I’ve said a lot of goodbyes over the past few weeks–classmates, old friends, family, exes, and now you, my dear readers. (Yes, yes, say it ain’t so!)
I started this blog almost 5 years ago (wow) to document the process of becoming a doctor, write about health policy, explain medicine, and provide an outlet to process and reflect on the things that I experienced. By all possible measures, I’d say it was a success.
The further I got into medical school, the harder it was to remember or understand what it’s like to be a patient–in terms of the knowledge and the experience. It’s hard to remember what it’s like not to know what a drug does, or the pathophysiology of CHF, or when a patient is ready for discharge. I think this is one of the biggest challenges we have to overcome–becoming doctors by definition requires us to enter a different space than our patients, yet we still must communicate and explain without trying to over- or under-simplify.
And along the way, I guess another goal was to show people that doctors are simply fallible humans that are, in the vast majority, trying their best, but are prone to the same flaws and errors and mistakes that all of us are. It just sucks that our mistakes have much bigger consequences. I will always strive for perfection in my practice of medicine, but know I will never achieve it. I wish more patients would realize this.
Thanks for all the comments, support, criticism, and linkage over the past 5 years. This book of my life is over, but who knows, you may see me again. My goals right now are to hit residency with a running start, learn New York, meet friends, find some love along the way, and if I find that I still have time to blog, perhaps I’ll be back. It’s been a great 5 years!
(I’ll be moving the archives over to http://www.grahamazon.com/over/ in the next week or so.)
Good Afternoon Dean Pizzo, family and friends, colleagues, The Guy Who’s Totally Uploading This To YouTube Right Now, The Undergrads Who Heard There’s Free Alcohol Afterwards, and of course, my fellow classmates, the Graduating Class of 2008,
Britney Spears once famously said, “Hit me baby—.” That was my ORIGINAL version of the speech. You weren’t supposed to hear that. Awk! Ward! Blarg. Wow. Uhm, okay. Let’s just pretend that didn’t happen.
Hannah Montana once famously said, “We. Need. Single-payer national health insuran—.” Okay fine, she didn’t. But, I’m kind of known for ranting about health care reform, so everyone probably thinks that’s what I’ll talk about today. But don’t worry. I won’t. Today, I would like to talk about something that’s been bothering me: name-calling.
During medical school (and my entire life) I’ve answered to just about any variation on the theme: Graham, Graham Cracker, Grahamazon, Grahambo, Grahamakin Skywalker, “Hey you,” Kilo, Graham Stain, Graham Positive, Graham Negative, and even, as one attending who didn’t care to learn the names of her students called me, “a medical student,” with the same tone one might use to ask, “Could you hand me a pen?” Man, I’m really going to miss medical school!
But lately, most people have been calling me doctor, and I’m not sure if I like it. Sure, people have said it all throughout medical school, but I always had sufficient grounds to correct them: “No no, not yet, I’ve still got 6 more months to go,” or “Gosh, I wish, but I still have to pass my boards!” But lately, I haven’t had a leg to stand on.
It’s almost as if I don’t want Graduation Day to be here. But too late now. Change happens. Today, we’re becoming doctors.
I remember at orientation an upper-classman saying that we probably thought becoming a doctor was a noble, selfless act—but any of you in the audience can easily vouch for how selfish it can be. We have demanded your patience, love, understanding, compromises, and support for all these years. So up front, I want to say to each of you, from all of us up here, I am sorry. But I promise to do better next time. Not to forget slash have to reschedule: your birthday, our anniversary, the dinner reservations we had, or that trip to Mexico.
But truly, we could not have made it this far without you. Not to get all Mr. Rogers on you, but to us, you are special. You are why we are dedicated to this: because our patients have their own families and friends like you. You are the selfless ones…not us. So from the deepest reaches of our hearts and souls, thank you so very, very much. Today, we celebrate becoming doctors as much as we celebrate you.
I guess I really worry about how the title of Doctor defines you. How it changes you. That I’m becoming a little bit more Doctor Walker, and a little bit less Graham. Sure, the title affords me some prestige and privilege—for example, complete strangers will now feel totally comfortable whipping out their strange moles at dinner parties—but at the same time, it makes people see me as primarily—or only—a doctor, not as a son, brother, partner, computer nerd, or Trader Joe’s enthusiast.
Maybe this is how it’s supposed to be. Maybe that’s the purpose of the title. To remind us and others of the Oath we take, or that patients’ needs are to come before our own.
But if becoming a doctor will change how people view me, there are several values I’ve learned here at Stanford that should get to represent me, too. And I have numbered these values, as I am going into Emergency Medicine, and have a short attention span. Oh, and just a sidebar: The next time you want to complain about your hospital’s Emergency Department, please remember that we’re probably getting distracted by… oh, I don’t know, coding patients, big traumas, (mumbling) bodily fluids being flung… at… us, or… … shiny… things.
Sorry. Back to my values:
Number one: I will continue to use objectivity, without forgetting the subjective.
Medicine is an art grounded in science. I’ll do my best to know the studies, the data, and the pathophysiology, and try to apply them objectively.
But I won’t forget the patient. I’ll listen. I’ll be compassionate. I’ll try to keep social context, “chief concern,” and patient perspective in mind.
And number two: I promise to ask questions, and on occasion dare to admit: “I don’t know.” And thank you to Stanford for encouraging this—in Gil Chu’s class, where we weren’t allowed to leave until we had collectively asked him 10 questions; with Dr. Wolfe, who teaches students to admit their own “Areas of Ignorance.” We are a generation of physicians who are unfortunately (or fortunately) still human. We are not gods. We still make mistakes, and we still don’t have all the answers. But, hopefully, we’ll know where to find them.
Number three: Don’t mess with the pancreas. Or, in the famous words of master pancreatic surgeon Dr. Norton, “I’m tellin’ you, don’t mess with the pancreas! You gotta believe me!”
And number four: I promise to be involved. Whether it’s researching, teaching, advocating, or volunteering, I will remember that health and medicine are often advanced and affected more by time spent outside a hospital than within one.
While passing clerkships and boards and memorizing facts may make us doctors today, it’s our values that will drive us to become great doctors, like the many we have met here at Stanford. Because the great physician is dedicated to the truth, but also to patient. She is a scientist, but also a healer. He tempers prognosis with hope. I think Kurt Vonnegut sums up medicine’s curiosity and compassion better than I ever could: “We are here to help each other get through this thing, whatever it is.”
So, today, fellow classmates, this is it, for better or worse. When our patients call us doctor, they’ll finally be right. (How scary is that?) While our profession may change how we see the world, or even how the world sees us, we must keep a part of ourselves the same. That part—our goals and our values—is what has gotten us to this point, up on this stage. You can call me Dr. Walker now, but I promise to remain just Graham. I’m too proud of each title to be dropping either anytime soon. Thank you.
I know it’s been pretty non-existent posting lately, but I’ve been busy seeing friends, wrapping up my med student life, and trying to get ready to start my residency one.
Congrats to all my classmates and fellow new doctors across the country. What a feeling.
So I had a wonderful trip to Guatemala overall. I learned a ton of Spanish, saw some great sights, and all.
But then the very last 5 days of my trip, spent in Antigua, Guatemala, were terrible.
(Warning, graphic description ahead.)
After eating a salad (I know, I know, I should have known better) in Antigua (very touristy, and I assumed that meant safe), I was puking. The next day I spent in bed rehydrating. The next day I felt a bit better. The next day I had overwhelming nausea, only controlled by around-the-clock dramamine (an antihistamine). Then finally the next day I went home.
I continued to feel sick for the next 5 or so days after I was home. About two days ago I got an appetite back and finally feel better.
I finished a 3-day course of Cipro, took an albendazole to de-worm, and a 4-dose course of tinidazole (anti-microbe, anti-amoeba). Apparently tinidazole isn’t approved in the US, as a compound similar to it causes cancer in rats. Whoops.
But I feel better. Finally. After 10 days of hell. And I’m 13 pounds lighter, down to 139, the lightest I’ve weighed since I was 19. (Eternal optimist that I am, I now get to eat whatever the hell I want to try to gain weight. Yum.)
Also: take any American who thinks this country is a terrible place (I was not one of them, I’m just sayin’), send them to a developing country for a month, and they will come back the biggest Patriot.
I’m incredibly thrilled and honored to have been nominated by my graduating classmates to give our Commencement Speech! Thanks for everyone’s support, I’ll do my best to say something profound, and if not that, entertaining.
Random thoughts that I’ve got to get out from the developing country that is Guatemala. And for me to rationalize wasting time on the internets, it’s in Spanish (and then English).
Primero punto: la polucion. Respiro muchas fumas de carros y autobuses todos los dias, y la polucion no ayuda mi asthma. Estoy tosiendo con un tos seco. Ugh.
Dos: necesito una escopeta. Todos la tienen aqui… en las escuelas, las farmacias, el centro commercial… increyible. Es mas por la espectáculo que uso, pero es un poco difficile a comprender.
Tuve un obsecion con mis intestinos por esta semana. Es completamente mejor ahora, pero al comienzo de la semana, un sonido pequeno de mi estomago me preocupe mucho. Tuve mucho miedo de problemas gastronomicas, pero ahora soy fatalista.
1st issue: the pollution. I’m constantly breathing fumes from cars, buses… it’s awful. My cough-variant asthma is in full effect.
2: I need a shotgun. Everyone here seems to have them. At schools, pharmacies, the mall… it’s incredible. It seems like it’s more for show, to scare people off than for actual use, but I still don’t really get it.
I have had a ridiculous obsession with my bowels this week, but now it’s better. I swear, the tiniest gurgle from my stomach would send me into a panic. I’ll still eat safe (no street food), but otherwise I’m giving up. I hope I don’t get anything, but it’s probably out of my control.
Voy a esperar de subir archivos algos photos si yo puedo.
I’ll try to upload some photos if I can.
(Feel free to correct mi espanol si quieres… escribo a computadora muy rapido!)
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!
Throughout this series, I’ve documented just some of the big, elephantS in the health care room that truly concern me as a physician, patient, son, brother, citizen, and person. I’ve suggested abstract and theoretical policy ideas for how they might improve things, while providing very little practical information on how they might be implemented (tax hikes, law changes, policy changes). Because I’m skeptical that any of them would ever happen in today’s health care environment.
We need a single-payer for all the reasons I’ve stated in the previous post. But we need a single-payer even more to provide some sort of direction in this damn train wreck of a health care non-system in America. Pick almost any issue I’ve mentioned–or haven’t–that concerns you, and ask yourself if you think it’ll go anywhere without some sort of organized plan or director at the helm.
As I said at the beginning, the goal of a country’s health care system–and note, we talk about a country’s health care system, because the whole country’s population is affected by it–should be to make its citizens the healthiest they can be. Right now we have a system that maximizes profit; this coinflip sometimes comes out with also optimal healthiness, but often it couldn’t care less if it makes its patients healthy. Case in point: the Hepatitis C outbreak in Nevada at a colonoscopy center, where 40,000 people may have been exposed to hepatitis and HIV because staff were re-using syringes to save money. Or the woman who finally sued and beat the pants off Blue Shield of California because they dropped her coverage when she started chemo for her breast cancer. (Sick people cost money!)
We currently have a system where each health care player is trying to pull the system in a different direction, and it really leads us to gettiing nowhere, fast. The private health insurance companies certainly have no interest in bigger national goals, since they for the most part don’t have huge national markets. 30% of people change health insurance each year (no surprise when people change employers so often these days). So it’s no wonder that the HMOs aren’t interested in having comprehensive preventative care or an electronic medical record: long-term benefits of long-term programs aren’t ever seen by these companies–their patients have gone to another HMO!
There are a ton of perverse incentives in our current health care system, and at least in health care, it’s worse for all of us. Hopsitals currently advertise that they have the best heart centers, the fastest ERs, etc.–hoping that they can make more money and often just keep themselves open (rightly so: what good is a closed hospital to its community)? So hospitals have invested heavily in profit-making centers–heart centers, new scanners, etc–while providing fewer resources to other more broadly-useful services like primary care. But since there’s no one at the helm analyzing the data saying, “Wow, this community could really use a new rehab unit, since it has a very high number of returning Iraq war vets,” no hospital has any reason to build a rehab unit–unless they can make it profitable. Again, money/profit is a top priority, not health care needs.
And when hospitals aren’t able to compete, they close. And hospitals over the past 30 years have typically closed in the poorest neighborhoods (which often have the sickest patients). So then these patients are now without a hospital and without a doctor. Which eventually makes it worse for all of us.
People Want Reform.
Look, take a gander at any recent poll on health care, and you’ll see that people recognize that this system is in trouble. Whether it uses the words “single-payer” or “national health care system” or “significant change,” significant change is going to happen. It’s just what kind of change. And as I’ve said before, if we don’t take an active role as the nation’s health care providers saying what we think is best for Americans’ health, some system worse than what we can even imagine will fall into place.
It’s not just the uninsured that are voting in these polls–it’s the insured, too. And I believe for people with insurance to put their faith in a new system, it has to offer them something better than what they’ve currently got. And that’s why I’ve made the case for single-payer: it would provide some level of leadership and direction for our health care system, and, because of that, I believe would drastically improve our health care system.
Why Would It Be Better
Better health service, policy, and epidemiological research. We could use some nationalized system to collect anonymous data to see how people do with condition X or treatment Y. Currently a lot of this data is confined to the Medicare or VA populations, which are often not good representations of the entire populations.
Doctors would have more time with patients. Currently so much time is spent with paperwork that doctors spend less time with patients, and have less time to keep up current data and research in the journals.
All the reasons stated above, including people never going without health insurance. I find it interesting that we can be frustrated with Medicare’s “never events” at an institutional level, but don’t apply that same perspective to individual patients. In a perfect world, should no one at a hospital fall and break their hip? Sure, but it’ll happen, no matter how hard we try to stop it. Similarly, should people never get sick when they’re uninsured? Sure, but it’s going to happen, and should they be forever punished for it? I don’t think so.
Single-Payer Won’t Solve Everything Throughout this series, I’ve presented a number of concerns for this health care system, without really mentioning “single-payer” as a solution, because it alone is not. Health care financing alone will not solve all the problems of health care in this country, but it will be a big step in the right direction. With a single-payer system there would motivation to fix the health care system, as we would have a publicly-financed system whose goal is to optimize our health care system in every way possible.
I don’t buy the argument that “all government is bad.” There are certainly good laws out there, and certainly bad ones. The No-Call List law has been amazingly successul; the NIH is a government organization that divides up billions of dollars a year for medical research; fire and police departments keep us safe, and libraries provide their communities with access to books and information. I certainly don’t believe that any of these would be greatly improved by privatizing them and adding a profit component.
Would single-payer (or any big health care reform change) cause massive changes in our health care system? Absolutely, but I believe to solve or improve many of our health care problems we need massive change. Massive change happened when we gave women the right to vote, or decided that segregation wasn’t acceptable, but I’d argue we all now view these things as fundamentally improving society.
Many of you I’m sure will not be convinced by my arguments. That’s fine. But if that’s the case, it’s your job to come up with a better answer that also has the ability to address the other issues this country is facing besides just paying for health care.
(For example: ED docs love to bitch about EMTALA and people taking ambulances because gas is expensive, but I have yet to see other reasonable ideas for solutions from them.)
You knew it was coming, my single-payer post. It’s a nice wrap-up to the series. (I figured since I was agreeing with KevinMD and Panda so much I had to do something.)
I could make my argument for single-payer in any number of ways, but you’ve probably already heard them:
Human dignity. Everyone should have health care as a human right. That people deserve health care, and as a wise family practice doc from Idaho wrote, the uninsured pay for their health care with their dignity. That almost all of the uninsured and underinsured are hardworking, tax-paying people who either make “too much” money to qualify for programs for the poor like Medicaid or don’t make enough for their employers to also provide health insurance. Or that health insurance is often way too expensive for their families, or even if they bought health insurance, it wouldn’t cover their major problems, like their kid’s asthma (sorry, pre-existing condition).
We the taxpayers and insured are already paying for the uninsured in the form of higher taxes, higher insurance premiums, and longer waits for our own health care (remember, we’re all connected). Since we’re humane enough to have EMTALA and not let people die on the streets, people are going to get some level of care, no matter how poorly planned, poorly organized, or terribly chaotic it is. We might as well just pay for everyone and get a better bang for our buck, no? Isn’t that the American way, to at least get a good deal?
Economic growth is seriously stunted by our current non-system. Why did the Jelly Belly factory cross the border? To get cheaper health care costs in Canada. (True story.) In our global economy, take a look at any American industry and you’ll see our health care costs stick out like a sore thumb–and this makes American companies have higher costs and are therefore less competetive. US automakers currently pay more for their employees’ health insurance than the steel to build their cars (which is why renowned health care economist Uwe Reinhardt refers to the American car companies as health insurance providers financed by selling cars).
Many people–especially potential small business owners/entrepreneurs–simply forget any aspirations they have of starting their own business because of health care costs. If you quit your job and lose your health insurance and then get sick, you’re screwed. So there’s an incentive to stay in a job one hates, no matter how unproductive the worker is, because it provides them with health insurance.
We already ration care. Many people cite a valid concern that single-payer would lead to ominous “health care rationing.” They do not realize that we already ration care: based on ability to pay, not health care need.
Single-payer will save us money. Take a look at any proposed health care scheme, as many economists have in multiple previous studies (California Health Care Options Project, The Vermont Single-Payer Study, The Maryland Single-Payer Study, Massachusetts Health Care Studies, and Maine’s Single-Payer Microsimulation. Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting, two economic analyst groups. Not single-payer supporters), and you’ll see that single-payer is the only one that provides health insurance to everyone while actually costing overall less. It does this by doing bulk-purchasing of products, just like you do at Sam’s Club. It also majorly simplifies administrative overhead–think of the billions spent on duplicate forms a doctor has to process from the thousands of health plans out there–and the costs of increased health care usage are still absorbed in the savings. (I’m not about to deny that Medicare has paperwork requirements, but they’d be one set of paperwork requirements only.)
Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to.On To Single-Payer, Part 2
My classmates and I had an incredibly successful Match Day, most people staying at Stanford, a record number heading to Boston, and others going to UCSF and New York! Time to celebrate!
I’ve always found it curious that we spend so much research and clinical time and money on drug treatment, debating which antihypertensive is best, or which chemo combination cures the most people, but quickly gloss over the requirements to get a pill in a patient’s mouth. To take one extreme, consider the following thought experiment: say a researcher develops a cure for cancer and HIV (yes, at the same time!) but that each pill costs $5 million. While the theoretical efficacy of the drug may be 100% at providing a cure, its practical efficacy is near 0%: without money (or more generally, access) for this pill, it cures no one.
Study after study after study has shown that a lot of people skip their medications, and in the US, this is often due to cost. You take someone and say, “Hey, here’s $100, do you want food for the month or medications,” and funny enough, they choose food. Certainly there are other reasons that people do not take their medications–and these affect people in all countries–but patients in the US are much more likely to cite cost as the main reason they do not take their medications.
A few reasons this doesn’t really make a whole lot of sense:
We pony up and pay for the acute consequences of poorly controlled chronic diseases already. Let’s take my oft-picked-on disease, diabetes. If someone needs a foot amputation, or they need dialysis because their kidneys have shut down, we pay for it. So we wait until they’re super sick and then require a huge investment in resources, but before that, they’re simply out of luck. How is that a good financial investment? How does that minimize costs in our business-run health care world?
We pony up for acute care which we know saves lives, but not the chronic follow-up care which we know saves lives. If someone has a big heart attack, we throw an insane amount of resources toward that patient: emergency room staff, we often call in a team of cardiologists to go open up a clogged artery, and operate expensive machinery in the process, because we know it may save his or her life. But we take that same patient at discharge, when we have similar data saying that a drug like a beta blocker may save his or her life after having a heart attack and don’t provide the same resources to the patient, even though the beta blocker is a much cheaper intervention.
Yes yes, acute issues are by definition more immediate and often more life threatening, but if we’re providing resources, shouldn’t we provide them on some logical, rational basis or principle?
I’ll touch more on this in some of my concluding posts (which are coming up) but at the very least we should be providing better medication access to patients who have known indications for said drugs. I’ve seen uninsured patients with urinary tract infections who can’t afford their antibiotics and have simply returned to the ED with pyelonephritis (a kidney infection due to an untreated bladder infection) and require IV antibiotics and a hospital stay. It makes no sense for any player in our health care system: the patient, the nurse, the doctor, or even the health insurers, who’re getting billed more from hospitals because the hospitals have to care for the uninsured. We should all be angry, frustrated, and annoyed at yet another example of our health care non-system which, at the end of the day, costs us all more in time and money.
I applaud Wal-Mart, Target, et. al for making a huge list of their generics $4. It certainly makes things much more affordable for many people.
America loves to medicate its problems away. Can’t sleep on a plane? Take a pil. Nervous? Take a pill. We want to be in control of our bodies to the nth degree: we’re too busy to be sick, just give us antibiotics that may or may not work; we shouldn’t be fat, just give me a pill to make it all better. We get to have our coffee any way we like it, so why shouldn’t we get to have our bodies however we want them, too?
The problem is that pills don’t work that way. Our pills are, for the most part, chemicals that muck with cells’ pre-existing hardware often by altering how a certain protein interacts with another. But because all our cells generally contain most of the same ingredients, our pills end up poisoning other unintended cells, causing collateral damage. (This is why chemo kills cancer but has such severe side effects: it works by killing cells that grow rapidly, as many cancers do, but other body cells grow rapidly too–the hair, the gut, the immune system–and so these cells die too.)
It would be much cheaper for society–and healthier–to prescribe “exercise” or “a healthier diet.” Often this is what we physicians do prescribe, but our patients do not (and often cannot) follow through. Exercise, diet, and other things that can have a major impact on health are often lumped together as simply “lifestyle,” and are often viewed as individual preference and choice. It’s often easier to simply prescribe a drug (even though we realize that lifestyle changes would be much prefered). The Happy Hospitalist often rants about this–how much money would we save if people just ate healthier and exercised instead of taking pills?
Well, people should eat better, have less stress, and exercise more. Duh.
Some of this might be improved by better city planning and social policy: encouraging walking and public transportation, changing our farm subsidies around to encourage cheaper produce and more access to it.
But the larger social change (and therefore, less likely one) is changing our lifestyles. If you want people to eat better and exercise more, you have to give them more time to do these things. In the short run, sure, it’s easier to medicate the problem away. But in the long-term, I think healthier lifestyles beat polymedicated Americans anyday.
Again, this would require massive changes in our culture and society. To lose our obsession on material goods and consumerism, to realize that taking care of ourselves should take priority over a nicer car or more stuff. To have a greater distribution of wealth. But I illustrate this “solution” more to suggest how difficult it might be to make inroads in this prescription mania in America than anything else.
Primary care in this country is dying. There are fewer available primary care doctors in this country, as more and more physicians either go directly into specialty care or choose a specialty after completing one of the primary care tracks (internal medicine, pediatrics, family practice, obstetrics and gynecology).
Why is this a problem? Primary care is the foundation of a health care system. Most problems and illnesses most people have can reliably be treated by a primary care doctor. When Iran wanted to develop its health care infrastructure, for example, they asked a family practice doctor to fly over and work with their medical leaders, not a urologist or cardiologist. If you don’t have primary care in your health care system, you end up way overpaying for unnecessary specialist care (think of sending a person to a urologist if they have a urinary tract infection instead of going to their family doctor, for example). You also can’t effectively triage people and get them to the right doctor. If someone is short of breath, do you send them to the cardiologist, the pulmonologist, the allergist, the rheumatologist, or the infectious disease doctor? Lose primary care and you lose the basis for your medical decision tree.
And it’s not just that physicians aren’t going into primary care, it’s that primary care doctors are often actually stopping practicing primary care. They find there are other ways they can make better money (or lose less money). When you see this in a health care system–that DOCTORS are quitting medicine, for whatever reason–think bad, bad health care system future.
Why is this happening? A number of reasons, but I’d argue it depends on who you ask:
Primary care doctors: Money. All about money. Low reimbursement rates for seeing patients (especially compared to specialists who get paid much more handsomely for procedures). Long hours, relatively low pay compared to your colleagues. Lots of paperwork.
Medical students: Time. All about time. 15 minutes to see each and every patient, no matter how sick they are? No matter if they’re crying for the first five minutes of it, or if they walk in having active chest pain and you need to get them over to a hospital via ambulance right away? 15 minutes even if they’re asking you to fill out 5 forms that take 5 minutes each? That makes no sense. (Primary care docs certainly care about time, and medical students certainly care about money, just illustrating two of the big issues for primary care today.)
I’d like to discuss each of these issues–money and time–a bit further, because I believe they have wide-reaching consequences on our health care system (since, as we said above, primary care is the foundation of a health care system):
Money. While you might just say, “Well duh, doctors, like everyone else, want more money,” it’s more significant than this. We pay doctors a certain amount based on what they do. Medicare sets these amounts, and most insurers use Medicare’s rates on which to base their own. The way that we pay physicians today, doing is rewarded much more than thinking is. Extreme example: A doctor who performs a surgery is paid much more than another doctor who sees a child for a rash and knows the rash will soon go away, since it’s just a virus. An even more real-life example: a physician gets to bill for a more complex visit (and better-paying one) by prescribing a medicine over not prescribing one. We wonder, “Gosh, why do patients always want something done–a blood test, a study, a scan–when often watchful waiting is the better choice for the patient?” Culture is certainly to blame, but perhaps so are doctors. Patients have learned that more (tests, studies, scans) is better because more is better: for physicians’ pocketbooks. There’s a clear incentive in the system for doctors to do more, so perhaps patients have just learned that more is better by watching us to begin with. (See this NYT article for a perfect example of “more is better.”) I’m not suggesting doctors do this consciously, or that this is the only reason, just one that should be considered as it has drastic consequences for health care costs and unnecessary procedures that unnecessarily place patients at risk.
Time. Borrowing this point from the Panda Bear: when doctors only get 15 minutes to see a patient, you leave them no choice but to start referring a patient out to specialty care when often the diagnosis just requires a bit more time to sniff out. A few more questions to come to the right one. But instead, in this system where each patient only gets 15 minutes of a doctor’s time per visit, everything is referred to a specialist (who often either gets a bit more time to see each patient, or at least is just dealing with one single issue). Can any adult medicine doctor manage someone’s heart failure leg edema? Sure! But put the heart failure in a 75 year-old with glaucoma, dry skin, lung cancer, diabetes, and peripheral neuropathy, and it’s no wonder someone might say “Hey, go see a cardiologist about your leg swelling, I’ve got enough other problems to fix.” This not only leads to increased health care costs from unnecessary specialist care, but also leads to patient confusion (why am I seeing ANOTHER doctor?). I just read some study (can’t find it) linked somewhere saying that most specialists get referrals from primary care doctors without ANY documentation of why the patient is being refered? Perhaps there’s no time for the primary care doctor to write up the referral?
One can look at concierge medicine, which I discuss here and here, as symptoms of this lack of time and money problem. Thanks to Roy Poses for this analogy.
In typical Over My Med Body style, I think we need to address the root concerns identified above: time and money. Lack of primary care affects us all. (We Are All Connected.) I’m probably going to piss off both primary care doctors and specialists with my suggestions here, so please, leave your two cents on how these ideas might be improved.
Money: The simple answer is “pay primary care doctors more.” I believe this should be at the expense of specialists, meaning that the gap between specialists and primary care doctors’ incomes should shrink. Primary care is an incredibly challenging field–one of the most, in fact–and doctors should be better-compensated for practicing it. Perhaps, as well, they should be rewarded for good long-term outcomes for their patients.
Another idea I’d like to float down the river: pay primary care doctors per hour, like lawyers, instead of per patient, with minimums and maximums based on a patient’s comorbidities. So if a patient takes 15 minutes to see and 5 minutes to document, and another 5 minutes to arrange a CT scan for, the doctor gets paid for all 25 minutes (currently they only get paid for the 15 minute visit). All other doctors would still only receive payment for the 15 minutes to see a patient. I’ve suggested this idea before–pay primary care doctors for their paperwork–and I think it would pay primary care doctors better, allow them to provide better care for their patients, and encourage more medical students, residents, and other already-trained doctors to go into the field.
Time: Simply, doctors need to be given more time to see more complex patients. With the 15 minute system we’re in today, I think it has had the effect of trimming the fat from the patient visit, but it leaves little to no room for patient complexity or severity of illness.
I do think also that there are plenty of primary care options that should be open to nurse practioners and physician assistants. There are lots of circumstances where a patient needs to be seen by a doctor, but if the diagnosis is viral upper respiratory infection, why not allow a physician assistant to reassure a patient? I have trouble seeing the other side of this argument.
Medical students spend an average of $139,000 on medical school in the United States, while other nations provide either fully-funded medical school education or at least greatly subsidized medical education. When you add in the costs of an undergradate degree (which is often either not necessary for other countries’ medical school admission or again tax payer-funded), it’s not uncommon to have medical students starting residency in $200,000 of educational debt.
Often medical students also need to purchase or own a car in order to work at the multiple hospitals which will comprise their clinical training. This adds significantly to their expenses (as they have to take out separate car loans at higher interest rates than most of their student loans, and any car loan debts they have get subtracted from their eligible financial aid amount as well). In order to match in certain specialties, students may have to apply to 50 or more programs and interview at a huge number of them. This enormous amount spent applying, booking flights and hotel rooms and meals on the road can easily add up to $10,000 — and unless the student has $10,000 sitting around, it all goes on the credit card, at an even higher interest rate.
Because interest accrues immediately following graduation, even a low interest loan at 2-3% grows quickly when the principal is $100,000 or $200,000.
While these are just numbers on a piece of paper for most of us medical students (translation: I can’t really fathom owing $200,000, so I just pretend it doesn’t exist), we understand it well deep in our financial souls. Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary. Being in the hole $200,000 is a gigantic Sword of Damacles that scares the crap out of me.
As I’ve said before, i would much rather have medical school be free (read: tax-payer financed) and either have an expectation of:
making less money after residency or
required service time to the taxpayers who financed my education
Maybe we make it a choice. You can choose to pay full price, or pay no price, with either a guarantee that you make less money for life or have required service time for the country.*
I know the government has made unsuccessful attempts to do this in the past by essentially providing too little of a sudsidy for physicians; I would recommend improving this strategy by altering tuition reimbursement based on specialty need and location served. (For example, a primary care physician working in a rural area might be reimbursed 75% of tuition per year, while a pediatrician in the Bronx might be reimbursed 60%.) Perhaps physicians who continue to practice in these settings might receive bonuses for 5 years served, 10 years served, etc. (Yes, I realize the military does offer some programs like this for tuition reimbursement, however it is not available to some physicians *ahem, me* because of don’t ask, don’t tell.)
* Many medical training programs in other countries already require their trainees to essentially complete a medical internship in a rural or underserved area of their country where they are the doctor for the entire community; only then can they go on to specialize in surgery, radiology, obstetrics and gynecology, etc.
Black Monday (today) is the day that medical students find out if they matched at all. (Just got my email, I did!) If not, they have to go through The Scramble. Good luck to everyone, and if you have to Scramble, hang in there. I’ve been told that it’s best to see if you can find a friend to help you send out CVs and stuff while scrambling.
HIPAA is like the Transportation Safety Administration’s requirements that everyone take off their shoes and only carry a quart of liquids and creams: it apparently makes us feel safe and protected, but really just it’s all a big pony show that wastes everyone’s time.
The idea of HIPAA’s privacy rules is this: health information is private. It’s nobody’s beeswax besides yours, your doctor’s, and whoever’s agreed to pay for your care (insure you). And I agree. It is nobody’s beeswax. But it’s so bogusly enforced that it just creates headaches. As I’ve said before, I could easily walk into any hospital in the United States, and dressed appropriately, start reading anyone’s paper chart. Guaranteed. So, see, your health information isn’t private. It should be, but it isn’t.
HIPAA also prevents information from being shared between physician and patient easily electronically. HIPAA lists 18 items that must be protected and cannot be included unless the information is transmitted securely. (Note to bloggers: this is why I change everything about my patients if I write about them: saying anything more specific than what state you’re in is Protected Health Information!) Patients clearly want the ability to electronically talk to their physicians; my generation of physicians would certainly want this as well. Quick question, or side effects of a medication becoming a problem? Want a list of your medications? Want lab results emailed to you? Want your physician to email you an appointment reminder? No no no no no. Instead, we have systems where your doctor sends a message to you in a system with ANOTHER username and ANOTHER password, and it’s a big headache. Even if it’s not that bad of a system, you don’t have access to the messages on your own computer. It’s not like an email that you can just go back and find the message.
What’s even more ridiculous is that HIPAA doesn’t apply to anyone that’s not providing health care or paying for it. So neither Google nor Microsoft even have to comply with any of these requirements, so they’re more free to make information exchange happen than your own physicians!
Make HIPAA opt-outable easily. Maybe this is already common thing, but I haven’t really seen it anywhere. A simple form: I hereby authorize Dr. Walker to unsecurely email me with my: ___ Medications ___ Lab Results ___ Diagnoses to blah@blah.com, and waive my right to HIPAA security protections.
Also: pay doctors for email consults. When in doubt, the physician should always bring the patient in, but it’s a waste of both the physician’s time and the patient’s for questions like, “I feel better, do I need to finish my antibiotics?”
Be consistent with privacy rules. Either require all hospitals to go electronic so that data is behind a password (although one could certainly argue that it’s even easier to steal more data more quickly electronically) or don’t be so damn ridiculous about privacy standards. Also in exchange, provide a more standard protocol to streamline the reporting of stolen identities and stolen health records.
New Zealand is the only other country in the world that allows direct-to-consumer marketing. Those Lipitor ads, the Mucinex boogers — they don’t exist outside of those two countries. The pharmaceutical companies claim that their advertisements provide important educational value to patients. “They can learn about diseases they might have!” the companies say. I say humbug.
Patients learn nothing from these ads, besides seeing ridiculously attractive, healthy-looking, active people pretend to have any number of diseases. I’ve said it before–if the companies were truly interested in educating patients, they would teach them about any number of topics that many patients do not understand. Instead, they hawk products half the time and quickly ramble a list of side effects with the other half left.
Remember–the Pharma corporations are responsible to their shareholders, not the public. Their goal is to make more money, by selling more pills. They do not “educate patients” because it’s good for patients. They “educate patients” because it’s better for their bottom line. Do we not trust physicians to make accurate diagnoses that we need patients to ask for Lipitor?
Ban direct-to-consumer advertising.
If not that, make the field “direct-to-consumer educatisng.” 95% of your advertising time teaches the public how scientific studies work, or what a cardiac stress test does, or why antibiotic resistance is a problem and why doctors don’t like to give out antibiotics liberally, or why CT scans aren’t always a good idea, or why vaccines are safe. There’s an almost limitless number of topics physicians are repeating over and over to patients. In the last 5 seconds, you get to flash your drug logo. “Brought to you by Pfizer.” Put out or get out.
A number of services like HealthGrades and RateMDs allow patients to rate their doctors. Most of these ratings are based on things like “ease of scheduling an office visit,” “Wait time before seeing the physician,” or “Helps patients understand their medical conditions.” Fair enough things to grade a physician on.
A number of services like Medicare’s Hospital Compare or Cal Hospital Compare allow patients to compare hopsitals based on a set of standard “quality indicators” for things that we know will help patients do well — things like making sure patients with heart attacks get the right medicines or treatments in the right amount of time, or giving older patients pneumonia vaccines. Not only are hospitals publicly evaluated on these indicators, but Medicare is considering paying hospitals (and doctors) based on standard indicators. This is know as “P4P” or “Pay for Performance.”
However, physicians and hospitals rightfully argue several things:
You’re only going to get the extreme patients to evaluate you (and often the unhappy ones
The unhappy patients will have the opportunity to publicly say how terrible the doctor is, but because of privacy rules, the doctor or hospital cannot comment or defend him or herself
There is too much emphasis on bedside manner and convenience, and not enough information on outcomes — “How Good A Doctor Am I?”
Even if there is information on outcomes (like in the hospitals’ cases) if this determines payment or discourages future patients because of a bad rating of outcomes, the physician will be much less likely to risk treating a very sick patient, who will likely have a bad outcome no matter what
These systems also ignore where a hospital operates or where a doctor works — hospitals with large populations of poor patients are likely to be sicker than hospitals in affluent areas. Academic hospitals which often care for many incredibly complex, sick patients might be compared to relatively straightforward, simple patients at another hospital down the street.
Medicare has run a trial of this P4P stuff, and it’s been written up in the New England Journal, called Pay For Performance: At the Tipping Point. Let’s look at the some of the outcomes — they took hospitals and either paid the hospitals for their quality improvements, or told the hospitals their outcomes would be publicly available online:
Now, some might say, “Wow, look at that, if you pay people for doing better on quality, they get better!” But the keen observer would point something else out: “Wow, even if you don’t pay people, but make results publicly available, people do better, too!”
Folks (and by folks, I mean doctors and hospitals), this stuff isn’t going away. If you don’t have patients blogging about their encounter with you by name, it’s only because they’re in their 20s or 30s and are young and healthy. (I happen to be friends with one Dr. Gilbert, who is mentioned on the Stanford Hospital Yelp page as the Stanford ER’s McDreamy.) Seriously. The personal evaluations about you are coming, whether you like them or not. It’s in our best interests to argue for the best, most objective and accurate standards. If you’re one of the people that says “Medicine is a business above all,” (I’m not) then fine, but look at every other business in the US: it’s getting revolutionized, criticized, and evaluated online.
We don’t need less transparency, we need more. And the only way we’re going to get there is by having more data.
Physicians and hospitals should certainly be judged by if they’re taking good care of their patients. That means a lot of things: patient rapport, having a “good experience” (whatever that means), but more importantly, outcomes and guidelines. These are, however, guidelines, not rules. It should be simple and straightforward for the hospital or physician to not follow a guideline: if the patient’s heart rate is already 40, they shouldn’t be getting a beta blocker, which slows the heart rate, for example.
For physicians: do patients want the gruff surgeon who’s the best, or the one who’s pretty good but is kind and nurturing (I swear, there’s nurturing surgeons out there)? This data will soon be out there–but in subjective form. “I saw Dr. Green and two weeks later, my cancer had metastasized!” We need accurate, fair standards to examine how we’re doing as doctors, that take into consideration things like patient complexity and compare apples to apples.
For hospitals: I think a lot of the P4P and outcomes and quality indicators stuff for hospitals is worthless for the public. Hospitals get patients for primarily two reasons:
The patient comes to the hospital’s ER and gets admitted.
The patient has a particular doctor who has admission privileges at Hospital X, so the patient gets admitted to Hospital X.
Patients, when sick, do not launch a web browser and see which hospital was more likely to give an ACE inhibitor to its diabetics. They go where their doctor tells them, or barring that, wherever is closest or where they’ve had a good experience before.
P4P and Incentives
One of the big concerns in P4P is “how do we define good, and how do we reward that?” Do we pay the doctors who are really crappy, but then start to improve, while ignoring the docs who are already outstanding? Both? Neither?
For physicians: It’s a little frustrating that we would have to pay physicians to practice appropriate medicine, instead of expecting them to simply keep up with modern medicine, no? Isn’t that what CME requirements are for? I’m not talking about the cutting edge, latest-issue-of-NEJM stuff, but stuff that we’ve known for 10 years? ACE inhibitors, beta blockers, aspirin?
For hospitals: It’s a bit more complex to improve indicators in hospitals, because there’s so many different steps involved to coordinate successes, so hospitals should be rewarded handsomely. But hospitals shouldn’t be competing for patients. They should be competing with other hospitals. Perhaps we create “reward funds” for 3 hospital types: community, academic, and county. And hospitals compete with each other for “most improved,” “best indicators, etc,” — again, apples to apples hospital comparisons. Each 6 months, the top hospital in each category gets a reward that gets split up between the hospital and its staff; this would create innovation between hospitals, everyone trying to do better a job. And let’s say the winning hospitals have to give away their secrets to “best pneumonia vaccine rate” to everyone else.
Perhaps for the next 5 years, we start with carrots. If you’re either improving or continuing to do a good job (as compared to your equals), you get a bonus. 5 years after that, if you’re not improving, or doing significantly worse, in comes the stick, with some sort of punishment.
(Look, I’m well aware that the indicators aren’t always practical or the best, and they certainly need to be improved drastically, taking into account the differences between community and academic medical centers, etc, but the evaluations and ratings are coming. I’d much rather setup a system that is created by health care providers and reasonably fair than be evaluated by the subjective masses whose opinions are often muddied by sad, tragic bad outcomes.)
Just got my scores back, less than 3 weeks after I took it. Success!
(Note for the test makers: scoring and standard deviations aside, the computer should tell you immediately after the test if you did well enough to have essentially ‘automatically’ passed, and that your final score will be sent to you.)
Fear of malpractice lawsuits with supposedly growing payouts in a litigious society have led doctors to leave states with high malpractice premiums, lobby to enact non-economic damage caps (”pain and suffering”), practice “defensive” medicine (order generally unnecessary tests that they would not generally order except to prove disease X is not present, even though it is usually vanishingly rare). These are concerns because malpractice premiums the doctors pay in many states have skyrocketed.
There’s reason to believe, however, that perhaps there aren’t growing payments or settlements in medical malpractice. Let’s take a look at this Public Citizen report on MedMal trends:
So the payouts aren’t bigger, and there aren’t more judgments or settlements.
But doctors are instead seeing plenty of lawsuits filed. Even though 4 of 10 are dismissed because they are groundless, the accusation that a doctor performed malpractice costs more than just time and money; it takes a mental and emotional toll on the physician as well. No one likes to get sued, of course, but physicians have dedicated their lives to helping people, and have gone through enormous personal sacrifice to do so. And even if the suits are being thrown out, the media publicizes big payouts, making recall bias a problem as well. Even with all that said, only 1-in-8 damaged actually sue, if you can believe it.
Perhaps, however, doctors aren’t effectively disciplining their own. The same Public Citizen report shows only 1/3 of doctors with 10 or more malpractice payouts against them were disciplined by their State Medical Boards:
And so, as I said, doctors have lobbied for damage caps. As this GAO report suggests, it may be working to slow premium increases. This report also suggests that in many of the “problem states” with high malpractice costs, doctors are either leaving the state or leaving a particular practice because of costs, leaving both Emergency and Newborn care at risk. A rural Pennsylvania hospital no longer has an Orthopedics department because their orthopedists left. This is clearly not satisfactory for the patients this hospital serves.
Another problem–when and if a case does make it to trial, it simply turns into a he said-she said, in a Battle Royale of expert witnesses. Plaintiffs’ bring in doctors paid to argue their side of things, and defendants’ bring in doctors paid to argue their side of things.
We can take a look at other countries. But first, we’ve got to look at our whole health care system. We as physicians have to look at a system where if we make a mistake, we’re making a mistake in a system that provides for little support for the patient to which it happened. That if you are negligent and cause a grave disability to another person, that person is sure shit out of luck. That until they’re 65, that grave disability is not just a disability, it’s often a major personal and financial liability. Because it’s now become a pre-existing condition. And at that point, without any guarantee that the problem or its complications–that you caused, mind you–will be paid for, of course people are going to sue sue sue! If a 30 year-old patient loses his health insurance tomorrow, he’s got a good 35 years of extra health problems to pay for. (And mind you, the patient knows his or her lawyers are going to take over half the settlement, anyway.)
But patients need to pony up, too. People should be compensated for malpractice, but not bad outcomes. Americans must realize that death is part of life. That, for the most part, doctors are slowing death and prolonging life. If we weren’t here, their loved ones would die without our life-prolonging treatments that we’ve spent so long to learn. Surely this low bar should not be the standard we hold ourselves to as physicians, but there needs to be a way to quickly nip classic “adverse outcomes” lawsuits in the bud. There are certainly cases where it’s murky, but there are plenty of cases where a bad outcome or known risk is brought to court. I’m sorry, patients–I know you’ve come to expect perfection from your physicians. But we are unfortunately all too human to live up to that standard. Bad things happen. If 5% of people die from surgery X, you could be one of them. This is why sometimes doing less is more.
And this is why I support a no-fault medical malpractice system. (This Slate article is a good start.) “No fault” is how malpractice works in a bunch of countries–and even how specific types of malpractice problems (bad birth outcomes) are handled in a few states. No-fault systems are great for problems like we face in medicine–that we try to avoid them as often as possible, but they admitedly happen. (They also take most of the money that currently goes to lawyers and gives it to patients that truly deserve it.) Quoting the Slate article:
In Sweden, when a patient suffers avoidable injury, whether through gross negligence, such as a botched surgery, or through a more understandable but avoidable mistake, such as a misdiagnosis or medication error, the patient—usually with help from the doctor’s office—fills out a form requesting compensation. That request, along with relevant doctor and hospital staff reports, gets reviewed by an adjuster who decides whether the injury might have been avoided had treatment differed. If the claim passes that hurdle, a panel of legal and medical experts considers it. If the panel decides the injury rose from avoidable error, the patient is compensated. The award varies according to the nature of injury, the degree and duration of the patient’s disability, the expenses incurred, and other factors; it may also include compensation for pain and suffering. The entire process usually takes less than six months. Patients who feel unfairly denied or undercompensated can appeal, but they cannot sue. The system is funded by premiums charged to regional organizations of medical facilities and physicians. These premiums are substantially lower and more stable than malpractice premiums in a tort system.
Such a system would generate more claims than does our present malpractice system—indeed, compensating more of the injured is part of the point. The system would save money, however, by eliminating punitive damages and legal costs. The legal and administrative costs of our present system (lawyers’ fees, court costs, paid experts) account for 60 percent of the estimated $24 billion the malpractice system consumes each year. A no-fault system would cut that to 20 percent or 30 percent, roughly doubling the money available for the injured.
Another option, which seems to be more bureaucratic (but have more precedent in the US) would be health courts, where malpractice cases would go to a specific branch of the Judicial system and cases would be heard by groups of medical experts, who could more objectively decide what is malpractice and what is bad outcome. (There are separate tax courts and patent courts for these specific types of complaints.)
EMTALA, the law that requires ERs to evaluate and stabilize everyone who shows up, is a good law. (There went half my readers right there.) If you’re still with me:
I would argue (as would the writers of EMTALA) that we are so advanced a nation that patients should not be dying on the streets because of their inability to pay for emergency medical care. The problem with EMTALA is that it provides too much potential for abuse. This is the fundamental art of social policy — how do I put together a rule to maximize its use for its intended purposes, yet minimize the opportunities for abuse and loss of personal freedoms for whom the rule applies? (Note: unfortunately many policy makers do not seem to follow or care about this. They trust lobbyists to do this.)
If you were to look online or eavesdrop in a doctor’s lounge, likely “abuse of medical resources by certain patients” would be near the top a frequency-of-complaining list. However if you were to look at how much, in reality, these patients actually cost the system, it would be a tiny percentage of that compared to the truly sick. So it’s more a matter of wasting a doctor’s time and energy — these patients are truly draining: they frustrate physicians and nurses greatly.
The other problem is that EMTALA is an unfunded mandate. This means that hospitals are required to follow the rules of EMTALA no matter what the cost may be to the individual hospital.
Often it depends on why the patient is there — which often is near impossible to discern in the first place. Others are straightforward: hypochrondriacs? Easy. Refer to psych. For drug seekers (note: boy would these patients be easier to spot a mile away if we had some sort of national medical record), make sure they’re only drug-seeking, and get them out.
Others seemingly have nothing better to do. While I’d argue that perhaps job resources, education, and opportunities in the long term and for future generations might be a better solution, I’ll stick to health care for now.
If we want these patients to either stop seeking care altogether (not good to alienate people from the health care system, I’d argue, see my other posts in this series) or start seeking more appropriate care, then we’ve got to use our carrots (rewards) and our sticks (punishments) to lead the donkey.
Maybe we just need to offer better options. For some patients who simply don’t know any better, and for whom a stern lecture by a doctor isn’t going to educate them, they just need another place to go besides the Emergency Department. For these patients, we should be supporting our community health centers for after-hours clinics. They’re usually just as well-placed and located as hospitals, they provide more appropriate care settings at much lower costs, and they would also get a patient tied in for follow-up at the clinic, maybe even start seeing a physician on a regular basis. These after-hours clinics should be funded, like EMTALA (see below).
For other patients, they need a stick, as the niceities of education and better options simply don’t appeal to their finer sensibilities. Two possibilities here: perhaps it’s three strikes out at the olllld ballll game. Once a patient has been seen for non-urgent care (which would obviously need to be defined) three times, they no longer qualify for EMTALA at the hospital. If they return, they get a vital signs screening by a triage nurse, and barring no abnormal vitals or other gross, obvious issues, they are turned away. Another possibility would be charging a patient for non-urgent issues. We say, “Sure, we’re happy to evaluate you,” but if you are not even urgent (remember, you’re at an Emergency Department), you’ll be charged. (Note: this latter option I don’t support if there are no other options for these patients, which is why I think we should offer after-hours clinics.)
Finally, funding. A colleague of mine likes to say that a heavenly program can be hell if not funded appropriately, and maybe this would lead to a chain reaction of EMTALA fixes. If the federal government (read: taxpayers) had to start paying for EMTALA care (note: we already are, in the prices of higher costs to subsidize unreimbursed care), we would immediately see the true costs, and take actions to fix it. Currently, it’s all just buried in inflated prices and percentages of costs and losses in hospital account ledgers. Either way, EMTALA care needs to be funded. Some states are trying to partially fund this effort by passing certain taxes, but a national source makes more sense, since it’s a national law.
(Note: “Repeal EMTALA” enthusiasts are either kidding themselves, heartless, or living on Mars. If you believe that Emergency Departments in the United States should check for insurance in the ambulance bay or require a funds verification before they see a septic patient or one after a bad car accident, like they do in India, you might as well stop reading. We’re not going to see eye-to-eye anyway. For-profit hospitals would have no problem doing this, and it’s unethical and immoral.)
A young, healthy person very close to me called me last night with “a fever and pain on [his] right side.” I had my diagnoses 1 thru 10 (appy!) by that first sentence. He had possibly the most classic story for appendicitis I’ve heard yet in my career. Luckily he was already at the Emergency Department, waiting to be seen by the doctor and was stable and fine, except for all the pain that had migrated over the past hour to McBurney’s point. (I called him this morning, appendix now gone, and he’s already passing gas and doing great.)
But the fact that I was very close to him made the phone call a little uncomfortable to me. Sure, I have plenty of friends that call for medical advice, and almost always it’s “Boy, sounds like a virus, but I’d follow-up with your doctor,” but this time it was different. I knew that by giving him the diagnosis of appendicitis, I was putting him under the knife, and it gave me pause. It made me question myself, in a good way. “Is this really appendicitis? Is there anything else it could be that I’m missing?” This is the good side of subjective medicine–that we should try to perhaps apply this level of questioning and hypothesis to all our patients. Thinking to ourselves, “Gosh, I’d really hate to put my friend under the knife, I really want to be sure I’m right on this one,” and apply this standard to all our patients.
So I did my doubting, asked a few more questions, and felt even more convinced. He then asked me, “Well, should I demand a CT scan?” and again I thought to myself, “Boy, I’d really hate to be wrong on this and risk an unnecessary surgery, maybe he should get a CT scan anyway,” and subsequently realized the flip side of subjective medicine: practicing incorrectly because I care about a person and don’t want to put him at risk. So I thought some more, and turned my friend into any other patient, and realized I wasn’t applying the same standard — and it’s often cases like these, with celebrities, VIPs, relatives — where we apply a different standard, and they often get much worse care than if they were just a regular Joe.
The key is that fine line: treating each patient as if you know them and care about their well-being with the same regard you have for your loved ones, but not doubting yourself so much that your judgment is blurred in the process.
(Yes, duh, I obviously ceded everything to the ER doc and surgeon who evaluated him, saying I would trust their opinion over mine, but I certainly considered the situation as if my friend was in front of me. The story was so classic, the surgeon took him up around midnight, sans CT scan, and took out the big white worm. Also good to recognize that a CT is note harmless, as it exposes patients to radiation.)
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?
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?
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.
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.
“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.
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.
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.
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.
I’m watching Baghdad Hospital: Inside the Red Zone, an HBO documentary about one of the major trauma centers in Baghdad, where they’ve gone from mainly doing appendectomies to daily shrapnel extractions and penetrating trauma explorations. Their blood bank so frequently runs low that they take a patient’s ID card, and someone must go to the blood bank in the patient’s name and donate blood to get the ID back.
Perhaps the Red Cross or hospital blood banks should use a similar tactic: there’s always a good 100 people (at least) waiting in the surgery waiting room or the ICU waiting area who are visitors or family of a patient. Why not ask them to donate blood? They’re not doing anything else, they get free cookies, and they’ll be repaying the donation someone else made to ensure that blood is available for the next person who needs it. How about it, Mr. Levy? You always seem open to trying new things.
(The film is incredibly depressing, and the images gruesome: children getting bilateral chest tubes and DPLs because they don’t have film for xrays; doctors taken hostage and killed. I can’t imagine the stress of the staff and the patients there.)
When we last spoke, we had just finished our application and were patiently waiting for…
Secondaries
Secondaries come in all shapes and sizes. Some schools have big long lengthy sections, others have a few quick questions. Be sure to save anything you submit (which is usually online now), as other schools are likely going to ask you similar questions and you can make it work, a la Tim Gunn.
The key in secondaries is to give schools something new about you, or something that you just touched on but would like to develop further (often the former is easier to do based on the question). Like I said before, the faster your turnaround on the secondaries, the faster you can hear back about an interview usually. I think I gave myself maybe a week per secondary–but again, did a ton of editing in that week. Here are some examples (looking back, I’ve found typos and grammar errors that I must’ve included–ack!):
Note, I also went back and updated my personal statement to include a couple drafts I went through with that one, too. Thought that might be helpful to see how they’ve changed.
Interviewing
Congrats! You’ve got an interview! You’re most of the way there. My feeling on interviews is this: you’re certainly a potential admit at this point. Now you just need to prove to them that your awesomeness on paper is equal to your awesomeness in person. Smile, be social, be friendly, be polite, be humble, and be yourself. (Some of that may be conflicting, of course.) Be someone you would want to be classmates with–because that’s how your student interviewer will be evaluating you partially.
But also be prepared. Here’s an insanely long list of interview questions I compiled. Certainly no need to prepare yourself to that degree, but give the list to a friend, and have him or her ask you questions for half an hour. It’ll do wonders for making your first interview easier–it’s one thing to review the questions on your own and think you know the answers, but another entirely to be able to say them and explain them aloud.
Being prepared also means coming in with a list of your own questions. Show you’ve done your research. They want to know why you want to go to their school, why you’d be a good fit for their program. They already know for the most part that you want to go to A medical school. Right before the interview day, I went to the school’s website, jotted down facts about the school, things unique to the school, other things I might be interested in (the school’s free clinic opportunities, opportunity to get an MPH, etc) and brought it with me on interview day. I also made a list of questions based on those facts, and brought a copy of my personal statement and the secondaries to the school, so they’d be fresh in my mind if anyone asked about them.
Interviews are the time to toot your own horn. Now is not the time to be modest. But be humble. There’s certainly a fine line between bragging and arguing for yourself, but your goal at the end of the interview day is to make them think, “Wow, we would be silly not to accept this person!” I go into interviews with two things in mind:
1) I have an agenda, and that is to let the interviewer know certain key things about me that are impressive, unique, or important about who I am and what I will bring (and I will make sure that I get those things across, somehow incorporating them into an answer)
2) I am there to argue my case and convince the interviewer that he or she should be fighting for me–that it would be their loss–and a huge one–not to accept me.
Second Looks
Congrats! You got an acceptance or ten! Now it’s time to decide where to go. It’s the same thing you’ll hear anywhere–go with your gut. Go with the feeling you get on the interview day. Do the people seem genuinely happy? Could you see yourself walking around there? Learning there? Will there be things to do there in your free time? You can make a “pros” and “cons” list, but in the end, I think it boils down to the feel and the location.
But if you’re not sure, or if you can’t remember everything, go do a second look. Most schools offer them. I actually didn’t have a great awesome interview day at Stanford (where I currently am). I really wanted to like it, but I didn’t as much as other schools. I ran into a couple Stanford students at an AMSA convention, who basically said I’d be stupid not to go there if I got in. So I did a second look at Stanford, and I was sold. Not because of the great things the administrators said about the place, but because of the people I met as my future classmates. Second looks may try to wow you with financial aid numbers, or class skits, or parties with free alcohol, but go to them to see who your new classmates might be. That should be what sells you. They’ll be some of the most important people in your life for the next 4 years.
Final Advice
All things being equal, go to a pass/fail school. I think it eliminates a lot of competition from the get-go, and weeds out and disables any would-be gunners or gunner-like behavior.
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.
(And the medical school of your choice!) I make no promises, but it worked for me, so I hereby provide my path and advice to those pre-meds out there:
Undergrad
Undergrad is the time for you to explore your interests. Okay–to have fun, and explore your interests. Figure out what you love. And then do that. To some it might be graphic design; for others it might be math. Or volunteering. Or lab research. Or foreign languages. Or acting. Do. What. You. Love.
You’ll notice that I didn’t say “majoring in math,” or “majoring in Biology.” If what you love happens to be a major–great! If it doesn’t–don’t stop doing it! Figure out what it is that keeps you up at night, so excited with thoughts racing that you can’t fall asleep. Figure out what lights up that fire in your eyes: when you’re talking with friends, when is it that you get that thrill in your chest? Talking about religion? Sports? Cooking?
Undergrad should give you a depth of knowledge in one area (your major) and pique your interest in others. Medical schools are looking for the well-rounded applicant who has shown significant commitment and passion to a particular love of his or hers. Medical school is similar–you have to love learning medicine so much that you’re willing to put up with a bunch of crap for 4 years and delay gratification for many more. If you can show someone that you’re passionate and committed to something–you’re already ahead of the curve.
This all being said, of course, you also have to let medical schools know that you know you’ll like medicine. There’s nothing worse than a medical school spending their precious time and resources to figure out who they’d like to admit, and then have one of their students end up hating the practice of medicine. So find some clinical setting in which you can shadow, volunteer, or something where you get to see doctors working. I did a summer internship with a local hospital where half the time I did data entry and half the time I got to shadow doctors in different parts of the hospital.
I think one of the smartest things I did–and best for my application–was drop medicine completely from my potential career list for a time. Sophomore year sucked academically: organic chemistry and physics together for three straight quarters–and it really made me question everything. “Do I really want medicine that bad? Isn’t there something else I could do with my talents?” So I took lots of different courses, to see if I could find anything I liked more. But I always came back to medicine. I figured I could do graphic design as a hobby, program as a hobby, take foreign languages as a hobby–but never medicine as a hobby. How did this strengthen my application? I could honestly say to interviewers that I’d really challenged the idea of becoming a doctor, and that I still wanted it badly. I knew I would love medicine. (And if you find that you don’t love medicine, that’s okay. But you should really find something else to do. Better to find this out now than after you’ve taken out $50,000 a year in loans!)
Try new things in undergrad. While in some ways you want to fit in with other applicants (good scores, good grades, good letters), you want to stand out. What did every single interviewer ask me about during my interviews? Not my research, not the student groups I helped lead–it was the current events radio show I hosted with my two friends. Stand. Out. (More on this later.)
And, not totally related, but it gave me a great deal of perspective and truly changed my life: if your school offers it, do an Alternative Spring Break trip! And if your school doesn’t offer it, look into starting an Alternative Spring Break group at your school!
The MCAT
Sorry to say it, but it’s important. Because schools have thousands of applications to go through, they’ve got to use some method to reject people right off the bat, and it’s usually some funky formula including one’s MCAT score. Doing very well on the MCAT will certainly help your chances at getting into your top school, but just doing well is important, too. In my experience, there’s some vague hazy cut-off below which you won’t get a secondary application or interview at school X, but that cut-off is fairly low. (I wish I could talk numbers, but I don’t know any!) If you do well but not stellar, and this is just how you test, no matter what you do–an otherwise strong application may pull you through. (And a word to you brainiacs out there–if you’re scoring 40s on your MCATs but have no personality or can’t interview or talk to someone for 20 minutes, you in some ways have a tougher time. I’d much rather have a classmate with good MCAT scores who I can interact with that someone with a 42 who can’t express him or herself.)
What to use to study? I took the Kaplan course, which was hella expensive. It certainly kept me on track with my studying, ’cause I didn’t want to get to class and not have reviewed anything yet, but if I could do it over again I would have just tried to buy the study books on eBay or something. I also did craaaazy amounts of practice tests, which my school had on reserve in its library. (Go, U Northwestern!)
The Application #1: Have your application ready by the day you’re allowed to start submitting. Have your letters in, your transcript sent, your personal statement ready. Medical schools work on a rolling admissions basis, so the earlier you submit, the faster you get the secondaries. The faster you submit the secondaries, the faster they can review your application and offer you an interview. And once your interview is over, if you’ve done it early, your application will be discussed in more rounds of deciding whether to offer you a spot. (Compare that to the person who submits in October, and your application gets two months’ more of time in committee.) For some of the faster schools (UChicago!), I had interviewed and been accepted by early September–before I’d even received secondaries from some slower schools. (And that first acceptance is the best, ’cause you know you get to be a doctor somewhere.)
The obvious: while you’re doing all this exploring and “doing what you love” stuff that I rambled on about, you’ve also got to be studying. Not just to get good MCATs, but also get good grades. This is likely something to make you learn how to find balance in your life–between your academic life and your social one (I still struggle at this, as most of us probably do).
Extracurriculars: It’s great to see someone with a ton of interests, but try to pare it down as you become an upperclassmen. Again–find what you love, and make a significant contribution to it. Take on a leadership role. Advance the field, or activity, or whatever.
Letters of Recommendation: I can’t remember the recommendations on how many science and non-science letters to get anymore, but follow them. If you fall in love with a class and a professor, and think, “Wow, I really love this topic, the professor seems great, I would really like a letter from this person,” make sure the professor gets a chance to know you. Does that mean kissing up and going to office hours for no reason? No. It means participating in class, making your voice heard, letting the professor know you’re thinking and processing the information in his or her class. When I knew I wanted to ask my Physiology professor for a letter, I made sure to start asking questions that I had during class, or going up after class to ask.
Next, ask and ye shall receive. Don’t just ask someone “for a letter of recommendation.” Ask the person, “Would you feel comfortable writing me a strong letter of recommendation?” or “Do you feel comfortable writing me an excellent letter for my medical school application?” People will tell you if they don’t know you well enough, or if they just don’t think they’d honestly be able to write you a strong one!
Finally, meet with the person if they don’t already know you extensively. A 20 minute private face-to-face, you with resume in hand, where they can get to know you and ask you some questions will make their letter much more personal, warm, and true.
The Personal Statement: The most important thing on your application. I read applications as a 2nd year at Stanford, and it was usually the Personal Statement that either impressed me or bored me the most, and weighed the heaviest on my voting. My tips:
Get the reader’s attention. In the first sentence. I do this with a lot of my non-blogging writing. Picture this scenario when you’re writing: the person reading your application is tired (true). This is either the first or last thing I’m going to do during the day. It’s late at night, I’ve just spent a long night studying, and now I’ve got 5 applications to get through. I’m in bed, with my laptop, my eyes are starting to drift as my parasympathetic (rest’n'digest) system is slowing me down. I’ve only got a reading light on, I’m so sleepy…. but I must… keep… reading… BOOM.
Hit me with your best shot by sentence one. Make me want to know more. Wake! Me! Up!
Have a theme; relate your life and your experiences back to medicine.
Next tip: Every word must matter. I went through a ton of revisions (see left) until I got it tightened up. I asked friends who are good writers to read it and give me their honest feedback until I got to something I liked.
Here’s my own personal statement for your viewing pleasure. (Update: I’ve included my final draft, as well as two other drafts if anyone cares to see how the thing changed over successive drafts.)
Next time: Secondaries (again with a few samples of my own), the interview, and acceptance! Good luck to all!
So I’ve discussed being out as a blogger on residency apps, so now it’s time for the harder (but more important and wide-reaching) subject: Being Out, Coming Out–whatever you want to call it–as an LGBT person on residency applications.
I don’t really talk much about my personal life on this blog–I think mainly because where I go hiking on the weekends or who I go grab a drink with wouldn’t really interest anyone, and doesn’t have much to do with the theme of this blog: becoming a doctor, thoughts on health policy–that kind of thing. But this doesn’t get talked about a whole lot–hell, gay anything doesn’t get talked about much anywhere in the world of medicine–but it should, so here we go (sorry, it requires some history):
As a gay man man who happens to be gay, it hasn’t always been an easy road in medical school. Overall, I’ve been incredibly fortunate to be at a medical school in the San Francisco Bay Area that is overwhelmingly gay-friendly–with Out gay, lesbian, and even transgendered faculty even. My classmates have truly been amazing in their embracing of me (it probably helps that I’m kind of awesome, too). I wasn’t sure what to expect, but I’m incredibly excited for my generation of physicians, if they’re anything like my classmates.
I decided to just be “the gay classmate” from Day One–none of that “coming out” stuff that can be awkward and uncomfortable. I’ve always preferred to just drop the hint than have to come right out and say “Oh, I’m gay.” I’d much prefer to mention my ex, and then use the pronoun he, or one of many other such schemes I have previously concocted. Easier for me that way, and I find it to be less direct and confrontational. I don’t have something to prove, or some vendetta or anything. I yam what I yam.
The residents I worked with were, for the most part, great too. I wasn’t out to most of them–rarely did it come up or have any import–but when it did everyone was very accepting (as they should be). I’m not what people might call “gay-acting” (translation: what you see in the media as gay stereotypes), but I’m always surprised when someone assumes I’m straight (’cause it’s so darn obvious to me that I’m not), which a few residents did. The one incident that sticks out in my head was a surgery resident–otherwise good guy–who called his intern who felt bad for a patient “so fucking gay,” as a put-down. Lost a lot of respect for the guy right then and there. My esprit d’escalier reminds me that I should have spoken up or said something, but I didn’t.
So for the most part, I’ve always felt like I’ve just been able to be me during medical school, and I decided that’s how I was going to continue to be on my residency application. Being gay is certainly part of me, but it’s not the only part of me. I decided to include it in my application. I was the LGBT-Meds president for a year (2004-2005, baby!), so there it went on my app. (It ended up being pretty buried in my application, as achievements and extra-curriculars are listed reverse
chronologically, and I didn’t really have anything else to say about it, so that was the only place it was on my application.)
My perspective was and continues to be this: I am going to be a great doctor. I’m smart, I work hard, I’m positive and I play well with others. If a residency program wants to drop me in their rank list because the fact that I’m gay somehow overrides all those other things? Their loss.
So applied to 13 places. And got 13 interviews.
The fact that I’m gay barely came up on the interview trail–in fact, less than the blogging did. I’m not sure if this was because people were uncomfortable (didn’t seem like it), they didn’t want to get in trouble for a rules violation (possible), or just didn’t see it on my application (also possible). A gay residency director (I think the only out one in Emergency Medicine) did talk with me about it briefly, saying it was strong of me to put it on my application. I think one resident did mention that Chicago is gay-friendly, and he has a few gay friends, which was a really nice way to both a) let me know he read my application and b) let me know that he and the program were gay-friendly.
So how did things turn out? 8/10 programs where I interviewed contacted me saying I was a great candidate–whatever that’s worth–so I’d say being gay certainly didn’t hurt my application (not trying to brag to make people feel bad, just trying to give some data to future LGBT applicants). If anything, it certainly makes me stand out as a unique candidate as well.
It’s hard to say how things would have gone had I applied in another specialty or at other programs. There’s certainly a selection bias at work here: I only really applied to major urban areas (LA, SF, Chicago, New York, Boston) for my training, which are by default more open and gay-friendly. If I was applying to more rural schools, I’ll admit I don’t know if I would have put it on my application. It also helped that I knew I had a strong application, with good board scores, evaluations, research, teaching experience, extra-curriculars, and letters of recommendation–this made it easier for me to apply to these major urban areas and still feel like I’d have a chance of matching at one of them.
I don’t know what I’d say about other specialties, really. Emergency Medicine types in my experience are usually pretty laid back, fun people who’ve seen it all, and really care more about doing a good job and being efficient than much else–so I really didn’t anticipate it being much of an issue. I have no idea about other specialties, besides that fact that I know LGBT people in many specialties–including the surgical ones–but again, they’re all in the Bay Area, too. It seemed to me like the Psychiatrists, Internists, and Pediatricians were the most gay-friendly on my rotations overall, but I’ve talked with general surgeons who have told me about their gay general surgeon friends, too. There’s a pretty outdated survey on the AMSA website about LGBT-friendliness for specialties and residency programs, if that helps anyone… I’d love to hear other people’s opinions.
I don’t think anyone has talked about this, because I don’t think it’s really ever happened before. But when I applied for residency this year, I debated whether I should put my website or my blogging on my application. I worried that people reading my application would be scared about blogging, or wouldn’t know what it was, or had only heard bad things about it. I worried they would just think it’s a great way to violate someone’s privacy, or a great way to get in trouble with a lawsuit. (One of the reasons I haven’t decided if I’m going to blog residency is because I’d like to discuss it with my future program director first.)
But I decided to go for it and include it in my application for a couple reasons:
I’m proud of it.
It’s something in my life I do weekly at the least.
It’s unique and sets me apart.
Being able to reflect and process things makes me a better physician.
I knew I was going to include my other projects, MDCalc and MedsList in my application, and those are casually linked to my blog, so they’d find them anyway.
And speaking of finding them anyway, if you Google my name, I’m either the first or second hit (always fighting it out with this guy)
At the brilliant suggestion of a mentor of mine (Hi Michelle!), I came up with a short list of some of my favorite posts (PDF) showing what my blogging was all about, printed it out, and brought copies to give interviewers if the blog came up.
And the blog did come up. I’d say at about one-third of the programs, I talked about it with at least one interviewer. The response was overwhelmingly positive. No one mentioned any concerns about HIPAA/privacy stuff, and as far as I could tell, everyone felt like it was a Good Thing ™. People liked the fact that I was reflecting, processing, and thinking about what it means to become a physician, and also liked the informal network medbloggers have created as a community. I think having the print-out of some of my posts was really, really helpful to reference. Very few interviewers (only ones that I knew before applying) had actually visited the site (that I know about). In hindsight it was probably silly to think that an interviewer that has to get through thousands of applications would dial-up my URL on his or her PC, but you never know.
My advice to future applicants: if you’re writing a blog, first, don’t be anonymous. While there are certainly bloggers who are anonymous to protect their identities and lawsuits and blah blah blah, there are way too many bloggers (medbloggers, especially, in my opinion) that hide behind a pseudonym so they can bitch and rant and complain about these horrible, horrible people (read: patients) who waste the blogger’s time. They would never say these same things to their mothers, friends, or in polite company. Being public and open about your blogging forces you to think about what you’re going to write–”do I really want my name to be associated with this?” I certainly try to follow something I learned in church camp as “Thumper’s Mother’s Rule”: If you don’t have anything nice to say, don’t say anything at all (my addendum is this: or at least be constructive).
If you’re proud of what you’re writing, and what your blog has done for you, put it on your application (including the URL)! It won’t even come up most of the time, but it certainly gave interviewers something to ask about, and definitely made me stand out from other applicants (which, as you know, is the key to getting into med school). It sure beats the same old, “So, tell me why you chose Emergency Medicine” question that I hope to never answer again in my life.
Finally, bring a list of some of your posts. It will help interviewers immediately see the things you write about, and will also help them to see you’re passionate about medicine, care about it greatly, and you’re also passionate and interested in the field in which you’re applying.
(That all being said, if your blog is just a bitch session about how terrible med school is, no one wants to hear that. Leave it out.)
I know I certainly can’t be the only one who is done with his Rank-Order List but just logged onto the NRMP website to make sure it’s certified one last time:
(You login to the website, enter your rankings, and then have to enter your password again to “Certify” the list and make it official. If you don’t have a “certified” list by 9pm Eastern tonight, you don’t participate in the Match this year and don’t get a job!)
In medical school, we take “Step 1″ of our Nationalized, Standardized Board Exams before we start seeing patients in the hospital. Then, in order to graduate and start residency, we have to pass two parts of “Step 2.” “Step 2 Clinical Knowledge (CK)” is a 9-hour, computerized exam consisting of 8 1-hour blocks of 46 multiple choice questions. “Step 2 Clinical Skills (CS)” is a 9-hour, practical exam where you see 12 standardized patients, perform a history and physical, and write a note about the patient with a basic idea of your workup and diagnosis for the patient.
Now, there is some talk also about combining both Steps 1 and 2 into one exam taken during the final year of medical school. I’ll address this issue and then address the Boards more generally.
I would strongly oppose combining the two exams into one, for one main reason: Step 1 is what a number of residency directors use to help determine who to interview for their residency programs, especially at medical schools which lack grades (Stanford, where I am, lacks grades). I think this would quickly lead to all medical schools adopting grades, which I think is especially detrimental to learning, especially in the pre-clinical years. Medicine is now, for the most part, a team sport. I think it’s incredibly important for medical students to learn how to effectively communicate with their colleagues (classmates) and work together. And I think you don’t learn that when you have grades.
Grades encourage competition, gunner-ness, and cut-throat behavior, when what you really want is the promotion of cooperation. Especially in the pre-clinical years, when all you do is study and take exams. If you eliminate the major way that gradeless medical students are deciphered by residency directors, you give medical school deans all the more reason to put grades back in the curriculum. (I believe grades in the clinical years are a different story, so I won’t comment on them. I do believe, however, if you encourage cooperation in the first two years, you’re more likely to have collegial relations with your classmates when working in the hospital.)
On Step 1
Step 1 seems like a necessary evil in retrospect. It sucks, studying for it sucks, and it’s painful and nerve-wracking. But it forces you to put all your knowledge from the first two years in preparation for seeing patients. It forces you to review everything you’ve seen and forgotten, and integrate and optimize that little brain of yours. This ends up being a really good thing for seeing patients. My main critique is the subject material, but I’ll cover that elsewhere in my discussions of the curriculum.
On Step 2 CS
An utter waste. An utter. Total. Waste.
As I’ve said before, the administrators of this test take in $17 million each year for the exam so that a few hundred students each year don’t pass, take it again, and then most of them pass.
First, there’s only five cities in which one may take the exam. So if you’re not in Atlanta, Chicago, Philadelphia, Los Angeles, or Houston, you get to pay for airfare and hotel for the night, out of pocket (the exam is 7-8 hours long, so it’d be hard to fly in and out without staying the night). Next, most medical schools already require their students to participate and pass an exactly similar exam with standardized patients.
These Step 2 standardized patients are much worse–they have absolutely no personality, only poorly acting their roles. You’re being graded–at least partially–by your ability to show compassion. So you’re constantly pretending to have sympathy, while they’re pretending to actually require your sympathy. You ask, “Do you have any fevers or chills,” and they robotically reply, “No, Doctor, I do not have any fevers or chills.”
You’re also judged on seemingly worthless physical exam criteria like putting your stethoscope in the right place. So to the creators of Step 2 CS, it’s more important to be able to pretend to examine a patient than to actually identify a murmur or hear crackles on exam.
Next is the silliness of the exam itself: once you leave the exam room, you’re not allowed to re-enter. What? Are you kidding? How many times do I think to myself, “Gosh, I guess I need to do a neuro exam too,” and dart back in the room to do one?
Finally is the stupidity of the patient note. You have to come up with a differential diagnosis for the problem in question (this is good), but there’s no description of how wide a net to cast. The “workup” portion of the exam is incredible. It’s apparently more important to be able to come up with a list of lab tests and studies to order than to know what to do if someone is dehydrated and can’t tolerate oral liquids, or to give someone with symptoms of a heart attack oxygen and an aspirin.
Add in the fact that you receive absolutely no feedback on how you did from the standardized patients (it’s fine to just grade us, improvement is beyond the Step 2 CS) just adds icing to the cake.
Look, either make it a real, practical test, and really test to see if people know what to do with patients, or admit that it’s mostly to see if people can speak English. If it’s the former, put some life into it. If it’s the latter, make the International Medical Grads take it and please quit wasting my time and money.
If medical schools are doing their own standardized patient exams, why not allow the schools to proctor their own exams? They can certainly determine English language ability and if the students are competent to become doctors–after all, they are the ones granting the person the MD, aren’t they?
On Step 2 CK
This actually wouldn’t be all that bad of an exam from the “review everything you’ve learned” point of view if it weren’t such a crappy exam. (No, seriously.)
First, most of us fourth year students take this exam and then spend much of the rest of fourth year vacationing in anticipation of the hell that is internship. So often most of what we learn from studying for the exam is lost to nicer memories like the sights of Europe or the beaches of Thailand.
Second, the exam contains way too much pre-clinical, worthless detail. You know, honestly, I truly do not care what the pathology might reveal on a tissue biopsy of someone with myxedema. It is not important to me nor my patients. It is, however, possibly important to know how to diagnose myxedema or treat it. (Thankfully, the exam is much more clinically-oriented than Step 1, but no way near enough.)
Third, the answer choices are often ridiculous. For a suspected pneumothorax, my options are not “ultrasound,” or “chest CT,” or “X-ray.” They’re things like a) thoracotomy b) needle thoracostomy c) MRI head d) diagnostic peritoneal lavage. I kid you not. If you want me to suspend disbelief for a minute and pretend I’m trying to manage these patients, then give me some realistic answers, people.
The Bottom Line
Keep Step 1.
Drop Step 2 CS.
Fix Step 2 CK.
You don’t have an MD after your name. There’s plenty of times when I’ve wished I was just a resident already. (I know, I know, I’ll be eating my words in July.) It’s frustrating when I can’t just sign off on something harmless and have to get approval for everything.
It’s also really, really frustrating when patients ask to “see a doctor, not a student.” This happened maybe twice during my whole medical career, so I certainly lucked out. You want to say to the patients, “Wow, maybe you shouldn’t come to an academic teaching hospital then,” but you bite your tongue. It’s hard not to take it personally. Sure, I don’t have as much experience as a resident or attending, and it’s certainly a learning experience to deal with that comment in stride, but you’re going to be seen much faster if a medical student is assigned to see you than if you get put back in the pile, and all the other residents and attendings are seeing patients already. But hey, go ahead and wait.
Loans, loans, loans. I haven’t added it all up (mostly because I’m frightened to), but I’ll probably end up with around $110,000 of student loans by the end of medical school. The average debt is somewhere between $100-$135k, so I’m somewhere in the average. (Add in undergrad loans and you’re easily looking at $200,000 for many people.) It can really suck going through your 20s accruing up debt, living the student life while your friends are working, making money, buying homes, cars, and other nice things, building up their investment portfolios and retirement IRAs. Again, wouldn’t trade medicine for anything, but there’s certainly been times where I’m jealous and wish I was doing something different.
Pre-clinical curriculum. In medical school, you spend your first two years in the classroom, memorizing literally books of information in preparation for actually seeing patients. These years, from an academic standpoint, suck. Sure, you have time to get to know your classmates, party, etc., (think college but more hardcore), but the rote memorizing sucks. You have no idea what of this information is going to be useful, and what of it is going to be an absolute waist. You don’t have any clue about what real disease is like, and you’re just memorizing random little facts like: Rose gardner = sporothix shenki and reheated rice = B. cereus. (I’m not kidding.) You’re memorizing a ton of facts about drugs that are not used anymore, and that’s just pharmacology. Which brings us to…
Med student syndrome sucks. If you’re at all high-strung or anxious or neurotic as I tend to be (if you’ve met me: I hide it well), you have this fantastic ability to diagnose yourself with every possible disease you’ve just read about. Since you have no clinical acumen, you don’t appreciate the fact that if someone has colon cancer, they have more than just blood in their stools. They are also usually old, have other constitutional symptoms, etc. Medical student syndrome tends to go with the unit you’re studying: I was absolutely, totally convinced I had lymphoma during our hematology block. So convinced was I that I made one of our hematology attendings feel my neck to feel one particular lymph node. On the positive side of things, it was then and there that I learned the ability of a physician to provide instant emotional and mental relief, as he told me it was nothing.
As we all know from being 9th graders, it stinks be the lowest on the totem pole. You know the least, you get picked on the most, and as we all know, “Shit runs down hill.” Eventually I began to jokingly volunteer for the blame: “It’s usually the med student’s fault, so I guess I did it.” Everyone you’re working with is also evaluating you, so even if the residents have to stick around and do paperwork, and you have little-to-no reason to be present, you end up sticking around more often than not–at least until you’ve proven to the residents that you’re a reasonable, decent guy who will not make more work for them.
It’s hard to get time off. This probably applies to all of medicine–residency too–but it always annoyed me, so here we go. Because you’re constantly jumping from rotation to rotation, it’s hard to find time for basic, time-offy things like, oh, going to the dentist, or anything else you have to schedule far in advance? You never know where on a call schedule you’re going to land that month, or how nice your resident is going to be about time off. Sure, you’re given X number of days off per month, but you generally don’t figure that out until the rotation begins.
It strains relationships. During my orientation, I remember a senior student saying that many people view medicine as a very selfless profession, but in her opinion, it’s an incredibly selfish one. That we require an enormous amount of patience and understanding from our families and loved ones in order to deal with our schedules and time limitations. The statistic is tossed around that doctors have a higher rate of divorce–unless they’re married to other doctors–and I believe it. Even during our medical school career, the vast majority of couples that started out together no longer are.
Combing through some old photos, I came across these I took when then-Senate candidate Obama stopped by our offices at PNHP back in early 2003. And for the record, as far as I can remember, he didn’t support single-payer then, either.
As promised, now that I’ve finished my Boards (cross your fingers that I passed them!), it’s time to take on some big themes of the past almost-five years.
I was one of those people that really enjoyed most of clinical med school. (I would say that pre-clinical med school wasn’t so bad, but I certainly didn’t enjoy it much of the time–my post is still the top Google hit for “i hate med school.”) Clinics were great for the most part. You’ve spent your first two years trying to figure out the basics of health and disease, memorizing countless facts, and you’re not really sure how they’re at all useful. And then you get to clinics, and–wow!–this is the stuff I went into medicine for! So let’s start with that:
You get to see patients. You get to take your knowledge, everything that you’ve learned, and try to figure out how to make it useful and practical for a person that comes to you with a complaint. I was simply amazed at the level of trust and openness my new patients provided to me. Asking probing, very personal questions and they answered. Men and women who might otherwise not feel comfortable expressing their emotions–be it through laughter, tears, or anger–would open up, for better or worse. And people get better! And many were appreciative! It’s fun to say “you’re welcome” when someone is thank you for helping them. It feels great to shrug, “Hey, that’s what we’re here for,” or “Don’t thank me, I’m just doing my job.” Because it’s genuine. One of the reasons I loved (and continue to love) Geriatrics is that it’s so, so simple to make huge gains in a person’s quality of life. The smallest actions can provide the biggest benefits. Discuss and decide to take a patient off their beta blocker and watch their energy rise! It’s fantastic.
You don’t have an MD after your name. I think there’s an assumption (that I hope to dispel) that if you’re a doctor, you have to know everything. That “I don’t know” isn’t an acceptable response to a patient. I think that’s going to change with my generation of physicians, but it certainly still exists today. The best answer you can give a medical student, second to the correct one, is “I don’t know, but I can definitely find out.” ‘Cause see, you’re not expected to know–you’re a student!
Another semi-benefit: you can’t sign orders. This becomes a pain when you’re ready to sign orders–but nothing annoys a resident more than getting called 20 times a day for stupid little orders to be written. (Brownie points are quickly earned by med students who write the orders for their resident and just ask them to review and co-sign them.)
It’s easy to beat expectations. I don’t know if the bar was just set low, but it really seemed like doing well was pretty straightforward:
Show up on time.
Don’t complain (unless the residents complain first, then you may join in and agree).
Try your best.
Do what’s expected of you (and know what’s expected of you).
Be genuinely interested. (The fake way to do this is to say “Why yes, I’m considering Neurology” when you’re on the Neurology clerkship.) But don’t be so naive to think that what you learn on rotation X will not apply to your chosen specialty Y. Answer: it will!
Ask questions if you can’t figure something out by yourself. (I remember my very first day of rotations, we were rounding in the ICU and my intern mentioned “Scids” and had no idea what they were. I finally asked, and found out OOOHHH, those White and Orange things, SCDs, sequential compression devices!)
Ahem, ask questions at an appropriate time. I’ve heard of people asking for anatomy tips while a surgery attending and chief are trying to trying to control a big bleeder.
All of these rules are actually just this simple gestalt: Do not make more work for your resident and intern.
People like to meet medical students. (And it’s fun to have people like to meet you!) After you get past that “Ooooh, a future doctor!” bit, you can easily become the life of the party with stories you’ve stolen from your residents or quirky little anatomy tips.
The classmates! I’ve met some of my best friends for life in medical school, and feel incredibly fortunate to have gone through this experience with them. They’re amazing, fun, interesting, creative, compassionate, and brilliant. I’m blessed. And from a larger, life-perspective, I know I have friends in every facet of medicine and in every major city in the country that I can think of if I ever have a question or concern about something going on in a loved one. Truly priceless. (Free lac repairs if you ever need them, guys.)
It’s a safe environment to make mistakes and learn. Some of this may be “Why it’s great to be a med student at Stanford,” but I can’t really tell. Thinking through my clerkships, I’d say 80, maybe 90% of my attendings were responsive and interested in teaching and education. Some certainly more than others; some certainly better than others, but it was a rarity to be around a jerk or malignant person. In fact, when briefly swapping stories with friends from other schools, Stanford seems incredibly benign–and incredibly trusting. Once I got the hang of patient care, I was more-often-than-not asked, “Well, what do you want to do with this patient?” forcing me to think through things myself. I wasn’t always right, or someone would teach me something that might be a bit better–the art of medicine–but it made a huge difference that I was even asked. The best rotations were the ones where I was actively involved–that I was treated like a valued member of the team. Just feeling included means a huge deal. Even if the team was going to start lisinopril whether I suggested it or not, just giving me the opportunity to respond instead of writing the order themselves was huge. (And on rotations where I didn’t have this experience, I was asked for–and provided–constructive feedback. They remain nameless, but know who they are!)
You can be proud of what you’re doing, if you love it! I’m sure we med students don’t all feel this way, and maybe it’s all just still romanticized in my head, but I feel like I’m truly doing something good. I have friends who hate their jobs; I have others who don’t mind them–that they pay the bills, at least. But I still think I’m incredibly fortunate to be given the opportunity to make this my life’s work. I couldn’t imagine myself doing anything else–and I’ve certainly tried. For some people, optimizing a bottom line is probably as much a thrill as medicine, but this is mine. There’s a lot of crap we have to deal with, and plenty of reasons to complain–but that’s everybody. I’ll take my headaches anyday!
It’s amazing to watch your brain learn. It’s a similar feeling to how I felt when my brain just started “understanding” French. I was reading a billboard one day in Paris (lived there for a summer during undergrad), and realized I was reading it in French without the need to translate. Similarly, it’s almost Matrix-esque to be able to spit out the doses of lisinopril without ever sitting down and memorizing them. You wonder, “Where the hell did that come from?” It’s just the osmosis of being around clinical medicine for long enough. (At least for me–I learn best by doing.)
Phew, that’s enough for today. Feel free to add your own. Next up: “Why it stinks to be a medical student.”
I couldn’t find this anywhere online, so for the love of all medical students studying for Boards, it’s a big ol’ list of the rheumatic diseases and their associated antibodies:
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.
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.
This blog, like my medical school career, seems to be wrapping up. Expect a bunch of long-winded, well-thought-out, strongly-opinioned posts on broad topics like “What’s wrong with our health care system,” “What I would ideally like to see to fix it,” “What I would realistically accept to fix it,” “Why it’s great to be a medical student,” “Why it sucks to be a medical student,” “What needs to change in the pre-med and medical school curricula,” “What needs to change in Boards Exams,” “Being Out In Med School and Residency Apps,” and of course, just to cause a controversy, “What needs to change in America.”
Back to “The Somogyi Effect vs. The Dawn Phenomenon.” (Answer: hypoglycemia at 4am in the Somogyi effect!)
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?)
(’Cause everyone’s been asking, “So did you get a job?”)
I find it best to begin at the beginning.
In your final year of medical school, you have to decide in which specialty you want to train. This could be anything from “Internal Medicine,” where you would become an internist, to “Pediatrics,” where you’d become a pediatrician, to “Urology,” where you’d become a urologist. Radiology, Neurosurgery, Emergency Medicine–it’s all there. (Except some Internal Medicine specialties, like cardiology, endocrinology, which require you to do an internal medicine residency and then another training session called “Fellowship.”) Anyway. You decide your specialty, and then try to figure out where you want to train for residency*.
So while you’re figuring out where you would like to train for residency (based on a number of factors like reputation, location, research opportunities, etc.) you’re preparing an application for these residency programs. It’s a big electronic folder of things like grades (if your school has them), board scores (standardized national exams everyone has to take), letters of recommendation, evaluations from your time working in the hospital, extracurricular activities, research, and a one-page personal statement. So you submit that to a big centralized clearinghouse called ERAS, which charges you a fee based on how many places you apply to . Depending on how competitive your specialty is (orthopedics, radiology, anesthesia are often at the top), you may end up applying to an insane number of programs. Like 40. This can be $500-$600 just to apply.
You want to get your application in ASAP, because residency programs can start downloading parts of it as soon as you pay, and can start offering you interviews whenever they want. Technically, they don’t have your full application until November 1, when your medical school releases your “Dean’s Letter,” a summary of your performance during medical school and sometimes has a ranking, grade, or keyword (”Graham is a good candidate,” vs “Graham is an outstanding candidate”) to differentiate students at the same medical school. But anywhere between late October and early November you’ve heard from most programs via email as to if or when they’re going to offer you an interview. For some of the more competitive programs, you may only get offered one or two dates (”Please come interview November 28 or 29″). It’s then a scramble to quickly email/call the programs back and confirm the date you want. You’re constantly balancing booking programs with trying to group them regionally, so you’re not flying back and forth across the country all the time. Because yes, you are paying for this yourself.
So you go around to different programs and interview. You’ll usually interview with 3 or 4 faculty or residents (at least in my experience), both for you to get a feel of the program and its faculty, as well as for the program to get to know you. You get a tour, breakfast and lunch, and often there’s a social event the night before to get to meet the residents outside of the hospital environment. They tell you the specifics about the residency program, why the program is unique or special, you get a chance to ask questions. (In fact, often the most common question you’ll hear is, “So, what questions do you have?”) And as I said before, you’re paying for all of this yourself. Airfare, hotel, meals on the road–it’s all on you**. I lucked out and had friends in every city where I interviewed (Thank you Eric, David, Sam, Deepika, Jesse, Eric, Eugene, Ed, Kenji, Dave, Allison, and Mike, I owe you all BIG TIME!) but still the process will end up being expensive for me to fly all over. People trying to match as couples often spend around $5,000 interviewing, depending. This is of course just loan money, so by the time we’ve paid it off it’s tripled in cost. But I don’t have ideas for a better system–you gain a ton by going to the institution and seeing it yourself.
Now to the Match part of it. I explain it this way. By getting an interview, you kind of have a potential job offer. How it works is this: the med student ranks all the places he or she interviews. The residency program ranks all the candidates they interview. Then a big crazy computer program (The NRMP, lovingly known as “The Match”) … matches everyone up. There’s a good explanation of how it works here. The Match favors the resident, so if two programs rank you #1, but you rank program A higher than program B, you go to program A.
Everyone finds out where they match this year on March 20, 2008.*** Technically we’re all supposed to find out at the same time–that is, students on the East Coast would find out at noon their time, and on the West Coast we’d find out at 9am, but often your friends on the East Coast are already calling and texting and emailing their results early, ahem. And then, July 1, or around there, you start your internship.* You are contractually obligated to go where you’re placed, so right now the thousands of medical students about to graduate and I are all anally pouring over our “Rank Order Lists,” to decide how we want to rank places.
And that’s the Match for you!
*Residency is the name of the training process you go through to become a doctor in a certain field. The length of residency depends on the specialty: pediatrics, internal medicine, and family practice are three years, others are four, some like plastic surgery or neurosurgery are seven. Internship is the name of your first year of residency, no matter what specialty. Most of the time you do your internship as part of your residency program, in some specialties like anesthesia, dermatology, ophthalmology, you do your internship separate from the rest of your training.
**There are some programs that will put you up in a hotel, or pay for your airfare, but these are rare. Often programs will have setups so that you can stay with a resident, however.
***There is a terrible thing called “Black Monday,” which happens the Monday before Match Day, where people who didn’t match at any program find out, and then have to enter “The Scramble,” where they quickly try to find an open residency spot somewhere, often not in their chosen field. (Knock on wood this doesn’t happen to anyone.)
Well, interviews are done! I had the great pleasure of meeting one Dr. Nick Genes whilst in New York. My first-ever in-real-life blogger meeting. He is even cooler in person!
Expect posting to be light for the next month or so: I’ve got both parts of Step 2 (”The Boards”) to take, which I’m already loathing.
There appears to be no published information about how we’re truly graded for Step 2 CS (”Clinical Skills”) besides if we went through the motions of “listening” with our stethoscope and speaking English. The patient note we have to write tells us to list “up to 5 possible diagnoses” and “up to 5 tests or procedures for workup.”
A mysterious physician apparently grades us, but on what basis we’re not told. For including a broad differential, or a narrow one? Can I, and should I include the great imitators, like HIV, TB, or syphilis on my differential? How about malingering? Should I go all out for the million dollar workup for patients? Classic ankle sprain. Ankle MR and X-Ray, please. But maybe we should tap it and send the aspirate for analysis. Or maybe he has disseminated gonococcus? Might as well get a CBC and test for GC/CT, too. Throw in an HIV there too, just for completeness’s sake. Is it honestly more important for me to know how to order a bunch of worthless, expensive tests than have a clue how to treat someone with an ankle sprain? (Treatment is not part of the “Clinical Skills” exam.)
Not that any of this matters, though. I speak English, am a pretty compassionate guy, pretty socially adept when talking to patients*, and know where to put my stethoscope. So I probably won’t be one of the 10 people that don’t pass this year — yes, that’s right, I have a 0.05% (those decimals are correct, 0.0005) chance of not passing the exam.
* I find it totally fascinating that I actually have a pretty darn good rapport with strangers-turned-patients, but put me in a social situation at a bar, club, party, or other social gathering and I freeze up socially pretty consistently. Little know Graham fact.
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).
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.
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.”
There’s certainly plenty we don’t agree on in the blogosphere–but plenty we do. That our primary care system is falling apart; that our Emergency Departments are severely overcrowded; that some laws and regulations (HIPAA, EMTALA, among others) need some serious re-thinking; that our health care system as it currently stands may seriously fail its citizens, especially with the coming-of-age of the baby boomers. The list could go on.
And yet our representatives in Washington have done nothing, and are not listening. (Granted they have plenty of issues on our plate–but if this one is not addressed soon, it’ll be too late. It may already be.)
So I say let’s stage a sit-in.
Of a certain variety, of course. We can’t simply ignore our patients. Many often depend on us to keep them… alive.
I suggest we demand all of Congress to spend a week of their vacation with the health care US health care system. Where and how we work in the United States, they sit and watch. 2 days with a primary care physician. 2 days with specialists. A day in the ED. And follow a patient from admission to discharge.
They’ll see how swamped we are; they’ll see how sick our patients are, what treatments are recommended for them, and how it’s impossible to provide proper care in 15 minutes. They’ll see how overcrowded our hospitals are. And that we must. Do. Something.
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 pollsor 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.)
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.
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.
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.
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:
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.
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 othershavesaid, 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.
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.
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.
I don’t think this approach that Shadowfax mentions is the right one. There’s a reason that every year, doctors are chosen by Americans as the most trusted profession. Despite some may think of us, they know we work our asses off to care for them. We dedicate our lives to the task. We embody the definition of the true professional: the person that puts the needs of his or her patient ahead of his or her own. We lose that trust from our patients–that we have their interests ahead of our own–and we risk losing much more than just money. (And ignoring economic theory of medical school being an investment in later higher salaries, when you look at it from the average American’s perspective, making $38,000 a year, doctors complaining about only making $150,000 a year will look pretty ridiculous to most of the US.)
I also fail to understand why physicians would be willing to “protest” by joining retainer/concierge practices yet still work within the current health care non-system than “protest” for reforming the entire health care system. Not to go all single-payer on you, but those hundreds of billions of dollars (we can argue if it’s $300B or $100B later) wasted on administrative duplication and entire billing departments in hospitals and clinics sure seem like a great pot of money that we could pay primary care physicians with. Call me crazy. Many do.
And as I’d mentioned before, Josh has been writing a lot about concierge medicine at KevinMD. One post shows a sample practice with a huge reduction in hospital admissions for concierge care-managed patients. That’s great! Fantastic! Awesome! Amazing! I have no doubt that it’s true. If you can spend more time with your patients and watch them closer, you can keep them out of the hospital. Which is good for the patients and great for our health care system. But why should we only provide this to the rich patients (yes, the overwhelming majority of these concierge patients are wealthy) that can afford it? Why not fix our whole health care system so that the diabetic gets a 45 minute visit instead of a 15 minute one?
We’ll go through Dr. Centor’s response piece by piece, ’cause I find it’s the best way to address points and give my own thoughts.
Graham is an idealistic 5th year med student (he spent a year doing research.)
Guilty, yes, as charged. I actually describe myself as an “idealist realist” (or “realistic idealist,” take your pick) in that I believe we can always strive to do better and improve: that we should always aim for and want the best. But I grudgingly accept and recognize that reality don’t always jive with that aim. Moving right along.
Upon further reflection, one must evaluate the current status of outpatient internal medicine (because currently the great majority of retainer practices are internal medicine.) Physicians are fleeing from outpatient internal medicine. Our current reimbursement model causes physicians to run on a treadmill, destroys their work life balance, and leads to a constant sense that they are delivering substandard care.
Look at our residents. Very few choose outpatient medicine these days. They either choose subspecialties or hospitalist jobs.
Look at practicing outpatient internists. They are leaving practice at a steady rate. Some switch to hospital medicine. Some go back to do fellowships. Some leave medicine entirely.
I totally agree with you, Dr. Centor. We joke that all the medicine residents at Stanford are going into either Cardiology or GI, because it sure seems that way.
Dr. Centor goes on to talk about the financial disincentives to work in primary care: the poor reimbursement due to third-party payers, the inability to spend the time truly needed with a diabetic, etc. Again, we’re in fully agreement here. I really like this bit:
Most outpatient physicians practice medicine in a way that insidiously harms their self esteem. They know that they are not providing the best care. They know that they cannot provide their patients with the support that they really need.
I believe that most retainer physicians see their practice style as the only tenable solution. I suspect that many of them would have left practice for another job if they did not have this option.
If retainer physicians are unethical, then what about physicians who quit seeing patients entirely and enter medical administration. What about any variety of subspecialists?
And this is where I think Dr. Centor and I are missing each other. My concerns are those from more of a public healthy, health policy lens, whereas Dr. Centor is viewing the situation from an equally valid perspective–that of the primary care doc on the front lines. He makes a great point: if the decision for the primary care physician is between retainer medicine and giving up medicine, that makes the choice seem more reasonable to me. And I have no doubt that many primary care docs believe they simply aren’t able to deliver high-quality care to their patient census. And speaking of ethics, I’m certainly in the guilty field here, as I’m not going into primary care (although I’ll be doing my share of ‘primary care’ in the Emergency Department and seeing uninsured patients, something I love about the field).
Dr. Centor then goes on to talk about how if retainer medicine succeeds, perhaps it will encourage more residents to go into primary care, which would achieve the goals of more primary care physicians in the US.
But hold on here, let’s give my perspective a look with some back of the envelope math. According to the 2006 Bureau of Labor Statistics data, we have
109,400 Family and General Practitioners in the US, and 48,700 General Internists in the US. That’s 158,100 primary care doctors in the US. With about 28% of the US being under 20, that leaves 236,000,000 adults that need a primary care physician. That’s almost 1,500 people per physician.
Say we even took all the physicians in the US–415,630–and told every single one they have to practice primary care. We divide it up again, and it’s still 567 patients per physician.
Let’s be practical here, people–retainer medicine will not work as a model to fix primary care. It will certainly make primary care physicians’ lives better and their wallets thicker (which I’m not opposed to), but it simply won’t fix the problem.
Dr. Centor, the ball’s back in your court.
PS: “Single payer systems do not provide social justice.” Huh? They are certainly far from perfect, but certainly do a better job of providing limited resources equally to all citizens than, say, our system.
I urge these authors and their ideological colleagues to look beyond the trappings. I urge them to perform a thought experiment. Why are patients increasingly willing to pay? Why are highly ethical physicians opting for this style of practice? If they are honest, they will find some truths that knee jerk opposition obscures.
Some might argue that these “highly ethical physicians” aren’t so highly ethical by practicing retainer medicine. One ethical framework would suggest if all physicians just practiced retainer medicine, there would not be nearly enough physicians to go around. In that framework, retainer medicine would be viewed as unethical.
(I also don’t really get how Dr. Centor combats the classist and racist arguments he brings up. They’re totally valid, and I can’t help but draw a parallel between retainer medicine and insurance company cherry-picking, the latter I find to be despicable in its bottom-line philosophy. By practicing retainer medicine, you are selecting out for people who can afford to pay extra, and health and SES are intrinsically linked (and also race), so you’re essentially picking out people who are already healthier. If you look at things through an equality and social justice lens, who needs a physician’s help more: the poor, smoking diabetic or the executive with an HDL of 39 who bikes 20 miles a day?) (I however absolutely agree with Dr. Centor that health care financing is a complete and total disaster in the US, but I would argue we need to fundamentally change the system–yes, with all the turmoil and terrible problems and growing pains it would cause–than work within it and continue to try piecemeal approaches we’ve been attempting since the 1970s.)
And Happy Holidays to everyone. We also celebrate Festivus, and the Airing of the Grievances went well, followed by the Feats of Strength. Here’s a photo I took from a few years ago:
Don McCanne points me to To Great A Burden (PDF), a report by Families USA which analyzes data on health care expenditures, and finds some pretty scary numbers and trends (my emphasis below):
More than four out of five people in families spending more than 10 percent of their pre-tax income on health care costs are insured.
50.7 million non-elderly Americans with insurance are in families that will spend more than 10 percent of their pre-tax income on health care costs in 2008.
More than three out of four people (75.8 percent) in families spending more than 25 percent of their pre-tax income on health care
costs are insured.
13.5 million Americans with insurance are in families that will spend more than 25 percent of their pre-tax income on health care
costs in 2008.
My point? These are the insured we’re talking about. The people who we quickly call “the covered.” And it’s gotten significantly worse in only 8 years:
Wake up, middle class. You don’t want to risk health care reform when you’re satisfied with your care, but how long until you’re part of the insured millions of families spending 25% of their income on health care?
And wake up, political candidates (and bloggers) that support individual mandates or continuation of the hodgepodge mess of private plans we have here–with their lifetime caps and pre-existing conditions, even the insured here are getting the rationing everyone’s so scared of under some sort of national system.
KevinMD and now the usually sensible Shadowfax continue to be wrong on teaching the business of medicine. (Don’t get my wrong, I completely agree these things should be taught, but it makes absolutely no sense to have the primary teaching be in med school.) Teaching it to pre-clinical students certainly makes no sense, they’re busy learning everything for Step 1. Teaching it to clinical students isn’t all that practical, as most are preparing for residency applications and wrapping up med school. (And my main point here: if you don’t use knowledge, you lose it. When will anyone but a senior resident be doing any sort of billing or admin stuff? You think an intern is going to retain knowledge of CPT codes? Perhaps if they’re in a continuity clinic or something–but then that’s something they should be learning on the job, in the clinic. Again, every single EM residency program I’ve seen so far has 2 weeks set aside for “Administration” in the final year, but honestly, if you all think it’s so important, residency programs could certainly find time for it. You could have it coupled with two weeks of X to make a 4 week block; you could have a morning lecture series for all the residents, or dedicate one noon conference every month or something to the topic. Med students are so far removed (remember, we’re not even DOCTORS yet)–what’s the point of filling our head with information that will just be quickly forgotten when it’s much more important for us to remember the possible side effects of ACE inhibitors we’re about to be pimped on?
Insurance does matter for cancer prevention, as Matthew runs through a recent study: “For all cancer sites combined, patients who were uninsured were 1.6 times as likely to die in five years as those with private insurance.” This is sadly one of those “duh” studies that has to be done anyway, because of well-insured, financially-secure naysayers who somehow believe their situations are no different from people without insurance.
Ignore those calorie burning meters at the gym. There’s almost nothing more inaccurate in the fitness/weight-loss/exercise world. I’d previously heard the eliptical machines overestimate by 20%, but this article claims they’re just plain wrong. Break a sweat (after approval from your doctor, Mr. Quintuple Bypass with Chest Pain at Rest), and exert more than you take in. 1 pound = 3500 Calories. 500 less Calories a day = 1 pound of weight loss a week. Slow and steady wins the race.
And finally…Google Talk introduces instant translation in IM conversations. This would be pretty awesome in medicine, if we ever chatted with patients. (Damn you, HIPAA!) The translation is actually pretty good, at least for Spanish. Your pretty typical conversation in the Emergency Department:
Trying out a new feature here at Over My Med Body. Short little commentaries on links, a la KevinMD, as there’s tons of great blog posts and health policy news, and so little time to discuss them! (Also, this will be more productive than watching The People’s Court and Montel.)
Dr. Wes pimps med students interviewing for residency on billing codes, and Kevin (I hope jokingly) says med students should have to get an MBA before starting med school. How silly. The point of med school (which most of the commenters point out) is to give you a foundation of knowledge to learn how to practice medicine, get exposed to all the medical specialties, and prepare you for internship. It’s residency that should be teaching doctors about how to be an attending. (All the residency programs I’ve seen so far have a specific “Administration” component to them where you learn about billing and getting paid.) Wes says med students “are woefully unprepared to enter the big wide world of medicine,” but if there’s some way to enter medicine without doing a residency, I missed that day in class.
Via KevinMD, this great quote about the two sides of medicine we’re trying to turn into one: “Today, we are in between two images of the doctor. One image is the heroic personal savior, who uses his own experience and intimate knowledge of the patient to make the best decisions. The other image is the trained technician, who gathers data, feeds it into a decision tree, and implements that recommended course of action.” Totally agree. The best is the caring, experienced doctor who knows the data, when to use it–and when not to.
College is not the time that many young women want to get pregnant, but Congress isn’t making that any easier, closing a provision that allowed drug companies to sell cheap birth control to student health centers. A monthly supply used to be $3-$10, now it’s $30-$50. Some members of Congress are aware of the issue, but can’t get it fixed, since birth control pills are so closely tied to abortion (that’s sarcasm). It’s amazing to me that tiny little oversights can have such huge impacts on people’s lives.
Speaking of bad daytime television, I saw this quack tell a poor woman suffering from pretty classic hypnopompic sleep paralysis that she was just doing “astral projection.” The poor lady was scared out of her mind, thinking the devil was visiting her.
This pilot program at UCLA sounds pretty awesome–bilingual docs who train in Spanish-speaking countries get help preparing for US board exams in exchange for 3 years working in under-served areas in California. More surprising in the article is the claim that only 8 of the 27 family medicine residents at the highlighted residency speak Spanish. (I’d imagine all of them can at least speak basic Spanish.) But I agree–there are certainly nuances that you lose only speaking basic Spanish, and cultural nuances that affect what a person is saying.
A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)
Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
Introduce yourself. Often the family has seen a number of different people caring for their loved one–doctors, nurses, techs, etc–so reiterate who you are, especially to the significant other.
Ask what they know already. It gives you a sense of their knowledge level, what they might be expecting, what they’re worried about, so you don’t repeat anything or speak above or below their level of understanding and medical knowledge.
Make a “preperatory statement.” This readies and focuses the loved ones for what they’re about to hear. A good suggestion from the lecturer: Don’t say “I have some bad news.” Try, “I have something very important I need to tell you right now.”
Deliver the news. Be brief, direct, and succinct, 25 words or less.
Pause, wait for a response. Be there and be present.
Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.
Could you please stop being so damn good? It’s truly quite exhausting ending pretty much every interview day and really liking each of you. I wish I had a boyfriend/partner/whatever that would rule places out so I could cross them off my list, because when it’s between excellent and excellent, making any sort of ranking is damn near impossible.
Canada’s single-payer system began in 1957, with several revisions years later. Man, 50 years under a socialized medicine, government-run scheme. Canadians with their single-payer system clearly have no motivation to innovate–because where’ the profit? Funny, then, that Canada’s had plenty of medical innovations:
1958 World first surgical treatment on cerebral aneurysms. (Lawson Health Research Institute — London, Ontario)
1960 First implanted mammary artery into the heart wall in order to restore functionality of the heart. (McGill University Health Centre Research Institute — Montreal, Quebec)
1965 First artificial knee joint in the world created. (McGill University Health Centre Research Institute — Montreal, Quebec)
1969 Discovery of a carcino-embryonic antigen, a tumour marker for cancer. (McGill University Health Centre Research Institute — Montreal, Quebec)
1987 World’s first pacemaker cardioverter defibrillator is implanted. (Lawson Health Research Institute — London, Ontario)
1989 Discovery of the gene which, when defective, causes cystic fibrosis, the most fatal genetic disease of Canadian children today. (The Hospital for Sick Children — Toronto, Ontario)
The most heavenly social program is hell underfunded.
Blind faith? When have any single-payer folks ever said we blindly support single-payer and appropriate government appropriations (say that three times fast)? Will health care reform be easy? Pass one law and everything magically gets fixed? The wool’s not pulled that tightly over my eyes. Fixing the health care system isn’t going to be easy, and it isn’t going to be cheap. It will take years of planning, tons of effort, and lots of discussion. But of course it can happen.
Why do I think we need to do it? Because of the mess. The mess of billions of dollars wasted on duplicated tests and administrative overhead. The mess that millions of people in the richest nation in the world decide between eating and buying their medications (which would often prevent doctor and ED visits in the first place), or that many honestly consider waiting out an appendicitis because they lack insurance and know their financial lives will be ruined by a $50,000 hospital bill. The mess that fragmented care complicates care so greatly. The mess that other countries can apparently do it–and for cheaper–and we apparently can’t. I could go on.
Why do I think we can do it? Because we’re America, god damn it. We’re the land of opportunity. Innovation. Creativity.
We invented the car. We flew at Kitty Hawk. Electricity. The telephone! We created a system of railroads across a gigantic country. And then later, we made gigantic highways to cover it even better. We can do whatever the hell we want with this country–that’s the beauty of it! And you’re honestly telling me we don’t have it in us to fix our own health care system? To take better care of ourselves? That it’s not possible? Of course it is! (I sometimes wonder what our health care system would be like today if our leaders back in 2001 fought so strongly for fixing our health care system the way they fought so strongly to fund and go to war. A trillion bucks could go a long way.)
Do I think the government funds things correctly currently? Often, no. Does that mean that it can’t in the future? Of course not. Do I think it’ll take a massive, gigantic change to our government and culture to fix things? Absolutely, just like it will take a massive, gigantic change to fix our health care system. People always bitch and moan about “the government,” but what is the government but its citizens?
I volunteered this past Sunday at one of our free student-run clinics and was working with mostly pre-clinical students. We talked a bit about applying to residency, and we practiced blood pressures on each other. One student remarked, “I can never hear the sounds!” and I told him to turn his stethoscope around. It was adorable. And reminded me of when I had to have that pointed out to me, and that I had to remember “earpieces point TOWARD the patient!”
Another student practiced presenting to me about a guy with GERD, and I asked a couple follow-up questions and the student said he hadn’t asked my follow-ups. I told him that was totally normal, fine, and not a big deal. I guess anyone can probably learn most things if they’ve been at it long enough (4.5 years and counting for me), but it was still amazing to me that I’ve become fairly good at making diagnoses on my feet, multi-tasking differentials while still talking to patients, asking pertinent follow-up questions. It’s pretty cool. A similar feeling to mastering a foreign language, I think.
Started Family Medicine this week (my last clerkship!) and very much agree with the philosophy, probably more than the Internal Medicine approach: that you must take the patient in context. That much of what we consider “health” doesn’t fit within the conventional boundaries of medicine, and that a person’s environment greatly affects his or her health. A couple of thoughts from the introductory lectures, one by a patient advocate on Advance (not Advanced!) Directives:
On the term “life support,” as in: We would have to place your dying father on life support or else he will die tonight: We should call it “artificial organ support,” not life support. Life is something that we define as people–and all “life support” does is keep the organs in the body working longer.
On making sure everyone has an advance directive: Maybe it’s a bit morbid, but what if on Thanksgiving or some family holiday, everyone brought out papers and wrote an AD? Then everyone in the family would have their wishes known, and there’d be less fighting later.
Did you know you can write people out of an Advance Directive? Say you have a child who hasn’t been around for a long time, or a trouble-maker in the family–you can specifically mention in your directive that you do not want that person to take part in health care decisions for you. (I hadn’t considered this as a possibility.) (Some info on ADs.)
On “Do Not Resuscitate”: In Georgia (and it seems, slowly spreading elsewhere), health care may be switching to the term “Allow Natural Death,” trying to make it known that death is a normal part of life, and that it cannot (and perhaps should not) be fought at any cost.
And because timing is everything, The New Republic’s Jonathan Cohn has a really fantastic piece on innovation in universal health care: Creative Destruction: The best case against universal health care. Just like he says in the article, I’ve yet to see an innovator in the academic sector (where much of innovation begins) be driven by profit. It’s driven by wanting to alleviate suffering, to find answers to questions, to let curiosity and discovery flourish. If you didn’t know, the invention of the CT scanner is shared between the US and UK. France was the first to discover the HIV virus.
The article’s a good 5-10 minute read, but well worth it. Key bits:
But it’s one thing to say that universal coverage could lead to less innovation or reduce the availability of high-tech care. It is quite another to say that it will do those things, which is the claim that opponents frequently make. That argument requires several leaps of logic, many of them highly suspect. The forces that produce innovation in medicine turn out to be a great deal more complicated than critics of universal coverage seem to grasp. Ultimately, whether innovation would continue to thrive under universal health care depends entirely on what kind of system we create and how well we run it. In fact, it’s quite possible that universal coverage could lead to better innovation.
Of course, the idea of involving the government in these decisions is anathema to many conservatives–since, they argue, the private sector is bound to make better decisions than a bunch of bureaucrats in Washington. But, while that’s frequently true in economics, health care may be an exception. One feature of the U.S. insurance system is its relentless focus on short-term good. Private insurers have little incentive to pay for interventions that don’t yield immediate benefits, because they are gaining and losing members all the time. As a result, money invested on patient health may very well help a competitor’s bottom line. What’s more, the for-profit insurance industry–like the pharmaceutical and device industries–responds to Wall Street, which cares more about quarterly filings than long-term financial health. So there’s relatively little incentive to spend money on the kinds of innovations that yield long-term, diffuse benefits–such as the creation of a better information infrastructure that would help both doctors and consumers judge what treatments are necessary when.
The government, by contrast, has plenty of incentive to prioritize these sorts of investments. And, in more centralized systems, it can do just that. Several European countries are way ahead of us when it comes to establishing electronic medical records. When fully implemented, these systems will allow any doctor, nurse, or hospital seeing a patient for the first time to discover instantly what drugs that person has taken. It’s the single easiest way to prevent medication errors–a true innovation. Thousands of Americans die because of such errors every year, yet the private sector has neither the will nor, really, the way to fix this problem.
The medical record, from flipping through it, to scrolling through it;
Abend, a 61-year-old neurologist, scrolled through the patient’s electronic medical record as the resident described the case.
The initial presentation of the patient, via instant messenger:
“When is our wedding date?” she quizzed. “Can you tell me that?”
“No :(”
I see it now, 20 years in the future:
“This is a 27 year-old male who presents using inappropriate emoticons while chatting and cannot remember how to attach a document in Gmail. Sounds pretty serious, probably should get admitted.”
Had a nasty, nasty virus about 4 weeks ago that provided me with nasty throat pain and pretty much constant fevers, chills, and night sweats. (I could practically tell you when 10pm hit, as my cold sweats would start.) I put myself on around the clock Tylenol and ibuprofen x 8 or 9 days (I know, I know) and somehow made it out alive. Rumor is it’s a parainfluenza virus going around the area.
Anyway–I usually weigh around 155 pounds; last week at the gym I stepped on the scale and was 147. I think that’s the lightest I’ve been since med school began. My pants no longer fit; my belts are too big. I lost 5% of my entire body weight (unfortunately mostly muscle).
Power of the fever and increased metabolism. Amazing, that human body.
I haven’t really seen much discussion of this really, really important 2007 Commonwealth Foundation Survey of 7 Countries (wait, don’t click!), so I thought I’d give you my take. Without all that pesky reading and analysis. We’ll just summarize the tables. (I know, I know, this is not the recommended way to read an article.)
7 countries, phone interviews conducted: Australia, New Zealand, Germany, the Netherlands, the United Kingdom, and the United States. At least 1000 people surveyed in each country. A wide variety of questions asked. These ranged from questions about primary care access to prescription drug costs to medical errors to going without care because of cost to electronic medical record usage to ER visits to elective surgery wait times to chronic disease to health care quality. (Yes, of course, some of these answers depend on culture and stuff. Hear me out.)
If you do look through all that data, you’ll notice something really striking: country to country, it’s really not all that different. Sure, there’s lots of variation. Germans are the most confident they’ll receive the “best medical technology”; people in the Netherlands are the least likely to wait greater than 6 months for elective surgery; Australians are the most likely to be able to contact their doctor on the weekends; Americans were the most likely to receive reminders for preventative or follow-up care; it’s very easy for New Zealanders to contact their doctor by phone during regular hours; the Brits are the most likely to have financial incentives for quality.
If you look at the numbers, however, again: things are fairly similar. As a general trend, what separates the best from the worst is only 10 or 20 percentage points’ difference. Overall, these 7 countries are fairly similar. Sure, in some areas there are countries that seem to really be doing a better job–but it’s not consistent for every area and for every country. There’s not one health care system that’s the best, and as the authors point out, all these countries (not just ours) are struggling, trying to figure out how to provide care for an aging population with technology that’s advancing faster than we can pay for it. In this way, I do agree with KevinMD–that if we’re going to redesign our health care system, we can’t just copy Canada or France–their systems are struggling just as ours is.
But there is one area where things are markedly different. (You knew where this was going, right?) Cost. In the US, we’re spending 16.0% of GDP on our healthcare system, where the next closest country in this survey, Germany, comes out at 10.2%. Now you say to yourself, “Self, that’s only 5.8% difference!” But that difference ends up being hundreds of billions of dollars (and $3,410 per person). And you look at percent uninsured, and New Zealand is our closest competitor, at less than 2%. We’re up at 16%.
So you look at all this survey data, where the United States is clearly in the middle of the pack (along with everyone else), and don’t you seriously have to wonder, “Then what the hell are we paying so much for?” If we’re not the fastest to get elective surgery (that award goes the Germans), and we’re not the most likely to see 2 or more specialists (again, Germany wins that one), and yet we’re the most likely to have people report forgoing care because of cost, and the most likely to have a problem with coordination of care (getting lab results or medical records sent to another doctor), again, where’s the money going?
For what we’re paying for, our health care system should be winning every single poll, every single year. What a disgrace.
I start interviews next week! Getting very pumped. Wanted to see if any of my blogging colleagues out there (especially you Emergency Medicine folk–I’m looking at you, Panda, Nick, GruntDoc, Dr. Whitecoat, Ten out of Ten, Shadowfax, etc) had suggestions for questions they would’ve asked on their residency interviews that they might not have thought of in my position. I’ve been brainstorming things I’d like to know about the programs (in addition to the obvious stuff) but anything that you don’t realize until you’ve started residency already would be great to know. Thanks!
I have a friend at another school whose attending specifically wears scrubs for no reason to Starbucks, hoping women will hit on him, and there are plenty of people who have no reason to be wearing scrubs to the campus gym.
My policy is such: if I’m going to/from work and need to quickly do something in public (like pick up a gallon of milk from the store post-call), I’m not going to make an extra trip home or bring extra clothes for something simple. Otherwise, I want to get the nasty hospital-y stuff off me and slip on some jeans or something.
My own ED is blogging? How did I not know this? Straight Talk from the Stanford ED: go Cardinal. Maybe people will realize we see more than just horse accidents down at the Farm.
Hello dear readers! I’m hoping to spend several months abroad in a Latin/Central/South American country getting my Spanish up to proper fluency standards, as well as volunteering and seeing the world. I’d appreciate any recommendations for programs if you’ve got them!
This is a post about immigration from an obstetric point of view.
I’ve seen (and delivered) a number of 1st generation immigrants over the past several weeks, and come to understand the immigration debate from a totally new point of view: governments, laws, and artificial borders versus the human spirit.
I have no idea if these women I saw were here legally or not–I know that any woman in active labor must be cared for by EMTALA law, but most of the women I saw had some degree of previous prenatal care, even if it was late. I probably used to know the policy and laws of insurance and everything, but my brain had to delete those to make room for the plethora of OB-Gyn facts I’ve been cramming in there recently.
I was most amazed by a woman at 39 weeks who arrived in this country 7 weeks ago from El Salvador. That means at 32 weeks of pregnancy, less than 2 months from delivering, she somehow got here, speaking little to no English. I wanted to ask her how she arrived–plane? boat? bus? pickup truck? walking?–but she was a little too ready to push, we were a little too busy, my Spanish is a little too poor, and it’s really none of my business.
I wondered what would drive these women to take such risks, even if they were here legally–move here while they were gigantically pregnant, picking up and leaving their families, support systems, jobs, houses, clothing, speaking almost no English–and it’s the human spirit and the maternal instinct. It’s the same thing that all of us want for our children and loved ones: a safe, solid place to grow up with access to education, health care, and jobs. It’s done out of love.
So many of our fairy tales, movies, and stories focus on this theme that I find it interesting there’s often such vitriol and hatred in the immigration debate. We love stories where the individual wins, love triumphs, often against all odds, but somehow, these immigrants, who seem to want the same things we all want–are different.
I guess the point of this post is that we can spend waste as much money as we want on borders and laws and regulations and security cameras, but the human spirit is so dedicated–exponentially so when you throw in the maternal instinct–that it seems like we’re almost trying to stop the inevitable.
If we want to prevent people from other countries from coming to ours to make a better life (and most of us “Americans” ended up here because our immigrant ancestors felt the same way), maybe money would be better spent trying to help other countries to better their own citizens’ lives.
(I’m well aware that the immigration debate is a hot topic and incredibly complex; I do not claim to be a scholar on the subject, just one man with a perspective I don’t often hear in the debate.)
I’m sure my male classmates will back me up on this one: I swear, every time I knock on a door, open it and say hello, I get a little look of awkwardness and discomfort from my patients. It’s a mix of surprise, disappointment and disapproval. Only once has a patient said, “Wow, great, a male in the field, you don’t really see that very often anymore!” Maybe I’m over calling it, and some of it is just made up in my head, a product of my own insecurity with the exam–but I swear it’s there at least half of the time.
In some ways, it makes me try harder, which I guess is a good thing. I try to be even more respectful and caring; I try to make even more outward shows of compassion than I do already. Empathize, use normalizing statements (”I ask all my patients about their reproductive and sexual health,” “This is an incredibly common problem among women, even if it’s not discussed very often in public,” etc.). I realize the exam puts a person in an incredibly vulnerable situation, and it probably doesn’t help that I’m a young man and that many of my patients are my age or younger. I also realize this may be the first time a male physician has seen their genitalia since before puberty (or any male unless they’ve been in a relationship with one), but I feel like the look still exists in many of my older patients as well.
I realize all of this, but still. It’s discouraging and frustrating. I’m not present to make my patients feel uncomfortable. If I could somehow learn everything I need to learn without making anyone uneasy I would, but I can’t. Unlike many other fields of medicine where you’ll never do another pelvic exam in your life, I actually need to know how to perform them adequately as a future Emergency Medicine physician.
For the most part, I’ve actually been enjoying my rotation thus far, but it’s been the first and only where I’ve felt so actively discouraged by patients. Usually my upbeat attitude and smile engender (no pun intended) some points from the patient, but during the past three weeks most of what I detect is disappointment. The nurses and attendings have been absolutely positive, enthusiastic, and encouraging, which has been immensely helpful, but I think I’ve discovered another reason why OB-Gyn is such a woman-dominated field.
(This is not a boo-hoo, woe is me post, just an observation I’ve made. I wouldn’t be surprised if it’s just as awkward–if not worse–for my female colleagues when examining men. It’s not the end of the world, and is a minor annoyance at best: I’m professional, get the job done, ask the questions that need to be asked, and do my best. This is what defines medicine as a profession: we put our patients’ needs and concerns ahead of our own. This does not, of course, mean that we as professionals are not affected by these situations, just that we work past them.)
The dreaded standardized patient pelvic exam was much less dreaded this time around. In contrast to Boobies, written three and a half years ago (seems much longer than that), the breast, genital, and rectal exams are no longer cause for alarm for me. They’re no longer mysterious, frightening territories full of stigma and social awkwardness, amazingly.
Six weeks of OB-Gyn started with a refresher on the female pelvic exam–which was greatly appreciated–and the nervousness I’d previously felt with prior genital exams just wasn’t there. I kept searching for it internally, waiting, expecting at some point to become shaky, laughing as to reveal my discomfort, but it never really happened. Maybe it was that the “patient educator” was a nurse practitioner, and so I felt more comfortable with another health care professional–that this was strictly education, passing information from one generation to another. Maybe it was her 2 foot long, plush, purple model of the female anatomy (Violet the Vulva, of course) that broke the awkwardness. I’m not really sure.
More than anything, I think, it’s just my level of maturity and comfort with patients. It’s a part of the exam that needs to be done for certain complaints, and I need to know how to do it. Step up to the plate, assume the responsibility, and get it done. It’s this new-found attitude and outlook–rapidly advancing especially during last month’s sub-internship–that I think is making me a more assertive, competent medical student (soon-to-be-physician). It’s this same outlook that probably also makes physicians sometimes appear cold or impatient to our patients. While we’re trained to always be emotionally, mentally, and physically ready to perform a potentially emotionally, mentally, and physically uncomfortable portion of the exam, patients aren’t. They often want and need time to “get ready” for it, especially when it’s unexpected. (Sometimes that time isn’t readily available.)
The attitude overall, however, probably makes the exam less awkward. Projecting confidence and normalcy to the exam–that you’ve done it many times, and that it’s pretty much standard operating procedures–helps alleviate some of the potential anxiety a patient may feel. Communication is key. I find using medical terminology to be helpful–asking patients to move their “buttocks” toward the end of the bed, instead of their “butt” just makes it at least sound much more objective–that I am simply the doctor asking a female patient to do something, nothing more. Telling the patient beforehand what will happen, and explaining what he or she may feel helps, too. Body language I think is also key. I often close my eyes and lower my head when listening to heart sounds to help me concentrate on them, but I believe it has the added benefit of ensuring patients that I am touching them for medical purposes only. You never know what prior experiences a patient has had that may make them uncomfortable.
It’s fun to go back and read old blog entries–one of the reasons I’m thrilled I’ve documented this experience–to see where I’ve been, and where I think I may be headed. (Oh, and by the way, Boobies still gets a ridiculous number of hits–it’s listed on the 14th page of Google search results for the word. I can’t possibly imagine what people are actually looking for.)
The short white coats are all over the hospital these past several months*: the visiting sub-interns are here, hoping to get a leg-up on interview season in their chosen specialties.
*We’re spoiled here at Stanford, as we as medical students get to wear long coats, too. (Our residents sometimes give us crap, saying we never went through the humiliation of a short white coat. We don’t miss them.)
To convey that a patient has a very interesting/fascinating disease process, syndrome or problem from a medical standpoint, which you would typically describe to your medical colleagues as “crazy,” “cool,” or “awesome,” but that you also want to convey that you realize this is obviously not good for the patient, and often, in fact, suggests a poor prognosis or outcome, and that you are not a cold, heartless bastard that just ignores this fact. You do, in fact, care about the patient, and are saddened by the fact that he or she has this problem.
I’ll start with my suggestions:
medically awesome, patiently bad
bittersweet badness
fasc-ible (combo fascinating and terrible)
RIBB FoMP (really interesting but bad for my patient)
Not to be too much of a downer on Monday morning, but over the past couple months (ICU and sub-internship), I’ve started to wonder if the healthcare system is doomed. (These are the fun, uplifting conversations that my roommate and I have after coming home from work.)
We talk about how the system’s already buckling under pressure, with ERs overcrowding and hospitals full, and it’s only 2007. (See the graph to the left to see how many more baby boomers we have to care for in the future.) And primary care doctors are becoming fewer and fewer, drowned in a world of paperwork, less income, and specialist care, and in turn, the ERs overcrowd even more as people use them for their primary care. And then you think how many heart attacks, rule out heart attacks, strokes, septic patients, pneumonias, and altered-mental-statuses get admitted now, and wonder how we can possibly sustain this when we go from having 3 million people over the age of 75 to at least double that in 20 years?
We certainly don’t have the hospital capacity to deal with all these patients, nor the staff (not just doctors, but hi, we’re already in a nursing shortage). I’ll leave solving the nursing shortage issue to the nurses, since I’m woefully ignorant of it. Is it too late to get more doctors for primary care? The only way I see things changing are 1) you somehow convince internal medicine docs that’ve already specialized to go into primary care 2) you convince many, many more medical students to go into primary care or 3) you encourage more nurses and NPs and PAs to do primary care.
Even if we do improve our primary care, however, maybe we’re too late. Maybe too many patients have not been treated for their hypertension for too long (hi uninsured and non-adherent!) that they’re going to have too many heart attacks for us to handle.
Maybe we’re just victims of our own success; we can keep ourselves alive longer (in 40 years the average life span will increase by 6 years) but not alive well, just alive sick.
It’s of course nothing we want to deal with, but something we have to figure out. And it’s going to cost… a lot. I have no idea where I’m going with this. It’s too depressing and I’m going to stop now.
You know, everyone rants and raves about how Bush is the worst president, or conversely, that he’s a great one, and how he will be remembered by history–but it’s all on the basis of his foreign policy. We hear so much about Iraq that that’s all we ever think about–but our President hasn’t done a thing for fixing health care (or any of the 20 other domestic issues), besides refusing to allow more children to receive health insurance. Frankly, if he’s remembered for anything, I think it’ll be for his obsessive focus on foreign policy, while ignoring most of our issues here at home.
(also known as ‘Health Care Environmentalism’ or ‘Green Health Care’)
The two parts to this piece.
We waste a ton of material in health care. Can we reduce this safely?
We waste a ton of material to prevent and reduce infection; other industries must clean up their act because to some degree, we can’t.
Number One.
I don’t hear much about the topic, and while there’s a feworganizations who are aware of it, we don’t discuss it much. It’s hard to imagine that hospitals create over 2 million tons of waste each year, but when you think how many nitrile gloves a person goes through in a typical day, it certainly adds up. Then add all the sharps (needles, syringes, guide wires, glass ampules, scalpels, instruments) and it adds up even more. Did you realize these kits just get thrown away? Metal tweezers and scissors, tossed away. Then add the gowns and kit packaging, and it gets even worse.
So first of all, can we do better? Can we reduce packaging, or identify recyclable materials? I would imagine some manufacturers are already looking into this as a way to reduce their costs, but certainly none of it is done around here, in the progressive stronghold of the Bay Area. (We certainly could save on paper by moving to electronic medical records as well.)
Number Two.
The reason there’s so much waste in the first place is to encourage sterility. When you typically open a package to do a procedure (a lumbar puncture, a central line, etc) you open up a water-resistant plastic kit with waxed-paper lid and find a paper-wrapped package inside, sterile on the inside. Often there’s also a gown inside to wear, as well as a standard size of sterile gloves to put on. You gown up, put on the sterile gloves, and now you can go through the insides of the package, which include: multiple needles, multiple syringes, guidewires, glass bottles with lidocaine in them, a disposalble scalpel, some suture with needle, and some skin-cleaning pads as well. All of this is packaged under sterile conditions, so that very limited bacteria will be present when you’re doing the procedure, to prevent the patient from getting an infection due to the procedure.
A lot of this we can’t easily eliminate without creating large hurdles to performing the procedure–and even if we packaged items separately, they would require separate sterile packaging, which may just add the trash mess as well, and taking more time to gather supplies. And the costs (financial as well as to the patient, obviously) to an infection in the blood are great–they can kill people. So a lot of this we can’t improve.
That’s why other industries need to do a better job of reducing their waste–because we in health care have some degree of “fixed” waste that we will always have (until we develop wireless IV tubing, of course). Other industries must work even harder to clean up their environmental acts to compensate for the continued mess that health care makes.
I just registered for Step 2, Clinical Skills. (I just passed Stanford’s own version, the “Clinical Patient Exam,” which is standardized by the state of California.)
I’d heard this before, but it never really settled in: alcohol-based hand gels and foams don’t kill Clostridium difficile, as its spores are incredibly resistant. You’ve got to wash your hands!
Well, that was much better than last time. I went into call with one patient, came out of call with… one patient. Our team went into call with 7 patients, and came out with… 6 patients.
Thank you, gods of call. (And I got most of my ERAS application done wasting my beautiful Saturday away in the hospital!) Now just that damn personal statement.
Pronounced my first patient just now. The hospice unit called down to our team room, so my resident and I put on our white coats, buttoned them up to look presentable, and headed upstairs.
Luckily there was no family in the room–I’m sure it would have been much more uncomfortable if there had been. Felt the patient: warm; checked for a pulse: none; saw no reaction of the pupils to light. It was very strange, putting a stethoscope to a warm, lifeless chest wall. You’re so used to hearing the rhythmic whooshing of the breath sounds or the lub-dub of the heart that it’s a little un-nerving when there’s nothing there. I moved my stethoscope to a few other places–wait, did I hear something?–but there was simply nothing there.
After a quick confirmation by the resident, we turned turned around to the nurse, looking at the clock on the wall. “Okay, we’ll call it Eight Thirty-Seven. Thanks.”
For my medical school applications, I had no difficulty writing my personal statement or secondaries. But for residency, it’s been difficult: I figure everyone who’s applying in the same field as me (Emergency Medicine) has similar interests and skill sets. So, anyone have advice for residency personal statements? (I have something done that I’m fairly happy with, but I think it’s still pretty generic and probably what everyone says.)
Patients without medical training but that actually understand all the nuances of their diseases and medications, I applaud you; most of your fellow patients, however, don’t. I strongly advocate for patients to read and learn as much as they can about their diseases and drugs they take, but this is not the way to go about it.
I’ll start by bitching, and then offer some constructive suggestions.
What the hell, Google/Microsoft:
This is supposed to be a medical record, right? For use by physicians, right? Because from the looks of it, you want patients to use medical terminology (which most don’t know, use, or understand) to create their medical record. You want people to know terms like “AV Nodal Re-Entrant Tachycardia” or “Partial Complex Seizure secondary to Temporal Lobe Neoplasm” or “Takayashu’s Thyroiditis,” right? Because that’s what I’m expecting to see in a medical record. Often I don’t hear these terms from patients. I hear that they have, in order, “a funny heart rhythm,” “seizures,” and “thyroid problems.” If the medical record was just for public display, like a web photo gallery or a Facebook profile, “funny heart rhythm” would be fine. But I actually use the medical record to diagnose and treat patients, and “funny heart rhythm” doesn’t cut it.
Are we supposed to trust this medical record? Now, I know as physicians we’re not supposed to trust anything we don’t see with our own eyes or done by our own lab or radiology department, but at least in a medical record controlled by a medical team, it’s a health care professional that’s putting information in there, so it’s a little more reliable (but far from perfect, doctors are incorrect too). I see patients that say they don’t have high blood pressure even though they do, and their medical record shows they’re persistently hypertensive in clinic; I see patients that claim they have “high sugars” or “pre-diabetes” when they don’t; I know people who read something online making them think they have symptoms of disease X and just decide that they probably have it. I also see patients with multiple allergies, which aren’t true “allergies” but just “adverse reactions.” The two are very different and have very serious differences.
Should I rely on this data in my management of my patients? Some of these medical records will be great, others will be okay, others will be terrible. How do I know which medical records of which patients to trust? Should we rank patients on their health literacy? What happens if your Google Medical Record lists your blood type as A-, and I give you AB+ blood?
What’s the point of the medical record if it doesn’t provide me with accurate and up to date data? There are subtleties to labs and reports and studies and findings that don’t often get reported to patients, because at the time they aren’t significant or important. (Note: I try to explain as much as I can to patients, but often it’s easier to explain basics.) For example, if a patient has certain changes on an EKG, it can indicate subtle signs of a heart attack–but if they’re also on an older EKG, you worry much less about a heart attack. I don’t want to see something in a chart that just says “EKG normal on 8/8/2007,” I want need to know more. Also, what if a patient forgets to update their medical record for several years, and has lots of problems in the interim? (Now I fully realize that today’s medical records often miss a lot of medical information and are often incomplete, but if people are proposing major changes to medical records, we should probably think a bit harder about this than just lurching forward.)
What if the patient leaves out medical information he or she is embarrassed or ashamed of? I need to know if you use drugs, or if you have sex with multiple partners, or if you have HIV, or if you’ve had STDs in the past, for example. (Yes, yes, I know, if it’s important, I’m still going to ask about it again, but in the current medical record, if we know about it and it’s relevant, we’re likely to know about it up front in the chart, because the chart hopefully contains relevant, important data, not just the data that’s not uncomfortable to discuss.)
(I know I’m going to piss off a lot of people with this post, but I’m truly not trying to be condescending. I know a lot of patients understand more about their diseases than their physicians, and many are very empowered and active. This is fantastic, but the vast majority of patients are not to this level, and I worry about a system which assumes that patients are active to this level, and even have any interest in managing their medical record. Add to this the fact that even growing up in a medical household, I didn’t really understand many medical conditions–and didn’t even understand them as a pre-clinical medical student, either.)
Let’s work this out, Google/Microsoft:
I would love you to be a national medical record. I would love for patients to be able to enter basic information about themsevles and then allow their doctors and hospitals to write notes in them and upload data to them. A central repository for EKGs, Xrays, CT scans, Echos, with full reports would be absolutely revolutionary. Absolutely. There’d probably be reactions from patients who read their doctors’ notes and don’t like the way they’re described “Obese gentleman in no apparent distress” or “Patient denies smoking” (as if we’re accusing the patient), but a system where I could see what other doctors saw would be hugely helpful. We get patients transfered from Nevada and Southern California routinely and often have very little information about what happened to them at other hospitals. Scary, huh?
Help us fix HIPAA. It’s kind of funny–since Google nor Microsoft are health care providers or payers, they don’t have to conform to HIPAA online privacy standards. Physicians, however, have tons of online standards we have to use to access online health information. (Now the question stands, if physicians access these online medical records, will they have to then conform to HIPAA privacy standards?) Please–make it easier to safely protect people’s information online–doctors want it to be less confusing and safer, just like patients.
I’m all for patients learning about their diseases, and facilitating this is great–but let there be a distinction between patient-entered information and physician-entered information. Or allow patients to add comments or extra information to what doctors say.
Those are starting points. I’d love to hear what other patients and health care providers think. As is now the case, comments are open, but keep it civil–constructively criticize my arrogance if you want. I fully admit that I have a doctor-skewed perspective, and I’d like to be educated about things I’m missing because of it. (Please also note that the people that are online that read health blogs are likely pretty highly educated or have health interests, so your own experience is likely not representative of the patients we normally see.)
My thoughts about the ICU, starting chronologically from my first day until now, starting my third week:
Pre-ICU:
Boy, I think I’m really starting to get decent at clerkships–I feel like I’ve got a good grasp of management for most diseases, I can present pretty well, I’m keeping up with the interns on my service. I’ll learn a lot in the ICU!
ICU, Days One and Two: (aka Why Being A Med Student Sucks)
I hate this. I hate hate hate this. I am stupid, I don’t know anything. These patients are too complex! They’re overwhelming! It takes me an hour just to collect data on all these patients! What the hell are all these ventilator settings? All these random numbers? And the numbers keep changing! And there’s like 4 ABG’s drawn every day! Ugh, this sucks! I don’t know how to present, I turned bright red trying to present this patient to the 19 person team, full of residents, fellows, and attendings (no interns, just med students), and my attending had to take over and explain everything cause I screw it all up! And I called LeMierre’s SyndromeMeniere’s Disease and ugh, did I mention I HATE THIS?
ICU, The Rest Of Week One
Well it’s a brand new team of residents and first year fellows, most of which haven’t done the ICU in a long time or ever before, so I’m on more equal ground now. Lectures are starting over with “What Is ACLS?” and “How do I manage shock?” and everyone is getting confused on how to present patients in morning and afternoon rounds. This is muuuuch better. I feel much less like a dumbass. (But still a dumbass.)
ICU, Week Two
Okay, I’m getting the hang of this. Stuff’s starting to make sense. I can round on my patients pretty quickly, get all the relevant data and not fall too far behind. Big picture. Remember the big picture–what’s keeping the patient in the ICU? What are we doing for them that can’t be done on the floor? Why are they so sick? Still getting lots of suggestions for management from the rest of the team, but I’m getting a better hang of things–what needs to be presented and what can just be recorded in the note. The patients are really sick, and really interesting, and man, one patient can be a review of every system in the body. Kind of… cool. (For learning, not for the patient.)
As residency application season rapidly approaches, I’ve gotten into similar conversations with many friends about why they’re choosing a particular specialty, and one particular theme keeps coming out:
In subspecialty outpatient clinics, there’s more time to spend with patients: visits are usually scheduled as 30 minutes long.
In a world where we’re trained in primary care clinics at the pace that our attendings can keep up with (15 minutes per visit) and we’re feeling completely overwhelmed by trying to address the patient’s hypertension, diabetes, hyperlipidemia, peripheral neuropathy, prior MI, stroke, and liver disease (not to mention learning all the drugs and dosages), of course we like the specialties where we have more time to figure out all our patients problems.
(I’d also argue that we got into medicine to help patients, not just cure their diseases–and that medical students, just like residents and attendings, prefer to have the time to get to know our patients as people, not just as the guy with poorly controlled diabetes with hemoglobin A1C’s in the 10-12 range.)
A bunch of people bit my head off on my A Better Way To Round post, assuming that I was ignoring patient communication. Idiot Savant’s comment pretty much sums it up–the point I was making was that because we spend so much needless time rounding, we often lack time for patients, in terms of communicating properly, frequently, and promptly, updating them and them families, doing procedures, etc.
I want to improve rounding so that we medical students, interns, residents, fellows, and attendings have more time for more important stuff than collecting numbers from a computer screen and copying them down multiple times. (Each person in the above list spends at the very, very least one hour doing this. Every. Day.)
Other ideas for improving patient care and communication:
A little notebook and pen for every inpatient. They write down their questions, and when we stop by we answer them. Easy.
For the less acute patients who are needing to reach some goal before discharge (I’m particularly thinking about fluid-retaining CHF patients who need to diurese but go to the cafeteria way too often): A calendar where they can list their daily weights, to motivate them. This could be applied to other patient populations as well.
I miss hearing people’s reactions to my posts! So from now on, comments are on by default (but will generally be off for some certain topics that turn low-quality and low-yield quickly–I think we can all name said topics ourselves).
No offense to the old school, but medicine today is a lot more complex than it was even 10 years ago. I’m not saying that residency was any easier, but there’s simply much more knowledge, information, data, treatments, diagnoses, studies, and procedures that we have today than we did previously. And residents (and medical students) are expected to know them all. Granted we have better technologies to make us more efficient (12 lead EKGs with rhythm strips and telemetry and not having to use suction cups, and computers that spit out lab values, and electronic medical records and digital imaging), but medical school is still 4 years long, and most residency programs haven’t changed in length, either. In the same amount of training time, we’re pimped on which genes are involved in which diseases, expected to keep up with all the new data and trials that are constantly being published, as well as know how to appropriately use new medications, titrate them, and anticipate their possible side effects. We have to be able to do basic reads of CT scans and other imaging. It is a lot to learn. (And at the same time, we can now sustain patients and keep them alive longer, and there’s all the ethical issues that now come along with that as well.)
Let’s say my generation does want a better balance of personal and professional life. (Just hypothesizing for now.) Can you blame us? We’re working just as hard as you old schoolers did in medical school and residency, but our average debt is so much higher! Many of us have also grown up (not me, fortunately) with parents and families who developed their professional lives at the expense of their personal and family lives, and it ended in divorce, frustration, or unhappiness–and we don’t want to repeat the mistake ourselves. And honestly, do you want an unhappy, jaded physician treating you, anyway? (Medical students are on average older now than they used to be, which also leaves fewer years to have a family or develop relationships.)
The 80-hour work week, just like everything else, has its pros and cons–no doubt about it. But who would you want writing your orders, if you came into the ER with chest pain. The groggy resident who’s running on empty, who might just forget the heparin, or might miss subtle ST depressions or elevations?
Or perhaps we’re just an egotistical, self-centered generation who require praise at every turn and who care more about our own happiness than our patients’ lives. (If you’ve met any of my classmates and seen their accomplishments or how they talk about their patients, I’d find this hard to believe.) But why else might our supposed “work ethic” have changed? Could it be the change in the practice of medicine? From an art and a practice to a business? From calling the preson you’re treating “your patient” to “your consumer” or “your client?” From focusing on what’s best for the patient to what’s best “medico-legally” as well?
Just some random opinions, devils’ advocacies, and thoughts.
People have said it before, and will continue to say it, but there’s got to be some better way to collect and review data for medical and surgical teams. Let’s brainstorm and figure this out, people; the current system just ain’t so hot. And if grocery stores and airlines can get themselves electronic and digital, we in the medical world should be able to, too.
I’ll first describe how we collect data nowadays, and then suggest some improvements. I welcome yours in the comments.
“Rounding” is where medical teams review a patient’s course and data over the last 24 hours and decide what to do or not to do. In order to do this, someone has to go around and actually collect the data, see the patient, etc. This is called “pre-rounding.” Currently a medical student, intern, or resident walks around to all their patients, with a sheet of paper in his or her white coat pocket for each patient. You either go to the computer or the chart, and copy down the patient’s vital signs (BP, Pulse/Heart Rate, Temperature, Respiratory Rate, and Oxygen Saturation), labs, and study results from the master copy in the chart or computer onto your dinky little piece of paper. Then you go see the patient, ask how he or she is feeling, if there were any problems or complaints, and examine the patient. (This is usually very early in the morning; you have to wake up the patient.)
You then write a note on the patient, which is a “master copy” that goes in the patient’s chart of everything you’ve just written onto your own sheet, but in a more standardized format and also includes what you’re going to do for the patient based on his or her problems. (Sometimes people just photocopy their note and use that as their pocket reference, but then you end up with a ton of papers per patient.)
Your own little piece of 8 1/2 by 11-inch paper is your lifeblood. It usually lists all of the patient’s medical problems, the medications they’re taking, their intial labs, their story of why they came into the hospital, etc. It also lists all the labs they’ve had while they’ve been in the hospital (sometimes this spills onto a 2nd page if they’ve been in the hospital awhile). If you lose this, you are screwed.
Why do we need this sheet? Because the note we write has to stay in the chart–either electronically or physically. But we also need to have quick access to all the patient’s data throughout the day, in case someone needs to double-check something, or the patient gets very sick during the day, you can recall what happened before he or she got sicker.
Then when you actually round, you sit down with your team (or walk around to each patient’s room) and discuss each patient. You repeat aloud everything you’ve already written down twice (once for your own sheet, once for the official chart note), and discuss what you think should be done for the patient.
It’s an incredibly inefficent system, especially when you consider how busy doctors are and how much time is spent doing it. It hasn’t changed in years–have we been rounding like this since 1900?–and maybe it’s time for a medical culture shock?
The problems:
We need to have immediate, constant access to patient data.
We also need to have a centralized source of patient data and care plans so that everyone caring for the patient can access it and see it.
We need to be able to have access to all data, but be able to filter it or customize it based on what is important to us (a surgeon cares about different data than an infectious disease doctor).
We have to go see each patient every day to re-assess them, see if there were any problems that we didn’t hear about over the last day.
Some ideas:
What if we just wrote a note once, but we could access it remotely? So you would write your full note, in official form, but then on a Palm-pilot device (or even more simply, a Nintendo DS or PSP), your note is also saved onto your own device as well, just in short form. I know, I know, everyone has their own system for how they track patients and labs, but perhaps it’s at the cost of efficiency?
What if we just rounded with a laptop or other wireless device that was hooked into all the other systems? So just one device per team, and you could automagically tap into all the data available at the hospital?
Both systems would allow templates and customization to some degree, so you could say, exclude certain types of data or organize it more efficiently.
What if outside every patient room, a one page, formatted, color-coded summary was shown (password-protected or something). So you could walk up to the room, see if there were any events or complaints, quickly skim lab values and x-rays to see if there was anything relevant you needed to ask the patient about? You would know that all the lab values were already pulled and ready for you, so you wouldn’t have to write them down twice.
Or perhaps the concept of a “note” is the entirely wrong format now that we have technology. (I’m just waiting to hear the cries and screams from the old-school.) Maybe it makes more sense to have a centralized patient “databoard” or “notebook” or “daily summary” that everyone accesses. It would list any new labs (with trends) over the last day, links to Xrays or reports, new complaints, new procedures done and the results, etc. And then from that patient databoard, you build a streamlined note that references the data. Drag and drop. Want to comment on a patient’s rising potassium? The note makes a link to that lab value, and you say what you want to do about it. Instead of seeing what a particular doctor or service would like to do, you could look at the data based on each problem (a high potassium, a consolidation in a chest film) and see what people are suggesting to do based on that problem.
Some of these suggestions are probably just because I’m on a consult service this month and don’t have my own patients, but I’d love to hear your thoughts on other problems with rounding and any ideas for solutions.
He starts out being upset with Medicare/Medicaid for requiring letters about denials for procedures or tests to be written at a 5th grade level–but I’d argue that’s not really too far off or inappropriate. A 1993 study (I know, almost 15 years old) showed 21-23% of adults functionally illiterate, and another 25-28% only marginally literate (equivalent to reading at or below a 5th grade reading level). I’d imagine this is why CMS uses the 5th grade standard–about half of the adult population cannot easily understand language beyond this (scary!). Adults with low literacy are also more likely to be poor as well (43% in poverty vs 4% in povery at the highest levels of literacy). See Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, US Department of Education;1993
Add on to this fact that health literacy is one step more complex than just reading basic information (you have to understand basic things about the body and drugs) and this can add to confusion. We also know that the elderly, immigrants, and the poor are more likely to have poor health literacy, and since those groups are often the people that Medicare and Medicaid serve, I don’t think this requirement is all that outlandish. (In fact, immigrants are more likely to be on Medicaid than their non-immigrant American counterparts.)
If we’re writing things or saying things to our patients that they don’t understand, what good is it to them or to us? How many times does Dr. Rangel–or myself, or any physician for that matter–say something that is so obvious to us that we don’t even realize our patients don’t understand it? It doesn’t even have to be “medical-ese;” just last month I overheard a patient asking about his heart arteries, wondering if they were blocked, and someone answered, “It appears to us that your plaque is stable.” Now, if you don’t know that a “clog” or a “blockage” in your coronary arteries is thought to be due to an unstable cholesterol plaque that ruptures and causes a clot of platelets, you won’t really know how the doctor answered the question.
He then goes on to talk about Medicare Part D (which I’m in agreement with–the implementation was and continues to be incredibly confusing, mostly because it was lobbied to death and one Representative called it “The Ugliest Night I Have Ever Seen”).
Next is the ultimate link to how terrible the world will be and how quickly the sky will fall when “socialized universal health care” takes over. The 5th grade reading level requirement is clearly unfair, since I’m sure he explains sensitivity, specificity, and positive and negative predictive value to all his asymptomatic patients who ask for whole body CT scans. And he’s never seen a patient who doesn’t know what his or her medications are for, or call their hydrochlorothiazide (a diuretic used mainly for blood pressure) a “water pill?” Or just refer to their pills as “the blue one,” or “the red one?” I’m all for encouraging and begging patients to take initiative and learn about the drugs they’re on and the diseases that they have, but you’ve got to meet them where they’re at. If they think they’re taking their diabetes drugs for “high sugars,” does it make sense to go way over their head with the pathophysiology of diabetes and insulin resistance?
I understand where he’s coming from–I really do–but I think it’s more a function of physicians being so entrenched in the medical world that we have no idea what it’s like to not understand medicine or drugs or disease. I think it’s actually almost impossible for us to truly understand the patient’s perspective sometimes, given all our background knowledge that we use and possess without even realizing it. Is it often overly simplified, especially at a 5th grade level? Sure, and this can cause problems, too. I guess I’d rather have all my patients have a basic understanding than some of them have no understanding at all.
He then jumps to this final conclusion, which I’m still trying to figure out:
If you think that you have it bad now with your private insurance company, just wait until the Federal government takes over and must severely limit health care consumption in order to be able to pay for the care of over 300 million Americans. At least your insurance company doesn’t automatically assume that you are 10 years old.
Quick bullet points, because there’s just a lack of understanding of health policy going on here:
The federal government already pays for about 60% of health care costs.
Under most “socialized universal health care” plans, money currently spent for private plans would be diverted to a centralized payer (ooh, scary!). All the money in the system would still be in the health care system.
You’d also gain tens of billions of dollars by simplifying administrative overhead and waste ($80 billion toward patient care would go a long way).
Economic predictions generally show an increase in health care expenditures over the first few years of a universal coverage plan, as folks that are uninsured or under-insured try to go get their health optimized, but this would then settle soon after.
I’d like to hear where your data for the “severely limited” health care consumption is, Dr. Rangel. I’m just not seeing it. Changes? Yes. Problems with the transition? Of course. Severe limitations? I’m just not buying it.
Shadowfax’s hilarious and freaking bizarre story of a guy seeing Christmas elves reminds me of a patient 2 months ago who, when asked if he knew why he was in the hospital, answered, “I’m here for a meat inspection.” He told this to multiple people.
And my roommate’s girlfriend had a patient who, when asked the date, would frequently answer “6007″ for the year.
So, what’s your weirdest chief complaint/response to orientation question? (Comments are open!)
(Update, I take that back, my best one-liner was in the ER awhile back. The chief complaint, which I’m sure the triage nurse got a kick out of writing–since she’d normally just write “altered mental status” was “911 called by roommate, patient was meeowing like a cat in his room.)
Or: Why Lab Results And/Or Your Doctor Is Frustrating You
I find a good number of patients don’t really understand how doctors make decisions about diagnosis and treatment, so I thought I’d try to explain it all out. Here we go.
We’ll start with background knowledge and information. All the information that we learn before we start seeing patients as medical students is there to build a foundation to try to guide our thinking. For example, we take anatomy to understand the body and the relationship of everything to everything else, so that we can start to think about what might be causing someone’s problem. (For example, if you have pain in your abdomen just below the lower ribs on your right side — we call that the “right upper quadrant” or “RUQ” — it leads us to think of things in that area that might be hurting. Not just your liver or gall bladder, but sometimes pneumonias in the bottom of the right lung, the stomach, or the small intestine.) Sometimes the body can trick us, so we have to make sure we aren’t guided solely by anatomy, but it gives us a place to start. (This trickiness is called “referred pain;” if your diaphragm hurts, it can actually cause shoulder pain; if your gall bladder hurts, it can actually cause shoulder blade pain. Curse you, confusing body!)
And that’s just anatomy. We learn physiology, which tells us the rules the body follows to keep itself alive; pathophysiology, which tells us what happens when the body messes up, but still tries to apply those body rules; pharmacology, which tells us how drugs work on cells and organs in our bodies, which drugs to use to treat certain diseases, and the predicted side effects of those drugs.
Like I said, this is all just foundation. As we say, “Patients don’t read the textbooks,” meaning that when someone comes in with a certain type of problem, they don’t always show the same symptoms or problems we learned about initially. Guidance but not absolute prediction. (The “classic” picture of someone having a heart attack is severe chest pressure, clutching their chest with their arm. But very often, people don’t have chest pressure–they may just feel weak, or have difficulty breathing.)
Now one of the hardest parts of medical school is inverting your knowledge. See, when we learn in the classroom for the first two years of school, it’s learning about diseases. But you patients don’t come to us with diseases, you come to us with symptoms. And the damned thing about symptoms is that there’s any number of body systems or diseases or problems that can cause your symptom. Only very rarely does one single symptom let a doctor immediately know the disease. (And of course we have to know the disease accurately to know the treatment, because some treatments can make certain diseases worse if we’re wrong.)
Here’s an example. Let’s take difficulty breathing, or “shortness of breath” or “SOB” as we call it. Here’s a very short list of the causes, based on body system (the real list is much much longer):
… and so on. So when you see a doctor for a certain problem you’re having, we try to tease together parts of your story, and add in your other symptoms, what we know about your other medical problems, what medications you’re taking, your age, your life, and your risk factors for certain diseases to come up with a list of things that we think it might be. It’s all educated guesses. This list that we put together is called a “differential diagnosis,” and it’s ranked in order of likelihood. The minute you start talking to your doctor, he or she has started putting together a differential diagnosis. And as you say certain things, or answer certain questions, that differential can immediately change. Heart attack can go from top of the list to somewhere near the bottom, with heart burn replacing it at the top.
By this point, just with talking to a patient and examining him or her, many common diseases can often be diagnosed, based just on this information. But our top guess on our “differential” isn’t always right. So even if we’re pretty sure it’s, say, hepatitis, it still could be other things. (This is all going on inside our heads while we’re talking to you, hence us sometimes seeming like we’re zoning out or not listening to you.)
Since we believe in “Above all do no harm,” and we generally try to only do things (give medications, recommend procedures or surgeries) if we believe that the benefits outweigh the risks (everything has a risk and a benefit, including seemingly harmless over-the-counter medications), sometimes we need a test to let us confirm that our diagnosis is correct. If you have a classic story and exam pointing toward strep throat, the doctor may just go ahead and prescribe antibiotics. But if the story isn’t exactly right, or the timing is off, or your throat doesn’t totally look like strep, the doctor may order a strep test to confirm that he or she is right.
Of course, my Op-Ed opinion piece for the local NPR station got trumped by another piece on the exact same topic, Health Literacy. Never mind them, I’ll just publish it myself. Enjoy. (Click on the play button to… play.) Or just read along.
I visited an elementary school last week to answer some students’ health questions, and it was fantastic. I was thrilled to see them engaged and learning about their health and bodies–because I have a number of patients who know nothing about their diseases or medications.
Being a medical student gives me a magic power: the ability to instantly recognize my patients’ eyes glazing over, confused or unsure about what a doctor is saying. Doctors these days are under immense time pressure, and often don’t even realize when patients are lost. I’m something of a quasi-doctor: I understand the basics of diagnosis and treatment from the medical side, but I’m still able to take a patient’s perspective and realize when something may be over his or her head.
Part of this poor communication comes from “doctor-talk,” the language that we speak to each other, with such wonderful terms as “diaphoretic” (that just means “sweaty”). (Part of my job as a medical student is to learn the doctor-talk so I can communicate accurately and effectively. It’s *not* to make patients feel stupid or small, although I know it often has that effect.)
Sometimes we forget to switch back into English for our patients. Other times patient confusion is due to cultural factors, poor translation, or a lack of understanding about the body or disease. And even if doctors *do* try to make sure patients understand, guilt or embarrassment make some patients nod their heads anyway.
A major component of this confusion is “health literacy.” People who are not health literate have problems understanding pill bottle instructions or side effects, or even realizing why diseases like diabetes or hypertension are important to control. There are almost 90 million adults in the US who have only limited health literacy skills–that’s more than 4 in 10.
We often see the consequences of health illiteracy in the ER–my future specialty. I may diagnose a patient with a kidney infection, only to find out antibiotics were already prescribed by another ER, but the patient simply isn’t taking them. The communication of “You must take these to get better” got lost somewhere along the line, for any number of reasons. An extra 30 seconds of explanation can often save a patient a lot of pain, an ER visit… and many health care dollars.
We often refer to “futile care” as the exhorbitant costs of sustaining a dying patient, but we clearly deliver “futile care” to young, healthy patients all the time, too–it’s effort just as wasted if the patient doesn’t understand what he or she needs to do to get better (or not get worse). Why diagnose and treat patients if they don’t understand the treatment plan? A magic cancer pill is useless if the patient doesn’t understand how, when, and why to take it correctly. As physicians, we must do better.
But we need your help as patients, too, because we’re in a time-crunched world with lots of sick patients with many problems. Here’s what you can do:
1) Ask questions if you don’t understand something.
2) Write your questions down so they’re efficient to answer.
These are simple solutions, and will help us all in the long run.
In fact, I propose a new health care button for doctors’ white coats, right next to the “Ask me if I’ve washed my hands” one. How about: “Ask me… what the heck I’m saying.”
One of the most obnoxious things about being a medical student is the yearly financial aid crap you have to submit. The FAFSA really isn’t that bad–generally you just type in numbers from your W2 and 1040 for taxes, but boy would it be nice if you could just upload your 1040 and have it auto-fill in the information.
The really obnoxious part is that I have to bother my parents so much about it. I’ll be 27 in two months, but according to the government and my medical school, I’m not financially independent (even though I am) and as such, I’m required to submit all of their financial and tax information, too. A big algorithm then spits out an “Expected Parental Contribution” which I guess is what my parents are “expected” to contribute to my education (which they don’t, and I wouldn’t want them to anyway) and I end up just taking out in more loans. But like I said, FAFSA’s not bad.
My ire is reserved for the bureaucracy and idiocy of the College Board. Yes, they’re the same brilliant folks that brought you the SAT and the scoring errors last year. They’re now in the Financial Aid game as well, using a terrible interface to collect mind-numbing number after mind-numbing number to squeeze every dollar out of your financial aid package (and then they charge you $23.00 for the pleasure of processing it).
They want every number with a dollar sign next to it that’s ever been associated with my family. Numbers from 2005 taxes (which the idiots at the College Board already have from me), the amount of savings in my brother’s savings accounts and IRAs–not just my parents’.
Again: I am financially independent. I do not take money from my parents to help pay for my tuition or living expenses, although the occasional care package does arrive. And I certainly do not take money from my 24 year-old brother in college. The only plus side is this is the last year I have to deal with all of this.
Congratulations to all my friends and classmates who are graduating today. I’m going to miss all of you immensely, even if you’re still sticking around at Stanford. You’ve helped make a difficult 4 years enjoyable. To those of you moving far away, expect a call from me when I’m looking for housing when I interview. No, really.
Okay medical blogosphere, let’s figure this one out (comments are open!). Is there a physiologic mechanism to “breaking the seal,” or is it just a drinking myth? (Breaking the seal, if you’re not familiar with the term, refers to the idea that if you’re out drinking, once you start peeing, then you’re going to have to go urinate every 10-20 minutes after that. “Don’t break the seal!” means don’t start peeing, ’cause then you’ll never stop!)
From Goodman and Gillman’s Pharmacology:
Alcohol inhibits the release of vasopressin (antidiuretic hormone; see Chapter 29) from the posterior pituitary gland, resulting in enhanced diuresis (Leppaluoto et al., 1992). The volume loading that accompanies imbibing complements the diuresis that occurs as a result of reduced vasopressin secretion. Alcoholics have less urine output than do control subjects in response to a challenge dose with ethanol, suggesting that tolerance develops to the diuretic effects of ethanol (Collins et al., 1992). Alcoholics withdrawing from alcohol exhibit increased vasopressin release and a consequent retention of water, as well as dilutional hyponatremia.
Vasopressin (ADH, antidiuretic hormone) causes your kidneys to reabsorb free water molecules, to maintain your sodium osmolality, so knock that out and you’re going to be peeing lots of dilute urine, making you hypernatremic. Combine that with ethanol’s peripheral vasodilation, making your kidneys think you’re hypovolemic (even though you’ve been drinking lots of fluid), and they’re going to try to clamp down to reabsorb all the possible sodium they can… aaand that’s all I’ve got. Maybe it’s just a feed-forward positive feedback relationship with the continued filtering of the kidneys, since they don’t realize ADH isn’t being released? I don’t think it really matters if you stop drinking or not.
I swear I experience this all the time, but maybe it’s just the drunkness and rapid passage of time. I’m stumped.
(Excuse: Was reviewing phys today for Anesthesia which starts on Monday, and boy can my mind wander.)
I went to LUCHA today, a San Jose elementary school, to teach 5th graders about health and their bodies. A friend from college teaches the class and thought it might be a fun, end-of-the-year activity to wrap-up their health unit.
It was lots of fun, questions ranging from “Why do we throw up” to “Why do we fart” to “How come we can live with only 1 kidney” and a bit of everything else. Not as many S-E-X questions as I was expecting, which was nice. It was a good chance to try to explain medical anatomy and physiology to children, which requires a lot of on the spot translating of terminology to their level, as well as including gross-out factors that will keep their attention.
I was very impressed that they all knew what the pancreas was, and the gall bladder, and where the kidneys are, and the chambers of the heart. Nice work, Ms. McGonegle!
Was thinking about technology adoption at the gym today (ahh, the thoughts of a nerd) and how we–especially Americans–use technology. Once a technology becomes life-changing and commonplace enough, it’s almost as if culture changes such that one must use it. Freezers and refrigerators started out as a nice convenience–now food won’t spoil so quickly!–so we now buy food in larger bulk quantities. We lay out our suburbs in huge, vast sprawls of land, because we can all have cars to take us from place to place–because we can, not necessarily because we should. And we now often substitute face-to-face contact with friends and loved ones with phone calls or emails or simply instant messages. Because we can, not because we should. I’m not trying to make the argument that we’re worse off with technology, or that I somehow yearn for the days I never knew when life was slower. Just that once we adopt technology, we feel that it should always be used, as if it is always better than a less technological solution.
And I wonder if we’ve applied the same standard to medical technology, namely, that we can now keep many people “alive” indefinitely. But should we? Are we applying a perverse technological standard to life and death? I’ve seen patients make miraculous recoveries–their bodies just needing a little bit of extra support for a bit while they let the tincture of time do its work–but when are we using technology inappropriately: prolonging death instead of extending life?
I initially had this inspiration to do this neat-o teaching post about Bell’s Palsy inspired by a young patient I saw who thought he was having a stroke, but eh, I’m just not up for it today.
Did start finding some interesting stuff on YouTube, however–will strangers posting their diseases online be the physical findings revolution?
Here’s a pretty severe (and long) case of Bell’s Palsy from Jennifer:
Getting burned is another piece of non-medical medical lingo I will try to translate. To “get burned” is to do something incorrectly, interpret something incorrectly, forget to do something, or to generally “mess up” or miss something, generally leading to Badness. “Badness” is usually either a bad patient outcome, or one that is at least delayed or sub-optimal.
Every attending (translation: every doctor) has at least one or two areas where they have previously “gotten burned.” These are issues that they vow to never, ever get burned on again. Issues upon which they rise to their soapbox and emphasize to those listening where things have gone wrong for them, so that the mistake is never repeated again. I would imagine if you ask any doctor he or she can pretty instantly tell you their burn stories. They are usually tragic, sad, and preventable. There is usually an air to the stories of “if only X, Y never would have happened.” They are shocking, and their foreshadowing is horrifying; we the listeners all realize that we ourselves will get burned in our own careers. No matter how hard we try to be perfect, we will represent, and later resent, our humanity, our imperfection. We will do something that will greatly harm a patient.
Only those in positions of responsibility and supervision are able to truly experience getting burned, as I am starting to realize, given that I am starting to have some actual responsibility. I’m starting to see errors and mistakes in my judgment that have luckily always been pointed out to me by a resident or attending that is double-checking it all, and I’m sadly starting to learn something that may explain doctor behavior and frighteningly my own: trust nothing.
The quick anecdote is such: an intoxicated gentleman comes in, found down, complaining of generalized body weakness for which he has been seen on numerous occasions. Nurses know him by first name, and note that this is his typical course–he comes in, sobers up, leaves. Being astute medical student that I am, I want to rule out Other Badness. Sugar normal, exam normal. I draw labs. Just ’cause. Much later my attending decides we should also get an EKG. Just as it’s printing out and I’m noting the U waves and the long QT, the lab calls with his low potassium and calcium results. Ugh. Had I just decided to get the EKG to begin with, we could’ve caught this much quicker. But I decided, “No, he comes in like this all the time, the nurses see him like this all the time, he’s probably just drunk.” Now, nothing bad happened to the gentleman–we fixed him right up–but I can just barely see other versions of the story, and it’s scary.
I’m sure my paranoia and distrust will only get worse when I have my own medical students reporting to me, but hopefully by that time I’ll have most of my close calls under my belt, without a scratch to my soul.
I’ve received a number of emails asking why I’ve started turning off comments on most of my posts. It’s something of a trial feature at this point, just to see what happens. I’ve been pretty unimpressed with blogs’, forums’, and the Internets’ (political punctuation jab, ha!) commenting/debates/discussions for awhile now, not just on this blog but in general. They usually range from “Wow I agree” to “You’re so wrong” but they never really change anyone’s mind or perspective. Often people don’t even read them, they just scroll down to the comment form so they can feel self-congratulatory that their voice has been heard.
Because it’s so easy to respond and often so anonymous, people say knee-jerk, silly things that aren’t well thought-out, intelligent, or even logical. Even if I do try to respond, there’s no guarantee that the person I’m debating/discussing with will even come back to the post to respond. It’s a low-yield waste of time that really doesn’t accomplish anything.
I’m happy to have an intellectual back-and-forth with people–if you’re interested, just email me.
We’ll see if it takes or not. I admit it’s nice to receive comments, just to see that people are reading and either agreeing or disagreeing with my thoughts–but my blog was never really meant to be a discussion board. Just a collection of my thoughts and experiences as I find my way through medical school. My feelings and opinions aren’t up for public debate. Sorry!
If you have an opinion on something I post, and feel that your voice just must be heard, you’re welcome to start your own blog or email me personally. I’m usually pretty good about writing back.
William Osler, noted physician and noted by many for his truisms, hits the nail on the head with this one:
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”
Talking with a friend who’s moving out here for residency, she told me that almost everyone passes the “Step 2: Clinical Skills” exam, which just started in 2004. Basically, you spend a day seeing standardized patients, writing up your differential and the labs you’d order.
98% of MD candidates last year passed it on their first try, and 97% passed it a repeat try. So out of 16,936 exams, only 10 students did not pass it, and almost all passed it on their first try.
What’s the point of even having a test if everyone passes? Answer: Money.
This of course doesn’t take into consideration that you can only take the test in LA, Philadelphia, Houston, Chicago, or Atlanta, so if you don’t live there, you have to fly there, get a hotel room, etc. That’s at least $500 more right there.
And if you don’t pass? You work something out with your home institution.
Dearest Mayor Newsom, could you please remove the crazy pills from the water?
The ED was like I’ve never seen it last night, just busy to the brim. And on the drive home, 7, yes, SEVEN people ran across the street in front of my car. They were just *asking* to get a PVA.
And to my patient who the deputies dropped charges on and you pulled out your IV and left, after I did all this work-up AND made the diagnosis of hyperthyroidism based on history alone, with a very low TSH and a very high free T4, you really should have stayed to at least get your diagnosis. I was proud of making it, and you’d probably feel better sooner rather than later if you had gotten hooked up with an outpatient provider. Sorry dear.
Random ED terminology I’ve made up (feel free to add your own):
Laction: The act of suturing/stapling/closing a laceration. “Man, I’ve had a lot of laction today.”
Awheezile: Like afebrile, but for wheezing. “Yeah, this patient with asthma was wheezing really bad, but after a neb, he’s awheezile.”
The season finale of Lost was amazing, but could we get some wound eversion for Jack’s laceration repair, TV ER doctor? Hell, that little thing could be dermabonded. And while we’re at it, you might not want to use absorbable, practically transparent suture since those need to come out in 3 days to prevent scarring. Snark off.
Was waiting for the bus to the hospital yesterday in my scrubs (last time I do that) when I walked past a disheveled man sleeping on the street. Had my Ipod on and went up to the bus stop. As I had just picked up a “man down” earlier, I turned around again just to double-check that his chest wall was moving.
Two women yelled over to me, “I don’t think he’s breathing,” and I said, “Yeah, he is, I just checked.” Initially I found this incredibly strange–strangers waiting for the bus never talk to each other. I’ve walked past homeless people sleeping while waiting for the bus. Never a peep from anyone. It’s a social taboo or something. But then I realized: the scrubs. They figured I was some sort of medical person (a doctor, nurse, tech, housekeeper?) and decided to alert someone who, just by the clothes he was wearing, might know something more about dead or not breathing people than themselves.
While I was doing my ride along, I was wearing jeans, a blue polo shirt, and some brown street shoes. No nametag, no ID. I walked into countless ERs and homes and residential facilities with the paramedics, and was never asked a single word about who I was or why I was there. Why? I had a stethoscope around my neck and sometimes latex gloves on my hands. (For one family, they often looked at me when answering questions asked by the paramedic, probably just because I had my stethoscope twisted around my neck.)
Never underestimate the power of the white coat or its accessories.
Very interesting new program San Francisco is doing for its IV drug users–after taking a basic course and getting certified, IV drug users can get 2 bottles of Narcan (naloxone) for if their friends overdose. They’re told to just keep it in the bathroom cabinet and use it if their friends stop breathing or responding.
This was after administrators found out deaths were so high because users a) didn’t want to call 911 and have the cops show up and b) were trying things to revive their friends that didn’t work, like ice baths, hot showers, and injecting them with milk.
As we helped from-the-East-Coast, intoxicated Ray into the ambulance, he began to harmlessly flirt with one of the paramedics, referring to her as Sugar, but slurring his speech through and through. We’d received a “man down” call–our last of the day–after a cellphone Samaritan had been driving by and saw him on his side lying on the sidewalk. The paramedic told him someone thought he was dead.
Ray had been drinking, so he staggered into the ambulance as we took him to the sobering center–basically, a facility with 24 beds and rubber sheet-coated mattresses for drunk people to sleep off their alcohol and get them in off the streets. As we took Ray’s vitals, I started up a conversation with him, asking him what he typically drank in an average day. “I start with a quart of Listerine,” he began, “and then a couple pints of vodka, an 18-pack of beer, and then I mix some Listerine with the vodka so it tastes better.”
“Listerine?” I questioned, probably with much more judgment in my voice than I had wished.
Ray kind of trailed off, and then became tearful as the rig started its engine. He told me of his 18 months in Vietnam–drafted when he was a mere 19 years old–and of the horrors that he witnessed, a few stray tears collecting at the corners of his eyes. Stories of 6 men he had killed, of friends he had loved dearly who had taken bullets to the head from snipers right in front of his face. Atrocities. Terrible things. The other paramedic thanked him for his service to our country. I told him I couldn’t imagine having to go through such a thing, and that no one should have to.
I asked him if alcoholism ran in his family. “No, not anywhere,” he told me. “Not my mother, not my father, not my brothers–nobody. I drink because it’s so hard to forget everything that happened over there. I blame that war.”
He had started drinking after he had returned from Vietnam. “My first night back, me and 8 buddies went to a bar, and do you know what they said to us? They called us baby killers,” he said, his voice quivering. “Baby killers. On my first day back to my country.” He recounted the huge bar brawl that ensued.
Ray’s whole experience hurt to hear. It certainly hurt to know that Ray has been on the streets and drinking for 40 years, and still doesn’t want to quit, and that he had to experience all that he has.
But I think it hurt even more to think that 40 years from now, a medical student will be doing a ride along with the paramedics, harmlessly start up a conversation with an intoxicated gentleman, and will hear the exact same story from a veteran of Iraq.
Shadowed/eavesdropped on calls today at the California Poison Control Center, which was pretty cool. The center here in SF shares the duties with 3 other centers in the state, operating the 24 hour, toll-free number to answer pretty much any question and either make sure people get the right treatment or some needed reassurance. Each state has its own poison control center and the people are incredibly helpful, knowledgeable and friendly–definitely call if you have any questions.
My one experience with it involved my mother making some sort of pasta or tuna salad, while also getting out some hydrocortisone cream for a rash or something, with a tiny bit of the steroid cream ending up in the bowl. Don’t ask me how this happened. I just remember my brother and I freaking out and SCREAMING for her to throw out the entire bowl of food, not wanting our mother to die. She called poison control and they said it would be fine (she’s a nurse so she knew this anyway) but I think we put up such a fit she tossed it anyway. (Or at least she told us she did.) So everyone does silly things, and children eat everything. No matter how silly, it’s no reason not to call. The call centers have heard everything.
Dad: Hi, my child just ate some Play-Doh.
Pharmacist: How much?
Dad: Like half a can.
Pharmacist: Okay, he or she should be fine–
Dad: Oh, wait, nevermind, he just had it in his hand.
Caller: I know this is a line for humans, but my puppy just ate some pills.
Pharmacist: Okay, well, I’d recommend calling your vet. There is a Poison Control Number for Animals, but they charge $55 per call.
Caller: I made some chicken chili last night, and left it out last night. Can I eat it?
Most calls dealt with toddlers eating pills. One “licked the coating off a bunch of Advil and Tylenol.” One important point: Tylenol is actually incredibly dangerous in overdoses–which is hard to do unintentionally in adults–but isn’t so difficult for small children, since overdoses are generally based on weight. Tylenol in overdose has been bad enough to cause patients to go into liver failure and require a liver transplant. Keep pills out of the reach of kids!
Oh, interesting fact: Those little freshness packets in shoe boxes that say “don’t ingest?” They’re just silica, and non-toxic. It’s like eating sand, apparently. (This is not medical advice!) Update from the comments:: Silica gel, the desiccant in “freshness packets,” isn’t always harmless. Sometimes it’s packaged with a moisture indicator and some of those are quite toxic.
Panda commits an error probably all too common for ER physicians: patients are how they are because they are who they are, and their situation and environment has but a small impact. Fundamental attribution error well at work.
Mr. P. Bear believes that doctors are helpless to help their patients and improve their health outside of the hospital or office–and even argues that advocacy work somehow “dilute[s] the only real authority they [doctors] have, the authority to make medical decisions on behalf of the small subset of the population who are their actual patients.” (I swear, Panda and I are opposite ends of a magnet.) To say that physicians are powerless to improve people’s lives is laughable, ridiculous, and more an effort to ignore our responsibility to do so than anything. Distributive justice is one of the four pillars of medical ethics, and I don’t know how Panda can so quickly write it off. I don’t care how hard we work, we are our patients’ advocates, and we should be demanding that they receive not only the best care possible but that they should have healthy environments outside of the realm of doctor’s office or hospital.
Panda Bear says “We have no special powers of persuasion denied to the general population… we are not magicians.” I beg to differ. The Cochrane Database reports that even “brief advice” from a physician increases the likelihood that a smoker will quit smoking, leading to a absolute reduction of smokers by 2.5%. If you consider all the cost and suffering continued smoking will cause, that’s not bad for “brief advice.” We are seen as knowers of the body and authorities of health. When doctors talk, patients do listen. It’s like when my dental hygenist puts the fear of god into me for not flossing enough and threatening me with a deep cleaning: she knows about oral health. I listen and try to change my behavior. (Flossing daily now, thank you very much.)
Doctors’ beliefs and advocacy does not fall on deaf ears. When doctors speak, people are happy and eager to listen. Often it is the opposite–they know that doctors’ time is valuable and rare, so any issue that physicians choose to spend their time on is even that more important. One of the great memories that has driven me through med school is a meeting with pediatricians, Chicago aldermen, and researchers at Children’s Memorial Hospital in Chicago. The pediatricians were upset that lead levels in many communities were on the rise, and wanted to bring the issue to the attention of the aldermen. They knew that no, they couldn’t go into their patients’ houses and make sure that they were eating healthy, balanced meals, but they also realized that their patients were being affected by an environmental hazard that lowered their IQs and made them chronically ill. So they decided to do something about it.
Who are people going to listen to on health matters? A physician, or an individual parent or patient? If you say anything but the former, you’re kidding yourself. We have so much power and influence when compared to most of our patients that to not speak for them is an injustice and an abdication of our responsibility as physicians.
Can we fix everything about our patients’ lives? Of course not. But are there areas where we as physicians can truly make a difference? Absolutely. Just because we can’t do everything doesn’t mean we shouldn’t do something.
Back in 2nd year of med school, I thought learning about tertiary syphilis was rather silly. I figured people would definitely get treated once they had a chancre or any signs of secondary syphilis. (Speaking about US-only right now.) Turns out patients don’t read the textbooks, and don’t live in my little imaginary medical bubble world. Life always comes back and bites you on the ass.
About two months ago, I open up a chart and see: “Patient here for lab results positive for neurosyphilis.”
Graham’s law: The disease you don’t study, or decide that you’ll read about tomorrow is the disease a patient will come in with today. It’s happened to me so many times I’ve lost count. Always makes me read that one extra chapter, ’cause I figure I’ll get burned if I don’t.
Another year, another reason not to get sick in July. That’s right, it’s the guide to clerkships/rotations/clinics/whatever you wanna call it. (If you’re not there yet, you should be reading Graham’s Guide to Boards.) Probably not worth reading if you’re not a med student.
Let’s begin at the beginning.
Get used to feeling stupid. I often forget this fact, but when I remind myself that I’m supposed to feel this way, it’s much less damaging to the ego. Every first week of a new clerkship, you will feel like the biggest dumbass in the world. You will make boneheaded mistakes, be totally overwhelmed and confused, and will often feel very alone, like you are the only person that has experienced this. It is not the case. In the pre-clinical classroom, you learn by memorizing. In the clinical classroom, you learn by experiencing (or at least, I sure do). And you learn much better and faster. I think part of the reason you pick up things so quickly is that there is so much to learn on each rotation that your brain doesn’t have any other choice. Back to my original point–it is okay to feel this way, so don’t let it get to you. You have residents who do this thing night and day, and attendings who’ve done this thing for 30 years, who argue about minutae for fun. You’re not going to be at their level any time soon, don’t sweat it! (Note: most of this is internalized stupidity or ignorance–in no way do I think anyone else should be belittling you or making you feel shitty. I had a jerk surgeon who humiliated me in front of the entire team my very first week, presenting my very first patient ever to an attending, but I felt much better when the entire team told me his behavior was uncalled for.)
“You gotta do your job.” I stole this quote from my surgery chief resident. Don’t half-ass your way through clerkships, do at least what is expected of you. If you don’t, you’re just making even more work for your already-overworked team.
Be enthusiastic. This goes ridiculously far, especially in your first 6 months of clinics. You may not know anything, but showing interest and trying counts for a lot.
Do. Not. Lie. Your attending or resident will ask you a question about a patient–because either you forgot to mention it in your presentation, or they’re curious, or they want to make sure you didn’t miss something, or I guess sometimes to pimp you–and you will be tempted to think “If I just say that there were no carotid bruits, then at least they won’t think I’m stupid for not checking them”–but just don’t. “There is nothing I hate more than liars,” quoth my Surgery clerkship director. “I can teach people that forget things, but I can’t ever trust liars.” Just be honest! Say “I forgot to check that, but I’ll make sure to right after we’re done” and jot it down. Or if you can’t remember what the patient said or what you found on exam, just say so. You’ll gain trust and credibility, because they are expecting you to miss stuff. You’re just beginning your training!
Be professional. What does that mean? Professionals put others’ interests (usually patients’) above their own. That means being on time–always–being appropriately dressed, being respectful of colleagues and patients. Figure out the team’s level of fun/sarcasm/joking/crudeness and don’t go past it, I’d say.
Ask questions. If you’re confused, or are lost, or need help, ask. It’s not a sign of weakness, it’s a sign that you’re thinking through things on your own. That being said, there is a time and a place for asking questions. “Which one is the superior mesenteric artery” is probably not best asked when your attending is screaming for suction ’cause he’s just hit said vessel.
Be aggressive, and ask for responsibility once you think you’re ready. Maybe I’m just a gunner here, but the clerkships I’ve enjoyed the most have been the ones where I’ve actually felt like I’ve contributed to the team. The worst ones have been me shadowing fellows or writing H&Ps that the intern or resident is going to basically write again him or herself. You’re paying a pile of money to work, you might as well get something from it and “help people” finally–isn’t that what you put on your med school application?
Clarify stuff up-front. If you don’t know if your attending likes long thorough presentations (medicine) or short’n’sweet ones (surgery), ask. You won’t waste their time, and you’ll need to learn how to present both types, anyway. (Presentation types to master: the one-liner, the consultation request, the 3-minute, and the 10-minute.)
It doesn’t matter what you take first. I know surgery residents who took surgery first and matched just fine, just as well as surgery residents who took surgery toward the end of their first year. It will not kill you. The earlier clerkships will expect you to have more pre-clinical knowledge, while the later ones will expect you to have more clinical knowledge. It all balances out.
Certainly not least: MAKE TIME FOR YOURSELF! While it’s great to go above and beyond, don’t stress yourself or drive yourself crazy. Clerkships are rough because you’re expected to learn clinical medicine, manage patients, and still be studying once you get home on both your patients’ conditions and the clerkships’ classic diseases, too. Do your best to find a balance. Make time for your significant other, if you’re lucky to still have one by this point (cynical much, Graham?), try to get together with friends once every week or two, go out, live. Appreciate the time you have outside of the hospital–clerkships really make you do this.
The transition to clerkships can be rough, and at times, very lonely. You go from spending every moment with your classmates as a preclinical student to being thrown around different rotations at different hospitals with different schedules. You often lose your support network, because they’re all busy, too. Lean on non-medical friends if you have them. They’ll enjoy hearing your gross stories about doing rectal exams and weird diseases you’ve seen, and you’ll get a chance to catch up with them.
I’m pretty sure one of the best parts of graduating from medical school (or, at least, being in your final year) is never having to file Financial Aid paperwork.
FAFSA isn’t actually all that bad–it’s mainly just typing in numbers from your tax return, but the “College Scholarship Service” application is ridiculous. “How much change do you currently have in your pocket?” I’m not that far off.
One of the most annoying things is the fact that I have to bother my parents with this crap. Although I have been financial independent (translation: racking up debt) since 2002 when I graduated from college, to the Financial Aid department I am not officially “independent” until I’m 30. It’s red tape crap so they can give me several thousand dollars more of loans, since there’s an expected “parental contribution” that I have to borrow money for to pay off.
I had the pleasure of talking with Atul Gawande last night at a mutual friend’s house while he was in town to do a book reading for Better, his new book. (Coincidentally he has an Op-Ed on the Walter Reed situation today in the NYT.) Although I haven’t read it yet, he read some excerpts, and they were fantastic.
I was kind of nervous to talk to him at first–he’s quite an amazing figure, being a surgeon and excellent writer (not to mention he’s a freaking MacArthur Genius). We got into an interesting discussion after I had asked him about his articles and their influence on people–I, for example, was sure he wrote his Geriatrics piece in the New Yorker to raise awareness about our unpreparedness for the aging population. He pretty much said I was wrong: everything he writes he writes because he wants to understand it, and writing is his way of thinking his way through things. He doesn’t write to make change, more because he has found an interesting paradox that he wants to understand. He said he doesn’t want his writing to “do bad,” and if it does good, it’s a bonus–but that in general he didn’t think that people reading an article is really the way that change happens, anyway. (He said, however, he believes that his Center for Surgery and Public Health, however, does have a role in implementing change–he would like to develop a “Surgical Apgar” score to finally get basic reporting data from surgeons so they can measure themselves and learn how to improve.)
It was at first disheartening to hear that this Genius grant Harvard cancer surgeon award winning book author who gets asked by the New York Times to write Op-Eds doesn’t write to change or improve things–especially when so much of his work is focused on why we fail, and how we improve. But I guess I can somewhat understand his claim. It’s much more fun (and less frustrating) to think through a problem and try to figure out why it’s happening than it is to propose a way to fix it. He said one of his goals in writing is to show that “the world is more complex than most people think it to be,” and maybe that’s in part why proposing solutions is so difficult. And maybe it’s easier to keep writing with a simpler goal in mind–understanding the problem–than fixing it. If you advocate for a fix all the time, and nothing ever happens, I can see it becoming frustrating.
Sometimes I wonder if my efforts in educating/advocating for health care reform would be better spent in another venue besides my little home, home on the web–or similarly to Atul–just educating people about a problem, without proposing a certain solution. I guess for me, however, it always feels like I’m just complaining if I don’t propose some way to fix the problem at hand. But then again, I’m no Atul Gawande, who has a way of discussing problems with such curiosity that he can get away with it much easier than I can.
I’m getting really sick and tired of the media’s portrayl of Cho as a mentally-ill individual and all the following of “leads” from his psychiatric hold and the fact that two girls complained about him to police.
People with mental illness–and that’s 1 in 4 of Americans–are NOT dangerous. Even schizophrenics, those with the classic disorder that comes up when someone says “crazy person”–are NOT dangerous. They are suffering, sick patients. Did you know that the prevalence of schizophrenia in the population is about 1%? That’s 2.2 million Americans. If schizophrenics are so dangerous, we should be expecting to have about 2.2 million more school or workplace shootings sometime soon. (t’s absolutely important that if people need treatment, they get it, and there’s follow-up to make sure they’re getting it.)
Are there exceptions to the rule? Of course. Was Cho a very sick individual? Absolutely. But if we take aggressive, radical steps against every student or person who gets evaluated or placed on a psychiatric hold, we’re going to be hurting a huge number of people based out of fear and ignorance–and wasting a lot of time, money, and energy in the process. Terrible things happen in the world, and I’m sorry World, but there’s not always someone to blame.
Mental illness often reveals itself in the late teens and early 20s, and it’s often genetic. It takes a terrible toll on patients–they go from functioning in the primes of their lives to becoming isolated, lost, and removed from the world that they know. Imagine for one minute that you’re schizophrenic. Voices from inside your own brain tell you things–they’re so real that your brain’s auditory centers actually light up as if they’re hearing things. They tell you terrible, horrible things, 24 hours a day. That you’re a terrible person, that the police are coming for you, that you’ve done something terribly wrong. Want to know why schizophrenics so often are wearing headphones or earplugs, or are singing to themselves? They’re trying to find some way to drown out the voices that speak to them all day long.
These people don’t need our judgment and punishment, they need our compassion and help.
One of the most amazing things that I read after the killings in Pennsylvania at the Amish schoolhouse was the Amish reaction. It brought tears to my eyes, and overwhelmed my heart.
They forgave the gunman. They invited his family to their own wakes and ceremonies for grieving.
I don’t know that I could react in such a way–especially so quickly. To be in the position of choosing revenge and anger–or on the other hand, forgiveness–is an incredible position of power. And to choose forgiveness is one of the most selfless and freeing acts we have left.
My heart goes out to everyone affected by today’s tragedy in Virginia.
I am so very, very disheartened that the world has lost Kurt Vonnegut. I’ve read almost all of his works, and his book God Bless You, Dr. Kevorkian — readable in 20 minutes — is such a beautiful highlighting of humanity that it’s thus far my favorite book of all time. I actually just re-read it again last week after feeling down and dejected, losing a young man that we coded earlier.
Vonnegut greatly influenced my perspective and world view, or at least gave words and sentiments to my thoughts about the world and how humans should treat each other. With that, I leave you with some of my favorite quotations (many from my favorite book):
“We are here to help each other get through this thing, whatever it is.”
“I am a humanist, which means, in part, trying to behave decently without expectation of rewards or punishment after you are dead.”
“So it goes.”
“One thing which Uncle Alex found objectionable about human beings was that they seldom took time out to notice when they were happy. He himself did his best to acknowledge it when times were sweet. We could be drinking lemonade in the shade of an apple tree in the summertime, and he would interrupt the conversation to say, “If this isn’t nice, what is?”"
And Vonnegut wrote for his own Epitaph:
“THE ONLY PROOF HE NEEDED
FOR THE EXISTENCE OF GOD
WAS MUSIC”
Us medical students don’t date attendings. Especially for 3 years. I know some classmates who’ve dated residents, yes, but aged 50+ year-old attendings? Uhm, no.
It always upsets me when someone goes along and reveals their bigotry to me–”I so wanted to like you,” I say to myself. “But my respect for you just went down the drain.”
Scalpel tells a story of two patients who needed abscesses drained. One a child, the other, a gay man. He then proceeds to compare how the child reacted (very tolerant of the procedure) with how the gay man reacted:
He tolerated the procedure like, well….
John Edwards.
I gave Scalpel the benefit of the doubt. I figured, there’s no way in hell he’s calling his patient a faggot, is he? Honestly? Maybe there’s some new big campaign to label John Edwards as a coward, or weak, or a wimp or something?
But no, in the comments, a reader challenges him on the point, and he doesn’t deny it. His reaction? “Well, I’ll probably keep posting anyway. Y’all can come and go as you please, I don’t mind.” You might as well just delete John Edwards and type faggot, Scalpel. We can read between your lines.
Should I begin with the fact that a so highly-educated and seemingly intelligent physician can be such a bigot? Or maybe I should replace faggot with the n-word, or some other derogatory slur and see if it’s still okay? Or how about the notion that faggots like me are just as tough and brave as any other person out there? (And if you’re in Scalpel’s camp, drop the stereotypes and meet more than your one gay acquaintance.) Hell, we’ve probably faced more harassment, hatred, and violence (from people like Scalpel) than he ever will–just for being who we are (Please correct me if you’re not an upper-middle class white male, Scalpel.)
I guess the silver lining of it all is that at least we get to know Scalpel’s true feelings. Apparently it’s still okay to be derogatory to a gay person, so he’s fine telling the world how he feels about them. I wonder what he thinks of black people, or Latinos, or the poor, or women. We’ll probably never know.
It’s sad to think that Scalpel has never met a gay person that has corrected him, put him in his place, or has made him change his perspective. I’m sure Scalpel actually knows plenty of LGBT people; they’re probably among his friends, family, and colleagues—but they all know what he thinks of faggots, so they know not to reveal themselves in his company.
Scalpel has the right to say whatever he wants, but we also have the right to object and take a stand. Do I think it will make Scalpel change his perspective? Not at all. But it’ll at least show him that he is in the minority, and that his bigotry is stupid, ignorant, and unprofessional. What a terrible face to give Emergency Medicine physicians and the profession in general.
I hope you’ll agree, and post your own reaction on your blog or the comments.
Have you ever read a comment someone posted on your blog, and then they double-dipped and turned it into a post on their blog, so you decide to triple-dip and post their comment from their blog from your blog back onto your blog?
I was intending to be snarky with my “Get Out of My ER” title, as I am far from the jaded, paternalistic assholery that would say such a thing. I got lots of great responses, everything from the short and sweet to the longer explanation to the scolding for ignoring a possible influenza to the “don’t do that you’ll just make trouble for yourself.”
I think Nick’s wins, or is at least the closest to what I try to do. I believe as ER professionals we’re not only supposed to evaluate, treat and determine dispo, but we’re also supposed to educate–all physicians are. We know the most about the human body out of the entire society, and it’s our job to not only provide education about the body, but also about normal and healthy.
This mostly happens seeing pediatric patients, and often it seems that the pediatric ER visits are frustrating for all parties involved: docs, nurses, staff, parents, and the kids themselves. Kids are, in general, healthy and resilient. And most pediatric ER visits that I’ve seen are in general, healthy.
These kids are fine. They have a cold, or a GI bug. They are eating well, peeing and pooping fine, they’re active and well-hydrated. Their vitals are all stable. Sometimes they have a fever.
These are kids that will, in general, do fine at home, or at the very most, need a sick child appointment at the pediatrician. It’s not an emergency. It’s not life-threatening.
Have things changed? Has it always been like this? If not, where’s this coming from?
Or how about the breakup of the extended family unit? When you don’t have grandparents around or aunts or uncles or friends with older children who can re-assure a parent, maybe they’ll take them to the ER more often?
Or lack of access to pediatricians? And maybe lack of health insurance? More and more patients tell me that the advice nurse in the pediatrician’s office told the parent with the kid with a cold and a 101 fever to go to the ER, since the pediatrician was booked solid for the day.
The “I want it now” culture? An inability to just let a child be sick for a week or 10 days? An inability to be patient?
Cultural norms? I read somewhere that seeing a doctor in Latin and South America generally means spending hours in a waiting room, so it’s perfectly normal to just go to the closest, most accessible doctor instead of calling one’s pediatrician to schedule an appointment.
Lack of education about what are normal things for a sick kid to do, and what are abnormal ones? Maybe it’s just that the population has grown, and we haven’t kept up to provide the resources to educate them all?
Sometimes I wonder if it wouldn’t be more efficient to have the triage nurse take a kid’s vitals, and watch the kid in the waiting room, and if he or she looks fine, suggest heading to the local clinic–the wait is probably shorter, anyway.
(All of this is spoken from a non-parent of course.)
Just to point something out that people are confusing: Walter Reed is not a VA Facility. It is a Department of Defense Army Hospital.
And honestly, I would be incredibly surprised if private hospitals and insurers aren’t just as bad with data loss as the VA. And of the 5 hospitals I’ve rotated through, the VA has had the best security (translation: the most annoying passwords) of any place I’ve been. Is it perfect, not at all, but its rankings and quality and satisfaction scores don’t come from thin air.
We’re seeing many serious cases of engagementitis recently, with at least 5 classmates becoming fiancé-positive lately. It’s freaking me out. We should really start checking the water, cause I’m seriously missing out.
Stanford lost an excellent teacher, anatomist, and physician earlier this week, and all the students are pretty shaken up about it. Dr. Larry Mathers died at his home on Wednesday night. He was one of our three anatomy professors.
I never really realized how much we all bonded over anatomy class–it’s an experience in its own right, but one that the class experiences together. Everyone is present for the class, and we all process it at the same time. Passing the final is probably one of the first big accomplishments of medical school. As you get older in medical school, everyone has different attendings–often your friends will have never met the attending you had, but every single student knew Dr. Mathers.
His primary work was as a NICU attending, but he also found time to teach us anatomy. He would always have little tidbits of information you couldn’t find in a medical textbook that made the anatomy more interesting and more relevant. His one-liners during class were the driest, funniest bits that would send the entire class into a belly laugh (I’m trying to find a clip). He was also the man who really set the tone for the class. I remember the very first day him discussing the fact that it was okay to joke and laugh while in anatomy lab, but to always respect those people who donated their bodies so that we could learn from them. We then paused for a moment of silence. We did the same a few weeks later on the anniversary of 9/11.
Here’s a photo of him judging our annual Anatomy Halloween Pumpkin Carving Contest:
And another of the Anatomy professor team on a trip we took to the wine country (I was lucky enough to be chosen as an Anatomy TA my second year) (from left to right, Ian Whitmore, John Gosling, Larry Mathers, and John Dolph):
Dr. Mathers was also an incredible jazz pianist, and would often be found playing in the atrium of the hospital for the patients. It always warmed the sterile walls when he played, and patients would gather around with their immunocompromise-masks or IV poles in their robes or pajamas to hear him play.
You will be so very missed, Dr. Mathers, and anatomy will never be the same without you.
Not really spoilers, but just a warning before my rant, so look away!
Tonight’s episode featured several residents and attendings performing CPR on patients, and boy did they do it wrong. Normally it’s fun to get mad at the medical dramas for their medical inaccuracy, because we medical folks know better, but I honestly think the producers and medical consultants for the show really did viewers (and the public at large) a disservice, as CPR is one of the areas of medicine that the public may be called upon to perform
20 million people watch the show (and that’s just in the US), and with no change in the plot, timing, or dialog, the writers, directors, and actors could have been demonstrating proper CPR technique. They got the ratio of breaths to compressions wrong, and they got the speed and force of compressions wrong, too. According to the 2005 guidelines (click the image for a full-sizer) , you give 2 breaths per 30 compressions (they did 2 breaths per 5 compressions), and you should be pushing hard, moving the chest wall. You should be trying to mimic a heart rate of 100–that’s almost 2 compressions a second. The 2 codes that I’ve seen have not been pretty; they’ve been violent, frantic, and aggressive. People performing CPR generally can’t keep it up for more than a couple minutes: it is exhausting.
So rather that demonstrate what it should look like when a real person is actually performing CPR, they demonstrated the wrong technique in a watered-down version. I hope to God that if a viewer has to perform CPR in the future, he or she doesn’t use Grey’s as their refresher course or example.
Update: Oh no! Dr. Karen Pike is the medical consultant, she’s an ER doc, she lives in the Bay Area, and she graduated from Stanford’s ER residency! Busted!
Okay, yes, it’s the caffeine drug reps, and it’s not free, but I predict that vending machine will get plenty of business. (If you don’t know what those drinks are, they’re “Energy” drinks full of caffeine and sugar, like Red Bull.)
Over 90 million of us have poor “health literacy”–that is, we don’t get what the doctor is talking about when he or she slips into medicalese. The linked article goes into strategies doctors should use, but I can’t believe this one was recommended:
Doctors should use plain language, not medical jargon, vague terms and words that may have different meanings to a lay person. They should say chest pain instead of angina, hamburger instead of red meat and, “You don’t have H.I.V.” instead of “Your H.I.V. test was negative.”
This is part of the reason that medicalese is confusing, but saying “Your HIV test was negative” does not mean the same as “You don’t have HIV,” and honestly, especially in a case like HIV, with false-negative windows of several months, it’s scary that that’s being recommended.
Whenever you do a test in medicine, there’s a chance that the test won’t catch whatever disease you’re looking for. This is called the sensitivity of the test. While we try to make sure our initial tests are sensitive ones, sometimes they miss things for any number of reasons.
So when a test is “negative,” that means the test didn’t find what you were looking for. If the test is a good one, it usually means you don’t have whatever disease or condition they were looking for, but it doesn’t always mean that you don’t have it–just that the test missed it.
Is this confusing? Yes, but I don’t think we should be jumping to false conclusions with patients just to simplify things.
Big name bloggers like Orac and Dr. RW and KevinMD are all up in arms about how “medical schools are going the wrong way” and asking “Does anyone in academic medicine care about the integrity of medical education?” They like to talk about the fluffy “woo” of medical school, as if we’re all hippies out in our commune who have sacrilegiously sacrificed our Evidence and Data to a golden cow.
Give. Me. A. Break.
They’re whining as if this is the most scandalous thing to have happened to American Medicine. Are you kidding me?
This is the same American Medicine (and academic medicine) that has played a part in the Vioxx scandal, who often have so many industry ties to their work that it’s hard to know if anyone is objective anymore. This is the same medical system where doctors at prestigious medical centers install medical devices and get a kickback, where doctors (academic and non) get paid big bucks to sign their patients up for clinical trials, and get flown to lavish vacations for industry-sponsored “education.” (I could dig up more examples if you really want.)
I’d ask these bloggers: Does anyone in medicine care about the integrity of medicine? If they don’t do any of these unethical things, great, but if you’re that upset about “integrity,” why not take a stand and try to change the system?
First off, do I believe in “Complimentary” or “Alternative” medicine (CAM)? I can’t say. It hasn’t been studied enough. Does this mean it doesn’t work? No. (I also realize this means that we can’t say it does work, either.) My own experience with acupuncture was that it helped my back. But I think some parts of CAM make sense: eating healthy, local foods, more produce, less processed foods. It’s extremely granola, but the American diet is so far from that, that a little overcompensation is fine in my book.
Either way, many patients use CAM, whether I think it’s a good idea or not–and honestly, I’d much rather have some sort of idea about what CAM is and what I need to know about it than be ignorant of it completely. Some herbs affect medication dosages, for instance. While I’m not ready to go advocate for my patients to take Chinese herbs for their liver failure, I unfortunately don’t get to control what they do in their own free time. I’d prefer to meet the patient where he or she is at than write them off or be ignorant when they ask me a CAM question. (And yes, Western Medicine is still lacking in the “cures” department–if a placebo effect helps someone, should we honestly ruin it for them if we don’t have anything better to offer?)
You know, it often comes back to the Almighty Dollar in many of these cases. And while I don’t think that most CAM people are in it for the money, the money is clearly there–people spend billions on CAM and vitamins and supplements that probably aren’t doing anything for them.
But if the CAM folks are in it for the money, who can blame them? What has American medicine (and by that, I mean doctors) focused on? Money, money, money. Specialists now try to do more procedures. Why? We put stents and devices into people all day long, sometimes without evidence or data of better outcomes. Why? Money.
There are many things in American medicine that disturb me. Is teaching a future doctor about treatments that aren’t proven bad? I’d say yes. But is that the worst of our problems? Hell no.
(PS: Did no one in medical school learn anything that turned out to be totally wrong, or totally bad for a patient? I know I already have.)
It’s funny what people can live their lives with thinking it’s just normal–that everyone operates on the same assumptions. If it’s always how it’s been for you, how can you know any better?
Three patients reminded me of this fact.
The first is a teenage Russian mother. Her 4-month old adorable little baby had a terrible case of eczema. She was seen in the ER a week ago, given some medications, and told to get a pediatrician at a local clinic. A week later, she shows up in the ER again. For the eczema. There are mutterings and under-the-breath annoyed words spoken–what the hell is she doing back here with her baby’s eczema? This is not an emergency. We ask her why she didn’t go to the clinic, as instructed, and she says, “I went there and they said I was going to have to wait 3 hours.” We say, “Well, yeah, you’re going to have to wait, it’s a clinic. But if you make an appointment, you’ll be able to get in faster.” She kind of nods, and we kind of stand there for an extra beat, hoping she gets it. We re-iterate to her that we cannot manage the kid–she needs to see a dermatologist, and get a referral from her pediatrician. Once we explained how referrals work, I think she figured it out.
My instincts were to think, “What, is she stupid, does she not understand how doctors work? Does she not realize this isn’t an emergency? Is she just lazy and abusing the system?” But the more I thought about it, I think she just honestly didn’t know how the medical system works. She didn’t know how to get care, or how to get a pediatrician, or get help for her baby, so she went to the one place she knows there will be doctors: the ER.
The next is a 30-something administrative clerk at a law firm, with an exquisitely tender ingrown toenail. Ouch. She tells me she gets these rarely, and I ask, “How rare is rarely?” and she shrugs, “Oh, about once a year or so.” (She usually gets a pedicure, but was too busy with the holidays to get one this year.) She has special clippers to prevent it from happening. She is bewildered when I tell her that I think that’s pretty frequent–that most people don’t get them so regularly. “They don’t?” I tell her there are ways to remove the nail matrix causing the ingrown toenail, and suggest she ask her doctor about it.
Again: she’s had ingrown toenails since she was a kid, and just thought it was your normal, everyday thing. Maybe her family had them too, so the notion was enforced. (This also supports my theory that “All families are weird,” because you’ll hear someone describing what traditions they do for Christmas, or birthdays, or whatever, and you think it’s totally bizarre because it’s not how your family does things.)
The last is a 24 year-old student with a chronic cough. He’s got a pretty good family history of atopy and a brother with asthma. He describes the coughing fits as generally after exercising, like running on a cold day–but sometimes even after weird things like drinking a Slurpee too quickly. They last for a good hour or so–but as far as he can remember, he’s had them his whole life.
Now you may be thinking that these patients are just uneducated about their disease, or don’t have a whole lot of medical knowledge or background. But this last one is nothing of the sort. Turns out he’s a medical student. Turns out his father is a doctor. His mother is a former nurse.
Turns out that it’s me, and my cough-variant asthma.
I had no idea–no freaking clue–that other people didn’t cough and cough and cough like me–I just thought that was normal human behavior, a normal reaction to exercise, or cold air, or… Slurpees. It wasn’t until I was reading about asthma that it finally hit me, Mr. Medical Student.
Don’t make assumptions about what you know, what you think you know, or what you think your patients know. Educate, educate, educate, and if something doesn’t seem “normal” or “right,” there’s probably a good reason (or maybe you’re the weird one, and there’s no good reason at all).
In the spirit of belated New Year’s resolutions, and the fact that I’m way past gay fat, and on my way to straight fat, I hit the gym today, and boy did it feel good to exercise again. I go through these cycles q 3-5 months, as I eventually will pull something and need to take a break and then just get out of the habit. But better late than never.
Go do something healthy today!
(I also believe in not being a medical hypocrite: if I’m going to tell my patients they need to find time and energy to do something — eat healthier, exercise, stop smoking, stop drinking — I’ve got to put in my own effort, too.)
If you’re not aware of it, just like everything else, the poor get disproportionately screwed in the health insurance world–as well as the health care one. (”The rich get richer, the poor get sick.” )
An intern I was working with mentioned that he had a friend doing an elective in Africa, and that there, without the medical infrastructure, there’s no such thing as a doctor or hospital that keeps track of a patient’s medical record.
The patient must keep track his or her own medical record; otherwise, the patient is assumed to be a new patient, with no medical history whatsoever.
Not saying we should switch to this system, but I think it’s just an interesting thought experiment to how it might change the healthcare system–patients would likely be forced to know more about their own medical conditions, which I think would be A Good Thing; currently it’s not uncommon to have a patient come in with 20 different medications, and they have no idea which pill is for what, or don’t even know what their diagnoses even mean.
Thought: Weird that many people get all active and knowledgeable and support groupy when they have a diagnosis of Cancer, but not when they have a diagnosis of Coronary Artery Disease, Congestive Heart Failure, or something else more/equally deadly. (Or maybe that’s just a false notion, but it sure seems like it.)
The Governator announced a “Universal Health Care” scheme. It’s “in quotes” because I’m, to say the least, “skeptical.”
First up we go with Ezra Klein’s post–I was really waiting for him to post something on this, and he finally got around to it. I should link to his stuff more often. I like Ezra’s analyses, and he just posts so damn much, I can’t keep up with it all. Ezra’s roundup is nice, but he gives the governor too much credit. Ahnold’s 4% funding plan will never pay for itself. (But okay, I like the community rating too. This means that insurance companies could only determine premiums by age and location, not other factors.)
The somewhat-obligatory, of-course-Graham-will-post-this piece from Don McCanne, single-payer advocate and former-physician turned health policy wonk. Rips apart the 4% funding scheme. Shout out to my man Don, strong work.
My favorite thus far (sorry, above 3!) is this one, by Sentinel Effect, a blog I’m not familiar with, but maybe should start reading more. He divides things up by pros and cons, winners and losers. (Maybe my mind has just become so full that it prefers to think in bullet points now.) Makes a good argument that the “85% of health care dollars must go to actual health care” is a perverse incentive for the insurers to just raise their rates in order to keep their total administrative costs the same. My bugaboo: I think doctors will definitely be losers; I don’t think they will be “stuck with fewer unpaid bills,” as the uninsured currently will probably have the minimal, $5,000-deductible coverage, and they will probably just forego seeing a doctor anyway.
Ok, so I’m a big geek and super excited about Apple’s new iPhone they just announced; is it just me, or are we getting close to the tricorder era already? (Yes, I’m a Star Trek nerd, too.)
Or, better titled: Why You Should Be Glad You Have Group Health Insurance, and Why Private Health Insurance Has Become A Joke
Or, even better: You May Be Denied Health Insurance At Any Cost If You’ve Had Zits or Heartburn (No, Seriously)
I’m compiling twostories about California HMOs from LA Times’s Lisa Girion, who reports on medical conditions that can make you uninsurable, common drugs you take that can make you uninsurable, and jobs you have that can make you uninsurable. Uninsurable = no matter how much you’re willing to pay them, they won’t agree to provide health insurance for you. (This applies to individuals trying to get health coverage–generally larger groups can bargain together to get insurance, but if you’re by yourself, good luck.)
(Talk about stacking the decks.) If private insurers get to setup the playing field this way, can I request that my professional sports team play only against high school students? I’d also like to make sure that the people playing poker with me only get crappy cards. Thanks.
Odds are that you or someone in your immediate family has at least one of these. I can check off several of these drugs, and at least two of the illnesses.
Medical illnesses:
AIDS
allergies
arthritis
asthma
attention deficit disorder
autism
bed-wetting
breast implants
cancer
cerebral palsy
chronic bronchitis
chronic fatigue syndrome
chronic sinusitis
cirrhosis
cystitis
diabetes
ear infections
epilepsy
gender reassignment
heart disease
hemochromatosis
hepatitis
herpes
high blood pressure
impotence
infertility
irritable bowel syndrome
joint sprain
kidney infections
lupus
mild depression
muscular dystrophy
migraines
miscarriage
pregnancy
“expectant fatherhood,” planned adoption
psoriasis
recurrent tonsillitis
renal failure
ringworm
severe mental disorders
sleep apnea
stroke
ulcers
varicose veins
Drugs (and illnesses they treat):
Accutane (acne)
Allegra (allergies)
Celebrex (arthritis)
Celexa (depression)
Concerta (attention deficit)
Famvir (herpes)
Imdur (angina)
Imitrex (headaches, migraines)
Lamisil (fungal infections)
Parolodel (menstrual disorders)
Prozac (depression)
Ritalin (attention deficit)
Tagamet (heartburn, ulcers)
Tapazole (hyperthyroid)
Topamax (epilepsy, migraines)
Jobs:
Air traffic control
Building, moving
Chemical/rubber manufacturing
Circus or carnival work
Concrete or asphalt work
Crop dusting
Firefighting
Furniture and fixtures manufacturing
Lumber work, including wood chopping, timber cutting and working in a sawmill
I have spent a little over a year in hospitals, working as an upcoming doctor, and I’ve seen 8 completely different electronic medical records. (This is working at only 4 different hospitals.) Some are better than others, some are definitely worse than others. The government’s own Veterans’ Hospital’s CPRS software is probably the best, and honestly leaves much to be desired. (This is what it looks like.)
Over the year I’ve tried to collect ideas about the best features (and worst) of these different systems, and I’ve put them all together in something I call (for lack of better): the GMR (Grahamazon Medical Record). It’s an interface only–doesn’t actually save patient data (yet!)–but sadly, I think it’s lightyears ahead of what I’ve seen (and I live in Silicon Valley). It’s mainly a proof of concept–that this could be done, and can be done. (Note: It works in all modern browsers: IE7, Firefox, Safari.)
Make the software work for you, not the other way around. I see many of my attendings bewildered when trying to figure out basic tasks on current systems.
Make it make sense. Chemistry panels should come out in the right order. Information should be easy to find and accessible. Information that needs to be known quickly in an emergency should be easily displayed.
Don’t act like a medical record. Act like a one-stop shop for getting hospital work done. Be context sensitive. Don’t make me call the operator to find out who’s on call. If a lab isn’t being processed, show me who to call for that lab.
Be legible, and easy to process. I see too many people having to squint and strain to read their monitor.
Note: This is obviously not optimized code for efficiency, it’s my hacking-so-it-works Web 2.0 interface. It could definitely be improved, but it’s a start.
Feedback, as always, is appreciated. (Oh–forgot to mention in the video–you can easily access any of the tabs by doing “Ctrl+letter” on a Mac or “Alt+Letter” on a PC, using the underlined letter.)
(Special thanks to Maria and Nick for their feedback!)
Okay KevinMD and Socialized Medicine, I’ll bite. (They quote Ontario’s deputy Health Minister.) His version, and then mine, with changes in bold.
Canada:
“[O]ur system could be much better. It lags behind the best international standards in waiting times and availability of new technology and drugs. Our medical staff are overworked and stressed. We seem to lurch from crisis to crisis with constant government attempts at micromanagement, punctuated with cutbacks and bailouts.
It is time for a different approach: less government, not more. Our current problems are caused by the failure of a rigid, centralized control system that inevitably follows from single-source funding. In the absence of economic user fees, paid directly to service providers, central funding leads to shortages and rationing as a means of cost control. We see the results in unacceptable waiting times and lack of adequate services. The current shortage of trained medical staff is the result of botched government decisions in the name of cost control. As a result, a significant number of people do not have a family doctor.
The way we fund health care rules out any market forces or signals that might improve efficiency. We provide free coverage for minor services to all, including the most affluent, so we don’t have enough funds for timely cancer treatments and catastrophic drug plans. This creates the ultimate two-tier system where the more affluent can pay for drugs and travel to the United States, while those of more modest means are denied service.
US:
[O]ur system could be much better. It lags behind the best international standards in access to care, infant mortality, life expectancy, and equit
KevinMD highlights some good posts
I find it curious for Kevin to have taken this position, when he recently started promoting 
Next tip: Every word must matter. I went through a ton of revisions (see left) until I got it 
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? 
We talk about how the system’s already buckling under pressure, with 
I had the pleasure of talking with 
these polycystic kidneys
