2~6September~2003-52~Feature~Drowning in Debt~As tuitions rise, medical students struggle with excessive loans. ~Jennifer Zeigler~~What's the price of becoming a physician? For Kevin Rufner, a third-year M.D.-M.P.H. student at Tufts University School of Medicine, it will be one-quarter of a million dollars by the time he graduates. And that's not counting the thousands of dollars he will pay over the years in loan interest. By the time he finishes residency and begins paying back his $250,000 to the government and private lenders, his monthly loan repayment will look very much like a home mortgage.

Thanks to his enormous debt load-large even by medical-student standards-Rufner has made a difficult decision recently. Interested in working in international public health, he realizes the low pay associated with such jobs is not going to make a dent in the financial monkey growing on his back.

"For myself and for a lot of the others in the program, most of us look at doing public health 10, 15 years down the road, after our loans are paid off, which is a shame."

So instead, he's turned to a more profitable primary care specialty-maybe internal medicine with its $120,000 starting average, which is what his financial aid office tells him he will need to earn after residency to make his loan payments. In fact, he says most of his classmates have turned to other specialties for the same reason.

"The hardest part for me is why am I doing the M.P.H. now? I'm going to need to spend the first part of my career doing another discipline just to pay off my loans. I think a lot of public-health people have the idealism that money's not going to be a factor." They would be wrong in assuming so. Experts have been tying rising student debt to decreases in family practice and surgery residents for several years. With primary care's low pay and surgery's long residency, extending the amount of time loan interest accrues before beginning payment, these fields can become specialty pariahs to a student facing more than $150,000 in loans. Future physicians will also say that post-residency fellowships are less appealing if applicants have large debts to pay off.

Medical student debt has been rising at an annual rate between 5 percent and 7 percent throughout the 1990s, according to the Association of American Medical Colleges (AAMC), and a Council on Graduate Medical Education study found the average debt increased 211 percent between 1985 and 2000. These increases mean the average newly minted physician went from owing $59,885 in 1993 to $103,855 in 2002.

Not unrelated, tuition hikes have been staggering at many schools, particularly at public universities as states struggle with budget deficits in the billions. And since each tuition hike means more loans for all but about 17 percent of medical students who unbelievably graduate debt-free, financial aid officers worry that future physicians are reaching loan levels they won't be able to manage with today's lower reimbursements and the higher costs associated with medical practice.

Hitting students' pocketbooks

The news isn't encouraging. As endowments take a blow from the sluggish economy, schools have increased tuition. Georgetown University medical students will see a 3 percent increase to $33,600 for tuition fees this year, which Dr. Ray Mitchell, the dean of medical education, says is the target for annual increases. "My heartbreak is that we don't have as much grant money as we need," he says. "Clearly the earnings of the endowments are down."

Drexel University College of Medicine students are digging into their pockets for the $34,000 it will cost them to attend this year, reflecting a 5 percent increase. "We have tried to maintain tuition at the 50th percentile of the private medical schools," says Dr. Barbara Schindler, Drexel's vice dean for education and academic affairs. In fact, Schindler is right on target for private school tuition hikes, which mostly hover between 3 percent and 5 percent this year.

Historically affordable, state schools are facing a more serious trend as they fall victims to the state budget crises. "I think it's a critical time. It has affected not only the private institutions, which have wrestled with this for a long time…but the public schools as well," Mitchell says.

Budget cuts caused public Eastern Virginia Medical School to raise tuition 15 percent to about $19,000 for in-state students. The first-years at the University of Virginia saw a 20 percent increase and are paying more than $22,500, which some would argue is getting into the range of a private medical education.

In cash-strapped California, where at press time legislators were deadlocked over how to resolve a $38 billion budget deficit, the University of California's Board of Regents was expected to dull the financial blow from a proposed $380 million in state funding cuts through fee increases. The state's seven medical schools already saw between 5 percent and 10 percent increases in fees last year, which the university charges students in lieu of tuition, driving costs to between $10,000 and $11,000.

Across the country, New York's public schools are not faring much better. The State University of New York (SUNY) system just handed medical students a 14 percent increase in tuition, jumping from around $15,000 last year to $17,000 this year.

And at the University of South Carolina, medical students expect to see a 30 percent rise in tuition, double the increases slated for law students, as the institution's trustees grapple with their share of the state's $51 million in cuts to higher education.

State schools will certainly learn the close relationship between tuition hikes and increases in student debt, for as the cost of medical education rises, so does the bottom line on many students' financial aid packages, especially at less expensive schools that attract those in the greatest financial need.

Amanda Little* is one such casualty. A student at the public University of Arizona College of Medicine (UA), she expects to have accumulated about $150,000 in education debt by the time she finishes school. Little has been financially independent since her teenage years; she helps support her disabled mother, and her father is deceased. And while just making it to medical school may seem like a huge accomplishment for someone who has had little help since high school, to do so she also accumulated $13,000 in credit card debt, which is risky for someone who will reach the federal educational borrowing limits sometime during her third year of medical school, forcing her to turn to private lenders, who more heavily consider consumer debt when making loan decisions.

All this debt weighed on Little as she decided where to go for medical school. Having already borrowed $60,000 for her undergraduate and master's degrees, she knew she had to consider the cost differences between UA and private Albany Medical College, at which she was also accepted. UA's $11,500 per year tuition is about one-third of what she would have paid at Albany. "That in conjunction with my credit card debt is the main reason I'm going to Arizona."

Right now, federal loans cover all but $500 of the $27,500 budget UA establishes for its students, which includes tuition, fees, books and living expenses. To make up the rest and pay the minimum balances on her credit cards, she works when school isn't in session, babysitting as much as 35 hours a week, but she can't do that when classes meet.

When she's not bringing in money, she says she has to get creative with her funds, buying food and gas on plastic and using her loans to make the $200 minimum monthly payments on her credit cards. "I need to keep my credit rating good. But that is a lot. That's a huge chunk out of a budget that doesn't account for it."

Little says she's concerned about selecting a school based strictly on where she got the best financial package. She says Albany was the better choice for her academically, but she's trying to put the best face on the situation that she can. "I'm a very regretful person, and I'm trying not to regret this decision. You're in school for four years, and you can get bitter, and residency doesn't get any better."

But it's not easy to stay positive. This year she's moving in with a new roommate who, with parental help paying for college and medical school, has about $3,000 in loans. "And that makes me bitter. But I just have to step back and say I have all this life experience, and that's important."

It's also important to make sure medical students will be able to pay off their education debts. Only a small percentage of medical students traditionally default on their loans, and their future income potential makes them attractive to lenders. Yet some financial aid officers worry medical education costs are at a point where some graduates won't make enough to repay their loans.

"I think the vast majority of students are being wise in their borrowing," says Irv Bodofsky, the assistant dean of students and director of financial aid at SUNY Upstate Medical University. "But in the last couple of years, we've seen some concern." He says any time a student hits the limit for federal borrowing, which is currently set at $189,625, he worries about whether the student will be able to earn enough to pay it back.

"You look at the indebtedness now, and in some cases, you're talking about a very hefty mortgage," says former academic financial aid officer Paula Craw, the director of student financial services for the AAMC.

Diane Gregory* might be someone to worry about. Already in debt $138,000 with about $47,000 to add for her fourth year at the University of Pennsylvania School of Medicine, she exemplifies many students in her aversion to the bottom line. "I've been trying to remain ignorant of the exact amount of my debt. Nothing about money interests me. I did think about it a little bit when I was picking a specialty," she says, but adds that in the end, she settled on lower-paying psychiatry over a more lucrative career in radiation oncology.

Future physicians' aversion to money issues is troubling, say financial aid administrators. Craw says one of the problems is that loan money never seems real-it's always there, and it's not particularly difficult to get, so it's not the same as earning a paycheck. "We used to refer to it as Monopoly money," she says.

"To me the number is so incomprehensible. It's like trying to comprehend infinity. You just can't get your head around it," says Daniel Doran, a fourth-year at the University of Colorado School of Medicine who will graduate with about $130,000 in loans.

Craw says many students struggle with this. "You mention money and their eyes just glaze over…. I've always referred to [student loans] as a necessary evil. They're just going to take them out. They'll have to, and at the end they'll figure out what it means," she says.

Gregory, who began medical school at age 32 after completing a Ph.D. in philosophy that cost her a mere $4,000 in loans, shares this casual attitude about finances. "I'll just find a way to make it work. Maybe I'm in complete denial," she says, but adds she has calculated that with a 30-year payment plan, she'll be 70 by the time she fulfills her loan payback. "Now that's bad."

Figuring it all out

You can't blame these debtors for their disinterest in education finances. Many say they're in medical school because they weren't good at math to begin with, and when you factor in the confusion about the different types of loans and all the options for repaying them, you can understand the endemic eye-glazing syndrome Craw sees.

The basic medical student loan is the federal Stafford loan, which has been around since 1987 and existed before that as the Guaranteed Student Loan Program. There are two types of Stafford loans: subsidized and unsubsidized. While both are loaned by the government and enjoy lower interest rates than loans on the open market, subsidized Staffords are more desirable. This is because the feds pay your interest: while you're in school; for the automatic six-month grace period Staffords offer after graduation; and during periods of deferment, in which you arrange with your loan servicing company to delay repayment, something medical graduates usually take advantage of during residency. Subsidized Stafford loans are need-based and carry annual borrowing limits of $8,500 with a lifetime limit, including undergraduate borrowing, of $65,500.

Unsubsidized Stafford loans are easier to obtain, as they don't require proof of need. Congress also set a higher limit for them: $30,000 per year as long as you remain within the combined Stafford aggregate limit of $189,625. But the drawback is that students are responsible for the interest while in school, although they have the option-one most students take-of capitalizing the interest during school years into the principal loan amount. While this tactic will fatten students' wallets for books and pizzas during school, it only adds to their final debts, so they should be aware of what the interest is doing to their bottom lines.

Schools administer Staffords either from the federal Department of Treasury through the government's Direct Loans program or through the Federal Family Education Loan Program, which draws on money put up by banks that use the government as a co-signer and to subsidize the interest rate. About one-third of schools have opted for the Direct Loans program, which is cheaper for the government because it bypasses the bank middleman. Borrowers are bound by whatever program their schools participate in, although the terms of the Staffords are identical for each one.

There are other federal programs, but none as substantial as the Stafford. Need-based Perkins loans are funded by the Department of Education and administered by schools, but they provide only small amounts of money. "You may want to think of it as the cement in a crack in students' finances," SUNY's Bodofsky says.

The Department of Health and Human Services' (HHS) 5 percent interest Primary Care Loan obligates graduates to practice primary care during repayment, but Bodofsky says with Staffords at 3 percent interest now, they're a better deal and lack a specialty requirement.

Once students have exhausted the federal loan options, they need to turn to private loans. There are about 10 programs to choose from, although Craw says the number is increasing. Financial aid officers will usually point students toward one program or another, Bodofsky says.

Private loans have higher interest rates and generally longer repayment periods than federal loans' standard 10 years. Generally, a third party will manage the program in partnership with a lender and a servicing company. For example, Craw manages the AAMC's MEDLOANs program, which offers private loans from Bank One that are serviced by Sallie Mae.

The aggregate limits on these loans are higher-for MEDLOANs it's $220,000, including federal loans-and Craw is concerned about programs with no limit, "which maybe says the sky's the limit."

One of the drawbacks to these loans, Bodofsky says, is that they aren't guaranteed like Staffords. "They're going to look at previous credit history."

This becomes especially important for students who expect to reach the federal loan limits during medical school, because, in the absence of a winning lottery ticket or a benevolent great-auntie, they'll be forced to turn to private loans for the rest of their education.

Once all this debt has been accumulated, it's time to think about repayment, which can be more confusing than the borrowing, for with repayment generally comes debt consolidation.

Consolidation combines all loans-even those from college-into one payment at a fixed interest rate for between 10 and 30 years. "Consolidation is probably the most complicated element in student loans right now," Bodofsky says.

Again, blame the economy, but this time there's a positive side effect amid the negativity. With interest rates ever sinking, federal student loan rates have dropped to a historic low of 3.42 percent this year for those in repayment, and 2.82 percent for those still in school or in the middle of their six-month grace period or deferment. That equals a $3,622.79 savings over last year's previously historic low rates for someone with $100,000 in Stafford loans.

It all sounds like a good deal, but here's the catch-several of them, actually. Just like refinancing a mortgage, consolidation resets the clock on loans, which makes it less of a good deal for those nearly finished with the standard 10-year repayment. And since consolidation triggers the start of the loan's repayment period, Bodofsky suggests cash-strapped grads get all the details on going into a deferment or forbearance status before signing consolidation agreements, although students who consolidate before the end of a six-month grace period, which will be ending in a few months for the class of 2003, can do so at even lower rates.

With interest rates so low, enrolled students have been confused about whether or not they should consolidate and lock in a rate before they graduate. Doran says his loan officer encouraged him to do just that, although he's not sure that would be smart.

"It's left me somewhat in the dark to what I should be doing. I'm not prepared as a fourth-year student, with no income possibility in the next year, to make that decision. I'm also a little bit afraid to not make that decision. I would feel like a fool if I waited and then classmates were spending hundreds of dollars less than I because loan rates became variable," he says, referring toa legislative initiative by education lenders to change consolidation rates from fixed to variable, saving lenders money in economic downturns because rates drop so low.

Only certain students can consolidate before graduation. Anyone attending a school enrolled in the Direct Loans program can consolidate. So can a student who is taking a year off from school. But it's not a decision to make lightly even then, Bodofsky says. "Sometimes problems have cropped up, and if you haven't finished, you might need to take out more loans. Then you'll need to combine them under an average [rate] between the two," which defeats the purpose of consolidating.

And why can't students just reconsolidate if they have to take out more loans to finish school? Here's another rub: Unlike a mortgage refinance, consolidation is a one-time deal. Loans can't be reconsolidated if the rates drop further next year, although no one expects them to.

As if this weren't complicated enough, there are other rules to consider. The great rates apply only to federal loans. So if a student has private loans he wants to consolidate, he must do so under a private program. And once he's graduated, the government turns his federal loans over to a servicing company-Sallie Mae is the most well known, for example. If one servicer holds all the loans, laws mandate borrowers must stick with that company's consolidation program.

"Loan consolidation was not intended to be this hard. It was simply set up to be a way to extend repayments beyond 10 years," Bodofsky says. "[But] nobody expected these low, low interest rates." However, students should take heart, he says. Even the confusing world of debt management can be a learning tool. "This is a way for students to begin to learn the way the economy works."

And they have some time. Since federal student loan interest rates change only once a year, future physicians have until June 30, 2004, to decide what is the best solution.

Fixing the problems

The Higher Education Act (HEA), which recently has been reauthorized every five years and whose current version is set to expire on Sept. 30, governs many of these federal loan matters. And student advocates are pushing for some changes.

"The biggest issue for medical students…is about annual loan limits," says Jonathan Fishburn, a legislative analyst for the AAMC. In January, 49 higher-education organizations signed onto a list of proposals for the HEA reauthorization that included exploring different options for changing federal loan limits. The coalition wants to see some movement on this, but because of differences among the group, the letter doesn't ask for a specific solution. Fishburn says the AAMC seeks loan limits adjusted for inflation back to 1992-the last time Congress increased them-which would put subsidized Stafford limits around $12,000. Others want limits spread like a line of credit over the years a student is enrolled in school, which would allow students with greater needs to draw on the aggregate amount without worrying about a yearly limit.

Most financial aid administrators favor these plans, believing they will reduce a student's reliance on private loans. "Tuition is going up. There are only two solutions: Ask parents for more money…or cut your budget. If you're being frugal to begin with, where are you going to cut your budget?" Bodofsky says. "The final choice is…a private loan you can go borrow."

But students' reactions are mixed, with some seeing it the way Bodofsky does, and others predicting a different outcome. "I think it's a problem. When you start giving students more loans, you encourage states to increase tuition," says Bill Walsh, a fourth-year at Indiana University School of Medicine.

The other medical student-related issue Fishburn expects to see discussed during the HEA reauthorization is a change in the length of time a student in repayment can apply for an economic hardship deferment. You can defer for three years, but Fishburn points out that many residencies last longer than that.

While these are both benign ideas that are expected to at least be discussed during the legislative process, Rep. Buck McKeon (R-Calif.) has proposed legislation that would force schools to keep tuition increases below twice the rate of inflation or lose their participation rights in federal loan programs.As the House's chair of its subcommittee in charge of HEA reauthorization, McKeon isn't kidding around.

The concept doesn't shock Fishburn. "The fact that accountability is going to be a buzzword in authorization this year was not a surprise," he says, adding that the penalty clause was an idea that medical schools didn't foresee and don't like.

Tuition caps are something Walsh would like to see implemented. He suggests rolling four-year caps, such as the Washington University School of Medicine uses. Students are guaranteed the same tuition during four years of medical school, although they "complain the entering tuition is just raised as high as they can when they start," Walsh says. Ultimately, he favors voluntary absolute caps, but he recognizes this is an unpopular idea among schools that would all have to sign on for the idea to work.

Regardless of the popularity of any of these ideas, don't expect to see Congress jumping through hoops to pass the HEA reauthorization before it expires this month. A built-in extension to the current law takes some of the pressure off, giving lawmakers the next year for debate. Political timing plays a part, too, Bodofsky says. "In fact, we predict it will be signed in August or September [of 2004], because it is an election year. Hey, money for education-that's as American as apple pie."

Yes, you can help

In the absence of real reform, you can do a few things to lessen your burden at each rung of the medical school ladder.

Premeds need to think hard about the financial responsibilities involved with medical school, Bodofsky says. Many students will tell you they were so excited when the acceptance letter arrived in the mail, they didn't even think about what it was going to cost until they arrived on campus, and that can be dangerous, if you're not independently wealthy. Instead, "spend a few days basking in the glow of your accomplishments, but then come down and do some future planning," he advises.

Part of that planning can involve getting your consumer debt under control before you begin accumulating $30,000 annually in education loans. For Gregory and Little, who both have accumulated $13,000 in credit card debt, this is a serious issue. They both say they are careful about making the monthly minimum payments on time, because they know the consequences of not doing so is a ruined credit rating.

But many students suffer under larger consumer debt loads. "Credit card debt and credit card education is probably one of the most pressing issues we're dealing with right now," Bodofsky says. Some private schools have been thinking about requiring students to submit a credit report so they can begin consumer counseling from the first year, he says. "I wouldn't be surprised to see some public institutions asking that as well, as tuitions begin to rise."

Some future physicians are already getting credit counseling from their financial aid offices. Fourth-year Shelley Schoepflin Sanders says she was shocked when she heard her financial aid counselor at the University of Rochester School of Medicine say to her that if you put a $12 pizza on your credit card and pay it off with your student loans, "I can't remember how much it was, but it was over $100," she says.

But many schools don't go beyond the entrance and exit interviews required of anyone taking out a federal loan. "I don't feel like I'm getting the kind of counseling that a debt of this amount of money should take," Doran says.

Craw says the common phrase students say near the end of their borrowing is "I wish I knew." So she likes University of Chicago Pritzker School of Medicine's (UC) requirement that students show up for mini counseling sessions each year they visit to sign their checks. "I really, really think that repetition is good."

And even if your financial aid administrators don't require counseling, ask for it. Schedule regular meetings with your liaison to discuss your debt and how it is going to impact you later. Sanders stresses the importance of knowing exactly what you're getting into. Even with her physician father, "I had no clue going in." She had disillusioned physicians tell her they wished they hadn't gone into medicine, but she paid them no heed-until a difficult third year on the wards almost convinced her to leave medicine.

Her husband still encourages her to drop out if she wants to, but she says it just isn't a financially sound decision for someone with $160,000 in debt and less than a year to go. "I will go on, and I will be a good doctor, but the fact that I had the debt-I looked a lot harder to find that niche," she says of her final decision to practice geriatric medicine.

Some of your peers have found creative ways to manage their debt. Yousef Turshani, a second-year at UC, expects to pay about $15,000 in loans by the time he's finished with his education that costs $29,500 annually. How's he doing it? By taking a full-ride scholarship at his undergraduate college and allowing his parents to invest the money saved, he can now use the funds for medical school. OK, this plan isn't applicable to most of you, but Turshani does have some other ways he keeps costs down, which allowed him to reduce his loans by $3,000 in his first year.

"I call it my trifecta: no car, alcohol or cell phone," he says of his frugal lifestyle. He also suggests bringing lunch to campus or going home to eat. "Don't use a credit card you aren't able to pay off. I think that's a huge trap for medical students."

Turshani also lives in a three-bedroom Chicago apartment with two other students. It's not the most private situation, but he's got his eye on the future. "I realize that I'll be able to live a little bit nicer, and in a few years after that I'll be able to live nicer than that. I'm happy with my life. Why make it harder on myself?"

This is not an attitude all medical students share. Bodofsky says he sees some who come to him with a sense of entitlement, saying, "'I've reached this point, and I don't want to be controlling my spending.'" But he cautions them, saying, "You can live like a student now, or you can live like a student later when you're repaying your student loans."

Some future physicians agree this attitude comes with the territory. "As a doctor, I feel like I want to be compensated for my work. I think there is a little bit of entitlement there," Doran says.

To aid that dream, Bodofsky encourages residents and practicing physicians in repayment to enlist the efforts of a good financial planner. And be careful about whom you select-Craw cautions that not everyone understands the complexities of physician finances.

A good financial planner can help determine the best repayment option for you, suggest ways to manage your new-found wealth after residency and guide you through business loan applications you might need for your practice. "The real issue is not can I pay my loan back, but how can I manage my loans in the most efficient way," Bodofsky says.

* Requested pseudonym

Editor's note: Some attributions in the online version of this article have been amended.
~THE COST OF CLASS

Back in the recesses of your mailbox: Does that tuition bill look fatter to you? What do schools do with all that money anyway?

"Nobody knows how much it actually costs [to educate a physician], and no one actually knows where the money goes," complains Bill Walsh, a fourth-year at Indiana University School of Medicine.

"That's a constant question at our school: Where does the money go?" says Kevin Rufner, a third-year M.D.-M.P.H. student at Tufts University, which boasts the highest medical school tuition in the nation at $39,579 a year, plus an extra $3,480 Rufner pays for his M.P.H. classes.

The answers are ones school administrators hold close to their vests, but Dr. Ray Mitchell, the dean of medical education at Georgetown University, says tuition is something he watches closely. "To me and at our school, because we've always had tight resources, we try to look at where every tuition dollar goes." He says these funds are strictly devoted to the "education of students," which could cover anything from the electric bill to faculty salaries, although it doesn't pay for infrastructure and construction, which are paid for by fund-raising campaigns.

But tuition alone doesn't cover the cost of educating a student. State and federal funds, research grants, gifts and endowment income as well as income from patient care all help run a medical school. A 1997 study in Academic Medicine found a school's instructional costs were between $40,000 and $50,000 per student per year. When you factor in research and patient-care expenses, which the study called "total education resource costs," the annual price tag rises to between $72,000 and $93,000 per student. "So it costs more to keep a school operating than it does for the student to attend," Mitchell says.

Christopher Kops, the executive director of finance at the University of Pennsylvania School of Medicine, says tuition revenue is "significantly less than the cost of an education" there, but he declined to say what percentage the dollars account for in the school's operating budget of $571 million. According to the Association of American Medical Colleges' (AAMC) 2003 Data Book, tuition and fees accounted for 3.5 percent of all medical schools' total revenue during the 2000-2001 academic year, down from 4.6 percent in 1965. But among private schools, it's still 4.4 percent, while tuition accounts for 2.5 percent of revenues at public schools.

But Dr. Barbara Schindler, the vice dean for education and academic affairs at Drexel University School of Medicine, puts the figure closer to 20 percent and fiercely defends the need for tuition dollars. A "mission-based budgeting school," Drexel disperses tuition dollars to individual departments based on the amount of teaching that department does. Research and patient-care funds are handed out the same way.

Osteopathic schools, however, appear to depend more heavily on tuition dollars. With tuition about equaling allopathic institutions', the osteopathic schools' average annual operating budget is about 10 percent of those at allopathic schools, and tuition accounts for 47 percent, according to Robert Jones, vice president of the AAMC's division of medical student services and studies, who presented these figures at the group's annual meeting last year.

So it's easy to see why future physicians are so confused about where their tuition dollars go when each school handles these funds differently. And Paul Teget, a fourth-year at Kirksville College of Osteopathic Medicine, says the problem goes further: "Students tend to live in a bubble, and they think tuition just goes to paying teachers' salaries. I don't think students fully appreciate all the things that go into the costs of an education." He cites a rise in liability insurance as one increased cost of education.

But as expenses go up and public funds go down, Mitchell cautions schools from simply increasing tuition to make up the difference. "Tuition alone will not save academic medical centers. It cannot be their salvation. The accountant might look at the books and say that money is discretionary, but I think most deans don't look at it that way." -J.Z.

_____________________________________

SCHOOLS TRY TO HELP

Despite what you might think, schools aren't ignoring the rising costs of medical education. Most try to combat the problem by offering additional grants and scholarships funded through their endowments, although fund raising has slowed along with the economy. But at Florida State University (FSU), where state lawmakers handed the fledgling medical school an 11 percent tuition increase this year, administrators have taken a different approach.

A handful of the small, rural hospitals in which students train have offered local students free rides-tuition, fees, books and living expenses-in return for four years of service at the hospital after residency. And while that may seem like a big undertaking for a financially challenged rural hospital, FSU's assistant dean Dr. Myra Hurt says the institutions spend less money funding medical students than they would on recruitment activities. "That's going to be a marketing tool for us. We're going to really work the rural hospital association," she says. "I wish we could give everyone a free ride and require years of service. We, as a society, by giving gifts, need to invest in [medical education]." -J.Z.

~~Drowning in Debt~Jennifer Zeigler is a senior writer with The New Physician. Direct questions and comments about this article to tnp@amsa.org.~Medical Student Debt~
6~4May-June~2003-52~Feature~On the Hill~Physicians find their places in the legislative process, whether as congressional fellows, staff members or even elected officials.~Scott T. Shepherd~~So You Want to Run for Office?

Congressional Facts

How a Bill Becomes a Law (PDF 241KB)

Like many medical students, Jennifer Lee had eagerly anticipated her clinical rotations and the opportunities they offered to positively impact the lives of her patients. Yet, while she enjoyed her training experiences at Washington University School of Medicine in St. Louis, she often felt as if she weren't doing enough, as if she were treating the symptoms and ignoring a greater illness. "I started doing clinical rotations and seeing people on the wards; then it just struck me that the biggest problem in medicine is not clinical knowledge or the research that is going on. We're pretty good at that. It's the delivery of health care," Lee, now a physician, says.

Her realization led her to Washington, D.C., working as a congressional fellow for Sen. Edward Kennedy's (D-Mass.) staff on the Committee on Health, Education, Labor and Pensions. Fellows are the aides and researchers who drive much of the work accomplished by Congress. Usually, they come to the nation's capital for one-year stints, assisting a senator, representative or one of the numerous committees in both chambers. They come to contribute their expertise, be it in medicine, business, engineering, philosophy, political science, law or any other area of interest to Congress-which means pretty much every area. Many fellows go to Capitol Hill through professional associations or educational programs. Or, like Lee, they go there completely on their own, looking to be a part of our democracy. "I wanted to learn more about what sort of issues there were and how I, as a medical student or future physician, could be part of the solution, fixing the problem."

THE HILL: A WORLD UNTO ITSELF

However, before Lee-or anyone, for that matter-can accomplish such a goal, she has to understand how things work on the Hill. "It's sort of like a different planet out here," she says. It certainly would qualify as its own little world. A collection of enormous stone buildings with thousands of offices, connected by a labyrinth of tunnels and miniature subways, Congress has its own restaurants, post offices, banks, hair stylists and shops, as well as two newspapers and hundreds of technical newsletters that follow specific issues in excruciating detail.

You may even need a translator. Hill language, while technically still English, is peppered with legislative jargon, bill numbers and thousands of acronyms. Remember the first time you heard a medical case presented? It's kind of like that.

Then there is the Hill's way of life. For a physician accustomed to making quick decisions based on physiological evidence and medical knowledge, this may be the biggest adjustment. It doesn't matter if you are a fellow fresh out of medical school or an elected representative leaving behind a thriving internal medicine practice, as was the case for Rep. Dave Weldon (R-Fla.), who was elected to the House of Representatives in 1994.

"Being a…general internist, you kind of do piecework in that you go to the hospital, you have your seven or eight hospitalized patients, and you have to see them in the morning. And then you get to the office…have to get through all of your appointments in the morning, then you get a breather at lunch, then you have to get through your afternoon appointments. Maybe if you admitted a few people, you have to run back to the hospital. It's very, very pressured as far as getting a lot of things done in a very limited amount of time. Whereas, here you go to a lot of hearings, you go to a lot of meetings…. You go to a meeting, and you might have to wait 45 minutes to get your turn to speak…. It's different. It's very different."

Unlike medicine, it is a rare event for a legislator to make a decision based solely on his judgment. After all, a legislator has to deal not only with his own interpretation of the data but also the interpretations by 534 other elected officials in Congress, not to mention the president. And then there are the various opinions on what, if anything, to do about the data, namely create and pass legislation.

"As a physician, you are trained to take a set of facts and make a decision. [Medical training] tends to make you a bit of a lone wolf, and that doesn't work in politics. In politics, there are endless meetings and endless sitting around, and there is a lot of give-and-take that a physician has to adjust to," says Rep. Jim McDermott (D-Wash.), a psychiatrist who has served in the House since 1989.

Secondly, physicians, particularly those in clinical settings, are accustomed to treating one patient at a time. "When you are a physician, sort of the ethos of medical decision-making is that the patient in front of you is your primary-and in some ways-almost your sole concern," says Dr. Murali Raju, a neurosurgery resident at SUNY Upstate Medical University who is a fellow with Sen. Hillary Clinton (D-N.Y.). While individual stories and cases may propel congressional action, a legislator cannot reasonably take action based on a single instance. In fact, it may not even be enough to find thousands of instances based on a single illness within a system. When taking into account the "big picture," they have to consider the interests of more than 290 million "patients."

And then of course, there are the rules. Every profession, be it medicine, law or the restaurant business, has its own set of guidelines. And in Congress, those rules are extensive (see "How a Bill Becomes a Law," p. 18, and "Congressional Facts," p. 21). In fact, at times, it may seem as if you're trapped by them. However, for the most part, those who work on the Hill believe they are accomplishing something, even if they aren't enacting laws. How can this be?

First of all, legislators and their staff come to understand that change is slow, and they don't necessarily view this as a bad thing. "[Our founding fathers] wanted a government that was cumbersome and somewhat difficult to operate and maneuver. And one of the features they put in there was a relatively independent and separated Senate and House, and it works," Weldon says.

The next thing to accept is that every little step-regardless of how small it may seem-is a move forward, and just because something doesn't result in legislation doesn't mean it lacks value. "One thing I have learned is that you don't necessarily have to pass a bill in order to make progress on a particular issue. Sometimes it's important just to get the issue out there," Lee says.

Generating awareness of and focusing discussions on an issue, as well as being a part of those discussions, is how senators and representatives spend much of their time. Members of Congress arrive on the Hill early in the morning to prepare for the day. In some cases, their schedulers will hand them cards outlining their activities. The day often begins with committee and subcommittee meetings, which include hearings, bill markups and, eventually, votes. These duties are then repeated with other committees and subcommittees. Representatives are usually assigned to two full committees and two subcommittees, while senators have four committees and three subcommittees.

Afternoons are spent going back and forth between the office and the chamber for various votes, and when the opportunity arises, to speak on the floor-speeches usually televised on C-SPAN. What the network doesn't show you, however, are the senators and representatives addressing frequently empty chambers, as their colleagues use that time to talk with constituents, lobbyists or reporters, or hold discussions with staff, colleagues or their parties. In all, most members of Congress work until the evening, at which time they may tackle a large pile of reading prepared by staff or be required to attend a social function or fund raiser. When you add the weekly trips back to the district for more meetings, there is very little time left.

"It's constant," Weldon says. "One of the things that amazes me is some of the things that I have to say no to. They were things that I could've never imagined I would say no to. Some visiting head of state will come in and have a meeting at the White House and then come down to Congress, some prime minister or foreign president, and I will get an invitation to go. But I will be in a critical markup of a piece of legislation in committee or there will be some other pressing thing, and I will have to say no."

STAFF: LARGE IN NUMBER AND IN DUTIES

With so many demands on elected officials, it is no surprise their staff does the majority of the congressional legwork, such as constituent relations, research, negotiations with other offices, speech preparation, drafting legislation and much, much more.

In all, there are more than 7,500 staffers on the Hill, not including the thousands in support positions, such as policemen, postal workers, maintenance crews and other employees who keep Congress operating. Staffers play a more central role in the federal legislature and in many ways are just as important as the elected officials.

Congressional staff is split into two basic categories: personal and committee. When it comes to personal staff, how each senator's and representative's office is structured varies greatly. But generally, each office includes a chief of staff, legislative and administrative directors, a scheduler, a press secretary, and a number of issue-designated legislative assistants or aides, known as L.A.s. An elected official, particularly senators who have significantly bigger offices and more staffers, may also employ a personal secretary, senior policy advisers, a deputy press secretary, a speechwriter, a systems or operations manager and staff assistants.

And that is just in their Washington offices. Back at home, there are more. Representatives can maintain one office or as many as six, depending on the geographical size of their districts, whereas senators maintain several offices. These home bases may be staffed with a director, regional directors, a state or local scheduler, press secretary, several caseworkers and staff assistants.

Besides personal staff, senators and representatives also have the assistance of committee staff. Although technically they support all committee members, these staffers can be very political. In part, this is because the partisan makeup of the committee also dictates the size of the staff for each party. For example, the House Ways and Means Committee is composed of 24 Republicans and 17 Democrats, so the committee staff is organized to reflect this ratio with the most senior, or ranking, committee members of each party given the authority to appoint the staff members. This usually means that staffers maintain a certain amount of loyalty to the ranking member.

Probably the most experienced and nonpartisan staffers are those who serve subcommittees. Known as professional staff, these assistants are loyal to and expert in specific issues governed by the subcommittees.

Now add the unpaid support of fellows, like Lee and Raju, who work with committee and personal offices. All of these people play essential roles in how elected officials produce legislation, correspond with constituents, relate to lobbyists and are portrayed by the media. Furthermore, these individuals heavily influence what their bosses stand for and fight for in Congress.

WHO REALLY CALLS THE SHOTS?

So when a congressman speaks, is he just repeating ideas fed to him by his staff? "I think it really depends on the office. I think for some senators, the words their L.A. says are the words that come out of their mouth. It also depends on the issue," says Bruce Lesley, the health L.A. for Sen. Jeff Bingaman (D-N.M.). Lesley, who previously worked for Sens. Bob Graham (D-Fla.), John Breaux (D-La.) and two members of the House, does not necessarily mean this as an indictment, just as a statement of fact. Elected officials are expected to speak in depth on an infinite number of issues and take stands on them. It is simply impossible for them to be knowledgeable in every area.

"Anybody who has been to medical school has been taught to learn everything. You just can't do that [in Congress]. You are always working with pieces of information," McDermott says.

As a result, Weldon says, members must learn to trust the research and judgment of their staff, which can be difficult for physicians. "In medical practice, you rely on your secretary or receptionist to do your scheduling and answer the phone, your nurse to make sure the patient understood the instruction and if they need a dressing changed…. Now I frequently will be presented with something, and they'll just ask me to make a decision, and I'll say, 'do this,' and that is the most my schedule allows me to hear about it. And you are totally dependent on your staff on a whole host of matters."

However, members do specialize in areas related to committee assignments or that are of great concern to their constituents. Naturally, physician-legislators have an interest in health care, and their opinions are viewed as credible by their colleagues and the press. Weldon's medical degree made him the point man for the Human Cloning Prohibition Act that passed the House in March, and he said he is frequently called upon to explain medical and scientific issues to his colleagues.

While previous work in a field is beneficial, it is not a prerequisite to becoming a "specialist." Often it is just a devotion to an issue over time, as is the case with Kennedy who has worked on health issues in the Senate for more than 40 years.

And then there is the unique circumstance of Clinton, who was thrust into the U.S. health-care debate spotlight in 1993 when she headed a task force to reform the national health system. As a result, her staff knows she has a wealth of knowledge and strong opinions on health issues.

"Sometimes, I am amazed by how much she actually knows. I'll come into a meeting and know I only have five minutes to really brief her on a complicated issue, so I'll just leave out some of the details and just try to give her the big picture. Then I go in there and give her the big picture, and next thing you know-I don't know how she gets all of this information-but she is asking me about all of these details," says Raju, who has been working for Clinton since September. "She keeps up to date and follows this stuff to a detail that is very impressive for the lack of time she has for this stuff."

ENTER THE LOBBYISTS

But staff aren't the only resources available to senators and representatives. Another integral player on the Hill is the congressional lobbyist.

When constituents envision lobbyists, they often picture back-room, backslapping shenanigans, involving big donations and weighty promises. Yet, many people on the Hill will tell you that is just a stereotype. "Most of them are good people. The public perception of lobbyists is sort of in there with used-car salesmen. The first lobbyist that came into my office was representing the Florida Fruit and Vegetable [Association]-not an evil industry or an evil person," Weldon says.

So while the public perception of lobbyists may be manipulators of the system, in Congress they tend to be viewed as assertive participants in democracy. "I think, overall, it's a good thing. This is how people can influence policy and influence the political environment," Lee says.

In fact, lobbyists often become partners with members and staffers. When Janet Martin went to work as a fellow for Sen. Herb Kohl (D-Wis.), she had no idea what to expect from interest groups, even though she teaches courses in government at Bowdoin College. While working on a bill to keep alive a school dropout prevention program, she discovered some of her best allies were lobbyists from the Council of the Great City Schools, a coalition of urban school districts from across the country. "They are people who really care about the issue," she says.

Of course, one of the ways lobbyists can be helpful-and in turn increase their influence over staffers-is by sharing their expertise. "Hill staff tends to be pretty young…. As a result, there is no institutional knowledge on the Hill among the staff, but there is among the lobbyists. The lobbyists are all older, have been around 15, 20 years. So, they know how it all works, and they know how the game is played," Lesley says.

And often lobbyists know how "the game is played" because they used to play it on the inside. After years working for low pay or because of unemployment when their bosses aren't re-elected, staffers sometimes make the switch to lobbying. The result is a rather cozy, and sometimes highly influential, relationship. For example, within the past year, Sonya Sotak left her job as Sen. John McCain's (R-Ariz.) health L.A. to work as a lobbyist for the Pharmaceutical Research and Manufacturers of America, while Daniel Turton, a former aide to former House Minority Leader Richard Gephardt (D-Mo.), and Alan Hoffman, the former chief of staff to Sen. Joseph R. Biden Jr. (D-Del.), went to work for Timmons and Co., a firm that traditionally lobbies on behalf of Republican issues.

And to get even closer to legislators, lobbying groups may hire people with guaranteed access: relatives. A litany of members' relatives are registered lobbyists, including the son of House Speaker Dennis Hasert (R-Ill.), the son of former Senate Majority Leader Trent Lott (R-Miss.) and the wife of Senate Minority Leader Tom Daschle (D-S.D.). While these relatives usually lobby for issues the elected official already supports, and while they must observe strict ethics rules, their relationships and powerful last names put them in unique positions when conducting business on the Hill.

How much influence these connections-and the money that often follows -have is the subject of some debate. However, some staffers acknowledge that who you know and what you can do for them are effective ways to push legislation.

Lesley recalls an instance when he was working as a lobbyist for children's hospitals, and his organization was pushing a bill heavily supported by members of both parties. Regardless, the legislation couldn't seem to make it to the Senate floor for a vote. During a meeting, Lesley says, a more experienced lobbyist recommended he contact Haley Barbour, then chairman of the Republican National Committee (RNC). Upon contacting Barbour, the hospitals were informed he could arrange a meeting with Lott if the organization was willing to donate $10,000 to the RNC, which it did. "So we met…and we got it scheduled. There is that side of it that I don't think people see. And even as a staffer, it's not always apparent," he says.

Of course, this sort of activity will theoretically be limited by campaign finance reform legislation signed into law last year; however, how the ban of soft-money contributions for party-building efforts will be enforced continues to be disputed.

PARTY POWER

Regardless of the future of soft money, however, party leadership, including the fund-raising arms-the RNC and the Democratic National Committee-will continue to impact the process.

For party leadership, much of this influence is inherent in the structure of the two chambers. In the Senate, where there is always a threat of a filibuster, the majority party is more likely to pursue support from members of the minority party. As a result, most legislation that makes its way through the chamber tends to have sponsors from both sides of the aisle. While there are also many bipartisan issues in the House, the natural imbalance of power favoring the majority party tends to lessen the need to develop an accord between the two.

"I never realized how different the House and the Senate are. I am certainly not an expert in the way the House functions, but it seems that it may function in a more partisan way in that there is much more that the majority party can do in terms of setting its agenda. But the Senate seems to work a lot more on consensus, and a lot of things get done based on bipartisan consensus, and even on unanimous consensus," Raju says.

However, this also doesn't mean the House majority leadership sets an agenda and members automatically get in line. Weldon says the relationship between the party leadership and the rank-and-file members is definitely a two-way street, and members always have the prerogative to vote against the party if they think it's in the best interest of their constituents. "When you are leading a group of elected officials, it's sort of like herding cats. You really can't get up there and say, 'We are going to do this,' because you will have a few people bolting, and then you will have a stampede after a while. It's a definite dialogue," he says.

With all of these influences-party leaders, fellow members, lobbyists and constituents-the Hill can be a whirlwind of opinion and information. Still, staffers say physicians have a role to play. "My health L.A., she' s a lawyer, and she's been doing health a long time, but she doesn't have a medical experience…. She knows the program. She knows the politics. She knows the laws. But [physicians] can complement that with those personalized stories and with what's going on on the ground, in the day-to-day of how medicine is being practiced…. There is definitely a need for physicians and other health professionals and a place where that expertise can be part of the debate," Raju says.

It is this role that has physicians on the Hill-whether they serve as elected officials or unpaid fellows-feeling optimistic about the legislative process and the ability to create change. Lee, for one, says her experience has only buoyed her belief in the system.

"A lot of people I know have kind of dismissed Washington, saying that nothing good is ever going to come out of there. But I actually have a lot of faith in the process. And change is really slow, but that's how I think it was meant to be, so that we can really examine things closely."




SO YOU WANT TO RUN FOR OFFICE?

So You Want to Run for Office?You are educated, a good speaker and have some ideas about how to improve U.S. government. Plus, you've seen that "Schoolhouse Rock" cartoon that explains how a bill becomes a law. So what's stopping you from running for Congress?

Well, technically-as long as you are at least 25 years old on the date of the election and have been a U.S. citizen for at least seven years-nothing. Of course, that's just if you want to run for the House of Representatives, as you need to be 30 years old and a citizen for at least nine years to be a senator.

However, before you throw your hat in the ring, there may be a few more things you want to consider. The first, and most important, is figuring out why you are running-and it shouldn't be just because you always wanted an office on Capitol Hill. "If you are in politics just to be a politician, it is the worst reason anybody could have to go to Washington," says Rep. Ron Paul (R-Texas), a physician first elected to the House in 1976 running on economic issues. So whether it's health care, tax cuts, the environment or military spending, you will want to figure out what matters most to you because it's the first thing voters will ask.

Besides issues, fund raising is also key to winning an election. Obviously, people will be more willing to donate to your campaign if your ideas are attractive, but often the most important part of fund raising is just asking for donations. According to Local Victory, a Republican consulting service, candidates on every level need to spend at least 50 percent of their time soliciting donations. "Rare indeed is the donor who, unsolicited, sends a check to the campaign. Successful fund raising requires that the campaign in general, and the candidate in particular, spend quality time planning and executing a fund-raising plan," the Local Victory Web site states.

Even with issues and money, a candidate can still come up short, especially in running for Congress. Since many federal legislators have been in office for several years and are well known by voters, it is rare that an unknown and inexperienced candidate can knock them off. So if you are new to politics, Rep. Dave Weldon (R-Fla.) recommends starting out by running for office on the local or state level, even though he broke that rule when he was elected in 1994. "I think if you are a doctor and you want to get involved in politics, you are much better starting out at county commission or city council or the state house or the state senate…. I beat the odds big time," he says.

Dr. Shawn Aranha followed this advice when he ran as the Democratic candidate for state representative in Illinois' 41st District in November (see "A [Medical] Man of the People," in the September 2002 issue of The New Physician). Even though he lost to the incumbent, Aranha remains determined to enter public service. "I will run again. Next time, perhaps my profile will be different, and my knowledge of issues will be further developed."

And whether it's for Congress or the local school board, Aranha recommends candidates remain confident. "My advice to others considering running is to firmly believe in yourself and what you want to accomplish and devote yourself completely to succeeding in your chosen endeavors." These are traits many medical students are already familiar with. -S.T.S.




C O N G R E S S I O N A L    F A C T S















    
SENATE


  • The House is composed of 435 voting members, each elected to two-year terms. Following the national census every 10 years, each state is allotted a share of seats based on its proportionate share of the national population. California has the most representatives with 53, while Alaska, Delaware, Montana, North Dakota, South Dakota and Wyoming have only one each.



  • Besides the voting members, there are also four nonvoting delegates-one each from the District of Columbia, the Virgin Islands, Guam and American Samoa. There is also a nonvoting resident commissioner from Puerto Rico. While unable to vote on the House floor, these delegates can vote in committees.



  • The political party in power-currently the Republicans by a count of 229 to 205 Democrats, plus one independent-is significant because it selects the speaker of the House, the chamber's presiding officer who wields a number of formal and informal powers.



  • The speaker rules on points of order, recognizes members who wish to speak and exercises extensive influence over the scheduling of legislation and the course of floor debate. The speaker also refers bills to committees.



  • In addition to these powers, the speaker also chairs the majority party committee, which determines the committee assignments, including chairmanships. The speaker also appoints members to House/Senate conference committees, which resolve differences between bills passed by both chambers.
    

  • The Senate consists of 100 members, two from each state. Senators are elected by popular vote to six-year terms with elections arranged so that approximately one-third of the Senate seats are up for election every two years. The terms are set to ensure seats from the same state are not up for election the same year.



  • Theoretically, the Senate is based on a principle of unlimited debate. Therefore, the responsibility for assuring that the chamber does not get bogged down in endless debate falls to the majority leader, who must reach agreements with members of his party and the minority party to schedule legislation and place limits on debate.



  • To move debate along, these agreements should have the support of 60 senators, since at any time a senator or a coalition of senators may filibuster to essentially stop debate. While not frequently used, this tactic was employed in March by Senate Democrats to block a judicial nominee. The only way to overcome a filibuster is to invoke closure, which requires a three-fifths vote by the chamber, or 60 votes. In March, Republicans fell five votes short.



  • The power to implement these tactics limits the formal powers of the majority leader. However, like the speaker of the House, the majority leader maintains a prominent role in determining who is recognized during floor debates and has significant influence over his party's committee assignments and chairmanships, as well as assignments to conference committees.





~CRAVE MORE INFORMATION ABOUT CONGRESS?

CHECK OUT THESE RESOURCES:

~~Physicians find their places in the legislative process, whether as congressional fellows, staff members or even elected officials.~Scott T. Shepherd is an associate editor with The New Physician.~Health Policy,Legislative Action~
7~4May-June~2003-52~Feature~Pushing an Agenda~Lobbyists make their voices heard on Capitol Hill.~Jennifer Zeigler~~Lobbying Do's and Don'ts

What About the Benjamins?

Four Pennsylvania scholars-one pursuing an M.D./Ph.D. degree -are out doing a little shopping this sunny February morning, enduring a winter snow melt that has turned Capitol Hill streets into rivers. In town for a few days, the students are looking for a souvenir of sorts to take back to their graduate programs. But they aren't seeking an FBI hat or a "Future President" T-shirt-trinkets that are a dime-a-dozen on Washington, D.C., street corners. No, they're after a pricier commodity: a senator or representative to introduce a bill that would amend the tax laws for graduate- and professional-school scholarships. They are, you could say, sponsor shopping.

All day, these four representatives, and about 80 others, of the National Association of Graduate-Professional Students (NAGPS) have slogged through the damp D.C. streets in their interview suits and some in their pinching high-heels that are reminding their toes of why they stopped wearing the shoes in the first place. By day's end, they will have walked past the brilliant-white Capitol dome at least three times, en route to the legislative office buildings that flank it on two sides; conducted a handful of hallway strategy sessions; knocked on seven of their legislators' doors; explained their position seven times to seven congressional staffers; and made time for a reporter's questions over lunch. All in a day's work, if you're a congressional lobbyist.


THE 'THIRD HOUSE'

Having derived their name in the 1820s from where they often conduct business, lobbyists have been working the halls of Congress since it first convened in 1789. According to the American League of Lobbyists, some say the term came from the "lobby-agents" waiting to speak with New York State legislators in the Capitol lobby, while others theorize the name is derived from the Washington, D.C., Willard Hotel lobby's reputation as a meeting place for elected officials and their favor-seekers.

Having since turned the term into a noun as well as a verb, lobbyists have become a formidable force in state and national legislatures. But don't think of them all as back-room, cigar-chewing wheelers and dealers looking to pay off politicians. Lobbyists can have a positive effect on necessary legislation that might otherwise get trapped in the political system. Student-lobbyists can take advantage of this role, using lobbying as another way to channel the same energy that brings you out to a political rally on a cold, rainy morning. In a way, it's the next step to voicing your opinion.

Joan Hall, a legislative advocate for the American College of Obstetricians and Gynecologists (ACOG) in California, came to lobbying in a similar fashion. A microbiology major who sidestepped medical school for law school, she passionately believes in the issues ACOG works for. "I can't argue an issue I don't personally agree with, and that's the reason I work for ACOG. What I work on is very much tied to my value system," she says.

And whether or not they agree with the issues they fight for, some lobbying groups wield great power over the legislative process. Hall says lobbyists are referred to as the "third house" in California, and they play a big role in the federal process, too.

There are 21,089 registered lobbyists working Capitol Hill, and they spend more than $1 billion annually on their efforts. According to Political-MoneyLine, which tracks lobbying expenditures, Washington special interests spent $143 million a month on influence peddling in the first half of 2002, representing a 7 percent increase over 2001 spending.

And health-care issues take a front seat on this gravy train. Political-MoneyLine counted the health-care industry as the top spender during the same six-month period-a position it has held the past three years. Health-care lobbyists spent $129.1 million in the first half of last year, an increase of $9.7 million from the previous six months. Legislative initiatives on the Patients' Bill of Rights, Medicare reimbursements and prescription drug benefits, medical device user fees and medical malpractice tort reform drove much of this spending.

And these 21,089 people with their armloads of millions don't begin to account for the thousands and thousands of grass-roots lobbyists-such as the four from Pennsylvania-who visit their state and federal lawmakers annually with their concerns, issues and legislation they want introduced, stopped or amended. Add the nearly 40 registered lobbyists for every elected official on Capitol Hill to this motley crowd, and you might begin to wonder what they do all day and how they impact the legislative process.

A DAY-IN-THE-LIFE

Madeleine Golde interrupts the conversation she's having with two other lobbyists in the hallway of the Hart Senate Office Building to flag down Sen. Jay Rockefeller (D-W.V.). "Thank you for FMAP," she says, referring to his leadership on a bill that would temporarily raise the federal Medicaid match that provides states with money for health-care services. Rockefeller says he's doing what he can. "I've got to go vote now," he says as he hurries down the hall.

"Sorry," she says, turning back to her companions. But being lobbyists as well, they understand you have to take advantage of these 10-second opportunities to address legislators when they're put in front of you.

Golde, one of four lobbyists for the Service Employees International Union (SEIU) and the only one who focuses on health-care issues, spends many of her days in meetings either pushing for legislation to be introduced or lobbying for or against bills that are already in play.

"So typically, I will have set up certain appointments for that day with staff people. You know, I don't spend that much time seeing a member-the actual members themselves," she says, which is why she jumped at the chance to have a brief, face-to-face encounter with Rockefeller. "It isn't to say it doesn't happen, but typically as a lobbyist, you develop your relationships with people in various staff positions, and those are the people that you end up speaking to-you try to lobby-and you educate." Oh, how you educate.

Most lobbyists will tell you that much of what they do is education. Legislators generally have health-policy aides on staff, but health-care issues, with their unending minutiae, involve highly technical information that not everyone understands. Dave Moore, the associate vice president for government relations at the Association of American Medical Colleges (AAMC), says he's always explaining how Medicare works to aides, especially every two years when new representatives take office. "We cover a lot of issues and…some are pretty esoteric."

"And as you know, staff turn over tremendously. So you're always in a position, at least in some degree, of having to re-educate these staff members. And it's difficult when you have spent a long time, for example, educating a staff person, and they're well versed on your issue, and then they leave, and you have to start over," Golde says.

"It's a process of both educating them and lobbying them-urging them to have their member advocate that they take a certain position on a piece of legislation, either in the form of having them co-sponsor it, you know, or if you're really starting out and you're trying to get this legislation introduced, you're doing a real job of trying to convince staff to tell their legislators to actually introduce the legislation for you," she says.

This is exactly what Alik Widge, a second-year M.D./Ph.D. student at the University of Pittsburgh and his NAGPS companions were doing with their proposal to change scholarship tax law. The visit in February marks their third lobbying call to Washington in the past year, and the repeated trips have helped the issue evolve, says Matthew A. Cronin, a Ph.D. candidate in organizational behavior at Carnegie Mellon University. On the first visit, they pressed legislative aides to roll back scholarship tax laws to 1986 standards, when the money wasn't taxable. But, having realized the bill would be up against union pressures not to change the status quo, their second visit focused on creating legislation that would be in harmony with other current tax laws. And so, armed with a bill draft that focused specifically on broadening the defined deductible expenses that students use their scholarships and stipends for, their third trip to the Hill took on the mission of finding a bill sponsor. "Each time we learn," Cronin says. "We still don't have that nugget, that sponsor, but I understand how large organizations work. They work slowly."

Congress may be accused of working sluggishly, but visits to legislative offices move fast. Golde says a typical meeting lasts about 15 or 20 minutes, during which the lobbyist explains her issue and initiates a discussion on her points. The staffer might ask a few questions, and the meeting usually ends with a round of handshakes and perhaps some promises from the aide to make calls or to bring up the issue with his boss.

Golde concentrates on the members of committees who oversee legislation she is generally concerned about. On the Senate side, they're the Health and Finance committees, and on the House side, they're the Energy and Commerce and the Ways and Means committees. But that doesn't mean she's not interested in the other members.

"There are times when your legislation is up for a vote on the floor, and then if you've been lucky enough to move it up to that level, and you're counting votes, you go outside the general purview-or if you're trying to get a bill introduced, and you're trying to build up a co-sponsor list. Even though, ideally, it's great to get the committee members from the committee with jurisdiction of the legislation you're working on, because they're the ones who are going to be advocating most strongly if it comes up for a markup. But there are times when you know your legislation is going nowhere, and you know the most important thing is to build up the co-sponsor list in terms of sheer numbers, so sometimes you just go in with whomever you can."

In other words, sometimes you need all the support you can get.


THE VALUE OF TEAMWORK

Golde says this was a strategy of the coalition working on resident work-hours reform legislation last year, of which SEIU is a member.

Dr. Rob Levy, an emergency medicine resident at Morristown Memorial Hospital in New Jersey, served as the American Medical Student Association's (AMSA) legislative affairs director at the time the legislation was introduced. He says the fact that the bill had 70 members of Congress signed on when it died in committee last year was perhaps the greatest success of the year.

Initiated by AMSA but pushed by a coalition of advocacy groups and labor unions, the resident work-hours bill had been years in the making when Rep. John Conyers (D-Mich.) introduced it in October 2001. Modeled after the Bell Commission regulations in New York, the legislation would restrict the number of hours medical residents could work in teaching hospitals. And although it expired in committee at the end of the 107th Congress last year, Conyers reintroduced a similar bill in March, and Sen. Jon Corzine (D-N.J.) was set to reintroduce the companion bill at press time.



The work-hours bill owes its success to the coalition of groups that shepherded it through its introduction in the fall of 2001, Levy says. "I truly believe forcing various organizations to work together as a team was the single most important factor in making progress."

It's a tactic frequently used in passing health-policy legislation. "I think to be successful in health-care reform, you have to have a broad base of meaningful participants," says Makeba Williams, a fourth-year Meharry Medical College student who took over Levy's position at AMSA last June.

The AAMC's Moore agrees. "Very few groups have the clout to go it alone," he says.

Not the least of which are student organizations such as AMSA, which lack the institutional history on the Hill that well-heeled, health-care groups with full-time lobbyists boast. For example, the American Medical Association spent $7.62 million in the first half of 2002 supporting at least eight full-time lobbyists to pressure Congress and another six to put the squeeze on members of the executive branch (see "Top 10 Big Spenders"). The American Hospital Association, a group AMSA expected to oppose the work-hours bill, spent $5.38 million on lobbying efforts during the same six months, and political action committees connected to hospitals and nursing homes gave $3.75 million to candidates during the 2002 election cycle, according to the Center for Responsive Politics.

To counter this kind of influence and to create legislation that had broad appeal, the future physicians pulled together a coalition of interested parties. But that's something you give careful thought to, Williams says. "I don't think physicians know a lot about working in coalitions, because working in coalitions is not one of those didactics you learn in med school. You have to think about who are your potential allies. Who are you trying to help? Students don't always understand you just don't bring in random people. You have to think about who has power and how you can wield it."

And she says working with a coalition can be a challenge. "People have their own agendas, and you have to be mindful of that. You have to know, at the end of the day, [coalition members] have people they answer to. The coalition strategist has to keep all this in mind."

To keep coalition members cohesive and working together, Levy initiated and attended countless meetings with the group that included AMSA, Public Citizen, the National Sleep Foundation, the Center for Patient Advocacy, and SEIU and its affiliate, the Committee of Interns and Residents. Through discussions, the group came to a consensus about what the bill should do and how it should read.

Lobbyists say coalitions can also help with divvying up the work of pushing a bill forward. Levy continued to meet monthly with coalition members after Conyers introduced the final product to strategize and determine who was going to lobby which representatives to sign on more members. Here, too, the coalition helped, because potential sponsors could see there were more than just medical students and physicians-in-training pushing for the bill. "In general, a coalition is always a good thing, because it shows a broad base of support, and that's as good as gold in Congress," Levy says.

But having had initial success in getting a House bill, Levy found himself still searching for a Senate sponsor for companion legislation, despite having a couple of positive conversations with some Senate aides. So he turned to the coalition for help and called Golde to see if she would throw SEIU's weight into this effort. "Obviously the nation's largest health-care union has that all-important political power that AMSA did not have on its own. The strategy worked-within a couple of months we had a commitment from Corzine's office to introduce the companion bill," he says.

THE MONEY PIT

Golde's influence with Corzine could stem from a relationship she has built with his staff in working on other health-care issues, or it could come as a result of the $2,000 SEIU's political action committee (PAC) gave to his campaign when he ran for the Senate in 2000.

"I don't think there's any question that if you have a PAC, it at least gets you noticed," ACOG's Hall says. She would know the difference-ACOG does not have a PAC in California, but she had the resources of a "big time" PAC for 11 years when she lobbied for the California Medical Association.

About once a week, after a day of meetings, phone calls and e-mails with legislative aides, Golde says she attends a fund-raiser paid for with SEIU PAC money. "That is part of my job; I have to go to these fund-raisers," she says, adding that of all the SEIU lobbyists, she attends the least number of them. The parties often draw the same core group of people who work on similar issues, who, for the price of admission, can buy a few minutes with an elected official.

"For those who can afford it and are able to go, there are these functions, as well," she says. "I'm not a big advocate of spending much time at these things. But they serve a useful function in terms of seeing the member-the member actually gets to see you and your face, and you remind him that SEIU is supporting him. And it's a good reminder. It's a good way for them to see, as a lobbyist, to see your face and put a name to a face, because you primarily deal with their staff people, and it's a very good opportunity to urge a member to talk about an issue that's of importance to you. Even if it's 30 seconds-which it's often not even that-you've at least had an opportunity to say something about an issue that's important to you. And that's an important counter."

It can be a tricky business. Campaign finance rules enforce strict reporting of donations and gifts to elected officials, and Golde says she has to be very careful about how she uses the access the PAC buys.

"So typically I'll talk about an issue, and a member will say, 'Oh, you should talk to this person on my staff.' So then you go talk to this staff person, and many times you'll know that person. But when you've gotten the entrée from the member to make sure that you raise something with a particular staff person, and you say, 'Well, so-and-so sent me over here,' it helps in some cases to get appointments with some people that maybe you've had trouble getting appointments with to talk about legislation."

Lobbyists and special interest groups are also affected by the campaign finance reform legislation, which kicked in after Election Day last November. The reforms ban soft-money contributions, those unlimited funds organizations may donate to political parties for "party building" efforts. The legislation's effect is still up in the air, as the law is sure to face a court challenge during the next election cycle, and in the meantime, proponents have charged that the Federal Election Commission's resulting rules contain too many loopholes.

FINDING A WAY

Despite the restrictions, it may seem to the unfunded lobbyist that money is all that matters on Capitol Hill. And to some degree, you might be correct. Ben Peck, Ph.D., a legislative representative for Public Citizen's Congress Watch, says he is aware of the access that money can buy. "When I lobby on prescription drug issues, I meet with staff, and [the drug company's] CEO meets with the senator," he says, pointing out that many corporate lobbyists have also worked as legislative aides, and therefore have a personal relationship with those they now lobby. "He calls up and says, 'Hey, Bob, can we talk?'"

But there are ways around the high finance, many lobbyists will tell you. "ACOG does not have a PAC, and yet we are very effective in the legislature, and I think that has to do with what we lobby on," Hall says, adding that the college has established itself as the expert on women's health issues-one that lawmakers often turn to when considering legislation. "That buys us a seat at the table."

California's restrictions on gifts are so tight, Hall says she doesn't even take staffers to lunch, let alone buy a $5,000 ticket to a golf outing, to avoid the complicated reporting procedures.


Just as Hall uses ACOG's reputation, Peck says any organization needs to find and use its unique strength to its full power. For Public Citizen, that means continuing to issue reports and publish information that can help shed light on a particular issue. For AMSA's work-hours bill, that meant finding strength in numbers and gaining public support through the media.

Levy says he began his year as AMSA's legislative affairs director with the understanding that getting to know reporters could influence both their reporting and the public's perception of the work-hours issue. He says his regular conversations with several reporters yielded articles that were accurate and even sometimes slanted toward his side. But, he says, he didn't fully understand until later that the media could also be used to exert pressure on the players involved in work-hours policy-making. "The Yale story is the perfect example," he says.

In May 2002, AMSA officials discovered that the Accreditation Council for Graduate Medical Education (ACGME) had rescinded its accreditation of Yale-New Haven Hospital's general surgery residency program. Many speculated that part of Yale's accreditation problems stemmed from abusive work hours; however, the ACGME would not confirm that. Levy says tipping off the Chronicle of Higher Education launched the story nationwide. "It was incredible how that story spread like wildfire once it came out…. It was great to read all the newspaper articles that resulted and all the quotes from program directors who said they would take reform of work hours more seriously," he says.

Yet perhaps more important than lobbyists' relationships with the media are those with the legislative aides themselves. "This is a town built on relationships," Moore says.

That's true, Williams says. "Not everything happens on Capitol Hill for the public good. There's a lot of 'You scratch my back, and I'll scratch yours.'"

Hall reserves time in her busy schedule for building relationships. For example, even after spending a morning in meetings about various pieces of legislation and giving a public address to a group of internists, she'll still settle down to lunch with a friend who works in the state's Medicaid office before running off to testify before a legislative committee on a bill. "Every minute I spend in Sacramento is doing business. So many people I work with are old friends-they've been around for 20 years, too." This is important in a state in which term limits keep the lawmakers and their staff in a revolving door.

California's term limits make Hall understanding of the difficulties part-time student-lobbyists might face in always being the new kid on the block.

But Moore says you have other advantages. "I think the students have a very valuable perspective to bring to issues, and there's a sort of bonding that goes on between congressional staff and students, in some part because they're the same age. Congressional staff is appallingly young and getting younger every day. They work long hours."

Moore's description is accurate-so much so that you may be taken aback by the aide standing in front of you at the beginning of a meeting. He's going to be a little different than you imagined. Yes, he's young. He's probably not even 30 yet. And yes, he's dressed more informally than you expected-none of that stuffy senator-wear. But trust us, he's your ticket to the inner sanctum of power, and his boss might just be the next vote you need, so it pays to get to know him.

The camaraderie that developed between the NAGPS scholars and the aides they lobbied in February took Kristy Shuda, a Ph.D. candidate in genetics at Thomas Jefferson University who was lobbying for the first time with Widge and Cronin, by surprise. She says the aides were more encouraging than she imagined, and she's been able to use the age similarities to her advantage. "For me it's good. We can bring up, 'Oh, you just graduated. Where did you go?' They're kind of in the same position-they work a lot of hours and for little pay. It's more of a personal reward."

But being surprised at any aspect of the legislative process is common. After all, to most people, legislators and lobbyists operate in a mysterious, complex world. Bernadette Thomas, a third-year medical student at Temple University, says she remembers being really nervous the first time she went to Harrisburg, Pennsylvania, to lobby state officials for continued financial support for private colleges and universities in the state budget. "I didn't understand that the process existed. I never understood my full right as a citizen to walk into my state and federal legislative office and talk about our concerns." But after years of lobbying on several different issues, she says now she appreciates the whole system-even with its flaws. "Whether I benefit in it doesn't matter as much."

Which, lobbyists will tell you, is what the job really boils down to-advocating a position for those who can't, even if some have more money to do that than others. So, if you're an aspiring student-lobbyist, you might want to get started. There are 21,089 people ahead of you in line, and Capitol Hill's not that big.




LOBBYING DO'S AND DON'TS


So, you're all fired up about some issue, and you're ready to hit the halls of Washington, D.C., to lobby. But before you pack your snazziest suit and polish your best arguments, you might want to consider some tips from those who have gone before you.

First and foremost, says Bernadette Thomas, a third-year medical student at Temple University who has lobbied both state and national lawmakers, is to dress appropriately. "It implies respect for the issue and that you're taking the issue seriously." But remember, also dress comfortably. Any legislative office is going to be a short walk from public transportation, and Capitol Hill comes by its name legitimately. You don't want to be limping into a congressional office because of poor shoe choice.

Thomas also recommends going to those offices with an appointment. It's advice that Madeleine Golde, a lobbyist for the Service Employees International Union, practices regularly. "Staff don't generally like people just to drop by, because they're trying to get some of their regular work done. That isn't to say I don't do it. I do it. I do it all the time, but I'm careful about how I do it."

Golde says she might drop by an office if she's with one of that member's constituents that day. "They never want to turn down the opportunity to meet with a constituent." And this is information a student-lobbyist can take advantage of. Everyone has two senators and one representative, and those lawmakers might be sitting on key committees.

For example, as a Tennessee resident temporarily living near Washington, D.C., Makeba Williams regularly checks in with Sen. Bill Frist (R-Tenn.). He may be the Senate majority leader to the rest of the country, but to the outgoing legislative affairs director of the American Medical Student Association, he's also her representation in Congress, something she uses to gain access to the leading health authority in the chamber. So, pay attention to who your representatives are and use this connection to your advantage.

You can find out all this information by doing your homework. Dave Moore, the Association of American Medical Colleges' associate vice president for government relations, recommends learning a little bit about anyone you're scheduled to meet with. "Did they go to medical school? Do they have a spouse who went to medical school? Did they apply to medical school and not get in? Where does their member stand on this issue? Have they taken a position on this issue?" Knowing this could help you and your cause.

This leads us to another tip-remember you're dealing with people, people who have good days and bad. "Part of the challenge of the job is the little idiosyncrasies of life. You might set a meeting with someone, and they had a flat tire or they had a fight with their kid that morning," Moore says. The whole process works through people-all with different personalities and work styles. And while it can be frustrating when an aide won't return your phone calls or is short with you when he does, it helps to remember what the process boils down to.

Once you've got an appointment with a lawmaker or his legislative aide, work quickly. "I don't think you should take more than five minutes to explain yourself," Thomas says. She suggests going in with about four key points to make before taking any questions. Don't be surprised if the whole thing is over in 15 minutes-remember, you're just one of a stream of people on the aide's calendar that day.

And with that in mind, Thomas says she gets the best results when she leaves information behind. "One thing that's really important…is that you're most successful when you leave numbers behind you." It's a tactic employed by students representing the National Association of Graduate-Professional Students (NAGPS) when they lobby Congress to support a bill that would amend the tax laws governing student scholarships. Arming themselves with three-ring binders of information, they pull out fact sheets when questioned by legislative aides on specific topics. Do the aides keep the information? Well, at a recent Senate meeting, NAGPS students witnessed an aide bring the information they gave her at their last encounter.

And don't forget, Thomas says, to follow up. "I think a week later, it's really a thank you." Then she lets the issue rest for about six months, unless it's pressing. Otherwise, you run the risk of being a bother to the aide, she says.

Lastly, at the risk of stating the obvious, this is a political process, and politics can get in the way. Williams says students she works with often don't understand when a lawmaker they met with doesn't sign onto a bill. "They'll say, '[The staff was] really nice to me.' But yeah, they were nice, but…," she says, adding that political alliances with other elected officials can often prevent even interested representatives from throwing their support to an issue.



WHAT ABOUT THE BENJAMINS?

Hey, buddy, can you spare a few million? When you think about it, this is often what lobbying is-organizations and individuals asking Congress to spare some change in the federal budget for a program, law or tax change. Money is the tie that binds public health and public policy.

"That's what aides want to know-at the end of the day, how much is this going to cost?" says Makeba Williams, a fourth-year medical student at Meharry Medical College who lobbied on behalf of the American Medical Student Association this past year as its legislative affairs director.

"So it helps to know the numbers before you go into a lobbying meeting. But Williams says this can be a challenge for medical students who will be in excess of $100,000 in debt when they graduate and have more pressing needs to focus on. "If people don't get it in their own finances, they're not going to get the federal budget when they're memorizing arteries and the Circle of Willis. Altruistic activists don't always look at the fiscal side. There are no free lunches, but it's easy to forget about that when you're a medical student, and you just want to help your patients. You're asking [students] to do leaps."

"So the next time you head to Washington to argue your case before the nation's decision-makers, you might want to pull out that economics book from undergrad and brush up on fiscal policy. The bottom line is that your cause will cost something, and Congress wants to know how much.

~

WANT TO LEARN MORE ABOUT LOBBYING? CHECK OUT THESE RESOURCES:


~~AMSA members meet with a representative from Sen. Barbara Boxer's (D-Calif.) office last June to discuss resident work hours. ~Jennifer Zeigler is a senior writer with The New Physician.~Health Policy,Legislative Action~
134~1January-February~2003-52~Folk Tales~Healing With Humor~CLOWNING AROUND ON THE WARDS ~Scott T. Shepherd~~On the road to becoming a physician, a medical student learns many things. How to diagnose and treat illnesses come first. Next stop—clinical skills. But what about humor? Where does learning how to administer the medication of laughter fit in? Of course, some educators and students would consider learning this type of skill a waste of their time; they just can’t see the point.


Fortunately for the patients of Steve Ko, he is not one of those people. In fact, the third-year Medical College of Georgia student takes clowning around very seriously. For you see, Ko is a clown—or more precisely, KoKo the Clown.


And KoKo the Clown is not just some guy with a red foam nose who does knock-knock jokes. He’s a full-blown professional clown. From the bottom of his oversized shoes to the top of his multicolored jester’s hat, KoKo clowns around in the tradition of Bob “Bozo” Bell and Emmett Kelly.


Ko’s clown persona was born when he was going to high school in Atlanta, Georgia. During a church carnival, his mother invited some of her friends—clown friends, that is—to entertain the crowd. While getting ready, the clowns announced they had an extra costume. “They asked if anybody wanted to dress up, and I raised my hand,” Ko says. “I really didn’t know what I was doing then, [so I] just dressed up and acted goofy.”


Despite the fact he didn’t know how to juggle or perform tricks, Ko still made people laugh with his silly antics and funny faces. From then on, he was hooked on the art of clowning and the reactions he could get from an audience.


Now, more than 10 years later, Ko has his own costume and a professional act to go with it. He juggles balls, bowling pins, Chinese flower sticks—two sticks used to juggle a third stick—and a diabolo, which is a small sphere balanced on a string tied to two sticks. He also has a plethora of card tricks, disappearing flowers stunts, oversized prop gags and, of course, balloon animals to keep a crowd entertained.


Often he’ll put these tricks together to entertain a large crowd in a 30-minute show. “When I do big shows in front of an audience, I do those sort of things set to music,” he says. “With a big show, I tell a story through the act.” These performances are usually for birthday parties, reunions, church festivities and other family-oriented events. Ko says he receives an offer to entertain somewhere practically every week. “I could probably finance my entire medical education if I only had the time,” he says with a laugh.


And being a medical student separates Ko from other professional jesters, providing him opportunities to perform for a unique audience: patients and their families. “There is show clowning, and there is walk-around clowning…that’s what I do at the hospital.”


And even when Ko has not transformed himself into KoKo, his clowning skills still come in handy on the wards. In fact, he says the many pockets in his short, white coat are perfect for surprising a patient with a little dose of laughter. “I remember this 3- or 4-year-old who was pretty timid…and I just tried to use my clowning skills to put him at ease…things such as the collapsing flower, an oversized thermometer or gags with a reflex hammer. What that really allowed me to do was give him a complete physical,” says Ko, who, not surprisingly, wants to enter pediatrics.


However, hospital rules prevent him from pulling out one of his favorite tricks, balloon animals, which also happens to be the children’s favorite. “Unfortunately, I can’t do the balloon animals because we’re a latex-free hospital. It’s too bad…balloon animals always work, sometimes on the parents too. Just to see a balloon flower give[s] them a smile. It kind of puts the whole thing in perspective—they are more than numbers or symptoms.”


Ko says his antics aren’t just reserved for patients and their families, though. He also likes to use his tricks to brighten the days for overworked hospital staff. “It can be great for stress relief,” he says. So how is his clowning viewed on the wards? He says teachers and fellow students have supported his entertaining endeavors, adding that they seem to appreciate humor’s place in a hospital setting.


Of course, some people compare Ko to Patch Adams, the comedic West Virginia physician made famous by the movie of the same name. In response, Ko points out he began clowning before he ever saw the movie or knew about Adams. Still, he says he and the clowning physician agree on the importance of laughter in the healing process. “The medicine of laughter is an integral part of the art of medicine, which so often falls by the wayside in the current era of HMOs. To me, healing means much more than treating physical ailments. A clown, albeit not a physical healer, is a healer of souls.”
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Student Life and Well-Being~
135~1January-February~2003-52~Feature~Stepping Out~~Jennifer Zeigler~~Students and organized medicine are critical of the high cost of a recently unveiled standardized patient exam.


It’s a Saturday morning in May. There are a million things a fourth-year allopathic medical student could find to do in the Philadelphia springtime: catch up with friends over coffee after a busy week on the wards, take a run in the park, and even tackle that stack of reading by the bed. Then there’s the bed itself—you do need your sleep.


Or you could go try out a new medical licensing exam.
Well, there’s a difficult choice.
For fourth-years at the University of Pennsylvania School of Medicine last spring and summer, there was no choice. And listen up, current first- and second-year U.S. allopathic medical students: This will be your life soon, and you’ll get to pay a hefty price for it.


Penn students, and those at neighboring Temple and Thomas Jefferson universities, spent May through
September serving as guinea pigs in a pilot test of a clinical-skills exam scheduled to become part of the United States Medical Licensing Examination (USMLE) in 2004. It’s an exam that has become a bone of contention with many allopathic students, not because they disagree with the need to learn clinical skills, but because current plans estimate the privilege of being tested on them will cost $950.


Fourth-year Penn student Meena Bewtra argues it’s a high price to pay for a test her school already administers to students on three separate occasions. “And you have to see I-don’t-know-how-many patients on our clerkships. The thought of having to come in on a weekend and be tested on top of all that was extremely annoying—and to have to pay $1,000 for it. Nobody that I tested with, myself included, wanted to be there,” she says.


LONG TIME COMING


The plans leading up to that May day when Bewtra sat for the pilot test go back decades. Medical students had been taking a national clinical-skills exam until the early 1960s, when the requirement was dropped because of logistical concerns and questions over the reliability of the exam’s evaluation procedure. Since then, the National Board of Medical Examiners (NBME), which offers the USMLE in conjunction with the Federation of State Medical Boards (FSMB), has been working toward instituting an improved clinical-skills assessment, most actively during the past 20 years. In the meantime, a similar requirement was made of foreign medical graduates who want to enter the country for residency; their exam carries an even higher price tag and is offered only in Philadelphia. Then in 1995, the FSMB called for the adoption of such an exam into the U.S. allopathic medical licensing process.


Exam authors hope that certifying students’ abilities to conduct a physical exam with strong interpersonal communication skills will increase consumer confidence and cut down the number of malpractice lawsuits.


So after studying the issue for 20 years and publishing some 30 papers on the subject, the NBME began a round of pilot tests in Philadelphia in May 2002, following with another round in Atlanta this past fall, giving students a first glimpse of the exam’s components.


The test, which is expected to become a prerequisite to Step 3 of the USMLE, is designed to be taken sometime at the end of third year or the beginning of fourth year. Unlike the multiple-choice questions on the other USMLE Step exams, the daylong test will consist of 10 to 12 interviews with standardized “patients,” each lasting about a half-hour, after which students will make their diagnoses. The trained actors, posing as patients, will use a specific set of guidelines to evaluate the students, generating their pass/fail scores. The sessions will be videotaped, but for quality-control monitoring only, not for evaluation purposes.


But standardizing an exam involving live patients as opposed to paper and a No. 2 pencil has proved to be a logistical challenge and costly to administer. Dr. Peter Scoles, vice president of assessment programs at the NBME, says these qualities make the clinical-skills test more expensive than the other licensing steps, which cost between $400 and $600 each. With 10 to 12 role-playing patients to train and pay for, staff salaries, scoring and result archival fees, cost projections continue to place a $950 price tag on the exam; the NBME maintains it will not make a profit on the test. To keep test administration and user-fee costs at a minimum, plans currently call for a limited number of core test centers, which the NBME will be building in five cities around the country for an estimated $2.1 million each. Philadelphia and Atlanta have already been selected; other potential sites include Chicago, a city in Texas and somewhere on the West Coast, according to Scoles.


FUNDING FRACAS


But students complain that limiting the test centers only adds to the cost for the 40 percent to 50 percent of medical students who are expected to travel to an exam city.


“It just gives you a sense that they’re just squeezing every last cent out of you—and I don’t know who ‘they’ is. I just think my money could be used in better ways,” says Ruthie Pannell, a fourth-year at Mercer University School of Medicine, one of the Atlanta pilot schools. She took the exam in September. “I think the whole test is just absurd. It was designed to test foreign medical students. It is a test most American medical students could pass anyway. If students can’t pass a test like this, well, then that’s something the school needs to address in its curriculum.”


In fact, Mercer already addresses clinical skills in its courses, testing students at about the same time as the new licensing exam would. This adds to Pannell’s consternation. “It’s not like my tuition will be less because our school’s not going to put on that test anymore.”


It’s an argument Dr. Eric Hodgson makes as president of the American Medical Student Association. “Many schools have standardized patients, but that’s not the same as a high-stakes licensing exam. It seems as if the burden should be put on the medical schools. [The NBME is] putting the burden on the students, when really they should be putting it on the schools,” he says.


Students’ concerns about the burden of the exam’s fee and travel requirements led the Association of American Medical Colleges (AAMC) to pass a resolution last July requesting the NBME to defer implementation until it located a third party to pay for the exam or until the state licensing boards agreed to pay a premium from physicians’ licensing fees to offset the costs. The plans were discussed at meetings in July and September 2002 between the NBME, the FSMB, the AAMC and the American Medical Association (AMA), says Robert Sabalis, Ph.D., the AAMC’s associate vice president for student affairs and programs.


But the talks weren’t successful from the student perspective. “It became clear that the FSMB couldn’t have the states handling the fees,” he says, explaining that the 70 state boards don’t always have the authority that they would need to do so. Attempts at finding a third party, such as a pharmaceutical foundation or malpractice insurance company, to underwrite the exam’s cost have also been unsuccessful.


One option still under consideration is the possibility of bundling the various USMLE fees together to be collected by each school as part of tuition, which could then at least be financed through student loans. About 95 percent of medical schools require students to at least take the USMLE exams for graduation, but Sabalis notes the idea is not without its kinks. For example, there is the question of how to handle the fee for students who decide midway through the educational process that clinical practice isn’t for them, eliminating the need to obtain a license. Plus, Step 3 isn’t even taken during medical school—physicians-in-training usually take this final phase in the first year of residency. And one more thing, he says. “Should the bundled fee include retakes? And that might be attractive to people because that might end up saving them money.”


For its part, the NBME says it will do what it can to keep costs down. “We can work with travel agencies and hotel chains—as we have done in Atlanta—to drive down travel costs,” Scoles says. “We would love student organizations to work with. We’d be happy to enter into a dialogue about reducing the entire cost of medical education.”


The AMA would rather see the NBME collaborate with schools to help drive testing costs down. David Rosman, a fourth-year at the University of Massachusetts Medical School and an AMA trustee, says the AMA model for a potential clinical-skills assessment brings the cost down to about $400 and eliminates the travel component. “When they break down the costs, a big part of it is us paying for the cost of building the test sites,” Rosman says. “We’d rather see them partner with schools that already have these sites built.” About 45 percent of schools already conduct standardized patient exams, Scoles says.


Rosman says that figure is closer to 100 percent. “Almost every school has a facility for teaching and testing.”


NECESSARY OR NOT?


The AMA has officially opposed the exam’s implementation since June 2002, when its House of Delegates voted to recommend suspending the exam until costs are reduced and further scientific analysis proves it would improve patient care. “The AMA is wholeheartedly an endorser of testing clinical skills,” Rosman says. “The problem is tying it to licensing. There is very good reasoning that testing for clinical skills is a good thing. They’ve also shown validity insofar as there will be a group of people who will continue to fail the exam. What they haven’t shown is that those people are the ones who need [to be] weeded out.”


The NBME expects about a 5 percent failure rate among first-time test takers and an ultimate failure rate of about 1 percent to 2 percent as students pass on later tries. These estimates are holding true during the pilot phase, Scoles says. That means each year the exam will deny about 180 to 360 students the opportunity of obtaining a license to practice medicine in the United States.


It’s a job that has been done largely by observant residency directors. “[Inadequate skills] are often found in residency, and the residency directors complain about that,” Scoles says.


Rosman says the AMA wants a longitudinal study of the pilot-test takers to determine if the ones who failed this summer and fall are the ones who become physicians with poor communication skills, inadequate bedside manners and higher malpractice lawsuit rates. “They’ve been piloting this, as they say, for quite some time, so they should be able to demonstrate that,” he says.


Hodgson says he’d also like to see some independent research to test for the necessity of the exam. “The number of people this will actually take out is minimal. The question is if this test is necessary,” he says. “If it is necessary, I believe the NBME has a product that is valid. The NBME is an expert at making tests. But a lot of the research that says it is valid has been done by them. [But] the truth is, if the test is needed, the NBME can do it.”


OSTEOPATHS NOT EXEMPT


If you’re an osteopathic medical student thinking, “Thank goodness I don’t have to take that exam,” think again. Your licensing board, the National Board of Osteopathic Medical Examiners (NBOME), has been working on a remarkably similar clinical-skills assessment since 1995. “It was like two great scientists working on similar projects in different parts of the world,” says NBOME’s president and CEO, Dr. Frederick Meoli.


The exams are closely aligned. Like the allopathic assessment, the osteopathic test will evaluate students on their communication skills, abilities to conduct history and physical exams, and their medical decision-making skills by sending them through a series of standardized patient situations. “The pencil and paper test and the computer test shows that [the student] knows his stuff, and he may even know how to do it. But the clinical-skills exam will show he can do it,” Meoli says.


The only major difference is that osteopathic students will also be tested on their osteopathic manipulation skills, a major component of osteopathic medicine. That part of the exam will be graded by physicians rather than the patient-actors who will grade the other competencies. “We don’t think the standardized patient alone can make the clinical evaluation as well as an osteopathic physician can,” Meoli says.


Students will take the exam as part of Step 2 of their Comprehensive Osteopathic Medical Licensing Examination (COMLEX), the counterpart to the allopathic USMLE. And, as you may have guessed, the exam is expected to cost about $950 when it rolls off the assembly line in 2004.


Same test, same price, same few number of testing sites as the USMLE assessment. So why haven’t we heard a collective outcry from osteopathic students similar to what has been building for months within the allopathic community? Some attribute it to a numbers issue: There are far fewer osteopathic students than allopathic, a little more than one-tenth of the M.D. numbers.


And those who are talking about the exam don’t see eye to eye on the issue. William Blazey, a second-year at the New York College of Osteopathic Medicine, says he’s in favor of the exam. “I feel that while we have been getting tested based on written knowledge and regurgitation for facts and figures, the real test comes with patients. If the addition of this exam is able to assist physician liability insurance reform, then the one-time cost would be well worth the affirmation to the public of providing quality health care that is accessible to all people.”


But William Shelby, a fourth-year schoolmate of Blazey’s, disagrees. “I think that the idea is really a waste of time and money of both allopathic and osteopathic students,” he says. “The place to screen students’ skills is the third and fourth year. A one-day test does not replace two years of supervision. If you are forced to do the right thing every day for two years, it will become a lifelong habit. If you only do the right thing for one day, it is quickly forgotten.”


Meoli says he has heard these mixed reviews from students: On the one hand, they’re in favor of learning clinical skills, but they have concerns about the costs involved. “But I don’t think they have been at the same pitch as the allopathic students. Perhaps as they get better organized, it will cause the osteopathic students to do so too,” he says.


Still, if further protest is going to be initiated, students—allopathic and osteopathic—had better do it soon. Both exams are in the final decision-making stages. Meoli says the fate of the new COMLEX Step is in the hands of the NBOME right now, while Scoles says the NBME is expected to make a final decision by March.


And students may want to consider their reactions carefully. In addition to the rising costs of medical school, the exam, like all licensing exams have done, is expected to generate some curricular changes as schools that haven’t been formally testing clinical skills would now begin to do so. Scoles says he can see changes coming in the NBME’s home city. “I know in Philadelphia, some schools do and some schools don’t, and the schools that don’t know they’re going to have to start. I would expect that most schools will take a look at their curriculum, and we certainly will be out helping schools,” he says. “Right now, we’re probably the country’s experts in standardized patient testing.”


Every indication now looks as if medical students are about 18 months away from seeing if they can become experts in taking that exam.
~RESOURCES


To learn more about the proposed
clinical-skills exam and get involved with student initiatives, visit these Web sites:


~~~Jennifer Zeigler is a senior writer with The New Physician. ~Medical Education,Osteopathic Medicine~
136~2March~2003-52~MedMentor Q&A~Beyond the Lecture Hall~OPTIMIZING YOUR CLINICAL ROTATIONS~Daniel W. Collison~~Many of you will soon be starting your clinical rotations. Welcome to the messy and wonderful world of patient care! Say goodbye to anonymous dozing in the back of the lecture hall; say hello to giving morning report after a sleepless night. Fret no more over the results of a histology practical exam; worry instead over the results of your patient’s computed tomography scan. Close the door on solitary studying; pull up a seat, if you can find one, to write your progress notes in the middle of a bustling nursing station. As a clinical clerk, no longer is your focus on yourself, but on the patient. Within the clinical setting, the means by which the patient receives optimal care is the health-care team. You will still need to learn large amounts of factual knowledge but usually with an emphasis on and within the context of patient care.


Your work as a clerk will be to learn and integrate the following:


  1. Learn the various roles of the members of the health-care team and facilitate relationships among them on behalf of the patient;

  2. Provide service to the patient and your team as you follow the patient, especially in tracking patient data, retrieving information and facilitating care; and

  3. Learn the subject matter and skills of your particular rotation.




ROLES AND RELATIONSHIPS


Get to know the roster and the players in each role. Ascertain the expectations of everyone in your chain of supervision as soon as possible. Don’t assume you know: Each team is different and may even change depending on the day or time of day, who is supervising, etc. Crosscheck and get different viewpoints, especially from allied health workers, on the way things run. Ally with as many team members as possible in getting things done. Learn how to debug or rewire relationships that have gone wrong or relationships that aren’t working as well as they should. Consider and allow for how your emotions may affect your work. Although orienting yourself this way will be uncomfortable at first, your work and learning will eventually go more smoothly. For as medicine becomes more complex, it will not be only factual IQ but improved emotional IQ and relationship IQ that will make your practice more effective and enjoyable.


SERVICE


Working hard is a given; working smarter is the new key (see The New Physician’s November 2002 “MedMentor”). It is easy to misunderstand your role as a student or even as a resident by taking on too much responsibility and getting overwhelmed or by taking on too little and not learning. If you have to err, err on the side of what is best for the patient and on taking on just slightly more responsibility than you might feel capable of—responsible stretching helps you grow.


CONTINUAL IMPROVEMENT


Add patients and clinical problems to roles, relationships and service, and your learning will mostly take care of itself. Still, there are a few more tricks to make the most of your clinical rotations:


Ask. If they haven’t been provided to you, ask what the core skills and knowledge sets are for the rotation. Find out your responsibilities. Ask (your patients especially) if you can help. Case by case, patient by patient, inquire of yourself or of others, “What can I learn from Mrs. X’s case?” Ask not only what, how and why, but also who. Who has written or can tell us about this? Who can help us get this done? Who does this best? Why assume and risk not benefiting from the experience of someone more expert?


Be Present. This can be as simple as just showing up. You can’t learn everything in books, especially not procedures or how to talk with patients or colleagues about difficult things. The famous physician–teacher William Osler wrote, “To study medicine without books is to sail an uncharted sea, while to study medicine only from books is not to go to sea at all.”


Being present means something else as well: It means being attentive and relating to the person or situation with as much of your being as you can. Some medical students try to disappear into the woodwork. The best students engage themselves as optimally as possible with others. Don’t underestimate this power—it is one of the best things we can do as physicians. The power of being present to others was humorously depicted in the movies “Being There” and “Forrest Gump.” Chauncey Gardener and Forrest Gump were simpletons, yet their ability to simply be present to others had an almost magical, empowering effect on the lives of others. Be that sort of person for your patients especially, but also for other members of the health-care team. I am not talking about being a frantic pleaser, like a golden retriever rushing around and slobbering over everyone. Instead, a person with “Gump-tion” interacts and works with peace and purpose. When I select students to interview for residency, a key trait I look for while reading the dean’s letter is the student’s observed ability to do the right thing at the right place at the right time. I think those students do so by always being aware, always working and always looking with open eyes at the results of their work.


Keep the Purpose in Mind. Before you do something, think things through. Ask, “Does what I’m doing truly move things along?” whether it be patient care, improving a relationship or adding to your learning. If it doesn’t help in any of these areas, why do it?


As a medical student, initially I had particular difficulty understanding the purpose of “presenting patients.” I recall giving complete but, in fact, horribly verbose case presentations until a cardiology attending kindly set me straight.


“You don’t need to prove to me you have memorized Bates’ [Guide to Physical Examination and History Taking],” he said. “Just tell me what I need to know to take better care of this patient.” After that, I got to the point much sooner.


There is a lot to learn on the wards. Look around you. Observe how the best work, ask yourself and others how patient care can be done better, and walk with your patient as you help one another with your respective predicaments. By doing so, you both will learn what superb care is.
~~~~Daniel W. Collison is chief of dermatology at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.~Medical Education~
137~2March~2003-52~Feature~Get Well~OVERWHELMED MEDICAL STUDENTS FIND LIVING HEALTHY IS EASIER SAID THAN DONE.~Scott T. Shepherd~~During medical school, you learn ways to care for your future patients, including giving them advice on how to reduce stress, eat healthy, exercise and avoid smoking and excessive amounts of alcohol. But what encourages you to apply these same behaviors to your own life? What ensures that you, the medical student, will look after your own well-being?


Well, the short answer is not much.


At medical schools around the country, future physicians may be making healthy living a priority for their patients, but it’s one of the last things they worry about for themselves.


“It’s because we have the large quantity of materials we all have to learn,” says Sher-Lu Pai, a first-year at the University of Texas–Houston Medical School. “No matter how much we study, there is never the end of it. Whatever we don’t learn well, it could be the necessary knowledge we need to save our future patients.”


Pai is far from being the only student who’s feeling this burden, believing that any time not spent studying is time wasted.


And for many, the problem begins early. “For me, the first year was definitely a transition period. [My classmates and I] fell into the pattern of crisis management.… We would have an exam. We would set goals. And then I would essentially cram because the volume was triple what we were used to,” says William Nunley, a fourth-year at the University of Louisville School of Medicine who’s taking a year off to serve as the director of student programming at the American Medical Student Association.


This is common behavior for new students, according to “Self-care in Medical Education: Effectiveness of Health-habits Interventions for First-year Medical Students,” a report by researchers at Indiana University published in the September 2002 Academic Medicine.


Surveying 54 medical students, they learned that future physicians felt a constant demand to study, while having little or no understanding of how to manage their time. “Students often fail to recognize their studying expands to fill the amount of time allotted, and therefore opt for short-term strategies to reduce stress,” the researchers write. Common problems include:


Up all night. Most medical students will tell you one of the first things sacrificed is sleep. “At the beginning, I told myself if I would just stay up for one more hour, my grades would improve,” Pai says. “Then, it soon became two, three, five more hours. Eventually, I started to skip bedtime during the exam week.”


Fast food. Studying leaves little time to prepare meals. The result is students depending on school cafeterias and restaurants, which often fail to provide the healthiest choices. The selection is further narrowed by the expense of eating out. “Most hospital foods have two things in common: They are unhealthy and expensive,” says Dr. Yoon-Hang Kim, an integrative medicine fellow at the University of Arizona. With little time and a limited budget, the dollar menu at Wendy’s doesn’t seem like such a bad option.


Then there are those free meals—rarely passed up by medical students. “All of our school-sponsored lunches, all of our student [organization]-sponsored lunches, every lunch that we had that was offered to us as students was pizza. And here’s a medical school preaching good health and nutrition, and providing just terrible food,” says Steve Turner, a third-year at the University of Virginia School of Medicine.


No sweat and no life. Other common casualties are exercise and social life. Like sleep and diet, the primary reason for this is lack of time. “I just felt like the idea of balance just didn’t fit in with the whole structure of medical school,” says Dr. Ina Grundmann, a recent graduate of the University of Maryland School of Medicine.


TURNING TO BAD HABITS


So what happens to future physicians who lack outlets other than school? In some cases, they develop short-term strategies revolving around alcohol. According to the Indiana University researchers, approximately 20 percent of medical students drink alcohol to the point where it is a problem. “[W]hile socialization decreases, the social occasions that do occur are more likely to be centered around alcohol, such as dances or post-test ‘binges,’ rather than non-alcoholic opportunities,” they write.


A survey of 548 students conducted by researchers at the Oregon Health Sciences University (OHSU) School of Medicine provides further insight. In “Tobacco and Alcohol Use Among 1996 Medical School Graduates,” published in the October 1998 Journal of the American Medical Association, the authors report that 18 percent of graduates admitted drinking three or more times per week, while 21 percent revealed at least one recent episode of binge drinking. Furthermore, 18 percent of females and 11 percent of males reported that their alcohol consumption increased during medical school.


This is little surprise to many future physicians. “I always thought the drinking was much more of a reaction [to medical school], like a reward or a stress relief,” Grundmann says.


While they may not always see the dangers of drinking, the message about smoking seems to have been heard loud and clear. The OHSU study found that only 2 percent of students reported smoking on a regular basis, which is the lowest rate ever observed among a large sample of medical students. And among those who do smoke, students often attempt to quit or, at least, try to hide it. “It gets pretty taboo. The people in my class who did smoke didn’t brag about it, and they didn’t show [it]. They were closet smokers,” Turner says.


Similar to smoking, medical students also view the regular use of drugs as unacceptable. However, how many students abuse these substances and simply hide the habit remains the subject of some debate. In a study from the University of New Mexico School of Medicine, “Perceptions of Academic Vulnerability Associated With Personal Illness: A Study of 1,027 Students at Nine Medical Schools,” published in the January 2001 Comprehensive Psychiatry, researchers found between 7 percent and 18 percent of medical students suffered from substance-use disorders.


The 25 percent of students who showed symptoms of mental illness also concerned researchers. In all, 47 percent of the students displayed at least one mental health or substance-abuse issue.


In particular, Drs. Jane Givens and Jennifer Tija, of the University of Pennsylvania School of Medicine, describe the problem of depression among medical students. In “Depressed Medical Students’ Use of Mental Health Services and Barriers to Use,” published in the September 2002 Academic Medicine, the researchers report 24 percent of the 194 surveyed medical students suffered moderate to severe levels of depression. More disturbing was the researchers’ finding that only 22 percent of those depressed students were using counseling services, while 12 percent had contemplated suicide.


Medical Education or Health?


The medical education community acknowledges that future physicians can suffer serious mental and physical health issues. But the question remains, why? Is it more than just a lack of time?


For many, the roots of the problem are entangled in the structure of medical education, which can promote high levels of stress and a competitive environment. In “Medical Education: A Neglectful and Abusive Family System,” published in the November–December 1989 Family Medicine, Dr. Catherine McKegney of the University of Minnesota Medical School compares traits of medical education to those of an abusive family. “Neglectful and abusive families are often characterized by their unrealistic expectations, denial, indirect communication patterns, rigidity and isolation. The medical education system has similar patterns of behavior that contribute to problems at all levels of the training process and include practicing physicians,” she writes. Just like abusive families, McKegney notes, each generation of physician-educators is likely to teach as they were taught, therefore perpetuating the abuse from one generation to the next. This is a pattern not lost on future physicians.


“The problem, I think, is just machismo. It is just ego. [Physician-educators say,] ‘I went through this; I was strong enough to survive this. These people following, why do they have to have a break?’” Nunley says.


PROVIDING THE TOOLS


Of course, not all physician-educators take this approach. In fact, many institutions have attempted to show medical students how to maintain more balanced, healthy lifestyles. For example, at East Tennessee State University College of Medicine, students have an opportunity to participate in well-being workshops and lectures; Baylor College of Medicine offers a women’s wellness retreat and mental health advocacy; the University of Pittsburgh School of Medicine celebrates a well-being week; and medical institutions nationwide offer similar programs.


However, student organizations—not the schools—sponsor many of these activities and services, which in turn limits funding and outreach. “Without schools prioritizing it, students are left to organize on their own and that changes from year to year,” Nunley says.


Some medical schools are trying to change. At Georgetown University School of Medicine, Donna Cameron, an assistant professor of family medicine, teaches “Well-Being: You and Your Patient,” a spring, eight-week elective available to first-years. The class educates students how to balance six crucial areas: social life, spirituality, physical fitness, emotional health, intellectual health and occupational satisfaction. Cameron says the 4-year-old class has been a success, providing students with crucial tools. Future physicians use the class to develop exercise plans, eating patterns and time management skills, along with finding social outlets.


However, Cameron says there remain limitations with the class’ length and availability. Furthermore, students receive this information after they have already begun medical school, meaning unhealthy patterns may be established.


The University of Louisville School of Medicine attempts to address this concern early on. In 1981, it initiated the “Health Awareness Workshop” for first-year medical students and their significant others one week before classes began. “It basically talked about healthy lifestyles, stress management, getting six hours of sleep a night and the like,” says Nunley, a graduate of the program.


The program’s founder and former director, Dr. Leah Dickstein, who retired last year, says two medical students came to her in 1978 and requested something that would ensure the incoming medical students “didn’t go through what we went through.” That resulted in the creation of a regular medical-student discussion group. Later, a colleague advised Dickstein to move the program to the beginning of the school year so first-years could focus on developing strategies before tackling medical school life.


What makes the workshop unique is the program’s content developers: second-year students who just completed their transitions. Over the years, the program has evolved and expanded to provide cooking tips, mental health lectures, networking opportunities and informational sessions for minorities. “One year, we had a student [who] said we need a panel on students who were nontraditional. I said, ‘OK, you’re in charge.’ We didn’t define nontraditional. If you consider yourself nontraditional, go,” Dickstein says.


And the second-years do more than simply develop the program. They are also available during the workshop to offer advice, lead lectures and let the first-years know they are not alone. Dickstein says they’re the primary appeal of the week, which usually attracts more than 95 percent of the incoming first-year class, despite being completely voluntary. “The reason they come is not because I invite them, but because the second-year medical students—40 of them—help me through that whole week. They cook, they shop, they clean, they give lectures, and they run groups. So the second-year students say [to first-years], ‘You better come to this. If you don’t, you are going to start school feeling very alone and more anxious than you need to.’”


Since Dickstein’s retirement as the dean for faculty and student advocacy and as a psychiatry professor, the program has changed names—now called “Med School Matters”—but the content and objective remains. “The point is before you can become a good, competent physician, you have to learn to take care of yourself first,” she says.


COMES DOWN TO YOU


But at many other schools, you are left to fend for yourself during that first year. And in the end, that may be what it comes down to: yourself. While a school can point the way and provide resources, many students say it is up to the individual to approach his medical education in an intelligent and realistic manner.


Some students are finding this possible. “Medical school has definitely made maintaining a healthy lifestyle much more difficult. It has required me to schedule activities, like working out, finding time to make relatively healthy meals, because free time has become very precious. But I haven’t allowed med school to be an excuse for not keeping a healthy lifestyle,” says Jessica Langenhan, a second-year at George Washington University School of Medicine.


But in medical school’s competitive environment, some students still believe any time not spent studying is time wasted. For this reason, Dickstein says they need to recognize their limitations and the importance of their own health. “In other words, we are not superhuman. We may be really smart, but a lot of other people are really smart too. People want us to take care of their health and their families, and that is fine. But we should not, we cannot, we must not sacrifice our own health. It’s simplistic, but in some ways tragic.”
~WORDS OF ADVICE


Often, the best people to turn to are your peers. Here are just a few of the healthy-living tips that were shared with The New Physician.


Know yourself and your medical school. “Sun Tze in Ancient Art of War, stated that ‘If you know yourself and know your opponent, you can fight 100 battles and emerge victoriously.’ My advice is that students take an inventory of themselves and find out as much as possible about the particular medical school that they are entering.”—Dr. Yoon-Hang Kim, integrative medicine fellow, University of Arizona
Seek guidance. “Try to find mentors who can help you achieve the vision and share their wisdom to guide you through your own journey without a road. This mentor does not have to be a physician. In my case, she was a healer and Aikido teacher.”
—Dr. Yoon-Hang Kim


Maintain a support system. “I think my friends and family have been the most important reasons why I have been able to remain somewhat balanced during these last five years.”—Akilesh Palanisamy, fourth-year, University of California, San Francisco, School of Medicine
Stick to a routine. “Establish a schedule and adhere to it early. If you can, maintain a regular sleeping schedule and find an activity or outlet outside of medical school to preserve your sanity.”
—Azalea Saemi, first-year, University of Vermont College of Medicine


Do not undervalue sleep. “Always get enough sleep! I need a minimum of 7 hours a night. That’s my priority, especially the night before an exam.”
—Dahra Perkins, second-year, University of Southern California School of Medicine


Find time for exercise. “Exercise is the biggest challenge for me and one of the most important things to do to manage stress. Minimally, I always take the stairs. Hey, every little thing helps! I also sometimes do a quick walk around the block during the 10-minute breaks between lectures—time otherwise spent sitting around chatting.”
—Dahra Perkins


Don’t forget who you were before medical school. “Try to maintain the habits and hobbies—the good ones, anyway—that you had before med school. Don’t let yourself become a person who can be identified as a med student and nothing else.”
—Jessica Langenhan, second-year, George Washington University School of Medicine


Take your own advice. “I feel that being a doctor who has been unable to maintain his/her own healthy lifestyle is like being an accountant whose own tax-forms couldn’t pass an audit; or being a dentist with rotten teeth and bad breath; or being a car salesman who only rides a bike. In some cases, patients who are told by their physicians to go on a diet or exercise 30 minutes a day would be perfectly justified in replying, ‘After you.’”
—Jessica Langenhan


For more advice from your peers, visit the American Medical Student association’s “Medical Student Well-Being” Web page at www.amsa.org/well/wellres.cfm. —S.T.S.
~~~Scott T. Shepherd is an associate editor with The New Physician.~Student Life and Well-Being~
138~2March~2003-52~On the Wards~A Misguided Tour of the ER~STARRING ME ~Simon Ahtaridis~~Like many of you, during my summers in college I worked at a number of odd jobs. After losing a bet, I spent a few weeks as a tour guide for a small museum celebrating the glorious history of the screwdriver. It was either that or I had to write my senior thesis on burlap. I was given a script that had specific instructions such as, “Please, no pushing, shoving, spitting or biting.” *pause for laughter* “Before we begin I must warn you, this place is all screwed up.” *pause for laughter* “The gift shop has a full collection of the latest screwdrivers, so there is no need to loot the displays.” *pause for laughter and point to gift shop* The script’s author underestimated the sophisticated humor of those frequenting screwdriver museums as I never got so much as a chuckle out of the jokes. Embarrassed and frustrated, my tours began to sound like this:


“OK, people, let’s get this over with. We will waste the next hour of your lives learning everything there is to know about screwdrivers. No whining or complaining. It serves you right for coming here on a perfectly good summer day.”


I would occasionally get a few laughs and, of course, angry glares from true screwdriver aficionados. My brilliant tours came to the attention of my manager, but rather than being hailed as a great reformer of screwdriver museum tours, I was dismissed from my position. I am only now able to write about this heartbreaking event. Feelings of inadequacy and failure prevented me from further pursuing a career in tour guiding. So instead I enrolled in medical school.


Now that I’m nearing the end of my medical school career, I wonder if I made the right decision. So humor me, as I attempt to combine my passion for tour guiding with my guarded enthusiasm for medicine. And there’s no better place to start (and end) than with my emergency medicine rotation.


OK, people, let’s get moving! My name is Simon, and I will be your tour guide through the emergency room. Please stay close; no pushing, shoving or biting. *pause* Umm...right. So we will tour the ER today, and yes, you will all be given a sample course of antibiotics before you leave. No one leaves the ER without antibiotics.


The history of emergency medicine is fascinating—or so I have heard. Emergency medicine was practiced in antiquity long before the invention of the car, at least before the Buick.


Before we enter the ER, I must warn you about a safety issue. There is a word that is feared in this department. Merely whispering it will evoke violent responses from all who hear it. That word is “quiet.” Shhh…. Never speak of this again. The commonly held belief is that the ER is never—is anyone looking?—quiet. Saying that word is like saying Voldemort’s (you know who’s) name in Harry Potter’s world.


As we walk through the doors, please remember, this isn’t a safari so you can’t shoot anyone. *pause* Well, maybe the utilization review people. *pause*


Oh, and another thing—ER patients are not referred to by their names but by their room numbers. Of course, there are those who believe that if we fail to use patients’ names, medicine will lose its humanism. This is probably true, but it can get quite confusing if everyone else is referring to Ms. Jones as the old lady in 12.


During my first days in the ER, I lost track of a patient who nearly ended up getting an MRI after a mix-up secondary to my use of his name rather than his room number. Oh, calm down. It’s not as if he were going to get a leg amputated. This is an ER, not a supermarket checkout lane. There is no time for endless chitchat and burdensome names when you are treating life-threatening conditions like head colds and ankle sprains.


OK, move along now. Over here we have the chart pickup area. Believe it or not, this is the highlight of the tour. Ah, yes, young lady, I can see by the light in your eyes that you’ve been waiting for this very moment. Well, I’ll have you know that 90 percent of what there is to see in the ER happens right here by this rack. After a patient is triaged—which is Latin for “made to wait a really, really long time”—he’s assigned a room, and then his chart is placed on this rack for the next available physician, resident or medical student. The daily ER culture can best be seen here. As a medical student, you will pick up a chart and begin seeing a patient at random. There are usually rules such as pick the charts up from left to right or in order of triage time. These rules may seem silly, but people will often look at a chief complaint and avoid the less “sexy” patients. If this were allowed to go unchecked, no one would see these patients and ERs would be overloaded with people suffering from impacted stools and penile lacerations.


Occasionally someone will skip a chart or pick a chart out of order. There will always be a chart watchdog who will catch that individual in the act and demand adherence to the rules with more resolve than a 5-year-old playing Chutes and Ladders.


The most interesting ER phenomenon occurs when things slow down (remember, it’s never quiet). There will be more residents and medical students than available new patients. The physicians-in-training will usually cluster around the chart drop-off area and wait for the next deposit.


Oh, here comes a chart! Shhh…. Let’s not alert anyone to our presence. Pay careful attention as the chart is placed on the rack, and look for the following species of physicians-in-training:


The Avoidant—This individual will make eye contact with the chart and then immediately look away, pretending he didn’t see it. “I think I hear my lab values calling me,” he’ll say.


The Martyr—He will charge at the chart like an infantryman leaping on top of a live grenade to save his buddies and get that posthumous medal of honor. He’ll then comment on how everybody else sucks and doesn’t care about their education or patients as he saunters off down the hall.


The Bradykinetic—This person will move toward the chart with the blinding speed of a three-toed sloth. His movements will remind you of those slow motion shots in “The Matrix.”


The Restaurant Bill Dodger—Ever eaten dinner with stingy friends at an overpriced restaurant? When the bill comes, everyone reaches for it with mock enthusiasm, but somehow it remains on the tray underneath breath mints that must weigh a ton. “Oh, please, let me get this one.” “No, let me.” “OK, if you really want it.” “Well, maybe I should get the next one.” “Well, you recommended this patient, so I’ll let you get it just this once.”


The Statistician—There will always be someone in the ER who keeps strict tallies on who has seen how many patients. This person will find a statistically sound reason why you should get the chart. “You may have seen two more patients than me, but I ordered three more tests than you and spent 2.3 more minutes with the patients I saw.”


Once a chart lands in someone’s hands, there are other species to look for, including:


The Educator—He’ll look at a chart, and if he doesn’t like what he sees, he’ll insist the educational experience would be wasted on him. If he’s an attending, he’ll say, “Oh, this is a great one for a resident.” The resident will look at the chart and say, “Oh, this is a good one for an intern.” The intern will grab the chart and without looking at it say, “Wow—what a great medical student case,” whereupon he will hand it to you. Find a pair of shoulder-length gloves and get ready to free impacted stools.


The Auctioneer—This person will look at a chart and try to hand it off. “Oh, another chest pain. I have done six already. Someone else take this—chest pain, chest pain, who wants a chest pain? Going once to the resident sitting idle. No? How about the young man with the short coat? Sold.”


Over here we have the nurses’ station, one of the most chaotic places on earth. See all the people running around doing random things? There are certain ER staff quirks that you should be aware of while rotating through the service. One in particular is how everyone wants to offer an opinion or interpretation of a test. It’s important to know who’s who in the ER. If someone hands you an EKG from your patient and says, “This EKG looks normal,” it might mean he’s an experienced ER physician who has done a thorough and systematic evaluation of the EKG, or it might be the pizza delivery guy saying, “Yes, there are little mountains and valleys on the paper, and the EKG machine has not run out of ink yet.”


Now at the conclusion of our tour, I thought we could poke our heads into an actual ER experience that I had during my rotation. We are about to walk in on room seven to see three gentlemen in need of laceration repairs. In ER speak, they will be referred to as the three guys in seven. By the way, this scene is being recreated by actors, since the real men refused to participate.


In the ER you will learn that getting the story of what happened is very important, especially in cases in which domestic violence or some other wrongdoing might be an issue. On occasion, you’ll get a story that just doesn’t make sense. This is such a case.


Here we see the three men in their mid-30s sitting around and joking with each other while fighting over which channel to watch on TV. All have lacerations or contusions on their heads or torsos. We assume that they were in some accident.


“What happened?”

“We were throwing rocks at each other, and this time we got beat up pretty bad.” Note how the patient stops as if the rest of the story should be obvious.

“You were throwing rocks?”

“Yup,” answers the man with a heavily bleeding eye.

“I got him pretty good, didn’t I?” says another, pointing at his work with obvious pride.

“Why did you throw rocks at each other?”

“Aw, you know, just for fun.”


And now, ladies and gentlemen, your minds are probably racing to think of an occasion during which friends would throw rocks at each other. I had those same thoughts too.


“Was this some biblical re-enactment?”

“No.”

“Did you guys just watch ‘Fight Club’?”

“No, but that was a great movie. It had Norton in it, right?”

“No, jackass, that was ‘American Beauty’!”

“I tried out for that part, you know.”


The room suddenly explodes in a series of curses and threats as the men attempt to sort out the cast of “Fight Club,” while arguing who should get an Oscar for their ER performance.


Uh, I think we should all be relieved there are no stones lying around. Let’s leave them alone and speak with the attending.


In the hall here, note the wives of the three guys in seven. Remember, you need to understand why the men are in the ER, exhausting all resources. “Excuse me, ladies, but what happened to your husbands?”


“They’re just guys. You know what they’re like.”

Yes, sir, I see your disbelief. I felt the same. Oh, here comes the attending. Let’s ask him what he thinks of the three guys in seven.

“Spend another month here and you won’t think this is so unusual.”

Well, there you have it. This concludes our tour. I am now discharging you with illegible instructions and an inadequate explanation. See the billing folks for your outrageous tour fee. Antibiotics prescriptions are over there on your right. Be sure to stop at the gift shop, which can be found to the left as you exit. I highly recommend the day-off work slips for $19.95. Thank you, and remember, no matter where you go, you are there. *pause*
~~~~Simon Ahtaridis is a fourth-year medical student at Temple University.~Medical Education~
139~2March~2003-52~Feature~On the Run~CHAINED TO SOARING LIABILITY PREMIUMS, PHYSICIANS CLOSE THEIR DOORS.~~~Every day, every patient arriving for routine care from Dr. John Nowins has a bizarre question for the obstetrician: “Are you planning on leaving the area? Are you going to stay?"


Bizarre question indeed, until you consider that Nowins practices in Las Vegas, Nevada. And no, expectant mothers are not worried that their physician will win big at the slot machines and take off for greener pastures; they fear Nowins will be forced to abandon the practice he shares with his internist wife in the wake of rising malpractice liability insurance premiums.


His patients’ fears are real. Many of them have come to Nowins in desperation, having lost as many as two previous obstetricians during their pregnancies. Thirty-three of Nowins’ colleagues have closed their doors since November 2001, choosing to retire early, focus on teaching or move their practices rather than pay the hefty premiums malpractice carriers can command in Las Vegas and the surrounding Clark County. The obstetrics capacity in the area is a mere 40 percent of what it was a year ago, says Nevada State Medical Association (NSMA) Executive Director Lawrence Matheis. “I’m afraid we’re going to see a second round of reduction because these doctors are just getting exhausted.”


In the meantime, Nowins remains among the 90 OBs left, but he says that if 2003 brings yet another rate increase—the state has already approved a 25 percent increase for one carrier, while a 90 percent increase with another is still pending—he could be forced out as well. “I will need to consider moving,” he says. It’s not an idea he relishes, pointing to his 10 years of practice in the area, his 30,000 patient files and his kids who are active in area schools. But, he says, the financial realities are hard to ignore. “There could come a point when you cannot afford to practice in Clark County.”


WHAT'S WRONG HERE?


Las Vegas obstetricians aren’t the only ones complaining about rising premiums. Every state, save Alabama and Alaska, saw rate increases between July 2001 and July 2002, according to the “Medical Liability Monitor,” which annually surveys carriers nationwide. Internists, whose rates are generally lower than those in high-risk specialties, still saw an average premium increase of 24.7 percent. General surgeons, who along with obstetrician-gynecologists and emergency physicians have seen the highest premium rates, were hit with 25 percent average increases, while OB-Gyns were not far behind with 19.6 percent increases. In some of the worst-hit areas, physicians with few previous claims are seeing premiums double and even triple. Nowins is one of them. He was paying less than $30,000 to The St. Paul Companies when the insurance carrier exited the medical malpractice market in 2001 after posting losses of nearly $1 billion for that division. Struggling to find coverage in a market growing increasingly narrow for high-risk specialists, Nowins finally secured a policy with a private company for $107,000—and that was only after agreeing to reduce his risk by delivering fewer than 125 babies during the year, including any emergency room drop-ins.


“So basically I’m paying a lot more money to do a lot less deliveries,” he says. “It’s kind of unfair, right? [The insurance companies] don’t care.”


So why are physicians like Nowins in such dire straits when it comes to medical malpractice liability? Well, it depends on who you talk to about what is fast becoming one of the most controversial issues physicians will encounter in their careers.


“It is caused by an out-of-control legal system that has resulted in dramatically increased [jury] awards,” says Dr. Donald Palmisano, president-elect of the American Medical Association (AMA), which voted at its annual meeting last year to make medical liability system reform its No. 1 legislative priority. The AMA contends the situation is the result of greedy trial lawyers who will take any patient complaint—legitimate or not—to court in the hopes of winning big bucks for both themselves and their clients.


“There’s no correlation between awards and negligence. The awards are related to disability but not to negligence,” Palmisano says.


Jury awards in malpractice cases have been on the rise. The median award in medical malpractice trials surged 43 percent between 1999 and 2000, according to Jury Verdict Research (JVR), which tracks personal injury claims. The median award was $500,000 in 1995; in 2000 it had risen to $1 million, the limit of most physicians’ insurance policies. The number of claims below $1 million that resulted in a payout had risen to 7.9 percent in 2001, nearly doubling since 1998, according to the Physician Insurers Association of America (PIAA), a consortium of physician-owned medical malpractice insurance companies. The median out-of-court settlement is also on the rise, although not as sharply as jury awards, increasing from $350,000 in 1995 to $500,000 in 2000, according to JVR.


There is a bright spot among the gloom, however. Eighty percent of the physicians who fight their claims in court win, says Lawrence E. Smarr, PIAA’s president. “But there’s enormous loss in the system.” And they have another repercussion, he says. Jury awards have been steadily increasing, and while few lawsuits ever go to trial and result in a jury award, juries set the standard for patients making claims against their physicians. “We’ve got the ‘Who Wants to Be a Millionaire?’ mentality here.”


Medical malpractice liability awards are mirroring what’s happening in other judicial areas, says Robert Hartwig, senior vice president and chief economist with the Insurance Information Institute. “The average jury award had doubled or tripled in recent years. That’s reflective of a judicial system that is out of control.” He says it’s easy for lawyers to wind up with a jury that will be sympathetic to an injured person, and that plaintiffs and juries often look at insurance companies as big business able to afford a hefty payout.


But the fact is, with rising costs in claims payments, the insurance companies have nothing to do but raise rates, Smarr says. He says insurance companies are spending $1.53 on every dollar they bring in through their medical malpractice businesses. “For insurance companies, [raising rates] is the answer, but that’s not the answer for doctors, and we’re very sensitive to that,” he says.


The Association of Trial Lawyers of America (ATLA) says that’s not the answer at all, and that the current high malpractice premiums are generated by bad stock investments that lost big when the market tanked and by the cyclical nature of the insurance industry, which tends to harden and soften in delayed tandem with the U.S. economy. Rising medical malpractice insurance rates are something the country sees about once a decade, although most players agree the current situation is more severe than in the past.


“The major difference this time [is] the doctors were far more in charge of their practices [in the past]. They were far more flexible in increasing their charges to ride out the storm. We can’t discount the role managed care plays in all of this,” Matheis says, noting that physician reimbursements are actually on the decline, creating even wider chasms between practice expenses and income.


However, he doesn’t deny “the insurance industry is heavily invested in stocks and other holdings because so much of what they have is cash.”


But Palmisano says insurance companies are required to be conservatively invested and that 80 percent of their investment holdings are in low-risk bonds. But even long-term bond rates have dropped, and Smarr admits this is cutting into the companies’ income. All carriers are required to purchase reinsurance as well—insurance against their own losses—and reinsurers, reeling from losses generated by the Sept. 11 attacks, have raised their rates too, further affecting insurance profitability.


Smarr says shrinking loss reserves that the industry set aside in the late ’80s and early ’90s, when medical malpractice insurance was profitable, compounds the problem. When claims, which take an average of 22 months to report and as long as 10 years to pay out, began costing the companies more money in the late ’90s, the reserves couldn’t keep up.


“All of that came to a head in 1999—that’s when the reserves ran out,” he says. “Our critics will say we should have collected premiums to pay our costs, but we passed the savings on to the doctors.” Inadequate pricing and steep losses led to several companies pulling out of the malpractice liability business, and at least one company filed for bankruptcy.


The trial lawyers also say rates are high because of a small percentage of incompetent physicians, a position supported by consumer groups. “The problem with medical malpractice insurance is medical malpractice,” ATLA says, citing the Institute of Medicine’s (IOM) “To Err Is Human” report, which estimates that up to 98,000 patients a year die of medical errors.


Between 5 percent and 10 percent of the nation’s physicians account for about 50 percent of medical malpractice lawsuits each year, and that risk is spread throughout the relatively small pool physicians compose. “As long as these bad doctors are in the risk pool, they are hurting the good doctors,” says Jackson Williams, legal counsel for Public Citizen’s Congress Watch division. “[Physicians] are not lobbying state medical boards to weed out these bad doctors, and I guess that might be because the insurance companies are largely owned by the physicians.” About 60 percent of the country’s physicians purchase medical malpractice insurance from a physician-owned company.


THE BLEAK NEVADA PICTURE


Beyond the finger pointing, Matheis says the physicians he represents are just trying to figure out if they can afford to care for their patients. And the answer, at least in southern Nevada and other crisis areas, is increasingly no.


Last July, Nevada’s malpractice liability crisis leapt to the nation’s attention when Las Vegas’ sole Level 1 trauma center—an enhanced emergency facility capable of performing specialized surgery at a moment’s notice—closed because all but one of its orthopedic trauma surgeons quit, citing their inability to pay rising malpractice insurance premiums. The individual surgeons, and not the University of Nevada Medical Center (UNMC) with which they contracted, often bore the brunt of malpractice lawsuits, as damage awards from the publicly run trauma center are capped at $50,000.


The closure, which began over the Independence Day holiday amid concerns of possible mass casualties from potential terrorist attacks in the area, placed a huge burden on other area emergency rooms, Matheis says. About a dozen more serious patients were transferred to trauma centers in California. “We did that for 10 days, and it nearly destroyed our system.”


A stop-gap measure brought the surgeons back 10 days later, hiring them as part-time hospital employees who are covered by UNMC liability policies. Permanent help came last August when state lawmakers passed tort reform legislation capping damages for trauma physicians at $50,000.


The situation was similar to a 30-day walkout by northern West Virginia surgeons, who in January took simultaneous leaves of absence from four hospitals to protest unaffordable malpractice insurance. At press time, some surgeons were going back to work after state officials offered a plan to provide tax credits and incentives intended to help buffer the cost of coverage, although other physicians continued to make plans to walk off the job. West Virginia is one of a dozen states the AMA says are in a full-blown health-care crisis caused by steep malpractice premiums.


Matheis says job actions of this nature speak to physicians’ desperation. “Doctors are not those kinds of risk-takers,” he says, noting that organized walkouts by nonunion physicians could lead to federal investigation under antitrust laws.


And in Las Vegas, a city that serves as a shrine to risk-taking, the desperation is growing. The metropolitan area, which includes Clark County and parts of neighboring Arizona, is the fastest growing metro area according to the 2000 census. The population grew by 83 percent in the last decade, swelling to 1.56 million people.


“Four thousand people are moving here a month, and many of them are pregnant,” Nowins says. The OBs, many covered by state and private plans that limit the number of babies they can deliver, can’t keep up with the demand, limiting patients’ access to prenatal care.


The population influx also increases the amount of claim risk that is being spread among an ever-shrinking physician population. Matheis says Nevada was 47th in the nation for physician-to-population ratios the last time anyone counted several years ago. The NSMA is gearing up for another count in the next few months, and Matheis says he fears the numbers will be even worse this time, as 170 physicians have closed practices in recent months, cutting the pool of 2,000 physicians by nearly 10 percent.


And there aren’t many new OBs putting out their shingles in the area, Nowins says. “We’ve seen a few,” mostly because their spouses took job transfers that moved them to the area. And Nowins thinks they ought to have their heads examined. “They’re nuts. I would not wish this upon anybody right now. This is not the place to go right now.”


He says none of the dozen OB residents at UNMC have any intention of staying in the area to practice, while prior to the crisis, most set up shop there. He’s even seen some residents leave medicine altogether because of what they’ve seen in Clark County, choosing instead to enter business or pharmacy school. And he thinks the malpractice liability situation has discouraged medical students from going into high-risk specialties such as obstetrics, general surgery and emergency medicine, prompting nationwide shortages in these areas. He says he can’t blame them. “If my son or daughter were graduating from medicine right now, I would tell them to think twice about OB right now.”


He says it’s just not as much fun to practice medicine in light of the insurance situation. He says his conservative approach to medicine has helped him stay in business by limiting the claims brought against him. “I’m very cautious. I don’t hesitate to get a consultation. I don’t hesitate to run a test. I practice defensive medicine because I’m cautious, and…you have to in Clark County. In Clark County you can never assume you’re right. It’s not enjoyable to worry. Until the baby is born and it’s perfect, I worry the entire pregnancy.”


The situation has spilled beyond the physicians’ offices. Medical schools are feeling the liability pinch, too. The University of Nevada School of Medicine went through its own crisis when St. Paul pulled out of the market, allowing the school’s coverage to expire in July 2002. Physicians at the Reno school had been largely sheltered from the crisis, which hasn’t affected the more rural north, as insurance companies determine rates on a regional level through a complicated actuarial process. The loss of coverage threatened to close the school, but it secured a policy three weeks before the St. Paul coverage expired. However, the new deal came at a price: The $2.1 million policy nearly doubled the school’s annual liability expenses.


Schools in other hard-hit states have suffered as well. West Virginia’s Marshall University School of Medicine has had to cut residency slots, and the Pennsylvania State University College of Medicine has had to increase efficiency and cut back on equipment purchases in the face of rising premiums.


HEALING THE SICK SYSTEM


Physicians’ groups and the insurance industry say the way out of this mess is legislative tort reform, which would place legal limits on jury awards. It’s an idea that 19 states have enacted, including Nevada.


The state’s solution to the problem came in an emergency legislative session last summer, called specifically to deal with medical malpractice liability costs. The resulting law, in addition to providing the trauma surgeons with the $50,000 cap on damages, limits all noneconomic damages—those “pain and suffering” awards beyond lost wages and treatment costs—to $350,000 and shortens the statute of limitations, which is an important part of the reform, physicians say. “You could deliver one baby, and you’re at risk because something could go wrong 10 years from now and you could be held liable,” Nowins says.


But Smarr says it doesn’t go far enough, since the noneconomic cap is full of exceptions and allows more than one plaintiff to file a lawsuit against more than one defendant in a single malpractice case. Each plaintiff—be it a mother and child, a husband and wife or a husband and other children in a typical obstetrics case—can collect up to $350,000 in noneconomic damages from each defendant—each physician, his private practice and the delivery hospital, for example.


“We don’t think it’s going to have much effect on medical malpractice premiums at all,” Smarr says.


And in light of recently approved increases for 2003 in Nevada, it hasn’t helped in the short term. Nowins says he is discouraged by the cap’s inability to encourage insurers to reduce their rates in the immediate aftermath of the bill’s passage. But therein lies the problem that plagues any plan to help bring malpractice rates down: There are short-term solutions—those that provide immediate financial assistance to physicians struggling to pay premiums—and long-term solutions such as systematic reform, and physicians in hard-hit areas need both.


Any tort reform initiatives are subject to court challenges by the trial lawyers, who lobby heavily against these laws, saying they punish injured patients for physicians’ misdeeds. Nevada’s law is too new to have been challenged in court, and “you can’t expect carriers to do much with their premiums before a law has passed a constitutional challenge,” Smarr says. It could be years before the challenges make their way through the legal system, Matheis says.


Which is exactly why the federal government needs to step in with a national tort reform measure, say congressional Republicans. Federal legislation is accepted as having a better chance at surviving a court challenge, and many say it’s time to step in for states that have failed to solve the problem. “We’re usually in favor of the states fixing these things,” says Dean Rosen, Senate Majority Leader Bill Frist’s (R-Tenn.) senior health policy adviser, noting the irony in a Republican-led initiative that centralizes regulatory control.


The Republican-led House passed a bill last year that would have: limited noneconomic damages to $250,000, similar to California’s gold standard of tort reform, the Medical Injury Compensation Reform Act of 1975; set a statute of limitations at three years or within one year of injury discovery, whichever comes first; and tightened guidelines for collecting punitive damages. The law would have pre-empted state regulations, unless they were more restrictive.


The bill stalled in the then Democrat-controlled Senate; however, with both Frist, a physician, and President Bush supporting the legislation, the issue appears to have a promising future in this Congress. At press time, Rep. James Greenwood (R-Pa.) was set to reintroduce the bill at the end of January. And Bush gave a major policy speech on the subject in January that called for tort reform similar to that proposed in Congress.


“What this is about is creating stability, so doctors will have a much better idea about what their costs will be,” says William Pierce, a spokesman for the Department of Health and Human Services. He says medical malpractice liability reform is one of the administration’s “top shelf” issues.


Still, Rosen says the bill will have a tough time again in Congress, given the opposition to tort reform. He says lawmakers may look at some more creative solutions this time, suggesting innovations outlined in the IOM report on medical errors and the idea of a “no-fault” system, which takes compensation out of the legal system and places it in an administrative process.


“Each side waives their right to a trial, and that would create a more stabilized system,” Matheis says. But since the program would cost more money in the initial phase, no-fault plans haven’t fared well in the legislative process. “It is possible that some states will explore it, but it will meet such massive opposition from the trial lawyers and ultimately the insurance industry. I don’t see it as the immediate resolution to our problems.”


ELIMINATING THE SOURCE


The problem with tort reform is that it punishes the victims of malpractice, Public Citizen and other consumers’ groups say. The real solution is to get rid of the incompetent physicians. Williams suggests using some of the IOM recommendations to build a better health-care delivery system, but he says “my personal favorites here are the personal responsibility approaches.


“All people who are professionals…they don’t want to be questioned. I’m a lawyer, and I understand that. [But] the problem is that hospitals are dangerous places to be.”


Public Citizen supports efforts to open the National Practitioner Data Bank, which has tracked malpractice awards and settlements against all physicians in the nation since 1990. Most physicians are against this, declaring that many of these claims are frivolous and aren’t reflective of their skills—Nowins points to an ongoing suit in Las Vegas in which a woman is suing her obstetrician over stretch marks she sustained from her pregnancy.


Public Citizen also supports strengthening the medical board licensing system through increased licensing fees that would pay for new staff to conduct more thorough reviews of physicians suspected of providing inadequate care. “The only federal legislative solution I see would be if the federal government wanted to subsidize state medical boards,” Williams says.


The group says the insurance industry should also change the way it classifies certain specialties, spreading the risk more broadly across the entire physician population and targeting physicians with active claims histories.


Consumer groups aren’t alone in their ideas for multifaceted reform. Matheis says he agrees with examining how physicians are licensed, saying it’s “part of this [issue] every state needs to confront. It seems to me that the court system, the civil justice system, needs to be modified. The insurance system needs to be modified. And, not a little bit, the health-care system needs to be modified. The problem is none of these systems are the same. They don’t speak the same language.”


Getting physicians to speak the same language as their patients has been one solution at Vanderbilt University. Studies have shown that the way a physician interacts with a patient after committing a medical error can greatly affect if he will get sued. “This is not just about communication. It’s about transmitting to patients that we’re treating them like human beings. We’ve got a lot of physicians who may be good communicators, but they’ve got a patient who’s so angry that by the time they get to them, the die has been cast,” says Dr. Gerald Hickson, Vanderbilt’s vice-chairman of pediatrics.


To help medical students learn how to prevent these problems before they arise, Hickson leads a mandatory role-playing class with fourth-years “so they get a sense of what it’s like to be knee-deep in alligators.” The course covers everything from “we’ve killed your momma” cases to those in which no one can determine if malpractice was even committed. The course has been so effective, Vanderbilt began putting residents and new faculty members through it too, and other schools have asked Hickson to establish similar programs for their students.


COPIC, a Colorado-based medical malpractice insurance company, has begun a pilot program for its physicians to put these principles to work in the exam room. The 3Rs program attempts to recognize, respond and resolve medical errors before they become malpractice lawsuits. An enrolled physician calls COPIC within 72 hours of discovering he’s made a medical error. The company counsels the physician on how to address the situation with his patient and pays the patient’s related out-of-pocket medical expenses plus $100 per day, even paying for such things as plane tickets for family members to be with the injured patient. Through an agreement with the state, the entire process is conducted outside Colorado’s medical errors reporting system, which helps to keep the physician’s insurance risk low, although serious errors are still reported.


COPIC’s vice president for risk management, Alan Lembitz, says the company knows it would probably win any cases that might arise—based on the medical errors in the program—“but it’s one of those things that for a little amount of money, we can make it right by the patient. We think avoiding one suit—even a meritless one—is worth it.”


Just two of the 80 cases COPIC has put through the program so far have resulted in further legal action, making the 3Rs more successful than the company expected. If the pilot continues to generate good news, it could eventually reduce premium rates to enrolled physicians.


Educating physicians to be better communicators is just part of the solution, Hickson says. First you’ve got to figure out who needs educating. “The more important work I think we’re doing is identifying the high-risk malpractice physicians by using patient complaint data. What we’ve done ain’t rocket science. Truck drivers have done it,” he says, citing the “How’s my driving?” phone numbers on trucks. “We believe that if you educate bright people that they stand out, most will get it.”


Physicians will tell you that someone, somewhere has to get it soon before they are all put out of business. Smarr says he sees relief a few years on the horizon, generated by federal tort reform, that should bring some carriers back into the market. But his sigh is audible when he says he has no answers for the short term. With newly filed lawsuits against physicians soaring to an unprecedented 180 in the month of November alone, Clark County physicians can be assured of a few more battle scars until someone does figure out an answer.
~WHAT IF YOU MADE AN ERROR?


It’s weird. No one can seem to figure out why the patient in room 254 isn’t getting any better. It’s a mystery to all involved—from the medical students observing right up to the attendings ordering treatment. But what would happen if someone discovered the reason the patient isn’t getting better is because of something you did?


First of all, don’t panic. Most physicians will tell you the reality of practicing medicine is that you will make mistakes. It’s how you deal with those mistakes that often makes the difference between an understanding patient and a lawsuit.


The key is disclosure. “You have to be open and empathetic. Anticipate your patients’ emotions,” says Dr. Alan Lembitz, the vice president of risk management for COPIC, a Colorado-based medical malpractice insurance company that coaches its physicians about the best ways to deal with medical errors. He says patients are looking for a few basic statements from a physician who has committed a medical error. “They want to hear an apology; they want to hear that you’re looking into it and finding out why it happened and preventing it from happening again. And they want to hear that [their physician is] not going to abandon them.”


Good patient communication is at the heart of what Dr. Gerald Hickson teaches fourth-year medical students at Vanderbilt University in a risk-management program. His suggestions include pausing and counting to 10, considering the patient’s expected responses to the news he is the victim of a medical error and expecting and responding to follow-up questions from the patient’s family.


Physicians agree the idea of public disclosure flies in the face of the “shame and blame” medical culture. “I get the feeling this is an issue that is pushed aside by many physicians,” says retired family practitioner William Elderbrock. “[But] we are all subject to being sued, and most [lawsuits] have no bearing on the quality of care they’re providing and no bearing on their medical qualifications.”


He says physicians threatened by lawsuits should not only talk to their patients, but also to their support networks—spouse, peers or clergy member—to deal with the internal feeling of guilt being sued often brings.


Elderbrock points to a colleague in Ohio who had been sued by a patient. None of the physician’s friends or co-workers was aware of the suit until the physician ended up in the hospital emergency room, the victim of a suicide attempt brought on by anxiety over the case. Elderbrock says talking about the issues can help physicians deal with the stress.


Open communication is a policy he put into action when he made a serious medical error. When a 16-year-old patient died because of a misdiagnosed case of appendicitis, Elderbrock says he wasted no time talking to family members about how and why their daughter died. “[Physicians] have to be totally honest with the family and not try to cover up their mistakes.” Because of the open dialogue, Elderbrock says the teen’s family continued to be loyal patients for years afterward.


It’s a practice physicians should take to every aspect of patient interaction, says Dr. Michael Woods, who offers three-month coaching sessions on communications for fellow physicians through his Pennsylvania consulting company, the Woods Development Institute. “It’s not a technique; it’s the way you should be because it’s the right thing to do.” He says physicians need to develop a “trust equity” with patients, because that will provide the benefit of the doubt if a case goes sour. “People don’t sue people they like.”


However, he says it’s a task made more difficult by today’s medical environment. “You can’t establish rapport in a 10-minute office visit.” —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician.~Health Policy,Practice of Medicine~
140~3April~2003-52~Folk Tales~Dancing to His Own Beat~ManiAAC, M.D.~Scott T. Shepherd~~When Doug Smith steps onto the basketball court at the American Airlines Center in Dallas, Texas, thousands of people have their eyes upon him, watching his every move as he spins and slides. Soon, many of the 19,000-plus fans are on their feet with applause for him and his teammates as they run to the sideline and wipe the sweat from their plentiful brows.


However, Smith is not a basketball player with the Dallas Mavericks. He’s a ManiAAC, a dancer whose troupe is composed of 13 spirited, hefty men who perform to the latest music for the pure enjoyment of Mavericks fans. He also happens to be a physician. “I had never been in front of that many people before,” Smith says of his first appearance with the ManiAACs, who derive the unusual spelling of their name from their fanatical support of the basketball team and the initials of the Dallas arena.


Ranging in age from 25 to 47, the ManiAACs are, to say the least, big men. The average member is 6 feet 3 inches tall and weighs approximately 280 pounds. Eight of the ManiAACs tip the 300-pound scale mark. And the 46-year-old, 6-foot-1, 300-pound Smith says he recognizes the group is a bit different. “I’m a pretty big guy, so it is really weird being in a room with guys I have to look up at.”


Of course, it was the potential entertainment value of a show featuring overweight men dancing that first led Mavericks owner Mark Cuban to conceive of the ManiAACs, getting the group together just before the team’s appearance in the National Basketball Association playoffs in April 2002. “[We were just trying to create] fun entertainment that was a little out of the ordinary…a reason for people to cheer and smile,” Cuban says. “We had no idea what to expect, but the fans have loved them and wanted more.”


Shortly before the playoffs began, the Mavericks ran an advertisement in local newspapers seeking just the right kind of performers. “I always read through the sports page with a fine-tooth comb,…and I saw a little blurb looking for big guys who could dance,” Smith says. The family practitioner, who grew up in nearby Arlington a lifelong fan of Dallas’ sports teams, couldn’t think of anyone who fit that description better than him.


Turns out, a lot of men had the same idea. More than 80 tried out for this peculiar dance squad, and the last one through the door was Smith, who showed up 15 minutes late. “[The other applicants] had already started their routine, so I had to catch up. Plus I had the last number, so every time they had cuts, I would have to wait until the end to hear my number. It was kind of like that ‘American Idol’ thing.”


But after each round, Smith heard his number called. Finally he was one of the last 13. Matt Fitzgerald, the Mavericks’ senior vice president of marketing and communications and one of the judges, says Smith stood out for several reasons, and being a physician certainly didn’t hurt. “[He was chosen for] his awesome attitude, his Fred-Astaire-like moves on the dance floor and his ability, if called upon, to resuscitate fellow ManiAACs,” Fitzgerald says jokingly.


But, some would say that being a part of a collection of overweight men does present a bit of a conflict for a physician, and Smith admits he has a difficult time justifying obesity, particularly his own. “I guess I can’t say a lot about that. I am a pretty big guy, anyway. I think I’d be pretty good at 250 pounds.” But when he is performing at games, Smith says he doesn’t overly concern himself with his and his cohorts’ weight, and he doesn’t lecture his fellow ManiAACs to shed a few pounds. “When I am ManiAAC-ing, I am not a doctor,” he says.


The patients in his Plano, Texas, family practice aren’t concerned about Smith’s weight or his participation in the ManiAACs either. In fact, the physician says the majority of them has come to expect this sort of behavior. “[My patients] love it,…and it fits with my practice pretty well. I would say most of my patients know my personal life, and it doesn’t surprise them in the least,” says Smith, who never wears a coat or tie in the office. He says he has developed an intimate relationship with a lot of his patients. He knows the details of their lives, and they know his. “I guess the people who would be bothered wouldn’t stick around anyway.”


When it comes to the rest of his life, Smith has always taken a unique path. He graduated from the University of Texas–Arlington with a degree in medical technology, but soon discovered the field didn’t satisfy him. The automation of most modern medical equipment left him feeling unchallenged. So he decided to become a physician and entered the University of Texas Health Science Center at Houston Medical School. After graduating, he completed his family medicine residency in Waco, Texas, before establishing a small-town practice in Decatur, Texas. After a few years, he had the desire to move again and settled in the burgeoning Dallas suburbs, becoming the first family practitioner at the Presbyterian Hospital of Plano.


But after working at the hospital and sharing a practice, Smith finally reached the point where he could maintain his own small, private practice. “I see all my own patients and do my own calls,” he says. Furthermore, it also frees up time for him to pursue his numerous outside interests, which include riding a Harley, playing the drums and guitar, and driving a stock car around the racing oval at the nearby Texas Motor Speedway. “I do cognitive stuff all day. I want to use the other half of my brain,” he says.


And the ManiAACs fit perfectly into this mold. However, that doesn’t mean there isn’t work involved. Under the supervision of Shella Sattler, the director of Mavericks Dancers, the 13 men must practice regularly to learn surprisingly intricate dance routines. “We have five-hour practices, and go to events and every home game. It eats up a lot of time, especially during a long home stretch,” Smith says. The amount of time becomes even more significant considering Smith is not paid for his efforts. His only reimbursement is one free ticket for each game at which the ManiAACs perform.


However, the work does pay off in other ways. With creative performances—such as a comical dance-off similar to the Jets vs. the Sharks in “West Side Story” between the ManiAACs and the glamorous female Mavs Dancers—Smith and his fellow ManiAACs are becoming rather popular among the Mavericks’ faithful, leading to public appearances and the creation of a group poster. “When people come up and ask for autographs, you totally feel like a celebrity,” he says.


How long this will last remains to be seen. But until the excitement ends, Smith is just enjoying the moment. “If there is any advice I have for medical students, it is live life to the fullest and have a life beyond medicine.”


In this regard, it’s obvious Smith practices what he preaches.
~~~~Scott T. Shepherd is associate editor with The New Physician.~Career Development~
141~3April~2003-52~Feature~WARNING: Hazardous Waste~~Avery Hurt~~If citizens’ groups, environmentalists and a draft report by the Environmental Protection Agency are to be believed, the health-care industry is healing with one hand while harming with the other.


Lori Thomas-Luna feared for her family—her mother and aunts were ill; her daughter had developed asthma. They live on the 372,000-acre Gila River Indian Community just south of Phoenix, Arizona. The U.S. government calls them Pima Indians—the name given to them by 17th-century Spanish explorers. They call themselves the O’Odham, meaning “the river people.” They have lived near the Gila River for at least 2,000 years, long before anyone in Europe ever suspected there was a continent on the other side of the Atlantic. The O’Odham were once farmers; it was said they could make the desert bloom.


Modern times have brought many changes, however. While many O’Odham still farm, the reservation now hosts a great deal of industry. One of the businesses located on their tribal land is Stericycle, the nation’s largest medical waste management company. The corporation hauls waste from health-care facilities around the country and burns it in incinerators like the one near Thomas-Luna’s home.


For quite some time, many tribal residents were unaware of the approximately 10-year-old incinerator on their land and the danger it posed. They did know, however, that community members were becoming ill, especially the children. In fact, so many O’Odham children have asthma that inhalers are almost as common as chalk and crayons in the local school.


Early last year, Thomas-Luna began to suspect a connection between the incinerator and her family’s and neighbors’ health problems. When Stericycle employees began telling disturbing tales of needles protruding from garbage bags, ripped containers of infectious waste and local dogs bringing home human limbs, it was clear to her that she needed to give the incinerator a closer look.


Investigating the facility, she learned that even when properly operated, medical waste incinerators are the third leading source of dioxin in the environment. Dioxin is a byproduct of the manufacture and incineration of polyvinyl chloride (PVC), a plastic used in many medical supplies and devices. After dioxin is released into the air, it’s eventually washed onto the ground and into the groundwater. Exposure to dioxin has been linked to birth defects, liver damage, immune system disorders, reduced fertility and several forms of cancer. According to a draft report by the Environmental Protection Agency (EPA), dioxin is a known carcinogen that may cause a lifetime risk of cancer 1,000 times higher than the acceptable risk level. Although 90 percent of human exposure to the toxin comes from food—animals eat contaminated plants, the chemical gets stored in their fat and ingested by humans—humans are sometimes exposed to it in the air. This is what was happening to the O’Odham.


With the assistance of the California-based environmental group Greenaction, which had helped other communities tackle polluters and which had been tracking the Gila River facility for a while, Thomas-Luna was able to organize her neighbors in an effort to shut down the incinerator. This was going to be a challenge; the O’Odham are a quiet, easy-going people, not the kind to protest in public. Thomas-Luna herself is so soft-spoken that you often have to ask her to repeat herself. The organization she co-founded, called GRACE (Gila River Alliance for a Clean Environment) was small at first. And Stericycle, a $620-million company with aspirations of becoming a billion-dollar company, was no pushover.


“Everybody said it couldn’t be done,” she says. But Thomas-Luna and other GRACE members proved the cynics wrong. With demonstrations, records of the facility’s illegal emissions and the EPA as a watchdog, the O’Odham had the upper hand. In November 2002, Stericycle agreed to stop using the incinerator and to only operate an autoclave, a safer technology that uses steam and pressure to disinfect waste, at the Gila River facility. Though Thomas-Luna admits it wasn’t an easy win, she says she found most of the government agencies, from the Centers for Disease Control and Prevention to the EPA, surprisingly cooperative once she made it clear what was going on. It was just difficult to get their attention at first. “Unless you live in the community, you are not aware of what is going on there. You have to explain it to people,” she says.


Not content to rest on her laurels, Thomas-Luna has taken a job with the environmental health division of the Gila River Health Department. She says her work is just beginning.


The Gila River residents haven’t been the only community to run medical waste incinerators out of town. In fact, in the Western United States, communities in Arizona, California and Nevada have all successfully cleared their lands of incinerators.


But dioxin isn’t the only medical waste hazard, either. The other worst offender is mercury. Along with being emitted from incinerators, mercury is found in hospitals and clinics, most commonly in thermometers, sphygmomanometers (blood pressure measuring devices) and in certain laboratory chemicals. It is a potent neurotoxin that affects the brain, spinal cord, liver and kidneys. Exposure to mercury can also cause learning disabilities in children.


Certain plastics used in medical care are sources of dangerous chemicals as well. Many medical supplies and devices contain di-(2-ethylhexyl)phthalate (DEHP), which is used to soften plastic for such applications as IV bags and plastic tubing. DEHP is a toxin linked to birth defects and hormonal abnormalities. In July 2002, the Food and Drug Administration (FDA) issued a public-health warning against DEHP. According to the agency, DEHP can leach into the solutions contained in the plastic bags, thus giving the patient a dose of a dangerous chemical along with the intended blood, glucose or medication. The most serious concern, according to the FDA, is the chemical’s effect on the development of the male reproductive system.


Ironic as it may be, institutions dedicated to healing and suffering are one of the primary sources of several dangerous pollutants. And while the health-care industry is getting the message—thanks to such groups as Health Care Without Harm, an international coalition of organizations dedicated to making health care more environmentally sustainable worldwide—environmental pollutants like dioxin and mercury still pose serious risks to the population and thorny problems for hospitals that will always make hazardous waste and have to get rid of it somehow.


IT HAS TO GO SOMEWHERE


The reduced availability of incinerators has only made handling medical waste more challenging—and more expensive—for hospitals. With fewer incinerators, hazardous wastes have to be shipped much longer distances, increasing hospitals’ costs and the risks of accidents. According to Gerald DeSilva, director of materials management at Cedars-Sinai Health Systems in Los Angeles, the expense of bagging, transporting and documenting the disposal of hazardous waste is a serious financial burden.


Nevertheless, having fewer incinerators has created one major advantage: “It has forced hospitals to address the issue of how much and what kind of waste they generate and what they do with it,” says Laura Brannen, the coordinator of Hospitals for a Healthy Environment, a joint project of the EPA, the American Hospital Association and the American Nurses Association. “Until recently, there was no infrastructure to make it easy for hospital staff to handle waste. In hospital organizational charts, no one is in charge of doing this. Most hospitals just rely on housekeeping to get the waste out of there.” By force of necessity, that is changing.


Despite the excessive costs of properly handling wastes, it is not something that can be ignored or skimped on, DeSilva says. “We know the rules and the regulations, and we can’t afford the fines and the bad publicity if we don’t do it right,” he says.


There are alternatives to incineration. A report issued by Health Care Without Harm, while not endorsing any particular technology, outlines several preferable methods for treating hazardous waste. Some infectious waste can be sterilized by subjecting it to high heat and pressure, which is how the autoclave works. Chemical treatments can render some wastes harmless, and shredding and grinding the material before subjecting it to heat and pressure or chemicals can aid the process.


Many hospitals have given up incineration altogether. In 1997, Max Richard, the director of occupational health and safety at the University of Alabama at Birmingham Health System (UAB), had no choice but to find an alternative to UAB’s on-site incinerator. The cost of bringing the facility in line with new emissions regulations was prohibitive, so UAB stopped using its incinerator for everything but chemotherapy wastes. Nothing is shipped out of state to other incinerators either. A shredder breaks down the hazardous materials and then feeds them into a microwave that sterilizes the waste. The resulting material can then be disposed of with normal refuse.


The UAB system is working pretty well for now, he says, “but we are always looking for better, cheaper methods.”


NO MAGIC CURE


The search for solutions often centers on new technologies, but new methods are not likely to be the answer. “We don’t need innovations. Ninety percent of the battle is just getting hospitals to pay attention,” says Glenn McRae, a partner at CGH Environmental Strategies, a company that helps the health-care industry develop and implement ecologically sustainable practices.


According to McRae, the best results come when hospital administrators understand they are responsible for their facilities’ refuse and take steps to segregate and minimize it. Aggressive sorting, recycling and purchasing programs cannot only reduce the amount of hazardous wastes, but can save enough money to offset at least some of the costs of the new disposal practices.


UAB has such a program. And in order to make its system work properly, the medical center implemented a mandatory training program to teach its employees how to sort and properly dispose of wastes. Keeping regular garbage separate from infectious—or red bag—waste is key to making a disposal system cost-effective, no matter what technology method is used, Richards says.


UAB isn’t alone in this effort. Catholic Healthcare West (CHW), the largest not-for-profit health-care system in the western United States, has enacted a comprehensive plan to protect the environment and the health of the communities it serves by reducing, recycling and making environmentally sound purchasing decisions. CHW’s vigorous recycling efforts have had a double payoff. While numbers aren’t yet available for the entire system, one of CHW’s hospitals, Dominican Hospital in Santa Cruz, California, reported diverting 431,000 pounds of waste from the hazardous-waste stream between 1996 and 2000. This reduction in red-bag waste saved the hospital $211,000. And this is just one aspect of CHW’s system-wide program.


But as important as it is to sort, recycle and dispose of dangerous wastes in ways that don’t pollute the environment, part of the solution is found at the other end of the waste stream—especially when it comes to hazardous substances such as mercury and DEHP. Buying safe materials in the first place eliminates the dilemma of what to do with unsafe substances later. “A couple of decades ago, when hospitals moved to disposable products, they went overboard,” Brannen says. The overuse of disposable materials has flooded the waste stream with potentially dangerous plastics. It doesn’t have to be this way, she says. “Many products can be safely disinfected and reused, and they are now making plastics that can be autoclaved.”


Some hospitals, including UAB and CHW, are finding that sterilizing and reusing such products as glass IV bottles and tubing can be cost-effective as well as environmentally friendly. These practices are not as widespread as environmentalists would like, however. Although many health-care facilities are moving away from plastics, most are not embracing alternatives to PVC, McRae says. Part of the problem could be billing practices. It is easy to know how to bill a single patient for a single-use device. It’s not so simple to determine how to distribute the cost to several patients. Figuring out how to handle this won’t be as difficult as resolving the health insurance crisis, but it won’t be easy, either. Nothing about this problem is easy, experts say.


ONE SMALL STEP


If a hospital could do only one thing to reduce its environmental footprint, McRae suggests that it be to eliminate mercury. “Hospitals have very complex waste streams. Most hospitals have hundreds, if not thousands, of chemicals in stock—a real chemistry set,” he says, adding that eliminating mercury is doable and would have a tremendous impact on the health of the environment. And now is the time to accomplish this, he says. Many manufacturers of mercury-containing devices have take-back programs. When you buy new aneroid devices—meaning nonliquid-containing—they will take the old mercury instruments and have them properly disposed of.


As easy as it sounds, however, getting rid of mercury-containing thermometers and sphygmomanometers has been extremely frustrating to consumer and environmental groups. While many leading hospitals and medical centers are phasing them out, there is still a surprising amount of resistance to the change. Despite several studies demonstrating the effectiveness of properly calibrated aneroid devices, many physicians aren’t convinced.


Richard has faced some opposition from UAB physicians in his program to replace mercury-containing tools. But it’s not physicians’ pure stubbornness that’s the problem; it’s their lack of information. “What they want is an equivalent replacement. If we can convince them that the aneroid replacements are just as good, then we’ll be over that hurdle,” he says. “The best place to start convincing them is in medical school.”


Brannen agrees. “Doctors are taught that mercury is the gold standard in these devices. If we are to get rid of these myths, we are going to have to take a look at the medical school curriculum.” Many experts agree that if medical schools would train physicians on aneroid devices, resistance to them would soon evaporate.


A LONG WAY TO GO


Stericycle’s mission statement declares that it intends to be “the leading company dedicated to the environmentally responsible management of medical waste for the health-care community,” and Health Care Without Harm intends to hold them to this. But if this goal is to be achieved, the hospitals that give waste-management companies business and the communities where they locate their plants will have to demand cleaner and better methods of waste disposal. And hospitals and physicians’ offices will have to change their purchasing practices to reduce the amount of hazardous waste they generate, before it gets to a treatment plant.


Despite the efforts of such groups as Hospitals for a Healthy Environment and the many health-care facilities that are making serious changes in their waste management and purchasing policies, there is still a long way to go before health care can truly be said to be doing no harm. Education is the first step, McRae says. “Hospitals are willing to address these problems when they are made aware of them.”


The second step may be more difficult. “We have to change the hospital culture,” Brannen says. “Getting physicians to take responsibility [for the waste they generate] has been one of the most difficult challenges.” Solving this problem will take hard work on everyone’s part—not just physicians and hospital administrators.


The efforts of GRACE and friends in Gila River shut down an incinerator and got the company to switch to a safer technology. The purchasing practices of hundreds of hospitals like CHW and UAB have reduced the amount of toxic materials going into the waste stream. The movement for harmless health care involves a great deal of effort and many changes, on the part of citizens, hospitals and vendors. Not everyone agrees on the best way to achieve this, but few will argue the necessity of doing it.


A tired but victorious Thomas-Luna speaks for all activists when she says, “If it were my choice, I wouldn’t be doing this at all. But if I don’t do it, who will?” If the task of cleaning up medicine’s waste is ever going to be accomplished, it is going to take a lot of Thomas-Lunas.
~HOW YOU CAN HELP


Inspired by Lori Thomas-Luna’s activism? Want to join the fight against medical waste? Think you can’t do anything? Think again. You can have a tremendous impact on the effort to clean up the health-care industry.


For example, Stanford University’s Students for Environmental Action at Stanford (SEAS) was instrumental in helping to close an incinerator in the area. According to Adrianna Hernandez, a Stanford senior and SEAS member, when students discovered that Stanford Medical Center was a big client of the company operating the incinerator, they were able to bring pressure on the medical center to reduce its dependency on this harmful technology. Environmental organizations such as Health Care Without Harm (HCWH) were already working to shut California incinerators down, and the students’ actions helped speed up the process by drawing greater attention to the problem. Their major tactics: protests and petitions.


In other activist news, Tulane University School of Medicine students wrote and circulated a pledge for departments to sign indicating they’re committed to environmentally sound practices. The pledge included a list of specific actions to take—such as “look for ways to reduce paper waste within your department”—and offered tips for how to make the pledge a success.


If you are interested in joining the campaign to reduce the medical industry’s impact on the environment, there are several things you can do. HCWH, in cooperation with the American Medical Student Association (AMSA), distributes a waste survey that you can use to find out just how much change your institution needs to make it more environmentally friendly. Visit AMSA to download the questionnaire.


In addition, AMSA’s Occupational and Environmental Health Task Force has produced a booklet called “Medical Students for Earth: Environmental Health and Activism for Medical Students.” The publication is full of ideas for how you can help and can be accessed online. Visit AMSA's Occupational and Environmental Health Task Force. —A.H.


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A GLOBAL PROBLEM


Despite the progress that is being made in reducing the environmental footprint of the medical industry in the United States, toxic emissions are not merely a local or national phenomenon. Research indicates that dioxin and mercury can travel thousands of miles in the upper atmosphere before coming down to pollute soil and waterways. We may be sending our toxic fumes to other countries, and they may be sending theirs to us. And fumes are not all we send. Now that hospitals are making an effort to buy less plastic and fewer mercury-containing devices, manufacturers are shipping those products to countries with less strenuous regulations—and fewer options for disposing of them safely. Like all environmental issues, reducing the health-care industry’s negative impact will take planet-wide cooperation. —A.H.


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ONLINE RESOURCES


For more information about medical waste and the fight to get the health-care industry to clean up its act, visit these online resources:

~~~Based in Birmingham, Alabama, Avery Hurt is a contributing editor with The New Physician.~Advocacy,Community and Public Health~
142~3April~2003-52~Feature~Healing Behind Bars~~~~When your patients are prisoners, and your practice is under high-security surveillance.


Physicians in prisons — sounds like a good topic for a gripping reality TV series, a combination of “ER,” “Oz” and “Survivor.” Actually, correctional medicine is intense and fascinating. But you don’t have to wait for it to be discovered by the masses. Now is the time to get in on the ground floor. Some physicians have found practicing behind locked doors provides them with more freedom in their practices and lifestyles than they ever dreamed possible.


WHY WORK IN A PRISON?


Dr. Steven Shelton, president-elect of the Society of Correctional Physicians, characterizes prison medicine as “a return to the practice of good medicine.” In private practice in Salem, Oregon, for 13 years before going into correctional health full time, Shelton’s reasons for changing career paths are straightforward: “I see a patient. I write a chart note. I never fill out an insurance form, never bill a patient, never have to look at accounts receivable. I see a patient. I take care of a patient. I don’t have to worry about whether the patient can afford medical care and procedures; I just treat them appropriately. It’s the practice of medicine not driven by the dollar or the insurance company—and you can live a normal life, plan days off, take vacations.”


It was not easy to leave a practice of patients he’d seen for a number of years. “It was tough to say goodbye. At the same time, a lot of patients who had been with me for 10 years or so had to leave me when the company they worked for changed insurance plans, and they were forced to go to other physicians.” The business of being a primary care physician was killing him, he says. He is one of many, many physicians who thought they had their lives planned out, who are tired of having their practices dictated by insurance companies.


When you get a bunch of physicians in a room, the first thing they will begin talking about, confides Bob Manchee, is how stressful it is working in managed health care. “The lifestyle that correctional health care offers is a big plus,” says Manchee, a senior administrator at Correctional Medical Services, a company that contracts with states and counties to provide management of health care for correctional facilities’ medical units. “Younger physicians, especially, are looking more for family-oriented hours than upward mobility.” Besides regular hours, for example 7:30 a.m. to 4:30 p.m., and less call—there’s generally a statewide rotation schedule, and call is often limited to phone contact only—benefits packages include health insurance, retirement contributions and malpractice coverage.


Professionally, there are increased opportunities to see interesting medical cases. “The pathology is fantastic,” says Dr. William Haeck, a consultant to the National Commission on Correctional Health Care (NCCHC), an organization that offers voluntary accreditation for correctional facilities’ medical units. “In general, this population has been medically underserved before their arrival in the system and chances to see and treat unusual pathology are enormous—from untreated STDs to [tuberculosis] to mental illnesses. Discovering the pathology, making a diagnosis and initiating treatment can be very gratifying.” Physicians who diagnose attention deficit hyperactivity or bipolar disorders, for instance, have a chance to change the path of a life, he says.


“And you don’t have the frustration of not being able to follow up on your care,” adds Manchee, “because the patients aren’t going anywhere.”


DOES CORRECTIONAL MEDICINE SUIT YOU?


It’s one thing to list the perks of a prison medicine job on paper. It’s another to walk through the doors of a correctional institution and have them lock behind you. “One thing everybody has to understand going in is that you practice behind locked doors, and your movement is restricted to the health unit unless special arrangements are made,” Haeck says.


Manchee points out that the facilities can be depressing. “Some of the new ones are beautiful. But some need considerable upgrading and maintenance. It can be claustrophobic.”


Going to work is a little like passing through airport security every day. If you bring your lunch, don’t bring glass or aluminum beverage containers or metal silverware—anything that might be used as a weapon. Although there are any number of medical tools that fit that description, they are kept under close watch.


Security is uppermost in everyone’s mind when they first think of practicing in a prison. How is the fear factor? “I have no fears about security,” says Shelton, who describes his prison health clinic as clean, quiet and pleasant. Although some prison wards may be chaotic and noisy, health clinics should be an oasis. “If we’re not having a medical encounter, it’s over. The patient is taken back to their cell. There is no swearing. Inmates learn that the f-word has no function in a medical dialogue,” he says. For many inmates, a trip to the health clinic is a mini-course in learning how to function in polite society.


“You have to be able to say no,” Manchee says. This is a requirement of any medical position. However, inmates are a particularly manipulative population, and some are very good at playing games. “Your BS meter must be on at all times. You cannot be a pushover because that snowballs. You have to take a firm position and not waiver because word gets around if you do, and it’s difficult to recover your authority.”


You will face patients who show up with a huge array of problems and symptoms and no medical history. Or, at the opposite end of the spectrum, you’ll see patients whose medical history goes back as far as being born in prison to an incarcerated female.


In addition, there are not a lot of warm fuzzies in prison practice. Unlike private practice, there are few senior citizens who think you are wonderful and no young children to brighten the day. You won’t be treating generations of families that you get to know and who invite you to their weddings and barbecues. It may often seem like your patients could care less about what you do for them—that it’s never enough. “You must get your emotional satisfaction from taking care of human beings who are not the greatest contributors to society,” Shelton says. But, as in any medical setting, you have opportunities to make a difference in the quality of people’s lives.


What kind of medicine do you enjoy practicing? Currently, most prison physicians have a background in internal medicine, family practice or emergency medicine. Correctional health care tends to be oriented toward chronic care because the average length of stay in prisons is years. Physicians who serve jails—which house individuals on more short-term bases—however, are often oriented toward urgent care since the length of stay is generally counted in days. Jails interact far more with the local community, and there are opportunities for a fair amount of interaction with the public health sector. Most of the patients in jails are going to return to the community. Women’s prisons offer opportunities to practice gynecology and obstetrics and to develop programs that involve parenting. Working in juvenile detention facilities presents all the challenges of troubled adolescents on top of medical treatment.


It’s important to work well with nursing staff if you’re interested in this field. “The nurses in correctional facilities are usually very strong and function independently. They may have an enormous amount of expertise about dealing with prisoners whereas a physician new to the facility does not. You have to be able to listen to the nurses,” Manchee says. “They are a valuable part of the health team and don’t take kindly to a doctor who tries to dominate the clinic environment.”


(Mis)Perceptions of Correctional Medicine
It has to be said that there is a perception that being a prison doc is a job of last resort for physicians. Controversy swirled around the revelation a few years ago that some jails and prisons had dealt with the shortage of correctional health professionals by staffing facilities with substandard physicians. A special report on health care behind bars that ran in the St. Louis Post-Dispatch in the fall of 1998 revealed that some states and counties were hiring physicians who had been convicted of crimes or were disciplined for professional misconduct. In addition, some states had granted restricted medical licenses for working in prisons to physicians who had lost their licenses in other states.


While specific instances of this kind of unethical hiring cannot be disputed, you don’t have to be an investigative journalist to evaluate a corrections setting and its standards of care. State departments of corrections are aware of the need to upgrade the perception and reality of medical care in prisons and jails. Negative publicity as well as the positive efforts of the NCCHC and the Society of Correctional Physicians have contributed to an increase in the professionalization of the field.


“Correctional Medical Services has a credentialing process that is just as stringent as any hospital,” Manchee says of the private company he works for that provides physicians for correctional settings. “We use a national practitioners database, see copies of licenses, check with the [Drug Enforcement Administration], and set up interviews between the candidate and site administrator and regional medical director before we place a physician. We check to make sure they have an unrestricted license and won’t touch physicians who have had their licenses revoked for clinical issues.” That doesn’t mean, however, that the company would not consider a physician who has had a drug dependency problem in the past. “If a physician has been through treatment and their dependency is in the past, we would have no problem.” Manchee is quick to point out there is a difference between an impaired physician and a physician who has full functional capacity after dealing with a drug or alcohol dependency. In fact, the structure of a correctional facility can provide a good match for physicians in recovery. It is a sobering experience to work with people who are in prison due to acts they committed because they had an untreated chemical dependency.


Another misperception is that quality of care is suspect because many foreign physicians practice in prison settings. “We have no problem with employing foreign physicians, if their English is good. Some of our best doctors are from Pakistan, Vietnam, the Philippines,” Manchee says. Different cultural backgrounds bring an interesting mix to the other health-care providers and the prisoners, he says.


Some of the negative perceptions have nothing to do with physicians at all. They have to do with how criminals are viewed by society. “Many people feel prisoners don’t deserve good medical care,” Shelton says. “My view is that all human beings deserve good health care. The vast majority of those currently incarcerated will leave prison and go out into society, where if someone was sick, you would normally say ‘this poor person has a disease and needs treatment.’ They are no less a human being because they are incarcerated.” To critics of the quality of physicians in the correctional setting, Shelton replies, “I would stack my doctors’ diagnostic skills against anybody’s.”


LOOKING TO THE FUTURE


Medical director Dr. David Burnett is the new guy on the (cell) block. Well, not really, since his office is in the Department of Corrections administrative building near downtown Madison, Wisconsin, rather than in one of the almost two dozen adult and juvenile facilities in the state. Stepping in last year to fill the shoes of a medical director who had actively worked in the prisons, Burnett had never worked in a corrections setting. A family physician by training, he entered medical management quality improvement 10 to 12 years ago in the private sector. He is part of the movement to professionalize prison medicine.


“The whole medical field has been evolving more toward a quality improvement focus,” he says. “It’s very difficult to manage a system unless you can measure the things you are doing.” Some of the things Burnett measures are the number of inmates getting access to health care through sick call, the number of diabetics who are getting their hemoglobin A1c checked and are receiving retinal eye exams. “We’re looking for clinical indicators for care just as if this was the private sector. I’m an advocate for both the people who work within the health-care system and for the inmates who receive care.”


Wisconsin prisons do not yet have NCCHC accreditation, which is part of Burnett’s mission. “At this point, the system is understaffed with health-care personnel, given the population of over 20,000 inmates in the 18 adult facilities.” In fact, 3,000 of Wisconsin’s inmates are incarcerated out of state, primarily with private vendors in Tennessee, Minnesota and Oklahoma.


Nearly one-third of state inmates and one-quarter of federal inmates reported having some physical impairment or mental condition, according to a U.S. Department of Justice, Bureau of Justice Statistics report released in 1997. A new report on the health status of soon-to-be-released inmates based on research by NCCHC will be published with the goal of generating policy recommendations for improving screening and treatment programs in jails and prisons, thus reducing the health and economic impact of serious conditions after offenders are released. Tens of thousands are released every year with undiagnosed or untreated communicable diseases, chronic diseases and mental illnesses.


“There is a significant burden of illness in the prison population that most people outside of correctional medicine don’t understand,” Burnett says. “There are a lot of unmet needs. This is an untapped area for opportunities to practice medicine with a defined population. It’s a great place to apply public health measures that will increase the health of the general public as inmates are released.” Rather than seeing correctional health as a step down in status for a physician, Burnett confesses, “Frankly, it’s been a breath of fresh air for me.”
~A NEW SPECIALTY IN THE MAKING?


Dr. William Haeck knows about building a specialty from the ground up. Currently a consultant who surveys jails, prisons and juvenile facilities that have applied for accreditation from the National Commission on Correctional Health Care (NCCHC), Haeck helped found the field of emergency medicine. “Correctional medicine is where emergency medicine was about 35 years ago,” says Haeck, who left emergency medicine in 1994 to become medical director of a large urban jail in Broward County, Florida. As in the early years of emergency medicine, “virtually the entire field of correctional medicine is filled with people who have chosen it as a second career,” he says. But he believes that as more individuals select it as their primary careers, and as the medical profession acknowledges the special skills and unique capabilities that prison physicians need, it will become a board-certified specialty.


Haeck notes that the field has come a long way since around 1970, when the American Medical Association began examining the health-care conditions of prisons, jails and juvenile facilities. There were no consistent standards from state to state at that point, and medical care of inmates was generally quite poor. In 1983, NCCHC was formed to create written standards that are regularly revised and a voluntary certification program based on an inspection by a team from NCCHC. Currently, there are more than 500 accredited facilities. How many does that leave? “A lot,” Haeck says, “for reasons that are often political.”


The rapid building of prisons that took place in the “get tough on crime” 1980s and “three strikes you’re out” 1990s appears to be over. Incarceration rates have more than tripled since the 1980s, but since 1995 there has only been an increase of about 4 percent annually. “Texas, which has over 100 facilities and in excess of 100,000 inmates, spent billions of dollars to build facilities and currently has no new ones in the planning stages,” Haeck says. Florida, too, has stabilized in the last five years. Figures from the U.S. Department of Justice, Bureau of Justice Statistics show about 2 million prisoners under state or federal jurisdiction as of Dec. 31, 2001, an increase of 1.6 percent from mid-year 2000. But cities like Las Vegas and Fort Lauderdale that are seeing rapid growth are still building additional jail space, and plenty of facilities need upgrading. It’s unlikely we’ll see a shortage of prisoners with health problems for the next few generations, however. And staffing of prison health clinics—often driven by state budget decisions—hasn’t caught up with the prison population, even if it stabilizes.


Physicians in the field say correctional medicine is wide open right now, but the buzz is growing. “The fall NCCHC conference has grown from 500 to 1,500 attendees,” Haeck says. “The opportunities for professional advancement, particularly in state systems, are good. Practitioners can use their administrative skills to organize systems of care. Clinicians can have nice, collegial experiences with the full range of health-care practitioners—nursing, dental, mental health, pharmacy.”


All indications are that the trend toward improving health care behind bars will continue. A good health-care delivery system for prisoners is important for the protection of public health from infectious diseases like STDs, tuberculosis, hepatitis C and HIV/AIDS (most prisoners will be released into the general population at some point) as well as for humanitarian reasons.
—J.K.


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


MORE ON CORRECTIONAL MEDICINE


The best place to start researching correctional medicine is on the Internet. Go to your favorite search engine and play with phrases like “correctional health care” and “prison medicine.” Also check out the “Department of Corrections” Web site for your state as well as the resources listed below.


ORGANIZATIONS:

The Society of Correctional Physicians provides support, education and professional development for physicians who practice in a correctional setting. One of its goals is to establish a recognized specialty in correctional medicine.

The National Commission on Correctional Health Care has developed nationally recognized standards for correctional health care and monitors accreditation according to these standards.


CHECK OUT PUBLICATIONS:





PROGRAMS:


The University of Texas Medical Branch (UTMB) in Galveston offers an emphasis on correctional health in its general preventive medicine residency program that includes recognizing: common infectious diseases encountered in prison populations; psychological diseases associated with crime and violence; diseases of fraudulent nature; problems due to the nature of incarceration; the economic and security constraints of practice in a correctional setting; and the integration of public health-care systems with correctional systems. The Institute for Medical Humanities at UTMB also offers a program on legal and ethical issues in correctional health. —J.K.
~~~Judith Kirkwood is a freelance writer based in Madison, Wisconsin. E-mail questions and comments about this article to tnp@amsa.org.~Career Development,Practice of Medicine~
144~3April~2003-52~On the Wards~Not a Monster~THE CASE OF A 43-YEAR-OLD PREGNANT WOMAN~Joseph Capriotti~~The nurses stood gathered in a circle, hissing like vipers. They had made up their minds. They wouldn’t participate, wouldn’t cooperate and wouldn’t look favorably on anyone who disagreed with them. The attending wasn’t surprised. She was annoyed and inconvenienced and resented the nurses for what she thought were small-town, fanatical, unintellectual ideas. I was new, only been there two weeks as a third-year medical student on my first rotation, and I hadn’t seen this before. It was 10 a.m. on a Saturday in July, and I was in the middle of something I hadn’t been prepared for.


“Patient is a 43 y.o. G4P3 with LMP of 2/12/2000 and an EDC of November 20, confirmed by second trimester ultrasound, at 23 weeks 4 days EGA who presented to labor and delivery for elective termination.” It was easier to hear it like that, in the depersonalized Spartan grammar of a case presentation. It didn’t set in at first. I was still at the point where every word I heard was digested separately, then put back together like a puzzle, after the abbreviations were decoded and the meaning of every phrase translated. Forty-three years old. Twenty-three weeks and four days pregnant. Elective termination. I went to room 15, at the end of a long hallway of laboring mothers and nervous fathers, to meet the elective termination. She was a quivering mess, and her husband sat in a padded armchair by the window, trying to be bold.


The nurses wouldn’t get involved—at all. They wouldn’t bring the patient to the procedure room or sterilize the abdomen or hand the attending the ultrasound jelly. The attending was frustrated and a little condescending. To her, this was a job and a service, and maybe a little late or a little unpleasant, but also something bigger, something more. It was a political statement or a badge of liberalism or an assertion of her essential different-ness from these country people and this small town. This was an undeniably sophisticated thing, cerebral and urban.


The upper-level resident had to stay on the labor and delivery floor with the laboring women. The intern was pragmatic and nonjudgmental, the veteran of an Indian education. This was nothing she hadn’t seen before. No grand emphatic gesture, no more exotic than a CAT scan. She was ready, and the attending was trying to call in someone else to help.


I was sitting at the square conference table in the resident’s room. The attending didn’t ask me, but before I even knew what I had said, I offered to help, calmly, like it was nothing, like it was just another Saturday. And as soon as I volunteered, we got called to multiple C-sections, complicated vaginal deliveries and a stream of triage patients and ER calls that kept us busy for the next 12 hours.


Only occasionally did I think of the flaccid woman or her darkening room. Instead, I focused on episiotomies and laceration repairs, on indications for Caesarean delivery and fascial planes in the abdomen. We finished an impressive day and met back to resume our final procedure. I wondered, as the moment drew inexorably closer, why I volunteered. Was I trying to impress the attending? Was this a reflex I learned—to ask to do everything, to be “aggressive”? Did any of this really bother me? Was I just trying to be severe? I felt the nurses glaring at me as we walked to the end of the hall. Entering the room, I tried to smile.


We thought it best if the husband stayed there. We helped the woman to a wheelchair, and I pushed her to the clinic office designated for terminations. I ushered her by the nurses who wouldn’t stop whispering even as we passed. The same nurses who I had seen stay past their shift changes to coach new mothers through the last moments of delivery suddenly seemed so venomous, so full of judgment and revulsion. The attending and intern walked ahead as I trailed behind with this broken woman who I wheeled in pieces down the hall.


Anesthesia wouldn’t come to give the epidural. Something about short staff and multiple motor vehicle accidents, but we all knew that if this were just a C-section, they’d be here. The attending and the intern were busy with the mechanics of setting up. The woman slid onto the exam table and spoke to me.


“Give me something so I don’t have to feel this.”


The attending overheard and explained about not getting the epidural. She’ll give some local and something to calm her, and she shouldn’t feel too much. What a lie, I thought, that she wouldn’t feel too much. She may not feel the 18-gauge needle or the potassium chloride injection into the heart of her unborn fetus, but how could she not feel this? She already felt it in the corridor of cold nurses and warm newborns. She’d feel it in 16 weeks when her due date comes and goes, and she’d feel it back upstairs, in her labor and delivery suite with the cable TV and the Amish quilts when she pushes through contractions and her husband holds her hand as they wait for the arrival of their stillborn child. Will they name it? Will they bury it? Will they even look at it? I only wanted to be done, for her to be done, for me to be able to say something that made everything OK, so we could all go upstairs and wash our hands and feel good again.


We had a tough time with the procedure, and it took longer than expected. The woman felt every probe of the needle and moaned with every twist of the attending’s hand. I operated the ultrasound console and held the probe cord off of the sterile field. I watched every jab at the fetal heart and saw the tiny arms jerk back in front of the face, as if it were trying to protect itself, to dodge the long stabs and push the needle right back out. I concentrated on the cord, distracting myself at first with every intricate detail I could remember about the physics of ultrasound. I focused on piezoelectrics, on the oscillations of a crystal in a changing electric field, and I could see the blue and white cover of Kittel’s Solid State Physics. I remembered the Doppler equations and the pulse pressure of a photon, and then drifted to Fourier transforms and nuclear spins and the warm summer soccer games of graduate school, where the only things I ever felt at work were elation that the experiment worked, frustration that it didn’t or fatigue from trying to figure out why.


“Please tell me I am not a monster!” She stared at me.
They were the hardest words I had ever heard. Please tell me I am not a monster. In this most devastating instant of her life, a shivering woman looked into my eyes. Please tell me I am not a monster.


“Of course you’re not a monster,” I wanted to say. You are a woman faced with something most people cannot ever understand. You are not a monster. You are gored and eroded and horrified by what you have to decide. You are not a monster, but you are the object of a monstrous campaign of self-righteousness and derision. You are alone here on the exam table with the three of us busy around you. You will be alone in your wheelchair when I push you back down the hall, through the rough glances and the condemning stares of those who choose not to care for you. You will be alone, ultimately, with this thing that we have done to you. But we choose to care for you. We choose to walk you back down the hall to your hardwood floors and your picture windows and help you look outside again. We choose to help you back into your bed and explain all this to your husband and to be there when you need ice chips or aspirin or clean sheets. And we don’t choose these things for monsters. We don’t choose these things for politics. We don’t choose these things for ancient religions or contemporary social movements. We choose them because you are abandoned and in pain and need help, and we can help you.


I wanted to say all these things but didn’t. The attending said something reassuring, and we continued. But I learned these lessons for myself, at least. We weren’t just making a statement or asserting this or that uncompromising position. This had nothing to do with the rights of women or the precise definition of the beginning of life. I learned at the foot of the bed, watching this fetus die and this mother beg for absolution, that there was no 43 y.o. G4P3 with LMP of 2/12/2000 and an EDC of November 20, confirmed by second trimester ultrasound, at 23 weeks 4 days EGA who presented to labor and delivery for elective termination. Instead there was a woman, a wife and a mother, who thought she was a monster; and there was my chance to tell her, in language as simple as rolling her wheelchair down the hall, that she was not. That may not have been my reason for volunteering that night, but it will be the next time.
~~~~Joseph Capriotti is a fourth-year medical student at Jefferson Medical College.~Ethics,Medical Education~
146~5July-August~2003-52~Feature~Bringing CAM to Class~~Jennifer Zeigler~~As physicians attempt to better care for their patients, they’re finding a need to better understand the healing arts of complementary and alternative medicine.


Jennifer Seda was standing in her first yoga class wondering how bored she was going to be for the next hour. All this touchy-feely stuff didn’t appeal to the Amgen researcher in neuroendocrine science. “I’m a hard-core bio-chemical skeptic,” she says.


But Seda, who is now a fourth-year at Mayo Medical School in Minnesota, had given her mother a set of yoga classes for Christmas and decided to go along. And in doing so, she found herself surrounded by women in workout gear, sprawled on mats, practicing breathing and thinking spiritual thoughts. Boring.


Today she chuckles at the memory, because that was the day the hard-core scientist began her five-year, 180-degree transformation into today’s Jennifer Seda: certified massage therapist, soon-to-be-physician who founded the American Holistic Medical Association (AHMA) chapter at Mayo and is working to integrate complementary and alternative medicine (CAM) into the curriculum.


Working CAM into the curriculum could mean teaching about a host of different medical techniques. CAM is the term used for everything from Chinese medicine to herbs to Reiki massage to personal well-being exercises. It’s taking parts of traditional medicine from non-Western cultures and incorporating them into high-tech, evidence-based medicine by using a more holistic theory that also builds on a belief that health is achieved through prevention. It’s a medical practice that many patients have embraced, and something physicians are finding themselves more frequently quizzed on.


And thanks in most part to the efforts of people like Seda, medical education is slowly beginning to integrate CAM into the curriculum and, in some areas, postgraduate training. Even where the idea meets with resistance, students have often found ways to receive CAM instruction on extracurricular levels.


CAM COMES TO CLASS


CAM—particularly instruction in homeopathy and herbs—played a strong role in medical education prior to the groundbreaking Flexner Report in 1910, says Dr. Ina Grundmann, a research assistant with the American Medical Student Association’s (AMSA) Educational Development for Complementary and Alternative Medicine (EDCAM) project. Driven by public interest, knowledge of alternative therapies was important for physicians of that time to know. But Abraham Flexner’s report, which triggered medical education’s focus on science-based, academic learning, largely quelled the practice until public pressures once again sparked a medical interest in CAM during the 1970s.


However, the medical establishment wasn’t fully aware of how prevalent CAM was among patients until 1993 when Dr. David Eisenberg published a study finding that one-third of Americans were using alternative therapies. The medical community was shocked again by Eisenberg’s follow-up study in 1998 that discovered the number of visits to CAM practitioners increased more than 47 percent between 1990 and 1997.


And a lot has happened in medical education since a 1998 Journal of the American Medical Association study found the percent of medical schools offering CAM instruction had nearly doubled to 64 percent in just two years. What’s driving this increase in CAM education? It has something to do with those 629 million annual visits to CAM practitioners that Eisenberg identified in 1998. He found that many CAM patients don’t talk to their primary physicians about alternative therapies because they think their physicians will disapprove of their use of acupuncture, herbal remedies, massage or one of the hundreds of other alternative healing options that compose CAM. This generates the potential for dangerous interactions between Western and alternative treatments, so physicians have slowly realized the need to at least be aware of the different therapies available in order to ask their patients about them.


While future physicians may also see this as a reason to better understand CAM, some push for more instruction because of personal experiences. Dr. Jodi Sherman, a surgical resident at Columbia-Presbyterian Hospital in New York City, had been through several top orthopedic surgeons in an attempt to alleviate an ankle injury when a co-worker recommended she visit a chiropractor. The result surprised her.


“This was exactly what I needed, and why didn’t my doctor tell me about it?” She says she soon learned the answer. “I actually put my chiropractor in touch with my orthopedic surgeon, and my surgeon wouldn’t talk to my chiropractor. And I didn’t understand why. This was a rude awakening.”


But with a healed ankle as proof, Sherman heeded this wake-up call, which led her to learn more about CAM therapies and why the medical establishment has been slow to accept that patients have found relief through them. “I think for a lot of physicians who have an interest in [CAM], there’s this fear. There’s a lot to lose. They can be criticized by their peers [for promoting a therapy seen as unproven and unusual],” Grundmann says.


There are still a lot of CAM skeptics, says Steven Turner, a third-year at the University of Virginia and a former EDCAM student director. “But that number is diminishing,” he says.


And in the wake of the CAM bandwagon is the opportunity for increased education, as medical schools become more receptive to the idea of teaching about alternative medicine.


CHANGING SLOWLY, BUT SURELY


Stacie Elfrink, a third-year at the University of Oklahoma (OU) College of Medicine, says she’s surprised at the amount of CAM education school administrators have begun offering in response to students’ requests. “I think they’re learning about CAM right along with us,” she says. “I think professors will do it if there’s enough students interested in it. It’s step-by-step.”


To maintain the enthusiasm for CAM education, OU can depend on Elfrink and her background in literature and medicine. “My dad’s a practicing [family] physician. I remember him saying he believes whatever makes the patient feel better is OK as long as it doesn’t have any adverse effects. I know writing is one of the things that has always helped me, and so I began taking a look at art therapy.” Her interest in alternative healing methods grew.


“Between first and second year, we do a rotation with primary care physicians. I began to see patients who had been taking herbs; I just began picking up things here and there. The second year is a lot more about the disease process, and they bring in patients to talk about their diseases. And as you listen to them, you realize there’s a lot more to it than modern medicine.”


As she has explored CAM, her school has begun offering a few hours of instruction through its medical humanities program. A literature-in-medicine course; a medical reader’s theater, in which medical students perform plays; and a two-hour lecture on herbs in the required behavioral science class are all part of the program. Although the program is in its infancy, it’s the right approach, Elfrink says. “I don’t think it needs to be a radical change. If they could just integrate it in bits and pieces, then students could learn more about it without pushing out other important science information.”


It’s the same philosophy behind the Georgetown University (GU) School of Medicine CAM education initiative, says its director, physiology and medicine professor Aviad Haramati, Ph.D.


“The goal of the initiative…is to seamlessly integrate CAM into the medical school curriculum—not to create CAM practitioners but to create educated physicians. We’re not teaching medical students how to do acupuncture, but we’re teaching them that acupuncture is out there,” he says.


GU’s program is the result of a five-year, $1.7 million grant from the National Institutes of Health’s (NIH) National Center for Complementary and Alternative Medicine (NCCAM), which from 1999 to 2002 offered funding for 15 education curriculum projects.


Haramati says his program is trying to get CAM information into as many courses as it can, and after two years, every basic-science course has at least one hour of CAM instruction. For example, there are lectures on the anatomy of acupuncture in anatomy classes and discussions of osteopathic manipulation in physiology classes.


Beyond the classroom opportunities, GU’s initiative also attempts to allow medical students to personally experience the mind–body connection in well-being through skills groups that explore such healing practices as meditation and journal writing. “We take a medical student and give them time to reflect on why they chose to become a physician,” Haramati says.


Students have identified with the idea. The optional 10-week mind–body skills workshops have more interested participants than the school can accommodate now, and third-year Kenneth Eaddy says it’s changed his entire view of medicine. “I’ve seen it help, and I know it helps me find my niche in medicine,” he says.


Eaddy, who says he didn’t consider CAM before medical school, has become an enthusiast. He says Haramati tells first-year students not to worry about their grades but about their well-being—a philosophy he didn’t embrace in the beginning. “When I first got here, I thought, ‘Man, this guy is full of it. I know what I did to get here,’ but somewhere along the line his initiative has really won me over.”


Haramati’s way of integrating CAM into the curriculum has also garnered favor among other members of the CAM community. “Trying to include parts of complementary medicine into required courses is probably the most reasonable way of doing it,” says former NCCAM director Dr. Wayne Jonas.


Administrators at other institutions agree. At their request, Haramati has visited five medical schools in the last six months to present the GU CAM method. He says one of the reasons the program is so highly regarded is because the school did not approach it from a position of advocacy. “It’s also a matter of pace and timing. We’re not trying to create a revolution here.”


GU’s initiative is unique. Turner says most medical schools offering CAM instruction do so through nothing more than a one-hour elective survey course. “One hour is really not enough,” he says.


“It’s getting a lot better than it was 10 years ago or even five years ago [but students are] not getting adequately trained,” Jonas says. “Even taking something as basic as drug–herb interactions, the information is quite spotty.”


A volunteer lecture or workshop series is something students at institutions lacking a solid CAM curriculum component can organize to gain access to alternative instruction. In May, Elfrink organized the first meeting of OU’s CAM interest group. Twenty students showed up wanting to know about mind–body connections in medicine, community service and cultural competency in the Native American traditional medicine that is so important to practitioners in Oklahoma but largely ignored by the OU curriculum. She expects the group will organize speakers, poetry readings and discussions as well as compile resources for additional opportunities. “It’s still evolving, but I know I want to hear from both physicians and patients,” she says. “If students didn’t take the initiative, I don’t think we’d have near the opportunities that we do have. It’s tough; it’s expensive for schools to bring in speakers.”


MONEY FOR CAM


Adding to a curriculum—no matter how worthy the instruction may be—costs money, which is why funding such as the NCCAM grants is so important in integrating alternative medicine into medical education. Jonas says the grants have played a large role in the increased learning opportunities students have had in the past five years.


In 1999, NCCAM issued the call for applications for 15 educational project grants that would pay $300,000 per year for up to five years. Before putting new grants on hold in 2002, NCCAM gave the money mostly to medical schools for the purpose of integrating CAM into their curricula, but it also dispensed some funds to allied health training programs and at least one residency program, as well as AMSA’s EDCAM project, to develop curriculum modules for other schools to use.


Jonas says the program got started because at the time, NCCAM—flush with money thanks to a bump up in stature from an NIH office to a center and the five-year congressional drive to double the NIH budget—had more money than it had deserving clinical research projects to fund. “I think that a research organization like the NIH has stepped in really says there is nowhere else to turn,” he says, but adds it’s not going to be a long-term solution. “Academic medical centers are in dire straits. The emphasis goes toward practice and research. Teaching never brings in money.”


This is the problem Haramati is grappling with at GU. His NCCAM grant is up in three years, so with the program’s main academic components in place, he is now turning his attention to how CAM education can continue without federal money. “Our long-term goal is that we would create revenue streams that will allow continuing the CAM program,” he says. The school has created a master’s program in physiology with a CAM emphasis, and Haramati hopes that income from the program’s clinical research can continue to fund education in the medical school. “The initiative is geared to education, but what will sustain it is research.”


AFTER THE MEDICAL DEGREE


One reason medical education has been slow to endorse CAM education financially is there’s no defined career path for CAM, Turner says. Sure, physicians can be board certified in holistic medicine, but all applicants must already be certified in another specialty before sitting for the exam, which is not regarded as a particularly challenging test. There is no CAM specialty, no residency, although several schools reportedly have programs in the works. In short, a medical student who wants to become a CAM physician still has to go through a traditional training program. And Grundmann says it is difficult for fourth-years to take a month off from their specialty tracks to take an elective CAM rotation—which some schools do offer—when there’s no practical application beyond medical school.


But CAM is more applicable to some specialties than to others, and dozens of residencies have begun integrating some education. Perhaps the easiest connection to see between an established specialty and CAM is in family practice. And one of the most innovative residency programs is at the Maine Medical Center (MMC) in Portland. The recipient of a $750,000 education project grant from NCCAM, the family practice residency at the hospital has spent the last two years getting four faculty physicians up to speed on CAM therapies and how they apply to primary care. These four, in turn, have provided educational opportunities for the rest of the staff.


MMC residents are required to attend a series of workshops in which they apply CAM practices on a typical Grand Rounds, watch acupuncture and osteopathic demonstrations, discuss homeopathy and listen to lectures from visiting experts. They also participate in monthly one-hour discussions with CAM practitioners from the Portland community. They cover case studies and talk about issues such as insurance coverage and liability. “We want our residents to be aware of what’s out there—what’s helpful, what’s not helpful,” says Dr. Craig Schneider, the MMC’s director of integrative medicine. “Our goal isn’t to create alternative medicine practitioners; our goal is to create practitioners who are aware, and that’s what good family medicine is.”


Beyond workshops and discussions, though, all third-year residents are required to do a one-month block rotation of CAM instruction. They have required reading, see patients at the alternative medicine consultation clinic Schneider has helped establish, and shadow CAM practitioners. “We also have them see what it’s like to be a patient, because I think that’s really important in these situations, particularly when the [clinical] evidence isn’t really strong,” he says. So residents might have a massage or undergo osteopathic manipulation, and Schneider says the experience helps them discuss alternative therapies with patients and perhaps even recommend some. “Or they might say that experience was just too weird, and I wouldn’t recommend it to anybody.”


The block rotation took away some of the residents’ elective time, which was a controversial move, he says. But beyond that, the reactions to the program have been mostly positive. This year’s Match brought the residency program an intern class full of top candidates. And the local medical community has benefited too. “There’s been an increased level of respect between the alternative medicine practitioners and the conventional practitioners,” he says, but adds that you can’t sway everyone. “The [residents] who were skeptical remained skeptical but more aware. You can only do so much.”


Schneider was the only new faculty member added when the program began in the summer of 2001, so funding issues are not expected to halt activities when the grant runs out at the end of this year. In fact, the program has generated a new source of income for the family practice department through the alternative medicine consultation clinic. But he says the grant has been instrumental in getting the program started. “I don’t think the interest was strong enough that it would have happened without the grant,” he says.


Graduates interested in CAM can also apply to a handful of postresidency fellowships. The most well known is Dr. Andrew Weil’s Program in Integrative Medicine, a two-year fellowship at the University of Arizona, although others include one-year fellowships in integrative medicine in primary care at Beth Israel Medical Center in New York City and in integrative medicine at the University of Maryland. Other programs offer postgraduate training in clinical CAM research.


The way we train physicians and treat patients is holding academic medical centers back from offering more postgraduate CAM training, experts say. “The whole system is built, in a lot of ways, on flawed principles. It is designed to manage diseases,” says Dr. Mark Hoch, the immediate past president of the AHMA. The holistic medicine approach is based on preventive care more than the acute hospital-care environment medical students and residents most often train in, and that makes for difficulties when trying to incorporate CAM into the curriculum.


The Consortium for Academic Health Centers on Integrative Medicine is wrestling with these issues. The group, composed of 19 teaching hospitals and their medical schools, is putting the final pieces together on a proposed set of competencies that it thinks medical students should be taught and tested on. It’s an idea that has some overlap with a recently proposed set of five core competencies the Institute of Medicine recommended all medical schools use in its Health Professions Education report (see “IOM Suggests Curriculum Changes” on p. 5).


Turner says this report, along with some other indicators, makes him believe that medical education is on the cusp of radical change. “And hopefully CAM will sort of sneak in there,” he says, adding that he expects to see CAM as a regular curriculum component within the next 10 years.


It’s a desire others share. Dr. Karen Lawson, who sits on two of the consortium’s committees, says she thinks change in the way we educate is the ultimate goal for CAM proponents. “I think where we are right now is on that razor’s edge…. Are we going to change [CAM] or is it going to change us? I really believe that what has to happen next is really even-ground participation of all the players, so it’s not the doctors saying, ‘This is a good idea, and we’re going to run the show.’”


Still, getting CAM fully integrated into the medical school curriculum—and the wholesale overhaul of the medical industry some think this might require—will never happen overnight. How many years away might we be? We’ve been talking about getting nutrition into the curriculum for 50 years, Jonas says, and we’re not there yet. “So at least 50.”
~RESOURCES


For more information about CAM in medical education, investigate these resources:

~~~Jennifer Zeigler is a senior writer with The New Physician. Direct questions and comments about this article to tnp@amsa.org.~Complementary and Alternative Medicine~
147~5July-August~2003-52~MedMentor Q&A~Crafting a Match for You~BECOMING WORTHY OF A GREAT RESIDENCY~Daniel W. Collison~~If you’re like most future physicians, your internship and residency will guide your career and success even more than your medical school experience ever could. So how do you prepare to obtain a great residency in an increasingly competitive world? I think an important mindset is to consider that medical school is simply a microcosm of life and just as in life, there are no guarantees. This is meant as a liberating thought—as the theologian Reinhold Niebuhr wrote in The Nature and Destiny of Man, “Man is most free in the discovery that he is not free.” With this in mind, a few principles and practical tips may help you flourish.


  1. Understand and accept that life isn’t fair. Students you know who are card-carrying jerks might get great residencies. Your Gandhi-like friend might not. Once you accept this, do the best you can through principle, fair play and smart work (e.g., form a study group with your Gandhi friend).


  2. Understand the lay of the land. Some students arrive at medical school with the next 50 years planned out month by month. Others have no idea what next week will entail. Perhaps it’s healthiest to be somewhere in between. Don’t miss out on opportunities through ignorance. Learn the basics (including timelines) for applying to residencies within the first months of medical school. You will need time to explore options, network, achieve top performances (especially for competitive residencies) and engage in dues-paying activities (such as conducting research). In all of this, please be kind to yourself and fellow students—don’t become a gunner. Your best sources of information about opportunities and timelines include the dean’s office and the students ahead of you, especially seniors.


  3. The surest way to get a great residency is to be worthy of one. The good and bad news is that there are no shortcuts. Your dean’s letter summary of your performance will be the most important document in your residency application folder. Don’t worry too much about a poor grade from the attending from hell. As in Olympic scoring, I tend to throw out the very lowest and very highest marks (after all, some attendings can be fooled). I will also discount the assessment by someone who doesn’t know the student well, so don’t bother getting a letter of recommendation from someone prestigious unless it pertains to your performance. Consistently good evaluations are bankable. “Excellent student, self-aware, well-motivated, good team member, loves kids and knows pediatrics is for him” is the summary of how a good dean’s letter might read.


  4. Set the stage for great letters of recommendation. Provide great service on the wards (see the “MedMentor” column in the March 2003 issue of The New Physician), and find mentors as soon as you can, in year one if possible.


  5. Gather intelligence from current residents in the specialty of your choice. God bless the residents at my medical school, one of whom told me about a program I hadn’t considered but added to my list and matched at. Other good resources: faculty members from young (more likely to have information about current conditions) to old (perhaps have better perspective and peer networks). Conversely, regard residency information from fellow medical students with respectful skepticism. I still hear students repeat the same false dictums I heard as a student years ago, such as choosing a program with the same population mix as that you wish to settle in. The fact is, if you choose to get the best training, you will be better equipped to practice with any patient group or population.


  6. Choose “away” rotations with caution. If you want to match at the University of Utopia’s program, it may be better to do your rotation in Shangri-La, get their rave support and let the folks in Utopia try to catch you on the open market. The unknown applicant is often more enticing than the known. Also, be wary of doing a rotation at a place that takes a lot of outside students—you may not stand out from the crowd.


  7. Make sure your curriculum vitae (CV) tells the story you intend it to. Use the personal statement to help connect the dots or to provide a few new dots that entice interest. The reader of a well-written CV should be able to connect the dots thus: “A candidate with tremendous promise for a career in (fill in the blank).” Here’s another example: “Worked for his achievements, took risks, didn’t waste opportunities, paid back to the community and explored medicine and the wider world.”



    Another analogy: If you were a stock someone would want to invest in, your CV should be a graph where the overall tendency is upward. A CV or personal statement with an isolated downturn or two is just fine. In fact, I find it useful to learn how an applicant deals with adversity. (If it’s pertinent to your story, the personal statement may be the natural place to mention how you responded to a challenge.) One of the great thrills for residency program directors is to find promising but overlooked applicants and see them develop into blue-chip physicians.


  8. He who lives by the CV dies by the CV. Not only should you never make false statements, but if you list something on your CV, be prepared to discuss it. Grandiose or padded CVs are detestable. Your CV entries should be pertinent to your story.


  9. Dream often, plan early and work always. Luck is what happens when preparation meets, recognizes and acts on opportunity. Harvey Mackay, a motivational speaker and author, once said, “A dream is just a dream. A goal is a dream with a plan and a deadline.”


  10. Jumping through hoops is a poor substitute for life. Whenever I see the residency application of an accomplished hoop-jumper, I mourn the waste of life. Students who have shown they are learning the discipline, craft and art of medicine while keeping their inner hearth fires burning are the ones I want as my residents (and, I might add, as my physicians). The philosopher Jiddu Krishnamurti wrote in Think on These Things, “The function of education is to eradicate, inwardly as well as outwardly, the fear that destroys human thought, human relationship and love. The function of education is to help you from childhood not to imitate anybody, but be yourself all the time. You may learn to…pass all your exams, but to give primary importance to these superficial things…is like cleaning and polishing your fingernails while the house is burning down.”




The best students are those who are mastering their profession and who have made the decision to develop and share their inner lights with patients and colleagues.


Fortunately, they are becoming more common; we are lucky to live at the dawn of yet another Golden Age in medicine.
~~~~Dermatologic surgeon Daniel W. Collison is the former chief and residency program director of dermatology at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. Direct comments to tnp@amsa.org.~Residency~
148~5July-August~2003-52~Letter from Afield~It’s a Jungle Out There~Delivering medicine in Ecuador~Joanna Brown~~Before I went to Ecuador for my international health stint along the Napo River, I was scared—scared of becoming little more than a limp vegetable in the oppressive heat and humidity; scared of piranhas snapping at my heels as I climbed into a tiny canoe; scared of anacondas as thick as an elephant’s thighs; and scared dengue fever would break my bones or that malaria would rage through my red blood cells.


On one hand, my journey to this country was tamer than imagined. The Mondaña Clinic, where I worked, and the Yachana Lodge, where I slept, were part of a larger Ecuadoran eco-tourism enterprise called FUNEDESIN—the Foundation for Integrated Education and Development, which went by an acronym that makes much more sense in Spanish than in English. My lodgings were designed for tourists, which meant I had flower-patterned window shades and pre-filtered running water heated by the sun and fermenting coffee grounds piled atop a water tank. As for my fears: The piranhas never materialized on our populated stretch of the Napo; the motorized canoes were larger than any canoe I’d ever seen; I never saw an anaconda or other dangerous snake (although I helped treat many who were bitten by them); and I escaped dengue and malaria. Still, I managed to find plenty of adventure.


The lodge and clinic were adjacent to the tiny town of Mondaña on the banks of the Napo, a tributary of the Amazon River. Many of the river towns, including Mondaña, were populated by the Quichua, an indigenous tribe that spoke a language by the same name. A consortium of these towns established the Mondaña Clinic. Each town had elected two health promoters, who were trained lay practitioners serving as intermediaries between the clinics and the locals. These health promoters allowed the clinic to serve people unable to visit the facility. “Most of our work is extramural,” said the clinic’s physician Pedro Menendez. A key part of this extramural care was the clinic’s radio system, which linked the clinic’s central radio to walkie-talkie-type devices carried by health promoters. With this system, Dr. Menendez—or simply, Pedro, as he was known—could provide advice to health promoters via radio and act in a triage capacity, deciding whether the health promoters could tend to the sick themselves or if they required a physician’s visit or transport to the clinic.


During my last week at the clinic, the sociologist working with FUNEDESIN told me we would be visiting a malaria outbreak at the town of Mango Playa, which was at the third line. Along the Napo, the jungle was divided into 2-kilometer stretches known as lines. The first line referred to the 2 kilometers of land adjacent to the river; the second referred to the next 2 kilometers deeper into the jungle and so on. All of the 25 towns we visited during our vaccination program were at the first line. To reach these, I had navigated narrow log bridges, crossed streams in dugouts and wallowed in mud up to the edges of my rubber galoshes. With no clear trail, I had climbed a hill led by a machete-wielding Quichuan woman. Still, I had never been deep into the jungle. I had never been to the third line.


April marked the beginning of the rainy season. The night before our trip to Mango Playa, the rain came down hard, battering my thatched roof. I had trouble sleeping, concerned that our route would be very muddy.


The boat trip lasted a little more than an hour for our group, which included sociologist Victor Paucas, an agronomist and native Quichuan Nilo Fanguila, Pedro and me. Being more experienced trekking through the jungle, either Nilo or Victor stayed behind me at all times during the ensuing hike. I wasn’t insulted; after all, I was the gringa and least experienced trekker. We began on generally flat terrain following a well-worn path with lots of puddles and mud. Logs and branches stretched across and underneath some of the mud, and I often used these to avoid undiluted mud, hoping the timber would hold my weight. In the mud, I was careful to lift my feet high and maintain a steady momentum.


Further down the trail, we encountered a small stream that could only be crossed by climbing the thick, rotting base of a giant tree. Later, the path narrowed so that we were brushed on both sides by tall weeds, buzzing with bees, in the midst of café and cacao plantations. While it seemed we were already in the thick of the jungle, much more arduous travel remained—the climbing.


To reach our destination, we had to go up a large hill, down the other side, then up another big hill. The next hour and a half was a blur of rainforest and misery. We traveled through a thick part of the jungle that was full of plants, exotic flowers, birds and, of course, insects. I gasped for air at the top of the climb, only to realize that after a short plateau there was another section of hill just as long as the first…and another… and another. A few times we climbed along a slick slope with a precipice immediately to our left. During these stretches, Nilo assured me that he would help me if needed. I had a palm walking stick and used it in my right hand while I gripped onto whatever branches or trunks I could find with my left. I knew that snakes loved to lurk in such flora and was paranoid that I would encounter one. At one point, I reached for a short root jutting out of the ground, and it snapped. I fell back, digging my feet in and looking at what appeared to be an endless plummet. “Oops!” I said, making light of the fact that my heart had just sunk to my knees. “Joanna!” Nilo said in half castigation, half concern.


A short distance before the village, we encountered three heralds: shirtless men from the town, machetes in hand, out to clear the trail. The town looked like any other I had seen along the Amazon: an expanse of mowed lawn, most of which was a soccer field, surrounded by several buildings, including a school, meeting house and small clinic. We were introduced to the local health promoter and told him and others to gather the villagers. As was customary, they blew a large snail shell—known as a concha—which made a loud, low sound calling people together for communal gatherings. It could be heard within a several-kilometer radius.


We set up shop in the school because it was one of the largest public facilities. Moving several desks to the front on either side of the chalkboard, we unloaded our supplies: chloroquine, slides, razor blades, stethoscopes and Tylenol.


Soon, the school filled with women with small children hung in slings from their shoulders, men leading older children, and groups of older girls and boys, all wearing T-shirts and shorts. Pedro gave a short talk about mosquitoes as vectors of malaria and dengue; he urged the villagers to cut down trees around their homes so the mosquitoes would stay away. He reviewed the drug regimens for malaria for adults and children. Then he invited parents to bring their children up to be checked.


Our first visit was a 2-year-old girl. After getting a brief history, we listened to her heart and lungs. We checked her belly for splenomegaly. We looked at her eyes for palor. As Pedro explained to me, people with malaria are often pale because of red cell lysis by the plasmodium organism. Dengue sufferers, on the other hand, often have injected conjunctivae. Then we would do a thick blood smear, for which I had strict instructions to prick the side of the finger, then hold the finger just above the slide, squeeze out a big drop onto one end of the slide, then smear it across with another one. We must have done at least 30 smears. The town had no microscope, so we had to take these back to our lab. In the meantime, we would empirically treat anyone whose symptoms and signs were suggestive.


When we were finished treating those with symptoms of malaria, we checked other sick people. One toddler, carried by her father at his shoulder, came to us screaming with an angry red lump at the back of her scalp. We told the parents their child had an abscess and should be brought to our clinic to have it drained. Another man said he had a problem with his foot. Removing his boot, we saw it was swollen. He explained he had stepped on una espina, a spine from a plant, a year ago, and it had remained in his foot. A few days later, he was brought to the clinic for surgery.


As was often customary during our visits, we were then offered a meal of chicken soup with rice and boiled yucca, to be eaten with a large spoon and one’s hands. I was unable to chew my leg-and-thigh combination. It was common for the chicken to be tough. The townspeople often would kill the chicken right before they cooked and served it, so the meat did not have time to soften. But in this case, I was simply unable to tear it, no matter how hard I gripped, incisors, molars and all. Nilo handed me a can of tuna, and Pedro gladly took my portion. “I love it like this,” Pedro said. “It makes your teeth strong.”
~~~~Joanna Brown is in her second year in the Brown University/Memorial Hospital family medicine residency program in Pawtucket, Rhode Island. She was in Ecuador in the spring of 2002 through an international health fellowship from Albert Einstein College of Medicine.~International Health~
149~4May-June~2003-52~On the Wards~Life Under New Guidelines~RESTRICTED HOURS ON THE WARDS~Megan A. Moreno~~For residency programs nationwide, the Accreditation Council for Graduate Medical Education’s (ACGME) recently approved rules on resident work hours are a looming force that will assume power in July. In general, they stipulate that residents may work no more than 80 hours per week (averaged over four weeks), spend no more than 24 hours on call (plus six hours to get your next day’s duties done), and must have four days off per month. The restrictions promise more humane treatment of physicians-in-training, implying better resident learning and improved patient care.


I am a third-year pediatric resident at the University of Wisconsin-Madison Children’s Hospital. My residency program elected to begin compliance with the ACGME rules in January, six months before all U.S. programs will be required to adhere to them. We hoped that instituting the system early would allow us time to smooth out the kinks before a new intern class arrives in July, a traditionally chaotic time.


What is life like under these new rules? In short, it’s a whole new world. At least it feels like it around here. The biggest change for us is that our residents now go home by noon (at the latest) on every post-call day. Here’s how it works:


When on a ward or intensive-care rotation, the post-call resident pre-rounds on her patients the morning after the call night. The resident then rounds with the team, as that is when much of the teaching for the day occurs. After rounds, the other residents offer to help with whatever work needs to be done to get the post-call resident out by noon. When on a clinic rotation, the post-call resident goes home by 8 a.m.


A big benefit from this new system is that our residents are more rested. This may seem a simple result or an effortless conclusion. However, it is much more than that. For decades, residents have argued that the worst aspect of their training is the fatigue. Beyond the scut work, the sadness of experiencing a dying patient, the frustration of feeling like you can’t know it all, the single most difficult aspect of residency has always been the exhaustion. Erase that from the equation and a whole new world opens up. Residents think better, feel better and learn better.


The first time I went home at noon post-call, it felt very odd. I had been up most of the night, but I still had a good reserve of adrenaline that kept me going through the morning. I didn’t feel tired at noon, so I felt guilty leaving the neonatal intensive care unit (NICU). After arriving home, I was dragging a little, so I decided to make use of the purpose of the rules and take a nap. To my surprise, I slept five hours. My husband woke me when he got home from work. We ate dinner together, and I went to bed at my normal time, rather than crashing at 6 p.m. like I used to in “the old days.”


The best part about the experience was that I awoke the next day refreshed. Many residents, myself included, often describe the post-post-call day as more difficult than the post-call day. Usually, adrenaline gets you through a post-call day, and the compounded fatigue hits you the day after if you did not fully catch up on sleep. For me, it would feel as if I were suffering a horrible hangover. I did not miss that sensation on my first post-post-call day under the new system, and I went to work in a rather cheerful mood.


A second advantage I’ve witnessed is that residents approach night call differently. It is common for residents in many fields to report feeling tired as they begin a call night, anticipating the fatigue of the next day. They spend the night trying desperately to grab a quick nap—40 winks between shrill pager tones. Under the new guidelines, however, our residents report entering their call nights without that feeling of anticipated exhaustion. They argue they don’t mind being up at night and that they can indulge in the learning, knowing they will not be expected to perform for a full 36-hour shift. I, too, have approached night call differently. Because I know I am guaranteed to leave for home by noon the next day, I try to get all the training I can from the night ahead.


With these great positive effects, what has not worked? Most of the challenges relate to the struggles of adapting to a new procedure. I would expect that some of these difficulties would come with any new system; they’re a result of change itself.


The first difficulty has been trying to coordinate everyone’s schedule. We’ve had to figure out which gaps must be filled and which rotations or clinics can function properly with the absence of residents. In the past, our residents have covered almost every aspect of pediatric care in our hospital: all clinics, wards and intensive-care units. With residents going home post-call, however, we have needed to scale back our involvement. Our priority has been to put residents in areas in which the most learning can be garnered, not where the most scut work must be done. For the most part, this has worked well. However, some attendings are surprised to learn there may not be a resident in their afternoon clinic one day a week. And some have complained. I reason it will take time to breed a different culture of expectations about resident training.


A second challenge has been the discovery that job descriptions need to be more flexible. We’ve learned this most distinctly at a community hospital in Madison, at which we provide necessary coverage in the form of two small teams. These smaller teams are more prone to disruption when a member must be gone by noon. When several members from both teams are absent, the remaining people find themselves working with a skeleton crew. So, we’ve needed to be flexible in our duties, to do our co-workers’ jobs when they are absent. The defining lines of teams and roles have blurred. For the most part, we’ve adjusted well. Our residents have pulled together and pitched in where necessary.


The third problem? You’ve guessed it—the occasional lack of support from attendings. Every program has its naysayers. Every residency has the attendings who say, “I worked 36 hours every other night in my residency, and I turned out fine!” This response has emerged, but not as often as we had feared. And we’ve learned to work around it. When faced with this attitude, we haven’t complained. We haven’t argued that times have changed or that we deal with sicker patients, or that we’re so very tired after last night’s call. We’ve responded by simply stating these are the new rules, and it’s important we follow them. Generally, this results in an end to the conversation and no further difficulty.


Occasionally, resentment comes from a more senior resident. “I rotated through the NICU last year and never got to go home. Why does she get to leave now?” Again, these comments were expected and are shrugged off.


So while we’ve worked to overcome these challenges and make adjustments, we’ve had time to reflect on the ACGME guidelines. And many of us wonder what the long-term effects on our training will be. I’ve concluded that even with the restrictions, the total amount of hours a resident works over the entire course of her training will not likely change much.


The reason for this is because many residencies, ours included, have traditionally “front loaded” their programs, placing the highest burden of work hours on interns. First-year residents could expect to work anywhere from 80 to 120 hours a week and perform almost all patient-care duties. For second-years, the hours improved. For third-years, the hours were even better, and the responsibilities were mostly teaching and supervision. Residents endured the first year by looking forward to the relief ahead.


These rules have forced us to spread the workload across all three years so that everyone is working an 80ish-hour week. They have also forced senior residents back into the intern role, writing notes and doing daily patient care after interns go home. This is perhaps more fair, but it offers little reward and fewer role advancement opportunities as residents progress through a program. To counter this, we’ll have to be vigilant in preserving the progression of responsibility that should come with a residency experience.


Overall, I think senior residents like myself have just struggled adjusting to change occurring in our last six months of residency. I was accustomed to the way things worked before, and I had few complaints about our old system. I see the new system is better, but it’s still different, and it will require time and effort to reconcile any conflicts. I expect that over the next few years, residencies will be in a state of flux. After all, we’re experiencing a major shift in medical graduate training’s culture and expectations, and it cannot be accomplished in one day or one year. Our biggest lesson has been that flexibility is essential to getting the most out of the new system. On the bright side, I have noticed that being flexible seems easier when I am not exhausted.
~~~~Megan A. Moreno has just completed her last year as a pediatric resident at the University of Wisconsin-Madison Children’s Hospital. Direct comments and questions about this article to tnp@www.amsa.org.
Have an “On the Wards” story to share? We’d like to hear it. Submit your tale to tnp@amsa.org.
~Residency~
151~4May-June~2003-52~Perspectives~Peter Parker and You~RECOGNIZING PHYSICIANS' GREAT RESPONSIBILITY.~Makeba Williams~~Growing up, I was never enchanted by superheroes or cartoons. In fact, I hated them. I was more interested in reading books and being scientific. Recently, however, I was convinced to see the new “Spider-Man” movie. And as I tried not to be captivated by the spectacular visual effects and action-packed plot, something the superhero said riveted my attention: “With great power comes great responsibility. This is my gift. This is my curse.” I immediately began to comb through the webs of my brain to tease out this quote’s potential relevance to physicians-in-training. And just as if a spider had suddenly spun down to bite me, I realized that we are a lot like Peter Parker.


As first-year medical students, we enter medicine wide-eyed and naïve, desiring our place in the world—a niche in which we can grow. We seek the skills that will enable us to provide the best service possible to our patients. Very idealistically, we feel that if we obtain scientific and clinical knowledge, we will be competently and completely equipped to stamp out disease worldwide. And then, through experience—a field trip to the clinic perhaps—we are bitten by the realities of the U.S. health-care system and come to understand that clinical and scientific knowledge alone will not heal our patients. Disabused from this unrealistic notion very early on in medical school, I realized I must seek additional avenues to change the system and improve the health of my patients.


So this past year, I took time away from school to serve as the American Medical Student Association’s (AMSA) legislative affairs director, a position based just outside of Washington, D.C.—the heart of policy-making. This, I had hoped, would provide me with a better understanding of how public policy affects the practice of medicine and would grant me knowledge I could share with other future physicians so that we could make a difference in our profession, for our patients and for the world.


I have attended many hearings, briefings and conferences focused on discussing and solving critical health-care issues. And during these meetings, experts report the latest statistics: data that leads some to refer to the way in which care is delivered in this country as the “health-care nonsystem.” Considering the millions of people who are uninsured, the great gaps in care for ethnic and racial minorities, and the escalating malpractice premiums forcing some physicians to abandon their patients—just to mention a few of our troubles—I am inclined to refer to U.S. health care the same way. But then, just as frustration is about to overtake me, I reflect on the lessons of my behavioral science course and the lecture on defense mechanisms and sublimation. And I have resolved that to help restore wholeness to our “nonsystem,” I must consciously take on the social, political and ethical responsibilities of the medical profession.


My work as AMSA’s legislative affairs director has taught me that physicians are not islands unto themselves. It has shown me that the practice of medicine extends from the exam room to the halls of Congress, from 1600 Pennsylvania Ave. to the shelter on Main Street, from urban teaching hospitals to the unnamed roads of Appalachia. And it has reaffirmed my belief that medical students and physicians have a role—a responsibility—in all of these places. Why, you ask?


Senate Majority Leader Bill Frist (R-Tenn.), the only physician serving in that chamber of Congress, once said, “Social, economic and political forces will—more and more—directly impact all that lies at the heart of medicine.” Even the briefest conversation with a practicing physician anywhere in this country will confirm these words as true.


Consider patient A.M. of Illinois. In 1995, she became disabled and a year later required a lung transplant. The surgery was a success. However, her prescription drugs cost more than $2,500 a month, and Medicare doesn’t pay for them. She is on Medicaid, but Illinois requires people to pay a certain amount before the federal assistance program will cover their drugs. Her monthly income is $960, and she is expected to pay $683 for her prescriptions before Medicaid takes over. That leaves her with $277 to live on each month—about $9 a day. How much longer will patients like A.M. have to wait as legislators and special interest groups quibble over proposals that could make U.S. health care more equitable, affordable and efficient?


I would argue that patients will continue to wait until all physicians and future physicians recognize health care in its broader social context. A.M. will continue to suffer until we realize we have a professional call of duty to become socially and politically active to improve the health-care system. Is it necessary to have an organization like Physicians for Social Responsibility? Shouldn’t all physicians be socially responsible? As the complexity of health-care delivery has increased, the provision of medicine has come to include not only clinical skills but also the ability to function in and manipulate an industry that has multiple priorities unrelated to the health of the patient. Just as legislators have a responsibility to act on behalf of their constituents, physicians have a duty to look out for and protect the interests of their patients—interests that are inextricably tied to their social situations.


Given such an imperative, what roles can and should medical students play in the ever-increasing sociopolitical health-care system? Each patient– physician encounter presents opportunities for advocacy. We can work on the local level to structure a system that respects the patient–physician relationship, patients’ rights and a physician’s clinical autonomy. On the national level, we can advocate for a system that places the right of quality, affordable health care for all as its highest priority. This doesn’t mean, however, that by focusing on such macro-level issues, we can ignore our responsibility to care for individual patients.


Like Spider-Man, we must be present in our communities. We must get to know our patients and engage them in discussions about how we can improve the system for them. We must be observant and vigilant in clinical and hospital settings to ascertain what we need to do to improve these operating systems. We must engage senior physicians in conversations about how the medical profession can address the problems many of our patients face.


And most importantly, as my experience this year has taught me, we must engage our elected leaders in discussions about policies that affect health-care delivery and outcomes, as well as the practice of medicine. Policy-makers, very few of whom are physicians or health professionals, frequently look to special interest groups for education. Lobbying and providing expert analysis and testimony are actions we can take to shape the health-care policy debate. Research has shown that physicians are effective lobbyists and that legislative staff welcome our input on a broad range of health issues.


In the past, physicians have primarily worked to defend their own privilege and autonomy. It is now apparent that unless physicians make a commitment to defend systemic as well as individual reform, the health of the nation is at risk. Lobbying provides us an early opportunity to influence policies dictating how health care is financed, organized, regulated and delivered. Our firsthand knowledge and practical experience with health care uniquely qualifies us to provide lawmakers with the guidance needed for creating sound, patient-centered policies.


While you may not have the time to take a year off from medical school to move to Washington, D.C., to lobby on Capitol Hill, you can still make your opinions known. Each member of Congress has a district office with staff who listen to constituents’ concerns. Most members work from these offices several times a month. Take a moment to visit your legislators and share your concerns with them. Telephone, write letters and send e-mails to representatives’ and senators’ offices to express your thoughts about policy issues under consideration. Invite your members of Congress to see you in action, to watch you care for the patients who will be directly affected by the policies they’re voting on and by the legislation they’re creating. Take them on a tour of your student-run clinic to demonstrate the magnitude of the uninsured. Share with them your patients’ frustrations with the “health-care nonsystem.”


By recognizing the responsibilities we have to our patients and by being proactive, hopefully we can restore our social contract with them and regain the trust the public once felt for the medical profession. Like Peter Parker, we have a choice. We can use our power for our own self-aggrandizement, or we can use it to help our patients, our communities and U.S. health care—a system in which we have chosen to serve. For me, the choice is simple. ~~~~Makeba Williams is a fourth-year medical student at Meharry Medical College. For the past year, she served as the American Medical Student Association’s legislative affairs director.
Direct questions and comments about this article to tnp@amsa.org.~Advocacy,Health Policy,Legislative Action~
152~6September~2003-52~Feature~Buyer Beware~Scott T. Shepherd~~~Everything and anything is sold on eBay. From antiques to zoo passes, a timeshare in the Caribbean to false teeth, someone is selling it, and someone else is willing to buy it.


So it comes as little surprise that among the items for sale are an otoscope and ophthalmoscope, the diagnostic kit most medical schools require their students to purchase. The otoscope—an instrument for examining the condition of the ear—and the ophthalmoscope—a device for viewing the interior of the eye, particularly the retina—are considered some of the tools necessary to conduct a basic physical exam, along with a stethoscope, a reflex hammer and a blood pressure cuff, also known as a sphygmomanometer.


It may come as a surprise, though, that this “like new!!” diagnostic kit was placed on eBay not by a wholesaler or an established physician who has upgraded his equipment, but by a medical student. Michael Ringler, a fourth-year at the University of California, Davis, School of Medicine, says he put his kit up for auction for one simple reason: He never uses it.


“I was told by my professors in my first year of medical school that this set was essentially ‘required.’ Although I found the set to be somewhat helpful when practicing physical exam skills on my wife, I never actually used it on any patients because I never needed to.”


Like many fourth-years conducting their rotations in clinical settings, Ringler discovered wall otoscopes and ophthalmoscopes in all of the clinics and emergency rooms. “I thought I would need to carry around my own set during my clinical years, but this was not the case at all. Given my financial situation, it was quite a struggle to scrounge up [almost $500] to purchase this item, and now that I realize I don’t actually need it, I’m trying to sell it to recoup any cost that I can,” he says.


And Ringler isn’t the only future physician who felt a financial pinch after spending money on medical tools rarely used. “We were given a big list of instruments at the beginning of first year, and everyone pretty much bought everything since we didn’t know any better at the time, and they told us it was all ‘absolutely indispensable.’ But it was all rather worthless. The only things besides a [stetho]scope that are absolutely necessary for third year are a black pen, trauma shear and possibly a penlight,” says Dr. Mabelle Cohen, a 2003 graduate of Finch University of Health Sciences/ Chicago Medical School.


Of course, practically every U.S. medical school requires its students to purchase more than just a stethoscope and penlight. Boston University School of Medicine’s (BU) Introduction to Clinical Medicine (ICM) course requires students to shell out money for: a stethoscope, a diagnostic kit, a linen tape measure, a flexible plastic ruler, a reflex hammer and tuning forks. Furthermore, BU third-years must have an EKG caliper, and all students are instructed to have access to a sphygmomanometer. In the end, a student can spend more than $600 on medical instruments, even though most items—except the stethoscope, diagnostic kit and sphygmomanometer—can be purchased for less than $20.


Dr. Lorraine Stanfield, the school’s ICM course manager, says working without these tools—especially a stethoscope and diagnostic kit—undermine a future physician’s ability to properly learn how to conduct a physical exam. “A diagnostic kit is very important for medical students to have, and I have seen a real drop-off in recent years, at least at BU, that students are not purchasing this,” she says.


Of course, part of this trend could be explained by advice in the Redbook, a guide compiled by a BU student committee for incoming first-years, which warns: “Towards the end of the semester, you will be given a list of medical instruments that are required for ICM. However, the only instrument students actually need for their second semester of ICM-1 is a stethoscope.… If you are nervous about not showing up with enough supplies, ask your ICM doctor[s] what they think you need. Don’t forget that you can always buy more equipment later when you have a better idea of what you want to invest.”


Not surprisingly, this advice worries Stanfield. “It’s hard. If you don’t have the money, what are you going to do? And it’s extremely difficult because [a diagnostic kit] is so expensive. But if you don’t have it, I find the students don’t use it. And when they go to do their complete histories and physical exams on hospitalized patients, they don’t document head and neck exams, …and it’s not because they forgot to do it.”


Yet while the Redbook tells first-years that much of the listed equipment can often be found in hospital rooms and physician offices, it also warns they may have to purchase equipment for third- and fourth-year rotations. Stanfield points out that while the diagnostic kits are sometimes available, they are not always functional or immediately accessible, and kits won’t often be placed in rooms where students conduct inpatient visits.


PRACTICE MAKES PERFECT


Combined with taking a patient history, the physician’s skills with a stethoscope, otoscope, ophthalmoscope, sphygmomanometer and reflex hammer account for 80 percent of a physical diagnosis. And in the opinion of some health professionals, because the next generation of physicians isn’t mastering the “recommended” equipment, the art of physical diagnosis is being lost.


In a September 1997 issue of the Journal of the American Medical Association, a study reported that medical students, interns and residents accurately identified only one-fifth of abnormal cardiac sounds, and there was no significant improvement in these skills as they advanced in their training. (For more information about this topic, see “Recapturing a Lost Art,” The New Physician, December 2002.)


“Because we have emphasized the physical exam less, it’s atrophied. Because we have such fancy, modern tests, we rely on them more, and we forget that we can learn a lot with our own hands,” Stanfield says.


And these are the skills she sees some of her students failing to grasp. She recalls observing a student use an ophthalmoscope while standing about a foot away from the patient, claiming she could see the patient’s retina. As it turns out, she did not own a diagnostic kit and had only briefly practiced with an ophthalmoscope that was completely different from the one at the clinic.


“If students don’t have it, they don’t practice on their friends,…and at the end of their year they don’t know how to use a diagnostic kit. Then when they get into a clinical setting, they are not as comfortable using it, and in many cases, I think, they graduate without ever really knowing how to use it,” she says.


In some cases, students have decided to focus on a particular specialty, such as pathology, that will not require conducting regular physical examinations. Yet Stanfield reminds all students that their obligation in medical school is to learn the fundamentals of medicine.


THE "RIGHT" DIAGNOSTIC KIT


Of course, even if you settle on buying a diagnostic kit ($300 to $1,000), there are still more decisions to make. Welch Allyn, one of the largest medical instrument manufacturers, produces more than 20 varieties of diagnostic kits. Also taking into consideration competing kits made by Riester, Heine Instruments and other manufacturers, future physicians are navigating a maze of techno-jargon and sales claims of hundreds of products, while weighing the expenses within extremely tight budgets.


The dramatic price differences for kits are related to the technology used in the ophthalmoscopes. The less expensive ones include the traditional ophthalmoscope with a rotating disc of lenses to allow observation of the eye at varying depths and magnifications. Meanwhile, the panoptic ophthalmoscope, made and patented by Welch Allyn, features optics technology that allows easier entry into small pupils, while also creating a wide illumination area.


“That provides five times the viewing area at a higher magnification,” says Cindy Kuipper, a product manager with Welch Allyn.


Some schools require that students purchase the more expensive panoptic ophthalmoscope. “There is some debate—which is understandable—that some, especially teaching institutions, believe that students should learn on the standard first, because when they go out for their preceptor shifts or go out to clinic, they may have the standard and not have their panoptic available to them. Since it is more difficult to learn and to use, they should learn that first so they are not at a disadvantage…. But there are other schools that say, why would you want to put students at a disadvantage? They should learn under panoptic because it will allow them to master this technique, master it quickly and really know and be able to use that tool,” Kuipper says.


One of the medical schools that fits into the latter category is Loma Linda University School of Medicine. Last year, the institution required its students to purchase a diagnostic kit that included both the panoptic and standard ophthalmoscope, which when bought together can cost around $550. This year, however, Loma Linda has made the purchase of a panoptic ophthalmoscope optional because of students’ increased financial burdens but still recommends it to those who can afford it.


Apparently the popularity of the panoptic is growing. Last year, 65 percent of the ophthalmoscopes Welch Allyn sold were of the traditional variety, while 35 percent were panoptic. Yet through June of this year, the percentage is closer to 50-50. Kuipper also notes that last year more than 3,000 third- and fourth-year medical students participated in a Welch Allyn program to trade in their traditional ophthalmoscopes for discounts on panoptics.


“With a traditional one, you basically only see a little piece, and then you have to follow a vein out and sort of pan around, and then take four or five different pans, and then in your mind put that together to see if someone has some sort of anomaly. That makes a real difference,” she says.


FEELING THE PRESSURE


Technology has also had advancements in the types and effectiveness of the sphygmomanometer ($40 to $220).


Blood pressure measurements are taken by stopping blood flow in an artery by inflating a cuff around the upper arm and using a stethoscope to listen for blood beginning to flow through the artery again as air is released from the cuff. The blood pressure is then recorded as two measurements: a systolic pressure, for the maximum pressure when the heart contracts, and a diastolic pressure, for the lowest pressure when the heart relaxes between beats. The latter is determined by a gauge reading when blood flow can no longer be heard.


There are two basic categories of sphygmomanometers: manual and electronic. The electronic blood pressure cuff uses a microphone to detect blood flow instead of listening with a stethoscope. Furthermore, it automatically inflates and deflates. While these types are common in supermarkets and drug stores, they are rarely used by health professionals. “We found that automated blood pressure machines...did not meet accepted standards of accuracy and reliability of measurement,” researcher Dr. Daniel J. Van Durme wrote in the May 2000 Journal of Family Practice.


Therefore, health professionals—including medical students—tend to rely on manual sphygmomanometers. These blood pressure cuffs are either mercury column instruments or aneroid devices, which use a needle on a dial to take measurements. The mercury column cuffs are considered more accurate but are bulky and easily broken. The aneroids are compact and inexpensive but can be difficult to use, and the dial gauges sometimes require recalibration.


Aneroid sphygmomanometers are most commonly purchased by students, Kuipper says. However, there are still choices to be made in this category. Specifically, future physicians may want to upgrade to a family practice kit, which includes multiple-size cuffs. “You’ve got football players that you could put a thigh cuff on, down to children, adolescents and very thin women. The whole idea of taking blood pressure is that if the cuff isn’t right, your readings could be highly inaccurate,” she says. Of course, how often students interact with football-player size patients varies. As with all instrument purchases, it’s up to the individual to decide what is right for him.


Not surprisingly, some medical schools “highly recommend” their students purchase sphygmomanometers. After all, blood pressure is a key part of the physical exam. However, Stanfield believes it is far less important for a student to have a blood pressure cuff than the other items, since it requires less practice and is more likely to be available at a nurses’ station. “[Having] the blood pressure cuff, it would be nice. But from my experience, the only students who get everything are in the Army because it’s all covered.”


And when deciding what to buy, future physicians who spend money on a sphygmomanometer sometimes come to regret it. “We were required to purchase one in my first year of med school, but I’ve only used it once since,” says Sophie Jan, a third-year at the State University of New York Downstate Medical Center College of Medicine.


Katharine Morris, a fourth-year at the Medical University of the Americas, agrees. “Blood pressure cuffs are readily available everywhere, and I have never used mine outside of the physical diagnosis class and checking my dad. There is little need to own one, in my opinion.”


THE MUST-HAVES


While there may be some debate over whether you really need to purchase a diagnostic kit or a sphygmomanometer, there is little debate over the necessity of having a quality stethoscope ($20 to $595). “You just could not function as a medical student if you didn’t have a stethoscope,” Stanfield says.


Besides general exam stethoscopes, medical instrument manufacturers offer specialized versions, such as cardiology, pediatric and infant scopes. Also, some feature a two-sided bell, one side serving for cardiology and the other for pediatric needs. These conventional, or acoustic, stethoscopes work by transmitting sound through hollow tubing. Two variables affect how well the sound can be heard: intensity measured in decibel units and frequency measured in cycles per second. An acoustic stethoscope best hears medium frequency sounds, while lower and higher frequencies need greater volume to be clearly heard. However, when the volume is increased, some of the important subtle sounds get drowned out.


To remedy this, manufacturers have begun to market amplified, or electronic, stethoscopes. But, besides the greater expense, there can be other drawbacks. “One of the problems traditionally with the electronic stethoscopes is that when you drag it across the chest…you can actually pick up the sounds of the hairs, and that would cause feedback that would end up distracting some of that amplification,” Kuipper says.


So, manufacturers have developed stethoscopes with sensors that both amplify and filter noise. Furthermore, they have added recording capabilities, allowing physicians to store and replay the sounds they hear. Of course, all of this is at an additional cost.


But few students will be delving into their pocketbooks to pay for a $500 stethoscope. For most, a standard acoustic model will work well. Yet, while low cost is always an attractive feature, Stanfield warns future physicians against getting a stethoscope merely for its price. “There are some very inexpensive stethoscopes, but they are not of a high enough quality for you to be able to hear the things that you are going to need to hear. If you’re a physician’s assistant and you’re going to be checking blood pressures, then having a $20 stethoscope is going to be fine. But being a medical student, you are listening to heart murmurs and other sounds, and for that you need a higher quality one that they call cardiology grade.”


Chicago Medical School graduate Cohen agrees. “Definitely buy a good stethoscope. It’s without a doubt worth the money to get a good one right from the beginning, as most people who bought a cheap stethoscope ended up having to buy another one when they started using it and found that it wasn’t good enough.”


And regardless of the type they end up with, many future physicians say they feel very attached to their stethoscopes and advise selecting one that you can have a long-term relationship with.


So while you may be able to find a student selling his diagnostic kit on eBay, you’re not as likely to find his stethoscope up for auction, unless, of course, he is upgrading to the latest electronic wizardry.


Yet before you rush online to sell equipment you bought but find you no longer need, Ringler cautions that you shouldn’t expect to make a killing. After not getting a satisfactory bid the first time, he had a second auction and ended up selling his diagnostic kit for $227.50. “I was hoping for more, but that’s better than nothing. I guess I ended up recouping approximately 50 percent of my cost. I don’t know if others spent as much as I did on a brand new [otoscope and] ophthalmoscope, though. Obviously, my buyer didn’t.”
~HERE COMES THE (SALES) PITCH


Purchasing medical instruments can be a daunting and stressful task, especially for first-years who typically desire to have the best instruments, yet are faced with the reality of extremely tight budgets.


For some students, the most pressure to buy equipment comes from the medical instrument orientation, usually held in the middle of first semester. During these school-sanctioned events, faculty, vendors and distributors inform students what tools to buy and why they should buy them. “The vendors are interested in showing the students their wares, and the people who run the Intro to Clinical Medicine (ICM) courses wanted to talk to students about what they will need and what the differences are—because you come in and you really have no idea what you need or how you’ll use it,” says Dr. Lorraine Stanfield, the ICM course manager at Boston University School of Medicine (BU).


Of course, free pizzas and sodas are what often draw students to these voluntary orientations. Yet, Stanfield hopes that in the process, students learn a little about the value of medical instruments, particularly stethoscopes, otoscopes and ophthalmoscopes. “I just say, ‘Here are things you might want to think about as you are deciding what it is you need. Here are things I feel like you really must have in order to do my course and gain the knowledge you need to as part of your medical education,’” she says.


After that, vendors give their sales pitches about their products, and then distributors explain why you should buy those tools from them. When no distributor is present, students may be encouraged to buy instruments from the school bookstore or directly from the manufacturers.


Some students feel the faculty is promoting the vendors and distributors, which makes them wonder whether instructors are receiving kickbacks. It is an accusation Stanfield finds laughable. “I just bought a new stethoscope and had to pay full price,” she says. “The students are under no obligation to purchase anything at that time. They can surf on the Web if they want, or their parents can go buy them something. I mean you can walk into the BU bookstore and buy a stethoscope. You don’t have to be part of this sale…. It’s just a good chance to play with the equipment and see what’s right for you, and compare a little bit.”


However, some groups proudly take a percentage of the profits. Student organizations, such as local chapters of the American Medical Student Association (AMSA), host medical instrument sales as fund-raisers. These events are similar in structure to an orientation, and they also include the presence of faculty to answer students’ questions. “The day of the event, we split a lunch with the [distributor], and supply pizza and a lecture about which instruments the students should get. We also try to have a few students helping out with the sale,” says Sneha Shah, an AMSA regional associate trustee and a third-year at Rush Medical College. Student organizations can get as much as 5 percent of each sale from the distributor.


So while buying medical instruments may never be a pleasant experience, future physicians can take some comfort in knowing there are many ways to find the products they need. —S.T.S.


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


SCHOOLS TRY TO HELP


Despite what you might think, schools aren't ignoring the rising costs of medical education. Most try to combat the problem by offering additional grants and scholarships funded through their endowments, although fund raising has slowed along with the economy. But at Florida State University (FSU), where state lawmakers handed the fledgling medical school an 11 percent tuition increase this year, administrators have taken a different approach.


A handful of the small, rural hospitals in which students train have offered local students free rides—tuition, fees, books and living expenses—in return for four years of service at the hospital after residency. And while that may seem like a big undertaking for a financially challenged rural hospital, FSU’s assistant dean Dr. Myra Hurt says the institutions spend less money funding medical students than they would on recruitment activities. “That’s going to be a marketing tool for us. We’re going to really work the rural hospital association,” she says. “I wish we could give everyone a free ride and require years of service. We, as a society, by giving gifts, need to invest in [medical education].” —J.Z.
~~~Scott T. Shepherd is an associate editor with The New Physician. Direct comments about this article to tnp@amsa.org.~Learning Tools and Technology,Medical Education~
153~6September~2003-52~Folk Tales~Old Premed~FROM PARTY ANIMAL TO PHYSICIAN~Scott T. Shepherd~~In “Animal House,” the film that spoofs college and fraternity life, students sacrifice their education for wild parties and crazy adventures, and are eventually expelled. For most dedicated, hard-working future physicians, that sort of lifestyle is hard to fathom. However, Dr. David Kelley, a resident at Dartmouth-Hitchcock Medical Center, can picture it all quite easily.


In 1987, the once-outstanding high-school student was fulfilling the party animal stereotype while attending the University of Arkansas. Through skipping classes and not studying, Kelley managed only a 1.25 GPA through 93 credit hours. “I actually dropped out to avoid expulsion for grades,” he says.


It was not exactly the type of performance that was going to get him into medical school, where he could fulfill his lifelong dream of becoming a physician. In fact, he was convinced he was destined to be a bartender or bouncer. Yet he didn’t completely close the door on going to medical school someday. Taking the advice of a college mentor, Kelley determined his best chance was to enter a related health profession, gain some experience and then do an undergraduate degree all over again.


At the time, though, it seemed like a long, unrealistic road. Kelley became a registered respiratory therapist, which made him responsible for assessing and managing patients’ cardiovascular and respiratory statuses. “I worked in pediatric intensive care, [pediatric] cardiology, [and pediatric] trauma. I worked in several of the top children’s hospitals…. I had quite a long career in respiratory. In fact, I loved it.”


Yet, it wasn’t enough. So, he began exploring other opportunities, such as going back to school for a related degree and maybe earning a Ph.D. He continued to discount his dreams of becoming a physician until his future wife, Wendy, insisted he at least explore the possibility. “My wife… showed an undying faith in my abilities…. And she’s like, ‘Why are you kidding yourself? You know you want to be a physician, so why don’t you go for it?’”


So at the age of 29, Kelley was starting all over again, enrolling as a freshman at the University of Texas at Dallas. And as one of only a handful of nontraditional students he knew of at the 6,000-student institution, Kelley says he often felt out of place. Over the course of four years, though, that changed. “I ended up kind of being a de facto big brother on campus.… I tried to pass along some of the lessons I learned in goofing up but not [in] the judgmental parent-style fashion. In turn, they taught me things I didn’t know how to do,” he says.


These lessons helped Kelley graduate magna cum laude with a bachelor’s degree in neuroscience in May 1996. From there he and his wife moved to rural northeast Missouri where Kelley was accepted to Kirksville College of Osteopathic Medicine. Besides adjusting to medical school, the Kelleys also had to adjust to life in the country. “It was like living in Mayberry.”


But as it turns out, Kirksville was the perfect place for Kelley. With few distractions, he settled on his studies. Furthermore, the school had developed an atmosphere conducive to older students. Of the 170 future physicians in Kelley’s class, he estimates at least 25 were 30 years old or older. “The school makes a deliberate effort—I mean the majority of students are still of traditional age—to balance the class with people who are more mature…because they have discovered what these people can bring to the classroom is a sense of life and professional experience that offset the sort of academic book orientation of the traditional-age people.”


However, Kelley says that not everyone was as receptive to older students. While he conducted research about medical education through a test review company’s Web site, Kelley says some of the responses to his message board queries were negative and discouraging.


“I felt myself being very, very chastised, exiled and ridiculed.”
And as it turns out, he was not alone. He met five other nontraditional students, including one who was already in medical school, who had similar experiences. “We started sort of commiserating and talking about our experiences. And through the process of all this, we decided we had to clear the same numeric hurdles as these traditional people, but we have all these other things we have to deal with.”


So Kelley and his comrades decided to create their own Web community where they could share experiences, ask questions and receive support. In 1998 they began a listserve. A year later, the list had grown from six subscribers to more than 400. Quickly, they formed a rudimentary leadership structure, with Kelley serving as president, to handle the exploding interest.


About the same time, the group began to refer to themselves as the Old Premeds, a tongue-and-cheek response to those who had previously discouraged them. “That kind of stuck and became a pretty affectionate term,” he says.


And it didn’t take long before the Old Premeds weren’t such a small group. By early 2000, the listserve had grown to more than 1,000, and communicating via e-mail was becoming difficult. “I was getting 200, to sometimes as much as 300 e-mails per day.… Think how schizophrenic your conversations are when you have 14 of them going on at once.”


Kelley and the other Old Premeds decided to take things to the next level. He filed the necessary papers in June 2000 to make the Old Premeds a nonprofit corporation, known as the National Society for Non-Traditional Pre-Medical and Medical Students, and took the group from a scattered e-mail environment to a more cohesive Web-based structure. Old Premeds—as most of its members still call it—does not charge dues and subsists on volunteered time and money. It has grown to more than 2,200 members.


As for Kelley, he is no longer an Old Premed; now he is an “Old Resident.” Still serving as chairman of Old Premeds’ board of directors, the physician-in-training studies anesthesiology and preventive medicine leadership in a residency program at Dartmouth.


In the meantime, he has come to believe that his age and experience may have actually given him an advantage in his pursuit of becoming a physician. “When I went back to school a second time, I was able to negotiate things. Plus my wife and I had been married for a couple years, and you learn the delicate skills of balancing and keeping your priorities right, and it makes you much more successful in your endeavors.”


But for Kelley, beyond the wisdom that comes with age, nothing has been more valuable to him than his wife. “It is definitely because of her support that I decided to give it a try, and I ended up being successful.”


And now, he has even more motivation with the birth of his daughter in February. “To me, being nontraditional, you can look at all of these things—like having a mortgage and having a wife—[and] depending on how you choose it, it can be something that can be a boat anchor or can be an asset. For me, my daughter is an incredible asset. It means I can come home from a long day at work…[and] I can sit down, decompress and play with my little girl.… I think a lot of the things that people see as being deficits of being a nontraditional, if you choose it and empower yourself, you can turn it around and go, ‘This is actually an asset. This is something in my favor.’”


Not exactly what you would expect to hear from an old party animal.
~~~~Scott T. Shepherd is an associate editor with The New Physician. For more information about Old Premeds, visit www.oldpremeds.org. Direct questions and comments about this article to tnp@amsa.org.~Premedical Education~
154~6September~2003-52~Perspectives~A Trickle-Down Education~REFLECTIONS ON CORPORATE VALUES IN MEDICINE~Rian Podein ~~“A $20,000 backstage pass.” That’s what a fourth-year medical student explained to me regarding tuition as I began my medical school clinical rotations. I assumed the “backstage” was where the profession of medicine was to be passed down from teachers to students in the time-honored tradition of medical mentoring. However, as I reached the end of medical school, I realized how incorrect that assumption was. Instead, I now view medical education as having compromised its teaching mission as a result of a health-care system that has adopted corporate values.


“I am sorry, but I am just too busy to teach today.” That was the echo of countless attendings and residents throughout my two years of clinical rotations. The incapacity to teach resulted from their enormous patient loads, massive paperwork, never-ending insurance hassles and insatiable pressures to discharge patients yesterday. The overburdened teaching physicians working in understaffed environments often demanded I act more like a support staff member than a medical student. And even worse, it made me feel unwanted. Instead of direct patient-care teaching, my medical education too often consisted of paperwork, photocopying, telephoning, dictating patient charts, tracking medical records, transporting patients and other scut work. Often, I felt torn between desiring a more substantial education and helping my teachers provide patients with the health care they needed.


In addition to a substantial lack of training, the content of my education within hospitals and clinics was too often driven by evidence-based billing rather than by evidence-based medicine. Regardless of a patient’s chief complaint, signs or symptoms, my differential diagnosis was taught to begin with insured or uninsured. This status dictated the patient’s interventions, medications and follow-up treatment (if any). When treating infections in the clinic, the poor and uninsured were given whatever antibiotic samples could be found in the closet, whereas the insured were guaranteed the latest and greatest bug-killers. This practice of “bottom-line” advocacy too often resulted in compromised or denied care. Then there was the surrendering of the art of medicine to the art of pharmaceutical marketing, whereby prescriptions were more influenced by gifts than by science.


So I often wondered: Why do I pay tuition? And, if my mentors don’t pass the profession to me, then what will I pass to future students? Was the fourth-year medical student correct that we should pay tuition and just be happy to be out of the classroom and in the hospital? Or was my gut feeling correct that something was missing?


My quest for an answer initially led me to my medical school’s mission statement that promised “to maintain high-quality graduate medical education programs” and to graduate exceptionally well-prepared students.


My training hospital’s mission statement guaranteed: “Providing the clinical environment and services to support the highest quality teaching and training programs for health-care students and professionals.…”


Therefore, according to my school and hospital, I clearly had a theoretical right to the highest quality teaching and education. Unfortunately, the rhetoric and reality often proved to be at odds.


Attempting to get to the root of my dilemma, I looked to the U.S. health-care system in which medical education is a component. Over the past several decades, it has increasingly become
a system controlled by for-profit, investor-owned corporations. Upon further investigation, I discovered that the primary legal responsibility of a corporation is to uphold its fiduciary responsibility to investors. It would seem to me, then, that corporate participation in our health-care system is unsound.


A system driven by the overriding motive of corporate profit is unstable, unpredictable and blind to human needs. Furthermore, just as the acceptance of corporate values and practices in health policy have eroded the equity and quality of our health-care system, medical education has been compromised as well. Corporate health care pits physicians against patients and patient care against shareholder profits, with every dollar spent on clinical services considered a “loss” to the profit-seeking entity. Likewise, corporate values pit teacher against student and education against shareholder profits, with every minute spent teaching considered time lost from revenue-generating activities and a loss to the profit margin.


Although many medical students may not understand the intimate details of health policy, due to a lack of inclusion within the standard curriculum, we definitely feel the downstream effects of health policy on our medical education and training. Challenging corporate power and questioning the right of corporations to exist within our health-care system is crucial to creating not only a more just health-care system but also an educational environment in which mentoring can flourish. The very soul of medical education is at risk along with the future of the profession.
~~~~A graduate of Temple University School of Medicine, Rian Podein is a second-year family medicine resident at the University of Wisconsin-Madison. Direct comments and questions about this article to tnp@www. amsa.org. Have an opinion you’d like to share with readers? E-mail your “Perspectives” submission to the same address.~Ethics,Medical Education~
155~6September~2003-52~Feature~The White Coat~~Howard Bell~~For some medical students and physicians, the white coat is a source of pride; for others it’s a source of controversy. Still, all agree the colorless garment wields great symbolic power for those who practice medicine and for the patients they treat.


Scott Blanke was a teenage orderly pushing hospital linen carts, but the white coat he wore was all it took for some to call him “doctor.” Today the 50-year-old otolaryngologist in La Crosse, Wisconsin, always wears his white coat around patients “because they come to me for my expertise and expect me to act and look like a doctor.”


Cinthia Deye also got an early taste of the white coat’s power. Working with caustic chemicals as a lab tech, she wore one of her physician father’s old white coats to protect her clothes. One day, when she was riding in the elevator, the dean of the college of pharmacy* entered on crutches and immediately gave Deye his medical history and asked for advice. Deye hadn’t even started medical school. Today, the second-year University of Illinois medical student believes the white coat represents the condescending, racist and sexist manner physicians have traditionally treated patients and nurses. “Doctors need to step down off their high horse,” she says. “The white coat may stand in the way of that.”


Love it or loathe it, most in medicine agree the coat is a powerful symbol, one that’s unlikely to go away soon, even though many wish it would. But at least it’s more dignified than those silly wigs English barristers wear, right? And even the most uniform-averse agree those deep pockets come in handy for carrying the tools of the trade.


Abbott Northwestern Medical Center in Minneapolis does not require its students or residents to wear white coats, but most do anyway, according to its internal medicine residency program director Dr. Terry Rosborough. “They almost always wear them because of what they need to carry.”


That’s also the biggest reason residents wear them at the La Crosse-Mayo family practice residency program, according to director Dr. Tom Grau. “That’s how we carry our ‘pocket brains’—PDAs, diagnostic tools and every reference you can stuff in there,” he says. “We don’t require they wear it. We only ask that they dress at least as nicely as the attending they’re with at the time.”


Inside Blanke’s coat—which is blue “because I like to be different, and it goes with my eyes”—you’ll find a prescription pad, an infectious disease manual, a ruler he uses for plastic surgery, a tape measure he uses for cleft palates, the classic ear-nose-throat (ENT) head mirror, “about 4,000 pens” and a first edition of The Wonderful Wizard of Oz (he collects them). The coat is also a handy shield. “We have a lot of blood in ENT, which is another reason to wear it.”


White coat or blue coat, anything’s better than the “ice cream suit” Blanke wore as an ENT resident at the University of Iowa. He says the high-collar, side-buttoned, white smock with matching pants made him look like a cross between a barber and a waiter. To mock the smock, Blanke would walk around with a towel over his shoulder, asking,‘May I help you?’ Boy did we feel stupid,” he says.


The University of Maryland Medical Center in Baltimore reminds its employees of a less obvious benefit to wearing the coat, according to Nancy Anderson, an occupational therapist. “The hospital is in a bad area, and they told us we were less likely to be harassed, because people in the neighborhood received free health care from the hospital.”


DRESS THE PART, FEEL THE PART


Like an actor who finds staying in character suddenly easier when dress rehearsals begin, many students report “feeling” like physicians when they wear their coats. Blanke first wore his in first-year anatomy class. “I really did feel I was becoming a doctor, because I was wearing this coat and cutting up a dead person,” he says.


Linda Nicoll, a fourth-year at the State University of New York Downstate Medical Center College of Medicine, first slipped on the colorless garment at the school’s white coat ceremony. “It made me feel like a part of the profession, and it made me look like a doctor.” Nicoll says she wears hers because it boosts her credibility with patients. “I’m young and look even younger. Patients take you more seriously when you’re wearing it.”


What Nicoll’s patients seem to recognize in the coat is its powerful symbolism—a reminder of the oath physicians take and the responsibilities physicians and medical students have toward patients and the profession. That’s the idea behind many schools’ white coat ceremonies, in which entering first-year students take oaths and are presented with their first white coats. Some students shrug off the ceremony as pomp and fluff. But for many, the event is an inspiring turning point in their lives. As Nicoll says, “It made me feel really good.”


Prior to the early 1990s, most medical students took the Hippocratic oath and received their coats at graduation. Now 91 percent of medical schools—allopathic and osteopathic—have some type of white coat ceremony at or near the beginning of training, according to the Arnold P. Gold Foundation, which awards grants to start such ceremonies. “Hippocrates administered the oath to his students before their medical studies began, not after,” says Dr. Sandra Gold, executive vice president of the foundation. “The purpose is not to give out white coats. It’s about taking an oath of professionalism and thinking about your future as a doctor and the responsibilities that come with that.”


However, there is some disagreement as to the timing of the ceremonies. First-year students don’t deserve a white coat, according to Dr. Robert Watson, dean of the University of Florida College of Medicine (UF). Instead, UF holds a ceremony for students at the end of their second years, as they cross that bridge to the patient-contact stage of training. “Beginning students have done nothing to earn the coat. They have no practical use for it and cannot fully appreciate its importance or symbolism. In fact, it might make some of them feel entitled.”


But whether the ceremony occurs in year one or two, it and the coat serve as lasting reminders to future physicians immersed in academic minutiae of why they’re putting themselves through this.


A CENTURY-OLD TRADITION


Physicians started wearing white coats in 1889. Surgeons were the first to wear them because they were the first to adopt the aseptic techniques coming of age at the time. The coat protected the physician from the patient and vice versa. Meanwhile, their nonsurgical colleagues wore business suits, often with frock coats called “Prince Alberts.” By the early 1900s, physicians of many specialties wore white coats.


Another reason physicians began donning the coats was to emphasize the laboratory discoveries dramatically expanding what they could do to help patients. Medicine was a primitive profession until the 1880s. Before then, physicians didn’t even know that bacteria cause many infectious diseases. With no antibiotics or other means to fight contagious diseases plaguing the population, physicians could do little to effectively treat most patients. Once bacteriology-based medicine was born, science and medicine merged, and physicians adopted the scientist’s lab coat as their standard of dress.


Lab coats were originally beige. They became white when physicians started wearing them, which is about the same time hospitals adopted white as the symbol of healing, cleanliness and hope. The same scientific discoveries were changing hospitals from houses for the dying to houses for healing. For physicians, white symbolized professionalism, purity of intent and seriousness of purpose. With the white coat also came the perception of power and authority—the scientist-healer’s authorization to do things to patients, like intimate examinations, that would otherwise be unacceptable.


BUILDING A WALL


However, symbols of power and authority frequently create barriers between those who wield them and those who don’t. Many believe professional distance between physician and patient is appropriate, even essential. But some medical students and young physicians believe the coat is too paternalistic and intimidating—that the wall it creates interferes with candid two-way communication between physician and patient. “White coat hypertension” is real, according to researchers, affecting about 10 percent of the population, mostly patients who tend to overreact to mildly stressful situations. Furthermore, some argue that patients want to be partners in their own health care, so there’s no place for “white coat snobs” wearing their “portable pedestals.”


Jessica Langenhan, a third-year George Washington University medical student, believes the coat does nothing but separates the caregiver from the patient and lends an aura of superiority to the physician. “It’s just a way for doctors to advertise to the world that they’re doctors,” she says. Still, she admits some patients may welcome that symbolic superiority. “It can be reassuring to patients—a sort of verification that this person has knowledge that can help them.”


Leonard Lesser, a second-year at the University of Rochester School of Medicine, believes the white coat “is just a device to make you feel special, when in fact it might just separate you from the patient.” Lesser wears his, though, because “it would be too revolutionary not to” and because the pockets are handy built-in briefcases.


Whether the white coat is bad for the physician–patient relationship depends on the patient and the situation, according to Desiree Johnson, a physician’s assistant at the Kettering College of Medical Arts near Dayton, Ohio. “Some patients appreciate a more relaxed atmosphere and a ‘real person,’” he says, “not just someone with a degree who treats them like an illness. I’d prefer that white coats be done away with in the office. My I.D. and my stethoscope pretty much define who I am.”


No one at Mayo Medical School wears a white coat unless they’re in a lab or surgery. “They told us during orientation the white coat distances us from the patient,” says Danielle Armas, a second-year. “It signifies a barrier of knowledge and privilege from the patient.” Instead, all Mayo medical students and staff wear business-professional attire. “It’s a gesture of respect to patients and signifies the professional nature of the patient–doctor relationship.”


Dr. Melanie Spritz is board-eligible in internal medicine and psychiatry, so what she wears depends on the type of medicine she’s practicing and the type of patient she’s seeing at St. Luke’s-Roosevelt Hospital in Brooklyn. “As a psychiatrist, I never wear my coat. It could inhibit the freethinking of my patients. For internal medicine, I usually wear it. The white coat reassures the patient that I have a certain level of clinical competence. When I’m conducting a physical or taking a history, the white coat has an authority that enhances my patient’s confidence and improves our rapport.” On psychiatry outreach to shelters or other places where she sees disadvantaged patients, Spritz wears jeans and a T-shirt or sweater.


Instead of creating barriers, the white coat—in most situations—helps establish “an almost instant rapport,” Blanke says. But he does take it off around children. “They’re petrified out of their minds by it.” Many physicians and parents believe children are frightened of people in white coats. Still, the research on this is inconclusive. In fact, a March 1999 study published in the journal Clinical Pediatrics concluded that slightly more than half of 50 children shown pictures of physicians preferred the ones in white. In fact, they strongly favored the ones in white who smiled and had cartoon pictures on the walls behind them.


Dr. Arnold Gold isn’t surprised by this study’s findings. During his 42 years as a pediatric neurologist at Children’s Hospital of New York, he has always worn his white coat “and the children love him,” says his wife, Sandra. “Children crying on their mothers’ laps stop when he talks to them. Those who advocate the barrier argument don’t have a leg to stand on.”


Indeed, if the white coat creates barriers, it may be because of who’s wearing the coat, according to Watson. “Some could dress in shorts, and patients would feel a barrier. Others could wear a crown and not create barriers,” he says.


Barriers can be good for a professional relationship, according to Rosborough, who says that patients and physicians are not supposed to be buddies. “A certain amount of professional distance is essential. The personal presentation a physician makes is part of the role that must be played. Especially for medical students and beginning residents, the white coat can play an important part in that role.”


Size matters: short coats, long coats
Some say white coats also create barriers between colleagues. At many health-care facilities, medical students wear short coats; physicians wear long ones. This establishes a hierarchy, and some medical students don’t like having to display their low rank.


“Some of my colleagues complain about having to wear short coats that leave their asses hanging out,” Deye says. “The attendings get to cover their asses.”


Short coats symbolize oppression, according to Niraj Pahlajani, a fourth-year at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School. “The attendings don’t wear white coats. The residents wear long coats, and students wear short coats. When I wear my coat, some doctors feel like they should not talk to me because I am inferior. When I don’t wear my coat, they smile and treat me like an equal,” he says.


Watson doesn’t blame students for being upset at the short coats, which is why everyone at UF—students, residents and attendings—wears the same length coat. And UF isn’t alone.


Rosborough says Abbott Northwestern has never had different coat styles for different levels of physicianhood. “We try to create a culture in which we’re all colleagues, just at different phases of our careers.”


The debate about the white coat may never go away, because white coats may never go away. But blanket criticism of “white coat snobs” doesn’t pan out. Too many caring, competent physicians wear them and seem to get along with patients just fine. If white coats vanished tomorrow, would the quality of patient care plummet? Unlikely. Would we instead see a dramatic improvement? Unlikely. In the end, many say the coat is just a coat. Some people like it; others don’t. Who’s wearing the coat matters most. And besides, it’s got great pockets.
~REFLECTIONS ON THE WHITE COAT


Every time I put on the white coat, I stop for two minutes. I stop for two minutes and remember Galen and Hippocrates. I pick up the coat. “To whatever house I shall enter, it shall be for the benefit of the sick.” At that moment, I am a doctor of medicine. I carry with me a 2,500-year tradition, and shame on me if I do not carry it out with dignity for the next eight hours. My problems are not the patient’s problems. For that period of time, I am the agent and servant of the sick. I put on that coat, and I’m a better person. All my petty prejudices should disappear when the coat goes on. That’s what the coat is all about.

—Dr. Gregory L. Henry, in a speech at the 1998 American College of Emergency Physicians Scientific Assembly


From the moment we met, I have never been particularly fond of my white coat. The relationship began as I struggled to put the jacket on at our school’s white coat ceremony. The coat was crisp with newness and fit my small frame much too snugly than desired. The relationship continued to deteriorate after I washed the coat and put it in the drier. After that day, the only thing I could fit under the coat was a spandex tee, not quite the ideal attire for an aspiring doc living in Minnesota in February. I tried to reconcile the relationship by releasing the hems on the cuffs, in order to make the sleeves longer, but that didn’t look too professional either. In addition, despite my repeated attempts to keep the relationship clean, that coat brought ring-around-the-collar to a whole new dimension. Finally, the straw that broke the camel’s back was when my pen exploded in the front pocket. Now, not only was I not professional, but I was an unprofessional nerd!


Looking back on the relationship, I am thankful for at least one thing—the coat’s large pockets. You certainly could stuff many necessities in those. I guess my white coat and I had a love–hate relationship, but I’m certainly happy to be moving on to bigger and better things next year at residency.

—Dr. Amy L. Williams, Class of 2003, University of Minnesota Medical School


The short white coat is a good gauge of the medical student’s progression through medical school. Fresh and sparkly white coats are worn by fresh, inexperienced, newly minted medical students. By the middle of third year, your coat has a yellow ring around the collar and stains on the buttonholes (from frequent buttoning and unbuttoning). Despite your best efforts, it doesn’t wash clean. By now, your mind has gone through some wear and tear, too, from sleepless nights and stressful demands. Your pockets are overloaded with mini-references and your PDA. Just when the stitches pull out and the stains have made your white coat yellow, you graduate and are given a new white coat—a longer one—to stain.

—Ricky Choi, fourth-year, Medical University of South Carolina College of Medicine


I have learned from the white coat ceremony to “love your patients.” Modern medicine has, in the eyes of some, sacrificed humanistic concerns in favor of an X-ray, a lab value or an EKG. Aspects of healing include more than physical acts. They include cultural, spiritual and societal issues. The white coat ceremony gave me focus beyond the physical remedy.

—Dr. Kai Sung, Class of 1999, Columbia University College of Physicians and Surgeons


Before the white coat ceremony, I had envisioned the doctor’s white coat as a symbol of prestige. Immediately following, I remember feeling very small, very undoctorlike, and even a bit silly, wearing this coat still marked by fresh-from-the-box folds. Any sense of prestige I had was very quickly replaced by a daunting mix of excitement and fear at the task of adequately “filling the sleeves” of this latest addition to my wardrobe.

—Dr. Sara May, Class of 2000, Columbia University College of Physicians and Surgeons


I was wearing my white coat when I got in a car accident that was clearly my fault. The police officers and the person I hit were older than me, but they all treated me with the utmost respect. The officers called a tow truck and offered to drive me to the hospital. That was eight months ago, and I have yet to receive any penalties to my driving record or my insurance premiums. I never identified myself as a physician or medical student. My only explanation for the pleasantly strange and sensitive treatment is that I had on the white coat, and they must have assumed I was some important surgeon late for a procedure. I’ve heard similar stories from other medical students—traffic tickets they were not given but should have been. A classmate told me the officer that stopped her speeding said he would not give her a ticket “because one day, you might just save my life.”

—Dr. Akilah Dallas, Class of 2003, Georgetown University School of Medicine


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


AN ODE TO MY WHITE COAT


I remember that August day when I
first saw you
in your gleaming, white,
anonymous austerity.


You among all the others were mine.
In your presence
my father’s eyes welled up with pride.
I took you home and wrapped my
hopes in your arms.


It’s been more than a year now,
and you are not so white anymore.
Nor do I drape you about my arm
with such reverence as before.
For I have chaffed beneath your stiffness,
and I have thrown you upon the floor.
Your sleeves are stained with my tears.


But I will always love you.
For you have been there
through all I have endured.
Waiting.
Until I have proven myself worthy
to call myself your own.

—Linda Nicoll, fourth-year
~~~Howard Bell is a contributing editor with The New Physician. Direct questions and comments about this article to tnp@amsa.org.~Medical Education~
156~7October~2003-52~On the Wards~Dancing at the Copacabana~CELEBRATING A LOVE OF LIFE~Keith Blechman~~Ana Guevara told me she loves dancing and mentioned something about coming back from the Copacabana the other night. With a smile that illuminated her dark-skinned face, she swung her arms high, rhythmically moving them as if she were still at the nightclub. Her black hair, intermingled with strands of silver, swayed back and forth.


But obviously Ana wasn’t at the Copa; she was sitting in a hospital bed in New York City. She had about eight electrodes taped to her forehead and temples, with nurses constantly monitoring her brainwaves, waiting for her to have a seizure. Physicians hoped the information gleaned from an electroencephalogram would reveal the root of Ana’s illness. But she had been in the epileptic unit four days already and still hadn’t had a seizure. Ana said she’s leaving tomorrow regardless. The Copa can’t wait, I suppose.


I had met about five other epileptics before Ana. There was Jane, a medical student with an inexplainable pupil that periodically dilated; Moishe, an Orthodox Jew from Brooklyn whose wife was also an epileptic; Myra, who lied about her condition on her driver’s license so she could keep earning a living; and many others, each with their own unique stories.* Ana, however, was the one who displayed the most excitement in just being alive.


Then there was me: a first-year medical student shamelessly asking these individuals questions about their jobs, loved ones and diseases—prying into their lives.


Conversely, the only question they ever posed to me was how old I was. Of course, they had little reason to ask me anything else. I am not an epileptic. I am not sick. I have never suffered from any major illness. The only incident in my life that required significant medical attention was a congenital hernia that was treated prior to my first memory. I don’t know what it’s like to be stuck in a hospital bed for days at a time just to have strobe lights flashed in my eyes or be deprived of sleep in the hopes that the neurons in my brain may signal aberrantly, causing my entire body to convulse, all under a medical expert’s watch.


Most of all, I have never experienced—nor can I truly imagine—what it is like to know that my only treatment option is to have a surgeon remove a piece of my skull and shave away a small layer of my brain from where my seizures seem to originate. I cannot understand that feeling. Yet, it is possible that one day I may be the surgeon performing that radical operation.


I used to question how much a patient can trust me if she realized I am not like her. I wondered if it would impact our physician–patient relationship. But in my meeting with Ana, our relationship became clear: It was not about Ana’s unique situation of coping with epilepsy. It was about her love of life. And that is something I can relate to.


I can already see how being a physician can force one to become almost entirely focused upon disease. As a first-year, most of my time has been spent studying. Why? So I can understand and learn how to treat disease. Fortunately, no courses are needed to understand the joys of life. I already know that. And Ana—for only brief periods and only through distant memories, sometimes at the Copa—knew what joys life can offer without the burdens of disease. That was our connection. That was why I was interviewing her. If I wasn’t thrilled to be healthy and alive, how could I help anyone else to be?


In the physician–patient relationship, disease is secondary. The most important thing is happiness, something that all individuals can imagine and empathize with, whether they’re the caregivers or the sick. The desire to be happy is why patients like Ana come to physicians.


When I left Ana’s room after interviewing her, it was only a minute or two before her husband came out looking disturbed. “She just seized,” he said. Returning to her room, I saw three nurses holding her body down, trying to control her violent spasm. Gurgling sounds from her throat shut out all other noise.


Watching her endure this, I thought to myself how nice it would be to see Ana smiling and dancing at the Copa once again.
~~~~Keith Blechman is now a third-year at New York University School of Medicine. Direct questions and comments about this article to tnp@amsa.org. ~Humanistic Medicine,Medical Education~
157~7October~2003-52~Feature~On Hearing and Being Heard~A MEDICAL STUDENT AND A RESIDENT SPEAK OUT ON A TOPIC DEAR TO THEIR HEARTS.~Joanna Turner~~In 1990, the Americans with Disabilities Act (ADA) helped open the doors of medicine to people with physical disabilities. And while technology assists future physicians who have unique physical needs, the road to practicing medicine can still be challenging, particularly in regard to attaining equal status with peers and colleagues. But this isn’t in terms of competency; physicians with disabilities are just as proficient at their crafts as their able-bodied colleagues. The problem, they say, is in being accepted, respected and understood.


So in an effort to foster better understanding, The New Physician asked a medical student and a resident to share their stories about being hard of hearing and on the road to physicianhood. They also offer advice to peers. The following pieces are in their own words.

—Rebecca Sernett, editor


JENNIFER LEE


I get curious stares and questions about my electronic stethoscope from time to time. People want to know what it is, what it does and how it works. The beige 5- by 3-inch box attached to a black, coiled cord with a diaphragm at the end certainly looks nothing like a typical stethoscope. Whenever I get an opportunity to explain it to other medical students, physicians and patients, I always start by proudly saying it’s the same stethoscope that astronauts use in space and that Medevac personnel use in emergency operations. Then I describe how I hook my hearing aids into the stethoscope so I can hear magnified heart sounds. Sometimes I let them try my stethoscope using separate headphones. Many walk away saying, “Wow, that is powerful. You don’t even have to strain to hear.”


This is just one example of my experiences as a hard-of-hearing medical student. I was born with a bilateral, severe-to-profound hearing loss of -110 to -115 decibels. Hearing aids in both ears allow me to hear normal range conversation, and I use a combination of lip reading and hearing to understand what is being said. While I may not hear the sound of a faucet dripping or crickets chirping outside, I can hear normal noises. People often ask me what it is like to be hard of hearing. The best description I can come up with is that it’s like being in a foreign country—you can hear people around you speaking, but you have no idea what is being said.


Although crushed when physicians first gave them the news when I was 8 months old, my parents were determined their child would live a full and normal life. They decided to teach me auditory verbal communication first, opting for American Sign Language (ASL) if no progress could be made.


Thus, from the age of 18 months until I entered kindergarten at 5, I made many long, three-hour trips with my mother to Easton, Pennsylvania, where I was taught at the Helen Beebe Speech and Hearing Center. There, I learned how to speak, repeat and recognize vowels and consonants. My communication abilities were honed and developed by my teachers often covering their mouths and making me practice understanding what was being said by using my hearing. This early, rigorous training, combined with the unconditional love and endless teaching of a strong-willed mother, allowed me to fully mainstream into regular, public schools from kindergarten through high school. I have never learned ASL.


So what led me to pursue medicine? I’ve always had a love of biology and admired what physicians do. And as I grew older, I came to realize the powerful knowledge and authority physicians possess—knowledge about the human body and ability to better it. However, during my undergraduate studies at Stanford University, I felt that perhaps my inadequacies would hinder my aspirations. I was afraid to become a physician, because I did not know how a hard-of-hearing person could be entrusted with the lives of others. Consequently, after graduating with a biology degree, I spent several years conducting molecular biology research. While I learned a great deal from my experiences in the lab, I felt something lacking; I longed for personal contact with others.


Fortunately, at that time in my life, I came in contact with an online support group for hard-of-hearing health professionals. Here, I met hearing-impaired physicians, veterinarians, nurses and medical students. After learning about their experiences and how they coped on a daily basis, I became encouraged. This was the catalyst for my decision to apply to medical school, and it continues to be my inspiration today as I attend Drexel University College of Medicine. I am now beginning my third year.


While all medical students share similar stresses and difficulties, my hearing loss has forced me to think of ways—sometimes creative—to compensate. During my first two years at Drexel, I relied heavily on our student-run scribe service. Students who wish to receive typed lecture notes pay a fee each semester for scribe services. Scribes are typically other students who take turns writing lectures in return for pay.


I have also used Computer-Aided Realtime Translation (CART) captioning for one class. In this system, a CART reporter—similar to a specialized stenographer, who is trained in medical terminology—types what the lecturer is saying into a computer so that I can read along on a laptop. CART is an amazing and invaluable experience for hard-of-hearing people because it allows us to actually follow what is going on “live” instead of filling in the blanks later.


Since the ADA covers my hearing loss, the school provides for many of these services. The CART reporters are paid by Drexel’s disability center. A typical CART reporter fee is anywhere from $100 to $200 an hour. I paid for the scribes myself, costing about $150 per semester. I’m sure Drexel would have paid for the scribes if I had wanted it to, but I felt that since other, nondisabled classmates were paying for them, I would too.


As my training moves onto the wards, I will be relying on many more resources and accommodations. Fortunately, more advanced equipment to assist hard-of-hearing health professionals is constantly being developed; in fact, I have recently switched from using the bulky electronic stethoscope to one that better resembles a typical stethoscope. CART will likely be used in the operating room since I will be unable to read lips hidden behind surgical masks. A paging system may have to be improvised—perhaps with numbers representing specific messages like “come to the nurses station”—so that I can be contacted easily. And an oral interpreter—a trained professional who helps repeat what others say—may assist me with patients, phone calls and rounds.


Ultimately, the clinical years will be more challenging because more is at stake. Things that hearing people often take for granted—like using the telephone—are frustrating for those of us who can’t hear as well. Without a doubt, I am anxious, and already I have met some challenges. Some surgeons have been resistant to CART, arguing for a microphone system instead. In this type of situation, it’s important for me to explain the nature of my hearing loss and to prove that a microphone system would only magnify sounds, not make them clearer. Documentation and letters on my behalf have been collected from audiologists, physicians and others to show that special aid is necessary. I am so grateful for the support of Drexel’s disability directors who are tirelessly arguing on my behalf.


Often, overcoming challenges boils down to confidence. One of the greatest lessons I’ve learned is to be comfortable with my disability and with who I am. I have grown more confident telling others about my hearing loss and being honest from the beginning. Whenever I interview a patient, I always tell him my name, explain that I’m a medical student and that I’m hard of hearing. I tell him I may need him to repeat things for me, that he may need to raise his voice slightly and that I may repeat things back to him to confirm what was said.


In the beginning, I was afraid this would be met with resistance. But I have yet to meet a patient who is unwilling to slow down for me. I have also received positive responses from my professors and peers. My professors have been willing to provide assistance, and in small group settings, my peers try to remember to face me when they talk. And I know I can always ask friends for help if I miss something.


Still, there is a great deal that others need to understand about hard-of-hearing medical students. We want to be treated with respect and as equals. We are not any less intelligent or proficient than our peers and colleagues. We just require a little more consideration and awareness of our needs.


I believe that a hard-of-hearing medical student can succeed in medical school and in the medical profession with hard work, perseverance and faith in her abilities. While it is important to follow your aspirations, it is also important to know your limitations. Advancing technology has allowed us to cope in ways we never thought possible, but it falls short of having two perfect ears. Ultimately, one must have a healthy blend of idealism and practicality to abide by every day.


Jennifer Lee is a third-year medical student at Drexel University College of Medicine.


JOANNA TURNER, M.D.


When thinking about a person with a hearing impairment, some may envision Sarah from “Children of a Lesser God.” Deaf since birth, Sarah communicates with the surrounding world through ASL. Others may think of an elderly grandparent who lost his hearing as part of growing old. What I’ve learned throughout my life is that hardly anyone envisions someone like me.


I am a recent graduate of Rush Medical College, and I was born with a mild hearing loss in my left ear, which worsened after I contracted meningitis at the age of 9. I have approximately a -60 decibel loss in my left ear and a -10 decibel loss in my right—nothing much in the world of the deaf and hard of hearing but enough to impact my life significantly. I wear a hearing aid and can speak and read lips thanks to undergoing rigorous speech therapy. In fact, I do this so well that most people forget I have difficulty hearing.


Some interesting encounters have resulted from this tendency to forget or not notice my hearing loss. Many people have asked, “Why do you wear a hearing aid?” (Didn’t you know it was the latest fashion statement?) Some, not recognizing my lisp, will try to guess where I was born. On one occasion, a guy I had just met asked, “Hey, baby, you got a tongue pierce?”

“No,” I replied sweetly. “I have a hearing aid.”


While people’s confusion about where I and my hearing loss fit in has created endless amusement for me, it has also created a significant amount of frustration. I politely tell everyone I meet that I am partially deaf, and they are usually eager to accommodate me at first. Yet as time goes on, I am met with an increasing level of annoyance from anyone for whom I have to continuously remind to speak louder and to look directly at me. I have a difficult time with accents, mumblers and men with significant amounts of facial hair. I am terrible at tuning out background noise, and even in a moderately noisy environment, I am left to guess at what is being said.


In high school, I learned ASL and over time became involved in the deaf community. What I have learned from them has opened my eyes to challenges I never thought about. For someone like me, noisy environments are the real problem. Quiet situations such as the physician’s office are fairly easy to navigate. But those who are deaf or severely hard of hearing must rely on some assistance to communicate. And I discovered many of these individuals have physicians who refuse to pay for interpreters, insisting the patient should read their lips or communicate by reading and writing.


There are two problems with this way of thinking. First, only 30 percent of spoken English is visible on the lips. Second, English is a second language for many in the deaf community. The average deaf person reads and writes at a fourth-grade reading level, while the average native English speaker does so at an eighth-grade level. Many barely write at all. When some members of the deaf community discovered I was studying to be a physician, they were overjoyed. “You want to be a doctor, and you know sign? Please don’t give up—we need you!”


With the deaf community, I knew I had found my calling in medicine. I have always believed in providing medical care to the underserved, and this was a group of medically underserved individuals that I related to in so many ways. My desire to create accessible health care for the deaf has fueled my drive to become a physician.


I was lucky to attend Rush. It paid for a classmate to take notes for me, using money from the student-tutoring fund so I would not have to pay myself. It already had an assistive listening system in place in each lecture hall in accordance with the ADA. During lectures, I wore a set of portable headphones that tapped directly into the speaker system via an FM radio wave.


My third and fourth years were more challenging, although technologically I did well. Rush provided a portable FM listening system for use in the operating room, and it allowed me to hear conversation I would otherwise not catch because of the surgical masks. Surgeons didn’t mind wearing a special microphone; on the contrary, I found they took a liking to their new toy.


I did encounter trouble on the floors, however, mostly at hospitals outside of Rush where I rotated. The first day of a rotation, I usually introduced myself and quickly explained that I need to read lips. It would be noted, and we would go about our business. But later, I would run into problems. I was more persistent than other medical students, because I wanted to ensure I was hearing and learning as much as I could. I butted heads with residents who thought I was too demanding of their time, when all I wanted was for them to have a little patience, look at me and speak clearly. Friends overheard attendings with heavy accents making fun of me and of my inability to understand them. It was a lot to handle, but what upset me most was that the physicians who made fun of me and didn’t have time for me are the very same people who end up caring for patients who can’t hear very well, do not know English, or have difficulty speaking and expressing themselves.


When I entered the Match process, I was nervous and excited. Like many of my classmates, I was eager to find a program I could fall in love with. At the same time, however, I needed a place that would meet my needs and be supportive of my desire to provide health care to the deaf community. In this age of managed care, many hospitals are forced to stretch every dollar. Such facilities are often reluctant to take on new projects that cost extra money. I could see this in the eyes of many who interviewed me. Although I didn’t encounter any direct discrimination, I do believe that some programs were hesitant to take me on because of this money crunch. Still, I was fortunate to have been matched with a family practice program that has welcomed me and my ideas with open arms.


My connections with the deaf community and my own awareness of the importance of being able to communicate completely with my patients have become central to how I want to practice medicine. I have chosen family practice in part because I feel it is the one specialty in which I can do the most good for the deaf community and for all medically underserved. Family physicians rely on communication to do their jobs well, and communicating with patients is the most important part of being a physician. This requires having an open mind and not making assumptions about others. I know from experience how essential this is, and I hope others remember my story as a reminder to always keep an open mind when dealing with their patients.
~PREMEDS: WORDS OF ADVICE


Have a hearing loss? Don’t know how to find a medical institution that’s right for you? Dr. Joanna Turner and Jennifer Lee offer these tips:


Research schools thoroughly. “Ask if they have ever had a deaf or hard-of-hearing medical student. If so, how did they respond to that student’s needs?” Turner says.


Network. “Does anyone know of a deaf or hard-of-hearing medical student or doctor? If so, where did they go to school? Did they like it? Were their needs met?” Turner says.


Be honest about your hearing loss. “You may want to discuss [it] in your personal statement, especially if it is a more severe loss. Talk about it during medical school interviews,” Lee says. “[And] gauge the types of responses you receive. Are they negative, positive or neutral?”


Explain your needs. “As stressful and intimidating as applying to medical school can be, it is completely OK to be upfront with admissions officers about particular needs,” Turner says. “[For] many schools, an applicant who has overcome personal challenges and knows what he or she needs to do in order to succeed are actually looked upon very favorably.”
Stay in touch. Once you’re on campus, “Stay in contact with school administrators and disability services as your needs change,” Lee says. “Let faculty and fellow students know of your hearing loss and ask them to help you.”


Repeat this procedure. When it’s time to search for a residency, keep the above advice in mind. “Be upfront about your needs and how the program can help you to be the best resident possible,” Turner says. —R.S.


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


WORKING WITH THE DEAF


Whether they’re patients or colleagues, Dr. Joanna Turner and Jennifer Lee say much of the advice is the same:


Treat the person as an equal. “Do not judge a student or patient to be dumb or inattentive because they missed something you said…. To most…a hearing loss means that the world sounds like a garbled radio, and they have to put the pieces together as best they can,” Turner says.
Face the individual. “Look at a deaf or hard-of-hearing medical student—or patient, for that matter—while you are speaking so they can read your lips. If they use an ASL interpreter, make sure the interpreter has ample time to translate everything you are saying,” Turner says. Also, don’t cover your mouth.


Don’t make assumptions. “Don’t assume a deaf patient can read your lips. Medical terms are tough enough when they can be heard—lip reading is a lost cause in such cases,” Turner says.


Don’t rely on the written word. “Do not communicate solely by reading and writing as many deaf have poor skills in this area,” Turner says.


Bottom line—get an interpreter. “Every hospital should have access to one. If they don’t, you should contact the local deaf club and obtain names of certified medical ASL interpreters. A small minority of hard-of-hearing patients communicate in formats other than ASL, but the interpreter is qualified to assess the situation and [should] be allowed to do that,” Turner says.


Feel free to be curious. “Do not be afraid to ask the individual about his or her hearing loss,” Lee says. —R.S.


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


ONLINE RESOURCES

~~~Joanna Turner is a recent graduate of Rush Medical College. She is now in her first year of a family practice residency at Evanston Northwestern Healthcare, based in Glenview, Illinois.
Direct questions and comments about this article to tnp@amsa.org.~Disabilities in Medicine~
158~7October~2003-52~Feature~Project Success~SEEKING TO EXPAND THEIR MEDICAL SCHOOL LESSONS, FUTURE PHYSICIANS CREATE INNOVATIVE INITIATIVES TO HELP HEAL THEIR COMMUNITIES.~Beth McNichol~~The building that broke ground in July at 54th and Prairie in downtown Chicago, which will house the long-awaited and first-ever headquarters for Chicago Youth Programs (CYP), is as much a monument to a former Northwestern University medical student’s ingenuity as it is functional office space. For nearly 20 years, CYP has gotten by on borrowed rooms and borrowed time to help pull the children of Chicago’s Cabrini Green, Washington Park and Uptown housing projects out of poverty, using parks and deserted college classrooms to further its cause.


“Gotten by”—that’s quite a misnomer. Through the years, the staff that has grown to 650 volunteers has helped 90 percent of the children it serves to reach age 18, having avoided gangs, criminal convictions and premature parenthood. Right now, with $50,000 in donations from former CYP volunteers, it’s helping fund the college educations of more than 40 at-risk youth, and 70 percent to 80 percent of them will graduate in the coming years. The going rate for minority college graduates overall is just 33 percent.


It seems that what Dr. Joe DiCara—just “Dr. Joe” to most—has done with the organization he and a handful of other medical students started in 1984 is nothing short of superhuman.


Or is it?


DiCara—who maintains his full-time volunteer status at CYP, along with being on staff at Children’s Memorial and Prentice Women’s hospitals, and while raising three kids of his own—has never believed his work with Chicago’s most impoverished children to be extracurricular. In fact, he says, it’s an essential part of being a pediatrician.


“There is no vaccination or lecture you can give in a clinic or medicine that could do anything better for a child than getting them out of poverty,” he says.


While a medical student, DiCara heard nothing about the disadvantaged youths who lived on the other side of his classrooms’ walls, and this bothered him. So one day, he went into Cabrini Green and invited some children to play ball. Lucky for him he had the keys to the school’s downtown gym. And what started as simple recreation has blossomed into a successful, nonprofit organization. It operates with a $621,000 budget from grants and foundations that funds 50 programs and services, including a free health clinic, SAT tutoring and a youth-to-youth mentoring series called Children Teaching Children.


From the time children enter CYP, sometimes as early as just months old, until the time they graduate from college and enter the work force, their progress is tracked—something DiCara says has become No. 1 on their list of reasons why CYP has thrived.


“There are tangible results that a difference is being made,” agrees Minesh Shah, a third-year medical and public health student at the University of Illinois at Chicago College of Medicine and a former CYP volunteer. “And that helps get medical students in particular to want to donate their time.”


The success CYP has enjoyed serves as a real-life textbook for today’s future physicians, many of whom are experiencing the same feelings DiCara had 20 years ago. On the following pages, you’ll hear the echoes of those keys jangling to open a gym and the futures of communities in the process. You’ll hear the story of how a medical student truly grows into a physician: by thinking outside the classroom.


Let’s turn the first key….


INSPIRING FUTURE DOCS


Third-year Lauren Stern knew she had a good thing going when a 10-year-old girl walked up to her and exclaimed, “I want to be a neurologist!”


“I said, ‘Oh, that’s great! I don’t even know what that means!’” Stern says.


All kidding aside, the Student Doctor for an Evening program, sponsored by the Women’s Health Initiative at the University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School, proved to Stern that giving back to the community doesn’t take a lot of money or a business degree. All it requires is a couple dozen medical students who remember what it felt like the first time they realized the wonders of the human body.


Student Doctor for an Evening arose from conversations Dr. Gloria Bachmann, professor and chief of OB-Gyn services at the Robert Wood Johnson University Hospital, had with students about creating an outreach program. The future physicians came up with the idea of creating a mini-medical school for children that would transform a classroom into six rotations, illustrating what it’s like to be a physician. Each station would be dedicated to a different aspect of medicine—the most popular one featuring organs borrowed from the school mortician—and staffed by a few of the 20 student volunteers.


“In a child’s life, there are so many things that can make an impression that sticks with them throughout the time they’re growing up and give them the feeling that they can aspire to something they’d never thought of before,” says Stern, who wanted the program to be a positive force for disadvantaged children in the New Brunswick area.


About 65 children ages 7 through 17 attended the first Student Doctor evening in April 2002—an outpouring so great, Stern says, that 150 children were on a wait list for the next one, held this past spring. While younger children got to “visit” the ER station and see X-rays of “random things people had swallowed,” Stern says, high-schoolers were advised on what it takes to get into medical school. But this wasn’t merely child’s play: Bachmann made good use of parents’ time by educating them in talks on health-care issues.


The total cost of the event? Less than $500. “Basically all you need is the space to set it up and the willingness to do it,” Stern says.


Well worth the priceless moment of seeing children get excited about their futures, she adds. “It was like watching little kids leave a basketball game and yelling, ‘I want to be an NBA player someday!’”


MENTORING YOUNG MOTHERS


When trying to save the world, the most important first step may well be realizing that you can’t. Second-year Harvard Medical School student Chelsea Elander, like her fellow volunteers in a teenage mother mentoring program called BABIES—Boston Adolescent and Baby Initiatives to Ensure Success—was energized by the idea that she could help educate the young women at the Whittier Street Health Center in the underserved community of Roxbury.


“We imagined being able to use our medical knowledge to answer questions the teens might have, or even to ask a doctor a question for them when they couldn’t or didn’t want to,” Elander says. “But the first time I was mentoring a girl, the first question she asked me was, ‘So, have you had any kids?’”


Last December, Elander and first-year dental student Caroline Laurent took over the ambitious 2-year-old program that had once included prenatal education and lactation consulting. To keep the volunteer effort manageable, they tailored it to focus on mentoring, matching first-year women with expectant teens. Together, they trained and matched about 25 students with teens for what Elander hopes will be a mentorship lasting at least six months to a year after the baby is born.


The early results? It’s the mentors who are getting one heck of an education.


“It’s such a different world than the one we’re being asked to work in as medical students,” she says. “It reminds me that needs are so much simpler sometimes than we realize—things like having transportation to well-baby appointments. The lessons are so simple, in fact, that you almost pass them over in an effort to find a deeper meaning that relates to your studies.”


When Massachusetts slashed its budget last winter, caseworkers at the Whittier clinic lost their jobs, leaving the student mentors with holes to fill for which they felt untrained. Now, Elander says, they feel their way through the darkness, letting the mothers guide them to their usefulness. Some medical students have even become Lamaze partners.


Elander also hopes to create a tool to measure the project’s impact. In the meantime, the students have learned a valuable professional skill, borne from the simplicity of everyday need: how to meet the patients where they are in their lives.


“Anyone who goes in thinking they’re going to be relevant based on their first year of medical school is going to become quickly irrelevant. There’s a big aspect of the medical student learning about the life of the young woman. That’s a much greater challenge than teaching about breastfeeding,” she says.


PROVIDING FELLOWSHIP, CARE


When the children at Camp Phoenix get together, it’s no secret what they have in common. Still, invariably, in pairs, the burn survivors will begin to notice each other’s scars and talk about the kids at school who make fun of them. And in this fellowship, necessitated by a past and sometimes present hurt, something magical happens right in the middle of a game of floor hockey: They begin to heal.


Paul Mullan, a fourth-year at Cornell University’s Weill Medical College, was inspired to start Camp Phoenix after spending his undergraduate college summers working at medical camps for children. He says the fellowship is what campers appreciate most about the program, now entering its fourth year.


“Some children with chronic conditions remember the times before their condition started, while others have lived with their condition for as long as they can remember,” he says. “When two children from these groups become friends, both of them accelerate their emotional healing process.”


Last year, about 55 medical student volunteers and 60 burn victims between ages 7 and 13 participated in the camp. Once a month, they meet for six-hour events that include games, music, arts and crafts and other activities designed to foster friendships and self-esteem. Then, each June, the camp holds a three-day overnight trip for the children, who Mullan and other volunteers meet in the New York Presbyterian Hospital Burn Center or its outpatient burn clinic.


Fire does not discriminate, notes Mullan’s camp colleague and fellow fourth-year Minal Patel: Camp Phoenix participants “run the whole gamut, from children who live on Park Avenue to those who are from foster homes.” None of the campers pay to attend the events, which are funded by the $15,000 to $20,000 that Camp Phoenix receives annually in donations, grants and financial support from Weill.


For Mullan and Patel, both of whom plan to enter pediatrics, it’s a chance to make a difference while stretching muscles not always exercised in medical school.


“Medical doctors do not only provide physical care but also emotional care,” Patel says. “Our organization helps medical students remember that a person must be taken care of completely.”


Mullan agrees. “We are always there to provide emotional support and to reinforce that getting a burn doesn’t change anything about a person on the inside.”


OFFERING GOOD, HOME COOKING


Like so many medical students, fourth-year Shayna Lefrak found something was missing from her life when she started the rigors of her studies at the University of Virginia School of Medicine.


“During my first year of medical school, I was overwhelmed with work and craving some real human interaction,” she says. “I found out about the Wiseman House, a home that provides a place to live for HIV-positive patients who have nowhere else to go.”


A light bulb went off when she visited the house to see how she could help. “Most of the residents rely on meal stamps and Medicaid. I decided that I would set up a program to send two or three medical students each week to the house to cook dinner in the kitchen with the residents and to spend time socializing with them. The program was successful because it provides students with a sense of fulfillment and the residents with a social evening and a home-cooked meal.”


Lefrak says students “gained an enormous amount from listening to the residents relay their medical stories and the effect [of HIV] on every dimension of their lives.” One resident, a man who had become an artist following his diagnosis 20 years earlier, shared with Lefrak his collection of paintings, which captured his emotions over years of battling the disease.


But Lefrak’s Cooking for a Cause program had to modify itself last year after the Wiseman House closed down. Third-years Carrie Straub and Thuy-Anh Nguyen offered volunteer services to the Charlottesville Ronald McDonald House once a week instead. It was a perfect fit, they say. For about $30 a meal, the medical students—many of whom are passionate about cooking—whipped up their own creations from ingredients they brought, and then dined with the parents and sick children staying at the house. New directors will continue these activities this year.


“It’s a nice combination of doing something we love and helping others,” Straub says.


Straub and Nguyen also have earned an invaluable education about applying for grants for service projects that will serve them well in the future; Cooking for a Cause receives funds from the American Medical Student Association, the American Medical Association and others. And Lefrak says she’ll always remember the people at the Wiseman House for the lessons they gave her.


“This program gives medical students time to focus on activities away from their studies and [helps them] remember why they came to medical school in the first place. There is always time,” she says.


EDUCATING THE UNDERSERVED


The inmate was one of the youngest ever to participate in the Healthy Transitions program at the North Carolina Correctional Institute for Women, recalls fourth-year Duke University School of Medicine student Victoria Mobley. The woman told of how she was brutally raped and almost beaten to death.


“The story was one of the worst I have ever heard,” Mobley says, “and it broke my heart. I had no idea what to say, and probably couldn’t have said anything anyway, because my throat felt so tight as I tried not to cry. At that moment, the silence felt appropriate. And then one of the other inmates began to tell her story and then another….”


Mobley, along with seven other Duke medical students who operate Healthy Transitions, say the scenario is one that happens all the time in the program begun in 2000. Over the course of a year at the institute, the students hold eight classes designed to facilitate healthy lifestyles for new inmates. About 20 prisoners volunteer to participate in each class after being recommended by their social workers.


“The class ends up being more about emotional healing and self-confidence than about physical health,” says fourth-year Angela Ries. “If a woman does not believe that she is worth anything because that is what she has been taught through abuse and previous relationships, she is not going to care about preventive health or maintenance.”


Navigating a prison structure can be a challenge, the students say. For example, classes have been cut short at times during lockdown, when all inmates are counted. But the future physicians agree that the keys to Healthy Transitions’ success have been finding an advocate for the cause at the correctional facility and laying down ground rules that acknowledge the distance between inmates and students.


“One of those rules is that we will make no judgments about them, but in turn, we would like them to make no judgments about us,” says Mobley, who adds it’s difficult at times to keep a professional distance from the prisoners. “The premise is that none of us, the med students or inmates, knows what life experiences the other has had, so to say things like, ‘How would you know?’ or ‘You just wouldn’t understand,’ are not fair statements.”


Healthy Transitions has been awarded for its efforts, receiving more than $15,000 in grants in its second year. Now that it’s established, the costs are minimal, and the payoff is immeasurable.


“The knowledge that I could be any of those women if I had been born to a different family or into a different neighborhood is humbling,” Mobley says. “I don’t know what decisions I would have made if I had been in the situations many of those women found themselves. This experience has helped me to become more empathetic.”


AUGMENTING THE CURRICULUM


It may be a little-known fact that, in the mid-19th century, the American Medical Association was formed partly to discredit physicians who practiced homeopathic medicine. It was certainly news to Columbia University College of Physicians and Surgeons third-year Max Fischer, who learned the tidbit while organizing a complementary and alternative medicine (CAM) lecture series on campus last fall.


Like some of the other projects detailed on these pages, Fischer’s seminar series is meant to bridge a gap in his medical school curriculum. But before he graduates, he expects to do nothing less than change long-standing attitudes toward CAM.


“We started the seminar series with the clear goal of bringing CAM into medical education,” he says. “Whether the series itself were to continue was not so important as whether it was adding to this greater movement.”


The eight sessions he and collaborators have held so far have featured prominent speakers and covered topics like acupuncture and Dominican folk medicine.


“I have had doctors tell me that they wish they learned about CAM in medical school, because so many of their patients use it, and they know nothing about it,” he says, adding that he’d like to have such CAM methods as acupuncture and yoga be parts of his family practice one day. “It is sad, because students leave school with a bias against things they didn’t hear about in the course of their education.”


Surveys taken of the 103 participants at the first lecture told how much work Fischer and his fellow volunteers have ahead of them: Although more than half of the respondents—who included faculty and students from other health sciences and universities—said they had sought alternative care on their own, many doubted whether they would refer their patients to CAM practitioners.


While Fischer did merit an audience with a faculty committee about CAM and found support from Columbia’s dean of student affairs, he knows adding it to the curriculum means cutting elsewhere, making his quest a long shot.


Still, he says, open-mindedness must be fostered. “The seminar series has reaffirmed for me that the best medicine is blind to the limits of what is called allopathic and what is not. No matter what field of medicine…one chooses to go into, there are ways we can benefit our patients by learning what other healing modalities can offer, and medical school is the place where this learning should start.”
~COMMUNITY SERVICE IN THE CLASSROOM


Brown Medical School professor Dr. Stephen Smith acknowledges that the elective he teaches, “Serving the Community Through Student-Initiated Projects,” is rather unique, but he hopes that changes in the future.


“I’ve been trying to do this for 30 years,” Smith says of his efforts to make student service a routine part of medical school. “I was inspired by the experience I had in my student programs through [the American Medical Student Association (AMSA)], and I’ve made that a goal of my own as a physician and as an educator to pass that on to medical students today.”


As a second-year at Boston University School of Medicine in 1970, Smith took part in the Appalachian Student Health Project, one of AMSA’s first efforts to place students in community clinics in rural and other underserved areas. Last year, when students came to him hoping to create an elective based on their work with the Rhode Island Free Clinic, Smith got the course started.


As a matter of principle, Brown already requires medical students to pass a competency-based curriculum in nine different abilities that is separate from the academic curriculum emblazoned on a transcript. Known as MD2000, it includes such skills as problem-solving and self-awareness, as well as understanding the social and community context of health care. The latter requirement is met in Smith’s elective, in which future physicians commit to working at the clinic for one year and participate in reflection sessions every six weeks. For the truly committed medical servant, the class can be even more.


“The idea was that in the course of volunteering, if the students were inspired to do something else, start another project, I would help them see that through, and they could then earn academic credit for it as well,” he says.


Introducing students to service can become a weeding-out process, Smith says, separating the résumé-builders from the sincerely philanthropic. To help students understand what it takes, Brown holds retreats twice a year to educate on advocacy and activism in medicine.


“It’s as much character as anything else. It’s perseverance. It’s juggling the pressures of being a medical student and having very little time. It takes a lot of fortitude to continue in a project. Often, student volunteers count on their colleagues to help out, and when their colleagues end up backing out because they can’t take it on anymore, it’s very discouraging to them. Student service projects are really a cauldron for leadership skills.” —B.M.


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TIPS FOR STARTING AMD CONTINUING PROJECTS

Set Realistic Goals.
“Define who you hope to impact and how the impact will be achieved,” BABIES’ Chelsea Elander advises. If you want the project to continue after you’ve graduated, she says, be proactive in training and selecting the next leaders.

Recruit Sincere People.
“We brought volunteers in who believed in what we were doing,” Healthy Transitions’ Angela Ries says. “That was the key to keeping our program going year after year.”

Delegate Responsibility Thoughtfully.
Medical students who start projects often expect new volunteers to take on a large amount of duties immediately. Instead of overwhelming someone who has good intentions, give her a small level of leadership at each meeting and build on it, advises Brown Medical School professor Dr. Stephen Smith.

Through Every Window, See A Resource.
Chicago Youth Programs has run more than 50 programs for children by using parks, libraries and university classrooms, where the electricity is on regardless of whether anyone’s home. “We feel like there is so much underused space out there and so little money for charities these days, we shouldn’t be wasting it,” Dr. Joe DiCara says.

Shake the Trees for Funding.
It’s out there, and all you have to do is find it. Organizations like the American Medical Student Association, the American Medical Association and campus charitable groups are all places to turn to for money, as well as charitable foundations and corporations. Think about groups that have an interest in your cause and approach them. But, advises curriculum reformer Max Fischer, “Don’t wait for money to start following your passion—take the risk, and you’ll be surprised at how funds will follow.”

Don't Make Time Your Excuse."
“Time is a real issue,” Smith says. “And I guess what I would tell students is: It never gets better. A lot of students will say, ‘I’m too busy this year. I’ll do it next year.’ Well, next year will never come. And one of the tasks as someone who wants to be a student advocacy leader is to find the time, even when you are overwhelmed. You have to find a way to be efficient in your planning; you have to learn to delegate, to build authority in others. Don’t let the perfect be the enemy of the good.” —B.M.
~~~Beth McNichol is a contributing editor with The New Physician. Direct questions and comments about this article to tnp@amsa.org.~Community and Public Health~
159~8November~2003-52~Feature~In Desperate Need~WHAT'S KEEPING DRUGS FROM THE HIV-INFECTED?~Scott T. Shepherd~~In Haiti, a small Caribbean nation where 80 percent of the 7.5 million people live in abject poverty, HIV and AIDS are more prevalent than anywhere else in the Western Hemisphere. Eight percent of adults in Haiti’s urban areas and 4 percent of adults in rural areas are infected with HIV. But it is doubtful that 26-year-old Enna knows any of these statistics. She just knows what she’s been through and what she has to live with.


Born to an impoverished family in the village of Savanette, she was sent to the capital city Port-au-Prince as a “restavèk”—a child servant—at age 10. At 14, she was raped. “A man who was a friend of the family where I was staying raped me. He waited until no one was home, then he jumped on me. I was just a child. I did not know what was happening. This happened four times, and then I was pregnant. The family [in Port-au-Prince] sent me away,” she told physicians. After becoming pregnant, Enna returned to Savanette where she barely survived childbirth.


To help her and her family make a living, she sold produce at regional markets and in Port-au-Prince. At 18, while sleeping in a communal market depot, Enna was raped by three men. “I didn’t see them, so what could I tell the police? Besides, I was afraid of the police,” she said. She regards her “entire life as a disaster. I had three children from two different men, but neither of them would help me [financially].” In her mid-20s, with five children and another on the way, Enna found herself sapped by recurrent fevers and chronic diarrhea. Soon, she was diagnosed with a tuberculosis and HIV co-infection.


Enna’s story left a significant impression on the physicians at a health center sponsored and staffed by the nonprofit organization Partners in Health (PIH) in the village of Cange. However, hers is just one of millions of similarly alarming tales shared by men, women and children in poor and developing nations around the globe. But unlike Enna, who received drug treatment and the care of PIH volunteers, few of these individuals have access to health care or to the highly active antiretroviral therapy to treat HIV and AIDS.


Organizations such as PIH, Doctors Without Borders and Doctors of the World are attempting to administer HIV and AIDS therapies to the infected in poor nations where the governments are unable or unwilling to provide treatment. However, the pandemic is too vast for them to help the majority.


“[In the] global scene, HIV has replaced tuberculosis as the leading infectious killer of young adults in the world today. In the space of a single generation, a previously unknown pathogen has swept across the globe, taking more lives than did the black plague,” says Dr. Paul Farmer, co-founder of PIH and a medical anthropology professor at Harvard Medical School. (To learn about PIH’s other co-founder, see “Following a Mission,” p. 33.)


It is estimated that 40 million people worldwide are infected with HIV, and 95 percent of those people live in poor, developing countries. In 2001, approximately 5 million people were newly infected with the virus, and 3 million died in that year alone. Worldwide, HIV/AIDS has killed more than 20 million people. It is the leading cause of death in Africa and the fourth leading cause of death worldwide.


Despite these staggering numbers, very few of the infected will receive treatment. According to UNAIDS, a United Nations program advocating for global action on HIV and AIDS, “only a fraction of those in need were receiving antiretroviral treatment at the end of 2002—about 800,000 people worldwide, 500,000 of whom live in high-income countries. In sub-Saharan Africa, where 2.4 million died of AIDS in 2002, only about 50,000 people were getting treatment. In Asia and the Pacific, where an estimated 485,000 people died of AIDS in 2002, only 43,000 people were receiving treatment.”


Many problems contribute to the obstruction of HIV treatment in developing countries, including: unstable and corrupt governments; paralyzing national debts; a lack of education on the benefits of HIV diagnoses and treatment; a scarcity of programs providing crucial counseling and psychological support; an absence of affordable HIV diagnostic equipment; and a shortage of health-care facilities and professionals, particularly those with knowledge of proper prescribing practices for antiretroviral therapies and of how to monitor treatment.


However, none of these obstacles are discussed as frequently or as passionately than the relationship between drug patents and the cost barriers to developing nations obtaining antiretroviral HIV/AIDS drugs. “Let’s say cost isn’t the only issue, but if the drugs aren’t affordable, you aren’t going to have a program. It’s a deal breaker,” says Dr. Briggs Reilley, an epidemiologist and project manager with Doctors Without Borders—commonly known by its French designation, Médecins Sans Frontières (MSF).


For advocates of global HIV treatment programs, the debate has been a struggle to obtain affordable drug prices, either by having individual nations negotiating lower prices from drug companies or, as is more often the case, promoting the production of generic antiretroviral therapies, despite patent protections.


In fact, global intellectual property rights agreements already permit nations to ignore patent restrictions in the times of a health crisis and to produce generic drugs. Unfortunately, few countries—particularly those hit hardest by the pandemic—have the facilities to manufacture drugs or the money to build them. Furthermore, trade agreements have prohibited other countries from producing generics and sending them to nations with the greatest need. This means that while middle-income nations, such as Brazil and India, have the option of producing generics, they cannot share the drugs with poorer countries, such as Haiti, Kenya, Mali, Somalia and Panama.


Moreover, the idea of international trade of generic drugs still under patent protection has met with resistance from the United States and the pharmaceutical industry. They argue that importing generic drugs to developing nations could lead to smuggling of the drugs back into wealthier nations, which would cut into the drug companies’ profits and into funding for research and development. Furthermore, the U.S. Trade Representative [USTR] Robert Zoellick and pharmaceutical companies have argued that many of these developing nations do not have the necessary health-care infrastructure to properly monitor widespread antiretroviral therapy programs. And if taken incorrectly or inconsistently, the therapy could lead to the development of drug-resistant HIV strains in patients, making it impossible to treat them with antiretroviral therapies in the future.


“Viruses—and it’s not just the HIV virus—have the instinctive abilities to learn medicines.… It’s why there is a shortage of drugs for viruses. If you do not take the regimen at the required times, you are more likely to develop these resistant strains,” says Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America (PhRMA), the industry group for research-based U.S. pharmaceutical companies.


These arguments led the United States to be the lone nation to vote against an agreement during a summit of the World Trade Organization (WTO) in November 2001 in Doha, Qatar, that would have permitted poor nations to buy generic medicines to fight HIV and AIDS. The United States further supported its dissenting vote by stating that advocates were attempting to expand the definition of a poor nation and the types of drugs that could have their patents overridden. “This approach could seriously undermine the WTO rules on patents that provide incentives for development of new pharmaceutical products, including those to treat diseases of a nonepidemic nature,” the Office of the USTR said in a statement at the time.


The action was greeted with hostility by developing nations and AIDS advocacy groups. “The United States is perhaps the worst offender on the issue of drug patents.… One hundred forty-five out of 146 countries represented…in Doha were ready to sign on to an agreement that would suspend patents in the event of public health emergencies. Guess which country blocked this rather mild proposal? It’s shameful,” Farmer says.


NOT JUST PATENTS


But some physicians working abroad with the HIV-infected believe there is some validity to the arguments made by the USTR and PhRMA.


“I view [the obstacles to HIV treatment delivery] as a much bigger problem in a lack of infrastructure. Any issues obtaining antiretrovirals are really near the end of the list. Often there is just not a sufficient infrastructure to provide and monitor the treatment. The whole issue of drug patents and generic drugs has been severely overblown,” says Dr. Mark Kline, director of the Baylor International Pediatric AIDS Initiative in Houston, Texas, which runs treatment programs in Botswana and Romania.


He adds that the concerns over development of drug-resistant strains are legitimate, especially when drugs are provided by an unstable health-care system. He is aware of uneducated physicians providing half doses of antiretrovirals because they feel a need to ration the drug, and he is concerned that in the long run it may do more harm than good. “I may be in the minority opinion that if you are going to do this, you need to do it right. Otherwise you are just setting yourself up for failure.”


In some cases, he says, governments may be playing the blame game with drug companies, using them as excuses for ignoring their own internal problems; he points to affluent nations like South Africa, as an example.


Meanwhile, other countries may be taking cheaper drugs—obtained through deals with pharmaceutical companies or with the financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria—and inflating the prices to make profits off their HIV-infected citizens. According to a World Health Organization (WHO) study released in May, the prices of antiretroviral medicines have been inflated in developing countries by taxes, tariffs and retail markups, sometimes raising drug prices to be even greater than what consumers in wealthier nations pay.


However, progress can be made when the disease finally has the full attention of the government and public, Kline says, referring to efforts in Botswana. With an estimated 35 percent HIV-infection rate among adults, the country’s epidemic is the worst in the world. So with the attention of the government and public, and with the financial support from the Global Fund, among others, an infrastructure is being created to safely and consistently provide antiretrovirals, plus properly educate patients and health-care workers, he says.


Specifically, he has been pleased with his organization’s ability to provide pediatric AIDS care. “In Botswana, that national program is reasonably well funded. We have free clinical trials for 600 children and money to provide treatment to many children not in the trials. In that case, we put a lot of the pieces in place before we started giving treatment.”


And Kline has witnessed some companies’ efforts to make drugs available, including making large donations to nongovernmental agencies fighting AIDS in developing nations. The Baylor International Pediatric AIDS Initiative receives substantial donations of antiretroviral medicines from Abbott Laboratories and Bristol Myers Squibb. At its Romanian center alone, Kline says, it uses $300,000 to $400,000 in donated medicines each month.


Furthermore, he says that the costs of antiretrovirals have fallen dramatically in recent years. According to UNAIDS, as of early 2000, the price of an antiretroviral therapy for one patient was $10,000 to $12,000 annually. By the end of 2000, it was between $500 to $800 per person, per year in low-income nations. And as of May 2003, the least expensive brand-name combination recommended by the WHO was approximately $675 annually per person, while the least expensive generic combination was just under $300.


SPEAKING UP FOR TREATMENT


While the drops in costs are certainly substantial, the price for therapies remains well out of reach for most poor, debt-loaded countries needing to treat thousands of HIV-infected citizens. At this point, those governments need to step up and demand lower drug costs, says MSF’s Reilley.


“It takes a government, and there is equal responsibility here [with pharmaceutical companies]. A government needs to take charge and say we can’t afford brand-name drugs, so we are either going to—not circumvent but—import generic drugs, which is completely legal under the World Trade Organization in the case of a public health crisis, or they can talk to brand-name [drug manufacturers] and get them down to a cost they can afford. They have to do one or the other. If the brand names match their price, then great. If they don’t, then the country has the right to go to generics,” he says.


In fact, many poor nations facing the AIDS pandemic have demanded less expensive drugs and better access to generics. These pleas led to concessions by the United States in August during a WTO meeting in Geneva and an agreement that will loosen global patent regulations to allow drug makers in middle-income nations to sell inexpensive generics to poor nations.


The USTR reportedly agreed to the deal after winning assurances that “countries would not take advantage of the arrangement to increase exports of generic drugs to nations that are not poor and do not have a medical emergency,” according to the New York Times. Furthermore, the agreement would require that special measures—such as unique packaging or colored tablets—be taken to prevent drugs from being smuggled back to wealthier markets.


However, word of the agreement was met with skepticism by advocacy groups because of reports of several stipulations, including: restrictions on the definition of “humanitarian use”; heavier burdens on suppliers to change the packaging of products; and a “review mechanism” creating another layer of bureaucracy to monitor usage and potential diversion of generics back into wealthy countries.


“[The WTO] deal was designed to offer comfort to the U.S. and the Western pharmaceutical industry. Unfortunately, it offers little comfort for poor patients. Global patent rules will continue to drive up the price of medicines,” Ellen ’t Hoen, coordinator of MSF’s Access to Essential Medicines Campaign, said in a press release.


STORIES OF HOPE


While the debate wages on, nongovernmental health organizations continue to fight the war against AIDS battle by battle, attempting to overcome the obstacles to treating the HIV-infected.


For Dr. Gildon Beall, that battle began at the age of 75, after retiring as chief of allergy and immunology at Los Angeles County Harbor-UCLA Medical Center Hospital. Fulfilling dreams he had since residency, Beall accepted an assignment from MSF treating the poor and HIV-infected in Surin, a city in northeast Thailand. “These are poor people that could not afford the medication, even if it is available,” he says.


But he was in Surin to do much more than just dole out medicines. His assignment was equal part education and public information, even if it was all conducted through an interpreter. “It was a bit of a teaching job to do because, although there is publicity about AIDS in Thailand, there is not much understanding in the community about taking the medicines and what they do, and of course understanding that there are side effects and you have to put up with them.”


Yet, Beall says, once the message gets through, most patients adhere to the HIV treatment, and the improvement could be quite visible. “It’s dramatic. Being a physician a long time, I have a tendency to dwell on the unusual and the problems. The usual thing when someone is in treatment is they start getting better.”


In one case, a middle-aged man was hospitalized with severe meningitis and was semi-comatose. Complicating matters, his wife had already died of AIDS, and he was the sole caretaker of their 5-year-old daughter, who was showing signs of the infection with severe weight loss and bad skin rashes. Both of them, thanks to MSF donations, were placed on antiretroviral therapies. “When I last saw the two of them, they were smiling and happy, and we helped him get a pig so he could make a little money…. Basically, he would’ve been dead and she would’ve been alone and dying without treatment.”


And there are similar success stories around the globe when medicine and treatment are made available. Dr. Greg Goodear, now a gastroenterology fellow at Tulane University School of Medicine, saw some of these hopeful cases while working at an MSF clinic in Homa Bay, Kenya. Thirty percent of the town’s citizens are HIV positive, almost triple the national rate. And in many cases, patients do not come in until they hit the absolute bottom.


Goodear says one of those cases was a 26-year-old man weighing 90 pounds. Testing showed he had a CD4 cell count—a measurement of T-cells that indicates the progress of HIV infection—of only one. The standard for needing antiretroviral therapy is having a CD4 count below 200. “When I first saw him, he was a walking skeleton that could barely walk. He could barely hold himself up in a chair,” Goodear says. But after months of treatment, the man’s CD4 count rose to 70, and his weight increased to 145 pounds. Soon he was back at work and living a normal life. “That is someone I know that if we weren’t there, he would be dead. It’s somebody we kept alive.”


Of course, not all patients survive or rebound from the onset of AIDS. Many are unable to make the trip to seek proper care, while some are too sick by the time they seek help, making treatment almost impossible. And in other cases, regardless of their health and apparent recoveries, some patients can’t be helped because of their approaches to the disease.


Goodear says this was the case for one woman who spent six months on therapy and was showing great signs of improvement with an increased CD4 cell count and significant weight gain. But only four months later she had to be hospitalized in a febrile state with meningitis and partial paralysis. “Turns out she got an infection because she stopped taking her medication. She thought she was cured,” he says. So the MSF physicians instructed her that she must always take her medication regardless of how she felt. After five months, she returned to the clinic where Goodear noticed she wasn’t filling out her drug information data properly. “So I ask her why, and she said, ‘I stopped taking my medication three weeks ago…because my herbalist told me that I don’t need to take those medications since these herbs will cure me.’”


Finally, health-care workers had to remove the woman permanently from therapy because of the possibility of creating a resistant strain. They were also concerned she would sell her medications to someone without proper medical supervision or a consistent supply, which would then put that person at harm. “So treating you is more of a danger to the community than just letting you go ahead and actually die. It was one of the tough decisions that we had to go ahead and make for the best interest of the overall community,” he says.


As for Enna in Haiti, she was one of the lucky ones, or as fortunate as one can be living with AIDS in extreme poverty. Despite the loss of her sixth child to severe jaundice, Enna has regained her health. After dropping to 108 pounds, she was started on an HIV treatment regimen and has shown steady weight gain. She has returned to a normal life, and as long as she has a supply of medicine, she will remain that way.
~HELPING HANDS


For many medical students and recent graduates, the first thought after hearing about a health crisis is “How can I help?” But when the health crisis is a global pandemic that affects millions of people primarily in nations far from home, it may seem as if the problem is just too big for them to have an impact. But by participating in programs sponsored by nongovernmental organizations, future physicians can help.


As a recent graduate, Dr. Greg Goodear, now a gastroenterology fellow at Tulane University, spent six months in a town in northwest Kenya treating HIV patients. While he knew little about the country or what he would encounter, he accepted the assignment from Doctors Without Borders because it enabled him to get personally involved in the fight against AIDS and still allowed him to return to the United States in time to start his fellowship. But more than convenient, it gave Goodear an unforgettable and valuable experience.


“I learned clinical medicine better than I would have learned in the U.S. You have to rely on your hands and stethoscope, as there was no available blood, liver, MRI tests. You just rely on your clinical knowledge and common sense. I feel like I have really made an impact in my patients’ lives and in the communities I have worked,” he says.


Along with Doctors Without Borders, there are other organizations that can help you assist HIV patients in developing nations, including Doctors of the World, the Global Service Corps, the Eritaj Foundation and the International Federation of Medical Students’ Associations.


Obviously, not everyone has the time or resources to travel abroad on medical and humanitarian missions. However, that doesn’t mean that you can’t get involved. Besides the usual actions of staying informed on the issues, writing to your congressional representatives and voting in elections, there are other ways to contribute to the cause. The quickest way is to make a financial donation or to even just buy a stamp—a UNAIDS stamp, that is. An extra 6 cents added to each commemorative stamp goes to the Global Fund to Fight AIDS, Tuberculosis and Malaria.


Other than money—something not many medical students have to spare—some nongovernmental organizations also seek donations of unused HIV therapy medicines. The Asociacion de Salud Integral and APAES-Solidaridad use a Web site to collect general medicines, antimicrobials, antifungals and antiretrovirals to be distributed in Guatemala and Latin America. Convincing hospitals and physicians to become contributors would be a big help, activists say.


But for many students and young professionals, the first step is to simply become part of the discussion. Groups such as the American Medical Student Association’s Health Professional Student AIDS Advocacy Network can help you learn about the issues. For more information about this network and other ways to get involved, go online www.amsa.org/global/amsaglobalaids.cfm.
—S.T.S.
~~~Scott T. Shepherd is an associate editor with The New Physician. Direct comments and questions about this article to tnp@amsa.org.~Advocacy,Community and Public Health,Health Policy,International Health,Pharmaceutical Industry~
160~8November~2003-52~Folk Tales~Following a Mission~CARING FOR THE POOREST OF POOR~Jennifer Zeigler~~It is the peak of the SARS outbreak. Dr. Jim Yong Kim is on the phone with a reporter in his office at Harvard Medical School’s (HMS) department of social medicine. His cell phone has already rung once—a member of his Partners in Health (PIH) team in Haiti called to check in with the PIH executive director. The digital ring sounds again. “I’ve got to go,” he tells the reporter. Geneva is calling, and he has to put everything else on hold.
Geneva, Switzerland, that is. At the time, Kim’s friend, Dr. Jong Wook Lee, had just been elected the World Health Organization’s (WHO) director general and asked Kim to come work as an adviser—a thrilling offer for this man who has committed himself since medical school to curing the incurable among the poorest of the poor.


But Kim hadn’t even packed for his trans-Atlantic transition when the newly named disease began raging its way through Asia and Toronto, and everything else took a backseat for a while to SARS. Until the epidemic died down, that cell phone—really any phone he got near—just wouldn’t stop ringing. What we let our friends get us into….


Not that things have slowed down much today. Kim, who’s regarded as one of the world’s experts on multi-drug-resistant tuberculosis (MDR-TB) and ran TB and AIDS treatment programs in Haiti, Peru and Russia, is overseeing the WHO’s recently released plan to get 3 million Africans on AIDS drug regimens by 2005. “I would say it’s the worst social disaster we’ve had in 600 years. We just need to get going,” Kim says.


His path to Geneva began years ago while he was a boy growing up in Iowa. “From a very young age, I was always interested in social justice,” he says of his involvement in the civil rights movement there. “I decided in college to sort of act out and participate in social justice. I didn’t know how that was going to happen in medical school, but then I met Paul, and it just happened.” Kim is referring to the friendship he forged at Harvard with fellow medical student Paul Farmer, who had already been volunteering his time with a community-based health program in Haiti. Taking the program several steps further, the two students founded Partners in Health (PIH) in 1987 to provide health care to the indigent population in Haiti’s Central Plateau region.


“You don’t need a lot to move beyond the intellectual and the moral to the practice. I can’t imagine being in a situation where I can’t feed my child. I’ve never lost the outrage that comes from seeing something like that. For me, it’s the pain of it, it’s the unjustness of it that keeps me going.”


It wasn’t long before PIH began sparring with the very organization Kim now works for. Convinced the WHO’s directly observed therapy, short course (DOTS) plan for treating nonresistant TB would never work with the MDR-TB that plagued PIH’s service area, the partners developed DOTS-Plus, a community-based treatment program that trains local residents how to effectively treat their neighbors with costly second-line TB drugs.


The WHO had dismissed the program as too expensive when PIH began using it in 1996 and had refused to fund the plan. “It wasn’t that we were having acrid debates, but instead of sitting back and taking pot shots, we’ve engaged them,” Kim says.


His diplomatic skills paid off: By 1998, the two organizations were working closely on DOTS-Plus; by 1999, PIH was lending workers to the WHO on an exchange basis; and by 2001, Lee, who was leading the WHO’s TB program at the time, came to Peru to see the innovative regimen for himself. That’s where he met Kim, and the rest is history.


Well, not quite yet. “I hope my experiences in starting programs that no one else said could be done will be helpful in [the WHO’s AIDS] efforts. I think the reason I’m being asked to go is that I’ve worked on problem solving,” he says. “It’s not as if we are such heroes. All of my work at PIH has been based on a mission statement that is preferential treatment for the poor. I’ve rejected cost-effective analysis. You can’t just ignore everything that’s happened in history. When we have heard that it is impossible to do, we have said, ‘Oh, yeah? Let’s show you that it is not impossible to do.’ I think that’s what the WHO is facing right now. Without enormous action, sub-Saharan Africa is just going to be destroyed.”


He says previous successes came from looking beyond the disease to the contributing problems: poor infrastructure, extreme poverty, illiteracy. “It’s not an academic discipline. If anything, it’s an engineering process. When you’re doing something like that, you have to be in a very detailed, problem-solving mode. I think that’s going to be so important in the future. I don’t think we can go out, collect the evidence. We need to be in a problem-solving mode as we go. I don’t mean to sound anti-intellectual—we’re not at all. [But] if we could sit down and tell you the number of problems we deal with every day—it’s been a pain in the neck, of course, but it’s been a tremendous learning experience.”


He may not be anti-intellectual, but for now, Kim has hung up his teacher’s hat, having given up his duties at HMS and Boston’s Brigham and Women’s Hospital, where he was an attending in the internal medicine department. But he says he could never leave PIH no matter where the WHO takes him. “PIH is a mission. Part of what I’m doing is moving to Geneva to work on that mission.”
~~~~Jennifer Zeigler is a senior writer with The New Physician. To learn more about Partners in Health, visit www.pih.org.~Community and Public Health,International Health~
161~8November~2003-52~Letter from Afield~The Quesadilla Diaries~OCCUPATIONAL HEALTH IN MEXICO CITY~~~There were many reasons to move to Mexico City. Among them was my desire to learn Mexican Spanish, to have an adventure and to see if the city is really as polluted as they say. However, the most profound—yet simple—of those reasons was Talia. We had been seeing each other for more than three years, and although much of that time was spent apart, there was no way I was going to let her leave California without me again.


I took two months or so of Spanish lessons, and I landed a job with the Economist magazine. My assignment was to look into the oldest story there is in Mexico City: the state of air pollution in the infamously coined “dirtiest city in the world.” My editor wanted to know what was being done about it, who the players were and how politics and corruption were involved. Even though I had no clue what I was doing, lacked journalism experience and skills, I looked forward to the research and the chase. Unlike everything I had previously written, what I wrote for the Economist had to be decisive and fresh.


However, my struggles with journalism were about to become quite insignificant. Shortly after beginning my assignment, Talia’s mom found a lump in her right breast and, a month later, she was diagnosed with breast cancer. Talia made plans to head back to California to be with her mother during treatment.


That left us with one month together in Mexico City until she would head north to spend the first summer with her family in many years. While we tried to enjoy our time, it was painful to watch Talia anticipate all of the possible outcomes of the cancer. So we desperately sought distraction. In the evenings we watched TV and videos, while Talia spent her days immersed in work and left me to my own devices.


With fractured Spanish and time to myself, I decided to throw myself into the investigation. I thought the best place to study the pollution was on the streets—specifically at Quesadilla Reyna, a closet of a stand that prepared the best quesadillas in the city. Of course the secret to the stand’s popularity was that the quesadillas were not quesadillas at all, but tlathuitlos, deep-fried corn tortillas, stuffed with cheeses and meats and folded into thirds, topped with beans, salsa and queso fresco. I was shared this secret by the owner, Polo, who gladly accepted my offer of an “unpaid internship.” Polo had owned the stand for more than 17 years and ran it with his sons, Alejandro and David, and his wife, Reyna, who the store is named after. These were the people with whom I would spend my final five weeks.


My official payment was two quesadillas and one drink each day. Unofficially, however, Polo committed to “teach me and show me things that no gringo has ever seen or learned.” In our time together, Polo taught me words that I would not have learned in years of Spanish classes: he taught me how to speak like a Mexican, how to take an insult and how to deliver one. He instructed me in the vocabulary of negotiations, then sent me out to the market to buy the week’s order of meat. “If they try to rip you off because you’re a gringo,” he would tell me, “just start yelling that they’re selling dog meat.” It worked.


Polo also showed me things only a native would know. He took me to the pulquerias, not-so-reputable institutions dedicated to serving pulque—an inexpensive drink made of fermented cactus but much stronger than tequila—to the city’s lowest class. The sign on the front listed four things not allowed inside: gringos, women, police officers in uniform and underage children, although no age was specified. Thanks to Polo, an exception was made for this gringo.


My boss and mentor also took great interest in the work I did for the Economist. One day we were discussing an article I had done concerning air pollution regulations. When I commented how air quality had improved since 1989 legislation prohibited dirtier cars from being driven one day a week, he laughed and told me to come with him. He drove me in his 1972 Volkswagen Beetle to an alley a few kilometers away. There we found a man with a new Audi and an emissions testing machine. Polo paid the man 500 pesos (about $50 dollars), and we watched as the man ran the machine on the Audi. Polo took the clean bill of health to use for his car, smiled at me and said, “Ahora puedo circular todos los dia”—“now I can drive every day.” He said politicians in Mexico City could make laws but people did what they needed to do to get by. And as long as 9 million residents lived in poverty, he said, the city would run under a system of corruption and mordidas, Mexican slang for bribes.


Of course, when it comes to poor air quality, Quesadilla Reyna had its own issues. The little stand was without ventilation, and fumes from the deep-frying filled the entire store, drowning us in it. Whenever a big order would come in, the smoke and particles became so unbearable that I would have to leave the stand, my eyes watering, mind racing, head pounding and chest contracting. I experienced what life must be like for the majority of the world, where work is a necessity, and healthy working conditions are an unimaginable luxury. Polo and his family had endured this for 54 hours a week for 17 years. While they were certainly accustomed to it, their lungs, upper respiratory tracts and eyes were not immune.


One day I asked Polo if there were any laws requiring him to install ventilation to mitigate the exposure. He said there were regulations but he couldn’t afford to comply. It is cheaper for him to bribe the inspector annually than to install a fan, he said. Through the fumes and heat, Polo inadvertently taught me a great lesson in occupational health— that policies aimed at protecting people’s health on paper could potentially threaten their livelihood in reality. He reaffirmed my belief that everyone should have the right to healthy and safe working environments but showed me how this idea is rarely realized.


Most importantly, what I learned from Polo and my time at Quesadilla Reyna was that everybody has the right to take pride in their work, be it art, health care or quesadillas. The technique that went into making those quesadillas took skill and practice. Whenever I would make an error—as I often did by leaving uneven folds, lumps of cheese or uncooked corners—Polo would let me know and insist on perfection. At first I thought that he was being unreasonable. After all, these were just quesadillas. But to him, they were more than that.


To him, the quesadillas represented a lifetime of struggles and disappointments leading to the point when he could own his own business and support his family. Watching the joy and pride with which he would greet his customers, I didn’t doubt that what he was providing to the people of Mexico City was just as significant and important as anything a physician, lawyer or politician could offer.


As I later came to understand, medicine is a profession filled with egos. It is easy to feel that what we do is more important than other jobs, that what we deliver is inherently more valuable, and therefore we are entitled to a certain level of respect and awe. I was filled with more respect and awe for Polo and his work than I ever thought could be possible. I pray that someday I will be able to approach my work with the same pride, enjoyment and precision as Polo did.
~~~~Eric Amster is a second-year at the University of California, Davis, School of Medicine and still makes quesadillas for friends and family.~Community and Public Health,International Health~
163~8November~2003-52~MedMentor Q&A~To Report or Not Report?~CONCERNS ABOUT SUSPECTED CHILD ABUSE ~~~I am a third-year medical student, and I just started inpatient internal medicine…. My question deals with patient confidentiality and child neglect/abuse. The third week into my hospital service, I took care of a patient who had overdosed on amphetamines and was in the intensive care unit. She was transferred to our medicine service a few days later. I asked about her social history as part of the work-up, and she told me that she had two young children who live with her. Per the psychiatry consult, I read that she was doing drugs every day. I asked the attending if we should report her to Child Protective Services, and he said that, even if we did, nothing would happen. Also, we had no reason to suspect abuse. Children cannot decide for themselves who they live with or what their parents do, so is it fair to grow up in that environment? We wound up not making any calls, and the mom left our service against medical advice that evening. What would have been the best course of action?


Dr. Robert W. Block, chair of the American Academy of Pediatrics’ Committee on Child Abuse and Neglect, responds: This question identifies several issues common to the field of child abuse: What is a reasonable suspicion of abuse? Who should report? And when and what should happen after a report is filed? The issue of patient confidentiality is important, particularly as the medical field learns how to deal with the Health Insurance Portability and Accountability Act regulations. However, in all states and the District of Columbia, child abuse reporting is mandatory, and protecting children supercedes all other rules.


Let’s approach the answer by first considering another question: What is a report of suspected child abuse? Is it an accusation? No. Is it a diagnosis? No. The key word is “suspicion,” meaning a medical professional has good reason to believe a child may be in an “at risk” situation. The report is best seen as a request for further investigation by professionals trained to visit homes, interview parents and collateral individuals, and collect information to confirm or rule out abuse. Since child neglect is overwhelmingly the most common form of abuse, and since it is reasonable to assume a drug-addicted mother may be incapable of caring for her children without support, a report in this case—made in good faith and with reasonable cause—should have been made. We should be reminded that failure to report a reasonable suspicion of abuse is a crime in most, if not all, states.


The comment that, even if the suspicion were reported, “nothing would happen” may be true. However, it is an unprofessional attitude that assumes child welfare cannot do its job. If—after an investigation by child welfare and perhaps by law enforcement—no clear evidence of abuse is documented, the case cannot legally go forward, although the mother may be offered services on a voluntary basis. However, without an investigation, obviously nothing will happen. Unfortunately, if the children are judged to be deprived, the chances for successful treatment of the mother and unification of the family are slim. Equally distressing is the small chance that the children would have a smooth transition to and continued success with good foster care.


Each of us has a role to play in a situation like this. The physician’s role is to recognize the biopsychosocial issues, to decide if he should reasonably suspect abuse or the potential for abuse in a situation, and to report that situation appropriately if abuse is possible.
~~~~Robert W. Block is also the Daniel C. Plunket chair of the department of pediatrics at the University of Oklahoma College of Medicine.~Practice of Medicine~
164~8November~2003-52~Feature~A Tale of Two Personas~~Jennifer Zeigler~~Surgeon General Richard Carmona was having lunch with his four kids at a fast-food restaurant not long after the Senate unanimously confirmed him to the post. It was a normal, fatherly thing to be doing in Pima County, Arizona, where the trauma surgeon held a host of civic and educational jobs before President Bush nominated him to be the 17th surgeon general. His son pushed a box of French fries over the table to him, offering a sample. Instinctively, Carmona took one of the golden temptations and put it to his lips before noticing the entire restaurant was watching to see if he’d eat it. It was at that moment, Carmona says, when he realized his actions had repercussions on the entire nation’s health. He put the French fry down.


It’s not that the new surgeon general isn’t used to the limelight. Carmona’s rags-to-riches story of a high-school dropout from Harlem who made good in the military and went on to medical school is the stuff of movies. When you pair that with his flamboyant public service career, his persona starts to become action-hero big.


Growing up in an underserved Latino community in New York City, Carmona got his first taste of the provider side of medicine when he enlisted in the U.S. Army in 1967 and served as a medic in Vietnam before becoming a member of the Army’s Special Forces. Later, he pursued his undergraduate and medical school studies at the University of California, San Francisco, having already earned his GED in the Army. He went on to a surgical residency, eventually becoming a trauma surgeon. He’s worked as a registered nurse, paramedic, hospital CEO, and a professor of surgery, public health and family and community medicine.


He’s also worked as a deputy sheriff for Pima County, dangling from a helicopter to save someone stranded on a cliff, and shooting and killing a murder suspect during a roadside shootout in 1999. He’s a certified peace officer with expertise in special operations, emergency preparedness and weapons of mass destruction. He not only served on the county’s SWAT team—he also trained other officers.


So he’s not your average physician, but so what if his escapades have earned him the media’s and Hollywood’s attention—the helicopter save was turned into a made-for-TV movie. Carmona’s critics complain that for all his larger-than-life adventures, he’s practically invisible now that he’s the surgeon general—the nation’s physician.


“Most people don’t know who he is. Where is he?” Rep. John Peterson (R-Pa.), who sits on the Appropriations Committee’s Health and Human Services Subcommittee, complained to the Associated Press earlier this year.


Most likely, he’s on the road. He travels more days than he’s home some months, heading this past spring to Dallas to speak to the Federation of State Medical Boards, to Baltimore and Harvard University to speak about prevention, to tiny Princeton, Kentucky, to talk about prescription drug reform and to Capitol Hill to testify before Congress on tobacco policies. He often speaks before children—childhood obesity being one part of his focus on preventive medicine—and in April he launched his “50 Schools in 50 States” campaign, in which he aims to visit one school in each state before his four-year tenure is up in 2006.


But the complaints about his public disappearance may be more connected to his administrative philosophy than to his travel schedule. Unlike outspoken surgeons general before him—such as Dr. C. Everett Koop, who regularly sparred with President Reagan over the administration’s AIDS policy, and Dr. David Satcher, who tested President Bush’s conservative positions with his report on sex education—Carmona has been reluctant to speak out against current Bush administration health policy, which has been criticized during the past year for such policies as a decision to remove a government fact sheet on condom use from a Centers for Disease Control and Prevention Web site and a smallpox vaccination plan that was called overly ambitious by some. He says he sees his role as more of an advisory position.


“My style is that I’d rather bring people to the table and achieve a consensus on issues than trying to be the lightning rod, maybe, and maybe causing further divisiveness. And you know, everybody has a different style. And there may be times when I have to step out and really be forceful, but I can tell you from my personality, generally I would rather work quietly behind the scenes when necessary to bring the appropriate people together to achieve a consensus so that everybody feels they’re moving along in this, and nobody is left out,” he says. “Obviously that doesn’t always work, and when and if the time comes that I need to step out in front of an issue and be very visible and maybe take a position contrary to others, I’m prepared to do that. But I really haven’t been confronted with anything like that.”


Carmona has made one step outside the Bush line, however, telling Congress in June that he would support the abolition of all tobacco products—much to the surprise of administration officials. Still, he says, when it comes down to policy decisions, “we all get to weigh in, [but] the president gets to make the decision.”


It’s certainly not a position you would think a take-charge kind of guy would be comfortable with, but Carmona says he’s satisfied with his first year. “There are so many things that I’ve accomplished just in surviving and learning Washington and finding out who the stakeholders are and bringing diverse groups of people together to try to move an agenda forward.


“You know, I mean, it’s a very complex situation…trying to get your arms around the entire nation—300 million people almost—and then to learn that really the position is also a global position, because so many of our allies and others around the world rely on what we say and what we do as the standard…. So I think there’s incremental benefit, but as you know, something this large, it’s tough to measure it after a year.”


Besides, he says, he can proselytize about health policy all he wants, but if Congress doesn’t jump on board to authorize and fund programs, little would get done on his priorities, which include preventive medicine, emergency preparedness and health disparities.


“So far, I don’t know if I have so much sway, but I’ve been spending time meeting our elected officials. I’ve established very good working relationships with them. My goal is that they see me as their consultant, as an asset, as an ally, so that as things come across their desk that they need to weigh in on, that they feel that they can speak to somebody, because that’s part of my job…. [On] a number of other initiatives that require funding, so far we’ve done very well,” he says, referring to such Bush initiatives as his commitment to fund 1,200 community health centers to alleviate health disparities in underserved areas and the influx of dollars appropriated to increase the nation’s state of emergency preparedness—although both of these programs were started before Carmona arrived in Washington.


“Now, we don’t always get everything we want, but incrementally, we’ve improved. And it’s not just funding, but it’s, in fact, tying together research, tying together clinical programs, and moving the country along so that they understand a lot of this improvement is within their reach,” he says. “We’ve gone a long way. So overall, I’m fairly pleased that the president, the [Department of Health and Human Services] secretary [Tommy Thompson], the Congress, that we all seem to be in sync and understand some of these critical issues.”


So what is his role on Team Health?
“You know it’s one of the unique aspects of being surgeon general that you have that bully pulpit, and one of the things you can use it for is to educate….


“I think the measure of effectiveness of any surgeon general is largely going to be left to the public and the press. And if I look back historically, there have been some surgeons general who have done very good things but they’ve done them quietly and almost anonymously. We’ve had others that have been larger than life and have accomplished things too. So I think, you know, I think it’s something that is a legacy that is looked on historically to see what you’ve accomplished.


“And certainly I would think that the surgeon general being a visible leader on health issues is one of those measurable outcomes. Others would be incremental change in any of those projects that we engage in. But realizing that the surgeon general is but one person…it involves our elected officials, appointed officials, you know, Congress coming to terms with issues, and so on.”


The issues Carmona focuses on are dear to his heart, he says. “My whole life, really, has impacted on the way I see health today. I was a poor child. I was one of those health disparities. I was one of those kids who couldn’t access care, [who] had toothaches but couldn’t get to the dentist. I came from a Latino family, grew up in a poor neighborhood. I understand the issues that are facing the underserved populations today; I’m very sensitive to them because I was one of them….


“And as I move forward, and I look at my [career history] in retrospect, it’s almost as if I have been training for [this] job my whole life, because every one of these priorities before me, I have some very real experience as well as the academic training…. So it’s really been truly an extraordinary experience, because now as I sit at the table and I have to deal with issues like this, I really draw on those past experiences…. So it’s been great for me.”
~~~~Jennifer Zeigler is a senior writer with The New Physician. Look for further updates on the activities of the surgeon general and on Bush administration health policies in future issues of TNP.~Advocacy,Community and Public Health,Health Policy~
165~8November~2003-52~Feature~Developing the Right Relationship~~Jennifer Zeigler and Rebecca Sernett ~~Let’s face it: Drugs—and the
companies that make them—are going to be part of your future practice. But how you choose to interact with pharmaceutical reps will be entirely up to you. With little or no information coming from medical education, you might want to turn to the guidelines offered by everyone from organized medicine to the industry itself. Here’s a look at many of the policies, as well as an introduction to some students who learned about the industry firsthand while working as drug reps before entering
medical school.


Dr. Michael Goldrich, an otolaryngologist in New Brunswick, New Jersey, is recounting, with some disgust, times now largely past: days when aggressive pharmaceutical representatives would invite physicians on all-expenses-paid trips to sunny Puerto Rico for educational pharmacology workshops. But, he says, the reality was that the trips “amounted to little more than weekends on the beach with a little chat over lunch.” Spouses were included on these excursions, of course.


Dr. Bob Goodman, an internist at New York Presbyterian Hospital, backs up these stories with some of his own: Broadway tickets, fancy dinners and the infamous “dine-and-dash” events in which drug reps would order takeout for physicians to pick up and bring home to their families. “And that morphed into all these other things—the ‘gas and go’ and roses on Valentine’s Day,” he says.


Goldrich and Goodman agree that while some of these drug marketing tactics are still being used by reps today, many of them have been eschewed for less tempting gifts. “I think most of the egregious stuff has stopped,” Goodman says.


Why the slowdown? Goodman says drug companies don’t need any more bad press about their tactics, and that exposure has come thanks in part to a flurry of new policies providing guidelines for interactions between reps and the physicians who prescribe their products. A little education can have a serious effect, say those who watch this issue closely.


AMA BREAKS GROUND


While many of the policies have sprung up in the past couple of years, the American Medical Association’s (AMA) policy has been around since 1990. Goldrich, who serves as the AMA’s chair of its Council on Judicial and Ethical Affairs, says the policy resulted from physicians voicing concerns about some of the marketing tactics
drug reps were using at the time. “I think the history of it is very much a reflection of the marketplace,” he says.


So, into the AMA’s Code of Medical Ethics went Opinion 8.061, which holds that gifts should be of a benefit to patients and not of significant value. Texts, modest meals and other gifts are OK; cash is not. Gifts from drug reps should be related to the physician’s work, and money should only change hands to cover participation at continuing medical education events, but not if it goes toward travel expenses to get to the event. (The money should go first to the conference organizer and then to the attendee, because a direct link from drug rep to physician “could influence the use of the company’s product.”) Scholarships are OK only if medical schools decide who should get them, and finally, if strings are attached, the gift is a no-no.


At first, Goldrich says, the policy was deemed a success, as there was “a quieting of these activities.” But when the AMA began to notice an upswing in overly generous gifts within the last five years, it began a three-year initiative in 2000 to further educate physicians about the guidelines and the ethical pitfalls that can come from not adhering to them.


Through direct-mailings and a series of educational modules on the AMA’s Web site, the initiative has reached out to medical students, residents, practicing physicians and the pharmaceutical industry. Goldrich says the move has paid off.


“If you look at the initiative as a whole, I think it’s been enormously successful. It’s put the brakes on some of the egregious practices.”


Goodman—who also heads up the No Free Lunch initiative, which works to get physicians to stop accepting what he calls “bribes” from the pharmaceutical industry—admits that while the AMA policy might not go as far as he’d like, the Web-based learning tools are pretty good.


Yet Dr. Lauren Oshman, president of the American Medical Student Association (AMSA), charges that the AMA’s efforts are flawed because the educational initiative was funded by grants from nine pharmaceutical companies. “I think the stumbling block for other medical organizations is that they take money from pharmaceutical companies. It’s really a tough conflict of interest for them.”


Goldrich says the criticism of the AMA’s initiative is generated by confusion over the type of grants the companies gave. “An unrestricted grant is different from putting $100 in the pocket of a physician,” he says.


SPRINGTIME TURNS TO THOUGHTS OF GIFTS


With the AMA’s guidelines generating increased awareness, many in organized medicine saw a need to pass their own sets of standards, with several new policies hitting the streets in spring 2002.


AMSA was no exception. “Other medical organizations such as the AMA were passing these guidelines that they have no intention of enforcing because they are just guidelines. AMSA wanted to pass its own policy,” Oshman says.


And so it did, passing a guidance at its 2002 convention that asks medical students, residents, physicians, hospitals and residency programs to refuse any gift, honoraria, lunch or even any interaction with drug reps. “I think as long as the policies reflect convenience and modest-scale gifts, there’s a problem. The natural conclusion is that medical students should not take gifts from the pharmaceutical industry, including lunch,” says Oshman, a recent graduate of Baylor College of Medicine.


Ouch. Anytime you cut into a hungry medical student’s access to free food, you’re bound to ruffle some feathers. To be sure, there are future physicians who say they don’t think the policy needs to be that restrictive, but Oshman says signing AMSA’s PharmFree pledge—as only several dozen students have done so far—can improve education. “Medical students use the pharm reps as a crutch and never truly learn the pharmacology behind a medication.”


She says the policy is part of AMSA’s future goals. “We focused on the strategic initiative, ‘transforming the culture of medicine,’ and it’s just been a ramping up of this. I think students appreciate having an alternative to this,” she says, waving the AMA guidelines in her hand.


And alternatives abound. Soon after the AMSA policy began generating controversy, the pharmaceutical industry unveiled a set of voluntary guidelines for its sales force. The Pharmaceutical Research and Manufacturers of America (PhRMA) Code on Interactions with Healthcare Professionals limits gifts’ values to under $100 and eliminates those, such as the dine-and-dash events, that have no clinical value. For example, for those representatives who choose to comply, anatomical models are in, and golf bags are out, even if they have a drug name emblazoned on them.


PhRMA consulted with the AMA before issuing the policy, and Goldrich says the guide has been effective. “This has been a wonderful example of cooperation of both interests. I think there has to be ongoing discussion between industry representatives and physicians.”


A spokesman for PhRMA, who did not return calls from The New Physician for this article, told the magazine last year that its voluntary policy eliminates the need for governmental intervention, such as the law passed by Vermont last year, which mandated pharmaceutical companies track and report physician gifts worth more than $25. The first reports for the 12-month period ending in June 2003 are due to the state’s Board of Pharmacy on or before Jan. 1, 2004, and the secretary of state is expected to release her findings in March. Although the first year’s forms will not require drug reps to name the gift recipients, a spokeswoman for the Board of Pharmacy says the matter is still under some debate.


Governmental regulation is not unheard of, although Vermont is the first state to try it. Goodman says the AMA policy was born from a series of Senate hearings convened by Sen. Ted Kennedy (D-Mass.) in which the nonprofit, public interest organization Public Citizen got involved. And while federal reform didn’t evolve out of the hearings, Oshman says she hopes some regulatory body, such as the Liaison Committee on Medical Education (LCME), which accredits medical schools, will step in and issue a policy with some teeth to it.


Her wish might seem radical in the current climate of voluntary guidelines, but one of the LCME’s two sponsors, the Association of American Medical Colleges (AAMC), did issue five “guiding principles” in February, and executive director Dr. Jordan Cohen says the organization is “monitoring the situation closely, and in the future we might see the need for some more specific guidelines. I don’t think the public’s being well served at all under the current system.


“This, of course, is not a new issue. The issue that’s becoming increasingly clear [is that] the kinds of interactions, particularly the gifting, does have an influence on prescribing practices.”


The principles came out of the AAMC’s Organization of Resident Representatives and aim to ensure that residents are properly educated on the issues involved. Some residents say that with little formal education on how to deal with drug reps, they find some of the marketing practices too much of a surprise in the early weeks of residency training, and they don’t always know how to determine what’s the best personal policy for themselves.


So, the AAMC’s principles encourage residency programs to look to their specialty societies and hospitals for guidance in setting policies for resident–drug rep interactions and to teach their residents about how to evaluate drug industry information.


The federal government did jump into the gifting arena in April, although the guidelines issued by the Department of Health and Human Services’ Office of the Inspector General (OIG) are also voluntary. “We’re simply laying out what our expectations are. We think it’s in your best interest to comply with this regulation. This is an outreach,” says Ben St. John, an OIG spokesman.


The guidance is directed at pharmaceutical manufacturers and is designed to reduce drug costs and help the industry avoid federal investigation under kickback laws. It regulates only activities with physicians and other medical providers who bill federal medical programs such as Medicare and Medicaid, and its guidance cites behaviors similar to those found in PhRMA’s policy, even referring drug companies to that code. It also addresses the resale of free drug samples, which can be illegal under the False Claims Act.


The federal guidelines were needed, Goodman says. “There’s no question that what the government calls a kickback—these [gifts] were kickbacks.” And the policy has scared people a little, he says.


St. John says it’s the OIG’s duty to offer guidelines to this industry. “That’s our responsibility—to protect the integrity of federal medical programs. Certain conduct that’s acceptable in the private sector is different from what goes on with Medicare and Medicaid providers.”


CHANGING BEHAVIORS


Goodman says all the talk about different policies is a good thing. “Just by talking about it and educating students and the public about it, most people would come to realize [taking gifts is] wrong. Practicing on the basis of promotion, that’s a bad thing.”


So he’s encouraged by the host of new policies out there, even if they aren’t as restrictive as his No Free Lunch organization’s dream of no interaction between medical providers and drug reps. “I’d like to think that [they came about] because of more attention that has been brought to the issue. It was such a part of the culture. No one really gave two thoughts about it [before],” he says.


But through increased education, more physicians and students are thinking about what the perfect fit is for physicians and the pharmaceutical industry. For example, at Goodman’s New York Presbyterian Hospital, drug reps must have an appointment to meet with a physician, but they may not leave free drug samples behind, and they have no interaction with medical students and residents. “It’s so easy to get information now about drugs,” Goodman says, ticking off handhelds, journals and the Internet. “Residents should never have gotten information from reps.”


But Goodman doesn’t shy away from the subject entirely with his residents. “I’m not saying we shouldn’t talk to students and residents about this,” he says. He leads residents in discussions about pharmaceutical marketing strategies in an effort to help them discern the reps who know what they’re talking about from the ones who don’t, “which can be fun—picking apart drug ads,” he says.


And at Loyola University’s Stritch School of Medicine, the internal medicine residency program has also ended pharmaceutical-sponsored lunches and conferences, although sales representatives are allowed in the department two afternoons per week.


Recognizing that these issues hit residents without much warning, some schools have heeded the call for increased discussion and instruction. Wende Gibbs, a second-year at the University of California, Irvine, College of Medicine (UCI), says she organized a presentation on the subject for other first- and second-years as part of UCI’s Ethics and Professionalism Project. “Students seem split on this issue. They are also very interested in it. We do not hear about this topic anywhere else in our first four years, so I thought it was important to introduce these ideas to the students early in their medical education,” Gibbs says.


The topic is also up for debate at the University of Rochester School of Medicine and Dentistry, and lively discussions ensue at many gatherings, says second-year Corey Fehnel. But despite the exposure to some of the ethical questions surrounding interaction with drug reps, Fehnel says making up one’s mind on the subject can still be challenging. “It can be incredibly difficult for young medical students to make an independent decision when the role of the clinical preceptor is even more intrinsic to their functioning during the first year. Many students feel considerable pressure to yield to decisions made by their preceptor and not by themselves.”


That’s why Goodman says the key to better ethical marketing practices is education and better role modeling. “Physicians have to change, and the policies are an important part of that.”
~IN THE LIFE OF A DRUG REP

Keith Carter

For Keith Carter, working as a product and pharmaceutical rep in the South for almost four years helped him realize what he wanted most—to return to the clinical side of medicine, but this time as a physician. So the paramedic who had been marketing new advanced cardiac life support and recommended American Heart Association guideline drugs, among other items, to emergency rooms, fire departments and emergency medical services (EMS) went back to school, took the MCAT, “and here I am, in medical school.” The U.S. citizen is now a second-year at St. Eustatius School of Medicine in the Caribbean.


“I can say that being closer to all aspects of the health-care system allowed me to set my goals and know what I wanted. This is to be [an] emergency medicine physician that can liaison into the EMS area without hesitation.”


Like many future physicians who have navigated medicine from this other side, Carter says the sales stint taught him a lot about the business of health care, particularly how the pharmaceutical and product industries interact with practicing physicians. And while he felt comfortable in the sales role—with his clinical knowledge and the four weeks he spent learning about new products each year—he was less sure about some of his colleagues. “Unfortunately, the truth is that [drug reps] do not have the proper education and background. You have good-looking liberal arts majors selling angioplasty products. [And] the turnover is the biggest concern.”


Carter usually marketed the products face-to-face, occasionally communicating with physicians by e-mail or fax. Sometimes he’d leave pens and product literature, and other times he’d send notes on delivered cookie baskets. He’d also provide lunches to physicians’ offices and sponsor lunch conferences for residents at teaching hospitals. “This service provides an invaluable conversation piece and gets [the] client comfortable with the product line.”


The future emergency medicine physician says he’ll welcome drug reps in his practice, but he’ll establish some guidelines. For one, he’ll be honest with representatives about what he wants from them. “I know physicians that will listen to 15 minutes of a sales pitch and then say, ‘No.’ This leaves the rep with a bad taste in their mouth. I also know sales reps that only know their 15-minute sales pitch and cannot hold an intelligent conversation about their product.”


He advises soon-to-be physicians to deal with reps in a similar fashion, stressing the “honesty” factor. “Never play the rep for freebies, trips, food. This will always come back to haunt the situation.”


And how should medical students intermingle with the pharm sales force? “There is no need for any first- or second-year med student to [have] any interaction with any rep. But in the third and fourth years, it would be OK. The young med student would be too much of a pushover; the rep would think they are getting something out of it when they are only wasting their time, not to mention the medical student’s.”


Even with these caveats, Carter says he sees these salesmen and women as essential to medical practice. “Physicians and nurses cannot stay on top of the topics and research. The drug reps play a vital role in getting the latest information out to patients, via the physician.” —R.S.


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


IN THE LIFE OF A DRUG REP

Chris Walker*

For six months, Chris Walker visited Los Angeles-area physicians’ offices, marketing ACE inhibitors, beta-blockers and an angiotensin receptor blocker.


“I became a drug rep mainly because it paid well and allowed me to reintroduce myself to medicine, which was always my career interest,” says the now fourth-year medical student. “The job had great hours, flexibility, fun events and lots of independence.” With a background in biological science and some sales experience, he says it “was a good fit.”


But the U.S. citizen who is pursuing his degree in Europe doubts the impact his half-minute drug spiels and brief medication fact sheets had on physicians’ prescribing habits. “I felt the job a bit silly, as insurance coverage tended to dictate prescription writing. If your drug was on the formulary, it sold well. Dealing with doctors was actually a small percentage of the day. We were happy to get one minute of face time with a doctor. As we often bore gifts and always had samples, they were usually happy to see us, as long as we didn’t get too pushy….


“…[But] we mainly served to remind the folks of our trade name and drop off samples. It is hard for me to imagine that a drug rep can go into a physician’s office and convince him to change his prescribing ways. I know how hardheaded docs can be. I really think that most prescribing habits come from residency, from what your attendings want you to write for. And the impetus to break these habits would tend to be from an insurance company not paying.


“To change a prescription pattern, a doctor would basically have to throw away some comfort level, dealing with a drug he knows and switching to another, with a different dosing regimen, side effects that he is not familiar with, etc. I just don’t see a minimally trained drug rep—when compared to the medical education of the doctor—being able to overcome that with some pens and a 30-second pitch on why he should use this beta-blocker over that one.”


But he’ll allow visits from a select few at his practice, which will either be OB-Gyn or general surgery. “If I have time, absolutely. If they prove to be a well-informed resource, I will continue to see them as time permits. If they prove to be merely a pretty face or a salesperson who offers little value, I will not continue to meet with them….


“I think that docs can certainly get enough information without the drug reps, but it would [come] with a higher cost of time investment to the doctor. I think that by using a combination of sources—peers, meetings, reps, literature, etc.—a doctor can be well-informed without having to read up on new drugs every evening.” —R.S.

*Requested his name be changed.


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


IN THE LIFE OF A DRUG REP

David Smith*

David Smith has been taking allergy medications since he was a child. “It’s the only medicine I personally use,” says the second-year medical student who attends a West Coast medical school. “It was not a challenge for me to go in and sell these drugs because I believed in them so strongly. I think that is really important—especially in this field. If you don’t believe in what you are selling, how can you make others believe in its benefit?”


A biology grad who wanted to pursue an M.B.A. as well as an M.D., Smith became a drug rep believing it would offer him good work experience and an understanding of the field that couldn’t be gleaned from medical school. He says he wasn’t disappointed with the almost seven months he spent working for a pharmaceutical company. “I feel that it gave me an excellent perspective of the medical field from the other side.”


After a five-week training period, he visited a variety of health-care and economic settings, gaining insight into physicians’ routines, especially their interactions with the drug industry. One eye-opener, he says, was learning some medical practices were inundated with as many as 15 to 20 reps daily. “It was interesting to see so much money being spent on these sales forces.”


Although he didn’t give gifts to physicians, he thought the competitors who did had the upper hand. “Those little gifts keep the drug in mind,” he says. He saw his sales role more along the lines of “reinforcing the science part of it.”


And while he says he felt “completely confident to the benefits and safety of the drugs” he pitched to physicians, he wouldn’t take every drug reps’ words as true or completely trust their information. Before he begins prescribing medications to patients—in a field yet to be determined—he will do his own research.


Still, he says, drug reps “are great resources to tap into. They have hands-on experiences that you can never learn from reading a textbook or sitting in a classroom. They spend days on end interacting and building relationships with medical personnel from all parts of the world—and industry—and understand a very different aspect of the medical field. Armed with that knowledge, a student will develop a well-rounded understanding of the field.” —R.S.

*Requested his name be changed.


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


IN THE LIFE OF A DRUG REP

Bryan Canterbury

“I was never uncomfortable with any aspect of my job; I rather enjoyed it,” Bryan Canterbury, a second-year at Flinders University School of Medicine in South Australia, says of his five-year career as a pharmaceutical rep in the Washington, D.C., area. “I was reliable, both in my actions and my data, and was respected by both my peers and the health-care professionals I called on.”


But he didn’t feel the same about some of his colleagues. “There was one occasion where I had a representative from a competing company tell me they were hoping for a bad allergy season to really boost their sales numbers. I’m not kidding—she was hoping for misery to pad her bottom line. I was appalled by her and the statement.”


The U.S. citizen, who plans to return to the states to practice, is undecided about what medical specialty he’ll pursue—“Most likely internal medicine, although I still toy with doing emergency medicine or cardiology”—but he is sure of how he’ll interact with drug reps and offers the following advice to fellow future physicians:


“Remember, they have a product to sell—keep that in mind. That is how their info is oriented. They are no different than Ford or Coke.


“Make sure if a rep shows you data, they can back it up with a paper or journal article. You can make pretty graphs that can say anything. Go straight to the data for the real story, though.


“By all means, talk to the reps. Listen to them. Get to know them. But learn the ones you can trust. Like anything else involving big dollars…[the drug industry] does attract people who are only out for the bottom line: making money at the expense of all else—i.e., your patients.


“Let reps see you during lunch. It gives the staff a free lunch, gives you a few minutes worth of a break and gives the rep a chance to tell you something you might find intriguing—more than you can learn in a 20-second sound bite.


“Dinner and other programs are nice, and they can be social, but do them in moderation. [There’s] nothing worse than being known as a dinner hog.


“Also, at programs, the speakers are usually hired guns and will speak accordingly. Make sure their data is good and not over-slanted towards the host company’s products. I know of several physicians who made over six figures speaking for one drug company, and that was in one year. Guess what they will promote?


“Finally, drug reps are not evil bottom-feeders. There are some you hope never enter your office again. [But] most are really nice and know their stuff, and [there are] the exceptional few who can speak wonderfully on disease states, their products and have insights that are valuable.” —R.S.


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


ONLINE RESOURCES


To learn more about various organizations’ guidelines for physician–drug rep interaction, visit these Web sites:

~~~Jennifer Zeigler is a senior writer for and Rebecca Sernett is editor of The New Physician. Direct comments and questions about this article to tnp@amsa.org.~Pharmaceutical Industry~
166~9December~2003-52~Perspectives~Commodity or Public Good?~PROPOSING A PARADIGM SHIFT~Anjali Taneja~~In 2005, I will graduate and become a physician. Graduation will afford me the ability to prescribe medications, promote good health and prevent disease among my patients. I should be more excited about the prospect of healing, but I’m already jaded. While advancing through my medical training, I’ve witnessed the gaping holes in our health-care system and have experienced the frustration that comes with knowing they exist. It is frightening to realize that despite my years of training, physician title and absolute dedication to the service of healing, I will often not have the means to guarantee my patients the medications and care I know they need.


Although the United States is home to some of the most advanced medical technology and services in the world, the inequities in our system are not only striking, they’re deadly. More than 43 million—or 15 percent—of Americans are uninsured. The U.S. Census Bureau’s most recent tally indicates that last year marked the largest single increase in the number of uninsured Americans in a decade.


Many more millions of Americans are underinsured and unable to receive coverage for important preventive health and medical treatment services. A 2002 Institute of Medicine report—“Care Without Coverage: Too Little, Too Late”—revealed that more than 18,000 people die prematurely every year from a lack of insurance. And this year, the National Committee for Quality Assurance estimated that 57,000 Americans—insured and uninsured—die needlessly each year because they do not receive the best care. Influencing this statistic are patients’ inabilities to pay for physician visits, mental health services, prescription drugs or nursing home care.


Sadly, I have encountered many elderly patients who split their pills in half or take their medicines only every other day to avoid facing the economic hardship of refilling their prescriptions. I’ve also watched with alarm and sorrow a diabetic patient die of kidney failure because he went years without access to care. These tragedies remind us there are lives behind the statistics. More than anything else, the crisis of the uninsured is a human crisis. So economic solutions and political rhetoric aside, we must ask ourselves this basic question: Is health care a public good or is it just another individual luxury in our culture of commodities?


We live in a country in which markets permeate every aspect of our lives. Even something as freely available as water is packaged and sold to us. Markets also invade health care. After all, doesn’t economics tell us that markets often increase competition and lower costs? Unfortunately, health care does not work this way. Health insurance is not something that can be marketed to be efficient for society as well as good for business.


One problem is the quest for profits. A private insurance company’s primary responsibility is to its investors, to make as much money as possible. As a result, these companies compete to cover the healthiest people, abandoning the sick by designating conditions as “pre-existing,” raising premiums when a patient becomes sick and not renewing costly patients’ coverage.


Our market-based system is also riddled with inefficiencies. In the private insurance industry, up to 25 cents of every health-care dollar is spent on administrative and overhead costs, while in Medicare less than 3 cents of every dollar goes to costs other than direct medical care. However, the greatest inefficiency is the fact that although 60 percent of U.S. health-care costs are financed by public programs and taxpayers, more than 43 million people still lack health insurance. This results in a system in which the uninsured do not receive inexpensive preventive care, so when they do become sick, they turn up at the most expensive venue our system has to offer—the hospital emergency room. This is truly an ineffective use of our resources.


Furthermore, the unpredictable nature of medical needs, the lack of knowledge of the intricacies of health plans and the fact that insurance companies or physicians—not patients—make treatment decisions and, therefore, cost decisions makes purchasing health care very different from purchasing commodities like cars or DVD players.


On a more fundamental level, we must examine the human condition when we talk about health care and the uninsured. As a society, we should be more aware of the suffering that accompanies poor health conditions, and we need to recognize that it extends far beyond the scope of medical problems. Poor health damages individuals’ livelihood and well-being. It ruins many Americans’ abilities to find work and raise a healthy family.


Moreover, the stress incurred by tight financial situations intensifies when families incur overwhelming medical debt, which is the second most common cause of personal bankruptcy in the United States. These financial situations can prevent children from going to college, and they can lock entire families into poverty.


The United States has the most unequal distribution of wealth and income among industrialized nations. Treating health care as a commodity only exacerbates the inequalities and results in a rationing of care by the ability to pay and not by need. In addition, commodifying care pits the haves against the have-nots. The moral trade-offs that our nation’s leaders make in choosing regressive cuts that benefit the wealthy over providing universal health-care coverage at a fraction of the cost of the cuts further worsens the inequities. A shift toward looking at health care as a common good would create more incentives for preventive care and healthy societies, as well as relieve economic strains, ameliorate suffering and prevent thousands of deaths each year.


The most basic health-care need is a paradigm change, from commodity to public good. We have made the decision as a society that everyone has a right to public education through 12th grade, but not everyone has a right to health care. Rep. Jesse Jackson Jr. (D-Ill.) has introduced national legislation, H.J. Res. 30, that adds the right to equal, high-quality, affordable health care to the U.S. Constitution. Since life, liberty and the pursuit of happiness are so integrally related to health status, without the right to health care, other rights we hold as Americans are rendered meaningless. A guarantee of life is the most basic of human rights, and health care realizes this right.
~~~~Anjali Taneja is a fourth-year at the University of Medicine and Dentistry of New Jersey–New Jersey Medical School. She’s taking this year off to serve as the American Medical Student Association’s Jack Rutledge Fellow, working on such issues as universal health care, domestic health disparities and global HIV/AIDS. ~Advocacy,Health Policy,Universal Health Care~
167~9December~2003-52~Feature~Denied: The Crisis of America’s Uninsured~AMERICA'S WORKING CLASS BEARS THE BRUNT OF A DISPARATE HEALTH-CARE SYSTEM.~Rebecca Sernett~~The number of the uninsured has risen again. The U.S. Census Bureau estimates 43.6 million people now lack health insurance. It’s an incomprehensible statistic, almost numbing one to the lives—the people—behind the numbers. With Denied: The Crisis of America’s Uninsured (Talking Eyes Media, $15), photographer Ed Kashi and writer Julie Winokur open the worlds of the uninsured to us. The men, women and children are people like you or someone you know. They, too, have hopes, fears, dreams, struggles, pains and joys. Their stories are unforgettable, and the following pages contain a sampling of them. We begin with Denied’s account of the working class and finish with a handful of personal portraits. More information about the authors and the book, which was produced in conjunction with the “Cover the Uninsured” educational campaign, can be found online at www.talkingeyesmedia.org.


To be both uninsured and working class in America is becoming redundant. As time goes on, employers demand more and more from their workers, while providing less and less benefits in return. Currently eight out of 10 uninsured Americans live in working families, a reality that is creeping up the income scale. Simultaneously, the rise in premiums has outpaced the rise in income for nearly 30 years. The only salvation for the working class is a community clinic, like the Open Door Health Center, pictured on these pages. Located in the middle of farm fields, tract housing and shopping malls in Homestead, Florida, this small, single-story building is a beacon for a community that is so used to going without health care that many of its clients use herbs sent from Mexico rather than see a certified physician. Open Door cares for the people who pick our food, build our houses and staff the aisles of the local Wal-Mart.


These are the people our health-care system has forgotten, people whose lives have been deemed more expendable than those on the outer edges of the economic scale. Open Door is the progeny of Dr. Nilda Soto, a Puerto Rican immigrant who grew up in the slums and knows firsthand that every hardworking individual deserves dignified care. Dr. Soto founded the clinic two years ago with help from a coalition of physicians and community organizations. It has registered 1,600 patients, mostly Latino, and sees 40 to 50 patients per day. Dr. Soto’s staff works overtime to secure free treatment and medications, often sending patients to specialists and hospitals that donate their services. Open Door is a prime example of how health care is a community issue. Patients and physicians alike helped build the facility, and local volunteers help keep it running. “If you don’t come down in the trenches and mingle with the people and find out what their real problems are, and let people get involved in their own solutions, health-care reform is not going to work,” Dr. Soto says. At Open Door, the patients have a stake in their own health care, and for many, it’s the first time their needs have ever been met.~THE STORIES

Denied: The Crisis of America’s Uninsured also includes stories from 41 individuals who recount how living without health insurance has affected their lives and those of their loved ones. The circumstances in which the men and women found themselves without health insurance are similar to what many of the 43.6 million uninsured experience. TNP has excerpted six stories here.


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IN 1996 TIM RUMFORD MOVED TO HAWAII with his new wife and started his own business installing computer networks. His business grew until he had three employees, all of whom he provided with insurance. “I had medical insurance for my employees but could not afford it for myself and still cover payroll,” he says. Since he was healthy, he figured the odds were in his favor. Then the worst-case scenario unfolded. Tim contracted viral encephalitis, which he probably picked up on an airplane from another passenger. He thought he had a severe flu, but when he became delirious, his friend raced him to the hospital. Initially, the hospital refused to treat him. “They made my friend put me back in the car and drive 35 miles each way to get my wife to accept responsibility. Somewhere along that drive, I lost consciousness,” Tim explains. When he awoke, he had a headache that lasted a year. He had seizures and neurological problems, his IQ dropped 50 percent, and he could no longer read or concentrate. Tim had to shut his business down, his wife left him, and he was plagued with chronic pain. He spent the next three years fighting to regain his health. Now he’s struggling to manage with few resources. His Social Security disability checks for $1,000 a month barely cover his medications, which cost $900 a month. “Every month I choose between food and meds,” he says. He doesn’t qualify for Medicaid because his disability checks are too large, and he can’t buy insurance because he has a pre-existing condition. To make matters worse, every month $120 is taken out of Tim’s disability check to pay off his $40,000 hospital stay. Tim has to pay cash at the time of each physician visit, so sometimes he just doesn’t go. Even dentistry has become an issue. “I’ve had several teeth pulled that didn’t need to be, just to get the pain to go away,” he says. If Tim works, he will lose what few benefits he receives. For a man who has worked full time from the age of 15, this situation is devastating.


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JOANN HARRISON LOST HER INSURANCE a year ago when she and her partner, Rob, moved to help take care of his elderly parents. She is a respiratory therapist and works in the emergency room as a PRN, which is medical lingo for “use as needed.” PRNs make $1 more an hour than full-time employees but they don’t get benefits. “The hospital is hiring a lot of workers on contract to save money and avoid paying the rising cost of health benefits,” says Joann, who works an average of 12 hours a week. At her hospital, she says there are posted signs warning that patients without insurance will not be treated unless they have a life-threatening condition. Joann’s late husband, Phillip, was diagnosed with a type of acute leukemia when he was just 32. At the time, both Joann and Phillip had health insurance, but the cost of the leukemia treatments exhausted his million-dollar policy and her $500,000 policy in just two years. Tragically, Phillip was on his way to the Mayo Clinic for a bone marrow transplant that might have saved his life when their policies capped out. He died in 1994. “In my opinion, he was left to die,” she says. Recently, Joann had a kidney stone and was sent to the hospital, where she was kept overnight and treated. The next day, the hospital called for her payment of $3,900, which did not include the radiologist’s or the physician’s bills. She can’t afford a $400 follow-up test, so she plans to go without. Joann, who suffers from asthma, pays $160 a month for medications. Her significant other works full time and has health benefits, but because of her status as a widow, it is not financially feasible for them to get married.


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TONY BRADLEY HAS HIS OWN BUSINESS selling T-shirts. He is also a minister who volunteers his time helping others in his community. His wife, Dorine, is a counselor who works with underprivileged women who need prenatal care or live in battered women’s shelters. Both are uninsured. In February 2001, while Tony was on a business trip in Florida, he had a stroke. His eight-day hospital stay cost more than $20,000, which he couldn’t pay. Around the same time, Tony was diagnosed with prostate cancer. Physicians predicted that surgery and treatments would cost more than $50,000. Tony didn’t know what to do. “I waited a year-and-a-half to have the surgery because I had to figure out how to pay for it. I already owed $20,000 in Florida, and I didn’t want to burden my family.” Fortunately, Tony was able to strike a deal with his physicians, who offered to reduce their $11,000 fee to $1,400 on condition that he pay it off within one year. Tony struggled to make his monthly installments, but in the end, his ministry community helped foot the bill by holding special church events and bake sales. Still, he was unable to pay the remaining $13,000 hospital bill. He applied for Medicaid but was refused because, ironically, he and his wife make too much money. “I don’t want to be sick,” Tony says. “If I ask for help, I’m asking for help out of need. Usually I’m not the person who needs help, but when you do and you see that door slammed shut, it’s hard.” Tony is still determined to pay off his debt somehow, someday.


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REBECCA DUCKWORTH WAS DIAGNOSED with epilepsy when she was 18. At that time, she was covered under her father’s insurance, which was comprehensive because he was in the military. When she turned 21, she aged out of her father’s plan. Since then, she has learned how restrictive a pre-existing condition can be. “For years I searched and searched for options,” she says. “Now I just keep my fingers crossed and pray that I do not have another seizure.” Rebecca currently has what she calls “fly-by-night insurance”—the only option available to her—and it’s questionable whether it’s worth having at all. Her insurance costs $147 a month and covers her epilepsy medication for only half the year. It does not cover anything else related to her epilepsy, so if she has a seizure and breaks her arm or someone calls an ambulance, she will have to carry the bill. Rebecca is supposed to get regular checkups for her epilepsy every three to six months, which include blood tests to make sure her medications haven’t become toxic to her body. She has not had one of these checkups in three years. In the meantime, Rebecca is applying for graduate programs in clinical neural psychology because she wants to become an epilepsy researcher. “It does not matter who you are, how much you make, or where you come from; if you have a pre-existing condition, health insurance companies retain the ‘right’ to deny coverage for your condition,” she says. “This is simply unacceptable.”


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ROSEMARIE JURVIS KNOWS that the insured and the uninsured live in separate worlds. For 46 years she worked as an office clerk and was accustomed to a steady paycheck and good health coverage. Over the past five years, she has been diagnosed with tumors in her adenoids, breast cancer and cervical cancer. The treatments for these ailments were all hardships in their own right, but at least they were covered. “I didn’t mind going to the doctor then,” Rosemarie says. Throughout her absences from work, Rosemarie’s employer let her keep her job and her insurance. Then, in September 2002, just 13 months shy of her 65th birthday, she was given two-weeks’ notice. She looked into continuing her coverage through COBRA, but it would have cost more than $1,000 per month. With her pre-existing conditions and her age, she couldn’t find a single private plan she could afford. Rosmarie owes about $1,000 in medical bills, and she is forced to pay out of pocket for her physician appointments, so she doesn’t go as often as she should. Her medications cost $158 per month so she relies on free samples from her physician when she can get them. “I have trouble falling asleep at night,” she says. “I try to keep busy so I don’t think about it, but sometimes it creeps into your mind and you worry.”


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WITH A LIFE-THREATENING DISEASE, Trevor Sprague has no options. He cannot get government assistance. He cannot get health insurance. He cannot afford to see a physician or buy prescriptions. His only hope is that he can graduate from school in time to get a job with insurance before his health runs out. Two years ago, Trevor was diagnosed with IGA nephropathy, a slow deterioration of the kidneys. He requires medication on a regular basis and eventually will need a kidney transplant. To make matters worse, he has an undiagnosed disorder that results in syncopal episodes, or periods of unconsciousness. Over one three-month period, his condition became so severe, he passed out every two weeks. As a result, he ran up tens of thousands of dollars in hospital bills that he can’t pay. “I just put the bills aside and hope one day I can do something about them,” he says. When Trevor was diagnosed, he still had insurance through a COBRA policy after leaving a job as an assistant manager at a bank. Now he is a full-time student at Kent State University, and he has been turned down by every insurance agency he has applied to. He has gone without medication or physician visits for nearly two years. With proper care, the deterioration of his kidneys could be slowed down. “The only problem is that if my kidneys fail or one of my syncopal episodes results in heart failure [which has happened before], I will never see graduation day,” he says. ~~~~Advocacy,Health Disparities,Health Policy,Universal Health Care~
168~9December~2003-52~Folk Tales~Literary Medicine~DISCOVERING THE POWER OF WORDS~Scott T. Shepherd~~On a crisp October day in New York City, about 100 people gathered in a room to listen to poetry and prose. The audience sat attentively as writers read the thoughts and emotions they had previously only communicated through their pens—or keyboards, as the case may be.


No, this literary event was not held at a coffee shop in Greenwich Village but in the rotunda at Bellevue Hospital, where the Bellevue Literary Review hosted its fall reading under the watchful eye of editor-in-chief Dr. Danielle Ofri.


With Dr. Martin Blaser, the chairman of the department of medicine at New York University School of Medicine (NYU), Ofri founded the literary journal in 2001 to provide a platform for writings about the human body, illness, health and healing. Furthermore, it offered the two physician–educators a medium through which medical students could improve their critical-thinking skills. As an associate professor at NYU, Ofri requires her students to write narratives about one of their patients, in addition to the standard clinical history and physical reports.


“I think it’s a chance to remember that the patient exists outside of just the narrow window of patient-hood. Often, we see them just as they are: just a sick patient on the ward or in room 1691 or in our clinic. But, in fact, they have a life that’s a whole tapestry, and we are just a few threads in that tapestry, and you really can’t understand the patient without knowing the whole picture, the whole story,” she says.


Nowadays, Ofri spends much of her time immersed in the written word. In addition to serving as editor-in-chief of the literary review, she’s also a published author. Released this year, Singular Intimacies: Becoming a Doctor at Bellevue is a collection of stories about her experiences as a resident and an attending at the Manhattan hospital. (For a review of her book, see p. 31.)


The book is part of a transformation for Ofri, who never really envisioned herself as a wordsmith. She just wrote what she saw and what she felt as a way to release stress. “Medicine is so emotionally intense. After a few days in the clinic or a week on the wards, there is all of this energy inside you that has to go somewhere. And for me, writing is a very helpful way to channel that energy.


“I wasn’t at all intending to write a book. I just had all of these stories that I wanted to write down from these 10 years [working] at Bellevue,” she says. But that is exactly what has happened and has led to Ofri joining the ranks of physician–authors.


It’s quite a change from the scientific-minded teenager who grew up in New York’s Hudson Valley. Back then, Ofri was focused on the core sciences, which is what she believed practicing medicine would be like. “I remember in high school, that if you were interested in science, it was assumed that you’d go into medicine, so I assumed I would do that too…. If I knew what I know now, I’m not sure I would’ve done it.”


While earning an undergraduate degree in physiology at McGill University in Montreal, Ofri began to learn how much more there is to life and to medicine. Still, she was drawn to the concept of research science and enrolled in the M.D./Ph.D. program at NYU. For 10 years, she walked the halls of the university and Bellevue, spending three years in medical school, four years obtaining a Ph.D. in biochemistry and then completing a three-year residency in internal medicine.


At the end of this arduous study, Ofri needed a break. So, she headed south to Mexico, Costa Rica, Guatemala and Peru to learn Spanish. To finance these excursions, she worked as a locum tenens, a physician who fills in temporary positions at health-care facilities. “I would work in a practice in New Mexico for a month or two and then go travel in South America for as long as the money would last…. Then when the money would run low, I would call my [placement] agency collect from [Peru] and say, ‘What do you got next week?’ [They would say,] ‘How about New Hampshire?’ And I would say, ‘Great,’ and off I would go.”


For two years, Ofri lived this nomadic life, absorbed the Spanish language and used her free time to stretch her literary muscles before finally returning to New York City and Bellevue. But upon her return, she found the hospital in a hiring freeze and, eventually, only able to offer her a part-time position. “But since I was broke, I took it and worked three days a week in the clinic.”


Those free days would turn into a blessing as Ofri delved into her literary craft and enrolled in some writing classes. When she was offered full-time work at Bellevue, her growing passion for writing gave her something else to consider. “I thought, ‘Gosh what would I do with all this extra money? I don’t need a car. I have enough clothes to wear. It still wouldn’t be enough to buy an apartment in Manhattan. The one thing I would most want to buy would be the one thing I wouldn’t be able to buy: time to pursue the hobbies I enjoy.’ So I figure I bought that for myself by turning down the full-time offer, and I bought myself these two days to continue writing.”


This was also when Ofri started submitting her work to medical and literary journals. Her first published essay appeared in the Journal of the American Medical Association in 1998. Ofri, who is now a wife and mother of two, compares seeing her work published for the first time to giving birth. “It’s something that existed in your mind and on your paper and in your computer. Then suddenly it’s on a printed page all over the place. Other people are seeing inside you. It’s a little bit frightening.”


However, the fear subsided for Ofri with each additional publishing and was practically eliminated when her essay “Merced” won the editor’s prize from the Missouri Review in 2000. It was this recognition and the encouragement of one of her writing teachers that led to the creation of Singular Intimacies, which Ofri says still leaves her a little lightheaded every time she sees it in print.


In the meantime, she began to see the value of writing in medical education and discovered that Blaser, the newly appointed chairman at Bellevue, had a similar philosophy on the benefits of narrative medicine. “When the patient comes complaining of headache and back aches and stomach ache and nausea and vomiting, they are often speaking in a metaphor. If we simply take their words at the concrete level, we will miss their diagnosis,” she says. “I think that people realize now that you do need to be able to think in a more sophisticated manner, to think metaphorically to figure out what is going on with the patient. But also, I think it gives us a chance to pause and see our own humanity with the patients.”


So at a conference in the summer of 2000, Blaser and Ofri were brainstorming ways to encourage their students to write, and the idea of a national literary journal came up. Soon after, the Bellevue Literary Review was born with Blaser serving as publisher, and Ofri, editor-in-chief.


“[Blaser] gave me a few dollars and said, ‘Here, we’ll support you, give you space, see what you get.’ So we got some editors together, put out a call for manuscripts, and suddenly we were flooded with submissions.”


The biannual review has published five issues, developed a Web site and garnered thousands of subscribers. Furthermore, twice a year it hosts an evening of poetry and prose reading like the one this fall at Bellevue. Not bad for someone writing simply to relieve stress.
~~~~Scott T. Shepherd is an associate editor with The New Physician. For more information about the Bellevue Literary Review, visit www.blreview.org. To learn more about Dr. Ofri, go to www.danielle ofri.com.~Creative Expressions~