95~1January-February~2004-53~Feature~Much Ado About Medicine~FUTURE PHYSICIANS SING, DANCE AND MAKE FUN OF MED SCHOOL.~Scott T. Shepherd~~In February 2003, despite blizzard conditions, hundreds of people packed the Roxbury Community College auditorium outside of Boston to enjoy more than two hours of dancing, singing and comedy. However, this wasn’t the local theater troupe putting on their version of “Music Man.” Instead, the performers were Harvard Medical School students, who continued a long-standing tradition of poking fun at what they know best: medical school.


Harvard’s future physicians are far from alone in their theatrical endeavors. Future physicians at many U.S. institutions—Albany Medical College, Baylor College of Medicine, Cornell University Weill Medical College, Duke University School of Medicine, Finch University of Health Sciences/The Chicago Medical School, the University of Pennsylvania School of Medicine and the University of Pittsburgh School of Medicine, to name a few—have similar traditions. And who can blame them for seeking creative distractions from their stressful lives? What medical student wouldn’t jump at the chance to take some good-natured shots at his faculty, administration and the world of medical education?


That ability to tease the sacred institution of medicine is one of the reasons the crowds come out to see Harvard’s Second Year Show. The 2003 production featured a rather intricate plot with the associate dean of student affairs losing the school’s notable endowment during a night of debauchery. The remaining money was enough to support only one department, so the battle to win over the student body began. Some departments instituted “no-fail” policies, and others formed pop music, boy bands. Eventually the pharmacology department resorted to drugging the entire student body into a group of pharmacology-loving zombies. Naturally, one future physician avoided the drugging and developed an antidote to snap classmates out of their trances. The antidote was also found to cure male-pattern baldness, and the miracle drug was then patented and sold, the profits used to refill the school’s empty coffers. Ah, everyone likes a happy ending.


They also enjoy being part of the joke, says Alejandra Casillas, who produced and performed in the 2003 show. “Although we poke fun at them, our dean of student affairs once said that it was more of an insult to not be mentioned in the show versus being made fun of.”


At the University of Pennsylvania School of Medicine (UPenn), faculty members are also performers, opening the annual show with a skit. Last year, they showcased their unique talents in “Penn Medicine Idol.”
“Our anatomy professor recited a poem about his mustache, members of the admissions office had a hula-hoop contest, and a trauma surgeon waxed eloquently about the joys of the surgery clerkship,” says fourth-year Kitty O’Hare, who has served as everything from a producer to a cast member to an usher in the productions. “It’s traditional, at the end of the skit, for the dean of the medical school to burst onstage and say, ‘Live from Dunlop Auditorium, it’s Spoof 2003!’ or whatever the year may be.”


Not everyone appreciates being parodied, though, says Alik Widge, a fifth-year M.D.-Ph.D. student who participated in the University of Pittsburgh School of Medicine’s 2003 Scope and Scalpel Society production. “Some faculty have, of course, not found their portrayals to be particularly funny, [but] the administration seems resigned to the fact that they’re going to be the butt of most of the jokes,” he says.


Mind you, Pittsburgh students don’t seem too concerned about negative feedback. After all, they’re about to graduate and with the Anus Equinus award are finally free to acknowledge the faculty or staff member who made their lives the most miserable. The infamous award is considered to be the antithesis of the Golden Apple award, which is also presented during the show. In the Anus Equinus ceremony, top nominees are “recognized” with dramatized testimonials. Not surprisingly, Widge says, the honoree is rarely present to accept the Anus Equinus. “Winners are the type of person who wouldn’t care what med students thought of them anyway,” he says.


Nevertheless, the majority of Pittsburgh’s faculty and staff is supportive of the production. “Students see [Scope and Scalpel] as a way of getting things off their chest—good, bad and indifferent,” Dr. Richard Moriarty, the society’s faculty adviser and a member of the 1966 “The Sordid Life of Wally Pimpstein” production, told Pittmed, the medical school’s magazine. “The students say pretty truthful things. What they wind up saying is important to say. That’s why the Golden Apple is a part of the show, and the Anus Equinus—it’s the yin and the yang.”


In fact, venting frustrations is at the heart of these shows. According to the Scope and Scalpel Society, the annual musical was born from a medical student’s and department chairman’s “gripe session” at a local bar in 1955. By the end of the evening, the two had concocted the idea to produce a class play about students’ grievances. Later that year, with the ardent support of the school’s dean, the society debuted to a packed house with a performance of “PMS IV.”


Since then, the show has become an annual parody of not just medical education but also of pop culture, featuring such performances as “Coldfinger” in 1965, “Scar Trek” in 1975, “Miami Slice” in 1986, “Thoracic Park” in 1994 and “Crouching Patient, Hidden Finger” in 2002. In 2003, a team of writers—who along with the director and producer are elected by the fourth-year class—created the medical-student version of HBO’s hit series about mob life. The result was “Sopranolols.”


Future physicians at UPenn achieve similar theatrical feats in their annual Spoof production, which is open to all students but tends to be staged by more first-years, fourth-years and mixed-degree students. “In designing the show, we try to maintain a balance of singing, dancing and nonmusical skits. It’s all comedy, or a reasonable attempt at it,” O’Hare says.


Each year, Spoof is given a different title or theme, yet there’s only a loose association among the sketches, she says. For example, “Spoof 2003: The Fragile X-Men” included a skit involving the inherited genetic abnormality but also featured: “Staphylococcus Hunter,” a parody of the “Crocodile Hunter”; “Pimping through the Ages” in such classic times as Homer’s Greece and Shakespearean England; “Pelvic Exam” put to the tune of John Mellencamp’s “Jack and Diane”; “Match Another Way,” a spin on the James Bond thriller “Die Another Day”; and “What Would Paul Dabrowski Do?” with students’ rewording a song from “South Park: the Movie” to pay tribute to the school’s beloved trauma surgeon and director of medical student education.


“My favorite memory was a skit in which ‘Staphylococcus Hunter’ was wrestling with the attending, explaining to the audience that the key is to ‘control the jaw’ in order to limit the number of pimping questions the attending can ask,” says second-year Brian Ash, the production’s band director.


Obviously, Spoof and most of these shows are littered with the language of medical school and inside jokes. Program notes usually provide enough explanation to let “outsiders” in on the gags, which has proved helpful to students’ loved ones. “My now-fiancé came to see the show, and though he didn’t get many of the jokes, he had a new-found understanding of my life and now revels in the use of such unique med school words as ‘gunner’ and ‘pimping,’” says fourth-year Stacey Garfield, who performed in Spoof 2003.


But the shows aren’t just fun and games. There are expenses to worry about. In many cases, the productions are financed by student governments, ticket revenue and advertising. Also, it helps if students and faculty do a lot of the work themselves.
“The show is very inexpensive to put on—we make our own props and put together our own costumes,” Garfield says. “We do two performances in one night, performed in one of the med school’s auditoriums. Advertising is all by e-mail and word of mouth. The biggest expenses are renting the spotlight and paying the sound guys.”


It’s a similar situation at Albany Medical College’s annual talent show. By limiting expenses to renting a 300-seat auditorium and audiovisual equipment, $5 tickets are usually enough to cover the production and then some.
In contrast, Harvard’s Second Year Show is supported primarily by donations. Through the school, support organizations, the student affairs office, alumni, staff and faculty, plus fund-raising projects, the production—which usually has a budget of around $20,000—is completely financed prior to the selling of tickets. As a result, the students are able to donate the show’s revenue to a charity of the class’ choice. In 2003, more than $7,000 went to Project Star, a Roxbury-based charity for children born HIV-positive.


Even when a show is barely able to cover its own costs, students still find ways to use it for a worthy cause. At UPenn, future physicians hold a bake sale to raise money for a local Ronald McDonald House, while Albany students keep their costs so low that there is always money left for charity.
“The ultimate goal of the show, in addition to having some fun, is to raise money for a local charity,” says fourth-year Anthony Plunkett, who has coordinated Albany’s show for the past three years. “So far, we have been able to raise about $1,000 per year from the show.”


Charity, however, is not the only reason performers get involved with and crowds come out to the Albany talent production, which usually includes about 18 acts, ranging from singing and dancing to martial arts, piano performances, comedy routines and slide shows. For performers, it’s the chance to exercise muscles not frequently used in the rigors of medicine. For the audience, it’s an opportunity to see the hidden talents of friends and colleagues. “I have found some of the most amazing qualities in my classmates that I never would have known had they not demonstrated them in the show,” Plunkett says.


Some participants have previous theater experience, but it’s certainly not required. “It’s a mix. The skit directors and writers tend to have some sort of theater or writing background,” O’Hare says. “I was the vice-chair and music director of a theater company as an undergrad. However, for the vast majority of the cast, this is their first time on stage. [It’s] a good opportunity for those whose only experience is singing in the shower.”


“I think most of us have acted in ‘something,’ but I’d certainly never sung on stage before,” Widge says.
And whether future physicians end up performing, moving props, selling tickets or working as ushers, there is always some way to get involved. “Show up. Be breathing. They’ll find something [for you] to do,” Widge says.


Once they’re participating in a show, many students say it’s a wonderful escape from the hardships of everyday medical education. “It’s also reassuring to make fun of the difficult parts of med students’ [lives]. In a lighthearted way, it helps us all feel like we’re not going through these times alone,” Garfield says.
The shows aren’t easy, though. There are lines to memorize, skits to rehearse, props to make, promotional fliers to distribute…. “It is really stressful, but it’s a good stress, and if I could, I would do it all over again,” Casillas says.


Yet, under these conditions, strong bonds can form. “It’s a wonderful way to bring people together...getting to know people you never really worked with before,” she says.
In fact, for some future physicians, their favorite memories of productions are offstage. “The best part was waiting backstage to go on, watching the other skits—we had video feed—with the other performers, laughing and excited, greeting the attendings who were performing and congratulating those who just finished their skits. It was an entirely different way of getting to know classmates and attendings,” Garfield says.


And the greatest moments may occur long before the curtains come up. “Last February, Philadelphia was battered with about 2 feet of snow in one day. We were supposed to rehearse all day, but while it was actively snowing, and the city was in a state of emergency, we hesitated,” O’Hare says. “By late afternoon it had stopped snowing, so we asked everyone in walking distance to come in. The cast slushed through waist-high deep snowdrifts in the middle of the road to get to rehearsal.”


Even in blizzard conditions, the show must go on.
~~~~Scott T. Shepherd is an associate editor with The New Physician. Direct comments and questions about this article to tnp@ amsa.org.~Creative Expressions~
96~1January-February~2004-53~Feature~What’s the News, Doc?~PHYSICIANS ADD ACCURACY AND DEPTH TO TELEVISION NEWS REPORTING.~Jennifer Zeigler~~It’s October and the Gupta Girls are online discussing what the good doctor should be for Halloween. One suggests he go as himself, Dr. Sanjay Gupta. Another says no, he should wear a thong. The conversation deteriorates from there, a perfect example of the star power surrounding the 34-year-old CNN medical correspondent.


OK, so his hair has that slightly rumpled look—that these women obviously find sexy—most mornings when he enters our living rooms and workstations on his “Paging Dr. Gupta” segments. And sure, his young, ethnic good looks that earned him a spot on People magazine’s 2003 “Simply the Best” list are a far cry from most other television medical reporters—a largely white, male, middle-aged crowd. And his breezy style makes us forget his specialty is neurosurgery, but really: A Yahoo! group with at least 35 devoted fans chatting about whether or not he has a girlfriend? A blog page on InfoHunks? “I just want to know anything about Dr. Gupta. Is he a Hindu? What [is] his favorite color, or car or food?” one fan posted. How many physicians can claim this kind of following?


Few of the growing number of physician–reporters experience such worship, but most can relate to Gupta’s celebrity status. These physicians enter our lives via cable lines and satellite dishes, and increasingly we hinge medical decisions on what they report. But most of them say communicating to thousands—sometimes millions—of viewers is not much different from what they do one-on-one in the exam room.


EXPERT REPORTING


Fifteen years ago, there weren’t many medical reporters—let alone health correspondents who had gone to medical school, says Dr. Teresa Schraeder, a fellow at the New England Journal of Medicine and a former medical reporter for ABC-affiliate WCVB in Boston. Schraeder is about to publish a scientific study on how physicians think medical journalism impacts themselves, their patients and health-care delivery.


“And now, as you know, it’s just pervasive. I think medical reporters have become major disseminators of medical information and, in some ways, have become public health educators. The beginnings of both professions, we’re really public health servants and educators, so I do think it’s a natural relationship,” she says. “It is understandable that physicians, particularly in their role as public health educators, would want to be journalists.”


And there’s no question that TV stations want physicians to be journalists too. Why? Medical news sells ads. A recent study in the Journal of Health Politics, Policy and Law found that 40 percent of viewers followed medical stories “very” or “somewhat” closely over six years. Shannon Brownlee, a senior fellow at the New America Foundation, opined in the Washington Post that the unfortunate, unwritten rule in print and TV journalism is that “if your ratings are low, run a medical story. If your ratings are really low, run two.” So if stations from markets both large and small can call on “our medical reporter, Dr. So-and-So,” to wade through the daily barrage of health news, all the better in many cases.


“You’re probably the worst-quality reporter they have at the station, but you bring a professional level that editors want,” says Dr. Harlan Gibbs, a Los Angeles emergency-room physician whose television and radio news reporting has won him a local Emmy award. “That’s why I think it’s important that physicians are medical reporters—we still hopefully know what is good medicine and what’s not.”


Dr. Lillian Beard, a pediatrician in the Washington, D.C.-suburb Silver Spring, reports medical news on the city’s ABC-7 News station an average of three times a week. She says viewers get more medical information from the TV these days than from their physicians. “Consumers are taking a more active role in determining their health destiny. It’s not a matter of going to the doctor and someone dictating and giving a prescription, and that’s the end of it. We’re much better informed.”


Because of this change, she—and many other physician–reporters—think M.D.s and D.O.s make the best medical reporters, “but then I recognize that when I say that, I’m reflecting a bias.” Most say that, as physicians, they can better grasp the underlying science of health coverage and skillfully wade through the overwhelming number of pitches from medical journals, pharmaceutical manufacturers and other physicians hawking “medical breakthroughs.” Beard says her degree and training have also allowed her to see a real story where others haven’t.


“Because I am a physician, there’s a credibility that I enter with…. I don’t have to try to find the ‘aha factor’ in that story angle to the same extent. I’m able to say, ‘Well, this is really over-hyped.’ …SARS was an excellent example. No matter where you turned…there were always three or four SARS stories, and you would see file footage of people with masks, and you saw Asians all the time, so there were just certain conclusions that one would draw immediately…. It was absolutely necessary that it was reported—absolutely, without question. Whether it was necessary to have 300 stories in two days about it, I don’t know.


“I did a couple of stories on SARS. And one of the things…had to do with children and how it may have impacted children differently, because there had not been child deaths in an early study that was done…. So I thought that by doing that aspect of it, at least someone would say, ‘Oh, well, you mean then there are people who had the SARS virus who recovered,’ or what-have-you….


“No one was reporting about that until weeks after…. But you see, they probably got the information when I got it…. Because I was a physician, I could immediately see the news value as well as the greater public health value of the story.”


But that’s not to say that only physicians do the job well, Gupta says. “I think there are terrific medical reporters, first of all, out there. Really top-notch medical reporters who do the work. But I do think that going to medical school and really having seen some of these issues and patients firsthand, working in hospitals, is key to being able to do this well and lend that degree of authority to it,” he says. “And that brings up the point that I think is important, which is that I think doctors who practice and take care of patients regularly are the best people to do this sort of thing. That may be a little bit counterintuitive, but I don’t think you should just go to medical school and then do this sort of thing. It doesn’t make a lot of sense to anybody. I mean, you’re a doctor, and now you should practice medicine, but if you want to use that knowledge and experience in different ways, I think that’s very fair.”


Dr. Timothy Johnson, who calls himself a medical journalist—not a reporter—for ABC News, is one of the few who has given up his practice for a career on television. The emergency-room physician stopped practicing in 1984, having already spent 12 years on air, which makes him one of the grandfathers of physician-reporting many young TV physicians say they grew up watching.


“Ultimately, [ending my practice] was kind of a gut-level decision,” he says. Many patients were beginning to recognize him in the emergency room, and ABC made an offer he couldn’t refuse. The network allowed him to work from Boston, where he lives, instead of New York City, where the news operations are based. “I got into it by accident, and it took me a while to realize what an opportunity I had been given. Obviously in what I do, I am primarily a medical journalist…but in my heart I’m a physician.”


Most physician–reporters agree with Gupta on this issue, though, and you’d be just as likely to find them in front of exam tables as you would teleprompters. Gupta is the associate chief of neurosurgery at Emory University’s Grady Memorial Hospital, where he teaches residents and cares for patients as high profile as Dan Snyder, the Atlanta Thrashers hockey player who underwent emergency surgery and died after a September 2003 car accident.


Beard says she “absolutely” considers herself a physician first and reporter second, but then says, “If I had to identify one thing, I’m not sure which it would be.” Yet she emphasizes her physician-first point when she interrupts an interview to check on a patient whose wails have suddenly overpowered the hum of the ventilation system in her busy office. The honors lining her office walls—“Washington’s Top Doctors” reads one, “[Maryland’s] Top 100 Women” says another—also speak to her dedication to her patients, some of whom are the children of children she cared for early in her career.


“No matter what I’m doing, I am a physician. I don’t turn that off at all,” she says. “I am a physician. There are times when I’m at the station, I just turn my pager to vibrate, but I’m still on call. You can’t be an occasional physician, because what will happen is you will start to lose touch with the real patient. You start losing some of your clinical skills and knowledge. It’s a tool that you have to keep sharpened if you want to use it.… I keep my skills sharp by doing both. You can do both.”


THE TELEPROMPTER'S APPEAL


So if physicians are not ready to leave the exam room fully, why even bother with broadcasting?


Most TV-physicians fell into the jobs like Johnson did. “It’s one of those strange stories of a total accident,” Johnson says of the offer in 1972 from a colleague at Massachusetts General Hospital to host a local, 30-minute call-in show. When producers at ABC’s “Good Morning America” asked him to appear on air, the rest became his TV history, which he’s still working on.


It was a chance meeting that brought Gupta in front of the camera. He met CNN then-chairman Tom Johnson while serving as a White House Fellow in the late 1990s, and the two began discussing how people get their medical information. “I was interested in that as well, which is why I was at the White House working on various projects with Mrs. Clinton at that time,” Gupta says.


By the summer of 2001, the CNN leader had convinced the young physician to give up his new neurosurgery practice in his native Michigan and move to Atlanta to begin a different kind of medical career. “You know, when you decide to do neurosurgery, pretty much that’s what you’re deciding to do,” Gupta says. “I spent a decade of my life, essentially, training to do that…. I thought [news] was an interesting thing that I wanted to be involved with, but I never dreamed that I’d be involved with it to the degree that I am today.”


Dr. Brian McDonough, a medical reporter since 1989 on Fox 29 News in Philadelphia, had sought out broadcasting jobs since residency, but even so, his life is far from what he expected. He was working toward a Ph.D. in English when a rejection from the Rhodes Scholarship Selection Committee made him consider medical school. “I learned that I loved family practice because, think about it, it’s communicating.”


So for two full days and three half-days a week, he directs the family practice residency program at Temple University-affiliated St. Francis Hospital. “But then [on my half-days], I go home, shower, put on nicer clothes and head to the station from 3 to 11 p.m.”


Gupta has a similar schedule. “Sometimes it’s 50-50. Sometimes it’s 60-40 one way or 60-40 the other…. The best way I can sort of liken it to something is people who are in academic practices who also conduct a basic science laboratory or do some kind of research as well. CNN and media is that for me. I still practice medicine, but…I now spend [time] in my own sort of laboratory, which is television.”


Jumping from studio to hospital is a humbling experience, McDonough says. “You go from being on TV, where you know everything, and then you get to a patient, and it’s not clear-cut like TV or radio…. [And] they’re both careers where they want you when they want you. They don’t lend themselves to having a summer home.”


And there are other similarities between the two jobs. “The underlying principles can be similar in that you’re trying to sort out what is the truth,” Johnson says.
That’s not always the easiest thing to do when producers are pushing for sexy, medical breakthrough stories
or scary disease tales to sell ads. McDonough says this is particularly true during sweeps months. But, he says he’ll do whatever story his producers want, as long as he can add a professional perspective. It’s important to get information to viewers, he says, but just as in medicine, his first concern is their welfare.


Schraeder says having physicians in the newsroom can help temper the sweeps and ratings hype, and most physician–reporters would agree.
“The great thing about it is that, as a doctor, you can throw in your own two cents on an issue,” Gibbs says, adding that he might save 10 or 15 seconds at the end of a report to debunk a study or offer an opinion. “If you’re doing it as a doctor, you’ve been through four years of medical school and residency. You know what’s right and wrong when it comes to medicine.”


And it’s not the reporters causing the sensationalism, Gupta says. “A lot of times I will say some of the writing that goes into these things—the teases especially, the tease of an upcoming story—may be construed as being overly hyping. But the bottom line is: Is this a story that’s important to people or not? And if it gets them to watch it, then I think that’s important.”


Besides promo writers, Gupta finds fault in his own community of physicians. “It’s very interesting. When we have doctors on as guests who are not television people, the sort of universal sentiment among the medical unit is that those are the folks who tend to hype things the most…. Especially if it’s their own product, [they’ll say], ‘This will lead to the end of heart failure as we know it.’ …I won’t even say who it is, because he’s a very, very well-respected cardiologist in the country, and we interviewed him for a segment we were doing, and he said, ‘We have started a revolution in medicine today.’”


Both Johnson and Gibbs admit there are physicians who look at TV reporting as a way to build their practices. “Let’s face it. If CBS comes to you and asks you your opinion, the impression is you must be good,” Gibbs says.
And Gupta says there are those patients who think it’s cool their physicians are on TV. Of course, he says, there are also those who say, “‘You know, I want my doctor thinking about my procedure every moment. And when he’s on television, he’s not thinking about it.’”


Gibbs says it’s some of these ethical issues that make him support Johnson’s idea to create a certification process for medical reporters—including physicians. He envisions a certification exam that would ensure journalists have a basic knowledge of both medicine and media.


“Each physician who does this has to figure out how to do this in the most ethical manner,” Johnson says.


ANSWERING THE CAMERA'S CALL


If you’re a physician interested in being a journalist or correspondent, there are only a few resources to turn to. The American Medical Association hosts the annual Medical Communications and Health Reporting Conference—this year’s is set for Las Vegas in April—at which physicians can get tips for becoming better speakers in the media. There’s also the National Association of Medical Communicators, which offers courses on how to break into the business. Gibbs sits on its board of directors. “I wound up teaching the guy who wound up replacing me at CBS,” he says. Students may also want to consider doing a medical reporting rotation (see “Training for TV,” p. 15).


Beard points interested medical graduates to journalism schools. “You know, they need to really pursue it in the most professional way, just as they pursued becoming a physician…,” she says. “It’s a very competitive niche of the market…. This is not for the faint of heart. They look at any on-air talent as someone who might be doing something for them.”


Physicians learn pretty quickly that the news business—especially broadcast news—is a fickle friend. You’ve got to be the right face at the right time. “It’s an age-driven business. It’s a sex-driven business,” says Dr. Steve Salvatore, a medical reporter at Fox 5 in New York City, and Gupta’s predecessor at CNN. “The lifespan in this is very, very short.”


Beard says she knows she serves at the pleasure of someone higher in seniority who might decide tomorrow she’s not what the station needs.
“There is no security whatsoever,” Salvatore agrees. “You could get hired today and fired this afternoon. Your boss could love you, but he could get fired tomorrow.” Still, he whistles on the way to work. “They’ll probably kick me out before I’m ready to go.”


The payoffs, while not monetary in value, can be great. The job is “just a hoot,” Gibbs says.
Last year, Gupta rode his CNN opportunity all the way to Iraq, where he spent part of the war embedded with the U.S. Navy’s Devil Docs medical unit. As the only neurosurgeon, he was called to duty several times to patch up injured soldiers and Iraqi citizens—something his online fan club lauds him for, but for which he was criticized by some journalism ethicists.


“Certainly as journalists, we came here to cover the story, not to be the story,” Gupta told viewers in April 2003, reporting from south of Baghdad. “[But] medically and morally, I thought that was the right thing to do…. I play a small part. These doctors over here play a very large part.”
Whether covering the news from a war-torn nation or from the security of an anchor chair, physicians say the job does feed the ego. “But, there’s something to be [said about being] able to move in obscurity,” Gibbs says. “You want to be able to go to a restaurant and spit on yourself without everyone noticing.”


McDonough also relishes the off-camera time. “Jon Bon Jovi was in the other day, and you’re meeting those people, but then [station managers are] getting serious about where we are in the ratings, and it’s like, ‘Does it really matter?’ So it’s nice to go back to the hospital.”


Still, the perks are great. “Given Christmas party choice, [my wife will] go to the media one as opposed to the doctors’,” McDonough says. And the station’s box seats at Eagles games are pretty sweet too. “So that’s the fun side of it. And when you’re giving health advice, there’s no downside, because that’s positive.”


Positive for sure, Beard says. “I’ve also fulfilled my dream of being a writer, a correspondent, reporter, expert. I mean, it’s like, wow.” Wow, indeed. Perhaps an online fan club is next?
~TRAINING FOR TV


As a fourth-year at Georgetown University School of Medicine, Alexia Moutsatsos was growing accustomed to clinic patients asking if she had heard the news about a new wonder drug. “And [each time] I said, ‘What do you mean, wonder drug?’”


But that got her to thinking what it is that makes patients ask these questions. “I could see how important it is for a doctor to keep up with what’s new—not just the journals, but what’s on the news.”
So last fall, Moutsatsos spent a month of rotation time working on Philadelphia ABC-affiliate WPVI’s “HealthCheck,” which airs daily on the TV station’s local news programs.


The rotation is offered through Drexel University College of Medicine, and Moutsatsos was the fourth or fifth student to rotate through. While there, she worked with the station’s on-air physician to research potential stories, interview sources and determine the best way to package a piece for the 25 seconds each “HealthCheck” spot is allotted. She also manned the station’s health answer phone line. “It was really weird, because I’ve never done media before. Media is so hard—I totally have a new respect for it.”


It’s undoubtedly something fourth-year Ricky Choi will learn when he leaves the Medical University of South Carolina (MUSC) in March to spend a few weeks on a rotation with Dr. Sanjay Gupta, a CNN medical correspondent. “Clinicians put [in] an enormous amount of energy to treat and provide health guidance,” Choi says. “On a good clinic day, they may reach 60 people. Dr. Gupta can reach millions in 5 minutes. I am also interested in bang for the buck, and in that formulation, health reporting is by far the winner.”


It isn’t a normal rotation at MUSC. Choi’s opportunity arose through a friend of a friend who greased the CNN wheels for him. He says attendings have been surprised but supportive of the rotation.
Gupta says he regularly takes medical students as interns, and many physician–journalists say they encourage future physicians to join them on air. “It’s an evolving field. I think 10 years from now there probably will be classes in this sort of thing, but I think that we are sort of charting some new territory…,” Gupta says.


And while Choi and Moutsatsos are looking at more mainstream specialties for their careers—not medical journalism—Choi says he’d like to make good use of what he learns with Gupta. “Professionally, I would like to find the right balance of using large-scale health promotion methods as well as individualized care in order to make the most meaningful difference in the lives of individuals and the greater population.”


And Moutsatsos says she’s already put her new skills to use. She spent part of the final two weeks of her rotation working in a Philadelphia clinic. When patients asked about the latest medical news regarding their diseases, she was ready to answer them. “It was so neat because I was so up-to-date with stuff…. I really applied it.” —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct questions and comments to tnp@amsa.org.~Medicine in Popular Culture~
97~1January-February~2004-53~Letter from Afield~A Story of Trust~CHILE, PHYSICIANS AND TEENAGE GIRLS~Tarayn A. Grizzard~~Like a row of dolls, they sit in the clinic waiting room, a dozen or so 14- and 15-year-old girls dressed in navy-blue school uniforms. With a television blaring a “reality” show overhead, the clinic staff and I float about getting charts and pill packs, preparing for the next patient. It’s just another morning in the Santiago de Chile adolescent health clinic.


As a fourth-year medical student, I am in the capital of this coastal South American nation interning and treating patients. I call out the next name, Carolina*—a slight girl with frosted-purple eye shadow and the uncertain, gangly gait favored by adolescents and baby deer—and guide her to the exam room. She sits, and with little preamble, the physician of the day, Dr. Alvarez*, asks her excruciatingly detailed questions about her sexual activities. I’m curious to see her reaction to his seemingly invasive interview. To my surprise, Carolina seems comfortable in her responses, reporting she would prefer monthly birth control through inoculations. Alvarez replies curtly that he doubts she needs anything other than standard oral contraceptive pills and points for her to undress for her internal exam.


Behind an inadequate curtain, Carolina calmly undresses while Alvarez finishes his notes, and I scramble to prepare her for the exam. Draped in a gown, she slips into the stirrups. Secretaries and other physicians come in and out of the room without knocking, and the curtain barely shields Carolina from the traffic. As Alvarez talks with me, he also hangs out in the doorway yelling questions at the receptionist. When we finish her exam, Carolina sits up expectantly, and Alvarez tells her she should go on the pill and return to the clinic in two months. With a nod of his head, Carolina is dismissed, dashing out of the exam room and back to school with a backward glance and friendly smile.


Probably the most amazing aspect of this clinical encounter is that Carolina was able to be there at all. As I learned from many conversations with my Chilean colleagues in OB-Gyn and social services, adolescents in Chile face many difficulties and potential barriers in caring for their reproductive health. As in other South American countries, abortion is illegal in Chile, mostly due to the strong influence of the Catholic Church. The abortion law in Chile, however, is one of the world’s most restrictive, forbidding the procedure even if a mother’s life is at risk.


With such strict laws, six illegal abortions occur for every 10 births in Chile, and those abortions—either surgical or through mifepristone, RU-486—frequently have such life-threatening side effects as sepsis or hemorrhage. Chilean adolescents who find themselves pregnant and choose to marry face a lifelong decision without recourse or solution, as the country is the world’s only democracy without a divorce law, another result of the strong influence of the church.


In general, cultural taboos about sex education limit the availability of important information about sexuality and reproduction. Although some colegios in comunas—the secondary schools in diverse and more liberal, urban areas—are more likely to offer inclusive sex education, views on sex and abortion remain predominantly conservative. It should be considered an accomplishment for a young woman like Carolina to have found her way to the clinic before a pregnancy, regardless of the visit’s outcome.


I was also amazed at Carolina’s maturity, in spite of Alvarez’s callousness and paternalism. However, I soon discovered that most patients were fairly comfortable with the extensive questions about their sexual lives, the clinical commotion that frequently disrupted pelvic and other private exams, and the physicians who sometimes made decisions about their care that directly opposed what they might prefer.


The most striking thing about working in Santiago as a health-care provider was the profound cultural differences in the patient–physician relationship. In an effort to explain to me his clinical reasoning during Carolina’s visit, Alvarez said that the physician’s goal in any clinical encounter is to decide what is best for the patient. His job is not to be a friend or an intermediary between her and her parents, but to protect her welfare and do what he thought best. This is the reason why patients come to physicians, he said, adding that this is especially true with female adolescents, because a physician must act in place of the adolescents’ parents in granting them permission to use birth control. While the young women frequently do not want to involve their parents, they do want an adult to take charge of these decisions, he said. Many of my other Chilean colleagues agreed with this reasoning.


So, far from being affronted that her physician was acting—as Ferris Bueller would say—as a parental unit, Carolina was satisfied because she expected that type of patient–physician relationship, and she trusted us to focus on her needs. In fact, most of the patients I saw in Chile seemed to desire this and trusted their physicians—a stunning contrast to the litigation-ridden U.S. health-care industry.


It’s this lack of medical litigation that seems to make all the difference in Chile, although cultural expectations and sexual politics undoubtedly play roles as well.


Furthermore, while there are many profitable hospitals and clinics in Santiago, Chilean physicians are typically not wealthy, especially when compared to their U.S. counterparts. Most struggle for income and must pay high fees in order to pursue their education. As a resident told me during my second week, patients believe their physicians must be dedicated to medicine to pursue it—an attitude toward physicians that, at least in the United States, seems to have been lost long ago.


My experiences in Chile have led me to conclude that perhaps a benefit of the U.S. health-care system’s financial disarray—and physicians’ declining income—will be improved patient– physician relationships and an increase in patients’ trust in their physicians.
~~~~Tarayn A. Grizzard is a fourth-year Harvard Medical School student. She spent the 2003 summer in Santiago, Chile, working in adolescent reproductive health and sexual health. Direct comments and questions about this article to tnp@amsa.org.~International Health~
98~2March~2004-53~Feature~Healing the Poor~~Avery Hurt~Practicing medicine in extremely poor communities calls for skills and creativity far beyond what’s required in a typical medical practice. But for many physicians, the rewards are more than worth the struggle.~When Brenda Grant, a third-year at Texas Tech University Health Sciences Center School of Medicine, arrived for work one morning at the San Elizario health clinic where she was doing a summer preceptorship in family medicine, she was not surprised to see an elderly man waiting in the shade of the clinic’s sign. The morning’s temperatures had already begun to climb in this small Texas town southeast of El Paso, along the Rio Grande. Lupe Ramirez’s* appointment wasn’t until the afternoon, but because he had to walk many miles from his home to the health center, he wanted to make the journey before the day became unbearably hot. Grant says she found unusual patient behaviors like these common at the border clinic.


San Elizario, a Kellogg Community Partnership clinic sponsored by Texas Tech University, serves some of the poorest people in the nation. Working in an impoverished community like this can be one of the most challenging ways to practice medicine. It can also be one of the most rewarding. It is likely, however, that nothing you learn in medical school will fully prepare you for this environment. When you get to the border clinic, the inner-city emergency room or the rural community health center, you are most definitely not in Kansas anymore.


WALK A MILE IN MY SHOES


Because of their poverty, patients at clinics like the one in San Elizario often make decisions and develop behaviors that seem strange to the predominately middle-class professionals who try to provide them with health care.


Beverly Williams, Ph.D., a medical sociologist at the University of Alabama at Birmingham (UAB), recently concluded a three-and-a-half-year study examining the ways low-income individuals handle the social problems accompanying illness. She says “physicians have to walk in the shoes of the poor before they treat them.” There are so many differences that without an understanding of the people and their communities, any attempts to serve them are likely to fail, she says. That’s because middle-class health-care providers are unfamiliar with the accommodations the indigent must make and the strategies they must employ to survive.


In poor communities, patients rarely seek health care until they are very ill. They are frequently late for appointments or miss them altogether because their access to transportation is precarious and taking time off work to visit a physician may mean losing a hard-to-come-by job. They often do not get prescriptions filled until payday or until they can sell a piece of furniture to pay for the medicine, and even then they are likely to save some of the medication for later or share it with family members who may be experiencing similar symptoms. Parents will frequently take one sick child to a physician and then distribute the medicine among several others at home.


For many reasons, including feelings of embarrassment and alienation, poor patients are less likely to be honest with their physicians. And even when they are, communication can fail in ways so subtle the physician may never know it failed. Grant remembers caring for an older man with high cholesterol who assured her he always cut all the fat off his meat before eating it. Only later did the medical student learn he lived on the one meal a day he received from a local soup kitchen. “He didn’t want to say, ‘I eat what I am given; I have no control over my diet,’” Grant says.


The challenges in caring for this unique community of patients reflect deeply entrenched social issues. In Health Work With the Poor: A Practical Guide, Christie Kiefer, Ph.D., an anthropology professor at the University of California, San Francisco, School of Medicine, says that the poor are particularly vulnerable when it comes to health care. Their choices of providers and treatment options, along with their ability to question or influence treatment decisions are all compromised by their lack of resources. In addition, he says, the power relationship between the physician and the poor patient is particularly unbalanced. The poor patient typically sees his physician, a well-educated, well-dressed authority figure, as someone representing an alien and oppressive culture.


DR. SOCIAL WORKER


Many of the difficulties experienced by caregivers are practical in the extreme.


When the staff at the San Elizario clinic discovered that a kidney transplant patient, Maria Garcia, had received no specialty follow-up care after her operation, they knew something needed to be done. Many phone calls and hours of paperwork later, a nurse practitioner managed to arrange for a charitable foundation to pay for Garcia to visit a nephrologist across town. After navigating three buses and a long walk to get to the specialist’s office, Garcia was told she couldn’t be seen because she could not pay. So she made the long journey back to the clinic. The problem was finally resolved after a nurse spent three hours on the phone with the specialist’s office.


This is just one example of how nonclinical concerns can greatly interfere with a poor patient’s health care. Making creative payment arrangements, juggling medications to take advantage of free pharmaceutical samples and overcoming language barriers are all routine aspects of this type of medical practice.


Of course, most of this is new territory for young physicians. “You don’t learn this kind of thing in medical school,” Grant says. “But in this kind of practice, you often do more social work than medicine.”


Dr. Matt Symkowick, a chief resident in family and community medicine at San Francisco General Hospital, a low-income health center, agrees. “I spend lots of time writing letters, making phone calls, tracking people down when they miss appointments, doing home visits….”


Being an advocate for patients is part of every physician’s job, but for those who work with low-income patients, the advocacy doesn’t stop with following up on referrals and researching new techniques and therapies. For the underprivileged, medical problems are intertwined with and often the result of social and political concerns.


“If a doctor really cares, he or she needs to think seriously about becoming an ally, an advocate, an activist outside the clinic,” Kiefer says. Many physicians caring for the poor find that they can’t do their jobs any other way.


DIFFICULT, BUT NOT DISMAL


Though the problems and challenges are enormous, it is a mistake to think of this work as depressing. Physicians say it can be frustrating and exhausting but also energizing and entertaining. One only has to visit an indigent-patient health-care facility to witness this.


A day spent at St. George’s Clinic at Cooper Green Hospital in Birmingham, Alabama, is full of heart-warming moments: An elderly patient dances in the hall to demonstrate how he’s improved since his last visit. A nurse calls to him, “Oh, Mr. Harris, you better watch out! I think you may be feeling too good!” Another nurse fondly addresses an AIDS patient who is walking around until his turn to have blood drawn: “Don’t you go too far—I don’t have time to come looking for you.”


Patients often wander casually in the halls here, chatting with each other and the staff, who ask after patients’ relatives. Laughter is frequent; yet when tears do come, patients as well as staff are on hand with tissues and shoulders to cry on.


As in most low-income, inner-city clinics, waits can be long at St. George’s. This problem is not unique to indigent care, but perhaps how patients and caregivers react to it is. On this day, the staff is further behind than usual, and patients are piling up in the waiting room. A nurse sits down with them to explain that a patient who had come in earlier had serious health problems and took longer than expected. She apologizes for the delay in the manner one might express regret to hungry guests when the Thanksgiving dinner isn’t quite ready—with sincerity, but with the expectation that everyone would understand and the knowledge that everyone was a part of what was going on. The patients seem to accept the situation. They understand that when their time comes to see the physician, they will not be rushed. It also helps that a midday visit to St. George’s includes having lunch sent up from the cafeteria.


Dr. Susan Ferguson, the clinic’s director, explains that a desire for a meaningful and quality life isn’t diminished by a lack of income. “The poor are open and humble, and gracious and grateful. They enjoy life as much as people with money do.” Ferguson appears to thoroughly enjoy her life at the clinic. Her small, messy office is filled with pictures of her family, her patients and her patients’ families, and she’s known to give spontaneous hugs to patients and other visitors.


Kiefer agrees that the poor are often surprisingly well adjusted to life. “The sheer difficulty of surviving—and helping one’s loved ones survive—in a harsh environment seems to give a sense of purpose to the daily activities of many,” he says.


Williams warns, however, that it’s important not to romanticize the poor. Romanticizing or identifying too strongly with them can cause physicians to deny their natural anger and frustration should a patient be demanding, irritable, manipulative, disagreeable or ungrateful—behavior problems encountered in all types of practices. Such denial can seriously compromise the physician’s relationship with her patients and her own mental health.


THE ART OF CARING FOR THE POOR


This kind of medicine can be done well, if one learns the art of practicing in poor communities. Just like the poor, physicians must develop strategies and accommodations to better deal with their situations. The three key strategic areas to develop are: communication, community involvement and trust.


Communication. Of all the tricks to practicing successfully, effective communication is the most important. At its most basic level, this often means translation. Many poor communities have large populations of non-English-speaking patients. At the San Elizario clinic, Spanish is the second language of many of the patients, the first being their Native American tribal language.


While it’s not necessary to be fluent, health-care workers must make an effort to learn the languages of their patients. Translators are helpful, and Dr. Darryl Williams, the executive director of the Office of Border Health at Texas Tech, recommends enlisting the help of community members. Patients’ languages often contain subtle meanings that can make cross-cultural communication difficult without good translation by those who are familiar with the patients and their circumstances.


Communication requires more than speaking the same language, however. “You have to ask the right questions and phrase things in the right way,” Beverly Williams says.


For example, following conventional medical wisdom, many physicians suggest their patients get more exercise and eat plenty of fresh fruits and vegetables. That’s good advice, but for someone who works two jobs and cares for three grandchildren, finding time to exercise might not be a priority, and fresh fruits and vegetables are expensive. A physician who is aware of this can take a different approach.


“Trying saying, ‘How can you work in more exercise? Do you have a stroller so that you can take walks with the children? Can we see about getting you one?’” Williams suggests. She also points out that you shouldn’t be condescending about nutritional matters. “Their diets aren’t all bad. What they eat is affordable and comforting, and that can be worth a lot.”


Ferguson says another important rule to remember is listening. “Medicine requires active listening. You are always listening. And patients will usually give you the most important bit of information when you aren’t expecting it. You have to stay focused.”


In addition, good listening requires an understanding of the cultural context of the message. Without that understanding, physicians eager to redress injustice can lose sight of the real problem and do more harm than good. For example, when a woman is living with an abusive husband, the tendency of a middle-class person might be to get him out of there. But his income, no matter how meager, may make the difference between whether or not she can feed her children. The problems of the poor are often more complicated than outsiders understand, even when they are trying very hard to listen.


Get involved with the community. If you want to talk with clinic director Dr. Tony Islas and can’t find him at San Elizario, you might try looking on the soccer field at the local high school. Islas doesn’t limit his interactions with his patients to the exam room. He is the physician for the high-school soccer team and involves himself in many other aspects of the community.


“The key to practicing effectively in an underserved environment is getting to know the townspeople,” he says. He suggests physicians attend local events, such as fairs, bazaars and festivals. “Seek out the people who are in the booths, the folks who are working the fair—not the tourists.”


He also recommends making house calls as a way of getting to know how your patients live. “Go see the elderly woman who can’t walk, has no car and is confined to her home. She’s 104 years old and the matriarch of the family. You’ll get to know her, but you’ll also get to know everybody else in the family.” Knowing your patients better will help you come up with creative ways to get them the care they need.


Earn their trust. Communicating, getting to know the community, learning to be a social worker—all are key tools for practicing effectively in underserved communities. And they all contribute to what may be the most difficult challenge of practicing medicine among the poor: earning their trust.


It is not easy for a middle-class, professional authority figure in a white coat to gain the trust of people who have little control over their lives and less reason to trust those who do. “Poor people are often intimidated by doctors,” Beverly Williams says and adds they may have good reason to mistrust them. “A lot of research suggests that the socioeconomic class of the patient determines how the doctor relates to that patient. The socioeconomic inequality is so great that doctors can treat poor patients differently without even realizing that they are doing it…. Often the doctor doesn’t even have a clue [what life is like for the patient].”


Good communication and an understanding of patients’ cultures are essential in gaining trust. However, a true relationship goes deeper than this. It requires subtle changes in attitude and a unique kind of understanding. According to Kiefer, the way to achieve this is by developing humility.


“It takes a tremendous amount of hubris for a physician to set him- or herself up as a healer. You can’t know everything; you can’t do everything,” he says. “There are many tragedies in life we can’t avoid. When you face that fact, you’ll develop a humility that will bring you closer to your patients. When the doctor truly sees that we are all co-sufferers in a universe that we did not make and cannot control, he or she is on the way to earning the trust of his or her patients.”


CARING FOR THE CARETAKERS


Though all this extra effort is necessary to practice effectively in underserved areas, it can have a great emotional, psychological and physical impact on the conscientious physician. “The burnout rate is high in this environment,” Darryl Williams says. But just as there are strategies and accommodations for taking care of patients, there are also strategies and accommodations for taking care of yourself.


Part of this is accomplished with the right attitude. “I never bought into the idea that medicine is a business,” Ferguson says. “I feel that this is my purpose in life—what I was born to do. I’m here because I’m supposed to be here…. Those who aren’t passionate about it won’t stay.”


The St. George’s director has a deep commitment to her job and her patients, but she also knows her limits. “I don’t buy trouble. I know what I am responsible for and what I’m not,” she says. Being aware of what you can change and what you can’t is essential to surviving in this environment.


Like Ferguson, Symkowick chose medicine as a career because he saw it as a way to help people. But maintaining a balance between his patients’ needs and his own is a constant struggle. Exercise and meditation help him cope, but much of his support comes from other people. “My spirit is continually replenished by relationships with colleagues,” he says. The resident’s biggest support system, however, is his family—a wife and two young children. “Spending time with my children is a forceful decompression.”


As with any demanding profession, creating boundaries between work and home, between the personal and the professional are essential to success and survival. In this kind of practice, however, those boundaries may be even more necessary. The question of where to live is a case in point. Physicians who practice in underserved communities are often criticized if they do not live in that community. How connected can you be to the people you serve, some might ask, if you leave it every night for better quarters? While acknowledging the potential for criticism, Darryl Williams says living outside the community may be necessary for some physicians. “Going home to a different part of town every night can be a good way to decompress.”


Caring for the poor is challenging, requiring skills beyond those developed in medical school and demanding levels of energy, creativity and patience that can test even the strongest souls. So why do people do it? Because, it seems, the rewards are as extreme as the demands.


“You can’t buy what these people give me,” Ferguson says.
~PRACTICAL REWARDS


There’s at least one very practical reward for practicing in an underserved area: “It’s a good way to get your loans paid off,” says Dr. Tony Islas, director of the San Elizario clinic.

To explore this option, visit the National Health Services Corps online or the Indian Health Service.


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


HANGING OUT A SHINGLE


Practicing in an underserved area can offer a young physician a chance to
establish a community practice that offers independence and autonomy, plus earn him the gratitude and respect of the community. “If you are looking for the old-timey, family physician feel, this is a good way to do it,” says Dr. Tony Islas, director of the San Elizario clinic.


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


RESOURCES


Investigate these resources for more
information on how to care for the poor:


~~~Avery Hurt is a contributing editor with The New Physician. Direct comments and questions about this article to tnp@www. amsa.org.~Career Development,Community and Public Health,Health Disparities,Practice of Medicine~
99~2March~2004-53~Feature~The Politics of Health~~Scott T. Shepherd~~In October 2003, TNP spent
two days shadowing Dr. Eric Whitaker
to learn what life is like for a
physician in public office.


It’s 8:40 a.m. and Dr. Eric Whitaker is nowhere in sight. A helicopter, scheduled to leave 10 minutes ago, sits out-
side the Illinois Department of Transportation’s Division of Aeronautics, and the pilot peeks into the waiting room every 5 minutes to see if all of his passengers have arrived.


Minutes later, Whitaker rushes into the waiting room with his cell phone pressed against his left ear. He greets those waiting and signs in without removing the phone. With silver spectacles, graying hair and broad shoulders that have no need for the padding in his sleek, gray suit, the 38-year-old physician exudes confidence. As he strolls across the tarmac and hands his baggage to the pilot, it is impossible to tell that he is about to take his first helicopter ride.


There have been a lot of firsts for Whitaker in the previous seven months since first-term Gov. Rod Blagojevich (D) appointed the Chicago physician director of the Illinois Department of Public Health (IDPH) on March 25, 2003. Only seven days later, on April 1, Whitaker officially took over a state agency with 1,200 employees and a $330-million annual budget. “April Fools’ Day. There’s a joke in there somewhere,” Whitaker says, laughing.


It certainly seemed like a practical joke when he was first approached by Blagojevich’s gubernatorial transition team. After all, Whitaker had never met the governor-to-be and didn’t know anyone in his circle of advisers and confidants. So when he was asked for a résumé, Whitaker didn’t think much of it. “At the time, I thought I would be offered a position on some sort of body—some sort of state board, like a state board of health—because that is something I have done a great deal of…. Two weeks go by, and then someone calls and says, ‘We would like to interview you.’ I was a little bit shocked, because I wasn’t applying for a job.”


It turns out he was applying for a job; he just didn’t know it yet. An associate of the governor’s had floated Whitaker’s name as possible head of public health. A telegenic and well-spoken physician from the South Side of Chicago, Whitaker had gained a great deal of recognition—including stories by the Associated Press, PBS and local media—from his success with Project Brotherhood: A Black Men’s Clinic.


UNDERSTANDING BROTHERHOOD


Project Brotherhood was created in 1998 in the Woodlawn section of Chicago, where black men face high rates of heart disease, hypertension, diabetes, AIDS and death by homicide but have little desire to seek health care. As a result, the life expectancy for black men in Woodlawn is 58, almost 20 years less than for men in the affluent Hyde Park neighborhood only blocks away.


With the support of community organizations, Whitaker set about to address this problem the most logical way—he asked the men why. Focus groups discovered they wanted several things: a health center that showed them respect, where they can relate to the health-care provider; a center that wasn’t seemingly designed for women and children; and, most of all, a way to seek help without appearing “weak.”


For Whitaker, there was an obvious solution: the barbershop. In many black communities, the barbershop is a place of refuge for men, a place where they can speak freely and frankly. By establishing a facility with a free barbershop in the front and health care in the back—staffed entirely by black men—Whitaker started drawing between 20 and 50 men to the weekly clinic. Project Brotherhood has become such a success that it has garnered not only national media attention but also received the National Association of Public Hospital and Health Systems’ highest award in 2000.


THE GOVERNOR'S CHOICE


With these accolades, it’s easy to see why Whitaker caught Blagojevich’s attention. But, it was still difficult for him to imagine being offered such a lofty political position. After all, he was just an internal medicine attending at Cook County Hospital. He wasn’t a politician or a bureaucrat. His most significant previous political experience was the year he served as national president of the American Medical Student Association (AMSA). He was hoping that and all of his other experiences might lead to an influential public health position someday. But not yet.


“The fact of the matter is that a lot of my role models that I learned about at AMSA, they did a job like this in their lifetimes. [And] I thought I would do [something like this] eventually. I just thought it would be 10 years from now,” he says.


However, his age and lack of bureaucratic experience wasn’t particularly important to Blagojevich’s team. What they saw in Whitaker was an innovative vision of public health.
“When I walked into the interview—I am interviewing with the chief of staff for the governor—and I basically outlined for him a social-entrepreneurial vision of what public health could be at the community level—I mean I basically consider myself a social-entrepreneur, you know, taking ideas and making programs, with no money. So I laid out how you could empower communities to do similar things like we were doing with black men’s health in the community where we worked. He sat there and listened to me, and then he called some other people into the room, and he asked me to tell them what I just told him.”


From that interview, Whitaker learned he was one of five candidates for the director of public health post. A couple more rounds of interviews, and that number dwindled until only Whitaker remained.


TAKING OFF


That was March 2003. Now it’s late October and Whitaker sits in a state-owned helicopter with George Rudis, assistant deputy director of the IDPH’s Office of Finance and Administration and a 27-year veteran of the agency. Minutes into the flight, Rudis shouts over the roar of the rotors the name of a possible appointment to the department’s vacant head of vital records. Whitaker notes it’s one of the few empty top-level positions—not that there aren’t more to come, but he’s still in the process of evaluating the organization and has decided not to make major personnel or structural changes until he’s done. “Some people come in and sweep everyone out…. That’s not my style,” he says.


Soon, the helicopter makes a pit stop to pick up John Pitzer, who is the regional health officer (RHO) for the Edwardsville Region, an area covering counties in central southwest Illinois. Pitzer is also the acting officer for the Marion Region in the predominantly rural south and southeast counties of the state. While he has many responsibilities, his position often boils down to being a focal point of communication between local health departments and the IDPH. And at IDPH headquarters in Springfield, it is Rudis who acts as a liaison to Pitzer and six other RHOs.


With the late start, they are running behind for a 9:30 a.m. meeting. Of course, Whitaker’s delay was caused by an early morning cabinet meeting at the governor’s mansion, which means his tardiness receives automatic forgiveness. On this day, that understanding will come from health board members and staff of the Southern Seven, a coalition of the seven southernmost Illinois counties. With more than 72,000 people spread over more than 2,000 square miles, the geographic obstacles in this region alone make it difficult for local health officials to serve their communities.


Shortly before 10 a.m., the helicopter sets down on a small landing pad at Shawnee Community College in Ullin. A van takes the director and his party to the other side of campus where the Southern Seven Health Department sits and where more than 25 people wait to meet with the director.


Whitaker begins his first visit to the Southern Seven by diving into the issues concerning them most: the cost of malpractice insurance, the uninsured, state scorecards on public health, the monitoring of nursing homes, the use and distribution of data collected by the agency, the allocation of bioterrorism money and the lack of health-care personnel. He closes his speech by announcing there will be changes in the IDPH philosophy. “[The previous administration] told [the IDPH], ‘We don’t care what you do, just don’t get in trouble.’ Well, I’m trying to get in trouble,” he says.


The call for change is welcomed by Southern Seven health officials, but they remain skeptical. As is the case in many rural communities, local administrators often feel overlooked in favor of the more populated Springfield, East Saint Louis and, above all else, Chicago. With a new IDPH director from Chicago, there may be an even greater sense of apprehension, but it is unapparent today.


MAKING TROUBLE


In Whitaker’s case, the sense of change is profound. After all, his predecessor, Dr. John Lumpkin, served for 12 years under two Republican governors. So beyond changing IDPH philosophy to be more social-entrepreneurial, as Whitaker would put it, there is also a need to transform the culture. That is why Whitaker is quick to point out that Blagojevich has encouraged him to “get into trouble.” In this case, trouble means challenging accepted practices and finding new ways to get things done.


Just days before this trip to Southern Illinois, Whitaker and Blagojevich found a great deal of “trouble” when the governor’s office issued a report declaring the state should seek an exception from the U.S. Food and Drug Administration (FDA) so it could purchase prescription drugs from Canada. The report, which was based on a trip to Canada by an 11-person delegation led by Whitaker, said the state could save more than $90 million a year by establishing a program to buy prescription drugs from Canada for state workers and retirees. And contrary to the FDA’s stance, Whitaker’s delegation found that drugs from Canada pose no significant safety concerns.


The story gained national media attention and consumed much of Whitaker’s time early that week as he fielded questions about the report and provided counsel to the governor. And that media frenzy came on the heels of another big story as Illinois became the first state to receive the highest rating from the U.S. Department of Homeland Security and the Centers for Disease Control and Prevention (CDC) for its preparedness to rapidly distribute pharmaceutical and medical supplies in the case of a bioterrorism attack. Under the plan, Whitaker is the state’s designated official who, in consultation with the governor, would trigger a request for deployment of supplies.


Before that, there was another national story to deal with—the outbreak of monkeypox after an infected prairie dog was sold from a pet store outside of Chicago. However, what could have been a public health disaster—not to mention a public relations nightmare—was instead a shining moment for the IDPH.


With last minute notice from the CDC that it was investigating the pet shop, the IDPH set into action. “Over the next 10 hours, we assembled this group who worked through the legal issues for quarantining; we set up an 800 number for people who had prairie dogs and Gambian rats so that they could call for information; we worked together with the [state’s] Department of Agriculture to reach out to veterinarians and to pet store owners to let them know this was occurring; we also informed all infectious disease doctors in the state; and we sent state police out to contact people…. We marshaled all of the forces and coordinated an interagency solution to this problem.”


All of this occurred only a month after Whitaker and the IDPH participated in TOPOFF2, a massive, five-day, $16-million terrorism drill conducted simultaneously in Seattle, Chicago and Washington, D.C. Barely a month into the job, it was a wake-up call for Whitaker on how demanding the position could be and how much he would have to learn on the fly. Regardless, the IDPH and the state received high marks for their performances.


Whitaker believes these achievements set the tone for the IDPH to have a good relationship with the governor. “You learn about people in the midst of crisis, and they learned I would work with my team to do what is right for the public: Keep them informed and stay ahead of problems. As they get confidence in your ability to manage and be a good representative to do things, you get more freedom to do things.”


ON THE ROAD


Following his speech to Southern Seven health officials and a tour of a Head Start program, Whitaker sits down with local staff members for a catered lunch. Not surprisingly, the menu is barbeque—word is out that it’s one of the director’s favorites. But before he has a moment to savor the food, he’s back in the helicopter, leaving Ullin and heading about 20 miles away to the town of Anna for a meeting with more local health officials.


The helicopter lands at Union Hospital in Anna a little after 1:30 p.m., and a van rushes Whitaker, Rudis and Pitzer to city hall where an audience awaits them. While the crowd is smaller than expected—only 25 people are in attendance, as compared to the 60 anticipated—it makes little difference to Whitaker. He jumps into the issues facing the IDPH and local health officials and appears to strike a chord with the audience, reinforcing the importance of rural health and noting that the department considers rural residency to be one of the many factors contributing to health disparities in Illinois. As he did in Ullin, he also touches on the importance of providing reinforcements for an aging health-care work force.


After taking a moment to speak one-on-one with audience members, shake hands and pose for pictures, Whitaker dashes back to the helicopter. Mercifully, the day’s meetings have come to an end. Still, there is more work to do.


NO PLACE LIKE HOME


Since the moment he accepted the position, Whitaker has been moving at this pace. The past week alone, he had press conferences about the drug importation report and the Homeland Security rating—and that was while he was at home in Chicago on paternity leave, celebrating the birth of his second child, Caitlin, with his wife, Cheryl.


Since the job requires him to be in Springfield at least three days a week—five days when the legislature is in session—he knows that he will miss many of his daughter’s early achievements, not to mention the “daddy phase” his son, Caleb, is going through. “My previous position, I had a lot of flexible time where if I needed to pick up my son from school because he was sick or other things, I was there,” he says.


When thinking about his family, Whitaker wonders how long he can keep this up. At those times he thinks he’ll merely be a one-term wonder. But at other moments—when he feels he’s making a real impact—he thinks he’ll do this as long as he can, or at least as long as Blagojevich remains on the job and wants him to continue. “I have never been more happy professionally than I am right now…. The only reason [my wife] allows me to be away from home the way I am is that she knows I can make a meaningful difference.”


Landing just before 4 p.m. at an airport in Mascoutah, about 25 miles east of St. Louis, Missouri, Whitaker is on his cell phone with Rory Slater, special assistant to the director. Slater and Quin Golden, Whitaker’s chief of staff, are deciding when they’re going to leave Springfield and head down to Fairview Heights, where Whitaker and Rudis will be spending the night. Surprised they haven’t left yet, Whitaker strongly advises them to leave soon and reminds them to bring his laptop.


By 7 p.m., Whitaker, Slater and Golden huddle around a table in the hotel restaurant with a box filled with documents occupying the extra chair and urging their attention. Whitaker refers to Slater and Golden as his right and left hands. He also says he’s not sure who’s in charge of whom sometimes, but for Slater and Golden there is little doubt. They say Whitaker is a demanding but fair boss who drives them to make the IDPH a better agency. Golden says it’s nice to work with someone so committed, noting Whitaker asks a lot of them, but expects a lot of himself too.


For tonight, however, there seems to be a respite in the work. As all three have had a long day, Whitaker declares at 8 p.m. he’s going to take advantage of a rare opportunity to watch “The West Wing.”


A COUNTRY DOCTOR


By 6:30 a.m. the following morning, Whitaker and his right and left hands are already at work. The day does not begin pleasantly for Whitaker, who learns that the 15-minute talk he had planned for today’s St. Clair County Health Care Consortium Conference in nearby Belleville is, in fact, an hour-long presentation and participation in a town hall meeting with three other speakers. He’s not overly concerned, though; the conference is about health disparities, and Whitaker has been asked to speak about Project Brotherhood.


They arrive at the conference on schedule, and the meeting gets underway with some opening remarks. Then Whitaker, joined by a local state representative, makes a $12,500 check presentation to Southwestern Illinois College Programs and Services for Older Persons for an initiative that provides AIDS care and education to the elderly. Following some stereotypical political pictures—Whitaker and others standing behind a giant check—the first speakers step to the podium and present a variety of charts and graphs illustrating the severe health-care disparities between whites and blacks in St. Clair County.


After 35 minutes of numbers and statistics, it’s Whitaker’s turn. However, there are no charts or graphs in his presentation. That’s not his style. The Chicago physician prefers to address the large audience much as he would speak to longtime patients. He uses casual language and moves his speech along at a leisurely pace, interjecting fond personal memories and stories. For a discussion on Project Brotherhood, this is particularly easy.


Unfortunately, like time with his family, Whitaker’s clinical work has been sacrificed for the IDPH. “Hopefully as we get better control of the agency, I’ll be able to do more of that,” he says.


As the town hall meeting begins, an audience member contests the racial element in Project Brotherhood, saying that for St. Clair County it may be inappropriate and unnecessary to have a clinic staffed solely by blacks. Whitaker explains that’s not the point. He says the point is to learn what keeps people from seeking health care and then doing something about it. Next, he outlines common problems facing the disadvantaged in urban and rural areas, opening with a favorite line. “I’m a simple country doctor from the South—the South Side of Chicago, that is,” he says with a grin.


Making a connection to this and other rural areas of Illinois is an early priority for Whitaker. “The major issue for me is to get out to areas that I don’t have a lot of information about from personal experience and to hear issues that get raised.”


And with the distrust rural health officials have developed of their urban counterparts, trips like these become even more important. “There are some commonalities to issues from the urban to rural areas, problems with access to medical care, access to oral health. But there are unique issues, like the medical malpractice issue…. I can’t sit in Chicago and make decisions in a vacuum, because otherwise I would be missing the whole picture.”


After grabbing boxed lunches, the IDPH group continues its tour of Southern Illinois, traveling from Belleville to Granite City, a steel mill town along the Mississippi River. They arrive at Coordinated Youth and Human Services, a United Way-run facility. A moving van sits outside, and workers carry in furniture from the organization’s Marysville clinic, which was closing due to a reallocation of Medicare funds. The loss of funds is one of the many subjects touched on by the program coordinator during a quick tour of the facility, which is followed by a brief meeting.


The visit lasts about 30 minutes, and Whitaker and his staff are back on the road, going to Madison County Health Department, which is located in a vacated hospital in Wood River. Toni Corona, the recently hired county department administrator, greets Whitaker, saying, “We welcome your enthusiasm. I have to tell you, you get me fired up.”


After a tour, Corona leads Whitaker to the lunchroom where local officials have gathered. Immediately upon entering the room—just as they did in Belleville—Slater and Golden move to the back to work. Golden plugs in her laptop, and Slater taps feverishly on his Palm Pilot. Wherever they go, the work never seems to stop. “I’ve never seen a group so plugged in,” Rudis says.


While they attend to IDPH correspondence, Whitaker works the crowd, sitting with local health board members and asking about their experiences, both personal and professional. In this environment, he looks like a polished politician, not just some physician-turned-bureaucrat. “I love politics. I think all relationships in life are political, and this is just taking it to a much, much higher level,” he says.


As his speech begins, it takes a familiar tone to those of the day before. When he begins discussing the IDPH’s bioterrorism response effort, an audience member’s cell phone rings—oddly, it sounds like a siren. “[That’s] the last thing you want to hear when talking about bioterrorism,” Whitaker says.


He wraps up his speech by promising changes within the department and the commitment to make serious changes in the state’s public health. “I can be ambitious. I don’t know any better…. My being here is a fluke. I didn’t even know this was a career path.”


With the audience hanging on his every word, that’s difficult to believe.
~PUBLIC HEALTH CAREERS


If you envision yourself in a career shaping public health policy—be it as part of an agency or, dare to dream, as the U.S. surgeon general—there is no prescription for how to get there. Some positions are highly political, but a great place to start any public health career is with a master’s degree in public health (M.P.H.). Dr. Georges Benjamin, executive director of the American Public Health Association (www.apha.org), says a master’s degree in hospital or health administration, or even in business administration, can be useful as well. “But the M.P.H. is the gold standard,” he says. Information about getting an M.P.H. is available from the Association of Schools of Public Health.


Networking is also crucial. “Talk with those people [already there] and find out how they got into those positions…. Word of mouth is the best way to find information,” says Betty Addison, director of career services at Johns Hopkins Bloomberg School of Public Health.


And get experience early. It was his year as president of the American Medical Student Association (www.amsa.org) that Dr. Eric Whitaker says best prepared him for his current position, the director of the Illinois Department of Public Health. After getting his M.P.H. at the Harvard School of Public Health, Whitaker led an organization of more than 30,000 members and testified before Congress.


But Benjamin warns physicians-in-training not to be too eager to get behind a desk. “Do not get too far away from clinical experience. It’s a very valuable background for anyone entering a public health policy or an administrative career,” he says. —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.~Community and Public Health,Health Policy~
100~2March~2004-53~Feature~Rich Man, Poor Man~BOUTIQUE CLINICS: NEW FUNDING SOURCES FOR TEACHING HOSPITALS?~Beth McNichol~~Something odd happens when you dial the Pratt Diagnostic Center at Tufts-New England Medical Center (NEMC). A person picks up. This is quite a revelation for those of us accustomed to talking to our dogs while listening to recorded options for service. When the same person repeatedly apologizes for putting you on hold, you want to hug her and tell her everything will turn out OK. How strange, you think to yourself. And then, you remember: This is a concierge medical practice, where personalized service reigns for patients who can afford it.


While the Pratt clinic just opened its doors in December 2003, concierge or boutique medicine—retainer practices, if you prefer—isn’t a new idea. Since the mid-1990s, about 130 primary care physicians nationwide, fed up with managed care, have left their traditional practices to open a kind of VIP lounge of care. For an annual fee that once topped $10,000 and can now be found for as little as $1,200, physicians go above and beyond the usual call of duty for patients who sign up with their practices.


Instead of 8-minute office visits, patients get 30 minutes; instead of waiting two weeks for an appointment, they get in right away or the next day. And the clincher: 24-7 access to the physician, via his personal pager. Concierge care patients must still pay for nonpreventive office visits; but they get special features with their annual checkups that other patients don’t, like more intensive screenings and comfier waiting rooms. It’s like buying a DVD versus a videotape.


What is different about the Pratt clinic, though, is that it’s the first concierge practice to be operated by an academic medical center. Admittedly, the two entities seem as if they come from opposite sides of the tracks: A downtown Boston teaching hospital with a record of indigent care meets a country club clinic with a membership fee. But Pratt’s medical director, Dr. Brian Cohen, says that unlike in John Hughes’ 1980s teenage angst movies, the two sides will get along just fine in Boston.


In fact, he says, in this case, the rich kid will give the poor kid his lunch money, funds that are direly needed at the teaching hospital. In 2002, Tufts-NEMC lost $12.5 million in operations, partly due to dipping Medicare and insurance reimbursements and the costs associated with providing its free care services. Its general practice clinic alone loses about $1 million annually—about $70,000 per primary care physician—because it receives lower reimbursements than such procedural-based practices as surgery, a rather sad refrain at many teaching hospitals.


“People looked around here in Boston and saw that within a few blocks of here are a number of high-end condos going up,” Cohen says. “We thought we were in the position to provide [concierge] services to those interested. In the process, we can put the surplus that we earn back into our medical center. Because we’re not just near high-rises, we’re also near Chinatown and South Boston, true working-class communities where the need is great. That’s the sole reason for doing this.”


In March 2003, Tufts-NEMC administrators turned to Wayne Lipton, an executive at the 3-year-old concierge care company MDVIP, to learn how they could create a retainer practice. Lipton had more than a little experience in the matter: The Boca Raton, Florida-based organization manages the business details of 30 concierge physicians in private practices nationwide, collecting annual fees, processing contracts and launching marketing campaigns for its clients.


As one might expect, this form of medicine isn’t without controversy. Since MDVIP’s inception in February 2001, the company has come under harsh criticism from health-care economists and advocates for the uninsured, who charge that boutique medicine would drive down access in the U.S. health-care system by forcing patients to pay a premium for quality care.


“It’s just an inevitable thing,” says Paul Ginsburg, president of the Center for Studying Health System Change, a Washington, D.C.-based research organization funded by the Robert Wood Johnson Foundation. “It’s the development of new products and services for wealthy people that’s gaining steam. It’s happened with luxury and near-luxury cars, and now it’s something that’s happening in the medical community. I suspect a lot of patients respond with fear, that rather than losing their doctor and being crowded into another practice, they’ll just pay the extra money to keep the doctor they like and know.”


Lipton saw a partnership with Tufts-NEMC as a way to soften MDVIP’s image. There was just one problem: How would they make concierge care work in a public setting?


“We looked at it and thought it was a long shot,” Lipton says. “It’d never been done in academic medicine before, where you have to balance teaching responsibilities and administrative duties. It’s not an easy thing. You also have to meet all the needs of the different parts of an institution—the university, boards, hospitals, physicians.”


One of the biggest concerns among concierge critics is that patients who don’t want to stay with a physician who opens a retainer practice are left with nowhere to go. A typical primary care physician has about 2,500 patients, and some physicians who’ve come to Lipton have had more than 6,000—a situation he calls “medicine on roller skates.”


To make its product work, MDVIP caps patient rolls per physician at 600. This means more time spent with patients, and more free time for overworked, private-practice physicians. But it also means a great deal of lost access, and Tufts-NEMC didn’t want that kind of press.


So, Cohen says, the teaching hospital approached the boutique clinic with caution. “We were careful to set this up to deflect some of the criticism that’s beset private practices doing this—that they leave their patients hanging without a physician unless they join the concierge services.”


And so a new model for concierge medicine was born: Each of the three physicians at the Pratt Diagnostic Center work only half-day shifts in the concierge setting, spending the remainder of their workdays treating patients in their existing general practices at the Tufts medical center. If a concierge patient pages Cohen while he’s working on the general side, for example, the patient has to see the concierge physician on staff for that shift instead. Theoretically, none of their general practice patients should get left behind. And because they work half-shifts, the physicians are also limited to only 300 concierge patients each, spots Cohen and colleagues intend to fill from their 1,200-patient rosters at the medical center. Two additional physicians will see fewer numbers of patients at the Pratt clinic.


“Spending more time with patients, being more personalized—this is medicine the way we all want to do it. But I’ve had some of these patients for 10 years, and I don’t want to give up those relationships because they can’t pay a fee,” Cohen says.


One casualty Cohen says he can do nothing about is losing the time to teach; he says he hates “giving that up, but something had to go.” Now, instead of doing rounds with students, the only interaction he’ll have with physicians-in-training is with the hospital’s house staff when he’s admitting patients. And while students do rotate through Tuft’s general practice, they won’t be allowed at Pratt Diagnostic Center.


“This crowd would not want students,” he says. “We’re catering to people in the financial district who don’t have a lot of time, and medical students need a lot of time. We’re also promising to be on time, and that’s something that’s just not possible when medical students are involved.”


And if he were planning to teach, chances are he wouldn’t advise future physicians to go into concierge medicine. “I’d never be able to do this more than half-time, because you hear about these guys—oh, they have a great life, they only see 10 patients a day. Well, I look at that guy and say: He’s rusting. You’ve got to see patients.”


This comment intrigues one critic. “It sounds like Tufts is really planning what this means to the doctor, and in doing so, adding to the discussion of this issue,” Ginsburg says. “No one has examined what it’s like for the physician in concierge medicine. It seems better to not go full steam ahead with a concierge practice. But who knows what drives [concierge] physicians. You have to remember there are entrepreneurs involved in this who go to the media and get the attention. The difference at Tufts is that they’re figuring this out on their own, instead of just signing on the dotted line.”


No matter how Tufts justifies its new venture, some people won’t be swayed. “This kind of thing infuriates me almost beyond rational thought,” an employee at Tufts University Sackler School of Graduate Biomedical Sciences, who asked to remain anonymous, wrote in an online forum last fall. “It feels like something from a horrible dystopian fiction. But why should medical care be any different than anything else? You get what you pay for, and if you can’t pay, you get what you deserve. Is that the motto of a healthy society?”


To be sure, some Tufts administrators were wary of the idea from the beginning, Lipton says. “Certain people thought it wasn’t something they would have done and not something that would have been done 10 or 15 years ago. But they recognized that it’s not 10 or 15 years ago anymore. It’s now. And times are tough.”


If projections hold true, the Pratt clinic should bring in “several hundred thousand dollars a year,” Cohen says. That’s enough to add a couple more primary care physicians to Tufts Medical Center. Unlike in most concierge arrangements, none of the Pratt physicians’ current salaries will increase with the switch.


Finding innovative funding sources for indigent care is nothing new to academic medicine, Ginsburg says. “The Tufts idea corresponds with the longstanding practices of many hospitals—especially teaching hospitals—that they would use the surplus in centers that make more money to cover for the costs of those that don’t generate as much revenue, whether that’s in research efforts or in teaching or in caring for the poor. [Yet] this could be a new model of using concierge practices.”


Indeed, the Tufts project has become so fascinating at MDVIP that Lipton recently received a new title: director of institutional growth and programs. MDVIP has approached “40 or 50 other institutions” about its group model and is in talks with four of them. He would not say which medical centers, only that they “are rather well-known institutions.”


The American Society of Concierge Physicians, a Michigan nonprofit begun last year to advocate for concierge medicine, will hold its first national conference in Denver this May. The speakers include Dr. Deeb Salem, Tufts-NEMC’s chief of medicine who has overseen the creation of the Pratt clinic; and Dr. Douglas Tilt, whose Camellia Medical Group opened in early January as part of the University of Alabama at Birmingham (UAB) Health System. The Camellia Medical Group is the nation’s second concierge clinic to be associated with an academic medical center.


Tilt, who says he prefers the term “personal care medicine,” decided to open Camellia after returning from a two-year stint in the United Arab Emirates, where he helped overhaul the country’s medical system. He visited prominent concierge clinics in Seattle and elsewhere and came up with his own template for the UAB clinic.


“This is the way I practiced when I first started [25 years ago], when I was brand new and had very few patients,” he says. “Each time I’ve started a new practice, I’ve been able to provide that kind of care, at least until patient rolls swelled. I want to get back to that.”


Tilt, whose daughter is a third-year UAB medical student, says he’s worried about the future of primary care and what students may be picking up from their superiors about its lifestyle. “The problem with universities is that the primary care physicians are asked to see more and more patients so they can make more money to recoup the losses. It’s a sense of frustration, a sense of failure, that makes many of us feel bad. The more patients you see, the less time you can give to patients and the more you go home and worry about whether you’ve done everything you were supposed to do.”


Camellia charges $3,000 per patient for annual membership, which will likely be filled by UAB donors whom “the university wants to be sure…have easy access to the institution and get well cared for.”


“[But] it’s not a cash cow,” Tilt says. “People say, ‘How can a university do a system like this? What about indigent care?’ We do more than our fair share of that, gladly. We’re proud of it. But we also need other revenue sources to allow that to happen. To have a healthy university, you have to attract all types of payers.”
~~~~Beth McNichol is a contributing editor with The New Physician and a freelance writer based in Durham, North Carolina. Direct questions and comments about this article to tnp@amsa.org.~Health Disparities,Health Policy,Practice of Medicine~
101~2March~2004-53~Folk Tales~Balancing the Scales of Justice~MEDICINE, LAW AND THE UNDESERVED~Scott T. Shepherd~~Harvard Medical School (HMS) fourth-year Drew Colfax works with people who are facing death head on. An attorney with the Equal Justice Initiative (EJI) of Alabama, Colfax provides free legal representation to indigent defendants and prisoners, particularly those on death row.


“There are almost 200 people on death row here…. And the state of Alabama does not guarantee representation to people beyond the first stage of their appeals…,” he says.


Thirty-five-year-old Colfax has been with the EJI since 1995, working on the cases of hundreds of death row inmates. “When I started working here…I realized there were egregious miscarriages of justice practically in every case. And furthermore, I would go to death row and I would meet with people, and they would come into the meeting yard for the first time in 10 or 12 years, literally. And being able to provide them with some sort of hope and some sort of sense of there being somebody fighting on their behalf was extremely important.”


The desire to help people was instilled in him by his parents. Colfax and his three brothers grew up in a remote area north of San Francisco. “We developed a very raw piece of land and basically created a self-sufficient homestead on the place,” he says.


After becoming one of the few home-schooled students accepted to Harvard University and getting an undergraduate degree in anthropology, Colfax did a fellowship in Africa. “I spent nearly two years in and around the Sahara Desert working in very rural health clinics, as well as developing water systems for villages in Burkina Faso, Mali and Niger….”


Back in the United States, he started making plans for returning to Africa and thought the best route would be to go to medical school or get a Ph.D. in biological anthropology. He settled on attending the University of Michigan for his Ph.D., “[but] it wasn’t quite hands-on enough. I didn’t want to become an academic anthropologist the rest of my life.”


So he reset his sights on medical school and fulfilling his premedical requirements. Earning a law degree was just a bonus. “The University of Michigan had a program that sort of allowed me to compact law school a great deal, so I was able to complete law school effectively in two years and, in addition, also complete my remaining premedical requirements.”


Colfax never intended to become a practicing attorney. “I knew that whatever I was going to end up doing, that it was a degree that would allow me to be able to argue and articulate my views in a manner that I otherwise couldn’t.”


Those plans changed in 1995 when he assisted a visiting professor who was also the director of the EJI. Colfax passed the bar in 1997 and soon found reasons to keep practicing law. “Once I became involved in capital defense work in Alabama, what I saw here, what occurs here, became extremely compelling to me and made it very hard to ultimately go to medical school.” So even though he had already been accepted to HMS, Colfax kept deferring his admission.


The work can be very frustrating. “It’s exhausting. As you work on these cases, you get to know the individual. You often see these cases affirmed and proceeding to execution without the courts—without any of the legal system—really looking at what occurred in the case.”


Because Alabama has no public defender system and limitations on expenses paid to hire defense attorneys, death row prisoners appealing in state or federal courts must fend for themselves.


One of his more frustrating, but also compelling, cases was a mentally retarded inmate. While the state acknowledged his low IQ, prosecutors pushed for his execution. After the U.S. Supreme Court ruled against the execution of the mentally retarded, the state then declared the inmate no longer legally retarded.


“That total disregard for justice, the law and the facts can be dispiriting and, at times, infuriating. But then I would go to see this individual, and seeing his obvious limitations would leave no doubt that the work was necessary and important. He couldn’t really follow my explanations of his appeals, but after coming within several hours of execution once, he thanked me for keeping him ‘out of the ground, which is a bad place to be.’ He didn’t really know how or why his execution was stayed, but he was alive the following day, and for that he was happy.”


Colfax acknowledges that they aren’t always able to help the convicted. “Every inmate I have ever represented I have gotten to know quite well. And I can’t always provide everything that they need, and I certainly can’t always obtain a reversal of their sentence. But just being able to be there for them for what is enormously difficult years and provide them some sense of hope, some sense of support is what I think compels most of us in this work,” he says.


Despite this satisfaction, his work with prisoners has become less and less frequent as he’s committed more time to his medical education. “So it’s been a tough process in that I have been more distant from doing the day-to-day litigation in the last year and a half. That being said, I haven’t really doubted my decision to go into medicine, as well as being confident that I will return to doing this work once I am through with residency. Perhaps not full time, but I will remain quite involved.”


As Colfax applies to emergency medicine residencies, he knows he’ll have to give up his work at the EJI for much of the postgraduate training period. However, he hopes that someday he will be able to balance his medical and legal practices. “I think there is considerable room for the joining of the two…. So I foresee myself being involved somewhere in that realm five or 10 years down the road…if I am not in West Africa.”
~~~~Scott T. Shepherd is an associate editor with The New Physician. For more information about the Equal Justice Initiative of Alabama, visit www.eji.org.~Advocacy,Health Policy~
102~3April~2004-53~Perspectives~“Doc Steinberg?”~NOPE, JUST PETE~Peter L. Steinberg ~~“Have a nice day, doc,” the clerk said as he handed my bag of groceries to me. At first I was wondering to whom he was talking, since I was just a third-year and other than my OR scrubs, there was little to suggest I had a connection to the medical field. Aside from jokes made by friends and family, this was the first time somebody called me “doctor” outside a hospital. In the hospital, amongst a crowd of physicians, someone could be fooled into thinking I was a real doctor; however, to the trained eye, my short, white coat gave away my true status. But how many patients—and for that matter, grocery clerks—know that subtle identifier? And I certainly wasn’t wearing my coat in the checkout line.


Older physicians have erroneously introduced me as “Dr. Steinberg” on innumerable occasions during my clinical training, but they knew I wasn’t an M.D. After being incorrectly introduced, I would usually offer a proper introduction to patients who assumed I really was a doctor by making the corny, conciliatory remark, “I’m actually just a med student; you can call me Pete.”


If the man on the street assumed I was a physician, then so be it. Rather than start a semantic discussion with a store clerk, I just wanted to take my bread, milk and eggs home. “Thanks,” I said to him. “You have a good day, too.”


Since this episode in May of my third year, the occurrences have increased in frequency. Now I’m even getting mail addressed to a “Dr. Steinberg,” who technically won’t exist until May 18. On that morning, I’ll awake as Peter L. Steinberg, civilian; and then, by magically donning a robe, getting hooded by a dean, obtaining a diploma and walking off stage, I’ll transform into Peter L. Steinberg, M.D.


Even my barber, Mrs. P, a woman I’ve known for almost 15 years and whose kids I used to play Little League with, is intimating she may call me “Dr. Steinberg” when I come back for a haircut after graduating. I told her it wasn’t necessary since I certainly won’t stop calling her Mrs. P—no reason to change the name you call someone after a decade, is there?


And even my mother’s friends, when they were over at the house eating cake and sharing stories, asked for a curbside from “Dr. Steinberg,” wondering if they could take nonsteroidal anti-inflammatory drugs with beta blockers. The fact I had an answer both delighted them and, in their eyes, gave legitimacy to my ultimate title.


On May 18, as much as I would like decades of accumulated scientific knowledge and experience to seep from my diploma and into my skin, transforming me into a master clinician, I’m afraid that won’t happen. Much to my dismay, graduation will not transform this humble medical student into an all-knowing physician. Even though in a medical, legal and even social context, it will transform me into Dr. Steinberg, graduation will not make me a competent doctor. Rather, the four years of study, experience and knowledge I’ve gained—including the knowledge and heaps of information that I must still learn—will make me Dr. Steinberg, not the Latin scrawl on a piece of parchment.


The journey is the key, not an individual event like passing an exam or garnering a degree. Sure, diplomas and parties and pomp and circumstance are great. Graduation is a worthy and needed tradition, plus you can get great photos of everybody dressed presentably and the like. Still, these milestones aren’t enough to make me a skilled physician, and that diploma isn’t going to help me take care of somebody who’s sick in the middle of the night.


Starting internship in that new, long white coat, I will be no more or less a doctor than I was the day I graduated. Since I started medical school, however, there certainly is a vast difference: I am more confident around sick people; I know a few new things about health and disease, and on rare occasions, I am even downright helpful. But more than anything, graduating will merely signify how much more I need to learn and experience to become a good doctor.


So come May 18, you can call me Dr. Steinberg if you really want to. It won’t bother me, and technically you’ll be correct. But, just remember, you can still call me Pete.
~~~~Peter L. Steinberg now wears the long, white coat as a general surgery intern at Dartmouth-Hitchcock Medical Center. Direct comments and questions about this article to tnp@amsa.org.~Student Life and Well-Being~
103~3April~2004-53~Feature~Growing Pains~OSTEOPATHIC RESIDENCIES STRUGGLE TO KEEP UP WITH THE GROWING NUMBER OF D.O. GRADS.~Jennifer Zeigler~~Yeah, spring—robins, flowers, young love and all that—but let’s get serious: Spring is when third-years’ thoughts turn from the rotation of the month to residency and the rest of their lives. Melissa Pearce, a third-year at Touro University College of Osteopathic Medicine (TUCOM), is no different. She dreams of a combined program in family practice and osteopathic manipulative medicine that won’t take her far from the San Francisco area home she shares with her husband. The only problem is that the closest program is thousands of miles away in Missouri. There isn’t even a general osteopathic family practice residency within 400 miles of Pearce, despite TUCOM graduating about 100 D.O.s each year.


The number of quality osteopathic residency openings doesn’t even come close to meeting the annual need—a far cry from the allopathic side of medicine, where hundreds of residency positions go unfilled by U.S. medical graduates each year.


The situation has begun a trend in the osteopathic profession that many find disturbing: As the number of D.O. graduates increases, the number of those going on to osteopathic residencies has decreased. The American Osteopathic Association (AOA) is working on finding ways to deal with the problem, and students and residents say any resolution will have lasting effects on the future of their profession.


GROWING PAINS


Compared to allopathic medical education, which saw the first new school in 20 years open its doors three years ago, osteopathic schools are growing at a frenetic pace. The number of osteopathic medical schools has gone from 15 in the mid-1980s to 20 this year, and the number of annual D.O. graduates has increased 36 percent in the last decade.


But as the number of graduates rises, the number of D.O.s in AOA-approved residencies has fallen 30 percent since 1998, despite the fact the profession has added 410 positions during that time. In 2003, about 46 percent of D.O. graduates entered allopathic residencies, according to the American Association of Colleges of Osteopathic Medicine (AACOM).


For some D.O. students like Pearce, the problem is one of real estate: location, location, location. It’s a fact not lost on Dr. Mitchell Kasovac, a past AOA president and director of medical education at Mesa General Hospital in Arizona. “From the osteopathic profession’s standpoint, we’re trying to grow, and we do want that student to go back to their home state for training and to practice,” he says, but he knows the reality is that those opportunities don’t always exist.


A map pinpointing the 20 D.O.
schools would show the profession heavily favoring the Northeast and Midwest, and because of osteopathy’s community-based medicine philosophy (see “What’s Osteopathy, Anyway?” at right), large teaching hospitals with lots of residency options nearby are not the reality. Seventy-five percent of all osteopathic graduate programs are in just six states: Florida, Michigan, New Jersey, New York, Ohio and Pennsylvania, mostly at small, local hospitals. So Pearce and others who spend four years at school building ties to their communities will often find they’ve got to uproot themselves to find an osteopathic residency.


For others, choosing an allopathic residency becomes a decision not of location but of program availability. Dr. David Russo, a second-year physical medicine and rehabilitation resident at the Mayo Clinic in Minnesota, looked at the lone osteopathic offering but settled on allopathic training at Mayo as his first choice. Other specialties have no osteopathic offerings—oncology and occupational medicine had no positions in the 2002 AOA match—while specialties such as preventive medicine and psychiatry have only a few.


The profession also loses training options as the small, community hospitals that often host AOA-approved residencies close or get swallowed up in the current hospital merger trend. In January, tiny Eastmoreland Hospital in Portland, Oregon, closed its doors and shuttered the only osteopathic residency in the Northwest, forcing its 16 residents out of state to finish their training.


Yet other students point to a lack of faith in osteopathic training as a major reason for the declining residency numbers. Ironically, after osteopathy spent years fighting a quack-doctor stereotype, some D.O. students now say they wouldn’t go into an osteopathic graduate program because they’re not as good as the allopathic ones.


Cathy Sims-O’Neil, a third-year at the University of New England College of Osteopathic Medicine (UNECOM), says she won’t consider an osteopathic residency because AOA-trained physicians have to “jump through extra hoops” to gain privileges in some allopathic hospitals, implying they’re not as well trained.“While I am very excited about the integration of manual medicine, I am not impressed with the osteopathic association at large.” She points to the differences between the allopathic and osteopathic licensing exams, calling the Comprehensive Osteopathic Medical Licensing Examination “poorly written.”


“They obviously don’t have the kind of money that the [United States Medical Licensing Examination] folks do. But if they run their residencies any way they run their tests, I’m sorry. I don’t want any part of it,” she says.


Kasovac says he’s aware of these concerns. “I think it’s a reality out there, but I don’t think it’s universal. I would ask, what part of the country are you looking at? Our people have had more clinical practical experience at the end of year one than those in year two and three at the big M.D. programs because [the M.D.s] have to wait their turn.”


AACOM dismisses a lack of faith in the system and says the reason fewer D.O.s are staying within the profession for postgraduate training is because the allopathic programs are recruiting them. “Osteopathic medical schools have a long history of training excellent clinicians. This, coupled with the osteopathic profession’s emphasis on training physicians for primary care specialties who understand the importance of the whole person and the musculoskeletal system to health and wellness, is very attractive to allopathic programs. Additionally, since the tragic terrorist events of September 2001, federal restrictions on foreign medical graduates that can train in allopathic programs have changed, resulting in more openings in allopathic programs,” the association said in a statement.


“We used to say that we were like AVIS—No. 2, but we try harder,” Kasovac says.


DEALING WITH THE DECLINE


The AOA, seeing these trends, convened a task force in 1999 to address the lack of osteopathic options for its students. At first, it contacted hospitals in the states most lacking opportunities and asked administrators if they would be interested in starting D.O. programs. A few came on board, Kasovac says, but the group soon realized a more cost-effective way to increase residency numbers: approach already established allopathic programs and encourage them to apply for AOA accreditation as well. “Looking out there, I see networking between the two programs [as] a very good thing,” Kasovac says. “I’m a graduate from 40 years ago, and the doors were closed to us.”


They’re not anymore. “As D.O.s are accepted into programs, our allopathic colleagues see they are just as well-trained,” says Dr. David Broder, president of the New York College of Osteopathic Medicine (NYCOM) Educational Consortium, an organization of NYCOM and 18 local hospitals.


So the task force approached 800 allopathic programs that had either D.O. faculty members or residents, and since 2000 has had 97 programs in 14 states apply for dual accreditation. The programs must teach the six osteopathic core competencies in the first year under a D.O.’s direction, as well as offer some type of training in osteopathy’s signature procedure—osteopathic manipulative treatment (OMT). For this, the AOA gives graduates credit for an osteopathic internship year, a preliminary training year about half of D.O.s take after graduation. The internship, or transitional year, is required of D.O.s seeking board certification in osteopathy.


The plan has proven popular among D.O. students, many of whom, while shunning wholly osteopathic programs, have sought out dually accredited ones. “I personally chose to only apply to dual-accredited…pediatric residency programs,” says Meredith LeQuear, a fourth-year at NYCOM. She explains that five states require D.O.s to have graduated from AOA-approved residencies for licensure. “Being from South Jersey, a neighbor of Philadelphia…, I would find it frustrating to know I could not practice over the bridges in Pennsylvania. The dual-accredited programs…will hopefully allow me to continue to foster my manipulative skills. I am able to later apply to both osteopathic and allopathic fellowships…without having to process additional paperwork.”


An AOA survey last year of D.O. students and residents found 84 percent of students and 81 percent of residents would be more likely to apply to a program with dual accreditation than to one with only AOA approval.


“Dual accreditation is going to continue to be extremely popular among D.O. medical graduates. It allows them to keep one boot squarely in each world,” Russo says.


Kasovac says he’s convinced the dual-accreditation route is the way to go—starting new programs from scratch just isn’t realistic. “The profession is going to sustain itself. I truly do not feel it’s selling the profession down the river,” he says.


FOSTERING A DIFFERENCE


There is a concern that as more D.O.s cross into the allopathic world, the osteopathic philosophy will get lost in the journey.


“I personally think osteopathic students in allopathic residencies is a bittersweet situation...,” LeQuear says. “Unfortunately, training in allopathic residencies may not afford opportunities to osteopathic doctors to continue to strengthen their musculoskeletal diagnostic or manipulative skills.” She adds, however, that D.O.s will continue to practice according to the profession’s standards regardless of their residency training.


Broder echoes LeQuear’s concerns. “I’m not sure that [osteopathic training is] watered down or lost—it’s more that they don’t have that reinforcement.”


Pearce would agree. “I think the trend away from osteopathic residency programs is bad for our profession. It’s very difficult to develop skill in osteopathic medicine while being precepted by allopathic physicians, though not impossible.”


The secret, many say, to sustaining the profession is in promoting OMT. “That is the difference, and we should take it [to allopathic medicine] and offer it,” Kasovac says. Thanks to an increased interest in alternatives to standard drug therapies, D.O.s are seeing more M.D.s making efforts to learn about OMT—Sims-O’Neil says an M.D. even runs the OMT clinic at one of UNECOM’s clerkship hospitals.


But Russo says osteopathy isn’t embracing OMT the way he’d like it to. “The sad reality is that at most D.O. residencies, there’s not a lot of hands-on treatment going on. Maybe there’s lip service given to it, but there just aren’t a lot of opportunities to practice it, because for the last 100 years we’ve been trying to be more like M.D.s,
so we’ve gotten away from it…. I think the challenge in the next 100 years is to get the message out that we have something different to offer the U.S. health-care system. To do that, you’ve got to build back into programs the osteopathic piece.”


In the meantime, D.O. students give all indications that they will continue to seek out allopathic-affiliated residencies, and Broder says they should. “It’s another route to practice, and D.O.s owe it to themselves to get the best training they can.”
~WHAT'S OSTEOPATHY, ANYWAY?

A therapeutic approach to the practice of medicine that uses all the usual forms of medical diagnosis and therapy, including drugs, surgery and radiation, but that places greater emphasis on the influence of the relationship between organs and the musculoskeletal system than traditional medicine does. (Mosby’s Pocket Dictionary of Medicine, Nursing, & Allied Health).


Founded by Dr. Andrew Taylor Still in 1874, osteopathic medicine touts a “whole person” approach to medical treatment. D.O.s look at the entire body instead of just certain symptoms, paying special attention to the musculoskeletal system.


Some D.O.s say that unless you look at their nametags for the letters after their names, you’d be hard pressed to pick them out of a crowd of physicians, but this makes sense to Cathy Sims-O’Neil, a third-year at the University of New England College of Osteopathic Medicine. “[Dr. Andrew Taylor Still]…never intended to create a separate profession. He was an M.D. and was trying to extend the skills of the M.D., reflecting the path of the physician as it had once been practiced,” she says.


But D.O.s do learn, and many use in practice, a unique hands-on technique called osteopathic manipulative treatment (OMT). Osteopathy teaches that the body’s systems work together and disturbances to one may impact function elsewhere, so D.O.s use OMT to diagnose and treat, but also prevent illness or injury. “[Still] said the goal of the profession is to find health; anyone can find disease,” says Dr. David Russo, a physical medicine and rehabilitation resident at the Mayo Clinic in Minnesota. —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.~Career Development,Osteopathic Medicine~
104~3April~2004-53~Feature~Reaching Diversity~THE SUPREME COURT WEIGHS IN ON AFFIRMATIVE ACTION, BUT WILL IT REALLY CHANGE YOUR MEDICAL SCHOOL?~Jennifer Zeigler~~Monday morning. The pain of it is just about too much, and a lecture on the Krebs cycle doesn’t help. Your gaze wanders around the lecture hall. Let’s see, who’ll be with you for the next four years?


For the most part, your first-year class of 100 looks much like others across the country. About half men, half women. Very white. About 20 Asian students, six blacks, six Hispanics and the lone American Indian.


Not a very diverse picture, when you compare it against the roughly 12 percent of the population that is black or the same percent that is Hispanic. Asians are the only minority group that has entered medical school at rates higher than the general population—about 20 percent of students compared to just less than 4 percent of the population.


Increasing diversity has been a concern at every medical school, says Dr. Jordan Cohen, president of the Association of American Medical Colleges (AAMC). “As far as I know, every medical school is anxious to identify underrepresented minority applicants…because of the need for physicians who are interested in serving underserved communities, and we know that underrepresented minorities are willing to do that. It’s essential to have a diverse student body and a diverse faculty as well for that reason.”


Schools have engaged in a variety of affirmative action programs since President Lyndon Johnson issued an executive order in 1965 requiring government contractors to use the concept in employment. Defined as a policy or program designed to compensate minority groups and women for historically discriminatory hiring and admissions practices, affirmative action has been limited and, in some cases, banned by a more recent series of court rulings, state laws and executive actions.


So, like many administrators across the country, Dr. Lauree Thomas, the associate dean of student affairs and admissions at the University of Texas Medical Branch (UTMB), was elated when she heard the news last June that the U.S. Supreme Court upheld universities’ rights to consider race in admissions. “I think everybody not just breathed a sigh of relief, [but] it was a new era, a new reckoning, a new beginning,” she says of the ruling in Grutter v. Bollinger, in which Barbara Grutter, a white student denied acceptance to the University of Michigan’s (UM) law school, sued the school and named former UM president Lee Bollinger in the case. “It gives us the opportunity to look at students who would otherwise not be considered for medical school. Minorities make up less than 10 percent of the health-care work force.”


DISSECTING A RULING


But wait a minute. How is a ruling that upheld current law “a new beginning?”


“It’s very significant because until the Michigan ruling whether you could use race as one factor…was a function of the state you lived in…because there was a split in the circuit of what Bakke meant,” says Thomas Perez, the director of clinical law programs at the University of Maryland School of Law and a former head of the federal Department of Health and Human Services’ Office of Civil Rights.


Perez is referring to the 1978 Supreme Court ruling in Regents of the University of California [UC] v. Bakke, in which justices struck down the use of quotas but, in an often-debated opinion from Justice Lewis Powell, found that schools could use race as a plus factor in admissions decisions because a diverse student body is beneficial to education on the whole. The case was rooted at UC-Davis School of Medicine where Allen Bakke sued for reverse discrimination when he was denied admission.


Powell’s opinion gave federal circuit courts something to chew on. In 1996, the Fifth Circuit Court of Appeals held in Hopwood v. the State of Texas that schools under its jurisdiction could not consider race in admissions, ruling that educational diversity was not a compelling state interest. While Texas, Louisiana and Mississippi are all in the court’s district, a still-standing federal order to desegregate Louisiana and Mississippi schools trumped the court’s ruling, and only Texas schools were forced to comply.


The Grutter case voided the Hopwood ruling but launched many affirmative action watchers into a sea of confusion—a fact illustrated by the praise the court’s ruling received from both sides of the issue.


The case is one of two the court heard and decided regarding affirmative action. The other case, Gratz v. Bollinger, concerned the UM undergraduate school’s policy of awarding an automatic 20 points in its 150-point admissions process to minority applicants simply because of their racial or ethnic backgrounds. In a 6–3 decision, the court found the policy unlawful because it did not account for “individualized consideration” of the applicants, a key point in the Grutter case.


In Grutter, however, Justice Sandra Day O’Connor wrote for the 5–4 majority that the law school’s policy was a “narrowly tailored use of race in admissions decisions to further a compelling interest in obtaining the educational benefits that flow from a diverse student body.”


O’Connor had some stipulations, however. Affirmative action policies must be “narrowly tailored” and the result of clearly defined goals to obtain a “critical mass” of minority students; they should be regularly reviewed, flexible and consider race as one of the applicant’s many positive “soft” variables. “The law school engages in a highly individualized, holistic review of each applicant’s file, giving serious consideration to all the ways an applicant might contribute to a diverse educational environment,” O’Connor wrote.


So, with the court throwing around such ambiguous terms as “flexible,” “soft” and “critical mass,” is there any wonder Perez thanks the cases for continued full employment among lawyers? While school administrators scratch their heads over what this all means, lawyers and admissions deans have been weighing in with opinions.


“I think things will change everywhere,” Perez says, encouraging schools to “take a good look” at their current admissions policies. “I think they need to revisit their policy.” And sooner, rather than later. He says we’re now at a point at which each school should have at least begun the process of combing through admissions criteria and mission statements. “I hope so. It’s now been in effect for [nine] months.”


CH-CH-CHANGES


Perhaps nowhere more than deep in the heart of Texas have the effects of Grutter been acutely felt. For the first time in seven years, Texas public schools have the opportunity to consider race in admissions. In the post-Hopwood years between 1996 and 2001, Texas medical schools saw a 13.6 percent drop in minority matriculants, compared to a 4.7 percent decrease nationally during the same period, according to the AAMC.


“Changes are in the making,” Thomas says. But it’s not a done deal. Although the UTMB president has said he would like to bring race into admissions considerations, like many government entities, the wheels at the state schools turn slowly.


Representing the medical school, Thomas sits on a UTMB committee tasked with drafting a position statement and a list of factors that the admissions committee could use to evaluate students. The committee is expected to have a final set of proposed rule changes in May, but policy changes affecting UTMB admissions aren’t expected to take effect until at least 2005. All other UT schools will form similar committees to determine if and how they will consider race in admissions.


Currently, UTMB selects applicants by considering their economic, social and educational disadvantages—other “soft” factors that come out in interviews and personal statements—in addition to test scores and grades. Perhaps someone is a first-generation college graduate or from rural west Texas or has overcome a significant adversity—“If you rank-order them [by test scores and grades], those people may be left behind. We feel you haven’t been given your chance to shine,” Thomas says.


The system yields a class that is about 25 percent minorities, but it’s not perfect, she says. “Even though our numbers in the school of medicine are OK, some of the other schools are not. We want openness and inclusiveness and embracing and welcoming. Yeah, you might have to go the extra mile to get underrepresented minorities to come to your institution, so what? Don’t you do the same thing for alumni because it’s in your vested interest? Or your basketball team?… You’ll make the opportunity for that student with a 2.0 G.P.A.”


But to David Jones, Ph.D., the associate dean of admissions at the University of Texas Health Science Center at San Antonio (UTSA), the Supreme Court has left the waters a little murkier. “The Michigan Supreme Court decisions—they’re really narrow interpretations. It comes under the banner of affirmative action, but to us, it’s much more narrow.”


Like UTMB, UTSA has been using a policy of considering socioeconomic diversity since the Hopwood decision. And Jones says the current system is working fine. “We’re talking about a much broader definition of diversity. The value that diversity brings to the medical education process to me is the different viewpoints, different backgrounds, socioeconomic differences bring to the classroom. It’s not just race….”


Jones says he’s not against the principles of affirmative action, but he thinks such a politically charged concept can get in the way of the admissions process.


But Perez says schools that have been legally prevented from using affirmative action should change their policies now. “This is not just the law of the land, it’s good [policy].… Does it mean that sometimes race may be the deciding factor? Yes, but that’s OK as long as it isn’t the deciding factor every time.


“I have always said advocating for diversity [is] most important in the health-care field because the lack of diversity there has life-and-death consequences,” he says.


Many other medical schools have been operating under affirmative action policies—whether they call them that or not—for years, having bought into the idea that a diverse medical profession will lead to better access to culturally competent care and fewer disparities. Jorge Girotti, Ph.D., came to the University of Illinois (UI) to serve as an associate dean and the director of admissions more than 20 years ago, just as the school was finishing a review of its admissions policies in the wake of the Bakke ruling. He’s in charge of selecting the 300 students out of 4,600 applicants who begin classes each year at UI’s four medical school campuses. He says the school had been responsible for years for the leadership role in educating the state’s physicians—not just in Chicago but in rural areas, too—so the goal of a diverse student body “was spelled out from the beginning.”


He says that between Bakke and Grutter, UI broadened its definition of underrepresented minorities to include more Hispanics and created an admissions policy that considers volunteer work, sports, arts activities, military service and academic achievement, as well as race, sometimes asking for clarification if the application check-off box for that category isn’t clear. “The Bakke case was very clear that race could be one consideration among many, and we’ve tried to do that,” he says. “Part of the issue was how to address [that] not every student came with the same academic qualification, but they had other qualities that were important to being a physician.”


The policy seemed to work under old case law, and Girotti says it has never been challenged. “Because of our track record in terms of enrollment and because of our size, I’ve always felt we could be an easy target.” The school has matriculated about 20 percent underrepresented minorities, and 11 percent of last fall’s incoming class is Hispanic, and 8 percent is black.


UI has reviewed and tweaked its policy over the years, especially to consider issues of disadvantage rather than pure race and ethnicity, when in the mid-’90s California passed its Proposition 209, which banned the use of race in state school admissions, and the Hopwood case was decided.


A key point in the Grutter ruling, Perez says, is that periodic reviews of admissions policies should eventually lead to a point where race-conscious decisions are no longer necessary. The Supreme Court expects affirmative action won’t be needed 25 years from now, but many say that’s difficult to believe. And some schools are still trying to get a handle on what the case means for them. Cathleen Kearns, a spokeswoman for the American Association of Colleges of Osteopathic Medicine, says that for many of the 20 osteopathic institutions, “I just don’t think the schools have worked through it yet.”


For those still mired in confusion, Perez has some suggestions. “You will not move the ball forward without leadership at your schools. You need the legal advice we’re giving you, but the places that are doing it well are those where it comes from the top.”


Thomas would agree, crediting UTMB’s leadership with progress made on the issue, while some Texas schools have not budged from prior policies.


Once the leadership is on board, there are some guidelines to follow beyond the justices’ opinions. Perez points to the set of guidelines released by the AAMC in October, which he helped develop. He also suggests the legal analysis from the Civil Rights Project at Harvard University. While not geared specifically to medical schools, he says the document is helpful to any school refining its policies.


The Institute of Medicine also recently weighed in on the subject, publishing a set of recommendations—some of which reflect the Supreme Court’s directives—for health professions schools to increase diversity on their campuses. “There are still many [schools that] don’t seem to do an appropriate balancing of the qualitative and quantitative considerations [in admissions],” says Judith Winston, a lawyer who sat on the committee that drafted the recommendations.


WHAT THE CASE WON'T SOLVE


Martin Michaelson, a partner at the Washington, D.C., law firm Hogan and Hartson, says the Grutter and Gratz rulings probably represent the “high water mark regarding affirmative action,” and he expects the next consequential rulings to come from lower federal courts during the next two to five years.


Court challenges could be aplenty, as affirmative action remains a contentious issue. (See “Do You Agree With Affirmative Action?” at left.) There are many people who think policies that consider race in any way are wrong and hurt both whites and Asians—so-called overrepresented minorities—in the admissions process.


Roger Clegg, general legal council for the Center for Equal Opportunity, works to block any use of racial consideration in education and employment issues. “You shouldn’t assume that because a student has black skin that they come from the ghetto. Diamonds in the rough come in all colors. There are more poor whites than there are poor African-Americans,” he says, adding that when you look at percentages, the opposite is true. “If you buy into this notion of underrepresentation, then that means there’s such a thing as overrepresentation,” which leads to increased tensions among different racial and ethnic groups.


But Thomas, who is black, says accepting more minorities into medical school not only increases the number of physicians who will go to the inner cities, barrios and reservations to practice, but it will increase the number of minority physicians who will serve in academic medicine as mentors. “You want people like me educated, because look at what I bring to the table. I don’t just look out for minority students. I look out for everyone.”


Without realizing it, Thomas’ argument that she cares for everyone could be making the case for Clegg, who says that membership in a certain racial or ethnic group does not eliminate the ability to care for others outside of that group. “In many cases, cultural competency can be taught,” he says.


Given the tensions that affirmative action provokes, Perez calls ballot initiatives the biggest threat to current law. The Michigan Civil Rights Initiative—which is headed by Jennifer Gratz, the plaintiff in the Michigan undergraduate case—launched a petition drive in January to place a question on the November ballot that would prevent Michigan public universities from making decisions based on race, ethnicity or gender. Perez suggests schools that want to fight these kinds of initiatives should collaborate with civil rights groups advocating diversity.


Institutions can also guard against challenges by increasing the amount of research about minority physicians and to whom and where they provide care, he says. “There remains a paucity of empirical data that having diversity in your medical school will help with cultural competence. [While it] absolutely makes sense, you can’t simply rely on ‘It just feels good to me.’”


Regardless of what position you take on the affirmative action issue, even advocates say they don’t see the Supreme Court ruling making an impact on the numbers of minorities matriculating into medical school—the real effects will be felt at the undergraduate levels. It’s a pipeline issue, they say.


At UTMB, Thomas says she doesn’t see the numbers of matriculating minorities going above 30 percent because of a lack of qualified applicants. In the UT system, in which all the medical schools compete for the same applicants, the number of Hispanic applicants increased 7.5 percent this year, but the number of those accepted remained steady, Jones says.


Dr. Kenneth Edelin, the associate dean for student minority affairs at Boston University School of Medicine, runs a program to combat this very problem. “Don’t forget public schools are funded by state taxes and real estate taxes, so if you live in a poor neighborhood, you won’t have some of the same opportunities,” he says. “There are minority students who graduate [high school] without ever taking a lab. Wow! So they get to college, and they’re taking labs for the first time.” He says the percent of students interested in medicine as a career is higher among minorities than whites, but because science courses become so challenging at the college level, by sophomore year many have changed their minds.


Looking around that first-year classroom, it’s difficult to imagine how any of those 100 students would have gotten there without exposure to labs and a quality education. And who knows where everyone will go to practice, or even if they’ll all graduate. But in her written opinion of the Grutter case, O’Connor clearly thinks the opportunity to get there should be open to all those up to the challenge. “In order to cultivate a set of leaders with legitimacy in the eyes of the citizenry, it is necessary that the path to leadership be visibly open to talented and qualified individuals of every race and ethnicity. All members of our heterogeneous society must have confidence in the openness and integrity of the educational institutions that provide this training.”


How schools craft that “openness and integrity” appears to remain an ongoing challenge, no matter what the courts may say.
~MORE THAN ADMISSIONS


When the U.S. Supreme Court speaks, the nation tends to listen closely. So when it ruled last summer on the use of affirmative action in higher education admissions, it wasn’t simply admissions deans paying attention. The decisions in Grutter v. Bollinger and Gratz v. Bollinger, which upheld federal law permitting the use of race in decision-making as long as it was only one factor of many, may prove to paint a broad stroke across other aspects of university life: scholarships, fellowships, pipeline programs and faculty recruitment.


Such was the case with the Minority Medical Education Program, which the Robert Wood Johnson Foundation began sponsoring in 1988 with a mission to increase the number of qualified minorities applying to medical school. As the schools that administer the six-week training program expanded their definitions of what a minority in medicine is—accepting such students as those from economically underprivileged or rural areas—the name remained the same until Grutter. Now, the Minority Medical Education Program is known as the Summer Medical Education Program.


Thomas Perez, the director of clinical law programs at the University of Maryland and an expert in civil rights law, says the Mellon Foundation made a similar decision that “might prove very sensible over time.” The foundation broadened the mission of its Mellon Minority Undergraduate Fellowship (MMUF) program, which it established to increase the number of qualified minority Ph.D. candidates in the arts and sciences, to reflect the court’s thinking on affirmative action. The new mission statement and selection criteria broadens the applicant net, allowing the program to admit students “from underrepresented minority groups as well as other students with a demonstrated commitment to the goals of MMUF,” one of which is reducing disparities, according to a Mellon statement. This program also got a new name: the Mellon-Mays Undergraduate Fellowship.


Perez encourages scholarship and pipeline programs to take a good look at their mission statements, as a stated commitment to helping the underserved will help make the case for the program in the event of a challenge.


Florence Allen, who coordinates a minority recruitment program for residents at Boston Medical Center, says the fact that about 70 percent of the hospital’s patients are underserved minorities is reason enough for her to continue the program there. “We are the safety-net hospital,” she says. Still, the facility’s faculty is only about 6 percent minorities.


And Perez says that even though scholarship and admissions programs are governed by a different set of laws than faculty recruitment policies, which are employment decisions, he thinks “there’s still plenty of room to consider race in these issues.”


But despite safeguards, affirmative action experts warn that challenges are on the horizon. The Center for Equal Opportunity (CEO), a conservative research group that works to fight affirmative action, filed complaints with the U.S. Department of Education’s civil rights office in January against several scholarship programs directed at minorities. “The various programs that we’ve challenged…don’t just give preferences on the basis of race and ethnicity. They’re racially exclusive,” says Roger Clegg, CEO’s general legal counsel. “We think the Supreme Court cases make clear that these programs are illegal. A program that says you can’t participate at all unless you’re black or Latino or Asian clearly does not give individualized consideration.” Of the more than 100 programs to which the CEO sent complaint letters, an “overwhelming majority” changed, he says.


Perez says adjustments to bring programs in line with the ruling may seem like tough pills to swallow, but “a lot of what civil rights work has been, in the last decade particularly, has been you’ve got to burn part of the village to save the village.” —J.Z.


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DO YOU AGREE WITH AFFIRMATIVE ACTION?


“Race-based distinctions… cover people who do not need any help, and they fail to cover people who desperately do. Affirmative action should be kept in place, but it should be socioeconomically and race-based…. In this country we do not have group rights; we have individual rights and affirmative action…as approved by the Supreme Court…fails to recognize that principle.”

GREG DOLIN
Fourth-year, SUNY Stony Brook School of Medicine


“I do not feel that I should surrender my spot in medical education in the name of number fairness. However, in order for a balance to be achieved between the
[underrepresented minorities] and [overrepresented minorities], the numerical solution seems both straightforward and necessary [but]… creative solutions must replace strict court-driven policies….”

WILLIAM HU
Fourth-year, Mayo Clinic College of Medicine


“I completely agree with the Supreme Court’s decision. Affirmative action simply acknowledges the continued glass ceiling that students of color continue to face in our society, regardless of income. Furthermore, increasing diversity in the health-care work force must continue to be a priority…to address our country’s crisis in racial and ethnic health disparities.”

SOPHIA JAN
Fourth-year, SUNY Downstate Medical Center


“There’s a definite value to having more minority physicians if it improves the health and well-being of communities, but I don’t see any specific societal benefit in artificially high numbers of black dermatologists or Pacific Islander radiologists.”

LUKE WHITE
First-year, Arizona College of Osteopathic Medicine
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct questions and comments about this article to tnp@ amsa.org.~Diversity in Medicine,Legislative Action,Minority Affairs~
105~3April~2004-53~Feature~On the Rez and Beyond~~Scott T. Shepherd~~With limited Indian Health Service
funding available, American Indian and Alaska Native tribes find creative ways to care for their health.


More than a decade ago, Dr. David Yost was standing with thousands of other people transfixed on a girl dancing around a bonfire on the Fort Apache reservation in eastern Arizona. Clad in the traditional buckskin clothes of her tribe, she twirled and moved as part of her Sunrise Dance, a ceremony celebrating her passage into womanhood. “It’s a weeklong preparation…, and the week culminates with a very intensive weekend of ceremonies that involves a lot of activity, in terms of dancing, and there’s a lot of emotional and physical pressure,” Yost says.


The sight was quite awe inspiring, especially considering that only hours before Yost and his colleagues at the Whiteriver Reservation Service Unit, a U.S. Indian Health Service (IHS) hospital, were treating the girl for pneumonia with signs of sepsis. “We were sure—as we thought we were highly competent, trained physicians—her only hope was to go into an intensive care unit and abandon her ritual. But the elders intervened on her behalf, and said, no, this was necessary that she complete this ritual.”


So after several hours of receiving antibiotics and fluids, the girl was taken by ambulance to her ceremony, leaving Yost stunned. “She went from being stretcher bound and not even being able to sit up to within 24 hours she was up and dancing around a massive bonfire.


“It was just an amazing turnaround. We were left to wonder how much of this was our penicillin, and how much of it was the prayers and the intense spiritual support she got,” says Yost, who is not an American Indian but has spent most of his life on Indian reservations as the son of an IHS physician.


In some ways, miracles like this happen every day in the IHS, just not so dramatically. Part of the Department of Health and Human Services, the IHS is responsible for providing health care to federally recognized tribes of American Indians and Alaska Natives, as provided for in the unique relationship between the federal government and Indian tribes established in the U.S. Constitution and shaped by numerous treaties, laws, Supreme Court decisions and executive orders.


As a result, the IHS provides health services—either directly or indirectly—to more than 1.6 million American Indians and Alaska Natives belonging to more than 560 tribes in 35 states. To carry out this mission, the IHS provides technical assistance and training to tribes, coordinates health planning and resources of federal, state and local programs, and serves as the federal advocate for health services to American Indians. Furthermore, the IHS provides comprehensive health-care services, including preventive hospital and ambulatory care, and assists with the rehabilitative services and development of community sanitation facilities. This system consists of 49 hospitals, 236 health centers, 176 Alaska village clinics, 133 health stations, 33 residential treatment centers and 34 urban projects. The IHS employs approximately 921 physicians, 2,653 nurses, 326 dentists, 448 pharmacists, 353 engineers and 145 sanitarians. And in 2004, this is all financed with a $3.67 billion budget.


Those numbers may sound impressive, but the IHS spends an average of only $1,914 per patient. This amount is dwarfed by the $5,065 per capita health-care spending of the general U.S. population.


Despite the apparent lack of funds, the improvement of American Indian and Alaska Native health is widely recognized and attributed to the managed care provided through the IHS. Since 1973, the infant mortality rate has dropped by 54 percent, while the maternal mortality rate fell by 65 percent. And from 1940 to 1990, the life-expectancy gap between this minority population and whites decreased from more than 13 years to six years. Furthermore, the Centers for Disease Control and Prevention (CDC) found that the IHS has implemented a successful vaccination program with more than 90 percent of American Indian and Alaska Native children receiving all recommended vaccines, with the exception of the chicken pox vaccine and the fourth dose of the diphtheria-tetanus-whooping cough combination.


“Few bright spots exist in the shared history of the American Indians and the federal government…. A notable exception is the sustained campaign by a little-known agency, the Indian Health Service, to improve the health of this population,” wrote University of Washington professor Dr. Abraham B. Bergman in a 1999 issue of Milbank Quarterly, a public health and health-care policy journal. “Except for the intractable problems associated with the abuse of alcohol, the health status of American Indians raised to approximately the level attained by the rest of the U.S. population. This achievement is amazing when one considers the appalling poverty and harsh physical environment in which many Indians live.”


CHALLENGES REMAIN


But in apparent contradiction to these accolades, American Indians and Alaska Natives continue to have the poorest health of any minority population in the United States. According to an August 2003 report by the CDC and IHS, American Indians and Alaska Natives have higher rates of diabetes, bronchiolitis and injury than all other racial populations.


“Clinically, the rates of most leading cases of death for Indian people remain more than double the rates for the rest of America: For accidents, the rate for Indian people is 280 percent of the rate for the general U.S. population; for alcoholism, 770 percent; for diabetes, 420 percent; for homicide, 210 percent; and for suicide, 190 percent,” says IHS director Charles Grim, an Oklahoma dental surgeon and a member of the Cherokee Nation. “We have contributed to increasing the life span of Indian people from 58 years in 1955, when we transferred to the Department of Health, Education and Welfare, to 71 years today; but that is still six years lower than the rest of the population.”


In his annual State of the Indian Nations Address in February, Tex Hall, president of the National Congress of American Indians, called on President Bush and Congress to address these disparities. “In spite of the disproportionate health-care needs we face, today the per-capita expenditure for American Indian and Alaska Native medical services is less than one-third of the average annual expenditure for individual Medicaid assistance and is even less than our per capita health expenditure for federal prisoners.” Hall went on to request that Congress provide the IHS with a budget of $5.4 billion in 2005. The request was made a day after Bush proposed a $3.72 billion budget, a mere 1.4 percent increase over 2004.


Chris Walker, the senior director of health policy and planning for the Cherokee Nation, argues that not only is the IHS not receiving a significant budget increase, but the reality is that the agency’s funding is being cut. Besides not keeping up with inflation, Walker says the budget includes two previous spending mandates—a pay increase for personnel and a diabetes treatment program—which means that the general IHS 2005 budget is really decreased by $17 million.


While he applauds the salary increases and need to address the diabetes epidemic in the American Indian community, Walker says these required budget allocations come at the expense of other projects, rather than as true increases in funding. For example, Bush’s proposed budget calls for no increase in funding for maintenance and improvements or equipment, and a $52 million funding cut for facility construction.


“When you only have 2 percent increases year to year, and then an administration that says federal employees deserve a 3.1 percent increase in pay…. Where does that money come from? IHS has to totally eliminate programs or staff positions, or not deliver services…,” Walker says.


While the battle to increase IHS spending continues, life goes on at the reservation clinics and at the urban Indian health-care facilities around the country. And contrary to the perception of some, IHS administrators and physicians argue that fiscal restraints do not lead to substandard health care for their clients.


“I think the most common misconceptions about Indian health care and the Indian Health Service that I have encountered is that it is believed that the providers and the care delivered to Indian people is substandard. This could not be further from the truth,” says Dr. John Farris, a member of the Cherokee Nation and the clinical director of the W.W. Hastings Indian Hospital in Tahlequah, Oklahoma, the nation’s capital.


Farris and Yost both say they work with exemplary nurses and physicians—the far majority of whom are board certified in their specialties—and are able to provide most of the services available at a private clinic. Yost says that often when physicians or medical students visit the Whiteriver clinic, they will make a comment such as, “‘This looks like a real hospital.’ This is a real hospital, and this is high-level care, and people out here get high-quality care from outstanding physicians. This is an eye-opening experience for people sometimes…,” he says.


Not that the IHS facilities are unaffected by limited federal funds: It’s just not to the point where fundamental care is sacrificed. “There are certain things we would love to do that we just can’t do,” Yost says. At Whiteriver, such things as dentures, eyeglasses and wheelchairs are often considered nonessential in the overall budget picture. If there happens to be money left at the end of the fiscal year, then maybe those purchases can be made.


Also, in order to get the best deal on an MRI exam, Yost and his colleagues may send a patient to the Veterans Affairs (VA) hospital 350 miles away rather than to the closer private hospitals in Phoenix or Tucson because they have a deal with the VA that saves them thousands of dollars a year. “Sometimes we really have to sacrifice convenience,” he says.


Another sacrifice made by IHS physicians is in support staff. Yost says his physicians can be in their offices late into the night writing letters and completing paperwork because they simply don’t have enough office help. “I think there are a lot of things that if I was in private practice I would just ask one of my support staff to do, and I end up doing it myself,” says Dr. Marc Traeger, a Whiteriver clinician.


SELF-DETERMINED HEALTH CARE


Exactly how these budget shortfalls are dealt with varies greatly on the tribe and the reservation. The reason for this variety is the Indian Self-Determination and Education Assistance Act of 1976, which provides tribes with three health-care options: direct from the IHS, as was done historically; contract with the agency to provide services, which allows tribal governments more operational control; or compact with the IHS by taking over administrative, operational and financial control.


“Under self-determination, whether the IHS or a tribe provides health services for their members, standards and quality of care are maintained. And tribes have more flexibility in how they manage their resources and the IHS funds transferred to them and, as a result, sometimes can offer additional services,” Grim says. “Almost all of the 562 federally recognized tribes provide some level of contracted health services to their members, and approximately 52 percent of the IHS federal budget is transferred directly to tribes and urban Indian health programs.”


However, how much control a tribe exerts usually directly correlates to the size, wealth and geography of that nation. Wealthier tribes find it particularly beneficial to contract or compact with the IHS because they are able to supplement the agency’s services with their own. For example, wealthier tribes in Alaska have compacted with the IHS and now administer 99 percent of the agency’s funds in the state and supplement them in order to operate hospitals in Anchorage, Barrow, Bethel, Dillingham, Kotzebue, Nome and Sitka.


On a smaller scale, it’s similar to the system implemented by the Oneida Nation in Upstate New York. Supported by the nation’s revenue, the tribal government has established a fully functioning outpatient health service to treat more than 4,000 clients, about 1,000 Oneida and the rest from neighboring tribes and relocated American Indians. “We opened the doors in ’93, starting with a double-wide trailer set up. [Now,] we are averaging adding a dozen to 15 [new clients] a month,” says Mike Cook, the administrator for government programs and services for the Oneida Nation. However, rather than manage its own hospital, the nation supplements the IHS care with insurance for the Oneida, so they can use nearby hospitals for inpatient care.


In Oklahoma, the Cherokee Nation manages six outpatient clinics, an EMS service and a chemical dependency treatment facility. In taking over clinic services from the federal government in 1990, the nation essentially began paying the IHS for its employee pool, with employees either switching over to work directly for the tribe or remaining employed by the IHS and contracted out. “[We signed an agreement] where we take over a clinic or we take over a hospital, and we want the same management that is there, and we want the doctors that are there. And if those people choose to stay in the federal system, then we buy the federal system,” Walker says. And through self-management, he says the tribe has been able to double the number of clinics in the nation and provide services that better fit its members’ needs.


Despite these benefits, however, the Cherokee Nation continues to have its hospitals managed and operated by the IHS. Walker says the primary reason is the decision by Congress to not fully fund contract support costs, which are the administrative expenses required to take over and then run a hospital or any health-care system. According to the IHS, the contract support costs eligible to be paid for by the federal government include start-up costs, annually recurring direct costs and annually recalculated indirect costs.


“At Cherokee Nation, we basically run an $80 million program for the federal government. We operate eight clinics. We have 700 employees. [And] a part of that is…the administration [costs], like what the government would pay Boeing or General Dynamics to make a plane. Well, [the federal government] pays them 100 percent [of the administrative costs]. They pay us 66 percent,” Walker says.


The IHS says contract costs are funded at about 90 percent but acknowledges that congressional appropriation doesn’t meet the 100 percent legislated for by the Indian Self-Determination Act. “Every year for us, it’s $4 million negative. The federal government is not paying us. For the whole Indian health-care system, it’s $111 million,” Walker says. Whether these costs will be covered may be determined by the U.S. Supreme Court, which could hear Tommy G. Thompson v. Cherokee Nation of Oklahoma this year after the U.S. Federal Circuit Court of Appeals ruled in 2003 that the IHS is obligated to cover all contract costs. The suit, which seeks unpaid support costs from 1994, 1995 and 1996, names the defendant as the HHS secretary, which is currently Thompson.


On the rural Fort Apache reservation, where Yost practices, the contract costs aren’t a pressing issue. Being in a more remote area, the tribal government has only taken control of the EMS service, the mental health service, and the alcohol and drug rehabilitation program. The primary health-care services continue to be managed and operated by the IHS. “It is a major decision for a tribe to do, and it often reflects economic stability, their resources and the number of tribal members they have, and who they have who are interested in and qualified to run what are often very complex health systems.… In our region, which is eastern Arizona, a lot of tribes have chosen to run the program sort of piecemeal,” Yost says.


WHAT'S RIGHT FOR THE TRIBE


Regardless of what services each tribe decides to fully manage, self-determination has provided tribes with more say in their local health-care systems. And with more than 500 recognized tribes, each growing and changing at its own rate, the ability to control the public health system is crucial. “There are generalities in Indian health, but each nation is different, just like California and New York and other states are different,” Cook says.


The Oneida Nation, located 30 miles east of Syracuse, doesn’t look much different from the rest of Upstate New York, with tribe members commuting to jobs in nearby towns, working at private businesses on the reservation or at the nation’s casino, golf courses, newspaper, textile design company or retail shops. “We are in essence an urban center, making this area an attractive area for American Indians to reside,” Cook says.


Meanwhile, it’s quite a different scene in eastern Arizona. The Whiteriver Apache tribe relies heavily on the local timber industry, which has been devastated the last two years by forest fires that destroyed hundreds of thousands of acres. “It’s caused [the tribal government] to sort of reassess how things are going,” Yost says. To supplement the timber industry, the tribe is also supported by summer tourism and from the income of the tribe’s casino. However, unemployment and poverty remain high.


Yost says he has to consider outside factors when treating his patients. “A lot of the economic factors can really make health care challenging, and there are just some basic logistics [problems], too. Some of them don’t have telephones. Some of my patients don’t have electricity in their houses. Less than a fourth of them even have a car. So some of the things that other practices take for granted, like the simple thing of telling a patient to come back the next day and be checked again, that could be very daunting for a person who doesn’t have a car or doesn’t have a phone,” he says.


However, Yost points out that that doesn’t mean the Fort Apache reservation—or any other for that matter—is out of touch with modern society. “When I was growing up on the Navajo reservation, television was a special thing that you got only one fuzzy channel out in rural Arizona. Now, our kids are connected as anywhere,” he says. At the reservation’s high school, students walk around with cell phones just as they do everywhere else. And the availability of satellite TV and the Internet has made medical information—not to mention superfluous pharmaceutical advertising—available to his patients, just like it is to people in Phoenix.


The end result for IHS physicians is a peculiar mix of problems, where one patient doesn’t have electricity in his home, while the next wants to know why he can’t get the most recent drug he saw advertised on TV.


LISTENING TO TRADITION


Another consideration for IHS physicians is the role of the tribe’s traditions in modern medicine. In many ways, it’s not that different from any other practice, in that communication is vital to understanding patients and their needs. “In our practice, we really have a wide variety of patients, from the very traditional and following a traditional Apache belief—and you have to be very cognizant and respectful of that—and we have others who have very openly told [us] that they are not traditional at all,” Yost says.


Traeger says the importance of local traditions has heavily influenced the way a physician will communicate with a patient. “As far as patient education, I have to make sure I am not going to offend them or say something that is culturally insensitive…. When we start talking about death, that’s not something that’s culturally acceptable because sometimes it’s perceived as wishing death on someone, even though all we are trying to do is plan for the future.”


The role of medicine men also continues to be an important factor in treating Apaches. Yost says Whiteriver physicians try to maintain good relationships with local medicine men and work with them to treat patients, but notes that many of his patients won’t tell him they’re seeing medicine men, as they’re afraid he’d be insulted. “People don’t come in with a big sticker on their chest saying, ‘I’m traditional and follow such and such.’ We have to learn to ask patients in respectful ways.”


Of course, asking a patient what he wants or feels is not unique to caring for American Indians and Alaska Natives. And Grim says there is a lot that U.S. medicine can learn from the IHS, especially about the role of the community in managing its own health. “[What can be learned from IHS is] that local involvement at the community level helps make health programs more effective. Public health models can help empower communities to identify their own health problems as well as actively involve them in developing the solutions,” Grim says.
~THE RESERVATION EXPERIENCE


Dr. David Yost, the clinical director at the Indian Health Service (IHS) Whiteriver hospital on the Fort Apache reservation in Arizona, may have grown up watching his IHS physician father care for Navajos, but he didn’t realize it was the career for him until he was a medical student rotating on a reservation. Many IHS physicians would probably say the same was true for them. In fact, more than 80 percent of Whiteriver’s physicians participated in the IHS as students. “We firmly believe that that makes an enormous difference in the ability to assess whether the Indian Health Service is the right place for someone to work,” Yost says.


Approximately four fourth-year students cycle through Whiteriver every month, working in the main clinic, the ER, the community clinic and in inpatient care. If you’re interested in a similar opportunity, you might have to do some
legwork, since there is no nationwide IHS medical student program. Some medical schools have developed relationships with individual IHS hospitals, but you may need to contact a regional or local IHS office to see what is available, Yost says. For more information on the IHS area offices and facilities, visit the IHS website.


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ONLINE RESOURCES



~~~Scott T. Shepherd is an associate editor with The New Physician. Direct comments about this article to tnp@amsa.org.~Community and Public Health,Diversity in Medicine,Minority Affairs~
106~3April~2004-53~MedMentor Q&A~Teen Girls and Sex~REPORTING STATUTORY RAPE~~~Do you report a patient’s boyfriend for statutory rape if he’s 26 and she’s 14? How would you handle this situation? Would your response vary depending on the patient’s cultural traditions?


Dr. S. Paige Hertweck, chair of the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Health Care, responds: A physician seeing adolescents has a primary goal to provide good, confidential health care for the adolescent. However, there are laws within every state that impact how the physician can carry out this important goal.


Before we go further, it’s important to understand that the situation described in this question is quite unusual. Generally, the age difference between an adolescent girl and her partner is not so dramatic. It is far more likely that the clinician will encounter an adolescent girl whose partner is between the ages of 16 and 20. Authors of the 1997 “Fertility, Family Planning and Women’s Health: New Data From the 1995 National Survey of Family Growth,” published as part of the National Center for Health Statistics’ “Vital and Health Statistics” series, report that for those females describing voluntary first intercourse before the age of 16, 7 percent said their partners were between the ages of 20 and 22, and 6 percent said their partners were 23 or older.


In responding to the scenario described above, a physician must consider two separate clinical and legal issues, and for each, the laws that can influence the physician’s actions will vary by state. Physicians aren’t trained in law, but they need to learn about the laws governing such situations so they can make informed decisions. To obtain up-to-date information on state laws, each clinician will have to identify a legal resource within his community or state. Many hospitals have legal departments that can offer guidance. Another resource would be a state medical society.


The first issue to consider is how you want to handle consent and confidentiality regarding minors in your medical practice. Confidentiality is critical to winning the trust of adolescent patients. When they’re concerned their confidentiality will be breached, adolescents will avoid necessary health services. In this case, there are many questions to explore in a confidential session with the 14-year-old girl, assessing what she understands and desires. Was the intercourse consensual? What is her relationship with the man involved? What are her relationships with her family? How does she want her family to be included in any subsequent discussions? Culturally based attitudes and norms (of both the adolescent and the clinician) will influence the entire discussion with the adolescent and any subsequent discussions with her parents. A physician should be aware of this and work to develop his cultural competency skills.


A good resource to help you talk confidentially with an adolescent patient and involve her parents in her care can be found in ACOG’s Health Care for Adolescents, published by its Committee on Adolescent Health Care. The chapter “Confidentiality in Adolescent Health Care” can help you map out a strategy to discuss sensitive issues with an adolescent patient and her parents, before you’re confronted with them. Visit ACOG online for more information.


Additionally, the Center for Adolescent Health & the Law has produced a 200-page monograph summarizing the minor consent laws for all 50 states and the District of Columbia: State Minor Consent Laws: A Summary, 2nd edition (2003). Information about the monograph can be found at here or via e-mail at info@cahl.org.


The second issue to consider in this case is what the physician must report about adolescent sexual behavior to either law enforcement or social services under the state’s child abuse reporting law. It is important to realize that there is no uniform legal definition of “statutory rape.” This term is often used to describe sexual intercourse with a minor that is illegal under a state’s criminal law even if it is consensual or voluntary for both partners. It may include sexual intercourse between an adult and a minor as well as sexual intercourse between two minors, depending on state law. Some, but not all, “statutory rapes” must be reported under child abuse reporting laws, again, depending on the state. The ways in which these laws are being interpreted and enforced have become controversial public policy issues in some states.


A difficult issue for the clinician and for public policy in this situation is distinguishing between sexual activity involving minors and older adolescents that is coercive, exploitive and involuntary, and that which is consensual activity between young people of similar age. The other critical issue for the physician is that the fear of reporting may deter adolescents from seeking appropriate health care. If the physician determines that something must be reported, it will be very important to explain to the adolescent patient why it must be reported. Even with this explanation, though, the patient– physician relationship may be lost in the process.


As in every clinical situation, it is important to remember that the primary role of the physician is to provide the best care for the patient and, as such, to ensure that the patient is emotionally and physically cared for whether or not a report is required.
~~~~Dr. S. Paige Hertweck is also an associate professor in the division of pediatric adolescent gynecology at the University of Louisville School of Medicine. If you have a question for “MedMentor Q&A,” e-mail it to tnp@amsa.org. All questions will be reated confidentially.~Practice of Medicine~
107~4May-June~2004-53~MedMentor Q&A~Advice for the Bedside~PASSING ON LESSONS LEARNED~Frederick H. Roever ~~As physicians, we can learn from our trials and tribulations, our successes and failures. I have practiced medicine for more than 30 years and have found that experience is a cruel but effective teacher. I hope the lessons I learned about providing an effective history and physical exam will help you succeed in your practice of medicine.


LESSON 1: Never become too busy to practice good medicine. An adequate history and physical takes time to perform. If you do not take this time, you’re shortchanging your patients, and you’re not doing your job. An overworked, harassed, tired and too busy physician is a dangerous one.


LESSON 2: Communicate with your patients. A physician is analogous to a detective seeking a villain, aka the disease. The detective’s job is to collect information from many sources. To be successful, he must develop good rapport with these information sources; otherwise, he’ll be unable to obtain evidence and will be rendered useless. Patients want to trust and confide in their physicians, and you must be worthy of their confidences. Only then will you be able to gather all the evidence hidden in the history. Communication is essential to being a successful physician.


LESSON 3: Be adaptable. Maimonides, a 13th-century physician, said, “Of the sufferer, show he only the man, neither good or bad, friend or foe, rich or poor.” An effective physician must be able to speak to and treat all social and intellectual classes. You must adapt yourself to the patient, so that patients and their families feel comfortable. One way you can accomplish this is by not using big words; sometimes they only hide your ignorance. Patients who are at ease will tell you more.


LESSON 4: Be a good listener. Always listen to your patients. Enough said.


LESSON 5: Be humble. Nothing destroys the physician–patient relationship faster than a physician’s pride and arrogance. Remember that the patient knows more about his symptoms than you do. It’s your job to extract this information in obtaining an adequate history. The God complex of the white coat syndrome dramatically reduces your effectiveness by placing a barrier between you and the patient. So be aware of this. You have many years of education and training, but with knowledge comes humility. Remember that the human body is the most complicated object on Earth, about which we know little. Today’s wisest physician knows less about medicine than a second-year medical student 100 years from now. Wisdom comes with time; you need to be aware of your ignorance and limitations.


LESSON 6: Read between the lines. Frequently, patients will talk around a symptom rather than openly admit it. For example, depression is common in elderly patients, but most depressed patients will rarely admit this problem. They will merely tell you that they are tired or sleep poorly. In order to collect information, you may need to speak to the patient’s family or caregivers. In some cases, the spouse may know the patient better than the patient knows himself. An intelligent spouse or partner is frequently a patient’s greatest asset, and you’d be wise to make the spouse your ally.


LESSON 7: Take your time. No matter how rushed you are, you cannot appear rushed to your patients. Always try to take time to sit at your patient’s bedside—even if it’s only for a few moments. Patients will appreciate this caring gesture, and this little and seemingly insignificant act conveys empathy and compassion. Without these virtues, a physician is worthless.


LESSON 8: Be organized and methodical. Performing a history and physical exam is an art that is done best in an orderly, methodical and sequential manner. At times, you will be rushed and interrupted. Interruptions can lead to errors and omissions. A methodical technique will help prevent omissions of important information and details.


LESSON 9: Use a quiet and well-lit room. Murmurs, rubs, clicks and gallops disappear in a noisy environment. You’ll waste your time listening for them, because you’ll never hear them. Shut the door, turn off the TV, and keep the room quiet. The exam room should be well-lit, too, preferably with natural light. Fluorescent light may mask cyanosis and jaundice.


LESSON 10: Carry your tools with you. They’re the instruments of your profession and act as an extension of your senses. If you don’t have your tools, you can’t use them. Then you waste your time waiting for someone to obtain them for you. You don’t want to postpone an important part of the physical exam because you don’t have the instruments you need. Your tools are your instruments of good bedside medicine. Use them.


LESSON 11: Ask the right questions. Knowing what to ask is an artful skill firmly rooted in your true understanding of pathophysiology. You can’t merely memorize signs and symptoms of diseases; you must understand why they occur. Although repetition and memorization may be the mother of knowledge, understanding is the beginning of wisdom.


For example, everyone knows that gout occurs most commonly in the foot and ankle, but not everyone knows why. Gout affects these areas because their tissues are more acidic. Tissue pH drops because the products of tissue metabolism accumulate in dependent areas. Lymphatic and venous drainage are poorest here, since they must travel against the force of gravity. Therefore, dependent tissues are more acidic. Uric acid tends to precipitate in an acidic medium. Gout crystals form, inflammation occurs, and the patient complains of sore, warm, red joints. Elevation of the feet will physiologically relieve a patient’s propensity for recurrent gout attacks.


Once you truly understand a disease process, you will remember it, and you’ll be able to ask the right questions.


LESSON 12: Keep an open mind. When examining a patient, always approach him with a free and open mind—a tabula rasa. Your mind must be free, unprejudiced and unpolluted by existing technical information and by the opinions of others in the chart. Your free and open mind is your obligation to your patient. Examine the patient first. Then, examine the chart. Finally, review others’ opinions.


LESSON 13: The patient is the final textbook. The examination of the chart never replaces the examination of the patient. Care of the chart never replaces the care of the patient. The chart never dies; the patient does. Always put patients first.


LESSON 14: Study to learn. True understanding in medicine is vastly more important than high academic grades. In real life, in the care of the sick, your true final exam will not occur on an answer sheet in a classroom. It will occur when you are alone, facing a critically ill patient who has placed his life in your hands. That desperately sick patient’s fate will be the real test of your knowledge; your success or your failure will be your patient’s life or death. Study to learn and understand; study to benefit your ill patients’ welfare rather than a selfish academic grade-point average. Patients are not interested in grades. They’re only interested in your effectiveness as a healer. Your patients’ clinical successes are the benchmarks of your academic knowledge. This is your true final grade-point average.
~~~~Frederick H. Roever is a geriatrician and internist at Helen Ellis Memorial Hospital in Tarpon Springs, Florida. He’s also an assistant professor of medicine at the University of South Florida College of Medicine. Have a topic you’d like to see discussed in a future “MedMentor” column? Send it in an e-mail to tnp@amsa.org.~Humanistic Medicine,Practice of Medicine~
108~4May-June~2004-53~Letter from Afield~Following Dr. Albert Schweitzer~PROVIDING MEDICAL CARE IN GHANA~Ricky Choi ~~Prior to setting foot in the airport in Accra, Ghana, in the summer of 2000, I knew Africa mostly from watching Discovery Channel programs and those “Save the Children” commercials, in which the continent was treated as a single country consisting of little more than civil unrest and AIDS.


I wanted to make the trip so I could explore the visions of Dr. Albert Schweitzer—the Nobel Peace Prize-winning medical missionary—while searching for my own role in the developing world. I selected the most affordable volunteer program I could find and arranged to fly to the West African nation at the end of my first year of medical school.


Ghana is a beautiful and friendly country, where the people and the land reflect the deep roots of the culture. A proud leader of the African continent, the nation boasts the legacy of the Ashanti tribe and is the home of such familiar icons as the richly colored Kente cloth. A former British colony, Ghana is composed of a mosaic of different tribes, each with its own language, including Ewe, Twi and Fanti. Fortunately for me, I got by with English in most urban centers, and the Ghanaians I met were kind and eager to share their way of life to those willing to learn.


All of this occurred in the shadow of reminders of Westerners’ dark history in Africa. I had the occasion to visit an old fort once used as a center for shipping slaves to the Americas. One of the exhibits displayed a map of slave trade routes on which a long, arching, white line was drawn connecting the fort in Ghana to my medical school home of Charleston, South Carolina.


I was assigned to St. Paul’s Clinic, which is located in a small village south of Lake Volta. Still under construction, the clinic was already the most modern building in the village and housed one of the four telephones in the area. Living in such a foreign land, I enjoyed entering the familiar medical environment each morning.


The physician running the clinic was a native Ghanaian trained at one of the country’s two medical schools. Being one of only three physicians in the area and the only one trained in surgery, Dr. Dagbui was the Renaissance physician I dream of becoming. On a typical day, he would conduct a prenatal checkup and a tubal ligation before lunch, while occasionally being called for an emergency surgery.


Armed with good humor, practiced medical skills and a crate of medications donated by an Italian missionary, Dagbui set to work each morning on a long line of patients forming behind his office door. At his side, my medical student mind took crude delight in seeing the advanced stages of diseases: hydroceles, hernias of all kinds and typhoid fever. I even witnessed childbirth for the first time—twins, at that.


Even with these varied responsibilities, though, Dagbui spent the majority of his time doling out chloroquine. Malaria ran so rampant that many of the villagers had six bouts a year, with the infection usually lasting about a week. It was frustrating to add up the patients’ days lost from working the fields or attending school. And I became enraged when I realized the effect of malaria in a broader context—the total impact of lost profits, individual enrichment and progress on the developing nation just because of a single parasite. Sadly, I know that a malaria vaccine is not a priority for Western pharmaceutical companies.


I spent my afternoons and evenings playing games with the local children and trading postcards. The villagers—from old to young—worked hard and seemed happy. Even in the absence of modern conveniences and what in my eyes appeared to be meager means, the villagers displayed a wholesome dignity.


I found my work in the clinic rewarding and eye-opening. I learned a lot from one child in particular—Fatima. She was a dark-skinned girl with a pink flowered dress that betrayed her frail frame. Except for her aged countenance, she looked young for her 10 years. She came to the office with her father, who would gingerly place her in the examination chair. Fatima had sickle cell anemia and endured pain crises. At the times when she would have to go without pain medication—either because of cost or availability—her daily life was racked with aches so intense and chronic that she was just too tired to cry. Witnessing her alarming threshold for pain made me feel self-consciously weak. During one visit, Dagbui felt her forehead, glanced at her tongue and suggested I palpate her abdomen, which revealed an enormous, throbbing spleen. Her treatment was limited to saline IVs.


Even with Dagbui’s adjusted fees for the poorer patients, I knew that repeat visits were costly. The expense was even greater considering the income lost from not being able to work during peak farming hours. I once asked Fatima’s father about their family, and he said Fatima had six brothers and sisters, but she was the sole survivor.


This family’s story struck a chord in me. The father’s persistence in getting care for his daughter issued a challenge and purpose to medicine that could only be satisfied with medical skill and care matching his dedication. I prayed that I would someday perform at such a level for my own patients. But partnered with this inspiration was a paralyzing sense of heaviness. For even though a simple intervention like treating malaria was rewarded with the knowledge that a real impact was made on a person’s life, the dizzying vastness of the need made all efforts appear futile. Still, I resolved it would not diminish my goals.


As I prepared to return to the United States, the clinic was in the midst of constructing a bedroom for visitors. Dagbui hoped to have a partner to work in his busy practice one day or to host visiting physicians. In response to his offer, I humbly made a reservation for the year 2007, or however long it would take for me to complete my training.
~~~~A graduate of the Medical University of South Carolina, Ricky Choi will be an intern in the University of California, San Francisco’s Pediatric Leadership for the Underserved program.~Humanistic Medicine,International Health~
109~4May-June~2004-53~Feature~Not FDA-Approved~~Scott T. Shepherd~~Your physician probably does it and you will, too—prescribe drugs for
unapproved uses. But how do you know you can trust what drug companies are saying about their products? Welcome to the nebulous world of off-label
scripting.


In 1994, Neurontin, a drug clinically known as gabapentin, was approved by the U.S. Food and Drug Administration (FDA) to help control seizures in epileptics. It was developed by the pharmaceutical company Parke-Davis, a subsidiary of Warner-Lambert, and approved for a very narrow indication, only to be used in severe cases and in combination with other epileptic seizure drugs already on the market. As a result, sales for Neurontin were expected to be minimal.


Yet by 2000, the sales had ballooned to $1.7 billion per year. So how did this happen to an “add-on” drug with such narrow applications? Through the practice of off-label prescribing, when physicians recommend drugs to patients for purposes not approved by the FDA. (For a guide to the drug approval process, see “Up for Review,” p. 20.)


Over the years, physicians have prescribed Neurontin as a pain medication to treat a wide variety of conditions, including: bipolar disorder, pain syndromes, peripheral and diabetic neuropathy, reflex sympathetic dystrophy, attention deficit disorder, restless legs syndrome, trigeminal neuralgia, posthepatic neuralgia, migraine headaches, and drug and alcohol withdrawal seizures. Some physicians also began prescribing Neurontin alone to treat epilepsy. And why wouldn’t physicians use Neurontin in these ways? After all, two studies published in the Journal of the American Medical Association reported how the medication significantly reduced chronic pain, while research published in other journals praised the drug for its effectiveness in treating bipolar disorder.


Unfortunately, those studies weren’t as reliable as physicians might have believed. According to court documents from a 2001 whistleblower case filed in the U.S. District Court in Boston, Parke-Davis and Warner-Lambert, which has since been purchased by Pfizer, had hired marketing firms to write articles to endorse Neurontin’s off-label uses. As part of this “publication strategy”—as it was referred to in company documents—the firms then found physicians willing to sign their names as authors, even though they were not involved in the research. An invoice from one of the marketing firms showed that Parke-Davis agreed to pay $12,000 to the firm for each article and a $1,000 honoraria to each physician willing to serve as an “author.” Also, in order to maintain content control, the articles were reviewed by Parke-Davis and Warner-Lambert officials before being sent to medical journals for publication.


However, the whistleblower, David Franklin, who worked for Parke-Davis for five months in 1996, testified that the fraudulent studies were just a small part of the company’s efforts to promote off-label uses. Additionally, the company paid physicians—tens of thousands of dollars a year, in some cases—to speak to their peers about the benefits of Neurontin, while other physicians received payments in exchange for allowing pharmaceutical sales representatives into exam rooms to meet with patients, review medical data and even make prescription recommendations. It was all part of a marketing campaign to drive off-label sales. “If we are going to market Neurontin effectively, we have to do it for monotherapy, for epilepsy, also for pain and bipolar and other psychiatric uses,” a Parke-Davis marketing executive told sales representatives in a recorded voice-mail message submitted to the court.


And as it turns out, that marketing push worked. Pfizer reported that in 2000 nearly 80 percent of prescriptions written for Neurontin were for purposes other than treating epileptic seizures, and the drug’s profitability continues to grow, exceeding $2.3 billion in 2002. Meanwhile, Franklin’s lawsuit still lingers in federal court.


NEURONTIN NOT ALONE


The aggressive off-label promotion of Neurontin is an extreme case of a company marketing a drug for a use not approved by the FDA. However, companies frequently push their drugs’ off-label uses.


On a daily basis, pharmaceutical sales and detail reps meet with physicians to discuss their companies’ various products. And while they’re not allowed by the FDA to promote an off-label use, they are allowed to dance on the line between promoting and providing information.


“When the sales people go out, they can’t affirmatively tell the doctor, ‘Hey doc, we got this new study just in. It’s really terrific. It shows that the drug is very safe, very effective for whatever [the off-label use] is,’ and build a following in a market for it,” says Jerome Halperin, the president and CEO of the Food and Drug Law Institute, an organization composed of more than 500 manufacturers and suppliers of medicines, medical devices, food and cosmetics subject to FDA regulation. “Now they can come very close to that, legally. Because if a physician says, ‘Do you have a reprint of the study that can be provided?’ and if the physician reads the reprint and makes a judgment that, ‘Hmm, looks like this drug will work,’” then Halperin says that’s OK.


Of course, determining the validity of that study is also an issue. That’s why the FDA, in addition to promotion restrictions, requires drug companies to provide the agency with all relevant statistical data once they become aware of unapproved uses. However, FDA officials acknowledge that because they have to rely on companies to volunteer such information, the rule is difficult to enforce.


But if a drug does successfully treat a condition, then why doesn’t the company seek approval? “When the off-label market is small, but they find out that the drug really works, it’s really a cost–benefit issue for the company,” Halperin says. “If there are enough people with this particular indication out there—even though the market may be smaller than they would like—they may still go ahead and do a study and try to get it on the label. If the population of people with this indication is so low, it just may not pay for them to do it.”


Without the submission of data, the FDA’s Division of Drug Marketing, Advertising and Communications (DDMAC)—staffed with approximately 20 people—is left to not only evaluate the flood of direct-to-consumer and physician-targeted advertising for on-label uses, but also the sources and validity of journal articles, not to mention the interactions between drug sales reps and physicians. With so much on the DDMAC’s plate, it should be no surprise the agency has cited companies approximately only 70 times for overt off-label promotion since 1998, and the agency hasn’t taken legal action against a drug company for off-label promotions since 1993, according to a November 2003 report by Knight Ridder Newspapers.


IN THE NAME OF FREE SPEECH


Of course, how much authority the FDA has to regulate off-label activity is debatable. In 1997, the agency issued a final guidance regulating companies’ scientific and educational activities, attempting to make a distinction between activities related to on-label and off-label uses. However, the new guidance couldn’t survive a 1998 lawsuit brought by the Washington Legal Foundation (WLF), which bills itself as a public interest law and policy center, that accused the agency of violating pharmaceutical companies’ First Amendment rights.


In Washington Legal Foundation v. Michael Friedman—the acting FDA commissioner at the time—Judge Royce Lamberth of the U.S. District Court for the District of Columbia struck down key provisions in the FDA guidance when he wrote: “In asserting that any and all scientific claims about the safety, effectiveness, contraindication, side effects and the like regarding prescription drugs are presumptively untruthful or misleading until the FDA has had the opportunity to evaluate them, [the] FDA exaggerates its overall place in the universe…. [The] conclusions reached by a laboratory scientist or university academic and presented in a peer-reviewed journal or textbook, or the findings presented by a physician at a [continuing medical education] seminar are not ‘untruthful’ or ‘inherently misleading’ merely because the FDA has not yet had the opportunity to evaluate the claim.”


And in the wake of an overwhelming legal victory, commercial free speech advocates also won a political victory when Daniel Troy, the WLF’s lead attorney in the case, was named the FDA’s chief legal counsel in August 2001. “The whole philosophy over there [now] is pretty consistent with the case. It’s pretty hard to parse the two,” says William Schultz, a former FDA deputy commissioner for policy.


However, Alexander Tabarrok, an associate professor of economics at George Mason University in Virginia and the research director for the Independent Institute, a nonprofit research organization, says it doesn’t matter who’s guiding current FDA philosophy or which party presides in the White House—the ruling alone will have long-lasting effects on the agency. “Regardless of which administration is in power, the FDA must now operate in a world in which manufacturers have well-recognized rights to commercial free speech.”


THE POPULARITY OF OFF-LABEL


But just because it may be illegal to promote unapproved uses for a drug, it doesn’t necessarily mean that use will cause harm. Tabarrok, who is also a co-author of www.FDAReview.org for the Independent Institute, says a lack of FDA citations of off-label promotions is not a reflection of agency philosophy or even authority but indicative of a lack of detriment in the practice.


“Getting FDA approval for a new use of an old drug can be expensive and time-consuming. As a result, the best, most advanced treatment for a disease is often an off-label treatment,” he says. “Off-label prescribing is common, for example, in AIDS, cancer and psychiatric treatment, and most hospital patients will be prescribed at least one drug off-label. Disseminating information about off-label uses is thus a vital aspect of good medicine. Physicians have many sources of information about off-label drug uses, including pharmaceutical compendia, medical journals and HMO formularies. Manufacturers are another important resource, because manufacturers have both the incentive and the ability to provide the information to physicians in a timely and efficient manner”


In fact, off-label scripting is a popular medical practice, and it is widely accepted that it benefits more patients than it harms. (For advice on off-label prescribing, see “Going Off-Label,” p. 15.) According to an analysis by Knight Ridder Newspapers, more than 100 million off-label prescriptions were written in 2002, which is nearly double the number written five years ago. And according to a 1991 study by the U.S. General Accounting Office, 56 percent of cancer patients have been given off-label prescriptions, and 33 percent of total cancer treatment prescriptions were for unapproved uses. Other studies have estimated that 81 percent of AIDS patients received at least one drug off-label and that 40 percent of all reported AIDS medication use was off-label. Even in general medicine, off-label prescribing is common. Physicians were recommending aspirin to heart attack victims years before the FDA officially sanctioned such an indication.


“One of the most important things to know is that the FDA label is very much behind science,” says Dr. Raymond Woosley, the vice president of the University of Arizona Health Sciences Center and a former chair of Georgetown University’s department of pharmacology. “It is also limited by what the industry applies for. There may be unapproved indications that are clearly beneficial effects of drugs in certain uses, but if the industry doesn’t apply for that use, the FDA won’t have that data or even the stimulus to act on it and even include it in labeling.”


And nowhere is this more apparent than in pediatric medicine. In congressional testimony, Dr. Sumner Yaffe of the American Academy of Pediatrics said 80 percent to 90 percent of pediatric patients are prescribed off-label drugs. “This does not imply that 80 percent of our drugs are contraindicated, unsafe or disapproved for use in infants and children. Rather, it means that necessary testing has not been done to produce the data that would enable the Food and Drug Administration to grant approval status for specific clinical indications and uses in pediatric populations,” he said.


The reason for this is the absence of research, industry-sponsored or otherwise, on medications’ effects on children. “There are tons of children that can be benefited by drugs, but it will be off-label most of the time, because even right now we don’t have a law that says companies should evaluate their drugs in children,” Woosley says. “So the industry very often doesn’t do the work, or they do it very late after the drugs are on [the] market.”


And without the research submitted, the FDA isn’t able to make judgments on such uses, so physicians are left to extrapolate a dosage to treat the child and see if it is effective. “Any physician can administer any drug to any patient, as long as the physician understands he or she is at risk if that administration causes some adverse reaction or toxicity in the child…,” Halperin says. “But when a kid is really sick, somebody is going to take what is possibly a very prudent risk. And in most cases it is probably going to turn out fine, but in some cases it’s not going to turn out fine, and a child is injured or a child dies. And that is what everyone worries about.”


RISK AND REWARD


Measuring risk is part of the off-label equation. For physicians, they have to comprehend the health risks to patients, as well as the legal risks to themselves. “The truth is we are not bound to practice by the label,” Woosley says. “Physicians are bound to practice by what they can defend in court, and if there is an adequate science base, the label is irrelevant…. If a physician has some scientific basis, usually a report in literature, which often has not been substantiated, that can be a sound enough basis for most physicians to go ahead and use a drug off-label.”


For pharmaceutical companies, there may be greater risk in going on-label with certain treatments. Woosley says that a drug company may not be interested in applying for approval for high-risk uses because it would make them more vulnerable to liability issues. And if manufacturers can make the same sales without exposing themselves legally, then even the better for them.


Of course, whether or not a pharmaceutical company crosses the line into illegal behavior is often debatable, because it’s unclear where the line is. “It’s something that I don’t think is very clear in the law,” says Larry Sasich, a pharmacist and researcher for Public Citizen’s Health Research Group. “If you ask the company, I’m sure that they will tell you that their study in the Journal of the American Dental Association (JADA) was a scientific communication. You ask me, I’d say it was commercial speech and subject to regulation by the government as commercial speech and not as academic speech or political speech or anything like that.”


WATCHDOGS WITH BITE


Because of a lack of authority within the FDA, drug companies’ marketing practices are being scrutinized by outside agencies and organizations more and more frequently. In the wake of the revelations of the Neurontin whistleblower case, the U.S. Attorney’s office in Boston, as well as attorneys from 47 states and the District of Columbia, have begun investigating whether Parke-Davis officials violated federal and state marketing regulations with their promotion of Neurontin.


A lawsuit regarding Neurontin was also filed against Pfizer in February 2003 by Community Catalyst’s Prescription Access Litigation project, the California Public Interest Research Group, the Congress of California Seniors and USAction. “We intend to show that Parke-Davis intentionally manipulated FDA exemptions intended to promote professional dialogue regarding pharmaceutical science to illegally promote off-label use,” Steve Berman, the plaintiffs’ lead attorney, said in a press release. The suit is being filed in California state courts, citing violations of the state’s unfair competition laws and advertising code.


In the meantime, the Congress of California Seniors has also filed suit against Pharmacia in December 2002 for illegally promoting the off-label use of Bextra, which is approved for treating osteoarthritis, rheumatoid arthritis and menstrual pain. Specifically, the suit claims that the company hired a clinical testing firm owned by a large advertising conglomerate to study the medication. The result was an article in the JADA, trumpeted by press releases from Pharmacia, which declared the drug could provide relief for acute pain caused by impacted molars. What the article failed to note was that the FDA had rejected that conclusion only six months before.


“I can’t ever remember getting a press release about an article that is going to be published in a dental journal about something as mundane as dental pain after somebody’s impacted wisdom tooth is removed,” Sasich says. But once again, the drug company’s efforts seemed to have worked as Bextra sales jumped 60 percent in the three months following the article, according to the New York Times.


Drug companies aren’t the only ones under attack, though. Public Citizen has filed a suit against the FDA over Bextra, contending that the agency omitted public information from Bextra’s approval application. “By regulation, once a drug is approved, the FDA’s analysis of data submitted by manufacturers goes into the public domain. We looked it up, and we found that everything that had to do with acute pain in the FDA reviews was redacted—it was removed from the file,” Sasich says. “What we did…was to file suit to get an unredacted copy of the FDA reviews placed into the public domain to see what was submitted by the company for acute pain and what the FDA thought of the data that was submitted, and then to put that into the public domain so that patients and prescribers can use it.” Sasich and Public Citizen are unsure why the FDA would omit such information. As of presstime, the FDA has not responded to the lawsuit.


KNOWLEDGE IS POWER


One of the benefits to these lawsuits—besides discouraging pharmaceutical companies from zealously promoting off-label uses—is an increase in the amount of information provided to physicians and patients.


Sasich says the agency must play a bigger role in sharing data about off-label drug uses. “I think the FDA really needs to change some policy that I don’t think they would need to go back to Congress to get laws changed. So we wouldn’t have to sit around and file suit to get all of the information we want about Bextra. The agency can be much more transparent with this kind of information, and we could do a much better job communicating it to the public and to professionals. I think that’s absolutely necessary, because I don’t think you’ll ever find a business that’s not going to try to push the envelope as much as possible, depending on the competitive environment they find themselves in.”


Woosley says, however, not to expect too much from the FDA. “It’s very limited what they can do, and I think that’s generally what the public and physicians need to recognize…that [the FDA’s] resources and even their legislative mandate are very limited.”


Sasich also notes the need for more skepticism from both medical journals and mass media outlets. “Journalists have to be a lot more critical. I think the news media—some elements of the news media—has turned into an additional advertising platform for the pharmaceutical industry. Every time a story runs about a new drug that is based on a company’s press package, they are not serving the public at all.”


The bottom line, in regard to off-label scripting, is that physicians and patients must rely on the ancient doctrine of caveat emptor—Latin for buyer beware. “As every consumer knows, manufacturers have an incentive to provide information that puts their product in a good light but not information that suggests problems,” Tabarrok says. “To deal with this problem, consumers supplement advertising with information from their own previous experiences, from friends and from disinterested, reputable organizations such as [Consumers Union]. In the same way, physicians [must] supplement information from manufacturers with information from other sources.”
~GOING OFF-LABEL


As a future physician, it’s likely you will prescribe a drug for an unapproved use.


The rate of off-label prescribing is so high that Alexander Tabarrok, an associate professor of economics at George Mason University, estimated in the policy journal Independent Review that most hospital patients receive at least one drug off-label. “If a new drug has been put through scientific clinical trials that demonstrate its basic pharmacological properties—safety trials—then why shouldn’t doctors be able to prescribe that drug if they think that it would be best for their patients?” he says.


But how does a physician know when to go off-label? In most cases, it’s because there are no other reasonable alternatives on the market. This is when studies on a drug’s off-label use—even ones sponsored by pharmaceutical companies—can be valuable, says Dr. Raymond Woosley, the vice president of the University of Arizona Health Sciences Center. “What physicians have to do is look very carefully at the publications that are in the literature, recognize the limitations of the study or even a few studies and how they may or may not be applicable to the patient sitting in front of them,” he says.


However, Woosley cautions that physicians are not being educated to conduct this sort of analysis. “We have very little training in clinical pharmacology in this country. That’s where doctors learn this aspect of medicine, this gray area. They have to be a clinical pharmacologist. They have to know dose and how to correct it,” he says. Over the years, the number of medical schools offering pharmacology programs has dwindled from about 50 to only 20. Additionally, Woosley believes these skills are getting lost in the general atmosphere of medical education.


As a result, physicians become more and more dependent upon pharmacists and less skilled at understanding how a specific patient will react to a specific medication. “A pharmacist can probably understand a drug better than any physician, but you have to understand the patient, too…. Many physicians today really lack the ability to critically review a scientific paper and find out what can be applied to the patient that they are looking at.”


Until such changes occur, physicians must seek out independent literature and unbiased continuing medical education sources, as well as discuss a drug’s off-label use with their patients, so all parties understand the risks involved. “There is considerable risk burden on a physician who uses a drug off-label and the drug ends up hurting the patient…,” says Jerome Halperin, the president and CEO of the Food and Drug Law Institute. “If things go wrong, that is his liability or her liability.” —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.~Health Policy,Pharmaceutical Industry~
110~4May-June~2004-53~Feature~Up for Review~~Jennifer Zeigler~~Hundreds of drugs enter clinical trials each year, but only about one-fifth will eventually win FDA approval. How does the process work? Let’s take a look….


The line at the pharmacist’s counter is a constant flow of coughs, colds and chronic diseases, all clutching little squares of paper with unintelligible writing. As their physician, you might have written it out just 10 minutes before—a defense for the sick and the hurting. Behind the counter, the pills and potions offer a dizzying array of help. And for the price of their co-pays—or, gulp, full price for those without drug coverage—the pharmacist doles out the medicines they need, when they need them, even 24-hours-a-day in many cases.


The agency that decides which of those bottles and pill packs may sit on the pharmacist’s shelf and how they may be used also sees a constant flow at its door, but the turnaround time for drug companies seeking approval from the U.S. Food and Drug Administration (FDA) is much longer than the seconds it took for you to scribble the prescription—about a year longer. In fact, the time the FDA takes and method it uses to approve drugs have been contentious issues among both Congress and watchdog groups for decades. And even the fix lawmakers and industry leaders came up with in 1992 generates complaints. So what takes so long for a drug to get from the chemist’s lab to pharmacists’ shelves? The answer to that question begins with a look at the process itself.


GIVING THE OK


Congress created the FDA in 1906, but it wasn’t until President Franklin Roosevelt signed the Food, Drug and Cosmetic Act in 1938 that lawmakers gave the agency the power to approve drugs for sale based on newly required safety tests. And for about 25 years, safety was all a drug had to prove. Then the 1962 Kefauver-Harris amendments mandated drug companies show their products are safe and effective before marketing them, which established the risk–benefit scale on which the FDA still weighs each chemical compound brought before it.


The safety tests, conducted and funded by the pharmaceutical company or government agency developing the drug, involve a series of steps triggered after positive feedback from preclinical research on animals and an institutional review board. Before a drug can move into the clinical study phase, the FDA’s Center for Drug Evaluation and Research (CDER) encourages a meeting between the agency and the applicant. At the least, the company must file an investigational new drug application notifying the FDA of its intent to test the drug on humans and seeking permission to ship the unapproved drug across state borders to clinical investigators in other states.


If all goes well, the drug company can initiate Phases I through III clinical trials, in which humans take the potential drug for the first time. Phase I looks at the drug’s reaction on healthy volunteers. Phase II helps determine the drug’s effectiveness and any potential side effects. And, after another meeting with the FDA to determine whether to continue testing, Phase III expands the number of subjects—sometimes to thousands of volunteers—to generate more data on the benefits and risks.


It’s a lengthy process—often taking years of study—and a huge and costly gamble to the drug company, according to a study released last year by the Tufts Center for the Study of Drug Development (CSDD). The average cost of developing a drug, from the first ray of hope in the lab to the new bottle behind the pharmacist’s counter, is $897 million, and only 21.5 percent of the hundreds of drugs that enter human trials will eventually win FDA approval.


The FDA uses the data from the preclinical and clinical phases to determine if a company is allowed to put a drug on the market. All of this information—pages and pages of binders—gets submitted to the FDA along with samples of the product labeling in a new drug application. The documentation required in the application is supposed to tell the whole story, including what happened during the animal and clinical tests, what components the drug consists of, how it behaves in the body, and how it will be manufactured, processed and packaged, especially noting any quality controls, according to the FDA Web site. (The agency declined repeated requests to comment for this article, referring The New Physician to the FDA Web site.)


The breadth of materials that accompany a new drug application makes for some extensive reading for a review team consisting of a physician, a chemist, a microbiologist, a pharmacokineticist, a pharmacologist and a statistician. According to the FDA, their job is to answer the question, “Does this drug work for the proposed use?” while looking for adverse effects, weighing the benefit-to-risk relationship.


Sixteen discipline-specific advisory committees support the review teams, another product of the Kefauver-Harris amendments. Advisory committees consider applications whenever reviewers require assistance on a specific issue, and while the politically appointed experts never have the final say in the approval of a drug, reviewers use them to confirm or redirect the team’s thinking, says pharmacokineticist Funmi Ajayi, Ph.D., who first served on and then led a review team at the FDA between 1991 and 2002.


For example, when the emergency contraceptive pill Plan B went before the FDA in an attempt to gain over-the-counter status, review teams sought comments from both the Nonprescription Drugs Advisory Committee and the Advisory Committee for Reproductive Health Drugs, which heard presentations in December about Plan B’s safety, effectiveness and the risks for eliminating physicians as the link between patients and the drug.


Sometimes reviewers need all the help they can get. “It was not unusual for some of these applications to come to the FDA via an 18-wheeler that backs up to the loading dock and unloads skid after skid of documents,” says CSDD director Kenneth Kaitin, Ph.D.


And while the advent of electronic files has cut down on that somewhat, Ajayi says the trucks were still showing up while she was at the FDA. “The workload is always high, and I believe it will always be high,” she says of her old job. Medical reviewers averaged 10-hour days and regularly put in time at home on the weekends. “We joked that it was a never-ending story.” As a result, turnover was and continues to be high, she says, and her 10-year stint was unusual.


This immense workload stalled approval time and is part of the reason why for many years the FDA heard complaints from industry officials and members of Congress about the long approval process. Prior to 1992, average approval times for new drugs was between 30 months and three years, according to Kaitin. Today, companies wait about a year for the FDA’s OK.

So what changed? Meet PDUFA.


CONGRESS COMES UP WITH A PLAN


Although passed under FDA Commissioner Dr. David Kessler, the Prescription Drug User Fee Act of 1992 (PDUFA) was the brainchild of President Reagan’s FDA Commissioner Dr. Frank Young—his attempt to combat the growing responsibilities and stagnant funding Congress saddled the FDA with during the 1980s, according to New York Times reporter Philip Hilts’ recent book, Protecting America’s Health: The FDA, Business, and One Hundred Years of Regulation.


The law is designed to provide additional money for the agency by having pharmaceutical companies pay for each new drug application they submit. The fees are set yearly—for fiscal year 2004 each application that requires clinical data costs $573,750 and $286,750 for those not requiring clinical work—and this year the agency expects to collect $250 million from the program—a substantial chunk of its $1.7 billion budget.


There are some exceptions: Applications for orphan drugs—those to combat rare diseases that will have little mass-market appeal—sometimes have fees waived, as can applications from less well-heeled companies. “[The fee is] not a lot to a Merck or a Pfizer, but to a lot of the smaller companies it is a tremendous burden,” Kaitin says.


In return for the fee, pharmaceutical companies have a stopwatch put on the their application reviews: 10 months for standard applications and six months for those submitted under the FDA’s priority drugs program, which deals with such high-profile diseases as AIDS and cancer. Kaitin cautions these deadlines, however, are expectations of when action will occur, not total approval times. Under PDUFA, standard applications take an average of 12 months for approval, although the agency tries to keep high-priority drugs to about six months.


Thanks to this give-and-take, PDUFA has been wildly popular among industry leaders. The Pharmaceutical Research and Manufacturers of America, which declined to comment for this article, put out a statement two years ago calling PDUFA “an enormous success for patients,” citing reduced review times and the 712 drugs the FDA approved since its passage, compared to the 473 in the previous decade.


The program was able to cut review times so drastically because PDUFA funds are required to remain with the divisions at the FDA that handle drug and medical device approvals. Most of the money pays for increased staff—the agency has already added the equivalent of 1,201 new full-time positions since 1992, the majority of which have been within CDER, and expects to increase that by another 293 by the end of fiscal year 2007—but some also goes toward operating costs.


While PDUFA has given the agency more hands on deck, it has also given the industry a window into the decision-making process, says Dr. Nora Zorich, the medical director of the pharmaceutical division at Procter & Gamble, who has shepherded several drugs and the food additive Olestra through the application process, as well as overseen the switch of the heartburn medication Prilosec from prescription to over-the-counter. Prior to PDUFA, “as a sponsor, you had no idea what was going on,” she says. “What PDUFA did was kept those people on your project more than less. I know what’s being submitted; I have committed to a 12-month clock. I have a chance to plan for that.” And so does the agency. “They know four months down the road, they might need some help from pharmacology…. There’s something to be said for planning for extra help when you’re going to need it. PDUFA encouraged the agency to bring that kind of discipline into their work.”


Under the law, CDER staff must now respond to industry requests for meetings to hash out problems and update progress within 30 to 75 days of the request, depending on the type of meeting, Kaitin says.


And the meetings are important. Prior to 1992, many companies didn’t contact the FDA at all during the drug development process, Ajayi says. “Being a reviewer, you were dumped with information that had been gathered over three, four or five years…. You’re at the end of the process, and it was difficult to say, ‘You know, we could have gotten more information if you designed your study [differently].’ You don’t want them to have to go back. It’s like crying over spilt milk.”


Former Commissioner Dr. Mark McClellan, who left in March to head the Centers for Medicare and Medicaid Services (see “No One to Steer the FDA,” p. 22), told a group of industry officials in November that the process is designed to make research and development less costly. “A big contributor of those costs is in the increasing cost of clinical trials,” he said. Efficient trial design will provide the most information in the least amount of time, he added. “We’re trying to make the process more predictable.”


So now, a company can call a meeting with reviewers—and get it within 75 days—before establishing study parameters to ensure the results will be data the reviewers will need to make their final decision. “What the user-fee system has allowed is the ability to have more hands and more brains for thinking. There is more hand holding, more collegial relationships,” Ajayi says. “One enjoys the type of relationship we have with the pharmaceutical industry. It is much more a partnership.”


It’s a change Zorich says she sensed particularly in 2000 when Procter & Gamble submitted the osteoporosis drug Actonel for approval. “I thought the agency very much understood the new clock,” she says. “It’s within their purview to ask for more data…. I would agree that the agency is pretty rigorous, but as a consumer, I have to say, would I want them to be any other way?”


CONCERNS ABOUT THE PROCESS


Not everyone is as satisfied with the approval process. Rep. Henry Waxman (D-Calif.) wrote the original PDUFA bill and has supported its two successful reauthorizations, but as a longtime critic of the FDA, he still has some concerns. “Now, some of the problems can be blamed on the agency being underfunded for decades. User fees solve some problems, but they created others as well,” he says.


Having the industry the FDA regulates contribute so heavily to its budget creates a conflict of interest, contends the watchdog consumer group Public Citizen. But pharmacist Larry Sasich, a research analyst at its Health Research Group, says the bigger problem with PDUFA is that all the extra help to approve more drugs more quickly has created a backlog of work for FDA staffers who focus on post-approval regulation—ensuring the newly approved drugs don’t start causing side effects that didn’t turn up in the development studies and that drug companies market them as they said they would. “All these new drugs required extra monitoring for advertising, etc., and none of that [PDUFA] money was available,” he says.


“The last time the legislation came before Congress, I fought that some of this money could be used for post-marketing study,” Waxman says. He won that battle and continues to be a fly in the ointment over FDA funding. “There’s a lot they have to do, and they don’t have the resources to do so.” (For more information on drug companies’ off-label marketing, see “Not FDA-Approved,” p. 12.) “The other side of it is when we wrote the user-fee legislation, we required the FDA to approve drugs more quickly,” Waxman says, adding that sometimes a faster process leads to more mistakes.


And mistakes have happened. The period between September 1997 and June 1998 was particularly bad for the FDA. During those 10 months, five drugs had their FDA approvals withdrawn for safety reasons—often because they were killing patients—and editorials across the nation called into question the hastened approvals. Hilts calls 1997 a “nightmare year,” reporting that five drugs approved that year were also withdrawn in later years, and two more drugs received black-box warnings on labeling—the strongest advisory the FDA can insist on while still allowing a drug on the market. He hastens to note that 1997 was not a normal year in that a huge glut of drugs was submitted for review. And Ajayi points out that drugs submitted in the mid-1990s were under development before PDUFA was passed and so were created without the FDA’s extra guidance.


But Sasich thinks differently. “It’s a pressure to approve. The FDA has always been between a rock and a hard place,” he says. “The problem lies with Congress in that there hasn’t been real congressional oversight since about the mid-’80s. Previously, if the drug gets recalled, Congress would look into it. [But] in terms of drugs that have come off the market, it’s the equivalent of 15 plane crashes with the [National Transportation Safety Board] saying, ‘Too bad.’ In a democracy we should not have to do that.”


Sasich cites a 2002 U.S. General Accounting Office report that found the percent of drug withdrawals at the FDA went from 1.96 percent between the pre-PDUFA years 1989 and 1992 to 5.34 percent between 1997 and 2000. However, the report notes that factors including physician and patient error contributed to some recalls, and that it only takes a couple of withdrawals to spike the percentage.


But Kaitin adamantly refutes claims that PDUFA has resulted in more drug withdrawals. “This is just not the case. FDA documents [that] the number of removed drugs has remained the same pre- and post-PDUFA.”


TIPPING THE RISK BALANCE


The turn-of-the-21st-century withdrawals, coupled with a series of damaging court decisions against the FDA, called into question the power of its regulatory authority. Patient advocates have been saying since 1992 that the cozying up of the FDA to the industry it regulates is troubling, but Ajayi says no one gets a free pass. “The ethics of the profession of those at the FDA doesn’t allow certain things. There is no way any group of reviewers would cross any boundaries. The regulation is really very tight,” she says. Besides, “every year, you get checked” through audits and government investigations.


Kaitin says it’s all part of the important public debate about where society is willing to set its “risk bar” on the scale of a drug’s benefits and risks. “Congress and the FDA react on each other” to create balanced policy, he says.


PDUFA, which came in the wake of AIDS activists protesting the turtle-paced drug approvals in the late 1980s when there was little to offer dying patients, tipped the scale in favor of quick approvals and increased risk. “With the passage of PDUFA, the view of the FDA changed dramatically,” Kaitin says. Prior to 1992, he says CDER looked at an application for reasons not to approve it. Today, when an application is submitted, reviewers consider that it should be approved, unless something signals that it shouldn’t. “The reason why is this level of trust…because the agency and the industry have agreed to work more closely.”


But he says he can see the scale tipping the other way now. “There’s no one pressing for a less rigorous approval of drugs.” The AIDS activists who protested FDA policies in an effort to get some drugs—any drugs—on the market two decades ago aren’t standing in front of the agency’s suburban Maryland buildings anymore. Approval times have recently inched back up, and while he says current FDA structure doesn’t make a pre-PDUFA process possible, he applauds McClellan—with his M.D. and Ph.D. in economics—for having achieved balance between the two sides. “What Mark McClellan did…he managed to reframe the debate…. He put a public face on it.”


But McClellan couldn’t remove the agency from political infighting. Waxman says this is a problem, although he clearly is taking sides in the battle. “The Bush administration’s willingness to place ideology ahead of science” caused the agency to lose credibility, he says. “It hurts all the science-based agencies when decisions are made using politics.” He points to the FDA’s recent postponement of a decision regarding Plan B, despite its advisory committee approval, calling it a political move. A final decision is expected this month.


With politics weighing so heavily on the FDA and a new commissioner in the distant horizon, no one can say for sure where the scale will settle in this ongoing debate. In the meantime, the work piles up at the FDA. How it continues to go from a binder on an 18-wheeler to a bottle behind the counter will surely be a function of both politics and professionalism.
~NO ONE TO STEER THE FDA


Dr. Mark McClellan, with his dual doctorates in medicine and economics, was the dream nominee when President Bush put his name forward in the fall of 2002 to head the U.S. Food and Drug Administration (FDA). After an exhaustive 20-month search and several unacceptable suggestions, McClellan appeared from the White House Council of Economic Advisers like a wonder drug himself: Republicans approved, Democrats gave a thumbs up, and even consumer groups found nice things to say. He won unanimous approval from the Senate and went forward with great expectations.


But just 16 months into his tenure, Bush tapped his FDA commish to head the Centers for Medicare and Medicaid Services, and by this past March he was gone, leaving the agency with the prospect of another long period with only a stand-in at the wheel. Already Congress, industry and consumer groups miss the young internist with the head for business.


“McClellan has set a new standard for FDA commissioners,” says Kenneth Kaitin, Ph.D., director of the Tufts Center for the Study of Drug Development, which researches the drug approval process. “He’s the first commissioner who had an economics background, so he was acutely aware of the importance of maintaining an environment for [research and development]. He understood that there will be no drugs without creating an environment [conducive to] R&D.”


Rep. Henry Waxman (D-Calif.) was also pleased with McClellan’s job. “As a doctor and a scientist, he tried to keep the agency insulated [from political pressure],” which he says is key to a strong FDA. “I think it’s important to have a commissioner who’s unbiased…who doesn’t have ties to the industry.”


The ability to weather the political climate is necessary for the job, says Procter & Gamble medical director Dr. Nora Zorich. “You need smarts, but you also need to know how to get something done,” she says, adding that experience beyond medicine—such as McClellan’s economics background or former Commissioner Dr. David Kessler’s law degree—is also important.


Finding that right balance again is going to be difficult, most agree, and Kaitin says convincing that person to take the job will be a big challenge. “I’ve known several people who have turned down the position. It’s a very political position to put yourself in.”


So no one seems to expect Bush to find McClellan’s replacement before the November election, and Waxman predicts, with a hint of a smile, that “President Kerry” will be nominating the new commissioner next year.


It leaves the agency in the lurch, say some observers. Without a strong commissioner, initiatives tend to lose their momentum, and McClellan left as the FDA was rolling out plans for the next five years under the recently renewed Prescription Drug User Fee Act (PDUFA). Under him, the agency issued guidelines to provide researchers with additional direction, allowing them to better plan for and shape their clinical studies in an effort to speed up the review process even more than PDUFA has. “No one wants to be pinned down as to what they need to be working on. This is a scientific process, and there shouldn’t be a recipe. [But] McClellan realized the more specifics, the faster new drugs can get on the market,” Kaitin says. “So now he’s going to be leaving, and the FDA has its initiatives in place, but he won’t be there to guide them.”


Instead, Deputy Commissioner Lester Crawford, D.V.M., who led the agency while Bush searched for McClellan, will stand back in as the acting commissioner. He’s got his own set of initiatives, Zorich says, mostly concerning food safety, and she expects him to push for more work in that area.


The fact that there doesn’t appear to be a permanent commissioner on the horizon bothers Kaitin. “The FDA should not go a lengthy time without a commissioner. It’s just too important of an agency.” —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.~Health Policy,Legislative Action,Pharmaceutical Industry~
111~4May-June~2004-53~Perspectives~A Whistleblower’s Story~REFLECTIONS ON MAKING THAT REPORT~~~Yes, I blew the whistle on Johns Hopkins Hospital’s internal medicine residency for work-hours violations. Yes, I would do it again. But first, let me clarify a few things.


It was early July 2003. I had just graduated from Johns Hopkins University School of Medicine and was starting my residency in emergency medicine there. For my first month, I was to rotate in the internal medicine program. Now, I’m not sure that was such a good idea.


I had always been somewhat outspoken on residency work-hours issues, talking about it regularly with classmates and even authoring a letter about it in the Annals of Internal Medicine the year before. And, if it hadn’t been for the Accreditation Council for Graduate Medical Education’s (ACGME) new work-hours regulations, I probably wouldn’t have done a residency.


Maybe I was too idealistic. I tried to hold onto this concept of “true medicine,” of compassionate medicine, of seeing patients as more than obstacles to a few hours of sleep. But as a Hopkins medical student, I saw the dehumanization of patients, and I felt residents’ work conditions played a significant role in their desensitization and cynicism. The Hopkins residents with whom I had been as a student regularly worked 120 to 140 hours a week. When the ACGME regulations were proposed in the summer of 2002, I changed my mind about residency. I figured I could do 80 hours and hopefully maintain some humanity.


Yet the internal medicine program had little, if any, intention of changing things. I don’t say this to be dramatic. I say it because before I contacted the ACGME, some internal medicine residents openly shared their disgust with me concerning Hopkins’ disregard for the rules. After my first four days—during which the required 10 hours off between shifts meant nothing, throughout which we, as interns, had been informed we might have two days off during the month and during which our senior residents emphasized they would not have any days off—some medicine interns approached me and asked me to speak up.


“Troy, we’ve got too much to lose,” they said.
Little did I know....


So I said something. I spoke openly with my supervising residents, my attending physician and my emergency medicine program director. I have been criticized within the Hopkins community for not following the “chain of command.” I’m not sure what more I could have done. This much, though, I didn’t do: I didn’t talk with the internal medicine program director. I’ve known Dr. Charles Wiener for quite some time, and, admittedly, I was intimidated by him. So I didn’t see the value in talking with him.


Some internal medicine residents told me they had formed a committee the previous year to propose how Hopkins could adhere to the regulations. They came up with a number of proposals, all of which were rejected. When residents proposed bringing internal medicine residents in from off-site rotations to provide adequate coverage, the response, according to these residents, was, “Do you have $50,000? That’s what they pay us to have you rotate there. Do you have that kind of money?”


In the end, that’s what I believe it was about—money. Sure, I was under the impression that the department hadn’t put a lot of effort into compliance, but it didn’t have much money to work with either. An administration official later told me that the hospital’s residency programs had received no additional funding to assist in ACGME compliance measures and had been told simply to make it work by the July 1 deadline.


With this in mind, then, I couldn’t imagine my weak appeals to one administrator after another would have made much of a difference. And, with this in mind, I wrote “the letter.”


It was a five-minute e-mail. I sat at a computer in the physicians’ lounge, and I wrote to the ACGME. I stated the facts: Residents had worked more than 120 hours during that first week; we had been told we would have only two days off that month; the medical intensive care unit (MICU) residents were on an every-other-night call schedule; on-call periods had reached 40 consecutive hours in some cases; and time off post-call had been far less than 10 hours. I wrote that e-mail on July 7. Early? Absolutely. But I wrote it at that point for a number of reasons.


First, I was angry. The department had promised new interns during residency interviews that they would be in compliance by July 1. Resident proposals for compliance had been rejected. The administration’s efforts at compliance had been anemic and practically nonexistent, amounting to little more than a senior resident assigned to four interns to help them get their scutwork done and get out by hour 30.


Second, I had climbed the chain-of-command ladder in seeking help and had nowhere else to go. Realistically, I had spoken to all of the relevant individuals a resident should approach. The response was, “There’s nothing we can do about it.”


And finally, the work-hours situation hit a very personal note. I almost hurt a patient. It was the first patient who remembered my name, who called me Dr. Madsen through his sleepy-eyed grin. That was what pushed me over the edge. I forgot to order a second set of cardiac enzymes on him. Post-call, on hour 32, the test had not been done. I had ordered it earlier, but at that point I should have drawn it myself. And I just plain forgot. Fortunately, the test was performed sometime later that day.


When I returned the next day, though, my attending physician said they had been preparing “end-of-life issues” for the patient the previous night, and I was to blame. That’s what made me write to the ACGME. I blamed myself for the mistake but couldn’t help but question, at least for the millionth time: How can inexperienced residents be expected to function and take care of patients after being awake for 30 consecutive hours? I couldn’t help but think, “The system’s just messed up.” And so I wrote that e-mail.


Reporters and friends have asked me: “Would you do it again?” To reporters, I say, “Yes.” To friends, I give a qualified “yes.”


Under those same conditions, yes, I would report again. But I was somewhat naïve. I assumed these regulations meant something, yet residencies continue to violate them. Sure, they’re close. Maybe residents work 85 hours a week, and 32 or 34 hours on call. But I thought the rules were supposed to be fixed—a threshold not to be crossed.


I’ve also learned that, unfortunately, residency is about survival. Most residents just want to get through, and they want to do nothing to rock the boat in the process. I saw evidence of this when the knowledge of my e-mail became public. Residents knew fairly quickly who authored the e-mail; my supervising residents said they had seen it and that Wiener had asked them if I might have been the one who had written it. The ACGME had sent the e-mail to the hospital with my name and certain details removed, but the letter was so specific that no amount of omissions could have masked my identity.


Wiener also called my program director and said he felt I had written the letter and that, because of this, I would not be allowed to work in the MICU when my time came—a rotation required for my completion of the emergency medicine residency program.


Within a few short weeks, all residents in the internal medicine department had received a copy of my letter. One resident, who had warned me to “watch your back,” suggested I might want to consider transferring.


Some were vocal in their criticism of the whistleblower and the ACGME. A few said they wanted to “kill” the author. And in that environment, wouldn’t you want to keep your mouth shut? I didn’t expect to get a bullet in my back, but, yeah, I was scared.


Finally, I learned that it’s easy to make an outsider emergency medicine intern a scapegoat. I became the scapegoat for the institution’s failure to prepare for the ACGME regulations. I became the scapegoat for the threatened loss of accreditation.


And whistleblower protection? It doesn’t exist. There are no statutes to protect someone who reports to an accrediting body. I was exposed to the elements, whatever those may be.


So, yes, I made the report, but I spoke not just for myself. I spoke on behalf of the residents who asked me to speak up for them. I said what they were unwilling to say. I expressed their anger and their disillusionment. So, no, I wasn’t the only one who made that report.


Under those same circumstances, yes, I would report again. But knowing what I know now? No, I wouldn’t make that report. Maybe I’m wrong in saying that, but knowing what I know about the lack of protection, I would have kept quiet. I would not encourage anyone to make that report. Or, if you make a report, go into it knowing what you may face. I had no idea.


Is the system better off for it? I don’t know. Sometimes I think nobody cares much. We’re all just surviving. Sure, work me those 34 hours; I’m not going to say anything. At least it’s not 40 hours. We’ve gotten to where we are by jumping through hoops. Premed courses, the Medical College Admission Test, medical school, boards….


We’re asked to jump, and we ask, “How high?” Perhaps, though, that can change. Maybe future whistleblowers won’t have to worry about retaliation, because residents will stand behind them. Maybe, as a profession, we will question the years-long abusive practices of residency training. Maybe we’ll stop asking “How high?” and simply ask “Why?” I hope so, because I believe the premed idealistic desire to “just help people” doesn’t have to get lost in residency’s hours and demands. I believe that compassionate medicine is far more important than medicine’s machismo. I believe that the practice of “true medicine” is possible, even in residency.


And I believe that continued work-hours reform is one of the most important steps toward bringing compassion, toward bringing the practice of “true medicine” to residency training. I believe things can be different. Still.


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


RESPONSE FROM JOHNS HOPKINS


Editor’s note: TNP asked Johns Hopkins if it wanted to comment on Madsen’s story and was provided with these words from Dr. John Dooley, a senior internal medicine resident at Hopkins.


The Hopkins internal medicine program drew a lot of attention last summer, and it is true that residents sometimes spent longer hours caring for patients than was permitted under the regulations. However, after a lot of thought and effort, Hopkins fashioned a new system that is fully compliant with the ACGME, and we were granted reaccreditation.


This much is widely known. What is less appreciated is the phenomenal character of the Hopkins environment—something I have been privileged to experience. I would like to blow the whistle on the inner workings of my residency and expose the reasons why I have no regrets about training there.


Hopkins residents are known for the intensity of their work, and our approach has nothing to do with testing endurance limits or being victims of abuse. Rather it is a reflection of our commitment. We believe shift work to be antithetical to the responsible practice of internal medicine and that nothing dehumanizes patient care more than abdicating responsibility for a patient at an arbitrary hour. Aside from what the ACGME mandates, we would never seek to constrain the time we spend at patients’ bedsides.


I have found the faculty and program leadership approachable as well as deferential to our needs and concerns. Faced with the ACGME challenge, our chairman and program director promised that a solution would be in place as soon as possible. Working closely with the entire institution, they committed time and money to the restructuring process. When residents said they needed “stat” phlebotomy services 24-hours-a-day to improve care of critically ill patients, we got it. I have never felt any less than fully supported by our program and hospital leadership.


In other forums, some have indicted Hopkins residents as “toxic,” but it is an insult to equate frustration with the obstacles to patient care with cynicism toward patient care itself. It is more telling about the program’s character to ask: What makes Hopkins residents “toxic”? The answers include: distraction from our patient-care mission by threats of loss of accreditation; the logistical glitches inherent in complex medical care; and our seemingly futile struggle with a health-care system that often neglects the needs of the poor.


Our program’s spirit is characterized by the word aequanimitas, from the title of an essay by the physician Sir William Osler. To us, it means being composed and competent even in the face of severe illness and medical emergencies. I confess that my aequanimitas faltered after the ACGME investigation. I was discouraged by the negative press and concerned that medical students might never learn our perspective on training and medical practice. I hope, however, that word will spread that we do practice the truest form of medicine at Hopkins, and that will never change.
~~~~Troy Madsen is an emergency medicine resident at Ohio State University Medical Center. Direct comments and questions about this article to tnp@amsa.org. ~Residency~
112~5July-August~2004-53~On the Wards~Getting to Know Mr. G~FROM A PATIENT TO A FRIEND~Grace Chen Yu ~~“If you’ve finished your H&P on that last case, you’re done admitting for tonight. You should stop by Room 330, though. The patient has a pretty interesting rash,” my intern said.


I was a freshly scrubbed third-year, eight weeks into my clinical rotations and still getting used to my role. I had begun the second leg of my internal medicine rotation—this one at a managed-care hospital—and after four weeks at a Veterans Affairs hospital, I was eager to see something other than older, white males with three pages of medical histories.


I paused outside Room 330 to read the intern’s notes. Mr. G had come in complaining of chronic low back pain but was subsequently found to have a rash on both legs. I introduced myself. “Hi, my name is Grace, and I’m a medical student on the team that will be taking care of you. I understand you are having some back pain and a rash over your legs. Would you mind if I take a look?”


Mr. G was a thin, older man in his early 70s, with sparse white hair covering his head. “Why not?” he answered. “Everyone else has already. I don’t know why they’re all so interested in that rash, though. It’s my back that’s hurting me.”


I assured him we would do our best to take care of his back pain but we would also have to find out what was causing the rash. I did a thorough exam of his legs and, satisfied, covered Mr. G back up, telling him I would see him the next day.


The next morning he was complaining about his back to an older woman by his bed. “You must be Mrs. G,” I said.
“Yes, I am,” she said. She told me her husband had been discharged three weeks before from a skilled nursing facility and was doing fine until the rash developed several days ago.


I said I would try to get to the root of the problem. As I took Mr. G’s medical history, I realized his back pain had been the source of many hospital admissions. I inquired about incontinence, and he admitted he sometimes had difficulty “keeping it in.” An alarm bell went off in my head.


When my team rounded later that day, I dutifully reported the new findings on Mr. G. An MRI of the spine was the next logical step, I explained, to rule out the presence of cauda equina syndrome, a serious condition in which the spinal cord fibers are compressed, requiring immediate surgery.


Unfortunately, our hospital allowed only two inpatient MRIs a day. “How sure are you about this?” my attending asked.


“Fairly certain,” I said, though I regretted making such a big deal about it as soon as I said it. Neither my intern nor my resident seemed as excited as I was. Perhaps incontinence was more common than I had thought, and who was I to know when an MRI was necessary?


But they agreed, and we wrote the orders for Mr. G to have one later that day. “For educational purposes,” my resident said. Sure enough, the MRI came back negative for cauda equina syndrome, and I humbly realized that my medical education had taught me to be so alert to abnormalities, I had failed to recognize a condition’s normal variants.


During the next few days, we obtained a dermatology consult, experimented with pain medications and arranged for daily physical therapy. By this time I had grown quite fond of Mr. G and had taken him on as one of my patients so I could be more involved in his care. Because I was a student, I had the luxury of time and considered myself an ally of my patients.


Our morning pre-rounds always consisted of jokes and stories of his younger days when he played tenor sax in a jazz trio. He would wink at me as I entered the room, give me an update on his rash—which nearly disappeared—and grumble good naturedly when I asked him to sit forward so I could listen to him breathe.


By the end of the week, his rash— diagnosed as “idiopathic” (a term I now know we use when we don’t know the cause)—had cleared, and he was slowly progressing in his physical therapy sessions. He was ready to be discharged to a skilled nursing facility.


On the day of his transfer, I stopped by to say goodbye and wish him good luck. But hours later I learned Mr. G was still in the hospital. As he was being moved to a gurney, his oxygen saturation fell and his heart went into rapid atrial fibrillation, despite numerous medications.


From that point on, his medical course fluctuated not by the day but by the hour. His oxygen saturation levels continued to teeter in the low 90 percentiles. We supplemented oxygen through a nasal cannula, but more often than not, he would pull it off. His nurses and I tried numerous approaches: first setting an alarm on the pulse oximeter, then taping the cannula to his face. But these didn’t work either.


“You could write for restraints,” one of the nurses suggested. I cringed. It seemed inhumane, but we had exhausted nearly every possibility. Reluctantly, I asked my resident, who agreed it was the wisest thing to do and wrote the orders.


On some level, they worked beautifully. Now that he wasn’t able to pull off the nasal cannula, his oxygen levels stabilized, his mind cleared a little, and I was able to catch a glimpse of my old patient. By his ninth day in the hospital, he began to wink at me again. At the same time, though, it broke my heart to see him strapped to his bed all day.


By now, I was talking regularly with his wife and sons to update them on his progress. Although it was unusual for a medical student to be the family liaison, I believed it was the most natural thing to do, given the constant turnover of interns, residents and attendings on our team.


Near the end of his second week in the hospital, Mr. G’s creatinine levels started to rise, and despite our efforts to keep him well-hydrated, he continued to progress toward renal failure.


“It’s time to have a family meeting,” my resident said, and I understood her implication. “It’s just better if everyone has a clear idea what his condition is and how we should manage him.” We scheduled it for the following weekend.


When I returned the next Monday and asked what Mr. G’s family had decided, my attending surprised me by saying, “They said they wanted you to be present for that decision, since you were there from the beginning.” I was touched by their level of trust in me. It was the first time I had felt the true weight and privilege of caring for another person’s life.


At the same time, though, I felt helpless. Nothing seemed to alter the course of Mr. G’s illness, and I felt responsible that his condition was rapidly spiraling downward. During the three weeks he was in the hospital, I must have reviewed my notes dozens of times, trying to figure out where we failed. I couldn’t believe that someone who had come in with a simple complaint of back pain and had been ready for discharge one week later could now be facing comfort care. I also believed to some extent that the longer Mr. G stayed in the hospital, the worse off he was.


I asked Mrs. G how she was handling it all. She said she didn’t know what to do; she and her husband had been married for close to 50 years, and she felt like she should continue to push for him, even if he was no longer able to. At the same time, she didn’t think he would have chosen this for himself. She decided she needed more time, which I agreed was reasonable.


But two days later we heard a code called for a patient in Room 404—Mr. G’s room. “This is it,” I thought.
But it wasn’t. Despite all the insults hurled at his body, Mr. G still hung on. He was hardly conscious most of the time, unable to speak due to the mask on his face but still able to give a feeble wink. It was only after two more codes that his wife and sons said they realized his body had been through enough. The pain on Mrs. G’s face as she informed me of their decision spoke to her courage. We walked the family through the logistics of taking him off the ventilator.


After the nurse had removed the IV, turned off the machines and given Mr. G morphine, we left the room so the family could be together one last time. I didn’t know how long it would take for him to pass away; my attending said it could be 10 minutes to an hour, so when half an hour had passed, I knocked on the door.


One of his sons let me in, and I could see from the redness in his eyes that he had been crying. They had scattered rose petals all over their loved one’s body, and as I held Mr. G’s hand, I realized it was the first time I had ever seen a dead person. I noticed his cold, yellow, waxy skin. I was also aware how quiet the room was without the machines. But I hadn’t expected to feel the sense of peace that was present in the family and, to my surprise, myself.


Mrs. G hugged me, which I think brought more relief to me than it did to her. One of his sons showed me some pictures of Mr. G as a young army pilot with his plane, dressed up for his wedding, with his jazz trio, with his young family, and then as he celebrated his 65th birthday.


The hospital chaplain entered the room. “Would you like to join us in a prayer?” Although I wasn’t a religious person, I was grateful for the invitation. As we held hands, I realized Mr. G had been so much more than my patient. I had learned more about him from the pictures and thoughts his family shared with me than I had in the three weeks when he had been under my care. And I felt again a sense of gratitude to Mr. G and his family for allowing me to become a part of his life.
~~~~Grace Chen Yu is a family practice resident at San Jose Medical Center in San Jose, California.~Humanistic Medicine~
113~5July-August~2004-53~Feature~Keeping Workers On the Job~OCCUPATIONAL MEDICINE: A LITTLE-KNOWN SPECIALTY OFFERING A WIDE RANGE OF CAREER OPTIONS~Jennifer Zeigler ~~Dr. Phillip Franklin is helping to redesign the way we build cars in America. It’s not something the University of Colorado School of Medicine trained him for back in the early 1980s, but to be sure, he’s now standing on the assembly line floor in the General Motors (GM) plant talking about the most ergonomic way for an autoworker to build a car.


The Wilmington, Delaware, factory, which until now has built cars for GM’s Saturn division, is about to begin rolling out the Pontiac Solstice, a zippy little two-seat convertible slated to hit car lots in the fall of 2005. But first, plant engineers have to create the assembly line. And as the plant’s medical director, Franklin is a sort of go-between for the workers and those who design how they do their jobs. “You’ve got to listen to the patient,” he says. From what he learns about their complaints, he can tell the line engineers, “You’ve got a bad bend and twist here; you’ve got a bad bend and twist there. Why do that to people?”


And so they won’t. Thanks in part to Franklin’s constant study of how plant jobs cause injuries and why, Solstice’s assembly line is expected to employ new techniques in car-building technology that should reduce workers’ injuries. It makes one wonder what might have been different in car manufacturing if Henry Ford had collaborated with an occupational medicine physician 100 years ago.


REPETITIVE STRESS INJURIES AND MORE


“I shadowed an occupational med doc.… All I saw that day was a whole bunch of physicals and disgruntled truck drivers who couldn’t get their licenses renewed because their HbA1c was too high,” a medical student posted recently on an online bulletin board.


“A lot of people think that’s what occupational medicine is—doc-in-a-box sort of thing,” Franklin says. “But there’s so much more.”
For instance, the workshop offerings at a recent American College of Occupational and Environmental Medicine (ACOEM) conference included: “Depression in the Workplace,” “Waterborne Disease,” “New Eye and Face Protection Standards,” “Agricultural Chemicals,” “Helping Workers and Their Families Quit Smoking” and “Molecular Epidemiology.”


“What I like about occupational medicine is that it’s a really wide-open field. You’re really taking care of patients,” Franklin says. As medical director, he oversees a team of physicians, nurses and EMTs in the on-site, inpatient medical clinic, and he says he loves caring for patients. But with an M.P.H. under his belt, he also enjoys the epidemiology.


When he arrived at the plant in 1999, the facility was plagued with GM’s second-worst accident rate. “The good thing was I couldn’t make it any worse.” But, putting his epidemiology skills to work, he pieced together what was causing the injuries and determined ways the plant could curb them. One of the solutions was to evaluate the plant’s 2,500 workers on whether they were physically suited to their jobs; if they weren’t, they were moved. “We’ve put people in the right job for them so they’re not getting hurt,” he says.


When employees do get injured, Franklin keeps track of their locations at the time of their injuries, what protective gear they were—or were not—wearing and other details in a handheld computer that maps out the information. He shares the graphics with the plant’s area supervisors along with instructions on how to prevent future accidents.


Through these efforts, Franklin and his team reduced the plant’s injury rate by 90 percent, saving GM more than $1 million in health-care costs. “I like to touch people. I want to improve their health—but I’ve moved beyond just that,” he says, adding he enjoys caring for a patient population in which most are in the prime of their working lives.


“What you’re doing in medicine is treating a disease, but in occupational medicine, you’re actually getting to work with a healthy work force,” says Dr. Pamela Hymel, a former medical director for Hughes Electronics in El Segundo, California, who recently finished her term as ACOEM’s treasurer.


And Franklin says he sees even more opportunities for the occupational medicine physician at GM: The company is considering expanding its services to also provide primary care for workers and their families and better educate them from a health promotion standpoint. He’s seen workers struggle with suicide, homicide and drug dependencies—outside issues that affect workplace health. The company can help, he says. “We have a captured population. We should tap into that.”


Hymel says population health management through a benefits program is relatively new to the specialty. As Hughes Electronics’ medical director, she crafted prevention policies for 52,000 employees. “One of the most challenging things I did…was working on the health and wellness of our employees and working with our benefits people.… We need to look at a patient from a variety of perspectives and teach them how to stay healthy because there are some benefits to going to work.”


CLINICAL CARE WITH SOME COMPLICATIONS


Of course, occupational medicine can simply be clinical in practice as well. About 80 percent of Dr. Steven Hendler’s Kansas City-based physical medicine practice involves treating on-the-job injuries, despite the fact he is not board certified in occupational medicine (see “The Road to Occ Med,” below). Hendler did a residency in physical medicine and rehabilitation, but “over the years my practice has evolved. I’m doing this type of work in a progressively increasing amount.”


Employers refer most of Hendler’s patients to him, and the vast majority suffers from musculoskeletal, back, arm, neck, and compressed nerve injuries. He sees more manual labor injuries—mostly because of his Midwest location—but there are desk-bound workers who have wrenched their backs moving a box of copier paper.


This brand of clinical practice has its challenges, though. A lot of psychosocial issues become intertwined with their physical injuries, he says, “and so you need to have a very good understanding of those issues.” For example, he cites a study that found patients with active workers’ compensation claims do not respond to treatment as well as those who have settled their claims. It all has to do with how you see your employer, he says. “In a good economy, and you sit at a desk and get a little arm pain, you’re going to put up with that because you’re raking in money. In a down economy, you’re not.”


And if you think patients check those issues at the exam room door, you’re wrong. “You have to be a little steely-eyed to do this,” he says.
His conscience raises a red flag whenever a patient says his boss made him come in for an exam because he believes the employee is faking the injury. The same is true whenever a referral comes with an employer complaint about the worker simply wanting a vacation. “That’s a situation where I can see the patient is not going to get better,” he says. Complications also arise when employers use workers’ comp cases to resolve human resources issues and look to Hendler for an excuse to fire a problem employee.


“It’s almost like doing battlefield care…, and you’re in the middle of it because you’re trying to get the patient better, and that’s a challenge, and sometimes it’s an annoying challenge.


“In traditional health care,” he says, “you’ve got the patient, the provider and health insurance. In occupational medicine, you’ve got the patient, the provider, health insurance and the employer.… And the other is the judge.”
That’s right. Some occupational medicine physicians spend a lot of time as experts in court cases. Hendler says he gets deposed in workers’ comp disputes between two and 10 times a month. And about twice a week employers submit surveillance tapes for him to review, in an attempt to prove an employee is faking an injury. “That’s the funny ones—where the guy says he can’t lift anything, and they have videotape of him lifting boxes, aquariums….”


These issues turn some patients nasty and even threatening, Hendler says. They may be trying to get the physician to refuse treatment, so their exasperated employer will allow them to see any physician, potentially someone who is unfamiliar with their background. “In those cases we hold on a lot longer,” he says. Some of his patients have already been through several physicians before him.


Franklin says his work can get complicated as well, particularly when he feels trapped between union disputes and management. In those situations, maintaining a neutral position and developing strong working relationships with union leaders is key. “Sometimes my job is to get management and unions to understand what they can and can’t do,” he says. “My job is to be the collective conscience of the plant.… As a doctor, you have certain ethical and moral [standards] you have to adhere to.… I go to workers’ comp. I testify against people. I just don’t make it personal.” He says if he did, he would lose perspective of the causes and effects of problems and how to resolve them.


But determining the root administrative causes of injuries isn’t usually Hendler’s focus, so he admits it’s not always the ideal clinical experience. In fact, when a premed neighbor asked to shadow him for a day, he told her it wasn’t such a good idea.


Still, he tries to look at the challenges optimistically. “It’s like panning for gold in that when you have a success, when someone comes in who’s failed everything…and you get them to a place where they are better than when they came to you, that’s rewarding. I mean, yeah, there are days where every patient is a problem, and I think, ‘Oh, I’ve got to get out of here. I’ve got to retire, be a garbage man, whatever….’ [But] I enjoy the process of figuring out what is going on, even if I can’t make it better. And frankly, as a business owner who has to pay workers’ comp premiums, I do want to make sure people aren’t taking advantage of the system.”


IN THE FIELD


Complications aside, though, occupational medicine’s lifestyle can be very attractive. “I won’t be dishonest. It is financially rewarding,” Hendler says. What other specialty can boast a 100 percent coverage rate among its patients? Everything Hendler does is billable, either to workers’ compensation or, in the case of his depositions, to the lawyers calling him to testify.


Franklin agrees the specialty offers a better lifestyle than others. He says he makes “less money than a surgeon, but I also don’t have the issues they have.” It’s a 9-to-5 job for the most part, although every now and then he has to deal with a problem on the night shift. But GM understands he has a life outside of medicine, he says. “You get treated more like a real person.”


A 2002 ACOEM survey found the average total compensation—including salary, bonuses and consulting fees—for an occupational medicine physician is $188,000, and Hymel says it can range from $150,000 to $200,000. This depends on your training and practice—in which the options are broad.


Of the roughly 5,000 occupational medicine physicians in the country, 18 percent work in an administrative capacity, similar to Hymel and Franklin. Another 65 percent are clinicians like Hendler. Others consult with companies and the federal government—about 20 percent of ACOEM members are government employees working with state and federal policies—and small percentages teach and do research.


The opportunities continue. Hymel says the military employs one of the largest groups of occupational medicine physicians—their expertise in chemical exposure and toxicology is invaluable. Franklin was recently offered a job with the National Aeronautics and Space Administration (NASA). While the tug of outer space is strong, he says he can’t uproot his family. He admits, though, that working for NASA would be one of the coolest jobs—still, there seem to be plenty more here on Earth.
~THE ROAD TO OCC MED


If variety is the spice of life, training for a career in occupational medicine is the educational equivalent of a good Indian curry.


The routes medical students can take toward board certification are plentiful, but most of the 32 U.S. residencies follow a basic template: Programs are two years long, require a completed internship year and include an M.P.H. But beyond that, the sky’s the limit.


Dr. Ann Dew directs the occupational medicine residency at Loma Linda University in California. Her residents, who have already completed an internship, are unique in that they do three years in the program, including a year spent rotating through departments to hone orthopedics, dermatology and pulmonary skills, among others. By focusing on these core issues, Dew says residents learn about common problems occupational medicine physicians see in California patients. The program is also unusual in that Loma Linda integrates the M.P.H. curriculum with residents’ clinical rotations. Most occupational medicine residencies treat them separately.


Dew looks for physicians who have spent their transitional year in a primary care program, often family practice or internal medicine. “We get a lot of people who got interested in occupational medicine” while doing family practice residencies, she says. For physicians who complete their residencies before specializing in occupational medicine, some programs, such as Emory University’s, offer the training as a fellowship.


Clinical and research opportunities vary by sponsoring institution, Dew says. For example, Loma Linda residents rotate through a Veterans Affairs hospital, and some do research with the National Institute of Occupational Safety and Health at the U.S. Centers for Disease Control and Prevention.


A handful of schools offer four-year combined specialty programs; the University of Illinois’ Stroger Hospital of Cook County trains residents in both internal medicine and occupational medicine, allowing them to sit for two certification exams when they’re finished.


Although an occupational medicine residency is required to sit for the board exam, offered twice a year by the American Board of Preventive Medicine, other physicians have chosen to enter the field simply by setting up practices. Typically, they’ve completed a residency in family practice, internal medicine, physical medicine and rehabilitation, or preventive medicine. It’s the route Dr. Steven Hendler, who practices occupational medicine in Kansas City, took. His physical medicine and rehabilitation specialty allowed him to focus on musculoskeletal injuries, giving him more flexibility post-training, he says. Plus, “the demand is sufficiently strong in most areas that you won’t be hurt by not having your residency in occ med.”


He suggests students considering occupational medicine determine what their primary interest is in the field. For example, if the epidemiological and public health aspects are the most intriguing, then he recommends they apply to occupational medicine residencies.


Dew says some of her residents know just what brand of occupational medicine they want to practice; yet others figure it out along the way. But in all of them she looks for “people who really make the patient feel at home…because by the time a patient gets to the occupational medicine physician…, [he] might have some emotional baggage” about his injury and his employer. —J.Z.


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


OCC MED AT A GLANCE


HISTORY: Occupational medicine dates back to ancient times when the Greeks and Romans noticed increased illness rates among miners. Occupational medicine physicians began earning their board
certifications in 1955.


TRAINING: An occupational medicine residency is typically three years and includes time to earn a required M.P.H. Practitioners also often come from family practice, internal medicine, preventive
medicine, and physical medicine and rehabilitation specialties.


AVERAGE SALARY: $188,000


PHYSICIANS IN THE UNITED STATES: About 5,000


MORE INFORMATION: Contact the American College of Occupational and Environmental Medicine. Also see www.opsf.org for information about the Occupational Physicians’ Scholarship Fund, which pays the stipends of a handful of residents each year.
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.~Career Development,Practice of Medicine~
114~6September~2004-53~PremedRx~Your Questions Answered~ON APPLYING TO MEDICAL SCHOOL~Rebecca Sernett~~How important are Medical College Admission Test (MCAT) scores and grade-point averages (GPAs)? Should I consider an off-shore school? What are my chances as a nonscience major? To find answers to these common questions, The New Physician has asked several premed advisers for their insight into the admissions process.


BESIDES MCAT SCORES AND GPAS, ON WHAT ELSE WILL PREMEDS BE JUDGED?


“Medical schools certainly want to know that a student has academic ability, an affinity for science and the foundation necessary to begin medical school studies,” says Carol Baffi-Dugan, Tufts University’s program director for health professions advising and the editor of The Advisor, a journal published by the National Association of Advisors for the Health Professions. “But just as importantly, they want to be sure the student has the experiential foundation and the personal foundation necessary to become a competent, caring physician.”


What is this? “Students need to know for themselves that medicine is the right path, and only then communicate that to medical schools,” she says. “A variety of experiences in health or human service settings can help students develop a sensitivity to and respect for others, an appreciation for the complexities of patient care and public health issues, a commitment to serving competently with integrity, and a sense of responsibility to do things correctly, completely and effectively. I talk to my students about the two parallel paths of preparation to med schools—the academic and the nonacademic. They are equally important.”


Tom Bond, a retired provost of the University of California, San Diego, Revelle College who has advised about 300 premeds during the past 20 years, agrees. “First, it seems to me that most premeds claim they want to become doctors to ‘help others,’ but it is those with a track record of doing so that are more successful…,” he says. “A second weakness occurs when premeds simply don’t know a lot about the current status of health care in this country. Such applicants are often idealistic, but out of touch with reality.”


WHAT CAN LIBERAL PREMEDS DO TO INCREASE THEIR CHANCES?


“For this person, the MCAT scores make all the difference in the world,” says Angela Frey, an assistant professor of biology and a premed adviser at Alverno College. “If a science person scores average on the physical science part of the MCAT, the admissions committee may look at their individual grades in the courses. Unfortunately, the liberal arts major does not have that opportunity.”


Baffi-Dugan doesn’t advise nonscience majors too differently from other premeds. “If the student has an interest in getting a bit stronger background or he/she had a slow start in his/her sciences, I do advise additional course work, usually in biology courses such as genetics, physiology, cell biology, molecular biology or biochemistry,” she says. “With strong basic science credentials, though, a nonscience major has an equal chance of admission, in my experience.”


Barbara Huntington, the director of San Diego State University’s preprofessional health advising office, agrees. “Take some upper division science [courses] and do well. In most cases, [nonscience majors] have an equal chance or better, as they tend to do better on the MCAT verbal and sometimes the science.”


WHAT ELSE SHOULD PREMEDS DO TO PREPARE THEMSELVES?


“Above all, demonstrate a genuine interest in helping others,” Bond says. “This is more than simply four hours a week for 10 weeks volunteering in a hospital. It should be something the student really loves to do and…not something for a résumé.”


“I encourage students to engage in three things; these can overlap,” Baffi-Dugan says. “A student must gain some experience in the health field—this is more for the student than the admissions officer. How can a student make such a monumental decision without having some objective contact with healers…and patients, and judging how they see themselves in this setting?


“I also urge a student to pursue some interest or activity outside the classroom to develop leadership, organizational and communication skills.


“Lastly, I encourage all students to perform some service during their college years.”
Huntington recommends getting clinical experience by becoming a certified emergency medical technician, among many other health profession options. “[Also], become a leader for a service activity or club; get to know [professionals]; for certain schools, do research; [and] know the issues in medicine,” she says.


DESCRIBE A STRONG APPLICANT:


“The great danger in any answer to this …is the implication that there is a formula,” Baffi-Dugan says. “There is not.”


Bond offers a starting point, at least from his familiarity with California schools: “In my experience, grades and test scores come first—lots of students who might become caring, competent physicians won’t make it…because their GPAs are low—below a 3.3—or test scores [are], say, less than a total of 29 to 30. Such students, if really committed, may need to consider other careers or other routes to an M.D. [like off-shore schools]….


“So a strong applicant first is intelligent…and a person who has shown they can handle a tough curriculum. Then, they should be a person with good communication skills and some proven commitment to helping others. [Also], maturity counts a lot, especially in the interview phase,” he says.


And having a perfect GPA doesn’t make one a perfect applicant, Frey says. “Good grades and MCAT scores [are important]…, but not all 4.0 students make good doctors or should be medical students. They must demonstrate that they have an idea what the health field is really like…and [that] they can be understanding to those in need.”


WHEN SHOULD PREMEDS SUBMIT THEIR APPLICATIONS?


“The first day possible,” Huntington says.
“The minute the [American Medical College Application Service] window opens,” Frey says.


Bond believes this is controversial. “Some of the rip-off MCAT prep courses give the impression that if your application isn’t submitted June 1, you are out of it. Not so, in my experience, but July 15 seems like a good target. April MCAT scores are available. Students who plan to submit August MCAT scores with their application are at a disadvantage, unless there are some special factors involved,” he says.


Baffi-Dugan recommends a similar timeline. “Students should definitely submit their applications…by mid-summer, regardless of whether they are taking the April or August MCAT of that year. Anyone who has worked so hard for years to prepare herself for medical school should take advantage of the plus of being an early applicant.”


SHOULD OFF-SHORE SCHOOLS BE CONSIDERED?


Bond says this is a difficult question to answer but offers this advice: “When students with relatively weak records tell me they really want to be a doctor, but then say they won’t consider an off-shore medical school, I sometimes question that commitment.”


Baffi-Dugan agrees that premeds should keep their options open. “In my view, all students should consider all options and all careers,” she says.
And while Frey says international medical graduates desiring to practice medicine in the United States may face more challenges than U.S. graduates, “If they are at the top of their class in the off-shore medical school and can get a good residency, it may pay off.”


ANY ADVICE FOR OLDER PREMEDS?


“I have run a postbac program for 15 years, and I find that older applicants are judged on the same basic criteria as traditional applicants,” Baffi-Dugan says. “Perhaps it is more important for the older applicant to explain his/her motivation for medicine given their circuitous route, but they need to demonstrate the same foundation…as the traditional applicant.”


“Age discrimination,” Bond says, “is, of course, illegal, and the med schools… don’t need to be reminded. But they are looking at what kind of a physician they will graduate and how much that person will be able to give back.”


Frey says some schools may inquire about an older applicant’s personal life. “Unfortunately, asking these types of questions is probably not legal, but, honestly, they are still asked. Some admissions committee members are probably truly concerned for someone’s future,” she says. “In this case, someone with children or a spouse needs to demonstrate that they have a strong support system. A single, no-kids, older applicant needs to demonstrate why a change of career now and that this is not some midlife-crisis, flash-in-the-pan thing that will soon pass.”


SHOULD PREMEDS WHO ARE GAY OR LESBIAN COME OUT DURING THE APPLICATION PROCESS?


“If a student’s sexual preference has had a significant impact on some life experience, career decision, leadership on campus, etc., then it seems reasonable to discuss it as part of the application,” Baffi-Dugan says. “If not, it is no more critical or relevant than mentioning that you are heterosexual.”


Other advisers agree. “It should be like any other piece of information in the personal statement—only write about what has influenced their career choice,” Frey says.


Bond recommends coming out in an application, or admitting strong political or religious preferences, only if it’s essential that the school know this. “I always recommend telling the truth. I wouldn’t make a big deal out of it, but if something is important to an applicant, they would not be happy at a school where that might be a problem—just as applicants who are strongly pro-choice might not be happy at a school where that might be a problem.”


In fact, advisers tell premeds to be honest about anything that has significantly affected their decisions to enter medicine. “If their strong beliefs had an impact on their career choice or what kind of physician they will be, then yes, [mention it],” Frey says.


DESCRIBE SOME COMMON MISTAKES:


“Sounding arrogant in an essay, applying with an extremely low MCAT or GPA, calling too often and driving admissions officers crazy” are behaviors Huntington recommends against. Another is not beginning the process soon enough, whether that be contacting a premed adviser or applying to medical school.


Bond says some premeds aren’t careful with all their applications. “People spend hours on the primary, get outside people to proof it and comment on it, and then crank out secondaries without a second thought.


“Another mistake is trying to project yourself as something you are not…,” he says. “When the application, letters of [recommendation] and interview don’t all reflect the same person, an acceptance is rare.”


On a scale of 1 to 10 (10 being the most), how subjective is the admissions process?
“I would say a 5, and thank goodness,” Baffi-Dugan says. “Of course, you want some relatively firm criteria for admitting students, but you also want experienced admissions individuals to make judgments based on less tangible factors in the application.”


Bond says a 6.5. “It’s a little more subjective than some applicants would like…. [But] if it were purely objective, I think MCAT scores and GPAs would be the only factors used, and that would be a disaster.”


Huntington agrees. “7—MCATs and GPAs are big, but, thankfully, many admissions officers look at the whole person.”
Frey points premeds to schools’ admissions policies. “It depends on the school…. If the school is a 1 and looks only at the numbers…, a student with great numbers and not-so-great interview skills or experience should apply there. If the school is a 10 and looks at other important qualities like service and experience, a student who has more experience but less punch in the numbers should apply there. I advise students to contact the admissions officer at the school to find their criteria for admissions.”


IF YOU COULD GIVE ONLY ONE PIECE OF ADVICE, WHAT WOULD IT BE?


“Stick with your dream, but put your money where your mouth is—i.e., be willing to work hard to get there, not just talk about how much you want it,” Baffi-Dugan says.


And start sooner, rather than later. “Be prepared and get your information early,” Frey says.
Bond advises to “be sure you know what the profession is like, and be sure you know what is involved in getting an M.D.”


And finally, Huntington offers: “Be sure you really care about healing. If you do, you will do everything you need to do to be a good candidate while preparing yourself as a caring human being.”
~~~~Rebecca Sernett is editor of The New Physician. Direct comments about this “PremedRx” to tnp@ amsa.org.~Career Development,Premedical Education~
115~6September~2004-53~Perspectives~Getting Past Rejection~PURSUING MEDICINE FOR THE RIGHT REASONS~Sachin Bansal~~Six years ago, my high school guidance counselor asked me what I wanted to do when I grew up. I still recall my automatic response: “I want to be a brain surgeon.”


And why not? At the time, I was first in my class, the star of the tennis squad and involved in more extracurricular activities than I could list—medicine just seemed the appropriate career. The sky was the limit, and the word “settle” did not exist in my vocabulary.


Fast-forward four years. By the time I was a junior at a top-10 university, I had formulated a series of what I thought were valid reasons why medicine was perfect for me: It is challenging, emotionally rewarding, beneficial to society and an incredibly respected profession. The next step was to take the Medical College Admission Test (MCAT), and despite its difficulty, I left the testing room confident that I performed well enough that, with my solid grade-point average (GPA), I would gain admission to a top medical program. I recognized the challenge in doing so and, therefore, attempted to pave a similar path to the one I followed in high school. I strove to stay one step ahead of my competition in several areas, including academics and extracurricular activities, and developed close relationships with professors and research colleagues.


Then came the reality check: My lofty MCAT score and an honors-level GPA earned me three acceptance letters, two spots on wait lists and two rejections. Throughout the application process, I recall being told, “If you receive only one acceptance, it is a reason to celebrate.”


Despite that advice and the praise I received for gaining admission to a number of schools, I was bewildered. What exactly happened? More importantly, what did I do wrong? Would these rejections from some of the nation’s most prestigious medical programs impact my future accomplishments? Was it worth waiting another year to reapply and perhaps gain acceptance to what I considered to be a top university? These questions persisted for the next several months while I wrestled with my decision.


Fast-forward one more year. Having taken one of the acceptance offers, I am now in gross anatomy class. I look around the laboratory and see a vast array of expressions. Some individuals display sad, worn faces while lamenting their rejections from their top-choice programs, and others realize that medicine was not the right career for them.


Fortunately, for myself, the experience has been an awakening. I am excited to learn about the human body. I realize that my decisions of the previous years were perhaps driven more by the prestige of a particular school or this profession than by true career goals. My true passion to become a physician, which is now taking shape, had been long overwhelmed by my desire to outdo the rest of the competition.


So, this story has a positive ending. Despite my flawed reasoning and bias toward conventional thinking, I find that fate led me in the right direction after all. In anatomy class, I become engrossed in dissections and study. The importance of such factors as the prestige of my school, my potential income, even the two letters that will someday follow my name quickly fade. Each day I enter the lab to learn from human beings who have given their most cherished possessions—their bodies—so that I may enhance my knowledge of human anatomy and one day apply that knowledge to ill patients. The honor to learn from these individuals far outweighs any prestige that an institution could ever bestow upon its students.


Each and every day, I realize that the decision of what medical school to attend was not nearly as important as the decision to enter medicine in the first place. Perhaps the rejections from my top-choice schools were actually subtle blessings because attending one of them may have simply perpetuated my previous sentiments. Nonetheless, in the first few months of school, I learned to displace my competitive attitude in favor of learning for the sake of learning. I read with the intention of understanding; I listen with the intention of hearing; and I work hard to become a better physician—not to be at the top of my class. I find the prospect of being an average medical student on paper and an excellent physician vastly more appealing than being an extraordinarily competitive, top-tier student and a mediocre physician.


There are hundreds of thousands of applicants to about 16,500 first-year U.S. medical school slots each year. Many will be rejected by all their schools, and others will be admitted, but not to their first choice. I hope that my personal experience influences just one of these fortunate individuals to appreciate his situation instead of questioning his success as I once did. An acceptance to any medical college is a door through which we may accomplish our dreams.


So when you do receive that coveted letter of acceptance, rejoice. Rejoice in the fact that you are able to dedicate your life to healing others and, in doing so, improve the health of society. For those of us already in medical school, we should appreciate our situations, whatever they may be. We should all be proud of ourselves for accomplishing such major feats, and we should help one another in the long, arduous and delightful journey that is medical school.
~~~~Sachin Bansal is a second-year at Saint Louis University School of Medicine.~Premedical Education~
116~6September~2004-53~Feature~Global Lessons~INTERNATIONAL ROTATIONS AND ELECTIVES CAN OFFER A WEALTH OF EDUCATIONAL EXPERIENCES.~Scott T. Shepherd~~On the first day in her new hospital, fourth-year Alexia Moutsatsos walked onto her floor and saw medical students and residents rushing from place to place. Unsure why they were behaving this way, Moutsatsos went about her business and waited to begin rounds as she had always done. “I enjoyed a cup of frappé, thinking, ‘This is going to be so easy.’ I went up to the nurse asking for some labs, and she looked at me like I was crazy,” she says.


After muttering something under her breath, the nurse stormed off to deliver medications to her numerous patients. Bewildered by the reaction, Moutsatsos tracked down her resident for an explanation. The resident’s response was simple: “Here we draw blood, run it to the lab, and do anything else like EKGs, vitals, suctioning, write a note…. Have you done anything this morning? Well, what do you do in the U.S.?”


It wasn’t exactly how Moutsatsos, a soon-to-be graduate of Georgetown University School of Medicine, wanted to start her international elective at Athens Laiko Hospital in Greece. Nonetheless, it was the beginning of an unforgettable educational experience. And she learned lesson No. 1 well: “An international rotation is not meant to be a vacation,” she says.


Of course, that is exactly what some future physicians hope for from an international rotation, casually going on some rounds while making plans for the next sightseeing trip. Meanwhile, for some naïve first- and second-years, an international medical experience may instead conjure up visions of exotic locales with themselves acting as “super-physicians,” providing care to desperate and ever-grateful locals.


None of this is the reality, though. Not for most medical students, anyway. International rotations and electives are as diverse as the nations of the world, and offer lessons more valuable than any sightseeing trip could possibly provide.


THE POWER OF PERSISTENCE


One of those lessons is the value of hard work and persistence. And learning this often begins long before students enter foreign lands, as Dr. Daniel Park, an internal medicine intern at the University of Alabama-Birmingham, discovered while planning his overseas experience.


The then University of North Carolina (UNC) at Chapel Hill School of Medicine third-year had set his sights on Angola, a country that has been torn apart by civil unrest for most of the past three decades. Inspired by an Angolan family he met before medical school, Park was so determined to do a rotation there that, even if he had to take a year off and received no academic credit for it, he would do it. “My career goal entering medical school was to do international relief work. Going to Angola was a way for me to have an international experience in a war-torn country so that I could see what this type of work was really like, to test myself and see if I could handle the challenges of working under difficult circumstances,” he says.


UNC provided some financial assistance for his travel, but he says he was left to his own devices for figuring out how to get there.


“There were not many organizations willing to have a med student volunteer, mostly because it was an unstable environment [with tremendous] risks and costs of taking on volunteers,” he says. “I e-mailed and wrote many letters to all the [nongovernmental organizations (NGOs)] and individuals, churches, etc., that I could find on the Internet and through personal contacts before finally contacting Catholic Relief Services, who directed me to a Catholic mission hospital that agreed to have me come. They had never done this before, and it was not easy to get the documents done to get a work visa. It took a lot of perseverance and rejections before I finally got lucky.”


“Luck” led Park into Angola blindly. “I had no direct contact with the sisters [who run the mission] because they were isolated, and it was logistically difficult to have communication. So I basically committed without knowing exactly what to expect. Because of this, I had to do things with flexibility, accepting that things would be made up as we went along instead of planned out well,” he says.


Fortunately, Catholic Relief Services helped process his travel documents, provided transportation in Angola and assisted with communicating to friends and relatives back in the United States. It could also get money to him when necessary.


Dr. Daniel Clinchot, the associate dean for clinical education and outreach at Ohio State University (OSU) College of Medicine and Public Health, says students should try to affiliate themselves with an organization established in the foreign country.


“You really have two sets of students. You have a set that…either goes on the Internet or knows of an organization, and that organization has some of the same goals and objectives of the student, and the student links on with that organization…,” he says. “Then you have students, who on their own, will seek out and do some international electives, and really have to consider [all of these logistical issues] and set that up themselves.” The latter, he says, is much more difficult.


For students making their own rotation arrangements, most begin by going online, as Park did. “The biggest advice I could give would be to utilize the Internet and to e-mail relentlessly,” says Cully Wiseman, a second-year at the University of Texas Medical Branch (UTMB) at Galveston. “If you are starting from scratch, pick an area where you are familiar with the language, and start looking on the Internet for NGOs or medical groups that work in the region.”


Using these methods, Wiseman has arranged educational trips for himself in Australia, Guatemala, Peru, Tanzania and South Africa. “[Use the Internet to] find e-mail addresses, physical addresses, phone numbers, and contact these people as much as you can. If you e-mail 50 people, 10 are likely to write you back. If you only contact three people, you aren’t likely to get anywhere.”


And start this planning well in advance. “I think the biggest thing that students don’t usually understand is the time it takes to organize something like this,” Clinchot says. “I mean you don’t just decide you want to do an international elective and go do it.”


Besides finding a rotation and financial support, students need to get immunizations, visas and passports. And the longer a student waits, the more expensive transportation costs can be. “Not only may it take four months just to get a reply, but international plane tickets are much cheaper when purchased far in advance,” says Dr. Jennie Howland, a first-year medicine–pediatrics resident at Tufts University Baystate Medical Center.


As a fourth-year at the University of Massachusetts Medical School, Howland took electives in Nicaragua, Swaziland and Tanzania. It was a stint in Tanzania that posed some of her greatest challenges. “I had started a medical rotation at a remote hospital I had randomly contacted over the Internet. Unfortunately, there were no doctors in practice and a very sporadic patient load,” she says.


Luckily she also met a group of locals in the village of Nyamswa that was creating a community-wide development project. “I could see their main limitations were financial, but when I asked them what they needed, they asked for volunteers and technical assistance as well,” she says. So with some guidance from the International Federation of Medical Students’ Associations (IFMSA), Howland founded the Malaika Project, a student-run organization that not only provides medical rotations in Nyamswa but also coordinates other projects, including agricultural development, sanitary improvements and business promotion. Now, medical students and other future health professionals can go through the Malaika Project to volunteer their time in Nyamswa.


ORGANIZATIONAL BENEFITS


In fact, many wannabe international travelers turn to student organizations for assistance. “Most students go through AMSA, the American Medical Student Association, specifically the branch that is here for the international health interest group,” Clinchot says. “We have a very active international health interest group here, and they have sent students all over, and helped students find funding and make connections with people who are going.”


Dawn Mautner, AMSA’s global health education and opportunities coordinator, says some local AMSA chapters sponsor discussion panels that allow students to hear about classmates’ experiences. Also, chapters are often able to direct future physicians where to look for grant money offered by their medical schools or by community organizations.


On the national level, Mautner says AMSA’s international health Web page (www.amsa.org/global/ih) provides financing tips in “The Creative Funding Guide for International Electives,” an online handbook compiled by AMSA and the International Health Medical Education Consortium (IHMEC). “Funding the trip is often the stickiest part of getting out of the U.S. for many of us as students,” she says. And when debating where to go, students can turn to AMSA’s searchable database of international health opportunities.


Future physicians can also seek assistance from IFMSA, as Howland did. “For students looking for international work or education, IFMSA students can link them with projects, other medical student leaders and information in whatever they may be interested…,” says Jessica Evert, an OSU fourth-year and executive vice president of IFMSA-USA. “For example, IFMSA-Spain coordinates a project at an HIV orphanage and clinic in South Africa [in which] any IFMSA member from around the world can participate. Medical student members of IFMSA-USA run several village projects consisting of clinical and public health endeavors in Ghana and other developing countries.”


In particular, IFMSA can assist those who are financially strapped. “If price is not an issue, arranging an international experience is not that difficult. There are several organizations that can get you abroad if you want to pay several thousand dollars,” Evert says. “IFMSA is unique because their programs are available for minimal cost—i.e., like $100—so they are more accessible to medical students in the U.S. and abroad.”


Students can also organize themselves to share resources and find financial assistance. That’s what Wiseman did when he launched SIGHT—Students Improving Global Health Together— in 2003 at UTMB at Galveston. “SIGHT started on the back of some neuroscience notes I was working on last spring. I had had the idea in the back of my mind for a long time, but started writing them down on a piece of paper when I should have been studying brain lesions,” he says.


What may have seemed like procrastination turned out to be much more after Wiseman sent an e-mail to classmates, who he says made the idea a reality. Now, SIGHT has more than 100 members, who hold regular meetings to share their international experiences. They also recently compiled a guide for overseas educational opportunities. And SIGHT was even able to convince Dr. Stanley Lemon, the dean of the UTMB medical school, to provide $10,000 annually to the organization for financial assistance to students doing rotations or research abroad. “We had over 20 students apply for scholarships this year, and awarded scholarships to nine, [who are] going to India, Nicaragua, Togo, South Africa and Bolivia,” Wiseman says.


THE MONEY ISSUE


Not surprisingly, finances are a major concern. AMSA estimates that a six-week elective costs an average of $2,500. And in some cases, students end up paying those expenses with their school loan money.


However, like the scholarships offered by SIGHT, help is available. “Very rarely do students have to pay out of their pocket. The sources of those funds, though, can be varied,” Clinchot says. “Sometimes students will link up with a specific organization…. Other ways students can get financial assistance is grants [through their medical schools], but also the international health interest groups can help students raise funding, be that through local philanthropic organizations or groups that have an interest in a specific component of health care in the region where the student wants to go.”


AMSA’s and the IHMEC’s “Creative Funding Guide for International Electives” directs students to investigate sources ranging from the Christian Medical and Dental Associations to the Academy for Educational Development to the Rotary Foundation. In particular, it suggests future physicians may want to seek financial support from religious groups. “Many religious organizations are becoming more active in their support of service-related projects with an international focus,” the guidebook says.


Similarly, Howland advises students not to avoid an organization or missionary service just because it may conflict with their religious views. “If you are not religious, don’t shy away from mission hospitals. Missions often provide the majority, if not the highest quality, of health care in many countries, and their mission is to serve impoverished people, not necessarily to evangelize,” she says.


And depending on where the medical student wants to go, a religious organization may provide the best avenue to get there, as was the case for Park working with Catholic Relief Services for his Angola elective.


WHERE TO GO?


How does one decide where to do a rotation or elective? “You need to be motivated and interested. But there are a number of issues to be concerned with,” says IHMEC president, Dr. Andre-Jacques Neusy, who’s also the director of the Center of Global Health at New York University School of Medicine.


First off, if a student hopes to receive academic credit for the rotation, he’ll want to meet with the medical school’s office of international education—or the equivalent—to determine if it’s available for the desired rotation. Many administrators are willing to cooperate, as is the case at OSU, which recognizes international rotations as fulfilling students’ community project requirements. However, schools may not recognize rotations in certain countries. For example, OSU does not recognize rotations in Cuba or other countries under U.S. embargo. “Those countries we try to discourage students from going there for their own personal safety,” Clinchot says.


Of course, safety and health are concerns for anyone planning an international rotation. “Take care of your personal health, and go in with a realistic understanding of risks involved,” Park says. (See “Health and Safety Abroad,” p. 30.)


Language should also be considered. “I highly recommend going to a country where you have some basic communicatory skills in the native language,” Moutsatsos says. “I spoke solely in Greek. Though [I struggled] with unfamiliar medical terms, they respected the fact that I tried my best at being ‘Greek’ and was volunteering my time in the country of my ancestors.”


However, other future physicians say language barriers can be overcome if translation services are available. “At Raleigh Fitkin Memorial Hospital in Swaziland, none of the doctors spoke the local language,” Howland says, “but the translation worked well in the clinical setting, and I learned more in my three months there than I had in my entire first three years of medical school.”


Clinchot says students can also arrange for a translator, in a sense. “For example, we had a student this past summer who went to India, and he did not speak the native language. So he made plans with one of the other students who did, and they both went on the experience, and one was able to be translator for the other. So it worked out well,” he says. “But students definitely need to [consider language barriers]. I mean, it’s very difficult to communicate, especially medical issues, to a population that doesn’t necessarily understand medical terminology when you are not speaking in their native tongue.”


LESSONS TO BE LEARNED


While language, safety, cost and academic credit are essential considerations, so, too, are the location’s educational benefits. “I think the most important thing is finding a place where you’ll get the sort of training you are looking for,” Howland says.


Clinically, students are sure to see conditions they would almost never see in the United States, particularly if their rotations are in developing nations. “[T]hey get exposed to illnesses and disease processes that are preventable and rarer in the United States,” Clinchot says, “and they learn how simple measures of infection containment can make a big difference in different communities.”


However, Neusy believes future physicians should investigate opportunities that will directly benefit their medical practices in the United States. “In my view, the main focus should be to go to countries that are really relevant to your immigrant communities. So if you are going to see patients from Bangladesh or from West Africa in the place where you [are practicing medicine] here in the States…, then we think there is a benefit in going to those places,” he says.


Nevertheless, Clinchot and Neusy agree that future physicians have a great deal to learn simply by seeing how health care is delivered in other parts of the world. “It is very important for students when they go to the field to really be in these countries and be sensitive to these cultures, to the way people view health, to understand this is not a North American-centric model that they have to bring there, and they really have to be open to those experiences,” Neusy says. “And ultimately it will make them better physicians. It is not only to look at exotic pathologies—which they will find and that they will actually find back in the States when people come here—but it is more important to see that the health model that people have differ….


“They will come back here certainly more enriched by the experience, and I am certain they will actually be better clinicians.”
One way to encourage this is for students to immerse themselves in the culture. “Once in a foreign environment, being open and making friends with the people around you, especially the local people, is the key to having a good overall experience,” Howland says. “They can also teach you about the language and culture, and share a different view of the world that can challenge your assumptions. They can take you places that might not be in your tour book.”


And Park advises adopting the mindset of a visitor. “Understand that you are there as a guest and be grateful for the opportunity. You are receiving more than you give,” he says.


If future physicians are willing to receive these valuable lessons, the gifts of the overseas elective or rotation could have lasting effects. “International experiences have been the most life-transforming periods of my life,” Howland says. “I would highly recommend to everyone to take advantage of the opportunity you have to provide some service, experience a different way of life and change your way of perceiving the world forever.


“Even if you have to use your own loan money, $1,000 to $2,000 is a small price to pay in the grand scheme of your medical education for a learning experience, which will last a lifetime and from which you will continue to learn for years to come.”
~HEALTH AND SAFETY ABROAD


It’s in the headlines every day. Political instability, terrorism and disease outbreaks have touched practically every place on the planet, particularly areas that altruistic medical students may be considering for rotations. So it’s natural to feel apprehensive.


“Being an American citizen, I was a little leery going abroad post-9/11 with the general anti-American sentiment permeating throughout Europe. Would I be treated well?” Alexia Moutsatsos, a fourth-year at Georgetown University School of Medicine, remembers thinking before her rotation in Athens, Greece.


Despite her fears, Moutsatsos was greeted warmly, and this is the case for most medical students conducting international rotations. However, it’s good to be cautious.


“I really don’t think they consider enough the risks to their personal safety,” says Dr. Daniel Clinchot, the associate dean for clinical education and outreach at Ohio State University College of Medicine and Public Health. “Specifically, if they really follow the State Department travel warning and public announcements…, they can learn relatively quickly if the region in which they are going has developed some social unrest and if there’s violence.…”


Clinchot also advises students to take into account potential health risks. “Many times students don’t consider that they could potentially become sick and what it would cost to have health care delivered to them in that country or if they wanted to be evacuated out—it is very, very costly,” he says. The matter becomes even more complicated by the fact that many health insurance policies do not cover students traveling abroad.


And before leaving the United States, it’s crucial for students to get the necessary vaccinations, as recommended by the Centers for Disease Control and Prevention. Dr. Daniel Park learned this lesson while volunteering in Angola when he was a third-year at the University of North Carolina at Chapel Hill School of Medicine. “I started taking malaria prophylaxis but stopped due to side effects and ended up with malaria three times. It was terrible, and I will be extremely cautious about mosquito repellent and malaria prophylaxis next time,” says Park, who is now an internal medicine intern at the University of Alabama-Birmingham.


Simply put, future physicians studying in foreign lands need to look out for their own health, as well as their patients’. “A lot of time, students are looking at what the public health and disease are in a certain country, and they don’t really consider self-safety,” Clinchot says. —S.T.S.


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


RESOURCE BOX


From travel advisories to finding financial support, these organizations offer online resources to help you start planning your international rotation or elective:

~~~Scott T. Shepherd is an associate editor with The New Physician. Direct comments about this article to tnp@amsa.org.~International Health~
117~6September~2004-53~Letter from Afield~No Subscription Required~~Howard Bell~~With the introduction of a new, free online peer-reviewed medical journal this fall, the controversial open-access publishing movement continues to grow.


Imagine having free, online access to the most prestigious medical journals. No subscriptions. No pay-per-view fees. No trips to the library. Keep dreaming. It’s starting to happen, but old habits in journal publishing are hard to break, which is why the 5-year-old open-access publishing movement might transform how peer-reviewed medical journals are published—or it might not.


Open-access journals—whose subject matter runs the gamut from bioinformatics to dermatology, from international health and human rights to pathology, from evolutionary biology to women’s health—break the centuries-old tradition of the “reader pays” model of publishing. Instead, it employs the “author pays” model, charging authors a fee that funds the peer-review, editing and electronic publication processes, and promises faster, cheaper and more widespread information sharing.


And similar to the beginning stages of any communications medium, open access is seen by some as experimental. Can it sustain itself financially and still maintain scientific quality?


Medical societies tend to be leery of it, including the American Medical Association (AMA), publisher of the Journal of the American Medical Association (JAMA), and the Massachusetts Medical Society, which produces the New England Journal of Medicine (NEJM). Skeptical, too, are the big commercial journal publishers like John Wiley & Sons Inc. and Reed Elsevier.


Meanwhile, young, just-getting-started physicians and scientists eager to publish their research like open access’ benefits but worry that having their papers appear in such unproven publications might lessen their chances for tenure, promotion and recognition.


IT BEGAN OVERSEAS


London-based, for-profit BioMed Central is the biggest open-access publisher of peer-reviewed scientific journals. It set up shop in 1999, making BioMed the first to dip its toes in the new publishing waters. Anyone can freely read, download, print and reuse the original research papers in its 100-plus publications.


For many of its journals, BioMed charges authors $525 for every original research article accepted for publication. Advertising helps pay publishing expenses, as do institutional memberships. If an author is affiliated with one of its 425 institutional members, the fee is waived. For example, the entire University of California system is a member of BioMed, so all of its researchers can publish in its journals at no extra cost.


Though smaller and newer, the nonprofit Public Library of Science (PLoS) is perhaps the best-known open-access publisher, because of its outspoken efforts to promote subscription-free publishing. PLoS was created in 2000 by three science heavy-hitters: Dr. Harold Varmus, a Nobel laureate for his research on cancer viruses, a former director of the National Institutes of Health (NIH) and the CEO and president of the Memorial Sloan-Kettering Cancer Center in New York; Dr. Patrick Brown, a Stanford University School of Medicine professor and genomics expert; and Michael Eisen, Ph.D., a computational and evolutionary biologist at the University of California, Berkeley.


Frustrated by the subscription barriers to the latest clinical information, the three scientists circulated an open letter in 2000 requesting scientific journal publishers make their content free online no later than six months after publication. Thirty thousand scientists signed onto the call and agreed to publish only in journals that complied. Their demand was greeted by silence. Most journals refused to change, and most of the scientists who signed the letter continue to publish in traditional subscription journals.


Refusing to give up, Varmus, Brown and Eisen expanded PLoS’ mission, transforming it into an open-access publishing house. According to the organization’s Web site, the scientists hoped “to catalyze a revolution in scientific publishing.” Their first journal—PLoS Biology—was launched in the fall of 2003 and competes against such prestigious journals as Nature and Science. This fall, they launch PLoS Medicine, which will compete against such top-tier tomes as the NEJM and JAMA. Authors pay $1,500 to publish their articles in PLoS journals. Acceptance rates for both so far hover a little above 20 percent, which is more than double the 10 percent rate for the NEJM and 8 percent for JAMA.


Supporters say open access is the ethical approach to take. Most biomedical research is largely funded by the approximately $50 billion per year granted through such government agencies as the NIH. “Taxpayers have already paid for it,” Varmus says. “It’s wrong to make us pay for it again with subscriptions.”


The PLoS co-founder believes such research should have the widest readership possible—thereby speeding scientific advances. The SARS virus genome, he points out, was sequenced in a short seven days, thanks partly to open sharing of data and results, something that’s not as easy when research is locked behind subscription-only barriers.


Unlike most traditional publishers, open-access journals generally let authors keep the copyrights to their articles—another often-cited advantage. Retaining the copyright means medical school faculty can freely share their papers with colleagues, journal clubs and students. They can post them on their Web sites and make photocopies without having to get permission from a publisher. Such articles can also be incorporated into databases and used in many ways, as long as the author is given proper attribution.


PLoS sees its primary targets as the thousands of peer-reviewed medical journals published by big, commercial publishing houses like Wiley and Elsevier. These two companies publish most of the 50,000 to 60,000 peer-reviewed research articles written each year. Reed Elsevier is perhaps the biggest—publishing around 1,700 science, technology and medicine journals that generate a 30 percent net profit, according to the Wall Street Journal.


These publishers are also the favorite targets of university librarians and some researchers, who believe they monopolize the medical publishing industry and are, therefore, able to keep raising journal prices to sustain high profit margins.


As the biggest subscribers of biomedical journals, libraries could benefit the most financially should open access take off. Right now, they have to dig ever deeper into their pockets to pay for rising subscription costs. Journal prices in all scholarly fields have increased 210 percent between 1986 and 2001, according to the Association of Research Libraries (ARL). During the same time, faculty salaries have risen only 68 percent and the cost-of-living index only 62 percent.


Take the University of Minnesota (UM) Bio-Medical Library, for example. “In the past 10 years, we’ve cancelled 40 percent of our peer-reviewed journal subscriptions,” says UM reference librarian Kathy Robbins. “Our costs have stayed the same despite the cuts, because subscription costs for the journals we still get keep going up.” Subscription fees for libraries range between several hundred to several thousand dollars per year. Robbins says Minnesota’s subscription costs have risen 10 percent per year for the past 10 years.


UM’s story is repeated at every university biomedical library nationwide. The result: Between 1986 and 2001, libraries spent three times more on journals, but subscribed to 5 percent fewer titles, according to the ARL. During the same time, libraries needed to reduce their book purchases by 9 percent to offset the costs.


Meanwhile, more and more subscription journals are being published, resulting in steadily declining access to the body of biomedical research, Varmus argues. The “knowledge pipeline,” as he calls it, has production and distribution ends. “The distribution end of the pipeline powers the system, but it’s constricted by cost and access barriers,” he says.
Why, then, aren’t all researchers and publishers running to embrace it?


CAUTION: VESTED INTERESTS AT WORK


Open access threatens the status quo. Medical societies that publish journals rely on subscription revenues to not only cover production expenses—printing on paper costs much more than posting articles online—but also to help pay for scientific meetings, scholarships and staff salaries. The open-access model could hurt their organizations financially, and some might perish if they don’t publish the traditional way.


For the big houses like Wiley and Elsevier, open access endangers their profits. And if the subscription model has proven profitable, why change? Besides, they argue, most of their researchers are not demanding change. “We certainly haven’t heard an outcry from our editors to move to an open-access model,” says Eric Swanson, Wiley’s senior vice president of scientific, technology and medical publications. “Nor have we seen a decrease in submissions.”


Then there’s the fairness argument. Critics of open access say it’s not fair to make accepted authors pay the costs of reviewing and editing rejected articles, too. And what about small universities, independent researchers and those in developing countries who can’t afford the author fee? That lessens their access, critics say.


Not to worry, counters PLoS. If someone can’t afford the author fee, PLoS waives it. BioMed does, too. As for picking up the tab for processing rejected articles, PLoS says that $1,500 is a modest amount compared to the tens of thousands of dollars granted to fund the research.


Quality is another concern, traditional publishers and some researchers argue. Subscriptions pay for the peer review and technical editing necessary to produce a top-notch journal. Is a $1,500 author fee enough to cover these costs and still produce a high-quality publication? No, says JAMA’s editor-in-chief, Dr. Catherine DeAngelis. In a January 2004 JAMA editorial, she asserts that top-tier journals like JAMA and the NEJM would have an especially difficult time making ends meet should they switch to an author-pays model. When only 8 percent to 10 percent of submissions are accepted, where would the money come from to review and process the thousands of submissions that don’t get published?


“For us to jump on the open-access bandwagon would be extremely risky and irresponsible,” says Dr. Greg Curfman, executive editor of the NEJM. “We have a 200-year-old journal that plays an important role in medicine. We believe in our model. It’s been very well tested over time. A sophisticated review process is labor intensive and requires substantial resources we feel are best obtained through reader-pays subscriptions. We have real concerns about whether the open-access model would support our process.”


Still, Curfman, like other journal editors, welcomes the open-access model to the table—with some conditions. It may be appropriate for publishing the results of basic research, he says, but perhaps not for clinical medicine. “There’s no room for error [in clinical medicine]. People’s health and well-being may be at stake. You have to be scrutinizing,” he says.


DeAngelis worries that the need to generate revenue through author fees might motivate an open-access journal to publish more papers—perhaps of a lower quality—to remain profitable.


Varmus and other open-access supporters bristle at this suggestion. All peer-reviewed journals, they say, want to maintain quality, none more so than journals trying to prove themselves. “If we don’t maintain the quality,” he says, “we won’t attract established authors and readers.”


PLoS founders say theirs is the best model for peer-reviewed publishing, but they have not yet shown it can pay for itself long-term. Neither PLoS nor BioMed have broken even, which takes traditional journals about five to seven years to accomplish. Meanwhile, the British Medical Journal (BMJ), the first top-tier medical journal to adopt an open-access practice by offering its content free online, backed off from its 1995 venture, saying it will charge subscriptions for online access starting in January 2005. BMJ cites the need to maintain a source of revenue that would sustain its high-quality publishing practices.


Varmus admits it’s too early to tell if $1,500 author fees will be enough to sustain PLoS journals. For now, PLoS stays financially afloat primarily with a $9 million private foundation grant that expires in 2007. After that, Varmus says he hopes to obtain more grant money. PLoS will also rely on advertisements, just like a subscription journal. And it offers subscriptions for the print versions of the journals, generating some revenue that way. By 2007, PLoS wants to be publishing 50 to 100 specialty biomedical journals, all of them bringing in author fees. Varmus says PLoS is also counting on expanding its list of 85 institutional members.


The open-access publisher likens this revenue mix to public radio, but the NEJM’s Curfman thinks relying on private funding sources is risky. “Funding sources come and go,” Curfman says. “Some have an agenda or an ax to grind. Editors need to be free.”


CRITICAL MASS


To be financially sustainable, open-access journals must attract enough established authors to generate a critical mass of readers. Varmus says PLoS’ biggest challenge is convincing established researchers to “come on in—the water’s fine.” The problem: Researchers want the prestige, tenure and promotions that come with publishing in high-profile subscription journals.


Generating a critical mass to legitimize open access is well underway, according to Varmus. “A lot of prominent researchers are already published in open-access journals, including people who admit they never thought they would,” he says, and adds that PLoS submissions continue to increase in number and quality. Submissions to BioMed Central have risen as well, tripling since PLoS began banging the open-access drum.


As open-access journals attract more top-tier authors, prestige and awareness will come as well, supporters say. Other researchers and the media will cite the journals, further generating a growing snowball of interest. As this happens, libraries can cancel more journal subscriptions, and in order to compete, traditional journals may make more of their content free.


Dr. David Levitt believes in open access. The UM biomedical researcher has published more than 100 peer-reviewed articles during the past 40 years, mostly in traditional subscription publications. Now he prefers open-access journals, publishing six articles with BioMed in the past two years.


“Free distribution of scientific publications to everyone with access to the Internet, including the Third World, has to rank as one of the most important advances in the history of science,” he says. Levitt also likes how open access eliminates limitations on a manuscript’s length, and number and color of figures. “Removing these limits is a great help in describing results and making the article more readable.”


In response to critics who charge the journals publish lower-quality papers: “The manuscript review process is among the most thorough and careful of any that I have received,” he says.


Open-access publishers must also convince young biomedical researchers that open access can help, rather than hurt, their careers. Prominent researchers like Varmus and Levitt could publish on paper towels and still be read. Not true for young researchers trying to get tenures, promotions or build reputations in their fields. Even Varmus sometimes publishes in traditional subscription journals, “for the sake of the careers of my trainees,” he says.


With each accepted article, PLoS provides a signed endorsement explaining the importance of the published work and how it satisfies rigorous criteria for publication. “The letter can be used to support grant and job applications,” Varmus says.


Another part of building a critical mass is convincing subscription journals to switch to open access. That’s unlikely to happen with big commercial publishers, but Varmus hopes nonprofit medical society publications will take a different view. To encourage this, PLoS provides business planning and technical expertise to any journal interested in converting to open access. Declining to name names, Varmus says, “We’ve had quite a few journals declare their interest, including one especially prominent British journal.”


Another way to create a critical mass is to include money to pay author fees in research grants. “You have to consider publication as the final step in the research process,” Varmus says. For example, the Howard Hughes Medical Institute in Chevy Chase, Maryland, pays the open-access fees for all its researchers. So does the United Kingdom’s Wellcome Trust, an independent research-funding charity. Open access fees are now built into most research grants in the United Kingdom.


Institutional memberships are another way to streamline author payment. And some universities, according to Varmus, are considering creating funds to pay open-access fees for their researchers. Theoretically, institutional members and government funding agencies could require their researchers to publish in open-access journals.


In fact, Congress’ House Appropriations Committee suggested in a July report that the NIH make the articles of NIH-funded research available for free online no later than six months after publication. The language accompanies its spending recommendations for the Departments of Labor, Education, and Health and Human Services and is not part of the appropriations bill, on which the House had yet to vote when it had adjourned for the summer. Committee staffers say they doubt the suggestion will make it into the final bill.


Getting more universities to pick up the open-access ball and run with it is not going to be a slam-dunk either. Doubts lurk as to whether open access would really save them money. “Research-intensive institutions are likely to pay more under the open-access model,” says Ann Okerson, a Yale University librarian who researched the matter. To run the numbers, she examined how many journal articles Yale faculty publish in an average year, then assumed a $1,000 fee for each. Yale’s annual subscription journal budget is $4 million. A pure open-access model, at least based on author fees, not institutional memberships, would cost the university $4.4 million.


Duke University reached the same conclusion based on an author fee calculation, according to its librarian Rick Peterson. “The cost just shifts,” he says. “If we were to transition exclusively to open access for the 4,500 articles published each year by Duke authors, the costs would equal or exceed Duke’s current journal budget.”


“We don’t know if open access will save us money,” says UM’s Robbins. “At any rate, traditional journals aren’t going away in the foreseeable future even if the slow increase in open-access journals continues.” That could compound rather than relieve university budget pressures, because open-access journals will be an addition to, rather than a replacement for, traditional journals. Universities will get stuck paying for both.


Some open-access journals may one day be equals to the most prestigious subscription journals, but traditional journals are not going away. Over time, however, open access’ place in publishing will likely grow, especially if young researchers create a demand for it.
~ONLINE RESOURCES


For more information about open-access publishing, check out:


~~~Howard Bell is a contributing editor with The New Physician and lives in Onalaska, Wisconsin. Direct comments about this article to tnp@www.amsa.org.~Medical Education,Medical Research~
119~6September~2004-53~Feature~Planes, Trains, Automobiles and Yaks~~Jennifer Zeigler~~Physicians travel to the remotest corners of the globe to volunteer their services among those who need them most.


The rules for Dr. David Dyck’s annual trip to Guatemala are simple: Pack lightly; bring lots of heartburn and pain medications, plus pediatric vitamins; don’t forget your camera film; don’t drink the water except in the hotel; don’t travel in groups of less than three at night; and whatever you do, don’t even joke about buying drugs while you’re there. That will land you a nice little stay in a Guatemalan jail, where torture is most certainly an option.


An associate professor of family medicine at Kansas City University of Medicine and Bioethics, Dyck has led groups of physicians, nurses, pharmacists, medical students and residents on annual medical mission trips to Guatemala for DOCARE International, an osteopathic organization providing charity health care throughout Central America, for the past four years. For him, and for many physicians like him who travel to the ends of the earth to provide care to those who don’t otherwise have access, the reasons to volunteer his skills are pure, but most have a thread of self-interest in them as well: It’s just plain fun. Docs tired of practicing medicine in the defensive, U.S. style look outside the country for rejuvenation.


It’s like camping—really serious, perched-on-a-mountainside camping in some cases—but with medical instruments. They get to take a little vacation, travel to an exotic place and practice what many call “pure medicine”: no complicated tests or expensive machinery, no forms, no insurance companies, no lawyers, nothing but them and the patient. And maybe they’ll even care for a patient with a disease they’d never see in such an advanced stage in the United States. It’s hard work done with great joy.


MIXING BUSINESS WITH PLEASURE


You know those people you see in camping goods stores? You know the ones. They’re tanned and sinewy, wearing brimmed hats that look as if they’ve been through the bush a few times. They’re wearing sensible, outdoor shoes and pants with more zippers than a suitcase. They know how to keep bears from eating their trail grub and what to do when face-to-face with a cobra.


That’s the image one conjures up of Dr. Sue Abkowitz-Crawford after a few minutes conversing on the phone. She’s actually eaten a cobra heart while it was still beating, just one of many cultural delights she’s experienced while offering her services as an internist to Health Volunteers Overseas (HVO).


A bullet-speed talker, she begins ticking off her biennial trips: three months in Indonesia in 1991 “that was an insane experience, looking back on it”; then two months in Bhutan in 1994 and again in 2000; South Africa in 1996; Vietnam in 1998; and Tanzania in 2002. Plus, she’s just back from Kenya, a trip she took for another group, the International Medical Equipment Collaborative (IMEC). “I’m holding out for Ethiopia or Cambodia with HVO,” she says.


You could say the travel bug has bitten her with an unyielding jaw. “I grew up traveling a lot,” she says, and her orthopedic surgeon husband, Dr. Glen Crawford, earned a Rotary Scholarship after his undergraduate years to study anthropology in Tanzania. The two Stanford University School of Medicine graduates then spent the final months of their fourth-year rotations at the Kilimanjaro Christian Medical Center in Tanzania.


“It was just a great experience because they had so few doctors, so we saw incredible stuff. People came in with lion maulings or tuberculosis. You did what you could,” she says.


HVO now sends Abkowitz-Crawford and her husband—with their three kids in tow—around the world to help educate local medical personnel. The organization’s teaching mission is different from many other overseas charitable medical groups: Instead of focusing on treating as many patients as it can in the areas it operates, HVO attempts to establish a medical infrastructure that will be in place long after HVO volunteers leave the field. So, while Abkowitz-Crawford lectures on such diseases as tuberculosis and HIV, Crawford, armed with his suitcases full of orthopedic plates and pins, performs complicated surgeries to teach local physicians techniques of the trade. In doing so, “we’ve experienced a lot of different systems of care,” which is interesting, she says.


For example, in Bhutan, a tiny Himalayan nation of 1 million people, Crawford would teach orthopedics to the handful of Thailand- and India-educated physicians, while Abkowitz-Crawford, who brought the country’s internist count up to three, would discuss such topics as cardiac disease and typhoid.


And then they would spend their late afternoons and evenings seeing the sights. Bhutan allows only about 2,000 tourists in a year, but as guests of the government, the Crawfords—the kids spend their days in local schools wherever they travel—were treated like royalty. They were allowed to hike unguided, touring mountaintop monasteries as they climbed. They rode yaks and ate yak butter and cheese, took tea with monks and tried in vain to learn Dzongkha, the local language. “We find it wonderful family time,” Abkowitz-Crawford says, lamenting that it usually takes just 24 hours after returning from a trip for the kids to fall back into their harried American lives, shuttling from school to basketball practice to youth group meetings.


With her oldest child now in high school, however, Abkowitz-Crawford says the family doesn’t have a next trip planned yet. But there’s always an opportunity around the corner. Frustrated with insurance companies and paperwork, the internist gave up her Boston-area practice last year to devote more time to IMEC, which solicits donations for medical supplies and sends them to hospitals and health workers in developing nations. “So here I’ve spent all these years traveling and teaching and practicing medicine, and now it’s really great because I’m getting to send over all the stuff…. I know better than anyone what it’s like to practice medicine in a developing country without any stuff.”


And one imagines it won’t be long before the family is traveling together again. “We just love it. Not just because of the sense of fulfillment. It’s a lot more fun than practicing medicine in this country.”


If it’s February, Dyck is getting ready for a two-week trip to see friends and patients in Santa Maria de Jesus, Guatemala. “For me, it’s the opportunity to visit with these people. You make friends with people in that area, and those friendships continue to the next visit. It is also the opportunity to practice medicine for the sake of medicine.”


A group of osteopathic physicians who enjoyed piloting small planes founded DOCARE in 1961. They’d fly into remote areas, set up shop and treat the local population. Today, travel involves everything from commercial flights to bumpy trips on dusty roads in vehicles that might not pass muster in the United States. Volunteers pay their own way, just as they do for HVO, and like that group as well, sometimes trips become family affairs. Dyck has brought his wife and kids along to work in the team’s pharmacy. “We’ll take anyone we can get,” he says.


Santa Maria de Jesus is a poor community about 30 minutes from Antigua, where Dyck’s team stays, but DOCARE did secure a permanent physician to stay in the village and run a small clinic. The family practitioner says the longevity of the volunteer work has become important to his DOCARE service. “Our mission has always been to go to areas that are underserved, but that has evolved over the last decade. We see the value in having services in place,” he says.


But even with the satisfaction of seeing old friends and the year-round help in place, Dyck says the visit is also emotionally draining. “The difficult thing is seeing the level of care they’re getting and knowing there’s so much more out there they just don’t have access to.” The case that stands out the most to him presented at a clinic a few years ago in Mexico. Parents brought in their daughter with an apparent dislocated hip. The DOCARE chiropractor said her hip was perfect. So the volunteer surgeon took a look, and the bulge turned out to be a rare muscle cancer that had spread uncontrollably. “There really wasn’t much that could be done for her, and what struck me was how happy she was with life, and she was so unaware of her situation.”
The rewards, from even these helpless cases, come back tenfold, though. “Someone walks up to you and says, ‘Thank you for coming.… God bless you.’”


Dr. Frederick Roever is trying to get his new acquaintance to join him and other volunteers from Florida-based Medical Mission of Mercy (MMM) on their next trip to Jucuapa, El Salvador. “We’re leaving on the 16th,” he says. “We could arrange for you to come along, and it wouldn’t be that much money.”


His enthusiasm for MMM is infectious, but as enticing as the offer sounds, his acquaintance has to pass. Maybe it’s all the talk of the three armed guards that accompany the group 24/7—Jucuapa is in the mountainous, rebel-controlled region of El Salvador and “guns are everywhere,” he says—or perhaps it’s the luxurious travel accommodations on what Roever calls “TACA airlines.… You know what that stands for? Take a Chance Airlines.” Or maybe it’s the story about the vampire bat that bit his friend in the middle of the night or the one about the outhouses they use during their stay or it could be the cholera the volunteers treat and try not to get themselves.


No, thank you. But thank goodness for people like Roever, a Tarpon Springs, Florida, geriatrician and his daughter, a second-year at Ross University School of Medicine who has been volunteering with MMM since high school and encouraged him to as well. Calling himself a “socially minded old-timer,” Roever explains his frustration with the U.S. health-care system. “What inhibits the delivery of care is the bean counters. You have to have this form or that form…, so what has become important is not the treatment of the patient but the treatment of the chart. It’s no longer fun. So we go to El Salvador, and it becomes fun because we get to treat the patient, and they get well. We’re going to the heart of medicine. It restores my soul.”


The 4,000 patients they treat each trip walk as far as 10 miles through the mountains to see the U.S. physicians who arrive annually in Jucuapa. There are a few local physicians in the area—Roever says the best is actually the leader of the rebel group—and MMM is in the process of raising funds to build a clinic for volunteer organizations and for El Salvadoran medical schools to use. MMM’s presence is “an extension of American foreign policy whether they realize it or not. We’re doing a service to our country, too. This creates an American influence in [El Salvador].”


Although MMM is a relatively small group of volunteers, its effect on the locals is enormous. In 2001, an El Salvadoran congressman nominated it for a Nobel Peace Prize, which helped to increase the organization’s donations and funding.


But even the financial boost can’t help all the patients the team cares for each trip. Roever, who thought he was prepared to see poverty after serving in the Vietnam War, says the paucity of care is shocking sometimes. “It’s absolutely devastating, and as an internist, I rarely cure disease. I can’t cure hypertension. You realize how impotent you are. I just put a Band-Aid on [the problem].”


General surgeon Alan Lefor has paid $1,400 for this excursion to Guatemala and taken a week’s vacation from his position at Cedars-Sinai Medical Center in Los Angeles. But after 13 hours on a bus—six hours of those on dirt roads at 8 miles an hour—one begins to wonder how much of a vacation the trip really is.


For Lefor, though, it’s worth it. “I love medicine, and I love travel, and I wanted to find a way to put the two together,” he says. The group he volunteers with, HELPS International, allows him to take short trips—about nine days—each year and provides him with some opportunities to see the sights.


But at the end of the bus line there will be 300 patients waiting at the front gate of a U.S.-built clinic from the Reagan era. No one but HELPS uses the nine facilities scattered throughout the country’s highlands now, because Lefor says Guatemalan physicians don’t want to practice in the remote areas. During the next four days he’ll do as many as 96 operations, and together, the other physicians, nurses, dentists, ophthalmologists and pharmacists will treat about 1,300 patients. The team even brings its own cooks—food and water are so contaminated there that the team can’t afford to risk sickness by eating with the locals.


And while some of the cases are disheartening, “for example, I saw a kid with polio. You see things there that you would never see,” Lefor says the satisfaction of practicing “pure medicine” is worth it. “There’s no bullshit. A patient has a problem. We fix it.”


This instant gratification comes easier for surgeon volunteers than for internists. While Roever says he can’t cure patients’ hypertension because he’s not there long-term, Lefor can go in, fix a hernia or remove a gall bladder or an appendix and leave knowing the patient will have a better life.


And for those he can’t help—like the woman who needed a total thyroidectomy but couldn’t have one because she didn’t have access to the drugs she’d need to take for the rest of her life—he says he tries to remain realistic. “I can’t fix the whole world. Our success is one patient at a time.”


You might think pediatrician Caroline Dueger has found the fabled fountain of youth. Last year, at the age of 68, she cycled across the United States to raise money for a bacteriology lab for an HVO site in Cambodia.


“It was good fun. It was something I had been thinking about for a while, and I didn’t want to not have some good come out of it,” Dueger says.


Maybe it’s just something in the water at all of the places she’s conducted medical missions. Along with her internist husband, Dueger has been to Cambodia four times, St. Lucia, Brazil and South Africa—and that’s just with HVO. She has also volunteered in Kenya and in Nepal, where she trekked five days up a mountain to get to the village where she would see 50 to 60 patients daily before falling into bed in a hut with no plumbing. And she most recently returned from Guatemala, where a small religious organization is working to develop the economy among the Mayan people.


She says it is a grueling lifestyle, and it is time to slow down, but it’s been the right thing for her since 1993, when she quit her practice to volunteer full time. “There’s an adventure to it. It’s a challenge—you’re working with different cultures, so there’s all that to learn—and it’s fun. You get to travel and see the world.”


She certainly has. The most rewarding experience has been in Cambodia, where she travels repeatedly to teach young Cambodian medical graduates pediatrics skills. An on-site coordinator and Dueger arrange for visiting professors to come teach. “They have really taken the ball and run with it,” she says of the fledgling program.


In any country, HVO is careful to work within the confines of local customs, Dueger says, which makes it different from teaching residents in the United States. For example, the Cambodian students never raised any questions in the beginning, a cultural difference that took some getting used to. “That’s a great thing to teach them—to ask questions. You know, in the United States, they’ll question everything!” But there, as here, it’s rewarding to watch students grow and evolve in their education, she says.


SERVING CAREERS AND GOD


Not all the benefits of international volunteer work are grounded in a rejuvenating vacation or a pleasure in practicing basic medicine. Other physicians find the rewards can be more long-term—volunteer opportunities help shape future careers, and in Dr. John Greene’s case, the benefits are for eternity.


As Greene’s Baptist faith blossomed in the 1990s, so did his interest in volunteering. Quoting scripture commanding him to “‘go ye to the ends of the earth’” to use his talents, he says God has called him to use his medical skills to attend to the world’s physical and spiritual needs. The religious aspect is essential to him, he says. “Personally, I wouldn’t go on a trip…unless it had some spiritual value.”


His travel temporarily stymied by the demands of his two young children, Greene, the chief of infectious diseases at the University of South Florida’s H. Lee Moffitt Cancer Center and Research Institute, has traveled during the past 15 years to Guatemala, the Dominican Republic, the Ukraine, Tibet, Brazil and Africa to treat patients suffering from AIDS and other infectious diseases, and to build churches.


Yet while the evangelism is important, he says it is secondary to treating the basic medical needs of his patients. “You can’t [always] help people with their mindset for eternity because they’re just surviving day-by-day.”


Greene works with several medical missionary groups but has traveled most extensively with the Association of Baptists for World Evangelism and the Christian Medical and Dental Associations. He fronts his travel costs, and the organizations feed and house the volunteers in the host countries. Local missionaries tend to secure medicines and equipment, although Greene takes some antibiotics and other medications he knows will be hard to procure. “A lot of these clinics have no structure; a lot of times it’s just a room. Sometimes you just set up under a tree with your stethoscope.”


It is at those times, away from noisy hospital equipment, pagers and phones, that Greene says he does his best work on his relationship with God. “‘Be still and know that I am God,’” he says, quoting more scripture. Under the tree in the sweltering heat, he says he certainly does.


Early in her career, Kenyan physician Lulu Oguda did a calculation of her patients: About 70 percent had HIV. Struggling with their treatment, she wondered if the Médecins Sans Frontières/Doctors Without Borders (MSF) folks, with whom she spent two weeks volunteering during medical school, had a program that might help her determine the best treatment. “I called…, and she said, ‘Yes, we’re starting a program in Malawi.’ And I said, ‘When are you going?’ And she said, ‘Tomorrow.’ And I said, ‘I am going.’”


Two weeks later, Oguda was in Malawi serving in a one-year field director position, providing HIV patients with antiretroviral therapy and offering training to local health workers.


She, too, honed her clinical skills and learned management techniques. “We’ve forgotten our skills; we’ve forgotten our touch. If you give your all to the patient, you see them recover very quickly…. It makes you happy to see them get out of their beds and get back in their gardens.”


Unlike many other organizations, MSF pays its volunteers a small stipend. But even given that, Oguda says she doesn’t see herself going back to the organization. “You have to pay the bills, girl.” Instead, she’s parlayed her Malawi experience into a position with the Maryland-based International Partnership for Microbicides, which is working on a product to prevent HIV transmission to women during heterosexual sex. She’s managing the testing process in Africa.


But Oguda says she enjoyed her time with MSF, which is highly regarded in the areas it works. “Because they’re emergency-oriented, if there’s a problem, they’re going to fix it.” Such was the case with a patient brought into Oguda’s Malawi HIV clinic. The young woman had been found unconscious by the roadside along with her 2-day-old baby. After a few tests, she was diagnosed with meningitis—often a death sentence in the area. “I was determined this woman is going to wake up, and she will go home with her baby.” Three days later she regained consciousness, and two weeks after that she went home, having also begun the antiretroviral therapy she needed for her HIV. “A month later…her mother is saying, ‘Thank you, MSF, you saved my daughter’s life.’ [So], we prevented that little boy from becoming an orphan—from never even meeting his mother. She really sticks with me. I always remember her.”
~FITTING VOLUNTEER WORK INTO REAL LIFE


Your partner has that scrunched-up look on his face—the one he gets whenever he’s not happy. OK, so maybe approaching him about taking three months off to volunteer in Africa was not a smart idea.


This was a big concern for the American colleagues Dr. Lulu Oguda met while completing a 12-month volunteering stint with Médecins Sans Frontières/Doctors Without Borders (MSF) in Malawi two years ago. A Kenyan physician, Oguda says she didn’t have the same worries because “we don’t have the pressure to belong to an HMO” or to pay back student loans, but, “it is very hard for [my U.S. colleagues].”


Until two years ago, Dr. Sue Abkowitz-Crawford managed a position in a group internal medicine practice as well as a biennial two-month trip overseas, during which she taught medicine for Health Volunteers Overseas (HVO), giving up two months’ salary and scheduling her travels around her partners’ summer vacations.


“It’s something you have to do when you’re very young or very old. It’s very hard to take a month away from work,” says Dr. Jamie McElrath, a pediatric anesthesia and critical care medicine fellow at Johns Hopkins University School of Medicine. She was lucky to have an anesthesia residency program that allowed her to work a one-month HVO trip to Tanzania in February into her third-year rotations, plus helped her find scholarship funds to pay for the medical mission.


Taking months away from his practice just wasn’t something general surgeon Alan Lefor thought he could do 15 years ago as he was beginning his academic career. “[But], I honestly believe it’s the right thing to do,” he says. So he searched for more short-term opportunities, finally finding HELPS International, which sends him into Guatemala for about a week and a half once a year.


And how do patients feel about their physicians who leave for two months or two weeks? Most physician-volunteers say patients welcome the idea, sometimes even contributing funds to the relief organization. Abkowitz-Crawford says her husband’s orthopedic surgery patients love their physician’s volunteering hobby. “You’d think they’d get pissed off, but they want to hear about our trips,” she says.


And even when you negotiate the personnel and patient details, overseas volunteer work is not something to enter lightly, says Kate Fincham, an HVO spokeswoman. Because different organizations have different missions—some emergency care-based, some educational, some religious—everyone isn’t suited to every group. “People really need to ask [why they want to do this]. They need to honestly assess what those answers are and figure out the best match.”


And do your research on where you’re headed, volunteers say. “It’s not like being on vacation…. It’s difficult trying to fit into a society when you don’t even know the rules,” McElrath says. “For me to show up to teach in shorts [in Tanzania], it just wouldn’t have been respectful.” So she didn’t, despite it being as “hot as Hades there.”


It’s something to think about, Fincham says. “Maybe you don’t want to go to Cambodia in July.” —J.Z.


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


ONLINE RESOURCES


For more information about the international medical organizations mentioned in the story, visit these Web sites:

~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.~Community and Public Health,International Health~
120~6September~2004-53~Folk Tales~The Write Stuff~A JOKE TURNED PUBLISHING DEAL~Scott T. Shepherd~~Studying can be a dreadful and mind-numbing experience. And preparing for such tests as the United States Medical Licensing Examination (USMLE) can make reviewing for an anatomy quiz seem like a walk in the park.


For osteopathic students, there is another ring of Hades: the Comprehensive Osteopathic Medical Licensing Exam (COMLEX), a three-level test that’s similar to the USMLE but also includes material on osteopathic manipulative medicine. And what makes studying for the COMLEX difficult is the peculiar absence of COMLEX-specific review books. As a result, osteopathic students prepping for the exam have to make use of a variety of materials, says Naishadh Shah, a fourth-year at the New York College of Osteopathic Medicine (NYCOM) of the New York Institute of Technology (NYIT).


“[When we were studying], what we did was we mainly used books oriented for the USMLEs for the majority of the subjects from anatomy [to] microbiology…. Pretty much all of the subjects that are covered on the USMLE are 100 percent covered on the COMLEX as well,” he says. “So we used USMLE-oriented books for that, while for the [COMLEX] osteopathic manipulative medicine portions, we used whatever resources were available…. Some of them are geared toward the boards; some of them are just general review books of osteopathic manipulative medicine. We used those along with class notes.”


Of course, this isn’t the most convenient study method, but when Shah and fellow NYCOM fourth-year Rupen Modi were preparing for the COMLEX, there wasn’t a lot of time to do anything about it.


After completing the first step between their second and third years, though, they casually discussed the need for a COMLEX review book. “The idea started out as a joke,” Modi says.


However, that joke didn’t look so far-fetched after both students earned teaching fellowships at NYCOM. Shah teaches anatomy to first-, second- and third-years, while Modi gives them lessons on osteopathic manipulative medicine. And as fellows, they have delayed their graduation from 2004 to 2005.


But, really, what’s one more year for Shah and Modi, who entered NYIT’s seven-year Bachelor of Science/Doctor of Osteopathy program in 1997 and met while living in the dormitories on the Central Islip campus. Besides sharing many of the same classes, they discovered they also had a common cultural heritage. Shah was born in Gujurat, India, and moved to Queens, New York, at the age of 5, while Modi, who was born in Pennsylvania to Indian parents, lived in India for seven years before returning to the United States and graduating from high school in King of Prussia, Pennsylvania.


It was their ethnic backgrounds and interests that led them to their first undertaking. “If you go to [NYIT’s] Salten Center where all the club flags hang, you will see a banner for Ashram, an Indian cultural organization we started as sophomore undergrads,” Modi says. “Also, the very first NYIT date auction was our idea, part of a [student government association] and Ashram collaboration.”


While their auction dating efforts may leave the greatest mark on NYIT students, Shah and Modi decided to create a legacy, as well. “We were just talking [after earning the fellowships] about what can we do extra, what can we do more, what can we do different than the fellows that have been here in the past, and it started out as a joke, like, ‘Ah, we should write a book. It would be funny,’” Modi says.


Perhaps to test the limits of their senses of humor, Modi and Shah took the idea to a new audience: publishing companies. In March 2003, after a particularly tiring day on rotations, the two began writing. “We couldn’t think of anything better to do, so we said, ‘Let’s write a proposal and see [how] different publishing companies respond to our proposal,’” Modi says.


The three-page query outlined a simple concept: Write a COMLEX-focused review book. And apparently, the punch line was lost on book publishers, who jumped on the idea. “To our surprise, we actually got a very good response from several big-name publishers. It was like a joke gone too far,” Modi says.


In fact, Blackwell Publishing, which eventually won over the student-authors, saw a real business opportunity. “There’s a need in the market for a book like this, and the authors provided me with an impressive proposal that reviewed well with osteopathic students,” Nancy Duffy, a Blackwell acquisitions editor, said in a press release. She also said that the students’ professionalism, attention to detail and senses of humor have made them two of her favorite authors to work with.


And while some may view the authors’ status as students a liability, Blackwell didn’t. “The major advantage we had is that we were both students and teachers…, and the publishers really saw that to be the advantage that it is,” Shah says. “We are close enough to the students to relate to the issues that they are dealing with—what subjects they feel are not adequately covered or need further review before their exam and what format they like to study from—as well as being professors, to some degree…where we see firsthand the areas where students are having problems in and areas where students need clarification in.”


Their review book is set for release in spring 2005. And for two guys who had previously found the idea of being authors laughable, they seem to be making the adjustment well. “It is definitely challenging,” Shah says. “Though Rupen and I are well versed in our respective fellowship subjects, putting it all on paper is a different story.”


And the greatest challenge, as it turns out, is one that all medical students can relate to: finding the time to work on another project. “Writing a book requires a little vision, some planning and a lot of time. Anybody with these three can do it,” Modi says. “Our situation is the opposite. We had a tremendous vision, good planning, but we are always short on time. Between the workload from NYCOM, working on our MBAs, and all the other extracurricular activities we are involved in, time management is important.”


So several days each week, the student-authors dedicate three- to four-hour blocks to writing. “Usually, we will meet in the evening after our respective rotations are done. We will start work and take breaks for TV and dinner and still finish around 9 or 10 p.m.,” Shah says. “On weekends, we first finish our studying and weekly chores.… We usually meet in the late afternoon and work until the evening. In the back of our minds, we both know that once this project is over, we will be able to relax and enjoy some free time—which we have not had in many years. That motivation, in itself, is enough to keep us going and working hard.”


However, if past behavior is any indication, it is difficult to imagine either future osteopath resting on his laurels for too long. Maybe one of them will even think up another joke.
~~~~Scott T. Shepherd is an associate editor with The New Physician. E-mail your “Folk Tales” suggestions to tnp@amsa.org.~Osteopathic Medicine~
121~7October~2004-53~Feature~Curriculum Reform and You~HOW YOU CAN MAKE A DIFFERENCE~Beth McNichol~~“Can you tell I’m using my administrative voice?” asks third-year Miranda McCann, lapsing for a moment from her “new” grown-up voice to the more uneven tone of a nervous student. “It goes with the dress-up clothes.”


It also goes with her new perspective. In early 2003, halfway through her second year at Northeastern Ohio Universities College of Medicine (NEOUCOM), McCann had developed concerns about her medical education. She found classes disjointed. Lecturers would come in and teach for an hour on a subject, never to be seen again. Teachers didn’t know what students were being tested on, and testers didn’t know what was being taught.


“That just seemed to be a real disconnect from the way that I understood education should be occurring,” says McCann, who, contemplating a leave of absence, took her concerns directly to a dean’s office. But instead of leaving with empty excuses, she left with a job: the Educational Excellence Fellowship, which made her the first official liaison between students and medical school administrators and gave her a strong voice in NEOUCOM’s impending curriculum overhaul.


This past July, she finished her one-year stint inside the administration. And while her position may have been unique, McCann is just one of many medical students across the country who have questioned the rationale and structure of their medical education and parlayed those criticisms into action. No two schools are alike, but all the students interviewed for this story agreed on one thing: Future physicians have more power than they think in impacting their curricula.


TOTAL RECALL


Kristofer Smith understands this well. Smith, now a fourth-year at Boston University School of Medicine (BUSM), began questioning his school’s teaching methods after his first semester. “I felt like medical school was taking a lot of really smart, kind, interesting people and just sort of abusing them with a fact-based, heavy memorization learning experience,” says Smith, whose physician-father works in an academic medical center. “Ultimately, you’re not going to be an encyclopedia of facts; you’re going to learn to apply facts in a meaningful way.”


Smith felt BUSM’s letter-grading policy for the preclinical years was an uninspired, poorly considered system that encouraged a competitive, selfish atmosphere among students and fostered a focus on extrinsic rewards instead of intrinsic learning. “We’re in medicine. We want to do good; we’re studying for altruistic reasons. So it’s kind of insulting to say that I need grades to learn the art and science of medicine,” he says.


He thought a pass/fail grading system would be a “benefit to the quality of the learning environment, to collegiality, to students helping one another, where we see each other as participating in a community with a common purpose rather than just individual actors pursuing their own academic interests.”


Upon discussing these ideas with classmates, he learned many of them agreed the grading system needed reforming. But he also discovered a fervent undercurrent of displeasure in other areas. “People were pretty tired, pretty emotionally beat up, questioning why they came to medical school in the first place.”


When Smith spoke with upperclassmen, he heard the same moping chorus. At this point, he says, “You have to ask yourself, ‘How do we move beyond just complaining? How do we actually sustain real change?’ Because it probably won’t benefit my preclinical years to fight for this, but I didn’t want the problems to repeat themselves.”


So, he and other concerned students formed the Student Committee on Medical Education and “created some power for ourselves” through the language of basic science: hard data. They used student satisfaction surveys from other schools to guide them in creating one for BUSM, eventually getting a solid 85 percent response rate from their first-year class. “And we were very open about the process. We told everybody—the dean, chairs, faculty—this is what we’re doing, so they wouldn’t feel surprised or ambushed.”


The student committee issued a 20-page report to BUSM administrators, outlining the data they’d found and explaining three areas that needed mending: the grading system, course feedback procedures and faculty development—literally teaching instructors how to be effective teachers. Then they went one step further, proposing solutions to their findings and creating leadership groups for each effort, which met regularly with faculty members until changes were made.


And they were. In the fall of 2003, by the time Smith was beginning his third year, grading for preclinical students changed to a pass/fail system. The school implemented feedback systems and in January 2004 hired a faculty development coordinator. What’s more, after the Liaison Committee on Medical Education’s review team—which evaluates schools as part of the accreditation process—saw Smith’s report in March 2003, the entire set of bylaws governing BUSM’s curriculum was retooled, streamlining the process for any future curriculum changes.


Smith says he and his fellow students were so successful because they’d built a consensus for change and used it to methodically demonstrate their reasoning to faculty.


“Students need to appreciate how much power they have. You have far more power than you’re ever going to have as a resident or as a junior faculty member,” he says. Still, students may face some consequences for their actions, so he encourages reformers to be thoughtful in their efforts.


REFORM FOR ALL SEASONS


Dr. Jess Mandel, assistant dean for student affairs and curriculum at the University of Iowa’s Carver College of Medicine, echoes Smith’s advice. “If your criticism isn’t constructive, it can be perceived as whining,” Mandel says. “But if you suggest a better way to do it or an alternative that should be considered, then people really respond to that much better.”


Mandel should know. Iowa’s curriculum may be the most accountable model in the country, incorporating multiple avenues for feedback. One of the oldest is Caduceus, a medical student organization that for nearly two decades has addressed preclinical curriculum concerns by taking five to 10 student volunteers from each course to form a liaison committee for that course. Committee members meet with the course director before each test—generally four or five times during a semester, though sometimes as often as every other week—to discuss the progression of learning. Committee members are introduced in class so students with concerns know to whom they can turn, and Caduceus is explained to all first-years during orientation.


In addition to ensuring all the appropriate topics are being covered in the course, committee members offer suggestions about lecturers who didn’t work well and recommendations for teachers who should be emulated, says Dom Cirillo, a fifth-year M.D./Ph.D. student and a former president of Caduceus.


The system works, Cirillo says. “[The] liaison committees actually have a big impact on some courses. Just doing a course evaluation after the course is over doesn’t have as much impact as evaluating the course all the way through it,” he says.


Some of the changes Caduceus members have helped implement include tinkering with the timing of exams to ensure adequate study time for each course, refocusing a microbiology lab so important material was covered, and adding public health and service-learning courses.


Mandel says Caduceus and two other feedback mechanisms at Iowa—regular lunches that invite one-fourth of each class to discuss the course’s progress with an independent facilitator and anonymous, Web-based questionnaires that can be completed throughout the year—help reinforce the idea that students and faculty are colleagues, not combatants, in medical education.


“I think other schools have had some difficulty in respecting student insight because they sort of put all of their eggs in one basket when they have only one venue for feedback,” Mandel says. “You either take pains to have a collaborative discussion with students, or you don’t.”


WANTED: MORE KNOWLEDGE


But future physicians aren’t always interested in taking on the kind of whole reform efforts Smith undertook at Boston or those offered by Iowa’s system. Sometimes, they just want to add a subject they believe to be lacking in their curricula. But even small changes can be uphill battles.


Third-year Sarita Sonalkar has been interested in reproductive health issues since volunteering at Planned Parenthood in college. When she began her studies at the University of Medicine and Dentistry of New Jersey, New Jersey Medical School (UMDNJ-NJMS), however, she was surprised to see little instruction on abortion.


“Abortion is one of the most common surgical procedures in the country,” she says, citing a Planned Parenthood statistic claiming that nearly half of all U.S. women have an abortion by the time they reach the age of 45. “But it’s just not thought about in medical schools.”


Yet improving a microbiology lab is one thing; tackling such a controversial and divisive topic as abortion is quite another. So Sonalkar sought assistance from the UMDNJ-NJMS chapter of Medical Students for Choice. For the past three years, the group has helped organize a reproductive health lecture series at the medical school that doubled as an elective for students who attended at least six of the nine talks.


And with UMDNJ-NJMS on the cusp of a major curriculum reform effort, “We saw it as a window—an open period where the administration might be comfortable introducing [mandatory abortion education],” she says.


But after organizing a coalition of interested groups and lobbying at curriculum reform committee meetings for a dedicated course that would integrate women’s health, reproductive and sensitivity issues into a weekly class, Sonalkar and her colleagues soon found that window closing. Although faculty welcomed ideas and said they would consider adding some aspect of reproductive health to the new curriculum, “after that, it was like the curriculum was being developed behind closed doors,” she says.


Their request didn’t make it into the revised curriculum UMDNJ-NJMS began rolling out this fall. So they refocused their efforts on better publicizing the lecture series, as well as on building more hard data by tracking the peripheral mentions of reproductive health issues in existing classes.


Still, Sonalkar is not entirely discouraged. “I’ve learned it’s as important to have small goals as it is lofty ones,” she says. “I’ve found that people who have other leanings, if they’re really adamant about what they believe, it’s hard to talk to them. You have to strike a balance.”


Exactly, says McCann, who exchanges her NEOUCOM administrative suit this fall for scrubs. The third-year says she tended “to fall into the ‘faculty are our enemy’ perspective that a lot of students have: that the faculty only care about their research, that they don’t care about my education. The biggest lesson for me is that that’s just not true. The faculty love students. They want them to be phenomenal physicians. Not every decision they make is right for students, but decisions are arrived at through thoughtful processes….


“Students tend to sit in their rooms and complain. That’s great therapy,” McCann says. “But an even better idea is to go straight to faculty members and have a conversation with them, find out why something is done the way it is, and make a suggestion for improvement if you still think it’s wrong.”


Vairavan Subramanian, a fourth-year at Baylor College of Medicine, says he is lucky to be in an “innovative environment” for medical education: The faculty supported his move for a one-of-a-kind, hands-on surgical elective for third- and fourth-years, and the course is now entering its third year. But Subramanian and fellow students still had to use some elbow grease—finding funding for laparoscopic equipment and cadavers, drawing up the course syllabus and securing surgeons for classes. The upside? As a result, the future physicians had more control over what they learned.


“If you’re interested in something,” he says, “don’t be daunted by how difficult the task seems in theory. Faculty and students often have common goals. But as students, we may have a little bit more time for—and a little bit more invested in—change.”
~HOW SHOULD YOU APPROACH CURRICULUM REFORM?


Build consensus: Two voices—or 10 or 20 or 100—are louder than one. Ask around school: Do other students feel as you do? You need strong leadership, but you also need support. If you find students of like minds, you know you may be onto some legitimate problems. You may want to form a committee or a student organization to tackle the issue smartly. But before you do….


Schedule an appointment with faculty or administrators: Third-year Miranda McCann of Northeastern Ohio Universities College of Medicine says, “Go straight to a faculty member and tell them your concern; ask them to help you understand why something is the way it is. Ask if you can discuss some alternatives.” An early meeting will help you gauge the rationale behind the curriculum, steer the path of your reform efforts and prevent higher-ups from being blindsided by your campaign.
Take inventory of the current curriculum: Be certain you understand what’s covered in your school’s curriculum, who makes the decisions and how. If your goal is to add a course on a particular subject, find out if the topic is currently integrated into an existing course through one-time lectures. Boost your knowledge to gain credibility for your argument.


Get hard data: Nothing speaks to scientists like statistics and research. Find a way to poll your fellow students—using quantitative and qualitative measures—about the curriculum, what it lacks and why it needs your reform suggestions. Present it in a professional way to curriculum committees and administrators.


Secure a buy-in: Baylor College of Medicine faculty supported the addition of a surgical elective in part because students found funding for the course, offered to plan and organize it themselves, and presented it as a good recruiting tool to attract more students interested in general surgery to Baylor. That made it hard to say no.


Be specific; be constructive: “Faculty find it very easy to ignore generic complaints,” says Dr. Jess Mandel, assistant dean for student affairs and curriculum at the University of Iowa’s Carver College of Medicine. “If you say the textbook is bad, and there’s too much reading, you won’t get far. If you can say it didn’t cover thyroid physiology well, but this other textbook does a better job, people have to acknowledge what you’re saying.”
—B.M.
~~~Beth McNichol is a contributing editor with The New Physician. Direct comments about this article to tnp@amsa.org.~Advocacy,Medical Education~
122~7October~2004-53~Feature~The Great (Health-Care) Divide~PRESIDENT GEORGE W. BUSH'S AND SEN. JOHN F. KERRY'S PLANS FOR OUR NATION'S HEALTH~Jennifer Zeigler~~Health care has become a driving force in this year’s presidential election. A July ABC News/Washington Post survey of 1,200 voters found that given the choice among the economy and jobs, the Iraq war, education and health care, 12 percent of respondents said health care would be the deciding factor when they go to the polls Nov. 2.


Harvard University health policy and management professor Robert Blendon says although the effects of the terrorist attacks on Sept. 11, 2001, the war in Iraq and the federal deficit are voters’ primary concerns, health care is important. “In real life, the country is quite divided here. Half would like to do something big, and the other half has absolutely no interest,” he says. But here’s the hook: “If the election is close, [health care] could have an effect, because there is a share of the voters who want something done now,” he predicts. This year’s election is looking just as close as 2000, when 47.87 percent of the votes went to George W. Bush and 48.38 percent went to Vice President Al Gore, and health care could be a deciding issue.


So, where do the candidates stand on some of these issues? Let’s take a look at Bush’s and Sen. John F. Kerry’s (D-Mass.) proposals.


COVERING THE UNINSURED


Democratic strategist Celinda Lake and her Republican foil Bill McInturff sit on opposite sides of the dais during a Washington, D.C., policy conference nodding their heads in blue–red, bipartisan agreement: Health-care coverage is shaping up to be a major campaign issue.


“Health care comes out when you ask [voters] about ‘personal concerns,’” McInturff says, placing the issue directly behind national security and Iraq in importance to Americans. Lake cites a poll by the Service Employees International Union that found 35 percent of voters are what she calls “anxious insured”—those who can’t afford to lose their health coverage benefits. With all this agreement, it makes one wonder how the candidates can be so far apart on the issue of how to provide coverage to the country’s 45 million uninsured.


“There isn’t much that [Bush and Kerry will] agree on, in terms of policy,” says Chris Jennings, a Kerry policy adviser. “But I think we will agree on one thing, that there couldn’t be a bigger contrast between domestic policy priorities than the issue of health care in this campaign. I think it’s a really interesting issue in terms of not just overall investment, but also policy structure and the approach each side has taken to address an undeniable need.”


For first-term successes, Bush points to his 2000 campaign promises for health savings accounts (HSAs), which he signed into law as part of the 2003 Medicare reform bill; an expansion of Medicaid and the State Children’s Health Insurance Program (CHIP) eligibility guidelines; as well as a tax credit for health care in the 2002 trade bill to help displaced workers.


In this election, he maintains his support for association health plans, which would group small businesses into larger pools, offering them better health insurance buying power, and a refundable tax credit to individuals who purchase their own coverage instead of receiving it as an employment benefit.


According to Emory University health economics professor Kenneth Thorpe, Ph.D.—who worked in the Clinton administration but is looked to by many observers to offer a fair interpretation of the candidates’ proposals—Bush’s plan would cost $90.5 billion over the next 10 years and would extend coverage to between 2.1 million and 2.4 million previously uninsured.


While Megan Hauck, the Bush campaign’s deputy policy director for health care, disputes Thorpe’s numbers—saying the president’s plan would actually cover 6 million to 10 million uninsured at a cost of $69 billion—Thorpe stands by his analysis. “I would take campaign estimates at what they are: campaign estimates,” he says.


For his part, Kerry would offer a refundable tax credit to small businesses for up to 50 percent of the costs to cover their workers. The four-term Massachusetts lawmaker also proposes states expand CHIP to include all uninsured children who are ineligible for Medicaid coverage and some low-income adults. In exchange, the federal government would pick up the entire tab for kids on Medicaid, a cost normally shared with the states. Like Bush, his plan also provides for an association-type pool in which businesses and individuals could buy into based on the Federal Employees Health Benefits Program.


The cost of all this, according to Thorpe, is $653.1 billion over the next 10 years—which Kerry says he would pay for by rolling back the tax cuts to those earning more than $200,000—and would insure 26.7 million additional people.


While most of these policies aren’t new to health-care economists, Blendon says both plans include novel approaches. For Kerry, it’s a proposal to reimburse health insurance companies 75 percent of their payouts on catastrophic claims above $50,000, the idea being that if the federal government foots the bill on the most costly aspect of insurance, consumers’ premiums could be reduced about $1,000 annually. But, “how he’s going to pay for it is kind of mushy,” Blendon says.


Jennings admits the funding in Kerry’s plan is not guaranteed, since Congress holds the power to alter the tax structure. “And [Kerry] well recognizes that, and he will be the first to reach out to Republicans when he is inaugurated into office in January,” he says.


And although Bush also addresses catastrophic coverage costs by proposing to allow individuals with HSAs to deduct catastrophic coverage premiums from their taxes, Blendon says the innovative approach in the Bush plan is to exchange those traditional catastrophic coverage plans for ones with high deductibles and low premiums. “The way [Bush is] trying to design the plans is that preventive stuff would fall outside the deductible, so there is an incentive [to get preventive care] there,” Blendon says.


LIABILITY REFORM


Vice President Dick Cheney drove home his campaign’s position on medical malpractice liability reform while speaking to physicians and workers at the Medical College of Ohio in July: “We come at this issue with a practical point of view, which we believe is shared by the vast majority of Americans. All of us understand that when we are sick or the health of our loved ones is in question, we don’t need a lawyer. We need the experienced, trusted doctors that we’ve known and relied on for years.”


The speech was a jab at his Democratic competition, Sen. John Edwards, who made millions representing injured patients in malpractice lawsuits in North Carolina. Bush has long pushed for medical liability reform, taking the physician-friendly position that frivolous lawsuits increase health-care costs and push physicians out of business. He supports a $250,000 cap on noneconomic damage awards as well as restrictions on filing claims against multiple medical professionals, particularly those who are only marginally involved.


The problem, Blendon says, is that voters—beyond physicians and those in the business community—aren’t too concerned about the issue. “People know that it does something about rising costs, [but] there’s not an economist at Harvard that will agree to that,” he says.


The Bush camp disagrees. “I’d suggest that you go interview those women who have wandered around trying to find OB-Gyns to deliver their babies because their doctors decided that it’s too expensive to have the insurance to deliver babies,” says Republican strategist David Winston. “That has been a significant issue that has been covered and to suggest that there’s no proof—read the newspapers.”


In fact, a May Harris Interactive survey indicated malpractice reform is on the minds of voters; 55 percent of the respondents said lawsuit threats affect their care a little or a lot, and 62 percent support legal reform.


Kerry has a plan for liability reform as well. Calling it “one of the best-kept secrets in Washington,” Jennings says the plan will “make health care more predictable”—one of Kerry’s goals for his entire health-care package.


The proposal would eliminate punitive damages except in certain extreme cases, require a panel of medical professionals to review all claims and determine merit, and institute a “three strikes and you’re out” rule, to prevent lawyers from filing more than three frivolous cases. Attorneys who exceed this limit would be barred from filing another medical malpractice suit for 10 years.


“[Kerry’s proposals] really substantially address the problem, and most importantly…could be passed and enacted,” Jennings says. Congress has kicked liability reform around for several years but, largely because of Democratic opposition, has not passed any legislation.


“Edwards coming into this race is obviously going to put more focus [on] the role of lawyers within the health-care system,” Winston says. How much focus, though, still remains to be seen.


FUNDING STEM CELL RESEARCH


When the son of a beloved and recently departed Republican president stood before 4,353 delegates at the Democratic National Convention this summer and attacked Bush’s policy on funding embryonic stem cell research—a policy limiting federal funds to research involving 78 pre-established cell lines, many of which have proved to be useless—the fight over stem cells heated up.


Even before Ron Reagan insisted that stem cell funding must not become a partisan issue, the subject became just that, in some ways replacing a seemingly quieter discussion about abortion rights. “The stem cell thing got mixed up in abortion politics in a way I’m not sure most politicians wanted it to,” Blendon says. Because the research, which scientists claim could cure such diseases as Alzheimer’s, requires the de-
struction of human embryos, the two sides have shaken out along similar lines of pro-life and pro-choice advocates.


And it’s a policy on which Kerry believes Bush is vulnerable. “Kerry makes a stem cell reference in almost every speech,” Blendon says, adding it’s a wise strategy since voters are concerned about the issue. “Suddenly, it has made people say there’s something wrong with our policy. Americans love cures. They may be ambivalent about where stem cells may have come from, but they love cures.”


In fact, American Demographics reported in August that 20 percent of Bush supporters told Zogby International pollsters they’d switch to support Kerry or Nader, not vote or become undecided if Kerry announced a comprehensive plan for federal stem cell research. But Bush stands by his August 2001 policy, which made him the first president to federally fund the research, although Clinton OK’d funding in 2000 that was never appropriated.


As the summer wound down and the topic gained momentum, Bush relied on his wife, Laura, to do much of the talking. At St. Vincent’s Medical Center in Jacksonville, Florida, she agreed stem cell funding is a subject that should be discussed but chastised the media and medical professionals for giving the public the impression that breakthrough cures are imminent. “But the fact is, that’s not right…,” she said. “Embryonic stem cell research is much more preliminary than that; we’re not about to come upon a cure.”


PATIENTS' BILL OF RIGHTS


A hot topic during the 2000 presidential election, a patients’ bill of rights has taken a back seat this time around. That’s because managed-care companies have “loosened some of the reigns that were so offensive,” making campaign advertisements about patients’ rights less persuasive, says Jack Meyer, president of the Economic and Social Research Institute, which researches health and social policy.


Still, Democrats are trying to resurrect the issue. Kerry promises to push for legislation that would guarantee patients the right to see needed specialists, provide an external appeals process to managed-care companies’ decisions and offer whistleblower protections to health-care workers who report “quality problems.”


The campaign accuses Bush of promising a patients’ bill of rights in 2000, but then reversing his position by blocking congressional efforts to pass such legislation in 2002. Bush also sent his White House counsel to argue in a Supreme Court case against allowing patients to sue their insurance companies in state courts where damage awards are often higher. The court ruled last spring that because a federal pension law supercedes state law, patients must take their complaints to federal courts.


But Hauck says that as president, Bush had to defend federal law. She says Bush still supports a patients’ bill of rights, even if the media isn’t reporting his position. “I think there’s an ebb and flow to health-care issues.”


DRUG REIMPORTATION


The press and the candidates are paying great attention to the cost of prescription drugs, in particular, the recently passed Medicare prescription drug benefit and drug reimportation legislation.


“Under our plan…all Americans will be able to buy less expensive prescription drugs from countries like Canada,” Kerry said in accepting his party’s nomination in July. The Democratic candidate has maintained throughout the campaign that reimportation would lower drug costs; he uses the issue in many stump speeches.


The Bush campaign says the president supports reimportation—but it is quick to offer stipulations. While the Medicare bill allows for it, the law requires the secretary of health and human services to certify the drugs as safe, a process the Food and Drug Administration says is not currently possible. “So we have not been able to certify them as safe, and until we can, we will not support the proposal [to reimport the drugs],” Hauck says of the Bush administration’s position.


Safety concerns or not, the public finds reimportation a popular idea, forcing many Republicans to choose their words carefully. “I’m not opposed to bringing drugs in from Canada,” says Rep. Bill Thomas (R-Calif.), speaking for the campaign. Thomas, who chairs the powerful Ways and Means Committee, says he is going to work for a legislative remedy to the drug reimportation question.


“[But when] you set up a system, you better make sure that it is a safe system and that it’s as good as buying products at the local pharmacy. If we can achieve that, I have no problem bringing them in…. You don’t just go out and gin people up to the safety of this…,” he says. “[Kerry] offers a seemingly simple solution, which is difficult to achieve and would not make that big a difference.”


This is the other crux of Bush’s argument against reimportation: It won’t offer a tremendous savings to the consumer. Hauck cites an April Congressional Budget Office report that found reimportation in general would offer “at most a modest reduction” in drug spending, while reimportation from only Canada would result in a “negligible” difference.


“I think we have a real concern that we just open this up to something that…would have negligible savings, and then we have the potential to really damage the integrity of the drugs in this country,” she says.
~TRADING STETHOSCOPES FOR CAMPAIGN BUTTONS


It’s just a Thai restaurant on Washington, D.C.’s, Capitol Hill, but to Howard University College of Medicine fourth-year Alex Blum, it’s the place of his political birth.


“That lunch was—I don’t want to be too dramatic—but it really was a life-changing experience, because I got to see the inside of how politics works,” Blum says.


It used to be that really serious political strategizing happened over aged steaks on white tablecloths in dark-paneled dining rooms. But, this being the 21st century, Blum’s party bypassed those old bastions of power, and so had other young strategists. “I remember looking around and thinking, ‘Everyone is my age. Congress is being run by people just like me.’”


That afternoon, Blum sat in on a meeting between Dr. Andy Calman, the director of Physicians for a Democratic Majority (DemDocs), and a representative from the Democratic Congressional Campaign Committee (DCCC). “They went race by race and discussed which ones were the ones they want to target…. I never thought about the science of politics.”


That lunch sparked his political neurons. So when DemDocs approached him in May about spending four days in South Dakota campaigning for Democratic candidate Stephanie Herseth in a special election to fill a vacancy left by Rep. Bill Janklow (R-S.D.), who resigned in 2003 after a manslaughter conviction, Blum said yes. He would miss four days of his surgery rotation, but “at the time, it seemed like a once-in-a-lifetime experience, you know; when was I going to have that kind of opportunity again?”


One of a dozen medical students DemDocs sent that weekend, Blum joined the approximately 11,000 DCCC volunteers who canvassed the state reminding people to vote. “I think we knocked on 700 houses. On the last day, I was literally sprinting from house to house,” he says. But only to those with a Democratic affiliation: “To be frank, you don’t want to be reminding those who aren’t going to vote for your candidate to show up and vote.”


So when Herseth won by a mere 2,500 votes, Blum says it showed him how an election is run and won. And he was hooked. He followed his Memorial Day foray into politics with a trip to volunteer at the Democratic National Convention in Boston in July and a volunteer position with DemDocs in which he’s coordinating 20 teams of medical students to get out the Democratic vote in swing states the weekend before November’s general election.


“Part of the idea is that physicians need to become more politically involved,” he says. “I think people are slightly intimidated by the process, but if you’ve passed medical school, you can do campaigning.”


It’s a lesson Matthew Nunnelley learned as he campaigned door-to-door in Georgia to elect Republican Tom Price to the U.S. House. Hailing from former Speaker of the House Newt Gingrich’s district, Price had no Democratic competition, but plenty from his own party, which he beat in a July primary. So what made this political novice jump into Price’s campaign? “He’s been my state senator for four terms,” Nunnelley says. “He’s an M.D., [and] I just liked the candidate.”


So, for several months before the election, the second-year at Morehouse School of Medicine reminded people about the upcoming primary, compiled lists of previous voters and waved signs on street corners. “Pretty much whatever they needed done, I tried to do,” he says.


And while Nunnelley isn’t about to switch from medicine to politics, he says he enjoyed the opportunity to meet other like-minded people and to see how campaigns work. “There’s a lot that goes on behind the scenes that is not reported,” he says.


University of Connecticut School of Medicine third-year Nihar Desai would agree. After college, he spent 10 months working for President Clinton’s chief of staff, John Podesta. And back in March 2003, he began thinking about what he wanted his role to be in the 2004 election, settling his political loyalties with Sen. John F. Kerry (D-Mass.).


“Once the campaign first took wind, I started talking to some people and getting my feet in some doors. Last August things began to click.” He wrote some policy memos for Kerry’s health-policy team and reviewed the campaign’s health-care positions. Things were going well for Desai—who figured he’d stick with frontrunner Kerry through the primary season before taking this year off from medical school to complete an M.P.H. at Harvard University, conveniently placing him in Boston during the height of the campaign season.


And it was a great plan until about November 2003, when former Vermont Gov. Howard Dean’s political stock began rising in the Democratic primary. “So, in November and December, I mean everyone I would talk to in the [Kerry] campaign, I mean the tone was so somber, you could tell it was just a matter of days before everyone would wrap it up.”


It’s a good thing Desai didn’t. Having stuck with what once seemed like a losing campaign, he now has at least a daily phone call or e-mail from Kerry’s health-policy director, Madhu Chugh, who tells her volunteer army what the week’s focus will be and coordinates discussion. Out of those chats, a policy is born and an event to promote it is crafted. “The very, very specifics of the policy are not there, and that’s OK…,” Desai says. “That’s not how you win an election. It’s providing kind of a brush stroke.”


He’s expecting his role to be more diminished throughout the fall, as policy becomes established and the campaign swings into high gear. But Desai is, of course, hoping his hard work pays off. Election night 2000 found him working in the West Wing until 4 a.m., a side note to the chaos around him. This year, he would like the election to be more decisive, with his role part of a Boston or Washington, D.C., party celebrating a Kerry win—maybe even until 4 a.m. —J.Z.


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


ADDITIONAL HEALTH-CARE ISSUES


There’s no doubt health-care issues cover a
broad canvas, and while some are at the epicenter of public debate, others remain on the fringe—important to many but unlikely to dramatically affect the election’s outcome. These include:




























Issues Bush Kerry

Abortion

 Pro-life, with
exception; signed "partial birth" abortion ban		 Pro-choice
HIV/AIDS
Spending		 Pledged $15
billion through 2009 for all global AIDS efforts		 Promised $30
billion to the Global Fund by 2008
National
Institutes of Health (NIH) Spending		 2005 budget funds
at $28.6 billion, a 2.6% increase over 2004; completed doubling of NIH
budget		 Pledged to
increase NIH budget, but has not said by how much
Residents'
work-Hours Legislation		 Won't take a
position until bill passes House and Senate		 Campaign staff
refused to return repeated calls about the issue






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


THE DIGITAL STUMP
Looking for the candidates’ speeches? Want to learn more about their
platforms? Check out their campaign Web sites for more information:



~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.~Advocacy,Health Policy,Legislative Action~
123~6September~2004-53~Perspectives~On the Road in Iowa~HITTING THE CAMPAIGN TRAIL~Will Nicholson~~One day in mid-January, as news coverage of Iowa’s upcoming Democratic Presidential Caucus reached a fever pitch, I decided to take a road trip. After a year and a half of studying at the University of Minnesota Medical School, I realized if I was going to be effective at promoting patients’ health, I needed to help improve the climate in which they lived their lives. This was my chance to grill the top Democratic candidates on their policies, learn what Iowans thought about health care and promote the health-care issue to the international media. I was going to Iowa! And I wasn’t sure if I could accomplish anything.


I woke up on Saturday, Jan. 17, at 4:30 a.m., showered, shaved, packed, threw my things in the car and ate breakfast on the fly. For the next three days I was going to be on the campaign trail, racing from town to town, talking to every candidate, voter, reporter and volunteer I could find.


SATURDAY, 8AM - NOON, MASON CITY


Former Gov. Howard Dean (D-Vt.) was about to cook pancakes before an adoring crowd. I asked a veteran Iowa journalist, a Tokyo film crew and a cable TV reporter how to get in and question the physician-turned-politician. The consensus was: “Don’t even try. These guys stick to the script and don’t like interruptions.” This was a nice way of saying, “Stay out of our way.”
With this in mind, I moved to the front of the crowd. As Dean flipped his first flapjack into the air and onto a voter’s plate, I shouted, “Hey, Dr. Dean, can you do that with our foreign policy?”
“I better!” he replied. He flipped another pancake higher into the air.
“How about the health-care system?”
“The health-care system, too,” he said.
When he was done, he removed his apron and hung it on a chair a few feet away from me. I leaned over a press barrier, introduced myself and asked Dean why his universal health-care plan would work when the Clinton plan hadn’t. He said his plan was successful in Vermont, and he knew he could pass it in Congress. Next, I asked if this was his ultimate vision for health care or just a step toward a single-payer system. He said single payer was a nice idea, but it couldn’t get past Congress. Our conversation ended when he was called to the stage.


SATURDAY AFTERNOON - DUBUQUE


Sen. John Edwards (D-N.C.) was first in a lineup at Dubuque’s Grand River Center that included Rep. Dennis Kucinich (D-Ohio) and Sen. John Kerry (D-Mass.). As a rock-’n’-roll guitar solo played, Edwards entered the arena from a loading dock door, a giant “John Edwards for President” banner hanging behind him. He headed for the stage through a tunnel of cheering supporters.


An excellent orator, Edwards rallied the crowd using his well-known “Two Americas” speech, and afterward, as supporters and reporters swarmed around him in the lobby, I called out: “Could I get you to weigh in on global AIDS, Sen. Edwards?”


“Oh, yeah, huge issue! But can we do it outside? I just don’t want to keep people waiting,” he said.


I followed his instructions, exiting the lobby to where his bus was parked. I waited patiently, but when he and his people reached the exit doors, they ran—trailed by throngs of fans—across the sidewalk, past me and jumped into the bus. The fans screamed. Edwards waved. His rock-’n’-roll soundtrack blared. The bus drove away. I was lost in the crowd.


Next up—Kucinich. Although the media portrayed him as uncharismatic, Kucinich was a dynamic speaker. He spoke in paragraphs, outlining concise criticisms of the current administration and returning periodically to such underlying themes as “the truth shall set you free.”


After his speech, I asked him if his plan for a single-payer health-care system was a viable option for the 45 million uninsured. He said he’d talk to me in the lobby. Wary of being blown off again, I stuck close until a reporter shoved her microphone in my face and pushed past me, almost knocking over an Iowan waiting patiently for Kucinich’s autograph.


Stunned, I stumbled backward, losing my place in the international press swarm. Then, Kucinich’s campaign manager said they had to go, and the candidate apologized and left. Watching the Iowan glare at the journalist, I realized I wasn’t rude enough to compete with campaign reporters.


Kerry had canceled his appearance in Dubuque, so I hit the road to catch him at his next stop.


SATURDAY, 8:45PM - CEDAR RAPIDS


Two men stood in the median of the main drag holding large “Kerry for President” signs and shouting at passing traffic. They directed me to an intimate theater-in-the-round-style venue where Kerry was expected to hold a question-and-answer session.


It was past 9:15 p.m. Kerry was late, but according to his Des Moines headquarters, he was not going to cancel. His daughters, Vanessa and Alexandra, took the stage after a comedian and a Kerry biographer had run out of things to say. When their talk reached a lull, I thought I’d help. “Hi! I was wondering if you would take questions,” I shouted. They both said they would.


“You were talking about growing up with John Kerry,” I said, “and most of us growing up kind of thought our parents were a little weird.” The crowd laughed. “I’m pretty much grown up, and I still think my parents are weird. Is your dad weird?”


The sisters smiled and told of a time their dad wore a bathing suit on the outside of a full wetsuit and how he used to make pancakes in animal and alphabet shapes. This provoked more questions from the audience, which finally ended with someone suggesting they debate the Bush girls. Later I apologized for putting them on the spot, but they said it was fun.


When Kerry finally arrived, he had an unexpected guest—registered Republican Jim Rassman, the former Army Green Beret Kerry rescued under enemy fire nearly 35 years ago and hadn’t seen since Vietnam. Rassman had recently contacted the Kerry campaign and offered to do anything he could to help. The Kerry–Rassman reunion event earlier in the day was a public relations dream come true. I suspected this was the reason Kerry had canceled his Dubuque appearance.


After Rassman said a few candid words about the candidate’s courage and selflessness, Kerry took center stage, and the question-and-answer period began. I asked if he really had a plan to address the AIDS epidemic or if he were just blindly pledging money and making declarations like everyone else seemed to be doing. He fired back that he had written comprehensive HIV/ AIDS legislation in the Senate and then called on all Americans to redouble their efforts to battle the virus.


Kerry answered questions until well past 11 p.m. when campaign managers tried to drag him away. The senator refused, telling the crowd that if any undecided voters had unanswered questions preventing them from caucusing for him, he would not leave without giving them an answer.


An older gentleman took this as an opportunity to leave. As he made his way to the exit, Kerry thanked him for his time and asked if he could count on the man’s vote. The man said he favored retired Army Gen. Wes Clark, but if Clark wasn’t a “viable” option on caucus day, he’d vote for Kerry. Kerry smiled, shook his hand and said, “Thank you for your vote, sir.”


SUNDAY MORNING - NEWTON


The gravel parking lot of the local union hall was packed with U.S.-made cars. Flanked by Teamsters President James Hoffa and other union leaders, Rep. Richard Gephardt (D-Mo.) addressed a standing-room-only crowd, blasting the North American Free Trade Agreement and calling for new jobs. On the topic of health care, his eyes welled with tears as he spoke about his son who almost died of cancer as a child.


Afterward, he shook hands with and talked to every union member who approached. He paused for a brief interview via satellite and for one last photo opportunity with the local union boss’s family, then bid farewell to the crowd. I followed the candidate out the door, inquiring, “Why employer-based health care?”


He was about to answer when a reporter and cameraman asked Gephardt his policy toward Europe. Incredibly frustrated, I walked away. After responding to the reporter, Gephardt glanced across the parking lot, gave me a puzzled look, climbed into his sport utility vehicle and sped away. He probably thought I was a reporter, and I bet he’d never seen one give up before.


But I hadn’t. I jumped into my car, put the gas pedal to the floor and roared out of the parking lot, hell bent for Pella, Gephardt’s next campaign stop.


MONDAY - THE ROAD HOME


I left for home the same time Iowans filed into their respective caucus sites. Driving through the night, past the dusky outlines of pole barns and silos, I listened to the results. Kerry and Edwards had surged with 38 percent and 32 percent of the votes, respectively. Dean came in third with 18 percent. Gephardt was left with 11 percent, and Kucinich’s first showing was 1 percent.


As I reflected on my weekend trip, I decided my success at accessing the candidates had exceeded my expectations. Yet I felt I had learned the most from the people of Iowa.


On the whole, they thought it was nice I was promoting health care, but most Democratic Iowans didn’t separate the issues the way I did. They made me realize that advocating for health care was tied to a lot of other things. They had a profound sense of the peril of their own well-being. They looked at the yearly increases in insurance premiums and shrinking coverage, the astronomical costs of medications, the lucrative profits of insurance and pharmaceutical companies, the bank foreclosures of their family farms, the local jobs lost to foreign competition, and the billions of dollars Congress sent to Iraq as one issue in the same: Their way of life was vanishing.


They weren’t concerned with the finer distinctions among the candidates’ policies. They were focused on getting a Democrat—any Democrat—into office. A democracy of people voting against what they were afraid of instead of voting for what they believed in was not the kind of idealistic democracy I had learned about in high-school civics class.


As those last precincts reported in, it became clear that these Iowans, in their polite, understated way, were sending a simple message to the rest of America’s voters: Quit fighting over the details, band together and hold the line.


I wondered how different physicians are from them. What if we gave up on turf wars and infighting, and united as a profession? What if we joined our scalpels and prescription pads, and presented a united front against the lobbyists, the insurers, the health-plan bosses and the TV ads? What message would this send to the rest of the nation? Could we hold the line? Could we preserve our way of life?


Earlier that day, a campaign volunteer asked me if I should have been studying for school instead of driving around Iowa. A good point, I thought, then said, “This is medical school.”


The volunteer smiled, and we watched as the press pool of another candidate poured into the building like storm troopers, frantically fighting for another vantage point in anticipation of another dramatic entrance and another stump speech at another stop on the long haul toward the White House.
~~~~Will Nicholson is a third-year at the University of Minnesota Medical School. Direct comments about this article to tnp@amsa.org. ~Advocacy,Health Policy~
124~7October~2004-53~Feature~Wellness Rx~~Rebecca Sernett~~Future physicians need to look after their own health as much as they do their patients’ well-being. But this can be challenging when life becomes consumed by school, clerkships and preparing for residency. To learn how medical
students cope with the rigors of training, The New Physician asked readers to share their prescriptions for wellness. And while their advice ranges from starting a family to mountain climbing, a common thread connects each future physician’s prescription: making the time to pursue a passion that’s perhaps as equally rewarding as the journey to becoming a physician.
— Rebecca Sernett, editor


Kohar Jones -- Fourth-year, Yale University School of Medicine


For total body relaxation and soul rejuvenation, nothing beats spending time outdoors. Maybe it’s the need in all humans to connect with the sun, soil, water and air that give us life. Ventilators in the intensive care unit may breathe for humans, but the air they pump enables patients to sit in the sunshine again.


During my surgical rotation, I met a 43-year-old woman with pancreatic cancer preparing to leave the hospital 12 days after undergoing a Whipple procedure. “I am so happy I’m still alive and get to go to the shore again,” she said. “On the next sunny day, you’ll find me walking barefoot in the sand.”


The sun came out that afternoon. I stepped outside, slipped off my shoes and walked barefoot in the pansy-lined patch of grass in front of the hospital. I imagined her—scarred abdomen, dismal prognosis, reveling in the sunshine and sand at the shore.


When I play in nature, I remember how awesome it is to be alive and appreciate my growing ability to provide other people with the opportunity to fully enjoy being alive, too.


Peter Chien Jr. -- Fourth-year,New York University School of Medicine


I’ve started to deal with the stresses of medical school by photographing underwater life. This hobby developed four years ago at a medical conference in Oahu, Hawaii, where amid all the joy and stress of political activism, I decided to treat myself to a day of snorkeling in Hanauma Bay. However, it wasn’t until another conference in Hawaii four years later that I learned to scuba dive.


It was a challenging and thrilling experience. After 20-some years
of respirations above water, the concept of being able to breathe underwater took a whole morning’s pool lesson for the brain to appreciate. Learning how to stay calm and controlled in the face of leaky goggles or losing one’s regulator were also crucial skills to master. But I traded in these fears for the prospect of capturing sea turtles on camera.


After the lesson, our boat sped across Kahana Bay toward a
seemingly endless horizon. With my digital camera protected in an underwater case, I took the plunge and documented a fantastic world. The turtles were as curious about me as I was about them—or perhaps they were just curious about my camera. Whenever I whipped out the shiny metal object, they swam up to it. I was hooked.


Now I’m finishing my pediatrics clerkship. In two weeks, I’ll be scuba diving in St. Croix in the U.S. Virgin Islands to explore more marine life and get my open-water certification. This is a hobby I’ll definitely continue into residency and beyond.


Leana Wen -- Third-year, Washington University School of Medicine


Dancing and laughter are my life. Medical school is stressful and threatens to consume us on a daily basis—there is always more to learn, more to read, more to do. For socially conscious students, there’s always more we can and should be doing to raise awareness and help our communities. We could always spend every spare minute volunteering for causes and reading more about our patients’ illnesses; yet, we need to make time for ourselves and the people and things that are important to us. We need to grow as people and enjoy life.


That’s why dancing is a part of my daily life. Middle Eastern dance is a beautiful and expressive art form. Originating thousands of years ago, it began as a way for women to dance with other women in celebration of their culture. Today, it is performed all over the world. My dance troupe—Flowers of the Sahara Dance Company—performs in festivals and venues across the Midwest.


No matter how much I need to study, no matter how much the culture of medicine tells me to make it an all-consuming life, I always make time to dance and laugh.


Rachel Cramton, M.D. -- Temple University School of Medicine Class of 2004


Medical students are masters of delayed gratification. It is how the majority of us got this far, and for many it is the light at the end of the tunnel. “After gross anatomy it will get better,” they tell themselves—or “Just wait until this rotation is over...” or “After graduation….” With each milestone, they move the carrot farther away, to entice themselves to stay the course.


My prescription for wellness is to stop delaying gratification. It is not a prescription I have perfected, but it is one for which I strive. Not in all things all of the time, but in most things some of the time. I didn’t wait until after medical school to work out. Instead, I rowed multiple times each week and ran the Marine Corps Marathon in the fall of my second year. I didn’t accept that I wouldn’t see the sky until after graduation, but rather I hiked, rock-climbed and gardened with my husband throughout my four years.


Most importantly, I didn’t postpone the joys of family life indefinitely. In March 2004, spring of my fourth year, I gave birth to our beautiful son, Zachary. Zac compels me to slow down, relax and enjoy the ride. Now I can say that my prescription for wellness allowed me to finish medical school with my sanity, my sense of humor and my joy intact.


Elizabeth Eaman -- Second-year, University of Michigan Medical School


There is a place I visit to remember the big picture, a place where gloomy things are thoroughly chased away. Here, there is never a wrong answer, and everything matters just enough. This place is the barn, and within it is my prescription for wellness: horses. The instant the scent of the barn hits me, everything—quite suddenly—is good. Even if it is so cold that I can’t feel my feet, and the ground is too frozen to ride, I can hold a horse’s head and let its breath warm my hands. Even if it is so hot and humid that I sweat in places that I have never sweat before, I can run my head under the hose and give a cool bath to the horse—the both of us drying in the shade.


It is a combination of things that cures me—leather, hay, horse sweat and sweet grain along with the tang of manure and wood shavings. These, to me, are the greatest smells on earth. Horses have always held a power over me. The 6-year-old girl who was a member of the My Little Pony Fan Club has grown up. She is now a 27-year-old woman who still feels like a 6-year-old when she sits in the grass in a 4-acre field with three dogs fighting for her lap and a horse nibbling on her hair. This experience—a culmination of the smells, sounds and sights of the barn—is what makes me well.


Brian Lin -- Fourth-year, Mount Sinai School of Medicine


Medical students have to budget free time wisely in order to do academic and extracurricular activities justice. Thus, as a person who has always enjoyed competitive sports, recreational dancing and playing rhythm guitar, I’ve condensed all of these interests into a manageable wellness activity—the Brazilian art form Capoeira.


Rumored to be developed by captive slaves as a means of defying Portuguese slave traders, Capoeira has been alternately described as a dance and a martial art. It incorporates elements of physical conditioning, music and Brazilian culture. In many ways it has complemented my study of medicine, helping me to achieve a type of wellness that serves me on and beyond the wards. Performing in competitions requires split-second decision-making and creative application of an armament of movements in order to escape an incoming kick or takedown. On the wards, being quick on one’s feet and clear in one’s thinking are valuable skills when interviewing a complicated patient or responding to an overzealous attending.


Capoeira has been a social support for me as well—the great friends I have made have served as buoys when I feel I’m drowning in the sea of medical school. Finally, it has given me confidence in facing everyday challenges. In Capoeira and in medical problem-solving, one faces challenges head-on, approaching each turn in the circle with finesse and style in the hope that somehow, in the end, we can make it all seem graceful.


Monya De -- Fourth-year, University of California, Irvine, College of Medicine


Dancing—whether I’m using my right brain in lessons to learn new steps or enjoying a night out with friends dancing to big-band standards—is the ultimate release. For me, it represents fun, exercise, precious time with friends, laughter, music and mental release. It’s a mini-vacation from the stresses of medical school and the time that I reconnect with the real world through such nonmedical school friends as the one in the picture. Dance keeps me energized and lets me be a regular girl in her mid-20s once in a while, instead of the perpetually serious medical student. It’s made me a happier person and has added a treasured dimension to my four years here.



Erin Elizabeth McConnell -- Third-year, Wright State University School of Medicine


Felinothine
(fe-lin’-o-thine)
Chemical class: Felinus
Therapeutic Class: Anxiolytic
DEA Class: Schedule I
Clinical Pharmacology


Mechanism of Action: Acts to release innate endorphins, decreasing central nervous system overstimulation and reducing pre-exam anxiety


Indications and uses: Prescribed specifically for students approaching any of the United States Medical Licensing Examinations; *general stress management, *unconditional acceptance, *study companion and *overall diversion from testable material


Dosage
Henry: 4.54 kg of white-and-brown tabby, prn
Kali: 5.90 kg of brown tabby, prn


Precautions: Highly addictive; withdrawal symptoms include a pervading feeling of sadness when deprived of this therapy, rapid petting motions of inanimate objects, cooing at veritable strangers, as well as leaving one’s honeymoon early due to lack of sufficient treatment


Contraindications: Allergic rhinitis in the presence of domestic animals


Side Effects/Adverse Reactions
CNS: Pleasant distraction from all studies and other dreaded obligations, sedative response due to interaction with either variety, may increase sleep due to the
somnolence exhibited by both varieties of medication


RESP: Possible suffocation due to the Kali variety sitting on one’s trachea at 4:30 a.m. in the hope of procuring an early breakfast


HEME: Eosinophilic proliferation in the slightly or severely allergic


SKIN: Local wheal and flare reaction, due to the saliva of either the Henry or Kali variety of medication when it attempts to mark the patient as its own
* = non-FDA approved usages


(Drug reference format adapted from
Mosby’s Medical Drug Reference, 2005 edition.)


David Moskowitz -- Fourth-year, University of Washington School of Medicine


To stay balanced requires getting out to the mountains: hitting the trails, be it in hiking boots or snowshoes. I saved a rock that I found on the top of a mountain that I had hiked with some friends during the spring of my first year of medical school. I had just finished final exams and was so taken by that place. I was reminded of the parts of me that bring meter to my logical scientific mind. I toss that stone in my bag with my stethoscope, PDA and clipboard sometimes to find it in the middle of a busy clinic day. It reminds me to head out soon and find wild places, and to draw inspiration from author Edward Abbey as well as from Dr. William Osler.
~~~~~Student Life and Well-Being~
125~8November~2004-53~Feature~Healing the World~~Roxanne Nelson, R.N.~~HIV/AIDS, polio, tuberculosis
and diabetes are among the World Health Organization’s top public health concerns for the 21st century.


In 1969, U.S. Surgeon General William Stewart announced, “It’s time we close the books on infectious disease.” These were the heady days of the Civil Rights Act, the War on Poverty, Medicare and the space program, as well as an era of rapidly advancing technology. Scientists believed they could put microbes in their place and that the discoveries of “wonder drugs” and vaccines would relegate dreaded diseases to history books.


Fast-forward 35 years, and the world is quite a different place. Infectious disease remains a leading cause of death worldwide and ranks among the top 10 causes in the United States. The advent of close to 30 new diseases within the past two decades—including AIDS, severe acute respiratory syndrome, hepatitis C and Ebola—has been a humbling experience. Tuberculosis (TB), syphilis, gonorrhea and other old scourges once thought under control are re-emerging with a vengeance. And noncommunicable diseases and health issues may eventually threaten global health even more than infectious illnesses.


Many nations and communities lack the resources—financial, structural and personnel—to attend to these problems. This is where an agency such as the World Health Organization (WHO) can help. Established in 1948 as part of the United Nations (UN), the WHO acts as a coordinating authority on international public health, striving to help all people attain the highest possible level of wellness. Despite being part of the UN, the WHO has a significant amount of independence; it maintains its own budget, sets its own program priorities, and its 192 member states elect its leader, the director-general.


The organization’s priorities have shifted during the past half-century as old problems become resolved and new ones take their places. But many of the health problems afflicting the world in 1948 continue today. TB and malaria remain urgent priorities for large portions of the global population, and nations still struggle with epidemics, natural disasters, famine and wars. In addition, poverty, hunger, illiteracy, environmental degradation and discrimination against women persist, jeopardizing the health of hundreds of millions of people worldwide.


With all of these concerns to tend to, where do global health leaders place their priorities? The New Physician spoke with WHO representatives and other experts about their major focal areas for the beginning of the 21st century. Here’s what they had to say.
~WANT TO GET INVOLVED?


There are many ways to help improve global health:


FIND YOUR NICHE. Read up on the causes that interest you most. Explore the Internet and contact some organizations working on those global health issues. Ask them how you can offer assistance.


DONATE. If you’re pressed for free time, giving money to a global health group is always welcome, no matter how small. Tight on cash? Try initiating a community or school fund-raising event. If you have a few spare hours a week, donate your time. You could help maintain an organization’s Web site or stuff envelopes.


VOLUNTEER. Many groups send aid workers all over the world, and some only require a short time commitment. Contact global health groups for more information. An alternative is to volunteer close to home. Assist an infectious disease specialist with tuberculosis patient care, volunteer in a clinic providing reproductive health services, or explore the problems of malnutrition and vitamin deficiencies at a homeless shelter.
CONTRIBUTE. The perfectly good “disposable” supplies we throw away are desperately needed around the world. Rather than dumping valuable medical equipment in a landfill, begin a collection at your school or hospital. The items can be donated to numerous agencies that will deliver them to those in need.


NETWORK. Attend conferences. Take online classes. Ask physicians who work in the field about their career choices. Experts in various specialties will be able to give you direction, point you toward resources and answer your questions. Perhaps a career in research, public health or tropical diseases lies in your future. —R.N.


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


ONLINE RESOURCES

~~~~Health Policy,International Health~
126~8November~2004-53~Letter from Afield~Life in the Fields~CARING FOR MIGRANT WORKERS~Suresh Rangarajan, M.D.~~My parents moved to Texas before I was born. They came across the border from Mexico in search of work. For as long as I can remember, my family was on the road. My parents were migrant farm workers; picking and moving was a way of life.


And so began my introduction to Adrian, whom I met on a hot, muggy, summer afternoon during a rotation with the University of Michigan Medical School. As part of this fourth-year rotation, I spent one day a week with the pediatrics department, providing health care to migrant farmworkers in Lenawee County, Michigan. Adrian was one of several community volunteers at Clinica Rural, which is held every Thursday evening during the summer. Translators and social workers join the physicians and residents, meeting at a restaurant for dinner before heading out to care for migrant farmworker families. Tonight, we were to meet at Café Rendezvous, a Mexican restaurant in the small town of Blissfield.


Known for little more than the Old Road Dinner Train—a two-and-a-half-hour murder-mystery dinner show that entertains hungry tourists as they travel throughout the Michigan countryside—Blissfield is an indistinct, sleepy town. Although I wasn’t expecting much of a greeting when I pulled in, I wasn’t prepared for what I encountered either.


It was barely dinner time, and Blissfield, with its 3,123 residents, was dead-quiet. Resembling a ghost town, the main street stores and restaurants, including the Rendezvous, were closed. Everything felt surreal, if not eerie. Little did I know that more than 50 million people from New York to southeastern Canada had just lost power as a result of FirstEnergy’s Ohio grid failure; Blissfield fell victim, too. Unaware of the power outage and unsure of what else to do, I planted myself in front of Café Rendezvous, hoping other volunteers would soon appear. I didn’t have to wait long. Within a few minutes, Elda, Chris and Adrian arrived in a Community Action Agency van filled with medical supplies.


They told me about the blackout, and we wondered if we would still hold the clinic—all pager systems were down, and major roads were clogged as most traffic lights across the state were out. We decided to wait and walked to a corner café that appeared to be serving whatever cold drinks and hot coffee it had left.


I hadn’t met Adrian before, so I thought I’d drum up some conversation. I told him I was compiling a photo essay as part of my rotation documenting the lives of migrant farmworker children in Lenawee County. This was only Adrian’s second time volunteering at the clinic, but he told me he was quite familiar with the lives of migrant farmworkers, for he grew up in the fields. I asked him to tell me his story, and he was eager to share:


Picking and moving was a way of life. My first childhood pictures are those of me playing in the fields while mom and dad worked. We lived in Texas, Florida, Indiana, Michigan and Ohio before I started elementary school. My mom was strict about education. She knew it was the only way I could escape migrant farming. She pushed me from the beginning. She’s a strong woman.


I remember one summer when the harvest on a farm here in Lenawee County was really good. The grower made the migrants work late into the night. He had a huge row of lights on his tractor. The migrants would pick a row, and the tractor would move up. One night, after 14 long days in the field, my mom had had enough. She turned around and told the farmer she wasn’t going to work anymore. She flipped her bucket over and took a seat. The farmer was so mad. He climbed off the tractor and threatened to hit her. My dad stepped in and said if the farmer hit her, he would kill him right there. Soon, other pickers sat down on their buckets, too. The farmer’s wife heard the yelling and came out to see what was going on. My mom told her she couldn’t work any longer. She hadn’t had time to wash her or her children’s clothes in two weeks.


Since that night, life on that farm has never been the same. Farmworkers now have a half day off every week. I guess the farmer realized he was wrong. I also think he respected my mom for standing her ground because he no longer gave her a hard time or came to our door yelling, “Mojados!” in the morning to wake us up. He’s actually a nice guy now.


But my mom wanted me to have a better future so she kept me in school. I can’t remember how many elementary schools I attended because there were too many; same with middle schools. I went to six high schools and managed to graduate through a module-learning program. If you worked well on your own, you could get through. I also tried to do well because I was scared that if I didn’t, the school system would discover that my parents did not have papers and would deport them back to Mexico.


I would usually work in the fields before school in the morning and after school from about 3:30 p.m. until dark. There wasn’t much time for homework. It was difficult, but working in the fields as a teenager wasn’t that bad because I could meet girls. If a girl talked to you while picking, you knew she wasn’t after your money. The most exciting part of the day was racing for a shower, especially if you had a date. There were only two stalls for all the workers and their children. Everyone would run to catch the first and only two hot showers. But even a cold shower was better than none, for if you didn’t rinse off, you would be itching all night.


After graduating from high school, I got out of migrant farming by joining the U.S. Marine Corps. I knew I could make good money if I worked for Uncle Sam and that my parents would be safe from deportation. I also knew I would have a good shot at getting a job later on. I guess I was one of the lucky ones. My mom was right; education was the key to escaping the migrant farmworker life.


After hearing Adrian’s story, I felt as though I was witnessing something special. Sure I’ve spent hours chained to a desk to make it to this point in medical school, but my accomplishments seem small compared with Adrian’s.


Unfortunately, not all migrant farm children are as fortunate as Adrian. For many families, the economic reality of what an extra pair of productive hands can do hits as the children become teenagers. By the time they reach high school, the children often drop out of school or only go a few days a week—the pressure to work in the field is too great. This is not to say the migrant Latino community does not value education; rather, the family’s immediate survival takes priority.


As future physicians, we must ask ourselves what we can do for these kids. How can we help them break free of the migrant workers’ cycle? Every complex social question has more than one answer. To begin, most of these children lack the basic necessities—a safe and clean living environment, an adequate and balanced diet, access to health care and such injury prevention measures as car seats—to support a healthy life. These are basic human rights. Yet, in the most affluent country in the world, human rights are at risk for the migrant farming population.


But we can help. Whether by working in a migrant farmworker clinic, fund raising for needed child car seats or conducting research on migrant farmworkers, we can increase the chances these children will grow up to become productive members of mainstream American society.
~~~~
A 2004 graduate of the University of Michigan Medical School, Suresh Rangarajan is working at the Hospital del Niño in La Paz, Bolivia. He will return to the United States in June to begin a medicine–pediatrics residency.
~Health Disparities,Minority Affairs~
127~8November~2004-53~Feature~A Modern Analysis~ONCE CONSIDERED MORE SUPERSTITION THAN SCIENCE, PSYCHIATRY IS STARTING TO SHAKE ITS STEREOTYPE. ~Avery Hurt~~How do you tell the difference between the psychiatrists and the patients at the mental hospital? The patients are the ones who eventually get better and go home.


OK, so psychiatry has had its image problems. And not just in the public eye; its image hasn’t fared much better within the medical profession. Throughout the last half of the 20th century, the number of medical school graduates entering the specialty suffered a steady decline.


The increasing emphasis during the past 50 years on clinical research and evidence-based medicine cast an aura of uncertainty on psychiatry, whose practices seemed to be based more on instinct and humanism than on hard science. Medical students were—and in some ways continue to be—stigmatized for their interests in this specialty, which hit rock bottom in 1998, when just 428 U.S. medical school graduates matched into general psychiatry residency programs. (See “Overcoming Psychiatry’s Stigma,” p. 9.)


But the field is making a comeback. By 2004, the number of U.S. graduates matching to psychiatry jumped to 641. And with foreign medical graduates picking up much of the slack, the total entering the field this year comes to 979.


There are plenty of reasons for the renewed interest. Despite its lingering image problem, psychiatry is more appealing thanks to changes in the way it’s practiced. Today’s psychiatrist has far more options for helping her patients than her predecessors had. The field also offers a wealth of career opportunities as well as job flexibility and the kind of family-friendly employment opportunities that can be hard to come by in other areas of medicine. But perhaps psychiatry’s most attractive feature is that it is one of the few specialties in which physicians can take time to establish relationships with their patients—not a small thing when surveys continue to show one of the primary reasons for dissatisfaction with the practice of medicine is that physicians spend more time with their paperwork than with their patients. And all of this is happening at a time when advances in neuroscience are chipping away at stereotypes, offering exciting new avenues for research and a wealth of increased treatment options.


REUPHOLSTERING THE COUCH


The public image of psychiatry is based largely on one psychiatrist and the school of therapy he founded. Dr. Sigmund Freud, the father of psychoanalysis, casts a long shadow over the field. Although the early years of the 20th century saw the development of a variety of psychological theories and therapies—some based on sound medicine, while such others as electroconvulsive therapy and the frontal lobotomy proved more alarming—it was Freud’s psychoanalysis that grabbed the spotlight. Freud theorized that conflicts between different aspects of a patient’s unconscious are the roots of all psychological problems, and he developed the discussion-type therapy to locate and deal with them. It is his method, his couch and even his beard that shaped much of psychiatry’s image.


Yet, no sooner had psychoanalysis taken hold than, like a Protestant religion, disagreements over doctrine, competing factions and opposition movements splintered the faithful and spawned a variety of new therapies ranging from Jungian analysis to variant psychodynamic techniques. Today, a savvy consumer of talk therapy has almost as much choice in the mental-health market as she does in the cereal aisle of the supermarket. And with such a wide array of treatment options, psychoanalysis is becoming one of the least popular.


But it’s by no means dead. The American Psychoanalytic Association claims 3,200 members, and “psychoanalysis is still a vibrant, intellectual field,” says Dr. Phillip Freeman, a training and supervising psychoanalyst at the Boston Psychoanalytic Society and Institute. It’s just that if Freud no longer defines the field of psychiatry, neither does he define psychoanalysis.


“Psychoanalysis has changed over time, with a wealth of attention to refinements that help the analyst do a better job,” Freeman says.


So, in recent years, strict Freudians have had to make room on the couch for other methods, styles and theories. One of the most commonly used methods of psychotherapy is cognitive behavioral therapy, which focuses on modifying the patient’s beliefs and changing her problematic behaviors rather than searching her unconscious.


Cognitive behavioral therapy is attractive to patients, insurers and practitioners, in part because of its efficiency. Whereas meeting the goals of psychoanalysis can take years, patients undergoing cognitive therapy can see results in months or sometimes weeks.


It “tends to be very pragmatic,” says Dr. Judith Beck, director of the Beck Institute for Cognitive Therapy and Research at the University of Pennsylvania and the daughter of cognitive behavioral therapy’s founder, Dr. Aaron Beck. One of the goals of this approach is to reduce the patient’s need for therapy. The cognitive therapist gives the patient skills she can use when she is not in the therapist’s office. “We want patients to feel better at the end of their sessions, but more important, we want them to feel better all week,” Beck says.


Cognitive behavioral therapy and similar techniques are popular, and clinical trials have shown them to be relatively successful. But, they face some stiff competition from the prescription pad.


POPPING PILLS


Today’s psychiatrist has at her fingertips pharmacological resources that would have seemed miraculous 50 years ago, and they are time- and cost-effective, leading more psychiatrists to replace talk therapies with chemical treatments.


The mid-20th century saw the development of the first psychotropic medications. In 1949, lithium became available for treating manic depression and was soon followed by such antipsychotics as Thorazine and such tricyclic antidepressants as Tofranil and Elavil. The availability of these drugs brought major changes to the treatment of mental illness, moving it from the asylum to the community clinic.


But the real psychopharmacology revolution has come only within the past 15 years, led by the introduction in the late 1980s of selective serotonin reuptake inhibitors (SSRIs), a hugely popular new class of drugs for treating depression. It is estimated that more than 10 million people in the United States take some form of antidepressant, mostly SSRIs. According to many clinicians, the drugs are remarkably good at alleviating depression with relatively few side effects.


Others, however, are not so sure, and SSRIs have recently become the subject of much criticism. Several studies have indicated that in clinical trials, SSRIs do not perform much—if at all—better than a placebo. The common minor side effects, including sexual dysfunction, nausea and insomnia, can be quite unpleasant—and the major ones are deadly.


When they first came on the market, SSRIs were accused of inducing violence and suicide in some patients. Although these initial claims were never substantiated—the drug manufacturers settled out of court on several cases—evidence now shows SSRIs can cause suicidal thoughts and behaviors in children. In September, the U.S. Food and Drug Administration (FDA) said as many as 3 percent of children taking SSRIs could blame their suicidal tendencies on the drugs and not their depression. An FDA advisory panel recommended the medications carry the strongest warning the agency can mandate, although at press time, FDA officials had not made a decision on the matter. And GlaxoSmithKline, the manufacturer of the widely prescribed antidepressant Paxil, recently settled a lawsuit with New York state by paying $2.5 million and agreeing to publicly disclose all of its findings in clinical trials about the drug’s safety in children, for whom it is often prescribed.


Despite the negative publicity, physicians continue to prescribe the drugs, perhaps too often. “SSRIs are probably being overprescribed,” says Dr. Michelle Pent, a chief resident in the Harvard Longwood Psychiatry Residency Training Program. “Many of the people on SSRIs are struggling to cope, suffering from ‘modern malaise.’ In these cases, medication is not always the best first step. But for the majority of my patients—most of whom have severe, debilitating, chronic illnesses, such as schizophrenia, bipolar disorder, major depression—various medications are the mainstay of my practice. In my experience, these drugs are keeping people out of the hospital and functional.”


FROM THE COUCH TO THE LAB


The marked increase in the use of psychoactive drugs may have been due in part to the pharmaceutical industry’s energetic marketing and to the relief the drugs offer patients, but it was almost certainly not due to a clear understanding of why these drugs work. The search for the biochemical underpinnings of mental illness has been on for some time, and the fact that adjusting certain chemical balances in the brain often seems to help has been accepted for years. But why this succeeds is still largely a mystery, although a recent surge of interest in neuroscience has led to a better understanding—or at least some new theories—of how the mind works, and therapies based on science may be on the horizon.


Noboru Hiroi, Ph.D., director of the Laboratory of Molecular Psychobiology at Albert Einstein College of Medicine, has done seminal work on the genetic basis of mental illness. “We are finding out a lot about the molecular basis of mental diseases,” he says, predicting researchers will be able to offer treatments based on scientific findings in about 10 years.


This bench-to-bedside approach, common in such fields as oncology, is a new one for psychiatry. “Psychiatry is really benefiting from this more organized, formalized approach,” says Dr. Michelle Riba, president of the American Psychiatric Association (APA).


Srijan Sen, an eighth-year M.D./ Ph.D. student at the University of Michigan (UM), agrees. “Psychiatry is a very exciting place to be.”


Sen recently completed his dissertation on locating the genes responsible for depression. While finding particular biochemical causes for mental illness is still a long way off, he believes progress is being made: for example, in finding the differences in gene patterns between depressed and healthy people and in using MRIs to discern changes in the brain after medication or psychotherapy. These discoveries, preliminary as they are, are already helping to reduce the stigma associated with mental illness. “The stigmas are definitely there, but that is changing. The more we know about the chemical changes in the brain associated with mental illness, the less the stigmas will hold up,” Sen says.


A FLEXIBLE AND CHALLENGING CAREER


With new and better tools at their disposal for helping their patients, clinical evidence to support their decisions and better science on the way, more future physicians are becoming interested in psychiatry, rapidly moving the field from the fringes of modern medicine to the mainstream. But there are also more personal reasons the specialty is gaining ground.


“There are so many opportunities for psychiatrists today; it’s kind of like being a kid in a candy store,” Riba says. Psychiatrists can specialize in child and adolescent, geriatric, addiction or forensic psychiatry, or they can do research. And these are just a few of the options. Practice settings vary from private offices to state hospitals to community health clinics, and a psychiatrist can combine various opportunities in creative ways to meet her intellectual and practical needs.


“It’s very exciting,” says Dr. Deborah Hales, the APA’s director of medical education. “A psychiatrist can have several types of careers at once.”


It can be satisfying on a clinical level as well. “People really do get better. We can do some prevention and help patients and their families go on and have happier, healthier lives,” Riba says.


And the career satisfaction continues after the white coat comes off at the end of the workday. Thanks to the multitude of practice choices, psychiatry can offer a controllable lifestyle, especially to women trying to balance a family and career. “Psychiatry is a very family-friendly specialty,” Riba says. “I know of two residents, both pregnant, who job-shared, shared [emergency room] call and that kind of thing. It worked well for them.”


Hales adds that unlike some specialties, in psychiatry it is easy to have a part-time practice, possibly one reason more women than men choose it.


That is not to say the specialty does not offer challenges. There is a definite shortage of psychiatrists, and funding for mental-health care can be scarce. Despite the availability of new therapies and a lessening of the stigmas associated with mental illness, more than one-third of those sick enough to need professional care aren’t getting it. The reasons are varied, but cost is a major factor.


According to a recent article in Psychiatric Times, states are cutting funding for social programs, community mental-health initiatives and Medicaid, on which 65 percent of schizophrenics and 25 percent of those with severe depression rely. Mainly due to staggering state budget deficits, the cuts to these programs can have devastating effects on patients and their communities.


And public health is not the only area in which mental-health funding suffers. Managed-care companies and other insurance providers are increasingly likely to refuse payment for what professionals deem necessary care. Legislation pending in Congress—the Wellstone Mental Health Equitable Treatment Act—would require group health plans to cover mental-health care to the same degree they cover medical and surgical services, and while the APA is working to get the act passed, it is a big battle. “We are very hopeful it will pass, but there are a lot of distractions right now,” Riba says.


However, the federal government isn’t turning a completely blind eye to the issue. The president’s New Freedom Commission on Mental Health found the nation’s mental-health-care network in dire need of some therapy and issued some recommendations, including the development of evidence-based practices, a national strategy for preventing suicides and the integration of mental-health care into primary care settings.


For the most part, mental-health experts and advocates support these suggestions. However, they do not welcome the report’s insistence that all the necessary changes can be accomplished without additional funding, a finding few see as realistic.


While these challenges don’t seem to be keeping future physicians from the field, they are impacting psychiatrists once they get there. Pent says her practice is rewarding, “but the realities of the mental-health system are worse than I expected.


“The financial resources are very limited. Insurance companies are not paying for what patients need, and all too often my hands are tied when it comes to providing my patients with what they need, rather than what insurance will pay for.”


GETTING THERE


For those future physicians willing and eager to take on psychiatry’s challenges and flexible career options, it is possible to tailor an education to match those plans, something even premeds can consider. Most medical schools’ curricula provide a basic preparation for psychiatry training, but different programs have different emphases: Johns Hopkins University School of Medicine is known for its biological approach and research initiatives; the University of Pennsylvania School of Medicine is home to the Beck Institute with its focus on cognitive therapy; and UM has given Sen and his fellow students the opportunity to conduct innovative research.


Future physicians should find a program that suits their approach and interests, but looking for a place that offers a wide variety of experiences is a good idea, too, advises Hales, pointing to the University of San Francisco as an example. The school’s three psychoanalytic institutes and quit-smoking clinic offer medical students clinical opportunities, while its San Francisco General Hospital provides a glimpse into psychiatry in a public-health setting. Opportunities for research in neuroscience and schizophrenia are also available.


The research element is important, Hiroi says. He urges students to take the core courses in the hard sciences and to consider entering an M.D./Ph.D. program. “In the near future, a psychiatrist will really need a background in a scientific area,” he says.


Hales agrees: “There is a crying need for researchers in psychiatry. But there is also a need for people with strong clinical skills. We need scientists, and we need humanists.” She predicts psychiatry will maintain its basic humanism, even as it becomes more scientific and evidence-based.


“Humanists who read Hamlet to better understand indecision can work alongside lab scientists who want to understand the molecular basis for behavior. The fact is psychiatry needs to embrace its dual nature,” she says. This could appeal to greater numbers of medical students, many of whom are devoted to preserving humanism in medicine.


And while it may be a long time before the stigma completely fades and the jokes improve—two psychiatrists pass each other in the hall. The first one says, “Hello.” The other thinks, “What did he mean by that?”—the field has at least convinced increasing numbers of new physicians that the specialty itself is no joke.
~OPPORTUNITIES OUTSIDE CLERKSHIPS


When preparing for a career in psychiatry, students are often eager to get as much clinical experience as they can. Educational opportunities beyond a clinical clerkship can be found at:


—A.H.


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


RESOURCES


Interested in pursuing a psychiatry
specialty? Check out these Web sites:


~~~ew Physician contributing editor Avery Hurt is a freelance journalist based in Birmingham, Alabama. Direct comments about this article to tnp@www.amsa.org.~Career Development,Medical Education,Practice of Medicine~
128~8November~2004-53~Feature~Primary Concern?~REVIEWING THE PRIMARY CARE DEBATE AND EFFORTS AT REFORM ~Beth McNichol~~In 2004, when a medical student—the son of an ophthalmologist—bursts into his mentor’s office, wildly proclaiming his love for family medicine, she may spin around and check the calendar to be sure she hasn’t awakened in the early 1990s. Nowadays, family medicine’s low pay, long hours and perceived lack of prestige all make enthusiasm for the field an unlikely circumstance. But it was just last summer that Dr. Holly Cronau, assistant professor of clinical family medicine at Ohio State University College of Medicine and Public Health, experienced this scenario after one of her students spent six weeks in a family medicine externship program (see “Shoring Up Family Medicine,” p. 13), watching a preceptor in private practice introduce patients as “so-and-so’s neighbor or cousin.”


“He loved the continuity; he loved the aspect of someone just being so intimate with their patients,” Cronau says. “He told me that he didn’t realize there was this whole other world out there.”


Depending on whom you ask, that world is either richly in trouble or naturally diminishing with little cause for concern. If National Resident Matching Program numbers are to be given crystal-ball weight, primary care is becoming an oxymoronic term. In general, the numbers of U.S. medical graduates entering primary care fields have declined for the past five years. In this year’s Match, while internal medicine and pediatrics, including their subspecialties, saw modest increases—1.3 percent and 1.2 percent, respectively—family medicine and its subspecialty numbers declined 2.9 percent. While these percentages don’t take into account whether or not the 2004 Match offered fewer residencies in these fields, many primary care experts see trouble on the horizon. The bottom line: U.S. allopathic medical schools are training fewer primary care physicians.


But is the problem as bad as it seems? Dr. Michael Fleming, president of the American Academy of Family Physicians (AAFP), argues that the country’s ability to provide health care to its citizens will be sacrificed if more action isn’t taken to shore up primary care. Citing an April study published online in Health Affairs, Fleming points out that, among Medicare patients, those who saw more specialists spent more money and had worse outcomes than those who mainly saw primary care physicians.


According to research cited in the AAFP’s report, “The Future of Family Medicine,” which was published in the March/April Annals of Family Medicine, one in four office visits annually are with family medicine practitioners, and about half of all office visits annually are with primary care physicians. The report also cites a 2002 study from the Journal of the American Medical Association that concludes if family practice physicians were to become extinct, 58 percent of all U.S. counties would be federally classified primary care Health Professional Shortage Areas.


“There is a great deal of data now that shows that the only countries that have health-care systems that truly work—that not only have the economy of care but also the quality—are health systems that are based on a primary care model,” Fleming says. “We’re going in exactly the wrong direction, then. Primary care is, in fact, the closest thing to a savior for the system that there is.”


Some future physicians who have chosen primary care share this view. “The lack of students going into primary care is a huge problem,” says Margo Jenkins, a third-year at Xavier University School of Medicine in the Netherlands Antilles. Jenkins is one of a growing number of foreign medical school students who plan to pick up the U.S. primary care residency slots left vacant by U.S. medical graduates. “Most health-care issues can be solved at the grass-roots level of health care, saving time and money for patients, improving their health and decreasing their frustration with the system,” she says.


The problem, say Fleming and others, is getting the academic medicine community and its students to recognize the importance of primary care. “One of the biggest issues we’ve had is that within academic medical centers, [students] are discouraged,” Fleming says. “And they’re discouraged for a lot of reasons. One of them is money.”


Indeed, with U.S. medical school graduates carrying an average debt load of more than $100,000 and with the rising costs in medical liability insurance, making around $150,000 annually as a primary care physician can seem unwise to students when some specialties bring in nearly $400,000. When you add to this the controlled hours of a career in radiology, for example, it’s no surprise that future physicians—often spurred by their educators—reject primary care.


Just as damaging, students say, are the seemingly widespread assaults on the capabilities of primary care physicians—especially in regard to family practitioners. Kohar Jones, a fourth-year at Yale University School of Medicine—one of a handful of schools without a family medicine department—says instructors told her it was “a waste of a medical education to do primary care” and that she was both “too smart for that” and not smart enough. “There’s way too much to know. Don’t you want to know what you’re talking about?” she says instructors say.


Laura Klatt, a fourth-year at the University of North Carolina at Chapel Hill School of Medicine, experienced similar discouragement. “Even in schools that push primary care, there is still the undercurrent of thought that you are not very intelligent if you choose primary care,” Klatt says. “This is especially true of family medicine. I have had dozens of people try to talk me out of family medicine because I am ‘too smart’ and my credentials are ‘too strong.’”


Fleming says that perception is “patently wrong.” In fact, he argues, incoming residents’ test and licensing board scores indicate family medicine attracts top-tier graduates. “It is a broad field, and there is a lot to know. But the fact is that we are the mind of medicine. We’re needed.”


Not everyone agrees with his assessment. Dr. Richard Cooper, professor of medicine and health policy and the director of the Health Policy Institute (HPI) at the Medical College of Wisconsin, says there will be significant physician shortages during the coming decades, but that those shortages will be in specialist disciplines, not primary care—and certainly not in family medicine.


“If you were to call the flight controller’s union, what do you think they’d tell you about the number of flight controllers in the country? This is kind of an old mantra,” says Cooper, who specialized in hematology-oncology after training in internal medicine and has led the HPI for the past 12 years.


He cites statistics from the health-care recruiting firm Merritt, Hawkins and Associates that indicate a higher demand for specialists. He says market forces indicate the country still only needs about 80 physicians per 100,000 people—the same as in 1950, and what we have now. There aren’t fewer primary care physicians than before, he says, just a greater percentage of specialists and a growing need for more of them.


“Yes, our system is organized around primary care. But with the growth in nurse practitioners, it’s not necessarily organized around primary care physicians. It’s organized around primary care teams,” he says.


Family practice is the best to take over rural medicine—but with less than 20 percent of U.S. residents living in nonmetropolitan counties, we won’t need more family physicians, he argues. And primary care physicians in more populated areas no longer handle surgeries or deliver babies as they once did, he adds.


“These are all very powerful spokespeople for a philosophic position that is simply contrary to the way the people want to experience medicine. Primary care doctors only get one vote on how it should be, just like patients. And patients vote with their feet. The first thing they want to do when they’re sick is see someone who really knows a lot about it—specialists,” he says.


Other work-force analysts take a more measured view of the health-care horizon. Edward Salsberg, director of the newly established Center for Workforce Studies at the Association of American Medical Colleges (AAMC), has spent 20 years working in and studying health care, and he doesn’t think primary care is in trouble.


“The marketplace is very sensitive to changes,” he says, citing published 1990s data on anesthesiology residents having difficulty finding jobs, which led to negative communication among schools and medical students, and a perception that the job market was tight. “The job market probably was tight for anesthesiology at that time. But the numbers of people going into the field then dropped in half over a five-year period because of that perception, which in turn led to a shortage. So slight surpluses and slight shortages can end up looking very big. There’s no reason to send out a call that the sky is falling.”


Salsberg agrees with Cooper that physician shortages are likely over the next two decades and that the hardest-hit areas will probably be specialties serving aging populations, such as cardiology, oncology and urology. The AAMC and Council on Graduate Medical Education have recommended increasing medical school capacity by 15 percent over the next decade to keep up with the demand, yet reject a previously suggested target that U.S. medicine should achieve a 50-50 generalist-to-specialist ratio.


“But I don’t think that means that we’re not going to need family physicians or internists or pediatricians, too,” Salsberg says. “If you’re a medical student now, you should be pretty comfortable that there are going to be many opportunities over the next 20 years in almost every specialty.”


So how does U.S. medicine know when to sound the primary care alarm bell? According to Salsberg, it’s when primary care physicians see a continued marked difference in salary relative to other specialties. “We shouldn’t ask our primary care physicians to sacrifice more financially than other physicians.”


Ultimately, says Dr. Mary Mebane, a first-year resident in rural family practice in Harpers Ferry, West Virginia, the demanding aspects of the primary care lifestyle are not going to be attractive to medical students seeking residency—and she doesn’t blame them. Mebane worked in finance for 15 years before a volunteer health position prompted a career change. She believes incentives are the key. “It’s the same as business. You have to reallocate your funds a little bit, and what you can’t afford to give them financially, you have to give them in insurance, better retirement packages, things they can fold into their income statements.


“Unfortunately,” she says, “when you go into medical school at 20, 21 years old, you want what everyone wants at that age. You want good money, but you don’t want to work your tail off to get it.”
~SHORING UP FAMILY MEDICINE


Many academics, medical leaders and physicians concerned about primary care aren’t waiting for further decreases in primary care physicians’ salaries to act. In “The Future of Family Medicine” project, the American Academy of Family Physicians (AAFP) and seven other family practice organizations conducted an exhaustive two-year study of the field and based on their findings are creating programs they hope will increase medical students’ interest in family practice.


Chief among them, says AAFP President Dr. Michael Fleming, is the “new model of care” initiative, which stresses patient-centered and evidence-based medicine and promotes electronic health records systems, as well as flexible office hours and e-mail communication. All of these, the AAFP says, give patients services they desire while letting students know that family medicine plans to be on the cutting edge of technology and medical services.


Some medical students complain that medical schools focus on specialization because that’s where research dollars are spent, but Fleming hopes his plan to create more evidence-based education in medical schools will encourage more research in primary care and preventive medicine. Including practice management training in family medicine residency programs will help students ease the sometimes overwhelming transition to a family medical practice, he says. And to let residents get a head start on medicine’s technology age, the AAFP wants postgraduate training programs to begin using electronic health records, too.


Providing role models in private practices is another solution, advocates say. Ohio State University College of Medicine and Public Health’s (OSU) summer externship program, which places medical students in hands-on learning environments within nonacademic primary care practices for six weeks, has seen enough positive results to convince program administrator Dr. Holly Cronau to keep it going. Of the students who participate, about 40 percent end up selecting family practice over other specialties—“not that wonderful 80 or 90 percent we’d like,” Cronau says, but still much better than the national average of around 10 percent who go into the field.


“It could be argued that they are self-selecting themselves for the program,” she says, “but the fact is that we have a lot of students coming into medical school who say they’re interested in primary care, but once they are exposed to an academic medical center, you lose them to other specialties. The idea is, if we’re going to keep them interested, we need to offer these programs.”


OSU is also working to provide mentorships for premeds and high-school students to get future physicians hooked early on family medicine, before they are exposed to the discouragement at academic medical centers.


And Fleming, recognizing that academic medical centers receive much of their funding—and physicians earn their prestige—from research, is also lobbying the National Institutes of Health to create a national institute of primary care.


“It’s something whose time has come,” Fleming says. “We’re getting there.”
—B.M.


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


Interested in Primary Care?


For more information about the debate on the future of primary care medicine or to get involved in an effort to encourage more
primary care physicians, visit these online resources:


~~~Beth McNichol is a contributing editor with The New Physician and a freelance writer based in Durham, North Carolina. Direct comments about this article to tnp@amsa.org.~Career Development,Health Policy,Medical Education,Practice of Medicine~
129~8November~2004-53~Feature~Overcoming Psychiatry’s Stigma~TAKING PRIDE IN HEALING THE MIND~Christopher Stanley~~“Oh no, you’re not gonna be one of those psych guys, are you?” inquired my attending trauma surgeon incredulously. Those words echo in my head almost daily when I think about what I went through when I chose psychiatry for my career. It is part of the hazing process many third- and fourth-years endure as they consider a career in treating mental illness. No, this isn’t the type of hazing you might see on “Fear Factor”; no one has to live with snakes or eat spiders. It is far worse, as it is a constant challenge to overcome the stigma associated with becoming a psychiatrist. Attendings in other specialties, similar to the trauma surgeon I worked under, were just part of the problem. The more relentless attacks came from family, friends and even classmates.


I happen to be fortunate to have good grades and respectable board scores, but this only seems to add fuel to the fire, especially with classmates. When they learned I was seriously considering psychiatry, some were quick to say: “Orthopedic surgery is so much more respected,” or “Radiology is much more lucrative.” Others asked, “Isn’t internal medicine what real physicians do?” These are just a few examples that stand out in my mind. It seemed that during every rotation, classmates and some residents urged me to abandon psychiatry so I would not “waste my medical degree.” My family chimed in, saying I would eventually come to my senses and choose to be a cardiothoracic surgeon or something that conferred power and prestige. All of this for simply considering psychiatry.


The definitive decision came two summers ago during my psychiatry clerkship. I had a wonderful day at work with a child who had a major breakthrough, and I could not wipe the smile from my face. I awoke the next morning eager and excited to go to work for the first time ever. I had been through my other six clerkships so I knew this was not a fluke. The specialty of psychiatry, which admittedly had been my main consideration, was now my choice for a career in medicine. First, I told my wife, who is matching in internal medicine, and she was supportive.


Second, I told my mentor, a senior citizen who had been teaching me about the issues facing the elderly and how to communicate with his age group. He hit me with a bombshell, asking, “Doesn’t it take much more skill and intelligence to be a surgeon? Why would you waste your knowledge as a quack?”


I was crushed, but instead of acquiescing, I decided to discuss the issue with my tutor, a child psychiatrist who began his career as a family practitioner. I hoped he would have some perspective about dealing with the stigma. And he did. When I asked why he chose psychiatry, he said it is a wonderful and interesting profession, and it never gets boring. It takes all of your knowledge and skill along with superior patience and interpersonal talents. There is no topic or age group that is off the table, ever, he added. I remember not needing a follow-up question; his words were enough reinforcement for me.


Choosing a specialty is one of the most difficult decisions medical students make. And for those interested in psychiatry, the decision becomes more difficult because future physicians must overcome the associated stigma. Being a student representative for a psychiatry interest group, I have heard students say that they sometimes won’t admit they’re considering psychiatry because they don’t want to hear the disparaging comments. Others have said they will probably choose another field, even though psychiatry is their favorite, because they won’t be able to face their families if they become psychiatrists.


Such stories motivate me to proactively support my chosen profession. I have counseled several University of South Carolina medical students who are considering psychiatry. I always begin by explaining some of the issues I had and then educate them about my surprise at the pervasiveness of mental illness in our society and how we need more good—no, great—psychiatrists in this world.


I am also active in school functions, presenting myself as a positive role model and encouraging students to accept their desires to become psychiatrists. I would encourage other future physicians to be proactive in supporting their professions. The only way to truly change the stigma accompanying psychiatry is to start at the bottom level—the student base—and work our way up through the ranks. Then we can educate the public and hopefully eradicate this stigma.
~~~~Christopher Stanley is a first-year psychiatry resident at the University of Kentucky. This article originally appeared in the spring 2004 issue of the American Psychiatric Association’s Medical Student Newsletter. Direct comments about this story to tnp@amsa.org.~Career Development~
130~9December~2004-53~Feature~Caught Squealing~PHYSICIAN WHISTLBELOWERS VOICE CONCERNS ABOUT HOSPITAL CARE, OFTEN TO FIND THEMSELVES TARGETED INSTEAD.~Jennifer Zeigler ~~Dr. Thomas Wieters was living the good life. A thriving, 15-year vascular surgery practice at Roper Hospital in Charleston, South Carolina, afforded him many perks: two houses—one at the beach—several trips to beautiful places each year and a comfortable nest egg.


But that was five years ago. Today, he has nothing: no house, no savings, no decorated career. “You don’t know how I’ve lived for the last five years…. Everything I’ve worked for my entire life is gone,” he says.


Left in its place is a listing in the National Practitioner Data Bank (NPDB) warning potential employers about his “disruptive behavior.” Destined to follow him wherever he goes, the listing has prevented him from getting hired at the major hospitals in Charleston—or anywhere else in the country. The only reason he now has patients waiting to see him, he says, is because of a benevolent relationship he cultivated for years, before falling out of Roper’s favor, with a local community hospital that continues to grant him privileges despite the black mark by his name.


Congress created the NPDB in 1986 to provide hospitals a way to track unprofessional physicians and dentists across state lines. Physicians can be on the list for several reasons: They lost a malpractice case, or even were simply forced to settle one out of court, they lost their medical license, or perhaps they were summarily suspended by their hospitals for unprofessional behavior. Physicians at the payment end of a malpractice case, because of either a court ruling or a settlement, account for more than 70 percent of the listings. So how did Wieters, who was sued just once in a case that was later dismissed, make the list? Roper administrators placed him there for “disruptive behavior,” punishment he says for blowing the whistle on substandard patient care.


It’s a road he’s not traveled alone, nor one that’s paved with success stories. But some physicians say the culture of silence in medicine that has been used to railroad whistleblowers is starting to lift, even if only slightly, and while their careers may be in shambles, the experience has not dampened the spirit of their intentions.


PAYING THE PRICE


Perhaps it was Dr. Troy Madsen who first put a face on the whistleblower label for many medical students when he took the internal medicine residency program at Johns Hopkins Hospital to task for violating residency work-hours regulations in July 2003. His complaint triggered a disciplinary action by the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs. When he was outed as the anonymous whistleblower later that summer, he resigned largely because residents and administrators ostracized him for his actions (see “Monitor,” March 2004).


The upheaval in his career has caused Madsen, who soon after the incident said he would do it all over again to protect his patients from overtired residents, to rethink his decision. Now a second-year emergency medicine resident at Ohio State University School of Medicine, he says he would strongly caution others from speaking out because of the lack of protection the ACGME afforded him, after it assured him it would. He faults the ACGME for not having a stronger whistleblower policy. Proposed federal legislation would offer such protection, but the bill is mired in committee and not expected to move before Congress adjourns later this month.


ACGME’s director of field activities, Ingrid Philibert, admitted in August the council didn’t have a protection policy. “We don’t have anything that could be outright called whistleblower protection. We do, however, have fairly strong standards in our [accreditation guidelines] that have adverse consequences for programs or institutions that do retaliation or retribution against residents or to others who comment on deficiencies either internally within the organization or ultimately to the ACGME, so that has negative accreditation outcomes for the program. But we don’t have the kind of whistleblower provisions that are inherent in the [proposed] federal statutes,” she said on American University Radio’s the Kojo Nnamdi Show.


But others say it doesn’t matter what the consequences are; they’d blow the whistle all over again to protect their patients. Wieters is one of them. “This is a topic that begins to expose a conspiracy of silence that exists…since who knows when, but it also proves that there is a small group of people willing to put patient safety first,” he says.


Wieters’ problems began in 1999 when he complained to hospital officials about the care a patient on whom he was scheduled to operate received. The man, who needed surgery for an aortic aneurysm, waited four hours before hospital staff admitted him and then hours more before staff prepared a chart and began prepping him for the procedure. The only one of Wieters’ orders nurses did carry out, he says, was to administer a laxative—but at twice the dose he indicated. After a worrisome night monitoring the man’s falling potassium level, caused by diarrhea resulting from the double-dose laxative, Wieters operated the next day.


And while the tale has a happy ending—the man survived a successful surgery—Wieters says his patient’s treatment was just one example of the declining care in the hospital. He cites instances in which orders for immediate medications were ignored, and when medicine was administered, it was often not recorded in the patients’ charts. Each time, Wieters would ask the offending health-care worker to write up an incident report, a move he considered necessary to protect patient safety.


But Wieters says Roper’s risk manager reprimanded him for ordering his nurses to file the incident reports, saying they created a paper trail for future malpractice suits.


The Vietnam War veteran likens his actions to those of the armed forces. “A lot of those people live by a code that we will absolutely leave no man behind. If you practice medicine, the person in the bed does not look to the nurse. The person looks to the physician” for advocacy and care, he says.


But quality care was becoming more difficult in the face of what Wieters says were declining standards at Roper, which had been owned and operated by the physicians of the Medical Society of South Carolina from 1852 until 1998, when an outside corporation bought the hospital. And he says it’s no coincidence the term “disruptive physician” entered hospital vernacular during the mid-1990s, when for-profit companies increasingly bought physician-owned nonprofit hospitals.


“Disruptive physicians—well, they’re disrupting the flow of money to the hospitals,” says Dr. Verner Waite, a retired surgeon and the founder of the Semmelweis Society, which works to help unfairly disciplined physicians fight their legal battles. He acknowledges that physicians who speak up about unsafe practices put the hospital at risk for malpractice suits and lost business. “This is big business. We’re talking about billions of dollars” the hospitals lose, he says.


So instead of the squeaky wheel getting the grease, in this case it got the ax. After a year of internal committee investigations that determined Wieters’ behavior was disruptive and warranted a psychiatric evaluation and anger management counseling, hospital officials suspended him and added his name to the NPDB in January 2000. The listing is essentially permanent; only Roper officials have authority to remove him from the data bank.


Wieters sued, but the judge ruled in favor of the hospital, citing a 1986 federal law—the same Health Care Quality Improvement Act (HCQIA) that created the NPDB—that “gave hospitals a considerable amount of discretion, a great amount of authority in dealing with matters of discipline.”


The law allows hospitals to establish an internal peer-review system for judging patient safety and discipline issues. The HCQIA provides peer reviewers liability immunity from lawsuits filed by those they review. While this follows medicine’s longstanding commitment to using internal reviews to learn from mistakes, physicians who have been disciplined under the system say it’s unfair to essentially allow the competition—other physicians contracted by the hospital—to be judge and jury.


And therein lies the problem, many disciplined physicians say. The judge ruled in Wieters’ case that even though complaints about substandard care are in the patients’ best interests, the law makes that irrelevant. “It’s a license to kill,” Wieters says of the HCQIA. “The judge said, ‘I don’t care what you did. [The hospital has] complete immunity.’”


The law was actually meant to help physicians. When the U.S. Supreme Court ruled in favor of one Oregon physician who sued his hospital for firing him after an unfair peer review, the physicians on the peer-review board went bankrupt paying the judgment award, and Congress passed the HCQIA to prevent that from happening again, says Dr. Allen Tobias, a retired California urologist who also holds a law degree.


“Early on, [the law] worked. But I think it’s been flipped over 180 degrees,” Wieters says.


In addition to providing peer reviewers immunity and creating the NPDB, the HCQIA also prohibits physicians who have been disciplined under it from suing their hospitals for anything other than to get their jobs back, and then only if they can prove the peer-review committee improperly followed four procedural steps outlined in the law.


For their part, hospitals and their lawyers argue that disruptive physicians are rarely branded after one incident. “With a truly disruptive physician, leadership is more often faced with chronic complaints from employees, other physicians, and even patients. Even then, meaningful action often does not occur until there is a significant event like the resignation of a key employee, an adverse clinical outcome, or worse,” wrote Susan Lapenta, a lawyer with the Pittsburgh firm Horty, Springer and Mattern, in a recent issue of The Physician Executive.


Anesthesiologist and former president of the Pennsylvania Medical Society (PMS) and the Pennsylvania Society of Anesthesiologists (PSA), Dr. Edward Dench says his hospital would have used the peer-review system to get rid of him if there hadn’t been another anesthesiologist there who would have come to his defense. “It’s very difficult to railroad a doctor if there’s someone else there to defend them,” he says.


Difficult, but not impossible. Despite help from his friend, today Dench has no privileges at Mount Nittany Medical Center in State College, Pennsylvania, and instead makes his living by practicing anesthesiology in oral surgeons’ offices across several states.


Once a well-respected physician whom even the hospital CEO requested for his son’s wisdom-tooth extraction, Dench says his decline began in 1991 when he blew the whistle on a colleague. Dench says the physician was billing Medicare for simultaneous surgeries he was leaving in the hands of certified registered nurse anesthetists (CRNA). It was both fraud and a patient safety issue, Dench says. “There’s no way the doctor can come to the aid of the CRNA if something goes wrong [if he’s not in the operating room].”


At first, Dench said nothing. “Medicare was starting to crack down on fraud. I knew that the other doctor wasn’t practicing ethically, but I couldn’t do anything about it.” But as president of the PSA at the time, he says he was afraid someone would discover the fraud and accuse the medical organization of inaction. So, he wrote a letter asking hospital administrators to open an investigation.


“Well, they opened an investigation, but of me,” he says.
The hospital began reprimanding him for numerous infractions. In one instance, he says he upset hospital officials when he warned a patient about to undergo surgery that he had been awake for 36 hours and suggested they reschedule the nonemergency procedure. “So I told the truth, and they have a problem with that.”


By 1998 he was out, having lost his privileges when the hospital contracted exclusively with another anesthesiology group. Dench called it an antitrust violation and sued. He settled with the hospital for an undisclosed amount. He will say he requested one-day-a-week privileges to practice at the hospital at the request of a surgeon or patient, but the hospital refused.


And if his professional life has suffered, so has his personal life. Dench blames his divorce on the experience and says his story is just one example of how hospitals have strong-armed physicians into silence. “If the president of the Pennsylvania Medical Society can be gotten rid of, why would anyone else speak up?”


ALL'S WELL FOR SOME


But these stories, and others like them, don’t deter all physicians from speaking up. “We’re reaching a critical mass,” Waite says of the increasing numbers of physicians willing to take a stand against unsafe medical practices.


A neurosurgery resident at the University of Colorado Health Sciences Center (UCHSC) is a member of that critical mass. In July 2003, four residents there sent a letter to the university’s board of regents outlining concerns they had about their department chairman. “It was mostly selfish; it was more about how he was treating us, but some of it was about patient safety,” the resident, who has requested anonymity, says, declining to discuss specifics because of an ongoing legal dispute. “It was a concern among the residents that there was a problem.”


And while he says faculty support made it easier initially, the situation took a turn for the worse when the university opened an investigation, calling the resident to testify before a hospital committee. “I was guaranteed that everything I said would be confidential.” But he soon learned the extent of his whistleblower protection. “[The chairman] was handed a transcript of my testimony. I was no way protected by the university.”


Instead, he was reprimanded without an explanation or hearing. “I was hung out to dry. It was probably the worst year of my life.”


He says UCHSC’s handling of his disciplinary action was part of the reason the ACGME put the neurosurgery program on probation last summer. The council does not discuss specifics in its cases, but it reviewed the program in September and will consider reaccreditation in January. “The program now is great,” the resident says, crediting new residency program director Dr. Gary VanderArk with the improvements. The department chairman has since resigned his position, although he continues to practice in another city. “He’s still a prominent figure in neurosurgery,” the resident says.


But he isn’t worried that the experience will adversely affect his career, although he says it turned him off from academics. Before writing his fateful letter, he was planning a career in teaching and research. Now, he’s just not interested. “This has been a very enlightening experience as to the politics of academic medicine that most residents may never have.”


Despite the difficulties in getting to this point, he says he’s better for it and now has the strength to speak up in the future. “I’m glad for the experience. It’s made me a better person, which hopefully makes me a better physician.”
He says others weren’t so lucky; one of his colleagues developed an addiction, suffered a nervous breakdown and was eventually fired.


FIXING THE PROBLEM


So what’s the difference between the UCHSC resident’s metamorphosis and Wieters’ decent into what he calls five years of “abject poverty”? Some of it has to do with the circumstances of the situation, but part of it could be institutional differences.


Dench says it’s much harder for patient-safety issues to persist in a teaching hospital because of the scrutiny they’re subjected to under ACGME regulations. “You don’t get away with bad medicine for long in the academic world.”


But all hospitals are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Its compliance standard on due process and fair hearing, which is part of the leadership section of its guidelines, requires hospitals to have fair review systems for dealing with patient-safety concerns. “They must demonstrate a culture of patient safety from the top down,” says Dr. William Jacott, JCAHO’s special adviser on professional relations.


In his position, he spends much of his time listening to physicians talk about their work environments and says he’s increasingly hearing about conflicts between physicians and hospital administrations or governing boards but not necessarily because of patient-safety issues. “Mostly because of socioeconomic reasons, a physician wants privileges, but the hospital denies them because the physician is affiliated with another, competing hospital.”


JCAHO also has an anonymous reporting system into which physicians can tap, Jacott says. An evaluation team of physicians and nurses follow up on all complaints, possibly issuing a letter, a request for a report or even an unannounced site visit. But Jacott says of the 8,000 complaints last year, only 160 were from physicians; many physicians choose to go to their lawyers or specialty societies instead. And remember, he says, the commission deals only with patient safety—it doesn’t address complaints that peer-review systems may unfairly target whistleblowers because they allow physicians competing for business to pass judgment on one another. “We have no standards that deal with socioeconomic issues. We don’t tell a hospital how to deal with their financials.”


Dench says that’s part of the problem. Most surgeons he knows no longer have privileges in multiple hospitals, each instead settling for a contract with one health-care organization, which makes his employment contingent on his relationship with that one hospital. “It’s like they’re employees, but they’re not employees…. Remember, if you’re not on multiple medical staffs, [administrators] have the power to take away everything.”


Physicians’ employment agreements with hospitals are a serious problem for whistleblower wannabes, says Mary Louise Cohen, partner with the Washington, D.C., law firm Phillips and Cohen. “The False Claims Act contains a provision that’s supposed to protect employment. Of course, it only covers employees—physicians are often independent contractors. You’re not going to be covered.”


Cohen deals only with cases under the False Claims Act, which regulates billing processes and not the HCQIA. But she says a lot of times, fraudulent billing schemes are accompanied by patient-safety issues, which are an added concern to her physician–clients who then decide to blow the whistle.


And while protections beyond the False Claims Act do exist, she says it’s often a matter of state law. “Some states have very strong laws that protect whistleblowers from a public safety point of view, some even with punitive damages [for the violators].” She cites California’s law as one example, and Ohio’s, which is written to fiercely protect public employees, including physicians at public hospitals.


But the more pessimistic Waite says he doesn’t know of any state with strong whistleblower protections. He scoffs at the idea that physicians would make out better in California, which is the one state with more stringent peer-review immunity than the HCQIA provides, thanks to an opt-out clause in the federal law that permits states to approve more restrictive regulations.


Instead, Tobias and Dench advocate an independent peer-review system, in which disciplinary reviews would be overseen by an outside panel, not one of physicians from the same hospital. “The only way you’re going to get an unbiased jury is from another hospital at least 300 miles away,” Waite says.


“It’s not OK for us to make mistakes, but we’re all going to do it. You have to do better the next time and learn from it. [But] I’ve never learned anything from other doctors because it’s all secret. It’s all hidden behind peer review,” Dench says. “I believe statewide peer review is the solution to the problem…. If you could just get it up to a higher level of peer review, to an independent peer review, you’d get it out, and people would learn.”


He’s spent much of his time since leaving Mount Nittany fighting for a statewide system in Pennsylvania. Two years ago the state legislature passed a tort reform law that included some whistleblower protections, but more is still needed, he says. The state House passed a bill outlining a statewide, anonymous reporting system in June, but Dench says it has no chance in the Senate.


Tobias does see some progress throughout the country at the state level, though. In October, the PMS agreed to investigate the issue of unfair peer review, and the medical societies in Oregon and California have also taken similar ideas to their governing boards for consideration.


And until better laws are passed, Dench, like many physicians who have already brushed up against the system and lost, vows to continue to fight. “They need to speak up and make sure the hospital…has an outside group to review,” Waite says. “Become active in your medical staff. You get organized. You don’t just sit around like a bunch of cows and wait to be slaughtered.”
~THINK BEFORE YOU BLOW


Perhaps you’ve witnessed an egregious medical error, or maybe you’ve grown concerned about fraudulent billing schemes or residents working too many hours—it might be time to say something.


But before you blow the whistle, you might want to consider a few tips from those who have gone before you. In offering advice, Mary Louise Cohen, partner at the Washington, D.C., law firm Phillips and Cohen, says, “There are a lot of things to think about”:


Consult a lawyer. Before doing anything else, get some legal advice specific to your local laws, since they vary from state to state.


Keep thorough records. Make any complaints in writing—not verbally—so there is a paper trail.


Consider privacy laws. Redact any names from supporting documents when making your complaint—they can always be added later if needed.


Evaluate your role. Consider your future culpability in the situation. “If you’re a doctor and you see something is wrong, there is some risk in not coming forward,” Cohen says. “You may think you’re a small player, but sometimes that’s the best way to investigate a case…go after the big guys through the little guys.”
Examine the chain of command. Ultimately, whistleblowing is more effective in a system with checks and balances, where complaints can’t be covered up. For example, if you’re a resident, who in your program hears initial concerns? Who follows up? “I think it has a lot to do with the relationship and investment of your program director,” says one resident. “If your program director is your chairman’s right-hand man, then you’re not going to be able to say anything.”


Weigh the ramifications. Residents especially need to consider how blowing the whistle is going to affect their standing in their program. “What kind of recommendation are you going to get from your employer?” Cohen asks. She’s told at least one resident to consider tabling a complaint until after residency because of the possible effects speaking up could have on her career.


Evaluate your financial wherewithall. If the case goes to court, it could cost thousands of dollars. Almost every time a physician settles a whistleblower suit, it’s because he’s run out of money, says Dr. Edward Dench, former president of the Pennsylvania Medical Society. —J.Z.
~~~Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@www.amsa.org.~Ethics,Practice of Medicine~
131~9December~2004-53~Perspectives~Making the Connection~EFFECTS OF ENVIRONMENTAL AND SOCIAL FACTORS.~Jay Bhatt~~Candy was hard to come by growing up. We rarely had any at home, and as kids we didn’t have the money to buy it for ourselves. But on Sundays, if we timed it right, we could count on one of the elderly women in our neighborhood to press a peppermint or butterscotch into our hands. I naively assumed they carried the candy to make us neighborhood children happy. I learned later that the candy wasn’t just a treat. It was the women’s “medicine” to control their blood glucose levels. A quick candy could be just enough to stabilize their blood sugar, keeping their diabetes in check.


Looking back on the neighborhood where I grew up—an underserved, predominantly black community a little more than an hour southwest of Chicago—diabetes was a common complaint. The prevalence of hypertension and heart disease was equally worrisome, mirroring other communities with a similar demographic and socioeconomic makeup.


Although I didn’t realize the connection between environment and health until much later, when I did, it cemented my desire to become a physician. I began to understand that health care is a way of life, encompassing more than what goes on inside a hospital.


To better understand this association, I worked as a research analyst studying impoverished, inner-city communities during college. My clinical research showed me how patients’ socioeconomic conditions affected their health and subsequent care. I also learned how these patients understood their care, as well as how they responded to particular physicians, and I began to recognize the barriers to care they faced. Many of these residents attributed their health problems to environmental and social factors, but because they were poor and uneducated, they were unable to address, much less correct, the threats to good health. Coupled with the violence, crime and discrimination that plagued their neighborhoods, their health problems only increased.


These situational factors typically lie beyond the clinical scope of medicine, but I wanted to address all health problems, beginning with a patient’s living conditions. I quickly noticed that such health-damaging behaviors as smoking and poor nutrition were more prevalent in impoverished communities and that traditionally clinicians ignored them.


Public health and outreach organizations that attempt to address these health inequalities have succeeded by using a much wider range of activities and interventions than primary care physicians. One example is Project Brotherhood, a program in the Woodlawn community of Chicago. Dr. Eric Whitaker, a former American Medical Student Association president and the current director of the Illinois Department of Public Health, built a model to deliver care to an underserved population of black men. When these men were asked what they wanted from a health-care system, they said they wanted to be respected, for without respect they didn’t feel they had access to treatment. So Whitaker began to address their health-care needs at the social level. He started clinics offering the men free haircuts and food, and, if they wanted, time with a doctor. And the men began to gather. Some came just for the haircuts or the food, but others listened to Whitaker’s informal health education sessions and sought health care.


Since the clinic opened in 1998, doctors have held sessions on anger management, diabetes, hypertension, AIDS and cancer. While receiving medical attention, the men also get help with work skills and have access to computers.


Since college, I have worked in health-policy consulting and health-care delivery systems. Looking at the bigger picture of medicine, I am more aware of the health problems that handicap underprivileged populations like those in my own childhood neighborhood. It has shown me firsthand how such policy and prevention initiatives as screening programs, needle exchanges and counseling sessions can address a community’s multiple and debilitating health problems.


An example of the need to incorporate public-health efforts with medicine is apparent with a disease like diabetes. Care includes medical management as well as lifestyle and prevention aspects. Diabetics need attentive medical care to control their disease and prevent complications. To ensure they have access to this care, many will need to overcome the logistical barriers of financing and transporting themselves, as well as finding child care or even a translator. Community-health centers and home visits help, and such public-health strategies as population-based screening can detect diseases early on.


Considering the biological insignificance race, ethnicity and socioeconomic status have on disease makes the strong correlation between poor communities and health problems very troubling. I believe the unraveling of this connection is critical to combating the health problems of minority communities.


At some point in the future, I hope I can say that my patients are second and third generations of my earlier patients. I hope that as a community, we can reduce the incidence of diabetes and hypertension through preventive medicine, education and better lifestyle choices. Luckily, I have been able to work with public-health organizations, pharmaceutical providers and other outreach efforts to provide some medications for the indigent with these diseases, but there is so much more to do. Ultimately, we as clinicians need to understand patients’ cultural and socioeconomic environments as much as their medical complaints in order to provide holistic and effective care.
~~~~Jay Bhatt is a third-year at the Philadelphia College of Osteopathic Medicine. He received his M.P.H. from the University of Illinois at Chicago. Direct comments about this article to tnp@amsa.org.~Community and Public Health,Health Disparities,Humanistic Medicine,Minority Affairs~
132~9December~2004-53~Feature~Malignant Medicine~~Avery Hurt~~In 1999, the Institute of Medicine released its To Err Is Human report, exposing the extent of deadly
mistakes in U.S. medicine. Five years later, are patients any safer?


A 45-year-old developmentally delayed patient complained of abdominal pain. His mother brought him into the emergency room and told the attending her son had experienced similar symptoms the year before; the diagnosis then had been renal colic. The emergency room physician m aade the same diagnosis, treating the patient with painkillers and releasing him with a prescription for acetaminophen with codeine. He instructed him to drink at least eight glasses of water a day and gave him a strainer for his urine in case he passed a stone. The next morning, the patient was found dead in his bed. An autopsy revealed a perforated gastric ulcer and widespread peritonitis.


A pediatrician recommended a child receive a routine vaccination for hepatitis B as part of his annual school physical. The child’s father consented, and the child received an injection. When the physician recorded the lot number of the vaccine dose, he discovered the child was actually given a vaccine for hepatitis A. The only serious harm done in this case was to the relationship between the physician and the child’s family.


A hospital employee neglected to test a disinfectant solution used to clean endoscopes, and 180 patients were potentially exposed to HIV and hepatitis.


The public and the health-care industry were astonished when, in the fall of 1999, the Institute of Medicine (IOM) report To Err Is Human found that between 44,000 and 98,000 Americans die each year as a result of medical errors—mistakes similar to the ones described above. Depending on which estimate you use and how you crunch the numbers, this puts medical errors somewhere between the fifth and eighth leading cause of death in the United States, easily trumping breast cancer, traffic accidents and AIDS.


Before the IOM report, medical errors were largely unacknowledged by the industry and unknown to the general public. Now, Congress, federal and state government agencies, hospitals, patient advocacy groups and insurance providers seek solutions to preventing and correcting errors in medicine. Proposals have been offered, committees convened and initiatives undertaken, but has progress been made? While reform efforts abound, unfortunately, it remains unclear if patients are any safer.


LOW ON DATA


The fight to end errors in medicine is a particularly intricate and thorny problem, a lot like the fight against cancer. Cancer is not one disease, but many, with the work to develop treatments and find cures spread among thousands of researchers at hundreds of institutions worldwide. Each time a piece
of the puzzle is unearthed, other researchers take note, incorporate the new information into their work, if applicable, and carry on. The result is a slow and uneven progress that’s frustratingly difficult to measure. And like cancer, the causes of medical errors are rooted in a variety of sources, and no one agency or organization is responsible for addressing the problem.


The cancer analogy breaks down, however, when it comes to research. Cancer researchers have at their fingertips decades of data on every imaginable aspect of the disease in all of its manifestations. Those who are working to reduce the problem of medical errors have extremely limited research to which to refer. Beyond a few small studies and a judicious use of common sense, experts don’t know what works and what doesn’t.


Part of the challenge is that medical errors come in many forms: A nurse gives a patient an overdose of medication because she couldn’t read the physician’s handwriting; a busy or distracted internist skims a lab report and makes an incorrect diagnosis; a surgeon operates on the wrong side of a patient; an IV drip malfunctions. Overworked staff, human–device interactions that go awry, communication problems, system failures—all can be the root of errors. But pinpointing what most often causes problems, what kinds of problems are most common, and which interventions are most effective is a huge challenge.


Because medical professionals fear repercussions ranging from censure by colleagues to malpractice suits, they are often reluctant to report errors. And even when they do report them, determining if the errors were avoidable is another hurdle, says Dr. Carolyn Clancy, the director of the Agency for Healthcare Research and Quality (AHRQ), which is part of the Department of Health and Human Services and the organization at the forefront of addressing this problem. Clancy gives the following example: If an elderly woman falls and breaks a hip because of water on the floor, we know what caused it, and we know what to do about it. But if she breaks her hip sliding out of a chair, it is not so obvious what, if anything, could have been done to prevent the accident.


It can be equally difficult to track progress, and Clancy offers another example: Nosocomial infections are reported to the Centers for Disease Control and Prevention on a voluntary basis. If the reporting increases, is that because hospitals are seeing more nosocomial infections or are they just getting better at reporting them?


Any researcher will say that having good data is essential, but at the moment, there simply isn’t enough. “We are very, very early in our understanding of this problem, yet there is enormous pressure on health-care providers to act,” says Dr. Eric Thomas, the principal investigator at the University of Texas (UT) Center of Excellence for Patient Safety Research and Practice, one of several centers funded by AHRQ grants to address medical errors.


But not all physicians feel such pressure, and this may be another source of the problem. According to research published in 2002 in the New England Journal of Medicine (NEJM), 35 percent of 831 surveyed physicians reported making medical errors or having mistakes happen to family members, yet the vast majority didn’t view errors as one of the most important problems in health care today.


These responses come as little surprise to Dr. Donald Berwick, the president and chief executive officer of the Institute for Healthcare Improvement. “People still don’t believe it’s a serious problem,” he says, adding that part of the reason is statistical. “At the local level, in the daily practice of medicine, the problem doesn’t feel very big. You may have one or two deaths per month from errors. Errors happen every day, but this is accepted as normal. There is no sense of urgency about the problem. There is an illusion of safety.”


He compares this to the perception of auto travel. Most people know someone who has been in an automobile accident or have been in one themselves, but it doesn’t seem to happen all that often, so they feel safe in their cars. But nationally, approximately 40,000 Americans die in auto accidents annually, making it one of the leading causes of death in the United States, he says.


With as many as 98,000 people dying each year from medical errors, medicine can’t wait for reams of data before taking action. Those working on the problem, like AHRQ and UT’s Center of Excellence, are working to assemble useful information using what little data they have, and trying what, as Thomas puts it, “sounds like the right thing to do.”


LESSONS FROM THE SKY


In the late 1970s, problems with aviation safety appeared on the national radar screen in much the same way medical errors did in 1999. Aviation’s troubles were addressed, and air safety has improved tremendously. Robert Helmreich, co-principal investigator at UT’s Center of Excellence and a researcher in aviation safety, says two-thirds of aviation accidents involve failures in teamwork—“misunderstandings, dictatorial leadership, people not speaking up because they feared some kind of censure….” These are characteristics of medical culture as well, he says.


Like medicine, the aviation industry is hierarchical. “In aviation, the administration is a very, very long way away [from the front-line workers],” Helmreich says. And like medicine, it is dependent on technology and highly trained professionals working in conditions requiring alertness and good judgment.


So what worked for aviation, and how can those lessons be applied to medicine? Data is key, Helmreich says. Yet, because air disasters are blessedly rare, the best data on airline safety comes from the reporting of near misses—when accidents almost happened.


So medicine needs to focus on its close calls. Helmreich recommends placing observers in operating rooms and other key health-care areas to report the beginnings of mistakes. The essential component to this system is, of course, trust. If people are going to report close calls and allow observers in their operating rooms, then they have to be confident they will not be censured for mistakes.


Many organizations, including the American Medical Association (AMA), have been lobbying for legislation, such as the Patient Safety and Quality Improvement Act (PSQIA), that would create a voluntary reporting system for medical errors. The PSQIA would not protect from lawsuits those who report accidents or near misses; instead, it would shield their identities. It would also provide a centralized source of data and analysis, allowing hospitals and other medical institutions to see what most likely causes errors and how to make the changes necessary for prevention. The system would not make error reporting mandatory, but the legislation’s supporters say the confidential venue would encourage health-care professionals and hospitals to share information about their errors and near misses. Dr. Donald J. Palmisano, past president of the AMA, has described the legislation as “the equivalent of the Aviation Safety Reporting System applied to medicine.”


This past July, the Senate passed a version of the PSQIA similar to one the House passed in March. Congress now has to reconcile the two versions and get a presidential signature before adjourning later this month. The measure has bipartisan support and some powerful backers, including physician and Senate Majority Leader Bill Frist (R-Tenn.) and Sen. Edward Kennedy (D-Mass.).


SOLUTIONS IN THREE PARTS


Once more data is available, it will be much easier to see where reform is most needed. In the meantime, patient-safety experts say solutions tend to break into three categories: transforming the culture of medicine, instituting low-tech system changes and making use of high technology.


The culture problem is made evident by the lack of openness and a threat of punishment in medicine that keeps so many mistakes and near misses from being reported. An increasing awareness of the need for candor and open discussion is helping, but “health-care professionals do not yet feel safe” to report concerns, Clancy says. And the required culture changes go beyond simply making people comfortable enough to anonymously report incidents. Changes need to go beyond front-line workers and involve management-level physicians and staff.


Dr. Darrell Campbell, the assistant dean for clinical affairs at the University of Michigan Medical School (UM) and chief of clinical affairs at the University of Michigan Health System hospitals, is dedicated to implementing necessary culture changes. Each week, Campbell is joined by a team of UM administration officials and patient advocates in making unannounced patient-safety rounds at the university’s three hospitals. Campbell calls this technique “management by walking around.” The team meets with nurses, physicians, residents and technicians and asks them such questions as “What happened yesterday?” and “What’s the worst thing that has ever happened here?”


Staff members can speak freely without fear of repercussions, thanks to two new UM hospitals’ policies designed to help ensure what Campbell calls a “blameless environment.” All employees are urged to speak up about safety concerns. The first policy protects them from being ostracized or punished for reporting a problem, and the second policy provides full disclosure. “These are good people, and they want to do the right thing,” Campbell says. “We aim to be fully honest with every patient who suffers an error. Our legal team is supportive of this policy.” Hospital policy now allows, and even encourages, medical staff to be completely forthcoming with patients and their families when an error has been made. Doctors need not fear that they will get in trouble for telling patients too much.


Sherry Wagner, a UM University Hospital pharmacy technician, recently put the first policy to the test when she received an order for insulin she thought was too much for a baby. She immediately brought the matter to the attention of her supervisor, Diane Gaul. The concern was then shared with the physician who wrote the order. At first, the physician insisted the order was correct, but when Wagner and Gaul held firm, the physician took a second look and discovered an error. The order was changed, and Wagner suffered no ill consequences for her action. In fact, Campbell publicly commended her for her attentiveness and commitment to the safety of the young patient. “I knew I had the support of my supervisors,” Wagner says. “They are very trusting and depend on us to act when we see that a patient is in danger.”


Campbell’s approach is an attempt to turn the culture of medicine from one of “individual blame and retribution to one of systems analysis,” and he may be right on target. According to results from the 2002 NEJM survey, physicians and patients are inclined to attribute mistakes to the failures of individuals. However, a growing body of evidence strongly suggests that errors are more often the result of system failures rather than lapses of attention or judgment by individuals.


Moving the focus of attention from people to systems may provide more options for making improvements. Problems in aviation safety were addressed in just this way. System changes can be quite complex, but they usually require only simple, inexpensive low-tech solutions. “We are beginning to see more carefully designed care processes with built-in redundancies,” says Janet Corrigan, the senior board director for health-care services at the IOM.


Things as simple as putting concentrated potassium chloride, which can cause heart failure if given in too high of a dose, in a locked cabinet rather than open at the nurses station can prevent serious accidents, UT’s Thomas says. Other low-tech measures include increasing communication between team members on different shifts, routine systems of verifying patients’ names and leaving more detailed notes on charts. As health-care workers and administrators become more aware of the problem, small changes like these are being made every day at hospitals across the nation. The results are impossible to measure, but hospital workers are certain that such changes are making a positive impact.


But the solutions getting the most attention are high-tech—and they’re neither small nor inexpensive. The two most talked about are Computerized Physician Order Entry (CPOE) and electronic medical records systems.


In a CPOE system, medication orders are entered into a computer equipped with software designed to prevent prescribing errors. CPOE is one of the few areas that have been carefully studied, according to Claire Turner, spokeswoman for The Leapfrog Group, a consortium of private and public health-care purchasers working to coordinate patient-safety initiatives. In Leapfrog-member hospitals, such systems have reduced serious prescribing errors by more than 50 percent. This is significant as AHRQ research indicates medication errors account for between 34 percent and 56 percent of all medical errors.


Electronic medical records could have an even greater impact. Because many patients see several physicians at multiple health-care facilities, it can be difficult for any one physician or hospital to get access to all the necessary information about a patient’s care—especially on short notice. “Electronic records will make a huge difference,” the IOM’s Corrigan says. “Health-care providers need complete info [about their patients’ medical history] and immediate access to it.”


Clancy agrees that information technology will make a tremendous difference, but she warns, “Simply digitizing information won’t have a big effect. We have to make sure that the information can follow the patient and be consistent from department to department and from hospital to hospital.” She likens the situation to the early days of telephone technology. A telephone didn’t do you much good unless the person you wanted to talk to also had one. She does not, however, think that centralization will be required to create the seamless communication that will be necessary for information technology to be most effective. What is essential, though, is money.


While internal systems changes can be implemented at very little cost, information technology doesn’t come cheap. And the possibility for a return on the investment, in terms of dollars—not lives—is not always clear. “A hospital may or may not benefit financially from making these changes,” Thomas says.


To ensure the changes occur, Corrigan says, “We need national leadership to put this into place…. I do expect a return on the investment; the current system has many redundancies and inefficiencies.”


And an investment may be forthcoming. In October, AHRQ awarded $96 million in grants to help communities, hospitals and health-care providers develop and better use information technology systems. AHRQ also awarded an $18.5 million contract to the University of Chicago to create a National Health Information Technology Resource Center to provide the grantees technical assistance and serve as a repository for best practice ideas. The funding is part of a Bush administration initiative announced in April that would, among other things, establish electronic medical records for most Americans over the next 10 years as well as create a national coordinator for health information technology.


WHAT'S NEXT


Plenty of energy, great ideas and even some real dollars are now being applied to this problem. Still, the question lingers: Is any of it working? “It is my impression that the situation is probably getting worse. Hazards are the other side of the coin of technological innovation,” Berwick says, explaining how increasing the use of technological innovations also creates more opportunities for mistakes.


Others are less pessimistic. “It is an enormous step forward just to be talking about it,” Thomas says.


Helmreich agrees. “Once we are aware of the problem, we can’t put it back in the box.”
Now that changes to the medical culture and innovations, both low- and high-tech, are on the table—and in some cases, on the wards—what’s next? According to Corrigan, U.S. medicine needs to aggressively consider a redesign of payment systems. “Our current fee-for-service payment system is often an impediment to good care. We need to try some alternative systems, such as pay-for-performance,” she says.


Thomas concurs. “As a physician practicing general internal medicine, if I give high-quality care to a diabetic patient with traditional insurance, I will make less money on subsequent visits and treatments,” he says.


So, like the ongoing research into finding a cure for cancer, it may be a long time before we can be assured we are making progress in combating medical errors. But for now, we do know medical errors will no longer go unnoticed or unaddressed. In another five years, Clancy says, we’ll have more data in place, and then we can start to get some answers.


Meanwhile, medical professionals are doing what they can and hoping that it is working. ~WHAT CAN YOU DO?


Future physicians and residents can be enormously powerful in improving patient safety, says Dr. Donald Berwick, the president and chief executive officer of the Institute for Healthcare Improvement. He offers the following suggestions:

—A.H.


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CASE STUDY


Your hospital’s morbidity and mortality conferences offer great forums for evaluating and learning from mistakes, but their secretive nature doesn’t help those outside the institution. In order to make such resources available to everyone, the Agency for Healthcare Research and Quality has created the online journal WebM&M. Medical errors are anonymously reported to the journal’s Web site and then analyzed by a team of medical experts. A variety of case studies are offered for review, and new cases are added monthly. Several of the examples cited at the beginning of this article were adapted from the site. You can access WebM&M at www.webmm.ahrq.gov. —A.H.


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RESOURCES

~~~New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@www.amsa.org.~Ethics,Health Policy~
133~9December~2004-53~Feature~Opening the Borders~~Molly Novotny~~The controversy over prescription drug reimportation heats up, but many question whether it is the real solution to making drugs more affordable.


The bus trips could become unnecessary, the legality of the Internet purchases a moot point. Seniors could stop worrying whether they can afford their prescription drugs and instead purchase them from the neighborhood drugstore as they used to do—before the market outpriced them. Sound too good to be true? It’s not, according to supporters of a congressional bill that would legalize drug reimportation.


Nearly a third of U.S. senators
support Sen. Byron Dorgan’s (D-N.D.) Pharmaceutical Market Access and Drug Safety Act. If passed, which is viewed as unlikely before Congress adjourns this month, “people would be able to buy lower-priced prescription drugs from their local pharmacists, because their local pharmacists would do the reimportation,” says Barry Piatt, Dorgan’s spokesman. Ninety days after its passage, the bill would allow pharmacies to import drugs from Canada and from European Union countries, Australia, Japan, New Zealand and Switzerland after a year. The U.S. Food and Drug Administration (FDA) would certify all exporting pharmacies, assessing a fee to cover the cost.


“Seniors are forced to go to Canada because the price of prescription drugs in this country is out of control,” said bill co-sponsor Sen. Russ Feingold (D-Wis.) during a congressional hearing in July. “The Congressional Budget Office (CBO) estimates that brand-name drugs cost, on average, 35 [percent] to 55 percent less in other industrialized countries than they do in this country.” The CBO reported in April that Americans typically pay 67 percent more than Canadians for patented drugs.


Currently, U.S. law prohibits drug importation because the FDA argues it can’t ensure the drugs’ safety and efficacy. “Consumers are exposed to a number of potential risks when they purchase drugs from foreign sources…,” said John Taylor, the FDA’s associate commissioner for regulatory affairs, during a May congressional hearing. “These outlets may dispense expired, sub-potent, contaminated or counterfeit drug products, the wrong or contraindicated product, [or] an incorrect dose of medication unaccompanied by adequate directions for use.” And although the FDA has the authority to test the drugs, he says it doesn’t have the resources.


However, importation advocates dispute the safety concerns. Dr. Marcia Angell, a former editor of the New England Journal of Medicine and current lecturer at Harvard Medical School, calls the safety concern “bogus,” saying the drugs distributed in Canada are the same ones the FDA approves for distribution in the United States. Pharmaceuticals are, by industry standards, global products, she says, entering and exiting many countries during their production and distribution. “The implication that somehow crossing a border makes drugs less safe flies in the face of this industry.”


Alan Sager, Ph.D., professor of health services at Boston University School of Public Health and director of the school’s Health Reform Program, also doubts the safety concern. “I’m not familiar with any problems with Canadian drug safety, and the FDA apparently isn’t either,” since it hasn’t identified anyone harmed by Canadian drugs.


But Tom McGinnis, the FDA’s director of pharmacy affairs, says the agency lacks important information about Canadian drugs. “We really worry about the formulation being different and the patient not having the same therapeutic responses.” The Department of Health and Human Services (HHS) is studying the issue and will present a report to Congress this month on importation safety and costs.


Opponents also warn that importation would increase the amount of counterfeit drugs introduced in the United States. “If I’m living in Maine or Minnesota and go across the border, am I concerned? No,” says Merrill Matthews, resident scholar at the Institute for Policy Innovation (IPI), a think tank founded by former Rep. Dick Armey (R-Texas). “But what’s happening is, as this expands, the companies working in importations are going to have to find more supply.” Instead of depending directly on pharmaceutical companies, these sources may turn to other wholesalers, making the sources we considered secure, less secure, Matthews says. And although counterfeit drugs are not a large problem in the United States or Canada, Matthews says it is a huge problem in such nonindustrialized countries as China, Pakistan, India and throughout Africa.


Jeff Trewhitt, spokesman for the Pharmaceutical Research and Manufacturers of America, also warns, “If we have importation, we would open up what is essentially a closed-pharmacy system,” inviting more imitations.


Angell disagrees, saying counterfeits are more likely in the United States than in Canada because here, “there are usually many wholesalers, many middlemen, in getting the drug from the manufacturing plant to the user.” The higher prices invite counterfeits as they offer a lucrative incentive, she adds.


Concerns about imitation drugs aside, the CBO says the cost savings from importation would not be nearly as great as supporters predict. It issued a report in April warning that drug companies would alter their distribution methods before they lower prices. The report said companies may limit Canada’s supply or, if required to charge one price to all countries, choose a higher dollar figure that could outprice entire nations. Drug companies could also slightly modify the drugs they distribute outside the United States, essentially preventing the resale, because the FDA must approve forms, dosages and strength levels of all variants. Accounting for these changes in delivery method, the CBO concluded that importing foreign drugs would produce minimal cost savings to Americans, roughly $40 billion over 10 years, or approximately 1 percent of spending. If imports are limited to Canada, the report says savings would be “negligible.”


CANADA OR BURST


But that’s what more and more Americans, particularly senior citizens, are heading north for—savings. “The costs for the most commonly used drugs by senior citizens have been rising at over three times the inflation rate,” Angell says. Typically, seniors rely on multiple medications, yet many lack prescription drug benefits that would reduce their out-of-pocket expenses. Medicare, which insures more than 39 million seniors and disabled Americans, began offering its first-ever drug discount card in June, but the amount of savings and number of beneficiaries remain below the anticipated level.


Americans are spending millions of dollars reimporting the drugs they can’t afford to buy locally, Sager says. “Somewhere between $1 [billion] and $3 billion dollars worth of prescription drugs will be imported into the United States in 2004,” he says, estimating it will be closer to the $3 billion figure.


Despite the importation prohibition, citizens are benefiting from a 50-year-old FDA policy on personal importation that McGinnis says was developed to give patients who have not had success with FDA-approved medicines access to foreign drugs. “That policy was really meant for only things not available in the United States,” he says, recognizing that Americans are using it to import all types of medications. In spite of this, he says, the FDA will turn a blind eye until it can review the HHS’ December report.


Sager says the loophole acts as “a political safety valve, allowing people who really feel the pressure to escape the crushing burden of high U.S. drug prices. If the FDA ever blocked this importing, we’d have a political explosion….”


STATES GET IN ON THE ACT


After realizing his citizens were traveling to Canadian pharmacies or trying their luck with online vendors, New Hampshire Gov. Craig Benson (R) dispatched two pharmacists to investigate and identify a safe online Canadian retailer. The pharmacists, Frank Lukosius and Merton Dyer, returned saying they found a pharmacy that offered “a safe, cost-effective, confidential alternative for those wishing to purchase drugs through Canadian mail order.”


Since Benson linked the state’s Web site to the Canadian pharmacy in April, 400 New Hampshire citizens have filled their prescriptions online, says Kevin Smith, spokesman for the governor. Patients must either mail or fax a prescription from their U.S. physicians, which, according to Lukosius and Dyer, are verified by one of six Canadian physicians with whom the pharmacy contracts. To further assure authenticity, drugs are dispensed in the original manufacturers’ packaging, eliminating the need for the pharmacist to count pills.


Other states, counties and municipalities are taking similar steps to help their residents access lower-priced pharmaceuticals. Illinois connects its residents with state-inspected and approved pharmacies and wholesalers in Canada, Ireland and the United Kingdom, paving the way for patients to purchase their drugs online from safe facilities. And for more than a year, Springfield, Massachusetts, which funds an insurance program for municipal employees, has encouraged workers and retirees to purchase patented drugs from Canada by offering them a lower co-pay. The city also saves money when they do because it pays 75 percent of all medical costs, including prescription drugs for city employees, says Chris Collins, Springfield’s insurance program director.


All these importation practices are illegal, but at press time McGinnis says the FDA has sent only warning letters to violators.


SEEKING LONG-TERM SOLUTIONS


But Americans shouldn’t have to rely on foreign retailers for their drugs, says Patty Reilly, spokeswoman for the Alliance for Retired Americans, which supports Dorgan’s legislation as a short-term solution.


A permanent solution, many say, would allow groups to negotiate directly with pharmaceutical companies for lower prices. “Importation is a stop-gap policy for seniors who are desperate for medications,” says Jerry Flanagan, who lobbies for bulk-purchasing programs on behalf of the Foundation for Taxpayer and Consumer Rights, a California-based advocacy group. He would like the United States to allow Medicare to buy drugs in bulk, as it allows the Department of Veterans Affairs.


The pharmaceutical industry opposes such measures, Trewhitt says, because it would afford states and municipalities too much power. Instead of competitive negotiations involving many buyers and sellers, bulk purchasing by states, or groups of states, allows for one buyer who could potentially dictate prices or exclude entire drug companies from its formulary.


To sidestep the issues of equitability with bulk purchasing, Sager recommends a “prescription drug peace treaty.… If we cut prices by 40 percent to Canadian levels, worldwide drug revenue would fall by $60 billion,” he says. “[But] you cut prices, volume goes up,” offsetting most of that loss. He also argues that the cost to make the additional pills would be nominal, since the overhead has already been invested.


But Richard Epstein, a University of Chicago law professor and critic of Dorgan’s legislation, says drug companies charge high prices because of the costs of introducing pills. “You can’t run a complex system with heavy front-end costs unless there’s some degree of price discrimination.” Estimating that it costs between $100 million and $1.7 billion for pharmaceutical development, marketing and clinical trials to make the first pill, Epstein argues drug companies must be able to recoup those expenses or they won’t continue to be innovative. “America essentially provides research for the rest of the world…,” he says.


Trewhitt also warns against price controls, saying they do not acknowledge research and development spending and can discourage companies from making new medicines.


The IPI’s Matthews says it may depend on consumer activism to bring prices down. As patients become more active and question their physicians more intensely about their medications, they will begin to request drugs that fit in their budget, forcing companies to respond to demand. “[Pharmaceuticals] eventually will start to compete on prices. They don’t want to compete on prices, nobody wants to…[but] the way the market is moving, they basically are going to have to start…,” he says. A nonlegislative, bottom-up solution will be the most effective, he says.
~STUDENTS AND PHYSICIANS WEIGH IN


Q: Should the United States allow the legal importation of drugs?

A: “If Canada has found a way to balance both the testing/research aspect of the drug and the distribution, and has been able to keep the costs down in both areas, then I see no reason why the [United States] should deny people access to those drugs.”

Austin Pederson, premed
Arizona State University

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Q: Do you have concerns about the safety of drugs coming from Canada?

A: “As a dual citizen, raised in the United States but currently attending medical school in Canada, I think the safety issue is preposterous. I have been getting my drugs here for the past two years, and it strikes me that exactly the same level of quality control exists here as in the States. I think if reimportation becomes widespread, it will simply force addressing the larger issue: that people in the United States are paying for the vast majority of profits for drug companies, because it’s the only place [the companies] can get away with jacking up prices.”

Emily Gregory, second-year
McGill University Faculty of Medicine


A: “Because foreign countries have indisputably more lenient restrictions on the research and manufacture of drugs, doctors and politicians should be cautious about making it easier or more acceptable for our [citizens] to purchase drugs from Canada or elsewhere. So I do not think we should buy foreign pharmaceuticals in bulk or organize drug safaris into Canada. That’s tantamount to a stamp of approval on non-FDA approved drugs. Then what would our FDA be for?”

Bach-Mai Vu, premed
Stanford University

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Q: As a physician, would you advise patients that they could get cheaper drugs across the border?

A: “I have no ethical concerns about my patients purchasing meds from Canada. I agree with some states helping their citizens purchase those meds. I’m not sure that the [United States] should spend time [or] money supporting the importation of drugs from another country, however. Maybe that same effort could be used here via incentives to encourage pharmaceutical companies to decrease [the cost of] their medications, or [begin] a new drug program for elders.”

Jackie Nkrumah, fourth-year
University of Massachusetts Medical School


A: “I do not tell my patients where to buy their drugs, or even suggest [where], since there are so many variables, and I am no expert on this. Online shopping, including Canada, can be very tricky with meds, and the quality may vary all over the place. I suggest people shop around and check out prices at trusted big-name companies…. Again, I am opposed to the whole idea that people in this country should have to resort to shopping in another country, though I certainly don’t blame anyone for trying until we get a decent policy in this country.”

Dr. Charles Goldman, clinical professor
University of South Carolina
School of Medicine
~~~Molly Novotny is associate editor of The New Physician. Direct comments about this article to tnp@www.amsa.org.~Health Policy,Pharmaceutical Industry~