My classmate and fellow nerd from Kansas Chris Adams has created a short little blog to detail a walk-thru of the loan deferment process. He sent it out originally as an email, and I just completed it and got confirmation I’m in deferment!

(And if you’re reading this… a plea to contact your Congresspeople, as they’re trying to make it harder for residents to qualify for economic hardship. Please pass on to your own medical schools, as this will affect younger med students even more than it does us!)

The current rule by the Dept of Ed that allows residents to defer their loan payments until after residency is in danger of being removed because it’s too “cost-prohibitive.” For those graduating this year, this means you’d only get to do 2 years of deferment (with later years being a much less favorable type of deferment); if you’re graduating next year, only 1 year of normal deferment, and if you’re graduating after that, you’ll be SOL.

PLEASE contact your Congress people, tell them you’re a doctor or future doctor and it will greatly affect your ability to afford residency!

More info on it here (the AAMC and AMA are both lobbying hard to get this rule change reversed):
http://www.ama-assn.org/ama/pub/category/18024.html

This is a script you can use when you call them:
http://www.ama-assn.org/ama1/pub/upload/mm/16/script.pdf (pdf)

And please also make your voice heard electronically thru this script:
http://capwiz.com/ama/issues/alert/?alertid=11184256&type=co

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Quick update, got an email from someone at Student Doctor who showed me that the Stewart University website is dead. No idea what happened. I previously discussed it here.

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I hope you’ve enjoyed the series and it’s made you think a bit about health care, health policy, and how difficult it is to come up with solutions to our health care problems. I appreciate the civil discussion and debate, and continue to welcome any other feedback!

A few topics I wanted to cover but didn’t have time to:

• Science education - If we want our patients to understand medicine and the science behind it, they need to understand (and accept) the basic tenets of science — randomized studies, for example — and perhaps that’s where we’re failing. People seem to have a miraculous ability to accept the science they have chosen to believe (antibiotics for bacterial infections, germ theory) while ignoring rigorous science that doesn’t fit with their world view (thiomersal is not responsible for autism).
• Patient Autonomy - Has it gone too far? By asking patients or their decision-makers to decide, “Do you want to keep trying failing treatments or terminate care,” perhaps we’re putting too much decision-making in the hands of a person who clearly doesn’t want to feel responsible for “pulling the plug” on their mother (who would?)? While no one wants to die or wants a loved one to die, is it fair to other people who have a better chance of hope of recovery to take up a hospital bed to treat a demented 95 year-old man who won’t get any better?
• And many more!

On that note, it’s been a pleasure writing about my journey through medical school, and I appreciate everyone who’s joined me and supported me along the way.

I’m heading to Xela, Guatemala (aka Quetzaltenango) tonight for two months with Asociación Pop-Wuj to do some intensive Spanish and medical Spanish training (as well as seeing their cigar-smoking saint, Maximón, and hiking and exploring) before heading back to be in a friend’s wedding. I likely won’t be blogging much, but hey, who knows. Since I now have an official job as a doctor (scary), I’ll be wrapping Over My Med Body up in time for Graduation in June. Stay safe and healthy and I’ll see you on the flip side!

yours,
graham

Me on Match Day, blogging away:

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Q&A with the Graham Walker. Stay tuned to find out where I match! (I know you’re as excited as I am. And boy am I serious in that photo!)

Tomorrow seems like it really sets the dominoes in motion–that I’ve got several different paths my life could take, and it all depends on what’s printed on that letter tomorrow. If I’m at program X, I sell my car; if I’m at program Y, I need to go find an apartment, etc. Here goes nothing!

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Matthew Holt has a few posts about Jay Parkinson, MD’s medical practice in Brooklyn, which is cash based and all digital and electronic–electronic medical record, online chats, video chats, emails to patients–totally awesome. I love the practice style.

My main concerns? Two things: he’s stealing all the easy work from people, and while I’ll admit I don’t know much about preventive medicine residencies, how much training does he really have in treating adults, when he did a pediatrics residency?

On the first point: he will only see adults age 18-39. If you look at adult preventive health care guidelines for people 18-39, it’s really mostly blood pressure checks and physical exams, with an occasional cholesterol check and pap smear and STI check for women. After kids, 18-39 year-olds are the healthiest group of people there are. For the most part, their main health problems consist of viral illnesses and substance use. Are there sick 18-39 year-olds, sure, but they’re the vast minority. Bottom line: 18-39 year-olds are, for the most part, incredibly easy to care for. Do they need to be seeing a doctor, sure, but man, low-hanging fruit.

My second concern: adults are not big children. The majority of a pediatrics residency is spent taking care of very sick babes and children. (Or seeing them in clinic and learning all the rashes and viral syndromes that most kids get seen for, the milestones, the vaccines, how to talk to parents, etc.) The closest you come to adults in pediatrics are adolescents that come in for physical exams for school for the most part. But you certainly don’t see adults, besides the occasional 18 year-old who wanders in and hasn’t changed doctors yet. Maybe this isn’t much of an issue, since taking care of these patients is pretty straight-forward, but still, it doesn’t seem like the training fits the job description.

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Really great and interesting YouTube clip of a woman who is in a wheelchair due to multiple sclerosis being able to walk and interact in Second Life.

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About the shortage of primary care, which I’ll be discussing — and with similar recommendations to Kevin — later in my series. Way to go Kevin. Another point we can agree upon.

(Kevin is right; as a medical student, we can see the writing on the wall and do the basic math.)

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Great discussion-inspiring post, and summarizes a RAND post I hadn’t seen about how we might/should prioritize medical care.

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A really, super fantastic post on ethics, rationing, medical resources, and futility by UCSF’s hospitalist blogger. Illustrates my feelings on the subject very well and shows that we really need a solution.

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(I’m a sucker for alliteration.)

Shadowfax is shaving his head to raise money for neuroblastoma research. Donate now and claim your stake!

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Perfect timing, Maggie! A long and excellent piece on the huge variations in care in the US. States are ranked in terms of their health care quality.

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Oh, to be alive in the ’70s. Apparently this video is from 1971 by Robert Alan Weiss for the Department of Chemistry of Stanford University, and shows some totally free loving hippies acting out protein synthesis as interpretive dance. I personally like the synth organ / bongo drums theme of mRNA binding to the 30s subunit about about 4:36 into the video. Hilarious.

[via kitsune noir]

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Several comments and critiques as I watched Eric Schmidt, Google’s CEO, talk about Google Health:

• Please stop calling patients consumers. Patients are people with illnesses or injuries who need medical care; consumers are people who purchase goods or services and are informed about what they’re purchasing. (Most patients are not actively dictating what health care resources they’re consuming.) Note: there are certainly consumers of health information, but a person who comes to me seeking medical attention is not a consumer. He or she is a patient.
• The medical record is not the patient’s property. I believe the model we need to use for the medical record is “shared control,” that is, the patient controls who sees the information in their medical record, but the patient’s physician controls the actual information. A patient with HIV or a history of anaphylactic shock to penicillin should not be able to delete this from their medical record.
• Wow, it would be amazingly cool to have all XRays and CT scans from everyone in the country online. I would love that.
• Dr. Schmidt talks about young people, and how we already see the future of what will happen with society, what changes will occur and how quickly and says that the older people like him need to be ready to change and adapt. But I’d guess no one on their Health Advisory Board, with the exception of Matthew Zachary, is under 40 or 50; few if any likely have a Youtube account or Facebook profile. If young people are so in the know, get our opinions!

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Investigating a bit further into the Stewart Medical School craziness, there’s a Youtube account for someone claiming to be a med student there, and the videos the person favorited are craaaaazy lectures by this naturopath. (Medblogging gold, GOLD I say!) Like, seriously, seriously crazy, and you feel bad and worry for the students in the audience, ’cause there’s no way anyone could answer the questions in lecture, ’cause they make no sense:

“Tongues shaped like a hammer are the tongues of nymphomaniacs, as well as kidney problems.”

“If you get a patient who gets the flu, and a week later gets the flu again, what do you do? You have them throw away their toothbrush.” Also, if you have a high change in your morning cortisol levels, it’s “some kind of parasitic infection, some type of growth, some type of infection in the intestines.” A student asks him to explain these changes, and he says, “Oh, 15 years of gastroenterologists running correlations.”

A woman’s testosterone level is high because she is scared:

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So I come across this link for Stewart Uniersity: New Scotland International School of Medicine, which is apparently a “new medical school” and is somehow just down the road from Stanford. Funny, I’ve never heard of it. So I delve a little deeper, and my “sketchy”-dar (similar to gaydar) starts to go off. As I delve a bit deeper, I’m even more concerned for students and potential applicants (has scamming moved to medical schools now?). Let’s investigate the general info first:

• Right off the bat, the school claims to be “the #1 leader in US medical education.” Them’s some big balls you got there, Stewart.
• “Stewart University is the first medical school to open west of the Mississippi in the past 45 years.SM” Okay, fine, got me there — we need more doctors!

• Stewart University is an International School of Medicine. Our curriculum is the standard allopathic (MD) degree discipline. The accelerated 16 month MD degree curriculum completes the basic science courses in first four semesters.

  The World Health Organization (WHO) requires recognized MD degree granting programs to be at least 30 months in length. The Stewart University MD program is 34 months in length for a student with normal degree progress.

  So they’re somehow an “International Medical School,” operating in the US. While the WHO may recognize an MD program as one with 30 months of teaching, I’m pretty sure the AAMC and other licensing bodies require a 4-year medical school, no?

Next, Admissions:

• 2 years and ten months total program length
  3 starting classes per year: January, May, September
  No MCAT - NOT required for MD licensure
  No Bachelor’s Degree - NOT required for MD licensure
  No Minimum Undergrad Credit Hrs -NOT required for MD licensure
  No AMCAS Application, Apply Directly via School Website
  No Age Limit
  Provisional Admittance - for those without prerequisites
  Equal Admissions Process for All Applicants
  Immediate Admissions Application Review

  Okay, it is freaking awesome that you wouldn’t have to take the MCAT. But really–you don’t even need to go to college? No Bachelor’s Degree?

• Letters of Recommendation are not required.
• Interviews are done over the phone. Fine by me!
• $950 non-refundable “seat reservation fee?” That has to be paid, via Paypal, within 48 hours of “initial acceptance?” Skeeeeetchy.
• Stewart University School of Medicine reserves the right to change or modify tuition rates at will. So I could enroll, and two days later the tuition could be $100,000 an hour?
• I love the handy Tuition Comparison Chart. Wow, if you go to Stewart University, you save a whole $9,000 a year over Stanford or USC. And you receive, according to the chart, a Curriculum with “Equivalent books and instruction as other Calif Med Schools**”. I had no idea.

Faculty/Administration:

• This has to be a joke, right? None of the administrators (most of which appear to have their most recent photo from World War II) have an MD, and there’s only 4 faculty, and only 3 with MDs?
• Two big red flags here: Student Recruiter job posting and one of the 4 staff positions is Marketing Illustrator (shown at left).
• On further inspection: It’s called Stewart University because most of the university is run by The Stewarts! William Bullock Stewart, Sr. is Provost Emeritus, his son, William Bullock Stewart, Jr. is Provost, and his son, William Bullock Stewart, III is Chancellor. The Board of Advisors, Ronald S. Steward, Rosemary E. O’Hara, and James T. Stewart are all of the Stewart clan as well, as well as the Marketing Illustrator.

Curriculum:

• Okay, good, they say they cover all the basic science stuff for preclinical work, and their textbook list is probably pretty similar to what I mostly studied from.
• “The Basic Science phase includes didactic instruction (and may have cable television instruction available also).” Where are they getting the bodies for anatomy? Are they even allowed to have bodies to dissect if they’re not accredited?

• The Clinical phase of the curriculum is intended to be conducted at various U.S. Veteran’s Administration hospitals around the United States and Caribbean Island locations. This affords great flexibility to the student, particularly those on active duty or mobilized, to perform clinical rotations in military treatment facilities and tertiary care military hospitals around the world.

  I guess this is how international medical students do it.

Accreditation:

• It would seriously worry me if my school had a whole section on Accreditation, and the first sentence of the page was, “It is not illegal to operate a school without possessing an accreditation.”
• And the kicker, buried in the text: “For-profit institutions almost always have to wait 2 years after starting operations before they are eligible to submit an application for accreditation.” Oh, well there we go. You’re a for-profit medical school. I was guessing I’d find that somewhere. So you can teach, and provide the same training as any other California medical school, and take a cut as profit? Color me skeptical.
• There’s also a blank but present page on Known Falsehoods, whatever that means.
• Finally, there’s a big long-winded explanation about how the school is somehow on “Federal land,” not “California State Land,” so if you call California, they’ll say the school is not recognized, but it doesn’t matter, ’cause it’s on Federal land.

  It all leaves me pretty darn puzzled, ’cause when you Google the school’s address, you end up with A Postal Annex Store in Los Gatos, California — no medical school listing — and I’m pretty sure the Postal Annex isn’t Federal Land.

Finally, Beware any medical school catalog whose first page is entitled “California Living.”

Sure, some of these features go along with some of the features of the Caribbean Medical Schools — but an accelerated curriculum, with almost no requirements for admission, and a campus that appears to be a mailbox in a Mailboxes Etc. store? Stay away, pre-meds, stay far, far away.

(I know my tone in places is snarky or sarcastic, but in all seriousness, I think there are reasons that American medical schools require things like the MCAT, admissions essays, and letters of recommendations. Mainly those being that as an MD you will be responsible for people’s lives, and it’s not something you should be able to just “sign up and do ’cause you feel like it,” which seems like the gist of the marketing campaign of Stewart University. I’ll admit I don’t know a whole lot about the Caribbean medical schools or licensure process in the US for IMGs, but these groups at least seem more interested in putting out good doctors than just somehow skirting around the requirements to get an MD through a loophole.)

Update: I just spoke to a man who answered the phone, who was very confrontational when I asked “Where is the school located?” He started rambling about how ValueMD and StudentDoctor have been harassing and stalking people from the school. He admitted the address on the website is a PO Box, and said the school does not release the address or location of the school until an applicant has been accepted. (”Fine by me,” I said, “But it seems a little weird that a medical school wouldn’t be visitable or even map-able.”) He then noted that “members of Al Queda have been in contact” with the school, and the school had to file a “400 page document with the FBI” because of this. Yowsers.

Update 2: A spammer for Stewart University was banned from ValueMD, and a little more searching finds that Stewart University was removed from Wikipedia for possible fraud. According to this poster, none of the MDs from Stewart University were licensed in the state of California.

Update 3:
It looks like the school took over the high school in Oxnard, CA, because let me tell you, these photos are definitely not from beaches in Northern California, and it was trying to buy the high school apparently.

Update 4:
On Stewart University’s News page almost none of the links lead to actual stories. The Stanford Daily has published no stories about it, The San Jose Mercury News has no stories on it, nor does The LA Times. Hmmm.

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Sad to hear that Patrick Swayze has pancreatic cancer, but glad to hear he’s being treated at Stanford. Apparently he had a “serious GI procedure” back in February at Stanford — that would have been his Whipple procedure where they take out part of the pancreas along with a bunch of other surrounding structures, a surgery lasting a good 8 hours — and now he’s receiving chemo.

His oncologist Dr. George Fisher says he’s responding well to the chemo.

Pancreatic cancer is one of our worst enemies in the cancer world: the fifth leading cause of cancer-related mortality in the United States. There is a 4% 5-year survival rate. The problems are two-fold: first, due to the location of the pancreas, patients often don’t have any symptoms until the cancer has grown and spread to other organs that would cause symptoms (classically this is “painless jaundice” and weight loss). The second problem is that we don’t have great chemotherapy for pancreatic cancer, either.

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You know Airborne, that product “invented by a school teacher” that’s supposed to make you feel all better from a cold? It claimed it had a study done to show its clinical efficacy; turns out they finally admitted the “research company” was just two dudes, none doctors, created just to do the study. The company agreed to a class-action lawsuit settlement. Submit your claim if you have one.

(If it’s too good to be true, it probably is!)

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Not any surprise here, but my friend and classmate Cheri Blauwet (her previous wins noted) picked up her fourth marathon win in LA. Congrats, Cheri! (She’s even more awesome in person.) Visit Cheri’s blog.

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Pretty typical scenario for this real-life, accurate Flash game called Amateur Surgeon: Pizza delivery guy hits a homeless guy with his car, performs surgery on him using his Pizza Delivery Guy Tools, and homeless guy then teaches him how to perform other surgeries, as it turns out he used to be a doctor.

(If only closing wounds was as easy as stapling them and then burning them closed with a lighter! Especially lung lacerations.)

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KevinMD highlights some good posts from two of my favorite New Yorker bloggers about a new campaign encouraging people to get CT scans to catch lung cancer early, before it spreads–even though there’s no evidence to support this. Which I totally agree with. He says:

A deplorable campaign. Currently, there is no data suggesting decreased mortality from lung cancer screening. Asking the public to “demand” a CT scan simply drives up health care costs without a demonstrable survival benefit.

I find it curious for Kevin to have taken this position, when he recently started promoting Family Cord Blood Services, since there’s currently no evidence that private cord blood banking will provide any benefit to children, and the American Association of Pediatrics actually recommends against private cord blood banking, except in the case “when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.”

The AAP does recommend public cord blood banking, however–since public cord blood is available to… the public. Something I just learned that I didn’t realize–if your child ends up having a childhood blood cancer and needs a stem cell transplant, cord blood may have a higher successful transplant rate, but your own child’s blood won’t be used, because it likely already had the cancer growing in it. Someone else’s child’s cord blood will be used for the transplant.

I have no problem with Kevin’s blog advertising, and sure, Kevin, he makes it clear that it’s a “Sponsored Post.” And perhaps someday there will be a use for cord blood (I guess the 99.9% of us who don’t have our own cord blood available are just SOL). But as compared to Kevin’s other sponsors, who are selling magazines, or promoting their websites or electronic medical records, the cord blood post really makes it seem like he endorses/supports/agrees with private cord blood banking. Which is fine if he does–except the evidence isn’t there for private cord blood therapies, or lung cancer screening CTs.

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Maggie Mahar has some great history on the origins of the “good cholesterol” vs “bad cholesterol” stuff, and how we got to our thinking about cholesterol to begin with. I don’t know how the woman has time to write and research all this for her blog, but she’s absolutely amazing. When residency starts, I’m going to seriously be cutting back on my blog reading, but Maggie’s won’t be leaving my Feed Reader anytime soon. If you’re not reading it, I’ll say it again: you’re missing out on some of the best of the web.

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Google has now announced their Google Health product, now with a screenshot.

As I’ve said before, patients should not control their own medical records. If this Google Health product is an addition to the medical record for patients to use, fine. But if you think a physician is going to trust a patient’s listing of his or her weight over the scale in his or her office, you’ve got another thing coming, Google. (I’m also looking forward to a three page Google Health printout of a patient’s “allergies.”) It would, however, be nice to be able to get results of colonoscopies and stress tests, which it looks like Google may be able to do.

If you want an honest review of Google Health, feel free to contact me, Google. (I’m a trusted tester!) Until then, color me skeptical. (And Patient Sam Sample–watch your kidney function. Lisinopril plus ibuprofen is just asking to shut down your kidneys.)

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Okay so my idea for a daily randomness of linkage didn’t really pan out. But some random health care and non-health care goodies:

• Mythbusting Canadian Health Care, Parts One and Two. Brings up a number of good points I hadn’t considered before–doctors that spend less time with billing and financial headaches have more time to read and keep up with their specialty.
• My Favorite Liar: Blogger recounts a trick an Econ professor would use to keep his students’ attention during lecture. Brilliant. One of my best lecturers I’ve ever had was Dr. Gil Chu, who taught our Molecular Bio course. His trick was incredibly effective: 10 questions had to be asked during class before we were allowed to leave, and he kept a tally on the board. It fostered a classroom where the assumption was that the material was hard, that we were moving fast, and that he probably wouldn’t explain everything perfectly the first time. And because students felt comfortable asking questions–you were contributing to the class being able to leave on time–people also asked things they were curious about. We were thinking!
• Why Meth Is A Horrible, Horrible Drug. (Probably not safe for work.) A terribly sad video of a young woman, turned psychotic by the drug, from the A&E show “Intervention.” If you ever hear of a person running naked through the streets… they’re probably on meth.
• A quarter of teens thought Columbus sailed the ocean blue… sometime after 1750. Lord, they can’t even remember a freakin’ mnemonic anymore.
• Finally: children with accents are the most adorable thing ever:
  

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As if anyone would forget, the Rank Order List is due tomorrow! Can’t believe we match in less than a month. I’m pumped.

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I guess we’ve been trying to computerize healthcare since the days of punchcard computer systems. Humbling that we’ve been trying for 50+ years and still can’t get it right!

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Hey Jon Marshall, DO, thanks for recommending Hydroxycut! I know you’re just a “Resident Physician” as the commercial says (funny, it didn’t mention you’re a radiologist in training) but you radiologists interact with patients and advise them on weight loss pretty consistently, right? Look, you’re pretty hot and all, and I’m sure that helps sell the pills, but seriously, dude. You chose medicine for “the science behind it. I also like dealing with people and helping them,” and you’re hawking a product with pretty iffy science behind it (Hydroxycut was sued for making false statements about it being “clinically proven” and paid to settle). And you have to admit, it’s kind of funny that you “like dealing with people,” so you went into radiology.

(Side note: what’s with Midwestern University DO School? They seem to be churning out the resident DO physician product marketers–it’s where both Dr. Marshall and Dr. Swanson went.)

To be fair, at least the Hydroxycut site gives references for their scientific research (in one study of 30 whole patients, another with 60) plus two studies that seem to be about caffeine and green tea.

But also to be fair, the advertised weight loss of 29 pounds in 8 weeks actually isn’t healthy, Dr. Marshall. And I think people are really looking for long-term weight loss, not just 8 weeks’ worth.

Hydroxycut isn’t limited to DOs, however. They’ve got Nick Evans, a MD and attending orthopedist/sports medicine man hawking the product, too. (At least his specialty is related to exercise and weight loss.) Dr. Evans, dude, you look huge! (My favorite is the Bodybuilding Anatomy book with his head photoshopped on a drawing of a bodybuilder torso.)

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Maria’s got a great post that is funny, true, and speaks volumes. Questions.

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He staged an accident so he could cut off his right hand. A close psychiatrist colleague would’ve gone with a little Geodon action.

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The Zetia/cholesterol bit from last month and the tight glucose control deaths stuff has made me take a skeptical look… at medicine itself.

The old adage is “trust no one” in medicine, but sometimes, I think, maybe we should apply that to medicine itself. It’s certainly humbling to realize that what we hypothesize to be true and what seems to make sense to us, even from a physiologic theory, and even with supporting data, might not necessarily be true. It’s an important reminder–to both physicians and patients–that we’re all unfortunately human. That we don’t have all the answers, that even with the best of intentions–and best of knowledge–we can be wrong. After all, what is medicine but humans trying to understand, grasp, and alter insanely complex biological systems that have been under development for hundreds of millions of years? We set limits, values, and numbers to help us decide “what’s normal” and “what’s disease,” but in reality, they’re gross, gross simplifications we accept so that we can triage, differentiate, and make sense of what’s going on inside that black box that is the patient’s body.

It doesn’t mean that there are no absolutes, or that medicine or science is flawed more than anything else is flawed, or that there are not facts. Just that the physician who thinks he is always correct and is master of the human body is doomed to fail and do harm. I tie it back to this great quote from MedRants about unintended consequences:

The law of unintended consequences is what happens when a simple system tries to regulate a complex system. The political system is simple, it operates with limited information (rational ignorance), short time horizons, low feedback, and poor and misaligned incentives. Society in contrast is a complex, evolving, high-feedback, incentive-driven system. When a simple system tries to regulate a complex system you often get unintended consequences.

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Edwin Leap:

I believe physicians are unhappy because they believed the great lie.

What was it? What was the lie and when did doctors learn it? The lie was this: ‘if you become a doctor, your profession of medicine will be all you need for happiness and fulfillment.’ In short, physicians learned to validate themselves by way of a profession.

I believe my generation of physicians never grew up with a great lie. We knew we wouldn’t make the most money (or at least, we should have known this); we knew that medicine was time-consuming, but we chose it anyway. And the medical schools chose us for our diversity, life-experiences, and well-roundedness. They’ve selected out for people who have taken time off before school (almost half of my graduating class), who have had other careers, who have explored other interests. Found other things besides medicine that make them happy.

Look at the fields that are incredibly popular today: they either make a lot of money, offer a good lifestyle, or both (I’m looking right at you, ophtho). We want to have free time outside of our careers. We want to have families and relationships. Sure, we’re ready to make sacrifices, but we weren’t told a lie–or maybe we just never believed it. We’ve had the opportunity to study abroad; we’ve been exposed to foreign countries and cultures; we have taken courses in religion, anthropology, linguistics, sociology–and we know there are more things to life (exciting, interesting, thrilling ones at that)–besides a job. (For Dr. Leap, that appears to be his faith.)

Now, perhaps this is to the detriment of our future patients–that their future doctors want more out of life than just being great doctors for them. Perhaps it is for the benefit of them. I guess only time will tell.

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I for one am spending it with my significant other, my boards review book.

But it’s not all bad. There’s a new Indiana Jones trailer out.

And rejected Shoebox Greeting Cards:

Oh, and by the way? Paget’s Disease? I hate you and all the damn questions about you.

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Thanks, Dr. Bryce Swanson, DO, for recommending Rapid Slim SX to me on TV! I know you’re only a “Resident Physician,” but you said you read the study about Rapid Slim SX and it’s going to work, right? You’re in your last year of Anesthesia Residency, so you’re clearly an authority on weight loss. Which is why it surprised me that in your “Talk With Dr. Bryce Swanson” you glaze right over the health benefits of weight loss.

As an anesthesiologist, I would’ve thought you would’ve spoken most about how obese patients are more challenging to manage in the operating room, due to their decreased chest wall compliance and decreased functional residual capacity or talk about any of the other health benefits of weight loss (decreasing insulin resistance, decreases in cancer risks, etc). But instead, when you’re asked “In your opinion, what are the benefits to losing weight?” you say “I think that losing weight helps a woman feel better inside and out. She’s more confident, she’s more energetic, she regains that spring in her step because she likes the way she looks,” and mention that “also” there are health benefits. I’m also scratching my head, Dr. Swanson, because you say that “A major diet overhaul must be gradual so it can be sustained over time,” but then you go on to say that “I would recommend RapidSlim SX because it delivers amazing weight-loss results so quickly and because available published research reveals it to be a superior formula and brand.” [my emphasis] (Also, superior to what? And what’s the “available published research?” I can’t seem to find it, even though you flaunt the study all over the damn website.)

I’ve also been quite impressed with Chief Scientific Officer Marvin Heuer, MD’s work history. (Thanks, Angry Doctor!) I also love his resume, with most of his publications being listed as “Submitted for Publication.” I should fatten my resume that way. I’ve got TONS of things I could submit for publication!

Hey, if it really works, and you really believe in it, Dr. Swanson, that’s great. But a little more intellectual honesty might get you a lot further. (But I guess that doesn’t really sell pills, does it?)

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As I am counting down the days until I can get Step 2 over with (T-minus 10!), I’m going insane memorizing diseases I will never see in my lifetime. I need some laughs. So I’m asking everyone to please post their favorite medical joke. (And plus, it’d be a great chance to see people’s faces and comedic timing.) Oh, fine, if you’re anonymous, I guess you just can post the text, but come on, video is sooo 2008. (If you use YouTube, tag your video as “medicaljoke” so they’ll be easier to find.)

Either comment or email me the Youtube link or your blog posting, and I’ll start a running list here on this blog post. And if you don’t have a blog, just leave a comment! Please! I’m begging you! Help a guy escape from the hells of Boards reviewing. I’ll start:

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You know, that’s the thing about socialized medicine. There’s no motivation for innovation. There’s no research or development. It all comes from The United States of America. Except, apparently, growing new bones for a patient using stem cells harvested from the patient’s own adipose tissue.

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Great online resource for orthopedic testing of the knee, shoulder, and ankle from this professor at UC Fresno. Also available as a Podcast, so you can download the videos to your computer (or iPod, I guess!). Pretty cool.

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In which I agree almost completely. I’d add in a course on medical ethics, and one on health policy as well.

I think Organic Chemistry serves a purpose, but it’s not because Orgo is useful to a clinician. It’s to see if a person has the dedication and ability to memorize an insane amount of very abstract material in a very short span of time, and then be able to apply said material to a specific problem. (Which you have to do in med school.) This also does a good job of weeding out people.

I’d love to see a mandatory second language of one’s choosing in there too (which most of my classmates probably already meet anyway). Similar to the organic chemistry metaphor, medicine is learning a language. (And it also comes in handy with patients. Just two days ago I was doing a second look at a program and helping an intern with a lumbar puncture, and my seemingly-useless French allowed me to communicate with our patient.)

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Sorry for the dearth of posting lately; I’ve been busily hitting city after city on the interview trail–and the residencies, unfortunately, continue to be great (making my ranking decision next to impossible).

Two quick bits: Thanks to the LA Times for the mention about the placebo study (and very cool that the reporter found me via my blog).

And thank you to Chicago, where I’ve been interviewing as of late. After 11 years driving without a single parking ticket, thank you, Chicago, for welcoming your forgotten son (I went to undergrad in the area) back with open arms. Two tickets and my car towed today for a tow away zone sign that was crumpled and gnarled away. I missed you too.

(I’m really not that happy about it. I swear.)

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• My favorite article today–because it’s in line with my own experience–the quality of one’s workout music is directly proportional to the quality of one’s workout. With scientific proof and everything! I wish it’d be legal to share workout playlists with people–I swear I’ve got a knack for them. Currently playing: Rihanna’s Please Don’t Stop the Music, via Songza, an awesome site that lets you play almost any song you can think of–if it can find it. (thanks dad!)
• On to more serious matters–Harvard docs have found over 200 proteins that appear to be important to HIV’s success, using RNA interference, a technique I blogged about in the first month of med school! What a long time ago.
• And your daily policy reading: Ezra Klein (I wish I had time to read your whole blog, Ezra, but I couldn’t keep up) on the Commonwealth Study on amenable mortality: “in English, it assessed how effective health systems are at reaching the sick.” Again, we pay the most, we’re doing the worst, and our amenable mortality worsened while most other countries improved. (These are, of course, in scary “socialized medicine” countries. They’re not doing as bad as people would like you to believe, according to economist Paul Krugman.)
• The Executive Physician has a very fair analysis of Grady County Hospital’s problems and retail clinic unfairness. He says county hospitals need to compete for health patients, but that retail clinics shouldn’t be able to quietly sneak away from complicated patients (cherry-pick), and that governments shouldn’t allow them to, either.
• It’s the economy, stupid.
• And finally, Joe Paduda on HSAs, the rebuttal version. “One noted that they make “health care more affordable for the majority of consumers”; I think the commenter is conflating health insurance with health care. HSA plans may make insurance more affordable, but health care costs are not any cheaper under HSA plans. In fact, HSA plans’ higher out-of-pocket costs may make health care costs less affordable.”

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• I’m going to start with Health Beat Blog’s great summary of the US’s terrible ranking with preventable deaths. Great summary of the data, and the implications. Shadowfax agrees. In the comments, The Happy Hospitalist says no country is really doing all that great with preventable deaths, which I agree with, but as Shadowfax reminds us, “We pay $7000 per capita. Again, we pay the most, and get the least.” (France, the leader, pays less than half of that.
• Catron takes issue (”load of BS”) with my highlighting a recent poll showing support for single-payer over our current system, saying that the poll isn’t scientific and flawed. Well of course it is, Mr. Catron–all polls are. They also leave out all us young adults who have no home phone number and have unlisted cell phone numbers, too. Either never cite polls or surveys yourself, or be honest. All polls suffer from selection and other biases. (Still, having half of respondents say they support a system where “all Americans would get their insurance from a single government plan” is pretty damn impressive to me. I never would have expected the number to be that high.)
• Nick (who I’m meeting next week!) satirizes the talking heads describing the ER. Keep this stuff coming!
• Lower co-pays make patients less likely to skip meds. Not a surprise. When it’s food versus medication (especially anti-hypertensives which often have side effects patients don’t like), not a surprise they pick food for themselves or their kids.
  

  Many companies are already paying for disease management programs to help patients with chronic diseases such as diabetes. So why not encourage people to take the medicines they need. You “pay a nurse $65 an hour to call call a diabetic [employee] and say, ‘Take a beta blocker.’ And the employee says ‘I know it’s important, why did you raise my copay from $15 to $30,” Fendrick says. “It’s a classic example of the misalignment of incentives in the U.S. health care system.”

• Out of state licensing rules are a mess, according to California Medicine Man. Would definitely frustrate any physician trying to help.
• Nice interview in the WSJ Health Blog, Kevin!

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Sadly we apparently have to keep doing the studies, because parents who don’t understand science don’t believe it.

Autism rates in California continued to increase despite California removing the thimerosal-containing vaccines in 2001.

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The type of Emergency Medicine story that gets your heart racing. (Also got a nice kick out of him linking to MDCalc for the Parkland Formula.)

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• 45% of doctors who responded to a survey said they’ve given placebos to patients. That number certainly seems high, but sometimes patients don’t want to hear what you’re saying–namely, that no drug will help them. Giving antibiotics for a viral illness would almost count as a placebo, if they didn’t have the associated side effects and risks. I’ve certainly wanted to write for “Obecalp 1 tab PO BID” (’placebo’ backwards) but I find it totally unethical and undermining of the doctor-patient trusting relationship. (Then again, patients don’t always seem so keen on the whole trusting relationship either, but that’s why we’re professionals.)
• Linkage shout-out to Maggie Mahar’s Health Beat Blog, which has been around for awhile but I never gave proper… props to. Maggie wrote the outstanding Money-Driven Medicine (Amazon) and has her background in business writing. (The aforementioned book provides a lot of evidence for the problems of our health care system and perverse incentives within it.) Lately she’s been investigating the ICU Checklist for Central Line Place program that was stupidly halted and providing frequent updates about what she’s learning. One of my new favorite blogs in the last six months.
• Illinois’ state-wide smoking ban seems to be going over fairly well. Being at home lately, I’m proud my own hometown finally decided to adopt a smoking ban (better late than never, OP!) and our bustling urban metropolis of Kansas City is being forced to put it on the ballot. I for one am much less likely to go out where bars allow smoking.

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Panda Bear is great writer. A great, deceptive writer, but aren’t we writers always trying to use our words to influence and convince, anyway?

Panda Bear uses great analogy and examples (usually stereotyped) to make his point. The fallacy is perhaps not his fault–we often see the best and the worst of and in people in the Emergency Department, which may explain his selection bias. Here’s the fundamental difference between us, Panda Bear, with clichés in full force: you seem to believe that one bad apple spoils the barrel, whereas I don’t believe in throwing the baby out with the bathwater.

He writes:

But that’s the problem with Social Justice, especially as it is used to justify giving everyone free health care. It makes the assumption that everyone is a victim and doesn’t allow for the possibility of the freeloader who not only exists in droves but is aggressively selected for in every nanny-state ever created. People may be lazy but they aren’t stupid and, as most people do not love their jobs, if the conditions are set to obviate the need for work many people will tend to do as little work as they possibly can.

Social justice, as I understand, it about equality. Distributing shared, scarce public resources as equitably as possible. Nothing in it speaks of victimhood. The poor (because that’s who I think we’re really talking about here) are certainly in a terrible position, and some might think of them as victims, but I wouldn’t blanket the term on like that.

Look, our society is based on equality, equal opportunity, and justice for all. While I’m certainly not idealistic naive enough to believe that this will ever be attained, I fundamentally believe it’s something we should strive for. Will there be free-loaders? Always! It’s our unfortunate human nature. I agree that “many people will tend to do as little work as they possibly can.” But I believe that for the most part, the poor and working poor do the best they can based on their circumstances. These people are not the ones that freeload in the ED. You may never see them (until their appendix bursts). Because they’re doing whatever they can to make ends meet. I believe that these people–the large majority, in my mind–should not be punished because of the inevitable freeloaders that happen to be grouped in the same income bracket. We should do our best to create policies that discourage freeloading, but not at the cost of hurting those who already have the least. (And ahem, health care is certainly not free. I know what you mean, but if liberal wackos are going to get rightly called to task for the term, I’m an equal-opportunity call-to-tasker.)

Later in Panda’s piece he sets up the anonymous straw-man “the usual suspects” who are apparently “deeply conflicted.” I’m not sure who the usual suspects are, unless they’re tree-hugging, Communist free-spirited liberals from San Francisco. (Note: Having been in the Bay Area for 5 years, one of the tree-hugging strongholds in the US, I have yet to find a serious-about-policy, educated, truly informed “usual suspect” as Panda describes. Please report them to both Panda and I immediately.)

As if we don’t have enough trouble administering real justice we now have to gear up to dispense social justice, a highly nebulous concept the implementation of which requires that grievance, race, age, social status, intelligence, and other things that Americans should ignore be worked into an arbitrary and impossible behavioral calculus to give to each according to his need and to take from each according to his abilty.

Equality, Panda, is the word you’re looking for. Highly nebulous concept that it is, I’m all for it.

I certainly by any stretch of the imagination do not believe that highly-over-educated, job-pretty-darn-secure, world-is-my-oyster physicians (including myself) can understand what it’s like to poor in today’s society. Crappy education, dangerous neighborhoods, the convenience store and fast food for your dinner options. The medblogosphere’s tune would certainly be different if most people’s parents were poor and working poor.

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Sometimes a comment is so good it deserves highlighting. This comment by Dr. Roy Poses of the Health Care Renewal blog is one such comment. His first statement is a perfect summary: “Retainer medicine is an indication of a serious problem, and an indication that people actually value primary care. It should be looked on as a symptom, not a treatment.”

It strikes me that the increasing popularity of retainer practices suggests that people highly value care given by generalist physicians who have enough time and interest to take truly comprehensive care of them. They value this care so highly they are willing to pay for it out of pocket.

It also strikes me that the main reasons such care is not available to all people are that:
1) The reimbursement given to most generalists is inadequate to pay for such care. This reimbursement has been de facto dictated by Medicare, and in turn is determined by the secretive and unrepresentative RUC (see previous posts on this blog, Health Care Renewal, http://hcrenewal.blogspot.com/, and other blogs).
2) Most physicians’ office practice costs are driven up, and time is further wasted by numerous bureaucratic requirements imposed by Medicare, managed care, regulators, accrediting agencies, etc, etc.

These conditions seem to have developed because managers and bureaucrats believed that the practicing physician, particularly the generalist, is the cause of rising medical costs. Or maybe they just thought that the generalists were an easy target for cost cutting.

Meanwhile, the costs imposed by excessive bureaucracy, overpaid management, conflicts of interest and corruption in health care organizations go on and on.

The rising popularity of retainer practices should not be blamed for the current health care mess. It is an indicator how much people value comprehensive, generalist care, the sort of care that is now being stamped out by the bureaucrats and managers who run health care, often for their own personal benefit.

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I’d like to rudely insert myself back into the Retainer Medicine foray that Dr. Centor and Bad Medicine have kept up and offer a bit of… data.

There’s a good survey/article published from the JGIM: Physicians in Retainer (”Concierge”) Practices (also has a fantastic references section on the topic) which offers a bit of information on the practice size and demographics of retainer practices (for those who responded to the survey, obviously):

As you can see, retainer practices are likely to be MUCH smaller, and have wealthier, healthier patients.

And now two bits that certainly support retainer medicine that I hadn’t considered:

1. SteveSC’s comment about a physician’s duty to his current patients, which I agree with, but doubt that all physicians would truly close their censuses.
2. Uwe Reinhardt (renowned Princeton economist and health policy wonk)’s piece in the BMJ with this damning bit (the whole thing is only a page and worth the read):
   

   I consider boutique medicine for the upper income classes a harmless, almost playful fringe phenomenon. It is practiced by a handful of physicians who, I believe, do hide behind the shield of “quality” to protect their income. Let them. Not much harm done. The boutique medicine implicit in the Medicaid program strikes me as far more harmful and, indeed, inherently fraudulent. It strikes me as fraud when federal and state legislators pay physicians and hospitals a pittance for hard work under the Medicaid program and then pretend to God and country that they have looked after the poor. After all, what is a state legislator really saying to a pediatrician when, through the legislator’s own insurance, he or she is willing to pay the physician $80 for a patient visit, all the while paying the physician only $20-$30 for the same visit accorded the child of a poor family? Economists believe that the relative prices buyers offer signal relative values. The state legislators’ relative valuation of the treatment of their own children and that of poor children is crystal clear.

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Our talks of retainer medicine became more general talks about primary care, which is a great segue. A classmate emailed me his own sentiments:

I think you’re underestimating how screwed primary care physicians are… Primary care is royally f’d, and I don’t think its fair to pretend that their problems will magically get fixed by universal heatlhcare. As a lot of primary care’s f’d-ness has come at the hand of specialists.

As others have said, priarmy care is in trouble in this country. And I agree. Some of it is due to the lack of reimbursement compared to specialists; some of it is due to the lifestyle–seeing 8 patients an hour, including documentation and all that’s required for a patient visit–and the inability to properly care for a very sick patient with multiple medical problems in 7 minutes. (I do not ever mean to give the impression that “universal healthcare” would magically fix all these problems, just that I would rather deal with the problems in a fairly logical, rational, planned-out system than the patchwork disaster we have today.)

I’m going to attempt to discuss some solutions to the problems–both for an individual physician and health care/society as a whole. (While when I’m working as a clinician, my goal is the best care for my patients, when I discuss health care reform, I think it makes no sense to ignore the ramifications of a change to society as a whole.) If you solution is “people need to take more responsibility for their health and behaviors,” that’s a sentiment I whole-heartedly support, but if you think that’s sound health policy, Do Not Pass Go, Do Not Collect $200.

1. Income. Perhaps the biggest issue for most is the lack of reimbursement when compared to other specialties. By having a system that so heavily reimburses procedures over primary care (I wish I could remember where I read about the history of the RVU, Medicare’s unit of measure for determining who gets paid what for everything they do), you by default inequalize the playing field, and Sutton’s rule applies. One decent tutorial is from The Happy Hospitalist, “That’s Less Than Burger King Pays”, minus one gaping error of ommission:
   

   Imagine for simplicity that an internist has an all Medicare practice that generates $360,000 a year in clinic revenue. Let’s imagine the overhead is 50%.

   (I assume by “overhead” HH means expenses.) Overhead is 50%? Why not try to take a piece of this pie back? Administrative costs are a fierce proportion of total health care spending, even if you don’t like the numbers proposed. You do, of course, realize that in other countries, solo physicians can literally be solo physicians because they submit one form for their services, and get paid, right? And they certainly jump through fewer hoops with HMOs getting follow-up colonoscopies approved, or writing letters to non-medically-educated administrators to get treatment approvals, right? All of those things cost money.

   So we could certainly get money back into everyone’s pockets if we simplified the billing and administrative systems in the US, but I also think the RVU system needs to reward primary care work more and reward some procedures less. This would encourage more people to go into primary care and keep more people in primary care as well.

2. Lifestyle. Two big parts to this (correct me if I’m missing more)–time and paperwork. Panda sums up the former pretty well, and how the lack of time contributes greatly to costs (although he doesn’t mention costs specifically):
   

   The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

   Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

   Time. I’ve commented on this before, but it seems silly to give specialists more time with patients than primary care docs. Sure, primary care-ists see more acuity and less chronic disease, but that’s becoming less and less the case. Taking a page from the retainer medicine book, what if new standards were set for a patient based on the patient’s comorbidities? The annual diabetic exam gets 30 minutes at a minimum. The seemingly-refractory hypertensive patient gets half an hour so you can figure out what’s really going on. (Probably compliance.)

   Paperwork. Documenting is important — and not just for medico-legal blah blah blah. The US health care system is confusing and complex (and could certainly be simplified by health care reforms), but say we started paying doctors for their time–all their time. And perhaps to incentivize primary care, we only pay primary care doctors for all of it. That people practicing primary care can get reimbursed for their time on the phone, the paperwork they fill out–all of that. (Yes yes, I know this would create other incentives to send more paperwork to the PMD, but I’m brainstorming here, people.) I will also quote a poll that I can’t find right now stating that two-thirds of physicians would be willing to take a 10% pay cut for a significant reduction in the amount of paperwork they have to complete.

Look, to all of those who think retainer medicine will fix primary care, think again. It will fix primary care for individual physicians, but not for society as a whole. I’ve run the numbers. We need something in-between: something that encourages providers to stay in (and go into) primary care with better lifestyle and reimbursement, but that still allows them to see more patients than in a retainer practice.

I welcome your comments and criticisms, but I’m brainstorming solutions that would help both individual physicians and society, not one or the other. Offer something constructive–it seems like most people are happy to poo-poo an idea and complain (maybe that’s what the blogosphere is good at), but not to offer up their own solutions.