3~3April~2001-50~Feature~Alice in Universal Health-Care Land~Step into the single-payer rabbit hole.~Howard Bell~~In Lewis Carroll's Alice's Adventures in Wonderland, a young girl cautiously explores a fantastic realm and meets remarkable creatures. It is a classic tale. With the help of experts, we have also created a world-one that some may think to be just as incredible, and others may find to be just as desirable. Yet, on this trip you won't encounter a mischievously smiling Cheshire cat or a caterpillar smoking dope. And you'll be happy to learn that a queen will not shout, "Off with her head!"


For this world represents a vision of health-care reform. You've all heard the rhetoric: "Health care for all!" and "Everybody in, nobody out!" Yet how many of us really understand what this means and how it would work? To aid in clarifying this vision, we've asked three national health plan experts to help us create an imaginary realm illustrating the single-payer universal health-care model. Compared to other reform efforts-and there are many-single payer certainly demands a complete overhaul of our current market-based system.


Our guides for this tour are: Dr. Claudia Fegan, president of Physicians for a National Health Plan (PNHP) and a Chicago internist; Dr. David Himmelstein, head of Harvard's Center for National Health Program Studies and an internist at Cambridge Hospital; and Dr. Bob LeBow, former president of PNHP and a family practitioner in Idaho. Yet despite the knowledge of experts like these, no one knows for sure how a single-payer universal health-care system would exactly play out in the United States. Much of this story contains educated conjecture.


With these conditions in mind, enjoy your exploration with Alice and Dr. Hatter, for it's time to leap into the rabbit hole.


It was a day of firsts for Alice, a 30-year-old cashier at the 14th Avenue Gas 'N' Gulp. It was the first day of April and the first time she used her new health insurance. The National Health Plan (NHP)-universal coverage for all Americans-had become law two years prior. One card, one plan, one payer-Uncle Sam. But this was not the socialized medicine like they have in Great Britain, mind you. For although private health insurance no longer existed, at least not for things the NHP covered, private ownership of health providers still did. Uncle Sam was funding this plan, but he didn't own it. Physicians still ran their own practices. Nonprofit and for-profit entities still owned hospitals, yet all had to follow the NHP universal guidelines.


Before the NHP, U.S. health-care bureaucracy spending totaled $250 billion annually, so a lot of money was freed up when 1,500 private health insurers were eliminated. Seventy-five percent of those funds were redistributed to insure individuals like Alice, who had been among the 43 million uninsured. The funds were also redirected to improve preventive health care for everyone. The United States was still spending 14 percent of its gross domestic product on health care, so this new system didn't cost Americans any more than the old one, nor did it save money. The idea, NHP advocates had said, was not to spend less money but to provide better care and access to care.


And now Medicare and Medicaid were gone. So was the patchwork of safety-net programs states struggled to keep stitched together for the uninsured and underinsured. For Alice, health care was now a right, not a commodity.


Americans could have started using the program six months ago. A cautious woman, Alice decided to postpone her visit to the doctor-after all, she felt fine. Now tired of waiting, Alice chose today as her day to try out the new system.

VISITING DR. HATTER


Alice checked in at the Northland Clinic for her first routine physical since she was a child. A receptionist scanned the bar code on Alice's NHP card. "Kind of how I scan milk and eggs at the Gas 'N' Gulp," Alice thought. "Could it really be this easy?" she wondered while sitting in internist Dr. Matthew Hatter's waiting room. Her enrollment in the NHP was automatic. Her card came in the mail with a letter that said, "Enclosed is your National Health Plan card. Keep it with you at all times."


Alice studied her card. A walleyed pike stared back at her-the Minnesota state fish. Her brother in Wisconsin had a badger hologram on his. Had she lived in some other state, it might have been a cardinal, a cactus, a maple tree or another significant symbol. She'd prefer something more dignified than a fish, but she was willing to tolerate the finned fellow if it meant she could see a doctor when she needed to and in most cases pay nothing out of pocket.


While waiting in Dr. Hatter's office, Alice thought about what she'd learned last year at Gas 'N' Gulp's employee benefits meeting. The benefits lady, Ms. Caterpillar, had explained that Alice would still have health insurance if she lost her job or changed jobs. If she got sick while visiting her sister in North Dakota, she'd be covered. If she moved to Oregon to be closer to her parents, she'd automatically get an Oregon NHP card once she established residency, which would usually take several weeks or a couple months depending on state law. Oregon's card had a beaver on it, her parents reported.


"The NHP pays for all necessary doctor visits, routine physicals, screenings and tests," Ms. Caterpillar said. "It pays for prescription drugs, except for a small co-pay. It covers the care you get in a hospital, nursing home or even your own home." From mental health to dental health, Alice wouldn't pay a dime unless she wanted special extras like a private hospital room, orthodontic services or cosmetic surgery, like the laser de-wrinkling her sister had done.


"You're paying for it through a national health tax taken out of your paycheck," Ms. Caterpillar had said. "The more you earn, the more you pay, just like income tax. The average tax is 9 percent."


The NHP worksheets had explained that the tax wouldn't cost the average employee more than the old system's health insurance premiums, out-of-pocket deductibles and co-pays had.


"Gas 'N' Gulp is paying half that tax for you," chimed in Mr. Dumpty, the portly company owner. "I'll admit I was dead against it in the beginning, but I'm not paying any more now in health taxes than I used to pay in health premiums. Plus I've saved time and money by not having all that insurance company paperwork. And now all of you good people are insured, not just some of you. Plus, I don't worry about large premium hikes anymore."


"That's because the NHP controls costs by global budgeting and caps on spending," Ms. Caterpillar said. "Of course, smaller businesses that did not offer employee health insurance before have new increased costs through taxes. Employers can't opt out of paying their share of the health tax, just like they can't opt out of paying part of each employee's Social Security tax. This new cost, though, is partially offset by tax credits."


Alice's friend, Bill Carpenter, a tanker driver for Gas 'N' Gulp, voiced some doubts. "How can 43 million more people be insured for the same amount of money spent on health care before they were insured?" he asked.


"Because," Ms. Caterpillar said, "the NHP provides everybody necessary health care by skipping the middle-man-the private health insurance industry, which used to skim 9 percent to 15 percent of every dollar spent on health care. It's too soon to tell what NHP overhead will cost, but if it's anything like the old Medicare program, we're looking at 2 percent to 3 percent."


Alice's memories of that benefits meeting were interrupted when her name was called. "Dr. Hatter will see you now," the nurse said. Alice never had her own doctor before. She always relied on emergency rooms and free clinics for care, except for the brief time she qualified for Medicaid. Dr. Hatter smiled at Alice, looked at his pocket watch and apologized for the 45-minute wait. He explained that since the NHP took effect, previously uninsured people who had delayed care for serious illnesses were now scheduling appointments. "This initial surge will level off," he said. "But until then, we all have to be patient."


During the physical, Dr. Hatter examined Alice's leg, which ached in cold weather ever since she was a little girl and stepped into a rabbit hole. He also ordered a mammogram. She'd have to go to the hospital up the street for that. Under the NHP, high-tech services were concentrated at what were being called "regional centers of excellence." Alice's city of 150,000 had just one mammography center. "The more mammograms a doctor reads, the better that doctor gets at it," Dr. Hatter assured her. He explained there are 10,000 mammography machines in the United States. "If they were used efficiently, we'd only need 2,500. By making more efficient use of one machine, we'll get better readings at a lower price," he said.


Alice might wait a couple weeks for her screening, but probably no longer than that, despite what she'd heard from the naysayers about Canada's single-payer system. "We've still got so much more high-tech capacity and money invested in health care compared to other countries," Dr. Hatter said. "For example, there are more MRI machines in Orange County, California, than in all of Canada. It's not like we're going to smash all of our extra machines just because we have a single-payer system. Even if spending slows for such equipment under the NHP, the United States will still spend more on health care per capita than other countries do."


Dr. Hatter told Alice if she ever needed a specialist, she could pick the one she wanted. She may have to wait a few weeks, unless it's urgent, he said. "But don't worry, other countries that have waits for such high-tech services haven't seen a negative effect on outcomes," he said. A few weeks were nothing to Alice. On Medicaid, she once waited six months for a routine preventive mammogram.



Alice left Dr. Hatter's office feeling good about her visit. Her initial skepticism of the system had diminished. She liked Dr. Hatter, and she also liked the idea that she could see any primary care physician anywhere. The NHP would even pay for a chiropractor or midwife.


DR. HATTER GOES ABOUT HIS DAY


After his appointment with Alice, Dr. Hatter took the skywalk to Northland Hospital to read some EKGs in diagnostic services. Most hospitals were still community nonprofits. The ownership status had not changed for any of the city's small group practices or large multispecialty clinics. There were still some solo practitioners. In fact it was easier to go solo under the NHP. You didn't have to worry about being part of a health plan network or losing your patients with the stroke of an HMO pen.


"Life is good," he thought as he passed through the skywalk flooded with warm afternoon sun. "I make the same amount of money as I did before the NHP. I work the same number of hours and spend an hour-and-a-half less on paperwork each day. That used to be the most frustrating part of being a doctor." Now when he ordered a test, procedure or prescription, he didn't have a dozen forms to fill out. "And I don't have to wait six months to get paid," he said aloud, to no one in particular.


Billing was easier. Imprint the patient's card on a universal charge slip. Check some boxes to indicate complexity of diagnosis or service. Send the slip to the state's physician payment board, part of the state's department of health. It received money from the NHP and paid physicians in 30 days or less. Dr. Hatter still billed his patients for services not covered by the NHP, a tiny fraction of services provided.


"Now I spend more time figuring out how to help patients, which is what I was trained to do. Medicine is fun again," he said to himself as he waved to the head nurse at the end of the skywalk. "I'm seeing more patients, and I don't have to hurry through their exams." The NHP paid Dr. Hatter on a fee-for-service basis. "The more patients I see," he thought, "the more I can earn." About half of U.S. physicians are salaried like they were under managed care. The NHP allowed doctors to still work for capitated health plans like Kaiser and Group Health of Puget Sound.


As he entered the hospital, Dr. Hatter passed Dr. Walrus, the orthopedist. Dr. Walrus looked unhappy. "What's wrong?" Dr. Hatter asked.


"My salary has dropped under this NHP," Dr. Walrus said. As a result of NHP's preventive medicine emphasis, specialists were earning less than before. Primary care physicians like Dr. Hatter were earning the same. Reimbursement rates were negotiated between physicians' state medical professional societies and the state physician payment boards. Because of federal incentives, all physicians could earn more if they practiced in remote or underserved areas. Outside of specialists like Dr. Walrus, most of Dr. Hatter's colleagues seemed to be adjusting to the NHP.


"The program seems to be working well for patients," Dr. Hatter said, somewhat embarrassed at his inconsiderate response to Dr. Walrus's complaint. Dr. Hatter had learned at the monthly medical staff meeting that outcomes hadn't changed for patients who had employer-based insurance under the old market-based system. At the same time, outcomes had improved for the previously uninsured, mostly because they no longer delayed care or rationed their medicine. "Their death rates will soon go down," Dr. Hatter thought.


Surgical mortalities-deaths per 100 procedures-were remaining the same. They'd even gone down a bit in some states, Dr. Hatter had read, because specialty care was now concentrated. Northland, for example, was known as the regional heart "factory." Waiting times for coronary artery bypass grafts (CABGs) were either unchanged or only a bit longer than before. CABGs, angioplasties and catheterizations weren't done as often now. Instead, some patients received less invasive modalities, and this didn't seem to have a bad effect on death or reinfarction rates. And mental health services had improved. The NHP allocated more money to this area, with much of the extra funding used to care for individuals with serious mental health conditions.


Dr. Hatter knew from his own experience that preventable hospitalizations had declined for things like asthma, pneumonia and diabetes. They'd especially gone down in the poorer parts of big cities now that everyone could get good outpatient care. At the same time, inpatient lengths of stay had increased by as much as 30 percent for some procedures-a result of removing many managed-care restrictions on length of hospital stay.


Medical innovation was not suffering under the NHP. Cost-effectiveness still drove the system, so a demand for high-tech equipment and procedures that paid for themselves by offering greater efficiency remained. Dr. Hatter wasn't surprised by this. After all, laparoscopic surgery was invented in Newfoundland under Canada's single-payer system. And heart and lung transplants were developed in Toronto. Plus, he knew that rates for these and other transplants like kidney and bone marrow were about the same in Canada as they had been in the United States under managed care.


"Clinical research seemed to be faring better under the NHP," Dr. Hatter thought. The United States had lagged behind countries like the United Kingdom, Israel and Sweden but was now narrowing the gap, just as it was increasing the number of published peer-reviewed medical articles. "We're no longer just in the middle of the pack," he thought.


Dr. Hatter was still adapting to evidence-based practice guidelines, though. They were now being used more consistently than before. Some of his colleagues griped that big government had replaced big business, but that wasn't exactly true. "At least the new guidelines are written and approved by the internal medicine state medical society, instead of an insurance company," he had commented to a colleague yesterday. "Peer-developed guidelines are a good thing," he said to himself, remembering when he served as a medical director for a large metropolitan health system. Thirty physicians treated myocardial infarction several different ways. How one physician treated it was 10 times more expensive than how another one did, even though outcomes were the same.


CUTTING THE FAT


On his way to diagnostic services, Dr. Hatter took a shortcut through what used to be called "mahogany row." The long corridor of hospital administrators had been converted to exam rooms and storage space. Through a glass door that still bore the faint imprint of the former HMO chief's name, Dr. Hatter could see boxes of fluorescent light bulbs, toilet paper and cleaning products. A small contingent of hospital and clinic administrators remained, but they were focused on patient care, not market share. Gone was the herd of generic administrators who attended meetings all day. Dr. Hatter used to feel like an assembly-line worker in a Charlie Chaplin film, where the "product" passed by on a conveyor belt at faster and faster speed. Not anymore.


As he continued on his way, he noticed that clinical staffing in the hospital had improved; there were more registered nurses (RNs). In the final years of market-based care, many hospital-employed RNs were replaced by aides-an effort by managed care to cut costs and increase profits. Dr. Hatter liked this new emphasis on patient outcomes.


He agreed with many of his colleagues-the NHP interfered little in physicians' daily practice of medicine. He could take care of patients the way he was taught, not just give them what their insurance would allow. True, someone was still looking over his shoulder. If his complication rates or costs were consistently high and a difficult case mix wasn't the reason why, he might receive a note from his professional society and be required to attend some continuing medical education classes. "But that's a more collegial approach than being denied reimbursement by a non-physician," he thought. The cost of taking care of patients was now controlled through budgeting at the state and federal levels, not through micromanaging the physician. No more patient-by-patient utilization review. No more little red flags on patient charts. No more accounting for every aspirin and IV.


Dr. Hatter's small group of six internists used to have three full-time people who just did billing. Now it had one. Single payer was saving the 200-physician multispecialty clinic up the street tens of thousands of dollars in overhead. Physicians used to spend 10 percent of their gross revenues on billing costs. Now they were spending 1 percent. Likewise, the state department of health was spending less than 1 percent of its budget on NHP bureaucracy.


Nationwide, there were now 1.3 million fewer people employed in medical center billing departments and health insurance companies. Many of these personnel were retrained to handle paperwork in patient care areas, which freed nurses to take care of patients. Others became public health employees, helping through education to reduce the rate of nine preventable diseases that cause more than half of the deaths in the United States. Under the old system, only 3 percent of health-care spending went to prevention.


BRICKS, MORTAR AND MACHINES THAT GO BEEP


When Dr. Hatter arrived in diagnostic services, workers were busy next door renovating unneeded billing office space into more diagnostic procedure rooms. Capital budgets for renovations and new equipment were handled separately from the budget for operating the hospital day to day. "Separating these budgets discourages hospitals from skimping on care just so they can afford to add a new wing to the building," he thought.


If Dr. Hatter's small group practice wanted to buy new equipment, they simply would buy it, just as they did under the old system. But large capital purchases at a public clinic or nonprofit community hospital now went through a budget appropriations process done annually at the state department of health care. The state health planning board determined how much capital improvement money Northland Hospital received each year. When St. Mary's, a nonprofit community hospital across town, requested approval to buy a new MRI machine, their petition was denied, even though they had the money from private donations to pay for it. An additional MRI machine for a service area of 150,000 would unnecessarily increase future operating expenses for the hospital, the health planning board had said. Yet privately owned health providers could expand or purchase equipment without needing an approval, if they had private funds to pay for it.


To keep the hospital operating day to day, the state health planning board gave Northland a lump sum of money each month. The amount was negotiated yearly between the hospital and the state. Operating money could not be used for marketing, expansion or major capital purchases. In the old days, the hospital got paid per service or per patient. "Getting paid a lump sum based on an annual budget saves time and money," Dr. Hatter thought.


Dr. Hatter finished reviewing his patients' EKGs, then drove up the hill to Northland University School of Medicine, where he taught a class in clinical preventive medicine to third-year medical students. "It was too soon to tell," he pondered while driving, "but so far the NHP had not changed the type of person who enrolled in medical school. It might discourage a few who'd planned to make millions, but perhaps that weeds out those entering the profession for the wrong reason. If anything, the NHP seemed to make medicine more appealing. It reduced paperwork and bureaucracy.


"And it gives me more time to take care of patients like Alice."

~REALITY CHECK

Single-payer universal health-care supporters realize they face tremendous obstacles to achieving their goal. There are financial and public mindset concerns. Plus, they have to battle the propaganda generated by other health-care reform efforts, including those by the American Medical Association (AMA).

The AMA and others have said that single-payer universal health-care supporters are out of touch with what Americans want and with the political climate in Washington, D.C. "People who say single payer or nothing will get nothing," says Bob Doherty, senior vice president for government affairs and public policy for the American College of Physicians-American Society of Internal Medicine. His group and the AMA support tax credits to help the working poor and middle-class buy insurance.

Many proposals to reform the U.S. health-care system have surfaced in recent years, including three that were introduced in the 1999-2000 Congress: the Health Security Act of 1999 (H.R. 1200), the Health Security for All Americans Act (S. 2888) and the States' Right to Innovate in Health Care Act of 2000 (H.R. 4412). Only the Health Security Act of 1999 would have initiated a single-payer universal health-care system, and none of these bills became laws.

Realizing the national situation looks grim, many single-payer supporters are trying to turn states into incubators for universal coverage. Build popular pressure at the state level to trigger federal action-that was how Medicaid got started.

Last year, universal health care was on the legislative agenda in 12 states. Just like their federal counterparts, no major state bills became laws. Ballot initiatives in Maryland, Massachusetts and Washington were either voted down or never made it on the ballot. All met strong opposition from drug companies and the insurance industry that out-spent and out-spun.

The Massachusetts referendum would have required the state to implement a universal health plan within two years. It was defeated narrowly last November 52 percent to 48 percent. Supporters said they were pleased with how close the vote was, given the big-bucks, negative advertising campaign waged against it.

And in response to these failures and other difficulties, many states have retreated to the patchwork approach-creating safety-net programs. Some programs help people pay for prescription drugs. Others expand Medicaid eligibility. And still others provide new health insurance programs for those who don't qualify for Medicaid. Wisconsin's BadgerCare, for example, has helped earn that state the lowest uninsured rate in the country-8.4 percent. But like other states, Wisconsin constantly struggles to find the money to keep BadgerCare from disappearing into a hole.

So despite widely differing reform efforts, nearly everyone agrees something has to be done to make the U.S. health-care system fairer and more cost-efficient. But until some consensus is reached, the United States will continue to just get by with an inadequate patchwork of safety-net programs for the uninsured and underinsured. -H.B.


MYTHS & FACTS ABOUT SINGLE-PAYER UNIVERSAL HEALTH CARE

MYTH: It would cost too much money.


FACT: A single-payer universal system would cost no more than we're already spending on health care, according to studies by the Congressional Budget Office, the General Accounting Office (GAO), the Lewin Group, and the Boston University School of Public Health. The GAO estimates if the United States changed to a universal single-payer system, it would save in the short run: $34 billion in insurance overhead and $33 billion in hospital and physician administrative costs. This savings would come from providing timely care to those who would otherwise delay care, thereby becoming sicker and more expensive to treat.


The cost of serving the newly insured would be about $18 billion. The cost of providing additional services to the currently insured-due to elimination of co-pays and deductibles-would be about $46 billion.

MYTH: It is socialized medicine.


FACT: A single-payer universal health plan is not socialized medicine. Under socialized medicine, the government owns the hospitals and clinics. Doctors and nurses are government employees. A single-payer universal health plan preserves private ownership and employment. It has no more in common with socialized medicine than does Medicare. What's unique about a single-payer universal health plan is that all health-care risks are placed in a universal risk pool covering everyone.

MYTH: Americans would pay more.


FACT: Several studies show costs for middle-class Americans would not increase. All but the poorest Americans would pay more income tax, but in most cases the tax would be equal to or less than what they currently pay for health insurance premiums, co-pays and deductibles, which would largely be eliminated. Money to take care of the currently uninsured would come from money saved by eliminating private insurance overhead costs and by spending less on high-tech equipment that duplicates or exceeds what's needed in any geographic region.

MYTH: It would create a huge bureaucracy.


FACT: Experts say the employer-based managed-care system is already a huge bureaucracy. It consumes 9 to 15 cents of every health-care dollar. Medicare, a single-payer plan for seniors, spends only 2 to 3 cents of every dollar on bureaucracy.

MYTH: It would cost employers more, make them less competitive and force them to fire employees.


FACT: Experts say the employer tax would equal but not exceed what employers currently pay for health-care premiums and paperwork/billing overhead created by the current multipayer system.

MYTH: Medicine would be rationed.


FACT: Managed care already rations medicine. A single-payer universal health plan would ration services based on medical necessity. Managed care rations services based on profit. Under single-payer universal health care, no one would be denied care due to pre-existing conditions.

MYTH: Americans would have trouble getting in to see a doctor.


FACT: Canadians, who live in a single-payer system, see their primary care physicians more often than Americans do now. There are more doctors per capita in Canada than there are in the United States. Yet the cost of physician services in Canada is one-third less than it is in the United States. About half the cost savings in Canada comes not from offering less care but by reducing insurance overhead and paperwork. The rest of the savings comes from allocating money to pay for expensive equipment so there is less excess capacity and duplication. Ninety-six percent of Canadians prefer their health-care system to the U.S. model.

MYTH: Patients wouldn't be able to choose their own physician.


FACT: According to experts, a single-payer plan would give patients more choice than they currently have in most cases. The United States is the only developed country heading in the direction of less choice. Other countries are building more choice into their systems.

MYTH: The United States has the best health care in the world.


FACT: The United States has higher infant mortality, higher surgical mortality and lower life expectancy than Canada. The United States has a much lower rate of access to primary care doctors than Canada. Canada has the same acute care bed-to-population ratio as the United States. Patient satisfaction, quality of care and outcome of care in Canada equal or exceed that in the United States, according to the U.S. General Accounting Office. For this lower quality, Americans pay 40 percent per capita more than Canadians do on health care.

MYTH: There would be waiting lists for surgeries and high-tech procedures, which is why Canadians come to the United States to get health services.


FACT: The United States has waiting lists for specialty care, too. Canadians rarely come to the United States for health care. Less than 1 percent of Canada's health budget goes to paying for care Canadians get in the United States. Canada's waiting-list problem stems largely from underfunding, which is being corrected now. Waiting times would likely be no longer in the United States than they are now, because we would still spend much more than other countries do on health care and still have many more specialists and capacity.

MYTH: Physician salaries would be lowered, as would standards for physician training. It would discourage the best and brightest from going into medicine.


FACT: Primary care doctors would see little or no change in their salaries. Some specialists would see a decline. All physicians would be paid more if they work in remote or underserved areas. Education, training and licensing policies are so similar for U.S. and Canadian physicians that their credentials are virtually interchangeable.

MYTH: Canadian physicians are unhappy with their system.


FACT: Nearly two-thirds are either "satisfied" or "very satisfied." About 500 Canadian doctors emigrate to the United States each year-representing about 1 percent of all Canadian doctors. Some return to Canada.

MYTH: U.S. physicians don't want a single-payer universal health plan.


FACT: Despite pervasive negative spin, 57.1 percent of U.S. physicians believe a single-payer system with universal coverage would be the best option for the United States, according to a 1999 New England Journal of Medicine survey. ~~~Howard Bell is a contributing editor with The New Physician. He lives in Onalaska, Wisconsin.
~Universal Health Care~
210~1January-February~2001-50~Feature~Help Wanted: Geriatricians~THE CHANGING FACE AND INCREASING NUMBER OF AMERICA'S SENIORS RENEW MEDICINE'S MANDATE FOR TEACHING ELDER CARE.~Jennifer Zeigler~~The number of television advertisements for arthritis medication, hair loss remedies and memory boosters should tip you off—the baby boomers are getting older. In 10 years the first ones will turn 65, ushering in a whole new set of shared experiences for the generation that has shared every other stage of life with the world. The question now is: “Can medical education keep up with the rapidly aging population?”


To the people he treats, 40-year-old Dr. Thomas Perls is a young ’un. When they were his age, the War was just getting started. We’re talking the Second World War: Swing dancing was enjoying its initial heyday, and women were going to work outside the home for the first time. Hitler was the enemy, and patriotism was high. But Perls’ patients were not the dewy-eyed youths who stepped forward in thousands when Uncle Sam declared, “I want you!” No, these folks were already old enough to be sending their own sons off to European shores.


So to these centenarians, Perls truly is a youth. And he has dedicated his life to managing their health. As an assistant professor of medicine at Harvard Medical School, Perls heads up the New England Centenarian Study, which focuses on the new face of the elderly—men and women who have defied diseases associated with aging by living healthy lives into their 90s and 100s. Perls’ work has gained the attention of national media.


It’s a far cry from his early days in geriatrics care. His teen years volunteering in a Colorado nursing home introduced him to elder care, which back then was “really atrocious,” says Perls, adding that the homes were filled with patients who had no business being there.


But the experience taught him a lot. “I thought I had an easy rapport with these people,” he says. Little did he know that it would really be a future housing opportunity that would bind him to the field forever.


“It’s a little silly, really,” Perls says. He went off to medical school at the University of Rochester, where he met one of his mentors, well-known geriatrician Dr. T. Franklin Williams. When Williams left Rochester to head up the National Institute on Aging, Perls rented his house. And that’s what did it. “He put in the lease that I had to stay in geriatrics,” Perls says.


Kidding aside, it’s become an inspirational adventure, he says. His first two centenarians at Harvard dispelled any ideas that at 100 we should be on the downslide of life. Both still active, one played the piano for anyone who would listen, and the other—a tailor by trade—continued to stitch a living. “And when he wasn’t doing that, he was with his 85-year-old girlfriend,” Perls says.


And these patients transformed him. “I’m one of these guys trying to change public opinions about aging,” he says. “It’s not some bottomless pit.”


UPTAPPED MARKET


Old age is a far cry from a bottomless pit. A recent report from the Federal Interagency Forum on Aging-Related Statistics, a consortium of government agencies including the U.S. Census Bureau, stated nearly 70 percent of Americans 65 years old and older reported good health.


One doesn’t need to look too hard to find an example these days. Nursing homes have largely been replaced by “retirement communities” where elderly residents can swim, golf and bike their days away. Seniors are working longer and remaining active long past the traditional retirement age. Grandmas drive convertibles, and grandpas are living to bounce great-grandchildren on their knees. And for the first time, the long form in Census 2000 included a section specifically for grandparents as caregivers.


Plus, think of the numbers. The Census Bureau, which in April will release Census 2000 data on aging, estimates there are nearly 35 million Americans age 65 and over. That number will double to 70 million by 2030 —thanks to the post-war baby boom. And as the first boomers reach retirement age in 10 years, additional stresses will be placed on an already taxed medical system that is not up to the challenge of caring for 70 million elderly patients, experts say.


So from where Perls and other geriatricians are standing, geriatrics is the place to be—exciting work and loads of opportunities. “The baby boomers set the trends, and they are going to be at the forefront of those issues,” Perls says. “As we give older people more autonomy and allow them to make their own decisions, we are going to see things change for the better. The future is bright. You gotta’ wear shades.”


The future is being lit up in part by the influx of research in the geriatric field. Those in the field say there is no other medical specialty where you can still make research discoveries of the magnitude that you can in geriatrics, while other specialties have been largely tapped out.


Perls says this is a major reason medical students should look at specializing in geriatric medicine. It was a lesson he learned during a six-month stint at an Australian geriatric hospital.


“Hospitals like that don’t exist in the U.S.,” he says. “It was just a fantastic experience. It was just so cool that you could make clinical observations on patients that would lead to research questions. There are things that are untouched, and you just don’t have that in many fields anymore.”


Odette van der Willik, director of the grants program at the American Federation for Aging Research (AFAR), agrees. She says the field of geriatric research is full of opportunities. “You can really make some major findings in this field, which in others is hard to do,” she says. AFAR’s goal is to advance aging research, and it sponsors a program with the John A. Hartford Foundation for medical students to spend three months working in geriatric research in the hope of inspiring a few more academic geriatricians. Perls’ centenarians study takes a couple of students a year from the program.


One of those students was Dr. Brent Ridge, who two years ago spent a summer working with Perls. Now an internal medicine resident at Columbia University with an intent to pursue a geriatric fellowship, Ridge says medical education should highlight interesting work like the centenarians study to interest more medical students. “You could promote it in a way that makes it sexier,” Ridge says. “A geriatrician is not someone who just works with nursing homes.”


Nursing homes, hospitals, research facilities—no matter where future geriatricians decide to work, there will be opportunities. It’s economics, really. The growing number of elderly means a growing need for geriatricians. “They should really consider it because they really won’t have a problem finding a job,” says Kathleen Bond, a public health analyst with the Geriatrics and Rural Health Branch at the Health Resources and Services Administration (HRSA).


Physicians young and old would be wise to consider more geriatrics education. Dr. Christine Cassel, chair of the geriatrics department at Mount Sinai School of Medicine in New York City, says the idea was put into real terms when a colleague mentioned he was serving as the medical director at a local nursing home. “I didn’t know you were getting into my line of work,” Cassel said. “Anybody with any brains is getting into your line of work,” he replied.


Geriatrics is also a medical home where clinicians can live normal lives, Perls says. When a surgery specialty beckoned back in his training years, he says his ultimate allegiance to geriatrics also became a lifestyle thing. “I didn’t want to be up at 5:30 [a.m.] and staying until 8 [p.m.] every day,” he says, adding that geriatrics allows him to avoid that. Despite serving in an academic, research and clinical capacity at Harvard, he still finds time to give to the other end of the generational spectrum by coaching his young daughter’s soccer team.


CRISIS IN CARE


Not everyone has gotten the message about the advantages of a career in geriatrics. The American Geriatrics Society (AGS) estimates the current crop of elderly patients could support 24,000 geriatricians, but there are only about 8,000 practicing in the United States. By 2030, when one in five Americans will be 65 or older, the geriatrician need will have grown to 36,000. However, the Alliance for Aging Research projects only 10,000 physicians will complete the necessary training by then.


The shortage has been enough to make even the U.S. Senate sit up and take notice. In 1998, Sen. Chuck Grassley (R-Iowa) presided over a Senate Special Committee on Aging hearing convened to discuss the growing problem. Little has been done legislatively since then, although all participants that day agreed something had to be done.


And while some say we’re not really headed for a crisis if we don’t do something, Joan Weiss, Ph.D., a registered nurse practitioner and chief of HRSA’s Geriatrics and Rural Health Branch, admits elder care could be on the downslide if things don’t change. “If we don’t have providers that can care for the elderly, it will ultimately affect the quality of care,” she says.


Myra Hurt, Ph.D., argues the lack of geriatricians has already reached crisis-level. Hurt is the acting dean of the newly created medical school at Florida State University (FSU), which will apply a geriatric model to much of its medical education when the first class arrives this summer. Florida is definitely feeling the pinch in terms of a lack of physicians with geriatrics knowledge, Hurt says. “We have money—people can get care, but I don’t know that we can get the care we need,” Hurt says. “Well seniors would tell you they feel they’ve gotten lost in the process.”


An article recently published in the Journal of the American Medical Association reinforces Hurt’s concern. The study found Medicare recipients are not getting the medical care they should be, despite having coverage from the federal program. The gaps in care often lead to serious medical outcomes, researchers suggested.


Part of the problem stems from the unique way physicians treat the elderly. Geriatric medicine involves not just biological issues, but psychological and social ones as well. Elderly patients are often dealing with loss of loved ones, loneliness, changes in economic status and other issues that a physician wouldn’t necessarily have to deal with when caring for younger patients. “The elderly are just more complicated,” Weiss says.


Dr. William Hazzard, a past AGS president, sums geriatrics up: “It’s low-tech and high-touch.”


But that’s not a drawback; that’s a benefit, says Marty Evers, a second-year medical student at Mount Sinai, who intends to pursue a career in geriatrics. “Some of the great things about geriatrics are that it involves so many other areas of medicine,” he says. “It’s very much an art as well as a science. But it’s an art that I think to some extent isn’t being taught.”


There are biological differences too. Geriatric clinicians need to be well-versed in pharmacology because so many patients are on multiple medications. And geriatricians say physicians need to get past the idea they have to cure everything. Elder care has a lot to do with easing chronic problems instead of curing acute medical illnesses as many other specialists do.


Cassel stresses the intellectual demands of treating the elderly. “The clinical medicine required to take care of the healthy 80-year-old who has five chronic illnesses and is on eight medications—you need to be a fantastic internist to take care of that lady,” she says. “A lot of students think it is just social work; they don’t understand the science behind it.”


“The majority of things we see has an ameliorable component to it,” Perls says. “A lot of it has to do with making a dent in something and not curing it. All those dents add to a quality of life.”


And while not every person over the age of 65 needs a certified geriatrician, they all need a physician with some geriatric training. Experts say physicians in every medical specialty, save pediatrics, need to have a working knowledge of geriatric medical issues.


“I don’t think anybody will tell you that what we really need is enough geriatricians to treat everybody,” Hazzard says. Instead, he says the best outcome would be a world in which internists, cardiologists, urologists, gynecologists, oncologists and every other specialist are really good at geriatrics.


GERIATRICS IN MEDICAL EDUCATION


Most experts agree, then, that the way to improve elder care is to improve medical education to offer experiences in geriatric medicine. “Dr. Williams told me we don’t need more geriatricians to take care of older people; we need more geriatricians to train physicians to take care of older people,” Perls says.


This is, of course, an exaggeration—the deficit of certified geriatricians to care for the sick elderly is great enough to require thousands of additional specialists. But it is for this reason that Perls disagrees with a recent decision to allow residents to sit for the geriatrics certification exam after a one-year fellowship instead of the previously required two years. “The purpose of the fellowship should be to train more academic geriatricians,” he says. This requires at least a two-year fellowship because of the amount of research necessary to enter the field, he says.


Regardless of how many years they are, geriatric fellowships are underused, Hazzard says. The extra one-year fellowship is often difficult for physicians-in-training to commit to after finishing a seven-year education process that few escape debt-free. So instead of a one-year fellowship after a three-year internal medicine residency for the clinical geriatrician, Hazzard has argued the importance of geriatrics in internal medicine is so great that the internal medicine residency should be expanded to four years.


To see a boost in academic geriatricians, Cassel recommends a department of geriatrics be instituted at each medical school to provide students with more role models. “We all know students respond to role models,” she says. Unfortunately, geriatrics suffers from the same chicken-and-egg syndrome other less popular specialties have fallen victim to. That is: How can we encourage more clinical geriatricians if we don’t have enough academic geriatricians to begin with?


Internal medicine resident Brent Ridge says as a student, he recognized the need for more geriatric faculty. “I certainly have not met a wide number of people who practice geriatrics,” he says, citing just two mentors in particular. To help alleviate the problem, the federal government is pouring $10 million annually into HRSA’s geriatric education programs, one of which focuses on encouraging certified geriatricians to become academic leaders.


But the specialty still encounters barriers. A major reason for the deficit in geriatrics-trained clinicians is the relatively low pay they command. The median income for geriatricians is about $141,500—the lowest of the medical specialties, according to the Medical Group Management Association. “Health care of the elderly has the lowest prestige,” Hazzard says. “It’s not something that’s easy to embrace.”


In addition to low salaries, physicians are also faced with a patient population nearly entirely on Medicare, and low reimbursement rates scare some would-be geriatricians off. But Cassel says because deep discounts in managed care have pushed reimbursement rates progressively lower, Medicare rates may actually be higher now than other health plans, making elderly patients look better and better these days.


And as Perls optimistically maintains, the future of geriatrics is getting brighter in other areas—research and education funding has improved as boomers start looking into the future and wondering about the care they will be able to get as they age.


Hazzard suggests geriatricians should harness the power and money the boomers wield. “We should take advantage that the boomers are going to drive this,” he says. It was, after all, the boomers who helped spur medical education in the 1970s to better train obstetricians—just as they were having their own children. Now faced with their retirement years, their influence will undoubtedly turn to better elder care.


But perhaps it already has. Cassel points to New York City where geriatricians are beginning to command better salaries than in other areas of the nation. When it comes right down to it, she says, elderly patients prefer geriatricians, and hospitals use them to market their services. “There are so few of them [here],” she says. “It’s a seller’s market.”


CALL TO ACTION


The bottom line, experts say, is that we need to get geriatric care education to every medical student, regardless of the specialty they intend to pursue, and a few in medical education have heard this call to action.


One such person is Dr. John McCahn, associate dean of academic affairs at Boston University’s (BU) School of Medicine and a faculty member in BU’s geriatrics section. BU requires a home-health geriatrics rotation of its students in an attempt not just “to create people who will spend all their lives in geriatric medicine, but [to ensure] there will be training for all physicians,” he says.


Students are sent to hospices, nursing homes and retirement centers to see firsthand care for both the healthy and very ill elderly. “Problem is,” McCahn says of most schools’ lack of geriatric education, “the training uses not what are thought of as top-notch training sites. I think academic medicine needs to get over this notion that unless one is training in a teaching hospital, one is not getting relevant training experiences.” He points out that 15 percent to 20 percent of the over-70 population is considered ill and living in nursing homes, and students need to experience this reality in addition to that of the healthy elderly.


Amen, say hospice workers, who have been aware of the rapidly aging population for a while now. “Hospice can be part of the solution for dealing with the influx of elderly deaths,” says Dr. Bill Lamers, an early hospice leader who taught medicine in every state except South Carolina. He says the increased efficiency of hospice care over that in a teaching hospital can cut costs and provide the ideal location to train medical students. “There have to be opportunities for medical students to get involved with the care of the dying.”


Even if educational institutions aren’t getting the hospice hint, some students are. Evers, who went to medical school because of his experiences volunteering at a hospice facility, spent last summer with AFAR researching palliative care practices among the aging. He says the idea of pain management—essential to the palliative care movement—can be conveyed to elder care, regardless of whether patients are at the end of life or not. “Pain is underdetected and undertreated in the elderly beyond the last six months of life,” he says. “It goes along with the aging process, and there’s a lot we can do to manage it.”


IMPLEMENTING THE MODEL


Perls looks forward to the day when all students have a required geriatrics curriculum and home-care rotations. “In the face of the demographics, I think [to not do so] is just absolutely wrong,” he says.


According to the Association of American Medical Colleges, 122 of the nation’s 125 allopathic medical schools require some sort of geriatric course work. However, Cassel maintains that few schools require geriatric rotations, and she cites a statistic showing the number of students opting for a geriatrics elective—2.9 percent in a 1992 report—is decreasing. Van der Willik says most students believe that all geriatricians do is hold a death watch over their patients. This stigma contributes to the lack of interest.


But some schools have seen the light. The University of Missouri—Kansas City School of Medicine (UMKC) is beginning an intensive geriatrics experience in its six-year B.S./M.D. program with the help of a $100,000 grant from the Hartford Foundation. The initiative, which will kick off in February, will pair each student with a healthy resident at a local retirement village for the first two years of the program in order to give students exposure to this new breed of energetic retirees.


“The purpose of that piece [of the initiative] is to learn about the aging process,” says Louise Arnold, Ph.D., UMKC’s associate dean for medical education. “Unless physicians intimately understand the living circumstances of their patients, they are not going to be able to adequately care for that patient,” she says. “We may [lay] down a wonderful foundation of an appreciation of older people that may get washed out in a traditional…program that may have a different idea of older people.”


UMKC’s geriatric education in the program is more extensive than the mentor pairing. Medicine will be taught based on what Arnold calls a “life cycles approach” with an eight-week program on aging in each of the first two years. Year three will find students in a unit on communicating with older patients, where they will learn to look at things from the elderly perspective. Students will don oversized rubber gloves and glasses smeared with Vaseline while they are instructed to negotiate a medicine bottle. They will also take two-month internal medicine rotations in the final three years of the program where the experiences will be geared toward geriatrics. The students will be expected to make home visits to patients at retirement centers and to those they discharged from hospitals and nursing homes.


Arnold says early exposure to aging issues is essential to the program. “I wonder if they are more malleable at that time or if they will develop a better understanding of the elderly and aging. Certainly that is the hope of the program,” she says.


The hope of FSU’s new geriatrics-based education model is that it will churn out more geriatricians for its elder-care-strapped home state. Myra Hurt says the M.D. program will focus on the well elderly, in keeping with the country’s trend toward the more active senior. “Most medical students don’t get the opportunity to spend time with ‘normal’ elderly,” she says. “That may seem like a silly concept, but we don’t get the chance to look at that much. Too often the focus is on the last stage of life.”


It’s just what Lorna Fedelem, one of the first two students accepted to FSU, was looking for in a medical school. “I am not interested in geriatric medicine because the boomers are aging. I never really thought of it that way. I feel that it is a field where compassionate and patient doctors are needed….”


Hurt says it will be easier for FSU, as a new medical school, to beef up geriatrics-based education in the traditional curriculum. Usually much hand-wrenching accompanies a mandate to increase education in a particular area, and the question becomes “What do we cut?” But at FSU, “we have a fresh slate…. We can say, ‘OK, we want to develop the curriculum to look at the aging human.’”


And while Fedelem says it’s true some students may be turned off from applying to the fledgling medical school because of its unusual concentration, students need to step out of their “comfort zone” and be realistic. “People are living longer, and we cannot just ignore the older generations. Geriatric medicine is a very challenging field. If more students could realize that, maybe there would be more interest.”
~RESOURCES ON THE WEB


For more information about geriatrics and opportunities in aging research, visit these organizations on the Internet:

~~~Jennifer Zeigler is a senior writer with The New Physician.~Career Development,Practice of Medicine~
211~1January-February~2001-50~Feature~From the Other Side of the Gurney~HOW ONE MEDICAL STUDENT'S EXPERIENCE AS A PATIENT HAS AFFECTED HER LIFE ON THE WARDS.~Julie Larson~~It was 1:30 a.m. I was supposed to have left my evening shift in the emergency room (ER) at midnight. It was my second year in medical school, and I was on an early clinical rotation in emergency medicine. Walking briskly down the hallway, I tried to find the attending physician who was covering the back hall. I poked my head into one of the examination rooms and encountered a patient lying on an exam table with an IV in one arm and a splint on the other. He looked up at me, wide-eyed, wondering if I was there to help.


“Excuse me,” I said and darted back out of the room. I peeked into the next several rooms, still trying to find the attending physician. In one room a boy was undergoing a lumbar puncture, and his mother watched nervously. A nurse held his legs in an awkward position while the resident carefully maneuvered the spinal needle through the layers of tissue in search of the precious fluid. In another room, a man sat with his wife, who fell off a ladder and broke her wrist in three places. They patiently awaited the orthopedic team who would evaluate her case. It had been more than four hours since they arrived.


The pace in the ER felt natural to me—a quick darting in and out of rooms that required you only to focus on one or two pertinent items at a time without getting bogged down by details. I navigated the narrow hallway toward the medicine and supply rooms. Finally, I found my target—the man in the white coat rushing from the suture cart, laceration tray in hand. “Is there a laceration in one of the rooms?” I asked.


“Yes, it’s a triple finger laceration in 13b.”

“I was wondering if I could do the digital block and sew them up,” I said, forgetting for the moment that I had wanted to go home.

“As soon as the X-rays come back negative for a foreign body, you can have it,” he responded.

“Thanks.”


I turned, walked briskly toward room 13 and then stopped. I stood in the hallway immersed in thought, barely able to collect myself as I realized the absurdity of my behavior. I had just referred to a patient by his chief complaint and even worse, I didn’t even know his name. I had been rushing from room to room—moving as anonymously as possible without any real connection to the patients for whom I was caring. As I thought back to what attracted me to medicine several years ago, I was overcome with a deep sense of self-disappointment.


Much of my motivation for entering this field was based on my experiences as a patient. Only three years ago, I was a surgical patient lying on a gurney in this same hospital. It was my fourth surgery for endometriosis in eight years. For those who are unfamiliar with this disease, it’s a condition in which the endometrial tissue that is normally restricted to growth inside the uterus grows outside of it on nearby pelvic structures. It can cause severe pain with menses and can lead to intra-abdominal scarring and infertility. Before my diagnosis, I had suffered for several years from chronic pelvic pain and vague bowel and bladder symptoms.


Remembering what it was like to have doctors hovering over me in the operating room, I cringed at my behavior toward the ER patients. How would I have felt to be referred to as “the laparoscopy in room 4?” I would have felt demoralized, devalued and reduced to a bag of tissue and bones. And yet, here I was three years later doing exactly the opposite of what I had envisioned for myself as a physician-in-training. Time to refocus, I thought. So I began to write.


Since that night in the ER, when I was on my early clinical rotation, writing has become the vehicle through which I reflect on medicine’s daily challenges and attempt to define the kind of care I would like to provide as a physician. It has served as a constant reminder for me to take the patient’s perspective in my daily work even in the face of institutional and time pressures and my own self-interest.


Throughout this process, my perspective on my own illness and how I deal with it from day to day has changed. Here are a few excerpts from my journal that explain some of what I’ve learned over the past several years from both sides of the gurney:


JUNE 2000


Today is the last day of my neurology rotation, and I’m working with a resident to admit a woman with several vague neurological complaints. We discover that she has altered sensation in her limbs and falls to one side while walking. A discussion of her case ensues wherein one resident says, “You should have seen her walking down the hall. If I didn’t know better, I would say that she looks perfectly normal. It might be time for a psychiatric consult.”


The other resident nods and says he has seen many a patient, usually female, with vague complaints like these turn out to have psychological rather than medical issues. I listen intently, trying to make up my mind for myself. As I think about her case, I recall that my own illness presented with vague complaints that were difficult to explain with a unifying diagnosis.


The attending physician decides to have the team vote on whether the patient’s MRI will be normal or abnormal. He asks me to vote first so I’m not swayed by the others. I decide to stick with my intuition. “Abnormal,” I say. All of the residents vote for “normal.”


The next day an MRI shows that she has abnormalities consistent with early multiple sclerosis. When I research further, I find that patients frequently present with waxing and waning symptoms early on in the course of the disease. She had walked normally down the hall, which was consistent with this stage of her illness. I promise myself never to doubt a patient’s complaints until given a strong reason not to. My intuition is, in part, a product of my experiences as a patient—experiences that remind me to put myself in this woman’s place. In this way, my illness is a gift.


AUGUST 2000


It’s the third week of my medicine core clerkship, and my team is on call for admissions. I have just been assigned a patient with a diagnosis of systemic candida infection who is being transferred from a regional hospital. In a patient with a normal immune system, this is a grave condition. If she is immunocompromised, it becomes a near death sentence. I ask the senior resident for some details about the woman.


“She’s had a five-week hospital stay with multiple complications,” she says. “As far as I know, she isn’t immunocompromised in any way. There may be some problems with her transferring paperwork, however. She’ll be a tough case.”


When the patient arrives, the intern and I find that she has no discharge note. Her entire five-week hospital stay is contained within an unorganized folder of lab results, radiology reports and messy handwritten progress notes. The intern’s usual cheerful demeanor has vanished.

“Do you want to be the reader or the scribe?” he asks me.

“Scribe,” I say.

The intern and I spend the next three hours working to stabilize the patient, obtain a history and turn a mess of unorganized papers into a concise admission note. I resent having to generate a note that should have been done by the transferring hospital. It’s now 2:30 a.m. The intern turns to me and asks, “So, did you think this is what medicine would be like?”

I pause to think, then reply, “I thought there would be a little more intellectual work and a little less paperwork.”

“Not much glamour here, is there?” he says.

“No,” I say.


Finally, we get the chest X-ray back from the radiology suite. “Her lungs look like cotton candy,” the intern says. Standing in the patient’s room, we observe her from the foot of the bed. Her breathing is rapid, and she appears febrile. We examine her from head to toe and find that she has stool leaking from the bag that’s attached to her abdomen. She has a fistula between her colon and skin that developed after a simple surgery several weeks ago. I glove up and examine the skin around it. This is not the most pleasant of tasks. Stool has leaked down between her legs, and there’s blood in her colostomy bag. I ask the nurse to have someone come in and clean up the mess. The patient is awake, and she asks for some morphine. The intern is hesitant to give it to her.


“Where do you hurt?” he asks.

“All over,” she says.


The intern writes for a small dose of morphine with some hold parameters. We decide that a CT scan of the chest and abdomen is in order for the following day. We don’t sleep at all that night because the patient requires such an intensive medication management, and we’re worried about her respiratory function. We’re on the verge of calling the ICU team at the first sign of respiratory function deterioration.


The next day, we get the CT scans back. Her lungs are diffusely infiltrated with the infection, and there’s a question of pulmonary edema. She has two large clots of blood lodged in her pulmonary circulation. We’re left with the task of treating this with anticoagulants without causing her to bleed more from her gastrointestinal tract. By the end of the day I’m exhausted. I haven’t slept for 36 hours, and I would have been home by now had she not been such a difficult case. I have spent five hours this afternoon putting a gloved finger in almost every orifice of her body, managing her medication issues and trying to comfort her family. I think back to my own experience as a patient and to the people who cared for me during my roughest times. My feelings of resentment are offset by the hope of seeing this woman through to discharge from the hospital. Sometimes hope is the best thing we have to rest our hearts on.


SEPTEMBER 2000


This week I’m part of a team who admitted an elderly man with mental-status changes and a history of several minor heart attacks. The treatment team orders the entire stroke work-up: carotid Doppler ultrasound and an MRI/MRA. The patient becomes so agitated in the MRI machine that we have to sedate him. By the time we get him out of the radiology suite, he is in and out of consciousness and responsive only to pain for most of the day. We give him several different medications to reverse the sedation, but they don’t help.


On the third day of treatment, he begins to deteriorate and doesn’t recognize his daughter when she comes to visit. The standard treatment regime doesn’t control his blood pressure and heart rate, so the intern and resident order several medications to be given by continuous drip. By the end of the day, he’s on four different drips, and his heart rate and blood pressure haven’t improved. We put him through a battery of tests that confirm our suspicions. He has had a severe stroke in the parietal lobe and has evidence of early hemorrhage around the infarcted tissue.


When his daughter returns to visit that evening, he is still unresponsive. She looks bewildered and pained. “Why are all of these things being done to him?” she asks. “Why did he have to have all those tests over the last few days that no one asked me about?”


The team has known she has durable power of attorney since the day her father was admitted. As I ask her what she wants in terms of her father’s care, I realize that no one has done this. She says she doesn’t want us to withdraw supportive care, but that she wouldn’t have wanted us to do all of the tests in the extensive work-up. We simply assumed that we should do everything possible for this patient. We spent so much time adjusting drips, ordering sedatives and constantly monitoring his vital signs, yet never took the time to monitor how the needs and wishes of the family might be changing.


The decisions I had to make regarding my own care were often complex. They involved balancing what was available with what was tolerable from a quality-of-life perspective. My physician always took the time to ask me what I wanted and never assumed that every possible treatment should be attempted. When treatment decisions are more crucial (i.e., in an older patient or a patient with a life-threatening illness), it is even more important to make sure we’re communicating with patients and families about these issues. Sometimes the best skill we have as physicians is overlooked—the skill of conversation. One of my mentors once told me: “The greatest tool that we have as physicians is…the telephone.”


As I enter the realm of clinical medicine, it’s frustrating to see how the culture of medicine and hospitals’ institutional structure serve to detract from establishing a real connection with patients. There are things that we do as physicians, residents and medical students that fly in the face of providing empathic care. We have lengthy teaching rounds at the hospital, which take us away from patients. We refer to patients in a derogatory manner despite our dedication to compassion and beneficence. I have overheard consulting physicians deflect patients from being admitted to their service if they appear exceedingly difficult to manage or if there is a possibility that they might be handled by another service. Worst of all, I once heard a group of surgeons laughing outside of the operating room about a case in which too little skin was left during a leg amputation, which necessitated removing more of the patient’s limb than was necessary. If only they had ever been on the other side of the gurney at one point, I thought.


Illness requires that we look deeply into our own human frailty and that we become more comfortable with the fragility of the human body, knowing that we will all be patients at some time in our lives. It teaches us to accept uncertainty rather than fear it—to wake up each day wondering what we might encounter rather than dreading the unknown.


I have found my illness to be an educator and a motivator, and I’m eager to share my experiences with others. Yet I need to do this anonymously. This year I will be applying to residency programs, and I’m concerned that revealing this aspect of my life will hurt me. There remains a stigma associated with being ill, and it’s perceived as being a weakness among many in the medical profession.


I have never experienced my illness as a weakness. If anything, it has helped me to become a more empathic and dedicated medical student and has led me to take extra care in admitting, treating or discharging a patient. I have never missed a day of my training due to my illness. And each day I am reminded of how much my illness is a part of me and how I need to continually claim it, appreciate it and learn from it.


This morning, I woke up knowing that I will have a test to determine whether I’ve lost bone mass on my current medication regimen. As I ride my bike to the hospital, I realize that if my bone density falls, I will have to stop the treatment regimen that I have done so well on. I’m afraid, and I try to embrace this fear—knowing that many of my patients will encounter the same feelings today.


Before I go for the exam, I pre-round on my patients at the hospital. I find myself running late because one of my patients was vomiting during the exam, and it took longer than expected. When I get to the radiology check-in area, seven other people wait to be registered by a hospital employee. I realize that I’m still wearing my white coat and that my stethoscope dangles from my neck. Is everyone expecting me to walk back into the radiology suite, as a doctor would normally do? I look to the chairs by the wall and walk over to the first open one. I take a seat next to the last person in line. He turns to me and asks, “You too, huh?”


I smile and say, “Yes.” And for the first time I feel truly grateful for this fact.
~~~~The author is a fourth-year medical student at a West Coast medical school. She has chosen to write this story under the pseudonym Julie Larson.~Humanistic Medicine~
212~2March~2001-50~PremedRx~Deadlines for Dummies~HOW TO STAY AFLOAT IN THE APPLICANT POOL.~Paul Jung~~When applying to medical school, most applicants begin their application process focusing on the deadline the American Medical College Application Service (AMCAS) sets, typically sometime in late fall. What premeds don’t realize is that concentrating on the deadline is the wrong thing to do, for it can lull applicants into a false sense of security—regardless of the quality of their credentials.


Notice that the AMCAS application also indicates a date at which they begin accepting applications, typically in early June of the year before you wish to matriculate. Why would they list a “first date” of all things?


Well, here’s a scenario for you: Two students who lived near Washington, D.C., home of AMCAS, wanted to apply as early as possible to medical school. They prepared their applications and were ready to turn them in on June 15, the day AMCAS would begin accepting applications. So, first thing that morning, they drove down to the AMCAS offices and personally handed in their applications. When they arrived, the secretary gladly took them, stamped their return postcards “received” and handed the cards back. The students looked at the stamps, which read “#63” and “#64.” Apparently 62 people had somehow turned in their applications before these two had arrived, presumably by overnight mail.


What does this story have to do with deadlines? In the medical school application race, there are always people ahead of you. Therefore, you should try everything possible to stack the deck in your favor. Of course, good credentials on your application go a long way, but now we’re talking about the process of applying. And this process requires savvy skills just as much as it does high exam scores and perfect internship experiences.


Take full advantage of your “lifeline.” Yes, it’s true that your application will be accepted by AMCAS until that deadline in the fall. But in contrast to this date, you should consider the first day that applications will be accepted as your “lifeline.”


Most medical schools have rolling admissions. This means that they take applications in the order in which they’re received and admit or reject them at that time based on the quality of the applicant. This may seem painfully obvious to you, but think of it another way. When the admissions committee begins reviewing the first application, there is a wide-open class waiting for its seats to be filled. As application season winds down, only a few open seats remain, maybe only wait-list spots. When would you want your application to be considered? When there are numerous openings or only a few? To put it bluntly, the longer you wait on your application, the fewer the seats that will be available.


There are usually two lame justifications for waiting to apply: “AMCAS didn’t send me my application in time” and “I can’t complete my application that early!”


You can do two things to make sure you get your application in early. First, you can request the application well in advance of June. Although the mail may be tardy, ordering your forms early should give you enough time to complete the application and submit it on the lifeline day. Second, you can obtain a copy of last year’s forms so that you can practice filling out the application before the official application arrives. (Getting the spacing right on a typewriter isn’t easy for a generation that grew up with computers.)


One recent improvement to this process is the electronic version of the medical school application, known as AMCAS-E. You can download the application files from the Association of American Medical Colleges’ Web site, www.aamc.org, or obtain the software from your university health professions adviser. Regardless of how you apply, you should still adhere to the lifeline and keep the application dates prominent in your mental calendar.


The second argument, that you can’t possibly complete your full application that early, usually stems from the idea that once your application is typed, it is complete and the admissions committee will have no other material on which to judge your candidacy. Again, this is a misconception. And in this case, you can use an early, perhaps “incomplete,” application to your advantage.


Once you’ve submitted your application in June, you still have a full year of activities and courses to complete that aren’t part of your original application. So, each semester you can send a copy of your updated transcript to the individual admissions committees.


Assuming your grades are good, this is an opportune way for you to remind the committee of who you are and reinforce your name in their minds. This can also be done with extracurricular activities and any awards you may receive. For example, if you’re elected to Phi Beta Kappa or win a local award, you can write a letter to the admissions committee notifying them of this fact. Or, better yet, have your health professions adviser or another college adviser write that letter—it lends more credibility and formalizes your achievement.


Notifying the admissions committees of your achievements puts your name on top of the application pile a few more times. It never hurts to link your name with positive achievements for the benefit of the admissions committee, and this is a good way to do it.


Implications for MCATs. Of course, aiming for an early application lifeline affects when you should take your Medical College Admission Test (MCAT). If you take the spring MCAT and do well, you have no reason not to apply on the lifeline. And even if you didn’t do well or didn’t take the spring exam, you should still submit your application on the lifeline. By doing so, you put your foot in the door of the admissions committees; they become familiar with your name and achievements and when your September MCAT scores arrive (hopefully good ones), it reminds them to revisit your application.


If you wait until the September scores return before you even begin filing your application, the deck is stacked against you. Just think about all the other applications they’ve received and applicants they’ve invited for interviews before you’ve even pasted your stamp on the envelope.


Submitting your application before your fall MCAT may also be wise if you think your application isn’t up to par. In this case, the admissions committee may tell you exactly what you need to do to get accepted, whether it be a particular MCAT score or grade in a certain class.


To Early D or not Early D? A natural question at this point, then, is the issue of Early Decision (or Early D). This is a program that allows you to apply early to only one medical school on the condition that if you’re accepted, you must attend that school. In general, it is a bad idea to do this.


If you apply Early D, you will receive one of three decisions from the admissions committee: Accept (congratulations—if you’re accepted, you must enroll at that school, no exceptions), Defer (your application now goes into the regular applicant pile, and you are free to apply to any other medical school), or Reject (sorry, but you are now free to apply to any other medical school).


So, how could this be bad for anyone? It all has to do with your reasons for Early D, which is really only an option for the exceptional candidate who has one medical school in mind. How do you tell if you’re exceptional? One way is to ask yourself if you think you’re an exceptional candidate. If you have even a remote doubt that you’re exceptional, you’re probably not. But don’t worry; most good doctors weren’t exceptional applicants to medical school.


Early D is confusing because it gives applicants the mistaken idea that by choosing this option, you’re revealing an allegiance to a particular school and thereby scoring some points with its admissions committee. This is not how it works. One admissions dean told me that he’s amazed at how many good, but not stellar, applicants try Early D, hoping it will simply increase their chances of admission.


If you’re not exceptional, then Early D can only hurt you. First of all, medical schools make these decisions each year around Oct. 1. If you’re rejected or deferred, your application to other schools will be submitted far past the lifeline and close to the AMCAS deadline. The only thing you’re guaranteed with Early D in this case is a late application to other medical schools—not an ideal circumstance.


If you’re an exceptional student, you’ll probably get admitted to the medical school of your choice, regardless of whether you apply Early D or not. If you’re not exceptional, you shouldn’t abandon the opportunity to apply to other schools in a timely manner.


In sum, deadlines are just that—deadlines. Rather than playing that game, give your application a better chance by following the lifeline of early submission. And forego Early D. It usually only causes more trouble than it’s worth.
~~~~New Physician contributing editor Paul Jung is author of Getting In: How NOT to Apply to Medical School (1999, Sage Publications), available at MedBookstore. com. E-mail Dr. Jung with your questions and stories at GettingIn@hotmail.com.~Medical Education,Premedical Education~
213~2March~2001-50~Feature~Welcome to the Girls’ Club~ADVICE FROM WOMEN PHYSICIANS IS MEDICINE FOR THE FEMALE SOUL.~Jennifer Zeigler~~Hindsight is 20/20. We all know that. Wouldn’t it be nice if the toy in cereal boxes was not a pair of 3D glasses but special goggles that would allow you to look at the future with the visual clarity of hindsight? Think about all the medical school angst that could be prevented.


OK, reality time. Of course it would take more than special glasses to survive and thrive in medicine, particularly for women physicians.


So welcome to the girls’ club—a place where women physicians share advice, offer tips and, more importantly, tell stories. But the stories these women tell are not necessarily profound—they’re really just everyday tales of what life in a white coat is like for women. Still, the messages superimposed on them are ones that no female medical student should go without. They provide the insight needed for women to go where they want medicine to take them.


SPEAK UP, GIRLS!


Dr. Deborah Richter, a 45-year-old family physician in Vermont who splits her time between seeing patients and working toward universal health care in that state, grew up in a family that valued gender equality. But when she got to medical school, she found her principles challenged. It all happened during a course in physical diagnosis.


“There were three male medical students in my group and a male attending. We would do rounds in the hospital [visiting the attending’s patients], and he would say, ‘Listen to his heart rate. Listen to the murmurs,’ and whatever.


“So we did each organ system, and when it came down to doing the breast exam, he couldn’t get any of his [female] patients to volunteer for it. So he asked me to be the patient.


“Here I was a medical student, and I didn’t want to, but you felt this pressure. And the other thing that for me was hard was that my mother died of breast cancer. And I thought, ‘I don’t want these guys not to know how to do this.’ So I let my male medical student colleagues examine my breasts. Now I’m also a woman and a student, and [there is this] male locker room mentality; that’s the stage you’re at in medical school. So the next day I came in, and they were giggling.


“There’s no way that would have happened if it had been a testicular exam. There’s no way they ever would have done the reverse. And here they thought, ‘Well, these are just breasts and what’s the big deal? We’re all professionals.’ Well, bullsh--, they weren’t professionals.”


That single episode of gender discrimination reaffirmed those childhood lessons that taught her about equality. Richter knew she had to stand up for herself.


“Whenever anyone treated me like they were treating me differently because I was a woman, I just called them on it. And I mean, I basically stood up to attendings. I never let anyone talk to me disparagingly. I just didn’t allow it. I just had one attending who just screamed and yelled—and I don’t know, he probably screamed and yelled at everybody—and I turned around and said, ‘I can hear you. I want you to talk to me in a civil tone.’ And he did, from then on.


“I think partly we keep thinking that, ‘Oh he’s screaming at me because I’m a woman.’ Well, then you need to stand up to him and say, ‘I’m an adult, and I need to be talked to as an adult.’”


Knowing not to be afraid of standing up for yourself is important. Dr. Elizabeth Morrison, 37, an assistant professor and director of predoctoral education at the University of California, Irvine, shares this story:


“One time I had a male professor ask me out on a date, and I remember it [happened] in kind of a deserted wing at the hospital. It made me feel uncomfortable at the time. I thought, ‘I don’t think this is happening to my male colleagues.’ I don’t think they’re finding themselves down this hallway with this professor who you don’t want to offend, but yet you don’t want to follow through with this request. But also, you don’t want to jeopardize your grade. I just said, ‘No’—that I was not interested in pursuing any personal relationship, and I just kind of got back to the main hallway where the other physicians were as quickly as I could. It was strange. I didn’t feel unsafe; I didn’t feel threatened in any way, but I just felt that it was not appropriate.”


WANTED: GIRLS FOR THE CLUB


Women physicians say it’s also important to stand up for yourself when seeking mentors—and this isn’t always an easy task.


“I still think there are issues and old-boys’ clubs and people more likely to get advanced based on who you know,” says Dr. Helen Burstin, 38, director of the Center for Primary Care Research at the U.S. Agency for Healthcare Research and Quality. “[And] I think women probably have a slightly more hit-or-miss ability to get to the really high-level mentors who will move you to a different plane than I think men do.”


Part of this reason is a lack of women mentors. “[So] whenever possible, find people at those levels who are women. Most of my mentors have been men. I’ve been very lucky, though.


“I think people are not aggressive enough about saying, ‘This is what I want out of a mentor.’ To do that, you really have to think long and hard about who your mentor is going to be. And I think at times women particularly tend to be so willing to take what comes their way. ‘You’re going to be my mentor? Thank you so much.’ Instead of, ‘Thanks. I’m still looking around,’ and ‘Let’s talk,’ but still in your mind think, ‘Is this the right person?’ and don’t lock yourself in. I think women just tend to approach these things differently. I think it’s being choosy, really looking long and hard. Ask other women. Who’s really good? Why are they good?


“I’ve been incredibly blessed, and I think that I can attribute a large part of why I have gotten to where I am at my age because I’ve had really, really powerful, good mentors who have taken and meandered and moved me along in a way that offered me advantages and opportunities that I otherwise might not have gotten.”


Burstin suggests treating the mentor-hunt like a business venture. “Some of it is as deliberate as any other decision that you make,” she says.


DIVERSIFY YOUR SKILLS


Mentors aren’t the only key to success. Dr. Joanne Conroy, 45, says she has spent her 15-year career tapping out a hole in the glass ceiling at the Medical University of South Carolina, working her way to senior associate dean for the college of medicine, senior associate vice president for medical affairs and the chair of the anesthesia department. To successfully break through, she says, women need to be well-versed in areas other than medicine.


“You need to know what leadership means. And you need to be a student first of organization and leadership.


“Ninety-five percent of the [women] CEOs in the country come from all-girls schools. It’s interesting. And so you wonder if they’re doing something different to build leadership skills early on. That doesn’t always happen in other undergraduate schools. And translating that to medicine—if we want women leaders, we should probably be focusing on the medical students very early in their careers,” Conroy says.


Success in Conroy’s world comes from being focused. You’ve got to know what you want.


“[Women] need to make a career plan,” Conroy says. “I can’t tell you how difficult it is for me to get career plans from my female faculty. I ask that of all junior faculty…and I can get them from the guys, but the women have a hard time giving them. I don’t know if [they’re worried] to think that far ahead. But it’s not written in stone. Career plans can change. Not that I don’t think you shouldn’t take advantage of opportunity, but sometimes women’s careers are kind of haphazard, and they need to be pretty focused.”


Conroy says women need to know what their priorities are and stick to them. “Most men will think very carefully about a committee appointment or an additional responsibility, and most women say yes to everything.


“[Women] focus a lot on relationships, and a lot don’t want to damage the relationship with someone they respect because they say no to something. It’s OK to say no for certain reasons. Say, ‘I am simply overcommitted.’”


DR. MOM


While Conroy made a conscious decision early on in her career to give up diapers for a doctor’s bag—a decision these women say is important to think about while still in training—there are female physicians who can handle the balance of family and career. How do they do it? With organization, focus and lots of help.


Dr. Carolyn Kaelin, 39, is a leading breast cancer surgeon, an assistant professor at Harvard Medical School, director of the Comprehensive Breast Health Center at the Brigham and Women’s Hospital in Boston, and mother of two children.


“I was pregnant [with my first child] during my chief residency year and was actually in labor the night of the chief residents’ farewell dinner. But it was an excellent first pregnancy, and it was a slow labor, so I was able to have my IV removed and went to the chief residents’ farewell dinner. At the end of the dinner my water broke, and I trotted back to the hospital, and out she came. It worked very well time-wise. No one was burdened with extra calls.


“I actually took off six months for maternity leave between residency and then starting my first position…and initially worked three days a week and then for the next two years worked four days a week. And then I had my son, Tripp, and took three months of maternity leave. And several months after that, I transferred to the Brigham and Women’s Hospital—they were opening a breast center and had recruited for a director, and it was the perfect opportunity for me. So, to Brigham I went.”


The flexibility of her husband’s schedule and a dedicated nanny help her hold it all together.


“My husband is a physician–scientist at the Dana– Farber [Cancer] Institute. He’s stateside part of the time and traveling the other part.


“Fortunately when he’s home, his schedule is much more flexible [than mine]. He is able to wait for the nanny who gets in around 7 o’clock in the morning, and he doesn’t need to be at the lab at any particular time. If one of the children gets sick, he can accompany them to the pediatrician.” Kaelin’s husband also attends school events on days she can’t put down her scalpel. And when neither one of them can be there, the full-time nanny is.


“And sometimes I need some backup,” she says. “Fortunately my brother lives a block-and-a-half away. It’s good to have other resources. Having family in the area is not something that everybody has. But that’s worked out well.”


But if you’re not committed to keeping a schedule like Kaelin’s, other physician–mothers tailor their careers to suit their needs. Yes, this is possible. Take Dr. Rocio Huet-Cox, 45, an internist with a private group practice in Kentucky. She spent much of her two-decades-long career struggling to balance patients’ needs and those of her four children. Then she decided it was time for a change.


“Originally I was much more conscious of the fact that I had to prove that I could do this life, every third- and fourth-night call, and practicing and living in the hospital and being this physician who was available, available, available. I did buy into that, and I think that when I was home with the kids, I made it a point to be there and to have [a lot of] quality time. So I was trying to be everything—this supermom who stays home, who cooks, [and]…working all the time. It was impossible.


“But then later, as my kids were growing, I thought, ‘God, I’m not there.’” Huet-Cox says she experienced a shift in her priorities—a clearer focus of what’s important to her.


“That’s when I changed. And I said, ‘This is it. I am not going to take call like this anymore. And all I wanted was just a relief from call. I just wanted to have someone admit patients for us.

“And I no longer take call. So that is a major difference. So when I’m off, I’m off.

“I decided I wasn’t going to let [the children] go through adolescence without me there, because I think they actually need you more during those times.

“And so that was the choice I made, and it was hard for me. There were times when people would say, ‘Oh, you’re only part time’—which I’m not, but the assessment was that somehow I was no longer the same [as other physicians].” It took some time for her and other physicians to accept her new role. “When [I] made that transition, I felt somehow I was no longer as good a physician. But then I realized, ‘Oh, that’s ridiculous.’ [Other physicians have] also recognized that [I] give just as good of care as [I] did before, and the patients have recognized that, too. You can’t have it all.”


KNOW WHEN TO COMPROMISE


Dr. Kathleen Amman, like Huet-Cox, has chosen to work her career around her family’s needs. The 45-year-old Virginia pathologist has spent all of her 15-year career working three days a week while raising her two children. She echoes some other part-timers who say that while their kids are better off for their choices, they, themselves, are not—something that could be remedied if female physicians were taught better negotiating skills.


“The paradigm that I live is much different from the full-time paradigm. I work with a lot of full-time people; the majority are men. And their paradigm is they work long hours, and they have unemployed spouses at home picking up all the loose ends. And being a real physician is working long hours.


“I, on the other hand, [am] trying to raise my children and at the same time develop my career. So I need a balanced lifestyle. Working part time has worked from a family standpoint because my kids are fine and they’re doing great. And I don’t see the problems that I sometimes see with women who are working full time and just trying to do it all.


“And the problem I’ve come into is I’ve always been an employee. I’ve never been offered partnership except if I would go full time. And I’ve refused,” Amman says.


“When I was coming out of my fellowship, I was just grateful to get part-time work. And you’re trying to get confidence in yourself, and it’s not exactly the time when you say, ‘Why aren’t you offering me partnership?’ But now I’m 15 years into it, and I’m saying, ‘I have the same education, I have the same qualifications, I’m as good as you, and the reason I can’t be partner is because I work part time. Why?’


“Now that’s not to say I haven’t seen some groups that are making partners of part-time people. This is starting to be a trend in the university setting, where people are being put on tenure tracks prorated to how much they work. And I think what we are dealing with is just tradition and the way medicine has just evolved initially as a predominantly male profession where men just see no problem in working 60-plus hours and letting spouses raise the kids. [But] I can’t do that. I need time. I’ve been offered a partnership working a 40-hour week, and I said no.”


But there has been a price for Amman’s decision to work part time. It prevents her from voicing her opinions about the practice’s business operations, and she’s also encountered bias in the quality of work she’s given to do.


“I don’t think my career is exactly where it would be if I worked full time. And I don’t regret that, but I’m encountering frustrations now. I think because I see this as a developing process. I think women in my generation kind of started this.”


But now Amman finds herself butting heads with tradition. “When you go through medical school and residency, you work like a dog. And there are people coming along now who are saying, ‘Hey, wait a minute. Let’s balance our lives.’


“You need to speak out. Why should the time matter when often I’ve felt I contributed in valuable ways that partners are supposed to do? And yet I’m not offered partnership because of the hours I work. It is difficult. To me, you are left with having a more flexible career, but it may be far less challenging. And I enjoy the challenge, and I feel better about myself because I’ve achieved a certain amount of competency. And I think women deserve this, because it shows that we can do it.”


If you don’t know in what areas you can make compromises, you are headed for trouble, these women say. You’ve got to outline them early and learn to work within those parameters. Without strong mentors to guide her, Dr. Jean Howard, 59, an internist who manages inmates’ medical care at a California prison, learned that the hard way.


Howard says for years she made adjustments to a once-promising career in blood-banking research at the National Institutes of Health (NIH) to accommodate her husband’s career goals. But in the end, she says, she would have been better off considering her own needs.


“I made a lot of moves and changes based on my family needs rather than what I wanted to do. And then, I wind up with nothing. I wound up with a divorce, and your children grow up.


“But that’s basically what happens. If you can’t move when the opportunity arises or is necessitated, one or the other, you’re not in a bargaining position to improve yourself. Let’s say a job opportunity crops up across the country, but you’re tied down with your family, and you decide not to take it because of your family; you don’t have any bargaining chips left anymore with your current employer for a promotion. Or you can’t make the move, either way. And then, with the divorce rate soaring at over 50 percent nowadays, I don’t think it’s worth it to worry about your family and your husband. You have to think about yourself.


“I gave a paper at a major blood-banking meeting, and it worked out well. That was during my fellowship. Several people [from the NIH] came to my chief, and they were interested in recruiting me for a job. I never took the job because of the fact that they wanted something permanent; I could see that. And my husband agreed to move back to the East Coast for what had amounted to an improvement in his career, but he wasn’t going to stay. He was going to move back to California.


“So I never pursued that job and instead did something lesser which didn’t work out, and then another interim thing. And then at the end of two years, I moved back to California to a university there, and that lasted two years, and they ran out of money. And then after that, it was just like filling in, trying to find something locally in an area where it was not easy, and doing things which I didn’t really want to do, and struggling with a small child, and taking call; it was all very hard. And a husband who was away more and more, and then eventually he came home and announced he wanted a divorce. And as far as I was concerned, the last six years had basically been invested in trying to stay married and have a household and a family, and it just went down the drain. All those decisions were based on that, and I didn’t wind up doing what I wanted to do.”


Howard, who made all her own decisions without a mentor to help guide her, learned tough lessons about what is important to her. And for now, she says her role in the California prison system makes her happy.


Which is really what success is all about. It’s not how far you climb the ladder; it’s how happy you are in getting to the rung you want to reach. So heed these women’s advice and you’re golden: Don’t let medicine determine your life. Let your life determine what kind of medicine you want to practice, and you will get along just fine.


“In other words,” Richter says, “if you want to be a surgeon—that’s what your life’s calling is—then you’re going to find a way to do that. I think it’s stupid to go into family medicine if you want to be a surgeon, just because that might be more conducive to being a mom. You’ll find a way to become a part-time surgeon if that’s what you want to do. You have to make some sacrifices somewhere along the way, but if that’s what you want to do, you do it. You just find a way to work around it.”
~~~~Jennifer Zeigler is a senior writer for The New Physician. ~Women in Medicine~
214~2March~2001-50~Letter from Afield~The Influence of Leeches~AN ENCOUNTER WITH TRADITIONAL MEDICINE.~Shetal Shah~~I was trying to keep my mind open and my eyes closed, but I couldn’t help but peek. From my angle, they looked like boxed chocolates—brown in the setting Botswanan sun but truly dark-green in color. The only problem with this therapeutic delusion was the “chocolates” were living leeches sucking pus from my ankle in hope of feasting on the blood underneath. You’d have kept your eyes closed, too.


The situation—lying face up near a campsite in the southern African twilight while four leeches imbibed my bodily secretions—was entirely my own fault. Only a medical student would go so long without treating himself. Those who say doctors are the worst patients never saw a hospitalized medical student while on rounds.


My injury started with a simple fall from a bicycle. I spent the summer raising money for Habitat for Humanity—an international organization that builds housing for low-income families—as one of 30 cyclists riding across Botswana. However, the government of this France-sized country did not have transcontinental bike travel in mind when constructing public roads, and the loose gravel and tight cycling formations in which we rode caused a junk pile on the third day of the journey. Minor cuts and bruises were all that resulted, but over the next days I neglected treating my now severely scabbed-over cut. “I’ll do it tomorrow. Today I want to explore, or today I need to see…,” I kept thinking.


Within two days, the dull pain in my ankle had taken over my leg, and the swelling got so bad my cycling shoes didn’t fit. The scab had grown to a golf-ball sized abscess—a cocktail of blood and purulence camped out on my foot. For my health and comfort, it had to be drained.


But near the Tropic of Capricorn, along a gravel road at the southern edge of the Kalahari Desert, distance to the local emergency room is measured in days: one day by car, two by bicycle, six by donkey. Enter the leeches.


The “Leechmaster” was Ntemidisang—a native doctor from a village six miles from the national highway. Wearing blue jeans and a faded Syracuse Orangemen T-shirt, his body wrapped in a gray cloak to protect him from the “cold” southern-hemispheric winter, he was on the cutting edge of Setswane fashion. That is, he looked as American as possible. The doctor looked at the abscess, pushed it, prodded it and backlit it with a flashlight. I was a little feverish, and he agreed it must be drained if I were to continue riding the next day. Two days later, we would arrive in Francistown, a major city with a hospital and my antibiotic Shangri-La.


Ntemidisang smiled, revealing four metal teeth. He prepped a syringe and excavated from his pocket a needle that looked like it had been through at least four people and five dogs before me.


“Uh-oh, hold on a minute.…”

I was only a first-year medical student, so at the time I knew only one disease transmissible from a needle more popular than a buxom blonde cheerleader in a Catholic boys’ high school. Now armed with my M.D., I can name about five. But isn’t one enough when you consider it’s fatal?

I grabbed his wrist and protested the use of a needle. He understood; apparently staunch objection is a cross-cultural phenomenon. Flashing those metallic teeth, he opened a rusted Sucrets tin, respectfully showing me the leeches—the latest alternative to the Western “incision and drainage” procedure.

Old needle or leech?


My head arched backward so the stars seemed like glitter on a black lacquer floor—I was trying to think of other things. But the cool tingling burn of antiseptic on my skin called me to attention. The leeches were placed side by side on the scab. Seconds later, my muscles tightened after what felt like a sting from a Stallone-sized hornet.


Many thoughts infiltrate the mind when it knows there are leeches on the body—so Ntemidisang judged it best I didn’t think at all. He conspired with the other cyclists to make me laugh and forget about the perverse ritual occurring on my lower extremity. My eyes were closed, and their jokes were not funny, but I laughed. The psyche was amusing itself as a defense mechanism. I saw my “Past Significant Medical History” tainted forever. I’m 80 years old with a large prostate and in the hospital—giving my history to a medical student just days into school. He is being too thorough, trembling as he presents to the intern while he confidently states: “The patient’s past surgical history is significant for an abscess drained by leeches in the late 1990s.”


I was destined to be someone’s medical anecdote.


Ten minutes later, my ankle was bandaged and Ntemidisang’s teeth were reflecting the dull haze of the lantern light. We thanked him for his services, and he left, the orange blur of his T-shirt bouncing with each step. Two days and 150 miles down the national highway, I received my antibiotics, and I completed the tour without further incident.


The ways the human species seeks to cure its ills are endless, and as good physicians, we must be aware of how our culture and bias influence the care we give. No U.S.-trained doctor, even in the Kalahari Desert, would consider Ntemidisang’s procedure. Leeches don’t work, scalpels do.


But more and more, patients of Western medicine are seeking out treatments Ntemidisang would advocate. And ever so slightly, the medical world is making some changes.


My mind is changing, too. Now back in the United States, I have developed a good routine. In the middle of my patient interview, I ask about herbs, teas and acupuncture. I do not explicitly mention the use of leeches. Often, the patient says something noteworthy. I won’t forget to ask again. But in case my memory fades, I have the benefit of a thin, shiny brown, wrinkled scar on my ankle to remind me.


There are eight lozenges left in the Sucrets package in my medicine cabinet. Who knows what I’ll put in it next?
~~~~Shetal Shah is a pediatric intern at Duke University Medical Center. He was a medical student at Cornell University Medical College when he wrote this piece, a version of which appeared in The Lancet.~Community and Public Health,International Health~
215~2March~2001-50~Feature~Information Overload~DIRECT-TO-CONSUMER DRUG ADVERTISING CREATES A CONUNDRUM FOR PHYSICIANS IN THE EXAM ROOM.~Jennifer Zeigler~~A 40-ish woman is seated in the exam room when you enter. Mrs. Carson is a longtime patient, and her chart says she Òwants to discuss something with the doctor.


OK, you say. ÒWhat seems to be the problem?


Well, it'S this extra 10 pounds I cannot lose. I thought this might help, she says, pointing to a magazine advertisement. So I'd like a prescription.


This is Xenical, a lipase inhibitor meant for severely obese people. You've read both good and bad things about the drug, but it was never intended to be used by someone like Mrs. Carson.


You cannot help but let a sigh slip out as you open your mouth to explain to her that the drug is not for the occasional dieter trying to lose a few pounds for her high school reunion. And why did she want to lose 10 pounds anyway? She certainly didnot need to. she was quite healthy.


Well, funny you should mention that, she says. It is my high school reunion coming up, and I just cannot seem to get into the dress I want to wear. I really think this could help.


Now, the exasperated sigh is more audible. There is no good end to the situation sitting on the paper-covered table in front of you. If you donot prescribe Mrs. Carson her Xenical, she will find another doctor who will. If you do, you're prescribing something you know a patient doesnot need, and that could wind up harming her in the end. Sigh.


Dr. Margaret Planta sees this type of situation regularly in the large clinic she practices in near San Jose, California. In addition to overweight patients looking for Xenical to replace diet and exercise, she also has had allergy sufferers demanding Claritin between sneezes.


Planta blames the direct-to-consumer (DTC) advertising with which drug companies are flooding magazines and televisionÑpropaganda that was more strictly regulated before 1997.


TURNING POINT


Four years ago, the U.S. Food and Drug Administration (FDA) issued its draft guidance to clarify a requirement in drug advertising regulations. Since the early 1980s, pharmaceutical companies had advertised their wares directly to the public in magazines and newspapers. But television ads were largely unused because the companies found it difficult to comply with mandates to provide a brief summary of any possible risks involved with the drug, including a list of side effects, indications and effectiveness. Complying with the brief summary requirement in print advertising often means buying an additional page to fill with fine print, and advertisers found that a 30-second TV spot wasnot long enough to make the sales pitch and cover the minutiae.


So companies reserved TV for reminder ads, which generally just suggest viewers Òask their doctors aboutÓ drug XYZ and are exempt from the brief summary requirement.


But Thomas Abrams, FDA's director of the Division of Drug Marketing, Advertising and Communications (DDMAC), says pharmaceutical companies approached the agency about putting an 800 number in commercials for consumers to call for more information, hoping that would satisfy the summary requirement and allow the companies to create more extensive ads. It made sense to FDA officials, he says. There's a different type of person out there who may not get his information from print media, he says.


So in August of 1997, the administration offered a clarification to its guidelines, authorizing more extensive TV advertising to pharmaceutical companies as long as they created other ways for the public to access the brief summary information. TV ads now list any major side effects in the commercial and contain sources to contact for more information: an 800 telephone number, a Web address, or a suggestion to Òsee your doctorÓ or read a corresponding print ad in Sunday's newspaper.


We thought this was the way to get to everybody,Abrams says.


IN THE NAME OF INFORMATION


Pharmaceutical company executives certainly think DTC advertising is the best way to reach everybody. Increases in DTC spending grow annually, with 1998 marking the first year TV advertising spending outpaced print ads. By 1999, DTC ads represented 13 percent of drug companies total promotional spending. Our companies started doing [DTC advertising] more in the last couple of years, says Jeff Trewhitt, a spokesman for Pharmaceutical Research and Manufacturers of America (PhRMA). Patients were signaling them that in this day of managed careÉthey want to be informed.


Patients couldn't help but be informed. DTC advertising spending went from less than $800 million in 1996 to $1.8 billion in 1999 and was expected to top $2 billion in 2000. From the drug companiesÕ point of view, it is money well-spent. A recent study by the National Institute for Health Care Management found the 25 most heavily advertised drugs accounted for more than 40 percent of the increase in retail drug spending in 1999.


Folks like Trewhitt and the people he represents say DTC advertising for all the money it consumes really is a good idea. Proponents point to a better-informed public beginning to recognize health problems in themselves that have otherwise gone undetected. Patients are asking their physicians about so-called embarrassment illnesses like depression and impotence largely because of ads for chemical cures they saw on TV. Abrams says it's a DTC advertising benefit the FDA recognizes.


People are being undertreated so if we get more people in to be treated, thatÕs a good thing, he says. I've heard from physicians. This is good: Mrs. So-and-so never wanted to discuss depression, and now she wants to talk about it.


Of course, some of them might also be asking about toenail fungus, says John E. Calfee, a scholar at the American Enterprise Institute for Public Policy, who spoke about the issue at a recent media event. Current treatments for toenail fungus often create side effects more damaging than the rather innocuous fungus, a problem common among some of the medications touted on TV.


But despite any treatment benefit, physicians like Planta say it's not necessarily a good thing if your patients are asking for specific drugs. Consumers canÕt get enough information to make an educated decision, they say.


Dr. Peter Mansfield, a general practitioner in Australia and director of the Medical Lobby for Appropriate Marketing, says the problem with DTC advertising is not that it provides too much information to people who donot need it, but that it doesnot provide enough credible information.


Consumers should have access to reliable information, he says. There is a huge difference between reliable information vs. promotion, which tells one side of the story and uses emotion to motivate behavior change. Finding reliable information is like finding a needle in a haystack. DTC just makes the haystack larger.


The claim that we should tap into the expertise of drug companies for getting people with undertreated conditions to see a doctor deserves skepticism. What the drug companies have expertise at is how to brief an advertising agency, Mansfield says.


Trewhitt maintains the ads are truthful, and he reminds DTC opponents that advertising and marketing are done under strict FDA rules. He says PhRMA accepts complaints about its members, which get sent to the offending company's chief executive officer.


Pharmaceutical companies are required to send copies of all their advertising to the FDA for review at the time of its initial broadcast or publication. Abrams says reviewers are looking for violations like ads that overstate the effectiveness of a drug or don't convey the appropriate patient population. Drug companies are also not permitted to advertise a drug for an unapproved use. We don't want people to be misled, Abrams says.


If the administration finds a violation, it sends a letter to the company requiring that changes be made to the ad. DDMAC sent about 100 warning letters last year for violations in advertisements marketing treatments for allergies, asthma, high cholesterol, high blood pressure, hair loss and sexually transmitted diseases.


PHYSICIAN FRUSTRATION


Violations are caught only after the ad airs, leaving consumers with conflicting information, and they are taking what they learn in Time magazine or between segments of the evening news truthful or not with them to their doctors. Planta is not the only physician to complain about the new atmosphere in the exam room. Abrams acknowledges his division has heard complaints from physicians since the proposal to clarify the advertising regulations was made public. We heard people say this would be awful, that it would undermine the relationship between the patient and the physician, he says.


Dr. Gordon Schiff, director of clinical quality research at Cook County Hospital in Chicago, is one such physician. ÒHopefully [DTC ads] will backfire, he says. The doctors are getting very annoyed by all of this.


Schiff says the ads only serve to create an immediate confrontation between patient and physician. And this type of confrontation is leading to a self-prescribing society, Mansfield says. ÒStudies show that doctors often prescribe drugs that patients had demanded despite the doctors not believing that the prescription is in the patient's best interest, he says.


Prevention magazine has conducted an annual survey for the past three years to study this very issue. The surveys show that about 30 percent of patients who see a drug ad ask their doctor for a prescription. And about 84 percent of the requests are granted by the patients physicians. (A similar FDA survey puts that figure closer to 50 percent.)


The reasons for this are complex and probably include [doctors'] desires to not be paternalistic andÉto avoid conflictÉas well as [their] desires to not lose business, Mansfield says.


And while Planta says she doesn't know whether she's ever lost a patient because she wouldnÕt prescribe a drug, the situation is still frustrating. "You have a 15-minute office visit," she says. To have to spend time to talk them out of a drug they don't need is frustrating when you could be discussing other medical issues they might have.


Very few of Planta's highly educated, Silicon Valley patients sit back and say OK, you're the doctor, when she says no to a particular prescription. Still, she says she remains undaunted. ÒIf there's a drug I don't prescribe, I just don't prescribe it, she says.


Mansfield says asking physicians to just say no is unrealistic. Doctors who do so would lose patients, he says. Nor does he expect drug company executives to take responsibility for changing their advertising policies, given the enormous profits ads have generated. But he does advocate change, noting the United States is the only nation in the world--save New Zealand, which is actively trying to change its policy that permits DTC drug advertising. U.S. citizens should take responsibility via [their] government, he says. Around the world, the only way that has been successful for improving health care is for citizens to act via their governments.


This is not to say the FDA has been in a holding pattern since making the 1997 draft clarification permanent in 1999. The administration continually surveys consumers and physicians to determine whether the influx of DTC ads are beneficial or not. "It all comes down to what is in the best interest of public health," Abrams says. One concern people have is "Oh, gosh, all the benefits [of a drug] will be received and processed by the patients, but not the risks," but our surveys have found that people are getting the risks [through television commercials].


Abrams insists the FDA's study of the effects of DTC advertising is not done in a vacuum, and he encourages other organizations working on similar studies to send him their data. Physicians, consumers and pharmaceutical companies are all looking for the same thing: what is best for the patient, he says. These are hard questions, and that's why we are concerned about it.
~~~~Jennifer Zeigler is a senior writer with The New Physician.~Ethics,Pharmaceutical Industry~
216~2March~2001-50~Feature~A Physician’s Guide to Fixing Leaks~TURNS OUT IT'S NOT WHAT YOU KNOW. IT'S WHAT YOU DON'T.~Elizabeth A. McNichol~~We need to talk.


Yes, I see you there. Big smile, brand new medical degree. A certain air of newly found authority. Nice white coat you’re wearing. Something pleasingly snug about it. In fact, you’ve probably tried it on in front of the mirror a couple times, haven’t you? Maybe you even added some dialogue, nice and slow and definitive:


I am a doctor.

Well. Got a piece of advice for you. Find a good tailor.


Sorry. Don’t mean to be rude. See, you know your way around a clinic. There’s no denying that. You’ve got book smarts, too. Malignant neoplasms, hypertension, scoliosis, acute myocardial infarction, endometriosis, epilepsy, pneumonia, asthma—you know them all like the back of your hand. But trust me, eventually you’re going to want something a little more, shall we say…functional, than that white coat. Perhaps a garment with a little more elbow room in it. After all, you’re going to need it to fix the leaky pipes.


“What?” you ask?

Just listen to my story. Then you’ll understand.


First, let’s go to the Northeast, where many suffer from neglect. If Dr. Barry Zuckerman listens from his office at Boston Medical Center (BMC), above the din of ambulance sirens, beyond the domain of his profession—if he listens—he can hear the steady drip, drip, drip. That’s the gradual noise of decay, that leak, and when it mixes with the mites in the carpeting and the roaches in the floorboards, it has a steady way of infesting the residents of that home, too.


Zuckerman knows that the leaky pipe walks into his office all too frequently wearing a little girl’s clothing. He knows that she is on steroids, so sick that she can’t even go to school anymore, and he knows that she’s not getting any better. He knows that the United States ranks first among industrialized countries in health technology but 16th in living standards for impoverished children.


And this is what else Zuckerman knows: If the girl’s health problem is going to improve for good, it’s not going to be because of her doctor. Surprised? Don’t be. Hands can’t heal this sickness. Drugs can’t cure it. When you lift up a little boy’s shirt to examine him and a cockroach scurries out, you are no longer soft-shoeing inside a Norman Rockwell portrait.


So, Zuckerman picks up the phone and punts to someone else—to a lawyer from BMC’s Family Advocacy Program. The lawyer steps in front of the landlord, and soon, that leak is repaired and the carpet is replaced and the little girl is off steroids and back in school where she belongs.


“I have found,” Zuckerman says, “that lawyers [can] provide preventive medical care.”


So let’s talk about this: about how being a physician no longer means you know everything about healing, about how being a good physician more often means admitting you don’t. It’s about knowing when to ask for help.


In poverty-stricken sections of Boston, biomedical treatment is just the penultimate step toward health. That’s what you’ll face in so many urban areas nationwide, where poverty reigns like a tattered emperor over neighborhoods.


You can’t do it all. You’re only a physician.


“This is about using nontraditional resources to make a system more whole,” says Zuckerman, who founded the Family Advocacy Program eight years ago and oversees several other outreach programs at the medical center. “People are healing when there are social norms to help them. One of the things doctors can be is a catalyst to work with other people to give patients information and get patients to give doctors information. Because that’s what other people can do.”


DRIP, DRIP, DRIP


Hold on a minute—where are you going? Oh, you’ve got a future to get started on, do you? Well, we’re not done. Not nearly. Have a seat. Listen to me. Because I am your future, and we might as well get acquainted.


Got another story for you. Take this Midwest doctor. Dr. Eric Whitaker. Black man with a medical degree, an engaging manner as impressive as his skills as a physician. Any number of large hospitals would love to have him on staff. But after Whitaker finishes his residency at San Francisco General, he goes back to his neighborhood, to Woodlawn on the South Side of Chicago, to see his grandparents, and he is disturbed. It’s 1998, and nothing looks the same as it did when he grew up. The color of the faces he sees hasn’t changed, but their conditions have. There are no jobs, few buildings without plywood over the windows and fewer impromptu rap sessions on the front steps of neighbors’ homes. There is disease, compounded by a fear to be treated. What was once a community is now a statistic.


Whitaker grows curious when he walks into the Woodlawn Health Center and notices an absence in the patient-body—there aren’t any black men. He wonders why. Know what the clinic staff told him?


“We wondered, too,” they said.

But wondering doesn’t get the job done. Action is what is needed here. Whitaker is going to have a baby in a couple years, and he wants his child to know that Woodlawn is a place of hope. He wants Woodlawn to know it can be a place of hope. How can he make sure this happens when African-American men are leaving their families behind sooner than every other population group in the United States—10 years sooner on average than the life expectancy for white men, which is 73 years?


And in Woodlawn? For black men?

It’s 53 years.

“The shameful thing is that if you pick up a newspaper,” Whitaker says, “and read the headlines, you’d think that homicide is the No. 1 killer of black men.” But in fact, the tally goes like this: heart disease, cancer, HIV/ AIDS, unintentional injuries… and then homicide. Untreated, unnoticed, unmerciful disease is far more murderous than a bullet.


Now Whitaker could have played God with his neighborhood. He could have stood back and pronounced his own explanations for the disappearance of African-American men inside health-care treatment rooms. He could have mustered all the medical training he received from the University of Chicago and then pointed a few fingers in the appropriate direction.


But he didn’t. Because he hears the sound, too. Drip, drip, drip. Only this isn’t about a house. It’s about a community, and the hole that needs to be plugged is bigger than any law any man has ever made. So he asks the voice inside his head to help him admit something to himself, a truth about the limits the privilege of his profession creates. And the voice, one still connected to a boyhood time when his neighbors were connected to each other, answers: “You can’t do it all. You are only a doctor. Ask the people who know best.”


Ask. The. People.

“Why don’t you come into the clinic?” he says, approaching Woodlawn’s black men in focus groups and on the street. “What keeps you away?”

They answer—old and young, straight and gay, the fathers and the homeless and the addicts and the diseased. We don’t come because we don’t see ourselves there. We walk in, and we don’t see you, a black man, there. We see women and we see children and we see white doctors and white social workers, and nowhere in those faces do we see a place where we belong. We see weakness, and we are trying to be strong. We have our problems, but we also have our pride.


Something inside Whitaker clicks. He pictures the clinics. Black man walks in. Ten people in a waiting room, and at least seven are women, and likely all the folks wearing white coats have complexions to match.


Black man walks out.


They still remember Tuskegee around here.


That’s a tidy explanation, though. Because what’s happening inside that clinic doesn’t speak to them any more than the people who work there do. “We discovered that black men have a more expansive view of what health care means,” Whitaker says. “To them, it included not just prescriptions, but living in a safe environment, having a job. All of these things were part of health to them.”


Now, every Thursday afternoon at the stroke of 4 o’clock, the Woodlawn Health Center becomes what Whitaker calls “mellocentric.” It becomes Project Brotherhood: A Black Men’s Clinic. “All the doctors are African-American males, which is in itself an anomaly. All the social workers there are men. The waiting room is filled with men.”


Project Brotherhood also has its own Kinko’s of sorts, where men can get help with résumés, view job listings, have computer and fax access. “You know, in Chicago, you can’t just walk into a workplace and hand them a résumé anymore; they expect you to e-mail it to them. Right there, a whole segment of the population that doesn’t have access is disadvantaged.”


And in the front of the clinic is the key to it all, the reason that 20 to 50 men show up on a Thursday night these days. It’s a barbershop.


“The doctors get hair cuts at the same time as the men who come in,” Whitaker says. “It gives us an opportunity to break down barriers, answer questions they might not otherwise have answered.


“You come to the barbershop and talk and eat pizza and have a good time. And while you’re there, you get treated. Our idea is to get men through the door. Patients then get to know the doctors in a context other than medical.”


These are the sorts of lessons you’ll never learn in medical school. They’re so simple, don’t you see? Sometimes all you have to do to treat your patients, all you have to do to find the answers, is take off the white coat, hang it on the back of the door and look around you.


Dr. Eileen Catterson, a native New Yorker, a nun with a brusque manner and a strong accent, had to really look around when she deposited herself and her pediatrics practice in rural Pineville, West Virginia, 27 years ago. Dental care was awful. Diets were abysmal. Kids wouldn’t listen. Families wouldn’t listen. So Catterson went into the school system and asked them to listen, to change the food selection and the way it was prepared.


“I keep telling medical students that when I started medicine, it was individual-centered; then it became family-centered. Now, it’s community-centered. It’s the wave of the future.”


And why is that?

“Well,” Catterson says, “because the other ideas haven’t worked.”

You must do what you must do. Even if you have to sell tamales.


DRIP, DRIP, DRIP


I see that I have your attention. But I’m not the one who needs it. Look around you. Look over at the West Coast, in Santa Ana, California, for example. Poorest zip code in all of Orange County. It’s a Latino community, and 38 percent of the state’s Latinos have no health insurance. They hold down two jobs, but when they get sick, they won’t come to you. Why?


One word: fragmentation.


When Dr. America Bracho first witnessed this, she grew angry. She came to Santa Ana from Venezuela, and in Venezuela, life does not exist in a vacuum. You are not just a woman. Your farm is not property. You are the land and the water and the crops and the sky, and the matter that fills your home fills your soul and defines who you are more than your very name. Oh, but in Santa Ana, in the Latino community, what did she see? Everywhere, disconnection. Everywhere, lonely hearts. People who were neighbors only by definition, who didn’t know the families living across the hall from them, even if they did know their screams of abuse or their wails of pain or their sense of isolation. You cannot nurture your health when you cannot share your life.


“But this is the way life is,” they told themselves.


“This isn’t the way life is,” Bracho told them. “It’s what you make of it.” So she aimed to make it better. She told the local and national nonprofits who claimed to be helping Latino health to stop pretending. Then one day she realized she was the one who was pretending. If Latinos would not find their way to a clinic on their own, she would simply create some guideposts. Not going to light a fire under other people, she thought; have to help them light their own fires. Make the citizens officers of their own health, talk to them, show them their wealth, not their needs. Must give them some empowerment so they start thinking….


“I can read. So I can teach my neighbors who cannot.”

“I can plant a garden. So I can pull the weeds in our neighborhood.”

“I have diabetes. I am blind. But I can make sure my neighbors never will be.”

So, the first group of promotores reports for duty—local residents recruited to lead their community toward good health, to keep watch over it. One of them, a diabetic in a culture in which one in four people over the age of 45 has the disease, says he would have done anything, anything, to come up with the money for an operation that would have saved his sight, had he only known such a procedure existed. Anything, he said, “even if I had to sell tamales.”


And just like that, the Latino Health Access (LHA) group had a rallying cry, a Spanish saying that has long been used to evoke humility and pride in the face of adversity—what one does when there is no other path to take. From it sprung the tamalada, an annual fund-raiser during which Santa Ana Latinos host tamale-baking classes to raise money for low-income Latinos with diabetes who need costly eye surgery.


This year’s tamalada was just completed, and my, what a sight. Picture chief executive officers of HMOs and local hospitals paying money to learn how to make the Latino culture’s food, standing side by side with the patients who struggle to pay for their services, getting wrapped up in the very tedious process of creating a delicious reward: one dozen tamales to take home to their families and one unforgettable glimpse into their social network.


Nice white apron you’re wearing, Doc.


“We are an organization where people can come together and do something for themselves and not just wait around to die,” says Gerry Balcazar, a director at LHA.


DRIP, DRIP, DRIP


Let me ask you a question. Do you believe you could lose your soul if you had an operation to repair an ailing leg? Do you?


Then what do you believe?


Because we are back in Boston now. And maybe you’re treating a man of African descent. You’re telling him, “You must have the operation. You must or you could lose your leg. You could die.” And you’re frustrated, because he is telling you, “No, I will not have the treatment.”


The patient’s head is whispering to him, Yes, I know. I know that what you say is true, medically. But his faith is pronouncing something else. You don’t understand my God. You only understand yours.


Western medicine is a wonderful thing—if you were born in the West. You might know the name Lia Lee. She’s the little Hmong girl journalist Anne Fadiman chronicled in her book, The Spirit Catches You, and You Fall Down. Lia was diagnosed with epilepsy by her pediatricians in Merced, California. Her parents, refugees from Laos, diagnosed her with what is known in the Hmong culture as qaug dab peg—an illness characterized by evil forces that they believed had stolen their daughter’s soul. She was treated with 23 Western drugs. She was treated with Hmong rituals. But through it all, the assumptions and beliefs that both parties held were rarely discussed. At 5 years old, after years of miscommunication and overmedication, Lia was pronounced brain-dead after a powerful seizure.


Today, Dr. Linda Barnes, an anthropologist at BMC, is trying to change that lack of trust and respect between families and physicians. She has a quarter of a million dollars in grant money at her disposal right now, and she plans to turn it into the Landscape Project, for which graduate researchers from Boston University School of Medicine will go out to refugee communities and create partnerships.


They will knock on the doors of faith centers for the African Diaspora, because they know that religion is the first place refugees turn. They will frequent the owners of local markets and health stores, because they don’t yet know all the herbal remedies and tonics that refugees trust to heal them.


And in the end, they hope, they will take what they’ve learned to medical students, to residents, to established physicians on staff, and they will ask them to kneel before the altar of understanding.


“We want doctors to learn how to talk to patients about everything they do with their health, to become at least familiar with the terms, so that when a patient mentions a practice, they can at least nod their heads and say, ‘I know what you’re talking about,’” Barnes says.
“Most families put together their own health-care system,” she says, “and it may consist of family medicines, the health food store, the local market, traditional practices or complementary practices of other kinds…and then the doctor. The doctor is usually the last to know that he or she is the last piece in that framework. And it’s a little bit humbling for them. But no cultural group exists that doesn’t have a number of resources to treat its health. It’s important for doctors to know that. It’s a hard thing to ask them to realize, because part of the socialization of the profession is the belief that biomedical resources are the highest form of health services available.”


Maybe you won’t lose your soul to leg pain. But you might lose your patient to his.


I swear. You swore, too. Remember?


I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients….


For the benefit of your patients: There are leaks in pipes, leaks in health care—the leaks will find you as a physician; as a human, you can find the ultimate repairs.


No, you can’t do it all. You are only a doctor. But it’s a good place to start. Yeah. It’s a good place to start.
~~~~Elizabeth A. McNichol is a freelance writer and contributing editor to The New Physician. She lives in Chapel Hill, North Carolina.~Complementary and Alternative Medicine,Humanistic Medicine~
217~3April~2001-50~On the Wards~Look Out, "STAT!"~Yet another cause~Simon Ahtaridis~~My decision to pursue medicine was largely influenced by physician anecdotes describing how their sharp minds or dexterous skills had made a difference in a person's life. These talented physicians have earned society's respect and admiration. Day after day, night after night, they are the heroes that stand by patients through their most dire hours. They are the prodigies of the healing arts and the masters of a science. Unfortunately, this is not their story.


Rather, this is the woeful tale of a third-year medical student and how one day he was transformed into a leading advocate for one of medicine's most important and relevant issues-creating a universal, comprehensive, medical emergency word vocabulary.


My passion for this cause all began one week when I was on a pediatrics inpatient rotation. My confidence was building as I began to master basic rounding skills. I prided myself in my ability to survive four-hour rounds by leaning against objects that would not provide a skilled mountain climber a foothold. I could freeze my facial expression into one that said, "I am mesmerized by our eighth asthma patient this morning, so it would be pointless to pimp me." Meanwhile, my mind would be performing more interesting tasks such as counting the number of times my attending would say, "Stat!" - a supposedly secret "emergency" word that has become overused and exposed to the general public thanks to such hit television shows as "ER."


One morning I was rounding with our attending, a nurse practitioner and five other medical students. The morning had passed fairly well. I had finally completed a presentation without seeing my attending look as if he had just bit into a hot dog and found an unexpected fingernail. Feeling good about myself, I decided to expand my horizons and take on more responsibility. Big mistake.


In the nursery, we were examining a 6-month-old male with a severe case of diarrhea. My attending reported that one of us needed to change his diaper-"Stat!"

"Twelve... I mean I will do it," I said out of sheer boredom.


My attending went through the basics of diaper changing using medical lingo that would make a cardiothoracic-transplant surgeon blush. He warned me to keep the baby covered to avoid being urinated on. I cleaned the baby and lifted his legs into the air to place a new diaper underneath him. Suddenly, without warning, a stream of thick viscous yellow fluid erupted from the baby's anus and flew through the air with such speed and strength that it cleared the bed. I was so completely confused that I was only vaguely aware of a series of screams erupting from the far end of the room. It appeared as if the baby had a yellow-fluid-filled super soaker lodged inside of him. Seconds later my mind finally came up with a differential diagnosis of projectile diarrhea-if such a thing exists.


A wave of uncertainty washed over me as I began to scramble over my medical training hoping that something would help me deal with this situation. I began to move the baby's legs back and forth to try and get a better view at what was happening, but this produced the unwanted result of spraying my classmates and the nurse practitioner with an arc of yellow diarrhea, as they scrambled to get out of the line of fire. Finally, my mind concluded, "Aha! They must have been the source of the screams." I searched for something to say to help correct the situation. In the end, all I could come up with was a sheepish, "Oops."


"Simon!" yelled the attending, grabbing the baby's legs from my hand. This made the child panic, and he released a stream of urine onto the attending's coat.

After the liquid had settled, I realized that I was one of the few people not wearing excrement or urine. And for the first time in my life, I was not thankful for this. "I am in deep sh-t," I mumbled to myself.


I had clearly set myself apart from my peers and left my mark in a similar way on our patient whose mark still stained a far wall. My attending stood in front of us for a few seconds, probably counting to 10 in his mind. He raised his finger toward me and looked as if he were about to say something, stopped, counted to 20 aloud, and then gave me a stern lecture on the importance of keeping a baby covered and the need to clean up our messes.


It is said that we learn from our pain. The following week I rotated to the newborn nursery, where I developed the psychic ability of detecting which baby would need frequent diaper changes and then finding a good excuse to follow another baby. In the rare instance when I had to change a diaper, I would cautiously proceed with the adrenaline level of a bomb squad defusing a large, unstable, ticking nuclear warhead with an electronic voice in my head saying, "Ten seconds until detonation." My new attending never quite understood why I would fall to the ground out of breath muttering, "It's OK. It's over. It's over," when I finished the task.


After some reflection, I began to appreciate the valuable lesson that I had learned. I was not the culprit of this disaster, but rather the victim of a medical emergency word deficit. What word could I have used to warn my fellow medical students, "This baby is going to squirt all kinds of fluids at you. Please calmly move away very quickly?" Does "Stat!" convey this? I don't think so.


A single emergency word is not enough for the medical profession. Our health system is so complex and diverse that we need a new pocket manual of emergency words fitting all types of potentially dangerous situations.


It may be time for the medical profession to get together behind closed doors and come up with new words or phrases and make it our mission to hide it from the producers of "ER." Perhaps we could amend the Hippocratic oath to include keeping these new words a secret.


I would like to throw out the following ideas for debate and discussion: "Pop a wheelie!" the childhood phrase popularized by BMX stunt-bike riders everywhere. Physicians could slyly slip that phrase in to alert health professionals in the room that there is an impending crisis without alarming the patient or their friends and family.


Or perhaps we should avoid verbal warnings and create crafty hand signals that no health professional could miss. We could pretend to pull on an 18-wheeler freight truck horn as children do on long family car trips. Who would suspect that anything was amiss with such a clever, subtle signal?


Perhaps we could follow the example of other institutions and develop an elaborate standardized language. The military is far ahead of the medical profession in this area. Our government hired expert linguists to develop efficient cool-sounding movie phrases like "Lock and load, let's rock and roll!" Why reinvent the wheel? Why not borrow the phrases already used by military professionals and adapt them to health-care situations? For example, "Fire in the hole!" meaning - "I am about to change a diaper, so don't get angry at me if you get splattered since you have been warned. Besides, it's not my sphincter, pal." Or, "Incoming!" meaning - "Close your mouths and turn away from the baby! There will be time for explanation later."


These are just some of the ideas I've thought of while sitting alone in the darkness of a call room. But I've also wondered, why do we immediately draw multiple blood samples from a patient with suspected anemia? Why don't scrubs have more and better pockets? And why do hospital cafeterias only offer grilled, greasy, fatty foods or a microbe-infested salad bar that would make even the bravest infectious disease physician shudder?


I do not claim to have all the solutions to these complex problems, but I strongly feel that developing a universal, comprehensive, emergency word vocabulary is the first step toward making our hospitals a better place.


Make no mistake - our task will not be easy. We will have to strive forward with the understanding that our ideas may be viewed as unorthodox or even radical. The medical profession is resistant to change. Organized medicine will no doubt question the necessity of these changes, clinging to traditional phrases like "Stat!" and ignoring its inadequacy. Organized medicine might say that new words will burden students and physicians with something else to learn. We may be labeled as "troublemakers," "emergenists," "vocabularians" or other horrible things, but we must not give up! We must send organized medicine a wake-up call and let them know that we are here to shake the very foundations of the emergency word field.


The pharmaceutical industry didn't produce 54 identical painkillers by just whining - they worked at it for decades. Let us follow their example and fight on. We must persevere knowing that the sacrifices we make will ensure a better environment for a future generation of health-care workers, or at least more colorful "ER" scripts.
~~~~Simon Ahtaridis is a third-year medical student at Temple University School of Medicine.~Medical Education~
218~3April~2001-50~Feature~The AMSA Foundation's Sixth Annual Primary Care Scorecard~~Meredith Burke Lawler~~Now that the figures for the Sixth Annual Primary Care Scorecard are tabulated and the schools ranked, we can focus on the educational programs that are associated with the top-ranking schools' successes.


What are the top two allopathic and two osteopathic schools doing to steer their medical students into primary care careers? The common denominator among these four outstanding programs seems to be mentoring, especially in a nontertiary, community setting, and innovation within the curricular learning structures. Let's look at the University of Minnesota-Duluth, State University of New York (SUNY), Stony Brook and Lake Erie and Kirksville colleges of osteopathic medicine to learn more.


University of Minnesota-Duluth - This year, allopathic top-ranked University of Minnesota-Duluth (UMD) boasts a 71.2 percent match rate into primary care residencies. UMD is the only two-year medical school accredited by the Liaison Committee on Medical Education. Upon successful completion of their first two years at Duluth, students are automatically accepted at the University of Minnesota Minneapolis for their third and fourth years.


UMD students are exposed to an exceptional array of primary care opportunities, the most effective arguably being the family practice preceptorship, a clinical mentorship program required of all students during both years of the curriculum. This program moves medical education out of the classroom and into the community. First-year students spend almost 50 hours a year shadowing a practicing family physician close to campus. Second-year students are assigned a family physician in more remote communities in Minnesota, North Dakota and Wisconsin, and spend three days and nights with that physician "in order to maximize the students' exposure to the everyday working environment and lifestyle of the small community family physician," says the program's director, Dr. James Boulger.


In addition to seeing firsthand the rewards and realities of a career in family medicine, students are also encouraged to observe how the physician balances her personal life with her various professional and social responsibilities. Physician preceptors welcome the students into their homes, providing housing, meals and a unique look into their personal and family lives. The one-on-one clinical teaching experiences that preceptors offer have been, according to recent student feedback, the peak medical school experience for more than 70 percent of UMD students. Preceptors also have reported great satisfaction and gratification in being mentors for medical students.


SUNY Stony Brook - The primary care medicine program at SUNY Stony Brook uses a specially designed fourth year of medical school to guide selected medical students into the school's three-year primary care residency track. By doing so, the program builds a comprehensive and integrated primary care training experience that will continue through residency.


The four-year program concentrates on three principal areas: first, a strong primary care knowledge base in the prevention, diagnosis and management of health problems; second, a rich understanding of the psychosocial aspects and ethical issues inherent in primary care medicine, with careful attention to communication skills and developing a systematic approach to resolving medicine's ethical questions and; finally, an emphasis on such lifelong learning skills as clinical decision making, the effectiveness of an integrated multidisciplinary care team and an understanding of managed-care systems' expectations.


Lake Erie College of Osteopathic Medicine - Lake Erie College of Osteopathic Medicine prides itself on identifying and implementing innovative learning structures for its students. The school has three learning pathways for which students may apply before they start medical school: a traditional four-year lecture/discussion pathway, a two-year problem-based learning pathway, which leads students back into the traditional study route for the final two years, and a four-year independent study pathway, which will be implemented in June 2001.


In addition to the emphasis on primary care in the first two years of study, all students are required to complete a rotation in a rural, underserved area in their third and fourth years. "This has a lot of appeal for students," says Susan Lazzaro, Lake Erie's director of student affairs. "We've noticed a real service-oriented interest among [them]." A variety of rotation sites are offered domestically and around the world. For example, the sites in the United States allow students to work with preceptors in Amish and small, farming communities.


Kirksville College of Osteopathic Medicine - Primary care is central to the mission of Kirksville College of Osteopathic Medicine (KCOM). "As a 100-year-old institution that has always produced primary care physicians, we find many of our students are children or grandchildren of primary care physicians. Others have been sent by primary care physician role models," says Dr. Dixie Tooke-Rawlins, KCOMÕs dean and acting vice president for academic affairs.


The college's curriculum revolves around primary care and the skills and abilities needed to practice in rural, underserved areas. Osteopathic theory and methods are taught concurrently with the basic science and clinical courses during the first and second years. A two-week rural primary care clerkship in the first year, as well as required rotations in rural and underserved areas in the third and fourth years, are designed to show students the humanistic side of community medicine. Rural practicing physicians are an essential part of the KCOM student experience, and they help students develop confidence away from the tertiary care environment.


These top-ranking schools' programs highlight the valuable role mentors play in the lives of medical students, as well as the meaningful clinical opportunities and innovative learning structures that are key factors in matching graduates with primary care residencies. Early exposure in medical school to what primary care medicine is all about, both personally and professionally, is paramount to increasing the number of students selecting primary care.


Percentage of 1999 Allopathic Medical School Graduates Entering Primary Care Specialties











































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Medical
School		 %FP %IM/ %PEDS %IM/

PEDS		 %PC
1. 
Univ of Minnesota - Duluth		 47.5 16.9 6.8 0.0 71.2+
2. 
SUNY - Stony Brook		 5.3 51.1 13.8 0.0 70.2
3. 
Wright State University		 26.3 23.8 16.3 2.5 68.8
4. 
Univ of Illinois - Rockford		 34.1 9.1 20.5 4.5 68.2
5. 
Univ of Missouri - Columbia		 25.3 27.6 12.6 2.3 67.8
6. 
East Carolina University		 29.4 19.1 11.8 5.9 66.2
7. 
East Tennessee State Univ		 21.2 25.0 11.5 7.7 65.4
8. 
Oregon Health Sciences Univ		 32.5 20.5 12.0 0.0 65.1
9. 
Loma Linda Univ		 19.4 33.5 7.7 3.9 64.5
10.
Texas A & M Univ		 23.8 17.5 19.0 3.2 63.5
11.
Univ of South Carolina		 31.0 21.1 11.3 0.0 63.4
12.
Marshall Univ		 27.9 16.3 14.0 4.7 62.8
13.
Louisiana State Univ - New Orleans		 11.3 33.3 13.6 4.0 62.1
14.
Univ of New Mexico		 24.4 21.8 15.4 0.0 61.5
15.
Michigan State Univ		 24.5 17.9 11.3 7.5 61.3
16.
Meharry Medical College		 20.3 29.1 7.6 3.8 60.8
17.
Univ of California, Davis		 19.8 22.1 15.1 3.5 60.5
18.
Univ of South Alabama		 11.9 39.0 6.8 1.7 59.3
19.
Univ of Rochester		 4.9 36.3 11.8 5.9 58.8
20.
Univ of Maryland		 15.4 27.9 11.8 2.9 58.1
21.
Univ of Vermont		 11.6 29.5 16.8 0.0 57.9
22.
Univ of North Dakota		 23.7 11.9 15.3 6.8 57.6
23.
Univ of California, San Francisco		 16.2 22.8 16.2 2.2 57.4
24.
Univ of California, San Diego		 16.7 23.0 15.9 0.8 56.3
25.
West Virginia University		 22.0 20.7 7.3 6.1 56.1
26.
Univ of Massachusetts		 16.0 24.0 11.0 5.0 56.0
27.
Medical College of Georgia		 16.0 25.1 13.1 1.7 56.0
28.Univ
of Missouri - Kansas City		 15.7 21.7 15.7 2.4 55.4
29.
Southern Illinois Univ.		 24.7 20.5 6.8 2.7 54.8
30.
Univ of Louisville		 21.6 14.2 16.4 2.2 54.5
31.
Brown Univ.		 12.3 23.5 16.0 2.5 54.3
32.
Univ of Southern California		 10.5 26.5 13.6 3.7 54.3
33.
Mercer University		 16.7 27.1 6.3 4.2 54.2
34.
New York Medical College		 6.3 33.2 14.2 0.5 54.2
35.
Eastern Virginia Medical School		 9.7 21.5 21.5 1.1 53.8
36.
Wake Forest Univ		 14.2 26.4 12.3 0.9 53.8
37.
Univ of Minnesota - Minneapolis		 19.3 22.7 10.2 1.1 53.4
38.
Washington Univ.		 4.9 31.1 17.5 0.0 53.4
39.
SUNY - Buffalo		 9.0 25.6 1.3 6.8 52.6
40.
Emory University		 7.7 28.2 15.4 0.9 52.1
41.
Univ of Nebraska		 17.9 22.0 9.8 2.4 52.0
42.
Univ of Iowa		 20.1 17.0 13.8 0.6 51.6
43.
Univ of Arkansas		 24.6 11.2 13.4 2.2 51.5
44.
Univ of Illinois - Peoria		 8.1 13.5 10.8 18.9 51.4
45.
SUNY - Syracuse		 10.7 19.3 17.3 4.0 51.3
46.
Univ of Tennessee		 13.7 18.6 13.0 5.6 50.9
47.
Saint Louis Univ		 14.7 18.7 14.0 3.3 50.7
48.
Univ of Connecticut		 9.6 20.5 14.5 6.0 50.6
49.
Univ of Oklahoma		 23.5 13.2 10.3 2.9 50.0
49.
Univ of Miami		 5.8 30.1 13.5 0.6 50.0
49.
Stanford Univ		 12.2 20.7 17.1 0.0 50.0
53.
Louisiana State Univ - Shreveport		 13.4 22.7 11.3 2.1 49.5
54.
MCP Hahnemann		 15.6 22.8 9.7 1.3 49.4
56.
Medical College of Ohio		 15.0 19.2 9.2 5.8 49.2
57.
Virginia Commonwealth Univ		 15.8 22.4 6.7 4.2 49.1
58.
Howard Univ		 11.0 25.0 10.0 3.0 49.0
59.
Texas Tech Univ		 16.8 18.5 12.6 0.8 48.7
60.
Univ of Texas - San Antonio		 17.0 19.1 11.3 1.0 48.5
61.
Georgetown Univ		 7.1 27..7 11.6 1.9 48.4
61.
Morehouse School of Medicine		 9.7 9.7 25.8 3.2 48.4
61.
Ohio State Univ		 16.3 17.9 12.6 1.6 48.4
61.
Pennsylvania State Univ		 18.9 18.9 9.5 1.1 48.4
65.
Rush Medical College		 13.6 20.9 11.8 1.8 48.2
65.
Northwestern Univ		 7.3 33.5 7.3 0.0 48.2
68.
Vanderbilt Univ		 3.7 25.7 15.6 2.8 47.7
69.
Ponce School of Medicine		 6.8 23.7 11.9 5.1 47.5
70.
Cornell Univ		 9.8 29.5 8.0 0.0 47.3
70.
Univ of South Florida		 8.6 24.7 8.6 5.4 47.3
70.
Univ of Kansas		 21.3 13.0 9.5 3.6 47.3
70.
Univ of North Carolina - Chapel Hill		 11.0 19.2 14.4 2.7 47.3
74.
Univ of Cincinnati		 20.1 16.0 9.7 1.4 47.2
75.
Baylor College of Medicine		 8.7 18.8 18.1 1.4 47.1
75.
Univ of Colorado		 16.8 18.5 10.9 0.8 47.1
77.
George Washington Univ		 7.3 24.5 15.2 0.0 47.0
78.
Jefferson Medical College		 14.2 23.2 9.0 0.5 46.9
79.
Univ of Illinois - Chicago		 13.2 26.3 7.2 0.0 46.7
79.
Univ of Mississippi		 11.1 23.3 10.0 2.2 46.7
81.
Albert Einstein College of Med		 5.2 27.3 14.0 0.0 46.5
82.
Temple Univ		 11.9 21.6 9.7 1.7 46.0
83.
Univ of Alabama		 11.5 19.1 12.1 3.2 45.9
83. Univ of
Washington		 24.3 9.5 10.8 1.4 45.9
85.
Wayne State University		 13.2 20.6 9.5 2.5 45.7
86.
Univ of Kentucky		 8.9 26.7 13.3 6.7 45.6
87.
Johns Hopkins Univ		 2.7 27.7 12.5 2.7 45.5
88.
Indiana Univ		 16.0 13.0 11.1 5.3 45.4
89.
Univ of Hawaii		 15.1 20.8 5.7 3.8 45.3
90.
SUNY - Brooklyn		 3.3 28.8 10.9 2.2 45.1
91.
UMDNJ - New Jersey		 9.5 25.3 6.3 3.8 44.9
91.
Loyola Univ - Stritch		 12.6 17.3 11.0 3.9 44.9
93.
Univ of Virginia		 15.6 14.9 13.5 0.7 44.7
94.
New York Univ		 0.7 34.9 8.6 0.0 44.1
94.
Univ of Pittsburgh		 13.1 17.2 10.3 3.4 44.1
96.
Medical Univ of South Carolina		 17.9 20.1 5.2 0.7 44.0
97.
Harvard Medical School		 3.2 29.5 10.9 0.0 43.6
97.
Tufts Univ		 5.8 22.4 12.2 3.2 43.6
99.
Mount Sinai School of Medicine		 6.5 21.8 12.9 2.4 43.5
100.
Medical College of Wisconsin		 11.1 17.2 13.6 1.5 43.4
101.
Boston Univ		 6.0 25.3 10.7 1.3 43.3
102.
Univ of California, Irvine		 11.4 20.5 11.4 0.0 43.2
103.
Universidad Central del Caribe		 3.4 31.0 8.6 0.0 43.1
104.
Univ of Texas Southwestern		 8.2 27.2 7.1 0.5 42.9
104.
Univ of Texas Medical Branch - Galveston		 17.6 19.8 4.4 1.1 42.9
106.
Univ of California, Los Angeles		 13.8 17.9 9.0 2.1 42.8
107.
Tulane Univ		 7.5 19.2 11.0 4.8 42.5
108.
Univ of Utah		 16.0 12.0 14.0 0.0 42.0
109.
Univ of Florida		 13.7 14.5 12.0 1.7 41.9
109.
Albany Medical College		 10.5 12.9 15.3 3.2 41.9
111.
Dartmouth Medical School		 8.3 21.7 10.0 1.7 41.7
112.
Northeastern Ohio Univ		 14.7 13.7 10.5 2.1 41.1
113.
Uniformed Services Univ		 14.7 13.7 10.5 2.1 41.1
114.
Univ of Arizona		 7.0 12.0 16.0 5.0 40.0
115.
Case Western Reserve Univ		 6.3 22.4 10.5 0.7 39.9
116.
Univ of Nevada		 5.7 20.8 13.2 0.0 39.6
117.
Univ of Michigan		 7.5 19.3 9.9 1.9 38.5
118.
Univ of Chicago - Pritzker		 2.2 23.9 9.8 2.2 38.0
119.
Univ of Texas - Houston		 9.8 10.3 11.3 5.4 36.8
120.
Univ of South Dakota		 25.0 7.7 3.8 0.0 36.5
121.
Creighton Univ		 10.4 16.0 7.5 1.9 35.8
122.
Univ of Puerto Rico		 8.0 18.0 8.0 1.0 35.0
123.
Columbia Univ		 1.3 26.2 7.4 0.0 34.9
124.
Univ of Illinois - Urbana-Champaign		 13.3 16.7 3.3 0.0 33.3
125.
Duke University		 5.1 16.3 7.1 3.1 31.6
126.
Univ of Pennsylvania		 4.2 14.1 11.3 1.4 31.0
127.
Mayo Medical School		 7.5 10.0 7.5 0.0 25.0



Percentage of 1999 Osteopathic Medical School
Graduates Entering Primary Care Specialties



































































































































































Medical
School		 %TRI %FP %IM/ %PEDS %IM/

PEDS		 Unkn %PC
1. Lake
Erie COM		 57.5 45.2 44.2 1.9 5.8 0.0 97.1
2. 
Kirksville COM		 39.2 39.2 31.1 4.7 0.7 15.5 75.7
3. 
Ohio Univ COM		 78.9 42.2 25.6 4.4 0.0 0.0 72.2
4. 
Univ North Texas COM		 30.8 36.4 16.8 7.5 0.9 0.0 61.7
5. 
New York COM		 67.1 30.3 20.6 10.5 0.0 0.0 61.4
6. 
West Virginia SOM		 73.4 40.6 15.6 1.6 0.0 0.0 57.8
7. 
NOVA Southeastern Univ COM		 46.5 28.7 17.1 10.1 0.0 0.0 55.8
8. 
Western Univ COM		 __ 34.0 16.0 2.5 0.0 9.9 52.5
9. 
Oklahoma State Univ COM		 42.9 28.6 17.9 3.6 0.0 10.7 50.0
10.
UMDNJ SOM		 45.3 18.7 22.7 5.3 0.0 0.0 46.7
11.
Univ Health Sciences COM		 35.8 18.4 20.1 0.6 1.1 2.2 40.2
12.
Michigan State COM		 49.3 17.2 15.7 6.0 0.0 1.5 38.8
13.
Chicago COM		 43.4 18.1 15.7 4.2 0.0 0.0 38.0
14.
Des Moines Univ Osteopathic Med Ctr		 45.0 28.6 4.8 3.7 0.0 63.0 37.0
15.
Philadlephia COM		 52.0 6.7 9.5 4.4 0.0 9.1 20.6

~KEY































































PC Primary Care
FP Family Practice
IM Internal Medicine
PEDS Pediatrics
IM/PEDS Combined Internal
Medicine/Pediatrics
TRI Traditional
Rotating Internship
COM College of
Osteopathic Medicine
SOM School of
Osteopathic Medicine
+ Duluth is the only
two-year medical school separately accredited by the LCME. 
Graduates are automatically accepted into Univ of Minnesota-Minneapolis
for their third and fourth years.
^  Univ.
of Minnesota - Minneapolis data does not include Duluth graduates.
* 

UMDNJ
- Robert Wood Johnson figures are combined for the Camden and     
Piscataway/New Brunswick
campuses.
¡

University
of California, Los Angeles, includes students from the Drew and
Riverside campuses.

 °     

University
of Washington includes students from the WWAMI (Washington, Wyoming,
Alaska, Montana and Idaho) schools.
~

Data
for these specialties reflects both 1999 graduates entering directly
into residencies and current
(2000) placement of 1999 TRI interns in these residencies.

 s     

2000
residency data for 1999 TRI interns not submitted; figures represent only
1999 graduates directly entering residencies.




------------------------


The American Medical Student Association (AMSA) defines primary care as medical care delivery that encompasses the principles of comprehensive patient care, ongoing responsibility for the patient's health and
overall coordination of the patient's health-care needs -- be they biological, psychological or social.


The allopathic medical schools provided figures for the 2000 graduating class. The rankings were determined by calculating each schoolÕs percentage of graduates entering the four listed primary care residencies, then totaling the raw numbers from each residency and rounding this percentage to the nearest 10th (shown in the shaded column).


The osteopathic medical schools provided figures for the 1999
graduating class. Schools were asked to provide the following information: the number of students entering the Traditional Rotating Internship (TRI) in 1999, the number of 1999 graduates who matched directly into primary care residencies (e.g. family medicine) and the 2000 match results of 1999 TRI interns entering primary care residencies. Because osteopathic students are able to enter a TRI or a traditional (typically allopathic) residency, this scorecard uses 1999 and 2000 placement data of 1999 interns to ensure that the residency match information includes both subsets of students. Therefore, all data pertains to the
class of 1999.


The scorecard may include PGY-1 residents entering an internal
medicine preliminary year who may go on to specialize in a nonprimary care field, thus making the number of new physicians going into primary care specialties appear higher than actuality.


AMSA is considering adding an additional category next year to reflect the numerous internal medicine/primary care residency statistics received. This year, AMSA has included these Match statistics under "internal medicine." AMSA has also received many suggestions to include obstetricsÐgynecology (obÐgyn) as a separate primary care category. AMSA recognizes the important role of obÐgyns in primary care services, and while this year we did not include ob-gyn as a separate primary care specialty, we will consider doing so next year.


Any comments or suggestions to improve AMSA's Primary Care Scorecard should be directed to Shadia Garrison, at (703) 620-6600, ext. 214, or e-mail at shadia_g@amsa.org.
~~~Meredith Burke Lawler works on the PRIME project at the AMSA Foundation. Additional assistance was provided by Toi Cook, PRIME student intern, and Veronica Kennedy, PRIME project associate.
~Career Development,Medical Education~
219~3April~2001-50~Feature~Caring for the Dying~PALLIATIVE AND END-OF-LIFE CARE STRIVE TO PROVIDE THE ULTIMATE KIND OF MEDICINE.~Avery Hurt~~Jane Grant is dying. Her cancer is too far advanced for any hope of cure. She has, at best, a few weeks to live. She is in no pain, either physical or emotional. She is spending her last days at home, being cared for by her daughters, with the assistance of a team of medical professionals and volunteers who make sure that she is comfortable. Jane'illness is beyond cure. She is, however, more than ever in need of care-palliative care designed not to cure but to comfort, not to heal but to soothe.


Unfortunately in our society, Jane's
is not a typical situation. As a culture, we are not very good with death. We are uncomfortable talking about it, and medical schools don't teach much about it. Most people live the bulk of their lives under the vague illusion that they are immortal. Physicians spend most of their careers gamely reinforcing this illusion, doing their level best, in fact, to make the fantasy true. And when confronted with death, as all of us eventually are, physicians and patients alike still try to deny it or look the other way. As one medical student put it, "Patients don't die. They expire. Like library cards."



One result of this attitude is that death in the modern world has become unnecessarily lonely, painful and difficult for both patients and their families. However, a growing number of patients and medical professionals like Jane and her caregivers are realizing that it doesn't have to be this way.


Hospice care. Jane is enrolled in a hospice program. The hospice approach to death is to keep the terminal patient as comfortable as possible during whatever time is left. This means providing medication to relieve any uncomfortable symptoms, such as nausea, breathing difficulties or gastric disturbances. It also includes providing whatever medication is necessary to keep the patient pain-free. According to hospice pioneer Dr. Bill Lamers, there is no need for death to be painful. "We know that it is possible with the proper combination of pain medications to relieve pain without clouding the mind or suppressing the spirit," Lamers says. And these medications can easily be given at home orally, transdermally or in suppositories.


But hospice care goes beyond the physical. The patient's psychological and spiritual needs are addressed as well, whether this means contacting estranged relatives, arranging for visits from a minister or rabbi, or simply playing music or reading to a patient. Whenever possible, this care is given at home by family members (hospice uses a broad definition of "family" that includes close friends), hospice workers and volunteers.


The hospice movement was started in England in the mid-20th century by Cicely Saunders. As a medical social worker and later as a physician, Saunders spent a great deal of her career working with dying patients. She became convinced that through a combination of better pain management and enlightened care, death could be a better experience for the dying and their families.


The movement was taken up in the United States by pioneers like Lamers, founder of Hospice of Marin in California. It was one of the first hospice programs in the United States. "When we began our hospice," Lamers says, "we didn't even call it that. We just knew this needed to be done. Twenty-five years ago, we were thrilled that there were five hospices in the country. Now there are 3,000."


"But getting to this point hasn't been easy," says Dr. John Shuster, director of the palliative medicine program at the University of AlabamaÐBirmingham. "Hospice started out as a medical counterculture. It really was a grass-roots movement. The first hospices were run primarily by volunteers and nurses. It is just [now] beginning to be accepted as part of mainstream medicine."


Several factors have contributed to this recent swell of interest in palliative and end-of-life care. As the baby-boomer population ages, more and more people are facing the deaths of their parents and their own deaths. According to the U.S. Census Bureau, the number of Americans 65 years old or older is expected to double in the next 30 years.


Other, more subtle, factors also contribute to the rising interest in better end-of-life care. Dr. Joanne Lynn, director of the RANDÕs Center to Improve Care of the Dying, points out that over the last few generations, the United States has seen a significant change in the nature of the diseases that kill us. Chronic illnesses, such as heart disease and cancers, have replaced infectious disease and accidents as the leading causes of death among adults. According to Lynn, the U.S. health-care system is inadequate, because it has never faced these kinds of problems before.


Still the true change may be more in us than in our microbes. Chris Degnon, a second-year medical student at Pennsylvania State University College of Medicine and founding member of its death-and-dying interest group, suggests that expectations of medicine are changing. "Traditional medical education puts too much emphasis on the physician as someone who cures rather than someone who cares," Degnon says. "[But] as the public becomes more educated about medical issues, they expect more from physicians. They want more of their doctors' time, and they want more care." Degnon believes that the medical community is slowly, but surely, responding.


Lamers agrees that the growth in hospice and palliative care is more or less consumer driven. But, he says, patients aren't the only ones who are demanding this. "Today's medical students are absolutely wonderful -- some of the best I've worked with," Lamers says. "They are not going into medicine for the money, but to do good."

Medical education. Making end-of-life care an established and routine part of the practice of medicine, however, will require overcoming several obstacles. Dealing with the complex emotional and psychological issues surrounding death, as well as the necessary medical skills, calls for a great deal of training, and that training has not traditionally been a part of medical education. "American medical schools do a good job of teaching physicians how to recognize disease and work for cures," Shuster says, "but not so good a job of teaching them how to recognize suffering and provide care." Shuster says this is especially unfortunate because in all areas of medicine, not just end-of-life care, palliative care is an essential part of the art of healing. "Even when the goal is cure, a master physician learns how to provide care," he says.


In spite of a traditional weakness in this area, medical schools are increasing their coverage of death and dying. Dr. Joseph Fins, director of medical ethics and assistant professor of medicine at Weill Medical College of Cornell University, has noticed a significant change in recent years. "When I graduated 14 years ago, I had never heard the word "palliative" used in medical school. Patients had diseases, but they never seemed to die of anything," Fins says. "Today we are making remarkable progress in this area, though there is still a great deal more to be done."


According to the Association of American Medical Colleges, most medical schools report that they do offer some training related to death and dying. But as of the 1997-98 academic year, only six reported that they offer a separate course in the matter.


Course work, however, is not the only way to learn about palliative and end-of-life care. "We can't get students' minds [on] palliative care if we don't get their hearts," Fins says. And getting their hearts requires hands-on experience with dying patients.


Joe Deng couldn't agree more. Deng is a second-year medical student at Penn State and Degnon's partner in founding the college's death-and-dying group. Deng first learned about hospice care when his roommate asked for his help in caring for a dying friend. It was a transformative time. "After my first experience with a dying patient," Deng says, "I realized how poorly prepared I was to be a doctor." Understanding how to care for dying patients is essential to being a good doctor, and that, says Deng, requires "going out and meeting dying people, their loved ones, and experiencing the pain."


Hindering good care. The best intentioned and the best prepared caregivers, however, still encounter obstacles when trying to provide good end-of-life care. And many of these obstacles have little to do with medicine.


"Mr. Johnson has a lot of problems!," said Dr. Amos Bailey as he began the staff meeting at the Balm of Gilead palliative care center at Cooper Green Hospital in Birmingham, Alabama. It is the city's only indigent care hospital. Although it was a dark December afternoon, as a rare snowstorm threatened the city, the mood was cheerful. Volunteers played chamber music amid the festive holiday decorations that had been hung by the local American Medical Student Association chapter, as team members gathered to discuss their patients' needs and to devise strategies for meeting them.


Bailey, founder and director of the center, leads these weekly meetings. Nurses, social workers, volunteers and housekeeping staff attend them regularly, along with anyone who has an interest in the care of Balm's patients. The hospice team encompasses more than just the medical staff, because the problems that are discussed here go well beyond medical, and the care that is provided touches more than just physical symptoms.


Addressing Mr. Johnson's problems, as it turned out, involved making changes to his medication as well as brainstorming for solutions to several social and economic dilemmas. Other problems dealt with that day required helping a daughter arrange for flex-time at work so that she could help her sister care for their dying mother, and dealing with a family who could not bring themselves to give up their mother's apartment - even though they were struggling financially and their mother wouldn't need her home.


Anyone involved in palliative care has an intimate understanding of the frequently cited principle that there are four aspects to suffering: physical, spiritual, emotional and social. Good end-of-life care requires treating all types of suffering, and this in turn requires a great deal more patience and creativity than is called for in most areas of medicine.


Then there is the issue of who will pay for this type of care. Managed care demands increased efficiency, yet as Shuster says, "Good medical care is not always very efficient. The human side takes time." And palliative care is all about the human side.


Hospice and palliative care can be cost-efficient. With a routine hospital stay's average price tag around $1,500 per day, dying at home can be far less expensive than dying in a hospital. And even in an in-hospital palliative care unit, money can be saved by limiting the number of tests and interventions that are the usual part of a hospital stay whether or not there is any expectation of a cure. Still, funding problems exist.


Although many private insurance programs do provide a hospice benefit, the vast majority of hospice and palliative care is paid for by Medicare and Medicaid. But these federal programs, especially Medicare, don't adequately provide for end-of-life care, said Joel Cantor, professor of public policy and director of Rutgers University's Center for State Health Policy, in a recent teleconference.


"Medicare's focus is almost exclusively on covering acute medical needs and curative care," Cantor said. The hospice benefit does provide some help, but in order for Medicare patients to qualify for the hospice benefit, a physician must certify that a patient has less than six months to live, and the patient must give up any other Medicare benefits for curative care. This has resulted in too few patients getting referred to hospice, and it's usually too late for those who do - often only days before death.


Medicaid has fewer restrictions than Medicare. But at the moment, less is known about how it works in practice. A study to determine how Medicaid works in end-of-life situations has been commissioned by Last Acts, an organization promoting hospice and palliative care.


Aid may be coming on the federal level, though. A recent report by the U.S. Government Accounting Office sheds light on the many shortcomings of the Medicare hospice benefit. And last fall, the Senate Committee on Aging took up the issue of hospice and palliative care.


Despite the many obstacles and frustrations that get in the way of good palliative and hospice care, many physicians say it is still one of the most rewarding experiences medicine has to offer. "We've let our discomfort with death put us out of touch with the good things that can go on as death approaches," Lamers says.


"This is the best medicine I have ever practiced," Shuster says. It is incredibly fulfilling to be able to focus on providing relief from suffering. Hospice and palliative care are the guardians of the soul of medicine.
~EDUCATIONAL 'WIT'


The empathy and emotional sensitivity required for excellent end-of-life care cannot be learned in the classroom. But volunteering at a hospice or experiencing firsthand the death of a friend or loved one is not the only way to gain deep insight into this difficult aspect of medical care. Literature Nobel Prize-winner Aleksandr Solzhenitsyn said, "The sole substitute for an experience, which we have not ourselves lived through, is art and literature." And literature, it seems, is proving to be an extremely effective method of teaching medical students how to treat dying patients.


'Wit,' the Pulitzer Prize-winning play by Margaret Edson, is a fictional story about the last weeks in the life of Vivian Bearing, a patient dying of ovarian cancer. The play explores the relationships between the patient and her caregivers and offers the audience a chance to experience medicine from the point of view of the patient.


When Dr. Karl Lorenz, a health services fellow and general internist at the VA Greater Los Angeles Healthcare System, saw 'Wit' for the first time, he found it electrifying. "The emotional intensity of it really gripped me," Lorenz says. As a physician, he understood the seriousness of the play's issues. As a former student of literature (Lorenz majored in it as an undergraduate), he understood the play's power to teach empathy and compassion to medical students who have as yet no direct experience with death and dying.


So with the support of the Fan Fox and Leslie R. Samuels Foundation, Lorenz and his colleague Dr. Kenneth Rosenfeld put together a program called the 'Wit Educational Initiative.' It works with regional theaters to bring productions of 'Wit' to U.S. and Canadian medical schools. The program includes a pre-performance lecture by Lorenz or Rosenfeld, and post-performance small-group discussions. Other educational materials are also offered to allow students to continue their exploration of the themes introduced by the play.


Response to the project has been encouraging. After a performance at the University of Louisville, a resident told Lorenz that she was caring for a patient with ovarian cancer, and it was not until she saw 'Wit' that she really gave any thought to the inner life of her patient. A first-year medical student from the University of Iowa told Lorenz that the play had inspired her to make profound connections with real patients -- and this in the first year of medical school, when students typically form profound relationships with textbooks rather than people.


Not all of the evidence for the play's success at teaching has been anecdotal, however. According to Lorenz, audience surveys suggest that students leave the performance determined to get more out of their medical education.


The play itself is a powerfully emotional production - from the moment Vivian's doctor bluntly tells her, "You have cancer," to the day when she is near death but not yet comatose, and another doctor casually comments within her hearing, She's out of it. Shouldn't be too long."


To say the least, Vivian's doctors are less than sensitive, but Lorenz reminds us that "the play is not a documentary, nor is it intended [to be] a political statement about medical practice. It is a story about a person who is dying from cancer."


While physicians tend to identify with the doctors in the play and become a little offended, medical students are more likely to identify with Vivian, Lorenz says. Though a victim of both cancer and the excesses of modern medical research, Vivian is not portrayed as passively waiting out her remaining days. She is a strong and intimidating woman, and at times can be a difficult patient, as insensitive in her own way as are her doctors. VivianÕs complex personality makes getting to know her all the more interesting and instructive. "Death and dying is a troubling issue, and this play gives students a chance to think about what kind of care they want to give in this kind of situation," Lorenz says. "If the play fosters anything, it fosters empathy and self-reflection," concepts perhaps better taught by literature than by science. - A.H.


-------------------------


RESOURCES


When Dr. Linda Emanuel recognized the huge gap between the kind of end-of-life care that was possible to give and what patients were actually receiving, she decided to do something about it. With support from the Robert Wood Johnson Foundation and Northwestern University Medical School, she created EPEC (Education for Physicians on End-of-Life Care), a continuing education program. This information is also available to medical students. Visit www.epec.net.

- A.H.
~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~Humanistic Medicine~
232~4May-June~2001-50~Feature~59 Habits of Highly Effective Activists~THERE'S MORE THAN ONE WAY TO FURTHER A CAUSE.~Rebecca Sernett, Jennifer Zeigler~~We know, we know. You're a physician-in-training. You barely have time to eat and sleep. But we also know many of you out there secretly think you were born in the wrong decade. So for all of you dreaming of the 1960s activist life, here's a guide to get you started. But be forewarned: It's not all protests and sit-ins. These 59 acts of activism are as varied as the causes they can be used to advocate. We hope each entry on this list-the large and the small, the personal and the community-oriented/awakens a part of your inner activist, because we know the world will be a better place for it.


Go to medical school - You may not think so, but studying medicine can be an act of activism. By becoming a physician, you have signed on to making the world a healthier place.


Wear your white coat - A symbol in itself. This seemingly simple piece of clothing says something about you and for what you stand. Take advantage of that.


Inform yourself - Stay in touch with the news and issues that are important to you. Read newspapers and magazines. Subscribe to listserves and journals. Surf the 'Net. Information can be power.


Share the news - Once you've informed yourself, share the news with others. Put up a poster in the student lounge. Post a news bulletin in the mailroom. Do this daily, weekly or monthly so people can expect to be regularly updated.


Get on the airwaves - Got a message to share and want others to hear it? Start a radio talk show. Publish a newsletter, newspaper or magazine. Create a Web site.


Cybersize your message - Take advantage of the speed and efficiency of modern technology. Start a listserve or discussion board.


Be a printmaker - Create thought-provoking designs for T-shirts, hats and buttons. Wear them. Put a bumper sticker on your car.


Be a writer - Submit articles, story ideas and news items to journals, newspapers and magazines. Don't forget about the local papersÑthese outlets are always looking for good editorial material about a community project or event. Not good at writing? Give the editor a call. You could get a reporter at your event.


Compose an op-ed - Share your opinion on your newspapers' editorial pages. For a better chance of getting your letter in print, respond to a local or national event and use that as an opportunity to sneak in a message.


Hold a press conference - Call local radio and TV stations, and print media. Tell them you have an announcement to make.


Vote - It counts.


Run for office - Many local positions are part time and volunteer. Once elected, use your position to further your cause.


Attend local government meetings - Daunted by the idea of running for office? Start by going to public meetings and speaking out during comment periods. This can help you make connections with your community, and local officials are always looking for fresh faces to get involved.


Be a joiner - Every body counts in membership-driven organizations. Join an international, national or local activist group. You don't have to be an active member to be important--just be a member.


Get on board - Membership isn't always everything--get on an organization's board of directors. Make your voice heard once you're there.


Start an organization - It can be large or small; local or national. Remember, just two people working toward a common goal can be an activist group.


Be a globetrotter - Get on a plane, ride in a car, travel in a bus ... Travel, period. Expose yourself to a variety of learning experiences, whether they be in the next state or on the other side of the world.


Be a fellow - Find and apply for
fellowships that provide money for activists to take a sabbatical and work on an issue.


Initiate a community awareness
program - Connect to the community by starting local programs, fairs and other events at public places like a library, community clinic or meeting house.


Get involved in local schools - Contact the administrators, teachers and professionals at area elementary, middle and high schools. Ask if you can talk to classes or create programs to educate students on the issues you're concerned about.


Get involved at your school - Be a peer educator and offer to give presentations on a topic you care about.


Be Smokey the Med Student - Remember the impact Smokey the Bear first had on you? What about McGruff, the crime dog? Spread your message in a creative way to the young. Children could become some of your strongest supporters.


Fill the gaps - Do you see holes in the system? Fill them. Don't wait for someone else to provide that help. Reach out yourself. Be the person who organizes the clothing drive for the children at your clinic.


Attend a workshop or conference - Events like these are perfect for networking, gathering information and ideas for new activities, and getting energized. You may find a mentor or even make a lifelong friend.


Get hands-on experience - You may be feeling like you aren't "doing"
anything right now--nothing that's "real," at least. Well, don't wait for "reality" to come and find you. Seek it out yourself. Volunteer, get an internship, or find work at a place where you can be connected to the issues you feel closest to.


Write a letter - Enlist the aid of people who have the power to institute change. Lobby them by writing a letter, sending an e-mail, faxing a petition, or making a phone call. Don't be afraid of visiting their places of work, either. And if you do so, wear that white coat.


Tell them you care - Contact individuals and groups whose efforts you support. Thank them for their work and ask how you can help.


Support legislation - Hear of any legislative action you'd like to support? Contact the key parties and ask how you can help. They may recruit you to start a petition, call your senator or even testify before Congress. You don't know how you can help until you make that call.


Create legislation - Write a bill and ask your representatives to introduce it.


Hold a lobby day - Round up as many fellow supporters as you can and schedule meetings with your senators and representatives. Even if you can just get in with their advisers, take advantage of the opportunity.


Testify - Like Rage Against the Machine says, "Testify!" This could be before congressional committees as part of some legislative action. Make your voice count.


Collect signatures - Whether they're
for a ballot initiative, a petition for
a candidate or even a letter demanding change, the more names the better.


Sign your John Hancock - Don't
forget to support your fellow signature collectors.


Join a protest - Numbers really count here, so if you're passionate about an issue and want to stand up for your beliefs--join that protest or picket line. Just be sure you're aware of the risks.


Lead a demonstration - Show your parents that civil disobedience didn't die in the '60s and initiate a protest. See who can come up with the best rallying chant.


Hold a candlelight vigil - Less militant than a protest, a vigil is an effective way to share your message.


Cause a stir - Some people are better at staging publicity stunts than others, but getting yourself noticed because of something unusual you do is often a successful way to gain attention. Climb a mountain, ride a lawnmower cross-country, live in a tree, walk around everywhere on your hands.


March in a parade - Why not strut your stuff down Main Street. It's great publicity.


Act out in class - Turn one of your school projects into an act of activism.


Tailor an assignment to suit your issue - Write a paper. Conduct research. Propose a project. You may just get some extra credit, and if it's really outstanding work, you might get published.


Take it to the classroom - Suggest that a professor introduce your topic in class. Professors can be very receptive to this type of request, if you follow these suggestions: Introduce your idea in a nonthreatening way, i.e., send the appropriate professor an e-mail introducing yourself, your idea and what type of result you'd like to achieve (inclusion of the information in a lecture, etc.); offer to do the research and provide materials; if you're successful, be sure to follow up with a thank-you note and an expression of appreciation. You can also take this same tact and volunteer to give the talk.


Reform the curriculum - If you're looking for a bigger impact on the classroom, curriculum reform may be your route to take. This involves jumping through many hoops, but if you're successful at accomplishing change by creating a new course, elective or program, just think of how future students can benefit. Don't forget about new technology when contemplating curriculum reform. What about creating an online course?


Get credit for it - Perhaps there's already a course at school focusing on issues important to you. Don't miss out on this opportunity to get credit for learning about something that's dear to your heart.


Request reading material - Ask that your local or school library order issue-oriented literature so that others can be informed.


Host a breakfast lecture - We're all attracted to food--especially starving and exhausted medical students. So why not host a lecture series over breakfast, lunch or dinner? It could be a BYOB (bring your own bagel) lecture or BYOP (bring your own pop, pizza is provided) talk. Satisfying the stomach may be the element needed to encourage dialogue.


Party - No one said activism has to be dull. Host a mixer, happy hour or soiree for a cause. Celebrate a historical event, day or "win." Spread the word by having a good time.


Make music - We all know how
popular benefit concerts are these days. Host one of your own in a local coffee house, bar or even on the school lawn.


Host a movie night - Select movies that spark discussion. Don't forget the popcorn.


Brown bag it - Perhaps all you want to do is gather with fellow activists and discuss a cause. Start a brown-bag discussion group. Meet over coffee. Make late-night pizza runs together.


Car pool - Encourage discussion on the way to school or work. This doesn't have to be in a car. Take the bus or train together. The idea is to use normally wasted time to your advantage.


Give handouts - Distribute stickers, pins and leaflets--the more gimmicky the better.


Jump rope - Run, walk or ride in a
charity event. Spend a Saturday
afternoon as part of a local jump-a-thon. Make friends, get exercise and spend a couple of hours dedicated to a good cause.


Make some money - Do some fund raising for your favorite cause. Host a bake sale, sell T-shirts or wash cars. Write a grant proposal. Put your money-raising talents to work.


Spare a dime - Donate money to charitable groups. Add a quarter to the pot. It all helps.


Buy with a conscience - There are many ways to spend your money and maintain your principles. Buy charity-supporting foods. Purchase fund-raising postage stamps. Request the services of utilities that donate a portion of their profits to a good cause.


Use stamps - Want to send a message near and far with very little effort? Select appropriate postage stamps from your local post office, and use them on everything from sending letters to grandma to mailing that loan repayment check.


Donate your time - For many activists, it's the simple things that count. And for many organizations, it's the administrative things that can become a chore. So, give up a couple hours of your week to stuff envelopes, collate, answer phones,
man a table at an awareness fair,
provide transportation--you get
the picture. Your time is precious
to you and extremely valuable to
others.


Be a mentor - In the search for the perfect medical school mentor,
don't forget to be one, too--even if it's just for an hour each week. Allow a high-school student to shadow you, tutor elementary kids or be a Big Brother or Big Sister.


Talk - Whether it's with your spouse, friends or the mailman, talk to others about your issue. Don't assume that everyone is informed.


Listen - Don't spend all of your
time talking, though. Lend an ear
to anyone and everyone involved in the issue thatÕs important to you. Someone needs to be receptive to discussion.
~ACTIVIST ID

Name: Dr. Pankaj Jain

Age: 28

Education: M.D., M.B.A.

Specialty: urology

Issue: resident rights

Current activities: Jain formed the McGaw House Officers Alliance to raise awareness of resident issues at McGaw Medical Center in Chicago. He also regularly speaks out about this issue at hospitals and organized-medicine conventions.

-----------------------

Name: Dr. Laurie Vollen

Age: 45

Education: M.D., M.P.H.

Specialty: public health and preventive edicine

Issue: human rights

Current activities: As a member of Physicians for Human Rights, Vollen traveled to Bosnia to develop an exhumation and identification program for missing persons after the war there. Her efforts focus on making DNA technology available for this type of work.


-----------------------


Name: Drs. Randall White and Erica Frank

Ages: 40 and 38

Education: M.D.; and M.D., M.P.H.

Specialties: psychiatry; preventive
medicine

Issue: environment

Current activities: White sees patients three days a week and volunteers the
rest of his time. Both serve on national boards, write letters and organize events to draw attention to public and planetary health issues. On weekends, the couple lives in an energy-independent home in Georgia.


-----------------------


Name: Dr. William S. Gilmer

Age: 45

Education: M.D.

Specialty: neurology

Issue: gay rights

Current activities: As president of
the Gay and Lesbian Medical Association and a member of several local organizations, Gilmer regularly speaks out on gay rights and recently worked with his city council in Houston to write a nondiscrimination law for the community.


-----------------------


Name: Dr. Jody Steinauer

Age: 31

Education: M.D.

Specialty: obstetricsÐgynecology

Issue: abortion education

Current activities: The founder of Medical Students for Choice, Steinauer now researches the effects of including abortion education in medical school curricula. She also continues to speak out on pro-choice issues, provide abortions and teach medical students how to do so as well.


-----------------------


RULES TO ACT BY


Give yourself permission to help - With busy schedules and lives, it’s no wonder many well-meaning physicians-in-training aren’t sure they have time to help. But there’s an easy answer to this dilemma: Give yourself permission. Just by saying “Yes,” you open the door to a multitude of activist opportunities.


Recognize the rewards - Once you’ve opened that door, be sure to take note of how your actions positively impact your life and the lives of others. Recognizing the rewards is essential to maintaining your motivation.


Be an inspiration - Connect with members of your community and spark an activist chain reaction.


Think big - Believe that you can make a difference, and don’t let yourself get bogged down in the details.


Every little thing counts - You don’t have to move mountains to be an activist. Small acts are just as important as the big ones.


Make it fun - Activism doesn’t have to be a chore. Make a game out of it. Be creative. You’ll get more people involved this way, and you’ll feel better about giving up your free time.


Know the risks - Activism isn’t all fun and games, though. Be sure you’re aware of the consequences of your actions, because you’ll have to take responsibility for them. A smart and prepared activist is more effective than a reckless one.


Practice what you preach - It’s easy to talk the talk, but can you walk the walk? How you live your life is often more impressive than what you’re saying. Be sincere in your activism and do as you say. You will find yourself more fulfilled.


Love what you do - Speaking of fulfillment, be sure to enjoy what you do. It may be a challenging and difficult effort, but you should feel a connection to the issues and people involved. You should care about it. This makes the time spent so much more rewarding.


Remember, you can’t do it all - So you care about 50 million causes and want to be able to contribute to all of them? Don’t kid yourself. No one expects you to be an Ÿber activist. Exhausting yourself, your energy and time doesn’t help anyone. Focus on the issues that are most important to you.
~~~Rebecca Sernett is editor of and Jennifer Zeigler is a senior writer with The New Physician.~Advocacy~
233~4May-June~2001-50~Feature~Affording Altruism~REALIZING YOUR UNIQUE AMERICAN DREAM.~Rick Stahlhut~~Are you what many call an “idealist”? Do you want to help the poor, practice in rural America, volunteer overseas or be a family physician who still makes house calls? Unfortunately, these dreams can seem difficult to fulfill as you watch your debt accumulate or perhaps as the “realists” convince you that your humanitarian values are just not practical in the age of the seven-minute managed-care visit.


Even your career choice can be affected. You might be reluctant to go into primary care because of your debts. Some even think physicians have priced themselves out of primary care completely, and that nurse practitioners and physicians’ assistants will inevitably take their place.


Fortunately, the pragmatists’ “reality” is not the only one available. With a new perspective on life and work, you can make your otherwise impractical dreams possible. The way we usually live in America is not the only way. You have a choice, and you are at the ideal point now to make that choice--but only if you can learn to manage your money in a radically different way than most financial advisers have in mind.


If you think managing money is boring, even evil, and has nothing to do with your values and dreams, think again. To reach your goal, you will have to find a way to need significantly less money than the average physician to be happy. And to do so, you will have to stay clear of a common American sickness--consumption.


Physicians are particularly susceptible to this illness. Some of the symptoms of our particular strain: compromising dreams for practicality; making (and spending) far more money than most of the world’s people, but also working long hours; lacking the time to educate patients about their diseases and to help them make critically important decisions; lacking time with family and friends; and racking up high rates of divorce and drug abuse.


Why do we live this way? In part, because we are unaware of alternatives. If you think you must work for money your entire life (a myth), then you may as well spend all of the excess money you have. In fact, you must spend it if you are to maximize the little bits of time you have off-duty to lessen the pain of a life not-quite-fulfilled.


The current health-care system doesn’t make it any easier. “In the ideal medical practice, healing becomes a loving, human interchange, not a business transaction,” writes physician-activist Patch Adams in his book Gesundheit. “I believe the loss of this relationship fuels much of the lay criticism of modern medicine, malpractice claims and the health-care professional’s tragic loss of joy in practice.”


The data back him up. In six studies of career satisfaction among family physicians and general internists, satisfaction was associated strongly with the quality of the physician-patient relationship. Sadly, nearly one-third of these same people were not satisfied with their practices.


The alternative. Fortunately, there is a simple but dramatically different alternative. By resisting consumerism’s siren song and focusing on what is truly important in life, you will probably find you can live quite comfortably at much less than the average physician’s salary. This should not be surprising, since you will be extraordinarily rich by world standards.


Then it becomes a simple matter of saving the difference between your massive income and modest expenses. First, you use this money to pay off your debts. Then you save until you have essentially endowed yourself for life--in other words, until you make enough interest from your savings to live off it without needing additional income. You are then free to stop working for money, if you wish, and spend your remaining time on earth in whatever way you find most meaningful.


Seem impossible? No surprise. Advertisers spend billions of dollars a year trying to convince you otherwise. Their strategy is not just to sell a specific product but also to promote the beliefs and attitudes that create a frenzy of consumption and eliminate other options from public consciousness. Their main message: “You are not OK as you are--but if you buy this, everything will be fine.” This strategy is extremely successful, but you can resist their message.


Naturally, there are situations that increase the total savings you will need to reach nirvana--children, for one. But having children doesn’t negate your humanitarian dream. It only alters the numbers. Of course, it’s difficult to live simply when a child is begging for the latest trinket, but if the difference is between having that trinket and more time with happier parents, the child’s best choice seems clear.


As a student, you’re probably living simply now. That’s why you are in the perfect situation for this approach to your career. All you need to do is make sure your expenses don’t go through the roof as your salary does.


If you are not living simply now, you will need to start watching your expenditures and gradually determine how much spending is enough for you to be content. The book Your Money or Your Life is incredibly helpful with this process (see “Resources”).


Finally, here’s just one example of how it could work:


You complete a family medicine residency and start practice. Your annual salary is $90,000 ($70,000 after taxes). Your debt from medical school is $150,000, with interest payments of 9 percent. Through careful study and experimentation, you learn you can be perfectly happy while living at a modest American salary of $22,000 per year. You’re not starving or driving a beat-up car or living in a shack. You are merely conscious of where your money is being spent and whether it is worth it.


By devoting the excess money to your medical school debt, you retire this liability in less than four years. After becoming debt-free, you save for two years and pay cash for a $100,000 house. After that, you put your extra money into extremely safe, income-producing investments, such as long-term U.S. treasury bonds earning 6 percent interest. To make $22,000 per year from your investments (what you need to support yourself at your “enough” level), you will need to invest $370,000. By investing $48,000 per year (the difference between your net salary and your “enough” level), you will reach this point in seven years.


You can then practice medicine exactly the way you want. You can start your inner-city clinic, unencumbered by the need to make any salary beyond what’s needed to cover malpractice insurance and other expenses (and Patch Adams thinks you don’t need malpractice when you really spend the time to care for people). Or you can stop, hit the beach and recharge. Burned-out physicians don’t do themselves or their patients any favors.


So, for those of you willing to change your approach to the American dream, you can be free to live life and practice medicine spectacularly. Or you can put on the golden handcuffs. Ferrari or Freedom? The choice is yours.
~YOUR MONEY OR YOUR LIFE