt forgiveness program can give
us the primary-care
doctors we need.
Let's make primary care and medical education debt-free. We
will get the primary care
we need, and we will save millions of dollars in additional
medical fees in the process.
George Halvorson is chairman and chief executive officer of
Kaiser Permanente, the
nation's largest nonprofit health plan and hospital system.
Murali Doraiswamy: Don't Focus on Supply. Focus on
Demand.
Reduce demand. I will focus just on one field—psychiatry.
Currently, some 40 million
Americans are estimated to have a mental illness. These
numbers are likely to increase as
the field switches to diagnosing people using the new DSM-5
(the fifth edition of the
American Psychiatric Association's Diagnostic and Statistical
Manual of Mental

Disorders), which has looser criteria for some common
disorders. And some of the newer
conditions under discussion in DSM-5, such as Caffeine Use
Disorder and Internet
Gaming Disorder, could in theory affect tens of thousands more
(including I suspect
many reading this blog!). Psychiatric drugs have become the
nation's top-selling drugs to
the point where measurable levels of drugs such as Prozac and
Zoloft can be detected in
the public water supply. Minting more psychiatrists is one
solution—but this may also
simply create a supply-side cycle leading to more diagnoses and
more pills.
Unless we want a nation dependent on psychiatric pills, we
should broaden our narrow
definition of a normal healthy mind and prioritize ways to
enhance our mental resilience.
Diversity of the mind is just as important as diversity in nature.
As a society we should
nudge people away from seeking a pill for every minor ill.
Resilience results from
stronger family ties and relationships and healthier lifestyles
(e.g. meditation, more group

activities in nature). There is a vast literature on positive
psychology—attributes and
practices that allow people to flourish and be happy—that can
be taught to new
psychiatric residents and implemented on a societal scale. We
should prioritize
neuroscience research into serious mental diseases such as
bipolar disorder or
schizophrenia, so we can better classify these disorders and find
better treatments.
Toward this goal, the NIMH (National Institute of Mental
Health) has launched
theResearch Domain Criteria (RDoC) project to transform
diagnosis by incorporating
genetics, imaging, cognitive science and other levels of
information to lay the foundation
for a new classification system.
The DSM-5 serves a purpose for ensuring we as a society get
the care we seek and to
provide a common language for providing care. And certainly
psychiatric drugs have
helped millions of people, so I am not suggesting otherwise. But
to paraphrase the noted

physician and jurist Oliver Wendell Holmes, "If most of our
diagnoses and medicines
were to be thrown away into the sea, it might be bad for the fish
and good for humanity."
Training more psychiatrists who are mindful of these issues is
the best solution.
Dr. P. Murali Doraiswamy is professor of psychiatry and
medicine at Duke University
Medical Center, where he also serves as a member of the Duke
Institute of Brain
Sciences and as a senior fellow at the Duke Center for the Study
of Aging and Human
Development.
Harlan Krumholz: Our Assumptions Could Be Impairing Us
We need to think differently about health-care delivery and
extend the reach of doctors
rather than organize their days around documentation, clerical
activities and tasks that
can be handled by other health-care professionals. We have yet
to determine an optimal
number of physicians and how best their time ought to be
allocated. We know that the
amount of time that doctors spend with patients is shrinking.

Physician burnout is highly
prevalent. Many activities done by doctors don't require their
level of training and
education. Appointments in many areas of the country can be
hard to obtain.
When I was a student I saw such shortages solved by a novel
program in North Carolina
that placed nurse practitioners in community-build health
centers and provided them
support to deliver basic primary care. I spent four months
interviewing patients and found
that they loved the system and the access to care it provided.
What I learned was that our
assumptions about how care should be delivered might be
impairing our ability to
provide the best care and to do so with greater efficiency.
We can alleviate any shortages and improve the work conditions
at the same time by
better organization of the way we deliver care. We need to re-
envision the work of
doctors and how best to leverage their time. We should begin
with a commitment to

developing systems that match physicians with tasks that
uniquely require their
contributions. They should be supported in the clerical and
documentation tasks. To the
extent possible, other health-care professionals should be
working with physicians as a
team, taking on tasks that match their professional
competencies. We should be
employing telemedicine to spread the access to health-care
professionals. The system
ought to be allocating the professional resources in ways that
will increase positive
interactions with patients, facilitate communication and
coordination, achieve the best
outcomes, and promote job satisfaction. We have work to do to
achieve that.
Dr. Harlan Krumholz (@HMKYale) is a cardiologist and the
Harold H. Hines Jr.
professor of medicine and epidemiology and public health at
Yale University School of
Medicine.
Fred Hassan: Make It Easier to Become a Doctor
Make it easier to become a primary-care doctor in the U.S.

—Benchmark premedical and medical-school costs with other
advanced countries and
find ways to drop the present total price tag of about half a
million dollars to become a
doctor in the U.S. This cost in the U.S. can be double that of
many other countries.
—Open up more medical-school and residency slots so that the
"mission impossible"
image of getting into a U.S. med school is mitigated.
—Encourage existing primary care doctors to delay early
retirement via fairer
reimbursement and protection from litigation.
—If all else fails, accelerate the trend for nurse practitioners
and physician assistants to
do more prevention counseling, diagnosis and treatment of
easier-to-manage conditions.
Fred Hassan is the chairman of Bausch & Lomb
Bob Wachter: Location Is the Problem, Not Quantity
There really isn't a doctor shortage in the U.S.; there is a doctor
maldistribution, both
geographically and by specialty. There are plenty of
psychiatrists and cardiologists in

New York and San Francisco, but nowhere near enough
primary-care doctors virtually
everywhere. America is one of the few countries that doesn't
intervene to ensure the right
mixture and distribution of its physicians.
To fix the problem, we need to do a few things. First, we have
to address physician
payment disparities. The economic incentives are completely
skewed. For example, it's
just nuts that the average dermatologist or radiologist earns
twice as much as the average
primary-care doctor. In the United Kingdom, general
practitioners make about the same
amount as specialists.
Secondly, we need some real workforce planning. If we need
more primary-care doctors
and fewer anesthesiologists, the federal government should
adjust the subsidies they give
to the academic medical centers, which determine the number of
training slots.
Third, we need to continue to encourage the adoption of new
technologies and the
thoughtful use of non-physician providers. Our health-care

system should be one in
which physicians are only doing the work that they are uniquely
qualified to do, and other
clinicians (or patients and families themselves, supported by
appropriate people and
technology tools) are doing the work that they can do. If we get
this right, it will lead to
care that is both better and cheaper.
With the evidence that about 30% of U.S. health-care
expenditures add little value for
patients, and that physician-specialists create their own demand
(when another orthopedic
surgeon moves to town, it doesn't lower prices through
competition, it raises utilization
and overall costs, a phenomenon known as supply-driven
demand), training more
physicians isn't the best way to address our problems. It's like
putting more captains
aboard a sinking ship. Let's plug the holes first.
Robert M. Wachter (@Bob_Wachter) is professor and associate
chairman of the
Department of Medicine at the University of California, San

Francisco, and chair of the
American Board of Internal Medicine. He is the author of a
textbook on patient safety,
"Understanding Patient Safety," and blogs at
www.wachtersworld.org.
J.D. Kleinke: Increase the Number of 'Non-Doctor' Doctors
We already do have a shortage of primary-care physicians in the
U.S., and the "crowding
in" of tens of millions of new Americans with access to
coverage under the Affordable
Care Act in the next few years will exacerbate the situation.
(For the record, more people
with more access to primary and preventive care is a good
problem to have.) But there
will be an aggravated supply problem associated with the
release of this pent-up demand,
and there are two ways to address it.
First, we can and should significantly expand all efforts and
incentive programs (e.g., like
the National Health Service Corps http://nhsc.hrsa.gov/) that
will increase the number of
"non-doctor" doctors, also known as "physician-extenders." We
can train and mobilize

these types of providers—physician-assistants, certified nurse
practitioners and certified
nurse midwives—much faster and for far less cost than we can
traditional physicians.
And there is an added social and economic benefit: These are
good-paying, high-skills
based jobs, and would be excellent first (or second) career paths
for many highly
competent students (or displaced workers) struggling to find
good employment in a
sluggish job market.
Second, we can and should expand the scope of practice for
other "non-doctors" to allow
for many other types of caregivers to provide services currently
off-limits to them, thanks
to ferocious turf defenses by physician lobbies at the state level.
The most obvious
expansions involve allowing drug prescribing by clinical
psychologists and continuing
medical management by pharmacists, but they also include
many other types of care that
could be safely and effectively provided by chiropractors,
naturopaths and others with

state-regulated training, certification and licensing programs.
This can be led by guidance
and standard-setting at the federal level, but it will require hard
stare-downs on traditional
physician lobbies at the state level, and an expansion of
payment eligibility by health-
insurance administrators.
J.D. Kleinke (@jdkonhealth) is a medical economist, author,
health-care-business
strategist and entrepreneur. In 2012, he was a resident fellow of
the American Enterprise
Institute. Before joining AEI, Mr. Kleinke was co-founder and
CEO of Mount Tabor, a
health-care information-technology development company.
Gurpreet Dhaliwal: Lack of Access to Care Is the Greater
Problem
The predicated doctor shortage will exacerbate the larger issue:
The limited access to care
that already plagues our health system.
The government should increase funding for residency training
to remedy the current
shortfall, which prevents all U.S. medical-school graduates
from completing their

training and become practicing physicians. We should also
increase residency
opportunities for international medical-school graduates, who
disproportionately provide
care in rural and underserved areas.
Training programs and training sites that successfully develop
generalist physicians
(where the greatest need lies), as well as nurse practitioners and
physician assistants,
deserve the greatest support. Clinics, emergency rooms, and
hospitals can serve many
more patients when physicians, NPs and PAs are working side-
by-side.
Patients should be able to access any of those providers through
electronic
communication. Many more patients can be served via phone,
email, text and
videoconferencing than the current mandatory face-to-face
interaction, which frequently
wastes enormous patient and health-care system resources.
We need more doctors, but also more NPs, PAs, and IT experts,
just to reach the modest

goal of making basic care available to everyone.
Dr. Gurpreet Dhaliwal is an associate professor of clinical
medicine at the University of
California San Francisco. He directs the internal-medicine
clerkships at the San
Francisco VA Medical Center, where he sees patients and
teaches medical students and
residents in the emergency department, inpatient wards and
outpatient clinic.
Leah Binder: An M.D. Isn't Always Necessary for Care
Before we talk about shortages of doctors, let's talk about our
nation's capacity to provide
services Americans need—and build our future workforce on
that platform. That answer
won't come from physicians alone.
Indeed, we need to recognize that not everything physicians do
now requires a medical
degree, and then we need to distribute our workforce
accordingly. For instance, we
should follow the recommendations of the IOM (Institute of
Medicine) and other leading
expert consensus bodies and remove artificial barriers to
practice for certain advanced

practice professionals. Removing barriers for these nurse
practitioners, physician
assistants, nurse specialists, nurse anesthetists, midwives and
other professionals will
allow them to provide the services that they are well educated
and fully competent to
provide.
Currently, different states impose a variety of regulations to
restrict non-physicians from
offering certain services, because physician lobbies have fought
for those restrictions, at
least in part to protect their turf. Decades of studies show that
these restrictions don't help
patients or improve quality. Given the looming shortages of
physicians and other
caregivers, it's time to vastly expand our nation's capacity by
harnessing the wealth of
talent in a variety of health-care professions.
Leah Binder (@LeahBinder) is president and chief executive of
Leapfrog Group, a
national organization based in Washington, D.C., representing
employer purchasers of

health care and calling for improvements in the safety and
quality of the nation's
hospitals.
Atul Grover: Increase Federal Funding for Residency
Training
A growing, aging population demands that we train more
doctors. Medical schools are
doing their part by increasing enrollment. But that won't result
in one additional doctor in
practice unless Congress and the administration lift the freeze
on federal support for the
residency training that has been in place since 1996. You can
read more about my
argument in the debate in the Journal Report on Big Issues in
Health Care.
Dr. Atul Grover is chief public-policy officer of the Association
of American Medical
Colleges.
John Sotos: Let Doctors Be Doctors
In 1905, Dr. William Osler—the great co-founder of Johns
Hopkins Hospital, who was
cursed with a terrific sense of humor—jokingly proposed that
all men over age 60 should

be euthanized. Unfortunately for Osler, the newspapers took
him seriously. A gigantic
controversy erupted, and Osler spent the rest of his time in
America trying to explain
himself before fleeing to Oxford.
Being a man not far from the aforementioned age, let me be
clear: I don't support any
form of mandatory euthanasia as a method of reducing
physician workload. There are
much better ways.
I think that physicians should do only "physicianing." The
trends in medicine, however,
are exactly the opposite: Physicians are wasting increasing
amounts of time doing "un-
physiciany" things. They are being de-professionalized.
Two art works, shown below, that Dr. Abraham Verghese of
Stanford University, likes to
compare, illustrate one such erosive trend.
The painting, titled "The Doctor," appeared in 1891. The sick
child commands every
ounce of the doctor's attention and concentration. The drawing,

untitled, appeared in
2012. The sick child, who is also the artist, sits on an
examination table, amid family. The
physician is at the left margin, his head down, the hospital
information system
commanding every ounce of his attention and concentration.
If you talk to physicians today, every single one of them will
begrudge the time they
spend feeding the gaping, information-eating maw of insurers
and medicine-practiced-by-
teams. Some may admit there are benefits, but every single one
will talk about the costs,
which are all too obvious.
If Dr. Leonard "Bones" McCoy were among us, he would rightly
and indignantly remind
Captain Kirk that, "Dammit, he's a doctor, not a stenographer."
See the first image, "The Doctor."
See the second image, untitled.
Dr. John Sotos, a cardiologist and flight surgeon, was a medical
technical adviser to the
television series "House, M.D." and is the author of several
books, including "The

Physical Lincoln." His home page is www.sotos.com.
Carol Cassella: If We Want More Doctors, We Have to Pay
for More Training
Despite much doom and gloom spouted by practicing physicians
about the future of U.S.
doctors' autonomy and incomes, medicine is still a popular
career choice. Medical school
applications reached an all-time high as of 2011, and new
medical schools are being
opened to accommodate them. The problem is that after four
years studying basic
sciences and elementary patient care, medical-school graduates
hit a bottleneck when
they apply for a residency. That critical and expensive leg of
training, without which one
cannot be board certified, hasn't seen a federal funding increase
since 1997. Increased
funding was proposed in the Affordable Care Act, but it wasn't
approved. Meanwhile,
every year more physicians age out of full-time practice, and
more aging patients need
physicians. So the shortage grows. In the long term, if we want
more doctors we have to

pay more for their training.
But what about the short term? Beyond sheer numbers, the
distribution of doctors is also
a problem, both across specialties and across geographical and
income parameters. That,
too, might boil down to economics. As of 2012, 86% of
medical-school graduates started
practice with debts averaging more than $166,000, and the
income gap between primary
care and procedure-heavy specialties is millions of dollars over
a lifetime. These realities
have enormous influence over young doctors' career decisions.
Is it time to consider
narrowing the pay gap? Should we reduce medical tuition in
exchange for mandatory
one- or two-year service programs? Voluntary service-for-
tuition programs haven't been
very popular but they are gaining ground and support. Given
how much the government
and taxpayers invest in training physicians, maybe some service
shouldn't be voluntary.
Dr. Carol Cassella (@CarolCassella) is a practicing physician
and author of the novels

"Oxygen" and "Healer."
Peter Pronovost: Make Being a Doctor More Rewarding
Policy makers must make sure there are enough residency
positions for the bright,
talented students graduating from medical school. As my
colleague Atul Grover from the
Association of American Medical Colleges points out, Congress
and the administration
put a cap on support for residency training in 1996 and, unless
that cap is lifted, all the
other efforts in the policy arena "still won't result in one more
doctor in practice."
In addition to increasing the number of residency training
positions, other incentives are
needed to create a rewarding work environment that provides
purpose, supports
autonomy, develops mastery and presents financial rewards.
Bureaucratic hassles and changing reimbursement rates for
services influence what
specialties physicians choose. For example, fewer medical
students are pursuing careers
in primary care, which pays less than specialty care but requires

the same investment in
terms of student loans—nearly $200,000 on average per student.
Physicians also report
high rates of burnout: One in three plans to leave the profession
in the next three years.
Lower pay and high—even dangerous—workload has reduced
the number of critical-care
physicians. When critical-care physicians staff intensive-care
units, mortality and costs
are reduced by 30%. Yet only three out of 10 U.S. hospitals
have these lifesaving
physicians, in part because there aren't enough of them.
Policy makers can create incentives to encourage physicians to
go into needed specialties
by increasing payments and reducing the burden of student
loans. They can also help
make careers in medicine more rewarding by giving physicians
more autonomy. We can
maintain autonomy and ensure safe care is delivered by creating
mechanisms that hold
physicians accountable for patient outcomes and encourage
them to innovate on how to
improve those outcomes.

Peter Pronovost is a practicing anesthesiologist, critical-care
physician, professor, Johns
Hopkins Medicine senior vice president and director of the
Armstrong Institute for
Patient Safety and Quality.
Susan DeVore: Leverage Under-Used Care Providers
With the impending influx of Medicare and Medicaid patients,
coupled with our aging
physician workforce, our country's physician-shortage problem
is poised to only worsen.
Let's be clear—there's no way to replace the care a physician
provides when it is needed.
But one way to alleviate physician shortages is to leverage
underutilized agents in the
clinical and community setting, such as nurses and other care
providers.
For example, Mercy Health in Cincinnati has introduced a
coordinated-care program that
works in both inpatient and outpatient settings. Care-
management team nurses
communicate with patients at home and through regular phone
calls, providing coaching

as needed. The nurses also teach health-education classes and
refer patients with mental
health and life management issues to behavioral-health
counselors for further assistance.
They've also found that the best means of treating a patient may
have nothing to do with
clinical care. In some cases, improving their mental outlook
could be the motivation they
need to avoid admission. In one example, Mercy Health nurses
found that one of their
patients with a chronic condition had no furniture at home,
except a bed. Mercy Health
supplied her with a chair, promoting mobility while allowing
her to look out the window
and gain a different perspective.
In some cases, we might safely question whether a clinician is
required, or is as effective,
as someone else.
Heartland Health President and CEO Mark Laney, M.D.,
recently told a story about an
older man who visited one of their new, innovative life-center
clinics. He was
complaining that he wasn't feeling well, and wasn't sure why.
Staff at the St. Joseph, Mo.-

based health system came to find out that his wife of 35 years
recently died—turns out,
she always did the cooking, which ultimately had a lot to do
with why he wasn't feeling
well.
Heartland didn't treat his temporary problem. They treated the
root cause, which was
surprisingly not medical in nature: his diet. A non–clinical
caregiver called a "life coach"
took the man to the grocery store, and taught him how to choose
and prepare healthy
meals. This is just one example of how Heartland's model,
called Mosaic Life Care, has
proved successful for the people they serve, while alleviating
the need for physician—
and even clinical—care.
Technology can also play a significant role in lessening the
physician-shortage impact.
For example, the Charlotte, N.C.-based Carolinas HealthCare
System is implementing a
virtual critical-care program allowing clinicians to remotely
monitor patients in intensive-

care units at all times. If a problem develops, the intensivist on
call can be quickly and
easily notified, and intervene. It's an added level of care, like
having a critical-care
specialist at each bedside 24/7.
I feel strongly that our country has the best physicians in the
world, and there's nothing
that can be done to replace them. But our physician shortage
needs to be addressed, and
soon. One way to lessen this problem is to ensure people
receive the right care, in the
right place, at the right time.
Susan DeVore is president and chief executive officer of the
Premier Inc. health-care
alliance.
David Blumenthal: Allow Nurse Practitioners to Provide
More Care
As I discussed in the New England Journal of Medicine last
month, one option for
addressing the threatened shortage of primary-care doctors in
this country is to rely on
nurse practitioners to provide a wider range of services. Now
numbering approximately

180,000, nurse practitioners have become an important part of
the U.S. health-care
workforce. The literature shows that nurse practitioners provide
many types of routine
primary care that is comparable in quality to that provided by
primary-care physicians, as
measured by health outcomes, use of resources and cost. In
some respects, such as
communication with patients seeking urgent care, they perform
better than physicians.
However, this is a highly complex issue and several important
considerations merit
further thought and study. First, nurse practitioners and
primary-care clinicians receive
different training and have different skill sets. Physicians may
be more skilled
diagnosticians, especially for rare and complex problems. Also,
it isn't yet clear whether
nurses can manage patients with multiple interacting chronic
conditions with the same
skill as physicians. Patients also vary significantly and strongly
in their preferences

regarding who provides their primary care. And new team-based
models of primary-care
practice create additional opportunities and uncertainties,
perhaps alleviating the
predicted shortage of providers by increasing efficiency.
Ultimately, a flexible approach to crafting primary-care-
workforce policy is needed, one
that is responsive to the changing roles of health-care
professionals and to changes in the
organization and financing of health care. Policy makers should
rely upon objective data
on the competencies of professionals—rather than rigid state
laws—to regulate providers'
roles. And patients need to be given a voice in the debate.
David Blumenthal (@DavidBlumenthal) is president and chief
executive officer of the
Commonwealth Fund, a national health-care philanthropy based
in New York City.
Drew Harris: Market Forces Will Help, to a Degree
Fixing the doctor shortage will require new policy
interventions, but market forces will
also play a major role in ensuring everyone with the means will
get the care they need.

Research by Stephen Petterson et al projects a shortfall of
52,000 primary-care providers
above the current baseline of 210,000 doctors by 2025.
Interestingly, demand is driven
mostly by a growing (32,852 more doctors needed) and aging
(9,894 needed) population.
Only 8,097 more providers are needed to cover those newly
insured under the Affordable
Care Act. This isn't too surprising considering that the
uninsured tend to be younger and
healthier, while the older and sick people are more likely to
have coverage.
Several policy initiatives could address the shortfall:
• Expand the scope of practice of non-MD providers. By
allowing advanced practice
nurses, nurse practitioners and physician assistants to practice
all that they have been
trained to do, which is often more than their states allow, we
could free up highly trained
physicians to provide more complex evaluation and treatment.
• Increase the number of care delivery sites. In many states,
specially trained pharmacists

can give all recommended vaccinations. Patients must like this
option because
pharmacies have outpaced workplaces as the preferred place to
get a flu shot.
• Deliver more care in the home. Much of primary care is
making sure chronic conditions
don't get worse. New technology provides for continuing
monitoring of mental
status,blood sugar, blood pressure and other signs of a
deteriorating medical condition,
resulting in fewer unnecessary checkups and preventable
hospitalizations.
• Tie medical school loans to practice in underserved
communities. We need to recruit
medical students from underserved areas and provide them with
loans or grants to ensure
they return to practice where they are needed most—not
wealthier communities with a
physician oversupply.
Finally, the market will respond to millions of newly insured
people seeking care. If it
isn't the physicians leading teams of health professionals
employing innovative
population health delivery models then it will be large

corporations such as Wal-Mart
Stores Inc. and Walgreen Co. setting up highly efficient fully
integrated care centers
staffed with midlevel health providers.
Drew Harris (@drewaharris) is director of health policy at the
Jefferson School of
Population Health at Thomas Jefferson University in
Philadelphia, where he focuses on
the complex interplay between public health, medical care and
public policy.
Pamela Barnes: Think About Teams, Not Just Doctors
It isn't about finding more doctors; we need to think more
strategically about how we
deliver health-care services. A team-based approach to health
care shifts the
concentration from a few doctors providing specialized or even
general medical services
to an entire team that is able to leverage their skills, knowledge
and expertise. In many of
the countries where we work, nurses, nurse practitioners and
midwives, for example,
allow us to reach more women and families, providing the same

quality of care as
doctors. We need to examine our communities, determine their
needs, and develop the
types of health-care teams that work best for them.
Pamela Barnes (@PamWBarnes) is the president and CEO of
EngenderHealth and was
formerly president and CEO of the Elizabeth Glaser Pediatric
AIDS Foundation.
Charles Denham: Stop Stifling Medical Assistants
Unfortunately, the physician-dominated guild system that has
been U.S. health care has
stifled medical assistants, nurses, nurse practitioners,
pharmacists and many allied
personnel from operating at the top of their intellect,
certifications and training. Physician
assistants and nurse practitioners many times have more
experience in certain processes
than the average physicians that they serve, yet they aren't able
to work independently
because of the reimbursement structure and ancient regulations
that were put in place
many decades ago. As will soon be published by the Cleveland
Clinic's Dr. David

Longworth, even medical-office assistants can have tremendous
impact on quality and
the operational performance of a clinic when given the chance
to operate at the top of
their game.
The great performance-improvement collaborative programs
established by the Institute
for Healthcare Improvement (IHI), led by Dr. Don Berwick, our
recent Medicare leader,
and Maureen Bisognono, gave us the gift of rapid cycle
innovation that has broken
barriers of performance previously unheard of; and their motto
was "All Teach—All
Learn." By adding the methods of team-based work process and
the concept of servant
leadership to caregiving, which is what creates the wonderful
healing moments caregivers
cherish, a motto of All Teach, All Learn, and All Lead becomes
real.
The only way we can address the shortage of doctors is to
unleash the creativity and
power of millions of caregivers, allied health personnel and
assistants who would step up

in an instant to take on more responsibility. To quote the global
business leader and CEO
of Barry Wehmiller Cos. and visionary leader in the coming
documentary "Healing
Moments—Loved Ones Caring for Loved Ones," "We have
rented their hands for years
and could have had their heads and hearts for free…all we had
to do was ask." They are
ready…are we?
Charles Denham (@Charles_Denham) is the founder of the not-
for-profit Texas Medical
Institute of Technology, a medical-research organization, and
the for-profit HCC Corp.,
an innovation accelerator.
Helen Darling: Encourage a Team Effort
The first step should be to make certain that health care is being
delivered in the most
efficient and effective ways with each team member practicing
to the "top of his or her
license." Physicians should work in teams with other health
professionals who take on
tasks that don't require a physician. Advanced practice nurses
and RNs can do more than

they usually do and, in turn, jobs that they do may be just as
well done by a
paraprofessional, freeing them for those activities for which
they are licensed and already
highly qualified. There are dozens of examples, and doctors are
likely to enjoy practicing
much more if they are freed from tasks that don't require their
advanced training.
There is substantial research that nurses, nutritionists,
pharmacists, and so forth, can
deliver care, education, and information much better with
greater impact than physicians,
yet the way we all pay for care often means that if the doctor
doesn't provide the service,
it isn't reimbursable. Patient-centered, team-based care could
significantly decrease the
demand for additional doctors.
With the right system re-engineering and electronic health
records, time spent now by
doctors could be replaced or eliminated by smart technology.
Once all possible steps have
been taken to optimize roles and responsibilities of highly
skilled and expensively

educated doctors, then an independent assessment by an
objective, credible group should
analyze data and make recommendations for which specialists
(e.g. general surgeons) are
truly needed, in addition to the primary-care doctors and
advanced practice nurses needed
now. Medical-school classes (and relevant residencies) might be
enlarged slightly to
accommodate any gaps, but the nation shouldn't build more
medical schools. They are
remarkably expensive and once built will need to be supported,
predominantly with
public funds. This would add way more to the costs of health
care at a time when we
need to be finding ways to reduce costs, not add to them.
Helen Darling is president and chief executive officer of the
National Business Group on
Health, a Washington, D.C.-based nonprofit member
organization composed of more
than 360 of the nation's largest employers, including 66 of the
Fortune 100.

Example Portfolio Letter – Student #1
Dear Portfolio Reviewers,
Far be it from me to say that you are about to read what
I consider some of the best work I have written to date, but I
certainly would not be lying if I said so. I am incredibly proud
of my problem and rhetorical analysis essays, not just for the
final products but for the steps I took to get there. Much like an
essay, my process had a slow beginning, an arduous middle, and
a hard-worked-for end, and I am going to take you through it
with me now.
Upon reading the prompts for each essay, however
many weeks apart, I felt the same overwhelming sense of
despair and confusion. What problem did I have that I could
write an essay on that wasn’t strictly me complaining, and why
would anyone want to read it to begin with? What exactly is a
rhetorical analysis and what topic could I possibly choose? I
eventually settled on a topic for each, not entirely sure if it was
even going to be worth examining, and began the writing
process. Even after more than a year in college, I have yet to
shake that unfortunate high school tendency to churn out a draft
without any planning or preparation. It is what has always
worked best for me, and my true ability to write rears its head
in the revision process anyway. For the problem essay, a letter
to the editor addressing unsafe driving and how it can be self-
regulated, I thought about how frustrating my morning commute
is every day and I built on my personal experience to engage
with the audience. For the rhetorical analysis essay, which
compared an academic article about gossip and a corresponding
popular article, I relied on my experience as a science student in
research to discuss the accuracy of the popular science article
and where it differed from the academic article. With those
experiences and thoughts in mind, I began to write my first
drafts. I read and reread whatever resources were made
available to me in class, I did little bouts of revising as I went,
and I continually referred back to the prompt to make sure I was

really answering the question put in front of me. While it was a
struggle at times, I knew that with feedback and the revising
process, I would end up writing excellent final products.
While I may not have shed the curse of churning out
crappy first drafts, I have come to recognize that they are
indeed crappy and need revision. I believe the feedback my
instructor provided has been a huge help to me in the revising
process. It is always constructive, never critical, and it
illuminates weaknesses in my writing that I could not have
imagined were there. The first thing I did when I revised my
papers was to make whatever changes my instructor suggested.
Then I would read the essay aloud, and find places where the
wording was awkward or the ideas didn’t necessarily fit in with
the rest of the essay. Once I had made those changes, I would
make an outline in reverse to see whether or not the essay was
structured logically, if my thesis was present throughout the
body of the essay, and if my conclusion was relevant but not
redundant. If there seemed to be a problem with the essay after
outlining it, I would rearrange things or add new ideas to make
it more logical and well structured. Lastly, I double-checked my
spelling and mechanics, and asked a friend to read it and make
sure that it at least made sense to someone other than me. My
final reading of each essay proved to me that I had written
something that addressed the prompt, made a point and
supported it, engaged with the audience appropriately, and that I
was proud of.
It is my sincere hope that in reviewing my portfolio it
becomes apparent the amount of effort I put into writing and
revising my essays. While effort may not be a criterion for
grading, it has enabled me to produce essays that I find to be
meritorious on the rubric.
With many thanks,
Student #1

ePortfolio Cover Letter Assignment Instructions
See the red highlight part. Mention that in the cover letter.
thanks
Task:
You will write a letter that reflects upon what you have learned
this quarter and indicates how the essays included in the
portfolio are indicative of your growth as a writer.
While this task is similar to the cover letters you have been
writing all quarter, this should be more formal and have a clear,
cohesive theme. It should also be broader in scope, discussing
your developments in your writing over the entire quarter. For
example, you might focus on how you have improved your
organization throughout this quarter, or how revision was a
crucial influence on your growth as a writer, or how your
biggest take-away from the class is a strong understanding of
audience.
You can structure your letter in any way that makes sense to
you, but it should cover the following ground:
What have you learned this quarter? Make an argument for how
you have met the UWP1 learning outcomes.
To answer this question, you might consider: How did you
define “good writing” at the beginning of the quarter and how
do you define it now? How have you developed as a writer this
quarter? How will the knowledge, skills, or experiences from
this course help you in the future to accomplish reading/writing
tasks in other courses and in professional settings?
Why are the essays in your portfolio representative of what
you’ve learned? Support your argument by citing specific
examples from the projects in your portfolio

To answer this question, you will want to explain why you
chose to include your problem essay or literacy narrative, and
ask yourself: What does including this text tell you about how
you write, or about how you assess your work? How does this
essay compare with others you’ve written? (I choose the
literacy narrative because the revised of this one is more
changeling than the problem essay. Mention that in the cover
letter.)
You’ll also want to explain why the problem essay/literacy
narrative and the rhetorical analysis essay demonstrate your
ability as a writer. Use specifics from the essays as evidence
(you can paraphrase, describe, or use direct quotes).
What does this electronic portfolio say about you as a writer,
student, researcher, and thinker?
To answer this question, you might consider: Why did you
include the visuals you did? Why did you design your
navigation the way you did? How do the essays, your design
decisions, and this reflective letter combine to represent you?
Consider how what you learned about reading and composing in
UWP1 could apply to your future writing contexts.
Throughout the letter, you will want to provide evidence to
support your claims. Use this evidence to prove that you have
learned what you say you have learned. For example, when
discussing what you’ve learned this quarter, you may want to
look back at the earlier drafts of your writing, or compare first
and final drafts of your essays, or review the cover letters you
wrote throughout the quarter. When you describe how the essays
in the portfolio are representative of your learning, you will
probably paraphrase, describe, or directly quote from the
essays. Similarly, when you discuss the design of the portfolio,
you may use description, but you can also link to other parts of
the portfolio or include screenshots.Genre:
The genre is a reflective letter. You will write in first-person

and include personal examples, and can directly address your
audience.

Example Portfolio Letter – Student #3Dear Portfolio Reviewers,.docx

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