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.)

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And the text:

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.

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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.

(I’ll be posting my speech shortly.)

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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.

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Val on Foreign Policy (my friend Yana’s adorable 2 year-old, email me for child modeling offers!) (‘da’ means yes in Russian, which Val speaketh):

Gas Prices in SF:

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Tosferina is “whooping cough.” This was an educational poster I found at our clinic, featuring scary zombie girl:



In the US, simethicone is Gas-X. In Guatemala, it’s called “LabORGASIM”:



Yes, sure, he’s both a doctor AND a surgeon, but Dr. Byron Recino’s REAL specialty and passion is psychiatry.



Random funny magazine vendor selling Cosmo magazines from the 80s. Love that hair.



Ate at a Korean restaurant, please read the translation for the first meal choice. Love it.



And one sad one, at a classroom-turned-clinic: “I need light, I need a kitchen, I need books,” with the happy little white kids on the crayon box.

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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.

Anyone have suggestions?

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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!)

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

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

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

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

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

yours,
graham

Me on Match Day, blogging away:

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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.)

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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

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See you at St. Lukes’-Roosevelt!

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!

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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:

1. 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?
2. 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.

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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.

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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.

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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:

1. making less money after residency or
2. 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.

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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.

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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.

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US and NZ sittin’ in a tree, K-I-S-S-I-N-G.

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.

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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:

1. The patient comes to the hospital’s ER and gets admitted.
2. 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.)

Update: Case in point, I just last night got an email from a close friend who sent a group email to have us “check out this new site that shows hospital ratings on Google maps.” How are they determining who’s red and who’s green? The data I discuss above.

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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.)

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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.)

So doctors need to take a look at our system–if only from a malpractice perspective–and see if it really makes sense for our patients. Americans sue 350% more than Canadians, and 50% more than Australians or Brits. Perhaps this health care non-system of ours is actually worse for us from a malpractice standpoint.

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.)

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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.)

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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.)

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

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

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

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

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

Next, Admissions:

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

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

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

Faculty/Administration:

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

Curriculum:

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

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

  I guess this is how international medical students do it.

Accreditation:

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

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

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

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

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

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

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

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

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

38 Comments »

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.)

6 Comments »

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!):

UChicago Secondary
Yale Secondary
Stanford Secondary, including drafts (final version is at the bottom)

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.

Good luck!

13 Comments »

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.

1 Comment »

(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!

12 Comments »

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 hope this helps someone!

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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’ve had national news coverage of my blogging.
• 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.)

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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!)

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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.

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It’s not always hunky-dory as a medical student. In no particular order:

1. 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.
2. 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.
3. 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…
4. 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.
5. 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.
6. 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.
7. 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.

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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.

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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:

1. 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.
2. 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.)
3. 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.
4. 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.
5. 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.)
6. 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!)
7. 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!
8. 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.”

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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:

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

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

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

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

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Edwin Leap:

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

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

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

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

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

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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!)

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

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

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

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

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

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(‘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.)

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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.

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

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

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

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

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

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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.

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

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

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

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

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

He writes:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Wanted to address a few other issues:

Shadowfax comments that perhaps the retainer medicine trend will be a driver of change, saying that in order for change to happen to health care payments and financing, “physicians need to take the hard and painful step of saying, “No, I won’t see you,” to Medicare patients. And that is basically what concierge care is.”

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?

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We’re having a great debate on the subject of retainer/concierge/whatever medicine, starting with piece by Dr. Centor, an internist I high respect. I fired back this piece and now Dr. Centor has responded. I must give Josh at KevinMD some credit for getting the debate started (but please Josh, post about something else now and then!).

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.

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From Med Rants, about retainer medicine:

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.)

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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:

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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.

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• 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?
• Beautiful irises (irides?) from this artist. Of note, no Kayser-Fleischer rings appreciated (see photo).
  
• 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:
  

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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.
• Mitt Romney is taking heat for a Planned Parenthood fundraiser photo from years ago. People say this doesn’t go along with his views on abortion. But as we all know, esteemed readers, Planned Parenthood probably prevents more abortions a year than it performs.
• 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.

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And with that, med school was over. Kind of anti-climactic if you ask me.

I MADE IT!

(Okay fine, I still have to take Boards Step 2 CK and CS, and take ACLS, but really. I made it.)

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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.)

1. Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
2. 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.
3. 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.
4. 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.”
5. Deliver the news. Be brief, direct, and succinct, 25 words or less.
6. Pause, wait for a response. Be there and be present.
7. Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
8. Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.

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Dear Residency Programs,

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.

Yours,
graham

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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)

And on and on and on…

(via The Executive Physician)

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So here we go.

My response:

1. The most heavenly social program is hell underfunded.
2. 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?

And by the way, I’ve never gotten an answer from you HSA supporters as to how in the hell they’re going to make a dent in our health care expenditures.

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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.

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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 finally, via the wonderful Gooznews:

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KevinMD loves loves loves to talk about how universal health care will stifle innovation, and while theoretically I see where he’s coming from, I just don’t see the overwhelming data to support the hypothesis. His most recent link is to a Happy Hospitalist post about purchasing pens and limits to innovation, but I don’t really see the connection. I’ve seen plenty of surgeons get to choose which devices they’d like to use being paid by Medicare, the VA, or private insurance.

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.

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Another nice short vignette from Lisa Sanders, MD in tomorrow’s NY Times magazine. Quotes from the article, showing how technology has changed us:

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.”

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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.

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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.)

If you want to read them yourself: Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7. But really, here’s the summary:

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.

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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!

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As I’ve said before, I love McSweeney’s for all its literary humor and fun. And thus I present:

AN OPEN LETTER TO MY ACROSS-THE-STREET NEIGHBOR WHO ALWAYS DOES HIS YARD WORK IN HIS SCRUBS.

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.

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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.

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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!

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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.)

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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.)

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A psychologist in New Mexico has found variation in strippers’ incomes based on their menstrual cycle: lower average incomes while menstruating, and higher average incomes while ovulating. Women on birth control pills had no variation in their incomes.

This of course led my OB-Gyn resident to suggest an IUD–they’ll earn more money but won’t get pregnant!

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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.)

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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.)

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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)

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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.

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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.

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(also known as ‘Health Care Environmentalism’ or ‘Green Health Care’)

The two parts to this piece.

1. We waste a ton of material in health care. Can we reduce this safely?
2. 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 few organizations 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.

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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.)

What a waste of money and my loans.

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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!

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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.

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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.”

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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.)

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Can we just call the damn electrolyte Kotassium from now on? It’s potassium, it’s “K,” it’s the perfect combination, no?

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Oh lordy is this a terrible idea.

Google and Microsoft are trying to put patients in charge of their medical data, and there’s even some screenshots of the Google Health online application. I love you, Google, and my friends that work for you, but are you honestly this naive about people’s level of health knowledge? Roni Zeiger, primary care doc turned Google Health employee, what are you thinking?

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:

1. 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.
2. 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.
3. 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?
4. 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.)
5. 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:

1. 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?
2. 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.
3. 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.)

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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 Syndrome Meniere’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.)

Two weeks down, two weeks to go!

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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.)

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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.

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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).

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Dr. Centor summarizes a bunch of internists talking about the current state of residents and thoughts on work hours, but in my perspective leaves a number of things out:

• 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.

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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.

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Dr. Rangel’s piece, Lowered Expectations, makes a lot of hops, skips, and jumps of logic that I’m scratching my head at, as well as illustrates the issues that many physicians face in understanding and appreciating the health illiteracy of many of our patients. (Plug for my recent Op-Ed on health literacy!)

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.

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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.)

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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):

• Vascular Causes: Aortic Dissection
• Infection: Pneumonia
• Neoplasm: Lung Cancer
• Drugs: Amiodarone-Induced Pulmonary Fibrosis
• Idiopathic Causes: Sarcoidosis
• Congenital Causes: Heart Defect
• Autoimmune Causes: Lupus
• Trauma Causes: Pneumothorax; Toxin Causes: Aspirin Ingestion
• Endocrine/Metabolic Causes: Diabetes (Diabetic Ketoacidosis)

… 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.

And that’s just the beginning. (To be continued…)

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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.”

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Rant time.

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.

I can’t wait to be a resident.

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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.

Congrats!

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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.)

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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!

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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?

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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:

Whooping Cough from Anna Jane:

And a ton of nystagmus.

Great for rare conditions–or even common ones that young medical students haven’t seen before.

Tongue wag, unfortunately, doesn’t mean the same thing to Youtube users as it does physicians treating alcoholics.

Bring that sexy back, JT:

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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.

Yeah.

Right.

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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.

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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.”

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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.

The USMLE organization took in $1007 per exam: that works out to be over $17 MILLION that they received for this exam. It’s a waste of money, a waste of time, and just more loaned money that I have to pay back later for a stupid, ridiculous test that does nothing to ensure that medical schools are preparing their students for “fundamental clinical skills essential to safe and effective patient care under supervision.”

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.

What a crock.

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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.”

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The patient’s boyfriend noted leg swelling, dizzy/fainting spells, and severe shortness of breath in a woman on birth control. If someone becomes acutely short of breath, this is not normal, and it really needs to be checked out.

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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.

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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.

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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.

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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.

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Did an ambulance ride along over the weekend. One of our patients.

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Seriously, stuff like this is true, and how I so wish to post it, but I can’t, ’cause of the HIPAA. (via Nurse Kelly)

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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.

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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.

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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.

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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.

1. 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.)
2. “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.
3. 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.
4. 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!
5. 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.
6. 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.
7. 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?
8. 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.)
9. 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.
10. 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.

Oh, and I found a nice physical exam review site tonight if you’re interested. Those skills tend to weaken while you’re studying all night and day for Boards.

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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.

Last time ever for this crap!

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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.

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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.

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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.

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Inspired by my 72 hours of hell (aka, all of my weekend):

Oh I hate you flu
Aches, fevers, chills and coughing
Tylenol won’t help

Cytokines do suck
Interferon is the worst
Man I feel shitty

Couldn’t even sleep
Nyquil barely worked, lasted
only an hour

I got a flu shot
So maybe it was para-
influenza. Hmm.

Took so much Advil
Hope my kidneys are not shot
(I’m a worrier)

Felt better today
Could stand up without weakness
Happy ambulation!

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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”

Goodbye, Kurt. I’ll see you up in heaven.

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Just FYI, for those that watch Grey’s Anatomy:

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.

That is all.

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Well, this is the last time I read or link to Scalpel or Sword.

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.

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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 didn’t think so.

I’ve been meaning to follow-up on last week’s GOMER post, and Nick is just the inspiration.

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?

The medicalization of childhood, where everyone is freaked out their kid has some killer nasty terrible disease?

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.)

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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.

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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.

(Congrats to everyone!)

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The Radiology Picture of the Day is always cool, but unfortunately it goes over my head too often now.

But these polycystic kidneys that take up most of the patient’s abdomen and pelvis are too disgusting/cool to miss.

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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.

Update: Stanford has put together a nice article about him as well as a guestbook to sign.

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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.

Here are the latest CPR guidelines, and you can learn CPR at a class near you. (But remember, the most important step is early activation of 911. And also remember your ABCs: Airway, Breathing, Circulation!)

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!

Update 2: I love you, YouTube CPR.

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My Valentine’s Day plans include:

• Going to the DMV.
• Going to the dentist.

Not much love at either place.

The end may include drinking with my other single friends, which would clearly be the bright spot.

Carry on.

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While I’m proud to say that we ban pharmaceutical gifts, it appears the drug reps have started to go after medical students, as evidenced by the hallway outside the library:



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.)

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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.

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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.)

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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).

Ahh, medical ambiguity.

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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.)

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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.” )

One organization, Opportunity Agenda, has put together a Google Maps mashup showing hospital closures in New York over time–and no surprise, they’re mostly in poorer neighborhoods. (Even if you somehow don’t care, it’s pretty impressive to see how many hospitals there are just in Manhattan and the surrounding burrows.)

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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.)

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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.

The obligatory Matthew Holt article, which I was also waiting for. Another good analysis.

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.

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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.)

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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 two stories 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
• Migrant labor
• Oil well or refinery work
• Police work
• Roofing
• Sandblasting
• Sports, semi-pro or professional
• Stockyard work, with or without butchering
• Stables, all employees
• Stunt work
• Telecom installation
• Transportation and aviation
• Tree climbing
• Tunnel work
• War reporting
• Window work at heights exceeding three stories

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Doctors, nurses, med students, patients, we should be embarrassed.

Welcome 2007. You can email, send instant messages, order airline tickets in seconds, track that airplane as it flies across the globe, manage your calendar, work on documents and spreadsheets in real time with your friends and colleagues, even read newspapers from around the freaking globe. But our computerized medical records (or whatever you want to call them) can’t even print out labs in the right order. This is, in a word, ridonkulous. Hospitals and clinics should demand more. The big medical record makers should provide more. Their interfaces, truly, look like they’re from 1990.

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.)

I’ve put together a screencast that walks you through some of the features. Watch it, and then play around with the interface. My goals, basically:

1. 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.
2. 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.
3. 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.
4. 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!)

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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 equity. Our medical staff are overworked and stressed. We seem to lurch from crisis to crisis with constant double-digit increases in annual insurance costs, and government attempts at patchwork reform, punctuated with cutbacks and bailouts.

It is time for a different approach: less fragmentation and corporate control, not more. Our current problems are caused by the failure of a patchwork, ridiculously administratively wasteful system that inevitably follows from employee health benefits as a fluke from World War II. In the absence of access to prevention and primary care, patchwork funding leads to shortages and rationing as a means of cost control. We see the results in unacceptable deaths from lack of health insurance and undue suffering of those without–and sometimes with–health insurance. * As a result [of no health insurance and poor incentives for medical students to go into primary care], a significant number of people do not have a family doctor.

The way we fund health care rules out any public health or prevention efforts or signals that might improve efficiency. We provide free coverage for emergency services to all, including the most affluent, so we don’t have enough funds to prevent disease and illness before it becomes more serious; often even the insured end up owing tens of thousands of dollars for timely cancer treatments and catastrophic drug plans. This creates the ultimate two-tier system where the more affluent have access to health care without risk of bankruptcy, while those of more modest means are asked to weigh the decision between medical care and bankruptcy or severe financial difficulty.

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Aetiology is questioning the intelligence of Brits for the fact that “More than a quarter of [British] people believe that fate alone will determine whether they get cancer, not their lifestyle choices”.

Brits, here I come to the rescue–I agree. Fate causes cancer. (Aetiology’s Tara Smith is an assistant professor of epidemiology, which may have clouded her views on this one–that’s what statistics and population studies will do to you!)

If you look at groups of people, you can easily say that smoking increases your risk of many, many cancers. And other lifestyle choices definitely increase your risk of cancer. But look what I said–increased risk. Not guarantee. Not all smokers develop lung cancer, not all smokers develop emphysema. Not all obese people develop diabetes, and not all people who develop diabetes are obese.

You can say that X increases your risk of cancer by 99%, but when you go down to the individual level, that individual has to either develop cancer or NOT develop cancer. We can’t say which smokers will get cancer and which won’t, only that they’re more likely to. There’s still random chance–if you want to call it fate, so be it–that gives people cancer.

So there you are, Brits, you’re right.

If you want to reduce your risk of cancer, heart disease, and other big killers, prevention is the key, and lifestyle changes can do a lot. But we want to accurate for the individual, we don’t know who will get cancer. Is this an argument for patients to keep smoking, and playing Russian roulette with their bodies? Of course not. Maybe someday we’ll be able to tell which people will get cancer, but we definitely can’t now.

(Update: Orac agrees! I’m flattered!)

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Can bloggers and talking heads please shut up about New York City and now Universal Studios banning trans fats?

You’d think these entities were banning butter and fat outright. Trust me, there’s plenty of lard to go around, people. Plenty of people will still have the right to clog their arteries, lower their HDL, and raise their LDL. They’ll just have to work a little harder at it.

Trans fats, you will be not be missed. No one will notice the difference. Muffins and cookies have existed for much longer than trans fats. I think we’ll survive.

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Matthew Holt writes that the last year (or at least 6 months) of Gerald Ford’s life was a poor use of resources, and an example of what’s wrong with the health care system today. He thinks the money could have been better spent providing prenatal care to an uninsured woman.

So consider Ford’s last few months of life. He was admitted to hospital last January for pneumonia. Then spent much of July in hospital in Vail; then went to the Mayo Clinic for not one but two angioplasties in August. Then went back into hospital in California in October, and now has died in December. All that time he was obviously going to die within a year or so, and all that time he was at least 92 years old.

My guess is that over the last 12 months of his life well in excess of $100,000 was spent on his health care. And that money probably extended his life by three months at most.

Do we often perform “heroic measures” on people who might not want it, or don’t receive any quality of life benefit from it? Absolutely. Now maybe Holt has an in with the Ford family, or was following his health very closely, but there’s no way for me to know that he was “obviously going to die within a year or so.” Yes, he was 93, yes, he had had several hospital admissions. These are not Good Signs. But still–ask any doctor: internist, geriatrician, palliative care specialist–and they’ll all tell you we’re shitty at predicting when someone’s going to die. Because there’s definitely 93 year-olds out there that get a pneumonia, get really sick, but then recover and end up living 10 more years.

I’m all in favor of having people have these discussions with their family members–living wills, durable powers of attorney–but how can we tell if Ford was gonna kick it until 103?

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(And Where He’s Right.)

So Google Vice President Adam Bosworth posted a bunch on the Official Google Blog about his ideas for fixing health care information sharing, after the unfortunate death of his mother, after her cancer symptoms were missed for 9 months.

He talks about Google Co-Op, which lets users define high-quality websites–in this case, doctors can mark certain sites as providing accurate health information, so that patients could feel comfortable that a site is providing reliable information. This is really important–first, there’s a lot of bad or incomplete data out there on the web about medications, side effects, diseases, treatments, etc–and I’m always educating patients about things that are incorrect (or that they’re mis-read or mis-interpreted) from the web. Second, it’s important for providers to have access to accurate information, too–you might be frightened by how often providers Google a drug to find out the right dosage.

An even more interesting idea is his concept of the “Health URL”–essentially, one central website where patients could store and access all their health information, and could then give doctors access to said website to review their records. In theory, this is amazing. Right now, one hospital can’t get lab results from a hospital across the street electronically. We can’t view x-rays, read medical reports, even the most basic of things you can do with pretty much any other part of society now.

He’s gonna run into some major issues–namely HIPAA, that heart-in-the-right-place-but-implemented-so-incredibly-awfully law that is supposed to protect your privacy, but actually doesn’t, and impedes patient care.

And then there’s this post about “Google Scrapbook”, which could turn into the “Health URL.”

Now for the problems:

This is great for sick people and people with chronic disease. It’d be great to have this information, to know their history, see what tests have already been done, view previous scans, etc. And while more and more of medicine is chronic disease management, does Bosworth think patients are actually going to be actively involved in this? Those with cancer and other terrible, possibly-fatal illnesses or unclear diagnoses will certainly be interested. But getting the folks with diabetes to get involved? Much harder. It’s the classic issue with human nature–we’re much more likely to invest in things that provide relief or help for the present, but we’re not as good with short-term pain, long-term gain. (Often we have enough trouble just getting patients to take their meds, let alone maintain some sort of “health URL.”)

Will people trust Google with their data? Having a computer read one’s emails and supply ads is one thing–but will people be sure that people will be okay with knowing they’ve had an STD, or take Viagra, or have had an abortion, or on anti-retroviral drugs?

Finally, in a talk Bosworth made about his mother’s care, he writes:

Once she was diagnosed, it was extraordinarily hard to determine with whom she had the best
chance of recovery or remission. While in the end we found an amazing team, it was much harder
and scarier for her than was necessary. And recently, as she was dying, there was no way for her
physicians, nurses, health aids and hospice workers to collaborate online to ensure that they knew
what is happening with her, that the right medicines are being delivered and dispensed, and that
she was as happy as she could be. My mother couldn’t possibly keep up with all of this, and
neither could I. So, for lack of an easy way to find the right specialist and for lack of
comprehensive medical information about her that could have been shared between her doctors
and caregivers, she ended up being sicker than she should have been and dying sooner than she
should have.

We already have specialists that can often help with these issues. They’re great communicators, and work with different parts of the medical field to coordinate care: they’re called internists, or even more specialized, palliative-care physicians. But here’s the problem: we’re running short on internists, and we train very few palliative care docs every year. And why is that? Money and happiness with the jobs, plain and simple.

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After all the talk about Pfizer’s cholesterol drug failing, it got me wondering–what if we’re out of drugs to fix common diseases like high cholesterol and high blood pressure? After all, these drugs work by altering the body’s own enzymes and proteins–and there’s only so many enzymes you can alter. And sure, we can try to develop drugs that target certain enzymes in certain tissues to prevent side effects, but what’s really meant by “target?” It means that we develop a drug that is only active if certain other molecules are around it, or can alter or activate it. Or that there’s a portal on the cell wall that can allow the drug in. What if we’re out of portals? Or that they’re too small to fit our big drugs through?

What if we’re stuck? Sure, we can find more drugs to do more things, but what if they’re all so complex that they cause too many side effects (we’ll call “death” a side effect)?

I kind of actually think this would be a good thing. Now, it would be a terrible thing for older generations who ate Crisco and smoked without knowing any better–but for society overall, it would make us take a more realistic view of our lives. Make us consider the notion that there’s not a magic pill to fix our bad habits. That our actions have consequences for our lives and our health. That the magic doctors won’t be able to necessarily fix me–perhaps I need to fix me.

We would probably eat a little healthier, exercise a little more, feel a little less rushed, and spend more time with our loved ones.

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10 points to my mother, ex-nurse, current photo-stylist, for advising her healthy, 40-something co-worker to go to the hospital for his increasing shortness of breath. He had a pulmonary embolus (for unknown reasons at this point).

Moral of the story: If out of nowhere you start developing symptoms that make no sense, please see a doctor.

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I can’t believe I haven’t written about one of the most evil, most frustrating things about being a med student: the dreaded Attending Effect(tm).

The Attending Effect, by definition, is the magical, mystical powers that the presence of an attending has on your patient’s history. The mere sight of an attending will transform the words that come from your patient’s mouth from those he or she told you to a different story entirely.

You’ll get the story from your patient, “Okay, so it’s been 3 days of vomitting, but you’ve been keeping liquids down fine, and there’s no blood in your stool, or black, tarry stools.”

You go tell this fascinating story to your attending, give your assessment and plan, they agree, and you feel good–”The attending said I’m doing the right things! Yes!”

Then, you either go back with your attending to examine the patient again–or worse, your attending sees the patient without you–and the story the attending gets is totally different. Your attending tells you, “She told me it’s been a week and a half of diarrhea, sometimes bloody, and she can barely drink anything.”

The first few times this happens, your eyes bulge out, your jaw drops. You sweat, your heart races, you panic. You are convinced that the attending thinks you totally lied to him or her, or that you weren’t listened to the patient, or that you’re just a total dumbass. You quickly re-tell the story the patient gave you, and you swear you didn’t make it up. You are so totally pissed at this patient.

Once this has happened a dozen times or so, you just kind of shrug it off. You’re annoyed, wonder what the patient was thinking. But you know it’s just the Attending Effect at work, there’s nothing you can do about it, so you just adjust your assessment/plan and keep on moving. There’s more patients to see.

(Reminded of this by Flea, whose stories are totally depressing lately and really getting to me, and making me wonder “Is this really what being an attending is like?)

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KevinMD writes a whole lot about the “death of primary care,” why medical students aren’t choosing it (this is evidenced by the fact that most Internal Medicine residents choose to go into a sub-specialty as opposed to practice General Internal Medicine). And I hate to say it, but I’m not planning to go into primary care, either. It seems like most of the time he focuses on the money and income disparity:

While a family practice doctor often works long days and endures crammed waiting rooms for $155,000 a year, dermatologists average $197,000 — and many don’t work even five days a week.

And he’s not wrong on that end at all. Most of us are leaving med school with at least $100,000 (let’s read that again: AT LEAST ONE HUNDRED THOUSAND DOLLARS) of debt. But for me at least, that’s not the kicker. It’s a lot of money. But so is $155,000 a year. If I practice as a doctor for the rest of my life, I’ll pay it off eventually and still live a much more comfortable life than most people.

He also focuses on the time committment: long hours, lots of paperwork, no reimbursement for making phone calls, doing workman’s comp evaluations, etc. Again, this sucks, but most jobs suck like this to some degree. I still he’s missing the keystone here. And I wasn’t sure what it was until I read this piece that he linked to, about a woman’s wonderful experience with health care when she moved to Belgium:

I was also pleasantly surprised when she offered me an appointment the next day—and I was greeted by her promptly and had an unhurried consultation without having to fill out any paperwork. Instead of endless forms, she simply listened while I talked, jotting an occasional note on her laptop.

A typical doctor’s visit always includes filling out paperwork, updating your medical history, submitting insurance information and waiting, waiting, and waiting to see the doctor, who is normally overworked and visibly frazzled by the incredible pace and hours he/she is expected to keep.

After 18 months in Belgium and multiple checkups, I have yet to fill out a single form, let alone the scads of paperwork I had to do in the US at every single visit. All of my medical tests have been given by doctors; in the US specially trained technicians or nurses administer tests and the results are reviewed by the doctor later.

My family doctor here in Belgium normally spends a half hour with me (compared to less than 10 minutes in the US). My cardiologist spends nearly an hour with me. My perception has been that the doctors here are conservative, cautious, and thorough in their approach, something I appreciate as I deal with more medical issues than ever before.

This, folks, is what we’re missing from primary care.

Look, medical students are for the most part still very optimistic, caring, no mortgage-paying people who are in this to help people, not to make buckets of money (we could have easily joined our I-banking counterparts if we wanted money). I will tell you right now, if the practice of internists (general internal medicine) consisted of 30-minute appointments where I felt like I could get to know my patients and establish a relationship with them, I would become an internist in a tachycardic heartbeat. And I know I’m not alone. We’d be banging down the doors, gunner-ing like crazy to get these positions. Even if I still had to deal with the paperwork, still had to spend more time away from my family or my hobbies, and still got paid less, I’d choose internal medicine hands down.

Because honestly, for medical students, Clinton was wrong—it’s not the taxes, it’s the lifestyle, stupid. We want to get something out of this medicine thing besides just money. We didn’t go into this to have a job, we went into it to have a profession. A calling. But if you don’t give us the option of a lifestyle where maybe you have to work a little longer, and yeah, maybe you get paid less, but the humanitarian and emotional and helping-people benefits are amazing—well, uhm, yeah, I guess I’ll just take the money like everyone else seems to be doing (or at least find another profession that offers a little more balance).

All we hear about (maybe it’s because we read too much disgruntled KevinMD) is how much malpratice costs, how we sued for anything we screw up on, how reimbursement sucks, how HMOs suck, how we have to work overtime without any pay, and by that point, the job listing doesn’t sound so great.

Not to turn all single-payer on you, and I realize this is just one woman’s story, anecdotal and all, but I honestly believe that a big part of the problem is our system. It’s so mind-numbingly complex and wasteful (administratively and diagnostically) that by tolerating the system for so long, doctors have allowed it to become 15-minute office visits with reams of paperwork. They’ve allowed it to come to the point where some people are choosing to get their care from a stranger who works at Wal-Mart or Walgreens. Again, no system is perfect, but I truly, truly believe that reforming our health care system will improve so many of these problems with primary care (and health care in general) that it seems like almost a no-brainer. Would you honestly not take a pay cut in exchange for less paperwork, less overhead, and lower malpractice premiums?

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Liana Hwang, a medical student who blogs over at Medvalleyhigh has started a program to re-populate a medical library that was destroyed in the tsunami. Please donate your books! She writes:

I recently returned from an unofficial medical elective with Dr. Azharuddin, the sole orthopedic surgeon in Aceh province (population 4.5 million), Indonesia. He works at a government hospital in Banda Aceh, which is the capital of Aceh province and was the city closest to the epicenter of the earthquake of December 26, 2004. Much of the city was affected by the tsunami, and the hospital in particular was virtually gutted, resulting in significant loss of equipment and staff.

Prior to my arrival, he emailed me to ask me if I could bring him a power drill as he was using a hand drill for all of his cases. I was eventually able to get a drill for the hospital by fundraising and subsidies from Stryker (an orthopedic instruments company). It turns out that power tools are not the only thing they’re short of in Banda Aceh. Although the international response to the tsunami has been great, there are still substantial shortages of equipment and supplies. In particular, I was especially moved by a medical student who showed me a waterstained, creased dermatology book from 1996. He told me it was his most prized possession, and although he was probably half-joking, it underscores the shortage of medical textbooks in Banda Aceh. The medical school is up and running again, but the students need books.

I left some books with Dr. Azharuddin when I departed, and then started collecting books from graduating medical students to donate to the medical school in Banda Aceh. To date, we’ve sent almost $1,200 of books to Banda Aceh. At the present time, Tulane, University of Calgary and Stanford are involved in this project. I’d like to see many more medical schools involved, as there is also great need for medical textbooks in East Timor, Myanmar, the Philippines, and other countries. They need basic level medical textbooks in good condition… Netter’s, physiology textbooks, etc. If you’re interested in donating textbooks, funds or time to this project, please contact me at liana.hwang@med.ucalgary.ca For more information, please visit my blog at http://medvalleyhigh.blogspot.com/2006/09/update-on-banda-aceh-fundraiser.html

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After a number of requests from the UK, Australia, and other English-speaking but more-standardized countries, I’ve finally (sorry!) updated my medical calculations website to be friendly to the rest of the world. Introducing MDCalc version 2.0, now with a quick way to select either US or SI units. Once I get a few volunteers that use SI units regularly to just triple-check my work (I’ve already double-checked it), the SI site will be come the new full-fledged site.

It’s been fun to create and update the site–I’ve received great suggestions and feedback from residents, med students, and docs from around the globe. Please send me your comments and feedback, either through the contact form or in this post!

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I just got some requests for information on how to prep for the Boards (Step 1), so I figured I’d supply this to all you new second- and first-years. (If you’re a first year and you’re already prepping for the Boards, you’re a gunner. But the Boards books are really useful for getting through second year Path, Pharm, Micro, and Phys, so I’d buy these before I start any of those classes.) A note of warning: these will definitely help you prepare for boards, and will also help you prepare for your classes, by helping organize information and provide mnemonics, but likely won’t be in-depth enough for you to ace your class’s final exam.

Your bible: First Aid for the USMLE Step 1. You will, essentially, compile all information from every other board review book into this one. (This one already has a ton of information.) You will study from this every day. You will memorize every word of every page of this book. And if you do, you will probably do okay on the Boards. It has some good mnemonics you won’t find elsewhere, and some people say if you start studying from it from day 1 of med school, you’ll be better off, but I didn’t really use it until I started studying for Boards. I’d hold out until 2nd year to buy it, as you can get the latest edition, which has been updated for what the authors have learned about the previous year’s board exam and its subject material. Expert tip: go to Kinko’s, get the binding cut off, three hole-punch it and throw it in a binder. Much easier to study with. Example pages with my chicken scratch everywhere:

If you buy any other review books, make them BRS Pathology and BRS Physiology. I don’t think I could have handled the sheer amount of information in med school without these two books. They’re essentially bullet points of every body system and disease. They help you organize the information in your head, and give you the really high-yield facts you’ve gotta know. I think most, if not all of our class owned a copy of each. They’re that good.

Because Developmental Biology just sucks monkey balls, you’ll want a copy of High-Yield Embryology for yourself.

The rest of my suggestions, you can really just get used, or get a group of friends together and share. Pharm and Biochem were big challenges for me, and I really liked Lippincott’s for both of them–very complete, and very easy to read: Lippincott’s Illustrated Reviews Pharmacology and Lippincott’s Illustrated Reviews Biochemistry.

Finally, the rest of the High-Yield series are good short reviews, but not worth buying full price. Borrow from a friend or get them used.

And then there’s always the question of the dreaded, way-too-expensive Kaplan Q-Bank. I used it, probably everyone in my class used it. It’s not necessary, but I guess I have to recommend it. It gives you an insane number of questions, and does a number of things:

• Forces you to practice taking computer tests.
• Forces you to get used to not knowing the answer. (There are a ton of really random questions in Qbank that are totally minutae and worthless, but as a med student, it’s good to practice not freaking out when you have no freaking CLUE as to the answer to like 5 questions in a row.)
• Helps you get really good at eliminating bad answers and guessing.
• Gives you some feedback on what sections you are doing okay at and what sections you need more work on.

So there’s my little Boards talk.

Oh, and one more thing: Make a calendar for yourself and stick to it! Give yourself breaks during the day, and reward yourself: “If I finish this section today, I’ll go get a Frappacino,” or “I’ll go to the gym,” or whatever you like doing. And give yourself the illusion of choice. Sure, you have to study for 10-12 hours a day for weeks on end, but ask yourself, “Hmm, do I want to study in the library today or the study lounge?” So many choices. It makes it more fun tolerable. Really.

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We had a really nice brunch this morning for the Cardinal Free Clinics, which is an umbrella organization to support our two student-run free clinics. (We’re trying to recruit more physicians to get involved with our clinic and volunteer.) I’m a co-chair of CFC, so I gave a short little speech and we ended with our dean giving a talk, and one of his points really rang true.

He said that he felt like there had been something of a disconnect between medical advances and what people wanted from their doctors. That we’ve come incredibly far in the past 30 years in terms of medical progress–children with cancer used to mostly die, while now, they mostly live, for example. But seeing and communicating with the patient hasn’t advanced–if anything, it’s regressed. A patient wants a doctor that listens, one that cares, and one that sees the patient as the person, not the disease. But with all the financial and business changes that have come to medicine, we’re no longer really serving our patients the way they want to be served.

We can save and extend life in ways like never before, but our everyday interactions with patients have become dissatisfactory: rushed, pressured, and driven by the mighty dollar, not the needy patient.

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The non-medical life is all that it’s cracked up to be.

(Okay, the year-of-researching-and-TAing is all it’s cracked up to be.) Yes, I’m still alive and kicking, even though the blog may not be. (But it’s Adwords is–thanks Google!)

What of this new found optimism and gayity, you ask? A number of things. I’m very, very happy to report that I have ceased to be a horrible person (or maybe I never was to begin with) with only a couple months of medicine-free life under my belt.

A number of changes, my courteous one reader left (Hi, mom!):

1. Moving to a city. I forgot how much I love cities, and how much the burbs just don’t do it for me. The forced interaction between strangers, all the random little stores, the restaurants everywhere, the ability to people watch, the ability to walk lots of places. Public transportation!
2. A new appreciation for my patients’ lives outside of medicine. When you’re in the hospital all day long and reading about diseases and drugs and problems all night long, you forget that humans are these totally fascinating creatures, with quirks and hobbies and families and errands and stupid silly cell phone conversations. I guess you can’t really focus on that stuff when they’re in the hospital, but you kind of forget that your patients are the same people you see on the street picking up their dry cleaning or helping you pick out plants at Home Depot.
3. The time to actually do fun, non-medical things. I think in my over-achiever ways, I spent too much of the past year trying to be Mr. Perfect Medical Student, which feels kind of fun in a sick way, but is actually kind of sick. Sacrificing hobbies and pleasures and daily life for overboarding on medical knowledge. I’m not saying I should have slacked and not read up on my patients or tried to drink from the fire hose that is medical school knowledge, just that I should have played Slip’n'Slide with it more often. (I sadly must also blame my blog for sucking me away from life, too.)
   For example–I went hiking last Saturday. Hiking! And I hung out with friends the entire day Sunday. What med student gets to do that? I volunteered with Habitat for Humanity today. What a privelege! I’d never even have a full Saturday to give up during med school. As a close friend reacted, “Wow, that’s awesome, you have time to volunteer!”
4. I’m going to the gym again. Part of this definitely has to do with the fact that I’m not in a relationship anymore, so I can no longer afford to just be a fat ass and have the person love me for who I am, and all that long-lost-love crap. Feels good to exercise, something that also partially left because of lack of time.
5. Re-discovering some spirituality. In college, I was all about the world religions, and those interests escaped somewhere during medical school. I’m back to dabbling in Buddhist philosophy, and it just feels good to remind myself of some of the things that I guess I still believe but forgot what I believed. If that makes any sense.
6. I’m sleeping well and eating well. I have the time to sleep, and I have the time to cook. I’m surprising even myself, as I’m not polishing off a box of cereal in 2 or 3 days, as I used to, having it for breakfast and dinner.

I’m sure I’ll miss medicine, but I’m honestly not right now. I am fearing returning for my last year of clinics and having forgotten everything, but I’ll deal with that later. As they say, procrastinators are the leaders of tomorrow. (I guess that’s another one–I have time to procrastinate. And it feels wonderful!)

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I guess this post has been a long time coming, and probably why I haven’t written for awhile. It’s a culmination of a year of clinical training, and what effects it has had on me, from the good, to the bad, to the ugly. I think I’ll start with the bad and the ugly, because that’s what’s really been bothering me for awhile now.

Medicine has made me into a shitty person. Or, maybe more appropriately, the shitty-person side of me was always there, but the stress of medicine brought him out. Many of the problems, I believe, stem from behaviors in medicine that I can’t shake from my person when I’m not in my medical role. Shitty Graham takes several forms:

• Impatience. Often you’re sitting around waiting for a lab result, or a patient to go to x-ray, or waiting for a patient to get his new medication. Or you have a patient that talks on and on about unrelated things, when you know you have many more patients to see and you don’t want to get behind. But this attitude comes home with me. I want this now, I need to hurry to finish that, why are these other people besides me taking so damn long? I’ve lost the ability to live in the moment.
• No tolerance for incompetence. (It dawned on me yesterday why this one has happened.) The transformation from preclinical student to clinical student is a miraculous one, and the amount of knowledge learned is mind-boggling. But with this comes another step: beginning to feel like one understands medicine–and even if you don’t, patients ask you questions as if you do. When strangers ask you questions about medical stuff and you know the answer, it feels great. It feels like you went through all this training for a reason. But at least for me, it’s been a terrible boon for my ego. I really think it’s made me feel like a total know-it-all, even in the non-medical world. It’s weird. I’m incredibly guilty of “always having to be right” in the non-medical world, and honestly trying to fight this and tell myself I’m not always right and that I don’t always have to be. But at the same time, I’ve probably become much more confident and sure of myself (read: cocky), so that I don’t even question whether I’m right or not. Now granted, this never applies to medicine and rarely applies to anything of importance in my life, but it does impact my interactions with others, and how I probably make others feel.

I don’t want to make this sound like I’ve become some sort of terrible monster, but it’s just the little occasioal interactions and thoughts that run through my head that didn’t used to be there.

I haven’t really talked about this at all with any classmates, probably mostly out of shame and the fear that no one will feel the same way, and it’s just me that’s a terrible person. But somehow the pseudo-anonymity of the web and the written word makes it easier to type the words than to say them. I’m just trying to be honest with myself and figure out what I’d really like to focus on in the coming year–mainly why I went into medicine and how I can rediscover some of my humanity and virtue, because the path I’m taking right now won’t lead me anywhere I want to be.

The Good I referred to above will, I guess, be left for another post. Believe me, there’s plenty of it, but I’m just not feeling it right now.

As for this blog–what will I write about since I’ll be doing a year of research and not seeing patients? Several people have asked. I think I’ll spend more time reflecting on the year as a whole (I love reflecting, if you can’t tell), and then who knows, probably some thoughts on research, being a teaching assistant, and then of course my 2 month jaunt to Guatemala next year.

(And welcome back to MedPundit, who thought she was giving up blogging but it’s reeled her back in.)

(Editted, I total was unclear by what I meant by incompetence.)

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The end of clinics, year one, is now complete, and was completely anti-climactic to boot. It’s off to a family vacationn, some rest and relaxation, before I begin my research year that I don’t think I ever announced. (I guess that last sentence was the announcement.) More on that, as well as a wrap up of clerkships year one, when I return. Ciao!

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Some of these are inherent to going to an Emergency Department; others are just the difficulties of clinical medicine.

• Your doctor will assume the worst. This is something patient’s really don’t get, and only recently have I started to get myself. Emergency medicine trains a person to rule out the really deadly, nasty stuff. We treat, we diagnose when we can, but above all, we make sure you’re not having a heart attack or any other potentially deadly disease. Let’s remember, of course, that you the patient, have generally gotten yourself to an emergency department for some reason–and we’d like to figure out if it really is an emergency. For this reason, my lists of possible diagnoses have changed.
  I saw 5 kids a day with nausea and vomitting on my Peds rotation, and we primarily made the diagnosis of acute gastroenteritis and sent them on their way with fluids and education. But in the ED, it’s not just the stomach flu. It’s an appendicitis, or an incarcerated hernia. (I realize I should have been considering this more often in the outpatient clinics, but my awareness is definitely more heightened.)
  The correlate of this emergency paranoia is that you, the patient, will get poked and prodded much more than you would if you just went to your outpatient doctor. Your stomach ache isn’t just a stomach ache in the ED; it could be a heart attack, an aortic dissection, pancreatitis, a kidney stone, or an early appendicitis. (And this isn’t just exaggeration on the part of the ED–there’s many people who have heart attacks who don’t have the classic “crushing chest pain.”) It’s almost like once you’ve got a bed in the ED, you’re stuck there until we’re done with you. I know this sounds terrible. It probably is. But think of the physician’s responsibility for his or her patients: you’ve gone to an Emergency Department and want his or her help. Is it worth drawing blood and urine on patients who might have a heart attack (but might not) if you catch more heart attacks, or other deadly conditions? I’m inclined to say yes. I’ve been in the ED two weeks and I’ve already had at least one patient with a heart attack that I never would have suspected. She had no chest pain, but had a very significant history of heart problems. (Note: this does not mean go to the ER for a heart attack every time you have a stomach ache! Do not tell them I sent you!)
• On to number 2: You will wait. And wait, and wait, and wait. We don’t see people in the order they came in, like they do in your doctor’s office. We see them by seriousness of illness, and then by when they came in. If you’re next up to get a bed, and then a guy comes in with left-sided weakness, and another comes in with a broken arm, and then the clerk announces that a 3-person trauma from Life Flight is on its way, you’ve just been bumped. Again, emergencies go first.
  And even if you’ve got a bed, if someone more sick comes in and requires your doctor’s attention, that patient’s care goes first. Your labs may be done and your CT scans and drugs may be finished, but your doctor’s busy managing someone that’s not breathing. You wait. Is this suboptimal? Yes, but if you were the patient that wasn’t breathing, you’d want it that way, too. Have your partner or spouse or friend bring a book or magazine for you.
• If you don’t speak English, you’ll likely wait longer on average. I can’t imagine what it’s like in an area of the country that’s pretty homogenous. Even in central California, which has an enormous immigrant population, translation is a problem. Even at one of the many hospitals we rotate through, which has 24-hour, live and breathing translators, they still have to be paged, or they’re currently seeing another patient. I had several non-English speaking patients, both in pain, but without knowing what their problems were, we had a difficult time treating their pain adequately. I’m heading to Guatemala next year to get my Spanish up to fluency standards, but still most doctors only speak two languages: English and medicalese. (There are many problems with using kids as translators as well–if they speak one language at home and English at school, they may have never learned medical words like pancreas or palsy or gall bladder, for example.)
• You don’t get much privacy. Your neighbor can probably hear you when you tell the doctor you’ve had STDs in the past, or abortions, or use drugs, or whatever else you’re supposed to be ashamed of. They can probably hear your diagnosis, your intimate, private details. And it’s probably safe to say that the ED isn’t the best for grieving, or talking about death, or anything solemn and serious. There’s no peace, nor quiet, in the ED.

For next time: the great things about the ED, of which there are many.

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These are the words that start to change my diagnosis from “kidney stone” to “drug-seeking.”

Two weeks ago, I pull back the curtain, introduce myself, and see a woman writhing around in (supposed) pain, tears in her eyes. She tells me she’s had 4 kidney stones previously. They’re all uric acid stones, which are generally undetectable on X-ray. That she went to a urologist, was on allopurinol, but stopped it two months ago. This all happened in Texas. She tells me where her pain is, and that it radiates to her back and down to her groin. “Kidney stone! It’s a kidney stone!” I tell myself. I am brilliant. I examine her, find some tenderness on her right flank. Her urine has already been sent to the lab. I tell her I’m going to go talk to the doctors to discuss what we can use for pain control. She warns me that she is allergic to aspirin and Tordol–a strong pain reliever but not a narcotic. (Think super-Advil.) Her mouth swells up when she takes either of these. “What terrible luck, a woman with chronic, painful kidney stones and allergies to common pain relievers!” I think. She then finishes her pain medication story: “Whenever this happens, I usually get dilaudid and phenergan, and sometimes ativan because I have anxiety attacks.” And it all goes downhill from there.

I pause, skepticism and cynicism running through my mind, but I give her the benefit of the doubt. Assume nothing, I remind myself. Moments later, the patient’s nurse chases after me in the hallway. “She’s a frequent flyer here, you know. She was just here 2 weeks asking for the same thing. And I guarantee you next she’ll ask for Fentanyl.” Add more skepticism to the pot.

So we check her name–first time she’s been at the hospital. Maybe she’s using an assumed name? We check her urine, and it’s strongly positive for both blood (going along with the stone story) and white cells, indicating an infection. We’re stuck–her story and labs say maybe she’s telling the truth, but everything else is leaning toward malingering. So we start antibiotics for her infection, give her yes, some dilaudid and phenergan for pain control, and I tell her she’s going to need a CT scan. We get the scan setup, and she continues to ask for more pain medication–”It helps for like 2 seconds and then goes away!” Just when she’s ready to go to the scan, she starts asking for some ativan (similar to valium) for anxiety, because she gets claustrophobic in the scanner. We point out her head won’t be in the scanner, just her abdomen and pelvis. She continues. We tell her she’s already had a good deal of pain medication, and we don’t want to continue giving medications that could suppress her respiratory rate. She starts crying, and starts loudly asking, “Why can’t you just help me?? I’m in pain here, I’ve never been treated like this before.”

My resident pops into the room and helps with the authority bit, and later tells me she recognizes the woman too.

She misses her chance in the CT scanner, so we wait. She, as the nurse predicts, starts asking for Fentanyl, a very strong narcotic. She then starts cycling–”I’m in pain,” then “I’m nauseous!” then “I have a headache,” then “I have a sore throat,” then “I’m anxious,” each time asking for a different medication for her symptoms. She finally just goes to the CT scanner, but leaves the scanner with an anxiety attack.

If the woman does have a stone plus an infection, the infection could start climbing up toward her kidney. She could get an infected kidney, could get septic, could die. I discuss this at length with her. I tell her we believe she needs this scan to make sure she doesn’t have such an infection. She gets upset again and says she wants to leave. (I’m leaving out plenty of copious details, as this dragged on for hours.) We talk about why this is a terrible idea, but she wants to leave anyway. I go get the paperwork for her to sign to leave Against Medical Advice. I come back and note 2 things: her hand is down near her genitalia, under the blanket. (This was the case the last time she was here.) She’s either masterbating or giving herself an infection. I try my best to ignore this, which is totally disgusting, and hand her the paperwork to sign. She can barely grab the pen, she’s so sleepy and out of it from the narcotics. She’s still complaining of pain. She signs and initials here and there, and finally leaves. (I throw away the pen.)

Meanwhile, we have 10 other patients that have been waiting to be seen by a doctor; she’s wasted a bed for at least 4 hours. I’m angry, frustrated, and annoyed–and the rest of the nurses and doctors are, too. I sigh, quickly eat a granola bar for dinner, and pick up my next chart: a woman that’s been waiting 6 hours in the lobby to be seen for a simple clogged NG tube.

Update: I forgot to mention the final kicker–the woman asked for “Vicoprofen,” which is like Vicodin, but has ibuprofen in it instead of Tylenol, which is in vicodin. (She says the Vicodin makes her throw up.) My attending was smart, and realized the real reason she asked for the vicoprofen: it has a larger amount of narcotic in it per pill than the vicodin. Another trick of the trade, apparently.

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I have a habit (don’t we all?) of walking around the ER (especially in the trauma bay) to see what’s happening with patients. It’s all the rubbernecking goodness without wasting any gasoline. You see someone with some big gashes in his forearm, or an arm that’s totally deformed, and you think to yourself, “Man, that must hurt like hell. That sucks. Glad that’s not me.”

This same sick curiosity happened last week with a jaundiced patient. This guy was the brightest yellow I’ve ever seen in my life. The whites of his eyes were fluorescent-highlighter yellow. I had just caught him out of the corner of my eye, and the “Oh man, that really sucks” thoughts came flowing right in.

But then I did a double-take–I knew the guy. He was actually one of my favorite patients that I had taken care of back in February. And I felt really sick for giving him such a cursory thought–and one of pity at that. I went over and we talked for a few minutes–that I was sorry to bump into him in such circumstances, how his kids were doing, how he was feeling.

And then the conversation quickly went from superficial to serious, confiding in me that he didn’t want to be one of those poor guys that dies on the transplant list. His eyes filled with tears, and a lump grew in the back of my throat. I touched his forearm, and said I didn’t want that to happen, either. Right after that the transporter came in to take him to his bed in the hospital, and I said goodbye for the time being.

While I don’t know if I’ll ever be able to get the rubbernecking thoughts from my head, I know I’ll be less superficial with their impact–it’s not just that an arm is broken–it’s that the person’s arm is broken.

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So Dr. Rangel’s got a piece talking about taking away Medicaid benefits if people don’t use the ER correctly:

With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?

Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.

He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea, agrees.

I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today: “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?

What is it with these doctors? I’m at a loss. We’ll go point by point here:

1. Medicaid is broke. Check.
2. Poor people use the ER more often. I’ll assume for the sake of argument this is true. Check.
3. Only 16% of ER visits are truly emergencies. Now things get murky. The study Dr. Rangel is quoting seems to be looking at end-diagnoses, not symptoms. In my 4 ER shifts, maybe out 20% of the people I’ve seen have been truly emergencies or urgencies. However, the people’s symptoms have been a much higher percentage of possible emergencies! Sure, you see 10 chest pains for every 1 heart attack, but how the hell are our patients supposed to know that? A patient got poked in the eye pretty bad. Should he wait until morning? Or go into the ER? A patient feels nauseous and light-headed, and has one episode of shaking. We find nothing wrong with him, but I’d get myself to an ER immediately, too!
4. Next up: If we follow the “poor people” line, we’ll go ahead and assume they’re probably also the least educated, too. So now we’re asking the least educated of our population to properly differentiate between emergent and non-emergent. (Some things are “duh,” but honestly, most of them aren’t.) The rich get richer, and the poor get sicker. (As a commenter noted on Dr. Rangel’s site, perhaps Medicaid patients go to the ER more often because so few doctors see Medicaid patients anymore.)
5. If we want incentives and disincentives (carrots and sticks), let’s make an actual, viable system. If you go to the ER now with your Medicaid or whathaveyou, you may get a bill for several thousand dollars. Ha! That’s what you make in 3 months! What a joke! In a perverse system like this, people will respond just as perversely. No doctors at clinics? Ridiculous bills? Might as well just use the ER when I need it, since the whole system’s a joke.
6. And finally for Dr. Thompson’s doozy: of course you don’t have a problem with Health Savings Accounts and people making their own health care decisions. You know exactly what decisions to make–you’re a doctor! That’s what you’re supposed to do–make health care decisions. But as I’ve said before, people that need health care urgently pick the closest hospital; no one bargain shops (as if you could get prices anyway). And which patient has the time and energy (and background) to research the costs and benefits of a certain study, and to interpret what the research actually means clinically?

Can we please, please, PLEASE stop with the patchwork nonsense where we try to eliminate limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of your specialty. Zoom out one more time. The big picture of everyone.)

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They don’t call it the Emergency Department for nothing.

I’m sitting there, talking with a 40 year-old woman complaining of lower back pain who had a kidney transplant, and then she adjusts herself to try to get comfortable, and shakes a couple times. She starts gasping for air; she is unresponsive to my questions. I immediately call for help, and a nurse comes in. Neither of us can get her to respond, and her eyes are glazed over. The nurse goes to get the attending, who comes in. We’re having trouble getting a good O₂ sat on her (that gives us a rough idea of the oxygen in her blood), and once we do, we realize she needs to be intubated to help her breathe. We intubate, and then have to start CPR; she now has no pulse. Her blood pressure is dropping. We code her for 11 minutes. Her pulse comes back, and she’s maxed on the medications for blood pressure support. Her heart on ultrasound is pumping, but barely.

I have my hand on her femoral artery. We lose her pulse again. We code her for 24 more minutes, and eventually the family decides to do comfort care and have some time alone with her. We lose.

I could go into all my analysis of how my resident did a great job and set a good example of following the basics–Airway, Breathing, and Circulation. But something scares me more than not knowing exactly what to do when this happens next time.

What’s really bothering me is how okay with it I feel. That we spent 2 hours trying to bring someone back to life, that she crashed right in front of me–basically died right in front of me–and I was totally okay with that. That 5 minutes after it was over, after I finished writing up what happened, I just went about my business and picked up the next chart. I moved right on.

I keep waiting for some delayed grief reaction or something, like I’m going to be just walking down the street and suddenly feel really sad or something, but it’s not happening. I mean, this person I just met died, but I’m not all that upset about it. Maybe I just didn’t know her long enough to need to grieve about her. Maybe I somehow knew that after the first code, things weren’t looking good, and I didn’t have much hope when the second one began. Maybe this makes me a great, objective, detatched doctor. Maybe this makes me a terrible, distant, detatched human. I don’t know.

I’m hoping that either my over-analysis of this event over the past week is my grief reaction, or that whatever part of me I think I’m currently missing can come back, because it seems pretty damn ironic if I’ve somehow lost my compassion and empathy during the practice of medicine. Never saw this one coming.

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So Psych is over. I really, really liked it, and found the patients fascinating–how someone seemingly “normal” can become psychotic, hearing voices, believing strange things–and not even understand that the things they hear or believe are abnormal–is surreal, frightening, and incredibly terrible. I’ve also known people that think mental illness (especially depression) is a bunch of crap, that people should just suck it up–and these are clearly the people that have never seen depression. They’ve seen sadness.

Interesting cultural-cum-insurance caveat (how often do you find those!?): the psych service sees a good number of Stanford undergrads (at least 1 per week) in the locked unit for mania, psychosis, etc. One of the major problems is insurance, as some programs have terrible mental health coverage and won’t pay for hospital stays or outpatient programs. Notoriously difficult are students from Asia with insurance from their home country; there’s a pretty strong disbelief in the notion of “mental illness” in many Asian countries, so often these students have absolutely NO mental health coverage whatsoever. Disaster.

I will miss my team, as psychiatrists tend to have just the right amount of quirk for my tastes, and I will definitely not forget Gertrude walking down the halls screaming the most random of things, “These are the poisonous snowflakes of Santa Claus!” “I need a silver bullet… because I have acne! Zits! Pus! Pustules!” I would seriously just lose it in the halls. It was kind of bad. She later grew fond of me, “Hello gorgeous, you’re quite a ticket!”

Psych is great, but I always had something of a hard time with treating the black box that is the human mind. I’m sure it’s the art of the practice, but I’m so used to having more data, I guess. I also felt a little weird using my own life or experiences as the norm by which to judge a patient’s thoughts, actions, behaviors. I may pull off normal well, but I’ve had my share of issues and poor coping mechanisms, not to mention my, uh, “unique” personality traits and general dorkiness.

I’ve found that I really enjoy the psychosocial of medicine–it’s why I liked psych so much, it’s why I really enjoyed adolescent medicine. And I think it’s what draws me to the ED (Emergency Department, the correct way to refer to the “ER” now), too. I love the idea that you can walk in and see anyone, with anything, speaking any language. It’s a real cultural mashup.

This is also the reason that I’m nervous tonight about my first shift, tomorrow afternoon. I could see anything walk in the door. And it’s been a couple months since I’ve been on adult medicine. Granted stuff usually comes back pretty quick for me, but the idea that I could be seeing just about anything scares the hell out of me. (I of course assume I will only see very scary, serious things, no colds or chronic lower back pain.)

So there we are. The ED tomorrow, working my butt off. Back to studying for now.

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I don’t think this will come off as funny as my attending tells it in person, but she once had a medical student who thought that the abbreviations “BID” and “TID” were just doctor speak for “I agree” or “Yes, that’s all.” (BID actually stands for “twice a day” and TID stands for “three times a day.” As in, take this pill, three times a day.)

My attending found this out the hard way; she’d always ask the medical student about a patient’s medication doses. The medical student would say “The patient is on Haldol 5mg.” And my attending would ask, “BID?” And immediately the student would nod back with a smile, “BID!”

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(Before or after you read this, please, please take action. Especially physicians–Congress listens to you!)

I don’t know how I missed this disaster of a possible policy decision, but luckily Kate informed me of the bill. It’s supposed to allow small businesses to band together to buy health insurance together, but in the process also cancels many states’ required coverage items–that is, areas of health care that the state requires all insurers to cover. (The thinking being that small businesses could purchase cheaper plans if the plans don’t have these required restrictions. And this is big; small businesses employ half the work force in the US.) By a wide margin, these items are prevention programs. And what are prevention programs? Screenings that catch disease early so that it doesn’t cost us orders of magnitude more down the line–either in health care, education, long-term care, etc. Here’s how I view these programs, as a future provider (and likely future pediatrician). I’ll use California examples. If we cancel…

• Alcoholism Treatment: We have more drunk drivers, more deaths and more permanent disabilities. We have more fetal alcohol syndrome, which leads to learning disabilities and more costs for special ed. We have more lost workdays.
• Blood Lead Screening: We have more children with learning disabilities, permanent brain damage and mental retardation.
• Bone Density Screening: We have more women break their hips and require surgery.
• Colorectal Screening: More men and women get colon cancer, the second most common, deadly cancer in the US. In most cases, if you detect it early, you remove a polyp and STOP a possible cancer completely.
• Contraceptives: More teen births, more unwanted pregnancies.
• Diabetic Supplies/Education: Education and supplies are absolutely key to diabetes care. The complications: early heart attacks, amputations, blindness, non-healing ulcers, infections, more ICU stays.
• Emergency Services: People with these plans will pay 4 times as much for ER visits.
• Hospice Care: People die shitty, painful, scary deaths. Sigh.
• Mammography Screening/Prostate Cancer Screening: Hi breast and prostate cancer, the second most common of cancers in women and men, respectively.
• Metabolic Disorders (PKU): Near and dear to the Pediatrician’s heart, the newborn screening. This picks up diseases like PKU and hypothyroidism, which if caught early, can be treated and the patient can have a normal life. If not treated, kids die early, mentally retarded. (The treatment for PKU? Avoid certain foods, especially those with the artificial sweetener, aspartame–this is why diet drinks say “Phenylketonurics, contains phenylalanine.”)
• Off-Label Drug Use: This requires companies to pay for drugs that doctors prescribe for non-approved uses. For example, some drugs for seizure disorders also work for mental illness or chronic pain; doctors are allowed to prescribe it for seizure disorders as well as other diseases it might work for.
• Well-Child Care: When you take your healthy kid to the doctor to make sure he or she is growing and doing well. In these visits we look for hearing problems, cataracts, childhood cancers, hip deformities, brain problems, broken bones, child abuse, undescended testes, and other signs of possible abnormalities.

I can’t believe some of the stuff that I just wrote that Congress is considering allowing people not to cover. And I can’t believe we’re willing to go this route–allowing companies to provide crappy, inadequate insurance to maintain an already broken, patchwork, pathetic health care system.

(Before or after you read this, please, please take action. Especially physicians–Congress listens to you!)

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Besides maybe Emergency Medicine, there’s probably no other medical specialty that appears in pop culture and entertainment more than the pyschiatric diagnoses. And there’s definitely no other medical discipline with so much stigma attached to each and every diagnosis. Here now, in order that I think of them, my examples of pop culture psych:

1. Psychosis/Schizophrenia: Hearing voices, seeing things, having fixed incorrect beliefs (delusions). Probably the most skewed, stigmatized diagnosis of all medical diagnoses, including the other psych diagnoses and HIV. Schizophrenics are always the “crazy people that hear voices” and mutter to themselves, and are very, very dangerous. They are unstable, they attack people for no reason. The screaming naked guy from The Sixth Sense, for example.
   In the real world, these people are often managed and doing well on medications. Many of the chronically homeless are also schizophrenic. If they make strange movements with their mouths or tongues, it’s a permanent side effect from some of the older medications. They can’t help it. From the patients I’ve seen, schizophrenia is an incredibly sad, incredibly terrible disease. While there are definitely some people with the disease that scream or are violent, most of the folks I’ve seen are kind, quiet, confused, and scared. They hear voices talking to them all day long, or screaming at them, or narrating their thoughts. One patient is constantly being told she’s being arrested, or she’s bleeding internally, or that she’s done something awful. All. Day. Long. Another patient hears his friends’ voices narrating his day. If he drinks a cup of juice, they say, “He’s drinking some juice now.” If he walks down the hall, they say, “He’s walking down the hall.” I don’t think I could stand that for a day, let alone a lifetime.
2. Dissociative Fugue: Usually after some traumatic event, a person forgets their entire past life, moves to another city, and starts a totally new life. Geena Davis in The Long Kiss Goodnight, and maaaybe Kermit in The Muppets Take Manhattan, when he starts working in the ad agency after being hit by a car. Probably also “amnesia,” but I’ll just include it here.
3. Speaking of amnesia: it’s the perfect plot device for most crappy soap operas and movies alike. (But Memento was good.) Problem is, it’s quite rare, and usually doesn’t happen after getting hit in the head; it’s usually after a very traumatic life experience.
4. Munchaussen’s By Proxy: Someone purposely gets someone else sick (often their child) in order to get medical attention. (Think the mom in The Sixth Sense that was poisoning her daughter.)
5. Tourette’s disorder involves frequent vocal or motor tics. A tic is a repeated behavior that can be suppressed, but causes great distress to do so. The coprolalia form is your classic “Shit! Fuck! Shitfuck!” from classy movies like Deuce Bigalow, Male Gigolo.
6. Antisocial personality disorder: the pop culture “sociopath” that doesn’t abide by societal rules and shows little remorse. Serial killers in TV docudramas will fit the bill.
7. Hypochondriasis: Isn’t the guy on Monk supposed to be a hypochondriac? Oh, and Bob in What About Bob? Very significant anxiety and worry about having disease. (Also most 2nd year med students.)
8. Male Erectile Disorder: better known as impotence. Charlotte’s first husband on Sex and the City, anyone?

I could go on and on, but I think you catch the drift: psych diagnoses are everywhere, and they’re often totally off-base.

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Being on psych this month, learning and reviewing all the psych diagnoses, you can’t help but fearfully self-inspect for psychosis, personality disorders and the like. Look what I learned in school today: I’m a schizoid narcissist with passive-aggressive tendencies and a history of anxiety problems!

I’m really enjoying psych, and I wonder if it’s because I can relate to some degree. I think most of my classmates enjoy it, but some just don’t, and perhaps it’s because they’re just not neurotic enough, or don’t have a good sense of how challenging life can be with mental health problems.

Just a thought.

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Not anymore, at least. 40% of businesses do not offer health insurance to their workers, and that’s up from 31% in 2000. How can people possibly think this is working?

• More than one-third (34%) of adults ages 19 to 64 (both insured and uninsured) either had medical bill problems in the past year or were paying off accrued medical debt.
• The $10,880 average annual premium for a family of four in 2005 surpassed the yearly gross earnings of $10, 712 for a full-time minimum-wage worker.
• Forty-one percent of adults with incomes between $20,000 and $40,000 a year did not have health insurance for at least part of 2005.
• 51% of women without health coverage have not had a mammogram in the past two years, compared to just 9.2% of women with coverage.

What an utter disaster. We should be ashamed of this level of care.

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An attending told us today in our first psych lecture, “Medicine is not about stamping out disease, it’s about helping people.”

Boy have the days of medical school applications passed.

No longer do I try to figure out how to rephrase “I want to help people,” and fit it into a 500-word essay. But along with it went the whole initial notion of medicine–that is, a profession built on helping people, improving lives, easing suffering. Now for me it’s about turning a patient’s story, signs, and symptoms into a diagnosis, and then figuring out what to do for that diagnosis. Sure, often the goals overlap–but in the end, I’m not out to relieve suffering, I’m out to cure disease.

I expect (or hope?) that this will come back to me once I get the whole “diagnosing and treating” thing down pat–hell, a large part of the reason I write this blog is to remind me and others of the important stuff, because it’s just so damn easy to forget.

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Part of the reason I decided to study social policy in college was the fact that I knew that as a doctor, I’d primarily being trying to improve the health of individuals, but I saw far too many individuals for any one me to help. So when I read about the legal aid services for children, and the fact that it’s going national, I couldn’t have been happier.

It turns out that doctors tend to work in a pretty specific realm (the medical one, surprise surprise). But health tends to be affected by multiple realms. Doctors are great advocates for their patients for their medical health–giving medications, for example–but when it comes to more systemic, structural problems, I’d give doctors as a whole an F. That’s why we work with social workers, child life specialists, home health nurses–these people have better footing in the non-medical health arena.

What the Boston legal team has been addressing is another level of advocacy–administrative and regulatory advocacy. This entails ensuring that laws are enforced and people are held responsible for their responsibilities–for example, ensuring that a landlord keeps his apartments’ habitable. Lawyers know how to push the right buttons (and have the time to do so) that often doctors don’t.

It’s possible that these lawyers are having a greater impact on health than the doctors with whom they work.

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This story is awesome, in the sense of “full of awe.” It is almost unbelievable, in the most literal sense. It questions my assumptions about the limits of the human mind. It is what I love about neuroscience.

40 year-old AJ says that she can remember individual days of her life, starting in 1980. Researchers are calling it hyperthymestic syndrome. I first heard about this story on NPR, and there was a follow-up short interview with her today. I luckily found a free PDF of the published Case Report (thanks Google!) from the journal Neurocase, and it’s very readable–something in-between a New Yorker piece and a scientific journal.

AJ has been rigorously tested over the last 5 years by neurologists in Los Angeles to both confirm that she’s not a hoax, and to learn more about her condition. On two separate occasions, two years apart, she was asked to recall the dates of all the Easters since 1980 (this is especially impressive, as AJ is Jewish). She also recalled what happened on each Easter; these were verified from meticulous diaries AJ has kept since she was 8:

You ask her any date, and she says that she can go back and feel the day, almost relive it. A gift and curse: she vividly remembers each day of her childhood–her earliest memory is as an 18 month-old–but she remembers every bad day just as vividly. She doesn’t appear to have any other type of profound memory ability; she can’t memorize long lists of numbers, and she can’t tell you days of the week in her past or future. She has only an average IQ when tested (although her IQ memory component scores much higher). It’s almost too amazing to believe; you’ll have to read the report yourself to see all their verification steps.

Before this, I had assumed that the human mind would be simply uncapable of recalling so much detail–how neurons could somehow store so much information is beyond me–but it seems that it can recall, but perhaps at a price. AJ appears to also have OCD tendancies (as evidenced partially by her meticulous journaling); she appears to have some brain lateralization abnormalities; she appears to have some executive functioning deficits, as well as some dysnomia (naming objects the wrong but associated name) and decreased motor speed in her dominant hand.

It’s hard to imagine a world where all my days are recalled so vividly. Most of us only have small bits and pieces of our memories remaining; I remember going to the hospital to see my brother when he was born, but only in small faint outlines. I remember playing tetherball in the 4th grade. I remember a trip to New York in high school. But these are only little punched-out experiences that for some reason my mind chooses to recall, maybe only a couple each year of my life. But AJ can tell you the day she had conjunctivitis in 1987, or which boy she was going out with during high school when you give her a date.

I would imagine there’s a reason we don’t all possess this ability–that it perhaps distracts us from the rest of our lives, such that if we’re recalling so much about what happened on July 17, 1984, we won’t notice the tiger creeping up behind us to eat. I would imagine that the system of memory most of us have is at least somewhat optimized–balancing all the functions the brain has to manage.

There are three phases of memory: recording, storage, and retrieval–but it’s not yet known where AJ’s “talent” lies–is she just a better recorder? She was very retrospective as a child, looking back at her life often–did she teach her brain to do this? Or does she have better storage–she just can store more memories than you or I. Or is her brain better at finding the memories–is it more organized, like her OCD tendencies? And what would that mean for the rest of us–are all of our days just locked inside our brains, inaccessible, but actually there? Could this be turned on somehow?

I thank AJ for stepping forward and being so open to testing at her expense for the benefit of medicine–often in science, it’s the outliers that teach us the most about the rest of us.

PS: If you like this brain stuff, you’ll love Vilayanur S. Ramachandran’s Reith Lectures from 2003. He’s a neuroscientist at UC San Diego. Free streaming audio.

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Our clerkship director has a nice catch phrase that sums up the medical student experience pretty well: “You have one foot in the medical world, and one foot in the real world.” By this, she means that as medical students we’re not completely totally 100% sucked into the crazy world of medical jargon, probabilities, and doctor-think. And because of this, we’re a valuable asset to our teams; we’re able to spend more time with our patients and our families, and we often act as translators from Medicalese to English (or Spanish, as the case may be).

I’ve always prided myself on being very perceptive of the medical jargon, and I’ll even go so far as to interrupt my attending to translate if necessary–but I’m losing my touch. Because the Pediatric patients are pretty quick and to the point, I can usually do a pretty quick presentation. But between trying to improve my speed and translating for most of the past two weeks into Spanish, my brain hasn’t had enough processing power–I caught myself asking an English-speaking patient if her child has been “afebrile,” and got a confused stare immediately. “Uh, I mean, has she had a fever!?” I asked apologetically.

And yesterday, more evidence that my medical training is starting to influence the things I assume: a 6-year girl came in for a red streak (mom thought it was blood) around her stool, and going through my history with the mom, she said that cancer ran in the family. I ignored the fact–didn’t even present it to the attending–no way cancer is relevant to this case. My astute attending, however, asked mom: “Any intestinal problems in the family?” and the mother replied, “Yes, my grandma just died of intestine cancer, and it started with blood in her poop.” Of course! No wonder the mother is coming in–she had assumed her child might have colon cancer. Me, medical student that knows that colon cancer in a 6 year-old would be extremely, extremely, extremely rare (as well as most other cancers), just skipped over the fact, assuming that cancer had no role in this case.* (It did have a role–but psychological, not medical.)

The deeper down the rabbit hole you go, it seems the harder it is to even know your assumptions. Until you get burned. All of a sudden they become much more apparent.

* I know someone is going to comment about FAP or HNPCC or ulcerative colitis, and how those could have a child presenting with colon cancer. I know, I know.

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Love the idea of a medical school encouraging its students to blog, and no offense to the student bloggers over there, but it seems a little forced when you look down at the footer:

This page is maintained by UMHS Public Relations & Marketing Communications.
Contact UMMS
© 2005 Regents of the University of Michigan

The University of Michigan may monitor this blog about the information you’ll find or delete inappropriate content.

That’s some censorship I’m happy not to have.

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I’ve gotten a number of really great emails from high school and college students recently, asking for tips on getting into medical school, what my college major was, if I needed good math scores, if a person’s grades are good enough, and even “I have to go to medical school, it’s the only thing for me!” Here’s some advice, support, suggestions, tips, and tricks for what I can remember of the pre-med and med school process:

• If you’re in high school or college, and you haven’t shadowed a physician, or seen what a doctor does all day long, do it. Now.
  I had the most romanticized notion of medicine while I was in high school and part of college. It was exciting! It was helping people! It was… I don’t know what else! I don’t care if you come from a line of physicians including Hippocrates himself–you don’t know what doctors do until you go see for yourself. Hollywood conveniently edits out the paperwork, the phone calling, the mean patients, the mean nurses, and hell, the mean doctors. And all the people with bad breath. It doesn’t show the ass-kissing expected as a clinical student. It can’t possibly illustrate all the paperwork you have to complete. (I know, I said paperwork already.) It forgets the fear you feel that your patient’s life is in your hands. You don’t realize doctors spend all day long hanging around sick people, dealing with phlegm, urine, stool, and pus.
  So find all that stuff out for yourself! Shadow a doctor on his or her worst, most monotonous day. Not the best. Medicine is fun, it is exciting, it is helping people, but most of you considering medicine will love the best parts of medicine. The challenge is really to see if you feel like the best parts–that you sometimes maybe only get to experience once in a week–still outweigh the worst parts.
  If you find that medicine’s not right for you, that’s okay. That’s wonderful. Better finding out now than after you’re already a doctor, right? If you still want to be involved in health care, look into nursing, physician assistant programs, or nurse practitioner programs. All of these professions arguably contribute just as much (if not more) to patient care in many ways.
• Figure out everything else you could possibly see yourself doing, and either do it before medical school, or rule it out.
  I thought I might want to be a policy wonk; I was a social policy major in college. So I spent some time in college and before med school doing policy work. I’m also a big computer geek. But I realized that wasn’t for me, either. It came down to the fact that everyone has to do something to pay the bills, and if it’s between having the opportunity to practice medicine and something that’s maybe more steady or easy but more monotonous, medicine wins hands down. But you have to come to your own conclusions.
• Take some time off to learn about yourself!
  I spent all four of my college years living in the residence halls. I had no idea how to setup apartment utilities, how to cook, or even how to really live on my own, as a full-fledged adult. I couldn’t be happier that I took a year off before medical school to mature as a person before I started with the task of learning how to take care of other people. Get your life in order, do what you need or want to do. Want to see the world? Go now! Medical school doesn’t leave a whole lot of opportunities. I’d say at least half of my class took at least 1 year off before starting school. It’s a common trend. As long as you don’t spend your time solely playing video games in your parents’ basement, it’ll be worthwhile, and I think your application will be stronger.
• Be ready, willing, and prepared to sacrifice. A lot.
  I tell this anecdote way too many times, but it’s appropriate. We had a great speaker at our first day of med school orientation who said, “You know, you probably think that becoming a doctor is a really giving, honorable thing to do. And it is. But you forget how much it takes from the rest of your life–your significant other, your family, or your children.” Truer words have never been spoken. Learning medicine will at least suck up a decade of your life. It will make your schedule inflexible. It will strain your relationships. It will try your family’s and friends’ patience. You may miss out on friends’ weddings. Or ski trips. Or reunions. It will change the ways in which you think about and understand the world–for better and for worse. It will perhaps mean less time you get to spend with your child. The rewards are great, but, as you’ll be taught to understand: everything comes with a price.
• Do what you love.
  One of the most common questions I’ve been asked is “What should I major in?” My advice? Whatever keeps you up at night. Whatever makes your heart beat faster. Whatever excites you. Whatever you’re passionate about. Medical schools want to see that you care about something, that you’re dedicated to it, and that you don’t give it up. (You’ll need these skills to make it through medical school.) If biology is your thing, be a bio major. Do something really cool with it. But if you’re not head-over-heals for DNA and RNA polymerases, find something you care about, and dig in. Do research. Volunteer. Join or start a related student group. As long as it’s interesting, it’s fine. Don’t obsess about if it’s a “good” major for medical schools. If you can explain why you majored in it, why you care about it, (and perhaps how it may relate to medicine or health), you’re golden. I’d much rather have a classmate that’s passionate about 19th century politics than someone with a fleeting interest in cell biology.
• Are your grades good enough?
  Do your best in high school and college. A public school doesn’t preclude you from getting into medical school by any means, and a private school doesn’t guarantee admission, either. You need to have good grades in your major and your pre-med courses, but realize that except for several important concepts and ideas from chemistry, biology, and physics, they’re really testing your ability to learn, synthesize, and memorize. (I suck at math; I think Calc 2 is required? The most math you’ll need for medical school is simple algebra for renal physiology.) The MCAT is a test of confidence and time-management as much as it is knowledge. Remember: grades and scores are cutoffs; once you reach the cutoff, it’s the rest of your application and interview that make the difference.
• Again, make sure there’s nothing else you can see yourself doing besides medicine.
  Otherwise, you’ll spend medical school being jealous of your friends who are working in their 20s and partying and having fun and turning all adult while you’re still a student. (And you will still probably do this at some point, because med school just sometimes sucks like that.)

If you have other questions you’d like answered, please leave a comment, and I’ll consider writing up a Part 2.

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Joey is twelve. No, wait, fifteen. His face is twelve. His neck, scarred from pepper spray, is a bitter eighteen. His abdomen, with a line from a stab wound, is a harsh twenty-five. I guess it averages out. Okay then, fifteen it is.

Joey is the third minor I see by myself today at a well-child checkup in Fremont; his parents are working. I’m starting to get the hang of it–medical history is quick, social history is long and involved. Tells me his grandmother had just passed away and his one-year old daughter–yes, daughter–was sick in the hospital with pneumonia. (I double-check his age, yes, he’s 15.)

Up until this point, most of the other teens I’ve seen have tried to play it cool, or curse a lot, or are in good moods. They like to think they’re adults, but I still talk to them like they’re teenagers. Not condescending, but just not… adult. But Joey’s just lost a family member. “I’m so sorry to hear that” is my automated response. Not that I don’t care enough for spontaneity. That’s just what I’ve found as the easiest, non-judgmental, non-assuming thing to say whenever someone says someone is dead or has died. That, and some silence. Respect for the dead.

I find out Joey’s sister has diabetes, and Joey has a cough. He smokes cigarettes. We discuss coughing and cigarettes, and the irony. I smile, he smiles. He uses marijuana infrequently. He doesn’t drink alcohol.

Joey is sexually active, with his “lady.” He doesn’t use condoms. He doesn’t like they way they feel. His lady uses birth control. His “ex-lady” and him had a daughter.

Joey gets quiet. He tells me his daughter, the one with pneumonia, died yesterday.

He starts to cry.

I want to, too.

I’m speechless. The automated reply doesn’t fit. Only silence will do. I glance back at his age; he’s lost a child. He’s a parent who’s lost his one-year old daughter. I feel sick in my skin. I apologize profusely, painting him with empathetic words, trying to remain calm while my eyes water briefly.

We talk a little bit about it after he grabs a tissue–she had had a pneumonia because his “ex-lady” didn’t know how to take care of a baby (he does, he raised his three younger brothers). His daughter had had the infection for two weeks, and went into the hospital after it was just too late. I’m still in this shocked state of disbelief. We talk some more, and I try to let him know that we can talk about this as much or as little as he wants, and that there are lots of people who can talk with him and help him, too. I tell him that I find talking about difficult things helps me sort through it all in my head.

The rest of the talk goes on its way; I fumble two or three times, awkwardly trying to figure out how to continue the exam respectfully. He was beaten up by his stepdad when he was 7; he educates me about the two different gangs he has been in. He tells me that they have the right to take his life at any time because he left them.

I talk with him more than I usually do with the other teens. I go into more depth about what he wants to do in a few years. I educate him about the heart and the lungs and the thyroid gland. I have some foolish wish that an extra 4 minutes talking about hyper and hypothyroidism and diarreha versus constipation will magically grab his interest in science and medicine and solve all his problems, heal all his pain. It makes me feel better more than it does him.

Joey is fifteen, but life-wise, he’s eighty. He deals with these catastrophes as best he can. As best any fifteen year-old can. He tries to be tough. I can’t help but wonder if he thinks that this is just his lot in life–how his life (or anyone’s, for that matter) is supposed to be–or if he really knows how much adversity and despair he’s already experienced.

I sigh. I think it’s the former.

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• A pediatric back surgeon told us today that he has a harder time convincing parents that their children with lower back pain shouldn’t have surgery than he does convincing them to undergo surgery. (This is back surgery, notoriously full of complications and risks, as you’re potentially messing with the spine and spinal cord.) He says he believes in educating parents about surgery and the chronic nature of back pain–even in kids. But, he adds, sometimes it’s much easier to give the parents a referral for physical therapy (which he doesn’t support for kids).
• A pediatrician told me she finds that parents are much more reassured and comfortable taking care of their children with fever when she actually writes out a prescription for Tylenol (an over-the-counter medication anyone can buy) than when she just tells them to go buy it.

What is with this? Why do we want some sort of tangible intervention when we leave the doctor’s office? Why is education and discussion not enough, and how can we do a better job of both increasing patient satisfaction while decreasing unnecessary medications and other treatments? I’d be especially interested to learn if this is an American or Western concept, or whether this sort of expectation exists throughout the world–or even if this has only come to exist recently?

I wouldn’t be surprised if there’s a monetary “value for your money” component to it; either you pay a co-pay or a ridiculous amount for your health insurance, so you carry over the expectation of money exchanged for goods (arguably you don’t get “service,” as your doctor may be running late).

I think there’s also a degree of discomfort with “just watching” someone’s condition–either from an impatience standpoint or a worry factor. Or maybe the feeling of the physician abandoning the sick patient, or not showing the patient some sympathy or empathy. “You want me to what? Go home, rest, and drink some liquids? I’ve felt awful for 3 days already, and you’re not going to give me anything for it?” (I’m definitely guilty on this count.)

It looks like physicians as a whole are pretty clueless about patient expectations; perhaps figuring out what a patient wants to get out of the visit will help to head off some patient disappointment at the end of the visit. I also like the concept of not downplaying a person’s illness; I’m guilty of telling patients “it’s just a virus” many, many times.

A cursory Pubmed search didn’t turn up much, but I wouldn’t be surprised if patient satisfaction increased if all patients were just given a little one-page handout on their condition. It would satisfy the tangible need, reassure them that they have information–including when to expect to feel better, or medication side effects, or when to return for a follow-up appointment–and wouldn’t lead to excess antibiotic usage. It’d be simple to customize the handout with the patient’s name and some other personal info to make it feel even more individualized; anyone know if this has been studied?

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I’ve spent some time over the past couple weeks at Juvenile Hall. I think it’s one of those experiences where I learn more than I actually contribute, and I just hope that I’m sensitive and understanding to these kids’ problems, and not just look at them like they’re this foreign world to me (which they are) which I can’t do anything about (which I can).

• I’ve seen more stab wounds in my teen population than I did in my veteran population.
• I often don’t understand why these minors do what they do, but I don’t always try to. I could never understand their childhoods.
• It’s much easier to take a sexual and drug history from these teens than it is from adults. I don’t know if it’s because they’re younger than me, or if it’s because I expect them to be sexually active and taking drugs, or if it’s because it’s much more relevant to their care than it is to most adults, or if they’re just more comfortable and open about the topics. Probably a combination.
• For all of Pediatrics: I would love love love some sort of national database that keeps track of what vaccinations a kid has had. Man that would save time.
• Myspace is powerful among teens. I saw a runaway teen who doesn’t use Myspace and doesn’t have Internet access, yet he believed that Myspace was the most important way that young people like him found out how to participate in the immigration rallies. (His girlfriend uses Myspace; that’s how she and her friends found out.
• I’ve learned Gang Basics 101, including information about the Norteños, Sudeños, and Brown Priders.
• I cannot fathom doing at my age some of the things these teens have done: stealing mom’s car and leaving it on the freeway when it ran out of gas, experimenting with crystal meth and cocaine, being diagnosed with chlamydia. Thanks, OP!

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Would you mind having an extra $900 a year? (You’d also get another $900 per kid.) What is that–about the cost of a really nice vacation every year? Going to a great restaurant once a month? Several pairs of shoes, clothes, and diapers for a child?

Often people don’t realize that they have something to lose from this inefficient mess we call “The US Health Care System.” Even if they have health insurance. See, because every time that your employer’s health insurance premiums go up, that’s money that your employer can’t pay you as a raise. So all that raise that you’ve been wanting to get? Oh, you’re getting it–but it’s in the form of higher health insurance costs, not a fatter paycheck. (And you probably didn’t even spend more on health care this year than last, either.)

One of the things I really enjoy about Joe Paduda’s Managed Care Matters is that it reminds me of how much health care really costs. We spend over $5200 per person per year in the US on health care. The next closest count, Switzerland, spends about $1800 less than us. And the Swiss have lower rates of infant mortality and on average live longer than us.

Granted, these are not perfect comparisons–even if I’m half wrong–that the Swiss aren’t as health as us, and they’d need to spend $900 more a year to compare with us–that’s still $900 cheaper than the US. Imagine if every person in the US could receive the same health care, but had an extra $900 in their pocket. As a student, I’d be happy to have it. I heard on the radio last week a guest describing employers that pay the “minimum wage” are actually paying a “subsidized wage;” that is, the public is subsidizing the employer, since the employee is receiving social services (including health care) from a public, tax-funded hospital or clinic.

But because we hold on to this insane notion that our health care system is the best, or that health care reform is politically impossible, we sit here, being inefficient, wasting our own money away. Until people realize that people will get health care, no matter what their insurance status, we’ll continue to chug along in a wasteful system. We are blinded to the fact that providing health insurance, and therefore, preventive, primary care, is more cost effective, and saves us all money.

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You don’t know how frustrating and condescending it is when you’re doing your best to speak your patient’s native language as best you can (and not doing half bad given that you haven’t really practiced in a couple months), and your patient’s mother and grandmother start laughing and making fun of the way you pronounced a word. Yes, I had my stethoscope on, ladies, but it ain’t exactly soundproof. And I can understand much better than I can conjugate.

I’m as obviously gringo as they come, but it’s obvious that I’m trying my best, and I’m making an effort. I don’t care if I’m a medical student or your doctor or the guy who cleans your toilet; it’s rude, flat out.

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I’m all for doctors and medicine trying to be as objective as possible, but it’s just so damn cute when doctors think they actually are objective. As if we don’t bring our own values and assumptions to the table. I’m doing well-child checkups this week at a county health clinic. I walk in, see a 9 month old baby, a 40-something year-old woman, and a 16 year-old girl, and immediately turn to introduce myself to the 40-something year-old woman, because clearly she’s the mother of this child; 16 year-olds don’t have babies!

I cringe every time I recall this story.

Next is the number of superstitions we go through as physicians (luck and superstition are clearly objective, too). For example, I will never, ever mention how a day or night of call is going smoothly, or how quiet the pager has been, or how empty the floor is. I will think it, and consider bringing it up for casual conversation, but it stops there; for if I mention anything to that effect, I will jinx the team and we’ll magically have 20 new admissions that night. I know this is totally crazy, but I totally, 100% abide by this. I don’t know that I totally believe it, but I’d much rather keep my mouth shut and hopefully have fewer admissions.

And it’s only medical things that I’m superstitious of, which makes it even more ridiculous–in the medical world, where we base everything on risk, benefit, and predictions from data and randomized, double-blind controlled trials, I truly act in a certain way, hoping my behavior will somehow influence the outcome.

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Busy learning Peds, which I’m really enjoying. A quick eval, starting with the pros:

• The people–doctors, nurses–are just nice. You don’t realize how not nice some people are on other services until you do Peds.
• Your patients are for the most part, cute.
• Kids are resilient, and can make it through some really serious disease that would probably kill an older person.
• Most have reeaaally short Histories of Present Illness (2 days of decreased bottle intake and 1 day of cough), reeaaaally short Past Medical Histories (full-term baby) and usually are taking no meds.
• Peds is pretty straightforward. Kid is dehydrated and can’t keep food down? Give IV until kid can keep hydrated on liquids, then discharge.
• For the parentless hypochondriacs like myself, if you don’t already have any of the terrible pediatric diseases, you won’t have them.
• There are many pediatric specific diseases, but most of Peds is medical management.
• Kids have nice clean arteries and veins and organs, and for the most part haven’t screwed them up with alcohol and drugs and cigarettes. (I screw mine up, too, just like any other adult.)
• You throw antibiotics at everything.

The cons:

• Kids are germ factories, and you will get sick while you’re on service. I can’t count how many times a patient has coughed right in my face.
• If they’re young, they can’t tell you what’s wrong with them, or what hurts.
• One word: parents. I’m astounded at how different parents can react to certain degrees of medical illness. Some parents are great, others need to chill out and/or stop coddling their children. (Yes, I know people have different styles, yes, I know you have to work with the parent where they’re at.) It just seems like too many parents want their kids to be their friend, when the kid needs a parent, not another friend.
• For the parent hypochondriacs, your kid could have or get any of the terrible pediatric diseases.
• It’s hard to get IVs.
• You see a whole lot of kids with congenital or lifelong diseases that have no treatment.
• It sucks making babies cry.
• It sucks having to calculate drug doses and fluids by kilogram.
• There’s a lot of turnover, so you honestly can’t remember a kid you discharged 2 days ago.
• You throw antibiotics at everything.

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The Lancet has a commentary piece arguing that is unethical for doctors to force feed patients:

We write regarding the forcefeeding and restraint of Guantanamo Bay detainees currently on hunger strike.1,2 The World Medical Association specifically prohibits forcefeeding in the Declarations of Tokyo and Malta, to which the American Medical Association is a signatory.

Fundamental to doctors’ responsibilities in attending a hunger striker is the recognition that prisoners have a right to refuse treatment. The UK government has respected this right even under very difficult circumstances and allowed Irish hunger strikers to die. Physicians do not have to agree with the prisoner, but they must respect their informed decision. Those breaching such guidelines should be held to account by their professional bodies. John Edmondson (former commander of the hospital at Guantanamo) instigated this practice, and we have seen no evidence that procedures have changed under the current physician in charge, Ronald Sollock.

The bf asked me if we force feed patients in any other case, and we most certainly do. In people with eating disorders, often the treatment for their complications (often very slow heart rates) is force feeding for nutrition. These patients (and others) are generally judged not to be competent to make their medical decisions, and so their family members, or their physicians, make their medical decisions for them. However, if a person is judged to be confident, it’s my understanding that they cannot ethically be forced to do anything, including eating. I have to agree with the comments from The Lancet. Dr. Sollock is breaching his code of medical ethics.

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Oh hellll yes. Did my first lumbar puncture (aka spinal tap) today. On a 5 year old. Champagne tap! (A “champagne tap” is when you get clear CSF fluid without any red cells in the fluid, as they can often contaminate your results.)

My attending, being the awesome guy he is, ran out and bought me a mini bottle of Korbel to celebrate.

I love procedures.

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ABC’s new reality show–if you can call it that–is already rubbing me the wrong way. It’s called Miracle Workers. (Here’s an article about the show with its host, a Miami CT surgeon. (thanks KevinMD). From the show’s description:

Each week, the show will feature two stories of ordinary people who do not have the network, access to the necessary medical community or in some cases the resources to these procedures. Their seemingly overwhelming medical problems will be taken in hand by a renowned team of medical specialists. The patients’ lives will be transformed before viewers’ eyes as the professionals employ cutting-edge medical technology to heal those who need it most. The team will not only restore the patients’ health, but their hope in living a whole life again.

We’re apparently now leaving the really sick and uninsured to reality television as their care takers, as opposed to creating a better medical system where all “ordinary people” have “access to the necessary medical community or in some cases the resources to these procedures.” So, dying people without health insurance, I recommend either the really sad, depressing story, or perhaps the cute children perspective so that Miracle Worker’s producers will choose your loved one to live, while another’s loved one dies. If the producers are somehow able to figure out which patients “need it [healthcare] most,” I’d love to hear their algorithm.

I saw a commercial for the show last night, and I couldn’t be more frustrated with the portrayl of the physicians on the show. Physicians are not miracle workers. (I’ll include myself in the ‘we’ here, even though I’ve got a little over a year before I’m a doctor myself.) We’re not gods, as a patient’s mother told me and my attending last night. Physicians, contrary to popular belief, are humans. Falliable humans. We’ve devoted much of our lives to caring for patients, by means of understanding the intricacies of the human body, how it works in health, and how it dysfunctions in disease. This is the distinction. Gods and miracle workers snap their fingers, or wiggle their noses (wait, that’s witches) or do whatever they do and make effect without any prior cause. Physicians figure out what the disease is, so they can understand its cause, so they can change something to alter the effect. They’re two entirely different branches of healing. The former is perfect, effortless, and instantaneous. The latter requires training, experience, and knowledge and is definitively human. That’s human all senses of the word, including “imperfect.”

Part of the reason I make such a distinction is because of the assumptions patients make about physicians, based on their understanding of how physicians work. After being told that physicians are “like gods,” my attending responded that “We’re no more like gods than any other person,” which was the perfect response. When patients assume physicians are perfect, or god-like, or saints, or miracle workers, they start having irrational expectations. When an error occurs, or a proper diagnosis isn’t made, it’s often hoped (and also assumed) that everything will go perfectly–that the error rate is 0% and the success rate is 100%. And that’s simply not the world of medicine that exists.

Physicians are taught to understand everything–I mean everything–as risk versus benefit. There are risks to giving a patient oxygen. There are risks to giving a patient some IV fluids–or even just giving a patient a meal or water. And physicians only do any of these things if they feel that the benefits outweigh the risks. This is what’s meant by “first, do no harm.”

I’ll repeat it: physicians are no more like gods than any other person. Yes, we had quickly figured out that the mother’s child had a malrotation that required urgent surgery, and that surgery was performed, and her child’s life was saved. But it was because the mother realized the child’s vomitting was of concern and brought the child to the hospital. And it was because the resident who saw the child recognized the child’s age and symptoms and made the diagnosis. And it was because the surgeon was able to repair the malrotation. And it was because the anesthesiologist properly monitored the child’s vital signs, and because the nurses caring for the child watched him closely, and because the respiratory therapist helped maintain his lung function. There was no snapping of fingers, no wiggling of noses.

Often, miracles seem like miracles because some of the treatments physicians give can rapidly take someone from dying to not-dying over the course of hours or even minutes. There’s a certain condition in the elderly that often causes them to have episodes of losing their vision–and if steroids are given, miraculously their vision can be spared. But it’s because the physician recognized the condition, understood why it occurs, and then understood the way to stop it from occuring.

And miracles? They’re statistical outliers. They’re luck. Listen: if my loved ones were sick in the hospital, I’d be praying as hard as the next man–but I’d realize the odds. The miracle involves being the one out of ten thousand that survives a disease. That’s just damn luck.

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Great music.

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It is really, really refreshing when your patients have no other medical problems, are taking maximum one other medication, have a short history of present illness, and are really cute and wide-eyed.

And don’t talk back.

Thank you, Pediatrics.

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Now would be a good time to wrap-up my long two months on my Internal Medicine clerkship, seeing as though I start Pediatrics tomorrow, which totally scares me because kids definitely don’t get my wry sense of humor and frequent pop culture references. In no particular, bullet order, because I’m just not in a paragraph writing mood tonight:

• After ranting for 20 minutes to my parents about how much I hated it, medicine turned out okay in the end, probably because I had a fun team and better attendings my second month. And okay, fine, I learned a lot, despite my best effort.
• No wonder people specialize. There’s just too much to freaking know.
• Man are we obsessed with data and risk and studies and evidence. Trial X found a Y% drop in Z when using Drug A dose B compared to Drug C dose D. This is the reason medical research and spending will always have a rationale. There will always be something a liiiittle bit better than the last breakthrough. Or sometimes studies suggest something reeaaaaally expensive for milllllions of patients. Are we really going to put pacemakers in everyone with heart failure?
• We spend an awful, awful lot of money on really, really sick patients, and often we spend huge sums of money on people in their last 6 months of life. In one study in LA, almost 50% of patients were seeing more than 10 doctors in their last 6 months of their lives. Is that how they really wanted to spend their time?
• Can someone please, please explain to me why nurses record a “normal” respiratory rate as 18 or 20? Because it’s not. It’s like 12-14.
• As a patient, don’t piss off your nurse, because if you’ve got an unprofessional one, he or she will turn all passive-aggressive. If this happens, tell your doctor; if nothing improves, go to the Patient Advocate.
• There is a nursing shortage in this country. If you need something as a patient, obviously ask for it, but try to be reasonable. A hospital is not a hotel. Try to make sure your loved ones are reasonable too. This will be help avoid the preceeding statement.
• As a patient, you will have better, more efficient medical care if you know the names of your medical problems and the names and dosages of your medications. A list is even better.
• Kate has been writing about medical malpractice and there’s been a lot of discussion about practicing defensive medicine, and their associated costs, but I would not be surprised if a large amount of spending is also devoted to repeating tests that have been done at one hospital but are not available at another. This is INSANE. I can now pay people money with my cellphone, but I can’t see images or lab values from a hospital 5 minutes away? You’ve got to be kidding me.
• For people that take multiple medications, automatically assume that they forget to take them. Ask: “How often do you miss taking these?” It will make patients feel less worried about trying to please the doctor.
• Trying to please the doctor is a normal human reaction. It’s why you brush your teeth extra well and floss before you go to the dentist. Just be honest, that’s the most important thing.
• I will never ever ever be an oncologist. They save so many people that they think everyone can be saved, and often lose sight of the fact that everyone dies. I don’t know how often patients were encouraged to undergo another round of chemo when it was obvious to everyone else they didn’t have much time to live. Then again, hindsight’s 20/20.
• Giving people a comfortable, safe, and supportive place to die is one of the most compassionate things one can do for another.
• The surgeon’s 30-day mortality statistic can lead to some pretty perverse incentives to keep patients alive.
• Many of the problems in modern medicine, like most other areas of life, are due to laziness. As my surgery resident told me: “You’ve got. To do. Your job.”
• There was a NYT article last week talking about how doctors are on such a different playing field from their patients that they seem like they’re from a different planet. I would have to agree.
• I came in thinking the differential was kind of silly, like that more cases than not are cut and dry. I now know why doctors are so damn skeptical and suspicious and often agnostic or atheistic. They’ve been burned too many times assuming one thing when it turns out to be something else entirely, or have been sure about a diagnosis, and then they find that they’re wrong.
• You really do need to understand the physiology to understand the pathophysiology to figure out the treatment. This makes it hard for me to believe in new agey healing stuff.
• Want to know why doctors are so unhealthy? Because we spend so much freaking time taking care of patients that we eat crappy food at the hospital and don’t have time to get to the gym. Also, because we are hypocrites. Or at least, that’s my excuse. Feel free to use it if you like. I seriously should go ahead and start a thiazide and a statin.
• Interns get freaking worked. I am trying to vigorously avoid this from happening, and am hence taking a year off to do “research.”
• More bullets to come.

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I’m trying to get a(nother) site off the ground. If you’re a health care professional (physician, nurse, etc.) and work in a clinical setting, or a student, or just have a few extra moments, and you’d be willing to give me some feedback on a new website for clinical calculations, please contact me or leave a comment. Especially interested if you use a PDA! Thanks!

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Item 1: Medicare is paying employers to maintain their retirement plan health care benefits, to the tune of $4 billion. These health benefits compete with Medicare Part D benefits.

Item 2: We already subsidize health care insurance, primarily through making business expenses for health insurance tax-deductible.

Item 3: Medicare isn’t allowed to negotiate on drug costs, although another federal agency, the VA, can. Medicare pharmaceuticals cost sometimes double what VA drugs cost.

Item 4: Our President’s plan to fix the health care system, Health Savings Accounts, is primarily targetted toward the middle- and upper-classes, those who already have health insurance. It also ignores the fact that approximately 80% of health care costs come from approximately 20% of patients (the really sick ones).

What’s next? The government subsidizing the drug companies for taking part in the Medicare D benefit?

Is it just me, or does it seem like our leaders are just setting up the government to fail?

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My interns and residents had been talking for weeks about how bad a code situation is, and so when the patient was found unresponsive in his hospital bed today, I figured it’d be neat to go watch. Neat being my Hollywood, glam and glitz, heroic understanding of a code; terrifying would probably fit better. Yes. I figured it’d be terrifying to go watch.

I was amazed at the scene when I arrived, watching from outside the door. I got there only 10 seconds after the Code 66 had calmly been announced overhead (Code Blue scares patients, I guess), and already 25 people were in the room, with supplies, the crash cart, and it was loud. About 8 people were actively around the patient, with others supporting the 8, while some other people were trying to move the patient in the next bed out of the room. I did my best to stay at the periphery, out of the way, and help out when I could. People were quietly talking about how the patient was found, that he was supposed to be discharged today–and who knows where the rumor mill went from there.

A small woman was doing CPR on the gigantic patient (and luckily soon switched with a much larger male nurse), while others were checking pulses or trying to configure the defibrillator. Interns and residents were trying to start femoral lines, palpating weak pulses that trickled by with each chest compression. Two people were bagging the patient with oxygen. The ICU fellow was calling for meds and thinking aloud (I would soon learn the 5 H’s and 5 T’s), while the intern responsible for the patient was announcing the patient’s morning labs and vital signs (“K was 3.6 this morning! Blood pressure was 110/65!”), all of which were stable and within normal limits. The pharmacist was doling out medications from her kit as fast as they were being called for.

Toward the end, the senior resident responsible for the patient was in tears, and the room grew more quiet, with fewer audible voices drowning out the sounds of the code equipment and the oomph of each chest compression. There were fewer looks at the patient, and more at the clock. The pharmacist announced the passing time. “Four minutes since arrest” became “nine minutes” became “fourteen minutes” became finally “twenty minutes,” and the patient was pronounced dead.

“The key is to stay calm,” my resident told me. I told her I didn’t think I’d ever be calm in a situation like that, and she shared her secret: “I just assume the patient is already dead, and anything I do can only help them.” I think she may be right.

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The hospital I’m at has been on divert status multiple times this month (this is not uncommon). That basically means that the ED is full, and can’t accept any more patients. For us, it’s also worked out to mean that our entire hospital is full, including the ICU. There are no open spots. Anywhere.

This prevents surgeries from happening (because there’s no place to put the patients for monitoring after the surgery), and it prevents truly sick people that walk into the ED from getting hospitalized, too. Our schedulers and case workers and discharge planners knock on our doors daily, desperately seeking patients who might be going home. And with our aging population, I really can’t see this getting any better. Nursing shortages make this worse, because of staffing, especially on the weekend, open beds can’t always be turned into patient beds, because of nurse to patient ratios.

This obviously brings up something of an ethical dilemma, where the lofty goals and aspirations of perfect medicine hit the limited resources pavement. There are several people in the ICU who have been there for as much as 8 months or even a year–in comas, on respirators–with little hope of improvement. Yet their living wills insist that they remain on a ventilator, or their family members insist–even despite the patient’s own declared wishes. And so they remain. Then there are others who come back time after time with the same serious problem, sometimes self-induced.

I could easily argue this point either way, and where you stand probably boils down to where you sit on issues of individual or group mentality. Should we do what’s best for any one individual, at the possible cost to the group, or should we sacrifice an individual for the good of the group? (I myself am a total hypocrite, preferring the group mentality in theory, but the individual mentality when it comes to my own health.)

I guess I mainly worry that this problem won’t just go away, and that whatever solution we come to will be one decided either at the last minute, or will be decided based on the most unethical of deciding factors: money. There’s of course an alternative I haven’t discussed here: just build more hospitals, more nursing homes, more clinics, and try to squeeze everyone in, but that will probably just lead to worse nursing and doctor shortages, and lead us deeper into the red.

Any of my answers turn my stomach, so I guess it’s up to choosing between the lesser of two evils.

1. First-come first-serve doesn’t really seem appropriate; just because you got sick when there was an available hospital bed shouldn’t decide whether you get care.
2. There’s a “he who contributes most deserves most” idea, but it’s rotten, too–just because subjectively one person “contributes” more to society than another shouldn’t necessarily buy them more or better care than someone else.
3. You can also go by age alone–that children should get more extensive and intensive care than the elderly, because in someone’s words, “children haven’t been able to live their lives yet,” but some elderly folks may still have better prognoses than some very sick children.
4. There’s a functional cutoff–if you’re “high-functioning” and you get sick, you should get extensive treatment, but if you’re low-functioning (again, the definition is a problem), you’re out of luck.
5. Or how about an formula based on your chances of recovery, partial recovery, or no recovery, based on all the data we have available?

I don’t particuarly like any of these for many reasons. You can’t arbitrarily sign a death sentence for a person, and you can’t take away a person’s hope so quickly. I don’t know what’s going to happen, but it really, really frightens me.

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Flawed and unethical, but I bet it would work:

1. Alert the media that for the coming week, everyone will be DNR/DNI until proven otherwise, instead of full code.
2. Miraculously watch as everyone rapidly develops a living will, durable power of attorney, and talks about their wishes with their loved ones.

You would’ve thought the Terry Schaivo thing would’ve done this already, but I seem to get all the patients who have no idea what they want. Just last night, an elderly Hispanic man was admitted for possible heart failure and possible heart attack, and after a lengthy discussion about code status, he tried to give me this innocent little indecisive giggle-shrug-smirk, as if I asked him what type of food he wanted to eat for dinner and just wanted to be agreeable. This ain’t one of those types of questions. You need an answer.

On a more ethical but medically ethical topic, some people propose making the organ donor system an opt-out system, where one would automatically be consenting to donate their organs unless they specifically said they didn’t want to.

*A person’s code status tells the health care system what he or she would like done if their heart stops or lungs stop working–would they like everything done (full code) at one extreme, or would they like no measures taken (DNR, DNI – do not resuscitate, do not intubate). You can pick any level of code status, and have specific parameters as well.

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Mr. Jones has orthopnea secondary to pulmonary edema secondary to congestive heart failure secondary to ischemia secondary to a prior MI secondary to diabetes secondary to obesity secondary to poor diet and exercise regiment secondary to poor access to healthy foods secondary to poverty.

So what killed him, the heart failure, or the poverty?

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Call me crazy (“Hi, Crazy!”), but I think we need to start changing the medical school curriculum a bit.

One of the main focuses of the pre-clinical and clinical curricula is teaching the medical student the art of the differential diagnosis. You basically take someone’s symptoms, and try to figure out what’s causing their disease–any number of body systems can cause similar systems. And as the saying goes, “You can’t treat what’s not on your differential.” That is, you’ve got to consider everything, so if it’s not what you think it is, you’ve got a fallback 2nd or 3rd idea for what the problem could be. Obviously important to reinforce this concept into our heads. Over, and over, and over again. And then over some more.

But one area where I think we’re lacking–because medicine has changed so much–is the treatment of the chronic disease. We focus so much on the acute still in medicine, when our patients have primarily shifted to the chronic. Sure, as residents we have clinic time where we see patients as outpatients in a chronic disease setting–but most of our residency (and much of our medical school) training is still focused on the acutely ill patient. While this definitely hammers home important concepts in many diseases, which can then be translated to the outpatient basis, I wonder if there’s more we should be learning. If you look at physicians as a whole, they’re not working in hospitals, taking care of acute patients. They’re working in private practices, seeing outpatients.

What should change? A couple ideas:

1. Focusing on trends, not on specifics
2. Focusing more on prevention if the disease will be life-long
3. Time management with patients
4. Changing the culture so that patients expect to come in when they’re well and when they’re sick
5. How to stay energized and avoid burnout
6. How to maintain relationships with patients over years
7. How to work efficiently and effectively with other specialists/generalists
8. The differences between acute care and chronic care
9. Explaining chronic versus acute care to patients

A lot of this you can pick up on your own with trial and error, tips and tricks from attendings, and good social skills–but it seems like it’s this gaping hole that medical training is de-emphasizing, even though it’s the bulk of “practicing medicine” as professional physicians.

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I’ll often use “pimp” in a sentence, and non-medical folks give me a strange look. So, to set the record straight:

pimp, verb. To question a medical person lower than oneself on the spot about a medical fact or truism to see if said person knows the answer show how smart or dumb the person is in front of a group.

Examples:

• “Man, my attending pimped me mercilously about acid-base disorders in my patient, when I’d only seen her for 20 minutes!”
• I cannot believe my intern started pimping me about physiology in front of the attending. He’s supposed to be on my side!
• It was great. My resident was pimping me about medication dosages and I got them all right.

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Running was, apparently, Sam’s thing. I don’t know exactly why he runs–he’s a a friend from the neighborhood where I grew up, and we haven’t kept in touch–but he runs, and he loves it. So it was a huge, huge loss when he developed pretty severe pelvic pains every time he tried to run. Specialists one through four recommended rest, but Sam knew there had to be something better. So he turned to Google.

It turns out Sam had bilaternal sports hernias, also known as athletic pubalgia. (I had never heard of it, and most doctors haven’t, either.) He typed in his symptoms, queried away, and found news articles, papers, and PDFs on the condition and its treatment–surgery, performed by one lone sports medicine surgeon in Pennsylvania. (Apparently the intake form has a box, “Check here if you’re a professional athlete,” reassuring Sam that the condition exists in the world outside of textbooks and medical journals.) Sam underwent the surgery, the surgeon repaired the hernias, and he’s now recovering and excited to hit the ground running. Pun intended.

That’s the good–no, the great–side of Google Medicine. Enter symptoms in one end, spit out a diagnosis on the other. In no way is this a new idea: Meg Hourihan’s mom starting Googlecooking in 2002–you just enter what ingredients you have at home into Google, and the search engine spits out a list of recipes. If I’m trying to find the name of a song on the radio, and I only know bits and pieces of the lyrics, I’ll type them in, add the word “lyrics,” and I’m almost certain to find my match. Googlediagnosing isn’t that far behind. The BMJ recently had an article indicating that more medical journals are getting hits from Google Scholar than they are from PubMed.

In some cases–like Sam’s–this is great. Fantastic. Revolutionary. If I have a very specific set of symptoms–tooth itch, purple-hazed vision, and new-car-smell breath (the classic triad for the Grahamazon syndrome, of course), I can probably figure out a likely diagnosis, see my doctor, and get a treatment (dihydrogen oxide as needed). Hooray. In the most common of syndromes, this also works well. Runny or stuffy nose, fatigue, muscle aches can be a pretty common presentation of the common cold, and we see that this works pretty well–most of the top links have to do with the common cold or the flu. Common things being common, there are probably more webpages out there about common colds than say, dengue fever, and since Google results are essentially a web popularity contest, the common things rise to the top.

Again, this is great. Patients can get information about their possible diagnosis, read about over-the-counter treatments, when to seek medical attention, etc. But there are chasms of caveats to Googlediagnosing. In a world wide web of blogs and forums and comments, anyone can be anyone, and everyone can have an answer. And if Google ranks its information by popularity and not by accuracy, you can end up with some pretty mixed results. Let’s say I have fevers, chills, and muscle aches–holy shit! I have babesiosis? Or Rocky Mountain Spotted Fever? Or leptospirosis? No, I probably have the flu–but not according to Google.

When everyone’s an expert, no one is. I used to frequently respond to Ask Metafilter’s health section (it’s a website where members can post health-related questions), but I’ve stopped outright because there’s just so much bad advice from everyone and their mother. I’ve seen so many users give anecdotal evidence (“my great aunt had the same symptoms you’re describing and ended up having a pheochromocytoma–you should get an MRI before it spreads!”) that’s so scary and harmful and wrong that they must not even know what they’re doing. In other categories of questions–science, travel, computers, etc–I give my anecdotal advice or opinions as well, but I’m not potentially screwing with their mental or physical health.

And there’s potential for great anxiety when Googlediagnoses are incorrect–enlarged lymph nodes and a fever may net a person a diagnosis of lymphoma or HIV, instead of sore throat. The two diagnoses are pretty damn different. (HIV is the latest in a long line of “great imitators” like syphilis and TB that can present in many, many ways.)

Most diseases also present with a specific time course and other symptoms–that physicians are trained to recognize because of their experience seeing diseases so many times–and so often a patient may come in with a diagnosis that, while symptomatically correct, doesn’t fit the way the disease works, the age group, the time course, etc.

Add to this the fact that most patients don’t understand the concept of a differential diagnosis (I didn’t until I entered medical school), and you can get people posting that someone with syptom X definitely has disease Y, or you can get a patient who has done some self-Googlediagnosing, and is adamant that the disease they read about is the one they have. (Or even the disease Y they think they have is treated with drug Z, so they want a prescription for it.)

Another barrier exists between doctor and patient: medicalese. This is the ever-popular “diaphoresis” instead of “sweating,” “erythema” instead of “redness,” “edema” instead of “swelling.” If a patient doesn’t know the lingo, he or she may have the signs and symptoms right, but may lack the ability to learn about his or her condition. How many patients of yours would call a low platelet count a thrombocytopenia? Or how many refer to their diuretics as water pills? If you’re using the wrong keyword, you’ll get the wrong diagnosis–or miss the right one–every time.

Now, there are websites and companies and organizations that try to provide some sort of standard for health information on the web. And there are symptom to disease tools like Dxplain and Gideon that allow people to enter symptoms (both medicalese and non-medical) and, using algorithms and data, generate a list of possible diagnoses. But all of these are still far from perfect.

If we continue to move toward more and more Googlediagnosing (and it certainly looks that way) these tools and standards will be vital. Like the safer-sex mantra, if you’re going to do it (uh, Googlediagnose), do it safely.

Update: My wish at their command. Healthline is a search engine that tries to filter out the bad health info on the net.

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So I’m reading through this Wikipedia list of cognitive biases, and it’s pretty apparent that almost all of these factor in to our discussions of patient care. A sample, with the definitions provided by the Wikipedia:

• belief bias – the tendency to base assessments on personal beliefs (see also belief perseverance and Experimenter’s regress) All the time. We assume things about patients–what they do, how they act–based on our own understanding of “normal.”
• bias blind spot – the tendency not to compensate for one’s own cognitive biases. We don’t have to compensate. We’re the doctors; we’re right, duh.
• confirmation bias – the tendency to search for or interpret information in a way that confirms one’s preconceptions. Uh, pertinent positives and negatives? If I suspect cirrhosis, I’ll ask you about alcohol. And if you tell me you have 1-2 drinks a night, someone will say the “rule of doubling” so that you actually drink 2-4 drinks a night.
• disconfirmation bias – the tendency for people to extend critical scrutiny to information which contradicts their prior beliefs and accept uncritically information that is congruent with their prior beliefs. If I suggest someone might have HIV, someone usually says he or she “doesn’t have any HIV risk factors.” Translation: I think he or she is married or heterosexual, so they can’t possibly have HIV.
• endowment effect – the tendency for people to value something more as soon as they own it. If it’s lymphadenopathy, I don’t brag about my patient. But when it turns out to be fetus in fetu, I talk all about him.
• hyperbolic discounting – the tendency for people to have a stronger preference for more immediate payoffs relative to later payoffs, the closer to the present both payoffs are. Should we keep a patient or discharge her tonight? Discharge; it’s one less note to write in the morning.
• illusion of control – the tendency for human beings to believe they can control or at least influence outcomes which they clearly cannot. Oh boy. This just about sums up the physician mind.
• mere exposure effect – the tendency to express undue liking for things merely because they are familiar with them. “She’s just another CHF/COPD exacerbation.”
• planning fallacy – the tendency to underestimate task-completion times. “I’ll be right up to see the patient;” “He’ll be getting his CT at 2:30;” “The dictation should be online by tomorrow.”
• rosy retrospection – the tendency to rate past events more positively than they had actually rated them when the event occurred. “No, really, internship’s not that bad.” “This won’t hurt a bit, I had it done when I was your age.”
• selective perception – the tendency for expectations to affect perception. You label a person as “really nice,” and your team will probably think they’re nice. Label them as cranky or grouchy, and they’ll expect someone to be grouchy.
• status quo bias – the tendency for people to like things to stay relatively the same. We’re happy when the creatinine stays at baseline. We like uneventful hospital stays.
• Von Restorff effect – the tendency for an item that “stands out like a sore thumb” to be more likely to be remembered than other items. Attendings give anecdotal evidence: “During my residency I saw an Asian person with sarcoid, so it happens more often than you’d think!”
• Zeigarnik effect – the tendency for people to remember uncompleted or interrupted tasks better than completed ones. This is the intern’s defense mechanism. Everything gets done because you know you haven’t completed it yet, and no one else is going to do it for you.
• fundamental attribution error – the tendency for people to over-emphasize personality-based explanations for behaviors observed in others while under-emphasizing the role and power of situational influences on the same behavior. A person is over-emotional if they cry.
• ingroup bias – preferential treatment people give to whom they perceive to be members of their own groups. Hell yeah. If you say you’re Dr. So-And-So, you have a lot more clout that if you say, “I’m the medical student taking care of Ms. Jones.”
• self-serving bias – the tendency to claim more responsibility for successes than failures. It may also manifest itself as a tendency for people to evaluate ambiguous information in a way beneficial to their interests. “We really got her through that acute renal failure well” versus “She was really sick when she came in.”

Note: I’m not saying these happen all the time. Just that they can, and we’ve got to be on the lookout for them.

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I’m no expert on the topic, but now that I’ve worked with 4 electronic health records / electronic medical records (EHRs/EMRs), I’ve seen the good, the bad, and the ugly. (Usually the two latter are due to interface design and data display done by engineers, not by clinicians or nurses.) My rules first, and then my suggestions:

1. Spend time–lots of time–on the user interface. Test it with physicians. Nurses. Medical students. Techs. Administrators. People will unfortunately still buy a product with a crappy interface, but your days are numbered.
2. Let the system work for both beginners and experts. One of the things many people miss about the text-based systems when moving to graphic interfaces with icons and tabs is how quickly they could find information with keyboard shortcuts. Of couse, the keyboard shortcuts take awhile to memorize, so they’re not ideal for beginners, and make a pretty steep learning curve.
3. If you’re going to use icons, include their text equivalent. So many systems use cryptic icons designed by an intern using Microsoft Paint. Does that arrow mean go deeper? Go forward? Move to the next patient in the list?
4. Provide each user with a quick list of their most looked-up patients. I can quickly get access to all my recent patients without having to lookup their MR numbers; especially useful for consult services that don’t have a pre-assigned list of “their” patients.
5. Display lab values in the order that we human physicians think of them. Chem7s or Chem10s go in a certain order. Same with CBCs. Ask me. I’m for hire.
6. Provide a baseline lab value if a value is abnormal. If someone’s hematocrit is low on this admission, has it always been low? Is it trending down?
7. Quickly provide a way I can see a graphic trend of a lab value. It takes way too many steps currently.
8. Automatically calculate associated lab values based on abnormal labs. If someone has a creatinine greater than 1.0 or 1.1, and we know they have chronic kidney disease, and we know if they’re black or non-black, the MDRD should be automatically included. If I ask for a retic count, and the person is anemic, correct it. There are tons of clinical scenarios like this. Heck, have a clinical calculator included that pre-fills in values and spits out the answer.
9. Warn, fix, and prevent medication errors. Our current problem with medication errors, as a medical community, is inexcusable. If someone tries to prescribe metformin to a person with renal insufficiency, which is totally contraindicated, warn them, remind them, or stop them. And make the error messages helpful, not just “This medication is not allowed.” Or if they have a problem on their problem list of COPD, warn people about prescribing a beta blocker, or when ordering a P-thal cardiac scan.
10. One login for everything, and one program for everything. How secure is a system when everyone just uses a common login because they have a separate username and password assigned for the medical record, the radiology system, the echo cardiography system, the GI dictation system, and the pathology reports?
11. An alert when there’s been something new added to my patients’ chart–a new radiology report is dictated, the path report is back, etc. Or at least a chronology of the latest X changes or additions to the chart. It’s insane to have to view each menu separately, just to check to see if there are any updates.
12. Can we please, please, please figure out a way to make redundant, or “within normal limits” data hidden at first glance? With electronic medical records this is particularly a problem, because it’s so easy to cut and paste information into a chart. For a lot of things, I don’t need to know the information about the patient unless it’s abnormal. There is so much redundant information in a chart that it’s often difficult to find the important things. Hell, a frickin’ bold around pertinent information (patient with alcoholic cirrhosis hasn’t gotten his HepB vaccines) would help clinicians differentiate the really important stuff.
13. Keep track of screenings automatically. If a person’s due for a colonoscopy, or an optho exam, put up a reminder.
14. Suggest generic alternatives when prescribing meds, and list the cost next to each med–maybe it will encourage physicians to be more understanding of drug costs–for the health care system, and for the patient.

And the suggestions:

1. Could EHRs be any uglier? I’m not dealing with a freaking spreadsheet here. I could use a little color or visual design if I’m going to be staring at the thing all day long.
2. In charts with rows and rows of information, alternate the row colors (think iTunes) . It’s a simple visual clue and prevents your eye from skipping to the wrong row when scrolling horizontally.
3. Provide one-click access to patient handouts and education.
4. Make easy, patient-friendly instruction sheets based on what you enter in the chart. If you put in a lab request for the patient to come back for a fasting glucose test in one week, that should automatically make a note that’s easy to print out with instructions, directions, time, date, etc.
5. Provide some sort of access for patients to login and see their labs. Track their weights, their HgbA1Cs, etc.

I realize that a good deal of the time is spent on putting the database and backend together; I’ve seen the schema and code for our free clinics’ medical record system. But a little more attention to the front end (which is the whole point of the electronic system) would go a long, long, long long way.

More as I think of them, and please comment and add your own.

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I’m really enjoying a new medical school blogger, maybe because he’s writing what I’m scared to write, writing what I sometimes feel. And I’m ashamed, frustrated, and sad to say it, but I’m experiencing The Fade, as he calls it, too:

Yet, somehow, in a matter of months, I had begun fading from that which I had been into what I had now become, proficient in the mechanical daily tasks of being a physician (or at least a physician’s scut monkey) but having completely lost sight of the simple human picture that I had once firmly understood and promised to uphold in spite of the sheer nonsense and stupidity inherent in the first two years of medical school.

Only six months into my third year of medical school, my first sixth months as a semi-functional physician, and I had already started veering down that path of apathy, that fade into indifference that I see so many of my superiors and peers having already disappeared into. I could no longer feel the coldness of my surroundings, as I was now humbled by a frigid sense of shame I had never before felt and never wanted to feel again.

Racing back now, eager to get out of the cold and into the comfort of my bed to get my five hours of sleep, I realized that I was lucky this time, that I had someone call me out for my behavior (even if it was not done consciously), and that I was wise enough to know I was not wise enough to know better.

Suggestions are entirely welcome.

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You know, you’re in school for so long, for so many years when your papers or writings or assignments are only going to be read by your teacher. They’ll be skimmed or perused, commented on with red ink, and given a grade, but that’s the end of them. You get the paper back, maybe hold onto it for a bit, put it on the fridge for the family to see your gold star, but it ends there.

So sometimes I forget that my notes really do truly matter now. They’re no longer just going to be turned in to a professor or TA. They’re actually going to be used, and depended upon, for a number of people who are going to see a patient. They’re going to read my history and physical examination report, and then my assessment, and based on those, get a sense of what the patient’s problems are. It’s really different knowing that my notes matter. And by different I mean, “feeling like I’m contributing to the patient’s care, and also being kind of freaked out if I miss something or get something wrong.” I guess that’s why there’s interns, residents, and attendings double-checking me.

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So I’m watching this trailer for this documentary called “39 Pounds of Love,”, about a 42 year-old man with Spinal Muscular Atrophy Type 2 , whose doctor had predicted he would die by age 6. He’s now an animator, weighs 39 pounds, and goes in search of this doctor. From the trailer, I get the sense that he’s out to tell off the doctor for giving him such a grim prognosis. I don’t know if it’s how the story goes, but if it is, it surely isn’t fair.

As doctors, we’re in a predicament: taking away someone’s hope is, in my opinion, a mistake that I hope I never make, but probably will. At the same time, false hope is maybe worse. I try to remain cautiously optimistic, especially when things take a turn for the better. In fact, initial studies suggest that doctors are way too optimistic: one study found that doctors over-predicted prognosis by 5 times–so that in terminally-ill patients given, say, 10 months to live, they only lived about two.

This kind of makes sense–sunny-side up people are probably going to be more attracted to medicine than half-empty folks. Doctors like to imagine believe that we can truly fix every patient–or at least help them.

So especially in a condition as rare as Spinal Muscular Atrophy (4 cases per 100,000), especially back in the 1960s (there are 190 papers on it in Pubmed from 1900-1960, and only 40 in English), I don’t think the doctor was a bad doctor, or intentionally hopeless. If anything, if we believe the studies on prognostication, he was probably a little too optimistic.

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“Above all, do no harm,” is pretty much bullshit. Let me warn you.

You do not want to be a patient in a hospital. One, it means you’re sick enough to need to be in a hospital, which is pretty sick. Two, we’ll make you feel much worse until you feel much better. If you do get admitted, please just expect the following to happen. If you’re in a teaching hospital, with attendings and residents and medical students, more of this may happen. Be prepared in advance, so that you don’t get all crabby when I try to be happy-nice medical student and ask you some questions. (I realize you probably don’t mean to take it out on me, and that I’m always trying to put on my nice-happy face so that you won’t want to take it out on me, but you’re probably tired and frustrated and you’d take it out on Mother Teresa (may she rest in peace) if she were in my place, too.)

1. You will be poked and prodded, have your blood drawn–multiple times per day, from multiple arms and wrists.
2. You will tell your story to at least three people–not uncommonly 8 or more–and you will get annoyed, because we will ask you the exact same questions over and over again.
3. You will not get any sleep; people will constantly be bothering you with questions, physical exams, or lab draws.
4. You will be told lots of things, by lots of people, often things that use medical mumbo-jumbo. It will be confusing, probably–which test you’re getting, or what medicine you’re on. Many times people suck at explaining this stuff in normal terms, so please, please ask.
5. You may wet the bed, or defecate in your bed, and it may not be immediate that you get cleaned up.
6. You may be in a room with a noisy neighbor, or worse, a demented one that sits in a chair all day with her legs wide open and up in the air, making high-pitched shrieking noises all day.
7. You will probably smell, and when you do get washed up or get a sponge bath, it won’t be that fulfilling.
8. If you’re infected or contagious, people won’t want to touch you without gloves, and won’t enter a room with you without a mask. Necessary, but I’m sure isolating.
9. If someone decides you’re “an interesting case,” or you have something about your body that is different or rare or special, you may be made to feel like an object as a doctor teaches using you as an example.
10. Even if you’re not an interesting case, people may talk about your care with other team members like you’re not even there in the room, and many times, they will talk in medical code.

I’m not condoning this behavior or this system, but I’m saying often, it’s how it works. Many of the causes are medical–part of diagnosis or treatment–but others are political, legal, structural, academic, technologic and institutional in nature. We have a nursing shortage; we must teach future physicians; the law requires this; unions require that; paperwork must be done accordingly; technology is from the 1980s; there are limited resources available for health care. And on and on and on. If I could design the hospital system over again I would–and maybe I will when I’m older–but in 2006, this unfortunately may be your hospital experience.

Just more reason to stay healthy, eat well, exercise, and wash your hands, right?

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At the community hospital where I was working a couple months ago, a 10 second lullabye-type jingle plays over the intercom, signaling that a new baby has just been born. My attending says people either love the little reminder, or it drives them absolutely batty. I’m firmly planted on the side of the former. It reminds me that even if I’m busy, or tired, or frustrated waiting for a lab value to come back, at least someone has probably just become happy. That life goes on amidst all the hussle. Sometimes it’ll play twice. For twins.

And then I started wondering about a more solemn tone. Maybe it’s shorter, an elegant or graceful piano progression of chords, with a slower tempo. One recognizing that someone has just died. Now, granted, I think patients and doctors alike would get a little worried if it sounded 5 times within the hour–but I wonder how people would respond. Would it scare them? Upset them? Would they pause for a second? Think of their own mortality? Maybe it would remind them that life is short. And fragile.

But more than anything, I think it would upset them and scare them. Chime in here if you’re from another culture or tradition, but I think we as a society have some sort of obsession with youth–and some fear of death–that doesn’t exist in most other cultures. (I myself am utterly floored by the fact that I could (okay, fine, will) die.) And what kind of ramifications does this have for medicine?

First let me note that there are two deaths I’m speaking of here: one inevitable, one failure, both tragic. One may seem like clinging on to scraps of ife because of our fears, and the other is truly medical failure. Everyone has to die of something, and I think most doctors want it to be something other than what they specialize in. But medical errors do exist–mismanagement, drug errors, etc.–and it’s those that we must fix. The scope of them is vast, and truly unacceptable.

The ultimate deaths, as I guess I’ll call them, are a harder sell. I absolutely respect people’s wishes, but I wonder how much of their wishes are influenced by our anti-aging culture. Are we guilty of trying to have as many breaths possible in our lives, at any cost? And how much of this worldview is cultural, and how much is just the human spirit? And yet I’m still torn, because our ability to prognosticate as doctors is so poor. You can take two patients, seemingly very similar, with similar diseases, risk factors, and prognoses, and see one make a fully recovery, and see the other wither away.

I just see too many people who are dying, of course in my opinion, poorly. If you want to die in an ICU, with tubes and machines and beeps and alarms, that’s your choice, but I think too often both patients and physicians see death as a failure of medicine, or as a failure of family members to make the right decisions for their loved ones. I think we’ll all face this issue more and more with the baby boomer generation, and I hope that more people will become aware of hospice care. Did you know 70% of people will die in a nursing home or hospital? Take a moment to imagine your ideal death. Is it anywhere close to how people are dying today?

Who knows, maybe the progress is already happening, just happening at a medical (slow) pace. An attending today told the team, “Mr. Doe expired. He went home.” Initially we were very confused, but then she explained that with the patient’s last hours left, and no more medical treatments available, he went home to die, with his family at his side.

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Medicine, on my second day in, is kicking my butt, seriously. Expect this site to be quiet until I get a hang of things.

I presented my patient today and was horrible at it, but made up for it with handouts with a killer font. My interns told me, “Great Handouts!” Going at this rate, I’ll take any compliments I can get.

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I returned back to California after a wonderful and relaxing two weeks at my parents’ home in Kansas only to get a nasty, nasty bout of gastroenteritis (think stomach flu symptoms) two days ago.

Boy was that a long two days.

I’ll spare you the fluid-losing details, but suggest that for any South Park fans out there, I could have easily been featured in an episode. (Being the cautious optimist that I am, however, I will admit to getting a great abdominal workout from the wretching. Reverse peristalsis is pretty amazing.) After multiple bouts, feeling progressively worse, and progressively more light-headed standing up, I finally gave in and the bf drove me to the ED (Emergency Department–the more PC term for Emergency Room). I was hesitant at first, thinking I was somehow weak for wanting to see a doctor, or worrying that I was overusing the health care system while feeling completely rotten. Only in America, folks.

I was actually relieved when the triage nurse told me “I looked like crap” (we were on friendly terms, she probably doesn’t say that to everybody). I was treated really well, and after 2 liters of normal saline, 5mg of phenergan which made me really drowsy but didn’t fix my nausea, and 5mg of reglan that did the trick, I was released, 4 hours later. It’s amazing how much better you can feel after just getting rehydrated.

This isn’t a piece about health policy, or insurance, or lack of it, although it certainly could be. It’s just a reminder to those that are healthy, including my now recovering self: appreciate what you’ve got. I never do, and I will probably forget to. And to those that are ill: may you get well soon.

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Syndney Smith, author of Medpundit, is so out of touch with medical students (and probably the future generation of doctors) it’s not even funny:

Maybe medical schools should treat medical students the way an employer does an employee – make attendance count, and have quarterly evaluations of behavior in addition to grades. But do it for everyone, not just for the problem students.

The scary thing is, I can’t tell she’s the exception or the norm. Doctors? Doctors? Bueller? Bueller?

Make attendance count? Have behavior evaluations? I’m pretty sure I signed up for medical school, not choir class. I’m an adult. If there’s a problem with my behavior or attitude or professionalism, I expect my preceptors to discuss it with me–or at least bring it up on my formative comments of my clerkship evaluation. I don’t need another hoop to jump through, showing that I go to class and that I’m a caring, respectful, professional guy (I do, and I am, according to my evaluations so far).

That being said, I agree that medical students should be on-time, professional, and working hard. If a student isn’t, it’s a problem, and it needs to be dealt with. That also being said, I’ve seen examples (uncommonly) of attendings and residents act with prejudice, act using stereotypes, or make gross assumptions about patients–so the assumption that a preceptor is necessarily a model of good behavior and professional conduct isn’t all that valid for certain people.

“Attendance” is a problem when one’s classes are broadcast online for classmates who study better at home or want to pause the lecturer to write things down. “Grades” are a problem when they don’t exist at a medical school to begin with.

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Today is one of those days that makes me want to move to Canada, France, Spain, or Great Britain, because I’m just utterly disgusted by the Almight Dollar. I’m probably mesmerized by dreams of a greener grass, but today I’m willing to risk it–the weeds we’ve got here are downright rotten.

So we start off with Health Care Renewal’s postings about for-profit institutional review boards (the committees that are supposed to protect you and me from unethical trials like the Tuskegee experiements) and a Bloomberg article describing illegal immigrants desperate for cash being recruited for experimental drug trials. I’m *sure* they’ve all been adequately consented, and their translated consent forms have been approved. By a for-profit institutional review board. Now even Hopkins is using for-profit review boards. (In case you were wondering by bioethicists haven’t been up in arms about this.) The whole *point* of an IRB is that it’s supposed to be objective. It’s supposed to be free from outside influences that may skew the committee in one way or another. But *paying* them, oh no, that’s fine. He who pays the piper calls the tune.

And then I go read Kate’s find that we’re wasting hemorrhaging (that means we’re really wasting) money on the new Medicare Drug benefit. Had we just expanded the VA system, senior medications could have been automatically available and at hundreds of dollars per year of savings. (This matters a lot when you’re on a fixed income.) Note: ask your doctor if there are alternatives to the medications you’re on. For example, the “Protonix” example given could be changed to omeprazole (Prilosec), a much cheaper alternative drug in the same class as Protonix and nexium.

And then to top it all off, I go see Syriana. A perfect end to a anti-American day.

I’m a firm believer in the mantra that you can judge a society by it treats its most vulnerable members, and frankly America, we’ve earned an F.

(That’s with the grade inflation.)

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If you’re not having good days and bad days as a medical student, you’re just not trying hard enough. This whole experience is at least partially preparation for the real world of medicine–that there’s two sides to every story, that there’s an art to dealing with all sorts of people, and that you must learn from every encounter you have with a patient.

So there I am, two weeks ago, with a good day and a bad one in the same 24 hour period. It starts off with a patient with an autoimmune disease. I go see the patient with a fellow. (A fellow is a doctor done with residency that is now specializing.) This fellow is well-liked by all of his patients, as far as I can tell. His interview style is very focused, however. Question, answer. Follow-up question, follow-up answer with tangential comment… question to get interview back on track.

Today we walk in to see this patient, and I can already tell he’s a little agitated, or frustrated or uncomfortable, for whatever reason. I don’t know if the fellow doesn’t pick up on this, or just ignores it. Fellow asks a bunch of questions about how the patient is feeling, the patient says crummy, that he’s constantly aching, and isn’t getting any relief from his current medications. Fellow addresses this to some degree, but doesn’t offer any solutions. Fellow is looking down at his notes; I’m sitting on the exam table watching the interaction from the sidelines. The patient starts to say, “Well then, here’s what I’d like from you,” but is cut-off by the fellow’s next question, something about “any nausea or vomitting?” Aaaaand, the fellow has officially lost the patient. For the rest of the interview, the patient answers quickly with rapid nodding, wanting to get back to his request. I’m thinking to myself, “Do I say something? I mean, of course I say something, but how do I say it without butting in–” And then I realize I’m Super Patient Advocate, and it’s my duty to step in. I wait for a pause, which the patient then takes to start asking again, and gets interupted a second time. The patient is now eyeing me, and I’m kind of nodding in agreement, trying to let him know I’ll say something. The patient is getting more and more visibly annoyed with the fellow, but the fellow can’t see because he’s looking down taking notes. Finally, finding a half-second pause somewhere, I blurt out, “Did you want to say something?” to the patient, and he gets his request in for some pain medications.

Now, I have to admit, this encounter was fascinating. When presenting to the attending, the fellow described the patient as “a kind of cantankerous gentleman,” and I could clearly see the reason the fellow found the patient cantankerous–the patient was annoyed with being ignored! I’d be pretty damn cantankerous too.

At the end of the visit, I got a direct “thank you” from the patient, and I nodded, somewhat apologetically. In the end, each party got what they needed from the appointment, but it put both parties on the defensive to some degree.

Which makes my second encounter all the sweeter. That same day, in lung clinic, I pick up a chart of a new patient and start taking notes from his file (he’s an hour early, by the way, but there were no other patients at the time). He’s got a number of severe medical problems that have caused very catastrophic complications, making him wheelchair-bound. (He’s been waiting in the room maybe 7 minutes while I’ve been reviewing his file, and asking a question about a drug’s effects on the kidney.) Just as I’m about to stand up, he starts to leave, complaining to the nurse about how long he’s been waiting (he’s now 53 minutes early). I walk toward the room to introduce myself and apologize for making him wait, and he makes some snide remark to me about how he was just getting ready to leave. I go in, we talk, and immediately get the sense that for whatever reason, he hates hospitals and doctors. (I later find out he has good reason to be skeptical; he’s had several major medical problems caused by shoddy medical care.) He talks to me about how terrible doctors are, and doesn’t really know why he’s at this appointment, continuing with a tone I interpret as him blaming me for forcing him to come today.

I finish my history and physical, and tell him I’ll be back “in a bit.” I probably should have warned him that since he was so early, he would have to wait awhile so I could discuss his case with the attending (lesson learned). Granted, it’s still 20 minutes before his appointment is even scheduled. He opts to leave the door open, which is right across the hall from the workroom, and he stares at me while I work on the computer and talk with the residents, probably thinking I’m ignoring him, or not doing anything productive, just making him wait. 20 minutes later, the attending is ready for me, and I present his case quietly, as he continues to stare me down from across the hall. We then go in together to see him, and he loudly comments, “Finally, a real doctor.” I quickly retort, “Yes, I just play one on TV,” and go along with the joke. We see him, and he talks about buying his 16 year-old daughter cigarettes, and I can fully tell we are from practically different planets. As we’re leaving, he complains again to me about having to wait (it’s now 15 minutes into his scheduled appointment time), and that does it. I turn around, pissed, and get about two words out about his appointment time, “Well, it’s…” and I smartly bite my tongue, turn back around, and just walk away.

He knows he’s gotten to me. And I’ll admit it: he had. From the moment I entered the room. The community health side of me kept reminding me, “There’s probably a great reason why he didn’t seek medical attention early and now has all these severe problems that he’s angry with: maybe he didn’t have health insurance, or he knew a doctor that was a total jerk, or he didn’t have the education to recognize the warning signs of his disease, or he was too busy working three jobs to support his family that he never found time for it.” But with each jab (and the fact that I took it personally), the individualist crept in. “This is his own fault. He didn’t seek medical attention for a long time, he didn’t take his doctors’ advice, he thought medicine was a load of crap. He screwed up, big time, and now he’s paying the price.”

And therein lies probably one of my biggest challenges of being a physician: not taking things personally, not getting so easily annoyed, and continuing to provide the highest-quality care to all my patients, no matter who they are, or what they say, or how they react to me. And it’s definitely a challenge. Other professions don’t carry such an obligation. Part of the reason I’m writing this out is to get a handle on it, understand it, and do a better job next time. I think sometimes it’s soothing to rationalize behavior as pathology–that my patient has a personality disorder, and that’s why he was being such a jerk to innocent little me–but I don’t think that’s right, either.

I can see why physicians and residents get jaded now. For me so far, the late night pages didn’t seem like they’d be that bad. And while scut work sucks, it’s not jade-developing. But being treated poorly by someone you’re trying to help could turn me bitter pretty quick.

But there’s a part of me that wonders if my patient was annoyed with me for the same reason the first patient was annoyed with the fellow, and maybe that’s what frustrates me: not knowing if I could have done better.

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We’re still a long way from great electronic medical records, but it seems like we’re not even picking off the low-hanging fruit. I was at the VA last month (which, among some unofficial surveys of many physicians, is by far the best electronic medical record out there right now), and saw a patient with gout. He had had an acute attack 3 weeks ago, after his physician had put him on hydrochlorothiazide, a medication for hypertension, but one that can also cause attacks of gout, because it increases uric acid levels in the body. Now, he had a diagnosis of gout listed officially in the computer, and he was taking two gout medications. The physician made a mistake, for whatever reason, but the computer should have figured it out. We’re still better than computers, but I’d be happy to have one double-check my work in the background.

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Saw a really kind patient today that is a Harley rider, complete with the leather vest and boots and all. He’s a big guy, obese, and has obstructive sleep apnea (he stops breathing when he sleeps because there’s lots of fat around his airway). The usual treatment for sleep apnea is a CPAP machine (continue positive airway pressure. You wear this mask at night that’s hooked up to a machine that blows air into you so your airway stays open).

He hated the mask–felt claustrophobic with it on–so now he just goes out and rides his Harley down the highway, and tilts his head up a bit so his nostrils hit the air stream. Similar effect, and works well for him, he reports.

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As seen in this Metafilter post asking for what to spend $3,000 of a Flexible Savings Account on come a couple of responses that illustrate your favorite and mine… statistics! (I’m kidding. But if you need evidence that it’s difficult for everyday people to make informed health care choices, look no further than that post.)

Here’s the problem with medicine: our tests are not perfect. They mess up sometimes. Granted, we try to choose the best tests so that they (or we) mess up less often, but it’s inevitable in some cases. So a test that looks for colon cancer may every so often tell someone they’re normal when they actually have colon cancer. Or a test to decide if someone has HIV may tell someone they have it when they really don’t. There are more benign examples, but these illustrate why us medical folk are so obsessed with data.

And here’s where doctors come in: they have to interpret the tests. I’m simplifying it, but doctors basically take their current suspicion that you have a disease, and then use a test to make them more likely to believe you have a disease, or less likely that you have a disease. Take me: I’m a pretty healthy 25 year-old. If I come to the doctor and say I’m having a heart attack, he’s probably not going to believe me. He’ll do a test, maybe just to make sure (an EKG?), but even if it’s positive, he probably still won’t believe me. Sure it’s possible, but the odds that a healthy 25 year-old is having a heart attack are so low that it’s much more likely that it’s some other disease I have. (If I were a 60 year-old diabetic obese man with high cholesterol and smoked 3 packs a day for 40 years, however, the doctor might be a bit more concerned.)

Now if that made sense (it’s hard to explain it without getting into numbers, which scare me), you’ll understand why getting a full-body CT or MRI scan is pretty pointless. Or even a “treadmill test,” as another poster recommends. If you’re totally asymptomatic and healthy, and don’t have any risk factors for diseases, even if there’s an abnormal little speck on an MRI, your doctor probably won’t be too concerned, because odds are, it’s probably nothing. There’s a term for these specks or masses–incidentalomas–because they’re found incidentally, and usually turn out to be nothing. A ton of us have them–in our pituitary, our thyroid, our adrenal glands–anywhere. The problem is that once you find one of these, often you want to figure out if it truly is benign (usually it’s nothing), and this causes a ton of anxiety, worrying, and health care spending as a result.

If you’re interested, these test qualities are known as the “positive predictive value” or the “negative predictive value.”

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A couple examples, recounted in class today:

• Say “contrast” instead of “dye.” Avoids that whole “death” thing.
• If you’re prescribing a new drug, don’t say something to the effect of, “Start this, and we’ll see what happens.” What you mean is we’ll see how effective the drug is, or how well-tolerated it is, but patients might get the idea you’re experimenting on them.

More you’ve come across? Post them in the comments.

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A classmate recently recounted a story to me of some not-so-great assumptions one of her attendings had made about a young girl recently diagnosed with diabetes:

The girl, of Hispanic origin, was in clinic with her family and the attending was giving her family her diagnosis for the first time–diabetes. But what bugged me is that he told me he didn’t want to spend his time explaining the cause of diabetes to the family, because he assumed they weren’t educated enough to understand it in the first place.

Let’s assume, for the sake of argument, that this attending didn’t start off this way; I’m hoping this is a safe assumption to make, as I think it would be among my classmates. I hypothesize, then, that this is the downside of physician training. Physicians are masters of pattern recognition–one of the reasons we haven’t been totally run out of business by computers (yet). You start to see certain patterns of diseases, drug side effects, and diagnostic workups that things truly start to reveal themselves, and then burn themselves into your head. You tell me your list of drugs, and I can probably tell you which diseases you have. You tell me your dosages, and I can probably tell you how bad your disease is. Or show me a picture of someone with a certain symptom, and I could probably come up with a couple guesses as to other symptoms they’re having (I’m still working on this ability). We are predictors, trying to make sense out of the world with the clues we’ve gathered.

But there’s always two sides to a coin. Perhaps some of us (like the above attending) take our prediction powers too far, and use them not for diseases or treatments, but for people. Maybe the attending had seen several other similar girls before, and he tried explaining, and felt like he was wasting his time. Maybe he’s seen hundreds. Either way, I think we’ve got to separate one from the other. Otherwise, we risk missing golden opportunities with patients.

This is no easy task. I’d imagine the doctor spent his time getting something else done with the time that he saved–calling a patient with abnormal lab results, spending more time with another patient, etc. Were the patient white, would he have skipped the pathophysiology speech? We can’t say.

Maybe one solution is to give patients a handout to read over at first, so when the doctor comes in, she or he can answer questions about it.

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I’m supposed to help lead a session today with some preclinical students and discuss the challenges of being on the wards as it relates to maintaining perspective and understanding patients outside of a strictly medical realm. I’m starting to posit that it’s almost a physician’s duty to be compassionate, if only for the fact that we contain knowledge about a person’s disease or medical state that most other people don’t. I think an example will highlight this:

I saw a patient yesterday in clinic who was on chronic high-dose steroids for rheumatoid arthritis. He was totally Cushingoid from his steroids–he had a big round face, major abdominal obesity, thin skin, extra hair growth, and had fractured multiple bones because of the osteoporosis from steroids. And I thought to myself, “You know, I bet when she walks around, or is pushed around in her wheelchair, most people just assume she’s obese, call her fat, and think she just has no control over the food she eats.” Most people wouldn’t necessarily recognize a person with these features–or even realize that these features together equal a medical syndrome. Because we understand her disease process, we absolutely must show compassion–if we don’t, and we supposedly understand her condition, how can we expect anyone else to? (I’m of course not assuming that I understand what it’s like to have a chronic disease, or live with any of these symptoms daily, but just that we understand the pathophysiology behind it, and realize the cause is not primarily a character flaw.)

Or the Middle Eastern man who took tiny steps, wincing with pain with each; no one else could tell he had an enormous, incredibly painful rectal cancer. Or the woman with throat cancer who had to have her neck opened up to remove the lymph nodes, and had her shoulder and neck nerve (Accessory Nerve, CN XI) cut on both sides? Unfortunately these people are probably just assumed by passers-by to be weirdos, freaks, geeks, mentally retarded–the epithets go on and on. But it’s the health professional, who understands the disease, prognosis (chronic pain for many years? 3 more weeks to live?), and challenges of patients that must show care.

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Great noon-time talk today about prognosis and predicting outlook for terminal diseases (until about the last 72 hours). Summary, from a palliative care and Hospice doc: Medicine is still terrible at predicting how much time any one individual has left. We can say “Most people with your condition and your status will live this long,” but it creates a ton of anxiety for physicians if they’re asked for a specific number, because it’s totally worthless. I thought her analogy would be helpful in explaining this to patients.

It’s like weather versus climate. I can tell Californians that it’s probably going be sunny there, and I can tell Alaskans it’s probably going to be cold there, but if you ask me to tell a particular town on a particular date what the weather’s going to be, I might as well just pull it out of a hat. Until it gets very close to that date, I really can’t say if it’s going to rain or going to be sunny.

Her last list was really touching and rang true. The 5 Things All Patients Want to Tell Their Loved Ones Before They Die:

1. Forgive me.
2. I forgive you.
3. Thank you.
4. I love you.
5. Goodbye.

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The director of our Ambulatory Medicine clerkship loves to show this graph to try to put our medical education into perspective (or better, show its severe lack of perspective): if you take 1,000 people, 750 will have some ache or pain or medical problem, 200 of that 750 will actually seek a doctor for advice, even fewer will be admitted to a hospital, and even fewer will be referred to an academic medical center (that’s my patient population, mostly). So should I, or you, really be surprised that today was the first day I’ve seen a patient with a cold?

Probably… not. In fact, colds, flus, and sore throats were my probably main personal exposure to physicians as far as my own health went. But I’ve focused so much on the things that medical professionals consider common (lower back pain, right upper quadrant abdominal pain, hypertension, diabetes, dyslipidemia) that I had a few seconds of deer-in-the-headlights when my patient came in today complaining of “feeling terrible” and having a runny nose, stuffed up nose, and cough. Had I taken a step back to my own personal experience to think “what other problems did I have when I had her symptoms,” I probably would have done even better.

I almost get the feeling that I’ve become less comfortable with my own experience and gut instinct as I’ve been working my way through clinics. There are just enough treatments that are somewhat counter-intuitive on first glance that I’ll sometimes hesitate on what I would have been sure (and correct) about even before I started medical school. So my gut has been torn down, and will be rebuilt as gut-of-physican (another reason I’m dreading graduation; have you noticed your physician’s stomach lately?).

But luckily my mind’s still powered for faster-than-Google medical searches. Give it a few seconds to warm up, remind it of the category of information the patient requires (“antibiotics for sinusitis and bronchitis,” “common bacteria causing sinusitis,” “anatomy and drainage of maxillary sinus”), and it kicks into action. It’s pretty damn amazing.

(Oh, and just for anyone who doesn’t know this, I’m currently wowed with the transdermal sinus illumination trick. Next time you’ve come down with a sinus infection on one side, put a flashlight against your cheekbone–that’s the zygomatic arch–near your nose, and point it toward your mouth. The clogged sinus won’t show any light, but the clear one should shine the light into your mouth.)

(Medicine. Swoon.)

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I’m really enjoying clerkships so far. Besides the long hours, I can’t really complain. I have, however, been a little annoyed with the off-handed homophobic remarks made by certain people. In all other aspects, they seem like really great people, but I don’t think they realize how much respect I lose for them when they make some little snide gay joke to a colleague.

It’s never anything blatantly offensive, always just little things. Asking a straight male colleague if he’s dating anyone, and then saying, “Oh, did he break your heart?” for example. It reeks of the old boys club mentality, and hell, we’re 30 minutes outside of San Francisco. I can’t imagine what it’s like anywhere else. I’m always curious why this is socially acceptable, but if any person were to make a similarly snide racial or gender comment, they’d get disgusted looks from their team.

It’s really easy for me to type out here that I should challenge these remarks. I should try to change people’s thinking. That if I’m not part of the solution, I’m part of the problem, and that if no one ever stood up against this kind of thing, we’d be much more regressive in our thinking and behavior than we are now. But man, even if I was the most confident guy in the world (which I’m not, I just fake it), it’s hard to decide when to say something and how to say it, especially when it’s your superior, and they probably have some part in your evaluation.

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I’ve now seen two really excellent physicians really stumble when it comes to using an electronic medical record, and it puts them at a severe disadvantage. While they could easily perform a better and faster physical than me, take a better history, and come up with a better list of possible diagnoses, I’ve got them beat hands-down when it comes to entering orders, medications, consults, or clinic notes. They hunt and peck with two fingers, staring at the keyboard, and click everywhere very cautiously. They’ve learned one way to get the system to do what they want it to do, and while it works, it makes a lot of wasted time. One of the physicians even told me he has to come in on weekends to get all his notes written, because it takes him so long.

We’re moving toward a medical record; if you’re not comfortable with computers, and don’t know how to use them effectively, hire the neighborhood whiz to come give you a few lessons. You’ll save immense amounts of time in the future.

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Quote of the Day, to an 84 year-old Asian woman with Hepatitis C from an attending:

Doc: So we’d like to figure out what the subtype of your viral genotype is…
Patient nods.

This woman had no, I mean no idea what a genotype is, let alone a subtype of it. Please don’t forget, when you’re talking to a patient, speak to his or her level, not MEDICAL. I would look just as dumbfounded as my patient today, and probably nod as well if a lawyer spoke law to me, or if a mechanic spoke car to me. I’m sure I’m at fault myself sometimes, but I think I’m pretty good at catching myself, and pretty good at detecting the dumbfounded “what the hell are you talking about” look, too.

There’s evidence to suggest that patients will be more adherent if you speak their language, too. Everyone wins.

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Healthy Policy has some information on the impact of Medicare Part D on people’s drug costs. (Unfortunately, if no one signs up for it because it’s so damn confusing, we’re going to get nowhere.)

Also: If you don’t sign up by May 15, 2006, you have to pay a higher premium!

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I had dinner tonight with The Malcolm Gladwell, and I say “The” like David Letterman says “I like The Doritos,” as if he’s a household name, because, well, he (Malcolm) kind of, sort of… is. (My mom told me to say to him for her.) He’s the guy with the big hair that wrote Blink and The Tipping Point and writes for The New Yorker. He is long-time friends with a friend (Ann and husband Chris) and she was kind enough to invite me along to a dinner. He’s in the area speaking today with Atul Gawande, another literary idol (he wrote Complications: A Surgeon’s Notes on an Imperfect Science) and several other great New Yorker pieces.

So I’m kind of totally geeked-up excited about meeting him as it were; and he’s, like, pretty normal. Felt totally comfortable talking to him (the wine helped), and he was great to talk to. He’s interested in health care, so that definitely helped too; I find myself with less and less ability to relate to anything non-medical. I explained my cognitive dissonance theory to him, it being my latest theory to try to figure myself out, and the night progressed through health care reform, when it will happen, how it will happen, and even a little debate on Medicare Part D and the pharmaceutical industry. Although I still don’t fully see eye to eye with him on it, he convinced me on some points, and I’ll admit I didn’t know that generics were significantly cheaper here in the US. He also has an opinion on when health care reform will take place in the US, but I don’t want to spoil it if it’s his next article. We also talked about board game strategy, the UK version of The Office, and I ended up doing my terrible Cartman impression.

I think I’m infinitely envious of his job (or maybe more Atul’s–if I could read and write on fascinating things, plus do medicine, that’d be the ultimate), but, like a lot of things, it’s probably less fun when you have to do it as opposed to doing it for fun. I think one of his greatest strengths is his ability to take the everyday experience, make sense of it, find some data behind it, and explain all the facets of it. It’s almost like he writes things that you agree with on almost a “gut instinct” level, but then explains your gut away. (Me, I’m trying to lose my gut.)

And the kicker? I email Ann back after the evening thanking her for the invitation, and I get a great one-liner back:

Subject: to sum it up
malcolm gladwell loves you.

(Me? Big head? Never.)

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Being the goodie two-shoes student that I am, I’m reading ahead in the 2006 edition of Goroll’s Primary Care Medicine, learning about screening tests, and I see these two listings (my emphasis):

Condition: Susceptibility to hepatitis B virus. Risk factors: Male homosexual, exposure, occupation (health care worker), pregnany.
Condition: Syphilis. Risk factors: Male homosexual, other sexually transmitted disease, pregnany.

I looked at some of the other entries to see if I was being overly sensitive. They list a risk factor for sickle cell disease as “African American.” And that’s true, to some extent–it’s more likely that people of African descent will have the sickle cell mutations in their genes.

But this “male homosexual” bullshit is entirely different. It’s not like the “male homosexual” has some sort of genetic makeup or inherent compromised state that makes him more likely to contract hepatitis or syphilis. So what is it? Is it the HIV+ male homosexual? If so, why not just say HIV+? Is it the male homosexual who has unprotected sex? Why not say all people who have unprotected sex? Isn’t “exposure” to Hepatitis B a requirement for infection, as well as a risk factor? It’s not like us male homosexuals somehow grow Hepatitis B inherently, like some people of African descent make sickled red blood cells.

I’ll admit medicine (and society) is getting better with acceptance of all people that are different, but it’s these little remnants of inherent pathology or deviance that just piss me off to no end.

Maybe I’ll email Dr. Goroll and see what he says.

Update: Dr. Goroll emailed back in a day with a very kind response, and forwarded my question (stated a little more gracefully in the email) to the author of the chapter. He also noted the book is constantly being updated and corrected in OVID.com and eScholar.

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It always just amazes me that there’s so much variety in the human experience. That you and I can be so genetically similar, and yet have such different backgrounds and understandings of the world. I saw a professional today in clinic for high blood pressure, and as I was going through my laundry list of questions, I found a pertinent positive:

Me: Any recent illnesses?
Him: No.
Me: Weight loss?
Him: No.
Me: Fevers?
Him: No.
Me: Chills?
Him: No.
Me: Night sweats?
Him: Yes, every couple nights.
Me: Any cough?
Him: No.
Me: And you said no weight loss, right?
Him: Right.
Me: … Okay.

And he didn’t bat an eye. I followed up skeptically: “Night sweats that soak through your t-shirt?” And again, not batting an eye, “Yeah, soaked every 3-4 days.” Taking his perspective, I guess it doesn’t seem that strange–he’s just sweating a lot at night. Maybe due to a nightmare or something. But I instantly took my own perspective–at the first sign of night sweats like that, I’d get to a doctor! (You’re probably wondering, I’d imagine. Night sweats, coughing up blood, and weight loss are the “classic” findings in a patient with tuberculosis.)

Sometimes you forget not everyone has all this information and experience. You use your medical knowledge so frequently, and the medical associations and logic become so commonplace to your brain that you start to feel like they’re as elementary and commonly-learned as addition, the state capitals, or Shakespeare. “They have temporal arteritis? Well of course they’re having vision changes. Duh! Next you’re going to tell me you didn’t know Dorothy was from Kansas!”

So we’re placing a PPD (TB skin test). Another possible point for my diagnosis pickup. Cha-ching!

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Attention all clinical folks: there’s a reason you always at least listen to the heart and lungs. (I previously thought this was just a cruel med student joke.)

Guy comes in, typical geriatric patient with multiple chronic diseases, and I notice that he’s huffing and puffing, walking about the 30 feet from the waiting room to the exam room. I comment about this, and he and his wife note that he’s had this over the past month, but never before. Curious.

We talk through the rest of the visit, talking about his memory problems (dementia), his recent falling 20-30 times per week, his getting-up-to-pee 5-6 times per night, his chronic 10/10 lower back pain, and then I do the physical exam. Rales (also known as crackles) on both sides of the bottoms of his lungs. Pitting edema in his ankles. Curious indeed.

So I’m presenting to the attending and fellow, and they’re blown away. “Wow! Great job! Good pickup!” So we order an echo, get an EKG in the clinic, and put in an urgent cardiology request.

Not bad for a third year, huh?

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Another uninformed rant today from MedPundit on a nationalized medical record, claiming that

The government’s paramount goal in pushing a nationally-connected healthcare record is to be able to monitor and prescribe what kind of treatment everyone gets. You might be 85 years old and not want a mammogram, but too bad. The system will make sure you are harassed until you get one.

She’s clearly never even *used* the VA system for a patient. Yes, it reminds you about screenings like colonoscopies and mammograms, but in two mouse clicks you can turn the request off for any number of reasons. Add this to the fact that the VA does a much better job of screening its populations and doing diabetes follow-ups *because* of its electronic medical record, and you’ll realize she just wants to create an evil government enemy to satisfy her libertarian needs. She complains about a private insurance system, and then applies it to all medical records. (Also note that a recent Health Affairs study showed the US has the highest rates of medical errors as well.)

Update: Epiphanies has more with some linked articles–didn’t have time to find them this morning. And she’s right about EMR technology needing to be user-friendly, but this may be a case of a generation gap: I wonder if MedPundit’s generation is just not good with computers, and that’s the problem.

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I saw an elderly Russian woman in clinic two weeks ago, and through the translator, she asked me, “Why are you asking me all these questions? I’ll die when I die. You can’t fix old.”

I told her that she was right; we can’t fix old, but we can try to address disease. Many people confuse the two, assuming that getting old just comes with certain diseases, like urinary incontinence. It’s not true. Older people are more likely to have hearing loss and worse vision, but some things aren’t so much a product of aging as they are more common in the elderly population.

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I’ve spent a good part of my life trying to just be normal and average (secretly I’ll always know that I’m not) and so it’s nice to now be able to declare the world abnormal based on my own personal existence. Subjective as it may be, it’s my perspective that counts. Not the patient’s. When I report to my attending, I tell them what I think: “He seemed a little depressed; She seems like she’s a little demented; I thought his hair was a little weird.” Nevermind that I don’t follow-up and ask, “You seem a little down, why is that?” or “How’s your memory recently?” I am judge, jury, and executioner of diagnosis.

Medical schools don’t typically go for the “normal” students, if they can help it. Sure, there’s plenty of talk about “well-rounded,” but around here that means having done amazing research, or having won competitive awards, or having traveled to Africa to de-worm orphans. Not a normal activity in the bunch. So it’s funny that we’re given this power of normalcy. Doctor’s probably don’t fit the “normal” curve much better, either: they make more money than the average person, they have much more education, they’re more likely to get divorces and more likely to smoke.

I don’t know, however, that there’s a better system. Human behavior is just so diverse, so out there, that you have to hope that a physician gets a good idea of “within normal limits” because he or she has seen so many patients, and is intelligent enough to pick up on clues of abnormal.

Culture throws a cog into the well-greased normal machine, however. We’re trained now to recognize some of the big cultural differences: some cultures make decisions based on a community’s decision, rather than an individual one; others bring many family members to hospital visits; some want to care for their loved ones at home, while others feel that a skilled nursing facility is a better choice. I think one can get a sense of the obvious, outward cultural differences pretty easily, but it’s the subtle, internal assumptions that each party maintains that are much harder to address. Not that this is limited to ethnic culture, either–it’s probably just as common between families. (For example: I always find it fascinating how different families celebrate a holiday. In my house, we got to open one present on Christmas Eve, and left everything else until the next morning. Other families open everything on Christmas Eve night, or open them with their neighbors, or don’t even celebrate Christmas at all. Anything but my version seems weird to me.)

I have an assumption that pretty frequently gets me into trouble, and I have to constantly remind myself to break: I assume that if a patient has a problem, he or she will tell me about it. Is this an incorrect assumption? Absolutely, but from my own experience, I tell my physician every little ache and pain, and so I assume that’s how other people’s minds work. But you’d be surprised how often people don’t mention something until you ask them directly, or rephrase the question.

Me: Any other problems or difficulties I can help you with today?
Pt: No, I’m doing pretty well, I’d say.
Me: Do you have trouble with urination?
Pt: Oh, no, I’m fine.
Me: Are you waking up to pee at night?
Pt: Yes, about 5 or 6 times a night.

It’s difficult for me sometimes, because in many ways I’m an introvert. I internalize things, I think constantly but don’t say most of what I’m thinking aloud. And unless I ask, or say the thing I’m thinking out loud, I have no way of confirming what I’m thinking.

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Doing a little self-reflection, I’ve found myself having more and more libertarian thoughts running through my head–usually of a “personal responsibility” or “individual behavior” nature, and I’m trying to understand why they’re popping up. Here’s the theory; it may explain why many physicians are somewhat libertarian in nature as well:

Physicians want to help people. In practice, I think, much of one’s ability to help is limited by patient adherence: we can only give suggestions to patients. They can choose to take the medicines we prescribe, to get the additional tests we request. Many times I think we assume a patient doesn’t follow a care plan because of some intrinsic personality characteristic–when often it’s a problem with understanding or other situation that prevents perfect adherence. Many times things totally unrelated to medicine influence a patient’s ability to get care. If they don’t have transportation, how can they get to their doctor? If they don’t have money, how can they pay for medications–or even co-pays? If they don’t live in a good neighborhood, how can they be expected to eat fruits and vegetables, or get exercise if there are no safe places to work out, or no gyms in the area? If they lack the education and we don’t talk at a level they understand, how can we expect them to participate in their care? If we don’t have a translator, pantomiming and charades only goes so far.

So I think a lot of the time physicians feel like their work is in vein. The realm in which we try to help is that of the individual. So if an individual doesn’t follow-up appropriately, or doesn’t take their medications, we assume it’s an individual problem. We’re so intent on seeing that one tree that we forget that it exists in a forest. I think if more physicians took this approach (or maybe if more medical students were taught with this approach in mind), we might have more physicians advocating for institutional, society-wide changes in the foods our patients eat, the ads they see on television, and the lifestyles that they live.

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Blogging is probably like sending angry emails: you should wait until you’ve calmed down. But I just can’t help it right now. I’m livid.

So I’ve become something of a patient advocate recently with all this geriatrics and frail elders and polypharmacy and whathaveyou, so I thought it’d be a good idea to try to get a grip on the Medicare Part D stuff that’s going around to physicians and Medicare recipients. (My father and grandma tried to attend an information session, but it was so crowded even at the encore performance that they couldn’t get in. Note: this is not a testament to how popular the new plan is; it’s a testament to how damn bureaucratic, confusing, and complicated the thing is.) So I do a Google search for medicare part d to get some general results. I get a ton of ads (a clear sign that there’s money to be made by all comers), and I click on some ads, some links. A mish-mash of everything to get an overview, and possibly recommend a site or two to my one or two readers.

I come to my first site, and this is the one that drives me over the edge: AARPMedicareRx.com. I see AARP in the URL, and assume it’s a special site the AARP has created to help its members. Then I see the AARP logo in the top left corner, and assume I’m right. I click on “Learn the basics,” and get this first paragraph:

If you’re eligible for Medicare, you have a new option for getting coverage to help with the cost of prescription drugs: AARP MedicareRx Plan is a prescription drug plan that is approved by Medicare. This national plan is provided by United HealthCare Insurance Company* and begins January 1, 2006.

I’m confused. “What? I thought there were multiple options for the Medicare Part D plan, not just one.” I re-read, I scroll down to the asterisk, and reailze I’ve been had. This is not an AARP site at all; no, it’s a United HealthCare Insurance Company website with an AARP (“pharmacy services” bullshit) logo. And if a third year medical student with a major in health policy and a pretty good understanding of the US health care system makes this mistake, you can bet countless others will, too. I’m sure that’s the goal. Show the AARP logo so you get the confidence of the AARP, then tell consumers there’s *one* new plan to help people out.

I’m disgusted. If anyone knows who I could contact to complain about this blatant deception, please let me know. (Isn’t this what the copyright laws were supposed to be for? Protecting consumers from misleading or fraudlent information?)

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Polypharmacy is the taking of multiple medications for multiple medical problems. My winning patient so far had 24 when I saw him in clinic on Wednesday. If anyone honestly thinks that patients are taking all of those medications, with all of their different schedules (two of this one in the morning, 1 at night; 3 of this one every 8 hours; one-half tab of that other one every day), they’ve got to be kidding themselves. How many of us can reliably even take a course of antibiotics for 10 days?

Prevention is the only solution, people. Eat better, exercise more, stop smoking, and wash your hands. That’ll lead you to a healthier life than any pill.

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I’ve been on service a week, and I’ve already seen quite a range of presentations and stages of Alzheimer’s. I had no idea there was such variety.

The first patient, diagnosed at the young age of 57, had deteriorated rapidly. She was very aphasic–meaning she couldn’t find the words she wanted, nor could she understand some of the things I asked. She scored a 3/30 on the MMSE, a quick test of one’s cognitive functions. This is very poor. Often I would ask a question, and she would respond with “Well, I… you know, I am… and so, it is, because, you know, it… is. And it’s okay, because what it is… is.” It was very difficult emotionally to continue; I felt really uncomfortable asking her more questions. This was complicated by the fact that her partner was in the room, a psychiatrist. He looked like he was on the verge of tears with every question I asked. I asked him how he was doing, if he might like some help caring for his wife, but he said he was fine.

On the exact flip side, I met another woman who has Alzheimer’s and was very happy-go-lucky. Maybe her disease had just progressed less. She still recognized her children, but didn’t know much else. Besides that, she seemed content. When I asked her the year, she smiled and replied, “Oh, I don’t keep up with that.” What an outlook. Her children, who were at the appointment with her, seemed to have accept their mother’s illness. They smiled and joked with their mother, and tried to make the best of the situation.

Sometimes, I guess all you can do is laugh.

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I don’t know who these guys are, but posting a practical joke involving a cadaver with a full view of the face is incredibly unprofessional. As a former anatomy TA, I know I’ve had my share of laughs in the dissecting lab, but it was among classmates in a closed setting, not posted on the Internet for all to see.

If that was my father, brother, or friend, I think I’d be pretty pissed. Those that donate their bodies give us the privelege of using them to learn, not for the whole world to see us play around with.

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No, these numbers are not from France, Sweden, England, or Canada:

• 75% favor universal health insurance.
• 96% favor Medicare.
• 93% favor birth control.

These are from a poll of 2,200+ Americans. We’re not as conservative as our leaders tell us we are.

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Anyone know of a website or resource where I can find out what qualifies as a website that would need to have HIPAA standards on it? If people submit their information voluntarily to Medslist, would it really have to be HIPAA compliant?

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An idea for a meme that the medbloggers could start: bloggers posting their wishes/advanced directives/durable powers of attorney. As with the Terry Schaivo mess, everyone was talking about people writing out (or discussing) their wishes with loved ones. With a simple blog entry, a person could provide a written document of their wishes. There’s 5 million bloggers out there, maybe it’d help?

Medbloggers could draft a template, define terms, and explain some possible scenarios, and then people could copy->paste and link to other people’s? Whatchya think? (I realize a durable power of attorney form would be more useful, but this could be a start?)

People post their five favorite songs, or favorite book, or favorite quote, why not something a little deeper? (They could password-protect the entry if they felt that it was too private for the general public.)

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Two weeks ago, I was sitting down on a bench to eat some cheap Chinese food with my messenger bag around my shoulder, and I got a sharp, stabbing pain in middle left back. I get this once every couple months or so, somewhere in my back, but I either stretch or twist or bend over and everything fixes itself magically. This time, however, it wouldn’t go away. If I bent or leaned the wrong way, the pain would hit me–so hard it would stop me inhaling if caught off-guard. If I turned my neck, it hurt; even if I stepped the wrong way, the pain would hit.

Over the next couple days, I tried stretching, massage, IcyHot patches, and hot showers to no avail. Ibuprofen dulled the pain a bit, but obviously didn’t fix the muscle.

Lucky for me, the boyfriend’s brother-in-law is a physician in the area who learned acupuncture while he was in residency in LA, and kindly offered to acupuncture my back (is acupuncture a verb?). Now, I’m not afraid of needles, but I was a little nervous and skeptical, but willing to give it a try. (The physician has mentioned “opening up my chi” before with acupuncture, so it started to sound a little new agey, but I think I was just confusing “new age” with “non-Western.”)

So I lift up the back of my shirt, find the exact knot in my back, and he puts a couple needles in the spot, as well as around it. He also puts two in my trapezius muscles right over both my scapulae. Most of the needles go in without any pain at all–the most I feel is some pressure–and with one or two I feel a sharp pain for a second or two. I’m sweating pretty bad, I think mostly because I’m nervous; my palms are in hyperhidrosis. He asks me if I feel any ache, and at first I say no, but as I adjust myself ever-so-slightly in my seat, I feel what he’s talking about. The muscles just feel incredibly achy, almost sore. It’s so achy that it’s just mildly painful, so I sit pretty still for the next 30 minutes until he removes the needles.

After he removed them, I felt maybe 10% better. Nothing too impressive. I thanked him for doing it, but figured it didn’t do much for me. Oh well. Over the next day or two, however, I noticed my pain and tenderness had all but vanished. I can turn my head fully, twist my back, stand on one foot–with no pain at all. Was it the acupuncture, or just the tinctuer of time? I’d like to think the former. If you push on the spot where it used to hurt, it’s definitely more sensitive than the rest of my back, but it’s nowhere near as tender as it used to be.

Color me impressed. I should get my chi opened up more often.

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I don’t know where MedPundit went to medical school, but her experience couldn’t be different from mine. Other med students, are you on my side or MedPundit’s? Comment below.

It shouldn’t be surprising – medical school is a crucible of change.
Students leave their homes, their families, their friends.

It’s definitely a big change, and not without its stressors, but most of us have gone through this before when we went to college. Clerkships are, without a doubt, lonely. It’s nice to be on a service with a classmate, but I barely see anyone these days. Just more encouragement for me to do a better job with time management and setting some time aside for a mild, tempered social life.

They lose the academic standing they had in college and high school, and with it sometimes, self-esteem and respect.

Yet another reason to make things pass/fail like we are here.

They see and learn things they’ve never seen or heard of before. They learn, in fact, a whole new way of being. It is a completely transformative process in a way that few other processes (except perhaps joining the military) are.

Absolutely, but what an amazing transformation it’s been! There’s good parts to it, and bad as well, but I think my mind has been made 100 times sharper.

It is not a pleasant process. I remember one of my medical school classmates describing it as “the shrinking of her soul.” The reasons for this are all those mentioned in the above article, with the exception of one glaring omission – the role of the teaching process. The third year of medical school, when students enter the hospitals and see patients, also marks the moment that their teaching is handed over entirely to practicing physicians – and they are brutal. The brightest and best students are treated as know-nothing scum and burdens to be born by the rest of the medical team. There is never, never, any praise – only denigration. At least, that’s the way I remember it, with few exceptions. It’s like being stuck in a House episode.

This sounds like some other world she’s describing. Are clerkships hard? Yes. Do some of them suck? Yes. Is there some degree of scutwork involved? Sure. Do they turn your view of medicine on its head, and teach you the frustration of paperwork, hierarchy, and difficult patients? Absolutely. There are definitely days where I feel down, feel like I’ve worked hard and haven’t felt appreciated. There are days that I think, “This is medicine? I seriously signed up for this?” But my soul is not shrinking, and the attendings are not brutal. I’m given praise by attendings and residents, my family and boyfriend, and I dole out some healthy self-praise, too. Do I feel stupid for not knowing things? Sometimes. Do I feel loved and needed by the attendings and residents? Not always. But more often than not, I feel like I’m respected as a member of the team, feel like I contribute and can teach residents and attendings things they’ve forgotten, and I get feedback that is constructive about how I can do a better job. It’s natural for me (and probably med students in general) to beat myself up over not knowing an answer to pimping session question, but that’s because we have such high self-expectations. I don’t think the attendings are purposefully trying to shrink our souls or denigrate us.

So, how do we get through it? Our hides grow a little thicker (or is it that our souls shrink?); and if we’re lucky we meet some good roll models along the way. But, at some point, we come to the realization that our teachers are not gods, but frail, flawed men and women with bad management and teaching skills.

My skin is definitely thicker after 2 months of surgery already, and I’m thankful for it; I’ve been through the worst already. I’m less intimidated, and more willing to just do my best, keep up on my reading, and accomplish the goals I have set for myself during the rotation. My attendings are not gods either, but they’re hard-working, incredibly intelligent men and women with somewhat-decent management and pretty good teaching skills.

Let the record show that I’m in between clerkships while writing this, and just finished a relatively low-intensity month on pediatric neurology. This is also not to say that there are no depressed students here; I know of several.

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My plans for world domination continue with a fluff piece of the prevalence of PDAs in medicine. The writer had it easy; he used my email message as pretty much verbatim to fill his story.

In other news, I’m slow to post as I’m working on a top-secret new web application to do nothing all that exciting. Should be ready for comments this coming week. Over and out.

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That’s right, folks. Starbucks now spends more on health insurance for its workers than it does for the primary product it sells: coffee. We’re in trouble, folks:

Howard Schultz, chairman of Starbucks, announces his plans to spend more on health insurance for its employees this year than on raw materials needed to brew its coffee.
According to Schultz, the Seattle-based company has had double-digit increases in insurance costs for the last four years.
Schultz made the announcement at a Washington, D.C. meeting with lawmakers from his home state – one of several organized by Schultz to address “a growing health care crisis.”
Shultz said he hopes congressional leaders will put the issue “at the front of their agenda.”

It’s similar to the American car manufacturers; they spend more on health insurance than on the steel to build their cars.

Something’s got to change, but mark my words–if it hasn’t changed by the time the avian flu hits (if the epidemiology predictions are right), it’ll definitely change after.

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I’ve always thought that one way to tell if you’re truly fluent in another language is if you can make a joke in the language–humor requires not just meaning and proper grammar, but a level of comfort with the language and a good sense of comic timing. It’s totally true for the medical languages, too.

Case in point: at the beginning of this month’s rotation, I attended a weekly neuroradiology conference where the attendings kept making these only-funny-to-neurologist jokes about patient’s MRI scans, and I didn’t get a single one. They all went right over my head, but everyone else in the room was just cracking up.

Yesterday in clinic, I found myself making an only-funny-to-neurologist joke while evaluating a teenager with chronic daily headaches. As I sat down to present to the attending, I said, “Looks like a pretty classic case of giant cell arteritis,” and I got a good laugh from her.

Giant cell arteritis is a headache disease, but only presents in people over the age of 55. Ha! Err… ha. Sigh. Soooo lame.

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… is up at Sneezing Po. Go read this week’s best in medical weblogging.

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Rachel Gets Fruity is a sexually clever ad to encourage men to perform regular testicular self-examinations to help prevent testicular cancer.

Unfortunately, The US Preventative Screening Task Force doesn’t think testicular screening will be all that helpful; Rachel’s ad would have been better served encouraging screening for colorectal cancer, but we all know that putting something up your butt automatically turns you gay. I guess if that happened, Rachel’s ad wouldn’t be as effective anymore.

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Dear Google and Karen Wickre,

I loved your story “We Get Letters (2)” about new parents finding information to help prevent a blood transfusion of their newborn, but it’s inaccurate that the blood transfusion would be “extremely dangerous,” as the parents report. Blood transfusions are generally *extremely safe*, and the “danger” is a myth medical professionals have to dispel all the time. It’d be great if you noted this in your entries.

From Nelson’s Pediatrics:

“a current estimate for risk of transfusion-associated HIV is 1/1 million donor exposures, with estimates ranging from 1/800,000 to 1/2 million donor exposures. Similarly, the risk of viral hepatitis C is 1/1 million donor exposures. Transfusion-associated cytomegalovirus can be nearly eliminated by transfusing leukocyte-reduced cellular blood products or by selecting blood from donors seronegative for antibody to cytomegalovirus.”

Sincerely,
Me.

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Okay, I’m probably sacrificing my overall attractiveness with this one, too, but it’s all in the name of patient care and relieving suffering, which I hope are valiant and attractive enough to outweigh the too-much-information-eww-gross-disgusting part.

I used to make fun of my college friend Sam for doing this, because it really is pretty gross, and he did it in the public bathroom, but I’m sorry, Sam. You were right.

I’ll just lay it out there now: suck warm salt water up your nose.

If you feel a sore throat or cold coming on, get a mug of warm salt water, and suck it up each nostril. I have absolutely no evidence to support this, as I’m just not in the mood to search PubMed, but I’ve had good results.

And for you post-nasal drip sore-throaters like me, this will most likely cure your sore throat. It flushes the mucous off your soft palate that’s collected during the night. Gross? I guess. But if it saves one person a sore throat, I’m okay with that.

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The cure for canker sores in two paragraphs, but first, a little education: I’m talking about canker sores, also known as apthous ulcers, found inside your mouth. I’m not talking about herpes sores, which are usually found around the lips or on the genitals, or syphillis chancres, or chancroid, yet another similar-sounding STD. Canker sores probably have an unknown viral or bacterial cause from what I’ve read, and are not STDs, for the damn record.

If you get canker sores recurrently like I do (mine are generally from stress), you’ve probably tried every possible cure. I’ve tried vitamins, amino acids, yogurt bacterial cultures that you have to keep in the refridgerator, mouthwashes, toothpastes, numbing agents, and anti-viral drugs, with absolutely zero success. When I was in high school, I had 17 in my mouth at one time. I’m not kidding. (Thankfully I’ve learned to de-stress since then.)

But I’ve finally found a cure (for me at least), thanks to the doctor at the student health service: triamcinolone paste (it’s a corticosteroid). The stuff works wonders. Spread the gospel, please. Dry off the canker sore, put the paste on the canker sore just before bed, fall asleep, repeat for a couple days, and it’ll hurt less and heal much faster. Your doctor can easily prescribe it, and it’s a generic, so it’s cheap.

Please appreciate this advice, I’m probably sacrificing my kissing-attractiveness by posting this one.

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One of our national pimples is coming to a head, and it’s pitting those that understand medicine against those that don’t. The former group understands that there’s never a free lunch; that you don’t get something for nothing; that everything in medicine is a trade-off between risks and benefits. The latter group expects a perfect pill for every disease (or even just a pill for every disease).

An attending that I’ve really come to respect over the past weeks made a similar comment out of the frustration with Mexican immigrant family. The boy in the family wasn’t taking his anti-seizure medication regularly (which is important, both because it prevents seizures, which can be dangerous to the patient, and because it’s dangerous to quit an anti-seizure medication cold turkey). My attending, himself an immigrant, said “there was a cultural problem,” but I now think I see what he means.

Until we develop the perfect pills and vaccines and surgeries without any risks, side effects, or complications, everyone must understand this simple fact: everything in medicine is a trade-off between risks and benefits. We do our best to minimize these risks and maximize these benefits as physicians–by doing research to discover which drugs work better and which operations are safer, but even we cannot prognosticate. Leave that to the groundhogs. We can tell you with X percent certainty that a drug will work, or that Y percent of patients will have an infection after surgery, but right now, we don’t know which people are which, in most cases.

That’s the tough part about medicine: we do all this research and publish all this crap to do our best to predict the future; we’re the ultimate in control freaks. We want a good outcome for our patients, so we study and crunch numbers to try to have more control over the outcome, but nothing’s for certain. Life’s precious and fragile. We’re doctors, not miracle workers.

Now, this is no blame-free mantra. As physicians, we must make sure patients understand the above simple fact. But we must also provide them with as much information as possible, in as easy to understand format as possible. And, as we have learned from the Vioxx disaster, we must not allow any possible risks that are known to be hidden. I’ve spoken with several patients in chronic pain with stomach problems (the only group Vioxx should have been targeting) who say that they’re very upset Vioxx was taken off the market: it was the only drug that helped them. They said they were willing to take the risks of Vioxx; it should be each person’s choice.

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I totally ruined the last post with my humor-cum-neurotic antics. So back to the difficulties in examining pediatric patients.

The whole “take a good history and physical” mantra kind of goes out the window when the human you’re trying to help doesn’t do that whole “talking” thing or that whole “sitting up” thing, or especially the “can you do what I’m asking you to do” thing. It really makes you hone your ability to draw conclusions from limited information and to use tricks to get the information you need. A couple things I’ve picked up (post yours in the comments!):

Checking reflexes requires the patient to relax their joint, but it’s a tough sell on a squirming infant. Even distracting them doesn’t always work.
“Follow my finger” to check eye movements can be tough. Following a toy or a face seems to be much easier.
Use the parent. They can soothe the savage beast, and keep the child’s attention while you’re busy poking and prodding them. Plus, they’re usually all you’ve got for the history, if the kid’s too young to talk.
Let kids see your instruments before you use them. Makes them less scary. Warning: the hyperactive children will throw your reflex hammer, and may almost hit a nurse in the eye. Keep instruments away from them.
Get on the child’s level. You’re much less intimidating there.

Other tricks, my medblogging colleagues?

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This just in: it is certifiably impossible to walk into a room with a smiling baby without your maternal or paternal instinct immediately raising the pitch of your voice at least two octaves. It is simply uncontrollable.

The first week of my neurology rotation was incredibly dry. It consisted mostly of library time, awaiting the consults that never really came. The week was slow, and seeing as though it was the first week, I naturally felt stupid, frustrated, and lame for asking seemingly obvious questions. After a nice mature little internalized tantrum last Sunday (“I hate neurology! This is so stupid! Waaah!”), things are starting to make sense and get busier. Not a whole lot of sense, but plenty busier.

The problem with all of this, however, is the selection bias. Because only the really sick people end up in the hospital, you get a very skewed view of the population. While most of us will remain fairly healthy throughout our lives (minus some high blood pressure, high cholesterol or weight problems), the medical student and the resident see the worst of the worst. Since every patient we’ve seen so far in the hospital has been for a seizure workup, I’m thoroughly convinced that every child has had a seizure in their lives. (Time out for reality: a febrile seizure occurs in 2-5% of the population, but 2/3 of those kids never have a second seizure, so neurologists don’t generally get their panties in a bundle about a first-time seizure assocation with fever. Then again, 80% of neurologists prefer boxers to panties, so pantie-bundling isn’t all that common among neurologists, anyway. Surgeons, however…)

So I’m somewhat convinced that I had a seizure, and my parents are keeping it from me. That, or the old evil babysitter they hired named Alva Camp that made my brother and I eat only rice cakes and choose between taking a nap or cleaning our rooms while they chilled in Barbados just never told them about it. (And they say psychiatrists’ children are neurotic. Clearly I’m an exception to the rule.)

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Pardon the dust, won’t you? A new design is on its way.

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I’m a little worried it’s my institution (and former members of the team I’m on) that this woman rightfully complains about in the NYT yesterday. (I only say this because the woman is from a nearby city, and our service does a lot of breast surgeries.) However, in none of my experiences has anyone done anything remotely similar to what the patient describes:

Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital room.

Without a word, one of them – a man – leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.

Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, “Well, good morning,” a quiver of sarcasm in her voice.

But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical students in their 20′s, stared at Ms. Duffy’s naked body with detached curiosity, she said.

After what seemed an eternity, the doctor abruptly turned to face her.

“Have you passed gas yet?” he asked.

“Those are his first words to me, in front of everyone,” said Ms. Duffy, who runs a food service business near San Jose, Calif.

“I tell him, ‘No, I don’t do that until the third date,’ ” she said. “And he looks at me like he’s offended, like I’m not holding up my end of the bargain.”

I’d be just as upset as this woman if I was treated that way in the hospital. On my service, we always knock before entering a room, we greet the patient, we tell the patient what we’re about to do (“I’d like to take a look at your incision”), and we always cover a patient of any area that doesn’t need to exposed. Any time we remove a part of a patient’s gown, we make sure to close the curtain in the room.

Also, our teams are two medical students max–not half a dozen.

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Turned 25 today. Pretty damn uneventful. Me, internal monologue style:

Wake up, groggy.
Ugh, it’s 5am.
Look at phone.
No one called. Sad.
Oh, wait, you went to bed at 9:30, and the bf called at 10:10. You barely remember the conversation, but you’re sure he was sweet.
No one else called. Sad.
Oh, wait, it’s 5am. Who would be up this early, and even if they were, would they expect me to be up this early?
Get in shower.
Put shampoo in hand. Hey, it’s your birthday.
Joy. Rapture. 25. Car insurance now cheaper.
Finish shower. Get dressed.

Two days left of surgery, and on Monday I’ll start with Neurology. My, how time flies. Down to LA this weekend for a birthday celebration. A little delayed gratification is always good now and then. Especially when you have a scary surgery exam in two days and have no idea what to expect.

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Even though it’s sometimes hard to see a patient as more than just their disease, I’ve really started to think about how this is, for most people, just a tiny little part of their life. You forget that you’re seeing a patient at their worst–sick as stink, post-operation, and feeling crummy. They haven’t showered in days, they’re eating crappy hospital food, they’re too weak to do more than lay in bed most of the day, and they’re away from their families, their cultures, and their homes. Sometimes they’re unconscious, or so drugged up that they’re not even with it. And because this is almost all you see of the patient, it’s not uncommon to make what’s called the fundamental attribution error in psychology–believing that a person’s actions or behavior is due to the patient’s own personality than it is due to the situation he or she is in.

Even in clinic, seeing the patient before they’ve had any sort of procedure or treatment, the attribution error can stick. The clinic is usually running late, so the patient has been waiting for awhile; he or she is probably nervous about seeing the doctor and learning what kind of treatment will be necessary (especially when they know they’re in a surgeon’s office for a reason); he or she might not be feeling well, and any other number of reasons. So if the patient (or a family member in the room) is crabby when I enter the examination room, I automatically assume it has nothing to do with me or the other person. I’ve learned to take no offense. I automatically give the person the benefit of the doubt. It’s not uncommon for patients to get a disappointed look on their faces when I enter the room anyway–they’re expecting to see the surgeon, and then I introduce myself as “the medical student on the team.” (I do think, however, they are slightly relieved to find out that someone as young as me will not be performing the operation.)

This all came about because of a sick-as-stink patient we’ve had on our service recently. He’s been in and out of the ICU, unintelligible when he attempts to talk, and pretty much out of it–due to his own neuro issues or the psych drugs we give him to keep him calm. (He’s been pulling out his drains.) One day, however, I guess a family member must have brought by a little collage of photos of the patient and his family. I couldn’t believe it was the same man. Him as a 30 year-old with his wife. Him in his 40s riding a horse with his daughter. Him with his extending family at a 50th birthday party. Scanning from picture to picture, none of them matched the dehydrated, sickly, wasted man lying in the bed next to me. All this time I had thought of this patient’s life as culminating in his surgery, cancer, and hospital stay, and I hadn’t even realized it. The egotism of my idea of the man blew me away.

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An attending once told me a story about a colleague doing an abdominal operation on a morbidly obese patient, cutting through layers and layers of fat, only to hit the operating table on the other end. The surgeon, getting lost in the patient’s adipose tissue, went completely through a roll of fat, as opposed to cutting down to the abdominal wall.

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Although I’m spending countless hours in the hospital with little thanks or appreciation, the ice machines here rock. That is all. Back to your regularly scheduled programming.

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Working in a hospital with so many highly-educated patients that seem to know more about their diseases than we do, I think we probably run a greater risk of making assumptions about our patients’ education, intelligence, and vocabulary.

Many times I’ve noticed doctors, even when trying to explain things in “English” (as opposed to medical-ese), start using terms like “distal” and “proximal,” and patients start to get a look of confusion on their faces. I try my best to stick around and explain things better to the patient, but many times I don’t even think we realize we’re doing it. Even words like duodenum and common bile duct I would imagine could be very confusing. I assume that most patients have heard of the liver, the intestines, the stomach, and the pancreas, but don’t have a clue how they’re connected, where they are, or what they do. This has nothing to do with their intelligence or ability; they’ve just never felt the need or had the interest to learn. Many were probably never taught about them.

I’ve been thinking about carrying around some pictures of the abdomen to show them to patients and explain their problems and the surgical procedures to correct them. It’d probably go a long way to making them feel a little bit more in control of their care and their bodies.

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One of the things we’re taught in our ethics classes is that we, the medical staff, don’t get to decide what treatment a patient gets. The patient does. We can recommend until we’re blue in the face, and suggest as strongly as possible, but ultimately, it comes down to the patient’s choice. It shouldn’t be any other way, but sometimes it can frustrate both staff and patients, and patient care gets nowhere.

Before you get to this blue-in-the-face step, however, I’ve learned it’s important to make sure everyone’s on the same page, and everyone’s communicating on the same level. If a doctor understands a disease process differently from the way a patient does, each party may interpret the other’s actions, behaviors, or treatment suggestions as hostile, insulting, or punitive.

Take for example, Mr. Gouda. (Not his real name, but I’ve been craving cheese lately.) Mr. Gouda presented with all the classic–I mean, classic–signs of a small bowel obstruction. (A small bowel obstruction is when the small intestine gets blocked, either because it’s twisted, crimped, or squeezed from something outside of the intestinal tube. It’s usually caused by scar tissue from prior surgery or hernias.) He was throwing up, not pooping, not passing gas, and had lost his appetite.

The treatment for a small bowel obstruction is, for the first few days, watching and waiting (later it can be surgery). Give the patient some IV fluids to re-hydrate them (they’ve been throwing up and not eating), and also give the patient an NG tube–a tube that goes down your nose and into your stomach, which sucks out air and fluid that’s built up in the intestines. The only problem is this: having an NG tube placed is incredibly uncomfortable. Probably the most uncomfortable thing we do while people are fully conscious. We stick a tube up your nose, pass it down your esophagus as you gag, telling you to “Swallow, swallow” until it’s down in your stomach.

In the ER, they had tried to place Mr. G’s NG tube without any success. He hated it so much that he was willing to keep throwing up as opposed to having another tube placed. Please note that this was not normal vomit. This was feculent vomit. Translation: partially digested food, starting to look (and smell) more like poop than food. He was more willing to throw up poop than have the discomfort of another NG tube. That’s, uh, pretty severe in my book.

So we go down to talk to Mr. G, who absolutely refuses the NG tube. He says “Just put me out and do it!” We tell him that we can’t–if you’re unconscious and gagging, you can vomit and have it go into your lungs (this is called aspiration) and you get a really, really severe pneumonia and can die. Next, he asks us why we can’t just give him “some medicine to dissolve the blockage,” and I start to realize we’re not on the same page. This, my friends, is the key. That same visit, the team kept arguing with him, both sides got frustrated, and we gave up for the night.

Mr. G had thought, totally understandibly, that this “small bowel obstruction” was a blockage in his intestines. Something like a clogged drain. You pour down the Drano, dissolve the gunk, and voila, clean drain. There’s even a medical correlate: if you have a blocked heart blood vessel, you can insert some medicine inside the vessel to break up the clot.

My colleague and I went back to Mr. G the next day and explained that the blockage was external–like a kinked garden hose, or a clamp over a tube–and everything instantly changed. I get the feeling that he thought we wanted to do the NG tube just as punishment for being a “difficult” patient, but he finally understood that we couldn’t have him drink some substance–the obstruction was outside his intestines. Once he understood that, he was totally willing to try the NG tube. Our chief placed the tube, much easier than the ER resident, and two days later Mr. G was out of the hospital, with a referral from us for a primary care physician.

It’s always important to make sure everyone’s on the same page. We all have different definitions of words, especially in the medical field.

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I’ve come to realize in the past couple of days that there’s a huge danger associated with smoking that I’d never heard about before: smoking makes you a really poor surgical candidate.

Surgery is a really stressful event on the body: it basically challenges every organ in your body, from your brain to your heart to your lungs to your kidneys and everywhere else. But surgery is especially hard on your heart, and requires good lungs to provide oxygen to the body. Smoking hits both of these pretty hard. It destroys the lungs with emphysema and chronic bronchitis, and it leads to heart disease and damages your arteries as well.

So if you’re a smoker, and you find out later that you need surgery, some surgeons may consider you a “poor surgical candidate,” meaning you’re a high risk patient that may not respond to the surgery’s stresses well, and may have many more complications and a higher risk of death from the surgery. This is for all types of surgeries: everything from routine hernia repairs to cancer removals to gastric bypasses for obesity. Not only does smoking cause many types of cancer, but it makes you less likely that a surgeon will want to operate on you in the first place. And that’s a place that no one wants to be in their future.

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Surgeons, as a whole, are not the jerks you see on television. They are the jerks you see in the OR. Kidding! Really! Some of my best friends are surgeons! (Look. There are jerks in every field.) However. Surgeons, I’m going to fathom, are the most direct of the Homo sapien medicus sub-species. This took some getting used to.

“You’re holding this wrong.” “You’re moving too fast. It’s making me sick.” “Stand up straight and ask them to raise the table.” “No, that’s incorrect.” “No, that’s absolutely contra-indicated. That is the last thing you’d want to do.” There seems to be less gray in the surgical mind than is in mine right now, and for the first couple of days, I took all these direct challenges to my actions as a put-down to my post-Boards medical self-esteem. It’s not an uncommon association we make: someone gives us direct, blatant feedback about our actions, and we take it personally. This is totally inaccurate, however, in my experience so far.

If you make a mistake, or do something incorrectly, you’re being told how to do it correctly in the future. In surgery, if you fall down, you get back up, take a deep breath, and keep moving cautiously. As my chief relayed some advice for medicine in general to me: “What’s the worst thing a chess player can do when he knows he just made a mistake? Rush his next move and make another mistake.” We’re human, unfortunately. We have that whole “imperfection” thing going pretty strong for us. But it’s the actions that follow that are much more important to both the patient’s and the doctor’s success.

Mistakes are always worse if you never analyze them to learn from them.

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Last week I started to have patient dreams. They normally fill some sort of supportive role–rarely are they the main characters–but they’re generally lacking their disease or IV poles. I’d like to interpret this as “seeing the patient as the person, not the diagnosis,” but I’m not totally convinced.

At first this kind of freaked me out: I was diving too far down the rabbit hole, or obsessing too much, but I’ve come to the realization that I generally have dreams involving the people I spend time with or think about. And since I spend a pretty sizeable amount of time at a patient’s bedside, talking to them, and then talking about them to my team, it’s no wonder they’ve invaded my dreams.

I’m also feeling really attached to my patients, and I wonder both if this will fade with time, and if they feel the same way. On my service a couple of patients were “mine;” I saw them each morning and afternoon, and reported about them to the rest of my team on rounds. I’d start to get to know them, their personalities, and little tidbits about their personal lives, and I looked forward to greeting them each morning, watching them progress from very serious surgeries to almost full recovery. When one patient in particular was discharged from the hospital on a day I was off, I was a little offended. “What, he didn’t even say goodbye?” I thought to myself, and then had to remember that I was probably not at the top of his list of importance; he’d been in the hospital 12 days and couldn’t wait to leave.

I guess it requires me to add another type of relationship to my list now: patients. You expect certain things from different types of relationships: brothers are different than parents are different than friends are different than co-workers are different than significant others are different from teachers. I guess I was still applying the “friend” mentality to my patients, and expecting them to say goodbye when they left.

The patient relationship is a fine line, and is sometimes two things at once. On one hand, you want to be objective: the scientific, square medical doctor that provides advice and data without emotion or attachment to get in the way of the best treatment. But if you remain in that camp, you miss out on the reason you became a doctor: because you truly care about people, want to help them, want to do what’s best for them. Just like you do for your loved ones.

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In the category of “Things NOT to say to patients who just underwent emergency surgery the day before and are incredibly anxious people in general”:

I pull out my penlight to illuminate his temporary ileostomy, but the light is going dim. I say, “Shoot, it’s dying,” and my chief quickly corrects me, “Oh, your FLASHLIGHT is dying?” “Yes,” I say. “The flashlight.”

Stupid stupid stupid stupid stupid stupid stupid!

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In an interview with Stephen Colbert, we find out he’s deaf in one ear. Acoustic schawnnoma, anyone?

Colbert is forty-one, a native of South Carolina, one of eleven children, the father of three, a suburban guy, and deaf in one ear. “I had this weird tumor as a kid, and they scooped it out with a melon baller.”

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I get the feeling that surgeons like control (now now, don’t get testy; takes one to know one). “Management” sounds much better than “control,” so I guess that’s why they use the former, but I was really blown away by how much of surgery is patient, uh, management. And it’s my favorite part of the surgical rotation so far. I expected to just be in the operating room for 12 hours a day (sometimes it’s close to that), and wash my hands of patients once they’re stable in the recovery room, but the surgeon takes a patient from pre-op and diagnosis all the way to recovery and discharge from the hospital.

One of the neatest parts of surgery, says my attending (and I agree), is the fact that in surgery, you get to make a diagnosis, and then see if you were right. You see a patient acting a certain way, with a certain set of signs and symptoms, and you make an educated guess that their gall bladder is inflamed. So you open them up, go in, and see if your pre-operative diagnosis matches your post-op diagnosis.

The other great thing about surgery is that there’s really a limited number of things you’re really worried about. As opposed to internal medicine, where you’re trying to manage 20,000 chronic diseases with 30,000 medications to treat them, surgeons seem to care about, in order that I’m thinking of them: infection, farting, pooping, blood clots, fluids/dehyrdation, peeing, nutrition, vital signs, and walking around. If you’ve ever had an inpatient surgery, you have been asked these questions. Over, and over, and over, and over, and over again, by the medical student, the intern, the resident, the chief resident, the nurse, and the attending. We cheer if you pass wind, we applaud when you eat all of your meal, and we scold when you lay in bed all day.

This is not to say that a patient’s other medical problems are unimportant or ignored; many times a disease can affect something on the above list: diabetes can complicate nutrition, medications can complicate bowel movements, and so on. I think if surgeons had the time, they’d try to help manage a patient’s mental health status, or their heart disease, or their kidney failure, but sometimes the daylight’s wasting and there’s 10 other patients that require your management, too.

The cutting itself is pretty fun too-when you’re allowed to do anything. The medical student’s role is usually reserved for observing, being pimped (asked questions rapid-fire by a resident or attending), suctioning, retracting and, if you’re lucky, suturing incisions closed at the end. During the first week, you’re no help anyway: your sense of awe at the human body leads to an inevitable puddle of drool that collects at the bottom of your mask. I remember the first time I saw laparoscopic surgery (where they use a camera to look in the abdomen), and I was Simply. Blown. Away.

Next when I was invited to stick my hand in an open patient and feel a liver, a spasming colon, the aorta, and then the beating heart, it was almost too sci-fi to be real. This is a person. MY HAND IS INSIDE A PERSON! I’M INSIDE A PERSON AND THEIR HEART IS HITTING MY HAND! Does their heart have any idea this is going on? This whole surgery thing? That it has a HAND next to it?

And then the seriousness of it all comes down at you like an anvil from 100 feet above. The fragility of life is taken to a whole new level when something starts bleeding during your first surgery, even a little bit, and you think to yourself, “Holy shit. This guy could die. Right now. On this table.” It’s even stranger when you take care of the patient after their surgery, and you think to yourself, “My hand was inside you.”

I’m going to stop all this “hand inside you” crap now because I’m starting to feel a rectal exam joke coming on.

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And so our fateful hero returns (that’s me, if you were unaware), after an exhaustion-induced hiatus, secondary to starting clerkships. Specifically, the surgical clerkship. I’ll start with my thoughts about clerkships in general, and then maybe dive into the life of a surgeon (or surgical clinical student).

Quick background: medical students do two years of classroom work (known as pre-clinical), then take a really freaking hard 8-hour test (known as “The Boards” or “Step One”). Then we spend our next two years working in the hospital in different specialties, seeing which ones we like, which we don’t, and trying to get exposure to that which is actually medicine.

So it’s the Sunday night before I’m about to begin, and I’m just nervous as hell. I know that the next day is going to be only orientation, with no actual patient interaction or anything, but my eager/anxious pit in my stomach has been swelling all night. Monday is very orientation-ish, with nothing too boring, and nothing too exciting. We talk about expectations, learn how to scrub into surgery, how to get into sterile gowns, get a basic idea of how clerkships and clinics work, have a couple lectures on surgery, and a workshop on suturing and tying knots. More on that whole business later. I iron all my shirts, have the better half show me which ties go with which shirts, and try to go to bed early.

Tuesday is the first official day. I’ve reviewed how to talk to a patient (called “taking a history”) and examining a patient (called “examining a patient”). I’ve read suggestions from classmates and previous students, and I’ve excitedly received my first page to learn what time to report to my team. Tuesday arrives, I wake up early (“early” still means about 6am, ha!), shower, get dressed, and drive over to my hospital where I’ll spend the next month.

I meet my team, which consists of a chief resident, two interns, and myself. Lots of personal attention, but lots of responsibility. I’m starting to already realize everything in medicine (and life?) is a trade-off. More attention, more responsibility. Give a drug for this problem, it causes that one. Perform this procedure for a disease with risk amount X, and hope that it’s less than the new risks you’ve made from the surgery.

You’re really, I mean really, just thrown in there. You finish second year taking your boards, and you think you’ve got medicine down pat. You know what every drug does and what it treats, you know how every disease process works. And then you get into clinics, and you’re immediately humbled. You know nothing. There are new acronyms, strange new drug names, new locations, new computer systems, and new people. But to everyone else, it’s totally normal. You’re already playing catch-up.

You don’t want to seem like an idiot, but you’re also excited and inquizative. But you don’t want to be annoying, either. Your team isn’t just your team, it’s also people that are evaluating you, and trying to feel you out to see what kind of a team member you’re going to be. So you ask questions about things you’ve never ever heard of, and take notes to try to look up the rest later. You learn to mutter questions quietly and secretly to nurses and your interns, who will probably help you out (and aren’t really evaluating you as critically): they just finished medical school 3 weeks ago, so it’s easiest for them to remember where you’re at.

I quickly realized that real medicine is very different from ideal medicine. You’re supposed to give everyone a full check-up, look in their eyes, ears, and nose, and feel for their thyroid, but who has time for that? And different specialties want different things. Surgeons are obsessed with infections, fluids, nutrition, pooping, and farting. The obsession with the latter two is still novel to me. A patient told me he had a “tremendous fart,” and I was disappointed when no one else on my team even smirked at the description.

Feeling stupid makes you learn quickly, which is one reason I’m usually not too distraught when I get an answer wrong: I know it’ll be locked into my head from that point on. At the same time, “don’t get sick in July” is just way too true. Your doctors won’t be as quick to get a diagnosis, and your sutures won’t be as straight. Everyone’s supervised by multiple people, but July is usually especially hectic. You get a flood of new medical students, newly-graduated doctors, new residents, and new official attendings. Everyone’s trying to figure everything out, and it can be difficult.

The feeling has faded now, but I was so surprised at how very entitled I felt after my first week in the hospital. I was working 12-14 hour days, 80-90% on my feet, and I really felt like I should be getting some sort of special treatment because of it. That I should be rewarded or recognized for it. I wanted to go to the mall in my scrubs with my operating room hat hair so everyone would see that I’m a hard-working medical student. It was cognitivie dissonance at its finest: I’m paying $50k a year to work my ass off, so I figure there must be something I’m getting out of it right now. It was such a strong feeling that it really took some conscious effort to remind myself that I chose this path (and thank you, blog, for reminding me).

I’m incredibly exhausted, but incredibly happy. I’ve really started to get the hang of this whole clerkships thing (so far, at least), and it’s been a really amazing experience to see many of our patients go from the ICU to the wards to being discharged. I’m going to miss seeing them so frequently. And to you, the patient that we lost two weeks ago, and to your family, who allowed me to be part of the discussion about you: you’re one I will never forget. Thank you for your friendly smiles and waves each morning, and for trusting me into a most private part of your life. That physicians have the privelege and honor to be part of patients’ lives is a most amazing and sacred part of the practice.

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I heard this awful exchange between a nurse and my patient yesterday as he was getting up to walk around:

Nurse: Sir, your pants are falling down!
Patient: Oh really? Thanks for telling me. My pants don’t fit anymore cause I’ve lost all this weight.
Nurse (laughing to other nurse): Haha, I wish I could do that so easily!
Patient: Yeah, well I’d probably say it’s better *not* to get cancer.

What kind of shit is that? The nurse *knew* his diagnosis too.

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Any advice for the surgery clerkship? Any good books to buy? I start it on Monday; it’s my first clerkship ever. A little nervous. Advice appreciated. Thanks!

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This was the line I heard yesterday over the intercom 30 minutes into my flight from Minneapolis to New York, and it scared the crap out of me. I’m always freaked out that I’m going to be in a situation where I will have the most medical knowledge of anyone around, and I’ll have to use it. Luckily there were like 4 doctors on the plane; an elderly woman passed out at the back of the plane, I think from dehydration and heat (the plane was sitting on the runway for awhile, really stuffy). She was laying down in the aisle by the bathrooms.

When they made the announcement, I got this look of sheer terror on my face, hoping desperately there’d be someone else. And then my imagination started to run with it:

Me: Well, I’ve had two years of med school, but I’ve never actually treated anyone!
Flight Attendant: You’ve got to be kiddding! How can you be halfway done with medical school and you’ve never taken care of anyone?
Me: I don’t know, that’s how it works, you do your first two years preclinical, and then you take boards, and then…
FA: Okay, shut up already and help this lady!
Me: Okay, uh, get her some oxygen, and uh, water! And… stuff.
FA: We’re screwed.

The lady was sitting up and fine by the end of the flight; I hope she’s okay.

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Boards are done. Mexico is tomorrow.

In retrospect, I can say that studying for boards was actually worthwhile, but the actualy exam was extremely lame. It was really good to force me to review everything I’ve learned over the past two years and see it from different angles, integrate it, etc. But the test I took today had too much that reflected too little on practicing medicine. If I was studying to be a research scientist, test the hell out of me on biochemical pathways and cell signalling molecules, but I’m preparing to be a doctor, to take care of patients, not molecules. I couldn’t believe some of the questions that made it through the NBME’s screening process. Hey NBME-I don’t care about specific details about HLA types that some MD/PhD has written a question about.

Whatever, I’m done, hurrah. Expect a new redesign of the site in the coming weeks, as if anyone reads this anyway.

Yes, I’m cranky. Over and out.

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What?

With the exception of celebrities and politicians (our royalty?) you don’t really get preferential treatment based on your ability to pay. (in the US)

If MedPundit really thinks that insurance doesn’t get you any preferential treatment in the US, she’s totally jumped the shark. Newsflash: Getting treatment at all is preferential treatment, Dr. Smith.

And more to the point of her post: people die on waiting lists all the time in the US, too. And Canadians requiring emergency care get it.

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I’ve kind of learned it’s easier for my OCD/hypochondriac/med student syndrome self to just stop trying to diagnose myself, stop Googling every symptom, and stop palpating nodes, thinking that one will turn out to be Hodgkin’s (and still secretly knowing deep down that it won’t). But every time I read Effect Measure, I start to get a little scared. It’s a public health blog that’s doing some awesome blogging following the Avian flu virus (Influenza A H5N1).

A perfect example of a freak-out post. I really don’t think the writer is being alarmist; I get the sense he’s pretty well read, experienced with public health, and (gasp) uses data and facts for the basis of his posts. I’m mainly scared about this bird flu for my own personal concern: the flu seems to be hitting people in my age group. Combine that with the fact that that I’m an official first responder, starting work in the hospital in July, in California, in the Bay Area, with a constant huge influx of people from Vietnam and other bird flu hotspots, and you can color me nervous.

Yes, I know, it’s one of the risks I take as a future physician, but I think it’s absolutely ridiculous that this isn’t a bigger story in the news, or that our government is doing less for preventative measures. I guess that’s what happens when you’ve got a war going on to protect our security. My bet: when the bird flu hits, and if it hits as hard in the US as Effect Measure is reporting, “health security” will be a new buzzword, and could be the tipping point for a national health insurance system in the US. If there’s one thing the US is good at, it’s reacting once a problem has already hurt us. Go primary prevention!

The UK has ordered enough antiflu meds for 25% of its population; the US: 2%.

Sweden has ordered enough for half a million and tens of millions more doses have been ordered by Norway, Canada, Australia, New Zealand, Finland and France. The US has only ordered 2.3 million and may increase that to 6 million (enough for only 2% of our population). The UK is more ambitious with plans a $385 million for a quarter of its population. London wants 100,000 for its police fire and transport workers. WHO is trying to establish a “mobile stockpile” of 120,000.

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Why isn’t “Health Care for All” sexy?

We’ve got hundreds of thousands of people wearing those Lance Armstrong armbands, and tens of thousands I’m sure wearing those knock-offs, and I started wondering, “Why isn’t there one for the uninsured?”

If people can get behind supporting cancer victims, or donating money to Jerry’s kids, or walking for breast cancer, or basket-weaving to fight Prader-Willi’s, why not the uninsured? And where’s the celebrity spokesman? I started to think that it must just be that celebrities have insurance, and therefore don’t have any experience with being uninsured, but that’s completely untrue; almost all of them started out uninsured trying to make it big in LA or New York, I bet. Have they forgotten so quickly?

If people can so easily get behind some awful disease with no cure in sight (HIV, any number of rare genetic disorders, most cancers), why isn’t there more support for something that most other industrialized countries *have* been able to cure? (I’m using ‘cure’ liberally here, don’t get in a commenting tizzy.)

Is it that people think the uninsured don’t deserve insurance, or that it’s their fault they don’t have it? (There’s plenty of people that way about HIV, but it’s still supported.)

Or is it maybe that it’s easier to support something that we don’t entirely understand and know how to fix? That it’s something still beyond our grasp, beyond our means, that is dropped on unlucky individuals? There’s plenty of diseases out there that *are* 100% preventable; why aren’t we knocking those down quickly? (I’m thinking lead poisoning as an example.)

Maybe it’s that those diseases primarily affect the disenfranchised, impoverished, and the minorities? You don’t see a whole lot of funding out there for sarcoidosis, primarily affecting black people, or liver cancer, which is huge in Asia because of hepatitis.

So line right up celebrities and PR firms. Let’s make pre-existing conditions and 18,000 deaths a year the sexiest thing since testicular cancer.

On a side note: studying for the boards brings an insanely huge number of interesting ideas into one’s mind. My head is like an 8 year-old desperately trying to stall from having to go to bed. Boards studying is right up there with showering as far as number and quality of ideas go. I’m starting to think the great inventors and thinkers of all-time either a) took a lot of showers or b) studied for Step One for their entire lives.

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A quick jaunt through the little catch phrases that are my life right now (thank you, First Aid). And hey, you might learn a thing or two:

• Bladder Cancer (Transitional Cell Carcinoma) in your Pee SAC: caused by Phenacetin, Smoking, Schistosomiasis (thanks Kat), Aniline Dyes, and Cyclophosphamide. Pee Sac is just such a great way to refer to your bladder. Also reminds me of Forat from Ali G referring to the scrotum as the “testes satchel.”
• Citric Acid Cycle. Cindy Is Kinky So She Fornicates More Often. Citrate, Isocitrate, alphaKetoglutarate, SuccinylCoA, Succinate, Fumarate, Malate, Oxaloacetate. Replace “Fornicates” with something else for added fun.
• Urea Cycle. Ordinarily, Careless Crappers Are Also Frivolous About Urination. Ornithine, Carbamoyl phosphate, Citrulline, Aspartate, Arginosuccinate, Fumarate, Arginine, Urea.
• Burkitt’s Lymphoma. BurC-Myc’s. (C-myc oncogene, 8:14 translocation.)
• Complications of Lung Cancer: SPHERE. Superior Vena Cava Syndrome, Pancoast’s Tumor, Horner’s Syndrome, Endocrine/paraneoplastic, Recurrent Laryngeal Nerve Palsy, Effusions (pleural, pulmonary).
• SLE-like syndrome caused by drugs: It’s not HIPP to have lupus. anti-Histone antibody, Hydralazine (vasodilator), INH (TB), Procainamide (Ia anti-arrhythmic), Phenytoin (anti-epileptic).
• Hypercalcemia is a MISHAP! Malignancy, Intox of Vitamin D, Sarcoidosis, Hyperparathyroidism, Alkali Syndrome, Paget’s Disease of Bone!
• Dilated/Congestive Cardiomyopathy Causes: ABCD. Alcohol, wet Beriberi, Coxsackie, Cocaine, Chagas’s, Doxorubicin.
• INH: Injures neurons and hepatocytes. Prevent neuron damage by giving Vitamin B6.
• Vincristine and vinblastine: prevent formation of microtubules, anti-cancer drugs. VinCristine Crushes Neurons, and VinBlastine Blasts Bone Marrow.
• Causes of Fibronous Pericarditis: UReMIa. Uremia, Rheumatic Fever, Myocardial Infarction.
• Kawasaki’s Disease, a vasculitis: Kids, Koronaries, Konjunctivitis, Krusty Lips, Strawberry Tongue.
• Buerger’s Disease, a vasculitis: Try the world RENOWNED Smokey Burger! (Buerger’s has Reynaud’s phenomenon, plus gangrene, in smokers.)
• Post-Strep Glomerulonephritis: Sub-Epi (STREPI) humps.

And hundreds more where that came from. But I’ll stop boring you now.

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This new-fangled blogging software required me to approve comments, and didn’t email me when I got one to approve. Sorry about that. I’ve approved all the comments and fixed it so I should respond if you comment. Didn’t mean to offend or ignore, and thanks for writing!

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Dr. Quinn over at PushFluids has some words of advice for me and other second-years about to take boards. Thanks. I needed that. Always nice to know that everyone goes through this. (Except the insanely smart people with photographic memories in my class, who we all love to hate.) (You know who you are.) (And we do, too.)

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This blog will probably be pretty sparse for the next month, I’m sorry to say. Accept my sincerest apologies, faithful readers, but The Boards loom over my head. I take them on June 1.

It gives me approximately 5 weeks to review everything I’ve covered in the past two years, and even several large gaps in our knowledge that we weren’t taught. (Ahem, embryology and biochemistry.) I’ve got a calendar and everything to keep me on schedule, but the past couple days have been simply overwhelming. I’m basically fitting in 4 weeks of material into 10 hours of studying, if that.

Schedule as follows:
Wake up. Library by 8:30 at the latest.
Study until 12:30.
Lunch for an hour.
1:30 to 3:00, study.
By 3:00, I’ve lost all sense of hope, motivation, and drive, so I’ve been going to the gym then to destress.
Eat a snack, around 4:00?
Back to the library.
Eat dinner at some point.
Go home exhausted, and squeeze in an episode of Reno 911 to remind me that humor and fun still exist in the world.

Random thought collection:

• I think I diagnosed someone in high school with Cushing’s. I feel really bad, because all the people at school used to make fun of her for being fat, but now I’m really starting to think it was a hormone imbalance. She had the roundest moon facies I’ve ever seen. Can’t remember if she was hirsute or not.
• My computer is dead, for like the fifth time, but it’s probably a good thing: less time online to procrastinate and surf the web. The Lord works in mysterious ways.
• This test just seems like another stupid hazing ritual sometimes. Make us work our asses off so we get used to working hard, long hours.
• Other times it seems very valuable. I can’t count the number of times I’ve been reviewing something and think, “Oh, so that’s why that happens.”
• What I wouldn’t give for, like, a day where I could stay up late and play some stupid computer game all night. I miss undergrad.
• I probably would have already had a psychotic break, and be completely lazy and not studying when I’m tired if it weren’t for a special new significant other in my life. As my parents read this blog, they will inevitably start to pester me to find out more, but I’m really not in the mood. He is great, he is smart, he is cute, he’s a he. That’s not a typo, as someone once emailed me confusedly. Get over yourself.

Back to STDs and gynecological neoplasms. Woo.

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I’m reviewing cardiovascular and respiratory physiology for the Boards right now, and a little self-experimentation goes a long way. I have a little burst capillary in my cornea right now, and I’m pretty sure it’s from doing a Valsalva maneuver to refresh my blood pressure and heart rate physiology. And whenever I start reading about tidal volumes and functional residual capacities and dead space, I have this uncontrolled need to breathe really deeply.

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Jakob Nielsen’s alertbox on Medical Usability: How to Kill Patients Through Bad Design couldn’t have been timed better for me. Nielsen, a usability expert and consultant, picked up on a recent JAMA article that discussed a number of ways that poor usability and interface design can be significantly detrimental to patients. You might think that this is a little too nerdy for discussion, but the fact is that medical records will be electronic within in the next decade (or at least most of them will be), and unless we do a good job designing the system, and make it easy for medical staff to use, we risk only creating new types of medical errors, as opposed to using technology to eliminate the current ones. The article focuses on prescription drug errors, but there are plenty other systems that need a kick in the usability pants, too.

Take, for example, the radiology software Stanford uses, called PACS. It’s a GE Healthcare add-on to GE’s Centricity product, and has all-digital x-ray, CT, and MRI studies. It’s a network nightmare, and the backend is great, but the user interface is simply horrendous. I was given an introduction to the system, and it seems like it was thrown together at the last minute. Even the head of the Radiology residency doesn’t fully understand how to use the system. She said things like “I don’t know what this button does,” and “for some reason, the system requires that you do X, Y, then Z to locate a patient.”

The most ridiculous part is the fact that sometimes, for no explained reason, a note on an x-ray will disappear, and must be dragged back on screen. If you’re not aware of this “feature,” you can waste plenty of time trying to wish the note back again. It’s a shame that GE couldn’t think of a better implementation of its software-they should talk to Apple now and again.

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I’ve always thought of myself as a man of contrasts (okay, more like a guy of contrasts, because man is just too serious, or formal, or something). But contrasts, anyway. I compliment myself, if that’s at all possible.

What I mean to say is that I find that I tend to have interests and fascinations with the seemingly most polar of topics: I like both theatre and science, I’m an introvert and an extrovert. I love web design, coding, and being all alone, but I also love parties, dancing, and entertaining people.

This whole concept came to light yesterday, when we went over to the Palo Alto VA for a discussion on hospice care and death and dying. I could really see myself working in such a place-helping people to end their lives with peace, comfort, and dignity. The hospice wing is quiet, solemn, and looks out onto the nice green grass and trees of the hospital complex; there are two “family rooms” available for families to stay free of charge in the last days of their loved ones’ lives; the physicians there spoke eloquently about respect, dignity, cultural differences, and honoring those that had died. It really resonated with me as a way to really help provide for people when they need it most. What could be more frightening than dying with fear and anxiety?

On the other hand, only three days ago, I was in love with the ER. It was loud, hectic, busy, with all sorts of people and all sorts of injuries and diseases and conditions. It’s crowded, people are stuffed together. The exact opposite of the quiet, solemn hospice wing.

I’ve always been pulled in different directions in life-a teacher once told me the hardest decisions you have to make are often ones that end up closing doors, not opening them. If I only liked one little area-y’know, choosing between the heart and the lungs, for example-I feel like this would be a much easier set of decisions to make. I’m blessed and cursed all at the same time. I tend to just try lots of different experiences, pick one, and know that I was meant to be there anyway. It’s a weird predeterministic worldview, with a quasi-Fate influence. But it works for me.

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Such is the sinusoidal curve that is my mood.

I was on top of the world last night, after doing an incredible 8-hour emergency medicine shift, getting to assist a plastic surgeon repairing a couple big bike accident gashes, getting to put in two sutures on another case, getting a great IV draw with blood cultures, and thinking now that I either want to go into emergency medicine (look out, GruntDoc) or maybe even trauma surgery or plastics.

I was even in a good mood 2 hours ago studying biochemistry of all things, starting to think that maybe, just maybe, I was starting to understand this crap. That maybe, just maybe, there was a reason I should know this stuff.

And now I’m just totally defeated. I’m 14 questions into a biochemistry 50-question series on Kaplan’s QBank (boards study questions), and I feel awful. I feel stupid, I feel frustrated, I feel hopeless. If there’s any reason that anyone other than pediatricians, OB-GYNs, and PICU/NICU specialists need to know the minutae of the glycogen storage disorders, I would really love to hear the argument. I understand needing to know that they exist, but knowing how each one presents, and the mutation associated with it is really bleeping ridiculous. I hate you, NBME. Hate hate hate you.

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Yesterday we interviewed a patient with PTSD. I wish I could say more, but what he told us brought tears to my eyes. I’ve lived a pretty damn happy existence. The stuff people walk around with in their heads and carry around on their shoulders is just amazing. Reminds you never to judge-you just never know what the person has gone through.

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I watched Born Into Brothels a couple nights ago, and it made me think really hard about my life, my privelege, and all the opportunity that I’ve been afforded and always just taken for granted. It’s a documentary telling the stories of children of sex workers in the red light district of northern Calcutta. The filmmaker gives the children point and shoot cameras to document their lives.

They the children are incredibly stigmatized in Calcutta, even having difficulties being accepted to schools because their mothers are criminals. They live in crowded, dirty apartments, where the adults scream curses at each other and at the children, but they’re amazingly resilient and positive. Most of the girls know on some level that they too will eventually become sex workers, an admission that’s very hard to hear coming from a 10-yar old’s mouth.

Two parts especially moved me and brought tears to my eyes. The first was the realization that some of the children could be HIV+. It blew my stigma about who or what an HIV+ person is out of the water. Just the idea that these kids could be living with the virus, totally unknowingly, was really emotionally difficult. The other event involved a child named Avijit, who really had an innate gift with a camera. He took some really stunning photographs, and spoke incredibly maturely for such a young child.

Avijit had said that at some point he had wanted “to be a doctor,” and it really hit home. All the opportunity that I’ve had, and that Avijit will never have. When I think about complaining about not wanting to study for the boards, or my frustration with biochemistry, I have to remember that at least it’s available to me. At least, when I was Avijit’s age and said, I want to be a doctor, I got to have my dream come true.

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We recently started our psych coursework-our last official class-this week, and we watched a short, 3-minute clip of a schizophrenic man being interviewed about his day-to-day life. He was homeless and clearly delusional, asking his social worker to please put in a request for the man’s new eyeglasses frames not to have a transmitter placed inside them.

The man was clearly not sharing the same reality as the rest of us watching him. I had the inclination to smile-not to laugh, just smile-and saw many of my classmates reacting the same way. I don’t know what the smile’s really from: a defense mechanism on how to deal with someone that has totally lost touch with reality? Amusement? Humor?

And then I thought about the man a little deeper. How much suffering this disease has caused. Not only in his current mental state, constantly dealing with his anxiety and paranoia, but also all the suffering from his former self. The one that had goals and dreams as a kid. The one before his schizophrenia took all that from him.

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I haven’t eaten beef for 3 years now, thanks to Fast Food Nation, and this just reminds me of why I’m so happy I quit: Woman bites into finger at San Jose restaurant. Nast. Seriously.

Read the paragraph in FFN about how cattle are slaughtered, and you’ll understand why I stopped eating it. One hint: poop.

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I’m in charge of Grand Rounds this week. Please get your submissions to me ASAP. Use my contact form, or email me: grandrounds@grahamazon.com

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Just finished my final full quarter of preclinical work in medical school. Have a month of psych after this week’s spring break, but then it’s boards and then clinics. Be very afraid if you come to a South Bay hospital in July. You might get stuck with me.

Also, new photos are up. Some from the Monterey Acquarium, some from my backyard.

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Yours truly made it onto the stage for Hardball, and sat right behind The Governator. Arnold’s a politician all right; he was able to dodge and laugh through most of the tough questions. I was particularly disgusted with Arnold’s handling of steroids:

MATTHEWS: Are steroids bad for you?
SCHWARZENEGGER: What?
MATTHEWS: Are they bad for you?
SCHWARZENEGGER: Steroids can have side effects, if people don‘t do it under supervision with a doctor. I‘ve seen people in our own sports that have died because of it.
MATTHEWS: Yes.
SCHWARZENEGGER: That have had side effects, health side effects.
MATTHEWS: Right.

Even though he’s publicly admitted it, I’m sure he’d like to try to bury that 1977 article if possible. Steroids have plenty of side effects (note: HIV and hepatitis are on that list due to IV injections, they are not directly linked). I remember being really confused about steroids and my brother being “prescribed steroids” for his asthma, so I thought I’d take a minute to procrastinate explain what people mean by steroids.

Okay, so technically, a steroid is just any chemical with a certain structure. But the body uses 3 main types of steroids. Physicians usually prescribe one type, body builders usually use another, and while the third type is very important, you probably won’t run into it much. All three are made in the adrenal glands. And here we go:

1. Glucocorticoids. These are what are generally prescribed by physicians. They’re usually prescribed to lower a person’s immune system. Cortisol, hydrocortisone, prednisone. They reduce inflammation. They’re commonly used for autoimmune disorders, or transplant patients-both need to supress their immune system, because it’s either hurting them or their transplanted organ.
2. Sex hormones. These are the steroids you hear about all the time: testosterone, estrogen, progesterone. First, testosterone. Body builders will use testosterone to get bigger muscles. This is the “anabolic steroid”-anabolic just means metabolism that builds, like building muscle. Other chemicals can work too-either things that the body can turn into testosterone, or things that look like testosterone, so that the body thinks they’re testosterone. These have a number of scary side effects-”roid rage,” shrunken testicles, gynecomastia (male breast tissue development). Not hot. There’s also estrogen and progesterone. These are the hormones found in birth control pills and hormone replacement therapy during menopause. These are also the hormones involved in RU-486 and “the morning after pill.” These are made in the adrenal glands, but they’re also made in the ovaries and testicles. (And yes, men and women have both in their systems, just different amounts.)
3. Mineralocorticoids. These you probably won’t hear a whole lot about. Aldosterone is the main one, and it makes your kidney reabsorb water and sodium. If you’re getting dehydrated, your body releases this to tell your kidneys to make less urine, so you save more water and sodium. Some people’s diuretics (water pills) block aldosterone, so you pee more.

So there you have it. Now it’s back to neuropharm for me.

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I’ve managed to completely forget that medicine is about people.

I came to realize this over the past couple weeks, especially at a ceremony to remember those that donated their bodies for the anatomy course. The first-years were reading poems, talking about their experiences in anatomy, and I found it all very drab and boring. And then I realized that I was finding it drab and boring, and realized that these were people. Mothers, fathers, brothers, sisters. Friends, co-workers.

And about a month ago, while we were studying analgesics (pain relievers), our pharmacology professor reminded us that one of our roles as physicians was to relieve human suffering. “Suffering?” I thought. “Oh. Yeah. These diseases cause suffering. I almost forgot.”

In medical school you want so bad to learn that you dive right in, without looking where you’re going. At first, you get confused by terms like “dyspnea” and “syncope.” You learn the language. Then you go deeper. You learn the organs, the body, and how it can go wrong. You learn about infections, and pathology, and disease. You learn buzzwords, associate diseases with stereotypes, all in hopes that when someone says “night sweats, weight loss, and hemoptysis,” you can be the first one to shout out “tuberculosis!” and ramble off the drugs of choice and their side effects.

And while you’re in the library memorizing diseases associated with symptoms or organs, or at a cafe going over tropical infections and how you get them, you gather this big list of words in your head. You try to organize these words and tuck them away, so you can recall them later. All the while, you haven’t seen a single patient with this disease, or that infection. You know how to describe a certain type of rash, or how it’s supposed to look, based on a Google Image search, but you’ve never seen one in person.

I completely understand how physicians can view patients as only their diseases; there’s enough to know about any one disease that it’s just less mind-exhausting to try to reduce someone down to a few lines or bullet points. But then you think about someone you know with a disease, and it sickens you that anyone would ever reduce them down to a list of symptoms or a pathophysiology. They’re too good for that, they’re too three-dimensional. Too funny when they’re drunk, or too insanely brilliant, or even too annoying to just be a disease.

We had a written clinical case today that discussed a woman with “multiple spontaneous abortions,” and I instantly thought, “antiphospholipid antibodies!” and figured I was done with the case. I successfully matched the buzzword to the disease.

But then I read the words again: a woman with multiple spontaneous abortions. How absolutely dreadful, emotionally awful, and mentally scarring.

I’m at a stage in my medical training where my goal is just to get the diagnosis right, but that’s nowhere near my goal as a doctor. If you don’t see the patient as a person, we might as well just replace physicians with computer programs-they can probably make diagnoses faster than doctors. Click here for your diagnosis.

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Fever of Unknown Origin (FUO) is when a patient has a fever (that’s >99.7F oral, or >101 rectal) on three occasions or three days in the hospital, and nobody can figure out why the heck he or she has it. It’s usually due to an infection, cancer, or autoimmune disease, but I’ve recently recalled from my childhood one major cause that no one at Smartypants Stanford thought of:

Child faking a fever.

I was no expert at this, and having a nurse and physician as parents didn’t help, but on at least one occasion I took the thermometer my mom gave me and stuck it up next to the lightbulb of the lamp next to my bed. Voila, temperature of 106. Unfortunately, lacking the knowledge that I’d probably be dead, or at least look close to it, at 106 degrees, I was forced to go to school.

Also fun to say in the “Eff You” category: 5-FU, a chemotherapy / cancer drug.

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It was a dark and stormy night.

So I’m walking to Borders with fellow anatomy TA Ronnie, we’re just leaving the parking garage, and an elderly woman carrying an umbrella mis-steps and crashes to the ground. She doesn’t even get a chance to FOOSH it (fall on out-stretched hand). It’s like it’s out of a bad medical student training video or something. She kind of lands on her side, or so I think, and we hustle over to see if she’s okay; I instantly think broken hip.

She’s partially picked herself up, and she’s about to stand up, and I notice a little blood on her hand. I say, “Oh, you know what, you’re bleeding a bit, just sit down, let me grab some Kleenex from my car.” That is, until I see that the blood isn’t coming from her hand. Oh no, that blood is just some of the fresh red that’s gushing from her left temple. My eyes kind of do a zoom-out / once-over look at her, and there’s blood all over her coat, down her shirt, on the ground. I give my phone to Ronnie and tell him to call the paramedics, and run into California Pizza Kitchen to get some napkins or something.

My heart’s pumping. I grab the napkins, come back out, and she’s pressing some tissues onto her head, and the bleeding’s pretty much stopped. We wait for the paramedics, and I joke with her that she lucked out, falling right in front of two medical students. She rips back with “First-years or second-years?” and I get the feeling that she’s still with it. This Is Good. The paramedics arrive, check her neck and examine the laceration on her head, and the hematoma (big blood clot/bump under the skin) is bigger than a golf ball. I couldn’t believe how quickly the thing grew.

We eventually go off on our way; it feels kind of weird to just leave, but she’s in better hands with the paramedics anyway (let’s just be honest here). Ronnie and I start discussing all the possible complications-I’m focused on the hip, then he starts wondering about an epidural versus subdural hematoma. I just couldn’t help but think about how thin and delicate elderly people’s skin is, and how easily it can tear and rupture.

It was an exciting moment, and I of course use it as Clear Evidence from God Almighty that I should go into Emergency Medicine (my latest specialty of the month). Then again, after almost 2 years of medical training, I don’t know that my knowledge really helped me all that much; “apply pressure to wound” is kind of common sense by the time you get your second nosebleed in life.

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We were talking today about opportunistic infections (infections you get when you’re immunocompromised, due to HIV, on steroids, or you’ve received a transplant), and specifically about the effects of anti-retroviral therapy on changing the course of disease in patients with HIV.

Our lecturer, Dr. Montoya, mentioned something that I don’t think I’ve ever heard from another lecturer: he said that during the 1980s, the staff would meet once a month to mourn the loss of their AIDS patients, and to remember them. Rarely do we ever hear mention of patients dying, and even more sparse is the admission from a doctor that their patients affected them. That we’re not robots of information and treatment. We’re people, our patients are people, and that medicine is a human interaction. It was really refreshing to know that there’s emotion involved-or at least, there should be. All too often physicians are noted for their detachment, or at least, their ability to detach-to be objective in a time of crisis or emergency. But I think if you don’t let your patients get to you-or at least some of them-you lose something key to what drives you to continue practicing to the best of your ability.

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Sometimes I’m so amazed with the human body that I really start to think that there had to be some level of intelligent design in us. But Jim Holt makes some great, amusing points against the rise of “intelligent design” theory in today’s Sunday Magazine New York Times:

In mammals, for instance, the recurrent laryngeal nerve does not go directly from the cranium to the larynx, the way any competent engineer would have arranged it. Instead, it extends down the neck to the chest, loops around a lung ligament and then runs back up the neck to the larynx. In a giraffe, that means a 20-foot length of nerve where 1 foot would have done. If this is evidence of design, it would seem to be of the unintelligent variety.

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Us young folk are hot on your trail.

While I must agree that the tech changes even in the past 10 years of medicine have revolutionized the practice of medicine, I’m not so willing to give up on an older’s doctor’s level of experience. I may know the latest guidelines, and practice more evidence-based medicine, but until I’ve got a couple thousand patients under my belt, I’d much rather see someone older than a bright-eyed, bushy-tailed just-out-of-residency hooligan like myself in half a decade.

But now here’s the question: will it be easier for my generation to keep up, or harder? Now that we’re being trained in a computer and tech-aware world, will it be easier for us to a) keep up with change, b) learn faster and easier, or c) understand the new lab data and treatment options? That is, will we be just making more different types of antibodies, or will treatments become even more novel and hard to learn the second time around?

I’m hoping, of course, it’ll be easier. It’s like computers; we grew up with them, so we’ll (hopefully) always we able to understand the interface. Then again, I grew up with a Nintendo, and I can’t play anything more advanced than that worth a damn.

[via kevinmd]

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Recently, AMA President John Nelson, a Mormon ob-gyn, spoke out in support of The New York Medical College, which recently de-recognized an LGBT student group.

Dr. Nelson compared “it to Brigham Young University’s decisions to ban Coca-Cola from campus and to suspend four athletes accused of raping a 17-year-old girl.”

This makes me angry down to my core, for so many reasons. Dr. Nelson’s words are ignorant at best, bigoted and homophobic more likely. He’s a hypocrite, and he should apologize or give up his position.

Y’know, I thought when I chose medicine, I’d be among educated, informed people, working with the brightest minds. Nelson is clearly here to remind me that there are idiots everywhere. I find it a little confusing that just 2 weeks ago, Nelson spoke about racial disparities in health care, and said that there was ” “a generalized distrust” of doctors by many minority patients.” Does Dr. Nelson not see any connection?

Let’s have it your way, Dr. Nelson. Would it be okay for any private institution to choose not to allow blacks? Or females? Or people with color-blindness? What side of the line would you stand on in that case-the private institution’s rights, or equality’s?

The AMA’s official position is that “the physician’s nonjudgmental recognition of sexual orientation and behavior enhances the ability to render optimal patient care in health as well as in illness.” Now, is Dr. Nelson really speaking for the AMA, or is he speaking as a Mormon?

If you believe that Dr. Nelson’s comments are as offensive as I do, please contact the AMA and voice your opinion-as a medical professional, AMA member, or just as a human being. Or even a patient. The number’s 800-621-8335 (hit 2 then 6), or email lydia_oquendo@ama-assn.org. People used to defend racism and segregation on similar grounds, if you don’t recall.

My letter:

Dear Dr. Nelson,

I’m a medical student and son of a physician, and I was stupefied by your comments supporting The New York Medical College’s decision to ban a gay student group.

You spoke on February 1st on racial inequalities and distrust some minorities have with the health care system, and I can’t possibly understand how you fail to see the similarities between these two issues. If on one hand, you’re speaking out against racial inequalities, but on the other, you’re defending an institution’s right to deny equality to a minority group, it’s hard to really see where you stand. 50 years ago, the same “private institution” arguments were made to justify banning blacks from schools and lunch counters; if The New York Medical College wanted to ban an African-American group, or a Jewish group, or a Mormon one, would that be okay? Or what about one only for short people? Or the color-blind?

Your own AMA policy statements say that “the physician’s nonjudgmental recognition of sexual orientation and behavior enhances the ability to render optimal patient care in health as well as in illness,” but I can’t help but describe the NYMC’s decision as judgmental. And by banning the group, the NYMC is implicitly telling its students that it’s okay to judge, it’s okay to discriminate, as long as you have a justification for it. And by supporting the ban, you’re telling doctors that it’s okay, too.

Discrimination by any other name is still discrimination, Dr. Nelson, and it still smells just as rotten. You have a responsibility to uphold the values of your organization, and to encourage progress in medicine, as well as promote cultural sensitivity as you spoke about two weeks ago. I hope that you will see the inconsistencies in your positions and realize that the NYMC’s decision is not in the best interest of its students, its physicians, or its patients, and it is certainly against the ethical values of the AMA.

God bless,
Graham Walker
MII, Stanford University

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For a ton of reasons (computer died, personal issues, lack of interest), this site’s been a bit dead. But like the Phoenix, I’m rising from my ashes and posting again.

So. About 4 weeks left of preclinical work, then a month of psych and behavioral medicine, then it’s time to study for the Boards, Step 1. I’m scared to death. My only real saving grace is the fact that it’s multiple choice, so even though I might not remember the exact name of every drug and disease, I’ll recognize it when I see it on the page. Other than that, I’m totally screwed.

Wednesday, June 1st is the day. They say you can’t really do more than 5 weeks of intense studying without totally losing it, so 5 weeks it is. Then it’s off to a family vacation some place nice and relaxing, then I start clinics on June 27. I can’t wait.

By the way, if you have any suggestions or study tips, I’m all ears.

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By now, with 4 weeks left of my preclinical life, it’s become ingrained in me how to process diseases in my head. You learn the cause of the disease, you learn the symptoms, what it looks like on gross and histology, the sequelae, and the treatment (if it exists). Rinse, lather, and repeat.

I guess I always kind of knew that I was missing the patient experience of the disease, but I never really knew what exactly I was missing, until we finally learned about Amyotrophic Lateral Sclerosis. My grandma died of this when I was 12 (just around this time of year), and it’s really one of the few personal experiences I’ve had with disease. It’s kind of an ironic point to hilite-medical students, for the most part, have all been pretty healthy growing up. When we talk about treatments like surgery or chemotherapy, or what rounding in a hospital is like, our only knowledge is what we see on TV, or any shadowing experiences we’ve had.

It was amazing to me that a disease that affected me so profoundly–ALS–could be boiled down to about a page in my pathology book, and 3 minutes in class. I wanted to stop the lecturer and tell my grandma’s story. Tell my classmates about the pain of seeing my grandmother whither away, first moving from her big house on a hill to a retirement facility where we played pool and ate chocolate mints, then losing her ability to walk and moving to a nursing home shared with Alzheimer’s Adele, and finally to her own room where she lay in her bed and struggled to point at letters on a plastic board after she’d lost her ability to speak. I wanted to tell them about how much it scared me when she would choke on her food, and my mom or a nurse had to put the suction tube down her throat so she could keep living for another month or two, or that I cried in her bathroom when she was about to die and my neighbor took me and my brother home. And I wanted to tell them about the little things that made us all laugh, and the antique Candyland game her brother sent her; one she used to play when they were kids.

And then I think how many diseases I’ve already learned (and forgotten), and how I really don’t know anything about them. I know if it’s a virus or an antibody or a cancer that causes them, but I don’t know how they make the patient feel. Sad? Frustrated? Confused? Guilty?

I guess it’s a little frustrating that we don’t ever think about these things during our classtime, but then again, I don’t think it’s something you could ever really teach a person. Either they care or they don’t. You can teach them how to go through the motions–ask the right questions, provide a “caring” touch on command, give eye contact and nod affirmingly–but if it isn’t genuine, they’ll see right through you.

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I was tempted to post this image of a newspaper clipping under “Humor,” but more than anything, it’s just really sad. Smoking will do more harm than jackhammers ever will, Ms. Williamson.

Smoking during pregnancy has a number of risk factors for the mother and the fetus. Please, for the health of your child, don’t do it.

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We talked about diagnostic testing in our biostatistics/epi class yesterday, and I really think it was the first time that I realized how important statistics can be. It was probably the first time that I really saw how statistics affect patients–individuals–not big masses of people.

We talked about prevalence, pre- and post-test probabilities, predictive values, and likelihood ratios. Reading it now, it sounds pretty dry and boring, but it absolutely affects how likely a patient is to have a certain disease. It’s these kind of decisions and analyses that are absolutely vital to medical decision-making, and vital to being able to provide the most information and the best information to a patient; they also say a lot about how efficiently we spend health dollars in the US.

The big boom in “spiral CTs” or “whole body scans” can be pretty worthless if there’s no clinical suspicion of illness. Even a test that’s sensitive and specific 95% of the time will be a worthless test if the prevalence of a disease is extremely rare; one may increase their risk of some disease from 1% to 2%, but 98 times out of 100 you won’t have the disease, and you’ve just spent $6,000 to tell you that.

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We had our first lecture on psychiatry yesterday, and learned the basics of the DSM IV–the big thick tome-of-a-book that helps mental health folks to diagnose mental illnesses. Recently I’d been talking with a friend about his possible depression, and encouraged him to at least talk to someone at CAPS about his concerns, and I really hope he starts to feel more like himself again soon. Sometimes I wish these were things I could just do for people, but in mental health especially, I think it requires a certain amount of personal motivation. The individual has to want to change.

I guess all one can do sometimes is try to be encouraging and supportive, and to lend an ear. Unfortunately, sometimes even that can get complicated by one’s own feelings.

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I went to a dinner party on Monday night, and I was incredibly surprised and excited to learn that a classmate is pregnant! 13 weeks! This is very strange for several reasons, but mostly because it reinforced the fact that I am an adult, and that my friends are adults.

We were talking about genetic testing, amniocentesis, and chorionic villus sampling , and what should be tested, and what should be left up to fate. (The classmate is an Ashkenazi Jew, so there’s an increased risk of a number congenital diseases. Note: most Jews in the US are Ashkenazi. I didn’t know this until last year; I thought Ashkenazi was some rare group of Jews. Not true.) If some serious genetic diseases were detected, they would probably terminate the pregnancy.

Anyway, I joked that they should also check for the gay gene (see, that’s funny, because there isn’t one), and somehow it came up that if the gay gene was positive, they’d have to think if they wanted to continue the pregnancy, as if being gay was along the lines of Tay-Sachs or something. I couldn’t help but identify with the fetus, and felt a little offended (I’m sure the friend didn’t mean to offend). I was just surprised at how different a perspective I must have. I guess I can see my classmate’s perspective-you wouldn’t want your child to have any extra hardships in his or her life-but I just have a hard time thinking of the notion of me not being here because my parents learned something about me. (This probably stems from my human egotism of existance, but let’s ignore that part of it for a minute.)

If you haven’t noticed, yes, it’s not necessarily the best fate to be the lucky person chosen by the Universal Order to play the gay for this lifetime, but I’ll be damned if I’m not a much better person for it. I understand compassion, kindness, struggle, injustice, stereotyping, ignorance, and unconditional love and blind hate better than many people that have grown up in similar, heterosexual shoes.

It’s part of me, not the most important part, but part of me, nonetheless. I’m pretty happy with how I’ve turned out, and I wouldn’t change any of it, even if I had the chance. (Well, okay, maybe a little less neuroticism, and maybe a nosejob. And maybe showering more in the 7th grade would have helped.) But I’m me; I’m not diseased, I’m not sick. Within the normal limits. Or just outside them. But anyway, who wants to be normal? Normal’s boring, if you ask me.

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I’m curious how much of health is related to a person’s happiness. That is, how much of one’s mental health and health behaviors are related to a person’s happiness, sadness, loneliness, misery.

If people were happier, would they do fewer destructive things to their bodies? Overeat? Undereat? Exercise more? Smoke less? Drink less? Do fewer drugs? Have fewer negative or harmful thoughts?

How much of one’s health is related to self-image? If we had tighter communities, more social supports, more love and kindness in our lives, would we be healthier? I’m tempted to say yes.

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A number of totally random thoughts, after two days of class (we’re halfway through a week of derm):

• As far as STDs go, I don’t think the joke will ever get old where you automatically assume if someone asks a question about one, they clearly have it. And no, feigning ignorance in some sort of reverse-psychology way (“Do herpes sores hurt?”) is totally overcompensating, and I can see right through you. (I was tempted to ask this question today, as I honestly don’t know, but you probably don’t believe me now that you see the way my mind works its paranoid little magic.)
• Due to the miracles of videotaping and online streaming of classes, I bumped into a classmate on the way back from the gym that I’m pretty sure I didn’t see at all last quarter.
• It is extremely funny when your preceptor asks a generally quiet classmate about the “things you need to be monitoring status post surgery,” and, after having previously talked about the answer in more discrete terms, the classmate blurts out, “well, eating and shitting,” as if the word is standard medical vernacular. (Perhaps he was confused with dumping.)
• The television show, House is strangely intriguing to me, in a kind of this-is-so-fake-and-somewhat-offensive way. The doctor assumes all patients are lying, degrades his colleagues in a paternalistic hot-shot way, and probably freaks people out that they’re going to have Wilson’s disease and go “crazy,” or end up getting African sleeping sickness by having sex. Medical dramas are bad, but not that far-fetched.
• I was a late bloomer. Most kids get Fifth’s disease (erythema infectiosum, caused by Parvovirus B19) by the time they’re 10, but I got it when I was 14, in Mrs. Baxley’s typewriting class. She sent me to the nurse, and I got the day off of school in 8th grade. Sure fooled them; it’s not contagious once the rash appears.
• I keep feeling like I have all this time on my hands. I look at the clock, and it’s only 7:38pm, and I can’t believe it’s so early. And then I remember the difference: it’s the beginning of the quarter, I don’t feel entirely exhausted, and I’m not so tired that my body’s begging to let me take a nap about 7:38pm. What a difference a break makes.
• I just launched ericmah.com about 5 minutes ago. Eric is a good friend and running for City Council in Manhattan Beach, California. Vote early, contribute often. Please, Google gods, make those links help get him on your index list.

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After a red-eye and 3 hours of sleep, I’m back from Oahu. Had an incredible time. Just what I needed. So far removed from medicine that I came back to school today and was reminded of what med school’s like. Namely, being talked at by strange specialist professors who use way too many terms that you have no idea what they mean.

Also new: some photos from Hawaii.

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I’m deeply fascinated recently with the idea that life comes from life-or more realistically, life comes from death. And more personally, where did I come from? And more spiritually, have I been a cow, an insect, or a bacterium in a previous life?

If women are born with all the ova they’ll ever have, that means that half of me came from something of my grandmother’s, that she then passed on to my mother in the womb. Am I a piece of chicken? Or maybe a bean? Or a sloughed-off cell from the inside of her cheek? Or a bacterium?

And if it takes men about 74 days to mature their spermatozoa, what a fascinatingly microscopic idea that some little bit or speck that he ate was to become me. I picture a cheeseburger, or maybe some roast beef. Maybe a bit of bacon from his mother’s incredibly delicious green beans.

I realize this edges frighteningly close to the idea that I was not, in fact, delivered by stork or simple budding, but it’s somehow mind-boggling to consider all the forces and interactions and molecules and sequences that had to occur just to make me. Call it egotism or what you will, but some part of me-no, all parts of me-existed before I ever existed. Before even the concept or the thought of a me existed. In one form or another, at least. Everything’s connected to everything else.

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My favorite gift wasn’t the dress shirt or slacks so I can look spiffy in clinics; it wasn’t What’s The Matter With Kansas, or the sour watermelon gummies, or even the underwear. Not the sweaters or calendar of Paris, either.

My favorite gift this holiday was the knowledge that I’m not going bald, as I had been previously thinking for the past couple months, and frantically ranting to my classmate Yana about. No, no, dear readers. I get to keep this lucious mane of hair. My mom has the same hairline forehead V that I have.

Yes, Virginia, there is a Santa Claus.

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It’s inevitable. I’m getting old. And before you go off on “you’re not old, I’m old,” a few things. One, it’s all relative, and two, this is not so much me getting old as me turning…adult.

As I find myself at home for another non-white Christmas (Okay, that sounds wrong. Kansas is almost entirely white. Population-wise. What I mean to say was snow white. Not the Disney movie. But the weather phenomenon.), I can’t help but feel like a full-time, full-fledged, card-carrying… adult. I’m even getting along with my parents. This can’t be happening.

The list of disturbing, adult-like behaviors won’t seem to end. I saw some neighborhood kids (born in the 1990s-the 90s!) and the first thing that came to mind was “I can remember when they were born!” Others that I used to babysit are now in high school. And still others see me jogging down the street and stare me down, wondering who I could possibly be.

Some call it maturing. I call it getting old. I used to be the biggest sugar tooth this side of the Mississippi. I used to eat table sugar from the bowl, just for the taste. Now I look at a candy bar around the house and think, “Oh. That looks *too* sweet.” And for the first time, I’m dieting. Okay, not dieting. But just trying to watch what I eat. My metabolism hath slowed.

I watch TV and see nothing on MTV that I recognize. I drive around town and see new buildings and stores. Trees are gone; others have been planted. My parents got new counters. Our dog died. My dad has geeked out the stereo in the house. I understand the web design concern with fonts that are too small.

But there’s still hope. Margaret Atwood wrote it: “Another belief of mine: that everyone else my age is an adult, whereas I am merely in disguise.” I still check my mom’s secret hiding places for treats, like I used to-it’s just that they’re now dried blueberries instead of licorice or malted milk balls. I ran the old hill that gave me shin splints in high school, and the same muscles bother me (damn you fibularis longus).

But I think more than anything lately, I’ve somehow come upon movies and conversations and stories that have tried to teach me one thing: life is short and precious; it moves too fast, and it’s better to have loved and lost. Maybe it’s just the holidays, but I’ve found a renewed sense of hope and wonder with the world, something that I’d lost somewhere along the way.

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There’s an Amber alert out in the Kansas City area after two men and a woman apparently strangled an 8-month pregnant woman and cut open her uterus to remove the baby. They’re now looking for the three in a hatchback, carrying the infant.

Sometimes it’s hard to believe that humans are capable of such gruesome acts, especially in the background of the holidays.

I feel sick.

UPDATE: They found the baby.

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One of my favorite pieces is out again: The NYT’s The Year In Ideas. Interesting on the medical front: an exoskeleton prosthesis that takes the load off your back; eyeball jewelry, which really doesn’t seem that great, and a bit invasive into my freaking EYE; cancer music, where researchers are trying to listen to the vibrations of cells and diagnose neoplasia (how that will differentiate between benign and malignant, the important step, is beyond me); economic theory to encourage vaccine production, and skin literature (I’d have something by Vonnegut tattooed if I had to choose).

Also not to be missed is a short interview with Stephen Hawking. Some of my favorite bits:

What is your I.Q.?
I have no idea. People who boast about their I.Q. are losers.

With all your intense erudition, why do you bother writing pop-science books about the universe, the latest of which is the illustrated version of ”On the Shoulders of Giants”?
I want my books sold on airport bookstalls.

Are you always this cheerful?
Life would be tragic if it weren’t funny.

Seriously, how do you keep your spirits up?
My expectations were reduced to zero when I was 21. Everything since then has been a bonus.

Really puts one’s own challenges and upsets in perspective, huh?

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I’m done. DONE, I say! Hallelujah.

49 questions for a final. Doesn’t seem right. But whatever. I feel great, exhausted, wonderful. I should really bottle these endorphins and sell them. There were some questions that were insane.

But who cares. I’m free.

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As I sit here early in the morning trying to force myself to go through WebPath one more time, I can’t help but think how damn good I’m going to feel in 4-5 hours. I won’t even need all that heroin I bought last week. I’ll probably just sell it back on EBay.

This test today is basically one-third of the boards, and we’ve had less than a week to prepare for it. Here goes nothin’.

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I pray to the gods and the power of Grayskull, please help my neurons to dig up the lost memories of pharmacology from the depths of my mind. Specifically, the antibiotics, antivirals, antifungals, and anti-cancer drugs, as I’m thinking those are the ones that will be the focus of my exam on Friday. If I could get the toxicities back, as well as mechanisms, and all the mnemonics I made up for them, that’d be great.

Also, if it’s not too much trouble, all of microbiology would be awesome. If not, I’d like the major bacteria and viruses, specifically upper respiratory tract infections, pneumonias, diarrhea bugs, and urinary tract infections.

I’m really willing to make it worth your while, God.

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If you’re not reading Mimi Smartypants, your life is either a) not complete or b) totally lame.

Mimi totally picks me up when I really need it. Like today. When I did really crappy on an endocrine exam, and I have a cumulative Final O’ Death in one week’s time.

She also has a book of her writings. Yes, she’s that good. She’s literally the only weblog/journal/whatever I read that doesn’t have an RSS feed. That means a lot, in my sick little dweeb head.

Also, she lives in Chicago, where I used to be, so brownie points for that.

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I got into a nice yelling match with a close friend last night (who will inevitably read this, I’m sure). This is not news. We do this every couple months or so. Very healthy.

Reflecting back, it’s kind of interesting to see why I was mad at him-he had insinuated that I have loads of free time because during one of my study breaks, I had emailed him a website I thought he might enjoy. He found this suspect, because when he called me while I was “in the zone” studying, interupting my train of thought, I didn’t stay on the phone long, and excused myself to get back to work.

And then I realized how totally defined I am by my hard work. Other people are, too, I suppose, but what else do I have to show for it? No paying job, no major source of income besides hundreds of thousands of dollars of student loans. I can only impress people by my perserverance and my knowledge. So of course I was insulted; telling a medical student that he or she is not working hard enough is both a) nowhere further from the truth and b) insulting to one’s core definition (What a does a med student do? Study, study, study.)

I’d have (and have had) a similar reaction when the same friend, not coincidentally, denigrates my knowledge (or any other person). They’re usually kidding, sure, but I still take offense. If my knowledge is devalued, what else do I have to pride myself on?

I knew medical school messed people up, but this is really sad that I now define myself this way.

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When you study diseases and cancers and other terrible things all day long, you start to formulate the most invalid of hypotheses: this is pathology that affects other people. I will not get cancer. I will not have a risk of dying. I will go on my merry way, helping my patients. I will remain 24.

We need to know these diseases and their symptoms and complications to help our patients, never us. Maybe it’s an “us versus them” mentality, or maybe it’s just a psychological defense mechanism, but either way, I’m constantly reading about some disease and thinking to myself, “Man, that would really be awful to get that. I feel so bad for what they must have to go through.” But then a moment later, the reality hits me-and it’s frightening. I’m assuming that these awful cancers with awful prognoses and awful survival rates and awful treatments will somehow skip me. I’m just as likely to develop some of these cancers or diseases. I don’t get a “by” just because I’m going to be a doctor.

Perhaps that’s why doctors are more likely to smoke, drink in excess, or do recreational drugs than you’d expect. Less likely to get a regular checkup and physical. These aren’t diseases that affect all people. They affect other people.

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I love it when doctors who have seen hundreds (thousands?) of a certain class of disease make pre-clinical students feel stupid and inadequate for not understanding every possible physiologic consequence of said disease. Great way to encourage learning and turn people on to the exciting world of your specialty.

I’d hate to see how they react to patients who ask questions, get confused, or don’t understand something.

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December first. World AIDS Day. Protect yourself and get tested.

I read And The Band Played On (read the first 3 pages at the new Google Print), and it was absolutely excellent. It changed the way I thought about policy, the media, politicians, politics, and celebrity; it still has a lot of lessons that we can learn from. If you’re looking for a new book to read, pick this one up; it’s a page-turner.

I couldn’t help but wonder if we would have reacted to HIV if we only started to really see it now, as opposed to 20 years ago. Would the government continue to deny it? Would the NIH underfund and ignore it for years, only later trying to take credit for isolation and discovery of the virus? (The French discovered it.) Would the president keep from mentioning it for 6 years, or until 16,000 people had died from it, and thousands more were already infected?

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It appears that some doctors and other medical personel have been involved in “planning of interogations” at Guantanamo. What a disgrace. It’s sad to think that anyone who has had the privelege of becoming a physician-a role designated in this society as healer-could turn against the “first, do no harm” ethic.

The team of humanitarian workers, which included experienced medical personnel, also asserted that some doctors and other medical workers at Guantánamo were participating in planning for interrogations, in what the report called “a flagrant violation of medical ethics.”

Then again, it’s an even larger stain and bigger disgrace that my country-of freedom, justice, democracy, and due process-is involved in torture. How absolutely vile. I’m waiting for the moral outrage, Christian right.

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I’ve mixed feelings about this year. But none of that bittersweet stuff. No, this is an absolute dichotomy. Love, meet hate.

To catch you up, this is my 4th preclinical quarter (out of 6 total). I’m a second-year. You do two years in the classroom, and then two years in the hospital. In year two, they really turn up the intensity. I basically spend my days in class, and my evenings studying. Every three weeks, we have a block exam covering the physiology, pathology, pharmacology, histology, and microbiology of the organ block we’re covering. In non-medical-geek speak, that’s: how the system works, how diseases of the system occur and progress, how you treat the diseases with drugs, what the system’s cells look like under a microscope, and what bacteria/viruses/fungi/parasites infect the system and cause disease. You can imagine-or maybe you can’t-there’s a lot of stuff that can go wrong in our bodies. Most of the time it goes right. But then you wouldn’t be seeing a doctor, would you?*

So I go to the library, take out my lectures, review books, and TA handouts, and memorize. Pages and pages of facts. Some of which makes logical sense, based on the basic knowledge of how the body is supposed to work, but other times, it’s just rote, bland memorization. For example: there are a ton of types of liver cancer. That list is just the tip of the iceberg, and is 2 pages of a 17-page Word document that contains all the pathology I need to know for the exam. The human brain is not meant to take in this much information, repeatedly, in such a short span. I promise. And, because we clearly have nothing more important to do or learn, we get to memorize random facts about liver cancers, most of which we will never, ever, ever see. This would be where that whole hate thing comes in. Also the tests every three weeks is a major source of frustration. But more on that later.

So contrast all that fear and loathing with the other side-I finally feel like I’m becoming a doctor! Ahh, love! All this work, all this perserverance, and stuff is starting to finally make sense! I get it! What a feeling. We see patients once a week, and, get ready for this: they actually have the symptoms we’re taught about! And they’re actually on the drugs they tell us we have to learn! It’s this light at the end of the tunnel. It’s this belated acknowledgement that yes, what we’re learning does apply to actual people; it doesn’t exist in a vacuum, or only in our heads or on our tests.

Another, more subtle benefit of the “test you every three weeks until there’s nothing left” mentality, which I think will probably never leave medicine, and perhaps for good reason: I no longer seem to stress over tests, or many other stressors in my life. I’m much more content to just feel confident, do my very best, be true to myself about my work ethic, and just think calmly. I was a nervous wreck in undergrad (a story for another day), and while I still get butterflies as I’m biking to a test in the morning, it’s nothing like it used to be. I’m guessing this is some sort of unintended positive consequence of medical education: I’ve grown almost Buddhistly-detached from the testing experience. I accept it as part of the process, but realize that it is, not really, a great reflection of my ability as a physician or human being.

* A great proverb (I’ve heard Chinese, but who knows) goes something like this: How would the world be different if you paid doctors when you were well, and they paid you when you were sick? Talk about preventitive focus. Take that one and and munch on it.

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Osteoporosis is a common disease of bone wasting, predominantly in older, post-menopausal women. It’s an important disease mostly because it predisposes people to bone fractures (hip, femur) after falls, and breaking a bone late in life is correlated with poor recovery outcomes and morbidity.

So we’ve got Fosamax (alendronate) that many people take to prevent bone loss, but it turns out to be a pretty caustic molecule. So caustic, in fact, that you have to take it standing up, and stay upright for an hour after you took it, without food, and with a big glass of water. “After swallowing the tablet, do not lie down, remain fully upright sitting, standing or walking, for at least 30 minutes and until after you have eaten.”

If we can prescribe behaviors associated with prescriptions, I’ve got an idea for an excellent new blood pressure medication: a sugar pill that must be taken along with an hour of playing with a pet. I’m going to make millions.

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One of the leading Eli Lily researchers on PTH spoke to us yesterday about PTH and its actions. A good lecturer, but raised a couple thoughts in my mind:

• Should companies be able to patent drugs (hormones) we make naturally in our own bodies? Sell it, fine, but patent it?
• After he talked about the wonders of PTH (and glossed over calcitonin), I would’ve appreciated it if he had told me that it’s been found to cause osteosarcoma in rats. While there’s no indication that it causes bone cancer in humans, it seems a little suspect that we had to learn the fact from our pharmacology lecture today.

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Dear World and Future Patients,

If I ever act this superior to my patients, you may promptly slap some sense into me.

In this Ask Metafilter thread, Geoff is concerned about an endoscopy (where they stick a tube down your throat with a camera on the end):

So this upper-GI endoscopy thing I keep hearing about. Uh, is there anyway you can request one of those new capsule endoscopies? Apparently the also don’t knock you out. Personally I’d rather have to swallow a capsule then have them snaking a tube down my throat while I’m awake. Can I demand being knocked out? Am I the patient that doctor’s roll their eyes at?

So yeah this is hitting one of those “phobias” that we all have. God is smiting me. Here’s the conversation:

“So uh, they don’t knock you out?”
“No.”
“I see. This is stupid, how much does it hurt?”
“Well, many people have it done. You can still breath during it.”

Well thank God, I won’t suffocate. I want a capsule. My internet search results in it being FDA approved. How does one go about finding a doctor who does it? Can any doctor do it if I can find a place to order it? The doctors I’m dealing with are kind of, uh, “just do it, don’t be a wuss.”

After multiple responses, including the fact that a capsule won’t work for an endoscopy, some new Metafilter user doctor replies:

If I may take a breather from rolling my eyes…

Unfortunately a capsule basically won’t cut it. It’s used primarily to visualize the distal duodenum and small bowel, and only because you can’t get to it with a normal EGD or from the other end. The capsule essentially yields much less information because it’s under the control of peristalsis alone, and can’t be guided by a tech or doctor. So you end up catching only glimpses of things. It’s useless in your case because the area of interest is actually the larynx/esophagus, where the capsule would be for only a second before making it’s way to your stomach.

But there is an alternative perhaps, if you’re really against the EGD. If your problem does reside in the larynx, around the vocal cords (for example you may have a polyp there), then it may be worthwhile to see an ENT who can do some basic indirect laryngoscopy (painless), or (the slightly less invasive but still obnoxious) transnasal flexible laryngoscopy. Of course, this won’t tell us anything about what’s going on in your esophagus.

I can see where the doctor is coming from-to him (or her), there’s much worse in the world; more painful procedures, more gruesome operations and accidents. I’m sure it’s difficult, but as physicians we have to always remember that our experiences are not the same as our patients’. Most haven’t seen chest tubes in people. Most are totally outside the realm of medicine, hospitals, and procedures.

Dreama sums it up nicely:

drpynchon, I left a hospital AMA earlier this year because of a doctor who rolled his eyes as I cried my way through questions and belittled and brushed off my fears and concerns about a procedure I needed (actually, a modified endoscopy). If you can’t deal with patient fear without being condescending, arrogant and rude, please do everyone a favor and become a pathologist.

And most certainly spare us your attitude in AsMe.

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Now that we’re in endocrine, we’ve been talking about prolactin and other hormones that cause milk release, or, as the professor calls it, “milk letdown.”

My classmate Peter loved the phrase, just with a different definition: Milk letdown. When you have milk, you expect it to be really good, and it’s just okay.

Another interesting fact: the name galaxy (ex: our Milky Way) comes from the root galac-, which means milk. See picture below.

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