169~1January-February~2002-51~Folk Tales~Renaissance Man~PHYSICIAN LEADER LOST IN TERRORIST ATTACKS~Jennifer Zeigler~~There are many sides to every story and the story of Dr. Paul Ambrose is no different. The loss of Ambrose, who was on board American Airlines Flight 77 when it crashed into the Pentagon on Sept. 11 last year, is perhaps best summed up by his friend Chris Durso, who says, “I can’t be the only person right now who feels that he lost a brother. Or rather, two brothers: a trailblazing, peculiarly wizened older brother and a goofy, idealistic younger brother—all in one.”


That goofy side—full of charm and a zest for new experiences—may have earned him an upgraded hotel room or an invitation to go behind the bar to compete in a margarita-mixing contest with the bartender every now and then, but it also helped him in his health policy career. Ambrose used his charm to work the health policy system to his best advantage, racking up accomplishment after accomplishment in his short but wildly successful life.


A native of Huntington, West Virginia, Ambrose stayed close to home for medical school, graduating from Marshall University School of Medicine in 1995. While there, he became active with the American Medical Student Association (AMSA), landing the job of AMSA’s legislative affairs director in 1995.


It was at AMSA where he really began to flex his health policy muscles. “He had such a command of health policy that most people would be jealous of,” says Dr. Paul Jung, a friend who met Ambrose through AMSA. “Very few people are successful with health policy. He knew that knowing this policy exists is not enough—you have to know what to do with it.” And he wanted other medical students to understand this as well.


That’s why Ambrose created AMSA’s Political Leadership Institute, Jung says. The institutes, which AMSA renamed in Ambrose’s honor, are annual weekend sessions that use lectures and role-playing examples to teach medical students political advocacy skills.


“He wanted to do things bigger,” says Dr. Travis Harker, a medical resident who is one of Ambrose’s many mentees. “He really wanted to see if he could move the whole system forward.”


After earning his medical degree, Ambrose went on to do a family practice residency at Dartmouth Medical School. He had wanted to enter a residency program with a health policy component, but none existed at the medical school at the time. So Ambrose, in his typical fashion, created his own health policy learning experiences and began to forge a close relationship with former Surgeon General C. Everett Koop, eventually bringing Koop to Marshall for a presentation on public health and preventive medicine and home for supper at his parents’ house. The story goes that his mother burned dinner that night. Later, Ambrose worked with Dartmouth in his post-residency years to form the public health and family medicine program in which Harker now participates.


Ambrose was successful at meeting new people and making things happen. Jung recalls the first trip the two took together: the annual meeting of the Nonprescription Drug Manufacturers Association (NDMA) in Colorado in 1996 at which Ambrose wanted to lobby the NDMA for some project funding. Using his powers of persuasion, Ambrose was able to get the organizers to pay for everything from a side trip to Pike’s Peak to the buffalo burgers he and Jung ordered from room service. “So technically, they were paying us to lobby them. Only Ambrose could swing a deal like that,” Jung says, ruefully noting they didn’t get the project funding.


But Ambrose may have reaped something better. At the conference’s black-tie banquet, Ambrose spotted keynote speaker Mario Cuomo across the lobby. “He says, ‘Hey, there’s Mario Cuomo. Let’s go talk to him,’” Jung says. “And I said, ‘You can’t do that. He’s the [former] governor of New York.’” But Ambrose paid no mind to his friend, sauntering up to Cuomo and asking him about his flight. “Just regular elevator talk,” Jung says. “We wound up getting some great pictures with some very important people.”


Jung says tales like the ones from Colorado tell the real story of Paul Ambrose. “[His versatility is] what made Paul Ambrose. When you first looked at him, he looks like this really hip surfer dude, but after awhile, you realize this isn’t some punk guy. He could talk to one person about health policy, and then he could go talk to someone else about astrophysics.”


Which may have been one reason Ambrose earned himself so many admirers in so many fields. Erin Fuller, a former AMSA colleague, says Ambrose made friends with a librarian friend of hers at a New Year’s party, talking for hours about the First Amendment. He also bonded with Fuller’s younger brother—they liked the same alternative heavy metal bands—and her venture capitalist husband, with whom he enjoyed discussing financial issues.


“One of the amazing things about Paul is that he could move very easily between those…worlds,” Harker says.
Fuller says being able to succinctly describe Ambrose has always been difficult for her. “This is my friend Paul. He watches crazy movies; he climbs rocks; he listens to Goth music; he’s a doctor.” It’s the doctor part that makes her chuckle, given everything else Ambrose was into. “I always looked at it as one of his crazy hobbies.”


Hobby or not, being a physician was his calling. After residency and earning a master’s degree in public health from Harvard University, Ambrose landed the competitive Luther Terry Fellowship from the Association of Teachers of Preventive Medicine, which gave him the opportunity to work in the Office of Disease Prevention and Health Promotion (ODPHP) at the Department of Health and Human Services (HHS) in Washington, D.C.


Ambrose was put to work as part of the team writing Surgeon General David Satcher’s “Call to Action” on obesity. “As he worked on this project, he really began to take a professional interest in it,” says Kathryn McMurry, an ODPHP nutritionist who worked on the call. “He took what he was working on and put it into practice.” Which would explain the giant bottles of protein powder and vitamins in Ambrose’s office. The free weights he kept there were so big, McMurry says she doesn’t know how he got them there.


“We thought since we were working on [HHS initiative] Healthy People 2010, we should live Healthy People 2010,” says Harker, who also worked at ODPHP and calls Ambrose one of the best attendings he’s ever had. The two went to the gym daily, and when they couldn’t, they did curl workouts in Ambrose’s office.


Ambrose’s physique and good looks were legendary—and his friends say he played them up. “He took longer to get ready than anyone else I know,” says Durso, who compares traveling with him to traveling with his wife. But friends were accustomed to waiting for Ambrose. Anyone who went with him to lobby at the Capitol had to allow for extra time at the metal detectors so guards could check the steel-toed boots he wore everywhere and with everything. “He had very definite fashion phases,” Fuller says. “He was in his Donna Karan phase…last year.”


As a consequence of all that waiting and primping, Ambrose was rarely on time. The fact that he arrived on time for the flight to Los Angeles on that early September morning is the great irony of his death. “He was very much looking forward to [the obesity conference he was traveling to],” McMurry says. “He’s always late, and this is the one time he was on time for the airport.”


And while his HHS job ended up being the last move in a promising career, friends and colleagues say Ambrose’s on-target mind and dazzling charm could have taken him anywhere. This was supposed to have been only the beginning. “He was just so far and away more capable than any of us ever were,” Jung says.


“Paul Ambrose would have been surgeon general” is a phrase many friends and colleagues now speak with a melancholy wryness that captures the tragedy of this particular Sept. 11 loss. “He was a fantastic physician leader,” Fuller says, “and he would have been surgeon general, but he was so many other things.”


Durso and Harker both heard Ambrose talk about his ambition to become the public health commissioner for West Virginia, while others say they knew he never wanted to get too far away from the family medicine he practiced three days a week at a clinic for Spanish-speaking patients outside of Washington, D.C. Friends say one of Ambrose’s strengths was his ability to work the system. “Paul would have taken advantage of whatever options were in front of him,” Harker says.


We can almost be assured that those options would have been many. At Dartmouth’s memorial service for Ambrose, Koop told a story about a letter he wrote to Sen. John D. Rockefeller IV (D-W.Va.), telling him to keep his eye on Ambrose—the senator’s homegrown rising star. “We already know about Paul Ambrose, and we’ve been keeping our eye on him for some time now,” Rockefeller wrote back. It is in Ambrose’s death that the rest of the world now sees what Rockefeller long had recognized.


“People may have been put off by his initial appearance, thinking he was more style than substance, but anyone who talked to him for more than a minute knows that wasn’t it,” Jung says.
Fuller agrees. “He was…the real deal.”
~~~~Jennifer Zeigler is a senior writer with The New Physician.~~
170~1January-February~2002-51~Feature~Surgeons General: Defenders Of Public Health~~Howard Bell~~For a surgeon general, taking a stand on important public health issues frequently means defying politics, shocking the
public and risking being fired by the president of the United States. Still, for the past 131 years most surgeons general have been willing to take these risks in order to improve the health of all Americans.


Surgeon General Joycelyn Elders counted 30 microphones on her podium as she spoke at the United Nations’ headquarters in New York City during a teleconference for World AIDS Day in 1994. The whole world was listening as a psychiatrist asked Elders if children should be taught about masturbation. Safe sex is one way to avoid HIV/AIDS, and masturbation is part of practicing safe sex, Elders responded. Surgeon general says teach children to masturbate, Newsweek reported. Two days after the Newsweek article appeared, President Bill Clinton asked Elders to resign after serving only 15 months of her four-year term.


Once upon a time, most Americans wondered if the surgeon general is a real person or whether he’s a marketing image like Betty Crocker or Uncle Sam. Today, however, the surgeon general is frequently in the news—making headlines with provocative reports or comments. What’s going on? Has the role of the surgeon general really changed from when it was first established in the late 1800s? Not really. The Office of the Surgeon General has historically focused on critical and often unsettling public health issues, upsetting presidents, the public and Congress in the process. In fact, some of the most effective surgeons general have been the most controversial—speaking out for the better of public health. If earlier generations of Americans were confused, that’s only because modern media outlets weren’t around to spread news of the surgeon general across the nation and around the world.



THE FIRST PUBLIC HEALTH REVOLUTION


In 1877, state leaders attacked the first surgeon general, John Woodworth (1871–1879), when he pressed for a national quarantine system after a yellow fever epidemic quickly spread up the Mississippi River from New Orleans. State quarantine regulations were inconsistent and, therefore, ineffective, but state authorities didn’t like the federal government telling them what to do. Nevertheless, in 1878 Woodworth succeeded in getting a national quarantine act passed, which gave the surgeon general and what is now called the Public Health Service (PHS) full responsibility for quarantines, curbing the spread of infectious diseases.


States’ rights were again the issue during the “privy campaigns” in the early 1900s when Walter Wyman (1891–1911) was surgeon general. Most Americans had no concept of the germ theory of disease, which had just been developed in the 1880s. Ignorant of the risks, people built wells next to poorly constructed and maintained outhouses. In response to this public health threat, Wyman launched a nationwide public education campaign that included pamphlets, articles and diagrams about proper privy construction, care and maintenance. The campaign met public embarrassment and derision, but Wyman persisted and so did the PHS Commissioned Corps, and they transformed rural hygiene throughout America. “Wyman butted heads with state and local authorities who didn’t like the federal government telling them how to sink wells and build outhouses,” says John Parascandola, a PHS historian. “It may seem silly to us now, but the privy campaigns controlled infectious diseases and the spread of parasites like hookworms.”


Historians consider the first 20 years of the last century to be “the first public health revolution,” one of the most progressive periods public health has ever seen. Wyman and his successor, Rupert Blue (1912–1920), were national leaders in the “Sanitary Reform Movement” that helped control the most contagious diseases and greatly increased Americans’ life spans.


When bubonic plague invaded San Francisco in 1900, city leaders denied they had a problem, fearing bad press would hurt business. When they refused to abide by federal quarantine and immunization protocols, Wyman threatened to quarantine the entire state of California. By 1903, the plague was so bad that an emergency conference in Washington, D.C., recommended all travel into and out of California be stopped unless the state allowed PHS physicians to start an eradication campaign. San Francisco finally agreed.


When Blue succeeded Wyman in 1912, he would become the only surgeon general to also serve as president of the American Medical Association (AMA); Blue was elected president of the AMA in 1916. These were good times for public health and marked the beginnings of many modern-day government public health agencies. The Pure Food Act of 1906 was a precursor to the Food and Drug Administration. Disease control through quarantine and immigrant health screening eventually evolved into the Centers for Disease Control (CDC). And the Hygienic Lab on Staten Island, New York, grew and became the National Institutes of Health.


During Blue’s tenure, the AMA supported a system of universal health care, and there was strong public support for it, too. But before this system could be established, World War I enveloped national interests, and after the war, the vision and organizational support for universal health care had vanished. Conservative Warren Harding became president of the United States, and the next surgeon general, Hugh Smith Cumming (1920– 1936), maintained a relatively low profile. As the PHS retreated somewhat from its efforts at the state and local levels, the first public health revolution came to an end.


SIGNALING THE START OF MODERN TIMES


Thomas Parran Jr. (1936–1948) is considered the first of the modern surgeons general because he spent at least as much time educating the public as he did administering the PHS. An outspoken public health activist, Parran was lucky to be serving during the years of President Franklin D. Roosevelt’s New Deal, when the public was more accepting of government’s involvement in their lives. Parran advocated universal health care, which again was widely supported—mainly because of the Depression’s devastating impact on the nation. But again the country’s involvement in a war prevented this from happening.


Although Parran helped found the World Health Organization, he is probably best known for his national campaign to eradicate venereal disease, a crisis which blossomed first among U.S. troops during World War I. Before he became surgeon general, Parran headed the PHS’s Venereal Disease Division from 1926 until 1930, and in 1934, while serving as New York State’s health commissioner, he canceled a nationally broadcasted radio interview because network brass refused to let him say “syphilis” on the air. Calling a press conference, he announced to the nation that he’d been censored, giving his campaign far more publicity than the radio show would have provided.


When Roosevelt appointed Parran surgeon general in 1936, it was still taboo to talk about venereal disease in the media. Parran ignored this, however, and had the PHS produce posters, films and pamphlets as part of his controversial public education campaign. His book on venereal disease, Shadow on the Land, discussed sexually transmitted disease explicitly and thoroughly, and it became a national best seller. His efforts led to the enactment of the Venereal Disease Control Act of 1938, which lowered the incidence of venereal disease by increasing funding for sex education campaigns and for research into venereal disease diagnoses and treatment. The increased funding also allowed PHS personnel to become more involved in disease control.


Few recognize the name Luther Terry (1961–1965), but many of us have heard of the “Surgeon General’s Report on Smoking and Health” that Terry released in 1964. This report led to the mandate requiring surgeon general’s warnings to be placed on all cigarette packs, and it prompted a dramatic decline in smoking, especially among men. “It made the surgeon general a household name,” Parascandola says. “The smoking report was the first surgeon general report to have a huge impact on the public. From then on, a surgeon general’s report carried more weight—it wasn’t just shelved or circulated internally.”


Terry’s report identified smoking as a cause of lung cancer and chronic bronchitis, but he wasn’t the first surgeon general to attack tobacco. Terry’s predecessor, Leroy Burney (1956–1961), issued warnings about smoking in 1957 and 1959, after the first definitive research showed cigarette smoking caused heart disease and lung cancer. But Terry’s report had more credibility, partly because more evidence had accumulated and because his advisory committee was composed of scientists and physicians who had never taken a public stance on tobacco. He also gave both sides—Big Tobacco and anti-smoking activists—the opportunity to veto any proposed committee member.


“Terry’s report was certainly a departure from mainstream thinking,” says Dr. Fitzhugh Mullan, a former assistant surgeon general, a PHS historian and an author. Terry announced the report’s results at a Saturday press conference that was held behind closed doors at the State Department in order to minimize the report’s effects on the stock market and to ensure wide coverage in Sunday newspapers. “The report hit the country like a bombshell,” Terry told PHS historian Parascandola. “It was front page news and the lead story on every radio and television station in the United States.”


Two things happened in the late 1960s that forever changed the surgeon general’s job. First, in 1968, the surgeon general was no longer responsible for managing a huge bureaucracy—the PHS. That job went to the newly created assistant secretary for health (and was given to the secretary of health and human services in 1995). This meant the surgeon general had less control over budgets and policies, but it also meant he could spend more time exercising his tremendous podium power. A surgeon general’s management skills were suddenly less important than his communication skills.


Second, the creation of Medicare and Medicaid during the 1960s politicized health care like never before. “Health issues were no longer just a matter of scientific debate but of huge budget allocations,” Parascandola says. Debates on birth control pills, family planning and abortion further politicized health care. In this highly charged climate, the surgeon general was bound to upset someone—no matter his message.


Surgeon General Jesse Steinfeld (1969–1973) infuriated President Richard Nixon so much that the president fired him. “You can’t fire me,” Steinfeld told Nixon. “I’ve got a four-year term.” So Nixon took away Steinfeld’s office, his secretary and his parking place. At the beginning of Nixon’s second term, the surgeon general quit. Steinfeld once told The New York Times that although his departure was part of an overall Nixon housecleaning, he believes he lost his job because he raised concerns about second-hand smoke and television violence. Steinfeld and Elders are the only two surgeons general forced to resign.


The Office of the Surgeon General was essentially mothballed from 1973 to 1977, a time when Congress and the Nixon and Ford administrations tried to eliminate the position but failed. When President Jimmy Carter appointed Julius Richmond (1977–1981) as surgeon general, the physician said he’d take the weakened position only if it was combined with the assistant secretary for health. “I felt this would restore stature and power to the surgeon general,” says Richmond, who is now professor emeritus of health policy in the department of social medicine at Harvard Medical School. Carter agreed. So once again, the surgeon general managed the entire PHS, though no surgeon general after Richmond would do so until David Satcher was appointed surgeon general in 1998.


THE SECOND PUBLIC HEALTH REVOLUTION


A pediatrician, Richmond had served as the founding director of Project Head Start, a program for economically disadvantaged preschool children. As surgeon general, he pushed for adequate access to mental health care and health care for the underserved, and he aggressively assigned physicians in the Commissioned Corps to work in disadvantaged regions.


Richmond says the most challenging part of his job was “making sure the urgent doesn’t take precedence over the important.” He considered preventive medicine important. “You, the individual, can do more for your own health and well-being than any doctor, hospital, drug or exotic medical device,” Richmond said in his preventive health-care report—the government’s first official wake-up call to consumers about taking personal responsibility for their health.


Richmond began what Mullan and others refer to as the “second public health revolution”—educating the public on how lifestyle choices raise or lower risks for early death. This meant changing how Americans think about medicine, letting them know that it doesn’t just fix problems but prevents them, too.


Richmond’s 1979 “Healthy People” campaign, the first of its kind, set measurable long-term goals for reducing infant mortality and deaths from heart attack, stroke and cancer—all indicators of public health. Every 10 years since then, surgeons general have updated those objectives. “As a nation, we’ve actually met or exceeded many of those goals,” Richmond says.


KOOP D'ETAT


Richmond may have de-mothballed the office, but C. Everett Koop (1981–1989) gave it celebrity status.


As a pediatric surgeon, Koop tackled cases other surgeons wouldn’t touch—like separating several sets of Siamese twins—and made remarkable advancements in his field. As surgeon general, the outspoken Koop waged war against Big Tobacco and dared to talk about AIDS and condoms every chance he got. He once said: “As a physician, it has always been my passion to be a crusader, as well as a pioneer. I take on difficult issues and problems regardless of the opinions of others.”


Koop became such an icon for the surgeon general that some people think he still has the job. “Koop told the truth in ways people could understand,” says Dr. Mohammad Akhter, executive director of the American Public Health Association. “That’s what Americans want their doctor[s] to do.”
“Koop was indisputably terrific,” Mullan says. “He took a moribund backstage job and by force of personality transformed it.”


Sporting his trademark Captain Ahab beard and dressed in his starched white shirt and double-breasted navy blue suit with shiny brass buttons, Koop looked more like a 19th century ship’s sawbones than a pediatrician from New Hampshire. He was a physician Uncle Sam, his finger wagging and his voice booming in precise sentences.


Koop’s grueling confirmation hearings took a record 11 months. For years, he’d spoken out against abortion rights. He’d gone so far as to appear in an anti-abortion film that presented him standing on an island in the Dead Sea, a thousand dolls floating in the salty water around him. During the confirmation period, pro-choice supporters used the clip to unfairly portray Koop as a religious zealot. Meanwhile, social conservatives salivated.


Once in office, Koop was asked by Reagan staffers to issue a report about abortion’s negative health effects on women. The administration believed that surely the report would prompt the Supreme Court to overturn Roe v. Wade, which legalized abortion. They were wrong. Koop instead told Reagan that “scientific studies do not provide conclusive data about the health effects of abortion.”


“It was clear to me,” Koop says, “the Reagan administration saw the surgeon general’s job primarily as a means of promoting their social agenda—especially pro-life and family issues.”


“Koop’s politics changed,” Mullan says. “Once in office, he set aside his personal beliefs and became a humane and thoughtful figure who spoke out with enormous common sense and passion.”


Parascandola says it was a gutsy change for Koop. “He disappointed many conservatives who supported his appointment. They felt betrayed,” he says.


Koop never changed his views on abortion, though. He simply felt abortion was a moral issue, not a medical issue. “I maintained my [pro-life] support,” Koop says, “but removed myself from their tactics.” He says he was frustrated by “the sleazy tactics, lack of integrity and absence of scholarship on both sides [of the issue]” and was constantly caught in the crossfire. When asked about the ribbons of rank on his uniform, he often replied, “one row is for what the liberals did to me; the other row is for what the conservatives did to me.”


Koop instead aimed his cross hairs at Big Tobacco, against whom he used a new strategy. “I didn’t just talk about how they peddle a product that kills when used as directed,” Koop says. “I spoke out about the devious ways cigarette companies lead you down the garden path to addiction. Changing the tenor of the attack set the stage for today’s state and federal class action suits.”


Almost single-handedly, Koop got smoking banned from airplanes. Brandishing research conducted in Canada (because U.S. airlines refused to cooperate), Koop showed that a person flying on a plane allowing smoking inhaled the same amount of carcinogens no matter where she sat. The research also showed that flight attendants were inhaling the equivalent of three cigarettes per day—even if they didn’t smoke —and that nicotine metabolites linger in non-smokers longer than they do in smokers. Today’s smoke-free offices, shopping malls and restaurants are a direct legacy of Koop’s efforts.


So Koop had already distinguished himself as surgeon general when the AIDS epidemic came along in the early 1980s. Because AIDS was a highly politicized disease, Koop frequently butted heads with Reagan staffers, who chose to ignore the dire health problem. “No one in the Public Health Service bureaucracy wanted to deal with it,” Koop recalls. “So I stepped into a vacuum and became the government’s spokesman for AIDS. Essentially I said, ‘Mr. Reagan, you’re wrong.’ Most government employees don’t do that.”


Besides talking about AIDS to teens, parents, teachers and physicians, he defied Reagan by mailing a controversial pamphlet to every home in America that plainly explained the facts of the disease and debunked the myths. “History will probably say that we would have taken a lot longer to get to where we are with AIDS education if I hadn’t done what I did,” Koop says.


SURVIVING THE KOOP LEGACY


When Antonia Novello (1990–1993) took office after Koop, she had big shoes to fill. She was outspoken, but not controversial. As the first woman and first Hispanic to hold the office, she did so with effectiveness and tact during the first Bush administration. Unlike her most recent predecessors, Novello, a pediatrician, rose to the position through the ranks of the Commissioned Corps. Like Koop, she spoke out against Big Tobacco. She got Joe Camel banned from advertisements and shamed the alcoholic beverage industry for ads targeting young people.


Novello’s childhood vaccination campaign increased the number of school-aged children being vaccinated from 65 percent to 80 percent. She brought AIDS education to high-risk migrant populations and fought to increase health-care access for Hispanics. Every chance she got, she delivered the get-real message that “we need to start mingling with the world and become socially and culturally aware of the needs of different people who make up this country.”


In 1993 Clinton appointed Joycelyn Elders (1993–1994) to the position. The first African-American surgeon general and the second woman, Elders was also the second to be fired, or “asked to resign” as it’s politely put. “You bet I was fired,” says Elders, from her home in Little Rock, Arkansas, where she is professor emeritus at the University of Arkansas for Medical Sciences. “The job was pretty much what I thought it would be until the very end. I thought it was supposed to be apolitical. You’re not supposed to serve at the wishes of the president. You’re supposed to do what’s good for public health. That’s how I approached the job.”


Elders believes she might have survived the masturbation episode had Newt Gingrich’s conservative Contract With America coalition not been calling the shots in Congress. “Bill Clinton agreed with what I said, but he had too much on his plate and couldn’t afford the political heat,” she says. It is widely understood that Elders’ comments were misinterpreted and twisted for political gain, and she was surprised when Clinton asked her to resign.


Elders also might have been able to serve out her term had she not already set hairs on end while speaking publicly about AIDS and adolescent sexuality. “We’ve taught high school students what to do in the front seat,” she once said, referring to driver’s education. “Now we need to teach them what to do in the back seat.”


“Joycelyn Elders had a wonderful knack for putting her foot in her mouth,” Parascandola says. “It’s not what she said, but how she said it that made it easy for the press and public to misinterpret.”


“My mouth was my greatest asset,” Elders says. “I admit to everything I said because I don’t regret a word of it. Obviously I never said we should teach children to masturbate. They already masturbate. God taught them how.”


The “condom queen,” as critics called her, helped increase the number of high schools with primary preventive health clinics from 30 in the entire country when she took office to 1,100 four years later. “Pediatricians were opposed to it at the time,” she says. “They were afraid the clinics would steal their patients. School-based clinics have actually increased patients for pediatricians—so now they’re all for it.”


Pointing to some statistics—teen pregnancy rates among African Americans dropping 30 percent from 1991 to 1997; condom use among teens rising from 25 percent in 1991 to 60 percent today—Elders says her outspoken style contributed to improved public health. “Much of this is due to the willingness of me and others to speak out,” Elders says.


After Elders, it seemed it would have been hard to confirm even a monk to be the surgeon general. Could anyone be effective in a political environment in which proven ways to control sexually transmitted disease offended those who touted “traditional family values”?


Henry Foster Jr., an obstetrician –gynecologist, was named to succeed Elders, but his nomination failed after he acknowledged having performed abortions. By 1996, four bills had been submitted in Congress to eliminate the position of the surgeon general. “I think it’s rather pathetic,” Koop says, “that Congress, not liking Clinton’s last two designations, decided the way to settle the problem is to get rid of the office. It’s really an insanity.” The surgeon general’s office sat empty for three years until 1998, when Clinton appointed David Satcher (1998–2002).


Clinton thought he’d found the Elders antidote in Satcher. An African-American family practitioner and the son of poor farmers in rural Alabama, Satcher had a soft-spoken style and an impeccable record. The confirmation should go through without a hitch—or so Clinton thought. The confirmation hearings mired when Satcher supported Clinton’s refusal to ban late-term abortions. He was also attacked for research he supported as director of the CDC in which HIV-infected pregnant African women were used as a control group and given placebos instead of experimental medicine. And social conservatives protested Satcher’s support of needle-exchange programs. But unlike Foster, Satcher had the medical establishment’s backing and bipartisan support in Congress.


A cautious consensus-builder who nevertheless says what he feels needs to be said, Satcher still supports needle-exchange programs, saying research shows they reduce the spread of AIDS and don’t encourage drug abuse. His top issues include encouraging pregnant women to get good prenatal care, eliminating racial disparities in disease and giving mental health the same priority as physical health. He started the nation’s first campaign to combat suicide, the eighth leading cause of death in the United States. And most recently, Satcher has shifted his focus to bioterrorism threats.


Satcher has drawn the most criticism for his report calling for schools to teach safe sex. Most schools only educate their students about abstinence-until-marriage as a way to prevent pregnancy and sexually transmitted disease. The report says that no scientific studies have shown talking about sex in the classroom encourages teenagers to have sex, and it says that several studies have shown sexually active teens are more likely to use protection if they’ve had more comprehensive sex education. Moreover, Satcher’s report says that sexual orientation cannot be altered by force of will.


The church-based Focus on the Family organization says the report “calls severely into question the surgeon general’s ability to remain the chief medical officer of the United States.” The Bush administration distanced itself from the report without attacking it. Satcher says sex education is the most controversial and sensitive issue he’s faced as surgeon general.


It seems that sex bedevils every surgeon general. “Some people just don’t like to talk about sex,” says Dr. David Sundwall, who served as assistant surgeon general during the Reagan administration. “They don’t like to acknowledge that sexuality is a normal human function. Satcher is demonstrating that you can talk about it in biological terms, not just moral terms.”


Satcher’s term ends in February. President Bush has not asked him to stay on. Satcher has said even if he were asked to stay on, he wouldn’t. At press time, no one could tell The New Physician whom to expect as the next surgeon general. The only name that keeps coming up is Kenneth Cooper, the 71-year-old Texan and friend of Bush’s who’s groundbreaking 1968 book, Aerobics, sparked an exercise boom. Cooper has lots of ideas, many of which are already stirring controversy, including giving federal tax deductions of up to $1,000 for Americans who stay healthy. But no matter who is selected for the position, only one thing’s for sure: If he wants to take a stand on public health issues, the surgeon general is bound to make someone unhappy.
~WALKING THE TIGHTROPE


What makes a good surgeon general?

Surgeon General C. Everett Koop made enemies by talking about sex and AIDS, but this didn’t stop him from serving eight distinguished years during a conservative administration. When Joycelyn Elders spoke out on sex and AIDS, she was fired by a liberal president after serving only 15 months as surgeon general. Why do some surgeons general achieve celebrity status while others crash and burn or simply fade to historical footnotes no one remembers? Chalk it up to personality, politics and luck.


Personality is key. “Koop made the position what it was capable of becoming through his credibility and force of personality,” says Dr. David Sundwall, who served as assistant surgeon general during Koop’s years. “You need an iron jockstrap for the job, regardless of your gender.”


The trick is to be able to speak out on controversial issues without appearing as a loose cannon—a liability an administration can’t afford. That’s what happened to Elders. “You need to get your point across without being a lightening rod,” says Dr. Jo Ivey Boufford, who was the principal deputy assistant secretary for health during the Clinton years and who is now dean of the Robert F. Wagner Graduate School of Public Service at New York University.


Who you are affects how your message is received. Koop was stern and fatherly. Elders was young and at times came across as being brash. “It’s not what she said but how she said it that offended,” Sundwall says. “I don’t think Elders did anything to lower the stature of the job. If anything, she raised it. I agreed with everything she said, but she was a bit preachy and self-righteous. Koop was an older white man; Elders was a younger black woman. That might have had something to do with it, too.”


It’s essential the surgeon general be capable of speaking out regardless of the message and whom the message might upset. But it’s also wise for a surgeon general to choose his battles carefully. Boufford and others believe it’s more effective for a surgeon general to hammer away relentlessly, but tactfully, on a few broad public health issues. “You need to build credibility with Congress and the public on one or two issues,” says Dr. Mohammad Akhter, executive director of the American Public Health Association. “If you spread the peanut butter too thin, it loses its flavor.”


Stick to issues backed by science, Sundwall advises. Boufford agrees. “The surgeon general should not be speaking out about prescription drug costs and stem cell research,” she says.


Elders takes a different view. “The surgeon general should speak out about anything that improves the health of the American people,” she says.


Koop tempers that sentiment. “The surgeon general should have the freedom to speak out on all issues,” he says. “As long as you speak from an evidence-based perspective, no president should hog-tie you.”


The political climate during a surgeon general’s tenure can make or break his success. No president has outright censored a surgeon general, but presidents have withdrawn all support—moral and material—like Nixon did to Jesse Steinfeld, who even lost his parking spot and his secretary.


Luck, too, can work for or against a surgeon general. Elders happened to serve when the family values crusade held sway in Washington, D.C., under the banner of Newt Gingrich’s Contract With America. Would Elders have survived if she’d served during a different time? We’ll never know. Would Koop’s candid talk about sex and AIDS have survived eight years of family values crusading? That’s unlikely, according to former Surgeon General Julius Richmond, who served during the Carter years. “The Gary Bauers of today would have had Koop working on an ice breaker in the Arctic Ocean,” Richmond says.


Reagan’s staffers were perpetually peeved at Koop, but Reagan didn’t intervene. “Reagan was absolutely wonderful,” Koop says. “He never interfered with anything I said or did. Perhaps he realized the United States deserves a free, nonpolitical voice in the surgeon general’s office.”


Koop’s experience with Reagan is typical for a surgeon general, Richmond says. “Presidents can usually weather the criticism. It’s the people around the president who tend to react more,” he says.


Since the first surgeon general was appointed 131 years ago, the office has been restructured several times—sometimes to strengthen it and other times to weaken it. To allow for optimum effectiveness, where should the surgeon general be placed in the bureaucratic jigsaw puzzle? Should the surgeon general also be the assistant secretary for health (ASH) as Richmond was and as David Satcher was until Bush asked him to resign the post?


Most observers think Bush has the right idea—keep the two jobs separate. “You shouldn’t dilute the surgeon general’s effectiveness as a public speaker by making [him] an administrator,” says Sundwall, who strongly supports a separate and free-standing surgeon general.


Akhter agrees. “The surgeon general must be an independent voice speaking out about public health issues that may not be politically correct to talk about,” he says.


Richmond says he had no trouble balancing both duties and says the ASH position gave him more power as surgeon general. But even he wouldn’t recombine the jobs now. For one thing, Social Security was removed from the Department of Health and Human Services, lessening the responsibilities of the department, which in turn decreased the need for an ASH. For another, the Public Health Service (PHS) now reports directly to the secretary of health and human services, further weakening the ASH position. “They shouldn’t even keep the ASH,” Richmond says.


“You’re either a good surgeon general or a good assistant secretary,” Elders says. “It’s impossible to do both jobs well.”


“No question, keep the two jobs separate,” Koop says. “As soon as Bush asked Satcher to resign as ASH, you heard Satcher speaking out more about sexuality and cancer in blacks…. When the surgeon general has both jobs, the political part will always take precedence.”


Some, like Koop, believe the president should appoint the surgeon general from the ranks of the PHS Commissioned Corps instead of from the outside. Doing so would attract good people to the post who don’t come with political ties inhibiting them from speaking out on controversial issues, they believe. “After the [Henry Foster Jr.] confirmation failed,” Koop says, “I begged Clinton to depoliticize the post by selecting someone from the corps. There should be a law that says the surgeon general is not answerable to the president for what they say about public health issues.”


Others say it doesn’t matter where the surgeon general comes from as long as she’s qualified. Antonia Novello came from the Commissioned Corps. Koop didn’t. Both are considered to have done their jobs well. “The person’s stature and communication skills are more important than the career path they take to the office,” Boufford says.


“The surgeon general can be one of our nation’s most treasured assets, if it’s kept free of politics,” Koop says. —H.B.


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


SURGEON GENERAL FACTS-AT-A-GLANCE


Sixteen surgeons general have served since the position was created in 1871. Early surgeons general supervised a network of hospitals for merchant seamen and oversaw the Public Health Service (PHS) Commissioned Corps of physicians who staffed the hospitals. Over the years, the job expanded along with the PHS.


Until 1968, the surgeon general administered the entire PHS, a vast bureaucracy that includes an alphabet soup of mega-agencies, including the Centers for Disease Control and Prevention; National Institutes of Health; the Food and Drug Administration; Indian Health Service; and the Health Resources and Services Administration. In 1968, the responsibility for administering the PHS was given to the assistant secretary for health. Another restructuring occurred in 1995, assigning the PHS agencies to report directly to the secretary of health and human services. As the nation’s chief medical officer, the surgeon general’s primary responsibility is to improve public health through research and education and to oversee activities of the 6,000 members of the Commissioned Corps.


The position’s official title is Surgeon General of the United States. Surgeons general wear uniforms because they are part of the PHS Commissioned Corps, which follows a military model. Surgeons general are not really generals. They do hold the rank of three-star admiral in the Commissioned Corps, a rank equivalent to a Navy Vice Admiral. The surgeon general has an office in the Hubert H. Humphrey Building in Washington, D.C., and in the PHS Parklawn Building in Rockville, Maryland.


For many decades, presidents appointed all surgeons general from the ranks of the Commissioned Corps. Now, more often than not, presidents appoint them from the outside. By statute, they serve four-year terms, but there are no limits to the number of terms they can serve.


Surgeons general used to be bureaucrats first and public speakers and educators second. No longer burdened with administering a huge bureaucracy, modern surgeons general have more time to speak out on public health issues.


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


RESOURCES


To learn more about the Office of the Surgeon General and the U.S. Public Health Service:

~~~Howard Bell is a New Physician contributing editor.~Advocacy,Community and Public Health,Health Policy~
171~2March~2002-51~Feature~Down to Earth~SPACE PROGRAM LAUNCHES MEDICAL TECHNOLOGIES.~~~NASA has long been on the forefront of technological innovation, but have you ever wondered what happens to all of this technology originally developed for outer space? As it turns out, it is all around you—on the wards and in the clinics. It’s even at the corner drug store.


Since NASA’s inception in 1958, technology from the space program has been applied to practical uses on Earth. When Alan Shepard became the first American to enter space in 1961, NASA scientists developed a device to screen his blood pressure. That machine has evolved into the instant blood pressure monitor that can be found in almost every drug store in the nation.


In those early days, however, the majority of space technology’s alternative applications occurred only by pure chance, according to Roger Launius, NASA’s chief historian. Back then, the agency paid little attention to spinoffs of its technology and certainly did not make a concerted effort to commercialize its innovations, Launius says, and he adds that many spinoffs occurred simply through informal exchanges of information within the scientific community.


However, as the years of the space race with the Russians passed, agency officials found it necessary to establish NASA as a legitimate recipient of government resources by demonstrating to the public and Congress the benefits of space exploration. To do this, NASA began to institutionalize the spinoff process, if not fully promote it, Launius says. Beginning in 1991, the agency developed a network of six regional technology transfer centers, which are responsible for providing the private sector with greater access to NASA technology.


Within the medical field, however, a greater breakthrough in finding alternative uses of NASA-sponsored technology may have occurred in 1997 with the establishment of the National Space Biomedical Research Institute (NSBRI). Within the NSBRI are a number of research teams, each with a unique background and focus, studying specific health issues confronting the space program. Because the institute uses researchers outside of NASA, the NSBRI’s director, Dr. Jeffrey Sutton, believes it’s more likely they’ll see how a technology or idea can be applied on Earth.


Already many NASA technological advances have found a place on Earth. Here are some spinoffs you may encounter in your career:
~~~~~Career Development,Medical Research~
172~2March~2002-51~On the Wards~The Good, the Bad and the Ugly~GUNNERS ON THE WARDS~Simon Ahtaridis~~Their legends are heard in whispers in medical school halls. When they ride into town, patient charts close, computer screens get tilted away from view, halls become silent, and greetings are short and curt. When gunners come to the wards, everything changes. The following is a legend about my encounter with a gunner—well, not quite a legend since it happened recently.


It was a typical morning at the hospital—or so I thought—and I was about to round on my patients. When I arrived at the nurses’ station, I saw that my medical student partner, Sam, or as others liked to call him, “Yosemite Sam,” came in early again and was already finishing notes on his patients. Sam was a bit of a gunner. The term “gunner” can describe a variety of medical students. It might be used as a compliment to a friend who has done well on an exam, or it could be one of the worst insults connoting a malicious, ultracompetitive student, like Sam, who’s willing to use the slimiest tactics to get good grades.


For example, despite being a third-year medical student, Sam was still informing people of his Medical College Admission Test scores. “Just so you know where I’m coming from,” he usually said. “So you won’t wonder why I got a perfect score on my boards.” And then there was the rumor that he slipped extra-strength laxatives into the coffee he offered fellow medical students. Of course, there was also a rumor that he was in league with Satan.


“Hi, Sam. Early morning?” I asked.
Keeping his eyes on his notes, Sam yawned and said, “Yep. Want some coffee?”
“Uh, no thanks. I can’t handle the caffeine,” I muttered as I tried to hide a 24-ounce bottle of Mountain Dew inside my coat pocket. Then I made a quick escape to see my patients.


The first was Joe, a 49-year-old diabetic who was in for a rule-out myocardial infarction. Seeing me approach, he rolled his eyes and said, “Again?”

“We need to see each patient every day,” I said.

“But the other doctor already saw me,” he said. Believing he meant my resident, I continued the exam. Then I rounded on other patients. Afterward, I went to get the patient charts from the unit clerk, Blanche, and was surprised when she reacted to my routine request with more anger than was usual.

“Someone already took them this morning!” she said. “How many times do you people need to see the charts?”

“Hmm….” I began to wonder who else took the charts and again assumed my resident got in and rounded insanely early.


During the team meeting, we reviewed patients on our service. When we came to Joe’s room, Sam suddenly got a look on his face similar to that of a 10-year-old child making obscene phone calls—devious. Shrugging my shoulders, I started my update. My attending asked me for Joe’s potassium level from three days ago. I flipped my note cards over in search of the information. Out of the corner of my eye, I saw Sam’s hands move in a blur of motion. He whipped out a card and shouted, “4.3! 4.3!”


My attending turned to me and asked, “What was his 7 p.m. glucose?”

I said, “163,” but my response was drowned out by Sam as he jumped up and down, exclaiming:
“163, 163! I said it first!”

Sam was nearly wetting his pants in anticipation of the next question. Tension filled the room. Finally, as if he were Regis Philbin asking the million-dollar question, my attending said, “If Joe goes to the orthodontist, does he need to receive antibiotic prophylaxis?”


I paused and reviewed Joe’s medical history. Sweat trickled down my forehead. My lifelines were spent, and I had no friend to call. Then the answer came to me. I remembered Joe’s history of endocarditis.


But before I could even inhale, Sam leapt in front of me and said, “Yes! He has a history of bacterial endocarditis!”


Looking at me, my attending asked why Sam was answering all the questions. Sam spoke up again and said, “Oh, I’m really sorry if I overstepped my bounds, but I was finished with my patients this morning and saw that it was getting late and Simon wasn’t in yet. I couldn’t bear the thought of a patient not being seen before rounds.”


Before I could defend myself, the team moved on. Sam stood still for a moment, gloating. It was as if he expected a hospital administrator to leap out of a supply closet and erect a plaque in his honor.


I was dumbfounded. What just happened? Suddenly the world blurred and colors began to fade. The disappointed expression on my attending’s face made it clear: I had failed. I had been gunned down. The world continued to go dark, until there was a sudden flash of light accompanied by music.


Shot down in a blaze of glory….


Jon Bon Jovi’s voice filled the air. My vision had returned, and I discovered I was lying in the hall of a different hospital. Red dirt blanketed the floor, and a tumbleweed rolled across it. A young man wearing cowboy boots with spurs and a hat large enough to conceal a small high-rise building stood over me, poking me with a reflex hammer. Several heavy instruments bulged out from under his white coat. “Hello? You OK?” he asked.


I turned my head to get a better look at him. “Who are you?”

“Bonney. Dr. Bill Bonney. Shoot, you probably didn’t even realize that I’m an attending. Folks always think I’m a medical student ’cause I look so young. Everyone calls me ‘Billy the Pediatrician.’”

“Oh, so you’re a pediatrician?”

Billy laughed and said, “Nah, a neurosurgeon.”

“I’m confused.”

“Nice to make your acquaintance, Confused. Har, har!” Laughter erupted across the wards.

I winced at the bad humor and asked, “You don’t get out much, do you?”

A man wearing a bolo tie glanced up from his note and said, “Of course not. We’re gunners.”


Sitting up and feeling a little lightheaded, I saw that the wards were filled with physicians wearing white coats and a variety of accessories strapped to their belts. “Who are all these people?”


Billy the Pediatrician introduced me to the other members of the service. “That there’s Wild Bill Hematologist. Watch out for him. He’s always looking for a good stick, and those veins of yours are looking pretty accessible.” I rolled my sleeves down.


“The man with the bolo tie is Doc Scurlock, and over to his right is Doc Holliday. The young lady writing orders is Dr. Clonidine Jane…. She gets special favors from the Clonidine rep.”


Doc Scurlock walked up to me and said, “Son, looks like you got outgunned. You need to win back what’s yours. Now, let’s go over different patient-card strategies.”


At the mention of this, I zoned out and thought back to when I was shot down. Bon Jovi’s voice rung in my ears.


I’m going out in a blaze of glory….
Wait a minute—there was no glory. I shook my head, and the song stopped. I had to find a solution that would make rounds more bearable. Billy woke me from my daze. “Are you listening to us?”

“Something about patient-card strategies, right?” I said.

Scurlock threw his hands up in frustration and grumbled, “I talked about that half an hour ago!”

The gunners huddled around to prepare me for my impending wards showdown. Clonidine Jane suggested slipping highly potent laxatives into Sam’s coffee. Wild Bill Hematologist urged me to stick Sam with a 14-gauge needle. “I call them straws,” he said, laughing.

Scurlock handed a small package to me. “I reckon you’ll be needing this.”

Opening it up, I discovered a handheld device preloaded with all the latest medical software. I released the safety by snapping the cover off. Admiring the neon blue steel construction, I drew my stylus from its holster and fired off a few runs of Winter’s formula.

“Careful where you point that thing. You want to poke an eye out?” Scurlock said. “Feels good, don’t it?”

I nodded. Then, just as suddenly as I arrived here, the world faded, and I found myself slumped against a wall and back with my original team. “Was it only a dream?” I asked.

My attending looked at me, annoyed. “Are you nodding off again?”

I mumbled an incomprehensible apology and tried to reorient myself. My hand brushed against something strapped to my belt. My handheld—it wasn’t a dream after all. I quietly whispered, “Thanks, Scurlock.”

We were on a new patient—one of Sam’s. I drew the handheld and snapped back the cover, sending a resounding “click, click” through the wards.

“So, Sam, what’s the predominant age for Osgood-Schlatter’s disease?”

Quietly, I tapped the stylus against the screen and then shouted, “Ten to 16 in females, 11 to 18 in males!”

My attending nodded approvingly. “What about Ewing’s sarcoma?”

A few more taps of my stylus revealed the answer. “Teens to 20s!”

Sam’s face turned red. He reached into his backpack and retrieved the heaviest, largest, most colorful handheld I had ever seen. “Two can play at that,” he said with an evil cackle. “By the way, our elevation is 450 meters above sea level!”

“Expansion modules!” I shouted in horror and dove behind the nurses’ station for cover.

Blanche glared at me. “You better not try and sit in my seat,” she said.

Questions and answers ricocheted off the walls as Sam and I engaged in battle. Egos getting bruised, hate and resentment building, we focused only on each other.

Growing exhausted, I got up from behind the nurses’ station and shouted, “Stop!”

Sam paused for a moment, hand on stylus, watching my every move.

“Morning rounds are a time to learn, not a time to try and make ourselves look good at the expense of our fellow medical students,” I said. “Handhelds should be used for wholesome purposes—to supplement our education with useful medical software and, of course, to play Dope Wars.”


Sam slowly loosened his grip on his handheld, and a small parachute deployed (yes, the antigravity expansion module). The handheld fell gently to the ground. Sam nodded his head. “I agree,” he said. “Let’s work to build a medical student community based on cooperation and mutual aid. Let’s create a nurturing atmosphere that will foster the selfless compassionate ideals that all physicians should embody.”


I smiled, and we shook hands, saying, “To the future then—a future of gunner control, where we respect each other’s education during rounds, where we put an end to all the childish games.


“So, Sam,” I said, “how will we spread the word and enact meaningful gunner control reform?” But my words fell on deaf ears. Sam was busy trying to get a cap off a small, orange, pill bottle.


“Huh? Oh, yeah, sure. What you said. So, you want a cup of coffee?”
~~~~Simon Ahtaridis is a fourth-year medical student at Temple University School of Medicine.~Medical Education~
173~2March~2002-51~Feature~Physicians Without Wings~NASA FLIGHT SURGEONS PROVIDE SPACE TRAVELERS WITH NECESSARY MEDICAL GROUND SUPPORT.~Jennifer Zeigler ~~A trip into space isn’t for everyone. Some people are claustrophobic and couldn’t take being cooped up for weeks in a tiny spacecraft. Some have no desire to leave terra firma, while others can’t pass the rigorous physical examinations preceding astronaut selection. That’s the case for Dr. Terry Taddeo, whose less-than-perfect eyesight will keep him grounded at NASA. But that doesn’t mean there’s no place for physicians like him at the federal space agency—Taddeo serves his country another way, as one of 14 NASA flight surgeons.


Flight surgeons serve as general practitioners to the astronauts and their families. “You do everything but fly with the crew,” Taddeo says. “If the guy sprains
his knee playing basketball, your job is making sure he gets through the system and making sure he maintains flight status.” Flight surgeons can become astronauts, but once selected into the astronaut corps, they have other duties.


Dr. Sam Pool, the assistant director of Johnson Space Center’s (JSC) Space Medicine and Life Sciences Directorate, came to NASA as a flight surgeon in the early days of manned space flight, and he echoes Taddeo’s impression of the flight surgeon’s role. “I was sort of like a family practitioner. Most of the serious medical matters, of course, were handled by consultants. And that’s still the case, although…now we have psychiatrists, internists—a fairly broad spectrum of people.”


Taddeo, who did a residency in aerospace medicine at Wright State University and gained training in many specialty areas, spends most of his time at the on-site medical clinic at JSC in Houston, where he helps care for all the astronauts and their families. “Taking care of the families—that’s a real important job because if [the astronauts] know the families are being cared for, they can focus on the job at hand,” he says.


All medical care isn’t done in the clinic, though; flight surgeons are among the few physicians left in America who also make house calls. Taddeo says he enjoys the personal relationships he is able to develop with the astronauts and their families. “That’s one of the real rewarding parts of the job.”


T-MINUS 10...9...8...


When he’s not in the clinic, a flight surgeon is training with his assigned crew. Taddeo specializes in long duration flights; he’s served as the flight surgeon for a mission to the Russian space station Mir, for the inaugural expedition to the International Space Station (ISS) and for a shorter shuttle mission.


Flight surgeons are assigned to their crews several years before the mission—Taddeo has already been assigned to the ISS’s Expedition Eight, which isn’t scheduled to leave the launch pad until May 2003—but he says the real work with the crew begins about a year out. “You live, eat, sleep with the crews,” he says of that final year of training. “You become their representative. I have no problem going over and ticking off as many people as I need to for the good of the crew. And I have.” He says the crews need him to be their advocate because astronauts who voice medical complaints frequently get labeled “whiners.”


Much of the training in that last year is focused on ensuring the crew knows how to operate the volume of on-board emergency medical equipment. Once in flight, the crew has access to its flight surgeon only through radio contact, so astronauts must be prepared in case there’s a medical problem.


Once the crew leaves, flight surgeons take their place at mission control, where they monitor the health of the crew for the duration of the flight. For expeditions to the ISS, that could mean six months, during which time, Taddeo says, his duties really involve environmental and occupational medicine.


During regular conversations with crew members, the flight surgeon’s job is to ascertain the status of their physical and psychological health. These private conversations could be just casual chats, or they could be about a medical problem an astronaut solved in orbit. Taddeo says he does very little real-time guidance; mostly crew members will explain what they did after the fact. “‘Someone got something in his eye, we flushed it out with saline and didn’t see anything. He’s fine now; is there anything else we should do?’” are common questions for the flight surgeon, Taddeo says.


Launch prep for flight surgeons also means issuing a seemingly endless battery of medical tests each potential astronaut must take and pass. The medical standards are so stringent that even after astronauts are screened into the astronaut corps, flight surgeons administer even more medical tests in the months leading up to their launch.


Pool helped draft the stringent medical standards in 1977. “We borrowed heavily from the Department of Defense and from the [Federal Aviation Administration] in the development of those standards, but some of the standards…were a bit unique to NASA,” he says. “As time has proceeded, we’ve gotten a little bit more sophisticated in that area. The standards now truly do begin to reflect the kind of medical criteria that should be applied to people who travel in space.”


It’s a big book of standards, Pool says. “For example, in the vision area for pilot astronauts, their vision standards are more rigorous than mission specialists’ for obvious reasons. We are very careful about evaluating people for surgeries, for example—particularly surgeries that involve the abdomen. We’re very interested in ruling out cardiovascular disease in its early stages. Basically, the standards are put in place to try to select people into the astronaut corps who have a high probability, from the standpoint of their health, of being able to serve in this fairly demanding environment. If you’ve had, for example, a kidney stone, we do not currently permit you to fly in space. The reason is that if you are assigned to a long mission,…the problem with calcium excretion in the urine only compounds the likelihood that you would be troubled with yet another kidney stone.”


“These are the most highly selected and screened people on the planet,” Taddeo says.


And astronauts would agree. Biochemist Peggy Whitson, Ph.D., who is scheduled to spend five months on the ISS later this year to study the kidney stone problem, is in the last phases of her training and medical tests. The psychiatric tests alone lasted eight hours, she says, and the eye exam was several hours as well. “Pretty much every orifice you have, they look at,” she says.


And in the final week before launch, placing the crew in a medical quarantine further screens out the possibility of exposure to illness. “Families do have limited access, but we really try to limit that in the last week,” Taddeo says. “It’s kind of hard. I’ve had to tell friends, ‘Sorry, you just can’t go in there right now.’”


A DIFFERENT WORLD


Challenges in the flight surgeon’s world are more than medical, though, Taddeo says. “In some ways it’s not the job, it’s having to do this within this huge engineering system and trying to explain that the most important system is the human system.”


Taddeo says the hierarchy for physicians at NASA is different than that of a hospital. “We’re not on top here. We’re not the ones in charge. You could tell the [flight] commander, ‘This guy should not be flying—he’s got Ebola virus,’ you know, but the…commander could still send him.” He says he can’t imagine any of the flight commanders with whom he works ever overruling his advice, but he operates with the knowledge that they could.


And because he works mostly with long-term missions to the ISS, he also functions within the confines of the international partnership governing the ISS procedures and protocol, and in this case,
cultural differences and political agendas sometime conflict. “Even NASA thinks it owns the thing,” he says, adding that medical guidelines are really controlled by the Multilateral Medical Operations Panel, an international government body of medical personnel of which Taddeo is a member.


But even the challenges are rewarding, Taddeo says. He enjoys working for NASA. “Everyone is truly focused on what the job is,” he says. “Very few people can say they’re going to work to put people in space. They’re really neat people.”
~~~~~Career Development~
174~2March~2002-51~Feature~The Right Stuff~SO YOU WANT TO BE A SPACE DOC?~Scott T. Shepherd~~The life of a NASA flight surgeon is anything but ordinary. With such diverse responsibilities, it’s not surprising that flight surgeons come from various backgrounds and have a wide range of knowledge and interests. Flight surgeon and astronaut candidate Michael Barrett holds a bachelor’s degree in zoology, while flight surgeon Phil Stepaniak has a brown belt in karate and continues to work as an emergency room physician at a Houston hospital. And before coming to NASA, Dr. James Bagian was a process engineer at the 3M Company.


Dr. Sam Pool, the assistant director of Johnson Space Center’s (JSC) Space Medicine and Life Sciences Directorate, says the agency intentionally seeks people who have followed pursuits outside of medicine. “We look at [a candidate with only a medical background] and say, ‘Hmm, that’s not a very rich background academically. How about somebody with math and physics, like myself, or somebody with some other background which will make them a little bit better rounded,’” he says.


Regardless of their other interests, though, all flight surgeons end up with a medical education specifically addressing the unique demands of the job. Their schooling often begins in the broader field of aerospace medicine, which focuses on issues related to military and commercial flight, as well as the space program. Falling under the domain of preventive medicine and sharing characteristics with occupational medicine, aerospace medicine manages to be both extremely broad and very specialized at the same time.


Training in aerospace medicine is only offered through a handful of institutions. The Air Force, the Navy and the Federal Aviation Administration offer physicians “short courses” lasting between seven weeks and six months, while Vanderbilt University, Wright State University and the University of Texas Medical Branch (UTMB) are among the schools that include aerospace medicine in their curricula.


Beyond the preliminary training and basic medical studies, there are only four aerospace medicine residency programs—two military and two civilian—that lead to official certification by the Accreditation Council for Graduate Medical Education and the American Board of Preventive Medicine.


For military personnel, the Navy Operational Medical Institute in Pensacola, Florida, and the U.S. Air Force School of Aerospace Medicine at Brooks Air Force Base in San Antonio, Texas, provide physicians training for service on air bases or aircraft carriers, with the top physicians in each class given the opportunity to apply to NASA.


For civilians, Wright State offers a three-year residency program in affiliation with nearby Wright-Patterson Air Force Base in Dayton, Ohio. In conjunction with JSC in Houston, UTMB offers a two-year residency program in aerospace medicine as well as a four-year combined aerospace/internal medicine residency. The UTMB programs have developed into a physician pipeline for JSC, while Wright State has made steady contributions to the agency as well.


Dr. Richard Jennings, the director of UTMB’s aerospace medicine residency programs, says the programs are extremely selective; UTMB takes a maximum of two residents per year. Jennings looks for candidates with two distinct traits: an established clinical skill and a firm commitment to aerospace medicine. “We may not always pick the best candidate,” Jennings says. “I’m looking for someone who has thought about [working in space medicine] for a long time and wants to do this.… NASA is paying the money. We want to provide them someone.”


NASA has some educational programs of its own. The agency offers a four-week clerkship program at JSC to provide medical students with exposure to clinical, operational and research aspects of space medicine. For undergraduates, Kennedy Space Center offers a six-week training program on space flight and life sciences.


For medical students more interested in the research aspects of space medicine, the National Space Biomedical Research Institute (NSBRI) offers educational opportunities. Through Morehouse School of Medicine, the NSBRI sponsors an introductory course for undergraduates, while a summer research program specifically provides opportunities to undergraduate women and minorities. Furthermore, the NSBRI is developing a fellowship program for graduate students and postdoctorates. “I encourage people who have a flair for adventure, want to work on revolutionary advances, perhaps work that is a little higher risk but higher impact, [to apply],” the NSBRI’s director, Dr. Jeffrey Sutton, says. “We have fantastic opportunities, particularly if the person is from a school that does not have medical science.”


Despite already having many well-qualified, competitive applicants, both the NSBRI and NASA are expanding their student outreach programs to ensure there is a new generation of space medicine researchers and flight surgeons. “I did [not plan to enter space medicine], but the hook was pretty strong when I finally became aware of the opportunity,” Pool says. “So I took it with gusto and worked very hard in this field and enjoyed it a great deal. Like any job, I’m sure it has good points and bad points, but in my case they far outweighed on the good side.”
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Career Development~
175~2March~2002-51~Folk Tales~Rocket Man~PREPARING FOR LIFTOFF~Scott T. Shepherd~~It’s natural for children to dream, to use their boundless imagination to hit that big home run, to perform before thousands or to serve in the Oval Office. As a boy growing up in Montreal, Peter Lee was no different. In the innocence of youth, he easily envisioned himself as an astronaut, sitting in a rocket before it blasted off, floating weightlessly among the stars and scampering between the moon’s craters. Born in Germany to Korean parents, Lee showed an interest in outer space almost as quickly as he could walk.


However, as it is for most children who grow up to become adults, Lee eventually began to accept the realities of life. By the time he graduated high school, he had turned his attention from the cosmos to the doctor’s office, figuring the obstacles to becoming an astronaut were just too great. In 1990, Lee began attending Brown University to participate in its eight-year medical program, which provides undergraduates with automatic admission to the university’s medical school as long as they maintain their grades. Lee says he was attracted to the program because it allows him to focus on pursuits outside of medicine. “Being as you’re already in medical school, what [the program] encourages you to do is to explore your other interests,” he says.


So after dismissing his notion of becoming an astronaut as mere childhood daydreaming, Lee once again found his eyes wandering skyward. “It was when I was in college that I realized that this interest I have in space could really become more than an interest but an actual academic or career pursuit,” he says. “So it was at that point that I began taking it more seriously, started taking classes and getting involved in activities that would help me go down that path, especially with opportunities to explore different areas and find out what is out there.”


Lee discovered a field of space medicine and research far beyond his dreams. Through the Aerospace Medical Association and the American Society of Gravitational and Space Biology, Lee learned of numerous careers that combined his space aspirations with his interests in the life sciences.


As an early step toward becoming an astronaut, Lee began learning Russian. Already fluent in Korean, French and English, he figured the language could be useful in future collaborations with the Russian space program. As it turned out, the collaboration occurred sooner than he had anticipated. In 1997, he was accepted to Brown’s combined M.D./Ph.D. program but took a leave of absence to attend the International Space University (ISU) in Strasbourg, France. That year the ISU accepted only 33 students from 23 different nations to participate in its master of space studies program, which provides a year of instruction in various space-related fields and includes a 12-week professional placement. Lee was placed in Moscow at the Institute for Biomedical Problems, where he worked with Russia’s premier scientists in space biology. The opportunity allowed him to conduct preliminary studies of muscle atrophy in monkeys that had flown into space. This research would turn out to be an ongoing theme in his education.


Back at Brown, he began working in the laboratory of Herman Vandenburgh, Ph.D., a pathology and laboratory medicine professor who has been conducting research on muscle atrophy for the National Aeronautics and Space Administration (NASA) for more than a decade. With Vandenburgh’s guidance, Lee started his doctoral thesis, studying tissue-engineered muscles to pinpoint the cause of atrophy. One of his experiments even made it aboard the space shuttle Discovery’s October 1998 mission—the same mission that returned John Glenn to space.


So while Glenn made one more visit to the cosmos, Lee’s experiment was breaking new ground in testing genetically engineered cells’ ability to secrete growth hormones in zero gravity. “It was a really valuable experience in understanding how different it is to have a research project in space,” Lee says. “In the lab, you can dictate to a large degree pretty much anything that happens…. If you want to do a space shuttle experiment, obviously you are at the mercy of [NASA] management.”


Since then, Lee has been attempting to make sure his research project’s venture into space would not be a one-time occurrence. However, the cost of his experiment’s spot on the shuttle was donated by a commercial company in 1998, and free space will not be available next time. So he’s working to line up sponsors for a follow-up space shuttle experiment, which is planned for sometime this year.


In the meantime, Lee plans to finish his Ph.D. work after which he has two years of medical school remaining. He then hopes to do residencies in aerospace and emergency medicines. All the while, he will be reminding NASA officials of his ambition to join the space program. Even with his credentials though, Lee is well aware the odds of becoming a U.S. astronaut are still stacked against him—particularly because he’s Canadian. His nationality has already cost him opportunities to apply for U.S. grants, scholarships and NASA fellowships.


But as he awaits the approval of his green card, Lee remains committed. “I realize that…the chances for becoming an astronaut are pretty slim, but I am at least going to go ahead and pursue it.”
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Career Development,Medical Research~
176~1January-February~2002-51~Feature~Space, the Final (Medical) Frontier~PHYSICIANS FIND THEIR PLACE AMONG THE STARS.~Jennifer Zeigler~~During the frenetic days of the space race’s 1960s Apollo missions, Dr. Joe Kerwin had won a place in the National Aeronautics and Space Administration’s (NASA) astronaut corps, but he had yet to secure a ticket into orbit. For years, he had been sitting in on the Monday morning pilots’ meeting at NASA’s Johnson Space Center, but to no avail. “I kept raising my hand for Apollo missions, and Al Shepard would say, ‘Put your hand down. You’re not going to the moon.’”


Shepard was right—Kerwin wasn’t going to the moon. Eight years out of medical school, the physician–astronaut had landed his position by way of a National Academy of Sciences (NAS) recommendation for NASA to recruit scientists as well as the fearless test pilots whose “right stuff” made them the cornerstone of early manned space flight. The NAS saw space exploration as more than just an environment for the daring to test their nerves: Space was a boundless laboratory, and physicians and scientists alike should have their place in it.


Of the first five scientists NASA recruited into the astronaut corps in 1965, Kerwin was the only physician. He had already logged in hundreds of flying hours as a navy flight surgeon, but this NASA selection allowed him to chase a bigger dream.


“When I was a kid, I would sit in the kitchen and eat…sandwiches and read science-fiction books. And my brothers would come in and say, ‘Ah, little Joe. He’s going to the moon someday,’” he says. And while he never did get to the moon, in 1973 Kerwin made one giant leap for the role of physicians in space.


“Now, here comes Skylab whose purpose was, among other things, was to determine whether humans can withstand long-term space flight,” he says of the U.S. space station that orbited Earth from 1973 to 1979. “So it suddenly became a biomedical mission, and it was what I was waiting for.” When he raised his hand to volunteer this time, no one told him to put it back down.


And so, on May 25, 1973, Kerwin became the second physician in space—he missed being the first, because a Russian cosmonaut launched into orbit just a few days ahead of him—and began NASA’s first serious study of zero gravity’s effects on the human body, work that continues today on the International Space Station. (See how space affects the human body, p. 13.)


DOCS IN SPACE


So, welcome to the space doctor’s world—one that fluctuates between Earth and sky. Your job is to determine how to permanently put humans in a zero-gravity environment—a world where up is down and down is left or right. Confusing, huh? Well get this—even the organs you dissected as a first-year medical student are not where they should be as a result of this weightlessness.


It’s challenging work but easily linked to the practice of medicine. “The body was probably never meant to travel in space,” says Dr. Jeffrey Sutton, director of the National Space Biomedical Research Institute (NSBRI). “[But], medicine is all about physiology pushed too far. [Space medicine is] a really cool area because you have to think outside the box.”


In Kerwin’s day, there was barely a box to think outside of. “We were guided by the fragmentary, but interesting, data [about the human body] that had been gathered on astronaut flights from the beginning,” Kerwin says. But due to the brevity of early manned space flights, little was known about zero gravity’s long-term effects, and this knowledge was essential for NASA to have as it made plans to populate space and conduct interplanetary missions.


So when Kerwin and his two crew mates went to Skylab in 1973, it was to spend a month conducting research in life sciences, astronomy and other areas. While Americans were celebrating Memorial Day and pulling the lawn mower out of winter storage, Kerwin was using his medical background to study the weight loss, motion sickness and bone density reduction astronauts suffer. The crew performed aerobic exercises and measured changes in cardiovascular fitness; examined nutrition, creating a complete intake/output analysis for each crew member; conducted dental examinations; and investigated muscular capabilities.


Skylab reinforced NASA’s ability to conduct valid science in space, Kerwin says. “Suddenly we had a very sophisticated data set—still the best we’ve got.” Because the three Skylab missions were the last long-term, American-controlled space research missions, data gathered since then on numerous shuttle missions can only be applied to short-term flights, he says. “My personal experience in Skylab makes me proud of the good work we did. Since then we’ve been waiting—we’ve been doing a lot [of research], but we’ve been waiting [for another long-term research opportunity].”


Skylab wet the biomedical research whistle and established a role for physicians in space. Since then, 16 American physicians have made the trip on shuttle missions, trying to find answers to medical questions both 200 miles up and down here on Earth.


Dr. Drew Gaffney had been an associate professor at the University of Texas Southwestern Medical Center when he was recruited to be a payload specialist on Columbia’s 1991 mission, which was the first to be dedicated solely to life science research. Responsible for studying venous pressure in zero gravity, Gaffney became both scientist and subject on the mission, launching into space with a central venous catheter inserted near his heart so he could measure his blood pressure changes during the mission.


Circulation is a serious concern for astronauts because zero gravity prevents blood from flowing easily back into the extremities. “The blood hangs out in the head and chest and not in the abdomen and legs,” Gaffney says. Researchers expected that blood pressure would go up because of this, and Gaffney was surprised when the data indicated his pressure went down. “Quite honestly, I thought the system had failed,” he says, adding that he was so sure the data was incorrect, he reset the experiment’s entire system and checked it again. But the results were correct, and Gaffney says he finds satisfaction in the fact that he played a part in altering researchers’ thinking about blood pressure changes in space. “Having worked so long and so hard to get there, and then, by-in-large, having [the experiment] work was really satisfying.”


Just learning about the changes the body undergoes in space is not the sole challenge to physicians, says Dr. Bernard Harris, a physician–astronaut who journeyed into space in 1993 and 1995. “It’s going to be really important that physicians can [compensate for] these changes,” Harris says.


His work helped NASA get closer to the point where physicians can do just that. He didn’t fall into this business by accident; Harris says he had wanted to be an astronaut since childhood and chose medicine as his best way to get there.


His plan worked. In 1993 NASA sent Harris on a two-week mission to further study how living systems function in space. Harris spent time watching fish and tadpoles swim in circles—fish, like humans, have no concept of up or down in space, so they can’t swim in straight lines. He also served as the seven-member crew’s medical officer. NASA usually medically trains two crew members to tend to basic medical needs in space, but when physicians are on board, “we make the calls,” Harris says. (Crews are also supported by an on-ground flight surgeon. See “Physicians Without Wings,” p. 18.) “Every day is just like going to the doctor’s office,” Harris says. “You see common ailments—colds, muscle strains, headaches, diarrhea,” which, he adds, is even more uncomfortable in space than on Earth.


Kerwin had a similar experience with Skylab. “We had a general practitioner’s office capability in space. I couldn’t remove an appendix, but I could remove a tooth,” he says. “We could get back in 24 hours” if something more serious arose. “It’s sort of like camping in the Sierras,” he says—but at a much higher altitude, of course.


Harris spent more time in his high-flying exam room during his 1995 mission, which rendezvoused with the Russian space station Mir. Of the mission’s roughly 25 medical experiments, many focused on operational medicine. “In space, we don’t know what normal examinations are,” Harris says. “All of the windows for examining the organs are different.” For example, it doesn’t take a medical student to know that the heart is located down and to the left inside the chest cavity, so that’s where a physician would look for it on Earth. But physicians in space know that to find a crew member’s heart in zero gravity, they’ve got to steer their stethoscopes up and to the center because weightless organs float up.


But while in space, physician–astronauts don’t just examine crew members and conduct medical experiments; they also perform duties as astronauts. Both Harris and Kerwin went on space walks; Kerwin repaired a damaged Skylab heat shield during his.


RESEARCH PARTNERSHIPS


Research related to space medicine isn’t only conducted in outer space, however. The NSBRI’s Sutton says NASA recognizes how the wealth of talent at U.S. medical schools can enhance its space program.


“As the International Space Station [ISS] became a reality, it became enormously urgent not only to solve the motion sickness problem but others as well,” says Dr. Bobby Alford, the NSBRI’s chairman. At 240 miles above Earth, the ISS operates in zero gravity, and astronauts staff the facility for four to six months, making the long-term effects of weightlessness a serious concern. “And NASA, having realized that, saw they needed to go about research in a new way,” Alford says.


NASA realized the results of some Earth-based life science research could be directed to aid the agency’s search for countermeasures, or solutions, to the physical and psychological effects of long-term space flight. So, in 1997, well before the ISS launched, the space agency established the NSBRI—a consortium of 12 schools engaging in NASA-sponsored research—to tap into and help direct the wealth of life science research already being conducted. The NSBRI is based at Baylor College of Medicine.


“The real influence and power in terms of the research institute is all of the researchers across the country,” Alford says. “If [NASA were] to try to establish or create the resources that all these research institutions have, they couldn’t possibly do it. It’d be too expensive.”


It makes for a great bargain for NASA. The NSBRI researchers have secured National Institutes of Health (NIH) and private foundation funding in addition to some of NASA’s financial resources. These outside funding sources are lured to the work because of the potential Earth benefits. (See “Down to Earth” p. 25.) “This is a bold, new era, and [the research] is absolutely essential if the human space program is to go forward,” Sutton says.


NASA also works with Vanderbilt University’s Center for Space Physiology and Medicine, whose biomedical researchers try to solve the physical ramifications of space travel.


Some of the countermeasures being researched could include a system to deal with the high-power bands of radiation astronauts are exposed to once they leave the Earth’s orbit. Gaffney, who now serves as the space physiology center’s associate director, says that in addition to the radiation concern, the bone and muscle atrophy that is inevitable in zero gravity and the psychological challenges of being physically isolated with a few other people for years at a time are the biggest problems requiring solutions from researchers.


Dr. Sam Pool, the assistant director of Johnson Space Center’s Space Medicine and Life Sciences Directorate, echoes Gaffney’s top priorities and adds several more. “We’d like a breakthrough in better being able to deal with the bone loss, which is one of the most serious problems. We’d like a breakthrough in the area of neurophysiology…; we’d like to have some surgical techniques which could be used in microgravity.”


The need for more extensive medical treatments comes from the fact that travel beyond Earth’s orbit promises to be years long. “When you go to Mars, you’re a long way from the nearest hospital,” Kerwin says. “You could be three years from the nearest hospital.” So researchers are working on medical technologies that are lightweight and can be used to treat any problem that might arise.


“We are at a threshold of having a suite of new technologies,” Sutton says. Sutton’s research focuses on generating on-going, passive monitoring systems that will help physicians on the ground treat medical problems a world or two away. “We’re interested in doing completely noninvasive treatments based on computerized models of individuals,” he says. One example is finding a way to monitor blood without ever using a needle, since having blood drawn in space is very uncomfortable for astronauts.


TO MARS AND BEYOND


Many say the progression of countermeasure research is essential mainly because the future is here. The ISS maintains a continual human presence in space that we’ve never before had—in November, NASA celebrated its first anniversary of permanent space habitation. “Space will never have a time when humans are not there,” Harris says.


Space medicine has come a long way since Kerwin’s groundbreaking foray beyond our atmosphere. But the ISS is only a jumping-off point in NASA’s attempt to grab the golden ring: a successful manned mission to Mars. And to do that, many unanswered questions must have solutions in order to ensure the crew’s safety.


“We still don’t have a set of accurate countermeasures for people who spend a long period of time in that environment, and that makes the Mars mission rather difficult at best,” Pool says. “The development of countermeasures is very, very important.”


The ISS has always been considered the test environment for countermeasures, but with the station billions of dollars over budget and Congress weary of footing the bill, the station’s viability as a research laboratory is threatened. Plans for entire sections of the station have been scrubbed, and future crews have been scaled back from six to three people, which many experts say is barely enough manpower to keep up with routine maintenance. “Skylab was much simpler of a craft to fly,” Kerwin says, and he adds that the ISS should have a continual staff of at least six to complete the volume of research the station needs to conduct.


Many NASA officials and astronauts also express concerns over the Bush administration’s appointment of Sean O’Keefe to replace NASA’s former administrator, Dan Goldin. O’Keefe is better known as a management guru rather than as a space visionary. He served as the secretary of the Navy under the first Bush administration and, according to NASA flight surgeon Terry Taddeo, was known as “the Grim Reaper.” The current President Bush tapped O’Keefe for NASA while he was serving as the deputy director of the White House’s Office of Management and Budget.


“I’m worried right now based on the lack of knowledge [we have] about what Mr. O’Keefe is going to do,” Kerwin says. Many astronauts with whom The New Physician spoke are taking a wait-and-see approach. They say the potential for research cutbacks worries them, but there’s not much they can do about it. Kerwin says if O’Keefe can pull up NASA by its bootstraps into a better management plan, then “that’s great”—but other space experts have said the agency should not expect the wide-reaching, let’s-get-to-Mars-at-any-cost vision for which Goldin was famous.


Congress is also reining in its enthusiasm for the space agency as the ISS becomes increasingly expensive. “You can’t use the M-word in Congress right now,” Taddeo says of a Mars mission. “[NASA is] just like any other government agency. You’re there at the whim of the Congress and the president.”


But not everyone thinks NASA’s problem lies in expensive ideas and not enough money to pay for them. “The bottleneck, in my opinion, is not money, it is risk,” Sutton says. “Since [the] Challenger [explosion], we have been in a risk-averse culture. As a society, we have an expectation that we’re going to go up, and everything will be fine.” But this is impossible, he says, because NASA can’t screen astronauts for every potential medical problem, given the years needed for interplanetary travel. No matter where people go, they will get sick, Sutton says. “If you put seven people in their 40s and put them away for a year, people will become ill. There will be things that arise. That is just the human condition.” So, he says, we’ll never be able to avoid all of the risks of long-term space travel, a fear NASA—and society—will have to overcome if the space program is to continue on its current path.


However, for those who work in space medicine, the future is still starlight bright. “If you’re a space nut like me, the most exciting thing there is…is putting people in systems to go to Mars,” Kerwin says. “The challenge is out there, and we know we can do it.”
~The Trouble With Space Travel


Your body swells, you’re nauseous, you lose more bone mass than osteoporotic women do. Buzz Lightyear may look like the picture of action-hero health, but trust us: Infinity and beyond is no picnic for the human body.


With the 1-G gravitational pull we’re used to on Earth no longer tugging on us in space, the human body uses its defense mechanisms as best it can to adjust. “The body is very resilient,” says Dr. Bernard Harris, a physician–astronaut who has made two trips into space. But the problem often lies in how the body changes—adjustments to space’s zero gravity make coming back down to Earth all the more difficult. Here are some examples:


Bone loss — Without the need to hold the body straight against a constant downward pull, bones become less dense in space, mostly in the hips, spine and lower extremities. Bone density decreases at a rate of about 1 percent to 2 percent per month, and it never stops, making the prospect for long-term travel dangerous upon Earthly return, when the bones suddenly need to start doing their job again. This constant calcium purging in the bones is also believed to increase the chance of developing kidney stones in space.


Muscle atrophy — Muscle loss can be as great as 25 percent of the original mass, although research has shown that regular and lengthy periods of exercise while in a weightless environment can reduce this effect.


Fluid redistribution — Weightlessness causes bodily fluids to fill the sinuses, so astronauts tend to feel as if they have a head cold for much of the trip. Studies have found the sensation is relieved during exercise sessions, which force the fluids back to where they belong. Fluids also swell in the hands and chest, and researchers are concerned that long-term fluid buildup in the head could cause brain damage.


Cardiovascular changes — The body, sensing the fluid shifts, believes it to be suffering a fluid overload. This causes the brain to downgrade the cardiovascular system, lowering blood pressure and slowing the heart rate. While lower blood pressure and slower heart rates are the goal of every Earthly aerobic workout, eventually the slowdown causes a decrease in red blood cell production, which makes astronauts anemic.


Nausea — Because weightlessness plays tricks on the senses—astronauts have a difficult time discerning up from down and left from right—about 60 percent of space travelers suffer from motion sickness, although the body’s internal adjustments usually control it after a few days.


Radiation exposure — Beyond the Earth’s atmosphere lie the Van Allen radiation belts, which can be very damaging to long-term space travelers. Researchers are trying to develop shielded areas in spacecrafts for human travelers to seek shelter from the potentially cancer-causing rays.


Psychological challenges — Extended periods of isolation are a concern for long-term space travelers. A trip to Mars is expected to take three years, and researchers realize that is a long time to be locked up in a tiny vehicle with maybe six other people. The 16 sunrises and sunsets and the 45-minute day Earth-orbiting astronauts experience also play with the body’s circadian rhythms, and Mars travelers would potentially be screened for adaptation abilities to that planet’s 25-hour day.


Orthostatic disorders — Without the need to stand up straight, astronauts tend to develop orthostatic problems and for several days after their return to Earth have difficulty standing without fainting. This becomes a problem in re-entry into Earth’s atmosphere, as astronauts, who have adjusted to space’s zero gravity, actually feel a force greater than Earth’s 1-G on the way back down, causing them to faint at times, a potentially hazardous situation if they are piloting the space shuttle.


All of these changes make astronauts a little awkward and uncoordinated on Earth’s return, says Dr. Drew Gaffney, a physician–astronaut who flew on the space shuttle in 1991. “It’s probably a good week until you’re back to normal. If you want to beat someone at Ping-Pong, play them after they’ve been in space.”
—J.Z.


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EDUCATIONAL RESOURCES





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PROGRAMMABLE PACEMAKERS


One of the first medical breakthroughs derived from NASA research occurred in the late 1970s when a California-based company used technology from the space program to introduce a bi-directional telemetry pacemaker system, which allows a physician to gather information about a pacemaker’s function and to reprogram it based on the patient’s needs—all without requiring surgery.


Researchers created the innovative pacemaker by using two-way communication originally developed by NASA to talk with satellites. The pacemaker’s single microchip and rechargeable, long-life battery are also products of the agency’s research. The end result is a state-of-the-art pacemaker that closely matches the natural rhythm of the heart.


BONE DENSITY MEASUREMENTS


For years, NASA has been concerned with the dramatic bone loss astronauts suffer during extended time in orbit. Astronauts lose approximately 1 percent to 2 percent of their bone density in a month; compared to postmenopausal women on Earth, who average 1 percent bone loss per year.


To more accurately measure this bone loss, the NSBRI has developed the advanced multiple-projection, dual-energy, X-ray absorptiometer—a compact instrument designed to take precise bone and tissue measurements. The current measurement method uses a single-projection X-ray process and fails to take in account patient positioning or the natural density within the structure of a bone. “Bones are not symmetric; they are asymmetric. If there was more bone in the path of the X-ray, then I would say your bone density was higher,” says Harry Charles, the NSBRI’s associate team leader for technology development, who led the research and testing of the new device. The instrument resolves this problem by taking multiple, angularly spaced projections to provide a more precise measurement of bone density. This allows NASA to determine whether countermeasures are effective.


But before the instrument begins evaluating astronauts for bone loss, it may already be in use on Earth. “Obviously, it has great potential with osteoporosis. It can ultimately be portable. It can ultimately be in a physician’s office. It can be in clinical settings of all types,” Charles says. The device is undergoing accuracy studies on human subjects and soon could be in commercial use.


ROBOTIC SURGERY


When astronauts float thousands of miles above the Earth, every task is complicated, and completing intricate and precise repairs on a satellite is almost impossible. Therefore, NASA has long been at the cutting edge of robotics, using mechanisms to perform work in space. Now, some of that robotic technology is making its way into the operating room, allowing surgeons to conduct noninvasive, endoscopic procedures.


Endoscopic surgery is performed by inserting a slender camera into an incision to access a part of the patient’s body. Before using robotics, the surgical staff had to hold the camera while the surgeon used it to monitor the operation. With the new system, the surgeon sits in front of a monitor and uses hand-controllers to manage robotic arms performing the surgeries. Voice-recognition software controls the camera movement. The robotic arm provides steadiness and accuracy that simply isn’t possible with the human hand.


Electrical Disturbances in the Heart
In the early 1980s, Dr. Richard Cohen—intrigued by the relationship between minute disturbances in a patient’s heart rhythm and the risk of sudden cardiac arrest—sought NASA support to study microvolt T-wave alternans, which are minor fluctuations in the heart’s electrical activity. Cohen, a professor of biomedical engineering at Harvard–MIT Division of Health Sciences and Technology, believed T-wave alternans could help explain why some people suffer sudden cardiac arrest without any prior evidence of heart disease. Electrocardiograms are not sensitive enough to pick up the changes in T-wave alternans and, at the time, no other technology
was available to study them.


Cohen knew NASA would be interested in this work because some astronauts had noted changes in their heart activity during space travel. His research could provide the agency with a better understanding of the behavior of the heart in zero gravity.


So with NASA support, Cohen, who has since been appointed leader of the NSBRI’s cardiovascular alterations team, led the development of the T-wave alternans test, which when performed during a standard stress test, can detect the subtlest beat-to-beat variations of the heart. In April 1999, the test received clearance from the Food and Drug Administration (FDA) and has since found widespread acceptance in the medical community.


BREAST CANCER DETECTION


When NASA’s Jet Propulsion Laboratory began working on an ultrasensitive infrared photo sensor in the early 1980s, researchers figured the final product would someday be used to target launched missiles as part of President Reagan’s futuristic Space Defense Initiative, better known as the “Star Wars” program. But upon completion of the Quantum Well Infrared Photo (QWIP) detector a decade later, researchers found the Cold War had thawed, and they were left to find new uses for the technology.


That was when a small New York technology company stepped in and negotiated with the NASA technology transfer program to obtain the licensing rights to QWIP’s biomedical applications. Company officials believed the technology, which is sensitive enough to identify differences in temperature of less than 0.01 degrees Celsius, could be used to recognize cancerous breast lesions by detecting a tumor’s attempt to acquire a new blood supply, a common characteristic of malignant lesions. In order to acquire the supply, the tumor exudes nitric oxide, altering the blood flow and temperature of tissue around the cancer.


The company’s cancer detection system, which received FDA approval in 1999, has become widely accepted as breakthrough technology in the fight against breast cancer. It is considered a dramatic improvement over mammography, which detects the calcification of cancer cells only after they develop.


IMPLANTABLE INSULIN DELIVERY


NASA’s Viking lander missions launched in the mid-1970s provided the agency with invaluable images of the surface of Mars. And it has also provided much needed relief to insulin-dependent diabetics who rely on daily injections.


The Programmable Insulation Medication System, an implantable computerized pump that acts as an artificial pancreas, delivers insulin to the body at a controlled rate. The pumping mechanism is taken directly from a component of the Viking lander, while the remainder of the device—a refillable reservoir, a tube to the diabetic’s intestine, a microcomputer and a battery, all of which are encased in a titanium shell—was devised by Johns Hopkins University’s Applied Physics Laboratory in
collaboration with NASA.


The microcomputer is the key to delivering the insulin to the abdominal cavity in short pulses, with the rate programmed through a small transmitter placed over the implanted device. The same transmitter can also be used to obtain information from the pump’s stored memory and can generate performance records. Patients avoid further surgery by refilling their insulin reservoirs with special hypodermic needles approximately four times a year.


MUSCLE STIMULATION TECHNOLOGY


In order to get work done in zero gravity, astronauts rely on the Remote Manipulator System (RMS), the space shuttle’s six-axis, 50-foot mechanical arm used to move payloads and satellites weighing up to 65,000 pounds. As part of astronaut training, NASA’s Goddard Space Center developed an RMS simulator to allow astronauts to a get a feel for the powerful mechanism.


The computerized control systems for that simulator have since contributed to the advancement of functional electronic stimulation (FES)—a therapeutic treatment method for neuromuscular illnesses that uses electrical currents to initiate muscle contraction, which relaxes muscle spasms, prevents muscle atrophy due to disuse, increases blood circulation and range of motion, and reinforces muscle memory.


An Ohio-based company used the RMS control systems to develop an FES computer-controlled stationary bicycle, which sends low-level electric pulses to the user’s leg muscles, empowering the legs to pedal in a natural motion at 50 revolutions per minute. The equipment garnered national attention for its role in the therapy of actor Christopher Reeve, who suffers from paralysis after having fallen from a horse in 1995.


VENTRICULAR ASSIST DEVICE


Sometimes the inspiration to transfer NASA technology into the medical field can be very personal. This was the case for Johnson Space Center engineer David Saucier. After undergoing a heart transplant in 1984, Saucier worked with his physicians, Michael DeBakey and George Noon from Baylor College of Medicine, to develop a better heart pump.


This led to the development of a miniaturized and implantable ventricular assist device (VAD) that employs NASA’s turbopump design, which maintains the performance of the space shuttle’s engines. The VAD is one-tenth the size and approximately one-quarter the cost of current heart pumps on the market and provides a weak heart much needed rest by pumping more than 10 liters of blood per minute. Additionally, the heart pump weighs less than 4 ounces and operates on only 8 watts of power. In 2000, the new VAD was implanted in a 31-year-old woman. The device received approval from the FDA last year to begin multicenter clinical trials. —S.S.
~~~Jennifer Zeigler is a senior writer with The New Physician.~Career Development,Medical Research~
177~2March~2002-51~Letter from Afield~Witness to Devastation~OFFERING ASSISTANCE AT GROUND ZERO.~Herald Ostovar~~Herald Ostovar, a fourth-year medical student specializing in emergency medicine, took time off during his Somerville, New Jersey, family practice rotation on the nights of Sept. 12 and 13 to help with rescue efforts at the World Trade Center. The following story contains edited excerpts of letters he wrote reflecting on these experiences.


WEDNESDAY, SEPT. 12


I clearly remember the acrid smell of ozone and burning plastic as I stepped off the subway at Fourth Street, about 30 blocks from the wreckage site. As I started walking south, I was immediately struck by the silence. The only sounds were the beeping of distant dump trucks and the occasional somber “hello” of a passerby. Once in a while an emergency vehicle rushed by me. A makeshift sign saying “I § NY” hung outside a residence.


A little after 8 p.m. I reached the main checkpoint, which was crowded with police, media and other people. I nervously approached and told them I was a member of the American College of Emergency Physicians. The next thing I knew, I was thrust into a world I will never forget. The ground was dusty, and it was dark—the streetlights were out. In the distance, I could see the dim glow of the rescue workers’ lights and smoke billowing out of the rubble where the World Trade Center towers once stood. It looked like the aftermath of a volcanic eruption. As I continued to approach the disaster area, the dust on the ground deepened to several inches. I walked past a quarter-mile line of waiting dump trucks and nodded to the policeman or military guard who stood on each block. As I neared Ground Zero, the acrid smell became stronger, and large amounts of dust and debris flew into my eyes and mouth. I stopped numerous times to clear my eyes and throat, and I kept looking up as if I might see the two buildings if I looked hard enough.


The next thing I saw was beyond words or comprehension. The 7 World Trade Center building had been reduced to twisted shards of steel, wire and glass, and the building next to it leaned to the right with all of its windows blown out. Cars were flattened to the ground, their rubber tires melted off. A UPS truck had a huge hole in its roof. A firetruck was covered in soot, its windows shattered and the passenger cab filled with pieces of cement and steel. A New York City police car was burned almost beyond recognition, and other demolished cars were piled upon each other as if in a junkyard.


I walked around the massive debris field and ventured into an even more disastrous scene: 1 World Trade Center and 2 World Trade Center had been transformed into a five-block radius of rubble at which thousands of rescue workers feverishly worked. I was surrounded by lights, generators, cranes, Caterpillars, bulldozers and dump trucks with tires higher than my head. Soot, ash and concrete powder covered the trees. Windows below the 30th floor of every building in the surrounding area were blown out. One building had its top sheared off, and only its skeleton remained. A 40-foot-tall section of the outside wall of one of the towers had ripped a 30-story hole in the front of another building and was lodged precariously about 20 stories up. The Millennium Hotel had been completely sandblasted in the front. In its lobby lay masses of shattered glass, articles of clothing, reading materials, debris-covered couches and—an eerie sight—the hotel “welcome” screen on a front-desk computer, the only working electric-powered item in the building.


And then there were the World Trade Center towers. A portion of both outside walls still stood, but there were stories upon stories of rubble, and fire and smoke spewed from a 50- to 75-foot-deep crater—presumably the towers’ lower floors.


In all of this chaos, I was able to find one of the two triage units in the area. (All the other units had been converted into morgues.) I bumped into some other medical students, and we banded together. We were assigned posts, and then we waited. The only injuries we treated all night were those of rescue workers. No victims were found alive. Only body parts were discovered.


Feeling helpless, many of the medical students decided to aid the rescue effort. We grabbed work gloves, goggles and breathing masks and climbed the mountain of debris. The hundreds, if not thousands, of firemen, emergency medical technicians, policemen, nurses, physicians and other rescue workers looked like a sea of yellow and blue on the mass of rubble. People from all over the country—even the world—were helping. Buckets were filled with debris and passed along lines of hundreds of workers. At the end of the lines, they were emptied in the path of bulldozers, which transferred the debris to dump trucks. We ended up at the front of one of these lines, right next to the crater.


The level of this effort’s organization was amazing; massive quantities of water bottles, sandwiches, hamburgers, fruits and snacks were available for workers at every street corner. Hot meals and showers had been set up for anyone in need. Sledgehammers, shovels, crowbars, steel clippers, steel-cutting saws, acetylene torches, fiber-optic cameras and canine units were all used at some point by the teams. Every so often a team would yell “quiet!” and hundreds of workers would echo that call until it became absolutely silent—they were listening for any sounds of life coming from underneath the rubble.


At one point, one of the canine units signaled a specific area and fiber-optic cameras showed a leg buried underneath two feet of rubble. Surrounded by an audience, we dug feverishly only to realize the grimmest of our fears: It was just a leg, mangled and shattered. It was placed in a bucket and passed on down the line. Later, we thought we saw a flashlight from the 40th floor of a building right above our heads; a helicopter rescue unit went up with a floodlight only to discover it was a reflection off shattered blinds. At another time in the night, the ground shuddered and everyone ran, many falling as they attempted to navigate the debris field. Eventually the rescue organizers cleared the area of workers and brought in the big guns—cranes and torches.


It was evident the cleanup would take many months, if not more than a year, to complete, and by 6:30 a.m. I was exhausted. But before I left, I had the chance to treat an injured fireman, putting five stitches in his finger (unsupervised!). We won’t go into how I accomplished this in a completely dark room using only a flashlight for illumination or how much sterile technique was used. The nice thing was that the fireman was genuinely thankful.


I had to walk the same 30 blocks on my return to the subway station, but somehow they seemed a little less dark. It wasn’t because the sun was coming up but because I felt I had played a role, however insignificant, in the rescue effort. The train ride home was somber, but all sorts of people approached me to thank me for the job I was doing. This made me feel good, but I didn’t deserve their thanks. The rescue workers who are constantly risking their lives are the heroes. No wonder they call them “New York’s bravest and finest.”


THURSDAY, SEPT. 13


On my second evening at the site, we were asked to write our names and social security numbers on our forearms, “just in case.” I considered the danger and felt like I should leave, but something made me stay.


The main story of this night was rain—a very cold, heavy rain. My stethoscope will forever smell like the acrid air because rain leaked into it. During the night, there was the occasional discussion of how long the search for the living would continue. Some firefighters estimated 12 days. Others said it could be more like 14 to 16 days if the weather remained cool and if it rained every once in a while. Rain can hamper rescue efforts, but it can also be a source of life to those trapped underneath. The rain helped reduce the dust and debris in the air, but it made us all so cold. Fortunately, donations provided us with new, dry shirts, socks and underwear, as well as food and drink. The local Burger King (with windows blown out) was the staging area for the food relief.


At daybreak we were told that all nonessential personnel were to move the triage center from the firehouse because the 60-story building next to it was showing increasing signs of instability. Apparently nearby workers could hear the building groaning; lasers had also been placed on the building to detect any movements.


After a frantic move of our triage center from the firehouse to the Burger King and back, I went with a cardiologist into the rubble, where we helped by passing buckets. Even though I got soaked, and we didn’t find anyone, it felt good to be doing something worthwhile. We stopped our work when a battalion chief kicked everyone off that part of the hill because the area had become unstable. It was amazing to see many firefighters reacting with disgust. Most of them didn’t care about their own safety; they wanted to keep digging. After all, 200 to 300 of their brothers lay underneath.


Our group quickly moved to another side of the rubble, close to where we had been digging the night before. It was the only place that was almost too warm to work in; despite all the rain, fires were still burning below, and hot steam was escaping from the crater. We started digging (this time I deferred the bucket-passing to a firefighter). Every once in a while, during a break, a rescue worker would break down in tears. My eyes welled up from time to time also, and they still do when I think about the tragedy. The per-
sonal effects we unearthed profoundly touched us—teddy bears, caps, toys, monogrammed satchels, photographs, and ID and business cards. One of the business cards had a Web address, and when I later signed on to the site, I discovered the card’s owner was alive!


The cardiologist and I went back to the triage center and helped for a while with eye washes, after which we decided to put in one last effort outside. As we worked, we were surrounded by giant bulldozers, dump trucks, diggers, workers with powerful electric cutting saws, and welders who cut through the massive beams. Sparks flew in every direction. Sounds of grinding and crunching steel filled the air.


Then the sun came out. American flags flew from the beams above our heads and from the tops of emergency vehicles, bulldozers, cranes and many workers’ helmets. There was red, white and blue everywhere. One gets the sense that if this disaster accomplished anything, it made us realize again, much more than before, that every human being is precious. The attacks and responding relief and rescue efforts bring us closer together and unify us as a nation. Eventually, they will unify us as a world.
~~~~Herald Ostovar is a fourth-year medical student at St. George’s University School of Medicine in Grenada, West Indies.~Community and Public Health~
178~3April~2002-51~Feature~The AMSA Foundation’s Seventh Annual Primary Care Scorecard~~Simon Ahtaridis~~The New Physician has published the American Medical Student Association (AMSA) Foundation’s “Primary Care Scorecard” for the past seven years. Each year, the scorecard has been fine-tuned to best meet the needs of premeds and medical students interested in primary care, but this year’s card is drastically different. Previously, the foundation ranked all U.S. allopathic and osteopathic medical schools according to each institution’s proportion of medical graduates entering primary care residency programs. Although this format seemed effective in the past, the foundation decided it was time to make the scorecard more “user friendly.”


This year’s card focuses on specific primary care residency areas—family medicine, internal medicine, pediatric and combined internal medicine/pediatric residencies—and lists the top 10 allopathic and top three osteopathic medical schools with the highest proportion of medical graduates entering each residency area.* (True scorecard aficionados and loyalists can spend their free time perusing the foundation’s traditional ranking of all the schools on the Web at www.amsa.org/programs/pcscore7.cfm.)


But before you flip to the scorecard, let’s take a closer look at primary care medicine and how premeds and medical students interested in this field can better ensure they will receive the proper education and training.


WHAT IS PRIMARY CARE?


According to the American Academy of Family Physicians, “Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern…. [It] includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings…. Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.”


WHY FOCUS ON PRIMARY CARE?


Nearly every medical school exposes medical students to the glitz and glamour of the most current interventional technology used by specialists. But many schools do not adequately expose students to the rewards of primary care medicine. This is a great disservice not only to medical students who will make career decisions based on limited experiences, but also to our health-care system, which suffers a shortage of primary care physicians.


The decision to go into primary care medicine should be based on one’s interests and experiences. The scorecard is designed to raise awareness of primary care medicine as a career option and to help students think about the steps they may want to take in order to give primary care a fair consideration as a potential career.


WHO SHOULD USE THIS SCORECARD AND HOW


Premeds can use the scorecard to determine which schools foster primary care ideals. Medical students can use the information to assess programs at other schools and to help initiate curriculum reform at their institutions. That being said, this scorecard should not be interpreted as an assessment of a particular medical school. And if your earliest childhood memory is the day you decided you wanted to be a cardiothoracic transplant surgeon, then the scorecard may not help you with future career decisions.


Essential questions for premeds:


A medical school’s curriculum and focus can have a profound impact on the type of residencies and careers pursued by its graduates. So premeds, if you are interested in primary care, keep the following questions in mind when interviewing at a medical school.


What are the core third-year required rotations? More specifically, is there a family medicine rotation?


Many medical graduates who enter primary care residencies say their family medicine rotations heavily influenced their career decisions. Not all medical schools offer a family medicine third-year rotation. So if you’re considering this field, be sure to ask your interviewers about the institution’s third-year family medicine learning opportunities. The timing of the rotation is crucial, because most students have to make specialty and residency decisions early in their fourth year. Would you feel comfortable committing to a field of medicine that you have not experienced? Probably not. This is why schools that lack a third-year family medicine rotation do not have a high family medicine residency match rate.


DOES THE SCHOOL HAVE A FAMILY MEDICINE DEPARTMENT?


If the institution lacks a family medicine department, you may find it offers students a limited primary care experience.


How many full-time faculty members are primary care physicians?

You need to be sure there are sufficient mentors, ambulatory rotations and adjunct faculty available to help guide you through your education and to show you the diverse set of primary care career options.


Where and what do the majority of its graduates practice after residency?

Many schools do not collect this type of data, but those that do can give you a fair assessment of the types of students the school attracts and the types of physicians it produces. This will help you determine if the institution is the right match for you.


In general, does the school have an institutional commitment to primary care?
An institution with a strong commitment will have primary care opportunities woven throughout its curriculum. For example, find out if the school offers a continuity clinic where students can follow a group of patients over an extended period of time. Also, you may want to determine whether students are offered the opportunity to have a primary care-centered mentor or adviser.


Action items for medical students:

Medical students interested in primary care should check to see what opportunities their schools offer. And once you do this, ask yourself:


Do the opportunities reflect the interests of my class?

If not, get involved with curriculum committees and other administrative bodies to ensure that future students are exposed to primary care medicine. Discuss such ideas as establishing continuity clinics, expanding the number of ambulatory rotations, creating better mentor networks and giving all students an early exposure to primary care medicine.


It often takes several years for curriculum changes to be instituted—so, in the meantime, you should create a more comprehensive primary care experience for yourself. For example, you can arrange for primary care electives early in your training. Talk to fourth-years who plan to match in primary care residencies and ask them about the good sites for elective rotations.



GET INVOLVED WITH NATIONAL PRIMARY CARE WEEK.


The AMSA Foundation’s National Primary Care Week (NPCW) is a student-led, interdisciplinary effort to expose students to primary care. More than 120 schools participate in this program. This year’s NPCW will be held Oct. 20–26. The theme will be “Access: Bringing Health Care to Communities.” Get involved with NPCW and help plan events to raise awareness of primary care medicine at your school.
~TOP 10 ALLOPATHIC MEDICAL SCHOOLS WITH 2001 GRADUATES ENTERING ...































































































































































































FAMILY
MEDICINE RESIDENCIES
Medical
School		 %FM
1.  
Univ. of Illinois–Rockford 

35.7
2.  
Univ. of Minnesota–Duluth
  35.6 
3.  
Univ. of New Mexico
 27.9
4.  
Morehouse School of Medicine
 27.6
5.  
Univ. of South Dakota
 26.5
6.  
Loma Linda Univ.
 25.8
7.  
Univ. of South Carolina   
 25.4
8.  
Univ. of Arkansas
 25.2
9.  
East Tennessee State Univ.
  23.1
10.
East Carolina Univ. 
  22.5
INTERNAL 
MEDICINE 
RESIDENCIES
Medical
School		 %IM
1.  
Johns Hopkins Univ.   		38.9
2.  
Universidad Central del Caribe 		38.3
3.  
Mount Sinai School of Medicine 
    
32.7
4.  
Univ. of Rochester 		  32.1
5.  
New York Univ.    		   31.3
6.  
UMDNJ–Robert Wood Johnson  
 30.6 
+
7.  
Yale Univ.		   
30.4
8.  
Harvard Medical School 		29.9
9.  
MCP Hahnemann  		29.5
10.
Boston Univ. 		29.0
PEDIATRIC 
RESIDENCIES
Medical
School		 %Peds
1.  
Marshall Univ.    		  23.1
2.  
Albert Einstein College of Medicine 
    
21.7
3.  
Univ. of Illinois–Rockford  
  21.4
4.  
Texas Tech Univ.    		   20.2
5.  
Univ. of Nevada  		  20.0
6.  
Medical College of Georgia 		 19.9
7.  
Univ. of California, San Diego		 19.6
8.  
Univ. of Utah 		 18.1
9.  
Loyola Univ.–Stritch   		  17.6
9.  
SUNY–Buffalo		    
17.6
COMBINED
INTERNAL MEDICINE/PEDIATRIC RESIDENCIES
Medical
School		 %IM/Peds
1.  
Univ. of Illinois–Peoria
  13.5
2.  
Michigan State Univ.  
 10.8
3.  
Univ. of South Alabama
 10.0
4.  
Univ. of Kentucky 
 9.8
5.  
New York Medical College		  8.3
6.  
East Tennessee State Univ. 
  7.7
6.  
Marshall Univ. 
 7.7
8.  
West Virginia Univ. 
 7.4
9.  
Univ. of Kansas
 6.4
10.
Univ. of Missouri–Columbia 
   
6.1


Unranked
University of Washington and Eastern Virginia Medical School did not participate.


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


TOP 3 OSTEOPATHIC MEDICAL SCHOOLS WITH 2000 GRADUATES ENTERING ...















































































FAMILY
MEDICINE RESIDENCIES
Medical
School		 %FM

1.  
Des Moines Univ. Osteopathic Medical Center
  


57.8
2.  
West Virginia SOM		  40.0
3.  
Oklahoma State Univ. COM  		36.9
INTERNAL 
MEDICINE 
RESIDENCIES
Medical
School		 %IM

1.  
West Virginia SOM               

 30.0
2.  
Univ. of New England COM		  28.8
3.  
New York COM
 25.0
PEDIATRIC 
RESIDENCIES
Medical
School		 %Peds

1.  
Oklahoma State

8.3
1.  
West Virginia SOM		 8.3
3.  
New York COM		 8.2
COMBINED
INTERNAL MEDICINE/PEDIATRIC RESIDENCIES
Medical
School		 %IM/Peds

1.  
Univ of Health Sciences COM 

2.5
2.  
Univ. of North Texas Health Sciences Center
 1.9
3.  
Univ. of New England COM		 1.8



Unranked

Lake Erie COM did not participate.


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


*SPECIALIZATION AFTER RESIDENCY


It should be noted that not all residents in primary care programs end up practicing primary care medicine. Many subspecialize before entering the work force. In its “Fourteenth Report,” published in 1999, the Council on Graduate Medical Education (COGME) states that according to data collected by the Center for Health Workforce Studies: 95 percent of family medicine residents, 78 percent of combined internal medicine/ pediatric residents, and 78 percent of pediatric residents go into a primary care field. COGME estimates that 50 percent of internal medicine residents go into primary care.


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


KEY


FM - Family medicine

IM - Internal medicine

Peds - Pediatrics

IM/Peds - Combined internal medicine/pediatrics

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.


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


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


SOURCES AND RANKING


The allopathic medical schools provided figures for their 2001 graduating classes.


The osteopathic medical schools provided figures for their 2000 graduating classes. The schools were asked to provide the following information: the number of students entering the Traditional Rotating Internship (TRI) in 2000, the number of 2000 graduates who matched directly into primary care residencies and the 2001 Match results of 2000 TRI interns entering primary care residencies. Because osteopathic students are able to enter a TRI or a traditional (typically allopathic) residency, this scorecard uses 2000 and 2001 placement data of 2000 graduates to ensure that the residency match information includes both subsets of students. Therefore, all data pertain to the class of 2000.


Any comments or suggestions to improve AMSA’s Primary Care Scorecard should be directed to Shadia Garrison, at (703) 620-6600, ext. 214, or shadia_g@amsa.org.
~~~Simon Ahtaridis is a fourth-year medical student at Temple University. Laura Hoeksema, an AMSA intern, also contributed to this scorecard.~Career Development,Medical Education,Premedical Education~
179~3April~2002-51~Folk Tales~Balancing Act~RESEARCH, MENTORING, DANCE AND, OH YEAH, MED SCHOOL.~Jennifer Zeigler~~Fran Garrett can trace her M.D./Ph.D. candidacy all the way to her undergraduate studies at California State University, Fullerton. Having qualified for an international research internship, she left the country of her birth to return to the country where she grew up—Israel. It was there, working in the lab of a cancer center, that it hit her: The juxtaposition of research and medicine that affected the center’s patients every day was just where she wanted her career to land. “You get to see the effects [of research]. It’s cool,” she says of the symbiotic relationship between the cancer center’s researchers and physicians.


It will take 30-year-old Garrett, who is now six years into an M.D./Ph.D. program at Albert Einstein College of Medicine in New York City, about three more years to earn her doctorate in immunology and genetics. “That seems to be a paradigm where research and medicine overlap,” she says. Her laboratory study examines the DNA in B cells, which make antibodies to ward off disease. She’s trying to discover if there are multiple controls in DNA that regulate the expression of antibodies. The work has earned her a fellowship grant from the United Negro College Fund and The Merck Company Foundation. She says she doesn’t know where the research will take her in her post-doc career, but that doesn’t really matter much right now. “[The research] is important to me because I’m getting training in areas that are interesting to me,” she says.


Garrett has never been one to shy away from interesting experiences. Her life is full of them—each attempted and mastered with an undeniable will to succeed. For a woman who insists she doesn’t enjoy public attention, she certainly has garnered a lot of it over the years.


In childhood, she skillfully conquered uneven bars and balance beams and found herself at the top in gymnastics—the World Gymnastics Championships and World University Games. After high school, Garrett spent a year-and-a-half in the Israeli army—a service required of all young Israelis—where she gained an understanding of a hierarchy similar to what she would encounter later in medicine. (She has dual citizenship in Israel and in the United States.) And when a dismount from the balance beam snapped her knee, and her sporting career along with it, Garrett morphed herself once again, fulfilling a long-held desire to enter medical school. (Gymnasts are no strangers to physicians, and Garrett says she always looked up to hers.)


But she didn’t get to where she is today by accident. “I choose to do things that are interesting to me and I’m excited to learn about,” she says. “[But] obviously there’s always external forces.”


For Garrett, those external forces have often been mentors. Among meaningful mentor relationships she counts her mother, coaches and professors. Her mother, who moved the two of them to Israel when Garrett was 5, is “my greatest mentor in life. Of all the people in my life, I have learned the most from her.” And her mother’s advice counts for a lot. “She really experienced a lot of stuff before she had me,” Garrett says of the single parent who waited until her late 30s to have children.


In addition to support, Garrett’s parents gave her a dual-minority legacy: her mother is white and Jewish, and her late father was African American. What Garrett chose to do with her legacy demands drive and discipline similar to that required by her gymnastics training, a mind-numbing amount of schoolwork and extracurricular activities. She spent this past year as the chairwoman of the board of the Student National Medical Association (SNMA), a medical student organization dedicated to people of color and underserved communities, where she has worked to improve member services and increase funding levels for international projects. She got involved with the SNMA on a national level in 1998 as part of a premed mentoring program. “It occurred to me that my experiences might be helpful [to others],” she says. “[Mentoring] to me [is] about sharing life experiences. Sharing their life with me is a constant reminder that every person is different and every life is valuable. It’s about helping people accomplish bigger and better things.”


Garrett is known for her optimistic outlook. One of her mentees, Ali Lynch, a second-year M.D./M.P.H. student at New York Medical College, says the best advice Garrett has given her has been that “if you want to do something, you can. It’s difficult to call Fran, who’s juggling everything in the world, and say, ‘I can’t handle [medical school],’” Lynch says. “I mean, come on. You just can’t do that. But even if you did, she would be totally understanding.” Understanding perhaps because even Garrett has needed to sit out some activities every once in a while; she’s had to take a break from her amateur swing dance competition in recent months to dedicate more time to her studies and other activities.


One of Garrett’s other mentors, Dr. Betty Diamond, the director of Einstein’s M.D./Ph.D. program, says she thinks it’s partly Garrett’s unique background that drives her to take on all that she does. “She cares a lot about minority issues,” she says. “I think she cares a lot about physician education [because] in every situation she’s been in, she’s been a minority, minority student.”


“I would agree with that,” Garrett says. She is one of two women in her program at Einstein—another dropped out after the first year—and she’s among a handful of African Americans in the class. But she’s accustomed to breaking new ground. In gymnastics, she was the only person from her club to represent Israel on a national level, and the only Israeli competitor at the 1991 World University Games, where she earned seventh place in the balance beam competition.


“Sometimes people don’t know what to do with me—and that’s OK. It’s all what you do with it. It makes [life], in my opinion, more interesting.”


Garrett says all of her activities, particularly in this last year with the SNMA, have broadened her perspective on the world. She has spent her medical school career thinking she would work in academic medicine in some capacity; whether that would be in a laboratory or as a member of a clinical teaching faculty was still up for debate. “[But] as I do all these extracurricular activities, I realize the impact a person can have in an administrative position. It’s just made me think, ‘Well, maybe I can do more.’”


And, after all, what’s one more thing to balance in a life that was nurtured in the gymnasium on a tiny, four-inch-wide beam?
~~~~Jennifer Zeigler is a senior writer with The New Physician.~Creative Expressions~
180~3April~2002-51~Feature~Humans, Not Guinea Pigs~~Avery Hurt~~Deaths, violations, closures—what’s wrong with our clinical trials system? A lot, experts say. One suggested solution: Start treating human research subjects as “autonomous human beings,” not just
bodies for experiments.


In 1796 Dr. Edward Jenner began what may have been the first clinical trial in the history of medicine. In order to test his theory about a vaccination for smallpox, the physician infected an 8-year-old volunteer, a boy named James Phipps, with live cowpox virus. Seven weeks later, he infected the child with live smallpox virus. As Jenner suspected, the milder cowpox virus provided the boy with immunity to the much more serious smallpox virus. After this triumph, Jenner conducted more tests on volunteers. His experiments were astoundingly successful, eventually leading to a vaccination for smallpox that all but eliminated a disease that had previously ravaged Europe and Asia, killing and disfiguring millions of people.


Looking at Jenner’s research from a 21st-century perspective, most modern scientists would agree that his method’s results and the risks he took to get them are impressive. We will never know what agonies of conscience Jenner suffered as he considered the potential dangers and benefits of testing his theory. But we do know that the dilemma he faced is one that all clinical researchers face in one way or another. Even in today’s much more controlled medical environments, experiments on humans are not without risks. The potential good for the individuals who participate in clinical trials must be carefully balanced against the possible risks to a few volunteers. Dealing with these dilemmas is not made any easier by the current climate of biomedical research. An overworked oversight system, complex financial arrangements, and ever more complex and intractable diseases make the challenging job of a clinical researcher even more difficult.


WHEN THINGS GO WRONG


Ellen Roche was not sick when she enrolled in a study at Johns Hopkins Asthma and Allergy Center last year. A month after her enrollment, however, she was dead. The experiment in which she participated was designed to examine how healthy lungs keep airways open even when they are exposed to irritating substances. No new drugs or therapies were being tested in this trial. The drug Roche was given and that likely led to her death—hexamethonium bromide, a lung irritant—had been prescribed decades ago to treat hypertension and to reduce bleeding during surgery. Yet it was never approved by the Food and Drug Administration (FDA) to be inhaled, which was how Roche’s clinical trial was administering it, and it isn’t currently approved by the FDA for use in humans at all.


No one knows why Roche, a healthy, 24-year-old lab technician, volunteered for what was supposed to be a low-risk experiment. It may have been simple curiosity, an altruistic desire to advance science and help others, or perhaps she needed the $365 she would have received if she had completed the study. Roche was not, however, desperate for a cure for asthma (she did not have the disorder), and in any case, she understood that the medication she received was not a therapy and that she would gain no health benefits by participating in the trial.


After months of investigation, it is still not clear exactly what went wrong in the Hopkins asthma study. Federal investigators allege that researchers overlooked data detailing the dangers of hexamethonium and that the institutional review board (IRB) failed to follow proper procedures. It is apparent, however, that Roche’s death came as a complete surprise to everyone involved.


And as a result of her death, the Department of Health and Human Services’ (HHS) Office of Human Research Protections (OHRP) ordered Hopkins to stop enrolling new participants for federally supported clinical trials; previously federally funded trials could continue only if they were in the best interests of the individual research subjects. This suspension was later lifted.


The lab technician’s death is not the only incident in recent years to raise questions about safety procedures in clinical trials. Since 1998, concerns about the safety of human research subjects have halted hundreds of experiments. Perhaps the most disturbing case, as well as the most publicized, was in 1999—the death of Jesse Gelsinger, an 18-year-old volunteer in a gene therapy trial at the University of Pennsylvania.


Like Roche, Gelsinger was not sick when he entered the trial. He did, however, suffer from a rare genetic disorder, ornithine transcarbamylase (OTC) deficiency. The disease affects the body’s ability to break down ammonia and is almost always fatal; most children who are born with OTC deficiency die within their first year, and survival beyond the age of 5 is extremely rare. Gelsinger suffered from a milder form of the deficiency, and medication and a strict diet kept his condition under control. The trial was designed to help develop a therapy for babies with the disease. Ethicists had determined that parents of babies with OTC deficiency could not give truly informed consent for their children to participate in the study, since they may be unduly influenced by their children’s illness. Instead it was decided the experiment would be done on mothers who were carriers of the disease and adult males, like Gelsinger, who had a milder form of OTC deficiency.


The experiment entailed some risks, but Gelsinger was aware of this. He said that he was doing it for “the babies.” The teenager died of multiple organ failure after being injected with adenovirus vectors designed to replace the faulty genetic information with the proper instructions.


Gelsinger’s death, the first reported death in a gene therapy trial, was a tremendous blow not only, of course, to his family and friends, but also to gene therapy research. After his death, the University of Pennsylvania was forced to halt all genetic research involving human subjects—a major setback for the institution that leads the nation in genetic research.


A DYSFUNCTIONAL SYSTEM


The deaths of Roche and Gelsinger, as well as other recent clinical trials cases involving violations or errors, have provoked intense scrutiny of the U.S. clinical trials system and the procedures designed to ensure the safety of human research subjects—primarily those involving the OHRP and IRBs.


Dr. Greg Koski, the OHRP’s director since September 2000, calls the current clinical trials system “dysfunctional.” Other experts agree, saying the current system is in dire need of improvement, if not a total overhaul. Financial conflicts of interest, lack of full disclosure about the details of previous studies, and consent forms that are difficult to understand have all been cited as significant flaws.


For example, while Gelsinger knew that his participation in the study entailed some risk, he did not know the gene therapy he received had resulted in the deaths of some primates during the animal phase of the study. Nor did he know the study’s chief investigator owned stock in the company funding the research.


Concerns in relation to funding sources are common. In the past, government agencies sponsored the majority of medical research. Today, pharmaceutical companies and other private industries and foundations fund more than half of the research that is being conducted in the United States. Critics of the system say this can easily lead to conflicts of interest as well as restrictions on how information is shared among researchers within the academic community. The National Institutes of Health has expressed grave concern about the ability of private enterprise to protect academic freedom in scientific research, and to determine and enforce appropriate limits of financial interests.


Another major problem is the IRB system. IRBs are designed to scrutinize and approve every piece of proposed research that will involve human subjects. However, the recent explosion of biomedical research—an estimated 5,000 institutions conduct clinical trials —has resulted in IRBs that are so overworked that doing their jobs well is almost impossible.


“When Ellen Roche died, 2,500 studies were under review by the various review boards at Hopkins,” says Alan Milstein, an attorney who has filed numerous lawsuits on behalf of clinical trials volunteers, including representing Gelsinger’s father in his case against the University of Pennsylvania, which settled out of court. “At any given time, between 200,000 and 300,000 studies are being done that involve human subjects. With this much research going on, the oversight system simply can’t do what it is mandated to do,” he says.


Dr. John Zaia, chair of the IRB at City of Hope Cancer Center in Los Angeles, agrees. “IRBs are totally snowed under. The biggest problem is that IRBs don’t have the staffing to deal with the increased workload,” he says.


But even when the problems can be identified, correcting them is not easy. The biomedical research community is a huge conglomeration of academic medical centers, private research labs, government agencies and private foundations. Enforcement authority and regulations vary from institution to institution, and protocols and reporting guidelines often change depending on who is funding the research.


For example, in 1981, the HHS established a set of regulations that have since developed into what is now known as the Common Rule. These regulations are designed to oversee the protection of human research subjects and to detail the responsibilities of oversight committees such as IRBs. However, the rule applies only to federally funded research and any changes to its provisions must be approved by as many as 17 federal agencies.


“When the [oversight] system gets too cumbersome, it stops functioning as a protective mechanism for either the researcher or the patients,” says Dr. Carla Falkson, a cancer researcher at the University of Alabama at Birmingham’s (UAB) Comprehensive Cancer Center.


The OHRP’s Koski has repeatedly stressed the need for open and honest cooperation between institutions (researchers, universities and their IRBs) and the government oversight offices. Under his watch, he says, the OHRP has been willing to use its authority to enforce regulations, but it can’t reform the system on its own. Institutions need to improve research protections voluntarily, he says. Some institutions are doing this. After the deaths of Roche and Gelsinger, Hopkins and the University of Pennsylvania have increased the number of IRBs and changed the practices of the boards so they can more closely monitor the research.


And in April 2001, a consortium of organizations (including the Association of American Medical Colleges, the Association of American Universities, and Public Responsibility in Medicine and Research) created the Association for the Accreditation of Human Research Protection Programs (AAHRPP—pronounced “a-harp”). Experts say AAHRPP’s approach uses site visits, rigorous performance standards and precise outcome measures to guide institutions toward making research programs safer. The goal is to get to the point where all research institutions seek AAHRPP accreditation. The association began accepting applications for accreditation in February.


One of the program’s strengths, says AAHRPP’s executive director, Marjorie Speers, is that it gets everyone from administrators and researchers to advocacy groups and patients involved in the protection system. “Medical research is safe now,” Speers says, “but it is essential that we restore and maintain the public’s faith in research. Accreditation will help do that.”


COMMUNICATIONS GAP


Like many ethics experts, Rebecca Dresser believes there are serious flaws in the clinical trials system but points to another area of grave concern—communication. Much of the problem with the system stems from volunteers’ unrealistic expectations of the biomedical process, says the professor of biomedical ethics at Washington University School of Law and author of When Science Offers Salvation: Patient Advocacy and Research Ethics.


“Researchers haven’t done a very good job of informed consent,” Dresser says. “People already have an impression when they walk into the researcher’s office—usually a positive impression—about the research. This may lead patients to not pay as much attention as they should to what the researcher is telling them about the trial.”


Volunteers aren’t the only ones at fault, though. “Researchers sometimes have an understandable reluctance to be brutally honest with people who are dying, who may be desperate for a cure,” she says. “This lack of brutal honesty may mean that some people who are used in trials don’t fully understand the chance of benefit.”


Ethicists call this “therapeutic misconception,” and researchers, when they acknowledge it at all, soon realize that it is the thorniest of issues they face when trying to justify the use of human subjects in medical experiments.


The fact is that most trials—especially phase one and phase two trials—offer participants very little chance of therapeutic benefit. Yet, few participants in clinical trials are doing it “for the babies”; most desperately seek a cure. Falkson describes the patients who volunteer for her studies as “people who’ve tried everything but don’t want to give up hope. They know there is only a 1 [percent] to 2 percent chance of a response [to the experimental therapy], but they are willing to take that chance.”


When asked if she is confident that her patients understand the possible risks and benefits of the experiment, Falkson nods sincerely. But she adds that “sometimes people don’t want to know. We mustn’t overestimate the ability of patients to comprehend the situation. Sometimes they are too emotionally involved with this to be rational. We have to handle them very gently.”


The therapeutic misconception arises when patients, and often the physicians who recommend them for trials, confuse “medicine” and “science.” In medicine, the goal is to alleviate suffering, perhaps to heal. In science, the goal is to advance knowledge with the prospect of eventually giving medicine better tools with which to pursue its goals. The role of patients in the clinical trials process is to volunteer their bodies to help researchers test theories so the scientific community can increase its knowledge. The role of researchers is, in part, to ensure the volunteers understand this. This is not an easy task, and this is why therapeutic misconception can be such a problem.


As Falkson pointed out, many volunteers are willing to try anything—to take any number of unknown risks for a minimal chance that this new therapy will cure their diseases or at least buy them more time. But here’s the dilemma: If human research subjects were not so desperate, and if they truly understood the odds, would they still volunteer? Probably not, Milstein says.


“If patients truly understood the benefits and risks, fewer people would volunteer for experiments. People volunteer because they think it is in their therapeutic best interest. No matter what the researcher says, the patient will believe that the ‘doctor’ has the patient’s best interest at heart. You don’t find a lot of altruists in cancer wards and children’s hospitals,” Milstein says.


Dresser agrees there’s a great disconnection between the research community and the average patient. “Our expectations for biomedical research are probably too great,” she says. “Research definitely provides benefits, but if you spend time around medical schools, you soon realize that medical research is a slow and incremental process. There are many dead ends.”


But despite the risky nature of the beast, if cures are to be found and advances are to be made, experiments have to be done, and human subjects are, at least at some point in the process, essential. Dr. David Curiel, director of UAB’s Gene Therapy Center, is adamant on this point. One of the reasons he came to UAB to conduct his cutting-edge genetic research is because the university has an effective “bench-to-bedside” program.


“A strong linkage between the basic scientists and the clinic scientists is ideal [for research],” he says. “We design something in the lab, and then we are able to put it into a trial right here. We get answers in the clinic that tell us what we need to do to fix the problems in the lab.” And that’s the crux of the issue, he says. Human subjects are needed to fix, adjust and refine the science long before the science is ready to cure anyone.


So, back to that old ethical dilemma: Saving untold millions of people from the horrors of smallpox required risking the lives of healthy volunteers. Did Jenner’s volunteers understand the nature of the risk? Perhaps. Was it worth it? It certainly seems so now. But these questions come up again and again, every day, in academic medical centers. And they aren’t any easier to answer now than they were 200 years ago. But one thing, critics say, is certain: A responsible approach to medicine, whether in treating patients or recruiting them for studies, requires being as honest as possible with patients, even when they don’t want to know or don’t want to understand.


“If honesty with subjects means that the pace of research is slowed, then that is the price we pay for truth,” Milstein says. “There are more important values than research, such as treating people as autonomous human beings and not as means to an end, putting their immediate safety and needs ahead of other, less tangible, concerns.”


This is not a new idea. It is, in fact, one of the concepts on which the practice of medicine was founded: primum non nocere. First do no harm.
~FOR MORE INFORMATION VISIT:


~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~Ethics,Medical Research~
181~3April~2002-51~Feature~What Can You Recommend?~LETTERS CRUCIAL TO SECONDARY APPLICATIONS.~~~Now that you’ve turned in your applications to the American Medical College Application Service (AMCAS), you’re probably thinking you can just sit back and wait for the schools to make their decisions. Right?…Wrong. More work lies ahead.


If you survive AMCAS’ first cut, you’ll have to submit a secondary application to provide your medical school with more information. You will not receive an acceptance letter without completing one. Some institutions send out a secondary application that is essentially nothing more than a postcard verifying you’ve never been convicted of a felony, while others will require additional essays and descriptive information from you. Regardless of its format, the secondary application is a mandatory step for acceptance into medical school.


In some cases, schools consider the secondary application to be more important than the “primary” application. At these institutions, the first cut usually focuses on such academic qualifications as grade-point averages and Medical College Admission Test scores. The second time around, schools are interested in a personal history exemplifying your character and commitment to medicine. As part of obtaining this information, school admissions committees will frequently ask for your recommendation letters to be submitted with the secondary application.


In this phase of the process, you’re competing with the cream of the applicant crop, and the secondary application cannot be taken lightly. You should complete it diligently and adhere to all the basic rules as you would for a primary application, such as using proper grammar and submitting the forms as early as possible.


PUTTING IN THE GOOD WORD


Recommendation letters are an essential part of your application, so you must be prepared if medical schools ask you to submit them with your secondaries. To do this, you need to start collecting the letters long before the application process begins.


The best method for acquiring recommendations is to request them from your professors immediately after you’ve earned an “A” in a particular course or immediately after you’ve completed a notable project, such as a summer job or an extracurricular activity. This will ensure the letter writer will still have a fresh and positive impression of you in his mind.


You also need to familiarize yourself with how your premed institution handles recommendation letters. Each college or university has its own system for collecting and distributing these valuable testimonials.


If your school has a central premed advising office, have the letters sent there as soon as possible—yes, even in your freshman year—and have the office staff begin a file for you.


If there is no central office, ask your writer to have a letter ready and give him a time frame for when he might expect to send it to your schools. Since recommendation letters are left to the whim of the writer, you may have to be persistent about deadlines. When it’s time to mail the letter, provide the writer with prestamped, preaddressed envelopes; you can never make the process too convenient for him.


RIGHT VS. WRONG LETTERS


What do medical schools look for in recommendation letters? Think about the purpose of the letter: to validate your background and qualifications. You need letters that support your academic accomplishments and outside projects. If you really want to demonstrate your accomplishments, a recommendation should come from someone who has supervised or guided one of your projects and who will be able to explain to the admissions committee how you completed your project.


The “right” letter fleshes out your application by emphasizing your commitment and ability to manage academic and nonacademic projects. The “wrong” letter lacks details and simply repeats boring clichés about an applicant’s “hard work” or “ability to get along with others.” This may be true, but a recommendation should go beyond the obvious.


Here are some helpful hints on getting the “right” recommendation letters:




While many of these administrative activities may seem burdensome, they could make the difference between a medical school accepting or rejecting you. Secondary applications and recommendation letters are an integral part of your medical school application and should be taken as seriously as your initial AMCAS application. Hopefully these hints will make the process a little less painful.
~~~~New Physician contributing editor Paul Jung is author of Getting In: How NOT to Apply to Medical School (1999, Sage Publications). E-mail Dr. Jung with your questions and stories at GettingIn@hotmail.com.~Medical Education,Premedical Education~
182~3April~2002-51~Perspectives~Avoiding Research Project Perils~STRATEGIES FOR SUCCESS.~Robert H. Glew, Ph.D., and Diane R. Fernandez~~Most U.S. medical schools strongly encourage medical students to engage in research, and many of them require every student to complete a scholarly project as a condition for graduation. The degree of success and satisfaction you derive from the pursuit and completion of your research depends largely on two factors: the qualities of the mentor and the soundness of the research project. In most cases, your choice of a research mentor is carefully considered and one that ultimately turns out to be mutually satisfactory. Furthermore, for most medical students, the course of the collaborative study proceeds smoothly, culminating in a respectable final report or, with some luck, a publication in a peer-reviewed journal. Unfortunately, however, this is not always the case.


Each year at the University of New Mexico School of Medicine (UNM), for example, as many as one-fourth to one-third of its students run into problems with their research projects—difficulties so great as to compel a student to drop the project, find a different mentor, devise a fresh study and write a new proposal that must be approved by UNM’s medical student research committee. Not only is this disheartening, but it also leaves you with a deep and irrevocable distaste for research. How can you increase your chances for a successful project and reduce the risks of failure? Choose the right research mentor.


SELECTING A MENTOR


If your mentor is chosen wisely, a sound, significant, feasible and gratifying project will likely follow. And assuming you have an affinity for the research area in which she works, the most important factor for you to consider and assess is the productivity of the potential mentor.


This is a relatively easy task, and there are several routes to obtain such information. First, you can access faculty Web pages to quickly identify the potential mentor’s research focus and a listing of any published work. Second, thanks to the availability of such online search engines as Elsevier Science’s Scirus and the National Library of Medicine’s PubMed, you can obtain titles and abstracts of papers published by virtually every faculty member in a matter of minutes. Concrete information of this kind can inform you of a potential mentor’s scholarly interests, and it can serve as an objective means of assessing the mentor’s expertise and current level of productivity. The gap between a faculty member’s perceived and actual scholarly output can sometimes be considerable. If the faculty member being considered has not published a significant, full-length paper in the last three or four years, you should seriously consider looking elsewhere for a more suitable mentor.


You should also learn the number of medical students this potential mentor has supervised in the last few years. How many of them completed their project successfully and in a timely fashion? Have any failed to finish their project? If so, how many and why? The head of the medical student research committee should be able to provide you with this data. If a particular faculty member has never mentored a medical student in research or if one or more students failed to complete their projects under that faculty member’s direction in recent years, then you should weigh the risks associated with having that person be your mentor.


So what about a new faculty member who only recently joined the school, who is just beginning her career and hasn’t had the opportunity to mentor medical students or accrue a lengthy bibliography? While it is certainly unreasonable to expect a faculty member fresh out of training to have produced an extensive personal bibliography, there still ought to be some evidence of her involvement in and commitment to research during her graduate, residency or fellowship training. You should be able to assess her ability to complete a project and publish its findings. Again, do a little research. Don’t become the test case that determines whether or not a new faculty member is an appropriate research mentor.


And there’s a flip side to this: Be careful not to place undue emphasis on how highly esteemed that faculty member is as a researcher or how many National Institutes of Health grants she currently holds. In many instances, there is an inverse relationship between the dollar value of the grants a faculty member holds and the degree of access you will have with that individual. You’ll want your mentor to be available to you.


Consider the case of a department chairman who may have an extensive publication record but who is so preoccupied with administrative duties that he has little or no time to meet regularly and thoughtfully with you. In such a situation, the overextended mentor is likely to hand you over to a resident physician, postdoctoral fellow, graduate student or laboratory technician.


To prevent this from happening to you, ask other students who have worked on a research project with the mentor as to how often you would likely get frequent, periodic and quality “face time.”


DETERMINING THE PROJECT


Assessing the qualifications of a mentor is only half the task; the other critical factor in this equation is the nature of the project itself. In order to be successful with your research project, you’ll need to evaluate your interest in the topic as well as the study’s feasibility.


As a busy medical student, you have only so much time to devote to a project. Therefore, feasibility is extremely important. Before committing to a mentor or project, consider the availability of research subjects required for the study or, in the case of a more laboratory-based study, the probability that a sufficient number of specimens (e.g., serum, tissue) will be on hand to support the proposed project. For example, if a potential mentor outlines a project that will require blood samples from 100 individuals with sickle cell disease and there are only 13 such people scattered across the state, you should begin to question the wisdom of undertaking such a study.


Alternatively, a different faculty member may want you to work on a project that will require analysis of various enzyme markers of renal injury in the urine of uranium miners. A power analysis is performed, and it shows the study will require 600 human volunteers. When you inquire as to whether or not the urine samples have been collected and are stored in a freezer somewhere awaiting analysis, the prospective mentor says there’s no need to worry: “By the time you are ready to begin your analyses, we will have collected the 600 urine specimens.” Mentors often underestimate the problem of recruiting or securing, in a timely fashion, the number of subjects or specimens required for a project. You should be wary of signing onto a project for which there are serious questions and doubts about the availability of human subjects, biological specimens, or access to the necessary databases.


Assuming the study involves human subjects, another potential impediment is the task of getting the project approved by your school’s institutional review board (IRB) or human research review committee. This problem is compounded many-fold if the study population involves indigenous people (e.g., Apache, Inuit, Navajo) living on reservations. In the case of research involving Native Americans, the project cannot be initiated until it has been approved by both the university’s IRB and the corresponding human subjects review committee representing the interests of the Native American group; the latter process usually takes more than one year. If you’re anxious to get started on the project during your first year of medical school, you should think twice about committing to a study involving a Native American population that has yet to receive approval from the human subjects review board. Similar problems pertain to the study of public school children.


Another factor to consider is the availability of the analytical methods, reagents and equipment that will be needed to gather the quantitative information the project requires. You should determine before you begin a project whether the analytical methods and reagents are on hand to execute the study and, better yet, are currently being used in the mentor’s laboratory. It can be disheartening to collect blood serum or tissue and then discover that the analytical methods required to determine the content of some critical analyte in these specimens are not available in the mentor’s laboratory or elsewhere in the institution. Similar advice extends to the issue of questionnaires. If a research project is to be interview-based, you should check to see that a validated questionnaire is available. You need to ensure that the analytical capabilities and experience of the potential mentor meet the demands of the project.


Finally, once you have narrowed the list of potential mentors to those who meet the above criteria, the last question to be addressed is: Which project interests you the most? If you’re unsure, ask yourself: Which one seems more likely to yield a result that will be of significance to biomedical science in general or human beings in particular? Oftentimes, if you can find relevance in your project, your interest in the study will be enhanced. And what about a collaboration? Will any other students or peers be working on the same project? The opportunity for you to collaborate with a fellow student may provide you with the necessary support and drive to allow both of you to successfully complete the project.


When both mentor and project have been selected thoughtfully and deliberately, the likelihood is high that the research experience will be both enjoyable and rewarding. The opportunity to perform research can provide you with numerous learning possibilities. In addition to the expected accomplishments (learning how to propose a hypothesis, perform a literature search, collect and analyze data, write a proposal and final paper, as well as critically evaluate the research of others), you will also have the opportunity to develop a working relationship with a faculty member, to publish your work and to contribute to the ever-expanding corpus of biomedical knowledge. There is little that can compare with the satisfaction of seeing your name among the authors of a paper in a highly respected, peer-reviewed journal.


For any student interested in research, especially those without prior research experience, selecting a project and mentor can be confusing and overwhelming. As a student and a mentor ourselves, we understand that in any endeavor the first attempt is the most difficult. It is our hope that the strategies discussed here will help you navigate your research options. More importantly, we hope that—through self-determination and informed decision-making—you will create a research project that is enjoyable, successful and gratifying.
~~~~Robert H. Glew, Ph.D., is a professor of biochemistry and molecular biology at the University of New Mexico School of Medicine (UNM). Diane R. Fernandez is a third-year medical student at UNM. Both authors are members of UNM’s medical student research committee.~Medical Education,Medical Research~
183~3April~2002-51~Feature~Using Your Heart~~Avery Hurt~~Finding the right emotional balance between you and your patients is not only essential to practicing good medicine but
also important to your health.


It is the great paradox of practicing medicine: In order to be a good physician, you must be empathetic and caring, but in order to preserve your sanity, you must maintain an appropriate emotional distance from patients. You can’t get too involved, and you can’t be too detached. Finding and maintaining this delicate balance may well be one of the most important skills in the successful practice of medicine, equally as valuable as knowing how to take a medical history or recognizing the signs of sepsis. Yet it is something that is rarely, if ever, mentioned in medical school. In fact, the culture of medicine seems at pains to tell young physicians not to talk about their feelings.


“In training doctors, we tend to train the head and train the hands but leave out the heart,” says Dr. Sandra Frazier, an assistant professor of psychiatry at the University of Alabama at Birmingham (UAB).


Dr. Brad Stuart, the medical director of the hospice program at Sutter Health in California, agrees. “In medical training, you get a lot of points for being strong and putting your own needs aside. Keeping a certain emotional distance is rewarded.” This may be understandable in a profession in which dealing with pain and suffering is common, almost routine, but many physicians say this is not necessarily the best strategy. Distant, overly detached physicians rarely give their patients what they need or want. And repressing emotions is certainly not good for the physician.


CRYING THE IN THE STAIRWELL


As the director of UAB’s “Health for the Healer” program and a practicing psychiatrist, Frazier spends much of her time helping physicians cope with their emotional difficulties. Most of the physicians who attend the healer workshops either have problems interacting with staff or with patients. If the difficulty involves dealing with the loss of a patient, Frazier says she can relate to the physician’s feelings. When she was a young resident, she suffered the loss of a baby under her care. Overwhelmed with emotion, she retreated to the privacy of a stairwell and sobbed. The emotional release helped, but she says it would have been better if physicians had a less furtive means of dealing with emotions.


Crying, in the stairwell or elsewhere, is common, though rarely admitted, among physicians-in-training. For the past several years, Dr. Nancy Angoff, the assistant dean of student affairs at Yale University School of Medicine, has been asking medical students if they ever cried during clinical rotations. And of the 182 students she informally surveyed, 133 admitted to having cried at least once during their clinical training. Occasionally the tears were a response to stress or frustration, but far more often they arose from a deep empathy with and compassion for patients. In the Journal of the American Medical Association article that details her research, Angoff says students often worry that, in the course of their training and in practicing medicine, they will lose the capacity to feel compassion for patients. And she says other students fear that displays of emotion indicate they’re “not tough enough” to practice in this field. Many physicians say mentors can show students how to find that emotional balance. The only difficulty, they say, is finding a mentor who is good at it.


Dr. Michael Rabow, an assistant clinical professor of medicine at the University of California, San Francisco, says he has developed a specific way of coping with the death of a patient. “I spend time at the bedside of patients who have died in order to say goodbye. I also share my feelings about them with their families as well as with other clinicians. And I have a small, personal ritual that I perform after a patient has died: I fold an origami crane to serve as a visible reminder of the person I have cared for.”


Some physicians, however, don’t appear to have any emotions at all. In practice, this leads to what Stuart calls “the hand on the doorknob” syndrome—a physician listening to a patient while preparing to escape at the first opportunity. The physician may act as if he’s with the patient, but emotionally, he’s somewhere else. Obviously this is not good for the patient, but what may not be so clear is that physicians who do this are damaging themselves as well.


“In medical training,” Frazier says, “physicians learn not to show weakness; they learn how to distance themselves. Eventually that’s the only way they know how to respond.” This spills over into the physician’s private life and can create all sorts of problems, from difficulties maintaining relationships to depression and substance abuse.


Physicians can’t blame all their emotional problems on their training, though. “The training certainly may exacerbate problems, but it doesn’t create them,” she says. “Like the rest of society, physicians have a lot of baggage; many physicians come from dysfunctional families and carry deep wounds. The culture of medicine, however, makes it easy for doctors to stay busy and avoid addressing these issues. By their very nature, doctors tend to be the type of people who intellectualize their problems.” This makes it easy for physicians to neglect their emotional needs. When they do, “they often project their own needs onto their patients,” she says. “This can result in either getting too involved or staying too remote from patients.”


It is only natural that a patient’s suffering could evoke a similar response in the physician. Stuart calls this “resonance.” He says it can be useful but often causes problems, especially when it “evokes the doctor’s own unacknowledged suffering.” The best way to handle resonance is to pay very close attention to your emotions. Both Stuart and Frazier say that when a physician really dislikes a patient or finds himself particularly uncomfortable with one, it’s a sign he needs to examine any personal issues he may have that are being touched by the patient. “The practice of medicine is a path to self-awareness,” Stuart says.


Some physicians have been fortunate in their training. Dr. Amy Pedone, a family practice intern at York Hospital in York, Pennsylvania, says her early medical school years helped ease the transition from the classroom to the bedside. “I actually started seeing patients during my first year of medical school at the University of Virginia,” she says. “We had a course called DPI [the doctor, the patient, the illness]. In this class, we took turns gathering histories from patients and then would have small group discussions about how those encounters went and what our feelings were. Because of this experience, I found it relatively easy to make the transition to seeing patients on a more frequent basis as a third-year medical student.”


TIPS FOR FINDING BALANCE


Though it is not easy, some physicians manage, almost instinctively, to find balance between too much and too little emotional involvement. “Most truly compassionate physicians,” Stuart says, “get close to their patients within moments.” He says for these physicians, this can be done quickly because it is “not a matter of time but of presence. Excellent physicians are extremely ‘there’ with their patients, yet they still maintain their own center.”


If this sounds a little like Zen, that may be because there is a spiritual aspect to it. “It is spiritual,” he says, “in the sense that [once you learn how to do this], self-knowledge and wisdom come out of it.”


Like most disciplines—whether they’re spiritual or mental—with sufficient effort this one can be learned. Frazier offers some practical tips for maintaining balance. First, she urges all physicians to have a primary care physician. “Don’t try to self-diagnose or self-prescribe,” she cautions. “You can get into a lot of trouble trying to be your own doctor.”


Second, she recommends physicians consider seeking counsel during challenging times. “This can be an enormous help in such a stressful profession. Don’t get caught in the trap of trying to deal with everything yourself.”


Lastly, she suggests physicians take plenty of time off. “The medical profession rewards workaholics, but this is not good. You have to get away to get clarity on issues. Learn to nurture yourself with simple things.”


In a profession where the demands are so great, avoiding burnout takes a conscious effort. “Choose at least one thing to do that is as important to you as everything else in your life—something you refuse to compromise on,” Rabow says. “Whatever you choose—whether [it’s] meditation, psychotherapy, exercise, learning to dance, or making regular calls to family—make it a part of your ‘practice’ in the same way you ‘practice’ medicine. And, of course, have compassion for yourself.”


And if you can find a supportive working environment, that can help as well, Pedone says. “I recall a particularly challenging day when I was post-call on a new rotation and feeling very overwhelmed,” she says. “My colleagues picked up on my frustration pretty quickly and offered to help. I’m very fortunate to be in an extremely supportive environment. I feel as though I could go to any of my fellow residents and attendings with any issues that might arise.”


All physicians—new and experienced—face challenges when trying to manage this emotional balancing act. But new physicians have a unique opportunity: You can work toward getting it right at the outset of your career; you can develop a good emotional practice from the beginning.


“In medical training, we’re taught to disregard our feelings because they get in the way,” Stuart says. “Especially troublesome, we are told, are strong feelings like sadness and joy. But once you are in practice, you learn that knowing your own feelings is critical. Suffering patients—folks who just got a cancer diagnosis, people who are about to lose someone they love—all these people are either dealing with grief or hiding it. Being sensitive to your own grief lets you feel it in others, so you can help them become aware of it and work through it. But being able to help others through this process means being familiar with it in yourself.”


Medical students who worry about showing emotion shouldn’t fret. “What you now perceive to be your greatest vulnerabilities may turn out to be your greatest strengths.” Don’t worry about how you’ll know when you’ve got it right, he says. “Your patients will let you know.”
~~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~Humanistic Medicine~
184~4May-June~2002-51~PremedRx~Getting Past Rejection~THE NEXT STEP IN THE PROCESS~Paul Jung ~~When the results come in on medical school applications, what should you do if you don’t make the cut? Should you apply again? Well, that depends. There are considerable costs and time involved with applying to medical school, especially if you decide to take more undergraduate courses or enroll in a Medical College Admission Test (MCAT) review class to retake the exam.


Here are a few considerations that may help you make this difficult decision:




But what else is there? Let’s say you’ve tried several times to get into medical school—you’ve taken more courses, sat through the MCAT as many times as you could stand, but still didn’t get accepted—and now you’re fed up with the entire process. You must ask yourself, did you apply to medical school because you wanted to be called “doctor,” or did you apply because you really wanted to help people? If it’s the former, there’s not much you can do now. If it’s the latter, there’s a world of opportunity in the “helping people” business. Here are some options for those of you unable to obtain admission to a U.S. medical school:




So, many offshore medical students spend their basic science years on a tropical island and their clinical years at hospitals throughout the United States and Europe; many perform their clinical training alongside U.S. medical students and residents. And afterward, some graduates successfully obtain a residency in an accredited U.S. hospital.


One way to think about the prospects of an offshore education is this: If you go to an offshore school and do well in the first two years, you may have a small chance of transferring to a U.S. medical school. If you can’t transfer but continue to perform well during your clinical years at an accredited U.S. hospital, you have a chance to obtain a U.S. residency. But despite that, there are still significant obstacles for offshore graduates to obtain clinical clerkships and residencies in the United States. Nothing is guaranteed at these schools.


For example, even if you complete all your clinical rotations at U.S. hospitals, you’re still not home free—whether you’re a U.S. citizen or not, before you can apply to a U.S. residency, you must receive certification from the Educational Commission for Foreign Medical Graduates (ECFMG). This certification requires passing an English test (even if it’s your native tongue), as well as an extensive clinical skills exam. This test is offered only in Philadelphia and costs $1,200, but testing sites are expected to expand by 2004.


Graduates of U.S. residencies who have passed all three parts of the medical boards are eligible for state medical licenses, regardless of what medical school they attended, even if it was an offshore institution. Granted, if you’re an international medical graduate, your chances of becoming a dean at a prestigious teaching hospital are very, very slim. But if you simply want to practice medicine, an offshore medical education may be your ticket to a long, white coat.


As with any medical school application, be sure to research the institution before you apply. This is especially true for offshore schools. Remember, they’re very expensive, not including the costs of living in a tropical country or abroad. And think twice. You should never enroll in an offshore school without consulting at least one U.S. citizen who is a student at or a graduate of that school and without seriously investigating all the regulations and requirements of graduates of non-U.S. medical schools who wish to practice in the United States.


As a rule, I never have nor will recommend an offshore medical school as the first choice for any U.S. citizen, simply because the barriers to returning to the United States to practice are often too high. Because of the many hurdles their graduates face, offshore schools should be viewed as a second option only after unsuccessful applications to U.S. allopathic and osteopathic medical schools. This is not meant as an indictment against the quality of education at these schools or the quality of the physicians who graduate from them, but rather a practical consideration given the current political and administrative climate surrounding medical licensure and practice in the United States.


For more information on the certification process for graduates of offshore schools, visit the ECFMG Web site at www.ecfmg.org.


So whether your destiny lies with another round with the American Medical College Application Service, a pair of nursing shoes, or medical textbooks on a tropical island, I applaud your determined efforts to help those around you live healthier lives. Good luck!
~~~~New Physician contributing editor Paul Jung is author of Getting In: How NOT to Apply to Medical School (1999, Sage Publications). This is the last in his series of articles on applying to medical school.~Medical Education,Premedical Education~
185~4May-June~2002-51~Feature~Overcoming the Blues~~Monica Zangwill, M.D., M.P.H.~~If you’re feeling down and not sure if medicine is for you, don’t fret. These lurking doubts are common, and, yes, they can be overcome.


“I was trying as hard as I could,” says Thom Bollinger of his first year at the University of Miami School of Medicine. Buried in neurophysiology and neuroanatomy, only getting average and below-average grades, Bollinger was frustrated. Then, one day, he began to wonder…. “I was sitting outside one afternoon just looking at the trees,” recalls the now second-year medical student. “I just started thinking, ‘What the hell am I doing here? What have I done?’”


When he started medical school he assumed, as many medical students do, that he would be in the top of his class as he was in his undergraduate days. He also expected to have some free time—to be able to exercise and to be able to spend time with his wife and newborn son—but it wasn’t happening that way. And that afternoon, while he relaxed under the shelter of the tree, it all hit him: Perhaps he made a mistake in deciding to attend medical school. Maybe getting a medical degree wasn’t worth all the sacrifices, hard work and frustration. Perhaps becoming a physician wasn’t for him.


Bollinger’s reaction to his first year in medical school is not unique, says Dr. Rachel Goldstone, the director of the Medical Student Well-Being Program at the University of California, San Francisco, School of Medicine (UCSF). “It’s extremely common for people to have doubts all along the way,” she says. Through group or individual sessions, medical students in UCSF’s Well-Being Program can explore their reactions to the process of becoming a physician, and this helps, Goldstone says. She says it’s normal to question your decision to go to medical school at some point during your training. Some of you may do it transiently as a response to a bad grade or a negative comment from an attending, while others of you may slog through months of lurking second thoughts. But having reservations about medical school doesn’t imply that you won’t end up practicing medicine. “It doesn’t differentiate the people who finish from the people who don’t, because everybody has doubts. Medicine is a huge commitment,” she says.


THE PEAKS OF UNCERTAINTY


According to Dr. Phyllis Carr, an associate dean for student affairs at Boston University School of Medicine, there are two distinct peaks in medical school yielding the highest level of doubts in students. She says the first peak occurs in the preclinical training years—the first two years of medical school—during which time you may start to think the material you’re studying is irrelevant to what you want to do. “It’s not always easy to see the connection between biochemistry and taking care of a patient,” Carr says. The road to becoming a physician is long and winding, and it’s easy to become shortsighted when you’re studying so hard, paying large tuition bills and yet still can’t see the endpoint. Add to this a few poor grades or failed tests and some of you end up under the trees like Bollinger, wondering if it’s all worth it.


Pediatric ophthalmologist Charlise Gundersen remembers having second thoughts during her early medical school days. She says toward the end of her first year at Texas A&M University College of Medicine she started to think, “Was this really what I wanted to do or did I just sort of follow the system and here I am?” But she endured, graduated in 1991 and now fully enjoys her professional life.


If you get bogged down by the preclinical curriculum, Carr recommends taking an elective or shadowing a physician in a specialty you’re considering. She encourages you to balance the rigors of learning the basic sciences with a clinical experience in an area of your choice. Joining student organizations, especially specialty organizations in your field of medicine, can also be helpful, she says, allowing you to connect with other people who have similar interests. Goldstone emphasizes this point as well, saying it’s important for you to try to keep in touch with the reasons why you came to medical school.


And just when you think you’ve overcome that first uphill battle of doubt, here comes another. Yes, the second peak typically occurs during the clinical training years, Carr says. During your third and fourth years, you’re busy taking care of patients, which is typically what you ultimately want to do, but the hours are long, strenuous and demanding. “Sometimes, usually after several rotations in a row, people begin to feel incredibly fatigued and begin to wonder whether this is really what they want to be doing,” she says.


Compounding this fatigue can be issues of unrealized expectations. For example, some of you may discover you don’t like clinical medicine or working with sick people. These situations can be particularly disturbing when you’ve already spent two or three years of your life and tens of thousands of dollars toward becoming a physician.


Child psychiatrist Andrew Hudson,* who graduated from medical school almost a decade ago, remembers hitting the wards and hitting an emotional wall at the same time. He had always intended to become a pediatrician but when he started taking care of patients day in and day out, he wasn’t so sure. “It wasn’t what I thought it was going to be, and I started to question whether I could be happy doing it,” he says. Hudson became so discouraged that he took a leave from school to sort things out. He taught science to children for two years, then felt re-energized and ready to tackle medicine again. So he returned to medical school and found his niche in child psychiatry.


If you’re like Hudson and have serious doubts, Carr suggests that you give yourself enough time to reflect on your feelings about medicine, even if that means doing what Hudson did—taking a leave of absence. This will help you avoid making a hasty decision about your future. But if you’re a student who feels miserable all the time and extremely hopeless about your prospects in medicine, you should be screened for depression. Depression and anxiety in medical students is common, Goldstone says, and it’s important to get appropriate treatment that may include therapy and antidepressant medication.


But many of you won’t need to take time off from medical school; all you may need to do is seek out mentors who are in practice. “Not a resident, not an intern,” Carr says, “but someone who has a lifestyle of doing medicine and also another aspect of their life.” Spending time with a practicing physician will allow you to see the difference between working on the wards and working in the real world, and it should quell many of your concerns, she says.



While doubts may be common during a student’s medical school tenure, you shouldn’t be surprised to hear that every individual’s experience is different. This is mainly because each of you brings your own unique personal and family history to your medical school interactions. For example, a lecture on a serious illness may trigger painful memories if you have a family member with the same illness. And this may cause you to doubt whether you’ll be able to handle the responsibilities of being a physician. Others of you, however, may not have this problem. Goldstone says it’s important to understand your doubts in the context of your life.


But while your uncertainties about medicine may be disconcerting, they can also be productive, she says. “Doubts help people to have an informed decision. If students go ahead blindly, then they are more likely to be hit down the road with big questions. But if they question it all along, then they may have a better idea of what they are getting into and be more realistic in their expectations,” she says. The more prepared you are, she says, the better you’ll be at dealing with the real challenges of medicine in what will likely be a lifelong career.


FINDING SUPPORT AND RESOURCES


A medical school’s office of students or student affairs can be a place for you to raise your concerns in a confidential atmosphere. Bollinger met with his dean of student affairs to review his courses during his first year, and the experience was very positive. “The dean was fantastic. He just made me feel like: ‘We’re just concerned about you. We care about you, and we want to make sure everything is fine and that you’re coping fine with everything,’” he says. Feeling reassured by his dean, Bollinger found a compatible study group and finished out his first year with strong marks.


Carr says medical school administrators want to see their students graduate, so they make great resources. “We really do want to see [students] succeed,” she says. “And there’s a lot more these days in terms of accommodations for students who are having a hard time.” Many schools offer academic tutors, stress seminars and peer advisers.


Most medical students who talk to their dean of students or student affairs find the experience helpful, but some of you may be afraid to talk to your dean or a faculty member who may have influence over future grades or letters of recommendation. UCSF’s Well-Being Program was established independently from the dean’s office so it could be a secure refuge for students who suffer from a wide range of difficulties. Although medical schools with a well-being center are still in the minority, most institutions provide access to free counselors and therapists who can offer comparable confidential environments. So if you think you’re in need of these types of services, you should inquire about similar offerings.


Other schools try to address in their curricula the potential stresses of becoming a physician through introduction to clinical medicine or interviewing classes. At UCSF, Goldstone offers an elective course called “On Doctoring” that allows for small group discussions of students’ responses to the process of medical school. When the topics of doubts or difficulties arise, many students are relieved to hear that they are not alone. “It’s hard to carry those feelings yourself and to worry that it means there is something wrong with you,” she says. “It’s extremely helpful to talk to other people about it.”


While you may be afraid to admit your hesitancy about medicine to proud parents and friends, a strong support system is key to making it through the challenges of medical school. Bollinger says he relied heavily on the encouragement and assistance of his wife and friends. “I really felt I had to turn to the people who knew me and whom I love and who care about me, too,” he says. And with this support, Bollinger is able to approach his second year with more clarity and focus.


And, yes, this further reinforces the fact that life outside of medicine is crucial to success. Carr says it’s important to return to your personal pursuits, the ones that gave you comfort and pleasure in the past. She often advises students to focus on their hobbies and interests outside of medicine, such as playing the piano or visiting an art gallery. A fresh perspective can often revitalize your attitude.


So if you’re experiencing similar uncertainties, you should feel reassured: Even though many students have doubts along the way, most realize that medicine can be a good career after all. In fact, the majority of medical students graduate and find productive careers. As Carr says, “Medicine offers a tremendous amount in terms of intellectual stimulation, people contact, humanity and science. It’s a wonderful blend of a lot of different abilities and talents.”


Bollinger’s sentiments seem to mirror that perception. As he sat under that tree, reflecting on his life, he realized there was nothing else he’d rather be doing. “I really couldn’t see a future that was as enriching or offered as much as medicine,” he says. So with new-found resolve, Bollinger picked himself up off the grass and forged ahead toward becoming a physician.
~~~~Monica Zangwill is a medical writer based in Newton, Massachusetts.~Student Life and Well-Being~
186~4May-June~2002-51~Feature~The Road Less Traveled~HOW SOME MEDICAL SCHOOL GRADUATES GET A RESIDENCY OUTSIDE OF THE MATCH.~Scott T. Shepherd~~Death, taxes and the Match—for medical students, these are inevitabilities of life. Aren’t they? Not necessarily.


Each year approximately 31,000 applicants—16,000 fourth-years from U.S. allopathic medical schools and 15,000 others, including graduates from U.S. osteopathic schools, international medical graduates and “independents” who previously completed medical school—put their lists of favorite programs into the “magical” Match process, hoping the National Resident Matching Program (NRMP) sets them up with one of the 23,000 openings for first-year residency positions starting in July. While some specialty programs—thoracic, plastic and reconstructive surgeries, pediatric cardiology and others—use separate matching programs, the far majority of positions go through the NRMP.


So, with only 0.74 positions available per applicant, Match Day—the third Thursday of March when the NRMP announces placements—is a suspenseful and often stressful experience for students. Will they land their dream residencies, be forced to settle with their third or fourth choices or have to scramble for any acceptable vacant position? To many future residents, it seems life would be a lot more enjoyable without Match Day.


For graduates who find their residencies outside of the NRMP process, Match Day is nothing more than a series of second-hand anecdotes from their tortured comrades. Don’t let this make you think it’s easy to find a position outside of the Match, though, because it’s not. But before we get to how they do this, let’s take a closer look at the Match.


THE BIRTH OF THE MATCH


The first Match was implemented in 1952 to end widespread abuse by both residency programs and medical students. “At that time, there were so many more positions than medical students,” NRMP Director Liz Lostumbo says. “So programs were trying to sign up students as early as their second year of medical school. And on the other side, students were accepting an offer and then reneging on it when a better offer came along.” Ninety-eight percent of U.S. residency programs and 97 percent of fourth-year U.S. medical students participated in that first match, which was organized by the National Student Internship Committee. As a result, 6,000 U.S. medical school seniors were easily matched into the 10,500 available intern positions. With this success, a permanent program—then called the National Internship Matching Program—was established to direct this annual event.


Since then, the program has evolved into the NRMP, an independent organization sponsored by the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), the American Board of Medical Specialties, the American Hospital Association and the Council of Medical Specialty Societies. In addition, four student organizations—the American Medical Student Association, the AAMC Organization of Student Representatives, the AMA Medical Student Section and the Consortium of Medical Student Organizations—sit on the board of directors. However, only two of these student organizations are provided with voting privileges, as determined among the four groups at the beginning of each year.


Under this leadership, the NRMP enforces a two-sided ranking system with a variety of rules attempting to ensure confidentiality as well as ethical and professional conduct by all involved parties.


Here’s how the current process works: After exchanging information with programs and interviewing with them, students submit a ranking of their top program choices to the NRMP, while at the same time residency program directors submit a list ranking their top applicants to fill their July openings. It costs medical students $40 to rank up to 15 programs with a $30 fee for each additional program.


For example, student A ranks hospital X as his top choice; however, hospital X fails to list the student. Therefore, the Match process goes on to student A’s second choice, hospital Y, which ranks student A fourth. At this point, the student would be tentatively placed at hospital Y, as long as it has an unfilled position. However, nothing is written in stone yet. If any of the students hospital Y ranked above student A select hospital Y as their top choice, then student A gets bumped. In that case, the NRMP would then take a look at student A’s third and fourth choices until a match is found. In some instances, student A might not match with any of his choices, in which case he is left to scramble for an opening.


As you can see, the process can be confusing. The NRMP says it continues to tinker with the Match to make it more applicant-friendly. For example, in 1998, following a series of critical articles in Academic Medicine, the NRMP adjusted its matching algorithm to change the process from favoring programs’ interests to being more responsive to students’ rankings. However, the “student-optimal” system has seemed to have little impact. In 1999, 57 percent of students were placed at their top choices, while 15 percent were placed at their second. Nine percent of the applicants were matched with a program they ranked fifth or lower. That was hardly an improvement over a couple years before when 55 percent of applicants ended up with their top choices and 14 percent at their second.


Not surprisingly, the Match still has its critics and remains fraught with distrust on both sides. Research published in the American Journal of Surgery in 1999 said applicants of various specialties believe residency programs engage in questionable behavior, with more than half of all surveyed respondents wanting to see the process improved, and 8 percent believing the process should undergo a major overhaul or be completely eliminated. As for residency program directors, in Family Medicine in 2000, 94 percent reported they received commitments of being ranked highly by an applicant, but 84 percent of those directors said they were skeptical of such promises. In addition, 94 percent of those surveyed said they felt the Match pressures them to mislead applicants about their ranks in order to end up with the best matches possible.


Despite these concerns, allopathic medical graduates who want to practice medicine and start their residencies in July have little choice but to go through the Match or a specialty match. Besides specialty matches, osteopathic graduates can either be placed in a residency through the American Osteopathic Association’s (AOA) match or the NRMP. However, if entered in both, the osteopathic graduate is automatically dropped from the NRMP if matched with a position in AOA’s service, which is announced in February. Either way, they are going through a match.


Yet, for a few intrepid souls, there is still another way.


OUT OF THE MATCH


So what separates these Match-free residents from their colleagues? Well, it can be several things. Sometimes these applicants take advantage of opportunities afforded by a new program, which is not yet contracted with the NRMP to fill its July openings. Meanwhile, other applicants choose not to live by the same schedule as their contemporaries, and instead of beginning their programs in July, they look for those rare gems that materialize in October, December, January or even February. These positions usually become available when a resident is unable to complete the year, either for personal reasons or because the program director determines he’s not adequately qualified to fulfill his responsibilities. When this happens, the vacancy often leaves a void in the health-care facility’s staffing that can’t remain empty until the following July. A replacement must be found.


So the programs look to nontraditional applicants, interviewing graduates who completed medical school in August or December and who don’t feel like waiting until July to continue their education. They also come across graduates who have taken time off from training after earning their degrees (see “Time Out,” p. 18). These applicants interview directly with residency programs and can skip the Match.


In fact, Dr. Kenneth Iserson, author of Getting Into A Residency and a professor of emergency medicine at the University of Arizona, says as many as one-fifth of residency openings are filled outside of the NRMP process. And while it is unclear how many of these were filled through specialty matches or without a match program, he says that, for the assertive and well-informed applicant, there are positions available that allow you to steer clear of the NRMP. “I think there are a lot more people out there in the position to do it than actually take advantage of it,” he says. “I think most people don’t read that part of [the Match rules] and realize, ‘yes, it’s legal.’”


Dr. P. Travis Harker was able to take advantage of such an opportunity. Last August, the 2001 graduate of Ohio State University College of Medicine accepted a Dartmouth family practice and preventive medicine residency that begins this July at Concord Hospital in New Hampshire. While many of his classmates were trying to find their perfect residency during their senior year at medical school, Harker chose to wait and spend a year in a research fellowship at the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion. And while honing his health-policy skills, Harker heard about a couple of openings in Dartmouth’s new preventive medicine element of its residency program and decided to give the hospital a call. “It was just an opportunity that came along,” he says. “I feel pretty lucky they had a good program and that it was a pretty good fit for me.”


The future resident acknowledges there are risks involved with accepting a position before conducting extensive research of and interviewing with programs. In fact, Harker had taken the initial steps to enter the Match when suddenly the Dartmouth opportunity came along, and he took that position instead. He says it was the right decision for him. “It saved me a lot of money, because I didn’t have to fly around from place to place looking at something that might not be a good fit for me,” he says. “On the other hand, there may be [another residency program] out there that is better…. I won’t be able to find out.”


It seems that traveling expenses are a common reason some medical school graduates avoid the Match. That was certainly true for a first-year resident at Bethesda Hospital in Cincinnati, Ohio. The 35-year-old obstetrician–gynecologist, who asked not to be identified, received her medical degree in China in 1988 and came to the United States six years ago. After taking some time to adjust to American culture, she was ready to begin her residency but couldn’t afford to spend a great deal of money traveling from one interview to the next. So when a position opened up at Bethesda in October, she jumped at it. “I was applying to the Match, but I looked on the computer and found this spot,” she says. “It was a program that fit me. So I chucked all the others and came here.”


GOOD SPOTS VS. QUALIFIED APPLICANTS


It’s not always that easy to get a residency outside of the Match. Unpredictability can make this Match-free process incredibly nerve-wracking. Residency program directors say they usually receive a lot of interest, but the quality of candidates varies. Meanwhile, graduates may find it just as difficult to find a quality program with an opening. “[Program directors] know there are only a few good people out there, but there are few spots too…. It can be pretty intense,” says Iserson, who obtained his residency outside of the Match.


For the opening at Bethesda Hospital, residency program coordinator Kathy Thacker says she received many applications but had to sift through them to find a good candidate. “We got a really good response; I would say more than 100,” she says. “But for [an off-season opening], you see anybody and everybody.”


In some cases, a program director may be a little wary of off-cycle candidates. One program coordinator, who asked not to be identified, says she is skeptical of many of the off-cycle applications her program receives. “A lot of [the candidates] have been out of medical school for 25 years…. You get lots of interest from people who aren’t really qualified,” she says.


But this skepticism can run both ways. Dr. Carol McLaren, the assistant dean of student affairs at the University of Washington School of Medicine, says more and more students are graduating during the summer or winter and are considering off-cycle positions, but she usually advises them to approach these residency openings with caution. “What I may suggest to them is to send out a few applications to a few really good programs, but [unless the students receive one of those positions] just to enter a residency through the Match,” she says.


Many college advisers warn students that sometimes these vacancies occur because of problems within the program. “[The off-cycle graduates] have limitations when it comes to finding a residency,” says Dr. Brian Zink, the assistant dean for medical student career development at the University of Michigan Medical School. “For programs that have a lot of unfilled residencies, it is usually for a reason.” And like McLaren, unless an ideal situation comes along, Zink advises his nontraditional graduates to wait and obtain their residencies through a match.


Still many medical school graduates are uncomfortable with the concept of putting their education on hold, particularly with mountains of debt piling up around them.


TIPS FOR BEING MATCH-FREE


Perhaps you’re sensing that you may be a candidate for getting a residency outside of the Match. So how should you start? The biggest step may be simply learning that an off-cycle residency position exists. In many cases, programs don’t advertise them; they simply “spread the word” among their residents and collegiate contacts hoping to avoid a flood of unqualified applicants. So, it helps if you know the right people. However, Iserson suggests that you do what he did: Contact appealing programs and inquire about unexpected vacancies, either at the moment or in the near future. “Who can tell if one of the residents gets sick or drops out?… [Programs] still need someone to fill that spot,” he says. “You just have to find out by cold calling or by word-of-mouth.”


Some programs have begun to advertise these first-year positions, usually through industry-related Web sites, such as the AMA’s page dedicated to residency vacancies or the AAMC’s “FindAResident,” which requires a fee. “That is one kind of a more organized way to do it other than just keeping your ear to the ground,” Zink says.


But Iserson warns that these sites only advertise a few recent openings and suggests that graduates and students anticipating entering a program off-cycle should be working well in advance. “You really need to plan early and get your act together and start contacting programs that interest you,” he says. To aid this endeavor, refer to the Graduate Medical Education Directory—Supplement, which lists programs offering start dates other than July. This listing is not necessarily complete, though. In the end, the best method to find a program that has an opening or an alternate start date is simple—just ask.


In terms of new residency programs, many directors try to find applicants by spreading the word. So having the right contacts help. New programs also place advertisements in industry-related magazines—such as The New England Journal of Medicine, The Journal of the American Medical Association and The New Physician—or post notices on Internet sites.


To aid your out-of-Match search, Iserson suggests focusing only on the positions that are really attractive to you. “Be assertive, but don’t go applying to places you don’t really want to go. [Programs] are being selective, so you need to be selective,” he says.


It can also be difficult, though, to even decipher when a position is being offered. Unlike the Match process, most programs do not have a rigid structure for interviewing and negotiating with applicants for off-cycle positions. “We try to do everything we would do during the Match process on a smaller scale, but it can be difficult,” says Geri Kelly, assistant to the residency program director at Temple University Hospital. While in some cases this leads to an intimate, professional and informative interview, Iserson warns it can also mean a disorganized and confusing selection process.


He suggests that if you’re interested in a program, particularly a new program, be sure to get all available information about the faculty’s experience and the program’s expectations of its residents. Without senior residents on staff, the burden of responsibilities will frequently fall on first-year residents. But for some interns, this more intense training may be preferred.


That’s why the out-of-Match applicant needs to be more aggressive than his Match counterpart, Iserson says. So if you decide to go for a residency position without the Match, make sure you’re well informed and make sure the residency program is being completely truthful with you. “You have to [research it] just like a job, try to get all the information you can and use all your contacts,” Iserson says.
~RESIDENCY RESOURCES ON THE WEB



~~~Scott T. Shepherd is associate editor with The New Physician.~Residency~
187~4May-June~2002-51~On the Wards~Shakespeare On Call~LOVE, DEATH AND THE SOOTHSAYER~Simon Ahtaridis & Jaya Agrawal~~Two houses, Surgery and Medicine, in fair Philadelphia, where we lay our scene. From an ancient hierarchy arises new conflict, where a surgeon jealously guards his love. From forth this scene enters a star-crossed medical student, whose misadventure ends with a loss of true love. The fearful passage of their tragic love and the resident’s endless labors, which naught but death could end, is now the more than two-page tale in your hand. Which, if you with patient mind attend, what here shall miss, our toil shall strive to mend.


ACT I, SCENE I


A Hospital Lobby. Enter Will Shakespeare and Balthasar Andronicus.

Will: So begins our penultimate rotation on the wards, Balthasar.

Balthasar: Nay, our second to last it is.

Will: Which of us will be charged with the task of paging our supervising resident?

Balthasar: Not I, for I am always left to that vile task.

Will: And I do not wish to risk the wrath of our new resident on the first day.
Balthasar: Perhaps then we should retire to our quarters and page our resident on the ’morrow.

Will: Thou art a fool indeed, cowardly Balthasar, for that would be the worst of our alternatives. Lend me the digits, and I shall enter them most expediently into the device.


Enter Soothsayer.


Soothsayer: Beware the fines of March.

Will: What thou speakest of?
Soothsayer: The fines of March will be upon us.

Balthasar: We care not.

Will: Our resident returns our call and demands our presence anon. Let us make haste.


Exeunt.


ACT I, SCENE II


On the Wards. Enter Dr. Yersinia Bubonica.
Yersinia: Another rectal exam! Medical students, medical students, wherefore art thou medical students? Thinkest all that I have no better use of my time than to wait upon others? Oh wretched weariness, oh wretched call room, oh wretched beeper that haunts my dreams.


Enter Will and Balthasar.

Balthasar: Methinks we have wandered into the wrong ward.

Will: This labyrinth would test even that noble gunner Theseus.

Balthasar: I think that we have at last come to our destination.

Will: Behold yonder! Do you see that fair maiden clad in the long white coat? I would that Father Time suffer a torn ACL, that I may gaze longer upon her perfection. But, wait, she comes forth!

Yersinia: Art thou the two apprentice physicians? The medical students on my team?

Will: If you be Dr. Bubonica, then we are yours.

Yersinia: Aye, I am. But you may call me Yersinia.

Balthasar: Balthasar at your service.
Will: And I am…I am….

Yersinia: Make haste. We have much to do today.


Exeunt.


ACT II, SCENE I


By the Nurses’ Station. Enter Will and Yersinia.

Will: My lady Yersinia, I appear to have forgotten to give you my name.
Yersinia: Do not give what is not asked. I am too busy for trivial matters.

Will: Ah, ’tis true. For what is in a name? Yersinia by any other name would smell as sweet, as I am sure you do when not in last week’s odorous scrubs.

Yersinia: Look pal, I am post-call. OK?

Will: Aye, my lady, thou needest not take that form of speech with me.

Yersinia: I apologize for my outburst of the common tongue. Weariness has taken its toll.

Will: Nay, my lady, apologize not. But rather set me a task, any task, and it will be done.

Yersinia: Indeed, if thou will, fill these empty forms with words detailing the status of our patients; I will be able to sign off on thine note, lessening my load. If thou will draw fluid from a patient’s sinews that would remove a task from my ever-growing list. Lastly, get thou to the apothecary and make haste with a purified protein derivative—I mean, PPD.

Will: Worry not, my lady. All these tasks and any others that you desire will be done. Consider them a thought that no longer weighs heavy upon thy mind. I have but one query, whereto should I perform this PPD thou speakest of?

Yersinia: TB or not TB? That is the question. Knowest thou not the answer? If not, make haste to the isolation room.


Exeunt.


ACT II, SCENE II


The Apothecary. Enter Will and Narcoticus.

Will: Apothecary, I require a PPD for a maid with suspected TB.

Narcoticus: TB? I know of no such disease. Dost thou mean consumption?

Will: Aye, thou art correct. And another task I have for thee: I need the nectar of that sweet rose that Cupid’s arrow hath pierced. The juice of this flower, purple with love’s wound, will inflame the soul of she who drinks of it.

Narcoticus: I have none of this juice, save a pill made to keep thy helmeted head upright if ye understands.

Will: I am well endowed and need no such device, but rather a lure for my sweet Yersinia. A kingdom I’d pay for such a potion.

Narcoticus: Yersinia? Dr. Bubonica? Thou speakest of forbidden love. Residents cannot lay lustful eyes upon medical student apprentices. ’Tis against nature’s decree, or at the least the regulations that govern these halls.

Will: I care not for such a rule—be it by nature or other powers. Words, words, words, these rules are mere words.

Narcoticus: Then perhaps thou careth to know that she be spoken for by the surgeon Brutus Thorax. Forget thy love or get thee to a nunnery. For I say it again, such love is forbidden. But soft, Dr. Thorax doth approach.

Will: Forbidden? Forbidden? And if it were forbidden? Can one forbid the fiery morning sun to rise in the morrow? Can one forbid the nightingale to fill the night with song? Can one forbid the flower to bloom or the star to shine? What could be more tragic than a future without Yersinia? What sorrow does a terminal patient’s moan know? What loneliness does the patient in the TB isolation room feel? What is suffering if it is not to be without my Yersinia?


Exit Will. Enter Dr. Brutus Thorax.


Brutus: Do mine ears deceive me or did that lowly apprentice speak the name of my fair Yersinia? Speak, Narcoticus, there is a tale to tell. You will tell all or suffer my wrath.


Exit Brutus.


ACT II, SCENE III


Inside a Lecture Hall. Enter Merck Anthony, Will, Balthasar, Yersinia and Soothsayer.
Merck: Fellows, residents, countrymen, lend me your ears. I come to bury generics; don’t use them. The benefits of a pill live long past its patents, but its profits inter when they expire. Hail Dr. Caesar!


Enter Dr. Cruelius Caesar.


Caesar: Run along now, Anthony, thou shall not befuddle these young minds with thy wares and prattle.

Balthasar: Oh, I am fortune’s fool! I have been deprived of a mug holder!

Soothsayer: Beware the fines of March!

Caesar: What thou speakest of? Our inspections have passed.

Yersinia: Hast thou completed thy tasks?

Will: Aye, my love, that and more. I took the liberty to relieve our service of three patients who no longer require our healing.

Yersinia: Thou speech is music to mine ears. Three fewer patients! ’Tis like waking from a dire dream, to find oneself in the comforts of a warm bed—oh dear deprived bed that I have neglected. Oh, apprentice, thou hast won my heart with your discharging valor!

Will: My dear Yersinia, let us flee this place and be a stranger to your bed no more.

Yersinia: Thy words are bold, and yet this boldness fuels my passion. How strange that within one scene I learn thy name and swoon for thy bones as if Cupid’s arrow hath stung my heart.


Enter Brutus, wielding a scalpel.


Brutus: Shakespeare, this scalpel shall have as its sheath your lecherous heart that does bewitch the bosom of my fair Yersinia.

Will: Out reflex hammer, thou art my only defense.


Will swiftly strikes Brutus’ biceps tendon, stimulating the reflex arc, which sends Brutus’ blade flying. Alas, the blade lands cruelly in Yersinia’s neck.


Yersinia: I have been struck. My life’s blood runs fast from my inky veins. I am dead, Shakespeare. A plague on both your houses, Medicine and Surgery alike. Ah, but death is sweet. At last, I rest.

Caesar: O woeful medical error!
Brutus: Oh, I have murdered my love. Though my surgeon’s garb is oft speckled with blood, never so crimson as this juice of my sweet lady. Out, out damned spot!


Enter Hubris Occupus.


Hubris: The fines of March are upon you. You did not heed the soothsayer’s warnings. The Lords of Congress have writ and proclaimed that the hours that residents may toil are thus limited. You are fined for violation.

Caesar: Cruel fate that this proclamation passes after I have already done my resident’s toil!

Will: My heart bleeds. My love is slain. And my soul can bear not this vile practice of medicine if I cannot be of service to my fair Yersinia. If I cannot serve her as an apprentice, I will shun these hospital halls. I forsake this hammer and will don in its stead the playwright’s quill and scroll. Only thus can I immortalize my fair Yersinia.

Caesar: Go not, Will. Consider thy lucrative career that you forsake. And who will serve my patients, my resident thus slain, and this proclamation thus passed?
Will: I care not for pains and problems that know no end. I will write for the ’morrow, and the words I write today shall echo in eternity and will outlive thy physicians’ daily deeds.

Farewell cruel hospital.

Farewell callous teachers.

Farewell Merck Anthony, and farewell to thy tainted wares.

Farewell Medicine. I bid thee adieu.


Exeunt. Enter Narcoticus.


EPILOGUE


Narcoticus: If we clinicians have offended, Think but this and all is mended,
That thine endless toil day and night,
Hath blurred thy senses and thy sight,
Thou have hallucinated here,
While this tale did appear,
And this weak and idle theme,
No more yielding than a dream,
We pray that sleep shall soon befall.
Good night, sweet dreams unto you all.


Exeunt.
~~~~The playwrights: Simon Ahtaridis is a fourth-year medical student at Temple University, and Jaya Agrawal is a fourth-year medical student at Brown University.~Medical Education~
188~4May-June~2002-51~Feature~Time Out~~Jennifer Zeigler~~Many medical graduates find adventure, extracurricular experience
during time off between school and residency.


Dr. Alex Yang has a decision to make tonight: Olympic figure skating or ice hockey? At 7 p.m. he’s parked on the couch, talking on the phone and discussing the dilemma with his roommate. (Yang is voting for figure skating while his roommate is trying to change the channel to hockey.) By the end of the phone conversation it’s Yang 1, Roommate 0—Michelle Kwan is gliding across the television screen.


Yang knows he’s not like other M.D.s fresh out of medical school. Instead of gazing at the television, he could be watching patients multiply in the ER waiting room at the tail end of a 36-hour shift. The decisions that night could be a little more important than selecting figure skating or ice hockey.


Instead, Yang is putting all that on hold while he takes some time off between medical school and residency. He spends his days working for the business-strategy consulting firm McKinsey & Company in Los Angeles, where he’s working on a five- to 10-year business plan for a medical device manufacturer posting $10 billion in annual revenue. Don’t get him wrong, though. His daily decisions—which affect the actions of corporate executives—aren’t meaningless, but in “the worst case, nobody’s going to die,” he says. “It matters to some people, but at the end of the day, I’m not going to kill anybody with the decisions I make.”


Yang’s not alone. Each year about 400 medical school graduates—or 2.6 percent of them—leave the beaten path to residency for seemingly greener pastures. The reasons they give are varied: Some, like Yang, want to test the waters of corporate life, while others need some time for travel, volunteer work or even to earn another degree. Some come back to clinical medicine, while others never do. But no matter what they’re doing, most of these medical graduates learn that a little time out can provide the experience of a lifetime.


BROADENING YOUR HORIZONS


Yang, who also holds an M.B.A. and says he intends to go on to an emergency medicine residency in a few years, says he took on the consultant’s life after medical school because he knew he wouldn’t be able to take an opportunity like this after residency. “When you finish residency, it’s time to work now,” he says.


He says new physicians who go right to residency are often plagued with yearnings to have experiences different from day-to-day clinical medicine. “A lot of residents say, ‘If I had done this, or if I had done that….’ I won’t be saying that because I did ‘that,’” he says of his break. “Med students should know that they have a much broader array of options than they think they have.”


Dr. Amy Wagner certainly saw broader options than entering residency training right away. An internship in Belize during her fourth year of medical school piqued her interest in caring for underserved populations around the world. So as she entered the Match process to gain acceptance into a surgery residency, Wagner began to investigate clinical volunteer opportunities in Africa. While most organizations disregarded her because of her lack of a medical license, an American-born physician who operates a small surgical practice in Cameroon accepted her offer. And so, a few weeks after graduating from the Medical College of Wisconsin (MCW) last June, Wagner was off to Africa.


She began her work in a 200-bed hospital by rounding daily on the 50 to 70 patients for whom she and the American surgeon cared. “But it’s much easier, because there’s no paperwork,” she says. “And the only notes were the ones I would make for myself to remind myself.” It wasn’t long before Wagner was doing her own cesarean sections and appendectomies. “It was pretty scary,” she says, adding that she performed her first solo cesarean section after observing one and conducting another under the surgeon’s supervision. “She said, ‘You did so well with the last one, you just go ahead and do it,’” Wagner says of her mentor, sounding a little amazed at the liberty she was given in the operating room.


She says she decided to take advantage of the African opportunity because she knew that after seven years of surgical residency, she might have family and work commitments that would preclude her from working overseas. “Now’s the time to do this,” she says.


And while “I would never, ever regret what I did—it taught me so much about myself and what I value,” she says she is now craving the formal education a U.S. surgical residency can provide. She left Cameroon in December to interview for the Match and will be headed to Virginia Mason Hospital in Seattle later this summer. In the meantime, she is spending the months before her residency back in Cameroon, soaking up all that Third World medicine has to offer. “I’m dreading residency in that it’s going to be long and awful, but for me [that way of learning] just clicks.”


Like Wagner, Dr. P. Travis Harker also fully intended to go on to residency when he took some time off after graduating from Ohio State University College of Medicine in 2001. Having decided after his third year of medical school that he wanted a break before residency, he pursued several opportunities for his time away from the hospital, finally selecting a research fellowship at the Office of Disease Prevention and Health Promotion (ODPHP) at the federal Department of Health and Human Services in Washington, D.C. “I decided I wanted another experience in public health,” he says. “And Healthy People 2010 was a great opportunity to get my hands dirty in public health.”


Like Wagner and Yang, Harker says the time was right to take some time off from clinical medicine. “This was a good time for me to recharge my batteries and broaden my horizons,” he says. “As a med student, you don’t have a lot of time to reflect on things, and now I have an 8 to 5 schedule, and I come home, and I don’t have to think about work.”


SHOULD I STAY OR SHOULD I GO?


All of these young physicians agree that a year or two off after medical school can help you sort out what you want to do with your newly earned degree, but be forewarned: They also agree that time away from the hospital can make you never want to go back. It’s something Yang says he struggles with a great deal, especially since, unlike Harker and Wagner, there is no set end date for his consulting job. “The longer you’re here, the harder it is to go back,” he says. And who could blame him? Working 60 hours a week for more money than the average emergency attending makes, getting to influence powerful corporate executives and their companies, sleeping regular hours—what’s not to like about his job? “Is there a chance that I won’t go back? Yeah,” he admits. But he says at least he knows that if he does choose to do a residency, it will be the right decision. “I would just have much better perspective on what I’m doing. This [time off] would just sort of ground you. You would know why you were doing what you were doing.”


Yang says he sometimes misses medicine, so he volunteers his time in local emergency rooms. “I get reminded of what my life will be like,” he says. For all of the stark differences between corporate consulting and medicine, there is much that’s the same, he says. “I do enjoy medicine—seeing patients, the sort of thought processes that goes with diagnosing.” It’s a process similar to his work in the corporate world: He sees an ailing company and then figures out how best to leverage its resources to fix the problem. “I think the training you get from medicine prepares you for a lot of jobs in corporate business.”


Yang’s concerns about never getting back to medicine are certainly real. It’s not difficult to find physicians who don’t practice medicine, despite dedicating four years and countless loans to obtaining an M.D. or a D.O.


Dr. David Shih left his internal medicine residency at Johns Hopkins University just four months into the program, and he says he doesn’t see himself going back. “In the end, I decided I was sacrificing my relationships with my family and my girlfriend, my health.… It was a difficult decision. It’s really hard to let go of all that blood, sweat and tears—and money. Every now and then I still feel like I’ve really screwed up.”


Far from “screwing up,” Shih put his medical degree and a longtime interest in radio to work at a San Francisco public radio station where he’s spent the last year as the outreach manager for a brief, daily health program. He says his former life is always in the back of his mind, but “I guess I just decided that life is just too short. You can’t sacrifice time spent with loved ones. You can’t sacrifice your health.”


Yang says he respects people like Shih and others who never went on to finish a residency. “I wouldn’t say they’ve left medicine. They’re just using their skills differently,” he says.


DEALING WITH THE DIRECTORS


For those who do decide to go on to residency, there are always concerns about how program directors are going to view your soul-searching, see-the-world break from medical training. You know how hard it is to interview under normal circumstances? Well, try it when there’s an educational gap on your C.V.


Wagner says she was nervous about explaining her African surgical experience to U.S. residency directors. She says she knows that as a woman looking to enter a male-dominated field, she might come off looking “flaky.” So she incorporated the story into her personal statement. And to her surprise, about 50 percent of the programs in which she was interested were intrigued, even excited by what she did during her year off. However, “it’s definitely two extremes,” she says.


Wagner, who has had the unusual experience of going through the Match twice because of her last-minute decision to go to Cameroon, says one program that had been positive about her the first time around didn’t even invite her for an interview this year. “Definitely there were some programs who said, ‘Why do this now? Are you crazy?’ But those aren’t really programs I want to work for anyway. I definitely think that doing something like this helps me find a place that fits better.”


Because he arranged his residency at Dartmouth outside the Match last August, Harker’s future program was aware of his activities during his time off. “They see [my ODPHP work] as a benefit. They appreciate the prevention component,” he says, adding he knows his program’s attendings will be looking to him to add to the education of his fellow residents because of his unique experience. For example, while discussing a diabetic patient on rounds, Harker says he might be able to incorporate some information about the disease from the public health perspective, which could enhance the residents’ learning that day.


Of course, “if you take a year off and you go out to Colorado and be a ski bum, I think that sets off some red flags,” Harker says. “But if you work in health [-related fields], that says that you may [someday] be a leader in health policy, and programs are always looking for that.”


Program directors would agree. Dr. Douglas Miller, the pathology residency director at New York University Medical Center, says any time off on a person’s C.V. is a warning sign, but it all comes down to why the hole is there. “Did they take a year off because they were in drug rehab? Did they take a year off because they were under psychiatric care? And if it turns out that someone had enough money to travel the world, or they wanted to take time to do research or volunteer somewhere else, some of those efforts are quite laudable,” he says. “If everything else went well, if their grades were good, then I don’t see a problem.”


Miller would even encourage a little break between medical school and residency for a student struggling with what direction to take in medicine. He says taking time out then wouldn’t necessarily haunt a physician’s career the way a break or a program switch during residency would.


Yang, who like Wagner was in the middle of the Match when he decided to take the McKinsey job, says he contacted all the residencies he interviewed with to explain why they should no longer consider him. About 60 percent of them were positive, including his top choice program, which he says was receptive to his plan and whose program directors continue to welcome him when he drops by for a visit. Still, he says he gets “a lot of bimodal responses—people [who] think I’m either crazy and stupid or people who think I’m crazy and smart.” He says anyone considering a path like his will need to be prepared to explain the decision. “[Program directors] will want to know why you took time off, and the only acceptable reason across the board is research. ‘I wanted to take some time off and join Greenpeace’—that’s not going to fly with residency directors,” he says.


MAKING THE MOVE


Just a hunch, but the Greenpeace plan is also probably not going to fly with your dean when you tell her that come graduation, you’re off to a tropical island. And no matter what your plans are, telling your medical school faculty can be the most difficult part of any break. Wagner began by talking to her director of surgery at MCW. “It was totally the most frightening thing I ever had to do,” she says. “The chair of surgery doesn’t have the reputation as the most open-minded guy. I was frightened and pretended I was Madeline Albright… because who can say no to her? And it worked! He was really supportive.”


That was not true of all of her professors, though. “It was a difficult decision just because of the response of my mentors in med school. It was really hard for me to go against the advice of people who I respected.”


The decision for Yang was so difficult that he put it off until the last possible moment he could withdraw from the Match and not be blacklisted the second time around. He says in the more conservative, research-oriented atmosphere at the University of Chicago, where he went to medical school, he found few faculty who supported his decision. But talking to people can help. Many physicians who have taken a break or left medicine altogether say they began by speaking to as many nonclinical physicians as possible just to get a better idea of what options are out there for M.D.s and D.O.s.


And no matter how difficult the decision, it really needs to be made late during the third year of medical school. Wagner says early in her fourth year, when she began looking for an alternative to residency, was really too late. “In hindsight, I had no idea how long it would take to find someone who would take me,” she says. “In my case, I had to be very determined and set the whole thing up,” even applying for grants and corporate funding to pay for the experience.


Granted, organizing a trip such as Wagner’s is more time-consuming than applying for a job opening like Yang and Harker did. But if you enter the Match while concurrently conducting a job search that would require a year or two off before starting a residency, be aware that the cutoff date to legally withdraw from the Match process is in February of your fourth year of medical school. A sponsoring medical school must also endorse withdrawals, so it’s good to get your dean’s approval for your plans early.


Harker says the decision to take time out from medical education really comes down to determining what you want to get out of your learning experience and where you see your career going. “You really have to think long and hard, because you really can get on the wrong track,” he says, adding that it would be easy to feel that the time off netted nothing more than a year of wasted time.


But for those who plan it well, some time off can give you a unique learning experience and still provide you with a little time for relaxation that residency doesn’t offer. Just ask Alex Yang. But you might want to wait—he’s a little tied up right now: The bobsled competition is about to begin.
~~~~Jennifer Zeigler is a senior writer with The New Physician.~Residency,Student Life and Well-Being~
189~5July-August~2002-51~Letter from Afield~Land of the Free (Health Care)~GETTING TO KNOW CUBAN MEDICINE.~Archana Reddy~~Wearing my white lab coat, I walked down the street toward the clinic. The vintage Fords and Chevys rolling by made me feel as though I had traveled back in time to the 1950s, while the billboards lining the road were unlike anything I’d seen before coming to Cuba. They weren’t advertisements for car dealerships or cigarettes; they were political propaganda. One sign proclaimed Hasta la victoria, siempre (Toward victory, always) in bold colors, while another declared Todo para la Revolución (Everything for the Revolution).


I crossed through a garden of medicinal herbs to Consultorio No. 44, a whitewashed, two-story square building in Pinar del Rio, a city southwest of Havana. The first floor was the clinic of Dr. Jesus Daniel, the primary care physician with whom I worked. The second floor was where Daniel lived with his wife and child.


“Are you ready to get to work?” Daniel asked as I entered the consultorio. We interviewed and then examined a patient, a pregnant woman in her third trimester. Daniel placed a small, aluminum funnel on her abdomen and listened for the baby’s heartbeat. When it was my turn, I fumbled with the funnel and lingered longer than Daniel had, trying to focus on the heartbeat. The simplicity of listening for fetal heart tones this way stood in sharp contrast to the Doppler devices I’d seen used at my medical school in Chicago. No electronic amplifying device distanced me from the patient and baby. Finally, as I closed my eyes, I heard the heartbeat; I was amazed as mother, baby and I converged in an instant in time.


Each day I went to the consultorio, I learned a new skill. I learned to take a blood pressure, to percuss for the liver span of a patient with hepatitis, and to perform well-baby and prenatal physical exams. It was incredible. I began to really feel like a physician.


Daniel’s medical equipment consisted primarily of a stethoscope, a blood pressure cuff and his hands. With no lab tests to rely on, patient interview and physical diagnosis—formerly known as the art of medicine—became essential. Daniel told me that an intimate knowledge of his patients was just as important as any instrument.


He was responsible for the health of the nearly 500 people who lived in the five apartment buildings flanking his consultorio. Living among his patients, he said, gave him insight into their lives. He knew who smoked, who drank and who worked stressful jobs. He knew all of these things and more because he interacted with them as neighbors going about their lives.


Daniel not only lived among his patients, but he also spent most of his afternoons making house calls. We visited a variety of patients, from an adult with congestive heart failure to a child recovering from a tonsillectomy. We even saw people who weren’t sick; for example, we showed parents how to childproof their homes.


The first time I had ever stepped inside a patient’s home was with Daniel; with my American sensibilities, I felt as if I were intruding. Patients didn’t seem to act as if we were imposing, however. Offering coffee from precious grounds of rationed Cuban beans, they asked us to sit and chat about work, family and life in general. As I sipped the coffee and talked, medicine began to seem so personal, much more so than the clinical algorithms I’d learned in medical school. Surrounded by the artifacts of patients’ lives, I took note of the professor’s books, the toddler’s toys, and even the alcoholic’s empty bottles. These home visits gave Daniel the opportunity to get to know his patients from inside their homes and to better understand their perspectives.


Perhaps more unusual to see was how Daniel paid no consideration to the business side of medicine. Unlike offices in the United States where business and medicine seem interwoven, there was no clerk in the consultorio taking care of billing. There was no billing to worry about thanks to Cuba’s socialist structure.


I found Daniel’s physician–patient relationships to be simple. Removed from the influence of money, his priorities weren’t muddled. His role as a healer came first. I began to see, in contrast, the complexities of that relationship in the United States. American physicians are not only healers and patient advocates but also gatekeepers of health-care resources. The art of medicine lies buried somewhere beneath the rules of HMOs, Medicare and private insurance companies. Physicians have been forced into other roles, and I wonder if this leaves many American patients feeling alienated.


The Cuban medical system operates in a much different atmosphere. Cuba is a sort of “Galapagos Island” that has developed a distinct culture and life. Following the county’s sharp turn toward the political left, the United States placed an embargo on it in the early 1960s. This has led to its isolation from much of the world. And not only did the country’s cars and politics evolve into rare “species,” but so did its approach to medicine.


In the United States, physicians who live in the community and make house calls are a dying breed. In Cuba, they are the standard. Paid by a government that views health care as a right, Cuban physicians are taught that it is unethical and illegal to take money from patients. All Cubans have access to medical care, and they are never supposed to pay for it.


Of course, Cuban physicians have their own problems. They make only the equivalent of U.S. $20 a month, I was told. Although this is higher than most local salaries, Cubans can earn far more by catering to tourists as cabdrivers, waiters or hairstylists. And since most tourists tip in U.S. dollars rather than in Cuban pesos, this is money workers keep without government knowledge. The salary hierarchy is turned upside down, with professionals earning less money than service workers make. As a result, some physicians leave medicine to make more money in other lines of work.


My curiosity piqued by this system, I asked many Cubans what they thought of Fidel Castro. While their opinions were divided, many said Castro had made great strides in health care: He had made health care free to everybody and developed an immunization program for the entire country. For Castro, some physicians said, excelling in medicine despite the U.S. embargo had become a moral battle. Cuba’s medical schools have built reputations strong enough to attract students from many Caribbean and Latin American countries, while Cuban physicians are known around the world for their innovative techniques and excellent training. They are also known for their altruism: Teams of Cuban physicians are often sent abroad to provide crisis relief.


To conserve resources, Castro made preventive health care key. Pregnant women are required to come to the consultorio weekly, and the chronically ill are monitored closely. With such a strong emphasis on prevention, most physicians practice primary care medicine; there are few opportunities to become a specialist.


At some point while I was in Cuba, I started to believe that health care is a right of all people. I came to believe that the health of an individual is so important and fundamental that it should be kept outside the realm of money. Once money is introduced into the equation, I reasoned, there arises the possibility that some people will be left without access. I wondered about the system in the United States. How did we end up deciding that health care should be a profit-generating industry? How did we end up deciding that we would profit from the health problems of others?


Before I went to Cuba, I was jaded by the infiltration of business into the practice of medicine. I began to think the two must go hand in hand. In Cuba, however, I saw that medicine could be practiced in a more pure form, removed from the business aspects. It was more like what I’d envisioned when I decided to become a physician.
~~~~Archana Reddy is a fourth-year medical student at the University of Illinois at Chicago. She participated in the Medical Education Cooperation with Cuba program for one month after her first year of medical school.~International Health~
190~5July-August~2002-51~Feature~Odd Jobs~~Jennifer Zeigler~~Hi ho, hi ho, it’s off to work we go….

Students gain extra cash,

personal fulfillment

and professional skills

in unexpected,

extracurricular jobs.


Jennifer Knight knows how to give directions. She’s become an expert at recognizing someone with that dazed and confused look in their eyes. And while this comes in handy as she traverses the halls of West Virginia University (WVU) Hospital as a fourth-year medical student at WVU, it’s not a skill she learned on the wards. It’s something she picked up while working at a little-known place called Walt Disney World.


Knight has spent her medical school career moonlighting her way through school breaks as a guide at the Indiana Jones Epic Stunt Spectacular™ show at the Florida theme park. By trading her stethoscope for Mouseketeer ears during both summer and winter breaks, Knight has earned close to $2,000 a year for medical school expenses.


But extracurricular jobs are not something every medical student would take on. In fact, most advise against it, citing heavy course loads, long library and lab hours and a desire to spend what little free time medical school provides on decompressing from the realities of the classroom. Many schools even set policies forbidding students from working outside of school.


But there’s no doubt that most medical students could use the extra cash an extracurricular job provides. The Association of American Medical Colleges (AAMC) estimates that with tuition, books, licensing exams and medical supplies, the average first-year medical student could spend $32,685 at an in-state school and nearly an additional $9,000 at an out-of-state school. And that’s just the first year. The AAMC calculates that the costs rise with each year of medical school. For many students, this adds up to more than $100,000 in school debt by the time they start residency.


So they go to the local mall and sell the latest fashions to teens out on Saturday night, head to the downtown diner and practice staying up for 24 hours by serving coffee during the graveyard shift, or spend more time in the lab as a research assistant or even a human subject. But these are the usual jobs students look for during medical school. Others, like Sepi Fatahi, are bigger risk-takers.


RACING TOWARD MED SCHOOL


Fatahi’s shady past as a driver in the illegal sport of street racing belies her current role as a junior premed major at the University of California, Los Angeles (UCLA). And while she readily admits she once took up drag racing on deserted streets, she’s quick to tell you that she doesn’t do that anymore. A serious racing accident in which she was found to be at fault was enough to drive her to the professional drag racing track and off the streets. She’s put more than $20,000 into upgrading her 2001 Acura Integra for competition, fueling her desire to be known worldwide for her driving prowess. She says the thrill of the race is hard to give up.


“It’s just a totally different feeling when you’re on the track. It’s like a roller coaster ride, but you’re in control.”


But beyond feeding her thrill-seeking soul, Fatahi claims auto racing may also become her ticket to medical school. Yes, yes, we agree: It doesn’t make much sense that someone committed to becoming a healer spends her weekends hurtling her car—and herself—down a quarter-mile track at 90 miles per hour. The risks, Fatahi knows, are enormous. Her parents hate what she does—little wonder why—but she figures the pay is good for the winners, and medical school is expensive.


“My uncle said he’ll help me with med school, but I’m trying to be independent,” Fatahi says. The plan is to use the $150,000 purse that comes with a first-place finish at a world-class race to fund her medical school expenses. And while 19-year-old Fatahi knows becoming that good is a long shot, she remains optimistic. “If I can accomplish this, then there’s no reason why I can’t become a doctor,” she says.


But first she needs to get her car back from the shop. At press time, she was waiting on a $5,000 engine rebuild as the beginning of the drag racing season loomed. The fastest cars can do the quarter-mile in eight seconds; hers takes 11. “Every penny I’ve ever earned has gone into my car,” she says. To fund her habit until she starts winning some races, Fatahi also puts time in at a UCLA laboratory doing research into AIDS and cancer. But medical school is still two years away, and hey, somebody has to win the next race.


Dr. Ryan McCarthy’s extra cash for medical school came a little less daringly. But the internal medicine and pediatrics intern at WVU Hospital didn’t spend his summer before medical school just lying around, contemplating the next four years of his life, either. Instead, he sacrificed 10 precious weeks leading 20 teenagers through the wilderness of upstate New York’s Adirondack Mountains. Between the teen angst and hungry wildlife, McCarthy was hiking on tenuous soil. The $2,500 McCarthy earned that summer provided for the apartment furniture on which he now sleeps, eats and studies.


While many physicians-in-training rely on loans to provide for even basic needs like furniture, the students who are able to work a little on the side say it’s nice to have extra cash on hand to pay for necessities that the financial aid office often overlooks.


Knight says the $400 she earns at Disney during winter break and the $1,500 she was able to earn when she had her summers free gives her cash for things like Christmas gifts and other purchases “at the end of the semester when money’s kind of tight.”


And Knight says she spends “way more money than what is budgeted for books…because you also need the review books.” She also purchased a cell phone, because once the school provided her with a pager, she found she needed a mobile phone to respond to the pages. “And then there are things like the appropriate accessories to go with whatever rotation you’re in,” she says, referring to needing scrub shoes for surgery rotations as an example. And let’s not forget about clothes. When Knight made the transition from second to third year, she found her wardrobe needed a little lift, since she couldn’t wear the jeans, T-shirts and flip-flops she pulled on for class on the wards. All those unexpected expenses add up.


Still, Knight knows she gets off easy compared to many other medical students. With her tuition only about $10,000 a year and everything else running about $12,000, she spends far less than someone trying to get by at a private school in a big city.


MORE THAN A PAYCHECK


The real benefit for many of these physicians-in-training may not be the money but the pleasure of focusing on something other than medicine and learning a new set of skills, many of which can be applied to their future careers. “[Working at Disney] helps me financially. It also helps me mentally,” Knight says. “It gives me a free vacation. I think that, in my mind, that’s the benefit.”


And how could working at Uncle Walt’s playground not be fun? In addition to getting to know Mickey and his friends—the characters, not the actors inside them, of course—she’s met *NSYNC, Michael Jackson, Marie Osmond, the princess of Saudi Arabia, a couple of professional football players and even Neil Patrick Harris, who’s not a doctor but played one on TV. The park alerts the staff when someone famous arrives, who’s usually there just to tour Disney World with his family. “We have to treat them like any other guest,” Knight says, adding that the customer-service philosophy Disney follows is similar to the patient-service emphasis in medicine. And some guests provide good practice for dealing with difficult patients.


McCarthy reaped many more benefits from his summer job than just some furniture. He says there’s no doubt that he’ll be a better physician because of the wilderness experience. He spent a lot of time that summer working to bring people together to accomplish a common goal, whether that was pitching a tent or canoeing down a river. “It’s very similar to what I have to do today,” he says. “We need to do X, Y and Z today with [limited] resources.”


He says he also realized that being in a leadership position is “a really huge responsibility. Now, anytime I have my white coat on, I know that if I swear or do something [in poor taste], it would reflect bad on [the entire field of] medicine.”


McCarthy’s summer adventure even led him to his medical specialty—the man who, until that summer, had never spent much time around children, is now training to be a pediatrician.


Knight’s summer job has also shaped her future. Having spent so much time in Orlando, she’s come to like the community enough to secure two of her fourth-year rotations at area hospitals. This October and November she’ll spend her school days on the wards and her weekends working at Disney. And she’s hoping to match into a general surgery residency program in the area.


SQUEEZING IT ALL IN


These future physicians agree that it takes a special kind of person to be able to move beyond the summer job and take on extracurricular work during the school year. Dr. Russ Jaffe, for example, financed half of his eight-year B.A.–M.D.–Ph.D. education at Boston University (BU) through odd jobs back in the late ’60s and early ’70s. A seemingly miraculous feat today, Jaffe graduated with no student loans at all, having financed the other half through scholarships. Now the director of ELISA/ ACT Biotechnologies L.L.C. in Sterling, Virginia, Jaffe taught undergraduate classes, worked in a research lab, sold books at the student bookstore and secured a paying position with the American Medical Student Association to help finance his education. Apparently that still wasn’t enough, because he also jumped into the real estate business.


For two years Jaffe worked as both a real estate agent and broker, managing real estate deals mostly for friends and family. In order to do this, he had to have a license, which required more studying and another test on top of his medical schoolwork. And when he wasn’t selling real estate, he was managing it. Needing a place to live near the university, Jaffe bought a run-down house a few blocks from the school. After renovations—which he did himself, of course—15 students moved in with him. To some of them, Jaffe was not only landlord but also teacher. “Some of them I taught biochemistry to, and they didn’t hesitate to ask questions,” he says. What did he learn from the experience? “Be clear, be nice and be firm,” he says.


With a jazz musician mother and a father who played basketball for the Boston Celtics, Jaffe says his drive to work during medical school came naturally from watching his parents balance their busy careers. After school, sleeping and personal needs, a medical student has about 10 percent of his day left for extracurricular work and play, he says. “Med school kept most people busy, and to do extra things you were either very foolish or had a very great need.” He likes to think it was the great need. Jaffe’s unsure if BU condoned his outside activities, but he and his fellow working medical students figured “don’t ask, don’t tell.”


This jack-of-all-trades is certainly the exception to the rule of nonworking students. But who knows where these part-time diversions might lead the students who take them on? Knight is working on a second career of sorts—even if it has been unwittingly thrust upon her. “I’ve become the school’s travel guide whenever someone goes on vacation,” she says. “I get calls from random physicians planning trips.” It seems everyone wants to meet the Mouse.


And who knows, Fatahi may someday win that big race. In the meantime, we hope there’s a good physician waiting nearby.
~~~~Jennifer Zeigler is a senior writer with The New Physician.~Medical Student Debt,Student Life and Well-Being~
191~6September~2002-51~MedMentor Q&A~Discerning Your Path in Medicine~WHERE YOUR DESIRES, SKILLS LIE.~~~How do you know whether a career in medicine is an appropriate choice for you? At the core of every successful physician is a desire to serve others in achieving wellness through cure or prevention of disease, and there are limitless ways to achieve this. Yet medicine is not for everyone.


For most, medicine is a vocation; vocation comes from the Latin word for “voice.” One doesn’t choose medicine; one is called to it. Service is the work of one’s core or soul, and the call to medicine, with its heavy demands, should be in line with your unchangeable core traits and desires. Just as an acorn would be terribly frustrated if it tried to become an elm, you should not go into medicine unless you can grow into being a physician and not only withstand medicine’s demands but be energized by them. Parker J. Palmer, in his book Let Your Life Speak: Listening for the Voice of Vocation, writes: “Before you tell your life what you intend to do with it, listen for what it intends to do with you. Before you tell your life what truths and values you have decided to live up to, let your life tell you what truths you embody, what values you represent.”


Medicine is a profession whose key trait is selfless acts for the good of the patient or society in matters of health and disease. The difficulty of this responsibility is unsurpassed with the possible exception of the duties of public safety officers, armed services personnel or clergy.


Medicine is also a discipline. Discipline comes from the Latin word for “learner.” Western medicine is based on the mastery of a core of knowledge, behaviors, beliefs and decision-making tools based on the biopsychosocial model of disease. There is both an overt curriculum (the factual subject matter) and a hidden curriculum (the expectations of physicians by fellow physicians and by society). It takes daunting years of training to master the curricula. Those with other preferences might want to consider allied health careers, such as becoming a nurse or physician’s assistant. If you have no taste or ability for science, you should not choose medicine; other service fields, such as teaching or counseling, may be more suitable.


So if these are the core features of medicine, then what are the variables? A good place to start is to consider your talents and desires. Do you have an urge for inquiry, caring or teaching? If you have scientific interests, if you can translate the work of basic science into clinical care, medicine can offer you unlimited opportunities. The field’s gushing fire hose of scientific knowledge calls for those who can harness the flow.


And if you’re inclined to be mindful of a patient’s needs, values and individuality, you’re in luck. Medicine is always in need of humanistic care. Helping to fulfill these needs may simply mean refraining from interrupting a patient when he expresses his chief complaint. You can also fulfill your humanistic calling by focusing on improving a neglected area of health care. The etymology of “to cure” is the same as that of “to care.” While not every physician is capable of a great cure in every case, every physician is capable of small acts of great care (to paraphrase Mother Theresa). This ideal is remarkably consistent across cultures and the centuries—so is the need for excellent teachers of medicine.


And what about patient care? A wide variety of talents and tastes are needed here, too. The urge to fix or rehabilitate is at the core of the surgeon’s soul. The ability to make sense of patients’ stories and to explain (tell stories in return) is required of almost any clinical physician, especially those in primary care and psychiatry. Internists largely care for patients on the basis of abstract cognitive data—the patient’s symptoms, physical examination, blood tests, imaging studies, etc. Contrast this approach with that of dermatologists and radiologists, who work largely on the basis of visual data. Cardiology and endocrinology are good fields for those fascinated by physiology. In terms of their “customers” and breadth of knowledge, radiologists and pathologists are usually consultants or “physicians’ physicians” because they mainly serve other physicians. Anesthesiologists, on the other hand, serve physicians (usually surgeons) and patients equally.


In deciding whether medicine is the appropriate field for you, you’ll also need to consider the future of the field. As medicine becomes more technical and specialized, there will be an even greater need for physicians to be good communicators, good collaborators and relentless renovators of their skills and knowledge. In the past, physicians could largely work autonomously and sometimes rest on their laurels because of their sole control over medicine’s language, body of knowledge and treatments. Those days are long over. Greater access and choice is the future of every service field, including medicine. But compared to most of these fields, medicine and the individual physician have the widest range of freedom and practice, and have the greatest tradition of professionalism, openness, innovation and humanism.


The future of medicine is formed by this tradition. It was only in the 20th century that medical science allowed physicians to significantly alter the course of health and disease. The successes of science, as symbolized by the white lab coat, have perhaps separated physicians from the patient and the patient’s esteem. We need not be limited by this model, however. As in The Wizard of Oz, the isolating curtain can be pulled back and those serving health can work more intimately with those seeking health. The patient expects more than science and wizardry, just as Dorothy expected more when she learned the wizard was human. Being a wizard is a fine thing, but note that when the wizard asked Dorothy what she really wanted, he was acting as a human and true to his nature.


Listen to your life and discover where your greatest desires lie; see if there’s a field in medicine where you belong. Your guide will be when desire arises out of happiness—joy, discovery, respect, generosity—and not when it arises out of need—obligation, greed, fear, gain or even duty. In the face of desire, obstacles are immaterial; help will come, resources will appear, and your path will open before you.


Desire is happiness; satisfaction as happiness is merely the last moment of desire. To be wish and wish alone is happiness, and a new one over and over again.
~~~~Daniel W. Collison is chief of dermatology at Dartmouth Medical School. He specializes in skin cancer surgery. He considered a career as a literature professor before answering the call to medicine. Comments regarding this column can be e-mailed to tnp@amsa.org. Look for The New Physician’s next MedMentor column in November.~Career Development,Residency~
192~6September~2002-51~Folk Tales~A (Medical) Man of the People~TAKING A RUN AT ELECTED OFFICE.~Scott T. Shepherd~~In front of an audience, Dr. Shawn Aranha looks and sounds like many politicians. Sharply dressed and well-mannered, the 31-year-old Democratic candidate for state representative in Illinois’ 41st District speaks of the need to develop educational accountability, “new growth” economics, fiscal responsibility, community-based law enforcement and more effective environmental policies. And, of course, the first-time candidate hits the hot-button issue of the day: health care.


“The United States is able to offer the best health care in the world, but this means little to those people among us who have limited or no access to affordable, quality health care, especially the most vulnerable people among us: children, senior citizens, the less fortunate and even those who work but cannot afford decent health care for themselves or their loved ones,” Aranha told an audience of supporters in a rally for his Nov. 5 contest against Republican incumbent Robert Biggins to represent the suburban Chicago district.


Assertions like these often draw supporters, particularly among medical students, residents and physicians who witness the reality of U.S. health-care woes. However, voters have also heard similar statements from other politicians. The rhetoric about health care has become so common that it’s difficult to tell when it’s sincere or merely lip service to secure an election.


However, when the statement comes from Aranha, there is little doubt that he understands the need to provide better health care. “Since I’m coming from a medical background, people offer you a certain amount of respect just [because I’m] coming from the field,” he says.


Like many medical graduates, Aranha entered medicine with a desire to help people. After completing his undergraduate studies at Loyola University of Chicago with a bachelor of science in psychology and a bachelor of arts in political science—with minors in international studies, women’s studies, philosophy and theology—he entered Spartan Health Sciences University School of Medicine in St. Lucia, West Indies. Aranha says his grade-point average was insufficient to get him accepted by many U.S. medical schools. “I went to Spartan because they offered me a chance to pursue my dream of becoming a physician,” he says. “In my first year in college when I took the premedical requirements, I suffered a knee injury, which required extensive surgery and led to my doing poorly in the required classes for medical school.”


Despite the early obstacles, Aranha says he flourished at Spartan and at his clinical rotations in several Chicago-area programs. “People don’t say much about my [international medical graduate] status, especially if they know that I have done my clinical clerkships in U.S. medical school teaching affiliate hospitals,” he says.


After graduating from Spartan this spring, Aranha decided to temporarily set down his stethoscope and delay his plans to enter a preventive and internal medicine residency in order to enter the race for Illinois House of Representatives. To him, the move from medicine to politics came naturally. “I believe medicine and politics are related in that they are in the field of public service. I believe strongly in the potential of public service and what one can accomplish in public life,” he says.


Aranha decided the time between medical school and residency would be ideal to test the political waters. Of course, it didn’t hurt that the political iron was hot, so to speak. Aranha says the redistricting of the 41st District has improved the chances for a Democratic candidate, while the state Republican Party has been hounded by the scandals of outgoing Gov. George Ryan. “I have a good chance to win and work on the issues my constituency wants to see addressed, such as health care, education and economic management,” he says.


Born in Oak Brook, Illinois, to prominent Indian-American parents, Aranha says there has always been a mixture of politics and medicine in his life. His mother, Rosemary, is a social worker and a former president of the India Catholic Association of America, and his father, Gerard, is a physician and the chief of surgical oncology at Loyola University Medical Center (LUMC). “In our home, I was surrounded by books, pictures and images of political figures, which reflect my family’s interest in politics. Also my dad, being in the medical field, fostered an environment conducive to discussing medicine,” he says.


With this background, it was no surprise that at an early age, Aranha felt comfortable in the spotlight discussing social issues. He says his first interest in medicine and politics occurred while attending Visitation Catholic School in Elmhurst, Illinois. In the eighth grade, he collaborated with pathologists from LUMC and Hines Veterans Administration Hospital to create a winning science fair project. The same year, Aranha, who had already begun to idolize presidents Abraham Lincoln and John F. Kennedy, also got his first taste of politics and won his first election, of sorts, after being chosen by his classmates to be the school’s American Legion award winner for possessing the qualities of courage, honor, leadership, patriotism, scholarship and service. After that, Aranha says, “I knew that politics was something I would pursue and could be successful at.”


While the spark may have occurred early, the political flames were not fanned until Aranha attended college. While at Loyola, he took a class in American history from John Quinn, whose brother Pat Quinn was the state treasurer and a prominent figure in Illinois politics. Soon, Aranha found himself working on Pat Quinn’s campaign for lieutenant governor. And while the campaign was not successful, Aranha credits Quinn with encouraging his interest in public service and his belief that politics can be a noble pursuit.


Aranha’s pursuit now faces a challenge from Biggins, a real estate tax consultant who has served in the Illinois House since 1993. However, the veteran legislator represented the Republican-heavy 78th District, which is now part of the reshaped 41st District. Aranha says the result is a district that is divided between Democratic Cook County and Republican DuPage County. “The way the district is set up is pretty even…. I think there is enough to win,” he says. “The better I can state my message, the better chance I have to win.”


But if his first race for public office is unsuccessful, Aranha has no intentions of dwelling on failure. While campaigning, he is also preparing to participate in the 2003 Match. In addition, he would like to pursue a Master of Public Health degree. And while some people may consider Aranha’s political pursuits a distraction from medicine, he says he has received only support from program directors, instructors and fellow students. “Once they see my genuine sense of duty and purpose and my love for people, they wish me all the best and offer their support and encouragement,” he says.


With so much already on his plate, it would seem there would be little time for Aranha to concern himself with anything else. But, he is also finding time to train for his first marathon, the La Salle Chicago Marathon in October. He sees many parallels in his training to both his medical and political careers. “To run a marathon, one needs love, commitment, passion and dedication, the same qualities I will need to succeed in medicine, politics and life.”
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Advocacy~
193~6September~2002-51~Feature~Rule Breakers~IN THE MATCH, APPLICANTS AND PROGRAMS DON'T ALWAYS PLAY FAIR.~Scott T. Shepherd~~You’ve heard stories about him. You know, the Match cheater. He’s that student at the other school who made comments following his residency program interview. And those well-chosen words led to a side deal cementing him the prized residency program spot and saving him from the effort and anguish of the Match.


Of course, it’s always some other student—some mysterious unknown figure who broke the rules of the National Resident Matching Program (NRMP), the institution governing the Match. These stories have the ring of urban legend to them; they’re anecdotes future residents hear, immediately condemn and then secretly wonder if they could get away with it themselves. Well, for one fourth-year medical student, the temptation to make a special arrangement was just too great. And in the end, his actions almost cost him any chance of getting into the program he so desperately wanted.


You see, John Davis* felt he was in a precarious position. He was approaching his fourth year at a Midwest medical school and wanted to get into a highly competitive specialty program. To complicate matters, his pregnant wife was already a resident in the same program—a position she obtained through the military match. Davis felt there was no other place he could really go; he had to be in this program.


“I didn’t know what to do,” he says. “My adviser told me to just to go ahead and approach the program director to explain my situation, telling them that I needed to get into this program.”


Davis figured that because he was qualified and married to one of its residents, the program could give him some assurance that it would reserve a spot the following year, even though granting this request would be a violation of NRMP communication rules. Besides, if he were to get into trouble, he could use the tried-and-true naïve approach and just act as if he didn’t know any better.


So he approached the program’s director as planned. But Davis was not greeted with open arms. Instead, he received a lecture informing him that he would not be assured of a spot the following year. Furthermore, the director said Davis’ request might have cost him a spot.


Soon afterward, word spread among the program’s residents and the students who were attending the affiliated university—many of whom wanted to enter the residency program as well—that someone was trying to cheat, which would put their beloved program at risk of being admonished by the NRMP and the affiliated university. As Davis was already scheduled to do a rotation in the program and was visiting there regularly to see his wife, he frequently came in contact with people who greeted him with disdain.


“Word got out that I was an outsider trying to get in through the back door,” he says. “They sympathized with me, but they felt I might jeopardize their program. It was very awkward.” As if he were branded with a scarlet letter, Davis could feel—or at least imagine—the accusatory sideway glances from people he hoped would someday become his colleagues. It appeared his efforts had ruined that dream.


AN ATTEMPT TO END ABUSE


Of course, NRMP officials would like to think that this is what happens with most—if not all—of the future residents who attempt to cheat the system. However, with approximately 31,000 applicants maneuvering themselves to get into 23,000 first-year residency positions each year, it’s inevitable that someone will bend, if not outright break, the rules. And many of them will get away with it.


Ironically, the first Match was implemented in 1952 in order to end widespread abuse by both residency programs and students. Before the Match was founded, there was an abundance of residency positions and a lack of qualified applicants. As a result, programs tried to recruit students as early as their second year of medical school. Conversely, students regularly entered into agreements with programs and then reneged on the deals to accept better offers.


The NRMP, then known as the National Student Internship Program, tried to end this unethical behavior by enforcing a two-sided ranking system with a variety of rules seeking to ensure confidentiality, as well as ethical and professional conduct.


Under ideal circumstances, this is how the program should work: After exchanging information with residency programs and undergoing interviews, students submit a ranking of their top choices to the NRMP, while residency program directors submit a list of their top applicants. The NRMP configures the matches and announces them on a universally accepted day—currently the third Thursday in March, known as Match Day. Neither party makes any side deals or negotiates, but simply lists their favorites and lets the NRMP algorithm resolve any conflicts.


The system may sound nice, but many future residents have come to view it as a hindrance rather than as a benefit. Many believe the Match blocks their rights to openly compete for a program position and limits their abilities to negotiate contracts that would increase wages and provide better working conditions.


This displeasure with the Match is evident in a class-action antitrust lawsuit filed in May by three residents against the NRMP. The suit alleges that the NRMP, its sponsoring organizations and member hospitals have colluded to restrain competition in the Match process. While the lawsuit does not directly address the communication policy, the end result could be that what is currently construed as cheating would become the standard practice for students applying to residency programs. Dr. Paul Jung, the lead plaintiff who filed the lawsuit while he was a Robert Wood Johnson Clinical Scholar at Johns Hopkins University, says he is seeking a system that would permit applicants to consider multiple offers, negotiate with those programs, and then select the one that best fits their interests and needs.


“Let’s step back for a moment and look at what the matching program really does and what may happen if the Match is removed,” Jung previously told The New Physician; he is no longer accepting media calls regarding the lawsuit. “Students currently apply to multiple residency programs, have letters of recommendation forwarded to these programs, interview at several programs, and then decide how to rank programs on their preference list. All of those steps are consistent with a free market and would be the same if the matching program were dissolved.… But then instead of receiving multiple offers from residency programs and being able to choose one…we are assigned a position and are obligated to take it. What chaos would result if we received multiple offers…?”


UNDERSTANDING THE RULES


Many Match participants say the process is already chaotic, especially with the frequent misunderstandings or misinterpretations of the NRMP communication policy. According to the NRMP Web site, the policy on “Persuasion and Commitments” states: “The sole purpose of the Matching Program is to allow both applicants and programs to make selections on a uniform schedule and without pressure. Both applicants and programs may try to influence decisions in their favor, but any verbal or written contracts prior to the submission of Rank Order Lists is a violation of the Match. The final preferences of program directors and applicants, as reflected on the submitted Rank Order Lists, will determine the offering of positions and the placements of applicants.”


So what does that mean exactly? Well, mostly, it means students and programs can offer any information they want in order to persuade the other party to rank them highly in the Match. But neither party can ask for or offer a guarantee that they will be matched. “They are allowed to express the interest, but they are not allowed to ask the other party about their [interest],” NRMP director Liz Lostumbo says.


Despite these vague policies, however, Lostumbo says she believes that less than 1 percent of applicants and programs engage in unethical communication. However, others, like the University of Pittsburgh Medical Center’s pathology residency program director Dr. Jeffrey Kant, believe that rule breaking occurs more often than most people would like to think. And Kant, who has written several journal articles about the Match, warns that the problem is even greater among residency programs than among applicants.


“I think students are very good compared to program directors,” he says. Many program directors violate the NRMP communication policy because they feel the need to break the rules in order to compete for the top applicants, he says. Kant adds that program directors, unlike students, subtly violate the rules without ever announcing their intentions. “Students can propose it by saying, ‘Can you take someone out of the Match?’ Meanwhile, program directors propose it more subtly, by saying things like, ‘We really like you, and we want you in the program. Can you tell us in a week or a week and a half?’ Plus they’ll add something like, ‘Oh by the way, since you are not taking this offer, we assume you are not interested.’ Without directly soliciting, they’ve put a deadline on the student to pressure them.”


With these comments, Kant says, a program can place enormous stress on a student. “It’s very difficult [for an applicant] to turn down a program. The people who are good, but not absolutely outstanding, are put in the worst spot if they want to go to the best training possible,” he says.


With all of these attempts to influence the Match process, many students develop a high level of mistrust for the programs. This can often lead applicants to overstate their interest in programs, says Kimberly Anderson, Ph.D., a professor of surgery at the University of Texas Health Science Center at Houston. “The biggest issue is that there is a power differential between programs and students,” she says. “Students have accrued incredible debt loans and feel torn between ‘playing the game’ or laying out all of their cards and risking the chance of not matching into their field of choice.”


In “Is Match Ethics an Oxymoron?” an article published in the March 1999 issue of the American Journal of Surgery, Anderson and her co-authors detail just how frequently Match participants play this game. A survey of more than 300 post-Match seniors from the University of Kentucky, University of Minnesota and Michigan State University medical schools found that 57 percent of the students were asked by programs to “keep in touch” after their interviews. And 39 percent had follow-up communication with programs. More than 40 percent of those students said they stayed in contact with programs to remind them of their interest, regardless of their actual level of interest.


Meanwhile, 13 percent of the students said programs contacted them after their interviews to tell them they were a No. 1 rank order choice. And 58 percent of these applicants said they were skeptical of what the programs told them. One surveyed student told the authors, “I was flattered by the information but did not count on it. It was sort of a ‘feel good’ which lasted a moment…I didn’t assume anything.” Apparently this student wasn’t alone. Only 35 percent of students said their rank order decision was positively influenced by a program’s comment of a high ranking.


Perhaps this skepticism is promoted by the frequency of presumed verbal commitments; 43 percent of the surveyed students felt they received an informal commitment from a residency program. However, the NRMP warns that some students may be misconstruing comments to be commitments. On its Web site, the NRMP advises participants that: “Program directors and applicants frequently engage in the practice of sending letters following the applicant’s interview with the program. These letters often contain statements that can be misinterpreted by either party. Match participants must understand that such letters are not binding and have no standing when final rank order lists are submitted.”


Lostumbo says some students may feel cheated because of this misperception. “What people think is said or is not said is often just the result of a misunderstanding,” she says.


MATCH OUTDATED?


Anderson and her co-authors blame the widespread violations on the Match not keeping pace with a changing medical education environment. When the Match was founded, only 6,000 U.S. medical school seniors had to be matched into the 10,500 intern positions. With so many positions available, students had no reason to feel pressured to enter a top program early because a position would likely be available at another high-ranking program. With only 0.74 positions available for each applicant now, students are placed in a highly competitive environment and are easily distressed by the possibility they might be completely left out in the cold, the authors say.


In the meantime, budget-conscious hospitals are relying more and more on residency programs to provide work staff. Hiring competent residents has become a crucial part of their business; hence, recruiting has become highly competitive among programs.


And of course, all of these issues are further compounded by a lack of enforcement of NRMP communication rules—something Lostumbo says the NRMP is hoping to improve on by instituting more severe penalties for violations. Beginning next year, applicants who break the rules face a three-year ban from participating in the Match. In addition, the NRMP will report the incident to the student’s school and ask that the violation be included in the applicant’s permanent record. For programs, the penalties are equally stiff. The NRMP intends to report violating residency programs to the Accreditation Council for Graduate Medical Education and to the American Board of Medical Specialties. The NRMP will also “flag” a program to alert interested students of its past unethical conduct. Lostumbo says the mechanism for notifying students is still being developed.


Before this policy, the NRMP had no means to truly discipline violators of its communication policy. For programs breaking the rules, it could only inform the affiliated hospital or university administration, while students would be punished only at the discretion of their school’s dean.


“While the problem is not big, we are working to make sure everybody is playing under the same rules so that it is fair to everyone participating,” Lostumbo says.


Unfortunately, the more severe penalties may be rendered ineffective without greater reporting of violations. Lostumbo says applicants seldom report programs for trying to influence their rankings because they are wary of future repercussions. “It’s extremely rare that it is reported…. It is my impression that it is more frequent among programs, but we don’t know, ” she says.


So what does all this mean? Well, as Anderson and her colleagues discovered, to many students, it means don’t believe anything you hear and say whatever you need to in order to obtain a high ranking, even if you have only minimal interest in the program. And according to the 1999 article, this approach can do more harm than just rule breaking. “Such actions by both parties ultimately work against the Match process and may ultimately work to the detriment of both students and residency programs,” Anderson and her co-authors write.


SWEATING IT OUT


That was almost the case for Davis. So worried about the appearance of impropriety, the program director told the fourth-year medical student his query might cost him any opportunity to enter the program. Fortunately for Davis, though, his college adviser stepped in on his behalf. After some explanation and asserting Davis’ ignorance of the rules, the adviser had convinced the program director to soften his stance and to consider accepting him into the program through the Match. Davis’ chances were further buoyed when the program director stepped down from the post, and the replacement was unfamiliar and seemingly unconcerned with Davis’ breach of NRMP rules.


So on Match Day, Davis sweated it out, wondering if he would end up in the only program he had any desire to join and thinking about what he would do if he were forced to accept a residency away from his wife and newborn child.


When word finally came, however, all of those questions became inconsequential. Davis had been accepted. “It was elation,” he says. “I was happier than the day I had gotten into medical school…. I guess I was lucky there was a change of directors and some time had passed. In retrospect, I guess it wasn’t too wise to go in there as an outsider and announce my plan—that I intended to have one of these spots.”


Besides the relief of being located with his family, Davis says he has also been warmly received into the program, which is a stark contrast to how he felt during earlier visits. “It’s been a lot different tone,” he says. “Before they were saying ‘maybe’ or ‘we’ll see.’ Now, they are telling me that I was a top choice all along, and they were afraid I wasn’t going to match them. I guess they were just really, really following the rules.”


Ironically, Davis now finds it comforting that his residency program abided by the rules and behaved in such a straightforward manner. “In some ways, I have more respect for my program because I know they do everything upfront,” he says. “It makes me confident that there is nothing secretive going on.”


How many students and programs live up to that standard remains an unanswered question.
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Residency~
194~6September~2002-51~Perspectives~The Standardized Patient Exam~JUST ANOTHER (COSTLY) TEST.~Troy Madsen~~Standardization has become the norm in medicine. Physicians deliver a standard of care. Academic standards are upheld through licensing examinations. Standard billing and coding routines dominate medical offices’ daily practices. And the standardized patient exam, or SPE, has been praised as the long-sought tool for evaluating a physician’s efficacy in the clinical setting.


The effectiveness of the SPE in evaluating physicians’ clinical proficiency, however, remains to be proven. My personal experience with the SPE makes me wonder whether the National Board of Medical Examiners (NBME) has found the “magic bullet” of clinical evaluation in its proposed clinical component (to be given to the class of 2005) of the United States Medical Licensing Examination, or whether it has simply stumbled upon another “dud”—an exam tool that does little more than appraise students’ abilities to recite memorized information and perform rehearsed clinical rituals. In its essence, the SPE differs very little from traditional NBME examination tools. This time, though, the stage is the exam room, the patients are actors, and the high price of admission lands firmly on the student’s pocketbook.


But back to my experience. As part of my medical school’s clinical medicine rotation, course directors evaluate students’ proficiency in the outpatient setting by using a form of the SPE. Before taking the exam, the other students on the clerkship and I figured the undertaking would be an enjoyable experience; time spent in the clinic is much more interesting and much less painful than hours spent on a written exam. And an exam using real people placed in plausible clinical scenarios seemed a pleasant, objective means of evaluating our ability to communicate and solve problems in a clinical setting. After all, we were in this to be good physicians, and wouldn’t an exam evaluating a physician–patient relationship be just what we had always wanted?


When the exam day arrived, we reported to the testing site at 8 a.m. The exam proctor greeted us with an unfeeling, nonbiased handshake. She began by informing us the SPE would soon be incorporated into medical licensing exam procedures. The program’s cost was the only thing that was keeping it from becoming instituted, and students could pick up most of that cost, she said.


She then explained the logistics. We would read a short description of each case before entering the patient’s room. We would have exactly 15 minutes with each patient, all of whom were professional actors. We were told to focus on the patient’s history and physical exam. The actors would not be grading us, the proctor emphasized. The patients/actors would merely fill out a sheet with bubbles marked “yes” and “no” next to elements of the history and physical exam. They would also fill in bubbles with their impressions of our interpersonal skills. This form would then be passed through a machine that would calculate the results and give us our grade; once again, the proctor emphasized, the actors would not be grading us. A buzzer would sound at exactly 10 minutes. The final buzzer would sound at 15 minutes, at which point we must have concluded the encounter. We were to promptly leave the room; we would not be allowed to re-enter for any reason. The proctor smiled and praised the program for its ability to evaluate the full, functioning physician much better than a paper-and-pencil exam might be able to.


I entered the first room. A middle-aged woman wearing a flower-print patient gown sat with her legs hanging loosely over the edge of the light-blue upholstered exam table. I greeted her with a handshake. “What brings you in today?” I said.


She explained she was having difficulty sleeping. After a few more questions, I learned she was getting up three or four times a night to urinate. I wondered if she was urinating frequently during the day. She answered affirmatively. I began to think about diabetes. I asked if she had noticed any changes in her vision. She hadn’t. I asked about episodes of lightheadedness or loss of sensation. Negative again.


“Anything else going on?” I queried before beginning the physical exam.

“No….” she trailed off.

“Have you lost any weight?”

“Oh, you said, ‘Is anything else going on?’” she said. Apparently that wasn’t on her list of questions. “Yes, I have lost some weight. Five pounds in the past month, in fact.” I went through the physical exam, careful to maneuver the wall-tethered ophthalmoscope cord around her head.

“Good—you didn’t give me the medical-student strangle,” she said. After finishing the exam, I told her I would talk to my attending physician and return to discuss the treatment plan with her. Of course, I was not to re-enter the room under any circumstances, but we both knew that, anyway.


My next patient was in for hypertension counseling. His blood pressure was elevated at a health fair screening, and his wife had been urging him to come in for a checkup. I went through a series of hypertension questions and then jumped into the physical exam. I noticed a white sheet resting on one of the room’s hard-backed red chairs. I figured that was my cue to demonstrate my ability to drape the lower body while pulling the gown up to examine the abdomen. I asked the patient to lie back. I draped the sheet over his legs and pelvis as I skillfully lifted his gown to reveal his abdomen. I began to palpate the right upper quadrant.


“Oh, I’m so uncomfortable,” he moaned loudly. I looked at him quizzically. Had I missed something in the history? Or was this patient suffering from some sort of bizarre hypertensive gall bladder obstruction?

“Do you hurt up here?” I asked, pointing to the right side of his abdomen.

“No, I’m uncomfortable down here,” he blurted, shaking his lower legs. In the midst of draping, I had neglected to extend the leg rest at the lower end of the exam table. I apologized as I pulled the extension under his legs. I finished the exam, hoping my draping ability might counterbalance my failed exam-table-extension technique.


Patient No. 3 was a woman in her early 30s dressed in jeans and a button-down, pink shirt. She looked toward the ground as I extended my hand to greet her. A sea of dark-brown makeup stretched across the upper half of her left cheek. Four long streaks of blue makeup cut across the lower halves of each of her arms. The makeup was meant to represent bruises—the examiners had apparently decided to go just one step short of writing “I am abused” on the wall above the patient’s chair.


I asked the woman about her home situation. She said she wished she could work harder and do more, especially in light of her husband’s recent stresses. She was reluctant to admit her husband was actually abusing her, blaming herself instead for the domestic situation. She insisted I prescribe a sleeping medication. The buzzer sounded at 10 minutes. The patient began to cry. I felt a helpless ache in my heart. I talked to her about returning to see me soon. I mentioned the possibility of counseling and domestic violence resources. The 15-minute buzzer sounded. A hard knock rattled the door. Apparently I had other patients to see, and not even domestic abuse was going to let me stretch out my time limits. I bid the woman a quick farewell and left to push on in my conquest of the day’s slate of outpatient disorders.


Patient No. 4 had been through a morning of medical student torture. He was supposed to have been relieved of his duty, but the replacement actor had failed to show up. As the lone low-back-pain actor, this patient seemed to be suffering more from the pain of seeing his eighth medical student of the day than from the lumbar ache that had supposedly prompted his visit. Once the exam began, I pressed lightly on his spine. He nearly launched himself off the table.


“Oh, that HURTS!” he said. I continued to palpate softly up and down the spine. He moaned with each successive feather-weight compression. I moved my finger to the muscle paralleling his spine and pressed lightly. He moaned again.

“Does that hurt too?” I wondered.

“Oh, no, not really,” he said, catching himself. I pressed on the muscle again, and he sat quietly. I finished the exam amidst his occasional moans and spasm-like gyrations.


I left the room and completed my written summary of patient No. 4. As I wrote, I thought back on the patient encounters of the day. The proctor had praised the exercise as a measure of our effectiveness in a physician–patient interaction. As a patient myself, I thought about some of my encounters with physicians. Much of my trust came when physicians were willing to put aside the 15-minute limit to devote the necessary time to a deserving concern. I wondered if the physician–patient relationship had now been stripped to its essence: a checklist of trigger phrases and exam room rituals.


I thought about the tone of the patient histories and exams. It seemed each patient I had seen that day carried a certain air of combativeness. They reminded me of the few patients with whom I had interacted in actual clinical settings who appeared set on analyzing each move and each question, as if a lawsuit were in the front of their minds. I felt placed in that same sort of setting with the four patients I had seen as part of the SPE—as if the cooperation so necessary in medicine had given way to a game of sorts, a cat-and-mouse chase. The union of patient and physician was lost as the patients/actors smugly concealed the questions students missed and the symptoms they failed to elicit.


The SPE, I concluded, rewards an encounter that covers the elements of a checklist within a 15-minute time limit. Emotion and personal connection are secondary to a collection of required questions and physical exam maneuvers, elements that can be measured and graded objectively. In its attempt to objectively appraise the student’s proficiency in the physician–patient setting, the SPE seems to have dimmed the vision of much of the essence of this relationship: cooperation, confidence and even the bias that comes through a patient’s preference for a certain personality, a certain style and a certain trust that has developed over years of interaction.


Perhaps SPEs play a role in evaluating a student’s proficiency at recalling information and performing physical exam techniques. Participating in this type of evaluation procedure, at least the one proposed by the NBME, will require students to pay an estimated $1,000 to take the exam, and that doesn’t include the costs incurred to travel to select testing locations across the country. Whether performing this recall in front of a trained actor is worth the additional cost over current evaluation procedures seems a question worthy of serious consideration.


Certainly, medical licensing authorities can’t be blamed for their desires to incorporate licensing exams evaluating a physician’s efficacy in a clinical setting. The SPE, on the surface, appears to test a physician’s ability to interact with a patient and establish a comfortable relationship. By promoting this image, the exam implementers seem to appease educators’ desires to demonstrate their interest in physician–patient communication and effective clinical practice.


In its practical use, however, the SPE does little more than add another “hoop” for physicians-in-training to jump through in the process of medical education: an exam for which lists will be crammed, exam room procedures will be memorized and executed with precision, and exam review services will generate additional revenue. When the masks come off on the stage of the SPE, the exam is revealed to be just a test dressed up in physicians’ coats and patients’ gowns with a high price of admission and little evaluation efficacy beyond traditional examination procedures.
~~~~Troy Madsen is a fourth-year medical student at Johns Hopkins University.~Medical Education~
195~6September~2002-51~Feature~Where Have All the Surgeons Gone?~~Avery Hurt~~The typical general surgeon’s lifestyle is turning medical students away from the field, dwindling its numbers and threatening patient care. Can anything be done before it’s to late?


Nobody wants Dr. Kirby Bland’s job, it seems. And that’s surprising because he’s having fun at work, and who wouldn’t want that? Bland is the chairman of the department of surgery at the University of Alabama School of Medicine at Birmingham (UAB), and he spends his days (well, the majority of them anyway) doing what he loves most: operating on people. He finds the work endlessly fascinating, and his excitement is obvious to even a casual observer.


Arriving at the hospital early, 6 a.m. or so, Bland is bright-eyed and eager. He doesn’t shuffle around the nurses’ station hovering over a cup of coffee; instead he strides confidently down the halls, ready to begin his day. And even after 34 years of working as a general surgeon, he remains interested and focused. When he speaks with a patient before surgery, he listens carefully, bending near to be sure he hears her faint words. Later, when standing over the same patient removing a tumor—a procedure he has done many, many times—he points out details to colleagues, students and observers in the room, poses theoretical questions and comments on the procedure as he goes. He rushes from case to case with the zeal of a little leaguer between games of a double-header. When he talks about his work, one gets a sense of the deep satisfaction it brings. “Surgery is the most rewarding profession on the planet,” he says.


But fewer and fewer medical students seem to agree. Recent years have brought a disturbing decline in the number of future physicians choosing to go into general surgery. The number of applicants to general surgery residency programs has decreased by 30 percent in the past decade. In the March 2002 Archives of Surgery, published just before this year’s Match numbers were released, Bland and his colleagues estimated that by 2005, only 76.6 percent of the available positions in general surgery would be filled by graduating U.S. seniors. This was slightly optimistic; turns out only 75 percent of the available positions were filled by U.S. medical school graduates in the 2002 Match. And although foreign medical graduates filled many, but not all, of the remaining slots, analysts do not see this as a solution to the shortage. Visa restrictions and complications limit the number of foreign medical graduates, and analysts don’t expect the situation to improve soon.


For the profession, the shortage means too much work and an even more stressful environment for those who do work in this field. For society, the consequences may be even worse. With 20 percent of the U.S. population projected to be over 65 years old by 2030, the need for surgeons will only increase. The care general surgeons give is rarely the kind a patient can wait for until a surgeon becomes available. For many people, a shortage of general surgeons could be a matter of life and death.


GET A LIFE


If, according to Bland, surgery is fun and rewarding, then why are students turning away from it? Many theories have been proposed, from regulatory hassles to money. (General surgeons often make far less than their counterparts in surgical specialties; according to a survey by Physicians Search, the average annual salary for a general surgeon in practice for more than three years is $261,276. Cardiovascular surgeons in practice for more than three years average $558,719.) Almost everyone who has seriously studied the issue, however, agrees these are relatively minor concerns. The real problem is, as one resident puts it, “lifestyle, lifestyle, lifestyle.”


Surgical residencies are notoriously brutal; they are also long. A typical residency in general surgery can last from five to eight years. To most surgical residents, Bland’s 14-hour days of dashing from case to case and meeting to meeting sound like a week at the beach. Surgical residents typically work in excess of 100 hours a week, and these are difficult, exhausting hours. According to Dr. Howard Wilson*, a fourth-year surgical resident at a West Coast medical center, “It’s harder than most people think. One hundred hours is a good week; 135 is not uncommon.” That’s a grueling schedule even in a profession filled with overachievers and dominated by a hypertrophied work ethic. Wilson also says the work environment, while stimulating and challenging, can be overwhelming, thanks to the intense stress and the “high level of immediacy” in most surgical procedures.


In June, the Accreditation Council for Graduate Medical Education (ACGME) revised its standards to reduce the number of hours residents are allowed to work. Under the new regulations, residents cannot be required to work more than 80 hours a week, cannot be on call more than every third night, and must have at least 10 hours of rest between work shifts. Though this may come as a relief to exhausted residents who no longer see the irony in the phrase “36-hour day,” surgical residents are not holding their breath. The guidelines include a clause, a loophole if you will, allowing programs to request an exemption to these rules by presenting their cases to the ACGME Program Requirements Committee and to its board of directors. Many surgical residents say the reality of their residencies is not likely to change.


And lifestyle is extremely important to today’s generation of medical graduates—much more so than it was to previous generations. In fact, for many in the medical profession, the all-work-and-no-play (or rest) lifestyle is a respected tradition. The older generation of surgeons often considers this type of training something of an initiation, a rite of passage. But like many traditions, this one may have outlived its usefulness, for modern medical students represent a new breed of physicians.


In a recent Archives of Surgery article, Dr. Stephen Evans examines this issue. Evans, who works in the department of surgery at George Washington University Medical Center in Washington, D.C., notes that looks can be deceiving. For although the new surgeons are still, for the most part, a white male club, they have other goals, values and what Evans calls “lifestyle demands.” According to him, today’s physician-in-training “does not subscribe to the regimented, hierarchical thinking that marks surgical training” nearly so much as his predecessors did.


Bland agrees with this assessment. “Today’s medical student demands more time for family and leisure. A career in surgery simply offers less time for either,” he says, and future physicians echo his comment.


Bill Hudson, a third-year medical student at UAB, says he enjoyed his surgical rotation but has “pretty much ruled out surgery.” As of now, he plans to specialize in Ob-Gyn, where the lifestyle is better, but not by much. Hudson prefers Ob-Gyn, however, because he likes the continuity of care. “You get more good outcomes in Ob-Gyn,” he says. For Hudson, the issue is not just time, but quality of life.


Even Dr. Jennifer Boll, a second-year UAB surgical resident, looks to an eventual escape from the profession. “I chose surgery because I like the problem-solving aspect of surgery and I like working with my hands…. [But] I may go into plastics because I want a family. I want more control of my life.”


Lifestyle issues are important, but for some, the challenges and satisfactions of the job are worth the sacrifices. Of course, some physicians just manage it better than others do, thanks to tremendous support networks. Dr. Atul Gawande has survived seven years of an eight-year surgical residency while being a husband, fathering three children and writing a book about medicine called Complications: A Surgeon’s Notes on an Imperfect Science. When asked how he manages it all, he gives much of the credit to his wife, who stays at home and takes care of the children and household affairs while he’s working. She also makes sure he gets a few hours writing time on the weekends. “Family support really helps a lot,” he says.


SO WHO DOES GO INTO SURGERY?


There is a common perception, among the general public at least, that surgeons fit a typical personality profile—a profile that’s not terribly attractive. A surgeon is arrogant, insensitive and definitely not “a people person.” Is it true that it takes a certain kind of person to do this work? If so, is that kind of person becoming as rare as a Siberian tiger?


Gawande thinks the stereotype of a surgeon is just that: a stereotype. However, he does agree that the very nature of the job requires, and perhaps nurtures, certain traits. The old saying about surgeons, “sometimes wrong, never in doubt,” gets to a truth about the nature of the work, he says. To perform a surgery, one needs a “fierce sense of personal responsibility and a tremendous amount of self-confidence.”


Boll agrees. “Self-confidence is absolutely necessary. There’s no time to second-guess. You can’t be wishy-washy or the patient will die,” she says.


Surgeons may occasionally seem overly sure of themselves, but according to people who do this work, that’s a plus, not a negative. “If you have a hard time making decisions, this work is not for you,” Wilson says.


Gawande believes there are other personality traits necessary to being a good surgeon. “The need to make sure that things go right technically can lead you to forget the human aspect of what you are doing, and surgeons can sometimes be coldhearted, but most surgeons I know don’t fit the stereotype,” he says. “A good doctor, no matter what the specialty, must have two things: competence and kindness. And there is no reason, even in surgery, to sacrifice one for the other.”


Wilson concurs. “I’ve seen a little of the prima-donna surgeon behavior, but not much. The ones who are the most likely to fit the stereotype tend to be the worst doctors.” Fortunately, for all of us, the image of petulant surgical geniuses flinging scalpels and shouting at support staff seems to be more a feature of television than of the OR.


“I haven’t been yelled at all this year,” Gawande says cheerfully.


If the personality stereotype doesn’t hold up, there are still certain skills and habits necessary to succeed in this field. According to Bland, a surgeon must be highly organized, extremely punctual and pay relentless attention to detail. Manual dexterity is helpful but can be learned, he says. And these physicians must be willing to study and practice, practice, practice. Therefore, a strong work ethic is required.


Wilson says it also helps to be the type of person who can get by with little sleep. “I do well on less sleep than most people. Those who need sleep at night don’t go into surgery,” he says.


These characteristics may not be the stuff of drama, but they are certainly traits any patient would like her physician to have when she goes under the knife. Still whatever traits the job demands, choosing surgery as a profession is rarely a calculated decision. Surgeons say that medical students just seem to know whether or not it’s for them when they first encounter surgery. “For many people it does seem to be a calling of sorts,” Gawande says.


Watching Bland work, or even listening to him talk about his work, makes one see how this could be true. It’s difficult to imagine him doing anything else. And staying in the field for so long has its perks; now that he’s older and highly placed in administration, Bland operates only three days a week, spends one full day in the clinic, and one day is devoted to academic and administrative duties. But even when he is out of his scrubs and sitting around a conference table (a job he does with the same drive and energy he brings to the OR), his eyes glimmer a bit more when he talks about surgery.


SURGEON, HEAL THY PROGRAM


Even if surgery is a calling, the fact remains that fewer and fewer people are being called to it. The looming crisis can be averted, but doing so may require serious and fundamental changes in a profession not known for its enthusiasm for change. If lifestyle issues are indeed the primary reason for loss of interest in the field, then graduate programs in surgery may be forced to reduce their hours or face even grimmer numbers.


This will not be as easy as it seems. It’s not pure stubbornness that has made general surgery programs among the most resistant to the idea of limiting resident work hours. One of the reasons residencies in general surgery are so long and the hours are so demanding is that it takes time—lots of time—to get the experience necessary to perform the wide variety of procedures that come up in the career of a general surgeon. Learning the pertinent skills and developing the necessary confidence takes plenty of practice. Just as tennis players get good by hitting ball after ball after ball, surgeons get good by cutting incision after incision. The problem is not insurmountable, however. Several suggestions have been made that might help.


New technologies, such as online instruction and computer programs providing “virtual” surgical experience, could take the place of some actual OR time. Hospitals could hire more support staff and rely less on residents for paperwork and other tasks that could just as easily be done by others, freeing residents to spend the time they are at work actually learning and gaining experience. Dr. Janet Compton*, a surgical resident at an Eastern medical school, says she spends a lot of her time completing tasks that don’t really require a medical degree.


“In residents, the American Hospital Association has the best and cheapest labor force in the world,” Bland says. “If we were to pay residents according to the hours they actually put in, that would help tremendously.”


Because half the potential applicants for general surgery positions are female (50 percent of medical graduates are women), some consideration also needs to be given to such issues as maternity and family leave.


Other suggestions include ensuring residencies offer rich learning experiences and that students are introduced to surgery early. Many students get little or no experience with surgery until their third-year surgical rotation. Bland recommends first- and second-year students be offered tours of the OR and other surgical work environments, and have the chance to attend frequent seminars on surgical techniques. By gaining exposure to surgery early in their training, medical students would be more likely to develop a lasting interest in the field, he says.


Evans points out that for most students, exposure to surgeons is spent with residents at the hospital. And even during surgical residencies, physicians-in-training don’t get an accurate view of what the life of a surgeon is like beyond residency. Evans and Bland both recommend students be offered the opportunity to shadow a surgeon, giving them a chance to see not only what goes on in the hospital, but what clinic days are like, and letting them experience the lifestyle of a general surgeon in private practice.


Perhaps most important, teaching hospitals could adopt the suggestion of the American College of Surgeons and ensure that surgical residents work and learn in an environment that is “mutually supportive between attendings and residents” and one in which residents are “treated with respect and dignity.”


If the number of future physicians choosing surgery as a specialty continues to decline, changes must be made. Some of these changes are undoubtedly overdue and will be welcomed by physicians-in-training and attendings alike. Better working conditions and a chance to have a life outside the hospital may be just the incentives necessary to encourage future physicians to seek the pleasures and rewards of a career in general surgery.
~While big city and academic medical centers are worrying about the likelihood of a future shortage of general surgeons, rural America is already deep in the throes of such a crisis. In part because general surgeons are more likely to be trained in large urban areas and so have become accustomed to the lifestyle of the city, and in part because general surgeons have little experience or knowledge of what it would be like to practice medicine in a rural area, few surgeons choose to practice in rural regions.


Dr. Richard Field Jr.—a 75-year-old general surgeon who heads the Field Clinic in Centreville, Mississippi (pop. 1,771)—has been studying this problem for many years. His father started the Field Clinic 75 years ago, and Field followed in his footsteps, with his son continuing the tradition; Richard Field III is also a surgeon at the clinic. But the senior Field worries about what will happen when he retires, something he is sure to do soon.


“There is no one to replace me,” he says; his son can’t handle all of the work on his own. The shortage of surgeons is a serious problem for the 51 million Americans who live in rural areas. “These people can’t get by without a surgeon. There isn’t always time to get them to Baton Rouge,” he says.


Rural surgeons don’t make as much money as their urban counterparts. “A lot of the people here are poor,” he says. But the rewards of helping people and saving lives are just as great as in the city, he says. The work is also stimulating. “We see a wide variety of cases here, from appendectomies, to ruptured spleens, to car accidents and gunshot wounds.”


And although it may come as a surprise to some, a rural life can be advantageous. “We work hard, but the lifestyle is great. It’s a great place to raise a family,” he says. For surgeons seeking professional stimulation, but a relaxed and peaceful personal life, a rural practice might be an option worth considering. —A.H.


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


The American College of Surgeons’ Web site offers useful information to help you decide if surgery is for you. Find “So You Want to Be a Surgeon” at www.facs.org/residencysearch/
contents.html.

The Student Doctor Network also has a great deal of information (and links to other sites) for those considering surgery.

Women considering careers in surgery might want to investigate the Association of Women Surgeons. It has a useful manual called “Pocket Mentor: A Manual for Surgical Interns and Residents” posted on its Web site. Visit www.womensurgeons.org/.

Dr. Atul Gawande’s book Complications: A Surgeon’s Notes on an Imperfect Science offers a thoughtful and sometimes surprising look at some of the experiences and issues that arise during a surgical career.
~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~Career Development,Medical Education~
196~6September~2002-51~Feature~Tailing Disease~THE EPIDEMIC INTELLIGENCE SERVICE FINDS RENEWED SUPPORT FROM CONGRESS IN A BIOTERRORISM WORLD.~Jennifer Zeigler~~There are things that happen to you when you’re an Epidemic Intelligence Service (EIS) officer that you just don’t tell your mother. Mothers are worriers by nature, and so naturally, internist Daniel A. Singer didn’t tell his mom about his experience with that angry mob in India.


Working with the World Health Organization’s (WHO) global polio eradication program, Singer was traveling through the rather lawless area of Bihar when it happened. There are common-sense rules to follow when one sets out at night in this part of India with only a driver and a translator. Rule No. 1: If you get in an accident, just leave the scene. What would be considered a hit-and-run in the United States could very well save your life in Bihar.


Rule No. 1’s relevance was evident to Singer’s party as it encountered a roadblock: An angry crowd had gathered after a truck hit and killed a young girl. Sending his translator out to negotiate passage through the crowd, Singer knew this was a dangerous situation. So when the translator returned with a few of the marauders, he hoped they were climbing into his truck merely to guide it through the crowd.


No such luck. The men instructed his driver to go faster and faster, and Singer realized they were on a murderous search for the girl’s killer, and he was just along for the ride. “Now, to me, all Indian trucks look the same, but they see this truck ahead and make our driver speed ahead and force [the suspected hit-and-run driver] to pull over. The men get out to beat up the driver, and I said, ‘You know what? We have to get out of here.’”


They escaped the situation, but it was difficult for Singer to forget what happened. “I just felt horrible about it. I kept checking the papers [for a notice about the incident], but there never was.”


Now, Mother Singer, you might want to disregard what you just read. “I told my father, and he said, ‘Do not tell your mother,’” he says.


And there are lots of other people who are better off not knowing exactly what EIS officers are doing. Last fall, the housekeeping staff at the Washington, D.C., Holiday Inn was probably better off not knowing that behind a permanently hung “Do Not Disturb” sign was not a pair of frisky honeymooners or even just someone who needed a lot of naps, but the Centers for Disease Control and Prevention’s (CDC) Washington supply of anthrax vaccine—plus some for a few other nasty diseases, just in case.


And really, much of the nation is unaware of what EIS officers do, and this works to their advantage. It’s an aspect the program even promotes. Known as the CDC’s “disease detectives,” EIS officers seem clandestine—a Hollywood creation. But thanks to an unprecedented deployment in response to last fall’s terrorist attacks, more people now realize the EIS has been around for more than 50 years, identifying new diseases and quelling outbreaks worldwide, and lawmakers have shown their appreciation with an outpouring of cash.


In the beginning, there was Langmuir
The CDC created the EIS in 1951 as a two-year fellowship program in an attempt to train more epidemiologists to serve in state-level public health departments. At first, the EIS lacked federal support. “It was hard to persuade a lot of people 50 years ago there was a need for epidemiologists,” says Dr. J. Lyle Conrad, M.P.H., the retired former director of the CDC’s Division of Field Epidemiology. Luckily, though, Dr. Alexander Langmuir, M.P.H., the CDC’s chief epidemiologist at the time who founded the EIS, was a shrewd congressional lobbyist who knew how to squeeze lawmakers for cash. Pegging the program as a way to establish federal defenses against a Cold War bioterrorist attack, Langmuir won his funding.


Fifty years later, Langmuir’s legacy came true. The days after Sept. 11 found the EIS deploying the largest number of officers at one time to New York City, and many others were sent to find the source of the anthrax attacks. One hundred and thirty-six officers—just 10 shy of the total number of EIS officers employed by the CDC—were involved in the response in one form or another.


But for the past 50 years, EIS officers have spent most of their time doing more preventive and public health work—tracking disease outbreaks, rooting out the causes and reporting their findings back to the CDC. If botulism breaks out in Butte, meningitis menaces Michigan or cholera cripples Cancun, EIS officers are probably there, interviewing victims, taking samples and tracking microbe paths, practicing what is known as “shoe-leather epidemiology.” Along the way, the officers have fingered such previously unknown maladies as the Hantavirus and Legionnaires’ and Lyme diseases.


But EIS officers can’t investigate everything. The public health system in the United States is structured on the state level. Each state, and many municipalities, have their own public health departments that conduct surveillance and respond to outbreaks within their jurisdictions. The CDC doesn’t oversee these departments. It just aids them and those in foreign countries—when they ask.


“Without an authorization from a city or state, authorities from the CDC can’t go anywhere,” Conrad says. (The exception is cruise ships.) And that includes the EIS, which, as a part of the CDC, is an agency of the U.S. Public Health Service. “We actually think that’s a very healthy way to have it,” Conrad says, adding that Washington’s inside-the-Beltway public health bureaucracy necessitates the decentralized system. “The states know they’re on their own, but right from the start we put [EIS] officers in the state health departments.”


The CDC accepts about 73 officers each year—this year there were 89, thanks to an influx of funds from the bioterrorism response legislation in Congress. They take two-year posts based either at a CDC research center or directly with a state health department. More than just physicians, officers—about 60 percent women and 40 percent men—hail from a host of allied health fields: veterinarians, pharmacists, nurses and dentists. About 65 percent of the officers are physicians, who must complete at least their intern year of residency before joining the EIS, and about half of them have their M.P.H. The U.S. military and Department of Agriculture also sponsor their own officers in the program. Most EIS officers choose to enter the program through the Commissioned Corps and are assigned a military rank, which determines their pay, usually between $30,000 and $80,000.


Singer, for example, was based in Atlanta during his 1999–2001 EIS stint with the Division of Global Migration and Quarantine, which meant he was sent to outbreaks dealing with disease in immigrants, travelers and refugees. From their home bases, officers can be asked to go anywhere to do anything—and they may only have an hour to pack before the plane takes off.


THE STUFF OF MOVIES


Dr. Marc Traeger was in rural Madison County, Florida—far from any airport—on Oct. 4, 2001, searching for West Nile virus when he got a call. As a state-based EIS officer, Traeger had been working all summer on the first cases of West Nile virus to appear in Florida, and he had just returned to the field a few days earlier, having spent 10 days in New York City assisting with bioterrorist surveillance at Ground Zero. “I’m getting pages, but I’m in a cell-phone dead zone,” he says.


His boss’ secretary finally got through with a cryptic message: “Go to the airport and get on a plane.” With a shoddy cellular connection, Dr. Stephen Wiersma, Florida’s state epidemiologist, was finally able to give him a little more information: There’s a confirmed case of inhalation anthrax in Palm Beach County. Wiersma reiterated his secretary’s message—the plane to Palm Beach was leaving in an hour, and Traeger needed to be on it.


Racing down 50 miles of backcountry roads, Traeger made that plane—and a little history—as he became the first EIS officer on the scene in Boca Raton where anthrax first appeared in October.


“I called my wife on the phone and said, ‘I’m going to Palm Beach County, and I can’t say why, but if it’s what I think it is, it will be on the news tonight,’” he says.


That first night, public health officials met for a briefing. “Anthrax was always at the top of the list [for a possible bioterrorist attack]…but here we had just one case—it wasn’t like someone had sprayed a football stadium with it,” he says.


So the epidemiologist began looking for natural sources, such as animal skins, the victim, Bob Stevens, might have come into contact with. “We basically traced his steps of everywhere he had been for the past 60 days.” In the meantime, Traeger began establishing a surveillance system in the county’s hospitals, looking for other cases. “And actually, in three days we had an answer.”


The detectives broke the case when a co-worker’s nasal swab for anthrax spores and a desk sample at Steven’s office, American Media, tested positive on the same day. Traeger says basic shoe-leather epidemiology teaches you to look closely at the workplace and family any time there’s an outbreak.


From then on, the EPI-AID, as the CDC calls EIS deployments, was linked to a criminal investigation. “The No. 1 public health measure in this instance was catching the bad guy, because that will ultimately stop the outbreak. And we’re still working on that,” he says. Two days later, officials knew the spores came to the workplace via the mail, and from that point on, Traeger was primarily responsible for processing the American Media workers, conducting nasal swab tests, finding out where in the building each one worked and supplying antibiotics to those who needed them. By now, there were dozens of other CDC and law enforcement officials on the scene, but “since it was my state, it was clear that I was there for the long run,” Traeger says.


Turns out, he was in Boca Raton for about two weeks, although even in June he was still tying up loose ends. A family man himself, Wiersma had sent him home before all the anthrax activity died down. Traeger had spent only several days at home since the summer, when he and his wife adopted a baby.


This kind of personal sacrifice is common among EIS officers. They miss celebrations and family events—one nearly missed her own wedding—but the work is worth it, they say. Traeger says even with little George waiting for him at home, it was hard to tear himself away from all the action. “Seeing the U.S. president discuss it and the secretary of health discuss it and realizing that it’s what you’re working on…was just amazing.”


Even without a national tragedy, there are always loads of high-profile epidemiology to be done. “The fact is that every few years a big new investigation comes up that EIS is going to be a part of,” Traeger says.


Singer learned just how interesting new diseases are to the media. In addition to being sent to India to help find and vaccinate polio cases for the WHO, which frequently recruits the EIS’ help, he spent about four weeks in the summer of 1999 helping the New York City health department track down the first American cases of West Nile virus. Based in a tiny outpost health department in Queens, Singer spent his early days of the EPI-AID looking at maps and targeting neighborhoods for potential victims. The plan was to conduct a door-to-door search, taking interviews and blood samples. But Singer hadn’t counted on just how piqued the notoriously aggressive New York City media would be at the idea of a new disease emerging within its city limits.


“When we came out [of the health department], there was this bank of cameras,” he says. He knew he couldn’t conduct interviews with a pack of journalists in tow—it’s bad enough when a government agent shows up at your door asking health questions and drawing blood. So, officials sent out decoy teams who drove around for 20 minutes “until the media figured out they weren’t going anywhere.


“The best part about EIS is you learn basic epidemiology techniques, but you learn them with a political component,” Singer says. But that doesn’t mean EIS officers get mired in political wrangling about money, overseas spending or public health priorities. “Politics do happen, but…these decisions are made for you,” he says.


That’s the best way for officers to learn, says Jim Hayslett, a doctor of pharmacy with an M.P.H. who was with the EIS from 2000 to 2002. “There’s stuff that had to get done, and you didn’t want to get sidetracked by some political bullshit. I think it worked really well.” He understands the need for autonomy, having spent four months in Washington, D.C., investigating anthrax. He says he grew used to concern coming from a multitude of interested parties.


Hayslett spent the bulk of his October-to-February tour of duty in the nation’s capital communicating facts about anthrax and its treatments to postal workers. “I got here and the first thing I did was I ended up spending two weeks in an office in the back of the Capitol with half a dozen other people on the intervention team, and we transitioned out of there to the Brentwood post office for three days before it closed. And we all walked the floor and looked at the machines and did everything else. So all of us that were in there got 60 days of antibiotics, just like the rest of the workers. I stood right in front of the No. 17 machine that sorted that mail [at Brentwood].” And while Hayslett says he wasn’t scared—“It’s all personality”—he does admit that “my mother was a little freaked out.”


Communication was key for the CDC in the anthrax investigation, Hayslett says. It was also one aspect of the agency’s response that was criticized both in the media and by government officials. But for Hayslett, it was all about the postal workers. He traveled to 21 city post offices to talk about anthrax, the antibiotics to treat it and the vaccine, which the CDC was providing to those who wanted it. “If [workers] feel like they are a part of this intervention, then they may actually take 60 days of antibiotics,” he says. “If they feel like they’re just on the fringe, they don’t have any control anyway, so what’s the point of taking them now? So by making sure you have good communication with these people, you minimize the chance of any delayed case popping up and encumbering the system all over again—because it was stressed.”


JUST GOOD PUBLIC HEALTH


But not everything is as high-profile as bioterrorism. When they’re not on an EPI-AID, most officers are often running outbreak analyses or designing surveillance systems to monitor an area for disease or injuries. “Depending on your supervisor, there are supervisors who think you’re just a data monkey, that your goal is to put data in,” Hayslett says. “And that’s part of the gig, there’s no doubt about that.”


Dr. F. Douglas Scutchfield, an EIS officer from 1967 to 1969, spent all of his fellowship at Emory University focusing on family planning and obstetrical epidemiology. “This was a new idea,” he says. “Until then, EIS had been all about infectious diseases.”


Scutchfield ran clinical trials on then-new contraceptive technology, such as Depo-Provera and what would be the beginning of emergency contraception. His one EPI-AID didn’t even take him away from Emory: When the EIS was asked to investigate the cause of a series of perforated uteruses in women using IUDs at Emory, the program knew just who to send—even if it was from just down the hall.


Orthopedic surgeon Sandra Berrios-Torres also found a way to incorporate her clinical interests with epidemiology during the two years she spent with the EIS. The bulk of her assignments focused on developing a surveillance system and training manual for physicians in Central American countries to use when seeing patients with injuries. Far from a more traditional EPI-AID, this type of work is an important function of the CDC’s public health purpose, because by establishing systems to track disease causes, communities can then begin to prevent them altogether, she says.


A lot of what an officer does depends on what post she accepts, for the CDC doesn’t assign them to a specific position. New officers select their posts at an EIS conference every April. There are more positions than officers, and red tags on name badges identify new recruits. Singer calls it the closest thing to sorority rush week that he’s ever been to. “People would start talking to you about how great their division is and how much fun it is to work on, say, viral diarrhea,” he says jokingly. “At the end of the week you want to hide your little red ribbon.”


Personality types affect where officers go. Some don’t want to be sent on EPI-AIDs, perhaps because of family needs. They often end up in Atlanta or Washington, D.C., working in one of the CDC’s more statistic- and research-based centers. Those who want to be on the road all the time might go to the National Center for Infectious Diseases (NCID). Hayslett wanted the EPI-AID experience, but he also wanted to take charge of his own destiny, so he took a state-based position at the Texas Department of Health. State officers get first dibs on any EPI-AID within their borders, but they don’t have to take an assignment if they don’t want to. “I wanted a position where, when they came downstairs and said, ‘We’ve got a cluster of hepatitis A up in Paris, Texas… —and hepatitis A is pretty boring—I could turn that down. [But] if I worked for [NCID], I’d be up there. So when they came down and said, ‘Botulism,’ I said, ‘Sure!’ I traveled because I like to travel, [but] places I want to go.


“And you’re going to these places where…I mean, some of them are just wild. Just wild outbreaks. There were outbreaks in Kansas—was it hepatitis or tuberculosis—of strippers. I mean, that would be a cool one,” he says, jokingly. “And that’s not flashy public health. It takes the right person in the right place.”


Dr. Scott Harper was one of those officers in the right place. Having spent years abroad practicing internal medicine, he didn’t mind constant travel and joined the NCID, focusing on viral and rickettsial ailments. After working for a few months in the influenza branch, Harper got word in the fall of 2000 that he was needed in Uganda to investigate an Ebola outbreak. “I didn’t come here with the inclination to be a virus hunter,” he says. “I just happened to be in the right place at the right time.


“That was a difficult outbreak. It was my first. People wanted information in a hurry, and it had to be accurate information, and [the multilevel political hurdles of international work] make it more difficult.”


His job—finding and stopping the cause of this most recent Ebola flare-up—was made more challenging by the loss of a colleague. EIS officers will tell you they’re rarely afraid of their work. They take every precaution for themselves and at most come home with nothing more than exhaustion from working 14- to 20-hour days. But when local physician Matthew Lukwiya, who first realized the Gulu outbreak was Ebola, died of the disease, it hit the entire response team hard, Harper says. “There’s a trench mentality on outbreaks,” he says. “The work is reasonably dangerous, and you make friends fast. The loss was difficult.”


It can also be tough for physicians like Harper to work on an EPI-AID only as epidemiologists, leaving the doctoring to others. “Knowing what your role is is very important,” he says. “The main point is to control the outbreak, [but] it’s actually a two-way street. You have to know what your priorities are.”


But in the midst of all the suffering, the maverick personalities the EIS attracts also manage to find humor in almost every situation, and their stories become yarns for the ages. Hayslett’s best comes from working on a botulism outbreak in Dallas.


“You couldn’t have asked for a sweeter group of people. The woman who cooked the food put four of her sons on ventilators and her granddaughter and her great-grandson on ventilators. Can you imagine being a 75-year-old woman and just about killing half your family?


“So we go looking for…[any cases] that got misdiagnosed. And it turned out that this was a case where they thought this woman had a stroke, but it turned out she had a minor case of botulism.


“Well, obviously one of the things we need is a stool sample.” The older black woman was in her hospital bed, and “her wig is twisted off. She looks…like Don King’s mother. So [my colleague] says, ‘I wonder if I could get some poop from you.’ And the lady goes, ‘Oh lordy, I done give that to the city of Dallas.’ And so [my colleague] says, ‘Do you remember who you gave it to?’ and [the patient] goes, ‘Oh no, lordy, I gave that to ’em yesterday.’ And I said, ‘Megan, Megan, she’s trying to tell you she went to the bathroom.’ I said, ‘Ma’am, did you go to the bathroom yesterday and give it to the city of Dallas by the sewage system?’ And she says, ‘Oh, yeah.’”


AFTER THE EIS


After two years of traveling to and investigating outbreaks, the CDC hopes officers will take their on-the-job training and apply it to the many state and municipal health departments. Conrad says Langmuir’s experiment worked. “You can go to a state health department and about 50 percent [of the state epidemiologists] have come through the EIS.”


And to be sure, a quick survey of a handful of state epidemiologists proves that most of them did come through the EIS. But the same can be said for the CDC headquarters in Atlanta—hundreds of CDC employees have also come from the EIS. And both Traeger and Singer have left the EIS to apply their newly found epidemiological know-how in various areas of the federal government—Traeger at the Indian Health Service in Arizona and Singer in the Office of the U.S. Surgeon General in Washington, D.C.


About 35 percent of the officers go on to federal service, and 11 percent land at a state or local health department. Another 25 percent go back to private practice, 15 percent end up as university faculty, as Scutchfield did, 7 percent work for international health organizations and 6 percent work in some other area of the health-care industry.


But even though Conrad is satisfied with the program, these statistics don’t sit well with Stephen Wiersma, Traeger’s supervisor in Florida. As the chief of the state’s Bureau of Epidemiology, he says the federal EIS program isn’t building state-level infrastructure as it was intended to because officers take more comfortable positions at the CDC.


In a response to the need so clearly identified in the Florida anthrax investigation—the state had only one EIS officer to call, although the CDC sent others—Florida Gov. Jeb Bush authorized $350,000 in state funds to create a state-based EIS program. Until then, California had the only other state-based EIS program. The first six Florida officers began work in April and have been investigating outbreaks around the state.


The program differs little in structure from its federal counterpart: Officers sign on for a two-year, on-the-job training fellowship in exchange for a modest salary and benefits. State officials hope that by integrating officers into the state career system from the beginning, they will be more apt to stay on at the end of two years.


The program is scheduled to double its number of officers next April, and the increase in staff is part of a post-anthrax trend in Florida. “I was scheduled to take a five-person cut,” Wiersma says. Those positions—his five best epidemiologists—have since been restored.


PAYING THE PIPER


Florida is not the only public-health funding winner in anthrax’s wake. The CDC can give thanks for its additional 16 officers this year to stepped-up congressional interest in the wake of Sept. 11. “Folks have recognized the value of EIS officers—they’re trained epidemiologists when they finish,” says Dr. Doug Hamilton, the EIS program’s director. “There has been an increase in Washington in recognizing the importance of EIS. In many ways, EIS officers were the tip of the spear.” Hamilton is referring to the 36 officers flown to New York City on an Australian Air Force C-130—that just happened to be in Atlanta on Sept. 11—“on a day when only two nonmilitary planes were in the air: the president’s and this one.”


The program’s numbers have steadily grown since 1951 when 23 officers joined up. Congress gave $11.8 million to fund the EIS in FY 2001 and provided $11 million this year. Counter-bioterrorism spending provided an additional $8 million to the program.


But Hamilton says the boon to the EIS could mean hard times for other areas of public health, which could result in more work for the EIS in the future. “Priorities can change quickly. My impression is that other areas of CDC are being hit hard by cuts in funding.”


Each member of the federal government has his own priorities about where funding should go, and U.S. Health and Human Services Secretary Tommy Thompson is no exception. An early supporter of the EIS in the post-Sept. 11 scramble for money, Thompson began by publicly stating he wanted an EIS officer in every state. Until this year, about 20 states secured officers each year. Changing his mind, he then said he wanted an EIS-trained epidemiologist in each state to act as a resource. So the majority of this year’s additional officers didn’t go through the traditional match process at the EIS conference and instead were accepted into the program for a specific state or municipality. Hamilton says not every state can support an officer; a lack of available funds or a permanent epidemiological infrastructure can preclude some states from taking one on. In those cases, the program sends a team of about 10 EIS-trained CDC officials to build up a state’s capacity to train an officer.


But the increasing strength
in state programs is evident to Hamilton in the decreasing number of requests for aid. In Langmuir’s day, it was between 200 and 300; today that number is between 80 and 100. “State health departments are much better now at dealing with these investigations,” he says. But, he adds, the continued need for the EIS is evident in the officers’ busy days and many states’ incapacity for training.


Conrad thinks there is room for even more officers—as many as twice the number the CDC employs—which would cost around $100,000 per officer for salary and support, he says. “For my entire career…we’ve been screaming to Washington for more bodies.”


If more funding comes, it shouldn’t be difficult to fill the new positions, from the way Singer talks. “As far as public health goes, the most exciting work is EIS.”
~LEARNING THE ROPES


Think the Epidemic Intelligence Service (EIS) sounds like fun, but don’t want to wait until after your intern year to give it a go? The Centers for Disease Control and Prevention (CDC) hosts between 40 and 60 fourth-year medical students each year for an EIS elective rotation, and past students say it’s a great way to see what the EIS is all about.


“It’s a huge amount of gratification for what is a short amount of work,” says Dr. Daniel A. Singer, who completed the elective in 1996 before coming back as an officer.


A six- to eight-week elective, the program tries to accept nearly every student who applies. “If they can bear with me, I continuously try to place students,” says program coordinator Patsy Bellamy. Students are based in one of the CDC centers, and about 75 percent of them go on outbreaks with EIS officers. Singer says the agency makes a serious effort to get those who are interested on investigations.


The resulting experiences often go beyond normal student activities. Bellamy says many students end up with a lead authorship on a journal article.


She also says the program is a great recruitment tool for its parent fellowship program, with about 10 of the EIS officer applications each year coming from former elective students.


The program’s application deadline is in May of the student’s third year of medical school. For more information about the elective, call (888) 496-8347 or visit the CDC’s Web site at www.cdc.gov/epo/dapht/eis/elective.htm. For more information on the field of epidemiology, visit the American College of Epidemiology Web site at www.acepidemiology.org. —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician.~Community and Public Health,International Health,Medical Research~
197~7October~2002-51~Feature~Dr. IMG~DIVERSE INTERNATIONAL GRADUATES ATTEMPT TO GAIN RECOGNITION IN US HEALTH CARE.~Scott T. Shepherd~~For more than a decade, Dr. John Madden has been taking care of patients. When he first meets them, the usual small talk ensues with brief discussions about the weather or family life. And then on the rare occasion, a patient will ask him where he received his medical degree. He quickly replies, “St. George’s University.” The patient sometimes follows up with additional questions, but more often than not, the patient will shrug his shoulders and the exam will continue.


“Patients rarely ask about what school I went to, and when they do, they just think it’s a U.S. school they’ve never heard of,” says Madden, the associate chairman of the Emergency Medicine Unit of Christiana Care Hospital System in Newark, Delaware. “Patients just really don’t care about that.”


St. George’s is a medical school in Grenada and sends the majority of its graduates into the U.S. medical system. That makes Madden an international medical graduate, also known simply as an IMG.


However, this label means very little to patients and many fellow health-care professionals. Once you’ve established yourself as a physician, where you received your degree often becomes a non-issue, most IMGs say. “It has always been that the proof is in the pudding,” says Madden, who received his medical degree in 1981. “If you are a good clinician, then you’re a good clinician.”


But where you receive your degree is an issue during your medical training. For decades, IMGs have been the center of debate and controversy in the medical education community. Critics have questioned the quality of education that IMGs receive and argued that they’re contributing to a physician glut in the United States. The concerns were in part perpetuated by a 1991 report by the Educational Commission for Foreign Medical Graduates (ECFMG), the organization responsible for verifying the credibility of foreign medical degrees. The report indicated that IMGs scored significantly lower on medical licensing examinations than their U.S. counterparts. And while IMG scores have improved substantially, they continue to lag scores of U.S. graduates.


The reputation of IMGs was previously muddied when two Caribbean medical schools were shut down in the mid-1980s after being implicated for producing counterfeit diplomas. And then in 1992, the U.S. General Accounting Office discovered a school in the Dominican Republic granting worthless degrees.


These problems contributed to a negative image of all foreign medical schools and their graduates. “From the majority of my American colleagues, I heard that foreign medical schools were second-rate, and that I might find it difficult to obtain a good residency in the U.S.,” says Benjamin Davis, a second-year student at Ross University School of Medicine in Dominica and the international trustee for the American Medical Student Association (AMSA).


CHANGING IMAGES


However, time has slowly begun to erase images of fraudulent foreign medical schools, and it is becoming increasingly difficult to place these general criticisms on every medical student who has completed his preclinical work at one of the approximate 1,400 medical schools outside of the United States, its territories and Canada. IMGs have come to represent a group of physicians with diverse backgrounds and varied educational and clinical experiences.


“A lot of [the criticism] is not true and does not differentiate graduates’ nationality and where they went,” says Dr. Seth Tuwiner, a graduate of the Technion School of Medicine in Israel and a neurology resident at the University of Southern California. “The success of a foreign grad is a function of nationality, school, whether or not this person has done rotations in the U.S., connections, research experience, board scores. We are all not in one category.”


In reality, international medical graduates are just as diverse and unique as their U.S.-educated counterparts. Within the IMG group, there are U.S. IMGs, who are U.S. citizens or permanent residents; FNIMGs, or foreign national IMGs, who are not U.S. citizens and obtained their degrees at schools not approved by the Liaison Committee on Medical Education (LCME); and EVIMGs, or exchange visitor IMGs, who are physicians temporarily in the United States, often with J-1 visas, to study, teach or do research. And of course, all of these IMG subsets can be broken down further based on the type of education they received and, more importantly some IMGs argue, the type of clinical rotations they have done.


Regardless of their definition, there is little question that IMGs make up a significant part of the U.S. medical community. In 1998, they accounted for more than 176,000 physicians practicing in the United States, which represented approximately 23 percent of all physicians. They also accounted for nearly 24 percent of residents, including 37 percent of interns.


In the 2002 Match, more than 6,500 IMGs submitted rank-order lists to be placed in U.S. residency programs. Of those applicants, 52 percent were matched with a program of their choice. With more than 3,000 IMGs serving as first-year residents, their impact on U.S. health care is unquestionable.


And that number is deceivingly low, according to Dr. Thomas Moore, president of the American Association of International Medical Graduates. “There are also a substantial number of [residency] programs that sign up IMGs outside of the Match,” Moore says. “We estimate roughly that there are currently between 6,000 to 7,000 surplus residencies in the United States not filled by U.S. graduates. IMGs, osteopathic grads and a small percentage of Canadians fill these gaps.”


In fact, foreign medical graduates’ supporters argue IMGs have become necessary to U.S. medicine because they typically provide health care to underserved areas and at the primary-care level, which is frequently overlooked by U.S. graduates who favor more lucrative practice settings.


MEETING U.S. STANDARDS


When it comes to their qualifications, IMGs point to the rigorous standards of the ECFMG, which ensure that all foreign medical graduates meet the qualifications necessary to enter residencies in the United States.


“ECFMG certification provides assurance to directors of graduate medical education [GME] programs, and to health-care consumers in the U.S., that IMGs have met the minimum standards of eligibility to participate in GME programs and to provide supervised patient care,” says Dr. James Hallock, ECFMG’s president and CEO. “This process of certification is the reason ECFMG was established and remains the organization’s primary mission.”


To be certified by the ECFMG, IMGs must pass Step 1 and Step 2 of the United States Medical Licensing Examination, just like their U.S. counterparts. But in addition, IMGs must also pass the Test of English as a Foreign Language, and a clinical skills assessment exam—expected to be required of third-year U.S. medical students beginning in 2004—and have their medical diplomas verified by the ECFMG.


“Since ECFMG certification is a requirement for licensure of IMGs in nearly all U.S. jurisdictions, there are differences in licensure requirements for IMGs and U.S./Canadian medical graduates,” Hallock says. “However, each component in the certification process is important in evaluating IMGs’ qualifications.”


And all IMGs must meet these requirements, regardless of whether they are U.S. citizens or citizens of other nations, and regardless of whether or not English is their first language. But beyond passing standardized tests, there remain many variables among IMGs.


COMING TO AMERICA


The most common stereotype of an IMG is that of an FNIMG, someone of foreign nationality who received his education in his home country and then came to the United States to complete a residency or a fellowship and maybe looks to remain here. Certainly, there is a segment of the IMG population that matches this perception. In fact, almost half of all IMGs in U.S. residency programs are citizens of foreign countries, while 92 percent of the rest of IMG residents have become naturalized citizens or permanent residents in the United States.


As a result, several associations have been formed to work on behalf of foreign-born IMGs as they attempt to make their way through the U.S. medical system—organizations such as the American Association of Physicians of Indian Origin; the Chinese American Medical Society; the Venezuelan American Medical Association; and the American College of International Physicians (ACIP), an umbrella advocacy organization for all IMGs, but particularly those of foreign descent.


Many of these organizations were created, in part, to help IMGs battle discrimination within the U.S. medical community. Many residency programs will not accept IMGs despite federal law—the Health Professions Education Extension Amendments of 1992—preventing such discrimination. In part, it’s because selection committees believe it’s more difficult to evaluate IMGs; however, their evaluation capabilities have been improved by the ECFMG certification standards.


“We were created just to protect our members or to be the spokesman for foreign medical graduates,” says Dr. Alberto René Maldonado, the chairman of the ACIP. “Over the years, there has been some legally resolved discrimination. At one time we had a wing that specialized in anti-discrimination litigation to protect IMGs.”


FINDING A RESIDENCY


The best method for an IMG to obtain a residency in the United States is if his school has a prior relationship with the program. For example, several programs in New York, New Jersey and California have developed confidence in certain foreign medical schools, which makes it easier for selection committees to believe they are receiving a well-prepared graduate.


Without this type of relationship, it can be difficult for IMGs to obtain U.S. residency positions. Out of desperation, some foreign medical graduates accept unfunded positions referred to as “externships.”


Even once a residency position has been obtained, an FNIMG must become a permanent resident or work as an EVIMG, which requires him to obtain a visa. Often, these IMGs will pursue a J-1 visa, which is restricted to the time typically required to complete a residency. Approximately one-third of IMGs are working on J-1 visas, while another 8 percent hold H-1B visas for temporary employment.


RETURNING HOME


“For foreign grads and U.S. foreign grads, it really is different,” Madden says. “They have visa problems and sometimes they have to sit out a year before getting a residency. For U.S. IMGs, there really hasn’t been a problem.”


Most of the obstacles facing U.S. IMGs occur when they made the decision to attend medical school. In many cases, U.S. IMGs were students who failed to get into U.S. medical schools because of insufficient grade-point averages or poor performances on the Medical College Admission Test (MCAT). Many of them dismiss the requirements as not being true tests of their abilities and look to other avenues to obtaining medical degrees.


That was the case for Angela Markman, who is in her second year at Ross. After receiving disappointing scores on the MCAT, she was unable to get accepted by a U.S. school. Markman was counseled by her adviser at New York University to investigate foreign institutions. “While I was considering the idea, I began volunteering in several hospitals as I took a year off after graduating…,” Markman says. “I started speaking to residents from the hospitals, and I was surprised to learn that many of them were either [from] St. George’s or from Ross University School of Medicine.”


Like many students considering a foreign medical education, Markman had doubts. “Some physicians, I would overhear, would speak negatively about foreign schools,” she says. “And, of course, there was the initial stigma from students, some of who felt that a foreign medical school would be their last resort or would not even be an option for them.


“I honestly believe that I am getting the same opportunity that other students are being offered in U.S. medical schools,” she says. “I had the opportunity to speak with many [U.S. medical school students]…and we all use the exact same textbooks, we all have the same classes, and we all take the same boards to practice in the U.S.”


Of course, these similarities aren’t coincidences. Administrators at Ross, St. George’s, the American University of the Caribbean in the Netherlands Antilles, the Universidad Autonoma de Guadalajara in Mexico and several other “offshore” medical institutions attempt to duplicate the U.S. educational model in order to help their graduates acquire clinical rotations in U.S. teaching hospitals.


“We are a bit of a hybrid because so much of our curriculum is here in the United States,” says Timothy Foster, the CEO and chairman of Ross. “The fact of the matter is that the only element of our education that is outside of the United States is our preclinical sciences program, all of which is 16 or 17 months of a four-year effort. All of the clinical sciences program is in the United States, not just the U.S. model but with U.S. faculty and often side by side with U.S. students of U.S. medical schools.”


ROTATING THROUGH THE STATES


However, some in the medical community still question the credibility of foreign schools and the validity of their clinical rotations.


In the May 2000 New England Journal of Medicine, Dr. Jordan Cohen of the Association of American Medical Colleges called for measures to increase oversight of U.S.-based educational programs that provide rotations to students of foreign medical schools.


International medical institutions sometimes arrange for their students to do clinical clerkships at U.S. institutions by making payments to the hospitals on a capitation basis. Cohen argues that education is perverted through this arrangement and that IMGs might not receive true experiences and evaluations. “I think that is a reasonable concern in the absence of any oversight,” he writes.


However, other foreign medical schools have received the stamp of approval of the state medical boards in New York, New Jersey, Florida and California. These boards formally sanction the graduates of some schools and approve their participation in clinical rotations at teaching hospitals in those states. “For the most part, anyone who has anything to do with academic medicine has a healthy respect for our graduates,” says Margaret Lambert, a dean at St. George’s, a university receiving state approvals. “You still have pockets of prejudice here and there, but…we have made a lot of inroads.”


QUALITY OF EDUCATION


Throughout the years, critics have voiced concerns over the quality of education at “offshore” schools and the lack of oversight by local authorities.


Cohen argues that, under the oversight of the LCME, U.S. medical schools must specify educational objectives, organize their programs and resources to accomplish these objectives, and develop procedures to measure the effectiveness of accomplishing their goals. These requirements provide assurances of educational standards beyond what can be measured in a licensing exam, Cohen says. “LCME standards for accreditation establish an academic context…and specify such requirements as the academic cohesion of the faculty, centralized design and management of the curriculum, functional integration of geographically separate campuses, evidence that dispersed educational experiences are similar in educational quality, and evidence that the medical school controls its academic programs in affiliated hospitals,” he writes. “Although a few other countries are currently developing an American-style system of accreditation, most countries largely sidestep assessment of the educational process and merely accept graduation from a medical school as sufficient evidence of preparedness for practice.”


However, “offshore” medical school administrators dispute this, arguing that the U.S. Department of Education’s National Committee on Foreign Medical Education and Accreditation reports that 26 other countries implement accreditation standards comparable to U.S. standards—findings Cohen and others disagree with. Among those countries are several “offshore” nations, such as Costa Rica, Dominica, the Dominican Republic, Grenada and Mexico.


Administrators also defend their for-profit structure. “Any institution, whether it’s for-profit or not-for-profit, is required to generate a return on capital,” Ross’ Foster says, and he takes the argument a step further by saying that foreign medical schools have the opportunity to provide a better education by focusing solely on teaching.


“All we do is teach,” he says. “We do not operate our own clinical facilities, neither inpatient or outpatient, except for services that we render to students on the preclinical sciences campus. And that, of course, is a huge burden on American medical education today.” Foster says clinical operations have become a financial drain on many U.S. medical schools, which are now trying to spin off those services onto other institutions. And, he argues, U.S. medical schools are further burdened by overemphasizing research, which, rather than teaching, is a major tool in evaluating and promoting faculty. “We do one thing: We teach,” he says.


BEYOND "OFFSHORE"


While the debate may continue over the credibility of some foreign institutions, other medical schools are better regarded by the U.S. medical community. In fact, some U.S. IMGs were invited to attend medical school in their home country but simply thought they had better opportunities abroad.


“There are a number of international schools that would meet and exceed many U.S. schools, especially in places like Australia, England, Israel and Ireland…. These countries have very high standards of medical education and very high standards of clinical care,” says Mark Escott, a third-year medical sciences student at Flinders University in Australia. “Then again, there are many that would not be up to standards. Just like any other school, they should be considered on a case-by-case basis.”


In fact, graduates from Israel, Australia, Great Britain, Ireland, Mexico and other nations are routinely accepted into top-notch U.S. residencies. Some U.S. premed advisers even remark on the quality of these schools. For example, the University of Stony Brook declares on its Web site that some foreign institutions are “strong players in the field.”


“In a number of cases,” the Web site advises students, “admissions [to these schools] might be almost as competitive or just as competitive as admission to U.S. allopathic or osteopathic medical schools—even though criteria could vary in subtle ways. Are there students who have studied at foreign medical schools that are not listed…who have gone on to become good doctors? Yes, absolutely! Are there students who regret rashly made decisions regarding their education? Yes, unfortunately. So, research all of your options carefully, and make a decision that you are willing to live with, even if not everything goes according to plan.”


IMGs IN THE U.S.A.


It’s becoming more difficult to summarily dismiss IMGs, particularly when they have obtained prominent positions throughout the U.S. medical community. From department heads at major hospitals to celebrated social activists, IMGs have become leaders in U.S. medicine. Even Dr. Elias Zerhouni, the recently appointed head of the National Institutes of Health (NIH), obtained his degree at a foreign medical school, the University of Algiers School of Medicine. However, he says his peers don’t see him as an IMG, but as a physician.


“It doesn’t matter who you are or where you come from,” he says. “What counts is what you do. Actions speak louder than diplomas.”


Regardless of whether they’re working for the NIH or a rural hospital in Kentucky, IMGs believe the time has come to look at their individual performances and their commitments to help their patients.
“I believe that the determination, resilience and success of many IMGs, from any sub-group, is worth noting,” AMSA’s Davis says. “Of course we might point to the high-profile success stories, but the fact that many students endure the added challenges, certification requirements and potential stigma in order to contribute significantly to American health care should be recognized.”
~ONLINE RESOURCES