14~1January-February~2006-55~Feature~Building Professionals~Jamming the intangible into students~Pete Thomson~Somewhere between anatomy and zymosis, students are expected to soak up a concept called “medical professionalism” that will allow them to establish strong patient relationships and a highly principled approach to medicine. But can this stuff be taught in a classroom?~Late for class? You may only be missing the instructor’s opening humorism and all the forced laughter that follows. But could you also be setting the tone for the rest of your career? Could sliding into your lecture hall seat two minutes past the hour translate to poor patient care later? Similarly, could your aggressive, argumentative style in small-group discussions—in the classroom or on a listserv—predict the way you relate to your future patients?


In fact, studies at the University of California, San Francisco (UCSF), have linked “unprofessional” medical school behaviors to future censure by the California state medical board. Researchers identified the particular areas of “unprofessional” behavior among medical students that were most likely to signal future run-ins with state licensing authorities. Of the nine domains they examined, “poor reliability and responsibility,” “lack of self-improvement and adaptability” and “poor initiative and motivation” predicted eventual action by the state board once those students were practicing physicians.


The connection between professionalism and quality of care is well-recognized among medical education leaders, and their efforts to impart its component concepts to students take many forms. But along with that “instruction” comes the tricky task of measuring the nearly intangible concept of professionalism so that students and programs can receive important feedback on their success.


PINNING "IT" DOWN


But what is professionalism? Most medical students are at least tacitly familiar with the term, as most of their schools have some form of professionalism “training” integrated into the curriculum. Fortunately, it’s a topic on which there has been a fair amount of reflection in the medical community.


In recent years, researchers at the Centre for Medical Education at McGill University in Montreal developed their own working definition of a medical professional, relying heavily on the Oxford English Dictionary. They are currently using this description to frame further study. True professionals, they believe, “are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain,” according to their work, published in the journal Teaching and Learning in Medicine in 2004.


“The use of the words varies, but there is general agreement about what it means to be a professional,” says Dr. Richard Cruess, one of the authors of the article and a former dean of McGill’s Faculty of Medicine who has been long-associated with the topic of medical professionalism.


Many different definitions of medical professionalism are currently used by schools and residency programs, but all are similar in many respects: They hold that members of the profession of medicine must uphold certain standards in order to fulfill their half of a social contract. It is the definition—and application—of the standards that counts.


In 1999, the American Board of Internal Medicine created the ABIM Foundation to pursue two goals: improve quality in medicine and promote professionalism in the medical field. While the foundation treats both as separate efforts, there is much overlap between professionalism and quality improvement, executive vice president Dan Wolfson says.


“If you think about quality in its broadest dimensions—about finite resources, improving quality and then this one about social justice, involving some equity issues around access to coverage—[professionalism and quality improvement] are quite linked.”


Working in conjunction with the American College of Physicians-American Society of Internal Medicine and the European Federation of Internal Medicine, the ABIM Foundation released the Charter on Medical Professionalism in 2002. It was published simultaneously in the Annals of Internal Medicine and The Lancet.


The charter contains three fundamental principles: primacy of patient welfare, patient autonomy and social justice. It also lists 10 professional responsibilities, including commitments to professional competence, honesty with patients, improving access to care and the “just distribution of finite resources.”


The appeal of the charter is that as physicians grapple with making the commitments work in their practices, they become intimate with the more subtle ideas behind them. “One could think that it is a document that will continue to have commentary and further elaboration, and it’s just the beginning,” Wolfson says. “It is challenging to reconcile all of the commitments in totality.”


More than 37,000 copies of the charter were distributed to schools, hospitals and physicians in 2004 and ’05. Schools have used them in white coat ceremonies and as an entry point for talking about the topic of professional responsibility. The American Board of Medical Specialties, the organization that certifies medical specialists, distributes a copy of the document with its certificates.


The charter has spurred some heated discussions, especially over a perceived conflict that potentially pits the primacy of patient welfare against the commitment to the just distribution of finite resources.


“Some would say, well, how can you do both? And I think the challenge is to find ways where one can do both.” Wolfson says. “[Physicians] can do what’s best for their patients, but do it only using the resources that are needed and appropriate for a given condition.”


Since its publication, the charter has been endorsed by more than 120 national and international medical organizations, according to Wolfson. One group that has not endorsed the charter is the American Medical Association (AMA). The association’s position is that it was not involved with the development of the charter, and had previously created its own “Declaration of Professional Responsibility: Medicine’s Social Contract with Humanity,” ratified in 2001 and designed to be used alongside existing medical ethics policies.


For students, the issue can seem intangible, but often boils down to a simple idea. “Professionalism is an attitude that is expressed as actions that show the staff and patients respect—respect for yourself, respect for your patients, respect for your co-workers,” says Jared Lenz, a fourth-year at Kirksville College of Osteopathic Medicine (KCOM) in Missouri. Lenz has insight beyond many medical students—he spent eight years as a chiropractor before medical school. While his experience working with patients may have helped him define professionalism for himself, it has not necessarily given him an edge in his professionalism course work.


“Because I’ve already developed my professionalism style…to have to try and do things differently is sometimes harder than starting with a clean slate,” he explains. Each individual’s manner of defining and applying professionalism makes for some differences. “Something that somebody else thinks is perfectly OK, I might not feel comfortable with, just from my own experiences.”


TRUMPING THE MARKETPLACE


So where do all of these policies and charters meet the daily practice of medicine, and what does an increased focus on professionalism bring to the field?


Professionalism may sound like an internal issue for medicine, but it’s not, says Dr. Cary Sennett, the ABIM Foundation’s vice president for research and development. “One of the things that we recognize…is that the public at large has expectations for professionalism, and that public at large includes not just patients but, increasingly, the buyers of care.”


Those “buyers of care” include patients’ employers and health management organizations—groups concerned to a significant degree with the quality of care. Through pay-for-performance and tiered network programs, buyers are trying to find a system that inherently improves quality. But they won’t find sustainable quality improvement in those systems, Sennett believes. “The way that [buyers] would like to see quality improved and would like to see accountability established is through the exercise of professionalism by the profession.”


Wolfson points to a study the ABIM Foundation conducted of 39 small practices that were monitoring their own commitment to quality improvement. “The thing that they had in common was that they were doing it out of a sense of professionalism, rather than external forces like pay-for-performance or financial rewards,” he says. “They saw it as a professional responsibility to close gaps in performance between what they thought was their care, and what actually was their care after they measured it.


“Ultimately, professionalism will out-trump the marketplace. And it’s enduring, sustainable,” he adds. “The marketplace has initiatives, but are they self-sustaining over time, and how long will they sustain a physician who isn’t [trying to improve quality] out of professional commitment and responsibility?”


The road to future professionalism clearly starts in medical school. But according to Dr. Jordan Cohen, outgoing president of the Association of American Medical Colleges (AAMC), “The learning environments in which our students acquire their identities as physicians are too often failing to properly calibrate their professional compass.”


MEASURING "IT"


Those studies at McGill are taking a stab at gauging professionalism in students and residents. In Creuss’ opinion, academic medicine “has been evaluating professionalism—badly—on forms that are imprecise, and we’ve been using, essentially, value judgments, sort of subjective analysis. This is trying to make it more objective.”


But moving from subjective to objective measurement can be complex. “Professionalism consists of a group of attributes or attitudes or values. You can’t reliably evaluate somebody’s values. But when people behave, they reflect those values, and you can observe behaviors,” Cruess explains. “You can evaluate the action. But you can’t evaluate what is going on in somebody’s head.”


After developing their working definition of professionalism, the McGill team then outlined the attributes, or values, of the profession, including “altruism,” “morality” and “integrity.” To arrive at a set of measurable behaviors, 92 faculty members formed small groups and were asked to develop a list of behaviors that demonstrated each of the attributes outlined. Then they were asked to develop a list of behaviors that demonstrated a lack of those values.


There was a lot of overlap in the results, but it gave the team plenty to work with. “When we boiled them down, we were trying to get a group of behaviors that would allow us to evaluate the totality of professionalism—all of the attributes,” Cruess says.


The faculty had come up with 142 behaviors which were consolidated into 24. They included “showed interest in the patient as a person,” “insured continuity of care,” “advocated on behalf of a patient” and “demonstrated awareness of own limitations.” These behaviors were listed on a single form, called the Professionalism Mini-Evaluation Exercise (PMEX).


Attendings were then asked to evaluate single events—half-hour or 45-minute interactions between a student and a patient—on a four-point scale from “exceeded expectations” to “unacceptable.”


Their first test of the PMEX was completed in the spring of 2005. Seventy-nine students were evaluated, with an average of 2.9 forms filled out per student. The study was not intended to show the success of the school’s professionalism program as a whole, says Cruess. Rather, it demonstrated that the PMEX could generate reliable, reproducible results.


This is very important, he explains, when dealing with high-stakes evaluations. “You have to be able to defend your tool. You can’t be capricious when you are doing things like this. You are playing with people’s lives.”


In practice, the PMEX is intended as a “formative” assessment: Its results allow the individual student to see her weaknesses in the hope that she will improve her performance accordingly.


McGill is now studying the form for use with residents, though Cruess says they have no reason to expect different results in its effectiveness. The number of behaviors has been further reduced to 21.


TEACHING "IT"


Such reflection tools are one common and effective method of promoting professional behaviors in students.


“One reflects back on experiences and thinks about what they might do differently in the future,” Wolfson says, “and has a conversation, I think, with themselves about…their being in a situation, and how they react to it. It’s a very important learning device that is used in medical schools, and it’s part of the way people think about the professionalism charter.”


Some schools use peer evaluations to the same effect. Like the PMEX, these appraisals are generally employed for constructive intervention. Students may also reflect while they are evaluating others.


Another method of self-reflection that has been adopted at the Cleveland Clinic Lerner College of Medicine and other academic centers is the student portfolio, in which students keep track of their education by an online record of faculty and peer reviews, as well as self-assessments, including quizzes of medical knowledge. Students and their advisers review the portfolios together, working out strategies to address a student's weaknesses in any of the competencies, including professionalism.


The ABIM Foundation has tried to stimulate medical schools to infuse professionalism throughout the students’ experiences. “You have to take a medical school [that] has the vision and the objective of infusing professionalism within the curriculum,” Wolfson says. “The movers on this…are saying, how can we inculcate it throughout all of our curriculum? Not just a course, but how can it be a part of our daily work, and how can it be infused in many courses?”


The University of Texas Medical Branch (UTMB) has tried to do that, and even take the concept a step further, says Dr. Michael Ainsworth, associate dean for regional medical education. “What we are doing with the medical students…is really embedded within a culture that goes across the entire campus, meaning there are university-wide, campus-wide sorts of initiatives that form the backdrop.”


The principles of professionalism do not apply only to physicians at the institution, Ainsworth explains. The UTMB Professionalism Charter is an adaptation of the ABIM Foundation’s charter, with language adjusted to apply to everyone from health professions students to maintenance staff, secretaries, cafeteria workers and campus security officers.


“One of the principles is the primacy of human welfare. You don’t have to be a medical student or a doctor to think about that. Commitment to honesty, or commitment to confidentiality—that can be applicable to everybody in his or her everyday work,” Ainsworth says. “So this is just meant to be an example about how what we are doing in the school of medicine is not being done in a vacuum.”


For medical students specifically, UTMB’s efforts begin on day one at their white coat ceremony. A session with new students focuses on how professional behavior is central to their future roles as physicians. The ceremony is sponsored by the Honor Education Council, whose main function is to raise awareness of issues surrounding professional behavior. The council also sponsors talks on professional behavior.


First- and second-years take a longitudinal course called “The Practice of Medicine,” where they learn how to actually interact with human beings. Thus, while they are learning their medical building blocks, students pick up on important interpersonal tools of courtesy, sensitivity and confidentiality. Eventually, the course provides them with a controlled, “safe” environment for practicing those skills.


Professionalism is reinforced throughout the curriculum at UTMB, Ainsworth says, even forming part of mainstream grading. In every class, students receive a score on their ability to demonstrate professional behavior.


In all of these classes, unprofessional behavior is addressed whenever appropriate. For instance, if a student was being disrespectful to classmates during a small-group discussion, that grading component could come into play.


If the student’s behavior hasn’t risen to that level, but the instructor feels it should be addressed, an “Early Concern Note” could be submitted. Ainsworth himself has the responsibility of counseling those students. Together they examine strategies on how to address the problem in a supportive, nonjudgmental way, Ainsworth says.


Usually, these problems amount to a student underestimating the importance of a particular behavior, such as timeliness. “Perhaps an example they have faced before is ‘Do I need to show up for that lecture on time?’” Ainsworth says. “They underestimate how much of a leap that is, [but] showing up for patient care is probably substantially more important than what [the student has] experienced before.”


SOAKING "IT" UP


From many students’ perspectives, the formal teaching of professionalism isn’t always as provocative—or even as crucial—as medical education leaders might imagine.


John Reed, a University of North Carolina at Chapel Hill School of Medicine (UNC) second-year, says that while his school hardly ignores professionalism in the first two years, he doesn’t recall being handed a definition of professionalism in class. “There’s nothing that is set down for us that I know of, but I’m also not sure that there needs to be one. I think we should have a pretty good idea of what it is without having it defined for us.”


Reed is interested in either family practice or a specialty that involves long-term patient contact. While he hasn’t gotten on the wards yet, UNC students spend five “community weeks” shadowing physicians. During that process, they are told what behaviors are expected of them.


By the time students reach the wards, they’d have better picked up something about professional behavior, says KCOM fourth-year Lenz. “If you don’t have a clue as to what that is, then I think you might be in trouble, because nobody is going to sit you down and say, ‘This is what professionalism is.’” But at that point, students aren’t without a learning opportunity. “That’s where the learning by example comes into play, and hopefully having kind of an innate sense of what’s right and what’s wrong.”


In his final address as president of the AAMC, Cohen pronounced the inculcation of professionalism one of the most important tasks of academic medicine in the future, and said physicians in teaching roles would be the ones to provide that example.


“Students emulate what we do, not what we say. And what we too often do is patently unprofessional. Every time we demean a nurse, disrespect a patient, harass a student, exploit a resident, overbill for services, fudge data to gain a favorable journal review, permit commercial interests to bias educational offerings, shill for a pharmaceutical company, or do anything that would embarrass us if published on the front page of a newspaper, we chip away at the character we profess to cherish among the learners in our midst.”


But in the end, efforts to promote professionalism come from many different directions, including patients, buyers and academic centers.


“To the extent that we can align our efforts to encourage professionalism, encourage the growth of physicians as professionals with what is happening in the marketplace, I think everyone is better off,” the ABIM Foundation’s Sennett says. “We’ll be sending out consistent and reinforcing signals to physicians about what behaviors are appropriate, and we’ll get that with much less conflict, much less friction, much less redundancy…. Everyone wins.”
~HEALTH MODELS


Give me a doctor partridge-plump,
Short in the leg and broad in the rump,
An endomorph with gentle hands
Who’ll never make absurd demands
That I abandon all my vices
Nor pull a long face in a crisis,
But with a twinkle in his eye
Will tell me that I have to die.

—W.H. Auden



Much of professional behavior centers around physician–patient communication. But what are you communicating to your patients without even speaking?


W.H. Auden may have preferred an overweight physician with whom to commiserate, but some patients won’t look past “partridge plump,” and that’s no good if you are trying to get them to lose some weight. And while it’s hard for patients to take a cigarette-smoking physician seriously when they are told to drop the habit, studies have shown it’s also difficult for the physician himself to take his own approach seriously.


If prevention is such good medicine, and patients take cues from their physicians’ personal habits, how does your lifestyle affect your patients’ health?


A study published in Preventive Medicine in 2003 showed that patients receiving diet and exercise advice from nonobese physicians had more confidence in that advice than those receiving that advice from obese physicians. A 2003 French survey showed that physicians who smoked were less confident in their ability to help patients quit, possibly because they were personally familiar with the difficulties.


Not only are physicians-in-training not immune to the diseases they learn about, their stressful lives can lead to the same unhealthy personal habits they try to discourage in their patients. So, do medical schools have a responsibility to promote wellness to students so they can pass it on to patients down the road?


In surveys of medical students and deans conducted in 2002 and ’03, researchers at Emory University and the American Medical Student Association Foundation asked if medical schools “should encourage their students and residents to practice healthy lifestyles.” Most students and deans agreed. But when asked if their particular school actually follows through and encourages healthy living, students were split down the middle.

Perhaps popping chocolate during exam season isn’t just making you “broad in the rump”: Don’t forget your patients’ rumps are at stake, too.


—P.T.


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

RESOURCES


The Charter on Medical Professionalism

The charter, a joint effort by three medical societies through the Medical Professionalism Project, suggests three principles and 10 commitments for physicians.



The Declaration of Professional Responsibility

The American Medical Association has its own professionalism oath, comprising nine commitments.



Serving as a Role Model

The American Academy of Family Physicians offers suggestions on serving as a role model to your patients.


A Student’s Professionalism Primer

The American Medical Student Association offers some suggestions on “Revitalizing Professionalism.”

~~While professionalism is often associated with patient relations, the ABIM Foundation's professionalism charter includes commitments to advancing scientific knowledge and monitoring conflicts of interest.~Pete Thomson is associate editor of The New Physician. Direct comments or questions on this topic to tnp@amsa.org.~Career Development,Medical Education,Practice of Medicine~
22~2March~2006-55~Feature~Healing the Healers~Medical students’ busy, stressful lives make them vulnerable to addiction—and less likely to seek help.~Avery Hurt~The addictions and compulsions that wrest control of so many lives do not exempt medical students and physicians. But admitting a problem and getting help may be far tougher for them.~

“There is a silent but terrible collusion to cover up pain, to cover up depression; there is a fear of blushing, a machismo that destroys us. The Citadel quality to medical training, where only the fittest survive, creates the paradox of the humane, empathetic physician… who shows little humanity to himself.”


The Tennis Partner
Abraham Verghese, M.D.


Medical students typically graduate with tremendous debt, yet the costs of the profession cannot be calculated in dollars alone. The rate of depression and suicide among physicians and medical students is almost double that of the general population.


And despite having to manage the often dire medical consequences of patients’ alcoholism and drug abuse, medical students and physicians suffer addiction at the same rate as the general public: Ten to 15 percent will develop drug or alcohol problems at some point in their lives.


Addictions to gambling, sex, shopping and other compulsive behaviors also plague medical students and physicians overwhelmed by a high-stress lifestyle, but these tend not to show up in the literature or in surveys. And there may be a good reason for that. Often, destructive coping behaviors are not recognized for the problems they really are.


Nor can data account for what Dr. Abraham Verghese calls “dry drunks.” Verghese, founder of the Center for Medical Humanities and Ethics at the University of Texas Health Science Center at San Antonio, is also the author of The Tennis Partner, a memoir about a physician’s experience with an impaired friend and colleague. In his book, Verghese describes “dry drunk” physicians as those who use the “titles, power, prestige and money” associated with medicine just as addicts use drugs and alcoholics use drink to manage a greater suffering.


There is something about the medical profession that contributes to depression and substance abuse problems, say those who have worked with impaired physicians and those who have experienced it personally. Dr. Joseph O’Donnell, senior advising dean and director of community programs at Dartmouth Medical School, points out that the social esteem of medicine can often mask a great unhappiness. And according to Dr. Douglas Talbott, founder of the Talbott Recovery Campus in Atlanta, which specializes in treating addicted medical professionals, physicians are taught to concentrate on their patients and ignore their personal feelings—a habit known to lead to all manner of dysfunction.


STRESS AND DISTRESS




The pressures of medical school are legendary. Last December, Dr. Liselotte Dyrbye, assistant professor of medicine at the Mayo Clinic College of Medicine, studied the phenomenon of medical student distress, including substance abuse and depression. She found that students’ demanding workload, frequent exposure to suffering and death, ethical conflicts and difficulty with finances—particularly debt—combine to create a recipe for trouble. But although plenty of professions suffer onerous workloads, and excessive debt is becoming a typical American characteristic, the weight of all these stressors, combined with features unique to medicine, take an often-unrecognized toll on students.


Despite its many challenges, medicine is intellectually stimulating, emotionally rewarding and quite often a great deal of fun; the vast majority make it through training and career without serious problems. While the stress of medical school may be the factor that pushes a susceptible individual over the edge, the risk factors most likely to lead to drug or alcohol abuse are the same in the medical profession as in the rest of the world: a family history of abuse or pre-existing psychological problems. Dr. Laurence Blumenthal, director of student health services at the Medical University of South Carolina (MUSC), points out that problems leading to substance abuse typically have their origins long before the student gets to medical school.

That certainly was the case with Eli Penn.


ONE MAN'S ROAD




Penn, a fourth-year at MUSC, is currently applying for residencies and preparing to celebrate his graduation from medical school. He has something else to celebrate as well: two-and-a-half years of sobriety.

Penn’s journey has been a bumpy one. He began drinking as an adolescent, but thought he had it under control. He didn’t. “Exactly three months after starting medical school, I started drinking again,” he recalls. When asked if it was the pressure of med school that sent him back to the bottle, Penn thoughtfully comments that the pressure was less a cause than a justification. Penn’s drinking progressed to an addiction to stimulants such as Ritalin and Adderall that he initially used to manage hangovers.


Penn made it through his first year, then took a voluntary leave of absence, claiming relationship problems. He dropped out of med school but returned two times before a supervisor, noticing that he was drunk during a small-group session with a simulated patient, confronted him about his problem. The supervisor also reported him to the dean’s office. MUSC gave Penn the option of returning to school only if he completed a treatment program. He went first to the Talbott Recovery Campus, but when his insurance ran out, he transferred to St. Jude’s, an inner-city recovery program also in Atlanta. Eventually Penn returned to MUSC and will graduate this spring.

Penn’s story is not atypical. He never asked for help, nor did colleagues offer any. In fact, he had been in a recovery program for five months before he finally admitted he had a problem.


Denial can be especially strong among medical professionals. Doctors are taught by society to believe they are special—stronger, not subject to the weaknesses that beset others. After all, the process of getting into and through medical school and residencies tends to weed out the weak. And an overdeveloped sense of self may well be necessary for success in a field that calls on resources of time, commitment and emotional strength far beyond the ordinary. In such a world it is much harder to admit that one has a problem.

Even when the problem is acknowledged, asking for help is not easy. Medical professionals often resist seeking treatment because they fear the consequences of admitting their weakness and potentially losing everything they have worked so hard for—the ability to practice medicine.


They are right to be cautious: Drug or alcohol abuse can and has ruined many otherwise promising careers, and having it on your record can make life difficult. But a history of abuse does not have to be an insurmountable liability. According to Darlene Shaw, Ph.D., director of counseling and psychological services at MUSC, “If you seek help early and are successful in recovery, you will be a stronger person for the experience. Residency programs and other potential employers take this into account when evaluating you.”

Penn agrees. Because his problems are a matter of academic record, he has been open about it during his program applications. So far, his past problems have not seemed to present an issue.


The key, Shaw points out, is getting help early and making it work. “The most successful treatments are tailored to the individual’s specific problems [through] intensive therapy, either inpatient or outpatient. We are big believers in the 12-step program, with monitoring programs and support groups such as the Caduceus Group [a support group especially for medical professionals in recovery] as adjuncts,” she says. “In addition, we use written contracts that clearly outline the expectations and consequences of relapse.”

Fortunately, medical professionals are good at hard work and commitment. The recovery rate for physicians in treatment is higher than that of the general population.

Dr. Matt Hopkins, a psychiatric resident at Dartmouth-Hitchcock Medical Center, has a story reminiscent of Penn’s. His drinking problem began while he was in medical school at Texas A&M, and he continued to drink, at times heavily, during his residency. By his third year of residency, he had progressed, like Penn, to Adderall. Eventually he was caught presenting a prescription under a false name.

“When I was paged to come to the legal office,” Hopkins recalls, “it was like my death march. ‘My life is over,’ I thought.”


Hopkins’ problems were exacerbated by the legal issue, but he was able to get the charges reduced and was sent to the Next Step program at Pine Grove Treatment Center in Hattiesburg, Mississippi, a rehabilitation program for addicted physicians. His treatment was successful, but resuming his career was not as easy as it had been for Penn. In addition to $30,000 in legal fees, and additional fines from the medical board and other organizations, Hopkins had to “jump through all kinds of hoops” to get his license restored and his job back. Afterward, “everyone was suspicious of me,” he recalls. But things have worked out well for Hopkins. He is now a fellow in the drug-addiction treatment program at Dartmouth-Hitchcock, using his personal experience to help others.

Hopkins was not surprised to learn that the recovery rate for physicians is high. “If I relapse,” he explains, “game over. I lose my license. I never practice medicine again.” As O’Donnell puts it, “That’s a pretty big stick.”


A RESPONSIBILITY TO HELP




If recognizing an addiction crisis is difficult for the impaired individual, it can be even less apparent to instructors, supervisors and colleagues. Though it may seem counterintuitive, the signs are not at all obvious to many physicians. “Many of the students who have problems are the best students,” reflects O’Donnell.


For addicted students and practicing physicians, observers agree, the work is the last thing to go. And in a world where personal lives often play a secondary role to the work, trouble can be very deep indeed before colleagues notice and step in.


Still, intervention by friends and colleagues is crucial. Fortunately, “students are always the first to know when there are problems with their peers,” explains Shaw. Clues that don’t show up in the classroom or in the clinic often manifest in social situations where professors and supervisors rarely see students, but students are likely to see each other.


While students may be hesitant to confront, much less report, a troubled classmate, it can be argued that intervention is not only a kindness, but also a responsibility to both the impaired student and to the profession itself. According to Section 10 of the American Medical Student Association’s Code of Medical Ethics, “A medical student shall guard one’s own health and well-being; likewise, one should strive to promote wellness in one’s colleagues, including assisting impaired colleagues to seek professional help, and accept such help if one is impaired.” Such peer intervention has also proven to be exceptionally effective.


In early 1984 at the University of Tennessee Health Science Center College of Medicine, a group of students, faculty and administrators got together and came up with a novel approach to the problem of impaired students: the AIMS program (Aid for the Impaired Medical Student). Both the novelty and the beauty of AIMS is that “students serve as advocates for other students,” Shaw says. MUSC is in the process of joining many other medical schools that have implemented an AIMS program.


AIMS is typically administered by a council comprising an equal number of student representatives and professional members. Student members are elected by their classmates, while the medical school dean selects the professional members—chosen for their expertise in impairment and their lack of connection with the administration or faculty of the school. Students with problems can approach the council for assistance; students who suspect a colleague is in trouble can also approach the council on behalf of the student. If the council determines that a student needs help, he or she is referred to an appropriate source of assistance. If these efforts are successful, the student is not reported to the dean’s office.


SIGNS





AIMS programs appear to be successful because of their confidentiality and student-centered intervention. This success, however, depends heavily on peers recognizing problems in their fellow students. Signs to watch for are social withdrawal, inappropriate anger, problems getting along with friends and maintaining relationships, and serious and chronic financial troubles beyond the norm. But trying to determine if the problem is actually drug- or alcohol-related before stepping in is neither necessary nor wise. “When people start to behave abnormally, there is always something wrong,” says O’Donnell, “whether or not it is substance abuse or depression. Whatever the problem, it is important to let people know that someone has noticed and cares.”


Some programs are more expansive than AIMS, enlisting the entire community in an effort to address the larger problem of substance abuse. One is Dartmouth’s Center on Addiction, Recovery and Education (DCARE). Established in 2002 and funded largely by alumni contributions, DCARE utilizes the talents and energy of students—both graduate and undergraduate—faculty clinicians and outside agencies. DCARE sponsors education and training programs, scientific evaluations of treatment programs and support services to people with addiction problems. DCARE also provides a variety of opportunities for students who wish to learn more about treating and preventing substance abuse.


A RICH LIFE



Coping with the unique stresses of a life in medicine is best accomplished using the same techniques relied on by people in any stressful field. “Take care of your personal health, get to the gym, take time off and be sure to have something in your life besides medicine,” advises Dyrbye. “These things are essential to being a whole person, and being a whole person is essential to being a good doctor,” she says.


O’Donnell has noted that today’s medical professionals often experience a lack of meaning in their lives. Many medical students wonder if medicine is the right choice; older physicians consider retirement as a remedy for burnout. O’Donnell thinks that the phenomenon of “dry drunk” doctors is a manifestation of this ennui. Taking care of oneself in such a situation, as Dyrbye suggests, goes far beyond eating “five a day” and getting 30 minutes of exercise. A rich life outside the hospital is more important than most physicians realize.


Yet in this field, where people are so thoroughly trained to take care of others at the expense of themselves, the most practical answer may simply be reaching out. Imagine: a medical culture in which the competition, the independence and the isolation are replaced by a community of people watching out for each other, attending to those sitting next to them in the classroom or working next to them in the clinic, just as carefully as they attend to their patients. O’Donnell reduces it to a simple formula: “Care for each other.”


John Raser, a fourth-year at Dartmouth, exemplifies this peer-care attitude. He set up a program designed to intervene with undergraduates. He visits fraternities and talks about the medical model of addiction and the effects of different drugs. A question-and-answer period is a key part of the presentation. He also provides an e-mail hotline for students who have private questions, need help themselves or want to seek help for a friend.

Raser attempts to keep the program nonthreatening, friendly and informal. “I have been pleasantly surprised by the response. The formal feedback shows gratitude—they seem grateful for someone showing interest.”

Many undergraduates have sought help for themselves or a fellow student after attending one of Raser’s talks, and the experience has helped him as well. Medical students typically don’t get enough education about recognizing and addressing substance abuse. First, he says, they need to understand that addiction is not shameful; it’s a disease that some people are susceptible to, not a character flaw. “It is a good idea for medical students to spend a few weeks in a recovery center,” says Raser. “It helps to develop your instincts, and it can be very encouraging to see how recovery can be accomplished.”


Patients aren’t the only ones who benefit from medical students getting more training about substance abuse. “Learning to recognize abuse and intervene with patients would be very helpful in addressing the problem with colleagues,” says Raser.
~RESOURCES

Here are some programs designed especially for medical professionals struggling with addiction or dependence. While most groups that offer assistance, both on- and off-campus, try to protect your privacy, the only way to legally ensure confidentiality is to enter into a formal therapeutic relationship with a health-care provider.


~~~The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~Disabilities in Medicine,Student Life and Well-Being~
15~1January-February~2006-55~Feature~Spotlight: Is There HONOR Among Students?~Honor codes aim to fortify a culture of integrity in medical schools~Eric Levy~A student honor code is one way school leaders try to foster an atmosphere of honesty and integrity in the highly competitive medical education environment. We examine how effective these codes really are.~A medical student, newly exposed to clinical rotations, sees a resident mistreating a patient. He says nothing to the resident but, after pondering the incident that evening, decides to report the honor code violation to his school’s honor council. A judicial hearing ensues, and the council recommends harsh disciplinary action be taken against the accused. But to the dismay of the accuser, the resident is soon back on the patient ward, having received only a mild reprimand by the school’s dean.


What happened?


What did happen is all too common, according to Dr. DeWitt Baldwin Jr., scholar-in-residence at the Accreditation Council for Graduate Medical Education. His study of honor code violations at 119 medical schools over one year (1996) identified 297 infractions—2.5 per school. But only 60 disciplinary actions were taken: Six offenders were dismissed, 10 were suspended, and 44 were otherwise disciplined.


“I think these numbers are far too low, and it’s bothersome,” says Baldwin. “Medicine has been reluctant to look at its dirty laundry and take action on it. It’s the nature of the profession. We like to look at ourselves as pure and good, and we’re afraid that if we point out some of the bad apples, people will lose confidence in us.”


Many schools have faced unprofessional behavior by students and residents, Baldwin notes, but couldn’t make the allegations stick. “It’s very hard to say in a court of law that someone mistreated a patient,” he says. “You don’t often have the law on your side. It’s hard to prove it. Deans are afraid of litigation taken against the school, and they back off.” Students on the honor council, he says, “are often frustrated when they find a colleague guilty of academic dishonesty or unprofessionalism, recommend a sanction, and then the dean doesn’t follow through on it.”


Approximately 60 percent of medical schools now have an honor code and/or a code of professional conduct, compared with 50 percent in 1991. A rapidly expanding trend is to incorporate professional codes of conduct within an existing honor code that has traditionally dealt only with cheating and plagiarism. Standards of professional conduct may involve respect for self, patients, faculty, staff colleagues, hospital personnel, diversity and policies, as well as moral standards for faculty.


Traditional codes can be as short as one to three pages covering standards of academic honesty. Others expand to 15 or 20 pages, including great detail on the nuts-and-bolts procedures of appearing before an honor council, students’ rights at a judicial hearing, the sanctions imposed upon those found guilty by a dean or dean of students, and the appeal process.


Honor codes typically do not extend to unethical incidences occuring prior to admission and discovered upon enrollment. Such infractions, such as recording false data on an application, Baldwin says, are usually handled at the dean’s level. Codes do not generally cover unethical behavior off campus either, except in the case of criminal activity or when drug or alcohol abuse negatively affects a student’s behavior on campus. When students commit other honor violations off campus, schools frequently must wrestle with the appropriate response. For example, last September, three Duke University undergrads used counterfeit credentials that enabled them to deliver crates of water to Hurricane Katrina victims. Suzanne Wasiolek, Duke’s assistant vice president for student affairs, told reporters, “I suspect, technically speaking, we could have pursued some kind of violation of our honor code,” but administrators decided against it.


Honor code violations are handled by each medical school’s honor council, typically made up of students and faculty, although the final decision on disciplinary action usually rests with the administration. When students are accused of unethical or unprofessional conduct, they are entitled to a hearing. The council, or a special board or committee, conducts an investigation and then declares the student innocent or guilty. If a student is found guilty, sanctions may include a failing grade in the case of a course-related violation, a written reprimand, probation, suspension or dismissal. Sanctioned students are then entitled to appeal the ruling.


CULTURE OF HONESTY


Does an honor code at school prepare students for the ethical challenges they’ll face as physicians? Many faculty and students say no. “I doubt the honor code has such an effect later on in practice,” says Dr. Catherine Caldicott, assistant professor of bioethics and humanities at the State University of New York Upstate Medical Center. “I think our ethics courses do that. It would take much more than a code to prepare students to reason through ethical dilemmas.”


Nor, apparently, do honor codes reduce the number of students who cheat. Baldwin’s research shows only slightly fewer incidents of academic dishonesty at medical schools with honor codes. What does appear to make a dent in the reported cases of academic dishonesty is when medical schools create an overall culture of honesty and respect to back up and constantly reinforce their written codes.


At many schools, the code is hidden in a student handbook and is rarely, if ever, referenced, but others make an effort to keep it out of mothballs by consistently reminding students of their responsibility to adhere to it—for example, having students sign at the bottom of each exam asserting that they have not cheated and will report any other student they witness cheating. In addition, virtually all medical schools now have classes in professionalism, providing another strong reinforcement of the school’s commitment to integrity.


Although the proliferation of honor codes and professionalism seminars may imply that academic dishonesty is rampant at medical schools, it’s not. According to the most recent figures provided by Baldwin, only 5.5 percent of medical students admit to cheating. In his previous study, five years earlier, the percentage was almost exactly the same.


He also found that medical school cheating is significantly lower than in undergraduate school, where 16.5 percent of students admitted doing so. The reason for the lower percentage of students cheating in medical school, researchers and administrators say, is the sense of responsibility inherent in the practice of medicine—students tend to believe that unethical behavior in medical school reflects greatly on their future profession.


Veronica Catanese, senior associate dean for education at New York University School of Medicine, who proctors exams, says she has never seen a student cheat. “Our students are well-versed in professionalism; I’d suspect cheating is extraordinarily unusual.” Corrine Kliment, a second-year at the University of Pittsburgh School of Medicine and a member of its honor council, says that she recalls only two students having been reported since she enrolled. “Most of our presenting issues usually turn out to be a student realizing that his or her behavior appears as cheating, but not with that intention,” she says. “An example is ‘wandering eyes’ during an anatomy practical.”


THE COST OF SILENCE


One reason so few students are brought before the council, Kliment believes, is that the honor code “encourages students to take action on their own,” such as reporting violations they witness. “At times, this can be difficult, especially since the involved individuals are your peers or good friends.” Instead, a major function of the council is to help the offending student modify his or her behavior and learn “critical aspects of professionalism.”


Like Pittburgh’s, many medical-school codes encourage students to report witnessed violations or confront the accused directly, and will even impose sanctions on students who do not report witnessed infractions.


The onus on an observer to play informant is one of the thorniest applications of the honor code, but while students say they would find it difficult to report a colleague, they agree to the tenet in principle. “We should re-
port violations we see,” says Daniel Cormican, a first-year at Stony Brook University School of Medicine. “We are going to be doctors in a few years, and our classmates, for better or for worse, are going to be fellow members of our medical community. We’ve got to learn at some point to step up and make some sort of stand for right and wrong.”


When schools do not foster a culture where students see the integrity of others as reflecting on all classmates, ill-feeling and frustration fester. “Our school cohort [has] displayed some unethical behavior and is mostly interested in specializing in highest reimbursement,” grumbles one student who did not want to be identified. “Our professors don’t think we are ethical either, or at least hint at that in many ways.”


Many schools with codes seem only to pay lip service to the concept of honor while still monitoring students closely for cheating. But when Ohio University College of Osteopathic Medicine (OU-COM ) introduced its new honor code to first- and second-year students in 2004, officials announced that exams would no longer be proctored. This expectation of honest and professional behavior, says dean Dr. Jack Brose, reflects the college’s mission to train self-motivated, self-disciplined learners. Introducing the new code to students, he reminded them that “patients will expect that you are policing yourself, that you are responsible for your own behavior—for being honest and acting with integrity. And your fellow physicians will expect the same thing.”


The OU-COM code reads in part, “As a medical student, I will not cheat or plagiarize or tolerate that behavior in others.” That last phrase is particularly salient to the school’s educational goals. Brose, a member of Ohio’s state medical board, points out that if, during a physician investigation, the board finds that another physician was aware of the wrongdoing and didn’t report it, his or her license is also in jeopardy. “We want—from day one in medical school—to establish professional behaviors…that are expected and required as practicing physicians.”


PEER PRESSURE


Members of the honor council at Pittsburgh have found that encouraging students to confront colleagues is a very powerful tool. Most students, after being challenged, become more aware of their unethical behavior, and it ceases. “One of the most effective ways that we prevent unprofessional behavior,” says Kliment, “is to first teach students about professionalism. For example, last year we had recurrent problems with people cheating on anatomy practical exams. We sent out a class e-mail reminding students of the code and made announcements before every exam. As a result, the occurrences stopped.”


The University of California, San Francisco, School of Medicine (UCSF) offers a peer counseling course for first- and second-year students run by the psychiatry faculty as an elective. The students who take this course assume the status of peer counselors to whom their colleagues can go for advice. In addition, faculty advisers, deans and a psychiatrist provide free counseling.


One result of this, believes Dr. Emilie Osborn, former dean of students at UCSF and now an administrator at the Palo Alto Clinic, is that while dean, she rarely heard about a student cheating on exams, and no one was dismissed because of cheating or plagiarism during her tenure. “We occasionally had issues about students ‘helping’ each other, but we promoted peer counseling.”


Osborn adds, however, that there is never room for complacency because “we often don’t see what is right in front of us.” For example, it is difficult to assess dishonesty in cases where student collaboration crosses the line into cheating. Caldicott says that professors attempt to distinguish between acceptable types of collaboration, such as working on problem sets, and unacceptable use of another’s work in written assignments. “If a student has not accurately attributed the source of an idea or information,” she says, “he or she is disciplined as if it were any other type of academic dishonesty.”


A more widespread problem, as cited by students, administrators and researchers, is what has become known as “cyber plagiarism.” Medical faculty say that part of the problem may be that students don’t fully understand what can be pulled off the Internet without citation. While all honor codes explicitly list plagiarism in general as an ethical violation, electronic-aided cheating is not often specifically mentioned.


Cormican, who says he has never seen cheating on a classroom exam at Stony Brook, is less sure about the integrity of some students who hand in take-home exams. “At home, where we have Internet access, it’s easy to look up answers. This happened with an anatomy class, when the class average was a 54, but one person got a 99. The second-highest grade was 70. Something that far above the mean makes you wonder.”


Although such cases of explicit cheating are uncommon in medical schools compared to other institutions of higher learning, the majority of medical students and administrators still support honor codes because of their role as an integral part of an overall culture of honesty and professionalism. After all, medical students face a future where the stakes of their ethical behavior are as high as human life or death.
~WHITE COATS, PURE HEARTS?


George Arnaoutakis, a third-year at the University of Florida College of Medicine, receives his white coat from Dr. Robert Watson, senior associate dean for educational affairs. Around 90 percent of schools of medicine and osteopathy in the United States convene a “white coat” or similar ceremony, usually as part of first-year orientation, or when third-years begin their clinical training. Created by the Arnold P. Gold Foundation more than a decade ago, these ceremonies are intended to make students aware of the central importance of ethics and professionalism in medical practice. Students are often called upon to recite the Hippocratic or other oath of ethics and professionalism. Recently, many schools have adapted the ceremony to have first-years sign or recite the school’s honor code.
~~~Eric Levy is a freelance writer based in New York City.~Medical Education~
23~2March~2006-55~Feature~SPOTLIGHT: Old School vs. New School~How much has really changed since Flexner rocked the medical school establishment?~Barbara A. Gabriel~The pendulum of educational change set into motion by Abraham Flexner almost 100 years ago is swinging back again in sometimes fascinating ways.~At some point, almost everything that once seemed “old” becomes new again. This holds true for fashion, music, entertainment and… medical education. Although today’s students and physicians may assume the current educational system is vastly changed from decades earlier, it doesn’t take much digging to unearth fundamental similarities between what our academic forebears prized and what medical students value today.


Around the turn of the century, teaching future physicians was largely a haphazard process. Just a handful of medical schools were overseen by recognized scholars and connected to established universities; the remainder were proprietary, profit-driven “schools” that extracted cash from students to attend scholarly lectures and offered little or no patient-based education. By 1899, such diploma mills had effectively replaced the longstanding apprenticeship model of medical education in which young men learned by shadowing older practitioners, gaining hands-on experience until their preceptors deemed them qualified to work on their own.


The tide began to turn when the Johns Hopkins University School of Medicine opened in 1893. Under the legendary Sir William Osler, Hopkins’ first physician-in-chief, it offered an alternative teaching model marked by heightened admissions standards, a highly regarded faculty, rigorous evaluation, alliance with a teaching hospital and an extended school year. When the majority of the proprietary medical schools did not adopt the Hopkins model, it joined with other elite institutions and lobbied the American Medical Association (AMA) to conduct a quality survey of all North American medical schools. The result was the historic 1910 report that effectively devastated this country’s medical education establishment.


Anyone even peripherally connected to medical education has probably heard the name Abraham Flexner. The schoolteacher-turned-educational researcher visited all 155 medical schools, recording his impressions of each. His strongly worded report condemned the current state of medical education, deploring its lack of standards, poor evaluation methods and absence of clinical training. The bad publicity drove many schools out of business over the following decade.


In their place emerged a new generation of medical schools incorporating curricula modeled on Flexner’s proposals. He advocated rigorous and extended basic sciences training through laboratory work, followed by clinical training in hospitals affiliated with university medical schools. And he was adamant that these two aspects of medical education should not overlap. In 1925, he wrote that to do otherwise was merely an attempt to “amuse” immature students unwilling to expend the “intellectual effort” that mastering the basic sciences required: “Anatomy, physiology and pathology are themselves sufficiently fascinating; the student who finds them dull has presumably seated himself in the wrong pew,” he wrote.

Harsh words to the modern ear, certainly, yet Flexner’s educational prescription is instantly recognizable by today’s medical students and alumni. The two-part approach still holds sway, despite tremendous changes in medical and technological innovation over the years, as well as curricula experiments by many schools that overtly challenge the basic sciences/clinical practice divide.


QUESTIONING THE "LOGICAL ORDER"


Almost from its inception, the Flexner “logical order” model—basic sciences education followed by clinical training—has been challenged, decried and condemned as insufficient to meet the needs of both medical students and patients. “We definitely don’t want to return to the days of Osler,” says Dr. Naveen Garg, a radiology resident at St. Vincent Hospital in Massachusetts. But medical school “should not be boot camp; you shouldn’t have to pass tests of endurance to show your worth. The changes being made now are in the right direction.”


The changes Garg refers to began to build steam in the 1950s, when growing numbers of medical educators began voicing concern that adhering too strongly to Flexner’s “logical order” produced new physicians who had lost sight of an important goal: to care for their patients with compassion as well as clinical expertise. Two schools—Cornell University Medical College and the University of Colorado Medical School—began experimenting with a curricular approach called “comprehensive care” that emphasized continuity of care, increased patient responsibilities for students and the opportunity to treat a variety of patients with different cultural backgrounds. However, the programs ultimately foundered, partly due to older faculty’s resistance to change.


But over the next 30 years, other schools took up the torch and began revising their learning structures, such as integrating teaching across the basic sciences, establishing small-group learning and building in flexibility that allowed students free time for electives and independent study. Most notable among these pioneers was Harvard Medical School, which established its “new pathway” initiative in 1985, emphasizing small-group, case-study learning.

This integration of the basic and clinical sciences—that which Flexner called “premature playing with clinical problems” that was “bound to mislead” young medical students, is precisely what many current students and recent graduates value most in their education. Today, many medical schools encourage patient contact as soon as first-years’ first day of class.


“Seeing patients early gave me a lot of motivation,” says Dr. Bindu Akkanti, who teaches internal medicine at Boston University School of Medicine. “When I saw my first patient in my first year, I knew what I had to look forward to.”


Akkanti’s experience is shared by many first- and second-years who have heard their predecessors’ stories of being denied clinical experience until the third year. Sara Kirby, a first-year at the Medical University of South Carolina, believes clinical exposure should ideally begin before the first year: “Increased clinical experience [should be] encouraged before entering med school and during the first year,” says Kirby, who worked in an emergency room for two years before enrolling.


“Students meeting patients earlier in school and integrating the clinical information they are being taught with patient care is a very positive thing,” says Dr. Barbara Schneidman, a clinical associate professor at Northwestern University School of Medicine and vice president of the AMA’s Medical Education Group. “There are still some pretty traditional medical schools out there that teach the clinical sciences apart from patient care. The basic sciences need to be taught, but such teaching needs to be reformed.”


Schneidman adds that during her own first two years, the emphasis was on cramming as much information into students’ heads as possible. “We were in school all day, every day, even on Saturdays. We really didn’t have a life.… Today’s students have more fun. They have time to volunteer at clinics, to do good things. Much of this is because class time has decreased so much.”


PRACTICE MAKES PERFECT


Dr. Georges Bordage, a professor of medical education at the University of Illinois at Chicago College of Medicine, applauds the current trend toward integration. “One thing that we know in education is that it is difficult to transfer knowledge from one situation to the next,” he says. “The best way to foster transfer is to practice in varied contexts; thus the old adage, ‘practice makes perfect.’” In this way, students learn through osmosis; that is, by experiencing the same problem in a variety of case presentations, he explains.


David Lessens, a second-year at
the University of Michigan Medical School, says his father, an alumnus of the school, regrets that he did not have the integrated curriculum that his son is experiencing. But Lessens still believes his school overemphasizes detail and rote memorization in the first two years. “There’s a lot to remember,” he says. “Stuff about which you say to yourself, ‘I’m never going to have to know this unless I become, say, a hematologist.’ All material is presented on an ‘absolutely need-to-know’ basis. Although nothing we are taught is totally irrelevant, there is a lot of information to absorb.”


Leana Wen, a fourth-year at Washington University School of Medicine and president of the American Medical Student Association, agrees. “There is still too much focus on teaching the basic curriculum in terms of time,” she says. “Schools like Duke, Baylor and Penn have been very successful in condensing their two-year basic sciences curricula into one year without seeing test scores suffer at all. I do think the medical education community as a whole is slowly switching to this approach.”


THE BUZZ


“Curricular flexibility.” “Problem-based learning.” “Focus on professionalism.” “Integrated curriculum.” “Humanistic medicine.” “Cultural competency.” “Small-group learning.” These are the buzzwords that come to the minds of today’s medical students when asked to identify the most positive trends in curricular change they are now witnessing.

Gretchen Graff, a third-year at Yale University School of Medicine, cites “the emphasis on treating the patient as a complete human being—a person with emotions, feelings, hopes, desires and fears—versus just a collection of tissue showing pathology,” she says. “Many doctors have been fortunate to enter medical school with the innate talent of this ‘bedside manner,’ yet some have not. Therefore, I believe it is essential to give future physicians the tools to learn these skills.”


She continues, “Evidence-based medicine has improved treatment outcomes, but teaching physicians-in-training communication and the life skills to treat patients as honorable individuals can change the announcement of a poor prognosis into a beautiful human interaction that spreads hope and comfort to both patient and physician.”

But ironically, a deficit of teaching time makes transferring this particular type of medical knowledge increasingly difficult. Flavio Casoy, a second-year at Brown University Medical School, senses that “my professors were taught better than I am being taught. It seems that faculty have less and less time to actually teach.”

Faculty, too, mourn this loss of bedside teaching. Dr. Stephen Smith, associate dean of medicine at Brown, says he deeply regrets “seeing the departure of teachers from the bedside, where the most important learning takes place.” Smith attributes the loss to “fiscal and research pressures on professors, who subsequently have no time to teach.”


“I understand that one of the positive things about the ‘good old days’ of prior decades was that medical faculty had a relatively larger percentage of their time that they could devote to teaching,” says Dr. Elizabeth Morrison, associate professor and director of research in the Department of Family Medicine at the University of California, Irvine, College of Medicine. “There seemed to be a greater recognition back then that education was a primary function of American medical schools…. I worry that recognition is slipping more and more with all the economic and other pressures that academic medical centers are facing these days. I am not sure how we get back that ‘learning culture’ of the old days, but I think it’s a very important issue.”


Is it time for another Flexnerian revolution? Dr. David Baron, chair of psychiatry at Temple University School of Medicine, sees a push to go “back to the future” in his students’ interest in one-on-one teaching: “I’m always amazed at how it’s déjà vu all over again, and almost pre-Flexnerian that medical students really seem to enjoy and get the most out of the old type of mentoring. We’ve got some very sophisticated things at our medical school. They spend a lot of money on standardized patients and video and all types of things, but when it comes down to it, the students still seem to most enjoy walking around and rounding, either one-on-one or in small groups… [alongside] an experienced clinician with good teaching and communication skills.”


Once more, the old is new again.
~THE PRE-POWERPOINT GENERATION


While some students feel the endless number of slides faculty shuffle through during lectures inhibits more active learning, others praise PowerPoint as their savior from the tedium of endless note-taking.

“PowerPoint is huge; I can’t imagine going to school without it,” affirms University of Michigan second-year David Lessens. And having lecture slides on the campus Intranet gives students the option of not having to attend lectures at all, or of simply listening rather than furiously scribbling down notes. “[It] negates the necessity of note-taking!” he exclaims.

But just how edgy is the PowerPoint concept?

Dr. Barbara Young, who was a first-year at Johns Hopkins in 1942, recently published her recollections of that year, including her first day of physiological chemistry:

“Our fears did not abate when we saw that the huge blackboard was covered with complex chemical formulae and calculations. With awe we awaited the arrival of the wizard of the department, Dr. William Mansfield Clark. I wrote to my mother: ‘We now have chemistry lectures three times a week. Dr. Clark, who is a noted man, gives the lectures from many notes previously copied on the board. Last year the students photographed them so we will have pictures to copy from, the building being closed during most of our free time.’”


Young writes of the value of those photos: “Armed with our photographs of the blackboard, we were able to give our full attention to Dr. Clark”—thus negating the necessity of note-taking! —B.A.G.
~~~Barbara A. Gabriel is the managing editor of Physicians Practice and a freelance writer based in Silver Spring, Maryland. Direct comments about this article to tnp@ amsa.org.~Medical Education~
24~2March~2006-55~Feature~A Doctor Drought?~Conflicting theories swirl around a possible future physician shortage~Pete Thomson~How did we, in just a few years, go from forecasts of a physician surplus to warnings of an impending shortage? Anticipating workforce trends is notoriously complex, yet predictions of the future are driving how medical students are trained right now. Plus: The impact on international medical graduates; Fishing deeper in the applicant pool.~Imagine your city or town without enough physicians. The sick go unaided. Care goes to the highest bidders, or at least only to those who can afford it. Disparities affect huge blocks of the population, making today’s access barriers look like mere inconveniences.


Some experts—not to mention patients in underserved areas—think we’re already there. But if the charts and PowerPoints and health economists are to be believed, a true physician shortage in 15 years will wreak havoc on our nation’s health-care system, and by then it will be too late to do anything about it.


SURPLUS FLIP-FLOP


In the mid-to-late 1990s, researchers and economists were predicting a significant surplus of physicians in the coming years. Their dire prognoses had unemployed M.D.s and D.O.s out on the street, shaking cups and flashing cardboard signs at passing cars, thanks to the “improvements” of managed care. In anticipation, allopathic medical schools, which had expanded significantly in the 1960s and ’70s, stopped growing, and organized medicine called for limits on graduate medical education (GME).


But in the past four years, the oversupply theory has been turned on its head: Now the soothsayers conjure images of patients lined up around the block in every city, town and village in the world, only to be turned away by the nurse practitioner at the door—the sole doctor within 3,000 miles has just retired.


Certainly the truth about our nation’s future physician workforce lay somewhere between these two ominous extremes. But one fact is clear: The medical education system in the United States is now attempting to generate larger numbers of physicians each year, and at least one medical school association has called for incrementally increasing graduate numbers. But the matter of how many and what kinds of physicians we need to meet future health-care needs is far from settled. The workforce debate pulsates with complicated questions that hinge on the future of the health-care system itself.


RAMPING UP


Just over a year ago, the Association of American Medical Colleges (AAMC), responding to mounting evidence of a future shortage, issued a statement calling for a 15 percent increase in medical school enrollment by the year 2015.


By October 2005, allopathic medical schools had begun to respond, enrolling 17,004 first-time matriculants for the 2005-06 school year—the highest number on record and a 2.1 percent increase over 2004.


Florida State University College of Medicine’s Tallahassee campus led the way among allopathic schools, upping its class size from 58 in 2004 to 80 in 2005—a 37.9 percent increase. Six other allopathic medical schools increased their enrollment by more than 10 percent.


Meanwhile, osteopathic schools have been quietly expanding their overall physician output for several years, primarily by creating branch campuses, a method that allows schools to quickly add capacity in specific regions without doubling up on administrative facilities and staff. In addition, three new osteopathic schools are currently in the midst of accreditation procedures, including an entirely new school, Lincoln Memorial University in Harrogate, Tennessee. The other two will be branch campuses of Kirksville, Missouri’s, A.T. Still University and the San Francisco Bay Area’s Touro University.


Right now, allopathic schools seem to be focusing mostly on increasing class sizes. Typically, schools are considering an additional five to 15 slots, says Edward Salsberg, director of the AAMC’s relatively new Center for Workforce Studies. About half of the schools the center recently polled had expansion plans, but the data is still being processed.


In the meantime, the AAMC is working with its member schools to decide on cost-effective strategies for enrolling more students. There is little question as to where these new students will come from: outgoing AAMC president Dr. Jordan Cohen has said that the pool of qualified medical school candidates is quite deep, certainly deeper than the number of students admitted to U.S. medical schools every year.


Right now it’s common for qualified individuals who don’t get the nod from a U.S. school to head offshore, to places like Ross University or SABA University schools of medicine in the Caribbean. But with more spots opening up stateside, U.S. schools can accept a broader, but not unqualified, cohort of applicants. [See “The New Medical Student,” page 19.]


MORE AND MORE


But some academic medicine leaders are pushing for even more output. Last November, Cohen hinted that the AAMC may double its original goal, calling for a 30 percent increase. Further along the same warpath is Dr. Richard Cooper, professor of medicine at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “We need 30 percent more, 40 percent, 50 percent. We need 100,000, 150,000, 200,000 more physicians by the year 2020,” he says. “Even the smallest number [anyone is citing] is much bigger than what anybody is doing about it.”


Cooper has been warning of a physician shortage for years. During the heady days of Clintonian health-care reform, he says, his ears pricked up at every mention of a future physician surplus. “It just didn’t make any sense to me as a clinician,” he says. So he began to study the numbers and need, realizing that someone had to explore the possibility of a physician shortfall.


His research, based on economic and demographic trends, departed significantly from the models used to study physician supply in the past. Essentially, Cooper demonstrated a relationship between demand for health-care services and economic markers like gross domestic product. By combining population and economic projections, Cooper and colleagues extrapolated the nation’s physician workforce needs—at least from an economist’s standpoint. Regardless, the team pushed the right buttons for organized medicine to re-examine future physician supply.


The shortage will come about, Cooper asserts, primarily because of the pace of technological advancement. Perhaps counterintuitively, very few medical advances result in a need for fewer physicians. Many innovations actually create new medical subspecialties; at the very least they demand more physician time.


“When I was an intern, and somebody’s heart stopped beating, we didn’t call that cardiac arrest. We called it dead,” says Cooper. Advances like defibrillators certainly improve patient outcomes, but new devices need physicians to operate them, and new procedures need people specially trained to perform them.


He estimates that another 10 percent of the shortfall will result from transformations in physician lifestyles. Younger physicians trying to balance family life and work are devoting fewer hours to their practices. Older docs may be cutting back their hours as they approach retirement.


NEW PLAYERS, NEW POSITIONS


Cooper says the doctor drought is already creeping up on us. “It isn’t cataclysmic. But if you look around and kind of watch what is happening…nibbles here, nibbles there…. Slowly the practice of medicine morphs from the professionalism and broad social responsibility that doctors have been associated with.” There’s just too much ground existing physicians have to cover, he explains. Waiting times stretch out; patient communication is disrupted. “It is not that anyone has any malintent…. As a result of what’s going on, medicine just doesn’t cover all of the bases.”


He puts together a football analogy: “You don’t have enough players, so you no longer have a tight end. You no longer have a halfback, yet you’re still playing the game.” Perhaps you can fill in your positions with other types of players, like physician assistants and nurse practitioners. “Most of the time, a high-school halfback can probably do just as well as a college halfback. But some of the time, they can’t. And what do you do then? And that is where we are headed in medicine.”


Cooper stresses that such non-physician clinicians (NPCs) will be part of the solution, and that he has tremendous respect for what they do. Still, he feels that physicians should continue to play a central role.


BRICKS-AND-MORTAR SOLUTIONS


But how can graduate output be cranked up enough to meet future needs? Expanding class sizes won’t be the only answer. “They just can’t get any bigger,” says Cooper.


In the 1960s and ’70s, efforts to increase medical school enrollment was mostly accomplished by growing existing schools, and those facilities are now stretched to the limit. After polling schools, Cooper and his colleagues anticipate that all together, current U.S. allopathic programs have room for just 8 percent more students. That’s quite a deficit, he points out, from the 30 percent goal.


So how do you get there? New schools, and different kinds of schools, says Cooper. More efficient than constructing institutions from scratch is to build small satellite campuses that feature, say, just a clinical learning facility, or to create larger branch campuses that contain all the elements of a medical school but draw on administration from afar, as does the Philadelphia College of Osteopathic Medicine’s new campus outside Atlanta. Several osteopathic schools have opened branch campuses, many of them hundreds of miles from their main campuses.


Cooper says osteopathic schools have been successful at expanding quickly because they have a simpler, tuition-driven financial structure. But you don’t have to be an osteopathic school to grow swiftly, Cooper says. You just have to have a cost structure based primarily on tuition income rather than complex research commitments. “It just so happens that we’ve built these research-intensive schools that have a much more complicated financial structure,” he explains. “We have produced a lot of new knowledge…so the result for the public has been excellent, but I don’t think we need another 30 or 40 research-intensive schools.”


Instead, he suggests, new schools could focus specifically on medical education. While the basic sciences would not be eschewed, taking the focus off research will allow for rapid financing and construction.


THE ELUSIVE ART OF WORKFORCE PLANNING


Although the move to train more new physicians is now underway, the workforce debates are just heating up. Without the aid of a fortune-teller, medical educators and policy-makers need to conjure a clear picture of what kinds of physicians will be needed over the next several decades and how many of each type. Some will just throw up their hands with the attitude, “Just train ’em all and let the market sort it out.”


“We think there is a better way of doing it, rather than just letting the market decide,” says Dr. Frederick Chen of the University of Washington’s Department of Family Medicine. Workforce planning has changed a lot over the years, he says, and is very different in the United States than in many other countries, where numbers and types of physicians are carefully planned out through national quotas. Instead, the United States suffers with an overall health-care system in desperate need of specialty balance. In Chen’s view, our country wouldn’t need as many physicians if the existing workforce was centered on primary care.


Chen attributes the urgency for expansion, at least among some allopathic players, as a response to growth in osteopathic training and the increased influence of NPCs. Some M.D.s are concerned about losing market share, he says.


Workforce planning should go beyond churning out more practitioners, and should center on the health-care needs of the population, based on evidence that having more primary care physicians actually improves health outcomes, Chen believes. “That part, to be honest, is of no interest whatsoever to the people who are pushing this current agenda. They are not into decreasing health-care costs.”


The solution is beyond the reach of medicine alone, Chen asserts; society as a whole has to tackle the problem. “We need to be getting [physicians] into rural areas; we need to get people to work in underserved communities. And doctors just aren’t doing that on their own.”



OUT OF BALANCE


All sides of the issue agree that medically underserved communities are a part of the workforce issue, but there is strong disagreement on solutions. Should physicians be encouraged to go into rural areas and underserved communities by government programs like the National Health Service Corps? By altering reimbursement rates? By pouring so many new physicians into the system that they disperse on their own?


Or more radically, shouldn’t the balance of primary care physicians and subspecialists, of rural, urban and suburban practitioners, be kept in check simply through the bloodless market forces of supply and demand?


It doesn’t work that way, Chen insists. Because of the way health care is financed—through a complex system involving Medicare, Medicaid, private insurance and established reimbursement rates—the market’s drive has been overridden to favor specialty physicians. “That has created the medical technology skew. That has created the specialty skew,” Chen says. “It is a market, but it is not a pure market.”


The AAMC asserts that graduates should be able to pursue the specialties of their choice, and that schools and training programs should endeavor to keep those graduates well-informed of trends and needs in the system in the hope that they make a socially responsible decision. But Chen points out that for students, the altruistic choice is a hard one to make in the face of massive economic incentives like higher reimbursement rates for specialists’ work, not to mention growing student debt. “That is super-hard to go against. It doesn’t matter what kind of moral or social justice arguments you give.”


University of Hawaii School of Medicine second-year Erin Gertz has felt the pressure, both from seeing her school shift toward more specialty training and from planning her own loan repayment. Though she was fortunate to earn in-state tuition status, Gertz says her debt is a major factor in her specialty choice. “Although [my classmates and I] came to Hawaii with ideas of being primary care physicians, being generalists, we realize that might have to change despite our best intentions.” She is considering OB/Gyn as a way to balance her income needs with a generalist practice model.


And don’t look to osteopathic physicians to plug in the gaps in primary care. Though generalism has long been a mainstay of osteopathic medicine, D.O. graduates are now choosing subspecialties in growing numbers, according to data compiled by the Robert Graham Center, which studies family practice trends. According to their research, only 21 percent of osteopathic medical residents remain in family medicine residency programs. In 1996, those programs held 37 percent of the D.O. grads.


Such a trend is reflective of the same forces allopathic graduates face, says Dr. Stephen Shannon, the new president of the American Association of Colleges of Osteopathic Medicine. Those forces include the loss of funding to programs promoting primary care, as well as rising student debt. “You have to really want to do it to do it these days,” he says of the attitude it takes to practice in primary care. “So that is filtering down to students, and students see it in their training.”


Not that he considers this an ideal situation. “If you are thinking about providing quality health care, the idea of having a primary care physician as the pivotal person in that situation is being demonstrated over and over again,” Shannon says. “There needs to be strengthening of the primary care training, if anything. It shouldn’t just be left to market forces.”


EYEING THE TRENDS


Salsberg believes the real solutions to the workforce seesaw will come through continual review and further research. In May 2005, the AAMC held a conference to examine all existing research on workforce trends—everything from physician retirement to how graduates of foreign medical schools are distributed in rural areas—and the organization plans to continue to gather interested parties on an annual basis.


Additionally, no one can predict the impact when physicians of baby-boomer age consider hanging up their stethoscopes. There is little data on what sorts of numbers will be involved, and what role this demographic phenomenon will play in the shortage. The AAMC is currently working on two surveys, one of physicians over age 50 and one of younger physicians. The former is an attempt to anticipate retirement patterns among older physicians; the latter is to determine how the others intend to mix medicine with their lifestyles.

But finding answers, Chen laments, is bound to be hampered by recent cuts in federal funding for health-care workforce studies. Many workforce centers at U.S. universities will be shuttered, possibly including the one at the University of Washington.


In the meantime, the expansion ball is rolling—and gaining momentum. The intended increase of 15 percent is a cautious start—an experimental treatment of sorts.


“Some people think we need more doctors, some people think we need less,” Salsberg says. “We think this is a reasonable sort of middle road.”
~THE TROUBLE WITH IMGs…

“There is close to near unanimous sense that we need to increase U.S. medical school capacity,” AAMC’s Edward Salsberg says. But he notes that some advocates may see this as a golden opportunity to reduce the number of foreign-born international medical school graduates (IMGs) from setting up shop in this country.


Some have suggested that increasing the number of U.S. medical students while keeping residency caps in place will squeeze IMGs out of graduate medical education, thereby helping their home countries. Recent studies have shown the devastating effects of physician migration from poorer countries to the United Kingdom (U.K.), Canada, Australia and the United States. In a report published in the New England Journal of Medicine in October 2005, Dr. Fitzhugh Mullan of the George Washington University School of Public Health and Health Services showed that 60 percent of IMGs practicing in the United States come from “lower-income” countries. Only 6 percent come from the U.K., Canada or Australia.

This imbalance creates a costly “brain drain” for poorer countries who invest in developing physicians only to have them head off to greener pastures—at least dollar-wise—on graduation. While the United States relies heavily on foreign-born IMGs to fill workforce gaps, Mullan found that other developed nations don’t share the same dependence.

Concern over thinning the ranks of other countries is valid, but some have spun the argument too far, says Dr. Bernard Wollschlaeger, chair of the American Medical Association’s International Medical Graduates Governing Council and a family practitioner in Miami. “We are not living in isolated ivory towers,” he says, but in a global marketplace. And many IMGs’ countries benefit from their financial, intellectual and physical returns.

For some, he acknowledges, the “brain drain” argument could hide a jingoistic notion that IMGs are somehow not “as good” as U.S. graduates, an idea he finds preposterous. “That is an old argument, a stupid argument,” Wollschlaeger says, pointing out that IMGs pass the same exams and certification procedures as U.S. medical graduates. “This is just a very shallow argument of people who just cannot understand that we are living in a global world.”


THE NEW MEDICAL STUDENT


If medical schools expand, where are all these “new” students going to come from? Some believe the pool of qualified medical school applicants is plenty deep to meet the challenge—but what defines “qualified” is an open question.


Comparing today’s top medical school applicants against the pipeline of K–12 and baccalaureate students coming up over time indicates there won’t be enough of those academic stars to fill the new medical school slots, says Dr. Richard Cooper of the University of Pennsylvania’s Leonard David Institute of Health Economics. So if schools want to stock up on more students just like the ones they’ve already got, they’re out of luck.

Schools may need to accept a different kind of student, perhaps with slightly lower Medical College Admission Test (MCAT) scores or grade point averages (GPA). But is that so wrong? Not at all, Cooper says. In fact, schools will likely find some excellent future physicians in this second tier. “I think there are lots of people who would make good doctors, but we put them through hoops that…don’t necessarily help them be a good doctor,” like the MCAT.

“There are some very well-qualified people,” says Edward Salsberg of the Association of American Medical Colleges’ (AAMC) Center for Workforce Studies. “But it may be a challenge to the medical school about how to blend these students who don’t have, maybe, as strong a science background into the school—and who changes who.”


According to AAMC data, today’s average medical school applicant is at least as accomplished as those who were being accepted into medical schools 10 years ago, at least as far as total GPA goes. The average GPA for applicants in 2005 was 3.48, the same as the average for matriculants in 1994.

Unfortunately, expanding the total number of medical students doesn’t guarantee a corresponding boost in underrepresented minority students. Nonetheless, Salsberg stresses the AAMC’s commitment to increasing minority representation. In 2005, Hispanic matriculants were up 8 percent over the previous year, compared to a 2.1 percent overall increase in students. However, the number of black first-year enrollees actually fell slightly.

“We’re captive to K-12 education,” says Cooper, and the problem extends up the educational pipeline into colleges and universities. “If you look at baccalaureate education, it simply doesn’t reflect our society.”

—P.T.

~~~Pete Thomson is associate editor of The New Physician.~Career Development,Health Policy,Medical Education~
31~3April~2006-55~Feature~Inside the Safety Net~The community health center movement is still alive, but how well is it?~Martha Frase-Blunt and Pete Thomson~For millions of poor and uninsured Americans, all that stands between them and ill health is a network of independent and locally grown community health centers. Amazingly, the system works.
~Like some of the most innovative ideas in delivering health care to the underserved, this one started with a medical student.


It was 1957, and the fourth-year was working in rural South Africa. There he saw a burgeoning new model of health care that focused not just on treating the ill, but on disease prevention, public health interventions, education and community organization. And this all took place in one building, purposefully located in the very heart of the Zulu community it served.


Through that brief window, before it was shut by apartheid in 1959, Dr. Jack Geiger saw the future. After returning to the states, he wrote about this ground-breaking concept in primary health-care delivery for his M.D. thesis at Western Reserve University School of Medicine (now Case Western), proposing that the same model could prove effective in America’s poorest communities.


By 1964, Geiger was working as a field coordinator in Mississippi, providing medical care to civil rights workers. It was “Freedom Summer,” smack in the middle of the era that kindled the Peace Corps, Head Start, the birth of Medicare and Medicaid, President Johnson’s War on Poverty, and a growing unease among young baby boomers that just under the comfortable veneer of their nation’s post-war affluence was a world of hunger, joblessness, infant mortality, poor housing and sanitation, and entrenched racial discrimination.


Although he had once been sure of a career in international health, “I realized that I didn’t have to go to Africa, Latin America or Southeast Asia to make a difference. It was all here,” Geiger says.


The stage was set for Geiger to start building on his thesis. With Dr. Count Gibson, a colleague from Tufts University School of Medicine, he lobbied the government’s brand new Office of Economic Opportunity (OEO)—now the Community Services Administration—to fund a health center in the Mississippi Delta created on the South African model. The center would provide medical care but would also focus on health outreach, prevention, patient education and even broader services like job development, sanitation and other social supports.


Although OEO leaders, who included Peace Corps founder Sargent Shriver, were enthusiastic about the idea, they were concerned about the location; the Delta was well known for its racial strife and resistant local officials. It took 18 months and a good old-fashioned ’60s sit-in in Shriver’s office before Geiger received funding for the Mississippi project.


In the meantime, the OEO had funded Geiger and his Tufts colleagues to create a community health center right in their own backyard, within the troubled and destitute Columbia Point Housing Development in Boston’s Dorchester neighborhood. When Columbia Point Health Center opened, followed a few months later by the Delta Health Center in Mound Bayou, Mississippi, they launched what today is a broad network of community health centers spread across the United States serving some 15 million people a year. Forty years later, both sites—and thousands more—are still going strong, providing high-quality care to the underserved and uninsured in spite of rising numbers of patients and ongoing fiscal challenges.


With a Capital “C”


What defines a community health center? According to Geiger, who is now the Arthur C. Logan professor of community medicine at the City University of New York (CUNY) Medical School and a founding member of Physicians for Social Responsibility, it can be defined in the broadest sense as the set of principles that have always undergirded the movement. These principles include providing primary care to a defined area or population; public health interventions that address the social determinants of health; an emphasis on community participation, empowerment and control of these institutions; the use of epidemiological methods to identify problems and guide decisions; the use of new combinations of clinical and public health personnel; and the reduction of disparities in the health and health care of the poor and minorities.


In the narrower sense, the U.S. government defines community health centers as those meeting specific criteria for federal funding. These are the community-owned organizations known as federally qualified health centers (FQHCs), which receive grants from the Department of Health and Human Services’ Bureau of Primary Health Care (BPHC) under Section 330 of the Public Health Service Act.


To be classified as an FQHC, a health center must satisfy four basic criteria that align closely with community health’s broader principles: It must be located in an area designated by the federal government as medically underserved, or reach out to a medically underserved population. It must provide comprehensive care, which includes primary and preventive care as well as related social services. It must be open to all residents in the community, regardless of ability to pay, and offer discounts based on the federal poverty guidelines. Finally, it must be governed by a community board with 51 percent of trustees being clients of the health center.


In 1970, these federally funded centers served approximately 1 million patients. By 2004, that number had risen to 15 million. FQHCs serve 8 million people of color, 600,000 farm workers and 600,000 homeless persons.


These “official” sites are joined by an uncounted array of community health centers that operate outside of the federal reporting and regulations of FQHCs. Some achieve the status of what the BPHC calls “look-alikes,” which makes them ineligible for the grants but eligible for cost-based reimbursement under Medicaid and Medicare. Others fly completely under the federal radar, relying on private funding from such sources as faith-based organizations and charitable foundations.


Whether a health center is funded federally or on a grass-roots shoestring, the community aspect—with a capital “C”—is what sets it apart from other health-care outreaches to the underserved. Because community health centers are individual entities based at the geographical center of community life, “they are more limber in the choice of programs they offer, from what they focus on, to the hours they are open, to special needs they want to fill,” says Geiger. And they are free to pursue affiliations with other entities such as local hospitals and health systems, public health departments, family planning agencies, rural clinics, private practice groups, behavioral health organizations, social service agencies, faith-based organizations and multiservice agencies.


Anyone can start a community health center, and many are initiated by local activists with no health background. The Delta Center in Mississippi is a perfect example: It didn’t start with a bricks-and-mortar building, but as a series of meetings in homes, churches and schools. Residents of this very poor region created 10 local health associations, each with singular perspectives and priorities. Some places needed clean drinking water; others needed child or elder care. Community participation enabled these first advocates to broaden their conception of “health” to include food, jobs, housing and education, as well as personal and public health.


Geiger remembers, “Once we had the [Delta] health center going, we started stocking food in the center pharmacy and distributing it—like drugs—to the people. A variety of officials got very nervous and said, ‘You can’t do that.’ We said, ‘Why not?’ They said, ‘It’s a health center pharmacy, and it’s supposed to carry drugs for the treatment of disease.” And we said, ‘The last time we looked in the book, the specific therapy for malnutrition was food.’ There was nothing in the regulations that said otherwise, so we continued to do it.”


In another anecdote from the early days, Geiger describes how Columbia Point, where it all started, was on a peninsula, at the very end of which was a garbage dump. “The first thing the community wanted us to do was to get the dump closed and stop the trucks from rumbling down the street and killing the neighborhood kids. They saw this as a legitimate health activity, and they accomplished the goal.”


Geiger notes that a lot of hand-wringing goes on about minority groups’ mistrust of the health-care system. “But these centers restore that trust, in part because they are regarded as community institutions that belong to the people. They’re not just ‘in’ the community, but are also ‘of’ the community.”


Besides making a community healthier, these centers also offer health-care jobs and even long-term careers to local residents. Today’s FQHCs employ some 78,000 full-time workers—typically local residents—bolstering local business and stabilizing neighborhoods by stimulating community development and economic growth.


State of the Safety Net


So how is the community health-care system faring in 2006? “The current situation is one of giving with one hand and taking with the other. We have an administration and a president who appears committed to community health centers,” says Geiger, referring to the 2002 President’s Community Health Center Initiative, a surprising move for an administration that is so loathe to implement federal health-care programs. “But there are many who believe that one of the motivations [for the initiative] is to fend off more fundamental change in the health-care system.”


President Bush proposed adding 1,200 new and expanded health center sites over five years, and to double the number of patients served. But the other hand is doing its work. Even as the president publicly extols his commitment to community health, his 2006 budget proposal slashes funding to zero for the Healthy Communities Access Program, which last year provided $83 million in grants to support integrated community health-care delivery systems, including FQHCs, look-alikes and other community health sites.


Meanwhile, the proposed $36 billion in Medicaid cuts over the next five years will also certainly affect community health centers’ bottom lines, no matter how many new ones are built. In addition, 15 states have reduced Medicaid eligibility or made enrollment processes more difficult, while 10 states reduced Medicaid benefits. This means community health centers will be treating a lot more patients without reimbursement.


So ultimately, the state of the community health center system “is a mixed picture in terms of how they are doing overall,” says Geiger. By and large, “The [FQHC] grants don’t provide for much beyond the personal medical services and clinical care. They are an increasingly small percentage of funding for community health centers, which are becoming more and more reliant on Medicaid and other forms of reimbursement.” Increasingly, community health centers “have to go out and get foundation money, state money and local money where they can,” says Geiger.


Another huge challenge is the growing imperative for community health centers to adopt health information technology and the electronic medical record, which is increasingly essential for quality improvement. These tools will open up the possibility for all sorts of data gathering and health analysis, but it’s very costly to get the right systems adopted and employed, and there is no explicit federal funding available. “While community health centers have a superior record in quality, they will fall behind in all kinds of performance and efficiency measures unless they can adopt the technology,” Geiger believes.


But perhaps the most serious threat to community health centers is the pronounced decline in primary care practitioners. “If we have too few medical school graduates going into family practice, general internal medicine and pediatrics—the core of community health staffing—who will do the medical care?” Geiger wonders.


What really helps, he says, are the initiatives that financially support medical students, such as debt forgiveness, special stipends and programs like the National Health Service Corps (NHSC) that pay off loans in return for promises of service in underserved areas. National Association of Community Health Centers (NACHC) figures show that a third of NHSC participants stay on long past their period of obligation. “Expansion of these programs is really imperative and one of the few incentives for new physicians.” Yet the Bush budget reduces, rather than increases, support for the NHSC.


Still Setting the Tone


In the plus column, community health centers are still doing an excellent job
at caring for their neighbors. The NACHC has reported that FQHCs provide comprehensive health care for about $1.30 a day per patient served—averaging about $250 a year less than the patient would cost an office-based medical provider. Its data also show that these health centers save significant state and federal Medicaid dollars through fewer specialty care referrals and hospital admissions.


At the same time, the NACHC has found, the quality of care provided at FQHCs is equal to or greater than the quality of care provided elsewhere. Moreover, 99 percent of surveyed patients report that they are satisfied with the care they receive at these health centers. The Institute of Medicine has also weighed in: Its 2002 landmark report, “Unequal Treatment,” recognized the key role of community health centers in increasing access to care and improving health outcomes for all patients, especially minorities.


In a sense, this is the one U.S. health-care program that really works in eliminating disparities. “Just look at the difference in community health and private sector managed care,” says Geiger. “If you look at HMOs, even those providing Medicaid managed care to lower-income people, they draw their clientele from all over the place. Community health centers serve a targeted population. That’s the platform you need to be able to intervene more broadly.”


The nonmedical missions of community health centers struggle these days, however. “In retrospect, our original vision was grandiose, as it broadly embraced environmental issues, education and other aspects of going after the root causes in social determinants of health,” Geiger muses. “What’s happened, both because of costs and failure to go after social determinants, is that community health centers have been restricted much more to delivery of personal medical services.”


Still, the movement has set the tone for practical, far-reaching health-care reforms in many other areas, Geiger believes. “We’ve done more than most types of organizations to demonstrate the usefulness of mid-level practitioners like physician assistants and nurse practitioners. We’ve done more to demonstrate the effectiveness of having it all under one roof—doctors, dentists, mental health providers, social workers, environmental health workers. And we’ve done more to show the usefulness of training and using local community health workers to create career pathways to the health professions.”


Training Grounds


Medical students have played a key role in the community health center movement since its birth in South Africa. Local students created the very first center at Alexandra township in Johannesburg, giving rise to hundreds more that sprung up in rural and urban areas to care for the locals while also providing primary care training to visiting medical students from Pretoria.


Today, the community health center rotation is a centerpiece of primary care training at many U.S. medical schools. This exposure can have a fundamental impact on young students, Geiger believes. “I remember the experience of seeing patients in the exam room, surrounded by posters on the wall showing the prevalence of major disease problems affecting the immediate area.... You could not examine a patient without thinking of the health of the entire community.”


No one would argue that gaining clinical experience in a community health center isn’t marvelous training for students. But is it good for the centers themselves?


A study in the May 2000 issue of Academic Medicine showed that ambulatory care centers—including community health centers—involved in education undergo an increase in operating costs of up to 36 percent. With funding as tight as it is these days, that’s one item the centers’ budgets can’t absorb.


For this and other reasons, Duke University’s Department of Community and Family Medicine decided, after discussions with community members, not to include physicians-in-training in an initial community outreach expansion. Writing in Academic Medicine, representatives of the department explained that learners would “stress the process” of community program startups. “Second, many in the community had long histories of treatment by learners and felt it exploited their indigence.”


But there is significant value in training in—or at least learning about—the communities served by these health centers, say both program directors and students. One solution is the use of tangential, nonclinical experiences.


The University of Massachusetts Medical School’s Community Health Clerkship places first-years into all types of community health settings, but makes sure the newbies don’t get into anyone’s hair. Instead, they learn about the community the center serves by getting out into it. Students tour the neighborhood, stopping in at the various agencies that serve the community, and asking questions about services provided.


Premed Matt Greene is getting his exposure to community health while screening potential clients at a Volunteers in Medicine free clinic in Jacksonville, Florida. The clinic sees patients with incomes between 150 percent and 250 percent of the federal poverty level. Often, patients have full-time jobs but are caught in an unfortunate paradox: They don’t make enough money to afford health care but make too much to qualify for assistance.


Greene reviews clients’ tax and bank documents, and that has been an eye-opener, he says. “People I see are school bus drivers, people working in retail, people working in temp agencies who haven’t picked up the insurance coverage yet,” he explains. “When you look at how people make money, you get introduced to a lot of different lifestyles…lots of things that have gone wrong in people’s lives.” Jobs are lost; people live off of social security; deadbeat dads don’t make child support payments. The free clinic is the safety net for their health.


Learning in an Alternative System


The experience of coming face-to-face with a community “is a central part of being a doctor, because you need to relate to your patients as more than just
a disease,” Indiana University School
of Medicine fourth-year Shannon Gearhart says. “They are also individuals who have financial difficulties, cultural differences.” She points out that part of being such a physician is also learning about service programs people can access, such as the Women, Infants and Children nutrition program.


Gearhart has an Indiana Primary Care Scholarship, a program similar to the NHSC. After her residency, she will spend four years in a primary care setting, and right now she is working at the Westside Community Health Center in Indianapolis. She says one of her most interesting experiences has been working with the center’s advisory board. “You get to know the people who actually live in the community, the actual patients themselves,” she says.


A desire to know the patients, and their problems, has led Boston University School of Medicine student Chris Dodd to extend his learning experiences into the world beyond the comfortable campus. “I felt I needed to understand the problems of the underserved—specifically the social context of disease—from outside the hospital,” the self-described “fourth-/fifth-year” says. Dodd had already developed a wider perspective on community health by rotating at the Columbia Point center—now called the Geiger Gibson Community Health Center after its founders—and, on Geiger’s personal suggestion, doing a geriatrics rotation at the Delta Center in Mississippi.


His experiences there—specifically clinical experiences—are ones he says he couldn’t have gotten anywhere besides a community health center setting. “If you are at a private outpatient clinic site with whatever doc in whatever community, you are seeing a completely different segment of the population.”


While on a rotation at Boston City Hospital during his third year, Dodd decided to commit his professional energies to the underserved. Like Greene and Gearhart, Dodd is perhaps predisposed to sing the praises of community health centers, but he and a classmate are working on a program specifically for students who do not share their interest in working with those populations—yet. “We want them to understand the social context of disease. We want them to be exposed to it,” he says.


Titled “The Spectrum of Physician Advocacy,” the course includes a session on the community health center, featuring a talk by Geiger. “The sort of experience you can get in just four weeks at a community health center is invaluable,” Dodd says, “just in terms of broadening your understanding of the reality that so many human beings face.”


The Sophie Davis School of Biomedical Education at CUNY offers actual clinical experiences in community health centers. In fact, that is the first kind of clinical exposure students get. Eight years ago, the school reached out to eight different community health centers in the New York City area. The school wanted to provide early clinical experience in the health centers to support its mission of developing primary care physicians dedicated to treating underserved populations.


While it seems that the technical skills they’d develop would be the same in either environment, Community Health & Social Medicine professor and chair Dr. Marthe Gold says that is not necessarily the case.


“The value is the health system the students are in; it is sort of a different kind of a bird than what private practice is like—even if you were to talk about a more HMO-Kaiser sort of place.”


During the fourth year of a seven-year baccalaureate/M.D. program, Sophie Davis students spend five or six months working in the community health center setting under a curriculum developed jointly by the centers and faculty.


To compensate the centers for their training and administrative costs, Gold says, the school—despite being a “cash-strapped” public institution—pays the centers for the training opportunity.


The long-term investment in students may just pay off for community health centers. “One of the pitches we had to the health centers was that our mission was uniquely aligned with theirs,” Gold says. “We just had people earlier in the pipeline, and they had an opportunity to…shape them in the way that they would like to see their providers of tomorrow shaped, but also to sort of lure them.”


Gold says it is too early to know whether the program—which attempts to draw on underrepresented minorities for its students—produces more physicians to practice in underserved areas, but the reason for keeping it up is simple. “We wanted to show our students a model of good and stable health care in a community setting,” she says. “At the end of the day…do students in general have a good experience in the health centers? And the answer is yes.”
~~~~Martha Frase-Blunt is editor of The New Physician. Pete Thomson is associate editor. Direct comments about this topic to tnp@amsa.org.~Community and Public Health,Health Disparities,Health Policy~
32~3April~2006-55~Feature~States of Reform~States are blazing health-care reform trails where the federal government seldom treads.~Jennifer Zeigler~Tired of waiting for federal solutions to the nation's growing health-care crisis, state governments are experimenting with their own strategies for bringing quality, affordable medical care within reach of their residents.~

With the ink drying on his master’s degree in public health, for which he studied how best to alter society's health behaviors, Stulberg arrived at Cleveland's Case Western Reserve University School of Medicine in 2003 to clouds of cigarette smoke wafting over the school grounds and near the school’s affiliate University Hospitals. Long smoke-free inside the buildings, Case had yet to ban smoking everywhere on its properties, permitting smokers to light up in approved areas on campus-along sidewalks, in parking lots and in specially designed "smoking huts." And there Stulberg found his calling.

He became involved with smoking cessation advocacy programs in and around campus. "When I got here-all I wanted to see was University Hospitals and Case go smoke free," the now second-year medical student says.


But his work ultimately led beyond the Case campus. Stulberg conducted research that would support the anti-smoking cause, lobbied his legislators for anti-tobacco legislation and began presenting the university's "Tar Wars" education program at Cleveland schools.

The advocacy programs were successful: In June 2005, the University Hospitals Health System, which includes Case, announced it would ban smoking everywhere on its multi-hospital campus by November 2005 and provide smoking cessation education programs to interested employees.

But Stulberg wasn't satisfied. Seeing the possibility of a similar ban in public places throughout the city, he began working with a smoke-free Cleveland movement, which gained momentum and leapfrogged into SmokeFreeOhio, a collaboration among the American Cancer Society and other advocacy groups calling for a question on the 2006 state ballot that would decide the issue statewide.


Enclosed Arenas


The Ohio anti-tobacco effort is just a small-scale example of dozens of health-related reform efforts steadily gaining ground. Significantly, they are not taking place at the national level—where the words “health-care reform” are enough to doom most legislation to a slow death in a congressional committee—but in the smaller, state-level arena. And the reform initiatives are as varied as the 50 states in which they've found advocacy homes.


For example, as Ohio cities wrestled with tobacco's hold on society, Maine became the first state to pass a universal health-care coverage program. The 2003 legislation is expected to insure every Mainer by 2009.


In January, Maryland lawmakers overcame a gubernatorial veto to pass a law requiring employers with more than 10,000 state residents on their staffs to spend at least 8 percent of their payroll on employee health care or ante up the difference to Maryland’s Medicare program.



And there’s more: Officials in Illinois, Kansas, Missouri, Vermont and Wisconsin have addressed cost-containment concerns by authorizing their states to join the I-SaveRx program, which allows residents to access discounted prescription drugs in Australia, Canada, Ireland, New Zealand and the United Kingdom.


So what makes states such nurturing environments when federal reforms—excepting the recent Medicare prescription drug program—are often seen as dead on arrival? Many reformers say it's the same reason Stulberg had for getting involved—they see a need and jump in to make changes. And the more manageable pool into which they jump promises smaller constituencies, fewer obstacles and often a higher rate of success.


States Define Reform


"What's interesting is how different the strategies are from state to state," says Alice Burton, director for state health policy at AcademyHealth, a nonpartisan health-care research and policy organization. And while some of what is pursued at the state level is happenstance based on which strategies find broadest support, Burton says there are also "windows of opportunity that make things happen."


So, when Massachusetts officials received a revised waiver from the federal government on how it can spend its Medicaid money-one way states often try to reshape how they care for their uninsured residents-it came with a mandate to put a plan into action. "And that's millions of dollars at stake" if it fails to do so, Burton says.


It all just depends at which stage a state finds itself, she says. "They can have a discussion on an individual mandate in Massachusetts," she says, referring to the state's proposal to require all citizens to buy health insurance if they can afford it, "because they've already done some things to deal with affordability."


But other states might still be struggling with cost-containment strategies or smaller-scale efforts. In Georgia, medical students from Emory University, Medical College of Georgia and Morehouse are working together on access issues through HealthSTAT Inc., which advocates for statewide reform in several areas. But lately, budget cuts have forced students to narrow their efforts, says HealthSTAT president Larissa Thomas. "We spent a lot of last year lobbying against cuts to SCHIP [State Children's Health Insurance Program]," she says, adding that students would rather spend their energy trying to expand this program that offers federal- and state-funded health-care coverage to poor children.


This year, the Georgia medical students wanted to focus on creating needle-exchange programs to slow the spread of HIV/AIDS, one of the issues on which HealthSTAT lobbies legislators. "But we're just trying to retain the one needle-exchange program that we have in the state. So there's not a lot of room to advocate," Thomas says.


Common Dreams


But despite the diversity of state-based efforts, there are some commonalities, Burton says. Health-care affordability is a popular goal for reform initiatives, she says. "Almost every state is dealing with the issues of costs."


Examples of such initiatives are those that subsidize health-care premiums for residents who can't afford them on their own, and bulk-purchasing programs designed to bring down the cost of prescription drugs.


But other initiatives, such as Maine's universal health-care program, also take on issues of access and quality. The state's Dirigo Health program created a public-private partnership among the state government, insurance companies and health providers. The state offers a subsidized health plan through an insurance company administrator to small businesses and individuals, charging them based on their ability to pay. The system allows the state to pre-screen applicants, filtering those who qualify into the state's Medicaid program—allowing the federal government to pay part of the costs to insure them—and the private insurers pass the money they saved from having a larger risk pool and more people seeking preventive care back to the state to reinvest in the public health plan. Additional savings are expected through built-in quality assurance checks.


And the system seems to be working on some levels, says Jenny Rottmann, the statewide health-care organizer for Maine People’s Alliance, which lobbied for the Dirigo program. After much debate on exactly how much the program saved in its first year, stakeholders settled on $47.3 million, although Rottmann says the private insurers are now balking at paying the savings back to the state, and the entire program-which passed the legislature with bipartisan support-is now threatened by a political fight centered on this fall’s gubernatorial election. "It's a real shame the program has become a political football," Rottmann says.


And even with politics aside, initiatives addressing cost-containment and quality are much harder to make successful on a state level, believes Joel Miller, senior vice president for operations at the nonpartisan National Coalition on Health Care. With costs driven by emerging technology and an increase in the practice of defensive medicine, "it's very hard to control those costs unless you place some kind of limit on hospitals and physicians," he says. "That's hard to do on a state level."



But the fact that Mainers are taking on the challenge makes the Dirigo program the one initiative from which other states might learn the most, Burton says.


Home-grown


Despite the difficulties, states are acting. "I wouldn't characterize the states as just sitting around waiting. They're really moving forward with this," Burton says. She adds, "The frustration that a larger national policy solution is not coming any time soon is growing."


The feeling is shared by liberals and conservatives alike. "It's very hard for any proposal that isn't just mushy to get any support in Congress," said Stewart Butler, Ph.D., vice president for domestic and economic policy studies at the conservative Heritage Foundation, during a recent online discussion with policy experts and reporters.


Miller agrees. "States feel they have nowhere else to go other than within the boundaries of their own states." He notes that federal movement on the health-care coverage issue has been largely stagnant since 1997, when Congress created SCHIP.


But the recent energy at the state level also "speaks to how real the problem is and how it affects people’s lives," Burton says.


Still, since the Clinton health-care reform debacle in the early 1990s, many voters have been left with a bad feeling about any type of health-care reform. But Rottmann says Mainers were willing to put that aside. "We've been canvassing the state on this issue for years, so I think there's a high tolerance for the idea…. And the people in Maine don't really associate with the federal government, so just because it was tried in the '90s and failed, [that] didn't turn people off to the idea that it might work in Maine," she says.


Burton says there's also a feeling of immediacy at the state level that makes it harder for lawmakers to ignore the issues. "When you are working in a state capitol, it's more likely that you could pick up the phone and answer the call of the uninsured [constituent"


That immediacy is exactly why Thomas says students in Georgia are getting involved in state reform efforts. For many, the Atlanta state capitol is in their backyard. "It's a lot easier to have some face time with your legislators; it's hard to make a trip to Washington," Thomas says. "On the state level, you really can influence a lot of legislators."


Paul Ikemire, a first-year at Tulane University School of Medicine, is hoping he can influence some lawmakers in New Orleans, where he and a group of other local medical students and physicians hope to turn the tragedy of Hurricane Katrina into an opportunity for improvement.


Ikemire, a member of the American Medical Association’s (AMA) Medical Student Section, wants to see state and local officials replace the city’s multifaceted health-care system with one based on the AMA’s model of publicly administered, high-deductible, individual health savings accounts as a part of the New Orleans rebuilding process.


Ikemire says the plan, which allows those insured under it to take their coverage with them from job to job, would be a workable one for a city in which so many have lost their jobs and face an uncertain future.


“I think it’s an opportunity that we can use to rebuild the system into a workable one.… Now you see a lot more opportunity for plans moving forward because the table has opened up. Before [Katrina], it was hard to reinvent the foundation, and now there’s no foundation, and it just makes it easier,” he says.



Reform Laboratories


Using a small area—a state or even a city or county—to examine how workable a plan might be is a common idea in state reform efforts, according to Tanya Alteras, a senior policy analyst at the Economic and Social Research Institute who co-authored a Commonwealth Fund report on state-based reforms in 2004. “States are great laboratories for studying health-care reform,” she says. “And what we learned in doing the [report] is that counties are even mini-laboratories. People like to start small. Even federal grants often start on a pilot level. You really know your target population better. It costs less money as well.”


“The fact that it’s smaller and fewer people makes it easier,” Rottmann says of the Dirigo program in Maine, where the uninsured total was just 130,000 when the program was passed.


A Shot Heard on the Hill?


Reformers in Illinois hope the recent coverage reforms pushed for—and won—by Gov. Rod Blagojevich will serve as a rather larger laboratory experiment for the rest of the nation.


The state advocacy group Campaign for Better Health Care (CBHC) pushed both for Blagojevich’s All Kids plan to insure every Illinois child, and for the 2004 Heath Care Justice Act, which directs state officials to craft a proposal to provide universal health care to all Illinois citizens by July 2007.


CBHC executive director Jim Duffett says real health-care reform has to happen at the state level. “There has to be a major sea change in Washington, D.C. That ain’t gonna happen for years and years and years,” he says. “You have to take the bull by the horns.” And the result in Illinois, he hopes, will be a model for the entire nation. “But we also could model the process.”


The unique language in the Health Care Justice Act takes advantage of what Duffett calls “new relationships” formed throughout the 1990s among the hospital, business and reform communities. He says these relationships are essential to reform movements, because they direct the stakeholders to form a workable solution to the problem of the uninsured on which all can agree.


“We’re not interested in stalemate. We’re interested in moving forward and studying this issue,” Duffet says. “The act says we need to come up with something to insure everyone. It doesn’t need to be Plan A or B or C.” But the act calls for a decision nonetheless, a move reformers would view as historic.


“If Maine succeeds or California succeeds, that’s great,” Duffett says of ongoing universal coverage initiatives in those states. “But we definitely feel if a major Midwestern state is successful, that will be the Paul Revere shot that will send shockwaves across the country.”


Putting a plan into action and then studying it is a good idea, Butler says. “I think that’s the only way we can make progress. What we need to try to do this year is look at the state efforts and see what works.”


The forces making reform efforts more viable in Illinois are not limited to inside the state borders. National representatives from the business, hospital and insurance industries are anxious for success, too, Duffet says. They see that “broader coalitions are going to be a necessity. It’s a survival issue.… People are motivated by self-interest issues. People aren’t swayed by this idea, ‘Oh, we have 46 million uninsured.’ No, they’re motivated by increased costs. They’re motivated by higher co-pays.”


And the fiscal motivations for reform go beyond businesses’ bottom lines. The states themselves are in a financial bind, and that affects their actions. Recent financial indicators have suggested that states are just now clawing their way out of the budgetary hole they found themselves in after Sept. 11. But even as their financial situations have improved, they’re seeing major cuts in the Medicaid program, on which states rely to help them cover impoverished citizens.


Therefore, sweeping initiatives like those in Maine and Illinois are seen as out of reach for many states. “I think some states still see themselves in a financial pickle and can only take on incremental approaches,” Miller says.


Finding Flexibility


But the need for careful baby steps has actually led to some of the most creative reform efforts. States have long searched for ways to better tailor health-care programs to their own needs, and Medicaid, with the federal government’s longstanding willingness to issue waivers that allow states to alter the program as they need, is one way they’ve found that flexibility.


“I think states share that desire for more flexibility—let’s design something that works in our state for our needs,” Burton believes. “But they recognize that funding needs to come from somewhere, and that some of that help needs to come from the federal government. In a coverage program, it’s hard to do without federal dollars.”


The problem with federal matches, grants and loans, he says, is that it’s hard for folks in Washington to dole money out to one state without doing the same for all of them—almost like a parent wanting to be fair to each of his children. “Our federal government does not have a willingness to fund just a few [programs] in certain states.”


The result is too little funding spread too thinly. Which is why initiatives like Ohio’s smoke-free campaign are sometimes seen as more attractive to states with less money to spend, Burton says. “They don’t require such influxes [of federal money] and can be done on a local level.”


Thomas, who’s always on the lookout for funding for Georgia’s HealthSTAT initiatives, agrees. “That’s the other thing about having a state-based organization; it’s hard to get these huge grants, but it’s a lot easier to say, ‘Hey, Aunt Jo, check out the work I’ve been doing.’”


Reformers would probably agree the nation itself shouldn’t be left to the generosity of Aunt Jo.
~FOUR REFORM STRATEGIES FOR STATES


State-based reform initiatives may be as varied as the states themselves, but Tanya Alteras, senior policy analyst at the Economic and Social Research Institute, says most can be neatly filed into one of four models reflecting the most prominent reform activities in which states engage:



So, with four different strategy models to choose from, does any one work better than another? “All the themes are equally beneficial in different ways,” Alteras says. “I have an affection for all four.”


In her research, she and her colleagues were surprised at the number of disease management programs they found while evaluating care management programs in general. Noting that preventive care and disease management have certainly become buzzwords in recent years, Alteras says it goes beyond that. “I think states have realized that’s a really cost-effective way to make a big difference,” she says.



Fighting for their future patients: In many states, much of the pressure to enact health-care reform is coming from physicians-in-training who are willing to insert themselves visibly and vocally into the debate. This past January, 140 medical students traveled from all parts of California to the state capitol in Sacramento to lobby state representatives to pass Senate Bill 840, the California Health Insurance Reliability Act. The carefully crafted legislation aims to provide affordable health insurance coverage to all Californians in a manner that allows individuals to choose their own physicians, but also controls health-cost inflation. The plan involves no new spending on health care, and will be paid for by federal, state and county monies already being spent on health care, and by affordable insurance premiums that replace all premiums, deductibles, out-of-pocket payments and co-pays now paid by employers and consumers.


Speaking at the rally were University of California, San Francisco, School of Medicine second-year Renu Tipirneni (left) and University of California, Irvine, College of Medicine second-year Parker Duncan. Later that day, students met with their respective representatives—both Republican and Democrat, both in favor of and against—to talk up the benefits of the bill’s passage.


In recent years, students have rallied in Michigan, Maryland, Ohio, Connecticut, Texas and on Capitol Hill demanding that legislators act to transform the American health-care system.

~~~Jennifer Zeigler is a freelance writer in State College, Pennsylvania.~Advocacy,Health Disparities,Legislative Action,Universal Health Care~
33~3April~2006-55~Feature~SPOTLIGHT: TransMedicine~How will you treat your transgender patients?~Avery Hurt~Chances are you will treat a transgender patient in the course of your practice-no matter what your specialty. So it makes sense to learn and prepare for the exceptional concerns and health issues facing this growing population.~Circle One: Male/Female


For most of us, this choice doesn't present much of a challenge. But for a great many patients-far more than you might expect-this simple item on an intake form doesn't offer a selection that truly fits.


For the transgendered, there is the sex of their birth, the sex with which they feel psychologically comfortable and, sometimes, the sex into which they have transitioned, medically and/or socially. But choosing which answer to mark on patient questionnaires is often the least of their problems as they prepare to meet any physician for the first time.


"Many transgender persons fear doctors—so they simply don't see them," says Phoenix cardiologist Dr. Rebecca Allison, a member of the American Medical Association’s (AMA) gay, lesbian, bisexual and transgender advisory committee and a male-to-female (MtF) transsexual. "There is a potential for great harm here. A person can be hurt very much if the physician is not compassionate."


The word 'transgender' is not a medical term, and its use can be as fluid as the gender distinctions it attempts to define. A label self-adopted by the transgender community, the word broadly refers to individuals who do not feel comfortable in the gender of their birth. And like the concept of gender itself, the term encompasses a spectrum-from people who live all or part time as the opposite gender of the one they were assigned at birth, to transsexuals who have undergone complete medical and surgical gender reassignment-and all those living in the space between.


But wherever they land on the spectrum, transgender people face difficulties the rest of us can't imagine. One of the most critical can be getting quality medical care.


Which Patient Will It Be?


There are few reliable data points on the actual number of people who consider themselves transgendered. With so many still "in the closet," population estimates tend to be loose at best. The DSM-IV gives it a go, estimating that
1 in 30,000 males and 1 in 100,000 females would like to have gender reassignment surgery. When you include transgender people who do not, for a variety of reasons, want surgery, the number is certainly much higher, although there are no reliable estimates as to how much. If the DSM numbers are taken as a guideline-although transgender advocates believe they are conservatively low-it is very likely that every practicing physician will encounter at least one transgender patient during his or her career. If that physician is an endocrinologist or a psychiatrist, it is a virtual certainty. But it is equally likely that when that happens, the physician will not be adequately prepared.


Providing good health care to transgender people calls for a very specific set of skills, but none are beyond the capacity of a competent primary care physician who is willing to learn, believes Dr. Melanie Spritz, a psychiatrist and attending physician at a New York teaching hospital. Spritz is an MtF transsexual who believes she was one of the first resident physicians in the United States to be fully "out" with regard to her transformation.


"I was actually forced out [of one position] because I had to have a physical exam for the job, and I was honest on the form-I'm always honest with health-care providers," Spritz explains.


The reception she gets is sometimes shocking. "I've been called a "gelding" among other things," she recalls. When a physician interviewing her for a postresidency job asked how people deal with her "problem," she responded, "It's not really a problem unless people perceive it as a problem." Unfortunately, many people do perceive the transgendered as having a problem. And when it comes to health care, they often do.


Beyond Primary Care


Certainly, transgender surgical patients need good postoperative care, a closely monitored and individually tailored hormone regimen, follow-up care to catch and treat side effects from the hormone therapy, and routine care for reproductive organs, such as ovaries and the prostate, that remain in the body. In addition, transgender people are at high risk for affective disorders such as depression.


Rachael St. Claire, a psychotherapist in Boulder, Colorado, and an MtF transsexual, agrees that generalist physicians can provide most of the care, but "patients are enormously grateful for physicians who take the trouble to develop special expertise in this area."


Expertise is only half the equation, however. The other is compassion. Fear of mistreatment or unkind remarks are some reasons transgender people avoid medical care. Other causes are more psychologically complex. Female-to-male (FtM) transsexuals often skip routine gynecological exams because they do not want to acknowledge, even to themselves, that they still have female organs. It can also be very embarrassing for a man to visit a gynecologist. In her book The Riddle of Gender, science writer Deborah Rudacille tells of an FtM patient who called to make an appointment with a gynecologist and was condescendingly asked, "Do you know what we do in gynecology?" At the very least, seeking health care can involve lengthy explanations to receptionists and technicians as well as physicians.


Spritz points out that health-care avoidance seriously complicates the medical risks transgender patients naturally face as a consequence of the strong hormones they often take for a lifetime; many who shun medical care seek their hormones on the black market—a very dangerous practice.


Discomfort


Avoiding care is only one danger to the transgendered. Insensitive practitioners create their own hazards. One cautionary tale often cited by advocates is that of Robert Eads, an FtM transsexual from rural Georgia who, after being diagnosed with ovarian cancer, was turned away by more than two dozen physicians who feared that taking him on as a patient might harm their practices. Eads died of the cancer in 1999, but his struggles with the medical community are immortalized in the documentary "Southern Comfort," which won a Grand Jury Prize at the 2001 Sundance Film Festival.


The solution, Spritz believes, is openness and education. A physician who wants to provide good care to transgender patients has to do the same thing as when encountering any unfamiliar medical situation: Learn the medicine, develop the skills. "There are plenty of resources out there, and doctors must be willing to read and learn. They also need to learn to see these people as patients." And transgender patients have to do their part in reducing their defensiveness, too, she believes. "They can be difficult to deal with. They can be manipulative. But they have to be willing to deal with how things are said."


Learning to treat the specific medical needs of transgender patients is easier than it used to be, thanks to a variety of resources. (See "Learning Transgender Medicine," below.) And becoming comfortable with the particular social issues and concerns of transgender people is not as hard as you might expect. Dr. Nick Gorton, a physician at Sutter Davis Hospital in Davis, California, and an FtM transsexual, recommends that physicians do three things in order to provide compassionate care to transgender people: "Develop cultural competency. Show sensitivity to the needs of the patient. And approach patients from where they are instead of where you are." He also points out that "this applies to all patients, transgender or not. Don't make [treating transgender patients] into a difficult thing."


Sometimes the trick to conveying sensitivity and cultural competency in what for most physicians is a very unfamiliar and potentially uncomfortable situation is simply to ask questions. St. Claire suggests asking, "How do you consider yourself? What pronoun do you prefer?"-simple questions that not only help doctors give patients what they need, but also signal that the doctor is willing to learn and is truly interested in their needs, she says.


On the Margins


Although finding competent and compassionate caregivers is an obvious health-care problem for many transgender people, some can’t even get through the door. Jessica Carlsen, a premed at the University of North Carolina at Charlotte and transgender health adviser to the American Medical Student Association, points out that transgender people face widespread employment discrimination, so are less likely to have jobs with adequate health insurance. Their consequent low socioeconomic status can mean no access to basic health care, compassionate or not. "Transgender people are marginalized in many ways," she points out. And even when they do have good jobs and insurance, that coverage is likely to exclude sex reassignment surgery and hormone therapy.


But this is beginning to change, Carlsen reports. "Some big insurance companies are starting to cover these expenses-some even going so far as to cover sex reassignment surgery. However, "employers are often able to dictate what plans [employees are offered] and what those plans will and will not cover," effectively excluding many people from coverage even when the insurance company itself is willing to pay.



Transitional Times


Awareness of the health-care needs of the transgender community is growing. Perhaps one of the best signs is the AMA’s creation last year of an advisory committee on gay, lesbian, bisexual and transgender issues. Steven Heatherly, Ph.D., a medical student at Eastern Virginia Medical School, is on the committee. "This is a huge step for the AMA," he says, and asserts that attitudes toward transgender people are slowly improving.

Gorton agrees. "The perception is that medicine is very transphobic. In my experience, the reality is not quite as bad as people think." And Gorton isn’t merely speaking for the trans-friendly San Francisco Bay Area. He went to medical school in North Carolina and was a resident in Louisiana when he transitioned.


Society at large is coming around as well. Films such as "Southern Comfort" help create an awareness of the problems transgender people face. They also introduce us to the transgendered so that we can see them as individuals, and not freaks or medical anomalies.


"These people need help," says Carlsen. "Anyone who went into medicine for reasons of compassion should understand this." From that point on, good care for transgender people is just good medicine.
~TransStudent


Medical school is hard enough, but taking it on as a transgender student-particularly one in the midst of transitioning-may seem nightmarish. For Lee, a third-year medical student at what he deems one of the nation’s more conservative medical schools (his name and location are withheld by request), transforming from female to male as a medical student has been a challenge-but not a nightmare.


So far, Lee has undergone a hysterectomy and breast reconstruction surgery and is just beginning hormone therapy. Most of his friends have been supportive, he says, and since he has lived as a man for years, many classmates were unaware that he wasn’t biologically male.


The administration, however, knew. At one point, Lee was called to the dean's office and offered the option of transferring to a different school. He declined the offer, and the school did not press the issue. However, his request to have his dean's letter written with the male pronoun has so far been refused. Lee hopes that after he has changed his legal status to male and has a new driver’s license, the dean’s office will be more willing to comply with his request.


So far, things have gone relatively smoothly for Lee, although he is prepared for classmates to register complaints as his new status becomes clear. He does believe, however, that his attitude toward the change plays an important role, not only in how smoothly his own transition goes, but also in how society adapts to the idea of transgender people. "I don't feel like you have to rock the boat, but you shouldn't be afraid of who you are, either," he says. "It's by just being who you are that change can happen." -A.H.


Learning Transgender Medicine


While no medical schools offer transgender medicine specifically in the curriculum, a lot of material is available out there for the interested student. The following Web sites are useful in themselves and also offer links to further resources. In addition, transgender physicians and students recommend attending transgender fairs, workshops and conferences to learn more.


The Harry Benjamin International Gender Dysphoria Association. This professional organization has developed a standard of care for transgender patients, available at www.hbigda.org.


Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers, by R. Nick Gorton, M.D., Jamie Buth, M.D., and Dean Spade, Esq., is available at www.nickgorton.org.


American Medical Student Association Transgender Health Initiative Learning Center offers a wealth of information and useful links at www.amsa.org/advocacy/lgbtpm/transhealth.cfm.


Transgender Soul. Psychotherapist Rachael St. Claire provides medical information as well as insights that will help develop sensitivity for health-care providers, available at www.transgendersoul.com.

Dr. Nick Gorton (left), a transgender physician at Sutter Davis Hospital in Davis, California, with nurse practioner Liz Blair.
~~Eads died in 1999 after being refused treatment by dozens of physicians who were not comfortable caring for a trans-sexual patient.~The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~LGBTPM,Practice of Medicine~
34~4May-June~2006-55~Feature~SPOTLIGHT: Shades of “GREY’S”~The Anatomy of ABC’s Hottest New Drama~Linda Childers~NBC’s hit hospital drama “Grey’s Anatomy” is popular with physicians-in-training, even if the writers sometimes get the medicine wrong.~It’s early morning, and Dr. Preston Burke, chief of cardiothoracic surgery at Seattle Grace Hospital, is exiting the operating room after a particularly grueling procedure.


The surgery had gone well, and Burke is in good spirits. When he encounters his girlfriend, surgical intern Cristina Yang (Sandra Oh), in the on-call room, they share a steamy kiss.


The next day, back in Hollywood, Burke’s alter ego, actor Isaiah Washington, gets a call from a real-life surgeon at a local hospital. The doctor praises Washington’s performance on the hit television show, “Grey’s Anatomy,” but he also offers some friendly advice.


“He said no self-respecting surgeon would walk around the hospital wearing a stethoscope,” Washington says with a smile. “And then he chided Burke for disobeying hospital rules and dating an intern.”


Averaging 20 million viewers each episode, “Grey’s” is the fifth-ranked show in all of prime-time television and the fourth among the most upscale audience—viewers earning $100,000 or more—according to Nielsen Media Research.


The show features voice-over narration by the character of Meredith Grey (Ellen Pompeo), and follows the personal and professional lives of her surgical intern peers. The show mixes medical sensibility with overt sexuality, making it a primetime hit on which everyone—including most medical students and residents—has formed an opinion.


“It’s pretty inaccurate medically, but a lot of fun to watch socially,” says Mary Elizabeth Tetzlaff, a second-year pediatrics resident at Texas Children’s Hospital in Houston.


ACTING CHIEF


To prepare for his role as the cool and extremely talented Burke, Washington spent three months job-shadowing physicians in several Los Angeles hospitals. He continues to call upon local surgeons for technical advice to ensure his character is accurately portrayed. “I certainly don’t know everything about being a doctor,” he concedes, “but I’ve learned a lot about their behavior and how they respond to death and trauma.”


An actor with more than 20 years of experience, Washington takes pride in thoroughly researching his roles. From the beginning, he knew the kind of surgeon he didn’t want to portray: an arrogant, standoffish, token-African-American doctor.


“I want to appear honest and credible in the eyes of viewers who actually do this for a living,” he says. “I didn’t want to be put on a successful show and just be put in a box. My goal is to make being a heart surgeon cool because everybody can’t be Kobe Bryant.”


Washington admits his character has morphed into a kinder, gentler Burke since the beginning of the show. “He did start out sort of stone-faced,” he admits. “But he’s evolved into an effective leader and someone who learns how to love and be loved.”


Surprisingly enough, Washington initially auditioned for the role of Dr. Derek Shepherd, played by Patrick Dempsey. He didn’t land the part, but Shonda Rimes, the show’s creator, offered him the role of Dr. Burke, with the promise that he could make the role his own.


“Isaiah played Burke as someone who intensely loves his job,” Rimes says. “He brought a sense of honor to what Burke does. And with Isaiah, suddenly there was a sexiness to the role, an intelligence and a wit.”


To research his role as a cardiothoracic surgeon, Washington observed several open-heart surgeries, practiced suturing on a fake arm, and learned to mimic even the subtlest nuances of surgeons, such as attaching his wristwatch to his scrubs before surgery. His research and diligence have earned him the respect of local doctors and fellow cast members.


“If I had to pick someone from the cast to perform surgery, it would be Dr. Burke,” says Kate Walsh, who plays Dr. Addison Shepherd. “He thoroughly researches each procedure he has to perform, and he has the steadiest hands.”



ONE WACKY HOSPITAL


But the steamy scenes between his character and Yang is one area where his real-life M.D. counterparts have hesitated to offer him advice. “All the doctors I’ve spoken with adamantly deny that extracurricular activities take place in the on-call room,” Washington grins.


But that’s exactly what sets “Grey’s Anatomy” apart from other medical shows—its mixture of medicine and a large dose of personal relationships. Rimes is quick to point out that “Grey’s” is not a medical drama per se, but a relationship show set in a hospital.


A self-proclaimed “medical junkie,” Rimes briefly considered going to medical school before realizing that she was scientifically challenged. Before penning the show’s first episodes, she conducted her own extensive research, calling on friends like Dr. Karen Pike, a fellow Dartmouth alumna, to review scripts.


In addition, Rimes and the show’s other writers rely on a bevy of medical experts from the Centers for Disease Control and Prevention and the National Institutes of Health to help keep the episodes real. Surgical nurse Linda Klein serves as the show’s on-set technical adviser and medical producer, routinely coaching cast members through the detailed procedures they simulate on each episode. As a bonus for fans, The “Grey’s Anatomy” section of the ABC Web site lists all of the medical procedures covered in past shows, as well as a writers’ blog explaining the rationale behind some of the episodes (abc.go.com/primetime/greysanatomy/
writers.html).


The show’s first-year surgical residents have already confronted the death of a woman with a 60-pound tumor, extracted a set of keys from a man who swallowed them when his wife threatened to leave him and survived a “Code Black” in the operating room. Real-life residents say it’s a good thing they don’t routinely face the same challenges as the cast of “Grey’s.”


“Thank God there aren’t affairs with attending physicians, people having sex in call rooms and patients with live bombs inside their chest cavities,” says Tetzlaff. “If we had to work through everything that takes place on the show, our hospital would be an inefficient place to work.”


Tetzlaff admits that she, like many medical students and residents she knows, rarely misses an episode, even if the show does draw a fine line between fact and fantasy. One clunky conceit of “Grey’s,” she notes, is that “surgeons are consultants at most hospitals—not the primary caretakers of most patients.” Nevertheless, “the show accurately portrays the amount of time spent at the hospital and the closeness you feel with residents in your class. However, the lack of professionalism among the doctors who fraternize with one another is inaccurate.”


Some episodes in particular have struck chords with physicians-in-training viewers. “One of the most memorable shows featured Meredith having issues with a child who needed a heart transplant,” Tetzlaff says. “It was pretty accurate in that the child was angry at his mom for praying to get the transplant when, in essence, she was praying for someone else to die to give it to him. I thought it was one of the more realistic plots, and it showed a lot of insight.”


WAY OF THE VA-JAY-JAY


Rimes is passionate that the “Grey’s” cast represents real-world diversity. That’s why there is a black chief of surgery and numerous women preparing to become surgeons.


Overseeing the show’s residents is Dr. Miranda Bailey (Chandra Wilson), a relentless drill sergeant who is referred to as “the Nazi” by the interns at Seattle Grace. “Bailey is an African-American female surgeon working in a field composed primarily of white men,” Wilson says of her character. “She has the odds stacked against her, so she’s developed a certain thickness of skin and feels she needs to work extra hard to prove herself.”


Wilson not only takes pains to portray Bailey as a fearless leader; she also has observed several surgeries to ensure that Bailey is seen as a skillful physician. One of her most memorable experiences was watching as surgeons performed bypass surgery on an infant girl born with two holes in her heart.


“The first thing I noticed when I walked into an operating room was how calm everyone was,” Wilson says. “I expected chaos, but everyone was entirely focused on the patient. Nothing mattered except their tiny patient, and how they were going to repair the holes in her heart.”


Watching actual surgeries not only gave Wilson a crash course in surgical procedures, it also cured her of any squeamishness. “When Linda Klein, our medical adviser, brings in chitterlings for me to practice doing a GI procedure with, I don’t even flinch,” she says. “I’m more concerned with how I need to hold my hands, and what part of the body I’m suturing together. I don’t want to shame the medical profession!”


Jacquelyn Jackson, a second-year at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School—who has yet to miss an episode of “Grey’s”—says she identifies most with Wilson’s character. “She’s the doctor I aspire to be. Like me, she’s juggling motherhood with her work as a doctor. I’m interested in seeing how she balances both of these important roles.”


Since the cast often works long hours (14-hour days are typical), playing a fatigued surgeon isn’t that much of a stretch. But unlike their real-life counterparts, the doctors on “Grey’s” will never appear disheveled—each cast member’s scrubs are perfectly tailored to their bodies by the costume department. They have darts, tucks and are made with Lycra. “Fortunately, we wear masks during surgery, so if we slur our words at the end of the day, we can go back and correct the scene later,” Wilson says.


Perhaps one of Wilson’s most memorable turns was the Feb. 12, 2006,
show in which her character gave birth. (In real life, the actress had her first child, Michael, in October 2005.) The episode entered the annals of pop-culture history when Wilson introduced a new euphemism for a part of the female anatomy: “va-jay-jay.”


“For every 30 times you can say ‘penis’ on television, you can only say ‘vagina’ once,” Rimes explained in a recent interview with TV Guide. “All the other words that people use seem so childlike and insulting. It’s the kind of hip slang that Bailey would use, and the proof of that is we’ve heard from a lot of people that women all over the country have started saying it.”


So what’s up next for the interns of Seattle Grace? Cast members are forbidden to reveal any juicy tidbits, so stay tuned.


Or, as Rimes has often said, “If we tell you, we’ll have to kill you.”
~~~~Linda Childers is a freelance writer in Martinez, California.~Medicine in Popular Culture~
36~4May-June~2006-55~Perspectives~The Lotus Eaters~Cultural competency and the pleasure-seeking patient~Victoria Wong~Your hedonistic patient.~

Let us swear an oath, and keep it with an equal mind, In the hollow Lotos-land to live and lie reclined On the hills like Gods together, careless of mankind.

— Alfred Lord Tennyson



In our family practice rotation, we were trained to strive for cultural competence, an essential skill, particularly in our multicultural state of Hawaii. But as I started seeing patients, I encountered a culture I had never quite acknowledged before. I began to realize this was a culture with which I was very familiar, perhaps even a culture that was partly mine. But when it came to providing this group with medical care, I felt quite incompetent.


I speak of the culture of people who seek pleasure and avoid pain; the culture of instant gratification and seizing the day. These are the people who, when presented with a choice of eating Spam, Portuguese sausage and short ribs—staples of our local diet—or the promise of good health over the next decade, would heartily choose the former over the latter.


At the clinic, I saw a number of gout patients. Their gout exacerbations were painful enough to make some of these grown men cry. But among these patients, only one, when asked about diet and alcohol intake, didn’t give me either a noncommittal shrug or admit to some serious alcohol and pork abuse. This one compliant gout patient had come in with his wife, who proudly described in her Filipino-tinged English how she had decreased pork adobo and increased vegetables in her cooking. Meanwhile, the patient remained silent, and rather miserable-looking at that.


Another of my patients had been stricken with an awful headache one morning. He relayed to me his longtime history of migraines, complete with photophobia, phonophobia and nausea. I asked about past medical and family history, but all seemed mysteriously benign until I hit upon his social history. It turned out he was on a strict schedule of one pack of cigarettes a day; one episode of binge drinking a week, in which he got, in his own words, “shit-faced”; and five to six Red Bulls a day.


Upon researching the caffeine content of a Red Bull drink, I found it contained 80 mg of caffeine, more than double that of a can of regular Coke. Armed with knowledge, and a plan to “anticipate, ask, then advise,” my preceptor and I entered the room. The patient nodded attentively to our plea for him to decrease his Red Bull intake. But he nodded distractedly while we talked to him about the dangers of alcohol’s effects on the liver. By the time we got to smoking cessation, he had practically nodded off.


This group of patients, the pleasure-seekers who care little about health consequences, may not be united in any ethnic, social or economic culture, but they do represent a significant consumer bloc—one that votes with its cash to keep companies such as McDonald’s and Philip Morris in business.


They also often vote to stay away from those pesky physicians who, in their minds, only preach about the evils of pleasure. They presume to need preventive medicine like holes in their heads. Or perhaps that’s the wrong saying, because it’s the holes in their heads—their mouths—that allow them to smoke and drink, to eat and be merry.


Treating this large patient population, I’ve learned, can be extremely frustrating because we seem to care more about their health than they do. I have also come to realize, however, that it is their right to do as they wish with their lives; their right to choose their pleasures over their health.


Just as some religions may refuse blood products, and some cultures may prefer nonmedicinal methods of healing, this type of patient chooses his or her own lifestyle. And, as with other cultures, it is unfair to stereotype the instant-gratification-seeking patient as uneducated or incorrect in his or her beliefs.


After a complete cultural immersion, having seen so many patients with lifestyle-induced illnesses, I now realize that most of them know exactly what the consequences of their behaviors are. For instance, the gout patient is quite aware of the fact that overindulging in beer and pork will cause him immense joint pain soon after. And for the smoker who actively hacks her lungs out and still picks up a cigarette to smoke, there is no question she sees the connection.


Thus, a physician must be both medical educator and medical provider, but without overstepping his or her boundaries. As medical educators, it is right for us to educate all our patients to ensure that they make decisions with the proper background knowledge. But once such baseline knowledge is established, we should continue to counsel only those who desire assistance with behavioral changes. We may do the anticipation, the asking and the advising while keeping in mind that our advisory role is only complementary to the patient’s self-advising. A patient’s health is his own territory, so he must take complete responsibility and lead the way. The physician who takes it upon himself to impart unsolicited advice to the point of being overbearing is encroaching on that territory.


If a patient decides upon an unhealthy lifestyle, he should be able to do this without guilt on his part and without judgment on our part. For some patients, it is only our role as symptom-reliever and healer that they seek, and that is what we must graciously provide without commentary.
~~~~Victoria Wong is a third-year at the University of Hawai’i at Manoa John A. Burns School of Medicine. Direct comments regarding this article, or your own “Perspectives” topic, to tnp@amsa.org.~~
37~4May-June~2006-55~MedMentor Q&A~Mindful Medicine~In practice and in life, physicians should seek balance~John Inzerillo, M.D.~Just breathe.~Even with new restrictions on resident work hours, physicians-in-training average twice as much time on the job in an average week than the general public. Likewise, physicians in practice feel pressure to see as many patients as possible within a workday truncated by growing paperwork and administrative duties.


In many medical groups today, physicians who seem unwilling to double-book patients, start the day before sunrise and stay late into the evening are viewed by their colleagues as non-team players. But in reality, that practitioner may be searching for a life of balance, in which personal health, patient health and family matters share top priority.


A recent editorial in the Annals of Internal Medicine, authored by Dr. Harold C. Sox, noted that of a group of 3,500 internists certified in 1990, 1991 and 1992, 9 percent have left the specialty. A separate survey from 2003 found that 10.2 percent of doctors surveyed were considering leaving medicine altogether. Reasons cited were difficult working conditions (75 percent), lifestyle constraints (23 percent) and attraction to another type of work (9 percent).


But are these dissatisfied docs also feeling the absence of connection to the individuals for whom they are caring? Maybe they are the ones who come home at the end of the day feeling drained and used up because they feel they are working in a mill, seeing one patient after another with their minds more on the clock, and all that needs to get done by lunch, than on that person before them with physical, emotional, psychological and spiritual needs. Similarly, the physician’s sense of his own empathy, compassion and spirituality can be hindered by the frantic pace of patient care.


In the same edition of Annals, Dr. Joseph Cavanaugh expresses many of the same frustrations in his article “Twenty Minutes.” With his typical schedule of 13 patients on the morning docket, he recognizes that his first patient may have needs that he intentionally does not address, knowing that time will not allow for such questioning. Describing such an encounter, Cavanaugh laments, “The uncaring morning was shouldering past us, and he was sitting there with his undeclared sadness, his throat tied tight against an unending spill of grief. I was both afraid of that kind of grief and painfully aware of the three patients who were waiting and the six more to come.”


Sadly, this is only the doctor’s first patient of the day. Other practices—even specialties like oncology—have morning schedules of 18 to 20 patients or more. This “cattle call” mentality intensifies the time pressure and makes it obvious to patients just how little attention they will receive. How can a patient truly confide in and trust a physician who works beyond his or her limit day after day? And what good can a physician do, for his family and community, if an inhuman workload results in the higher rates of broken families and suicide that mark the profession?


But something has clicked in our culture. It may be that we as a society have re-evaluated our personal priorities after 9/11, physicians included. Increasingly, they are leaving behind the old-school mentality in which medicine is number one, and spouse and family are numbers two and three on the list.


Searching the current jobs available across the country for physicians, compared to 10 years ago, you’ll see many more that offer minimal call, second or third call or—less often, but most inviting—no call. Traditionalists might sneer that doctors who do not take call really don’t care much about their patients. But, in fact, these are the healers who care enough to ensure that their own needs are met so they are in a better position to assess all of the needs of their patients. They are recognizing that pressure to juggle competing responsibilities also robs them of time for quiet contemplation and the healthy habit of questioning life’s priorities regularly.


The idea of “mindfulness”—the trait of staying aware of and paying close attention to your responsibilities—is gaining recognition in many circles, including medicine. Beyond simply helping to manage life’s activities, mindfulness is central to yoga and meditation, practices that are becoming more integrated into traditional health care.


With the development of the National Center for Complementary and Alternative Medicine within the National Institutes of Health, there has been an explosion of research in the area of alternative medicine. For instance, new studies suggest that patients who suffer from asthma can benefit from practicing pranayama—simple breath control and one of the eight limbs of yoga. The practice is easily taught and can reduce the number and intensity of asthma attacks. Newer protocols will assess the role of yoga therapy in managing stress levels and insomnia in cancer patients.


The benefits are the same for physicians who practice yoga, tai chi or other meditative programs that allow the body to move into a place of natural balance.


But most of us have not had the opportunity, nor time, to develop and incorporate the attitudes learned through mindfulness into the compassionate care we provide to patients. This leaves us with a spiritual component lacking in our work and lives.


As men and women of science, we may hold some degree of skepticism about religion, spirituality and the mind–body connection. The question becomes: How do we in the medical caregiver’s position come to this debate with an open mind? Why is it that learned men and women always have to walk away feeling that they are right and know all of the answers? Why not make room for the mysterious and unknown?


This is what makes our lives and work exciting. It also opens up avenues for healing that are otherwise left untouched. Everything we do should be in a mindful manner, with our awareness focused on the task at hand. As we practice mindfulness, we will begin to experience the intertwined nature of spirituality, medicine and wellness.


Let me present myself as an example. At one time, my cholesterol was 360 mg/dl. Like any other person receiving this information, I began to eat better, deferring french fries, shrimp, pasta and all the feel-good foods. I also started on Lipitor, but quickly developed gastrointestinal side effects. Taking the medication before bed alleviated this side effect, so I stayed on the drug for about six months, and it brought my cholesterol down to 240.


So my treatment was successful, to an extent (ideally, I wanted a cholesterol level below 200), but I was taking a drug that I did not like taking. And, of course, I went back to the french fries, pizza and the occasional hamburger. But I was also practicing yoga on a daily basis, and eventually the cravings for my usual unhealthy foodstuffs began to abate, making healthy eating easier and more natural. I have been off Lipitor for about a year now, and my cholesterol is 204 mg/dl. My weight has also dropped 10 pounds without effort.


But how does a physician explain such concepts to patients when, in the scope of 10 minutes, he must conduct a review of medications, discuss new and existing problems, and perform a physical exam? Where does this leave time for a conversation about spiritual issues? It is time to commit to giving our patients our full attention, and to settle on seeing fewer of them in a day.


Perhaps the biggest obstacle to practicing medicine with a spiritual component may be incongruence among members of the physician group regarding the true mission of the practice. The group may believe it wants to deliver compassionate care when, in fact, members are working themselves into the ground, seeing too many patients in a day to be truly effective and centering their discussions on the bottom line instead of patient care.


If you find yourself in such a practice and note your discomfort growing daily, know that there is a way out. Begin to pray or meditate about your situation.


Talk with your spouse or significant other about your wants and family needs. It is difficult to be the “black sheep” of a practice. You may feel at times like an outcast, but by finding room in your medical practice for mindfulness, you will be making the healthiest choice for your patients, your family and yourself.~~~~John Inzerillo is a medical oncologist at the Marion L. Shepard Cancer Center in Washington, North Carolina, and a longtime yoga practitioner.~~
39~4May-June~2006-55~Feature~Life Support~Keeping Love Alive During Medical School~Beth M. Rogers~Medical-school romances can be distracting, even disruptive, yet many students manage to find love and form lifetime bonds during this hectic period of their lives. Also: Making room for baby and the dating game.~Medical school remains famous for a schedule that leaves little room for things like, oh, eating, sleeping and breathing, let alone maintaining a romantic relationship.


While some students embrace an ascetic lifestyle during this time, buying into the popular wisdom that the hardships and rigors of school separate the wheat from the chaff, others firmly demonstrate that, inconceivable as it may seem, it is possible to maintain some semblance of a normal personal life.


Dr. Katrina Hood, a pediatrician in Lexington, Kentucky, met her husband at the University of Louisville School of Medicine, and they married in her third year. Now a decade later, Hood says, “We always say that we spent more time together in our first four years of dating than most married couples spend in 20 years.” But it wasn’t all movie dates and candlelight dinners, she says; it was more like osmosis, sitting next to each other in class, having the same rotations and studying together. “That was helpful because we spent a lot of time together developing who we were as a couple,” she says, adding that in many ways, going through medical school with a partner is like surviving combat together.


But is starting a romantic relationship during medical school really a good idea, or could it be detrimental?


“That really depends on the nature of the relationship,” answers Dr. Mark Singer, director of Student Mental Health Services at New York Medical College in Valhalla, New York. “There are a lot of relationships that are very good and supportive and others, of course, that tend to be very distracting.”


He says that it’s not uncommon for “the stresses of medical school to put a certain pressure on relationships because people don’t understand what’s involved…. In general, when romantic relationships are going badly [while] these students have such difficult academic demands, that increases the overall stress that they’re feeling because the stakes are high. If they get distracted by things that are not going well, it makes it harder for them to focus on what they need to focus on, and the ante gets upped on the whole situation.”



WHAT THEY DID FOR LOVE


The question underlying any new relationship is whether one’s love interest is worth the sometimes-arduous efforts required to sustain it. One or both partners may wonder, “If I make this sacrifice or compromise, will we still be together in the long term? Will I be resentful if not?”


The path to becoming a physician is full of sacrifices and uncertainties about the future anyway. “The thing that’s hardest about a relationship in medical school is the pressure of having to know that four years down the road, you’re [both] going to want the same thing,” says Justin Sanders, a third-year at the University of Vermont College of Medicine. “You want some person now, but how do you know in the future…that you’re going to feel the same way you felt when you met, or when you fell in love?”


Meanwhile, as critical decisions about residency programs and specialties loom, student couples face hard choices about their common future. “Most aspiring students will prioritize and say, ‘This is medicine, and I’m supposed to be dedicated to this and go wherever my career takes me, and if the relationship fails, it fails,’” says Dr. Hannah Mude-Nochumson.


But she took a different approach. Now an intern at St. Luke’s Hospital in Bethlehem, Pennsylvania, Mude-Nochumson chose a less rigid path, deciding to limit her professional aspirations to accommodate her personal life. She met the man who would become her husband when they were both undergraduates at the State University of New York-Albany, and after graduation, she put her medical schooling on hold and followed him to Washington, D.C., where he earned a law degree. After he finished, they moved to Philadelphia so she could start her deferred training at Jefferson Medical College.


This academic tag-teaming illustrates a key challenge for couples who meet as undergraduates, notes Mude-Nochumson. Getting serious with a premed, she says, can mean “sitting by the wayside” waiting to discover where your romantic interest is going to be accepted. Most premeds apply to a wide swath of medical schools across the country to improve the chances of acceptance, creating a lot of uncertainty about the future of the relationship.


Mude-Nochumson took a risk but reduced that uncertainty by agreeing
to consider only Philadelphia schools. When it came time to apply for residency, she followed the same protocol, limiting herself to programs within commuting distance of the city. From the beginning, she and her husband decided their primary commitment was to each other, and they would make their careers work around that somehow.


The Hoods, too, made a critical joint decision early in their relationship: not to pursue surgery as a career, although both of them initially aspired to the specialty. “Those residencies are a lot longer and have more intense hours,” says Hood. “We both looked at each other and said we don’t necessarily want to be in training for five or six years if we’re going to try to start a family, so we chose other things, and we’re actually fine with it.”


For Hood, choosing to become a pediatrician rather than a surgeon meant “a three-year residency in a field where people understand kids and understand when I need to leave because I’ve got to get my son to T-ball…. In some professions, your family is supposed to take a back seat.”


Mude-Nochumson once considered a surgical career as well, but ended up in emergency medicine, which she now sees as the perfect fit for her. “I don’t know what I did in a past life to deserve matching [at St. Luke’s] because it’s been wonderful,” she says. In her experience, the culture of surgery is “almost militant.” The specialty carries “these great expectations that we’ll never get tired and...we’re not supposed to whine about anything. There’s sort of an unstated rule that you’re not supposed to have a personal life…. [Surgery] is very unforgiving for families.”


A surgical intern she knows recently took a day or two of paternity leave several months after the birth of his child, and was greeted with snickers of derision from his colleagues. In contrast, emergency medicine “has a much nicer lifestyle,” she asserts.


TRY A LITTLE TOGETHERNESS


Premed Christina Martin, 30, will start her first year of medical school this August at the University of North Carolina at Chapel Hill. As an undergraduate, she never planned on becoming a doctor, but was always interested in public health. About five years ago, she decided she wanted to go to medical school; at about the same time, she met Michele, now her wife.


From the time they met, Martin says, the two discussed how they would navigate their relationship amid the challenges and stresses of pursuing a career. This open dialogue “made us realize that we might be a good match for each other.” Martin’s personal physician, who has acted as an informal mentor to prepare her for the rigors of medical school, urged them to carve out time together each week and stick to it—for example, set aside each Wednesday to have dinner together, or reserve every Sunday from 3 to 6 for each other.


“I’m looking at that…free time as like a reward,” says Martin. The couple also plans to take a vacation before starting school “so that when I’m in the thick of studying over the next few years, I can remember that there is life outside medical school.”


“One of the things that people have to do is schedule time with each other and make it a priority,” agrees Mude-Nochumson—a piece of advice she has passed on to one of her half-sisters, now in her second year at Jefferson and in a serious relationship.


Donna Roybal, 32, a wife, mom and third-year at the David Geffen School of Medicine at UCLA, tries to set aside one full weekend day for the family, and will spend half of the other weekend day studying. Although this year has been more challenging, with overnights in hospitals, she still makes sure that when she gets home, she spends time with her child, studying only after his bedtime, and forgoing sleep of her own if need be. “I guess I’m losing out on sleep, but what mom doesn’t?”


Hood notes that her husband’s day is a little longer than hers, so when he is going over his notes in his home office, she often joins him, quietly reading or doing needlepoint. Even though they might not be interacting, they’re still in the same room and connecting with each other, she says.


Mude-Nochumson also attempts to nurture her spousal relationship through physical proximity. At night she often reads in the same room where her husband is working. “Even though we’re not talking, we’re still there and spending time together.”


It’s not always easy to make that time, she admits. During a recent month-long surgical rotation, Mude-Nochumson had to fight the urge to head straight for bed when she got home. “Sometimes you have to force yourself to say, ‘You know what? This is important,’ and try to make an effort because you forget that [other people have been] waiting for you, especially if you have children at home.”


MAZIMIZING THE MINUTES


Everybody has strategies for coping in medical school, but Singer stresses organization above all.


“One of the keys in medical school is efficiency. I think what happens with a lot of students is…they’re not efficient. When they’re not studying, they feel guilty, and when they’re studying, they’re sort of thinking about the fact that they’d like to not be studying.”


Singer tries to counsel students on ways to conserve time and effort, assuring them that, sometimes, “less is more.” He encourages them to study in smaller increments and focus on being able to concentrate for shorter periods of time.


Roybal, who is looking at neurology for her specialty and also debating a career in academic medicine, agrees with the strategy. “I figured out that I had to study a little bit every day. There’s no waiting for the last minute. I also realized I wasn’t going to get a block of five hours like I did before I had the baby.”


She now grabs time when she can, even studying in her car during lunch and downloading study questions onto her PDA. “During any break I have, I try to do something.”


Hood advises that couples who want to maximize their time should start by eliminating television: “My husband and I cut cable. Our TV is in a downstairs back room.… We do not watch ‘24’ or ‘Desperate Housewives.’ We have no shows that we are dying to get home and watch…. [T]he hour, two hours, that most people spend each evening [watching television] is a waste of time. We use that time to do other things, to get together and be together.”


LONG-DISTANCE LOVE


On the other side of the divide are couples who rarely see each other. And for many, a long-distance relationship suits the medical school dynamic perfectly.


Sanders is in a long-distance relationship that began a year and a half before he entered medical school. The advantages, he says, are long stretches of time with no distractions, and ample time to spend with friends. “That’s what’s advantageous about having a really long-distance relationship, because if you only live two hours from someone, you’re obligated to go see them.” Some of his friends spend weekends in the car driving back and forth. “I have friends who are doing that, and they don’t ever get to see their friends because every spare moment is spent.”


Sanders met his girlfriend when they were both traveling independently in Asia. He had just gotten off a bus at a border town in northern Laos. “I was walking down the street,” he recalls, “and saw her sitting by herself. I wasn’t immediately attracted to her, but I invited her to come along and drink fruit shakes with us…. Then within about three days, it became a moral imperative for me to pursue her.”


His girlfriend is now living in her native London while Sanders hits the books in Vermont. For the first two-and-a-half years of medical school, they saw each other every two or three months, but at one point they mutually decided to take a forced break, “just to see what that was like,” he recalls. For eight months, they only spoke by phone and, by agreement, dated other people. When they reunited, “it was amazing. It was really confirming for the both of us,” he says.


The downside of geographical separation, Sanders acknowledges, “is when you’re not together all the time, you can’t grow together in the same way. There’s so much about being together that’s important for communication. So much of the way we communicate is through body language, and when you speak on the phone, you lose all of your body language. I never realized how difficult a thing that would be until I started this long-distance relationship. What’s important is recognizing that and doing things that make up for that.”


Of her long-distance love, “there are definitely times when it’s hard not seeing him every day,” says Ali Horowitz, a second-year at Drexel University College of Medicine. “But it makes our times together more special, and I’ve had the opportunity to get to know him through his words and not just through his actions. I’m all for the long-distance dating in med school!”


Words can be the glue that keeps distant couples bonded. One of the ways Sanders compensates is by writing letters. “E-mails are quick, but they’re kind of unsatisfying because they don’t contain any element of you. Because they’re quick, they don’t symbolize much of a commitment. Just because you don’t live with someone doesn’t mean you don’t have to work hard in a relationship.”



THE OTHER HALF


Students and physicians have long debated the relative merits of coupling with their own kind versus someone outside the medical profession. In Singer’s opinion, though, the only thing harder than being a medical student is being the nonmedical spouse of one. “You have to go through all the stuff, but you don’t get the degree.”


Mude-Nochumson agrees: “I think in some ways, it’s harder for the other person because they’re sort of tagging along and waiting on the sidelines.”


Roybal’s grant-writer husband followed her to Los Angeles for medical school, and in another year they will be moving again, to a location now unknown. He has only requested that her internship not be north of the D.C.-San Francisco latitude. She has observed that couples in less committed relationships, where such compromises can take a toll, tend to let love fall by the wayside when they apply for residencies. “It’s definitely a point of contention. If I had been in a relationship that was more casual, I probably would have gone my own way,” Roybal admits.


Todd, a second-year who asked to remain anonymous, found himself in that position, but far too late. As an undergrad, he fell in love with another premed: “After we graduated, she went to med school and I took a year off to work before starting med school. It’s a long story, but I didn’t get into school the next two years. But we got engaged and married halfway through her senior year of medical school. We got divorced her third year of a very demanding
OB-Gyn residency—before the 80-hour rule was passed.” Now Todd restricts his romances to women outside of med school.


Sanders believes that relationships often work better when one person is less driven and more subordinate. “People who are in medical school are very much the controlling aspect of a lot of relationships because they have little control over where they’re going. And when they go there, whoever’s with them kind of has to be there too if they want the relationship to work.”


Roybal echoes that sentiment, noting that medical school attracts a lot of “type A” personalities. “I also think that there’s a certain degree of selfishness involved if you’re in medical school, so it’s hard if the other person has goals that involve time and more energy than someone who’s just working 8 to 5.” She points out that it’s not always positive to have two alphas in a relationship, especially with children involved: “I definitely appreciate the fact that my husband has a more flexible schedule.”


Sanders adds that it’s “calming to have a nonmedical-school influence around when you’re studying under great stress.”


Taking the other side of the debate is John Lusins III, a fourth-year at the American University of the Caribbean School of Medicine in St. Maarten. He met his medical-student fiancée in his first year—a time when most students are only thinking of staying on top of their studies, not companionship. But, he believes, “It’s important to have support.”


Lusins feels that the stresses of medical school, instead of acting as a wedge, have strengthened his relationship with his fiancée. “We said, ‘We’re going to make a strong bond together. No matter what happens, we come first.’ As glorious as medicine is, a relationship and life is more important.”


Once Lusins and his fiancée realized they had potential as a couple, they decided to stay together throughout their clinical rotations and residency. In their third year, they told their adviser that “the only way we’re going to go [do our clinicals] is if we get into the same hospital.” They ended up spending their third year in London, where they got engaged, and are now wrapping up clinical rotations at Wyckoff Medical Center in Brooklyn.


Joy Zia, a fourth-year at the University of Hawai’i at Manoa John A. Burns School of Medicine, says what she loves about dating another medical student “is that here is someone who knows what it is like to deliver a placenta—and who won’t get queasy talking about it over dinner—who knows the struggle of starting your first IV on a heroin addict, and who has felt firsthand the mental pain that was Step 1.”


Lusins does admit to one drawback of dating a fellow medical student: differing aptitudes. His fiancée is better at basic sciences, while he excels in clinical subjects. “Sometimes, if she didn’t do as well on a test as I did, it’s difficult because you want to go out and celebrate, and the other person doesn’t want to do anything.”


Another potential benefit of dating a fellow student is that the two can apply for residency programs and be matched as a couple—a nonstudent partner would have to agree to and arrange his or her own relocation. But Mude-Nochumson believes the National Resident Matching Program’s “Couples Match,” as it is called, carries its own limitations: “The algorithm is set up so that you have to meet your requirements and also the requirements of somebody else.”


Even though Zia and her boyfriend, Darren, went through the Couples Match, they ended up matching in two different states. “I am wary of being separated from my soulmate—to battle through residency without my better half—but I expect that will be another tale,” she says. In other words, there is always a compromise somewhere.


For Martin’s part, she is willing to make the ultimate compromise for her relationship: If the rigors of school ever threaten to dismantle her marriage, “I think I would very seriously consider taking a leave of absence…. I know the kind of work that I want to do, and I know that medical school isn’t the only way to do it.”
~MAKING ROOM FOR BABY


Yes, some people are just crazy enough to add another emotional, financial and sleep-robbing challenge to their lives while in medical school. But the reasons for the timing are usually justified: Female medical students are often reaching or passing their prime fertility years at this time, and students of both sexes worry that the coming workload of residency and early practice will prove too burdensome to start a family.


But it’s no picnic to become a parent during the med school years. Third-year Donna Roybal and her husband aimed to conceive a child in her second year that would be born during the two-week Christmas break of 2004. As is typical of anything pertaining to children, the most carefully laid plans tend to go awry—they overshot the date, and her son wasn’t born until the New Year.


“I was nuts,” admits Roybal in hindsight. She had been inspired by a classmate “who popped a baby out over Thanksgiving and was back in class three days later.” Roybal wasn’t so lucky. Her labor was difficult, ending in a C-section and major blood loss. Two weeks later, she got an infection and was bedridden for a month. The school accommodated her by letting her study from home and taking finals a week later.


After the birth of her son, Roybal started a support group at UCLA called BUMP (Babies Undertaking MoMD Pregnancies) because she wanted more information on how other medical student moms coped. BUMP meets several times a year, and its members share their strategies for juggling children and school. For example, one woman reported that she studies while her kids play at her feet, then she takes little breaks. Another classmate’s strategy was to go to bed early with her child, then get up at 2 or 3 a.m. to study.


What Roybal has gleaned from BUMP is that everyone needs a huge support system. “It helps to have a spouse who is not afraid to do a lot of child rearing. There are quite a few women at UCLA who have children, and I would say that every single one of them has a supportive spouse or a spouse that works at home.”


But having a child during medical school involves more than support and organization. It can also break your heart. Dr. Hannah Mude-Nochumson had her son during the fourth year. Now a first-year resident, she tries to spend time with him every day, but many go by when she doesn’t see him at all. Initially the separation was crushing, she says, but now that he is getting older and more autonomous, “I miss him, but it’s not painful.”


Working mothers in any profession grapple with guilt, she acknowledges, “but I think as women, we have to realize we can’t be 100 percent everything. I know I can’t be there 100 percent of the time for him, and I can’t be studying during all my free moments. I had to find a balance.”

—B.M.R.




THE DATING GAME


Dr. Amanda Meulenberg, an OB-Gyn intern at New York Downtown Hospital, is back on the dating scene after ending a rocky, long-distance relationship that spanned her four years of medical school. Of the breakup, she says, “He never really understood the time that was involved in medical school and the commitment behind it.”


Since coming off the shelf, she has learned a central irony about dating in New York City: There may be plenty of people here, she says, but the chance of running into someone more than once is remote, unless one takes a carpe diem approach. “I have no more inhibitions,” says Meulenberg, who recently turned 30. “I’ll approach someone. I’m more outgoing now. It’s not worth just sitting back and letting life go by. You have to be proactive about it.”


Her theory is shared by many medical students who feel that meeting as many people as possible will increase the odds of finding a love interest who can cope with the erratic hours of a physician-in-training. Meulenberg works 12-hour days, is on call on weekends and often works nights for a month at a time. “Unless you’re going out with somebody like a nurse, a firefighter or a cop—somebody who keeps weird hours—a lot of guys don’t really understand the commitment involved,” she says.


Medical men have it easier when it comes to meeting people, believes Lauren Nolan Welsh, a first-year at the Brody School of Medicine at Eastern Carolina University. “Men in med school are a hot commodity…. Men can tell a lady in a bar that they are in med school, and the woman will swoon,” she says. “I don’t like to brag that I’m in med school…because guys are either intimidated by me, or the whole flirting fun is ruined because they don’t want to come off as ‘stupid’ to someone who is ‘smarter’ than they are.” Welsh says she has dated even less in medical school than she did as an undergraduate at a women’s college.


Meulenberg has also found that many of the men she is attracted to—often blue-collar types—are too intimidated to be in a relationship with a doctor. “It’s kind of frustrating to me, because that’s not really what I’m all about. I don’t think my IQ is a lot higher than half the people in the country…and I owe the government hundreds of thousands of dollars.”


Such stories could make the case that students should only date other students. In fact, some have little other choice. Fourth-year John Lusins III, who attends the American University of the Caribbean School of Medicine in St. Maarten, met a fellow student in his first year, and they are now engaged. Of course, he points out, being in such an enclosed environment in a foreign country means that the vast majority of students date only other students. But that, too, causes problems. With a class size of roughly 160, it’s hard not to feel like you’re living in a fishbowl, Lusins says. “It’s really, really difficult to be private. It’s like you’re the Entertainment Television Network because everybody wants something to focus on.”


It’s for other reasons that Welsh is not eager to go out with a fellow student: “I cannot see myself with another person in the household having a strict on-call schedule like I am probably going to have. I’d rather have an earthy person, or an artist, to be with. Someone to add some spice to my life.”


Meulenberg echoes that sentiment, saying, “I don’t think I would want to date another intern because you’d probably just talk about work all the time. I think there’s something to dating somebody who’s not in the field because it’s like a relief somewhat.”


Beyond whom to date, students have to grapple with the timing issue. Lusins feels that during the first two years, there’s not really enough time to date: “I’ve seen other people start dating, and it screwed up their lives.” Personal schedules tend to open up during the clinical years, although Lusins advises, “Keep the studying and the relationship separate. Just because you’re dating somebody, it doesn’t mean you have to study with them.”


Welsh can attest to the effects of love on academic goals. She started dating a friend’s cousin who turned out to be such a distraction “that I made a 50 on my biochem exam during our third of four exam sets that semester. That kind of knocked me back into reality, and I began to study more and not hang out with him as much.” Ultimately, she says, “I think my strict schedule and my cutthroat attitude, which helps me survive [medical school], gave him the wrong impression of me…. It’s difficult to portray who you are to a man you like while you’re under the stress of medical school.”


From time to time, Welsh checks out Internet dating sites like myspace.com and match.com “to just browse some guys and to see what’s out there.” Ultimately, she has concluded that the people she sees online “are always weird, which makes me feel better, as if I’m reassuring myself that I’m not missing out on too much.”


Now Welsh is flying solo by choice. “I don’t mind being single; I think it’s actually very fun, and it allows time to fall back in love with yourself!”

—B.M.R.
~~~Beth M. Rogers is a freelance writer in Bethesda, Maryland.~Student Life and Well-Being~
41~4May-June~2006-55~Feature~CAM Crosses Over~When—and how—do nonconventional therapies go legit?~Pete Thomson~Complementary and alternative medicine is gradually entering curricula and exam rooms. But by what process does a once-obscure treatment find mainstream acceptance? Also: The return of naturopathy.~Have you decided how—or if—you will implement nonconventional medicine into your practice? Will you discourage your patients from exploring the ancient healing arts? Point them toward the scientific literature to form their own opinions? Or direct them to the nearest herbalist?


Physicians considering complementary and alternative medicine (CAM) tend to incorporate the treatments into their practices in varied ways and for different reasons. For many, CAM modalities cross into usage rather conservatively, through observing standard, double-blind, placebo-controlled research. Other physicians may allow increasing amounts of anecdotal information to sway their decisions.


“Often it is simply a matter of experience, and what you consider as evidence,” says William Elder, Ph.D., director of behavioral sciences at the University of Kentucky’s Department of Family Practice and Community Medicine. Elder studies the incorporation of CAM training into pre-existing courses at the school. “Most people are going to look at what they see working for their patients and what they are able to read about in the literature.”


But relying wholly on the literature regarding CAM can be problematic, because—as with many out-of-the-mainstream treatments—what’s “proven” one month can effectively become snake oil the next. In particular, some nutritional supplements have shown almost no significant efficacy in recent, randomized controlled trials.


For example, in February, researchers studying the effectiveness of glucosamine and chondroitin sulfate—widely used for the treatment of osteoarthritis—revealed in the New England Journal of Medicine (NEJM) that the supplements, when used in combination, were only marginally helpful to those with the most severe knee pain. Nevertheless, commercial sales for the supplements topped $730 million in 2004.


The same month, the NEJM published a study of saw palmetto, an herbal remedy touted for treating benign prostatic hyperplasia, which showed no effects on relieving symptoms or reducing objective measures of the condition. Likewise, echinacea, long used as a remedy for the common cold, showed no efficacy according to research published in the NEJM last summer.


“Perhaps the larger question is how patients can be better guided with respect to the issues surrounding the use of herbal therapies,” wrote Drs. Robert DiPaola and Ronald Morton from the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School in an editorial accompanying the saw palmetto report. “Even with the best regulatory provisions for herbal products, reasonable assurance of their long-term efficacy and safety will require clinical trials of the same quality required for the approval of standard drugs and, possibly, the development of pure compounds,” they concluded.


Although these studies might offer some ammunition to skeptics of alternative treatments, they also demonstrate ongoing efforts to integrate alternative medical treatments into practice by holding them up to scientific scrutiny in all the usual ways. But are the usual ways the right ones?


SO, WHAT IS "ALTERNATIVE"?


There are many stops along the CAM continuum—which can stretch from conventional osteopathic manipulation to more obscure and little-understood healing practices like crystal therapy. But regardless of where you stand now—at the tender beginnings of your career—you’ve probably been exposed to some theories of nonconventional medicine.


As of the 2003–2004 school year, 97 of the 125 U.S. medical schools were covering at least some aspects of CAM in a required course. Though the actual amount of coverage probably varies widely, the existence of CAM isn’t exactly a secret. Quite the contrary, it’s a pretty hot topic. Nothing provokes listserv flaming faster than a discussion of alternative medicine—or “quackery” to some of its detractors.


CAM debates tend to raise questions that reach down to the fundamental roots of medicine and healing, and where the art and science are headed in the future. And the answers can rise to the esoteric heights of faith: in the time-honored truths of bench research, or in the newer theories of evidence-based medicine—concepts that resonate on a highly personal level.


However, much of the debate about the worthiness of CAM is clouded by the nebulous terms used to talk about it. The name “CAM” itself offers a convenient bucket, but the contents can be variable and vague. (See “Defining the Terms,” below.)


The National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, provides one of the most commonly used definitions: “a group of diverse medical and health-care systems, practices and products that are not presently considered to be part of conventional medicine.”


Indeed, CAM is just that: diverse. Such an inclusive definition covers herbal supplements, traditional Chinese medicine (TCM), massage, chiropractic and—by default—just about any health therapy that you are not learning about in medical school. Some of these treatments and practices have untapped value to health; many don’t.


“It is like the blind man feeling the elephant; it means a little something different to everybody,” says Dr. Brent Bauer, director of the Mayo Clinic’s Complementary and Integrative Medicine Program. Bauer has been involved with extensive research in CAM modalities, including dietary supplements and wellness.


Breaking CAM into its component parts helps put the continuum into perspective. According to NCCAM, “alternative” medicine is defined as a medical system that is complete, but unconventional. TCM, for example, is a complete system of diagnoses, treatments and remedies.


“Complementary” medicine, on the other hand, comprises individual treatments and practices that can be used to augment conventional medicine, such as therapeutic massage.


OK, THEN WHAT IS "CONVENTIONAL"?


All of this defining leaves us with a slight problem: If alternative medicine is unconventional, what’s “conventional” medicine?


Some see “conventional” and think “Western,” yet many alternative medical systems also have Western origins, such as homeopathy—a system concerned with the idea that “like cures like,” i.e., highly diluted substances are given to combat symptoms the same substances would cause in larger doses.


Others think of conventional, or mainstream, medicine as “traditional.” But TCM has been developed and practiced for thousands of years. Systems we think of as alternative could be staunchly traditional for somebody else.


“Whether something is mainstream or not depends a lot upon local practice, and you can see differences between coasts in what’s mainstream, [as well as] what you see on the coasts and what you see in the heart of the country,” Elder says.


So how, if ever, do CAM therapies exit the realm of the “odd” and enter that of accepted medical practice? In fact, many have done so. Researchers in the field of CAM frequently cite the crossover of acupuncture, which can be used to combat nausea from chemotherapy, and has shown some efficacy as part of knee-pain treatment.


The existence of published research would seem to mark the point at which a therapy crosses over, but it’s not that simple. Standard research methods may not be the right fit for testing CAM therapies because finding appropriate placebos can be tough. The question is also complicated by difficulties in isolating specific therapeutic techniques, like placing acupuncture needles, from the larger systems in which these techniques are integrated.


THE PLACEBO PROBLEM


Testing herbal supplements is pretty straightforward, Bauer explains: “We can take the best recommendations from our herbal colleagues, put the things in a capsule and give the placebo an identical capsule, so it really is placebo-controlled.”


But researching the efficacy of other CAM therapies can be problematic. How does one give a placebo massage in a double-blind study, for example?


With acupuncture, even the use of sham needles or the intentional improper placement of needles—intended to provide a placebo—may provide some relief in itself, thereby reducing the significance of the results.


“A lot of the large trials that are coming out now on acupuncture are showing no difference between acupuncture and the sham, but the sham is shown to be an effective therapy in itself, compared to standard treatments,” says Eric Manheimer, field administrator for the Complementary Medicine Field of the Cochrane Collaboration, an organization that disseminates systematic reviews of health care. “So, one question that we struggle with is, what is the correct comparison to use when you are doing an acupuncture trial?”


Although randomized controlled trials eliminate as many variables as possible, this “reductionist” approach may also eliminate important spiritual elements of an alternative treatment, believes Dr. David Rakel, medical director of the University of Wisconsin Health Integrative Medicine Program. “Instead of trying to remove the belief from acupuncture, let’s let the acupuncturist provide their therapy within their whole ceremony and ritual…instead of trying to dissect out each little piece.”


Using combined research approaches may be the answer. “The randomized controlled trial, where we look at the pieces, is important,” Rakel says, “but the pragmatic controlled trial—where we look at the whole ceremony of the ritual of the therapy—is also important.”


“You can do acupuncture as another technique to fix someone’s pain, but that’s not how it was ever used,” says Robert Duggan, president of the Tai Sophia Institute, a school specializing in acupuncture and herbal medicine. Instead, traditional acupuncture was part of a healing practice that focused on wellness instead of disease management.


Because of the placebo conundrum, some researchers would rather see more studies pitting CAM techniques head-to-head against conventional pharmaceuticals in treating the same condition, Manheimer says. His group has put together literature reviews on a number of CAM topics, including a 2005 meta-analysis published in the Annals of Internal Medicine that found acupuncture effective for low-back pain.


But perhaps the foremost difficulty in researching CAM therapies is the perspective from which they are viewed and the expectations placed on the therapies. Generally, CAM and integrative practitioners view treatment from a completely different perspective than the “disease-oriented” model of allopathic care, which responds to individual crises in the body rather than the body as a whole.


“Does massage cure cancer? If that is your research question, I don’t think you are asking the right research question,” Bauer says. “But what in this milieu of therapies is going to help my patient feel better, sleep better, improve [his] quality of life…? Then the secondary level of that [is] if you sleep better, if you feel better, if your stress level goes down and your immune system improves, isn’t it possible that we will have a direct impact on the treatment of the cancer?”


“We are starting to understand how we can incorporate many of these things that were labeled CAM into just good medicine,” Rakel says. Folic acid, he points out, was once outside the allopathic box. Now, across the board, it is considered an important supplement.



CAM IN THE CLASSROOM


Rakel believes there is a danger in viewing therapies being adopted into conventional medicine as simply additional techniques for new physicians to learn. “What we need to do is change from a disease-oriented model to a health-oriented model,” he asserts. “If we just add more tools to our toolbox, we are not changing the system…. Right now, if we just add acupuncture for the treatment of osteoarthritis, we are still in the disease-oriented model.”


“These are very distinct bodies of knowledge, and nobody is going to be able to master all of them,” Tai Sophia’s Duggan says. “So if you are good at surgery, you are probably not going to be the greatest person in the world at herbs.” He posits that instead, the healers of the future—physicians and CAM therapists alike—will be skilled in understanding and educating their patients, but will focus their treatment methods in one particular area. Meanwhile, the patient of the future will be more aware of his or her own health and needs, thereby living a healthier lifestyle and requiring less care, Duggan believes.


But others see the continuous integration of CAM therapies into conventional medicine reaching the point where the terms themselves will become obsolete.


Elder, at the University of Kentucky, sees nothing but increased integration in the future—a perspective based on his students’ expressed desire to learn more about all types of medicine, conventional and otherwise. Students at Kentucky are exposed to CAM therapies alongside conventional treatments in courses ranging from introductory to clerkships.


Their responses to the CAM content spread across some of their medical school courses varies by individual, but because many use some CAM approaches in maintaining their own wellness, like vitamins or mind–body methods, they’ve become curious about the evidence that shows treatment effectiveness.


“In the past, there have been appeals made that students learn this material based on, ‘Well, it is something your patients use.’ Well, that’s a good reason. It is certainly patient-centered to know what your patients’ preferences are,” Elder says. “But…it is not a rational appeal based on what is the scientific value of this.”


The students want information on CAM therapies presented at the same level of evidence as any other therapy covered in class, Elder continues. “If you are receiving it in the same way you are receiving your other content, it helps you evaluate it better.”


But despite the number of academic CAM programs, some are still found lacking, and students want to learn more.


“We really have no formal introduction to CAM in any way,” says Laila Tabatabai, a first-year at Albany Medical College in New York. “Without being overt, there is a very clearly implied negative impression of CAM that is given.”


Tabatabai, an M.D./Ph.D. candidate, explains that she is comfortable with the concept of non-Western medicine. She is from the Middle East, and has some cultural experience with home remedies and other methods practiced for thousands of years. “It is not called CAM over there,” she points out. At the same time, she wants to learn more about it for her patients’ safety, knowing there are a lot of impure herbal treatments on the market.


As more studies are done and physicians become increasingly comfortable trying out treatments that are proven but formerly outside their purview, the need for the terminology may just slip away.


“Stop thinking within these boxes,” Rakel asserts. “We [need to] look a little bit deeper and say, what tools can we use, or what processes help facilitate health and healing?”


“We are going to come back and call this stuff simply ‘medicine,’” Mayo Clinic’s Bauer agrees. “We won’t have to designate [that] it’s wacky or it’s frou-frou or it’s ‘alternative.’ And even the concept of ‘integrative’ will just fall away, and the things that work, we’ll incorporate.”
~DEFINING THE TERMS


Any discussion of the treatments and principles of CAM should start with an understanding of the somewhat mystifying vocabulary: The following definitions are offered by the National Center for Complementary and Alternative Medicine.



Conventional medicine is medicine as commonly practiced by holders of M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied health professionals, such as physical therapists, psychologists and registered nurses.


Complementary medicine is used together with conventional medicine. An example of a complementary therapy is using
aromatherapy to help lessen a patient’s
discomfort following surgery.


Alternative medicine is used in place of conventional medicine. An example of an alternative therapy is using a special diet to treat cancer instead of undergoing surgery, radiation or chemotherapy that has been recommended by a conventional doctor.


Integrative medicine combines conventional medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.


Naturopathic medicine proposes that there is a healing power in the body that
establishes, maintains and restores health. Practitioners work with the patient to
support this power through treatments such as nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, homeopathy and treatments from traditional Chinese medicine.


In homeopathic medicine, there is a belief that “like cures like,” meaning that small, highly diluted quantities of medicinal substances are given to cure symptoms, when the same substances given at higher or more concentrated doses would actually cause those symptoms.


Chiropractic is a CAM alternative medical system that focuses on the relationship between bodily structure (primarily that of the spine) and function, and how that relationship affects the preservation and restoration of health. Chiropractors use manipulative therapy as an integral treatment tool.





THE NATUROPATHS


Naturopathy, an alternative medical system based on concepts of the body’s innate ability to heal itself, might be making a comeback after falling into near-obscurity for a couple of decades.


“At the start of the century, early 1905, half the docs in the United States were naturopaths/homeopaths,” says Shidfar Rouhani, a fourth-year at Southwest College of Naturopathic Medicine in Arizona and coordinator for the American Medical Student Association’s naturopathic medicine interest group.


Naturopathy originated in the West, although it can employ a number of alternative and complementary therapies from abroad, such as traditional Chinese medicine. Treatments used include homeopathy, herbs and “detoxification” methods for removing heavy metals from the body.


Thirty years ago, half of U.S. states licensed doctors of naturopathy (N.D.), but by the 1980s, that number had fallen to 12. Rouhani blames the anemia on a drop in the number of naturopathic schools. “There weren’t any naturopaths being produced, so states said, ‘Well, if there’s no naturopaths, why do we have a naturopathic board?’” In the last 10 years, however, two new naturopathy schools have been created, and the number of licensing states has begun to rise again.


While licensing states place various limitations on what naturopaths can
do, N.D.s typically can prescribe medication and perform minor in-office surgical
procedures.


Meanwhile, efforts to standardize academic naturopathic medicine, a field fraught with correspondence courses, are underway. And while different schools teach different systems of care, such as acupuncture or herbal medicine, that doesn’t matter, Rouhani says. “The philosophy of naturopathic medicine predominantly rules how treatments are done. It is not what’s done, but how it’s done.”

—P.T.




RESOURCES


The National Center for Complementary and Alternative Medicine at the National Institutes of Health provides a clearinghouse of information and research on CAM therapies for patients and providers.



The American Medical Student Association’s (AMSA) Educational Development for Complementary and Alternative Medicine (EDCAM) project offers a searchable directory of CAM courses and content at medical schools, as well as further background on CAM education.



AMSA also offers a fourth-year elective in alternative medicine, along with activism training. The Humanistic Elective in alternative medicine, Activism and Reflective Transformation (HEART) is accredited by the University of Florida College of Medicine, and runs in the spring. Applications for 2007 are available online.



The Mayo Clinic maintains a repository of knowledge on CAM topics. Though geared toward the patient, these resources offer overviews of treatments as well as
guidelines on navigating the often touchy topic of evaluating CAM treatments for effectiveness.






~~~Pete Thomson is associate editor of The New Physician. Direct comments about this article to tnp@amsa.org.~Complementary and Alternative Medicine,Humanistic Medicine,Medical Education,Practice of Medicine~
44~5July-August~2006-55~Feature~The Frontiers of Ability~Boosting the number of medical students with disabilities presents both challenges and opportunities.~Pete Thomson~We explore how medical education accommodates students with disabilities and the problems in producing “undifferentiated” medical graduates. Also: When should applicants disclose a disability? unseen disabilities.~Nat Gleason has achromatopsia, a lack of cones in his eyes, which prevents him from seeing in color and gives him low visual acuity along with significant sensitivity to light. Although he is legally blind, the lack of color vision has never bothered him—he says he doesn’t know what he is missing—but it does present some challenges during patient exams and other observational experiences. Gleason is a third-year medical student at the University of California, San Francisco (UCSF).


At 14, an ATV accident left Dr. Trey James with paraplegia, but he says it only took about three days for colleagues and attendings at the University of Missouri College of Medicine (UM) to stop focusing on his wheelchair. He recently began an internal medicine residency at Wake Forest University.


Dr. Maria Schwartz has cerebral palsy, which affects her daily life in innumerable ways that the able-bodied might not appreciate. For Schwartz, a board-certified physical medicine and rehabilitation (PM&R) specialist in Salt Lake City, taking notes is difficult. She must steady her hand, which is particularly challenging while on her feet. “I guess most people just don’t have to think about these things,” she muses.


When you consider cultural competency and groups underrepresented in the field of medicine, people with physical disabilities probably don’t come immediately to mind. After all, how effective can a paralyzed physician be? Or a deaf one? A blind one? Yet they are certainly present in the sphere of medical education—though not in the same proportions as they occupy in the general population.


Gleason, James and Schwartz have had different experiences with different disabilities in different places, each with unique challenges, but they share common experiences. Medical students with disabilities face the daily technical challenges of succeeding on the wards and in the classroom, and the more subtle efforts of navigating a system that often views such students as unqualified. (The latter challenge certainly varies widely from school to school, even from department to department.) Then add to these the self-doubt that comes with having to convince oneself that these external barriers are surmountable, and you have a sense of the uphill journey students with disabilities face on the road to becoming a physician.


Gleason describes UCSF as “fantastic” in working with him on accommodating his visual limitations during his first two years. He was able to use large photographs instead of a microscope in microbiology and histology classes, take large-print tests and was allowed extra time for reading exams. These classroom accommodations have helped Gleason’s medical school experience run fairly smoothly so far.


“Come third year—and I knew this would be the case, but it has been even more true than I imagined—everything got exponentially harder,” Gleason says. UCSF “is this nice little island…with
a handful of administrators and key course directors that you can get to know—and then you enter the hospital system.”


Though staff on the wards have been generally helpful and understanding, every six to eight weeks brings a new clerkship to which Gleason must physically orient himself. Before the beginning of each rotation, he presents a letter to clerkship directors explaining his needs, and meets frequently with them to “problem-solve.”


“YOU CAN'T”


Before any of the classroom or clerkship challenges, Gleason—like thousands of other potential medical students—had to face the prospect of application. But he found the vast majority of schools he looked at sent back a subtle but clear message: “If you have a disability, you can’t possibly come to our school,” Gleason says. He bases this on a number of informal and sometimes-anonymous phone calls he placed while weighing his decision even to give medical school a shot. The administrators he spoke with were surprisingly candid, even if their answers weren’t what Gleason had hoped to hear. “I almost convinced myself that it wasn’t possible, and it is very easy for me to imagine somebody just deciding, ‘I guess I can’t go to medical school.’”


With his paraplegia, James says, “It seemed like I really had to sell myself to get into medical school.” He feels that obtaining his slot at UM was thanks in part to attending the school as an undergraduate.


Once inside, his experience was relatively smooth. “Whenever I’ve sat down and thought it out, there has never been a problem I haven’t been able to find an answer for,” James says. For example, he used an anesthesiologist’s hydraulic chair during surgery rotations to boost him about 4 feet into the air for scrubbing in and reaching the operating table.


No one seems to know how common Gleason’s and James’ experiences are, since the lack of data on medical students with disabilities is startling. For all the statistics that track the representation of racial and ethnic participation in medical education, there have been no comparable studies of this group conducted in the past decade.


Ten years ago, Dr. Sam Wu, then at New York University Medical Center, published the most current study: a survey of U.S. and Puerto Rican medical schools that revealed, among other facts, that medical schools that accepted a student with a disability (the investigators recorded 64 such students at the time) were likely to accept others, indicating that the schools’ experiences with accommodating these students are generally positive ones.


BEYOND CIVIL RIGHTS


People with physical disabilities are ostensibly protected from discrimination primarily by two pieces of legislation: Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990. Section 504 states, “No otherwise qualified individual with a disability in the United States…shall, solely by reason of her or his disability, be excluded from the participation in…any program or activity receiving Federal financial assistance.” Thus, medical schools are compelled to adhere to the legislation because almost all receive federal funding.


But advocates of including more students with disabilities in medical training do not argue solely on the basis of the law and civil rights: There is a significant movement to include more such students to increase diversity in medicine, improve the education of able-bodied students and advance the care of patients with disabilities.


If the U.S. physician workforce is going to look anything like the U.S. population, there must be an effort to increase the representation of people with disabilities in training, believes Dr. Joel DeLisa, a PM&R specialist and director of the Kessler Medical Rehabilitation Research and Education Corporation. “We have done that with respect to gender. We have done that with respect to race.... We certainly have not done that with respect to disability.”


One way to improve care for people with disabilities is to raise the comfort level of able-bodied physicians who encounter them—and medical school is the perfect place for fostering that, DeLisa says.


“The most effective way to break down prejudice, stereotypes and barriers is to have equal-status relationships with people,” agrees Dr. Kristi Kirschner, director of the Disability Ethics Center of the Rehabilitation Institute of Chicago (RIC). “So if you have a physician who is deaf that you are working side by side with, you are going to have much more awareness of how a physician with deafness can function and what are some of the stereotypes, perhaps, that are not true.”


BEING "REASONABLE"


In 2005, the Association of American Medical Colleges (AAMC) produced “Medical Students with Disabilities: A Generation of Practice,” a primer to the ADA and the case law that governs the admission and accommodation of medical students with disabilities. But critics say the publication borders on being a how-to guide on exclusion.


“The trouble is, the schools can take this as a document to help them essentially keep the doors closed if they want to,” DeLisa says. “Part of that is that medical schools will argue that it is too expensive to make accommodations that are needed.”


Many schools use a “technical standards” document to clarify expectations of incoming students. Those documents generally include sections on observation, communication and what physical skills a student should be able to perform with “reasonable” accommodation. For example, at Dartmouth Medical School, students are expected to “perceive” the presentation of information in a variety of settings, including small-group discussions, lectures and one-on-one interactions. Those observation skills, by years three and four, include physical exams and the use of the basic examination instruments.


Other schools’ standards are more rigid and explicit. As part of an attempt to collect data on medical schools’ accommodation policies, Schwartz spoke to an osteopathic school that specifically requires students to be able to stand, considering this an unavoidable requirement for osteopathic manipulation. Students who were not able to do so were identified in a pre-interview questionnaire.


THE MEANING OF DISABILITY


To lump “persons with a disability” together under one semantic umbrella misunderstands their experiences and fails to address their challenges, believes Dr. Lisa Iezzoni, a professor of medicine at Harvard Medical School (HMS) and author of 2003’s When Walking Fails, a guide for accommodating adults with mobility problems. “That phrase is almost meaningless to me,” she says. “When you are talking about the context of educating individuals to care for patients—which is a very complex, multifaceted task—you have to decide what you mean by ‘disability.’”


Iezzoni, who was diagnosed with multiple sclerosis as a first year at HMS, believes that medical schools have already begun admitting more students with disabilities than most people realize—many are those with “invisible” conditions such as learning disabilities or mental illness. She doubts that the schools are even keeping count, though they are likely aware of their students’ formal requests for accommodations.


Iezzoni consults with medical schools nationwide on whether particular students’ impairments can be supported without drastically changing the nature of the education that student will receive. Another factor schools must consider is whether a student’s disability is progressive or fixed. For example, by the time Iezzoni graduated with her M.D., she was using a cane. In such cases, institutions have to decide whether future accommodations for a student in the earlier stages of medical education—and a disability—will still be reasonable.


Meanwhile, the outside world is working disability issues out, from prisons to cruise ships. “Right now, in every sector of society that is touched by the ADA, ...individual cases are coming up and decisions are being made,” Iezzoni explains. Those cases are helping to define what a disability is and what reasonable accommodations are.


This conversation needs to be happening in medical education as well, she asserts. “The AAMC would be the right place to have this happen—to decide what accommodations are reasonable and appropriate, and still allow somebody to have the basic product [of medical education]…. I don’t think that discussion has yet taken place.”


THE UNDIFFERENTIATED DIFFERENCE


That discussion will necessarily include the very nature of medical education in today’s world.


At present, the curriculum crams in a taste of all manner of specialties, all basic sciences and some specific technical skills as well. But with students matching themselves off to increasingly specialized niches, do all future physicians need to graduate with the theoretical ability to pursue any specialty they want?


The current model produces the “undifferentiated” graduate—an omnipotent figure ready to pursue any internship. This is a traditional model, and while some say it is not necessary in today’s medicine, almost everyone insists that all students need at least to be exposed to medicine’s full spectrum.


But that exposure need not be mastery, DeLisa believes. “The ‘purist’ individuals essentially believe you should be graduating medical students who—the day he or she graduates—are completely competent to do everything,” he says. “The fallacy in that is that medicine has become so specialized that students, from the day they walk into medical school, are trying to decide where they are going to be and how they are going to specialize.”


DeLisa prefers instead the “undifferentiated curriculum,” in which students are taught to work in an environment shaped by increasing specialization. Here physicians rely less on specific physical skills and more on cognitive ones, such as bringing information in from different sources, communicating with other physicians and working with advancing technology.


Still, DeLisa is not advocating a “tracking system,” in which a student is admitted under the narrow condition that they pursue a particular specialty.


“We want to have broad-based training programs that provide [everyone] with a range of skills, knowledge and abilities that will set them up for practice in a variety of areas,” RIC’s Kirschner agrees. “But I think that those areas are predominantly cognitive. I don’t think that the physical skills are as critical.”


That is because other health-care workers effectively can accommodate physicians with disabilities, and commonly do. The role of the physician extender—ranging from interpreting for a deaf physician to helping the patient of a physician with quadriplegia up onto the exam table—should be explored further. Medical school might be the place for extenders as well, she believes.


“[Medical students] should be held responsible for a body of knowledge from all of the various areas that are critical for medical students to know,” Kirschner says. “But I do think we can re-evaluate...what is absolutely critical for medical students to know by the time they graduate from medical school.”
~OPENING DOORS


Premeds, medical students and residents with disabilities face hard choices when applying to the next phase of their training. Faced with potentially biased admissions committees or interviewers, these applicants have to decide when to mention that they will need either accommodation or understanding.


“It is like being in a catch-22,” says Dr. Maria Schwartz, a physical medicine and rehabilitation (PM&R) specialist with cerebral palsy. “If I am up front and honest with these people, I know that I will never hear from the majority of them again. And if I go through and try not to bring up the issue…and I get to the interview—it is like, do I shoot myself in the foot right up front or do I wait?”


When Schwartz was applying to medical school, lawyers she spoke with advised her against mentioning her impairments in her personal statements. That way, the candidate might at least get an interview. Schwartz faced the same choice when she had finished her residency and began speaking with recruiters.


Now practicing in Utah, Schwartz faced friction from colleagues at almost every turn. Ignorance of her condition allowed fellow residents’ misconceptions to persist: Some raised patient safety concerns when she placed electromyogram needles; another referred to her as “mentally retarded.”


“I thought their perceptions of me would be one of equality and a colleague,” she says. “Now that I am in practice, it has gotten better. But leading up to this point, it has been a disappointment.”


Dr. Trey James, an intern at Wake Forest University, did not explicitly ask his references to mention his paraplegia when he was applying to internal medicine residency programs, but he didn’t ask them not to either. His experiences with actual interviewers ranged from very positive to “weird” obsessions with his wheelchair.


Then came the pigeonholing question: Why didn’t he want to go into PM&R? “And, frankly,” James says, “that’s kind of like, why don’t I drive a van? I want to do internal medicine; that’s why I’m interviewing here, and you’re asking me about PM&R?”


George Velasco, former premed representative on the American Medical Student Association’s Committee on Disabilities, suggests that premeds with disabilities—especially learning disabilities—only mention them during the application process if they absolutely have to, to explain a period of poor academic performance or time away from school that was due to the disability, for instance.

—P.T.






THE "HIDDEN" DISABILITIES


It seems the most contentious debates in terms of medical students with disabilities center on learning and attention disorders—considered “hidden” disabilities because they are not outwardly obvious.


These disabilities may justify accommodations on exams—including the MCAT—which is the flashpoint for discussion. Currently, MCAT scores for students that have received accommodations—be they extra time or a private room—are “flagged.”


According to the Association of American Medical Colleges (AAMC), the flagging process is necessary because “nonstandard” testing conditions resulting from some accommodations may prevent the MCAT from predicting the success of a particular student. Therefore, a school should know that a student’s MCAT score may not reflect his or her true potential for success.


Nonetheless, some students considering whether or not to pursue accommodations on the MCAT worry that those flags mark them as having a disability when the school has no right to know.


Learning disabilities and attention disorders are probably becoming more common in medical school, believes Dr. Lisa Iezzoni of Harvard Medical School. Those affected may not even be aware of their conditions until they reach the medical campus. “They’ve probably masked a lot of their impairments for most of their lives and have figured out ways for themselves to get around them,” Iezzoni says. But medical school’s intensity may force some to pursue accommodations they never have before.


These disabilities can cause friction with classmates as well, especially accommodations perceived by some as “special treatment.”


“Like most people who hear about learning-disabled medical students for the first time, I was skeptical,” remarks one medical student who wishes to remain anonymous. “It would seem contradictory that such students who had trouble learning could make it that far academically.” But after meeting some students attending a Marshall University summer program called Medical HELP and hearing about how they had learned to get around their learning disorders, he acknowledged their success.


“It seemed that their experiences in overcoming and working through a
disability made them better clinicians,” he continues. “They were more sensitive to the needs of people who were different or who struggled with tasks.”


—P.T.



~~~Pete Thomson is associate editor of The New Physician. Direct comments about this article to tnp@amsa.org.~Disabilities in Medicine~
45~5July-August~2006-55~Perspectives~More Than Just a Breast~Thoughts from the woman in the paper gown~Julie Fanning~Inside the paper gown.~Communication and compassion are skills essential for any person who goes into the medical profession, but it is probable you will find these topics crowded out of your medical training by more academic subjects. So allow me, a patient, to educate you in my own way as I relate a recent experience of mine.


One morning last fall, I discovered a lump in my breast—an experience that creates a terrifying jumble of “what-ifs” inside every woman’s mind. On that dreadful day, when swirling thoughts of my mortality could not be swept from my brain for even a minute, I made an emergency appointment with my primary care physician.


After an initial examination, my doctor guessed it might be an infected cyst. Nevertheless, her sense of urgency triggered a phone call to a colleague of hers, a general surgeon, for an appointment later that day to examine me further and perform some tests.


Arriving shaken and anxious at the surgeon’s office that afternoon, I checked in with the office manager—an abrupt and absent-minded woman I’ll call “Ms. Clueless.” Initially, she could not even confirm that I’d had an appointment. I filled out the requisite paperwork; then a nurse called my name.


“Nurse Cratchit” was curt, cold and, at times, hard to understand, as she mumbled and did not look at me as she spoke. She appeared to have no sense of the turmoil I was feeling as she directed me to strip down to my waist and put on the paper gown, then strode quickly out of the exam room, the door slamming behind her.


Eventually, “Dr. Nonchalant” made his entrance. After some preliminary conversation, he felt the lump and pronounced with certainty that it was an infected cyst, which he would drain and have tested.


After the procedure, Dr. Nonchalant casually mentioned that I would need to return to have the cyst removed in about six weeks—then abruptly departed. I was left with a sense of confusion and an open, quarter-inch gash on the tender inside of my cleavage, packed deeply with some sort of gauze. No one had explained why I required a further procedure, how I was to care for my wound or how much damn pain I would experience over the next few days.


Nurse Cratchit appeared again, dismissively suggesting over-the-counter pain meds and demanding that I “should not forget to make that next appointment.” Slam.


Two days later, my incision burning unbearably, I called the surgeon’s office and was put through to the wretched Nurse Cratchit. I begged for advice on how I should care for the open wound and lessen the excruciating pain: Keep it bandaged? Clean it with peroxide?


Nurse Cratchit’s next words launched chills up my spine and sent my stomach hurtling to my knees. I was to remove the 3 to 5 inches of packing material embedded deep inside my tender, throbbing breast to eliminate the “infected stuff” from my body.


SAY WHAT?


That’s right. She was instructing me to pull out the smelly, saturated, bacteria-laden length of gauze that was causing me an unbelievable amount of searing pain.


She said a few other things that I frankly don’t remember—as I was trying to control the heaving nausea suddenly rising up in me—before we hung up. I promptly called my primary care physician, hoping she would take this unthinkable medical procedure out of my hands, but was told that she could not provide care for a condition another physician was treating.


My next call was to Dr. Nonchalant’s office again. When Nurse Cratchit came on the line, she could not hide her impatience with me, saying again that “all you have to do” is pull out the packing material. After I insisted that this just wasn’t possible, she conceded that if I came to the office “after our break,” someone would assist me.


Two hours later, I was again standing before Ms. Clueless, and again arguing that, yes, I had an appointment.
In the exam room, Nurse Cratchit remarked absently how red and puffy my wound was, then pulled out the...“stuff.” She made some condescending remark about “how easy that was,” reminded me of my next appointment, then…slam.


Some of you may wonder why I’m still dwelling on this experience six months later. Besides the fact that I still have a red, pea-sized lump in my breast and no answers from that initial test, I still feel the anger and humiliation I experienced at the hands of these strangers. Because they are health professionals, I naively expected them to demonstrate that they had my best interests at heart. Instead, I was treated like a whining, attention-seeking child.


I cancelled that follow-up appointment and have not returned to my primary care physician either. I have a few lingering questions about this firm lump and whether I need further treatment, but truthfully, I just don’t feel like being put in that position again—scrutinized and made to feel as if my fear and concern are out of proportion when there are sicker people to treat.


Under these circumstances, it will be some time before I’m again ready to strip naked and don a thin paper gown.
~~~~Julie Fanning is art director for The New Physician.~Practice of Medicine~
47~5July-August~2006-55~Folk Tales~Cradle to Grave~A physician’s care stretches beyond death’s boundary~Anthony Hall~Pushing up daisies, organically.~Terminally ill and only 29, Christopher Williams Nichols had been clear about one thing: He wanted to be buried in a natural setting, wrapped in his poncho and with a tree planted over him, so he “could become part of the forest someday.”


That meant no chemicals. Skip the imported, hardwood casket and the 7-inch-thick vault. In point of fact, bring on the microbes. With his dreadlocks long and his hopes and ideals still intact, Nichols seemed to be saying this: I will not lie gratefully dead if anyone brings plastic flowers to my small, humble mound of earth.


Death is the terminus of most doctor–patient relationships. But not necessarily those of Dr. George William Campbell of Winchester, South Carolina, population 3,000. Though Nichols was not a patient of Campbell’s in life, he became one—to stretch the term bravely—when his life expired. For reasons that transcend the obvious—and the jokes that he is burying his mistakes—this family practitioner is possibly the only doctor in the nation whose office complex includes a funeral service.


Campbell started Memorial Ecosystems with his wife, Kimberly, in 1996. “It’s still helping people,” he says, explaining the leap from medicine to undertaker. On call, he has even had to drop a shovel—almost all the graves are dug by hand—to dash to the emergency room.


There is opportunism here, no question about it. But Campbell’s deepest motivation is a genuine concern for conservation, a passion that ranks him among its most creative practitioners. His goal, he says, is to save 1 million acres in the next 30 years by establishing “green cemeteries” that hold to a common set of guidelines, much as progressive architects did when they created codes for green buildings, which use recycled materials and energy-efficient heating systems.


Ramsey Creek Nature Preserve near Winchester is the 32-acre, de facto jewel of the green burial movement, which now includes sites in Florida, Texas, Maine, New York and California. Near the intersection of four states, the site is also defined by the confluence of three biomes, including the southern coastal plains, the Appalachian Mountains and the Piedmont Plateau. As such, 320 different vascular plants thrive in its red soil, so full of iron that some of the rocks are rusting in place. The mature woods are home to 35 tree species, including oak, magnolia, beech, hickory and mountain laurel. Rare trillium bloom in the shade on slender stalks—lampmaker Tiffany might have thought them up—while crane-fly orchid, coral bells, ginseng and Solomon’s seal compete for space in the matted turf.


Campbell is a cemetery guide beyond the pedestrian sense of the term. Many of the roughly 40 graves here belong to friends and former patients whom he knew well—inside and out. He can tell you their pathology, the treatment that didn’t work and which one of their family members currently has a cold. And he can give you the Latin names of the flowers growing on their graves.


Not many cemetery guides will point out that 0.6 gallons of water will be shed off each square foot of stone per 1 inch of rainfall—a useful fact to know if you happen to be encouraging the growth of southern lady fern. Further, the stones are all laid flat. They blend in, and are placed to provide a natural habitat for snakes—a bragging point not many cemetery owners readily put on their brochures.


Here, along the talkative Cauga Creek, mourners held a bluegrass party several weeks ago. A banjo player from Atlanta named John Stuart Studman, buried nearby, presaged the affair when he told his loved ones, “Host a weenie-roast when I’m gone.” So, they did. Kids scampered through the woods and jumped in the creek. It was so much fun, the Campbells say, no one wanted to leave.


“People tend to see the wilderness as a backdrop,” Campbell explains. “Either it’s a place that’s under glass or it’s a place you extract resources from.” This fragmented connection to the wilderness is what he is trying to heal.


Campbell has an undergraduate degree in biology from Emory University, which he earned in 1983. While in his second year at the Medical University of South Carolina in Columbia, a sign went up in the “brain closet,” where sample jars were kept, warning students of transferable spongiform encephalopathy. The warning inspired Campbell to read Kuru Sorcery: Danger and Disease in New Guinea, a medical anthropology text by Shirley Lindenbaum.


He read of ples musalai, or “spirit forests,” which New Guinea’s Fore people leave untouched—never to enter. “Ples musalai beliefs operate as zoning regulations for protection of small, permanent wilderness areas,” Lindenbaum wrote.


Campbell’s mission evolved after that. “Rituals, such as weddings and funerals, create a sense of everything feeling temporarily suspended,” he says. “The reaction for that can be normative or transformative.” This is the difference, he explains, between writing a check for a funeral service or forming a relationship with nature.


One goal, he adds, is to host as many weddings as funerals—tying important memories to natural places.


Now might be a good time for that. The weather is apt to be quite fine. The insects are tolerable, and the devil’s bit is sending up spikes. Azalea and rhododendron could be flush with flower; the creek, in the distance, will be conversational and cool.


And about a hundred yards from where Christopher William Nichols now lies, the wild strawberries are sure to be ripe.
~~~~Anthony Hall is a freelance writer based in Dryden, New York.~~
48~5July-August~2006-55~Feature~SPOTLIGHT: What Do Patients Really Think of You?~The 21st-century Doctor–Patient Relationship~Avery Hurt~The demands of delivering cost-effective care today can drive a wedge between physicians and their patients. As mistrust builds, health suffers. Are your patients at risk from their relationship with you? Also: Patient-actors teach empathy.~
“Doctors are the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.”

—Anton Chekhov




Though a quick jaunt around the Internet will turn up more than a few misanthropes willing to share sentiments like the one above, most patients still have considerable respect for the
medical profession and trust in doctors—at least their own.


A report commissioned by the physician careers network Docrates found that more than 90 percent of patients believe that doctors’ ethical standards are above average. And a Harris interactive poll indicates that although the image of the medical profession is slipping a bit, it is still near the top of professions thought to have “very high prestige.”


The devil is in the details, however. Another Harris poll that asked more specific questions revealed that patients attach a higher value to physicians who listen to their concerns, treat them with dignity and respect, and are willing to spend enough time with them than to those who have plenty of hands-on experience or who went to the top medical schools.


The most common reasons for changing doctors, the poll showed, is that the doctor didn’t listen carefully to the patient. Not treating the patient with respect ranked fourth on a list of 14 reasons for changing doctors; the top nine reasons involved communication or personal skills.


There is no question that Americans expect top-notch health care, but they want a good deal more than that. What it comes down to—for patients at least—is a relationship. And relationships come down to trust.


TRUST ME


Mark Hall, a professor of law and public health at Wake Forest University, studies these issues very carefully. In a literature review published in the North Carolina Medical Journal covering trust in the medical profession, Hall spells out the fundamental nature of
doctor–patient trust: “Trust gives the doctor–patient relationship meaning, importance and substance, in the same way that love and commitment give meaning and define the quality of spousal relationships.”


That’s awfully warm, fuzzy stuff for a medical journal. Yet that is exactly what patients seem to be asking for. The Harris poll demonstrated that patients’ appreciation for scientific knowledge and diagnostic skills was totally eclipsed by what are often called “people skills.” And people skills are, of course, what give meaning and substance to a relationship.


Lisa Connolly of San Antonio, Texas, describes a doctor she considers rare among doctors. “Dr. Cain had a way of making you feel you were her only patient. She greeted you warmly, leaned forward while talking to you and looked right at you the whole time. Most importantly, she remembered minor details about your latest conversation or your family members. On one occasion, there was something I was a little embarrassed about, so I didn’t mention it. After a long conversation, she stopped at the door, turned to look at me and asked if there was anything else. I hesitated, and she came right back over, sat down, leaned in and asked me what it was. I still miss her, and I have been gone from that city for 12 years.”


Now that’s a relationship. But delivering this kind of care is not as easy as it was even a few years ago. And it is getting harder every day.


CHANGING TIMES


The vast majority—an estimated 80 percent—of illnesses encountered by today’s physicians are chronic diseases, and many patients have several overlapping conditions. Unlike in the days when bacterial infections were still common and antibiotics still miraculous (and not so problematic), today’s physician is more supportive than heroic, often taking the role of managing illness rather than curing it. These circumstances offer valuable opportunities for building relationships.


Seeing patients regularly, getting to know their lifestyles and habits alongside their blood counts, are all a part of treating complex arrays of chronic diseases. A 64-year-old man with type 2 diabetes, high blood pressure, high cholesterol and a tendency to get a bit depressed about all of the above will require more thoughtful primary care than simply writing out a prescription to clear up an ear infection. Unfortunately, the time and resources to offer that care are decreasing just as rapidly as the need for it is increasing.


From the way health care is paid for to the way it is delivered, both patients and doctors find themselves in a world that seems to leave them marginalized, at the mercy of markets and businesspeople who know little about medicine and less about the people being treated. Patients and doctors alike are struggling to keep up, and in no small way to reinvent the practice of medicine.


When it comes to dealing with this difficult situation, doctors have one big group of allies: the patients themselves. If patients are demanding more, they are also bringing more to the table. “Doctors must realize that patients are our greatest untapped resource,” says Dr. Marie Savard, patient advocate and author of How to Save Your Own Life, a book devoted to empowering patients. “The more informed and involved patients are, the better the outcome. Patients have the most to gain and the most to lose from this encounter, and they can be a great help. We learned this in the early days of HIV. These patients were more expert in their condition than we were. We got it. Their lives were on the line,” says Savard.


INTERNET M.D.s


Most experts agree that health care—especially the care of chronic conditions that are greatly influenced by lifestyle factors—works better when the patient and the physician work as a partnership. And, of course, partnerships require trust, and trust is a two-way street. Some doctors, even the most well-intentioned, occasionally find well-informed patients threatening. When patients come into the office armed with printouts from the Internet and copies of recent studies the doctor hasn’t had time to look at yet, their efforts aren’t always met with a warm welcome.


“The problem usually occurs when a patient comes in with firm ideas about [his or her] condition and doesn’t trust the doctor,” says Dr. Dennis Boulware, senior associate dean for academic affairs at the University of Alabama at Birmingham School of Medicine (UAB). “For example, a patient with arthritis might have read that lack of vitamin C causes scurvy, and scurvy contributes to arthritis and, therefore, she’s convinced vitamin supplements will cure her. When you try to explain that there are many other causes for her condition, and vitamin supplements aren’t likely to help, she accuses you of not wanting to help her.”


Difficult as this kind of situation can be, Boulware says that the answer is simply to sit down and talk. Explain the situation as carefully as you can, and the patient will understand and appreciate you for it. “In order for patients to trust me, they have to feel that I respect them. It can’t be a top-down situation,” he explains.


THE 7-MINUTE SOLUTION


Of course, sitting down and discussing the connection between vitamin supplements and arthritis, or even sitting down and listening to a long-winded patient explain his problems, can take time—often more time than doctors have. With some insurers reportedly expecting their doctors to spend no more than 7 minutes with each patient, and other payers, such as Medicare, not allowing for much more than that, everyone feels rushed. However, this is where patients as allies can be most helpful. Savard suggests that you or your front office staff provide each patient with a packet of forms to be filled out before the visit. If the patient arrives with a list of medications, a detailed history and an agenda for the visit, the examination itself will be much more efficient.


But even without preparation, good patient communication can help enormously. Megan Siebert, a second-year at UAB, was pleasantly surprised when she went through the school’s clinical-skills program. “I expected time to be a major problem in doing a good interview, but I learned that when I went in with the attitude that I was going to take as much time as I needed, I actually got the interview done much faster.”


Boulware would not be surprised. He points out that time perception is a strange thing, and the rush so many doctors and patients feel might be more perception than reality. “Many years ago, a patient said to me, ‘You always take so much time with me. You sit down.’ Actually, I wasn’t taking any more time with her than was normal,” he recalls. “But the fact that I sat down made it seem like I was taking more time.”


It’s a concept Buddhists understand well. Actually being “in the moment” while you are with a patient can make a big difference in more ways than one.


CUSTOMER CARE


In March of this year, Dr. Peter Salgo, a professor at the Columbia University College of Physicians and Surgeons
and host of the PBS series “Second Opinion,” wrote a much-discussed commentary in the New York Times decrying the state of health care and a business model that has taken over the healing model. Patients became “customers” who “consumed” health-care “resources,” and doctors were urged to “keep things moving” in the interest of profits. Salgo wrote in his essay, “We can and must reduce health-care expenses. But we cannot do it at the expense of patients’ well-being. The doctor–patient relationship is critical to the integrity of the health-care system. It is not disposable. Turning doctors into shopkeepers who regard patients as customers is unacceptable.”


Though it may be unacceptable for doctors to view patients as customers, patients may need to view themselves this way. Salgo’s suggested solution is for patients to take the lead, realize that their doctors work for them, and demand the kind of care they want or take their business elsewhere.


Patient Rick McConatha of Fort Collins, Colorado, couldn’t agree more: “Just like others in the service industry, like your auto mechanic or your plumber, your physician delivers a service. Most other service industries perform customer surveys to help evaluate their success in keeping their customers happy. However, as a medical care ‘customer,’ I have never been asked by a doctor’s office to rate how they’re doing in the delivery of care.” If he were to design such a questionnaire, he notes, it would have questions on it such as, “Did the doctor answer all of your questions? Did you understand the diagnosis and the treatment plan? Do you understand how to take the prescribed medications?”


“As a patient, I want to be under the care of a physician I trust, not only because of his or her diagnostic skills, but because of an ability to communicate with me on a personal level. We’re dealing with my health here!” McConatha asserts.


Whether we see them as patients, customers or partners, it looks like we’re right back where we started: relationships. After all, when it comes to doctors and patients, we are all people. As long as everyone keeps that in mind, we can make this relationship work.




If you are interested in developing a series of forms to facilitate better patient communication, visit
www.mercksource.com/pp/us/cns/cns_patient_resources_savard.jsp. There you will find free .pdf documents that your patients could use to prepare for their visits with you.
~PRACTICING FOR PRACTICE


Medical schools are starting to realize that science alone does not a good doctor make. In the interest of training doctors in the art as well as the science of medicine, many medical schools have opened clinical-skills centers, where first- and second-year students practice doing patient interviews, taking histories and ordering the initial work-up. Ben DuBois, a fourth-year at the University of Texas Medical School at San Antonio, is preparing for his residency in general surgery, and may shatter the stereotype of cold, arrogant surgeons. “The best doctors empathize with their patients,” he believes.

At most clinical-skills centers, actors pose as patients presenting with a variety of symptoms—and attitudes, from shy and uncommunicative to defensive and aggressive. The student-doctor meets with the “patient” in an environment that is an exact reproduction of an examination room.


According to DuBois, the actors really get into their roles, making the
students forget that they aren’t dealing with “real” patients. They also forget the two-way mirror where professors watch in order to provide feedback later. “It’s vital to have this experience early on in training,” says DuBois. In fact, he believes that you can’t start too early or emphasize too much the humanistic side of medicine. These are people, not diseases, he reminds us.

—A.H.


~~~The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~Humanistic Medicine,Practice of Medicine~
50~1January-February~2006-55~On the Wards~“No Hope of Cure”~I didn’t expect my very first patient to die~Andrew Peter Jacques, M.D.~An unexpected death.~Medical school is filled with unspoken expectations. As I began my third year of medical school, I fully expected to pass tests and be able to answer an attending’s questions about thiazide diuretics’ mechanisms of action. And if you’d asked me what my future job as a physician would entail, I’d have expected 90 percent of it to be spent making people better and about 10 percent making people comfortable as they passed away.

This seemed a reasonable ratio to me at the time, but it probably demonstrates how strongly I held to one particular subconscious expectation: that the first patient I treated, I would heal.


My first on-call experience was uneventful at best. I didn’t admit a single patient and spent the majority of the night bored, all dressed up in royal-blue scrubs, sitting in the medical student lounge hoping to be paged. I slept fitfully in the tiny call room and felt disappointed when I was woken by my alarm the next morning. No one had needed my help.

So the next evening—my second night at the hospital—I was more than a little eager to get my hands dirty with this patient-care stuff. At around dinnertime, my senior resident sent me to the emergency department to see a case of suspected pancreatitis. The patient, it seemed, was complaining of abdominal pain.

On the elevator, I rifled through my pocket guides, quickly reading up on the topic, and organized the jumbled patient forms on my clipboard as I walked down the hallway to the emergency department.

That’s where I met Ed. And for the next hour and a half, something magical happened. We introduced ourselves. We interacted. We cracked bad jokes. And he and I formed a physician–patient relationship.


That night I told my fiancée, a fourth-year, that I was afraid if we looked too hard at my 77-year-old patient, we might find something bad.

My premonition proved hauntingly accurate. His symptoms didn’t fit the typical pattern of pancreatitis, and subsequent diagnostic tests detected liver lesions that were consistent with cancerous metastasis. I kept right on treating Ed, visiting him every morning to ask about his night’s sleep and pressing dutifully on his abdomen so I could detail my findings in daily progress notes. I talked with his wife, watched baseball with him when I was on call and listened to stories of his grandson, a basketball player traveling in Europe that summer.


Ed wanted me to go with him when he had his liver masses biopsied, so I asked the nurses to page me when they performed the procedure. Ed and I talked while they took samples of his liver to examine under a microscope. Eleven days later, we had to explain what all our testing meant.


Ed had cancer, and lots of it. It had started in his esophagus and traveled to his stomach. He had eight or nine liver masses. The disease had also spread to his anterior mediastinum, lungs and the lymph nodes around his celiac trunk—a major artery in the stomach. The oncologist wrote “no hope of cure” in Ed’s chart and prepared to discuss comfort care with the family.


For days I had been trying to prepare myself, knowing the most likely result would be an unpleasant diagnosis, and now it was time to break the news. We walked in as a team: attending, senior resident, interns and medical students. Ed paid close attention as our attending gave the terrible news. He took it calmly, and as always, he wanted to talk. He talked about friends and family who had battled cancer, and those who had passed on.


Finally, he looked directly at me and told me how lucky he was to have me as his doctor. This was all too much for me to handle, and I cried. Then without breaking eye contact, Ed asked me if people could survive this cancer like he had survived prostate cancer. I had to tell him the truth. “I’m sorry, Ed” was all I managed to choke out.


In tears, I explained to him again all the ways the disease had invaded his body. As I pointed to the sites of the cancerous growths, I couldn’t help but feel this was my last effort to heal Ed. If all our medical technology had failed, I reasoned, just maybe physical touch could produce the miracle no chemotherapy could promise.


But as I touched Ed’s pink skin, I couldn’t escape the truth of the cancer ravaging his body. So I cried some more. Then Ed told me it would be OK and that I didn’t need to be upset—something I thought would have been my job in such a circumstance.


We talked a lot more that day, and when I left him in the evening, part of me never wanted to return. But I did.

Over the next weeks I stopped by as often as I could to spend time with him and his wife. He gave me a watch he said he wouldn’t need anymore. I promised to pray for him and his family.

The back of the wooden pew was stiff and uncomfortable, but not as uncomfortable as I felt after I’d been mentioned by name during Ed’s eulogy by his son from New Jersey. Though I’d only known Ed for the last three months of his life, he and I provided one another with things we both needed—companionship, hope and bravery. I still carry the hastily scribbled address he gave me before I wrote his discharge instructions. I carry it neatly folded in my wallet as if to honor the memory of our relationship—and of a time when I truly became a clinical practitioner, and Ed drew an end to a life of 77 years.


I still don’t know who needed those conversations more, Ed or me.
~~~~Andrew P. Jacques is an intern at Akron General Medical Center.~~
52~1January-February~2006-55~Letter from Afield~Hope in Hlabisa~A physician rediscovers the roots of medicine~Neil Hadpawat, M.D.~Saving lives on a shoestring.~We’d begun the Caesarian section like any other we—my South African colleague, Ruben, and I—had performed together. There was no anesthesiologist on staff at the hospital: I placed the spinal block in our mother-to-be. Then, following Ruben’s lead, we began the surgery. But as we were incising the uterus, blood began to pour out as if a pipe had burst. Our archaic vacuum pump provided weak suction at best. Even through two layers of latex, I felt the strangely soothing warmth of blood as it pooled over my hands. I looked at Ruben. Conviction had replaced a fleeting moment of self-doubt. Then the shouting began.


“Put in another line! Blood!” But our hospital in Hlabisa, South Africa, was, as usual, sorely undersupplied.

“No blood again? Then bolus her with two liters of saline!”

As I applied pressure on the bleeding site, I glanced at the suction collector—blood had risen above the liter mark and was still rising. Ruben and I would have to get ourselves out of this mess. There was no other option and no one to call for help.


A few minutes later, I watched with relief as the newborn took his first breaths in my arms and his mother began to recover. I refused to focus on how, in this part of Africa, there was a 40 percent chance the now-smiling woman was infected with HIV. Instead, I looked around the room. From everyone’s calm demeanor, it was hard to imagine how precarious the situation had been just a few moments before. The nurses in the room were as hardened as they come. In the world they were trying to survive, death was a daily visitor.

My journey to this unknown territory began at the end of my third year of medical school, when I first considered postponing the start of residency training in order to expose myself to medicine in a resource-poor setting. I was certain that a short elective as a student would not be sufficient; I wanted the depth of understanding, responsibility and experience that only a longer foray could provide.

To put it mildly, support for my plan was lacking. Fellow medical students warned that I was hurting my chances of getting a good residency. My family cautioned me about the cost of this hiatus from conventional medical training. Young physicians felt I was being naive to work in such an isolated setting at my relatively early level of training.

But I chose to resist, and to listen to the few around me who approached medicine the way I did. I focused on the support of a mentor at the Fogarty International Center of the National Institutes of Health, Dr. Pierce Gardner. As a former dean of Stony Brook University School of Medicine, Gardner gave me simple but valuable advice: “You’re going to have to be persistent.”

Instead of applying for a residency position, I applied for an international health research grant newly offered by my school. Around the time my peers were learning their Match results, I received word that the grant had been awarded and would fund my travel and living expenses. I was thrilled.

In June of 2004, just a week after graduation, I began a long journey to a rural area known as Hlabisa (pronounced “Shluh-bisa”), located in the KwaZulu-Natal province of South Africa. I would never fully return to the world of medicine I knew before.

My assignment was with the Africa Center for Health and Population Studies, an internationally funded research institute built in the heart of the Zulu community it studies. In this setting, where approximately one of four people is infected with HIV, the institute’s primary research interest is HIV/ AIDS. I focused my energies at the rural government hospital at Hlabisa.

When I arrived, the 400-bed hospital was severely understaffed, being run by two contracted Cuban doctors and four South African residents fulfilling a mandatory community-service year of training after internship. These four young clinicians worked in this intense setting without the support of senior medical doctors. I was impressed by the incredible amount of clinical knowledge and experience they already possessed. I was also humbled by the great responsibilities they bore—for many patients, these young trainees were all that stood in the way of disease and death.

It seemed that 80 percent of the patients we treated were suffering from diverse complications related to HIV or tuberculosis, and often both. Every day I was reminded of the irony that preventable and treatable diseases could make us feel so powerless. Of all the challenges posed in this austere setting, I found this the greatest; my medical training never prepared me to send people home to die of something that I could potentially treat. To my regret, I soon became used to it.

I quickly realized that the situation in Hlabisa was so desperate, and medical care so difficult to obtain, that even at my early stage of training there was a tremendous amount I could contribute. I treated everything from common asthma and hypertension to a vast array of infectious diseases—many at severe stages that we in the developed world only read about in dusty medical textbooks. I quickly came to appreciate how medicines we take for granted, like antibiotics, are often lifesaving to people living in remote places like Hlabisa.

One day, the hospital received word that the government had finally incorporated Hlabisa into its antiretroviral treatment (ART) program, giving us access to tests and medicines we needed. But we knew change occurred at an agonizingly slow pace here, and we would have to overcome many obstacles to make AIDS treatment a reality. We started with a borrowed desk, a humble hut and a day’s worth of planning. But to our surprise, within a few months we received evidence that our low-tech program was progressing quite well: Nearly all the AIDS patients we initially started on ART now had nearly undetectable levels of the virus, and our enrollment was growing steadily. These people, once the walking dead, now had a new lease on life.

Taking the opportunity to work in this place was one of the best decisions I have ever made. Practicing “bush medicine” revitalized a spirit taxed by four long years in a super-specialized setting—forgetting information as quickly as it was memorized, waiting for a surgeon to grace me with the opportunity to tie a suture and trying to resist a system that has somehow evolved to be at odds with the sacred bond between physician and patient. While I learned a great deal about medicine during my conventional training, it was by practicing community medicine in Africa that I became a doctor.

I now know what graying physicians mean when they refer to “the good old days” of medicine, when it was not just an occupation, but a way of life, a cause. And most of all, it was still fun.

These attributes of the old ways of medicine are not lost from the planet. With the backdrop of a supportive system of medical training, all you need is the motivation and courage to seek them. By working in a resource-poor setting for a period of time during your training, you stand to gain even more than you contribute.

So drive to the other side of the railroad tracks or board that plane, and don’t look back. My experience tells me you’ll be doing a lot of that on your return trip and probably long after that.
~~~~Neil Hadpawat is an emergency medicine intern at New York Methodist Hospital in Brooklyn.~~
76~1January-February~2006-55~Feature~Planning the Fourth Year: A World of Options~~Avery Hurt~~From the time you start taking premed courses and preparing for the MCAT, until you are putting the finishing touches on your third year, the process of a medical education can seem very structured and organized: a dance with very specific steps and little room for improvisation. And this is just fine with many students. Although it’s more of an intricate waltz than the
twist, it can be a satisfying experience nonetheless. Then along comes fourth year.


In year four, options suddenly seem to multiply. Although a few general guidelines must be met, and some schools require more specific rotations than others, much of the year is wide open. Putting it all together into a package that will be both satisfying and beneficial to the rest of your medical career can be a challenge on many fronts.


Over the years, questions have been raised about whether the fourth year is even really necessary. In practical terms, students are usually ready to begin residencies after three years, yet students and administrators mostly agree that the fourth year is not a waste of time and money. Indeed, the benefits may go beyond accumulating more clinical experience.


“The fourth year adds to a student’s growth and development in becoming a physician,” explains Dr. Dwight Davis, associate dean for admissions and student affairs at Pennsylvania State University College of Medicine (PSU). “Rotations in the core areas allow students to take on more responsibility, [to] function more as interns.” But it also allows them to work on the practice of medicine, Davis says. “In the fourth year, you develop communication techniques and learn to see [the many concerns of medicine] from a broader perspective.”


Of course, the fourth year doesn’t take place in a lovely scholastic hideaway where you can follow your intellectual bliss without giving consideration to anything other than what you want and need to learn. This is also the year when you’ll be applying to and interviewing for residencies. Careers are at stake.


Deciding on a fourth-year program can be a bit intimidating, marked by abundant choice, but with so much to gain or lose—that dream residency or a one-of-a-kind experience that can change a career trajectory. And once you have decided what approach to take, getting the timing right can be another problem. Everything from scheduling away rotations to arranging for short-term housing in unfamiliar cities has the potential to make this year more headache than joy. Yet despite all these difficulties, most students enjoy their fourth year immensely, making the most of this opportunity to take control of their education and making some surprisingly creative choices.


Courting Residencies
The Match looms over fourth-years like Christmas to a child who is not sure he has been quite good enough. Because matching into the program of your choice (or at least second or third choice) is so important, many students plan the entire year around making themselves look good to potential residency programs. What have come to be known as “audition rotations” are increasingly popular. Doing rotations where you hope to secure a residency slot has two advantages. First, and probably most importantly, you’ll get a chance to demonstrate your skills in front of the very people who will decide whether or not to select you. Second, you’ll be able to check out the program and see how you fit in, as well as spend some time in the city where you may be living for the next several years.


This try-out tactic is more important for some specialties than others, according to Dr. Terry Blaschke, associate dean for medical student advising at Stanford University School of Medicine. For the more competitive programs and smaller ones that take only a few new residents each year, such as surgery or orthopedics, getting to know the people there and letting them see how you work can put you a step ahead in the selection process.


Not everyone agrees that audition rotations are a good idea, however. “We don’t encourage audition rotations,” says Dr. Maya Hammoud, assistant dean
for student programs at the University of Michigan Medical School. Although they might do some good for some students, Hammoud points out that a good application, recommendations and interview are usually enough to secure a residency. In some cases, auditions might even do more harm than good. “Some students might look better on paper; for those students, an audition rotation is not the best option,” she explains.


Instead, you may want to do a fourth-year away rotation for other reasons. A place with a strong program in a field you are interested in, but not planning to specialize in, might have great appeal. Considerations other than career might come into play as well. “Many students do away rotations for personal reasons. They may have a spouse or other family or friends in that area,” explains Blaschke.


Test-Drive
The decision may come easier for those who have chosen a specialty—and at this point most students have—but for those who are still not sure about where they are headed, the confusion of planning their fourth year quickly turns to chaos. It need not be that way, though. Fourth-year can actually be a great boon to those who just can’t make up their minds.


Students who have an idea of a general area, but just can’t decide on the specifics, can use the fourth year to narrow the field, says Davis. For example, if you know you want to match into surgery, but can’t decide on what type of surgery, you can start by applying to a one-year program in general surgery and use the fourth-year rotations to give you an idea of where you want to go after that, Davis suggests. Some students simply need more time to think about it. In this case, spending a year doing research or working in public health, community service or international health might be a good choice. This can be done after the third year or after graduation, explains Davis. “Most medical schools are very flexible in providing avenues for dealing with this dilemma,” he assures.


Davis also strongly recommends that all medical students take a look at the Careers in Medicine Program offered by the AAMC. (See “Resources,” page 43.) It takes both research and self-knowledge to determine how you want to spend the rest of your career. It is never too early to start working this out—but if you are still not sure by the beginning of the fourth year, all is not lost.


Rounding Out


According to Blaschke, most students take the latter part of the fourth year, after residency applications are complete, to fill in the gaps left after third-year clinical work, or to do rotations in areas that complement their chosen field. For example, a radiology elective is not a requirement at Stanford, Blaschke’s school, but most students take it because they know that whatever residency they pursue, they’ll probably be seeing a lot of films. Likewise, someone planning to specialize in family medicine might choose a rotation in geriatrics or pediatrics. Almost any field is complemented by a rotation in dermatology—rashes come up in all kinds of illnesses. Blaschke thinks this approach makes sense. “It is much better than taking a rotation in something just because it is different.”


Not all advisers subscribe to this idea, though. “We tell students, ‘You’ll be doing this for the rest of your life; spend the fourth year doing other things,’” says Hammoud. She does agree that it’s helpful to do rotations in areas that tend to come up in most fields of medicine: radiology and dermatology, for example.


Spending the fourth year doing something you may not get another chance to do has a huge appeal for many students. And the students who take this path bring an astonishing amount of creativity and energy to their plans.


ALONG FOR THE RIDEe


Andy Wagner and Ian Hoffman—and some 25 others—will be spending much of their fourth year neither in a hospital, clinic or lab. They’ll be spending it on their bikes. Wagner, a fourth-year at Ohio State University College of Medicine and Public Health, is the founder of an organization called Ride for World Health. He and Hoffman, a fourth-year at UMDNJ/Robert Wood Johnson Medical School, were inspired by Mountains Beyond Mountains, Tracy Kidder’s book about Paul Farmer, the medical anthropologist and co-founder of Partners in Health (PIH) who labors tirelessly on behalf of the poor in Haiti and around the world. Wagner asked PIH, which aims to bring the benefits of modern medicine to the poor worldwide, what he could do to help raise money for the organization. The folks at PIH, however, are as interested in promoting the cause of world health as they are in raising money for their own organization, so they suggested that Wagner do something to spread the message of global health issues and to educate others about what they can do to help.


Wagner left PIH feeling a bit deflated, but soon enough rose to the challenge. Along with Hoffman and several others, Wagner put together an ambitious plan: Starting in April 2006, a group of medical students, nursing students and students in other health-care professions will mount their bikes in San Francisco and ride across the continent, ending up two months later in Washington, D.C. Along the way, they will stop and speak at high schools, senior citizens’ groups and other nonmedical civic organizations that welcome them in their communities. They will also host events at select medical centers. The purpose of the talks is to raise funds for PIH, but also, and more importantly, to raise awareness of important issues facing health care today—HIV/AIDS, universal health care, infant mortality—and to educate people about what they can do to help. “Whatever passion medical students have,” says Hoffman, “we can find a place for them at Ride for World Health.”


Ride for World Health has already attracted the sponsorship of Raleigh Bikes and the Ohio State Medical Center. The American Medical Student Association (AMSA) is also involved through its AMSA 500 Campaign Challenge, which encourages each AMSA chapter to raise $500 for the cause.


The project has gone well beyond helping PIH; it is giving its leaders unparalleled new advocacy experiences. “Basically, we’ve been setting up and running a nonprofit corporation while attending medical school,” says Wagner. He and Hoffman plan to make the ride a recurring annual event, handing off the project each year to a new class of fourth-years with a new set of passions and causes.


This is certainly not a traditional rotation, but the benefits to the students will likely be as profound as the benefits to the charities they support and causes they champion.


OUT INTO THE WORLD


“Most residency programs look very favorably on students who devote some time to community service and international health work,” says Hammoud. And according to PSU fourth-year Dawn Mautner, the current chair of AMSA’s Global Health Action Committee, that is just one of many benefits of spending at least some of the fourth year working overseas. Mautner came to PSU from the Peace Corps, so she knows a thing or two about this kind of work. Mautner will spend some of this year in Geneva studying global health policy with the World Health Organization, followed by one or two months in the developing world.


During her fourth year, Dr. Margaret Planta spent four weeks in Pakistan visiting various villages and studying local perceptions of oral rehydration solutions in treating diarrhea. “The experience was…fascinating from the social aspects of how women [are] treated and regarded in that society,” she recalls. Her experience proved galvanizing: Now a family practitioner with Sutter Medical Group in Roseville, California, she started a free clinic for the homeless in her area, and she frequently volunteers there. Although pursuing a career in international health was a compelling idea, she says, “I couldn’t turn my back on the need that is here in our own backyard.”


The experience of working “out of your comfort zone,” as Mautner puts it, inevitably enriches the students who choose this path. “Putting yourself into the lives of people who live differently from us gives you a visceral sense of patients’ needs that is missing from the classroom experience,” she says. In addition to providing a new perspective for students, it also helps develop their roles as patient advocates. Because you learn to understand people in the context of their own lives and help them navigate the often-inadequate resources available, the experience is beneficial even for those who do not plan to continue working in international health, Mautner explains. “Ask anyone you know who has done it,” she suggests. “The vast majority will tell you that it’s the best thing they ever did.”


If you are wondering whether a stint abroad is for you, Mautner recommends that you think about who you want to be at the end of your education. Ask yourself, “Will this help me as a person?” She cautions that you will not be the same after the experience.


SEE THE BIG PICTURE


Those who are interested in the big picture of medicine and health care, but are more comfortable in the library than the field, may be intrigued by a rotation created by Dr. Cathy Sims-O’Neil, a recent graduate of the University of New England College of Osteopathic Medicine. As a fourth-year, Sims-O’Neil attended a meeting of the Sigerist Circle of the American Association for the History of Medicine, a group of historians who take a sociopolitical approach to their work. She discovered that they had no comprehensive bibliography, so she offered to prepare one in exchange for attending their meetings and lectures and working with the group at the National Library of Medicine at the National Institutes of Health. Sims-O’Neil arranged to receive credit for the experience and is now setting up the program as a regular rotation option for other fourth-year students.


In addition to learning more about the history of medicine and gaining insight into the way “we have imagined illness throughout history,” Sims-O’Neil got valuable experience in advanced Medline research. Another significant part of her experience was the opportunity to work and talk with the many intellectuals who visited the program while she was there.


Sims-O’Neil is currently working on a revision of a standard anatomy text and has become interested in what she sees as a clear shift in the way medicine is taught and practiced— from a synthetic approach, “where everything is taught in bits and pieces,” to a more holistic approach. “I came to medical school to make trouble,” she laughs. And her work with the Sigerist Group has given her more tools to do just that. She is spending this year between graduation and her residency conducting research in the emerging science of neurocardiology.



PREPARING MIND, BODY AND SOUL


Transcontinental rides, overseas journeys and apprenticeships with medical historians are certainly different, but the more traditional route can offer just as much value, with opportunities for creativity thrown in. When Dr. Robert Gray began his fourth year at Brown, he knew that he wanted to match into a residency in orthopedic surgery, an extremely competitive field. He did an away rotation at Rush University Medical Center in Chicago, where he had applied for a residency, and was subsequently accepted into the program. Gray believes that his rotation there was a big benefit. “This is the No. 1 best thing you can do to match,” says Gray.


For the second half of the year, once he had done all he could to enhance his match chances, Gray did a subinternship in medicine and finished a pediatrics rotation. And because for Gray, the only way to learn something is by doing it, he also spent many hours throughout his fourth year working on skills that would prepare him for his residency.


But in the end, he also followed Hammoud’s advice—he took some time off. Once you commit to a specialty, there are many things you’ll never be able to do again—nephrology, cardiology and urology aren’t likely to come up again in Gray’s career as an orthopedic surgeon—but at the same time, “You’re never going to be able to sit on your butt for a month drinking piña coladas again, either,” Gray points out. Although it turned out that more of his off-time was spent organizing for the move to Chicago than relaxing on the beach, when The New Physician caught up with him the week before he began his residency, he was rested and refreshed and looking forward to the experience awaiting him.


Not every student needs or wants vacation time before making the transition from medical school to residency. But many, if not most, do, even if they don’t always realize it. Learning to take time to rest, recharge and simply touch base with oneself may be as important a skill as any other for someone who is committing his or her life to the demanding practice of medicine. Don’t overlook this option.


A WORD ABOUT TIMING


Deciding what to do is only part of the problem. Once you know what you want for your fourth year, you have to figure out how to make all the pieces fall in place. “Timing is very important and one of the trickiest parts of the process,” says Blaschke.


“Timing is especially tricky when planning overseas rotations,” Mautner adds. Programs offering rotations are often on very different schedules than medical schools, housing for away rotations must be arranged and the timing of travel, whether across the globe or across the state, must be factored in. “It’s important to work closely with your advisers to make sure you put together both a realistic Match list and a detailed calendar for planning your fourth year,” says Hammoud. Getting to know your advisers and keeping them involved in the planning process is one key to a successful fourth year. She is reassuring, though: “Overwhelming as it may seem at first, with the right planning, this process can go very smoothly—and for most students it usually does.”
~Resources



~~~The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~Career Development,Medical Education,Student Life and Well-Being~
204~1January-February~2006-55~Folk Tales~President, M.D.?~Treating government’s ills~Scott T. Shepherd~~It doesn’t take long to figure out that Vermont Gov. Howard Dean is an atypical politician. He responds to reporters’ calls personally and then speaks casually and promptly, taking little time to calculate his answers. When he’s traveling cross-country in support of his 2004 presidential bid, the physician-turned-politician is without a large entourage. Instead, he’s joined only by an aide and a Vermont state trooper. And rather than enjoy the extravagant lodgings and luxury buses used by better-known candidates, Dean rides in whatever transportation is available and spends his nights in the homes of local Democrats.


With these idiosyncrasies, it should not come as a surprise that Dean has become an early favorite candidate of the national media. He has been cast by several media outlets—the New York Times, Washington Post, New Republic and CNN—as a political “outsider,” a candidate who understands what life is like beyond the Beltway. And it quickly becomes obvious that this is a label he’s proud of.


“People are waiting to find someone who responds to challenges,” he says. “Politicians get paid not to offend. I am not worried about telling someone something they don’t want to hear. I think people are looking for real leadership.”


Dean hasn’t always been viewed as an outsider. In fact, when he was born to an affluent family on Long Island in 1948, he seemed like the last person who would end up with that label. The son of a successful stockbroker, Dean inherited his father’s conservative nature on fiscal matters—a trait that holds true today. And early on, it appeared that might also pertain to social issues when he began to attend the traditionally conservative Yale University. However, it was 1967 and Yale was undergoing a bit of a transformation, as was Dean. He credits his three freshman roommates—two blacks from the South and one white from rural Pennsylvania—with helping him understand the experiences and points of views of minorities, Southerners and the poor.


However, while he may have been developing a better understanding of liberal points of view, Dean says he wasn’t ready to devote himself to the political left. “The truth is that the left always made me suspicious because I instinctively distrust ideologues,” he told the New Republic.


And despite his loyalty to his roommates, Dean even managed to avoid racial politics, declaring he would rather work in the inner city than participate in marches and sit-ins. In fact, for someone majoring in political science, he seemed to avoid most politics altogether.


That became even more apparent after his graduation. After a year supporting his “ski habit” in Colorado, Dean returned home to follow his father’s footsteps in the politically benign career of a stockbroker. But after a couple of years on Wall Street, something changed. In the early 1970s, he began to feel the need for two things: to help people and to escape the city life for the great outdoors. Soon, he realized he wanted the life of a physician. “I think it is a great combination of things where you can help people and be more transportable,” he says of medicine.


So at the age of 26, he began volunteering in the emergency room of St. Elizabeth’s Medical Center and taking night courses at Columbia University to complete the necessary premed requirements. Eventually, he enrolled at Albert Einstein College of Medicine and completed an internal medicine residency at the University of Vermont. After concluding his residency, Dean and his wife—Dr. Judith Steinberg, whom he met at Einstein—decided to open a private practice in Burlington.


For most physicians, this would be the end of a pretty good story. But as it turns out, it was only the beginning. As a new decade approached, the once apolitical political science major had his interest sparked by working locally for the re-election of President Carter. And even after Carter’s failed bid, Dean continued his political activities, working on behalf of environmental issues in the Burlington area.


Then in 1982, he made his first run for office and won a seat in the state legislature. In many states, this would mean becoming a full-time politician. But in Vermont, it is possible to maintain a private practice while commuting 40 miles to Montpelier to attend to legislative matters. So in 1986, Dean decided to take the next step, running for and winning the election for the state’s lieutenant governor.


However, Dean’s political career took its biggest step on a tragic day in the summer of 1991, when Vermont Gov. Richard Snelling died of a heart attack. Dean recalls receiving the news while conducting a routine physical exam on a patient; he finished the exam before rushing off to be sworn in. “I just felt it would be really inconvenient to the patient to come back, and I knew it would be a long time before he could reschedule,” he told the New Republic.


It turns out “a long time” was an understatement. In 2000, he won his fifth term and has become the nation’s longest-serving Democratic governor. He has not practiced medicine since and says he doubts he will ever go back. “I would hate to be my first patient [if I went] back,” Dean says jokingly.


Instead of medicine, he has spent the last 11 years trying to cure the ills of government—and has managed somehow to avoid the labels frequently placed upon politicians, mostly a result of his diverse political characteristics. He can be conservative and liberal but rarely can be seen fence-sitting on an issue. For example: He supported Vermont’s law guaranteeing parity of treatment for mental illness; he brags of “an A rating” from the National Rifle Association; he bought the development rights to thousands of acres to preserve farm and forest land; he has refused to raise the state income tax, while making spending cuts to balance the budget; and, as widely reported, he signed into law and publicly fought for Vermont’s controversial civil unions law, allowing gay and lesbian couples to receive all the legal benefits of marriage.


Dean says getting results is more important than trying to please everyone—a trait he claims he first developed as a physician. “One of the reasons I have been successful is doctors tend to be very results-oriented, while politicians tend to be process-oriented,” says Dean, who is not seeking re-election so he can focus on his presidential candidacy.


Of course, being a physician has also contributed to his stand on health care, a centerpiece of his 2004 presidential bid. “I think I have a better understanding of the complexity of the health-care system [than other politicians]…and I think every American should have health insurance,” he says.


While stumping to voters in Iowa, Dean declared his desire for universal health care, a concept considered political taboo since President Clinton’s health-care plan collapsed during his first term. But Dean takes the pledge a step further, saying Vermont is already moving in the direction of universal health care. He points to the state’s Dr. Dynasaur program, which expands Medicaid to cover all children under age 18 from families with incomes below 300 percent of the poverty line (approximately $50,000 for a family of four).


He says he would like to take Dr. Dynasaur national and expand it to include those up to 22 years old. For individuals between the ages of 22 and 65, he would build upon the current employer-based system by subsidizing private insurance for the self-employed, part-time employees and small-business workers. Finally, he would add a prescription drug benefit to Medicaid, a plan that would require higher co-payments and deductibles but one that would cover all drug bills beyond a certain point.


Of course, to pay for this, he would irritate many fiscal conservatives by rolling back almost all of President Bush’s 2001 tax cut. Still, this seems to be of little concern to Dean. “As a doctor, I am prepared to give bad news, and I am not overly concerned about trying not to offend anyone.”


Only time will tell if Dean will prescribe his own brand of medicine to the U.S. health-care system.
~~~~Scott T. Shepherd is an associate editor with The New Physician.~Advocacy~
317~8November~2006-55~Perspectives~The Courage to Change~Step 3 Is Not Just for Addicts~John Rhyner~Admitting you’re powerless~In the United States, a person is twice as likely to be killed by him- or herself as by someone else. When poor diet, lack of exercise, sexual indiscretion, medical noncompliance, failure to bring issues to the attention of a provider, and substance abuse are compounded, the leading agent of mortality for the vast majority of Americans is themselves. After the widespread availability of antibiotics and immunization, we entered a paradigm of self-directed destruction.

Behaviors of excess, recklessness and ignorance seem sufficiently pervasive as to be intrinsic. Perhaps in the past, immediate gratification was logical as general outcomes were so poor, prediction was impossible and investing for the future was disfavored. But as our financial markets and physical well-being are now clearly illuminating, that is clearly no longer the case. The Protestant Ethic brings health, wealth and increased likelihood of successful transmission of genes to future generations. Those most successful in adhering to this ethic are those most likely to succeed. Or in the words of Narcotics Anonymous’s (NA) Step 1, “Those who make meetings make it.”

Regardless of whether God exists, the pervasiveness and fecundity of religion strongly argues for its ability to repress vice and realize human potential. Twelve-step programs like NA understand this capability. In Step 3, self-designated addicts are asked to accept that when they exerted full control over their lives, they failed. In order to progress, they must recognize that they are flawed, and that they need help from a higher power—whether a religious deity, a faith in human connections or even NA itself.

More than 70 people were at the West¬minster Presbyterian Church in Durham, North Carolina, that Monday night last spring. They all introduced themselves as addicts but me. There were men and women; whites, blacks and Latinos; old and young; rich and poor; homely and beautiful; educated and ignorant. The evening was spent telling stories of what the third step meant to all those who wished to speak. Successes were applauded, failures were accepted, and at the end of each soliloquy, everyone said, “Thanks for sharing.” Key chains of different colors were awarded to addicts at various durations of abstinence. As they received their awards, they were embraced and cheered. People cried.

I stood in the back, wearing a necktie and a text-pager. No one was impressed. People kept offering me a seat. When the meeting ended, a gentleman in the back wearing Carhartt overalls and cracked work boots directed me to the literature table, gave me a card advertising his landscaping business, and told me that if I needed someone to talk to, his home phone number was written on the back. Then he smiled and walked away.

After the group adjourned, I made my way to the door. As I turned to close it behind me, I saw the congregation forming a circle, arms lain over each other’s shoulders. The NA leader caught my eye and waved me back into the room. I asked the participants for permission to enter their circle, and they all replied with a smile, “Of course.” The group began to recite a poem in unison, and I was tickled that I already knew the words. It was the motto for the Optimist Club, of which my father was a member for more than a decade and that had given me my largest college scholarship. It was the Serenity Prayer: “Grant me the serenity to accept the things I cannot change, the courage to change the things I can and the wisdom to know the difference.”

The principles that I witnessed exhibited at the NA meeting are principles that make people successful in life, not just in overcoming addiction.

Immediately before the meeting, I had seen a young woman in the Psychiatry Emergency Clinic at the Durham VA hospital who presented with stated plans to burn herself and her 6-year-old son to death. I took an extensive history, felt and expressed empathy, and gave her time to cry. I believed her when she told me that she had never felt this way before; that she had been abandoned by her husband, family, friends and caregivers; that she had never been hospitalized before; that she had never tried to hurt herself or anyone else; that she had used no recreational drugs; and that she took her medications as directed and was present for scheduled outpatient appointments.

But examining her records after the interview, I found primary diagnoses of borderline personality disorder and substance abuse, that she had a history of noncompliance, that she had recently fallen into dire financial straits and was unemployed, and that she had tried to hang herself with a noose she made out of her pajamas on a previous admission.

I felt duped. I felt violated. I knew that the patient was sick and that her sickness was likely beyond her control, but still I admonished myself.

But attending the NA meeting later that night helped me to accept my patient. I now more fully appreciate the severity and complexity of the disease, the influence of intrinsic human nature in its propagation and its similarity to so many other ailments. I suspect that my reactions to patients will often still need to be tempered by better judgment, but I believe that I will be far less judgmental to them as individuals.

This lesson of acceptance and understanding will likely be the greatest of any I will learn during my psychiatry rotation, and perhaps my entire medical school career. I appreciate the opportunity to have learned it.

John Rhyner is a third-year at Duke University School of Medicine.
~~~~~Medicine in Popular Culture,Practice of Medicine~
224~6September~2006-55~Resident Rx~Sharing the Load~In pursuit of a reduced-schedule residency~Eva Cesnek Novak, M.D.~A new approach to tortuous work hours.~I saw the writing on the wall. It read, “You’re through. Finished. Burned out. Used up.”


After a sleepless 32-hour hospital shift at the end of yet another 80-hour workweek, I felt a sense of sheer exhaustion. How could I go home to a neglected marriage, family responsibilities, piles of laundry and patient cases to read up on when all I wanted to do was sleep?


When I felt unable to improve my grueling schedule, I started talking to other medical students and residents about work hours. I discovered a growing group of disenchanted physicians-in-training critical of many aspects of our training system. Our conversations revealed the impact of 80-hour workweeks on some individuals.


The current medical training system does not always meet the needs of medical students and residents having other time-consuming responsibilities besides clinical work, such as parenthood, chronic illness or a disability. Faced with deteriorating personal relationships, poor health or other stresses associated with long work hours, many medical students are at risk for burning out and even dropping out. Others decide to postpone residency training after graduation and some wind up leaving medicine entirely.


Their decisions can negatively affect our health-care system. Individuals who leave medicine decrease the number of physicians at a time when a shortage of practitioners looms on the horizon. Not only do these disenchanted individuals often accrue staggering debt when they give up on their dreams of medicine, but aborting a medical career also costs taxpayers, who underwrite much of medical education, and society, which depends on an adequate number of physicians.


Few benefit when aspiring physicians leave medicine because of long work hours. The effect of physician dropout can be devastating, so it seems important to develop ways to increase the retention rate.


During my last two years of medical school, I focused on finding a way to reduce the number of medical school dropouts—the tip of the iceberg of dissatisfied physicians-in-training. I started with a vision of reduced-schedule residencies, a concept of medical training popular in other countries for retaining residents. Residents pursuing a reduced schedule within a training program work fewer weekly hours on clinical rotations than their full-time counterparts. In return, they extend the duration of their medical training and receive fewer annual benefits and a smaller salary from the residency program.


For instance, a resident in her PGY-1 year on a reduced schedule may work 50 hours weekly for two years instead of 80 hours weekly for one year. Reduced-schedule residencies can be part-time or shared. In a part-time residency, she may be the only person in her program participating in a reduced schedule. In a shared residency, two individuals share one training position, alternating days, weeks or months on clinical rotations with time off. They can be involved in such an arrangement for months to years. It can even span the entire duration of their residency training, facilitating a balance between medical training and other aspects of life.


After conducting an extensive literature review of these programs (results are pending publication), I stumbled onto an interesting fact. Although various U.S. medical organizations endorse them and the literature shows that they work, reduced-schedule residencies are uncommon within the United States. Curious about their lack of popularity and hoping to advocate for them, I set out on a long journey of discovery.

A thousand-mile trip begins with a single step, and my journey of advocacy began with a single strategy: learning about reduced-schedule residencies through total immersion. During my third year of medical school, I decided to seek out a shared residency solution for my own postgraduate education in family medicine.


The next few months were filled with a frenzy of activity: scouring various Web sites and online discussion forums looking for like-minded students, attending national family medicine conferences to discuss reduced-schedule residencies, and looking for the perfect combination of residency partner and program. Before long, I found another third-year who was interested in pursuing a shared residency. Many serious discussions later, we found ourselves interviewing for residency programs as a “couple,” discussing the various aspects and advantages a shared-residency pair could offer.


Program directors’ responses were mixed, however. Many were intrigued by the idea but expressed concern over logistics, working relationships between shared-residents and full-time residents, and the durability of the shared-residency partnership.


This last concern proved prophetic. Months into the interview cycle, my shared-residency partner told me that, upon further reflection, she had decided not to pursue a shared residency after all. She was concerned about not obtaining a slot in the 2006 Match. I felt unsure of what to do next until I put this setback into perspective.


Success happens when individuals pursue their dreams in the face of obstacles. Despite the loss of a residency partner, I felt a deep commitment toward reduced-schedule residencies, so I developed a new action plan. I founded the American Medical Shared Residency Association (www.sharedresidency.org).


Its purpose is to act as a resource for individuals interested in pursuing a reduced-schedule residency, and for residency programs interested in instituting such a plan. This organization provides a list of current reduced-schedule residents and interested programs; it also contains a how-to manual on ap¬proaching residencies with a proposal.


The emergence of this organization is only a beginning. It will take much work and even more time before part-time and shared residencies gain further acceptance, both by residency programs and aspiring physicians.


I have been fortunate. Although I have decided against pursuing a shared residency for myself, I am committed to this alternative, and am grateful for the support and willingness shown by my program at Hunterdon Family Medi¬cine after the loss of my partner. In contrast, most training programs—and residents themselves—are not yet open to considering reduced-schedule residencies, and the programs offering them do not readily advertise their availability.


More discussions, research, education and advocacy are needed to popularize this solution to burnout; we must act and dream, as well as plan and believe in our dreams. Christopher Reeve once said, “So many of our dreams at first seem impossible, then they seem improbable. Then, when we summon the will, they soon become inevitable.” If we band together in favor of reduced-schedule residencies, then perhaps one day they will become as commonplace as criticism of 80-hour workweeks. ~~~~Eva Cesnek Novak is a first-year resident in family medicine at Hunterdon Medical Center in Flemington, New Jersey.~Career Development,Residency~
225~6September~2006-55~On the Wards~The Lessons of Loss~Losing a baby helped me find myself as a clinician~Julie Balch Samora~The power of a personal tale.~Having completed my first two years of medical school, and with several clinical experiences under my belt, I knew the numbers. I had read the statistics. But it never crossed my mind that I would become a number.


On Feb. 15, 2006, during my first obstetrical appointment after discovering I was pregnant, it happened. Lena, the nurse-midwife, could not find the baby’s heartbeat with the Doppler. She then took me over to Sue for a vaginal ultrasound, just to make sure everything was OK. I heard Sue and Lena talking:


“Yes, I see the sac. It stopped growing at six weeks.” I was listening, but I literally had no idea what they were saying—it was as if they were speaking a foreign language. My mind was blank. Then Lena turned to me and said, “I’m so sorry.”


I still did not understand what was going on, even though I already had tears in my eyes. “No,” I thought. “I could not have lost my baby. There is no way I’ve had a miscarriage.”


But then I had to go back to the exam room and listen to my options: Wait to see if the “products of conception” expel naturally, take misoprostol to speed the evacuation of the dead embryo, or get a dilation and curettage (D&C).


This is my version of the truth. This is how I remember experiencing it, from the patient’s perspective. Although this event—which all together involved the initial appointment, further blood work to test hCG levels, trials of prostaglandins and a final progression to a D&C—was extremely distressing, it provided me with an awareness of how to be a better clinician.


First and foremost, the conversations with the nurses, physicians and residents that made the most impact on me were not about the side effects of misoprostol, or the chances the embryo would pass naturally, or the risks of a D&C, or even how soon my husband and I could “try again.”


No. What affected me the most were the personal stories told by my caregivers.


I still remember my OB telling me about his sister who got pregnant immediately following a miscarriage. Then there was the story offered by the ultrasonographer, who was trying desperately to get pregnant and now taking fertility medication to help conceive her second child. An anecdote from my medical student colleague revealed she’d had a miscarriage with her first pregnancy, leading her to postpone trying again for eight years. (She now has four beautiful children.)


I have heard many conversations in medical school cautioning that clinicians should keep an emotional distance from patients and not reveal private information. But these personal tales might be just what a patient needs to bounce back and realize he or she is not alone.


My experience also gave me a better understanding of why miscommunications occur between patient and clinician. Now I really appreciate why sometimes, when something is explained to a patient in as clear a manner as possible, it just doesn’t register. Of course, this can occur for many reasons, including educational or language barriers, hearing problems or memory difficulties. But emotional shock will now be on my differential for why patients do not follow instructions or cannot remember what has been explained to them. Sometimes they are simply not in a state to be able to deal with complex, cumbersome facts. Unfortunately, given time constraints, we must be able to “get across” pertinent information in a set period of time. Some messages may just need to be written down or conveyed to a family member.


My episode as a patient has made me realize how emotionally painful a medical trauma of any sort can be. It has sharpened my ability to have empathy for my patients, as I have been in a similarly heart-wrenching situation. I have realized that the emotional pain can be much worse than the physical pain, and we need to address this aspect of care. Just because the “event” is over, and the patient seems physically well, we still need to ask how they are handling the invisible repercussions, as healing the heart and mind can take longer than healing the body. We need to treat the whole person—not just the injury or trauma.


It is also important not to offer false hopes. To a patient diagnosed with cancer or suffering a miscarriage, we cannot say that everything is going to be OK, because that is an untruth. We can only provide statistics and probabilities about future outcomes, or paint best-case scenarios. We can only tell patients that each case is unique and hold their hands in the process.


Finally, we need to assure patients that whatever has happened, it is not necessarily their fault. When I finally had a chance to contemplate my miscarriage, I went through the blame game. I must not have taken enough folate (as if taking 800 mg daily for the past two years was not sufficient). I must not have eaten the right foods. My endothelial lining was sub-par. My stress levels were too high.


These thoughts were eating up my time and energy, and were neither healthy nor helpful. But once I came to accept that miscarriages are indeed very common phenomena, I was able to breathe more easily and to move forward. It is imperative that we stress to patients that what happened was not a result of something they did—unless of course, it’s a diagnosis of small cell lung carcinoma to a patient with a long history of smoking.


These all sound like such common-sense discoveries. It seems silly that I needed to experience such an unfortunate event to unearth such simple messages. Nonetheless, I am a firm believer that everything in life happens for a reason. My experience as a patient through a difficult emotional setback has helped me grow as a person, to realize that not everything goes as planned, to recognize that many events are out of our hands and, most importantly, to remember that patients need and deserve emotional support and empathy from their caregivers. ~~~~Julie Balch Samora is pursuing an M.D./Ph.D. program at West Virginia University.~Practice of Medicine,Student Life and Well-Being,Women in Medicine~
227~6September~2006-55~Perspectives~Black Bag Medicine~The tools of healing can’t all fit in your pockets~Frederick H. Roever, M.D.~Bagful of wisdom.~No one wants me anymore!


I am the clinician’s black medical bag. Once I was his or her constant companion—an inseparable servant, friend and ally. I was carried everywhere—to the office, to the hospital and even to the patient’s home. I was the clinician’s toolbox—essential to the art of physical diagnosis.


In the days of “black bag” medicine, physical diagnosis was an art instead of today’s perfunctory ritual. But now I am confined to the dark corner of a dusty closet—with “out of date” diagnostic texts. New physicians attempt to carry my contents in the small pockets of their white jackets. Unfortunately for the patient, essential instruments are left behind. Consider my insides, the essential tools of black bag medicine: stethoscope, blood pressure cuff, flashlight, otoscope, ophthalmoscope, percussion hammer, tuning forks, tape measure, magnifying glass, EKG calipers, pocket Snellen chart, red lens, gloves, lubricant, Hemoccult slides, developer, the anachronisms of a Palm Pilot and cell phone, and sometimes a lollipop for a sick child.


Indeed, no pockets can equal me. As a result, the physician exam has become abbreviated—a perfunctory, pseudoperformance of a meaningless liturgy with little clinical significance.


Today, black bag medicine has become a lost art, condemned to a dark closet or the primitive settings of the developing world. Technology has replaced me and the expertise I represent, as patient testing has replaced patient care. Physicians metamorphose into mere interpreters of tests.


But artifacts abound in technology; they also hide the truth. Consider these three asymptomatic patients: The first has potassium of 6.8. The second presents with a calcium of 12.8. The third exhibits the following lab values: a potassium of 2.2, a sodium of 152, a chloride of 126 and a hemoglobin of 8.2. In the first case, the hyperkalemia was due to RBC hemolysis. The hypercalcemia of the second patient was an artifact of prolonged venous stasis, produced by a tight tourniquet used to assist a difficult venipuncture. The bizarre lab values of the third patient were due to a blood sample erroneously drawn from a vein proximal to a distal IV saline infusion site, which was covered by a sheet.


Artifacts may become an expressway to the grave. So the patient, not the chart, should always be the final textbook. This simple approach permits the practioner to maintain an open mind, unprejudiced by others’ opinions or erroneous lab reports. The new physician must possess the wisdom and fortitude to doubt test results—especially when such results are inconsistent with the actual patient’s clinical condition.


In the great days of black bag medicine, charting was typically done at the patient’s bedside—not the nurses’ station or computer terminal. An enhanced level of direct personal care resulted. But today the physician’s senses have become dulled by the echocardiogram, chest X-ray and EKG. Classical physical findings—the cardinal signs of disease—become ignored or undetected. Gallups, murmurs, pericardial rubs, wet rales, Velcro rates, dullness, hyper-resonance and a myriad of other physical findings remain locked inside the lost black bag. The new physician is too hurried to listen and too stressed to understand or appreciate their significance.


A thorough patient history is also essential to black bag medicine. According to the Oslerian tradition, the patient will usually “tell” the physician her diagnosis—if he listens long enough. Unfortunately, most students, interns and residents have limited time. Therefore, the practitioner must know how to ask the proper questions, target the key symptoms and exclude extraneous information that may cloud the truth. However, a reasonable diagnosis can usually be made by the patient history alone.


Unfortunately, academic medicine has not adequately emphasized the development of the critical people skills that can dissolve cultural barriers and greatly assist in obtaining an accurate patient history. And when physician–patient communication is poor, lawsuits result. Many states now require physicians to take “risk management” courses, and even the United States Medical Licensing Exam has created a new part to assess a physician’s ability to avoid being sued.


Today, the new physician will embark on a profession in crisis—the malpractice meltdown; impersonal, generic patient care often controlled by “managers” instead of physicians; astronomical drug costs; unavailable and unaffordable health insurance; and underpaid, overregulated medical school faculty.


Much of this crisis is our profession’s own fault. The American people have given our profession a failing grade. Our educational system must correct its blatant shortcomings. It must produce patient advocates and healers, instead of merely cloning a generation of insensitive, arrogant, master test-takers, who regard patients as only vessels of diseases. It is time for change, not complacency.



The new physician can be the instrument of this change. As a future leader, you must not accept the status quo or our profession’s shortcomings. You can inspire change and create a new frontier of patient advocacy, social and moral responsibility, and justice in the medical business world of rampant corporate greed. You must be an idealist, an ally and the voice of the quiet desperation of the sick, old, frail and poor—those who can only cry with a silent scream.


The time has come for our profession to return to its Oslerian roots. Indeed, Sir William Osler, the father of bedside teaching, never left his black bag to gather dust in the closet. “The practice of medicine is an art, not a trade; a calling, not a business,” he said. “It is a calling in which your brain must be equally exercised with your heart.”


Inspired by medicine’s noble past, the new physician can improve the future. He can reopen the dark closet and permit his black medical bag to see the light of a new day. ~~~~Dr. Frederick Roever is a clinical assistant professor of medicine at the University of South Florida College of Medicine.~Medicine in Popular Culture,Practice of Medicine~
228~6September~2006-55~Reviews~Scrambling in the Foothills~A physician’s commitment to universal care~Mignon Metcalf~An uphill climb.~Whether it has been through deliberation in our medical ethics courses, an interaction with an impoverished patient or personal conviction, all health-care providers have confronted our society’s inadequacies in health-care provision. As students, we are all familiar with the long-running debate on how to obtain free health care for all of our nation’s citizens.


By recounting his interactions with several memorable patients during his medical career, Dr. Robert McKersie makes a noble attempt to address the topic in his book, In the Foothills of Medicine: A Young Doctor’s Journey From the Inner City of Chicago to the Mountains of Nepal (iUniverse, Inc., $19.95).


His book is a memoir of a period spanning his fourth year of medical school to his role as an attending physician. Each encounter is presented in the form of a journal entry, beginning with his voyage to Nepal to complete an elective rotation, through his interactions in the clinics of inner-city Chicago and concluding with his most recent return to Nepal.


Through his stories, the reader is able to connect with the plethora of patients typically treated by a family physician. Among them are Evelyn Howe, who suffered with metastatic breast cancer; Ms. Jackson, who fought diabetes; and a young Nepalese woman who was diagnosed with sepsis after having a miscarriage. For all of these patients, McKersie illustrates the identical dilemma that each faces—the absence of adequate health insurance—then presents the preventable ramifications that each patient has battled as a consequence.


The success of McKersie’s anecdotes resides in his presentation. He conveys each story compassionately and vividly, taking care to meticulously describe the physical attributes, emotions and auras of his patients. He also describes the resounding imprint each individual left in the foundation of his medical odyssey.


But while McKersie satisfies the reader’s curiosity by detailing the outcome of most cases, his idealistic presentation of patients, coupled with an almost overwhelming sense of naïve optimism, causes the delivery of some stories to be either too predictable or verging on unrealism.


Medical providers will read McKersie’s memoir with fluidity and familiarity, as the medical jargon and clinical scenarios are conventional. In order to accommodate readers who reside outside the microcosm of medicine, McKersie attempts to provide a thorough explanation of potentially confusing terminology. But this effort—as when he tries to explain adenosine triphosphate or the mechanism of HIV replication using only a few paragraphs—is illogical. Not only do these processes require a more extensive clarification, but even detailing them in the most colloquial, diluted format is difficult for a layperson to grasp. His venture to appease the medical amateur is surely appreciated by some readers, but a medical professional may quickly tire of narratives interrupted by weakened and inappropriate mid-story annotations detailing medical terminology.


Nonetheless, In the Foothills of Medicine makes for an enjoyable read that recounts McKersie’s personal growth and academic maturation from student to resident to attending. His valiant attempt to illustrate the necessity of comprehensive health-care coverage is respectable, and health-care professionals will be able to connect with McKersie’s memoir on both an intellectual and emotional level. His detailed narratives serve as an easy read and brief reminder of why we’ve dedicated our lives to the provision of humanism and medicine.

Mignon Metcalf is a fourth-year at the Brody School of Medicine at East Carolina University.



MINDING THE SPIRITUAL

Leroy Trombetta, M.D.

Physicians that manage severe disease witness the powerful role that religion plays in dealing with pain and suffering. Drawing on concepts in philosophy, theology and psychology to examine the relationship between illness and religion, Siroj Sorajjakool guides clinicians through their patients’ spiritual journeys in When Sickness Heals: The Place of Religious Belief in Healthcare (Templeton Foundation Press, $19.95). Sorajjakool’s academic background in theology and clinical background in pastoral counseling give him a unique perspective on the struggle to cope with disease.


In order to tackle such a topic, the Loma Linda University professor of religion, psychology and counseling must first define the terms. Sorajjakool puts forth a definition of spirituality as an innate quest for meaning, one stimulated by illness and tragedy.


When stricken with severe illness, we, as humans, turn toward ritual and divine intervention to gain control, ease anxiety and find purpose or meaning behind our suffering. This is exemplified when the newly diagnosed patient prays for a miracle cure for his or her terminal condition.


The concept of the miracle represents a longing to revert life back to a positive, meaningful state. Sorajjakool explains that when patients realize the miracle will not occur, they enter a new phase of spirituality, and begin to integrate their suffering into their system of meaning. Patients who make this “faith journey” are finally able to find meaning within their suffering. Religious symbolism assists with this journey by providing an avenue to integrate suffering with meaning. Soraj¬jakool also explores cultural and religious differences in the way mental illness is defined, perceived and managed.


These principles established, Soraj¬ja¬kool provides a means by which clinicians can assess a patient’s spirituality to determine his or her progress along the faith journey. Understanding the progress of spiritual transition can allow the clinician to interact with the patient and family in a manner that facilitates communication and minimizes anxiety. Spiritual care is then possible.


The caregiver does not lead the patient through the faith journey—it is an individual one—but provides space within which the journey can occur, without expectation or prejudice.


The author presents very complex philosophical arguments within a framework appropriate for the target audience. Sorajjakool begins each chapter with a brief summary of the discussion to follow. With the endpoint of the argument up front, the reader is able to enjoy the complex text that develops the intended message. In supporting his arguments, Sorajjakool draws examples from classic and contemporary philosophers, several diverse religious teachings, personal anecdotes and even contemporary cinema. These examples provide the reader with practical demonstration of the messages he conveys and add an element of flow to the reading.


While the author does an excellent job of incorporating his vast knowledge of both Eastern and Western religion and philosophy, the reader longs for more clinical anecdotes. The beautiful clinical experiences that Sorajjakool cites are the most pleasant part of the material. I found myself wishing stories were expounded upon and more numerous.


Still, for the physician who manages severe disability, this book provides indispensable insight into the religious transition and spiritual journey the patients must navigate.


Dr. Leroy Trombetta is a general surgeon on staff at Brooke Army Medical Center in San Antonio, Texas.
~~~~~~
229~6September~2006-55~Feature~Spotlight: The Big Squeeze~What’s being done about medical student indebtedness?~Anthony Hall~Newly minted attorneys and engineers have nothing on medical school grads when it comes to owing the big bucks. Medical students’ average debt load is roughly double that of graduating law students and four times that of engineering grads, according to recent analyses. And it’s still rising fast.~Newly minted attorneys and engineers have nothing on medical school grads when it comes to owing the big bucks. Medical students’ average debt load is roughly double that of graduating law students and four times that of engineering grads, according to recent analyses. And it’s still rising fast.


The Association of American Medical Colleges (AAMC) reports that medical student debt averaged $120,000 in 2005, a figure that has nearly doubled over the past ten years. Contrast this debt load with the salary typically drawn by first-year residents—$37,000 to $45,000—and it’s clear that new physicians are in deep trouble.


With monthly loan payments averaging $1,300, they are postponing car and home purchases and delaying marriage and children—decisions that negatively affect the national economy as well as the individual, according to Luke Swarthout, a consultant for the State Public Interest Research Groups. Purely from an economic point of view, “We like it when people make investments in large capital purchases,” Swarthout says.


Even more ominous is the demonstrated trend that indebtedness drives medical students toward higher-paying specialties and away from pediatrics, internal medicine and family practice, contributing to shortages in the primary care workforce.


Christina Pompey, a third-year at Wayne State University School of Medicine, says her debt load, which she expects to reach “well over $300,000,” will even affect where she chooses to practice. That kind of sum is likely to keep her away from the inner city, where she grew up and where physician shortages are rife. Debt, she says, has steered her away from urban pediatrics and toward a goal of practicing plastic surgery or dermatology in the suburbs. She feels the loss, because, “Naturally, you feel a little obligated to take care of people in your neighborhood,” she says.


Yet, she considers herself among the lucky ones. Her undergraduate degree was covered completely by scholarships. “I know some whose debt is going to be half a million,” she says.


Debt is also responsible for keeping kids from poorer families out of higher education entirely. “Hundreds of thousands of students who qualify for college don’t attend,” according to Karin Pellmann, spokesperson for the private lending institution My Rich Uncle.


Pellmann isn’t exaggerating. Two reports on college costs and financial aid released by the College Board in October 2005 point to big gaps in college graduation rates between the rich and poor. According to the reports, students from families with the highest income and education levels complete college at more than double the rate of high-scoring students from the lowest socioeconomic grouping.


Beyond that, 25 percent of qualified poorer students were not attending college at all and only 29 percent had completed a four-year program within eight years of finishing high school.


“It’s not about academic preparation, it’s about money,” says Sandy Baum, an economics professor at Skidmore College and an analyst for the College Board. According to Baum, total dollars spent on student aid has increased, but not fast enough. Further, merit-based grant funding has increased at a faster rate than need-based grant funding, which slants the odds against low-income students. With success in school “highly correlated to family income,” Baum says, “what happens is you get lots of low-income students who don’t get the need-based grants because the money is going into the merit-based grants.”


POOR DR. MEGABUCKS


The widening gap between rich and poor is mirrored in the growing cultural and economic gulf between doctors and patients. “As the population becomes more diverse, most medical schools recognize that…it helps to have people from those populations become physicians,” says Peter Mitsch, director of finance and administration at the University of Minnesota Medical School (UMMS). “Large debt looming over your head is just one more thing that kids from those populations look at and say, ‘Holy cow, I don’t want to do that.’”


But medical students’ debt burdens are not always taken seriously, given the public perception of the high salaries they can expect after training is complete. But the truth about those salaries is more complicated. A new study from the Center for Studying Health System Change shows that physician salaries have actually declined more than 7 percent in real dollars since 1995, while professional, specialty and technical occupations increased by about the same amount over that period. Meanwhile tuition costs are skyrocketing and interest rates are on the upswing.


ANTI-INTELLECTUAL POLICIES?


Politicians are beginning to weigh in on the matter. On June 28, three days before federal loan interest rates were to jump by almost 2 percent, Sen. Edward Kennedy (D-Mass.) introduced an initiative to thwart what appears to be a Republican-driven pinch on higher education loans. After releasing a state-by-state analysis of rising college tuition and student debt prepared by the Senate Committee on Health, Education, Labor and Pensions; Democratic staff; and the Senate Democratic Policy Committee, Kennedy, flanked by prominent Democrats, reaffirmed the party’s support for increased spending on higher education.


Perhaps most enticing among Kennedy’s proposals is legislation that would forgive a borrower’s federal loan debt after ten years of working in the public sector, a proposition that would include public health doctors and nurses.


His announcement came on the heels of the Student Borrowers Bill of Rights Act of 2006, a comprehensive bill introduced in May by Sen. Hillary Rodham Clinton (D-N.Y.) who proposed capping repayment of federal loans at 10 percent of the borrower’s annual adjusted gross income if it falls between 100 percent and 200 percent of the poverty line for the previous year, and 20 percent if the borrower’s annual adjusted gross income is above 200 percent of the poverty line for the previous year. Her bill also centers on transparency of information for borrowers, allows student debt to fit back into bankruptcy proceedings and suggests debt forgiveness for borrowers with good payment records after 25 years.


But any new education initiative may end up as little more than colorful, teasing headlines. “For whatever reason, we have a president who prides himself in being an anti-intellectual and a Congress that’s willing to go along,” says Mark Kantrowitz, financial aid consultant and founder of FinAid.com. He points to the government’s huge tax breaks that favor the wealthy, as well as the Higher Education Reconciliation Act of 2005, which tellingly was passed as part of this year’s deficit reduction package. The measure carved the lion’s share of savings—$11.9 billion out of an overall target of $40 billion—out of funding for higher education.


“It boils down to the federal government [having] to spend more money,” Kantrowitz says. “If government spending drops, tuition goes up. There’s a direct correlation.”


Baum believes optimism is the wrong bet. “In fact, there’s just not going to be any extra money at all put in to student aid in the short run. It doesn’t look promising.”


THE ONLY PLLACE TO PINCH


The federal government’s posture, which also includes an overall scaling back of research funding, is only part of the problem. Medical schools have a lot of different revenue streams, almost all of which are beyond the institution’s control and can be notoriously unstable. “Federal grants, state support if you’re a public institution like we are, philanthropy, contracts with hospitals—all sorts of things,” says Mitsch. “Tuition is really the only revenue stream where we get to decide what it is going to be.”


The AAMC reports that in the past two decades, median tuition and fees have increased by 165 percent in private medical schools and by 312 percent in public medical schools, growing far more rapidly than the consumer price index. But schools can’t be blamed entirely for rising tuition. In recent years, states have also rolled back their education budgets, some by as much as 30 percent.


Meanwhile, students—with the nation as a whole—are demanding high-quality medical education, cutting-edge programs and research-oriented facilities that must compete with private industry for top-ranked staff. If you try cutting costs, you risk “changing the product,” Baum explains.


Consequently, in an era when health insurance rates have skyrocketed for every employer, medical schools, with salaries and benefits as the cornerstone of their annual budgets, are also stumbling for solutions. UMMS has held annual faculty raises to 3 percent in recent years, Mitsch says, while forging ahead with updating curricula, hiring additional research staff and establishing a new stroke center.


“Even while trying to keep costs down, colleges are much better at adding programs and spending money than cutting back and being air tight,” Baum says.


So schools like UMMS and Col¬umbia University College of Physicians and Surgeons have worked hard to establish new scholarship drives, mostly through medical student alumni associations. “It’s not much, but everything counts,” said Mitsch, pointing to a matching scholarship offer at the Uni¬versity of Minnesota through which the medical school leverages money from the larger university system.


PENNYWISE OR POUND FOOLISH?


What can students themselves do to keep indebtedness to a minimum? Besides trading their medical services to the government in return for debt relief, the options are few.


This past summer, many students rushed to meet the July 1 deadline for consolidating their federal loans into one new Federal Consolidation Loan, which allows them to lock in a rate and pay back the loan over a longer period. The consolidation program has still left many borrowers with a “thanks for nothing” taste in their mouths, given the unprecedented rate hike: from 5.3 percent to 7.1 percent for old loans and 6.8 percent for new ones.


The good news is that the new federal rates are fixed, rather than variable, and the government’s Stafford Loan program is slowly phasing out its origination rate, cutting it down to 3 percent this year, then taking off half a percent per year until it reaches zero in 2010.


Further, the federal government has extended its Stafford PLUS Program—available to parents of undergraduates—to include a Federal Direct Grad PLUS program, opening a new option for medical students.


It still leaves a confusing mess. Medical school is a bargain considering the potential payoff in some specialties, but a tenuous one that hinges on both political and economic swings of fortune. Pompey is a case in point. To cover last year’s tuition, fees and living expenses—which topped $70,000—she accepted a $500 award from an in-school endowment fund, $17,371 from an “alternative lender” (code for a private bank or lending institution), a $7,000 Board of Governors Scholarship, and three federal loans totaling $47,944. That total—a whopping $74,815—will require $519 a month in payments at a 5 percent interest rate over a 20-year term. And that only pays for one year of medical school.


Experts, of course, point to three fundamental numbers that define the debt game. The first number is how much you borrow, referred to as principal. The second is the interest rate, which can be variable or fixed. The third critical factor is the length of the loan. Although each number is important, borrowers of every kind—from credit card users to car buyers—have a tendency to fixate on the amount they are borrowing and their monthly payments, glossing over the interest rate and the duration of the contract. It’s easy to see that a tiny change in the interest rate can vastly affect the total you ultimately pay if you stretch the contract out over 25 or 30 years. Consolidation, for all that, is a risky business—not the panacea that some might think.


The best-case scenario is to pay off quickly, Kantrowitz says, and to concentrate on paying loans with high interest rates first. (Can you say, “credit cards”?) But emotion—and one’s tolerance for peanut butter sandwiches—outranks reason in many cases. When students rush to consolidate loans, exchanging smaller monthly payments for longer loans, they risk upping the total amount paid over time.


Deferments are also tricky, as unsubsidized federal loans and private loans often “capitalize the interest.” This means that if you are not paying, your principal could be growing at almost the same rate as those skipped monthly payments.


There is another option—exchanging public service for debt forgiveness. While it may reduce some specialty choices and limit earnings for a while, it one of the most efficient tracks to debt freedom.


These service programs can provide funding to students as up-front tuition payments (in other words, scholarships) or as after-the-fact contributions to¬ward paying off educational debt. The National Health Service Corps (NHSC) scholarships offer payment of tuition and fees, books, supplies and a taxable monthly stipend in exchange for a minimum of two years’ work in a “federally designated health professional shortage area.”


The Indian Health Service Scholarship Program offers a similar deal, paying all tuition and mandatory fees plus a $1,126 monthly stipend in exchange for two years of service. Military branches offer similar programs in exchange for a military service commitment.


Loan repayment programs are also available through the NHSC in the form of the Disadvantaged Health Professions Faculty Loan Repayment Program—where the commitment is to teach at a health professions school—the Fellowship of Primary Care Health Professionals Program and others. The National Institutes of Health also offers loan repayment in exchange for clinical and health services research commitments.


And, last but not least, there’s always bankruptcy, right? Well, in fact that option has been taken away. Compliments of the Higher Education Act, bankruptcy for forgiveness of student loans is no longer permitted. The ruling was backed by the United States Supreme Court last December, which voted against the plaintiff, James Lockhart, who had petitioned the court because his social security check was being docked $149 a month to pay off $80,000 in federally guaranteed loans. He last attended school in 1989, but by 1992, he was disabled as a result of heart problems and diabetes.


Garnish the social security check anyway, the court ruled. And the ruling was unanimous. ~WORD$ OF WI$DOM

Financial consultants use a plethora of “rules of thumb,” that help their clients understand the true nature of their debt load and how to eliminate it. We’ve collected a few here:


“Live like a student while you are one, so you don’t have to live like one after you graduate. Don’t borrow more than you expect will be your first year’s starting salary.”


—Mark Kantrowitz, financial aid consultant and originator of FinAid.com



“Anyone using 10 to 15 percent of their income to repay loans [is] going to have trouble.”


—Sandy Baum, senior policy analyst, The College Board


“The idea is there should be a base level of around $19,000 where really you need to spend pretty much your income to live. Anything you earn above that level, you should be able to pay a percentage of. Essentially think of a sliding scale with a cliff at the bottom.”


—Luke Swarthout, researcher, State Public Interest Research Groups


“Shop around.”


—Karin Pellmann, spokesperson for private lending institution My Rich Uncle



RESOURCES

The American College of Physicians offers a comprehensive list of scholarships, loan programs and debt repayment options available to medical students and new physicians at www.acponline.org/srf/financing.htm.
~~~Anthony Hall is a freelance writer based in Dryden, New York.~Medical Student Debt~
230~6September~2006-55~Feature~Uncommon Departures~Students leaving medical school, whether they want to or not, is a rare sight~Pete Thomson~In 1990, Satre Stuelke was 25 years old and a second year at the University of Iowa College of Medicine. He hadn’t taken any time off since his undergraduate years, but his parents—especially his mother—were glad he was settling into the career they envisioned for him. But amid the common circumstances that surround many medical students, Stuelke did something very uncommon indeed: He quit.
Stuelke packed his bags and took off. He agreed to a one-year leave of absence only because the dean suggested it. Stuelke knew when he first walked out the door that he wouldn’t be back.
“The official line was I was taking a year off,” he says now. “At the end of the year, I went ahead and I wrote [the dean] a letter that said I was not coming back.” Stuelke, who turns 42 this month, has spent the intervening years as an artist in Manhattan.~In 1990, Satre Stuelke was 25 years old and a second year at the University of Iowa College of Medicine. He hadn’t taken any time off since his undergraduate years, but his parents—especially his mother—were glad he was settling into the career they envisioned for him. But amid the common circumstances that surround many medical students, Stuelke did something very uncommon indeed: He quit.


Stuelke packed his bags and took off. He agreed to a one-year leave of absence only because the dean suggested it. Stuelke knew when he first walked out the door that he wouldn’t be back.


“The official line was I was taking a year off,” he says now. “At the end of the year, I went ahead and I wrote [the dean] a letter that said I was not coming back.” Stuelke, who turns 42 this month, has spent the intervening years as an artist in Manhattan.


For all the bluster and fear of getting kicked out of medical school and the talk of dropping out, the reality is that—on average—only 4 percent of matriculating students leave school either involuntarily or voluntarily. According to data compiled by the Association of American Medical Colleges (AAMC), 1.5 percent leave for academic reasons, 1.5 percent leave for non-academic reasons, and 1 percent leave for financial or health reasons, including death. That’s among the “average” students.


White students—who weight the average—leave school at the 4 percent rate. Asian students are slightly less likely to leave. Black, Latino and Native American students are more likely to leave, further contributing to the discrepancy in graduation rates among underrepresented minorities. Though the AAMC is working on breaking down further their reasons for leaving, that data is not yet available.


According to school administrators, students choose to leave for three common reasons: Their commitment to medicine isn’t great enough to carry them through the next eight years of training; they have trouble dealing with perceived failure—being unlikely ever to have failed anything before—or sometimes depression plays a role. Aware of this, deans counsel students thoroughly about their decision to leave and their reasoning.


For Stuelke, the reasons for leaving were multiple. He hadn’t taken time off before entering a career path envisioned more by his parents than by himself. There was a girlfriend who wasn’t interested in being with a physician. And his tightly controlled high school pre-med course load kept him from even trying his hand at art until he majored in it in college.


“I went to med school…because my parents wanted me to,” he explains. “My dad was a doctor, and there was a great deal of pressure, not so much from him, but from my mother.”


The tipping point was biochemistry. He failed the class, despite being adept at the sciences. The experience shook him.


“It’s like the people who were the smartest in high school, smartest in college or close to it, never failed anything, and didn’t even have to know how to study,” he says. “You get to med school, and you have to know how to study. And I didn’t.”


Retaking the course, he passed with flying colors. “But I still wasn’t comfortable with the fact that I had already failed something. Like most people, if you fail something in med school, it is probably the first time you’ve ever failed anything.”

PACKING UP


“The days are long gone when you accepted a lot more people than you expected to graduate,” says Dr. Scott Waterman of the University of Vermont College of Medicine. In his two-year stint as associate dean for student affairs, Waterman believes he has seen just five students leave voluntarily.


“It’s certainly significant for those affected,” he cautions, “even though it is not significant from a numerical perspective.”


Though the numbers of students he’s seen leave during his time as a dean have been too small for sweeping generalizations, he says they are mostly people who’ve decided that the time and effort of school isn’t really worth it.


No matter what a student expected of medical school, the actual experience can be surprising. “Obviously, that dawns on everybody more or less…. If they are still convinced that this is the route they want to go, that makes it feasible to put up with a life that some might not find acceptable,” Waterman says. But if someone has “more than the usual degree of ambivalence,” or if they have another career option in the back of their minds, the rigors of medical school may no longer seem like such an acceptable compromise of work and benefit.


Most of the time, discussions result in students giving school another shot rather than walking out the door, Waterman says. “So far, the students with whom I’ve had the most extensive conversations along those lines are students who haven’t left.”


NO CHOICE IN THE MATTER


“The second year is probably the toughest in medical school,” says Richard Peppler, associate dean of
academic and faculty affairs at the University of Tennessee Health Science Center College of Medicine (UTHSC). Once students have cleared the hurdles of their second year and hit the wards, they tend to perform relatively well, he explains. “Their work intensity does not decrease, but they are going in and working with patients…. They are learning the application of the foundation they got in the first two years. And they are revved up and have some sparkle in their eye.”


But first, they’ve got to get through Step 1 of the United States Medical Licensing Examination, usually taken before the third year. “Not all students pass that exam at first blush,” says Peppler, noting that about 3 to 5 percent of his students aren’t successful the first time around.


UTHSC requires students to pass Step 1, and they have three tries to get it right. “Most students will pass it within three attempts,” Peppler says. “There are a few who don’t, and they leave.” Before the student is dismissed, however, they are given the opportunity to withdraw. “We counsel them at that point that maybe medicine is not right for them. Some of them have gone into pharmacy; some have gone into physician assistant school.”


If the student is dismissed, their transcript will reflect that. If they choose to withdraw, their transcript won’t say why. The choice, Peppler notes, is a humanistic one. “They haven’t been successful; they’re devastated…. This was their career goal and they are not going to achieve it. We try to make it a little bit more palatable.”


But before they decide how they want to go, Peppler advises them to check with the financial aid office. At least one student chose dismissal because it resulted in some loan forgiveness.


Why don’t more students have to leave school for academic reasons? Peppler points to the success of the Medical College Admission Test (MCAT), saying it’s highly qualitative as far as how a student will perform through the basic science years.


In a study of the 1992 and 1993 entering classes of 14 medical schools published in the journal Academic Medicine last October, the AAMC’s Ellen Julian found that the power of the MCAT to predict a student’s scores on Steps 1, 2 and 3 was strong, stronger even than undergraduate GPA.

Step 1 is by far the biggest reason students leave UTHSC involuntarily, but even that results in very few departures. On the average since 1998, roughly one student a year leaves UTHSC for any reason.


Students dread the academic dean or professors “because they are being evaluated,” Peppler points out. “I tell them, we’re not your worst evaluators. Your two worst evaluators are you yourself, and your future patients.”


SEEKING HAPPINESS


Ross Chavez was one who couldn’t stop thinking about his life before medical school. He began volunteering in ERs in high school, and on the advice of physicians he knew, took a couple of years off after college. During that time, he secured his emergency medical technician’s license and worked in a county trauma center and volunteered with the fire department.


He started his first—and final—year at Rush Medical College of Rush University in the fall of 2003. “It was great, but at the same time, it was really hard for me to leave my job,” he says now. “I had fallen in love with being in the ER and being out on the street and doing street medicine. It was kind of a shock going into medical school and being thrown into all of the academics with very little interaction with patients.”


Away from that interaction, and without a support network in his new city, Chavez begin to feel like the eight-year commitment of medical school was more than he was willing to sacrifice. “The bottom line was that I wasn’t enjoying myself,” he explains. “Granted, the first year of medical school isn’t supposed to be fun by any means, but I just kept thinking, how could I be happier?”


The answer was to get back out onto the street as a paramedic. “Rush was a great place, and I have to give them a lot of credit,” he says of the school’s efforts to work with him. There were counselors to talk to and education specialists to help with his studies. They offered a five-year track instead of the standard four. But that wasn’t going to be enough, and after just two terms in a trimester system, Chavez left school.


There had been pressure, from outside and within, to stay. He thought about how much money he wouldn’t be making as a paramedic. He thought about family and community obligations.


Chavez was the first from his family to graduate from college, and the first to attend a professional school. He had to weigh his decision to leave against that internal pressure. “And [I had] the pressure of me being Latino, having the ability to really represent my community, and be able to make a difference in my community,” he adds. “People have a lot of high expectations and people are depending on me.”


According to AAMC data, 92 percent of Latino students graduate, four percentage points lower than the average graduation rate.


As Chavez began toying with the idea of withdrawal, though, the pressure became a bit more external. His parents, especially his father, had been critical of his plans to leave at first. “He had worked very, very hard his whole life to be able to provide his children with all of the opportunities he wasn’t able to have growing up,” Chavez says of his father. “That was hard for him to comprehend.” But he says that after they saw how miserable he was, they supported his decision. And he believes it was the right one.


Still in Chicago, he works as a paramedic and in Children’s Hospital’s ER trauma center. He feels like he’s making a difference, and that he’s on the same level as his colleagues, even if they are physicians. And he works with a lot of Latino patients.


“When I’m out on the street in the ambulance, I have a good deal of autonomy and I’m able to make my own decisions in patient care,” he explains. “Although I’m limited somewhat by my scope of practice, I’m still able to do things that I deem are necessary…. That’s a great feeling.”


LOOKING BACK


On occasion, the “what-ifs” well up for Chavez. “Some of my friends from high school are already done with medical school; one matched at the ER I used to work at and where I wanted to do a residency had I gotten that far,” he says. “And that’s tough.” He receives letters from residency programs who have him on their outdated lists. But he doesn’t have any regrets: “I think I would have had more ‘what-ifs’ had I not tried medical school at all.”


Chavez is in the process of completing prerequisites for nursing school, and hopes to begin an accelerated nursing program at Rush in January.


For Stuelke, the decision to leave wasn’t easy, and it wasn’t nearly final: This fall, he returned to medical school at the age of 42, attending Weill Cornell Medical College. His art, which he calls “physical computing,” includes techniques like designing and programming microchips to sense human presence. A similar technology is being used now by cardiologists to measure stress, Stuelke says. “The field has completely changed within the last 15 years…. Not only that, but they are doing stuff that I do with my art.”

Stuelke will, for the time being, continue to teach some art classes at the School of Visual Arts in Manhattan, but the return to medical school brings his career full circle. “In the end, it turns out my parents were right about me, because they could see things in me that I couldn’t at that young age.” ~FEAR OF FLUNKING


FAILURE. Perhaps you failed a class, or came close. Then flooded in all the thoughts about why you’re even in medical school, and whether you’re cut out for the path you’ve chosen. You’ve probably never failed a class prior to medical school, and that “F” comes as quite a blow. But one bad grade—or even class failure—is probably a long way from academic dismissal.


“It feels—at the time—catastrophic,” says Dr. Scott Waterman, associate dean for student affairs at the University of Vermont College of Medicine. The solution is often just a discussion of how medical students rarely encounter failure prior to medical school, and how that failure usually proves to be a one-time experience.


“If—but more often when—things improve, people’s perspectives then change and they realize, ‘Well, I guess that was an anomaly.’”


But some students become depressed and very self-doubting, Waterman says. “It’s not that I bring them in and talk to them and convince them not to leave,” he says. “It’s much more a matter of exploring what led them to the conclusion that they should pack it in, and then recognizing that might be a premature, rash or overly generalized conclusion based on…insufficient data.” He explains to students that there are less drastic solutions, such as tutoring or treatment for depression if they’re pathologically pessimistic or unconfident.


But don’t your feelings have some merit? What if you really are having problems with your studies?


Richard Peppler, associate dean of academic and faculty affairs at the University of Tennessee Health Science Center College of Medicine, says that for those whose academic troubles are real, an undiagnosed learning disability might be the cause. He tells incoming students to self-refer as part of their responsibility for their own learning, and the school’s academic support service gives all new students reading tests to get some groundwork covered if a student struggles down the road. Sometimes, the office doesn’t wait until a student gets in trouble, but will approach the student with some tips on working with their learning disabilities.


Academic deans, despite whatever their reputation might be around campus, could be a good source for support, or at least direction, in the event of a bad grade. There are many options for students in the midst of real academic trouble, not to mention the ones who are in real trouble only in their minds. —P.T.~~~Pete Thomson is associate editor of The New Physician. Direct comments about this article to tnp@amsa.org.~Medical Education,Student Life and Well-Being~
231~6September~2006-55~Feature~Health Beyond Medicine~What does it mean to practice socially responsible medicine in today’s world?~Avery Hurt~After years of training in the science of medicine, many new physicians are surprised to discover that most of health care doesn’t have much to do with medicine. Despite impressive advances in the understanding of disease and its causes, most of the reduction in morbidity and mortality during the past century does not seem to have been a result of improved medical technology.~Did you know? The single most important thing you can do to reduce your chances of dying young—and of suffering from debilitating disease on your way to that premature death—is to avoid poverty.


After years of training in the science of medicine, many new physicians are surprised to discover that most of health care doesn’t have much to do with medicine. Despite impressive advances in the understanding of disease and its causes, most of the reduction in morbidity and mortality during the past century does not seem to have been a result of improved medical technology.


A marked decline in infectious diseases (such as diphtheria and smallpox) actually began before the advent and widespread use of immunizations and antibiotics. And a reduction in mortality from diseases that are still not generally considered curable (stomach cancer, for example) accounts for a significant portion of the drop in mortality.


A close look at the history of disease suggests that clean water, adequate housing and improved literacy are as necessary for a population’s health as the latest in medical care. In addition, political instability and war take their toll on the lives and health of populations caught up therein. Without attention to what experts call the “social determinants of health”—matters having to do with how people live in their communities—all the medicine in the world won’t do much to improve the health of the world’s people. As Stanford neuroscientist and writer Robert Sapolsky put it in his essay, How the Other Half Heals, “There’s more to health care than vanquishing germs.”


For most of history, however, little thought was given to the social underpinnings of disease. Then the 18th-century Enlightenment movement brought the notion that governments should be responsible for the health and well-being of their citizens. Acting on the concept took some time—and the government of the largest industrialized nation in the world still seems to be having a hard time fully implementing the notion—but the idea did spawn a revolution in the understanding of the causes and prevention of disease.


By the 19th century, scholars had begun collecting disease and mortality data, and observed a noticeable difference in life expectancy and overall health between the wealthy and the poor. Even though exciting scientific discoveries, such as the germ theory of disease, captured the lion’s share of attention, it quickly became apparent that social factors influence health to a significant degree. Thinkers such as Rudolph Virchow, Edwin Chadwick, Friedrich Engels and others began to argue that if the health of the population is to be protected, the living and working conditions of the people must be addressed. The idea of social medicine was born.


The basic premise has not changed over the past 150 years or so. Socioeconomic status is still the strongest predictor of health, even as the gap between the world’s rich and poor is steadily widening, and living conditions are rapidly worsening, for many in both the developed and developing world.


ON THE FRONT LINES


Despite these discouraging facts—or perhaps because of them—social medicine is alive and well today, with dozens of organizations dedicated to enabling physicians to live out its goals. In 1999, the independent international organization Médecins Sans Frontiéres (MSF)—in English, Doctors without Borders—was awarded the Nobel Peace Prize for its work with people affected by armed conflict, epidemics and other disasters, both natural and man-made. MSF provides health care, operates clinics, builds wells, and provides food, sanitation and shelter for those in need.


Physicians for Social Responsibility (PSR), a U.S. affiliate of International Physicians for the Prevention of Nuclear War, focuses its efforts in three main areas: nuclear proliferation, environmental degradation and gun violence. Both groups were awarded the Peace Prize in 1985.


Doctors for Global Health promotes health and human rights around the world, building relationships with other groups to find solutions to issues of social justice. Partners in Health works to combat AIDS, address women’s health issues and attack the problem of multi-drug-resistant tuberculosis. On a more local scale, the Association of Clinicians for the Underserved, formed by participants and alumni of the National Health Service Corps (NHSC), works to improve the health of America’s underserved populations and provide support for the health-care workers who serve in these communities.


The American Medical Student Association (AMSA) advocates for changing smoking laws, reducing work hours for resident physicians to ensure patient safety, and campaigning for universal health care. Yet perhaps AMSA’s most effective efforts are in continually generating fresh generations of activist doctors.


It really shouldn’t be surprising that the tradition of activism in medicine is still going strong. Since social conditions are so intertwined with health, doctors are in the right place to see and address these issues. Virchow, generally considered the father of social medicine, put it this way: “Physicians are the natural advocates of the poor.” And although the mainstream medical establishment has not been known as a hotbed of social unrest, there is a rich tradition of activist doctors. After all, most people come to medical school full of idealism and a desire to make things better.


RESUSCITATING IDEALISM


Reading about and talking with the people on the front lines of social activism will cause the idealistic medical student to swoon at all the possibilities. Yet even a brief look at the realities of the current health-care system can quickly temper enthusiasm. Accomplishing change in the world has never been easy. But now it may be harder than ever. An unprecedented number of uninsured, and funding cuts for most government programs that relieve the burden on the poor, make it a difficult—if all the more necessary—time to take on the job of caring for those in need. On top of that, medical students are graduating with record levels of debt. Giving up time or income to serve in this environment can be discouraging to all but the most committed.


Dr. Gordon Schiff and Dr. Mardge Cohen, a married physician couple working at at Chicago’s Cook County Hospital, are both long-time activists. They agree that times are hard. “The environment for this kind of activism has changed,” notes Schiff. “Students are getting out of medical school in indentured servitude and they have to serve that. They have to make their way in the world. But there are more people out there doing more things than there were 30 years ago.” Adds Cohen, “In some ways, thanks to groups like AMSA, it may even be easier now.”


Even when it comes to income, they don’t see a problem. “Cook pays below average, but we still make a good living and have a pension,” says Schiff. Besides, says Cohen, “Doctors have long made too much money anyway. They can make less and still do just fine.”


While it’s yet another item for the activist agenda, Schiff suggests that the government should take on the responsibility for funding medical training. “We need to see training and development as a public service. Debt that is huge for individual students is just a fraction of the cost of training them,” he points out.


In any case, physicians work for the underserved whether they intend to or not, believes Dr. Kyu Rhee, health officer for the Baltimore Health System. He’s also board member and immediate past president of the Association of Clinicians for the Underserved. Rhee points out that most residents’ training involves working with the poor. “We learn off the backs of the underserved,” he says.


DOING GOOD WITHOUT GOING BROKE


At many community clinics here in the United States, residents’ pay can be quite reasonable and the hours something other trainees only dream about. “At our clinics, doctors work 40 to 50 hours a week [and] have evenings and weekends off,” says Rhee. “It can be a good lifestyle, a flexible lifestyle, and still offer the rewards of knowing that you are doing some good.”


Rhee notes that, in fact, any potential income losses stemming from choosing to practice socially responsible medicine can be offset by debt relief programs offered by the public sector. Federal, state and local governments have many loan forgiveness programs for clinicians who work in underserved areas.


For example, the NHSC loan repayment program often gives $35,000 tax-free in loan forgiveness for each year served. Thus, if you were to add the average starting salary of a primary-care physician in an underserved community, approximately $120,000 + $35,000 tax-free, that equals a $155,000 annual salary. If you have an NHSC scholarship, which pays for tuition, stipend, and books for each year of service in an underserved area, your starting salary as a primary care physician in an underserved area could equal approximately $120,000 plus $70,000 in savings on money never borrowed, for $190,000.


When you factor in the offsetting of loans for doing this kind of work, the financial package can rival that of a cardiologist in private practice, and the hours are far better.


While Rhee does not downplay the challenges and frustrations of dealing with a health-care system that, as one activist put it, fights you at every turn when you are trying to help people, he does point out that you are not alone. “If you think of yourself as out there alone on your own island trying to do this, you’ll be overwhelmed. But if you work as a team, with nurses, social workers and all kinds of other people who are trying to do what you are trying to do, you’ll find it much easier,” Rhee says.


But for many who dedicate their professional lives to socially responsible medicine, in the end it is not a financial or even practical question. Dr. Lanny Smith, who works at a community clinic in the Bronx and is a leader in the socially responsible medicine movement in the United States, has this to say: “The situation right now is discouraging. There are people in high positions of power who are very threatened by the idea of health care for all. Yes, the environment could be friendlier, but it has been worse. Once, we didn’t have Medicare and we didn’t have Medicaid. We have a lot of work to do in the U.S. but we have a lot to work with, too.”


In any case, the odds don’t have much to do with the motivation, according to Smith. “I don’t think you’ve got to say ‘things are getting better so I’ll keep doing this,’” he says. “We must keep doing the correct thing whether it is working or not. We have to work to change the system so that it treats humans as humans. If I don’t do that, I am failing people—and what’s more, I’m failing myself.”


TEACHING UNCERTAINTY


Most people get involved in activism during their student years, no thanks, for the most part, to the medical school curriculum. “Medical training does not prepare you for this,” says Rhee. “We’re trained to think in terms of pathology and disease rather than health, and to treat people with pills and procedures. But health is about far more than that. Socio-economic status, the ability to read, whether or not you have a job, family support, decent housing—all these things are essential components of health or lack of it,” he explains.


Elisa Margolis, an M.D./Ph.D. student at Emory University School of Medicine, agrees. “The medical establishment thinks that if they teach you the science, you’ll figure out the rest of it along the way.”


Margolis came to medical school after doing a Fulbright in Bolivia, studying how improved housing could mitigate Chagas disease. She has worked with several non-governmental organizations, including PSR. “In medical school you are judged on grades and how well you can jump through hoops. No one is there trying to help you do it any differently,” she says. “In medical school there is always a right and a wrong answer; there is little debate about what the problem is.”


Few would disagree with Margolis’ assessment, and many are trying to do something about it. At Brown Medical School, Dr. Jay Baruch of the Center for Biomedical Ethics and Dr. Alicia Monroe, professor of family medicine, inaugurated a course in social medicine. Baruch and Monroe designed the course to address just the kinds of problems that distress Margolis.


“We wanted to get them out of the mindset of hard science and into the world of uncertainty that is practicing medicine, where there is not always a right and wrong answer,” Baruch explains.


The response to the course has been overwhelming. It is a popular offering, and students have commented that they’d never thought about issues of social medicine before taking the class.


Dr. Tim Holtz, adjunct professor of international health at the Rollins School of Public Health at Emory University, teaches a similar course. Holtz believes that small projects in school are what help launch careers in socially responsible medicine.


One of his students is a good example—although there is nothing small about the projects Brandon Kohrt takes on. Kohrt, an M.D./Ph.D. student at Emory, worked with Holtz to establish the Atlanta Asylum Network, a center for treating victims of torture. He will be spending next year in Katmandu, working at a center for victims of torture there.


While Kohrt enjoyed Holtz’s course and seems to be putting it to good use, he notes that if you want to get active, you have to create your own opportunities. “Seek out mentors and professional organizations that will support the kind of work you want to do,” he recommends.


SMALL IS BEAUTIFUL


As inspiring as it can be to hear stories of people caring for torture victims in Nepal or solving medical mysteries in Bolivia—or even facing down the establishment right here at home—practicing socially responsible medicine doesn’t have to be big and flashy to be effective or sorely needed. “Social medicine is more a way of thinking about health care than it is just volunteering,” says Shankar LeVine, a second-year medical student at Brown.


Although LeVine grew up in India with parents who were involved in public health initiatives, and is himself active with Doctors for Global Health, he sees the value of simple measures.


“Even in a few minutes with a patient, a doctor can put in a few words about the dangers of smoking and the benefits of exercise. He or she can ask about the patient’s home life and be aware of the cost of medications he or she is prescribing,” he says. “This doesn’t take any more time than what you are already doing, but can make a big difference.”


Little things do count. Much good would be done if every clinician who decided to stay close to home and simply practice good medicine would try to be aware in his or her daily practice of the bigger context of health—to look beyond the consulting room and into the community, to learn to see beyond the disease to the patient, to make an effort, as Smith says, in treating human beings as human beings. “Ah, yes,” says Holtz, “small is beautiful.”


REWARDS


Despite its obvious rewards and satisfactions, this kind of work is hard and can be draining. This is not work for people who need instant gratification, says Margolis. How do people keep it up year after year, especially when the situation doesn’t seem to be improving?


It’s not, it seems, the small successes that keep people going, for in many situations even small successes are few and far between. Nor is it necessarily the hope that the goal is just around the corner: Even the most optimistic do-gooders don’t believe that. But what does sustain them, and what are always there in this kind of work, are relationships. Whether with patients or with fellow health-care workers, it is that community of socially committed human beings that holds on to each other and supports one another.


“Getting to know patients, getting to be a part of so many lives,” is important to Cohen. “Knowing that you are a part of the challenge to the current health system keeps you strong and young, too,” adds Schiff.


Dr. Jennifer Kasper, president of Doctors for Global Health and clinical assistant professor of family and community medicine at the University of Arizona Health Sciences Center, says she treasures the relationships she has with other people who share her values. “It is energizing to be with like-minded individuals,” she says. “Staying in touch with people around the world who are doing this kind of work is very sustaining.”


Kasper practices in Tucson, Arizona, and recently invited to her home 25 or so people, all involved in global health in one way or another. Keeping in touch this way provides a network of support and prevents you from, as Rhee put it, feeling like you are working on an island all by yourself.


When asked if it was possible to practice socially responsible medicine in today’s health-care environment, Cohen says simply, “There is no other way to be a doctor.” If indeed the doctor’s job is to “remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm,” then she is absolutely right. There is no other way to do it.


And as more physicians become aware of the opportunities and responsibilities they have as healers in a world where health is a matter of so much more than dispensing drugs, they will soon see the enormous changes that can be made when we simply treat humans as humans. ~The October 2006 issue of PloS Medicine will focus on the topic of social medicine with articles by authors such as Drs. Paul Farmer, Tim Holtz, Rafael Campo, David Satcher, Leon Eisenberg, Arthur Kleinman and others. Access to the journal is free and available at www.plosmedicine.org.


RESOURCES


For more information on some of the most active organizations involving socially responsible medicine, Many have student chapters and welcome student volunteers.

Association of Clinicians for the Underserved
www.clinicians.org

Doctors for Global Health
www.dghonline.org

Health Volunteers Overseas
www.hvousa.org

International Physicians for the Prevention of Nuclear War
www.ippnw.org

Medécins Sans Frontiéres/Doctors without Borders
www.doctorswithoutborders.org

Partners in Health
www.pih.org

Physicians Committee for Responsible Medicine
www.pcrm.org

Physicians for Social Responsibility
www.psr.org
~~~The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.
~Advocacy,Community and Public Health,Ethics,Health Disparities,Humanistic Medicine,International Health,Medicine in Popular Culture,Minority Affairs,Practice of Medicine,Universal Health Care~
309~7October~2006-55~Letter from Afield~Living With the Monks~Refugee medicine in India~Sriram Shamasunder, M.D.~Among the monks~The largest Tibetan refugee colony in the world lies five hours from my grandmother’s house in Bangalore, India, where I spent the summers of my childhood. Neither my mother, nor my father, nor most of my Indian relatives who grew up in Bangalore knew of its existence—despite the fact that it houses more than 10,000 refugees.

I first heard about the colony when I decided to spend a part of my final year in medical school in India. In 1959, His Holiness the Dalai Lama was forced into exile as China invaded Tibet. As thousands of Tibetans followed him to India, the settlement at Bylakupee was established with the help of the Indian government, housing an initial population of 3,000 settlers. The present population is more than 10,500. The hospital attempting to serve the Tibetan refugee population desperately needed medical volunteers, and I wanted to experience rural medicine in India. I also liked the idea of returning to my ancestral home state of Karnataka and improving my Kannada. Though I was unsure how much of the language I would get to use, the rural location would allow me the chance to work with a refugee population that had been in India for generations.

After leaving Bangalore, I passed village after crowded village with their dozens of tea stalls and street food dabas, finally reaching a stretch of green forests and farmlands. The climate eased from suffocating heat to a cool, about-to-rain comfortable. The color of the faces turned from the familiar, beautiful brown to a lighter East Asian complexion. Out of the green earth rose several massive Buddhist temples and universities. Eventually I arrived at “fourth camp,” where I was to work, providing medical care to more than 3,000 monks and 600 nuns, mostly from Nepal. I had entered a place with entirely different notions about life’s purpose and productivity.

For example, soon after I arrived, I pointed out to a monk that a mosquito was sucking his blood. He nodded in acknowledgement and said something brief about the accumulation of merit and allowing another being to nourish itself off your own. (Luckily, we were in a region where the prevalence of malaria is low.)

Dining with another monk at the local Indian restaurant, a fly fell into my daal. The monk rescued the insect from the spicy bean soup and rinsed it with water. By the end of our meal, the fly was dry and ready to depart.

To go along with my many new experiences, the hospital was like none I had ever seen. There was no doctor. The last one—a retired physician from the city hoping for some extra money—had stayed on less than two months.

About a year and a half before I arrived, as the hospital first struggled to get off the ground, its only mainstay was Sherap Lama, a 30-year-old monk and schoolteacher who’d seen too many oozing, pus-filled ears, belly aches and children dead from unknown causes. Sherap studied a copy of Where There Is No Doctor and started a clinic to promote hygienic conditions in the monastery. At the time, more than a dozen boys were clumped together to sleep in each small room. Monks or not, groups of young boys with parents nowhere in sight do not willingly wash. People said that before Sherap set up his clinic, the stray dogs looked better than the children. He made enough progress in his project that the nuns soon grew interested and began their own clinic.

I spent my mornings at the monastery’s makeshift clinic and my afternoons at the nunnery clinic. At 7 a.m. the young monks would line up to see me. In my first week at the clinic, I met a 14-year-old boy who was coughing up blood. Crowded conditions caused the quick spread of serious ailments like tuberculosis (TB), so more boys with chronic coughs and blood-tinged spit started to present themselves.

The closest government distribution of medications was about 10 minutes away by car, in first camp, so I went to speak with the Indian government doctor in charge about the high rates of TB I had noticed. He knew the reality of fourth camp well: Six other monks had started treatment after they began coughing up blood, and another three had died of an “unidentified sickness.”

With highly effective treatment so close by, it seemed unacceptable to me that so many cases of TB should go undiagnosed and untreated. The government doctor gave the excuse that Tibetans were noncompliant by nature and difficult to keep track of since they regularly travel between different Tibetan colonies all over the country, and would not be able to follow up on their long-term treatment.

The reality, however, was that although the government had state-of-the-art treatment, it did not provide a doctor or health-care worker in the camp and had no program to train others to recognize TB symptoms, so many monks would continue to go undiagnosed until they coughed up blood and came forward on their own accord—all the while spreading the disease to those sleeping a few feet from them.

If a monk can show so much concern for the fate of a fly, I thought, surely we can muster up enough courage to stop him from dying needlessly in front of our eyes.

As my short month came to an end, it became obvious that we must start one on one, patient by patient, and expand out to include so many things we never considered to be medicine—race, poverty and class. Doctors must understand structural inequality and its underpinnings. We must understand the politics of funding projects—where the money comes from, where it is going and why. We must repeat the stories of those who died and examine the commitments, financial or otherwise, that could have prevented it.

Of so much good news from the subcontinent, the status of TB in the Tibetan colony is not part of it. But the key is to make it news—maybe it will turn good. As the poet June Jordan says, “We are the ones we are waiting for.” There are only so many like Sherap Lama who are ready and willing. I hope to be among them.

Sriram Shamasunder is an internal medicine resident at Harbor-UCLA Medical Center.
~~~~~Community and Public Health,Humanistic Medicine,International Health~
310~7October~2006-55~Perspectives~Big, Beautiful and at Risk~Countering black women’s body-size ideals~Michelle D. Wilson~A positive self-image can be deadly~“Pretty women wonder where my secret lies / I’m not cute or built to suit a model’s fashion size / But when I start to tell them / They think I’m telling lies. / I say / It’s in the reach of my arms / The span of my hips / The stride of my steps / The curl of my lips. / I’m a woman / Phenomenally / Phenomenal woman / That’s me.”

Maya Angelou’s paean to the big, beautiful black woman surely inspires many to take pride in their large bodies. But such attitudes may be doing more to harm the health of black women than they realize.

The Centers for Disease Control and Prevention (CDC) recently reported that 78 percent of black women in America are overweight, and fully half are obese. These percentages dwarf those of the national averages by 14 percent and 20 percent, respectively, and put black women at significantly higher risk for hypertension, coronary heart disease, type 2 diabetes and certain types of cancer.

Being obese or overweight is not limited to lower-income black women. Although socioeconomic barriers limit access to healthy foods for some, this does not adequately explain the heightened rate of obesity among black women. According to the CDC, black women across all socioeconomic groups are disproportionately affected. Also, if the weight issues affecting black women were mainly a function of food availability, black men would also have heightened obesity rates, but the rates of overweight and obesity among black men are below the national averages, putting black men and black women at opposite ends of the weight spectrum.

Instead, black women’s body-size ideals may be the culprit. A study from the Feinberg School of Medicine at Northwestern University reports that white women express “body discrepancy” (discrepancy between their current weight and their ideal body weight) at a body mass index (BMI) of 24.4, below the criterion for being overweight (BMI=25). Black women, on the other hand, express body discrepancy at a BMI of 29.2. This difference is equivalent to 30 extra pounds in a woman of average height.

Another study, from the Pennington Biomedical Research Center at Louisiana State University, found that among a group of overweight women, 83 percent of whites, compared to 55 percent of blacks, were likely to accurately perceive themselves as overweight.

Developing intervention strategies to lower the perceived ideal BMI among black women has been difficult. Firstly, denouncing black women’s body ideals may be damaging psychologically. Historically, the physical appearance of black women—dark skin, Afrocentric features, kinky hair—has been antithetical to popular conceptions of ideal beauty. There are fears that critiquing ideal body weight for black women may damage an already demoralized group. But although this concern is valid, there are many black women like me who would rather face such uncomfortable truths if it means improved physical health.

Secondly, the popular media show strong efforts to counter the cultural perception of thin women as the ideals of beauty. Dove’s current “Campaign for Real Beauty,” for example, features women who are heavier than typical models wearing only underwear. The slogan declares, “New Dove Firming. As Tested on Real Curves.” Dove wants women to be accepting of their body sizes. But for many black women, their abundant curves put them at risk for a variety of diseases. Although campaigns like this might greatly benefit some women, they cause disproportionate harm to black women and encourage an epidemic-level problem.

The rate of obesity among black women is increasing rapidly with each passing year, and the gulf between average obesity rates and those of black women continues to widen. Public-health officials must begin using the understanding of black women’s body-size ideals to counter this epidemic. Research must be done to determine the contributions of the media, black female role models and body-size ideals held by black men in perpetuating the problem. But even before the results are in, steps must be taken now.

Figure Rating Scales—drawings of figures ranging from thin to obese used for evaluating body image—should be used by all physicians and incorporated, like the CAGE alcohol screening and the domestic violence screening, into any thorough patient history. When a woman visits her physician, she should be shown the Figure Rating Scale and asked to identify her body-size ideal. If a patient chooses a BMI ideal that is considered overweight, she should be informed that women at such body sizes are at increased risk for numerous chronic diseases.

This very cost-efficient method lets both the physician and the patient know that her body-size ideal is contributing to her weight problems, and future counseling strategies can be targeted accordingly.

In addition, the media should be used to enhance public awareness of the relationship between black women’s body-size ideals and obesity. Television and radio talk shows on the topic of black women’s body image and health often portray unhealthy body-size ideals in a positive light, suggesting that these ideals protect black women from eating disorders and the associated health problems. Model and television host Tyra Banks, for instance, has told her audience, “Black women don’t have the same body-image issues as white women. They are proud of their bodies.”

The public needs to hear the other side of this issue. Public-health officials should encourage the Black Entertain¬ment Television network and the “Oprah Winfrey Show” to host programming featuring health professionals who can explain the role of body image in the heightened obesity rates among black women, and also speak specifically on the devastating health consequences.

Obesity among black women is an issue too important to ignore. Equity in health care means making a concerted effort to eradicate health problems suffered by all groups, including marginalized communities. This epidemic is an opportunity to demonstrate our commitment to indiscriminate justice.

Michelle D. Wilson is a second-year at Mount Sinai School of Medicine.~~~~~Community and Public Health,Medicine in Popular Culture,Minority Affairs,Women in Medicine~
314~7October~2006-55~Feature~SPOTLIGHT: Simply Telemedicine~A Q&A with Jay Sanders, M.D.~Martha Frase-Blunt~Think telemedicine is too expensive and complex for your future practice? Then think more simply. Dr. Jay Sanders, pioneer of the earliest applications of distance medicine, explains how basic, off-the-shelf tools like cell phones and secure e-mail messaging are changing concepts about caring for patients remoteley.~Just five years ago, telemedicine was being hailed as the high-tech solution for delivering advanced care to isolated and underserved populations. Breathless journal articles touted futuristic concepts like virtual reality, live video teleconferencing and robotics as 21st-century methods for allowing doctors to diagnose and heal patients from great distances.

That was the idea, anyway. But telemedicine failed to capture practicing physicians’ imaginations in the ensuing years.

Dr. Jay Sanders has been a leader in the evolution of telemedicine since the 1960s and pioneered the first in-home telemedicine devices. He is currently president emeritus of the American Telemedicine Association and adjunct professor of medicine at the Johns Hopkins University School of Medicine. The New Physician recently spoke with him about how expectations for telemedicine have changed over the years, and what’s in store for future physicians.


TNP–What happened to the high expectations for telemedicine we saw just five or six years ago?

JS–Telemedicine initially was conceived to address the geographic or circumstantial isolation of many patients, so the early focus was to provide access to subspecialty care for rural communities, prisons and the like. Early applications utilized high-tech videoconferencing equipment—most with diagnostic devices like stethoscopes and microscopes attached. This set-up required a room-sized facility and bandwidth that didn’t exist for the most part. Primary care physicians would have to travel to the teleconferencing site, and it was often seen as an inconvenience. The equipment was expensive, and insurance, most importantly Medicaid and Medicare, wouldn’t cover the physicians’ time.

But now the perceptual definition of what constitutes telemedicine is undergoing a real shift. It has dawned on many of us that perhaps our whole concept of where the exam room needs to be has been wrong all these years—it’s not where the physician or nurse is, it’s where the patient is.


TNP–How would you define telemedicine today?

JS–Telemedicine—or “telehealth” as it’s often called these days, is quite simply the electronic transmission of health information from where it exists to where it is needed. It’s less about the technologies involved and more about the information exchanged and the setting in which care is given. Over the past five or six years, there’s been a dramatic interest among some academic medical centers, like Partners Healthcare in Boston and the University of Arizona—and particularly at Veterans Affairs medical centers—to provide health care in the home.


TNP–What has enabled this change to occur?

JS–Really rapid improvements in telecommunications and enabling technologies—cell phones, PDAs, high-speed Internet—mean that the tools are now fundamentally off-the-shelf and affordable. It’s been a seminal change that’s dramatically impacting perceptions of—and actual—patient care.


TNP–In what way?

JS–The idea is simple and logical: We know that patients coming to the ER—especially those with chronic illnesses like CHF [congestive heart failure] and diabetes—began their downhill course leading to an ER admission weeks ago. If it had been possible to identify the beginning of the downhill process—like the CHF patient suddenly gaining weight—we could have determined she was retaining fluid. If we had intervened before she arrived at the ER in pulmonary edema, she could have avoided hospitalization. And, of course, that is the major cost of health care.


TNP–How complex is the technology for this type of intervention?

JS–Medical students are using these tools every day but calling it the Internet, e-mail, text-messaging and the cell phone. Many of the technologies they need in this new medical environment are in their pockets right now. Many companies are marketing cell phones, PDA software and other devices that can monitor blood pressure, glucose, weight and other health-care data. Even an off-the-shelf digital camera can be deployed in telemedicine: If a patient presents to you with a strange rash, just take a picture of it and digitally send it to the dermatologist for an immediate diagnosis.

TNP–Do you see telemedicine evolving as a prevention tool?

JS–Yes. Now we can talk about patients as consumers who want to prevent disease and even premature death. You’ve heard countless times about the elderly person “dying peacefully during sleep.” That might sound comforting to you, but not to me! It could have been a totally recoverable event. The patient could have developed ventricular tachycardia during REM sleep, which deteriorated into ventricular fibrillation, and never woken up. But a simple wireless monitoring device worn on the wrist or inside the pajama top could constantly assess the pulse during sleep, activating an alarm, and that person could have been saved by a spouse or family member with an automatic external defibrillator, now widely available for home use.

Today, companies like Tyco and its home-security company ADT are marketing home health monitoring devices as part of a total customer package.

TNP–What patients would benefit from this type of 24/7 monitoring?
JS–Patients with family history or past episodes of multifocal ventricular ectopic beats would be ideal for this. But for any one of the 400,000 people who die of sudden cardiac arrest in the United States each year, my prediction is that few of them had symptoms for the first time—they just weren’t identified before the arrest.


TNP–What are some other advantages of ongoing patient monitoring?

JS–Continuous monitoring of certain conditions through telemedicine is a bigger change to health delivery than you might imagine, because it lets physicians evaluate individual patients, rather than using a statistical norm. For example, someone with normally low blood pressure might experience a slight elevation, but still be within the statistical safe zone. But the fact is, it’s not “normal” for that person. If the vascular endothelial cells are accustomed to a BP of 100/60 and it’s now 115/75, those cells are going to be affected. Without ongoing monitoring, we’d have no idea what that patient’s daily swings are over a prolonged period of time that may indicate a problem. With it, we have a mechanism for practicing individualized medicine, freed from statistical “norms.”

TNP–How much more time will this type of monitoring require of physicians or other health professionals?
JS–It doesn’t require doctors and nurses to be available 24/7 scrolling through data. We can maintain “cyberfiles” on each individual being monitored, and when he or she exceeds personal norms, an alert goes out to a call center, to a nurse or nurse practitioner who can then access the patient via cell phone, e-mail or even a TV monitor.


TNP–Besides the home, where else can telemedicine be applied?

JS–Wherever the “consumer” may be. I applaud all the enthusiasm for home health care, but let’s not get caught up in the location—let’s think about it in terms of functional needs. With a little telemedicine, a child prone to asthma attacks can be monitored and treated at school, without having to go home or wait until the end of the parents’ workday when only the ER is open. And I believe the next major move will be into worksite care. What’s never talked about in the hand-wringing about employer health-care costs is the uncalculated lost productivity when the worker is regularly taking two hours off to go to the doctor for a blood pressure check. That worker can now do it from his desk.


TNP–How do patients feel about it?

JS–Patients seem even more receptive than practitioners. They love this technology. Every study done to assess impact and adaptation by patients has been overwhelmingly positive. The patient develops a sense of security and is much more likely to be compliant with physician instructions. For instance, if the physician has simply spoken to a patient in the exam room, by the time she gets home, she has retained only about one-third of the information. One of the nice things about a patient getting an e-mail from her doctor is that she can always go back to review it.


TNP–Are we seeing growth in physician-to-physician telemedicine as well?

JS–Yes. Perhaps the biggest area for this is teleradiology, which is widespread now. It’s much cheaper and more secure today to exchange images electronically—you don’t have to pay for film storage or replace lost films. Rural hospitals that have only one radiologist can contract out film-reading during off-duty hours.

What’s also exciting is how neurologists are using telemedicine in treating stroke. A patient has a three-hour window after a cerebrovascular event to begin receiving thrombolytic therapy, but in a small hospital with no neurologist on staff, that window might close in the time it takes to transport the patient to a larger facility. Massachusetts General Hospital is pioneering “telestroke services” in which a smaller community hospital or primary care physician can transmit images and data to Mass General’s neurology service for diagnosis, and can be walked through giving the appropriate treatment.

In this way, telemedicine is also an educational tool for physicians. Multiple studies show that when a primary care physician uses telemedicine to consult with a subspecialist while he and the patient are in the exam room—say, through a real-time audio-video interchange—he learns more. It’s like a bedside education for him. As primary care physicians learn, they create fewer, not more, consultations. They are learning how to treat the problem better.


TNP–What are medical students learning about telemedicine?

JS–It’s true that most medical students and residents don’t know much about telemedicine, but they may not realize just how much of it they are using day to day right now. Communicating with patients via e-mail is telemedicine. Using the fax, even the phone, fits into the definition. But getting a grounding in the more complex technologies really depends on your school and how enlightened the faculty are. I suggest you read as much as you can, ask questions, and press faculty to talk about telemedicine in the classroom and on rounds.


TNP–For new physicians wanting to practice this type of medicine, what technologies should they invest in initially?

JSJS–It depends on the specialty. A dermatologist or a surgeon concerned with wound healing, for example, may want to invest in digital cameras: A patient would use the camera to send images of the skin or wound so the physician can monitor healing. A cardiologist may want to provide a digital scale to patients with CHF to monitor weight. These are all off-the-shelf technologies, inexpensive and readily available.

For every physician, regardless of specialty, the most important device is, simply, the computer. Secure messaging between patients and physicians, and physicians and physicians, is the bread and butter of telemedicine today.

Martha Frase-Blunt is editor of The New Physician.

What do you think? Send comments about this article to tnp@amsa.org.~~~~~Career Development,Learning Tools and Technology,Medicine in Popular Culture,Practice of Medicine~
315~7October~2006-55~Feature~Pharm Freedom~Rejecting the sly tactics of the drug marketeers~Anthony C. Hall~Those "free" pens, lunches and luxury junkets offered by smiling, well-groomed pharmaceutical reps come at a cost to your patients. Do you have the will to join the resistance?~When a humble third-year at the University of Kansas School of Medicine puts on her lapel pin that reads “No Free Lunch,” it has all the earmarks of a Vietnam War-era protester wearing a “Stop the Bombing” pin.

In fact, when Paige Hatcher, wearing pins and carrying pamphlets, strides down the hospital corridors on her rotations, the telltale signs of youth-on-a-mission are all there. There’s a sizeable dose of charge-ahead idealism, a mischievous sense of bet-you-didn’t-see-this-coming, and the grass-roots improbability of taking aim at a system so entrenched that it is frequently described as the cultural norm.

“I’m OK with being seen as a troublemaker,” says Hatcher, whose sense of principles steered her toward a medical career in the first place, and has now put her head-to-head against an economic force akin to an iceberg. The pharmaceutical industry, while hardly unmoored, is a massive corporate infrastructure with only the most docile 10 percent visible above the surface.

Hatcher understands too well that refusing a free lunch or a complimentary stethoscope—in the name of unbiased, evidence-based medicine—might affect her relationships with attendings and other hospital staff, and not for the better. Still, she says, she will forge ahead with her message: “We cannot be bought.”

The “pharm-free movement,” as it is often called, pits student resisters like Hatcher against a corporate behemoth of an almost unfathomable size. Dr. Marcia Angell, former editor of the New England Journal of Medicine (NEJM), and author of The Truth About the Drug Companies—How They Deceive Us and What to Do About It, coined the phrase “mega-colossus” to describe this industry, which achieved worldwide sales of more than $400 billion in 2002.

With the largest Washington, D.C., lobbying presence of any industry by far, pharmaceutical companies appear prominently among the Fortune 500, and rank as the third-richest industry group, behind banking and oil. This level of success represents some serious purchasing power, laser-honed public relations savvy, and enough lawyers and lobbyists, it would seem, to lie down head to toe and encircle the nation’s capital.

Pharmaceutical marketing tactics stretch from the courtroom, where blue-chip companies battle it out with generic upstarts to maintain patent monopolies, to research and development efforts, to the activities of 90,000 well-groomed drug reps who congenially dole out pens, lunches and exotic “seminar” trips to gain access to prescribing doctors who may be swayed to favor a particular drug.

Even clinical trials are employed as marketing devices. For example, in June 2005, the NEJM reported that a series of drug trials for a promising new compound called torcetrapib, owned by Pfizer Inc., all linked the use of the drug to another Pfizer product, Lipitor, which happens to be the best-selling drug in the world. This approach would tie torcetrapib’s approved use to a guaranteed blockbuster, owing that future prescriptions would have to be written for both. Pfizer responded quickly, denying the trials were a marketing scheme.

In 2002, the Pharmaceutical Research and Manufacturers Association (PhRMA) created industry guidelines meant to curtail snazzy physician perks like new golf bags and luxury cruises, but many argue that the battleground has shifted only slightly. The guidelines are voluntary, self-policed and permeable, allowing gifts under $100—which still have a tendency to leap unchecked from boxes of donuts to box seats—and with no limit to how often the $100 is available. Besides, according to former drug rep Gene Carbona, now Executive Director of Sales for The Medical Letter, these salespeople have a counter-intuitive agenda: They are not praised for saving their companies’ money; they’re praised for spending—on doctors.

Young, stylish, articulate sales reps who often look like runway models are trained by prominent psychologists from top-shelf schools and by color consultants from Macy’s, Nordstrom’s and Bergdorf Goodman. They are trained in articulation and body language. And they are taught to artfully sidestep questions when profits and clinical data come into conflict, Carbona reports.

The training has one overriding purpose, he discloses: “They taught us [drug reps] how to create this quid-pro-quo environment that needs to exist for doctors to associate a drug rep with a product.” Pharmaceutical companies also hire consulting firms like Lathian Systems Inc., which develops sales-training presentations with titles like “How to Unlock the Mysteries of Physician Behavior.”

No sale yet? Try sex appeal. According to a New York Times report published last November, pharmaceutical companies now actively recruit female college cheerleaders—for their enthusiasm, among other things—to fill the ranks of door-to-door marketing staff.

Analysts now say there is one pharmaceutical sales rep for every four to seven U.S. physicians, all presenting their gifts and their pitches at any venue they can find. “No matter what you do, you simply can’t beat the force of 1 million face-to-face discussions that occur in the country every day,” says Carbona.

Even in this era of self-imposed restrictions on gift-giving, industry marketing expenditures have soared, reaching an estimated $5.5 billion last year, “which is more than medical schools spend to educate students each year,” according to Rep. Henry Waxman (D-Calif.), who has studied pharmaceutical issues since at least 1984, when the Hatch-Waxman Act was passed to help stimulate the generic drug industry.

The act, however, simply put marketing in the hands of attorneys. Industry lawyers have exploited the law’s loopholes to extend their monopolies on making blockbuster drugs and try to “evergreen their patents,” Waxman said.

According to industry watchdogs, pharmaceutical corporations’ marketing strategies include stretching out patent monopolies; adding expensive but marginally useful new drugs; and pressuring medical specialty associations to lower diagnostic criteria for certain diseases like high blood pressure or diabetes, thereby creating more drug consumers.

“It’s ridiculous,” scoffs Dr. Michael Wilkes, vice dean of the University of California, Davis, School of Medicine. “The reason we had a 25 percent rise in the number of diabetics is that we changed the definition.”

It is against this backdrop that Hatcher and others have vowed to refuse gifts from pharmaceutical companies. They have seen medicine’s image tarnished by public disclosures that paint almost every aspect of the profession as failing to resist the temptations placed before it by drug companies locked in on their profit margins. “The goal is restoring professionalism to the medical profession,” says Jay Bhatt, president of the American Medical Student Association (AMSA). “The public has certainly lost its faith and trust in physicians and, for better or worse, ‘Big Pharma’ has gotten intricately involved in every aspect of medical education and medical practice.”

To challenge students to consistently refuse pharmaceutical perks, AMSA promotes resistance through its national PharmFree Day, this year on Nov. 15, and an ongoing “counterdetailing” campaign that prepares students to educate others, including fellow students, physicians and patients, about evidence-based prescribing practices and the downside of accepting even the most innocuous industry gifts. As one of the rare medical organizations that accepts no pharmaceutical industry money at all, AMSA also asks medical students to sign a pledge that declares they will walk away from pharmaceutical freebies.


The Weight of That Pen
But how effective are the lunches, pens and notepads handed out by pharmaceutical representatives in buying access to doctors and their prescription pads? Studies published in the NEJM, the Journal of the American Medical Association and the American Journal of Bioethics consistently point to a correlation between gifts large and small and prescription-writing habits—studies given further credence by the simple fact that drug reps continue to do it.

In other words, the pens and paperweights are heavier than they appear. A pen with Pfizer’s name on it not only reminds doctors of Pfizer’s product line, but gains a Pfizer representative access to the office—as does a box of cookies, a happy-hour invitation or a pizza donated to the office staff.

“It’s as simple as if I called on you once a week, came in, shook your hand, brought your staff donuts or bagels, and just chewed the fat with you a little bit, [talking] about your children or football,” says Carbona, who speaks to medical groups around the country about drug-marketing tactics. “And if I knew you were a sports enthusiast, I’d give you some box seats to the New York Jets or whatever team you liked, and it’s a long-term relationship that’s being built.”

But their most successful tactic, Carbona believes, “is that these likeable, good-looking, well-dressed, affluent, articulate humans are coming into these offices, and they’re creating relationships with the secretaries, with the technical staff, with the physicians themselves, and saying, ‘What can I do to get you to write my product? You’ve got to write a product anyway; why not write mine?’”

So, what’s wrong with that? “They’re not maliciously out there telling a mistruth, but they’re not scientists; they’re not doctors; they’re not pharmacists,” Carbona says.

“Both on the real side and on the impression side, it’s a huge problem,” agrees Wilkes, who calls gifts “bribes and kickbacks” and offers a bitter analogy: “That’s why the military isn’t allowed to take small gifts from the makers of bombs and airplanes.”

Another common practice is to prop up physicians for the industry. Drug companies publish articles in lesser-known clinical publications that are ghost-written by corporate flacks but carry a practitioner’s byline. Physicians who mention their enthusiasm about a product to a drug rep could be asked to speak at a local specialty group’s monthly dinner. It’s a dynamic that works by mutual flattery: For the event, the doctor is paid an honorarium, but the dinner is, of course, free to the doctors in the audience, because the pharmaceutical company—without much noise about it—is paying for both.

Take the case of Dr. Dan Diamond, a family practitioner from Silverdale, Washington. When pharm reps began asking him to speak to physician groups, he found it lucrative, rewarding and requiring no heavy lifting. In time, he began his own “marketing consulting firm,” which he calls NogginStorm, LLC.

Polished as a speaker at pharmaceutical company trainings, Diamond now provides “motivational presentations” for such giants as Eli Lilly, Wyeth, GlaxoSmithKline, Novartis and Pfizer.

But NogginStorm’s own Web site, several pages long, makes little mention of science. Instead, it boasts of Diamond’s ability to present “mind-catching images, illustrations and animations to engage adult learners.” The doctor uses “dramatic multimedia presentations, audience participation” and even “live game shows” to get his points across. Although still practicing medicine, he’s found public speaking even more rewarding, “because I can impact more people that way,” Diamond says.


Bribery 101
The bribes might start during your first year in medical school with a stethoscope from Pfizer bearing a handsome logo on the back. Or it might be a coffee mug from Abbott Laboratories, a textbook from Wyeth or a pen from Merck. Prominently branded bookmarks, measuring tapes, paperweights and desk clocks create the impression that doctors are sponsored “like NASCAR drivers,” says Bich-May Nguyen, a third-year at Baylor College of Medicine and coordinator of AMSA’s Pharmaceutical Health Policy Action Committee. “I always ask people, what do you think of a doctor who has a drug company pen in his pocket, or a label on his stethoscope, or a label on those little ID cards you pin to your coat pocket? How do you feel when you see all those brand names pinned to the doctor? Do you really think that doctor is being unbiased?”

Newly enrolled medical students might embrace pharm-free practices initially, but according to Justin Sanders, a third-year at the University of Vermont College of Medicine and AMSA’s PharmFree coordinator, “You’ll see how much resistance [to gifts] can break down in two or three years, even after just a few interactions.” As students gain an escalating sense of entitlement, he observes, “some say, ‘We’re just students; they can’t influence us. If they pressure me, I can’t even write a prescription. So, I might as well take the lunch, because I’m just a poor med student.’”

So even among medical students, the influence game is on. It’s a game that Manhattan internist Dr. Robert Goodman might call “Quagmire.”

“The idea is that acceptance of gifts as a medical student will lead to acceptance of gifts as a resident, will lead
to acceptance of gifts as a full-grown physician, and always bigger gifts,” says Goodman, founder of the nonprofit advocacy organization No Free Lunch (www.nofreelunch.org), which encourages health-care providers to practice medicine on the basis of scientific evidence rather than pharmaceutical promotion.

He calls it “the ‘reefer madness’ argument,” referring to the shaky but often-told assertion that smoking marijuana will ultimately lead a user to harder drugs.

Whether you believe this theory or not, the headlines continue and the oddities mount up. At “Pfizer Night at Boston Billiards,” physicians were invited to “Rack ’em Up & Toss ’em Down.” The event offered no semblance of educational content, prompting at least one letter to the NEJM from an offended local physician.

The New York Times and the Washington Post have also chronicled a long list of marketing missteps, including an incident of hospital administrators attending a luxury retreat on the industry’s tab while advising pharmaceutical and medical device companies on how they could market their products most effectively to people like them.


Script Pads for Sale
A quid-pro-quo relationship, some suspect, was behind the American Medical Association’s (AMA) practice of selling information to IMS Health, a data import and export firm that combines AMA-provided Drug Enforcement Administration numbers with data collected from pharmacies, which it then sells to drug manufacturers. The information allows drug reps to track the prescriptions doctors are writing every week, and nets the AMA $44 million per year—16 percent of its budget, according to the NEJM.

Quid pro quo or not, these sales have become a political bone of contention and led to the AMA allowing physicians to opt out of permitting their prescription information to go to sales reps or their supervisors. Opting out is now mandatory in New Hampshire, which banned the sale of physician-level prescribing data last year.

The issue has also caught the attention of Reps. Frank Pallone (D-N.J.) and Peter Stark (D-Calif.) who drafted the Prescription Privacy Protection Act of 2006, based largely on New Hampshire’s ban.

Although he hails from a state heavily fortified with pharmaceutical dollars, Pallone introduced the bill to the Energy and Commerce Subcommittee on Health in late July. “It’s about privacy,” he says, although that was just one justification.

More to the point, he says, “We don’t want data falling in the hands of drug companies that really shouldn’t be there. Physicians should prescribe medicine based on clinical analysis without pressure from pharmaceutical sales representatives whose only goal is to increase drug sales for their specific company.”

PhRMA’s response came in a letter dated Aug. 15 from senior vice president Ken Johnson. He wrote, “Though we have not yet taken a position on the bill, we wholeheartedly agree with the [AMA] that prescribing data are an important key to detecting prescription drug diversion and can ensure that free samples are provided to physicians with patients who need the help.”

The translation, offered by PhRMA senior assistant general counsel Marjorie Powell, is that physician-level prescribing data contributes to drug safety by monitoring use, and helps marketers “to target physicians, when [they] want to get information and free samples to the appropriate doctors quickly,” she says.

The issue of free samples further complicates the marketing debate. Drug handouts, which cost the industry more than $11 billion each year, are seen as a transparent marketing device meant to “hook patients” into trying expensive new drugs, Hatcher says, even though “I think that there’s a lot of effective medications that are already on the market and already cheap and available.”

But what about the social benefit of free drug samples that many physicians hand out to uninsured patients? AMSA’s stance is that relying on free samples may not be the best way to manage a patient’s treatment, as they offer only a temporary solution. When the patient runs out of the brand-name sample, his or her physician will either switch to a cheaper drug, or the patient must continue buying the more expensive drug, both situations leading to potential noncompliance.

On top of that, says Dr. Patrick J. Brennan, chief medical officer of the University of Pennsylvania Health System, “Samples are a marketing practice, not an indigent drug program.”

Brennan recently helped draft new administrative policies that forbid gift-giving by commercial companies at any of the health system’s clinics and hospitals. The new rules also require drug reps to register with the appropriate offices and see doctors by appointment only. And no freebies of any kind are permitted.

“We’re not cutting off our relationship with the pharmaceutical industry, and we’re not trying to demonize them,” Brennan says. “We are trying to have a different sort of relationship that’s based more on evidence and science and education than on marketing.”

Other teaching hospitals have similar policies, which have been applauded by the public—if for no other reason than parking is now more readily available, given the number of drug reps who have abandoned these hospitals as potential targets. Brennan reports that several reps have turned in their hospital identification badges, and that the University Health System has recovered some 20 percent of the parking spaces at one of its smaller facilities.

Brennan questions the value of a relationship so easily abandoned by the curtailing of gifts. “If [the relationship] is valuable enough for a physician to set up an appointment and spend time with you [drug reps] and hear what you have to say, then so be it. But the wheels are not going to be greased by gifts and meals,” he asserts.


Who’s Buying?
Meanwhile, Hatcher, the self-described troublemaker, continues in her mission to rid her hospital halls of the pharm marketeers. In confrontational mode, she recently ran into a group of students on their first rotation. “I piped up, ‘Don’t forget, don’t accept the free lunches!’” she says, to which one of the students quickly shot back, “Why don’t you buy us all lunch, then?”

Hatcher was just as quick. “I told them, ‘Why don’t you ask your patients to buy you lunch, because that’s who’s really paying for it when a drug rep pays for your lunch.’

“That stopped them in their tracks,” she says.

Anthony C. Hall is a freelance writer based in Dryden, New York.~The Truth About Drugs

For physicians and medical students, unbiased, evidence-based information is the Holy Grail. But how do they find information untainted by the pharmaceutical industry’s appetite for marketing a particular drug?

Dr. Robert Goodman, founder of No Free Lunch, says that before the Internet made drug information a mouse-click away, “bumping into a drug detailer in the hallway might have been useful to you.” But today, medical information is a quickly growing business, allowing many avenues for accessing objective drug data.

When choosing a clinical decision-support system and the accompanying software, beware of suppliers in league with pharmaceutical companies. Some medical information businesses rely on industry advertising, while others profit from uploading information to their systems while you download from theirs. This doesn’t mean their drug information is wholly or even partly biased, however.

For reliable, independent, prescribing software, Goodman suggests that students look into Thomson Micromedex (www.micromedex.com) and Lexi-Comp (www.lexi.com/web/index.jsp).

As for periodicals, AMSA recommends the following online sources, which have been scrutinized for scientifically based objectivity:


  • The Prescriber’s Letter ($88 per year)—www.prescribersletter.com
  • The Medical Letter ($25 per year for AMSA members; $44.50 for non-AMSA students, interns, residents or fellows; $89 per year for all other providers)—www.medicalletter.org
  • Therapeutics Letter (free)—www.ti.ubc.ca/pages/letter.html
  • Drug and Therapeutics Bulletin (UK-based, £49 per year)—www.dtb.org.uk/idtb
  • Infopoems ($249 per year)—www.infopoems.com
  • Cochrane Reviews ($265 per year)—www.cochrane.org/reviews/index.htm



Let’s Do Lunch
Bribing doctors with food is so common that a new Web site, set to go national next month, will make ordering lunches a simple mouse-click away.

Called “Lunch and Earn,” the Web site, test driven in the Tampa area for the past 18 months, is specifically designed for pharmaceutical representatives. It will supply menus and specific ordering tips, so that pharm reps can just click and send a customized spread to the clinic of their choice.

The project’s founders, John and Amy Kristjanson, have even added a familiar value to the equation. Through “Lunch and Earn,” pharm reps will earn points, which they can cash in for tickets to sporting or theater events and other “fun gifts.”

“It’s to create loyalty and to keep people coming back,” John Kristjanson says.

Well, it might work. “The research suggests that even small gifts create a sense of reciprocity,” says Dr. Patrick J. Brennan, chief medical officer of the University of Pennsylvania Health System.

Ironically, he was talking about gifts from, not to, pharm representatives at the time. Either way, the luncheon table has been turned.

What’s the No Free Lunch take on the subject? Says Dr. Robert Goodman, founder of the advocacy organization, “We don’t need the lunches. We eat pretty well as a group.” —A.H.~~~~Career Development,Ethics,Health Policy,Medicine in Popular Culture,Pharmaceutical Industry,Practice of Medicine,Residency~
320~8November~2006-55~Well-being~Four-legged Therapists~Using horses to heal hearts and minds~Elizabeth Eaman~Horse whisperers~There is something about the outside of a horse that’s good for the inside of a man. —Sir Winston Churchill

While learning to ride horseback on his own, Keith, 15, practices using the reins to guide his horse, Sapphire. Keeping a firm hold on the reins is new for him, since he has only ridden with volunteers leading, controlling where the horse goes.

“I don’t like using the reins,” he tells his therapists. When asked why, he admits he is afraid to hurt her. He believes steering with the reins—attached to a bit in Sapphire’s mouth—causes her discomfort. However, Sapphire, wanting nothing more than to please her rider, will only do as she is told. Without Keith’s instruction, she will walk herself, nose-first, into a wall. And although another horse might realize her passengers are novices and take over the job for them, Sapphire needs direction more than most. Keith is reassured that sometimes you need to be a little firm to communicate. “You won’t hurt her,” Pat Wilkinson, his therapist, assures. “She won’t know where to go unless you tell her.”

Therapeutic riding is “more than just pony rides,” explains Wilkinson. It is an interactive therapy that uses horses to examine behaviors, address feelings, build confidence, teach new skills and much more.

Wilkinson is a certified therapeutic riding instructor and a practicing social worker. She is also a founding partner of Wishaponna, the therapeutic riding facility in Ypsilanti, Michigan, where Keith rides on Saturdays. She explains that while multiple studies have shown that therapeutic riding improves musculoskeletal and vestibular function, the effects on the patient’s mental health—equally important and more difficult to measure—are also profound. Working with horses brings about a sense of accomplishment, improves self-confidence and teaches important lessons about body language, barriers and communication.

Therapeutic horseback riding is a rapidly growing field in the United States and is considered a mainstay of treatment in other countries. In Germany, for example, it is so much a part of healing that some hospitals have riding facilities on campus. In Tucson, Arizona, a residential mental health facility uses horses to help treat adolescent girls with eating disorders.

Using horses to help people heal is hardly a new idea either. In ancient Greece, horses were used for lifting spirits and rehabilitating injured soldiers. Hippocrates himself spoke about the “healing rhythm” of horseback riding.

The North American Riding for the Handicapped Association and its subgroup, the Equine Facilitated Mental Health Association (EFMHA), have defined equine-facilitated psychotherapy (EFP) as mental-health therapy using horses, including activities such as handling, grooming, lunging, riding, driving and vaulting. They also specify that licensed, credentialed and certified equine and mental health professionals run the therapy.

The World Health Organization has reported that by 2020, child neuropsychiatric diseases will rise by more than 50 percent internationally to become one of the five most common causes of morbidity, mortality and disability among children. Children and adolescents have been a source of much mental health research, but advances in the field have been frustratingly incremental.

In addition, gaining rapport and ensuring treatment compliance for adolescent patients is an ongoing struggle for psychiatrists and mental-health professionals across the board. But research seems to demonstrate that EFP im¬proves compliance, and evidence shows that animal therapy improves rapport in the therapeutic milieu.

Cofounder Diane Thomson works as an occupational therapist for spinal-injury patients when she’s not at Wish¬aponna. She and Wilkinson are certified therapists and riding instructors, and had previously worked with another therapeutic riding program before deciding to start their own. Most of Wisha¬ponna’s patients have been referred by mental-health practitioners and pediatricians who heard about the program via word-of-mouth.

The vast majority of patients are children, ranging from 3 to 15 years old, with a diversity of neurological diseases including cerebral palsy, attention deficit hyperactivity disorder (ADHD), bipolar disorder and autism. Other patients are children from neglectful or alcoholic homes.

Sessions are mostly unstructured and vary according to the patient. One 3-year-old boy with spastic paralysis needs to be held atop the horse as it is led around the riding ring. Another little girl, 5 years old, has developmental delays and undergoes self-injurious behavior and tantrums every time she encounters something new, exciting or frightening. Both children have their own series of therapists, and while tactile and physical activity comprise a significant part of their experiences, EFP at Wishaponna has helped these children make huge leaps in their emotional development.

EFMHA listserves are rich with stories of how EFP has aided the therapy and recovery of substance abusers, victims of domestic violence, and patients with eating disorders, depression, anxiety and a myriad of other issues. Of those, the most reported and talked-about benefits of riding is increased confidence and self-esteem. Horses weigh around 1,000 pounds, and the ability to communicate, empathize with and control an animal that size evokes certain feelings that other animal therapies and therapeutic exercises lack. Riding has been shown to improve risk-taking abilities, emotional and self-control, as well as patience. This aspect alone is critical for a patient like Keith, who has ADHD and self-esteem issues.

One lesson Keith has been mastering is that of establishing personal space, which he learns by leading Sapphire. Taking the lead line into his hands, he uses his body language and some pressure on the rope to let Sapphire know to walk at a safe distance. This lesson is sometimes used in EFP for victims of domestic violence, so they understand how to set boundaries and create safety for themselves. For Keith, who is not accustomed to asserting himself at school or in public, and who is often taken advantage of, this is an important lesson.

One recent Saturday, Keith learned the “power stance.” This is a wider-based body position, communicating confidence and assuredness, and giving him the strength to hold his ground when challenged. In addition to the life metaphors that can be drawn from these lessons, Keith also learns he can master these tasks, building confidence in his horsemanship and increasing his bond with the horse and rapport with the therapists.

According to the Center for the Interaction of Animals and Society at the University of Pennsylvania, animals can be used in treatment as social facilitators, symbolic vehicles, agents of de-arousal, objects of attachment, sources of social support, and instruments of learning new skills and ways of thinking and behaving.

In fact, medical students at Stanford and the University of Arizona can take elective classes in which they interact with horses, and these experiences have been shown to improve their patient communication skills as they become more conscious of how they come across when interacting with others.

“Animals in general respond to people in ways that are so transparent and honest,” says Dr. Sam LeBaron, professor of medicine at Stanford and director of the Center for Education in Family and Community Medicine. “They hold up a mirror for [medical] students that they may not get from human patients.”

It is easy to see how the therapeutic horse can challenge and improve empathy. While large and sometimes threatening, the horse is a socialized animal, and patients easily find human traits in them, recognizing key emotions such as love and fear. Horses can also represent feelings that are hard to discuss or are repressed. Unconscious issues sometimes surface in working with the animals leading to therapeutic breakthroughs.

Further, EFP therapists frequently speak of a mysterious feature of the horse and its interaction with humans that many agree upon but few can explain. This has been often tied to mystical or spiritual aspects of the horse. Countless stories exist of therapeutic horses responding with exquisite sensitivity to a specific rider’s emotional needs.

Dr. Beverley Kane, who teaches the Stanford elective for medical students, says, “We’ve all been socialized into hiding our feelings and interactions, especially from somebody in a white coat. Horses will tell you in no uncertain terms how you’re affecting them—if you pay attention to the right signals.”

Wilkinson refers to horses as “agents of change”—evocative creatures able to effect positive changes in self-concept and behavior. She feels this is one of the most critical aspects of EFP. Horses are herd animals, and their evolutionary survival has depended on reading subtle cues and reacting swiftly. This attribute helps horses provide instant feedback to the patient, allowing him or her to see cause and effect, and understand how his or her behavior affects others.

The 5-year-old girl with tantrums and self-injurious behavior has picked up quickly on this lesson. She has learned her fits of temper might frighten the horse and make it go away. Her kind words and gentle motions are rewarded with an ability to interact with the horse. Since coming to Wishaponna, she has learned to channel her rage into squeezing a ball instead of stomping her feet, and has started developing productive ways of managing her behavior and emotions.

Keith has also shown dramatic improvement. His mother de¬scribes him as “a loner,” but remarks that his lessons at Wisha¬ponna have markedly helped his confidence and communication skills. He walks taller, talks louder and shows signs of an improved self-image.

When asked about his therapy horse, Sapphire, he states that “she likes boys best,” and this makes him feel special. Keith’s favorite activity is grooming Sapphire, “probably because it makes her feel good,” he hypothesizes.

And when pressed a little further, Keith admits that brushing her “kinda” makes him feel good, too.

Elizabeth Eaman is a fourth-year at the University of Michigan Medical School.~~~~~Community and Public Health,Complementary and Alternative Medicine,Health Disparities,Medical Education,Medicine in Popular Culture,Practice of Medicine~
321~8November~2006-55~Feature~Lessons of Pain~A Symptom Stretched Across All Specialties~Pete Thomson~Is your pain patient a drug seeker or a true sufferer? That question,
unfortunately, now colors almost every physician’s encounter with chronic pain. And it’s just one of several barriers holding back real progress in the science of pain medicine. Plus: fighting skepticism~What Rebecca Sadun knows about chronic pain has little to do with what she learned in two years of didactic medical school training. Nor did she learn about it on the wards.

Instead, during her first year of an M.D./Ph.D. program, she learned about it firsthand when she developed a deep, aching pain in her own back that would eventually evolve into agony at the lightest touch.

She also learned firsthand about what happens when a patient presents to a physician with a symptom that has no clear causation.

Sadun’s school, Keck School of Medicine of the University of South¬ern Cali¬fornia, is “fantastic,” she says, about teaching tangential elements of a patient-care curriculum, so “pain management is the sort of thing that I would have expected in our curriculum, but it is severely lacking. And in my experience, it is also rather lacking in the clinical repertoire of the physicians on the campus.”

Anecdotally, medical schools are falling short in training their students in pain medicine. In¬stead, trainees pick up stigmas about the use of pain control medication and disinterested attitudes from their preceptors.

Whose responsibility is it to teach students about pain medicine? Part of the problem is that several different specialties lay claim to the study of pain control. Another part is that academic medicine might hold some of the same stigmas toward pain medicine as mainstream practice: that pain without apparent cause is barely to be believed, and that the chance of a patient growing dependent on medication is too great to risk treating them.

Sadun’s pain, which ranged roughly from her T7 to her T12 vertebrae, worsened. Eventually, she was unable to sit for more than five minutes. Instead, she attended classes lying on a pallet on the lecture hall steps.

She moved from specialist to specialist. “It was many, many months before any doctor was willing to actually attempt to treat the pain, even without having identified an etiology.” The physician who was willing to try was a rheumatologist, although the symptoms didn’t fit any rheumatologic syndrome. Still, he was willing to treat her with medication so she could get on with her life. And most importantly, he asked to see her again.

Ameliorating her condition proved nearly impossible. Narcotics were incompatible with her academic load. Tricyclic antidepressants didn’t do the trick. A new painkiller helped with the pain but affected her memory, making studying impossible.

With all of the visits and tests she required, Sadun was lucky to have been a medical student on a medical campus, she says. “I would have quit or been fired or been on medical leave in any other capacity.”

One day, about 16 months after onset, Sadun’s pain suddenly subsided, replaced by a complete lack of sensation where the ache had been before. About six weeks later, sensation began to return, but the pain did not. Though the exact mechanism of her condition remains unclear, theories ranged from an autoimmune response that damaged nerves to the mechanical: She was eventually found to be osteoporotic in that region of her spine.

There aren’t very much data on how well students are versed in pain medicine, says Dr. Frederick Burgess, president of the American Academy of Pain Medicine (AAPM). “Some places have very good education on it; others have virtually none.” Pain management often falls through the cracks of medical education programs segregated by organ systems, he says, unless there is a particular proponent at a school.

Burgess, an anesthesiologist, once taught a 45-minute course to students on surgical rotations about pain issues related to surgery. “There was a substantial knowledge deficit. They knew what their residents told them to write for...but they really had no concept on how to use the medication, or even what the medications were and how they were related to one another.”

“Pain is one of the most burdensome things our patients experience, so I think our training should be more sophisticated in that regard,” says University of Vermont College of Medicine fourth-year Justin Sanders. “I certainly don’t recall having a good education in the physiology of pain, which would be a good start.” He adds that “there are a lot of psychological determinants of pain that I don’t think are well understood, but what is understood is not well taught.”

Students do, however, pick up on residents’ attitudes toward treating chronic pain, and learn to be on the lookout for drug seekers. “[Residents] have got their new license, and they are afraid of being taken advantage of. And it gets passed down,” Sanders says.

That attitude is reinforced at each stage of learning, he believes. “You’ve got two levels of medical educa¬tion…the one [where] people are being taught in class, and pain management is not emphasized enough, and then the clinical area, where pain management is looked down upon.”

The result, he thinks, is a cynical medical student. “The first time someone comes in requesting pain medication, it is like a knee-jerk reaction to think, ‘Oh, this person is a drug seeker.’ Which is terribly unfortunate, and it is part of the reason we don’t treat pain well.”

Fighting the phobia

Second-year Michael McCollum says the majority of students at New York College of Osteopathic Medicine (NYCOM) get about one lecture on pain management in two years, and it’s basically a pharmacology lesson. “It’s not about the art of pain management,” he explains.

Though McCollum is interested in internal medicine and cardiology, he spent six years working in a pharmacy before medical school, where he learned to recognize “opioid phobia”—the fear of prescribing pain medications—among some physicians.

“If it is anything above Vicodin, like a low-level opioid, they aren’t going to write for it,” he says. “They are afraid if they write too many, someone is going to question them, and they are going to be in trouble.”

He believes medical schools must act in the early years to combat such misunderstandings. “Once you get through [the first] two years, there are certain ideas that are ingrained, like the idea of pain management. That is one of those things I think people hear over and over again, from faculty and doctors, and even probably their parents: ‘Oh, that drug… you’ll get addicted to it.’”

Another problem frequently cited is the growing recreational use of prescription narcotics, and how they are “diverted” from the patient to the streets. Certainly, prescription drug diversion is developing into a major public-health crisis, Burgess says. “In terms of drug-abuse and addiction liability, somewhere around 10 percent of the population has a risk for that, so you are going to encounter patients who do have a drug-abuse problem,” he says, but the vast majority of pain patients have a legitimate need for painkillers. “[Physicians] are so afraid of…feeding the addiction that they are unwilling to treat the remaining 90 percent.”

The solution should not be holding back on medications patients require, he says. “[Physicians] need to understand how to monitor patients and how to avoid having their drugs diverted.”

But opioid phobia proves a significant problem for pain medicine to overcome. “There is such a paranoia, perhaps placed in part by the government and their mixed messages,” Burgess says. “They are encouraging us to treat pain on one hand. On the other, they are monitoring us, looking for evidence that we are contributing to drug abuse or diversion.” Instead, physicians simply choose not to risk it.

“Unfortunately, there just aren’t that many pain specialists around to pick up the burden.”

New umbrella needed?

“One of the issues with pain management is that it has, potentially, a lot of different homes,” says Dr. Josh Hauser, a palliative care professor at Northwestern University’s Feinberg School of Medicine. “It could be in the pharmacology class during the first two years…. It could be part of a course in palliative care, and it could be part of an anesthesia rotation.” But multiple opportunities for training do not necessarily lead to quality instruction. “When something has a bunch of different possible homes, in fact, it sometimes has no home.”

Northwestern has a palliative care service, an anesthesia pain service and a pharmacology analgesic dosing service through the pharmacy department. “All of us work well together,” Hauser says, “but from a student point of view, I think it might be unclear who the main actors are.”

While anesthesiology residents rotate through the palliative care department and vice versa, students may not know where to go for centralized information.

“It is very easy for a student to know where to go to learn about the heart. We call that the cardiology division,” Hauser says. “Same way with other organ systems. A symptom, like pain, traverses organ systems and traverses specialties, so it makes locating it a little bit more of a challenge.”

The AAPM’s Burgess believes that the problem is more fundamental and widespread than simply a lack of pharmacological knowledge among medical students. Pain medicine currently is highly compartmentalized. “That is creating problems because people are often trying to apply individual, specialty-related modalities.”

“A lot of anesthesiologists deal with chronic pain problems by wanting to do a lot of injections. Ultimately, they are not necessarily a very good solution,” he explains. “Physiatrists will put everybody into physical therapy; psychiatrists will put them all on antidepressants.” Instead, he suggests, a more comprehensive approach is necessary to combat pain on a patient-by-patient basis. “A single specialty cannot lay claim to it. It really has to be someone who draws on all different aspects of different specialties to apply to pain problems.”

The AAPM draws about half of
its membership from anesthesiology. About 30 percent comes from physiatry, with most of the rest from neurosurgery, neurology and psychiatry. They are working on a pain medicine curriculum, with modules to be published online, pending funding.

End-of-life care has been receiving increased attention due to efforts by the American Medical Association and hospice groups, Burgess says, and that sheds some light on pain medicine. But it is not enough. “We need more of a clinical approach so that when [students] get out, they actually have an idea of what medications you use, how to use them, and what are the problems you are going to encounter.”

At NYCOM, McCollum has already started working on putting together his own pain curriculum. He has located some experts to lecture on pain management, but something more ambitious may be needed. Required rotations with geriatrics or pain medicine specialists would be helpful, he says.

Brainstorming, Hauser sees bringing interested specialties together in training students, reinforcing pain medicine in each of the four years. For instance, pain management could be addressed in pharmacology. Two cases in a problem-based learning scenario could deal with pain. Two lectures on pain could take place during clerkships. Some electives could focus on the topic during fourth year—perhaps a couple of weeks each spent with a palliative care team and an anesthesiology service.

“It’s a really important topic, and it’s one that crosses a lot of boundaries,” Hauser says. “There are a bunch of different specialties that have an interest in it and an expertise, and I think that is wonderful, but it also makes it a little bit harder to coordinate.”

Pete Thomson is associate editor of The New Physician.
~To Believe or Not to Believe: The Chronic Pain Patient

Pain without an identifiable cause—pain for its own sake—is frustrating for both patient and physician. The former is left without the solace of a cure, the latter with questions about the authenticity of a symptom that can't be justified. But recognizing a patient's pain sometimes means looking beyond disbelief.

Dr. Frederick Burgess, president of the American Academy of Pain Medicine, says there is a bit of a battle going on in medicine, especially over the American Medical Association’s hesitation to classify pain as a disability in itself. “They really have never been very supportive of pain as being a disability condition unless you can attribute it to something specific.”

Because currently, pain can’t be accurately and objectively measured, physician encounters with chronic pain patients can test the relationship. “It becomes a matter of believing the patient. And physicians don’t believe the patients,” says Burgess. The American Pain Society has been funding research on pain, and progress is promising. But for now, it can come down to faith.

Rebecca Sadun, in her fifth year of an M.D./Ph.D. program at the University of Southern California’s Keck School of Medicine, saw cynicism from the patient’s side when she developed intractable bone pain in her back. “You could always feel that slight skepticism,” she says. “That slight, ‘is this all in her head?’ which even I asked myself sometimes.”

The experience has changed her interactions with patients. She finds that she often winds up “playing the social worker.” She knows that after the physician walks out, the encounter isn’t over for the patient. “I remember what it was like to wait those weeks for that next appointment, and put all of your hopes on [it] being able to make a difference.”

“You have to sort of believe that [patients] are telling the truth and that you can try various treatments,” Burgess says. “I think a lot of physicians will just look at it and say, ‘Well, you should be better. Go away.’” —P.T.


RESOURCES

Look to these online resources for more information on pain medicine:

The American Academy of Pain Medicine promotes the specialty. They hope to
provide an online curriculum in pain
medicine soon. www.painmed.org

The American Board of Pain Medicine
certifies physicians in the field.
www.abpm.org

The American Pain Society promotes research on pain and provides some
funding. www.ampainsoc.org~~~~Community and Public Health,Complementary and Alternative Medicine,Medicine in Popular Culture,Practice of Medicine~
323~8November~2006-55~Feature~SPOTLIGHT: Phantom Illness~
Few are immune from “medical student syndrome”~Linda Childers~Second-year medical students run a considerable risk of being diagnosed with life-threatening conditions like cancer, brain aneurisms and exotic intestinal parasites—at least when they are diagnosing themselves. We take a look at the surprisingly common “medical student syndrome.” ~Whitney Waldroup remembers becoming ill during her second year of medical school and diagnosing herself with nodular sclerosing lymphoma, a condition she had coincidentally just studied in class.

“I had been feeling a little under the weather for weeks, had some night sweats and a fever, and was convinced I had a mediastinal mass,” says Waldroup, now a third-year at the University of Nevada School of Medicine. “I went to see my primary care doctor at the student health center and after examining me, she laughed and confided how she had also suffered ‘a case of lymphoma’ in medical school.”

While Waldroup didn’t have a terminal illness, she did suffer from an acute case of medical student syndrome (MSS), a benign but annoying condition that can strike at any time. It may start with something as simple as a persistent cough or a pounding headache—symptoms you would normally ignore, but considering the fact that you just studied lung cancer and brain tumors in class, you can’t help but be concerned about.

For medical students and others who work in health care, hypochondria can be an occupational hazard. A 1999 article in studentBMJ estimated that up to 80 percent of future doctors at some point imagine they have the same diseases they study.

The condition, though common, can cause students considerable anxiety and often embarrassment. “MSS is basically a temporary form of hypochondria,” says Dr. Connie Stapleton of the Medical College of Georgia’s (MCG) Student Health Services. “MSS can cause students a great deal of psychological distress. They may not sleep well and have problems concentrating on their studies,” she adds.

Also referred to as “second-year syndrome,” or “sophomoritis,” MSS often starts with an illness that a medical student has recently studied. “I’ve seen the manifestation of symptoms to be extraordinarily more common among students of medicine and psychology than other disciplines,” observes Stacy Picek, a graduate student in the Department of Preventive Medicine and Public Health at the University of Kansas Medical Center in Kansas City. “In studying Surveillance and Control of Infectious Diseases, the risk of contracting diseases seems to increase just by learning the information.”


An Easy Trap

An extreme fear of becoming ill can happen to almost any medical student given the right circumstances. “It can be easy to fall into the trap of thinking too much when students begin to study exotic illnesses and syndromes,” says Dr. Greg Sawyer, a psychiatrist and medical director of psychiatry at Yakima Valley Memorial Hospital in Yakima, Washington. “A student can wake up sweating profusely and talk himself into thinking he has malaria when the real cause is the 14 pieces of pizza and two gallons of orange soda he had before going to bed.”

Sawyer believes almost all medical students have imagined some kind of serious illness they studied in class. Most cases, he says, don’t escalate to the point where students seek professional help. “In rare cases, I’ve heard stories of students who frequently visit the health center and find it hard to relax despite repeated tests and assurances from staff,” he says. “Most students laugh it off, or visit the health center once or twice for some odd thing during the course of med school.”

Students who have a history of anxiety and/or depression might find themselves more vulnerable to MSS. Experts say when you have psychological distress, you will more than likely have physical symptoms.

“The life of a medical student is often marked by a lack of sleep, an unhealthy diet and/or excesses of alcohol,” Stapleton says. “Depression coupled with fatigue can lead to excessive self-focus, which can lead to an inordinate amount of emphasis on one’s physiology. Even minor aches and pains can be interpreted as life-threatening illnesses.”


Diagnosticians Gone Wild

MSS can extend beyond the student’s own health concerns. Margit Kaufman, a third-year at the Robert Wood Johnson Medical School in Piscataway, New Jersey, admits to diagnosing her young son with various health conditions.

“My son got his first stomach virus after playing in the sandbox,” Kaufman says. “I was in the middle of microbiology class so I was convinced he had contracted toxoplasma gondii or some other rare microbial disease from cat urine.”

Waldroup remembers an incident during her second year of medical school when one of her roommates was having vision problems and seeing spots. “Several other medical students and I diagnosed her with everything under the sun, including Takayasu’s arteritis, temporal arteritis, a medication reaction and a parasite due to her recent travels to South America,” Waldroup says. “She ended up having dry eyes and was cured by lubricating eye drops.”

So how can medical students differentiate between MSS and a real medical condition?

“If you really feel something’s going on, then have it checked out by your doctor,” Sawyer says. “It’s worth the energy to undergo tests and prove yourself wrong. Think of it as an educational experience.”

In her job at MCG’s Student Health Services, Stapleton treats medical students for a myriad of issues, including MSS. “If any of the physicians suspect the student may be demonstrating signs of MSS, they send the student to me after conducting a medical evaluation,” she says. “Very often, the student is struggling with an underlying anxiety disorder or a depressive episode.”

While some affected students may have a history of anxiety and depression, others may recently have experienced a traumatic or stressful event such as a death of a loved one. “Stress can definitely exacerbate all illnesses,” says Scott Goldman, assistant director of the Student Health and Counseling Center at Saint Louis University and a clinical psychologist. “Immune [function] typically decreases during times of stress.”

For students who are experiencing periods of stress, Stapleton recommends practicing relaxation skills (like diaphragmatic breathing, visualization and meditation), adding exercise and adopting a healthy diet. If necessary, an antidepressant or anti-anxiety medication may be prescribed.

Stapleton says she has also treated a number of students who suffer from obsessive-compulsive disorder (OCD). “This can be confused with MSS by an untrained professional,” she says. “Medication is often necessary to treat OCD, but relaxation techniques are essential as well.”

Goldman also recommends looking at the frequency and intensity of one’s health fears. “Lots of people won’t eat food that’s dropped on the floor, [but] this doesn’t mean they have OCD,” Goldman says. “However, [if] you find yourself constantly worrying about germs and contamination, you might be experiencing compulsive anxiety.”

Rather than practicing self-diagnosis, Stapleton says, medical students should focus on practicing self-care—the same sage advice they will one day be handing out to patients. “It’s critical for students to take good care of their physical and psychological health while in medical school,” she says. “Avoid using alcohol, tobacco or drugs; get enough sleep; eat healthy; and maintain a social network of family and friends.”

Stapleton adds that a regular relaxation or meditation practice can help students avoid anxiety and depression and thereby decrease the chances of developing MSS.


Reality Check

One of the best plans for avoiding MSS is acknowledging that it exists, and seeking out a mentor or peer for a reality check if you find yourself starting to self-diagnose.

Students who have experienced MSS can help other students by sharing their experiences. “Sometimes knowing that others have struggled in the same way can have a very calming effect,” Stapleton says. “In addition, mentors and physicians can help to explain the syndrome and let students know where they can seek help if they do begin feeling anxious.”

Waldroup found that empathy can go a long way in helping other medical students confront their fears. After her own bouts with “lymphoma,” she feels more equipped to help others. “I was recently talking with some second-year students who were feeling their lymph nodes, convinced that they had lymphoma. We had just been discussing a patient who had been diagnosed with Hodgkin’s lymphoma and the symptoms that had brought him in to see his physician,” she says. “I was quick to share my own experiences as a second-year student and to let them know MSS is pretty common.”

Goldman says he’s found that “normalizing” students’ fears can help them realize their worries are unfounded. “It’s a psychoeducational process,” he says. “I talk with students about their fears and reassure them that we all experience times of stress. I work with them to assess their level of anxiety and challenge their cognitions.”

Ask medical school faculty
members about MSS and chances are they will recall and describe their own past medical school fears. Sawyer remembers making an appointment while in med school because he was having trouble breathing. “I was diagnosed with bronchitis every few
years, couldn’t sleep horizontally and coughed all the time,” he says. “My dad had a lung condition and at the back of my mind, I worried that I might have the same thing.” Sawyer’s doctor ran an X-ray, came up with a definitive diagnosis of, yes, bronchitis, and talked with him about his fears.

Picek, too, remembers that wary feeling. After studying animal vectors of disease in a recent class, “I walked into my apartment and looked hesitantly at my cat. Normally, I look at her adoringly, but that one day I remember thinking how I’m lucky that she’s an indoor cat,” she says. “After that class, I realized how many diseases she could possibly host, and how bacteria and parasites were only seconds from leaping into my airway.

“I’m just kidding,” Picek says with a smile. “Well, sort of kidding.”

Linda Childers is a freelance writer in Martinez, California. Direct comments to tnp@amsa.org.~~~~~Medical Education,Student Life and Well-Being~
324~8November~2006-55~Feature~Ethics at the Edge of Life~Meeting the needs and wishes of dying patients challenges students who are unprepared.~Avery Hurt~Medical students are likely to learn about death and dying not in the classroom, but at the bedside of their own patients. How will you handle the unavoidable ethical and medical choices at the end of life, and what will drive your decisions? Plus: sedation for emotional pain, page 16.~Those who rely on the lay press for information might think the ethical issue most commonly faced by physicians treating patients near the end of life is the question of physician-assisted suicide. But the fact is, that issue is “vanishingly rare” in the life of a physician, according to Dr. David Casarett, assistant professor of geriatric medicine at the University of Pennsylvania School of Medicine, where he directs the palliative care clinic. What is not rare, everyone agrees, is the issue of when to withdraw life-sustaining procedures and technologies.

“This happens commonly,” says Dr. Susan Dorr Goold, director of the University of Michigan’s bioethics program. “It would be very rare for a resident not to encounter such a situation, and it is the issue that residents say they are least comfortable with.”

Goold has just published a study exploring what residents need to learn in order to practice medicine ethically. According to the residents interviewed for her study, how to break bad news and how to help patients and their families make these difficult end-of-life decisions are both the most challenging ethical issues young doctors face, and the ones for which they feel least prepared.

While everyone acknowledges that letting go of a loved one can be extremely difficult for the family, it is really not surprising that it is hard for the physician as well. “The imperative to heal can make it hard for a doctor to make end-of-life decisions,” explains Dr. Behi Rabbani, a third-year resident in internal medicine at the University of Michigan Hospital. “Sometimes the family puts pressure on the physician [to continue to try therapies that can no longer help the patient], but more often, we do it to ourselves. The family often expects too much from medicine, but we tend to feed on that. Leveling expectations is important, but it is hard to do,” he says.

“I’ve learned—and I didn’t learn this in medical school—that [withdrawing life-sustaining procedures] is a part of the therapeutic process,” says Rabbani. “You are not ending care, you are just shifting the focus from therapies that can cause discomfort to ones that increase comfort. You haven’t stopped treatment, but the goals of treatment have changed.”

In many cases, the ethics of when to stop life-sustaining treatment are pretty straightforward, even if the decision can be hard to make. “Often, it is very easy to tell when there is nothing more that can be done medically,” explains Casarett.

However, at times the issue is not black and white. “You have to decide whether the benefits of the treatment outweigh the burdens,” he says. “Some patients, even when they know there is a good chance that a particular therapy will help them improve enough so that they might even go home from the hospital, still don’t want to go through the treatment again.”

And patients have a right to refuse any treatment they do not want, even if the physician is uncomfortable with that decision. The challenge is often not what decision to make, but how effectively to present options and discuss them with the patient and his or her family.


Heart to Heart

Though it might seem that good ethics at the end of life would require a close reading of Aristotle with a healthy dose of philosopher Peter Singer thrown in, it all seems to come down to communication. The physician’s responsibility to make recommendations and offer patients and their families the necessary information to make good decisions requires honest and candid communication. His or her responsibility to provide compassionate care requires it even more.

Goold’s study revealed that residents desperately want help communicating bad news. In her paper, she quotes a resident describing real difficulty with this task:

“Honestly I wanted to say the right thing, but…how do you say it? They had been waiting for me, and I had to tell them that their dad had cancer…something that would change their life, and that they would remember me telling them the news and how I said it….”

This resident, like most doctors, is keenly aware of her role in this family’s very personal crisis. She knows that her words will be committed to memory, and the tone of them can have an effect on how the family deals with the situation and how they make important decisions still to come. And she feels woefully unprepared.

“Breaking bad news is the hardest thing we have to do,” agrees Rabbani, “and nothing prepares you for walking into that room.”

This and other end-of-life issues are where medicine becomes more an art than a science, says Shayna Rich, an M.D./Ph.D. student at the University of Maryland and co-leader of the American Medical Student Association’s (AMSA) interest group devoted to issues of death and dying. “In end-of-life situations, you go beyond what you think as a doctor into what you think as a human being.”

Fortunately, Goold assures us, it is an art that can be learned. “The kind of language you use can be very important,” she notes. “For example, when saying, ‘We are going to give comfort care only,’ the family hears ‘only,’ and may get a sense that you are not going to be fully caring for their loved one.”

Goold suggests instead saying something like, “We are going to work very aggressively to make your son comfortable and alert enough to interact with you.” This way, family members are reassured that the physician is not giving up on their loved one, but is caring for him or her with the same commitment as when there was hope for recovery.


Consensus

Often, ethical dilemmas arise when a terminally ill patient’s family can’t agree on how to proceed, or resists the patient’s wishes set forth in an advance directive. Or family members may change their minds about a previous do-not-resuscitate order. In these cases, experts agree that the physician’s role is negotiating with and enabling the family to come to an agreement with which everyone is comfortable.

Yes, but how do you actually do this? Once again, the art of communication is called for. Goold advises focusing on the goals. What does the family really want from medical care? In most cases, the answer will be to relieve the suffering of their loved one. Rabbani adds, “I suggest that families—and the doctor—try to think about what the patient wants rather than what they want.”

“The best way to know what a patient wants, of course, is for the patient to tell you,” says Niti Chokshi, a second-year at Texas A&M University College of Medicine and co-leader of AMSA’s death-and-dying interest group. “It can be very difficult for families to make these decisions,” she points out, hence the importance of advance directives and living wills.


The Faith Factor

Discussions of living wills and good communication skills, while certainly important, tend to step carefully around the fact that when it comes to the end of life, medicine is edging into what traditionally is the territory of religion. “Medicine has no claims in this area; science cannot tell us what to do at the end of life,” says Dr. Farr A. Curlin, assistant professor of general internal medicine at the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Curlin has published several studies examining the role of physicians’ religious and spiritual beliefs in their clinical work. According to his latest survey, published in the May 2006 issue of the journal Medical Care, 91 percent of physicians believe that it is appropriate to discuss religious and spiritual matters with a patient if the patient brings it up, and 55 percent say that their religious beliefs influence their practice. And what may come as a surprise to many is that there are fewer agnostics in the medical profession than in the public at large.

Nevertheless, many patients—and physicians as well—expect doctors to put their personal spiritual or religious views aside when making professional judgments and decisions. But this is not really possible and may not even be a good idea, says Casarett. “You are not asking a machine to make a decision, but a human being. Medicine is essentially a human endeavor.”

Curlin agrees that separating professional life from spiritual life is “probably too much to ask” of a physician. “None of us come from nowhere. We have a framework, whether it is religious or not, for how we approach these decisions.”

He believes that the danger of attempting to disregard one’s personal views is that those views will come into play, but not necessarily in an open way. “I would not be surprised if physicians are somewhat unaware of how their religious and spiritual views influence their decisions and recommendations,” he says. “We need to get beyond the idea that we can be morally neutral, and concentrate instead on being aware of why we are making the recommendations we are making.”

According to Curlin, neutrality is unrealistic, but candor is not. Physicians, he says, should clearly differentiate, for themselves and their patients, recommendations based on what the profession endorses versus those based on the physician’s personal views. “Don’t say, ‘I’m recommending this feeding tube because it will help your father,’ if you mean ‘I recommend this feeding tube because I believe in the sanctity of life,’” explains Curlin.

While the last statement may sound like an odd thing for a physician to say, Curlin points out that by trying to be morally neutral, to shut away personal beliefs and spiritual values, physicians may actually become less neutral, because they are not so aware of why they are making certain decisions or recommendations.

Like the border between life and death, the border between medicine and spirituality is not necessarily a place to be avoided. In fact, “if we are not attending to these needs, we are not doing our job,” says Casarett. And this part of the job, while perhaps one of the most difficult parts of medicine, can also be one of the most rewarding.

Rabbani admits that it is not uncommon for him to be placed in the position of having to give spiritual comfort to patients and their families. “It’s difficult,” he says, “but that’s one of the times I feel medicine is really worth it. I’ve been involved in some amazing conversations with patients and their families; I have shed tears with families. These are profound experiences for me. I feel almost as if I am a part of the family at those times.”

Doing a good job with this tricky business of spirituality requires cultural sensitivity, but it doesn’t require sharing the beliefs of the patient. “Knowing the rationale and tradition behind people’s beliefs helps a great deal,” says Curlin. “But we need to remember that knowing a person’s religious tradition doesn’t mean you know what kind of decisions they will make under certain circumstances.”

Just being a caring human may be enough, though. Chokshi points out that people often become spiritual for the first time at the end of life, and so may not have a ready source of help on hand. “You have to be open to finding someone who can help. But sometimes you have to help with that, too,” she says. “I could pray with a patient if they needed it, or sit with them while they prayed.”

Chokshi, who is Hindu, is not likely to share the religious beliefs of the majority of her patients in the United States. That isn’t a problem for her, though. “I grew up in America and have seen lots of religions; I know where to find appropriate spiritual guides and can offer sympathy and caring,” she says. Religious beliefs can be very specific, but caring, it seems, is ecumenical.


The Learning Curve

As Goold’s study shows, medical students don’t feel they are fully prepared to deal with the issues they’ll face when treating patients at the end of life. Medical schools address these issues in various ways, often through ethics courses, seminars or workshops. Others have centers that offer courses and guidance, such as the MacLean Center at the University of Chicago and the Center for Medical Humanities at the University of Texas Health Science Center at San Antonio. But it is generally agreed that medical students are not being well prepared for end-of-life issues. “When there is nothing more we can do medically,” says Chokshi, “we just don’t know what to do.”

“There is tremendous diversity in how medical schools prepare students for death and dying, but the key things you have to learn are best learned by clinical experience,” says Dr. Sarah Hoehn, assistant professor of medicine at the University of Chicago who recently joined the MacLean Center. “People really have to develop their own personal style in these matters.”

Most students, however, would prefer not to wait until they are on a geriatrics rotation or in a residency program to start learning about these issues. Those with experience in end-of-life care agree: The best thing you can do to gain experience is to seek out opportunities in palliative care or hospice programs—the sooner the better. Chokshi volunteered in a hospice program in her first year. Rich, who plans to go into either geriatrics or hospice care, volunteered at a hospice before she began medical school. “All students should spend some time on a palliative care or hospice rotation, no matter what their specialty,” advises Casarett.

Other resources are available as well, for students who seek them out. Rachel Androphy, a second-year at the University of Massachusetts Medical School, took a seven-week elective course called Caring for the Seriously Ill. But she found the course served mostly to highlight how ill-prepared she was to deal with these issues. So this past summer, she took part in AMSA’s End-of-Life Fellowship program. “It was an amazing fellowship,” says Androphy. “We saw it from all angles: M.D.s, nurses, chaplains, social workers, patients and their families,” she recalls. “[End-of-life] is a very team-oriented kind of care. As a physician, you have to work with many other people and juggle all these approaches. When it comes to ethical decisions, a large part of it is listening to other points of view.”

Androphy recommends the fellowship to anyone interested in these issues.


The Political and the Personal

In the horrific days following Hurricane Katrina, health-care workers faced a situation that no training could ever prepare them for. Memorial Medical Center in New Orleans had lost all power and sanitation. Temperatures inside the wards were more than 100 degrees, there was no refrigeration for medicines, sewage was backing up inside the building, gunshots could be heard outside, and the sickest and oldest patients were dying. One doctor and two nurses have been arrested (though at press time not yet formally charged) for allegedly administering lethal doses of morphine and Versed to suffering patients whom they did not expect to survive.

All of the students interviewed for this article opted to reserve their opinions on this specific case until the facts are clearer, but Rich, who is currently taking a law course about end-of-life issues, did say this: “I don’t support euthanasia, but much of the question comes down to the intentions of the caregiver. When the primary intention is to stop suffering, that can shorten life. If these matters were simple, we wouldn’t be having these discussions. The laws are not always clear on these matters, and that may be good in a way. You can’t make a simple rule that applies to all situations.”

The legal aspects of the case will no doubt be fodder for discussion for years to come no matter how it turns out—as we are still talking about Terry Schiavo and Dr. Jack Kervorkian. This is the kind of situation that makes headlines and generates fascinating discussions in undergraduate ethics classes. Meanwhile, actual hard decisions and difficult discussions are taking place at the bedside every day. What we don’t hear about on the evening news are the daily encounters at the edges of life and death, medicine and religion, professionalism and humanity. This is where ethical decisions and ethical behavior are called for regularly.

These moments aren’t particularly sexy and rarely do they change law or set precedent, but they do change lives. “Medicine is not just about healing people; it is about improving the quality of life, and that includes improving the quality of death,” says Chokshi.

And that requires careful negotiation of the edges.


The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~Relief for a Different Kind of Distress

Palliative care at the end of life typically poses no ethical challenges. The goal could not be more straightforward: Relieve physical suffering to make death as peaceful as possible.

Suffering, however, comes in more than one guise. When it is physical, the primary clinical challenge is to keep pain at a minimum while keeping alertness at a maximum. In some cases, however, the psychic pain experienced at the nearness of death can be greater than the physical pain. When the patient’s existential pain is overwhelming, elimination of suffering may be possible only by complete sedation. This treatment poses unique and subtle ethical questions.

Those who support the ethical basis for palliative sedation point out that it is the responsibility of clinicians to provide whatever care necessary to promote the well-being of the patient, and existential suffering, like pain, is subjective and can be defined only by the person experiencing it. Shayna Rich, an M.D./Ph.D. student at the University of Maryland and co-leader of the American Medical Student Association’s (AMSA) death-and-dying interest group, points out that in weighing the benefits of any treatment (or decision to withdraw treatment), “Who are we to judge the quality of life of the patient?”

The ethics of palliative sedation for existential suffering have been challenged, however. Since it is not clear that sedation actually does eliminate psychic suffering, some argue that it may not be possible for the patient to truly give informed consent for such treatment. In addition, a sedated patient cannot change his or her mind.

Dr. Gail Austin Cooney, medical director of the Hospice of Palm Beach County in West Palm Beach, Florida, is somewhat troubled by the fact that, “when the patient loses the ability to communicate, we can’t tell if the suffering is relieved or not.” Particularly when the patient has a prognosis of weeks rather than hours or days, Cooney says, palliative sedation “makes me uncomfortable, but I can’t discount it ethically.”

Niti Chokshi, a second-year at Texas A&M University College of Medicine and co-leader of AMSA’s death and dying interest group, suggests treating psychic suffering at death as you would psychic suffering at any point in life—get the help of a psychotherapist and even use antidepressant medications if necessary. “Good medical care treats all of a patient’s problems, including psychological problems,” she says.

Cooney agrees that the first-line treatment would be to call on a psychologist or spiritual counselor to help address the “multiple roots of the problem.” In the end, however, it is largely up to the patient. “As care providers, we make sure that the patient, if at all possible, makes the decisions,” says Cooney.
It may not be so simple, however. Dr. William Shaver, a gastroenterologist who has written and spoken widely on the topic of human suffering, points out a further reason to question the value of palliative sedation for existential pain. According to Shaver, the existential suffering can be a “dynamic and transforming process in which the incomplete and fractured nature of the self begins to re-emerge into consciousness.” Shaver, it seems, sees death as a last-minute opportunity to remedy basic psychological angst.
On the surface, Shaver’s argument sounds a little like the “pain builds character” argument end-of-life caregivers have fought so hard against. But on closer inspection, his is a far more caring approach. Writing in the Journal of Hospice and Palliative Nursing, Shaver suggested that caregivers “reorient the locus of control from a search for cure to an active search for meaning.” He advises validating and mirroring the patient’s feelings and offering unconditional love. Simply “‘being in the presence of’ in a nonjudgmental fashion, moment-to-moment listening, mirroring and loving, is an incredibly powerful intervention,” asserts Shaver.

Perhaps death would be easier for everyone if we used these techniques sooner in life. —A.H.


RESOURCES

These Web-based fact sheets, educational tools and organizations provide help for medical professionals who work with dying patients and their families.

Medical Education and Training Resources: End-of-Life and Palliative Care Resource Center—www.eperc.mcw.edu

American Academy of Hospice and Palliative Care—www.aahpm.org

End-of-Life Care: Questions and Answers: National Cancer Institute Fact Sheet—www.cancer.gov/cancertopics/factsheet/support/end-of-life-care

End-of-Life Care: Ethical Issues in Alzheimer’s Disease: Alzheimer’s Association Fact Sheet—www.alz.org/Resources/FactSheets/endoflifeEI.pdf

Innovative Models and Approaches for Palliative Care: Promoting Excellence in End-of-Life Care (Robert Wood Johnson Foundation)—www.promotingexcellence.org/i4a/pages/index.cfm?pageid=1

Resources for End-of-Life Issues and Care: American Psychological Association—www.apa.org/pi/eol/homepage.html

End-of-Life Care for Children: Texas Children’s Cancer Center-Texas Children’s Hospital—childendoflifecare.org

Recommended Curriculum Guidelines for Family Practice Residents: End-of-Life Care: American Academy of Family Physicians—www.aafp.org/PreBuilt/curriculum/End-of-Life_Care.pdf

“Principles for Care of Patients at the End of Life: An Emerging Consensus Among the Specialties of Medicine”: Milbank Memorial Fund—www.milbank.org/endoflife

“The Physician’s Role: Palliative Care”: Griefwork Center, Inc.—www.griefworkcenter.com~~~~Complementary and Alternative Medicine,Ethics,Humanistic Medicine,Medicine in Popular Culture,Practice of Medicine~
326~9December~2006-55~Feature~Dark Crystal~Methamphetamine’s stranglehold challenges every level of the health-care system~Pete Thomson~Meth addicts are not only found in prisons, hospital ERs and the streets; you are likely to encounter plenty in the primary care exam room. But a simple office screening and intervention can prevent your patients from ending up in one of those other nightmare locations—or even the morgue. Plus: Meth’s march through the heartland.~Methamphetamine is medicine’s two-faced friend, the traitorous colleague, the backstabbing buddy. At its therapeutic best, this Schedule II central nervous system stimulant offers help to sufferers of extreme attention disorders. Its core ingredient, the decongestant pseudoephedrine, relieves the misery of millions of cold and allergy sufferers.

But its dark side is an illicit varietal manufactured in clandestine domestic laboratories into a highly addictive street drug that can be administered in just about every way imaginable.

According to the National Institute on Drug Abuse (NIDA), “meth” is the most potent of all illegal stimulants, producing three times the dopamine releaseof cocaine. Though most commonly smoked, the drug can be snorted, injected or even delivered by enema. The faster methods of delivery, like injecting or smoking, result in a sudden rush of euphoria, while snorting or swallowing the drug produces a more prolonged euphoric high. The drug reduces the appetite and increases wakefulness. Users can become paranoid and aggressive, and experience increased heart rates and respiration. Injecting users face many of the risks associated with that method, including disease transmission.

“In Los Angeles, in terms of injection drug use, [heroin] is still the biggest reason that people use needle exchange. Second would be methamphetamine,” Dr. Kristen Ochoa, a psychiatry intern at Harbor-UCLA Medical Center, says. “But in terms of just use, methamphetamine is probably right up there with heroin. Because most people…who use methamphetamine, in L.A. County at least, aren’t injecting it. They are smoking it.” Ochoa has been promoting and working with needle exchange programs since the late 1980s, when the rise of HIV among injecting drug users demanded some response.

She is currently working with the Los Angeles Overdose Prevention Task Force, which focuses on distributing information on how opiate users should respond when they fear they or a companion are having an overdose. “The way I always think of it is, the heroin overdoses end up in the medical E.R., and the methamphetamine overdoses end up in the psychiatric ER,” she explains. Their symptoms, like acute psychosis, are often indistinguishable from schizophrenia or bipolar mania.

The meth found on the streets, also called “chalk,” “crystal” and other names, is particularly insidious. An indication of its addictive hold is reflected in the overwhelming numbers: More than 1.4 million people in the United States over the age of 12 have used meth in the previous year—or .6 percent of the total population, according to the National Survey on Drug Use and Health, conducted by the Substance Abuse & Mental Health Services Administration. In 2004, meth—or other amphetamines—was the primary drug of abuse in 8 percent of treatment admissions, and that number has likely grown in the ensuing years.

The numbers of people entering treatment for meth do not yet reflect the depth of the problem. “We’re kind of waiting for it to ‘hit’ in terms of treatment, and often there is a delay,” says Kevin Doyle of Vanguard Services, a substance-abuse treatment provider in the Washington, D.C., metro area.

Although outpatient rehab and recovery is effective for some addictive substances—and is the preferred method for those who foot the bill—meth is not in that category. “I would think that would be extremely—capital ‘E,’ bolded, underlined—challenging because this is a very damaging, difficult—those words are understatements—drug to recover from,” Doyle says. “It’s just devastating.... There are a lot of physical effects. Not just the addictiveness, but the horror stories of what people’s bodies go through physically and the damage they do to themselves.”

Residential treatment programs—the less expensive, 21st-century alternative to the hospital inpatient programs of the ’80s and ’90s—are the typical route to meth sobriety, but a significant portion of those admitted for the drug relapse. In a recent study, Lynn Brecht at the Center for Advancing Longitudinal Drug Abuse Research looked at long-term results of 350 meth users. Of every 10, she says, four relapsed within the first month after treatment or never succeeded in achieving abstinence during treatment. Two more of those 10 had relapsed by the one-year mark. Three were still meth-abstinent two years after treatment. Only two were meth-abstinent after four years.

The final treatment option for meth addicts is often incarceration. “I’m not a big proponent of that, but it does take someone out of the environment,” Doyle says. “In treatment, [we] do support people experiencing some consequences of their use, and [prison] can get their attention.” In fact, according to NIDA, as many as 70 percent to 85 percent of inmates in the nation have substance abuse problems that justify treatment, but only 13 percent receive it during their incarceration.

Unlike treatment programs for alcohol or opiates that can be augmented with medication, there is no pharmaceutical salve for meth addiction. Research, of course, is ongoing, both with current drugs like antidepressants as well as new agents. The antidepressant bupropion, for instance, is being studied for its efficacy in the initial stage of treatment, according to NIDA. Early results have been positive among low- and moderate-level meth users, as withdrawal symptoms for meth include depression and anxiety along with cravings for the drug. Anti-epileptic medications are also under consideration for a pharmacological assist. Still, there is no magic bullet in the field yet.

28 Days—and Probably More

Despite meth’s uniquely addictive powers, current treatment methods mirror those for other substances.

“We don’t differentiate greatly in terms of the treatment based on your primary drug of use, or what some people call your ‘drug of choice.’ We try to get away from that ‘choice’ word because it isn’t the person’s choice any longer when they are addicted,” Doyle says.

The first step of a treatment program is abstinence. Then come the withdrawal symptoms, which Doyle says is one of the hardest periods. The remainder of the treatment program typically revolves around a 12-step model, but it doesn’t work for everyone, Doyle explains.

“Studies show that 12-step programs, motivation enhancement and other types of positive programs all seem to be...equally effective,” says Dr. William Lawson, chair of the psychiatry department at Howard University Hospital. “So the problem is not what program works, but in getting people into the program in the first place.”

Counselors use several methods to rate the control a substance has over a client. The Addiction Severity Index tool is widely used and very effective, Doyle says. Another method is looking at the length of time a person has been using, but patients who have used meth only briefly can become seriously dependent. “This is a pretty potent drug,” he says. “Crack is similar. I wouldn’t say, for someone who has been using crack cocaine for six or nine months, that it would be easy just because it has been a short time…. Some kids [have] been using only for a couple of years, but as a percentage of their lives, that is pretty great.... This has become a way of life for someone.”

Earlier Interventions

It’s no surprise to students who’ve spent any appreciable time in the ER that up to half of patients admitted, particularly on Friday and Saturday nights, have some alcohol or drug problem. But even in a primary care setting, says Dr. Richard Brown of the University of Wisconsin Medical School, that number can still reach 10 percent, and many of those patients are slipping away from a critical juncture in care.

Only one in 10 people with substance abuse problems get specialized assistance in a year, Brown says, but 70 percent of them will show up at a primary care practice over a two-year span.

“We can involve all providers and sectors in this issue,” Lawson says. “Primary care physicians, teachers, educators, social workers. What we’ve found is that [by] primary care physicians or pediatricians letting [users] know that this addiction does have grave consequences...that in and of itself can be helpful in getting some people to seek treatment.”

And that is where Brown hopes every physician—and every medical student—will come into play.

“There has been a lot of research in the last 30 years that shows we can identify most people with alcohol or drug issues—even those just on the verge of a serious problem—with some simple questions,” Brown explains. He is currently working to promote a primary care model for treating substance abuse. Called SBIR—screening, brief intervention and referral—he hopes to bring it into wide use among Wisconsin practitioners.

“For people who have earlier or milder issues, brief counseling—5 to 15 minutes and one to three follow-up sessions—can reduce alcohol and drug use to the point where people will be healthier,” he says. The savings from their decreased health-care utilization, criminal justice involvement and car crashes is believed to be about $1,000 per person per year.

“All this research shows that we can be using SBIR to help address this major public-health problem, but in most medical settings, we are not systematically providing those services.”

The screening process for SBIR is not particularly complicated, and patients will be more honest than you might expect. “There is a myth that every patient with an alcohol or drug problem is in denial. It is really not true,” Brown says. Most patients may seem like they are in denial, he explains, if they are approached in a judgmental way—or if the physician shows frustration. But patients may be looking for someone they can trust.

“A lot of patients do hide it when they are not sure how their [provider] is going to handle this information, but many patients are really looking for an opportunity to discuss this with somebody who cares, and they do answer these questions quite accurately.” Even if they do suppress some of their answers, hiding part of their addiction, there is usually enough information for a physician to deduce the problem and make an appropriate recommendation, Brown adds.

For example, a family physician sees a patient he’s had off and on for a few years. The man is an engineer by training, but works as an electrician and handyman, installing floor tile, ceiling fans—whatever. She asks: “Has your work been stressful?”

Yes, he has been moving from job to job, hired only through word of mouth. With real estate on the cusp of a downturn, homeowners have been hesitant to invest in improvements. Thankfully, his wife’s job lends some stability and benefits, so it has not been too bad. But it can be nerve-wracking.

“I can imagine,” the physician responds, noting that she is also effectively self-employed. “Do you have an outlet? Watching TV or something? Family dinner?”

The hours of his wife’s stability-providing job preclude dinner together. His schedule is also unpredictable.

“What’s your evening like, then? Do you have a routine, a ritual?”

He comes home—if he has even been out for work—and settles in front of the television with a drink.

“So you have a drink in the evening; perhaps a second as well?”

And sometimes a third, it seems. Three or four times a week, his head is spinning by bedtime. The physician has found an opening to discuss his habit.

So what’s keeping primary care from addressing every patient’s substance abuse problem, meth or otherwise, at the first interface with the health-care system? Time.

“It’s clear that we just can’t keep asking docs to do ‘one more thing,’” Brown says. “They are overburdened with what they are trying to do already.”

Handing out screening forms in the waiting room to be collected later by a nurse or physician’s assistant is one solution to the time crunch. The other stages of SBIR can also be spread around the office. “In some practices, we are finding out that the physician may not be the best one to deliver the brief interventions,” Brown says. “Maybe there is a nurse there who has a special interest in this topic. Or maybe there is a health educator who can do this along with the diabetes education they are doing.”

A “brief intervention” might consist of discussing with patients the consequences of their drug or alcohol use, suggesting methods of cutting back or eliminating their usage, providing them with written information and vowing to support them in their efforts. This conversation—and it’s important that it be verbal—might take up to 20 minutes.

Researchers at Boston University’s schools of medicine and public health found that 20-minute interventions resulted in a 29 percent reduction in cocaine-positive hair tests, versus a 4 percent reduction in the control group, demonstrating that brief intervention techniques have some applicability to drug users.

The other problem is one of chickens and eggs: If early intervention techniques are only being explained to active physicians, when are medical students exposed to these concepts? In students’ hospital rotations, “the patients they learn to recognize as having alcohol or drug problems are really only those people who are severely dependent,” Brown says. This leads to a distorted view of who substance abusers are, and how amenable to assistance they can be.

“It would be like medical students who only saw patients who had end-stage metastatic cancer,” he posits. “And if they did, they would get the sense, ‘Why bother to screen for cancer; you can’t help these people anyway—they’re all going to die soon.’”

Most schools, he says, have some training for substance abuse recognition in the first two years of the curriculum, but by the time students hit the wards, they find many of their supervisors have not been trained in the skills. “Whatever training the students had in their first and second year sort of falls by the wayside.”

What physicians-in-training need is better role modeling in later medical school and through residency, Brown explains. “And physicians can be trained to do this. They already have the basic skills. This is just introducing a little bit of a wrinkle into the kind of things they do day in and day out.”

Brown hopes to spread SBIR to all corners of health care, including pharmacies and dental practices. “The more settings where we can get these services offered, the more likely we are going to reach everybody.”

Pete Thomson is associate editor of The New Physician.~Meth Migration

Meth has been moving steadily eastward for the past decade, according to law enforcement reports for the Drug Enforcement Agency.

From 2001 to 2004, police in the South saw a doubling in confiscation of methamphetamine-related contraband, while New York and Pennsylvania saw “large” increases in laboratory seizures over the same period, demonstrating meth’s march, although the surge could also be related to increasing awareness and response on the part of police and the public.

Meth, for the moment, has a much stronger hold on rural communities than on urban areas. In Washington, D.C., meth use among youths aged 12–17 is a mere .1 percent, among the lowest in the nation. Dr. William Lawson directs the department of psychiatry at the city’s Howard University Hospital. In his view, the city’s respite from meth is likely a temporary one. He notes that the drug’s usage rate in the black population is still low, but “the expectation is that…is going to be changing in the near future,” he says. With increased efforts to stem the tide of other popular drugs in the District and other urban areas, including opiates and cocaine, meth “will become the new alternative agent,” he predicts.

The mobility of production is a large part of the drug’s growth and increasing availability, Lawson explains. “It becomes much more difficult to eradicate, versus transporting it from another country.... It can be made right here at home.” —P.T.~~~~Community and Public Health,Medicine in Popular Culture,Practice of Medicine~
327~9December~2006-55~Feature~“The Absolute Mistress of Her Body”~
A century after Sanger, women’s reproductive health still inflames partisan passions~Avery Hurt~Untangling the politics surrounding women’s reproductive health has never been more difficult. We take a look at four of the most salient issues of the day and how each side views the matter. As always, medicine is caught squarely in the middle.~In 1916, Margaret Sanger opened the first family planning and birth control clinic in the United States. It was raided by police several days later, and Sanger served 30 days in prison for disseminating information about birth control, one of many arrests and imprisonments as she attempted to educate poor women about limiting their family sizes.

Almost 100 years later, debates about whether a woman is “the absolute mistress of her own body”—as Sanger advocated—continue to fire up opposing sides of medical and social policy. From teaching sex education in schools to funding abstinence-only programs in the battle against AIDS, the issues keep rising up in new and complex ways. In one form or another, reproductive health continues to escape the clinic and turn up in the legislature, debate forums and, often, the streets. Among the latest hotly contested issues are questions about making the new human papilloma virus (HPV) vaccine mandatory for middle-school attendance, offering emergency contraception over the counter, teaching medical students how to perform abortions, and donating one’s eggs for medical research or for fertility patients. This month, The New Physician takes a closer look at these four issues from both sides.


A Shot Felt ’Round the World

If it lives up to expectations, the vaccine against HPV, recently approved for use in girls and women from 9 to 26 years old, may one day be considered among the great advances in medicine—and certainly a much-needed win in the war on cancer. Infection with HPV is a condition for developing cervical cancer, which kills almost 4,000 women each year in the United States alone.

Widespread use of the vaccine, marketed by Merck & Co. Inc. under the brand name Gardisil, would eliminate as much as 70 percent of cervical cancer and almost all cases of genital warts, experts believe. The vaccine appears to be both harmless and effective.

A no-brainer? Well, not exactly.

The HPV vaccine boasts an impressive list of “firsts.” It is the first vaccine primarily intended to prevent cancer, the first to target a single gender (though boys may soon be getting it as well) and the first approved for use in children to prevent a sexually transmitted disease (STD). If some advocates get their way, it will be added to the list of vaccines required for school attendance.

Because the drug is effective only before infection, the vaccine must be received before a girl becomes sexually active, hence its recommendation for preteens. And as with all vaccines intended to wipe out a disease, the public-health benefits will only be realized if it is widely used, so mandatory vaccination is being pushed in some state legislatures.

Although consensus among both liberals and conservatives is that the vaccine is a great medical advance, not everyone agrees that it is great for children. Conservative organizations such as Focus on the Family and the Family Research Council initially focused their opposition to vaccinating children on the argument that a drug to prevent STDs would encourage promiscuity and interfere with messages promoting abstinence before marriage and faithfulness within marriage.

But now that the vaccine is available, and states like Michigan and Illinois are considering legislation making it mandatory for girls entering middle school, opposition arguments have subtly shifted. Pro-family groups are now resisting efforts underway to require the vaccine for school attendance. “Governments should interfere with parental rights as little as possible,” says Linda Klepacki, sexual health analyst for Focus on the Family.

However, the group’s resistance to government-mandated vaccination does not extend to measles, chickenpox and other routine vaccines. “The behavior associated with this virus makes it a different issue,” explains Klepacki. “You can’t get HPV while sitting in a classroom doing math.” She says that the organization struggled with the issue because of the obvious public-health benefits, but ultimately decided that as long as there was another way to prevent the disease (abstinence), the vaccine should not be required for school.

Widespread inoculation is not the only reason for making the vaccination mandatory. Dr. Katherine O’Connell, assistant clinical professor of OB-Gyn at Columbia University College of Physicians and Surgeons and a member of Physicians for Reproductive Health and Choice, points out that the HPV vaccine is not cheap. According to the Centers for Disease Control and Prevention (CDC), a full series of HPV vaccinations costs $360. If the CDC advisory committee on immunization practices recommends that it be included with other routine childhood immunizations, insurance companies are likely to cover the cost. This could make a big difference in the public-health benefit of the vaccine.

Despite much press attention on the concerns of abstinence-only groups, resistance to mandatory vaccination seems to be relatively weak and getting weaker. Even opponents agree that when properly informed about the risks and benefits of vaccination, most parents will choose to have their children vaccinated.

“My inclination is to say that the treatment of and elimination of disease takes precedence over concerns [about promiscuity],” says Stanford University premed George Capps, who serves as vice president and publicity officer for the university’s Students for Life group, but whose opinion, he adds, does not necessarily represent that of the organization. David Mayans, a politically conservative third-year at the University of Kansas (KU) School of Medicine, agrees: “It would be silly not to get a vaccine that could prevent cancer. If people know the facts, they’ll get the vaccine. That’s why education is crucial, and I don’t think the HPV vaccine has been explained well.”


A Not-so-simple Plan

Over-the-counter (OTC) sales of emergency contraception, or Plan B as its manufacturers have named it, has been a contentious issue for many years now. In April 2003, Barr Laboratories applied to the Food and Drug Administration (FDA) to get its product approved for OTC sales, citing the drug’s safety and estimations that faster and easier access to Plan B would reduce the rate of unintended pregnancy by 50 percent and the number of abortions by 500,000 per year. Whether or not these last two claims are credible, a review of the safety and efficacy of the drug convinced 23 of 27 members of the combined FDA Over-the-Counter and Reproductive Health Drugs advisory committees to approve the drug for OTC sales.

Despite this overwhelming endorsement by its advisory committees, the FDA did not approve Plan B for OTC sales for three more years, prompting claims that the FDA based its decision on political expediency rather than scientific evidence. This prompted the resignation in August 2005 of Susan Wood as FDA assistant commissioner for Women’s Health. A few months later, Dr. Frank Davidoff, editor emeritus of the Annals of Internal Medicine, resigned from his post on the FDA’s Nonprescription Drug Advisory Committee for the same reasons.

Problems with offering Plan B OTC touch on several issues. Concerns that easy access causes an increase in STDs (because women might use it in place of barrier methods) is supported in one or two small studies, but there is not really enough evidence to make this a serious concern, says Davidoff. Claims that easy access to Plan B has not lowered the rate of abortions in countries where it is already available are also weakened by lack of evidence. “Even in countries where [emergency contraception] is already available OTC, the usage rate is too low to tell if it will lower the rate of abortions,” explains Davidoff.

Some have suggested that even though Plan B is safe when used as directed, it has the potential for abuse. If women use it too often in place of other contraceptive measures, they might risk health problems from the large doses of progestin in the pills. “Plan B is just a very high-dose birth control pill,” says Dr. Jane Orient, executive director of the politically conservative Association of American Physicians and Surgeons. “And hormones have side effects.”

O’Connell counters by pointing out that Plan B contains progestin only, and most of the health-damaging side effects of birth control pills result from estrogen. Progestin, says O’Connell, causes only “nuisance” symptoms—nausea, bleeding and disruption of the regular menstrual cycle. Davidoff asserts that the drug is not likely to be abused, first because of these mild but unpleasant side effects, and second, the cost will prohibit most from using Plan B as a routine form of birth control.

The most serious opposition to OTC sales of Plan B comes from pro-life supporters who see the drug as an abortifacient. In rare cases, the drug may prevent pregnancy by interfering with implantation after fertilization has occurred, but most medical experts who have reviewed the data on Plan B say that this is extremely unlikely when the pill is taken as directed—within 72 hours of unprotected sex. “We can’t absolutely rule out that Plan B interferes with implantation, but it is not very likely,” says Davidoff.

But that slim possibility is enough for many of Plan B’s detractors. Like many pro-life activists, Jill Onesti, a third-year at KU School of Medicine, believes that life begins at conception, not implantation.

“The ideal [contraceptive] agent would be one that prevents conception while not placing an already formed life at any increased risk. I am not convinced that we have found a method to prevent fertilization without risking the embryo,” she says.


Abortion vs. Academia

Debate about abortion often centers on the question of overturning Roe v. Wade, the Supreme Court case that established the right to an elective abortion. Meanwhile, other attempts to limit abortion have been successful in more indirect ways. Even when abortion rights are constitutionally protected, the procedure can be effectively denied to many women when clinics that provide the service are rare and distant, and few doctors are willing and trained to perform the procedure.

Currently, only about 12 percent of U.S. OB-Gyn residency programs require training for first-trimester abortions, according to the group Medical Students for Choice. In addition, only 7 percent of abortions are done in hospitals, and that’s where the residents do most of their training. Suzanne Poppema, co-vice chair of Physicians for Reproductive Health and Choice and a retired clinical associate professor of medicine at the University of Washington School of Medicine, points out that even when abortions are done in a hospital setting, they are typically done with general anesthesia and aren’t really anything like the elective procedure performed in most outpatient clinics. Students who want to learn the procedure have to seek their own clerkships or other opportunities to learn. It takes a great deal of motivation, time and effort for most students to get this kind of training, she says.

According to the National Abortion Federation, the number of abortion providers in the United States has decreased by 37 percent since 1982.

And many of the doctors who are still performing abortions are getting older. If there are no new doctors qualified to take their place, soon there may be too few qualified abortion providers to meet the demand, even if the procedure remains legal.

And abortion is in demand. It remains one of the most common surgical procedures performed on women, and according to the Guttmacher Institute, 40 percent of American women have at least one during their reproductive years. Controversial it may be, but unpopular it is not.

So why don’t medical schools make more of an effort to train their students in this very common procedure? The reason is fear, says Poppema, who spent her OB-Gyn career performing abortions alongside her other duties. “Universities are loathe to teach abortion because it is controversial,” she says. “They are afraid that potential donors won’t give their school money if they teach abortion.” Poppema knows about the effect a climate of fear can have on abortion access. After 15 years troubled by nothing more serious than occasional protestors, she was unable to renew the lease on her clinic in 2002 because the owners were worried about violence. “Once again, politics has trumped science,” she says.

University administrators may be fearful of the ramifications of providing abortion training, but not all who are committed to the pro-life cause hold such all-or-nothing views. Capps of Stanford Students for Life has this to say: “If I had my way, no one would have the option to learn how to perform abortions, but, if an abortion is going to occur, it is admittedly better for it to be carried out by a trained professional as ‘safely’—for the mother, if certainly not for the baby—as possible. I may protest the medical status afforded abortion, but, given that it currently has such a status, I am not going to go out of my way to protest the fact that medical students have the option to learn it.”

In 1995, the Accreditation Council for Graduate Medical Education (ACGME) attempted to address the problem by requiring OB-Gyn residency programs to provide routine abortion training. The requirement made a distinction between treating spontaneous abortion (miscarriage) and inducing abortion.

Although residency programs are required to provide training in spontaneous abortion, they are required only to “provide access to experience” in induced abortion, and the training does not have to be on site. The mandate does not require students to actually perform abortions, so residents with moral or religious objections are free to opt out of the training.

According to many, this distinction takes the teeth out of the ACGME mandate. Erin Cox, a fourth-year at Albert Einstein College of Medicine who is applying to OB-Gyn residency programs, is attending medical school on a military scholarship. “I have done some OB-Gyn rotations at military hospitals where abortions are not offered because it is illegal to use federal funding to pay for abortions. I think it is horrific that OB-Gyns are trained in locations where abortions are not done,” she says.

In 1996, Congress countered the ACGME’s requirement by passing the Coats Amendment, so residency programs that do not offer induced-abortion training will still be considered accredited by the federal government and thus still eligible for federal funds.

Many institutions, Catholic hospitals in particular, welcomed the amendment, but still have problems with the ACGME mandate. Since it is out of the question for Catholic hospitals to provide abortions, they are in a bit of a bind when it comes to complying with the regulation requiring them to provide the training to students who want it. According to the Catholic organization National Committee for a Human Life Amendment, having to farm out portions of their training could damage their competitiveness with other institutions as well as cause them to be seen as practicing “substandard” medicine.

Marie Hilliard, director of bioethics and public policy at the National Catholic Bioethics Center, agrees that the requirements place a burden on institutions that have moral or religious objections to abortion. She is also concerned with the provision in the ACGME’s statement that public teaching hospitals must provide abortion training, since, in keeping with the principle of separation of church and state, public institutions could come under fire for allowing students to opt out on religious grounds. “The First Amendment says that there shall be no state religion, but it also protects free expression of religion,” says Hilliard. While she notes that the ACGME requirements offer opportunities for both individuals and programs to opt out, “[The ACGME requirement] is another example of the creeping infringement on religious liberties,” she says.

The drug RU-486, also known as “the abortion pill” and sold under the trade name Mifeprex in the United States, may come to the rescue, although it is only effective within the first 63 days after the first missed period, creating many of the same barriers as a lack of local clinics. Cox points out that most patients, when given the choice between a traditional abortion and RU-486, choose the traditional method. Although taking a series of pills seems easier than having a surgical procedure, “Most people just want to get it over with and go home,” says Cox.


Ova-compensating

As one expert put it, egg donation opponents make for strange bedfellows. Most of the controversial issues surrounding reproductive health fall into clear and usual patterns. The right lines up behind their causes, and the left lines up behind theirs. But when it comes to egg donation, it can be more difficult to make partisan distinctions. The religious right tends to oppose egg donation for the purposes of medical research for much the same reason it opposes emergency contraception: fertilized eggs—thus potential human lives—may be destroyed.

Many on the right oppose donating eggs to infertile women as well. The Catholic faith opposes any kind of artificial conception, and some Protestant groups oppose reproductive technology because they believe it weakens the traditional family.

But opposition to paying young women for their eggs—no matter what the eventual use of those eggs will be—can be found on both sides of the political divide. Soliciting young women to donate eggs exploits women, opponents say, no matter what they think of the other issues surrounding the practice.

Despite the fact that these women are called egg “donors,” virtually all are paid, sometimes very large amounts. The clinics that seek donors have been accused of preying on young women who need cash—often college students with mounting educational expenses. People who are seeking eggs to become pregnant are particularly eager to get the ova of bright, attractive Ivy League students—students who may be facing tremendous educational debts.

When eggs are purchased under these circumstances, it can be difficult to give truly informed consent for the procedure, critics say. “Dangling large sums of money in front of people’s noses can make them less likely to consider the dangers of the procedure in question,” says Bonnie Steinbock, professor of philosophy at the University of Albany and author of several papers on egg donation and related topics.

On top of that, it is not clear that donors are accurately informed of the risks. Jennifer Lahl, national director for the Center for Bioethics and Culture Network, doesn’t believe that informed consent is ever possible, whether the donors are being paid or not. “Women can’t give informed consent because we don’t have adequate information to give them. No long-term studies have been done on the risks of repeated use of the drugs that are used [to stimulate egg production in donors],” says Lahl.

Steinbock also points out that when children are produced in this way, the court system often has to deal with ethical problems years later. Court cases concerning divorced couples fighting over who gets custody of embryos in storage and fathers who deny parentage of children produced by artificial insemination may be just a preview of things to come for courts wading their way through this new territory.

In an attempt to alleviate at least a few of these concerns, many legislatures are considering bills that would cap payments for egg donations. In September, a law was passed in California prohibiting scientists from paying egg donors any more than is necessary to reimburse them for their expenses. The law also increases the requirements for informed consent, but they apply only to eggs donated for medical research and do not address donors to fertility clinics.

It will likely take many years before clear regulations are formed on this issue. Meanwhile, perhaps, the strange bedfellows can work on some compromises in other contentious areas of women’s reproductive health.


The New Physician contributing editor Avery Hurt is a freelance writer based in Birmingham, Alabama.~~~~~Advocacy,Ethics,Health Policy,Medicine in Popular Culture,Practice of Medicine,Women in Medicine~
331~9December~2006-55~On the Wards~The Shoes Tell the Tale~A first trauma leaves a lasting mark~Bryan Gammon~Stepping in it~It is often said that you can tell something about a person’s character by the shoes he wears. This may be fanciful romanticism, but the saying holds within it a kernel of truth. At the very least, the shoes can tell you where a person has been. My own will forever remind me of my third-year surgery clerkship in Dallas and the painful lessons I learned there.


It was my first trauma call, and I was unabashedly scared. I had heard my fellow students’ stories about their trauma experiences, but how can words do the reality any justice? Thankfully, I had three medical student companions. If misery loves company, fear insists upon it.


The four of us—so out of place with our fresh, powder-blue Parkland Hospital scrubs; our pressed and blemish-free white coats; our quick smiles and nervous laughs—stood awkwardly against the walls of the trauma hall. We read our manual on the ABCs of trauma and listened to our second-year resident, Chris, explain our place if a level 1 trauma rolled through the doors.


That place, he explained, was “out of the damn way.” He emphasized this message with a particularly vigorous tobacco spit and a furious wipe at his lower lip.


At 3:00 a.m., 12 beepers chimed simultaneously—an insistent chorus that induced panic in the four medical students. From down the hall, a disembodied voice floated toward us: “Level 1 coming.” The rustling papery sounds of everyone putting on the blue, knee-high trauma boots that would keep us clean in ankle-deep blood reminded me of Christmas morning. Or maybe it was just the frenzied anticipation of the residents and nurses bouncing up and down next to the coolly reserved attendings, their arms folded across their chests like parents observing the swirling shreds of crumpled paper and glittery bows.


Seemingly as an afterthought, Chris looked back at us, one little fleck of tobacco on his lower lip, and asked, “Who’s going up?” Somehow, the camaraderie of fear dissipated in an instant and I found myself alone, my fellow students quietly lurking behind me. Chris looked at me: “OK, you. Bryan, right?”


Moments later, the EMTs rolled through the doors, holding a bag-mask, ventilating a kid in his late teens or early 20s. GSW to the axilla.


Now everything blurs and smears, an impressionistic watercolor of utter devastation. At the head of the bed, Chris secures the airway and intubates. I grab my shears and cut away the kid’s blue jeans. I notice that I wear the same brand. He gets a chest tube. No anesthesia. In seconds he has two large-bore IVs. “Blue card” blood is already in the warmers. I get another hemocue. It’s dropping. I find myself staring at the crumpled pile of bloody jeans with my shear marks up the thighs. There is a small lump of congealed blood on the floor next to them. It’s darker than I thought it would be, and it glistens under the oppressive glow of the fluorescent lights. Someone has stepped in it; I can see the imprint of a shoe.


“Hey, med student!” I snap to.


“Get the elevator, we’re going. Now. Hurry! Go! Go! Go!”


Heart pounding, I’m worried that I’ll get this wrong, that I won’t be able to get the elevator, that I can’t even do this right, and this kid’s life depends on it. This kid could be my brother. They’re running toward me behind the stretcher. The elevator doors open, and I notice that I’m sweating.



In the OR, I stand there, arms akimbo, cold sweat dripping down from my elbows, raining on the toes of my shoes, as I wait to be gloved.


“Stand there. Don’t move. We’ll get to you when we can.” I stand.


The surgery tech fixes me with a look, embodying both total dismissal and pity. She gives me the same look when my damp hands stick to the glove she holds, and I push two of my fingers into its one. She lets it go with a snap and holds the next one. I can fix it on my own time.


At the table, I am ensnared in the lines for the electrocautery and suction, hovering, not knowing what I can touch and what I can’t. I watch them perform a left-sided lateral thoracotomy. A shower of small black metal pellets, shiny with blood, drain out of the kid’s chest and tinkle on the floor.



A fifth-year resident motions me over. “Get closer,” he says. He’s wearing a black surgeon’s cap with the brand name of an anticoagulant on it. He’s pointing into the space between the silver jaws of the clamp, deep in the chest.


“What nerve runs through here?”


“Uh, uh…pericardiocophrenic?” I have no idea where that comes from.


“Yeah, so what happens if I cut that?”


“He stops breathing?”


“Yeah, and what’s that?”


“I don’t understand.”


“That’s bad, that’s what it is. It’s bad!”


My heart is beating so hard in my chest, I think I’ll need cardiac massage. My mask is distorted in streaks where my hot breath condensed and dripped down, refracting my field of vision. My gown is sticking to my arms.


“Hey, give me your hand.”


The fifth-year takes my hand, placing it on the flaccid, smooth surface of that vital muscle. My fingers slide over the surface. I’m holding a stranger’s heart in my hand.


“What is that?” the fifth-year asks.


“The heart?” I think maybe I don’t understand the question.


“It’s dead! That’s what it is. Dead.” He looks at the attending. “Ready to call it?”


“Call it,” the attending says. “Let the med student stitch him back up. Make it look as good as you can.”


“Know how to whip stitch?” the resident asks me. I shake my head.


“It’s easy. Just like a baseball. You’ve seen a baseball before, right? Come on, I’ll do the first one.”


Afterward, stuffing my blood-streaked gown into the laundry, I notice a port-wine-red drop of blood on the toe of my tennis shoe. I didn’t wear trauma boots. I think about cleaning it off, and then think again.


Walking the lonely hospital halls that night, sadness and emptiness consumed me. In retrospect, though, I also feel a growing sense of gratitude to that kid and his family, to that pile of shredded jeans and those BBs showering the OR floor. They remind me how precious and ephemeral this life is, and how quickly it can all be taken away.


Those unwashed shoes are still in my closet.
~~~~Bryan Gammon is a fourth-year at UT Southwestern Medical School.~Medical Education,Residency,Student Life and Well-Being~
332~9December~2006-55~Feature~SPOTLIGHT: “Aren't You a Nurse?”~Female medical students continue to grapple with gender stereotypes~Linda Childers~At more than 40 U.S. medical schools, women first-years outnumber men. But at these very same schools, female students still face old-fashioned stereotypes and assumptions about their “proper” role in medicine.~Kate Young is no longer surprised when people ask if she’s a nurse. A third-year at the University of Nevada School of Medicine, Young faces the misunderstanding on an almost daily basis.


“When I tell people I’m in medical school, they typically ask if I’m planning to become a nurse,” Young says. “And when I walk into my patients’ rooms, they often assume I’m their nurse.”


Rebecca Bedingfield, a second-year at the Medical College of Georgia (MCG), is also frequently mistaken for an RN. “When I tell people I’m in school, they assume I’m pursuing a career in nursing,” she says. “When I explain I’m going to be a doctor, it often surprises them.”


Even in 2006, these cases of mistaken identity are hardly unique. While the journal Academic Medicine notes that the number of female medical students has increased from 7.7 percent in 1964 to 48.5 percent in 2005, many women in medicine continue to face gender stereotypes and subtle discrimination.


Stereotypes aren’t just annoying—they can also affect a student’s academic performance. In a recent University of British Columbia study published in the Oct. 20, 2006, issue of Science, women who were told that men were better equipped, genetically, to solve math problems performed worse on math tests than women not exposed to this notion. Their findings highlight the power of what psychologists call “stereotype threat”—a phenomenon in which individuals from stereotyped groups often “choke” in situations where those stereotypes are put to the test.


Often, stereotyping becomes obvious before a student even enters medical school. “Before I was accepted, I had several co-workers who tried to convince me to become a nurse or physician’s assistant,” Bedingfield says.


Mentor Gap


According to the Association of American Medical Colleges (AAMC), female medical school applicants have slightly outnumbered men in the past few years, and by 2010, 30 percent of all physicians in the United States will be women. But the disconnect between the large numbers of women entering medicine and lingering judgments about their suitability for the role persists, perhaps in part because the percentage of women in top medical faculty roles has lagged well behind their student counterparts.


The AAMC’s latest data show that only 15 percent of full professors and 27 percent of associate professors are female. Only 12 of the 125 deans of U.S. medical schools are women.


“I remember a [male] professor in medical school telling me no one would think badly of me if I just quit the program, went home and had babies,” says Dr. Kathie Horrace-Voigt, an osteopathic intern at Bay Area Hospital in Corpus Christi, Texas. “He didn’t realize I already had two children.”



“I’ve been told that in some male-dominated specialties, such as surgery, it might be frowned upon if I am pregnant while interviewing for residency positions,” says Shannon Klucsarits, a first-year at MCG. “I find it frustrating that as a female, I’m expected to make a choice between starting a family and beginning a competitive residency program.”



Perhaps the biggest challenge for female medical students and residents is proving to their peers that they are capable of successfully balancing work and family. Unfortunately, women in medicine say they often have to demonstrate proof that they are capable of this juggling act—one that for women in other professions receives little attention.


And the criticisms don’t always come from their male peers. Sometimes, it’s their childless female colleagues who voice disapproval of the desire to combine medicine with motherhood. “Surgery interests me, but I was told by a female surgeon that I needed to make a choice between being a surgeon or a mom,” Klucsarits says. “Her advice was to become a surgeon and to hire someone to raise my kids. But why can’t I be a good surgeon and a good mom?”



While a surgery career for a mother may be hard work, it’s not impossible, says Dr. Shannelle Campbell, a third-year resident in general surgery at the University of North Carolina Hospitals in Chapel Hill. Campbell says that being a member of the Association of Women Surgeons (AWS), and having exceptional role models, has helped her gain a more optimistic view of the field.


Campbell credits Dr. Julie Ann Sosa, an assistant professor at her alma mater, the Yale University School of Medicine, as being one of several women mentors who helped her learn what it meant to be a woman surgeon. She also received insight and support from something called The Pocket Mentor—a free resource published by AWS. The manual is based on the experiences of a number of women surgeons, and was written to help make the medical school and residency years easier for up-and-coming women surgeons.



Campbell says that being involved with the AWS has exposed her to many positive role models. Many of the organization’s members juggle motherhood with part-time jobs in private practice or staffing a medical center that offers flexible scheduling. “I think it’s possible for women surgeons to have both a career and a family,” she has concluded.


“I believe women in medicine can have it all if they are willing to juggle the responsibilities that come with their career, marriage and family,” says Bedingfield. “I know that I need to find a specialty that will be reasonably accommodating…. However, I would never choose a field that I find less desirable or less compatible with who I am, just to have a better work schedule.”


Bedingfield has found that student interest groups within the AWS and the American Medical Women’s Association provide good resources. These groups often host activities like panel discussions on issues of gender stereotyping and discrimination, and presentations by female physicians in varying roles.


Even though women have made headway in nontraditional specialty areas such as surgery, some don’t think it’s possible or desirable to be both Super Surgeon and Super Mom, and they believe that their feelings on the matter should not be used as an excuse for discrimination.


“Surgery is an 80+-hour week,” says Horrace-Voigt. “My children are older now, but I can’t imagine trying to juggle a baby during a surgical residency. I don’t think most young women want to make a choice between surgery or family, but they often don’t receive the support that allows them to accomplish both.”


Specialties for “Ladies”


Some women students say their colleagues immediately assume they are going into a traditionally “female” specialty area because of their gender. “I’m often asked by male physicians if I am going into pediatrics before I ever tell them anything about myself,” Young says.


Yet it’s clear that in certain specialties, especially primary care, women dominate the field. According to 2005 data from the American Medical Association (AMA), the specialties having the greatest percentage of women residents are OB-Gyn (76 percent), pediatrics (70 percent) and dermatology (62 percent). By contrast, the fewest women residents are found in orthopedic surgery (9 percent), urology (15 percent) and otolaryngology (21 percent).


But between these two extremes fall an abundance of women choosing to go into a broad range of nonprimary care specialties. For example, 51 percent of pathology residents, 53 percent of psychiatry residents and 31 percent of anesthesiology residents are women.


Although Jenny Schroeder, a fourth-year at Creighton University School of Medicine, has chosen to pursue a career in pediatrics, where many of her colleagues will be women, she still gets questioned about her commitment to the field. “I’ve found that some attending physicians do not expect as much from me as they would from a man,” she says. “In addition, I’ve frequently been asked by male physicians whether I am going to work full or part time when I finish residency. I think some physicians are bothered by the fact that women physicians are working part time in order to raise their families.”


“When choosing a specialty field, I think lifestyle is a big factor for many women,” admits Bedingfield. “Ultimately, I hope that women make a specialty choice based first and foremost on what they find satisfying and rewarding.”


“It’s not my personality to let someone else dictate how I should think or feel because of my gender,” adds Horrace-Voigt. “The dean of my school is a powerful woman who definitely doesn’t let others tell her what to do. I think she’s a great role model.”
~RESOURCES


The Association of Women Surgeons offers peer support, mentoring and the popular handbook The Pocket Mentor, available free from www.womensurgeons.org.


The student chapters of the American Medical Women’s Association (www.amwa-doc.org) promote leadership and advocacy to advance women in medicine and improve women’s health through leadership, advocacy, education, expertise, mentoring and strategic alliances.


Online discussion forums such as www.mommd.com and www.studentdoctor.net offer women a chance to interact with others who are juggling the demands of careers with family.


Books such as Women In Medicine: Getting In, Growing, and Advancing, by Janet Bickel and available from Sage Publications (www.sagepub.com), offer advice on overcoming gender stereotypes, finding a mentor and choosing a specialty.


For women who don’t have ready access to mentors, the American Medical Student Association offers its members mentoring contacts and services through its Web site (www.amsa.org).


The American Medical Association sponsors the Women Physicians Congress, which offers programs addressing women’s health and women physician professional issues on an ongoing basis. Congress activities and resources can be found online at www.ama-assn.org/ama/pub/category/18.html.


The Association of American Medical Colleges’ Women in Medicine program (www.aamc.org/members/wim/start.htm) assists deans’ offices and individual faculty members in addressing gender-related inequities and improving the pathways for women to contribute fully to academic medicine.


~~~Linda Childers is a freelance writer in Martinez, California.~Advocacy,Ethics,Women in Medicine~
333~9December~2006-55~Perspectives~Eye Contact~Disengaged doctors and the death of hope~John Inzerillo, M.D.~Eye shy~I hear the word “contact,” and my mind fixes on a World War I biplane with its rotary engine that required a man to hand-crank for ignition. This was quite frightening to do since the entire 300-pound engine spun with the propeller. Once the preflight was complete and the pilot was ready, he yelled, “Contact!” The long, three-pronged propeller was spun clockwise, engaging the engine as a puff of black smoke cleared the cylinders.


This manual cranking gave way to the present-day air compressor that starts the engine with a push of a button. In a patient–physician relationship, though, nothing can take the place of contact, especially eye contact.


Being involved in the medical profession does not exempt any one of us from illness. We and our family members at one time or another have to go to the doctor. My 6-year-old’s symptoms started as eye irritation, scratchiness and excessive blinking. We discovered that his symptoms became much worse when he rolled in the grass or crawled under a dusty bed to hide. Naturally, we thought his ailment was allergy-related, since an attack would quickly be relieved by a cold, wet washcloth over his eyes.


Eventually, we determined it was time to visit a dermatologist, who prescribed hydrocortisone valerate cream for the face and Visine drops for the eyes. We developed a ritual for applying the treatments, and my son enjoyed the hands-on attention from both Dad the doctor and Mom the nurse. But after a few weeks of these treatments, his symptoms failed to improve. The next step was a visit to the ophthalmologist.


I was at work on the day of the eye visit, but after the appointment, my wife called me, alarmed at the line of questioning the doctor had taken. He was concerned that there was a mild degree of optic disc swelling and asked if our son had experienced any headaches, nausea, vomiting, listlessness or other difficulty. When she had pushed him to elaborate further, he hedged, saying that he doesn’t see many children in his practice, that maybe in this age group this is just a normal variant and that a good plan would be a consultation at the “mecca.”


Like other spoiled, red-blooded Americans, when it came to our child’s health, we went up market, making an appointment for two days later at the eye clinic at the major medical center 90 minutes away. During the ride, I kept thinking, just a normal variant.


The technician performing the initial eye tests was a pleasant, professional young woman, and it was easy to tell that she had spent a great deal of time working with children. Her expertise was evident as she seamlessly directed my son’s gaze to where she needed it to be. When Disney’s Nemo appeared on the television screen in front of us, all eyes, except those of the technician’s, automatically focused on the cartoon. My son, like other children his age, was mesmerized by the colorful images on the monitor.


Shortly after, we were greeted by the ophthalmology resident, whose demeanor was quite different from the technician’s. She spoke in a muffled tone, and I could not catch her name. She limply shook my wife’s hand, and only as an afterthought did her drooping eyes glance over to me.


In her interaction with my son, she appeared oblivious to his responses, or lack of responses, to her directions and questions. She didn’t notice he was not understanding a word she was saying. I was having a hard time myself, feeling a definite disconnect with her. As she proceeded to examine his pupils, she backed up in mild frustration and asked us why “they” did not dilate his pupils. We had no idea, so she let it drop.


After another trip to the waiting room, we were called in to see the man we had been waiting for. His exam room was plastered with diplomas and awards. I was familiar with this office environment. Sometimes competition in the big medical centers is such that anything to stroke the ego is seen as beneficial to the self. It is as if these fancy pieces of paper decorated in calligraphy act as a substitute for honest contact.


Upon entering the room, the doctor glanced briefly at my son and wife. I stood to shake his hand, but the handshake did not take place. As he began to address his comments directly to the chart, I muttered to my wife, “No eye contact.” She thanked him for seeing us so quickly, having heard that he was about to leave on vacation, and we were one of the last exams of his day. He shrugged it off, but let us know that it was a 50-patient day, and that he had a long way to go until he finished.


I explained my son’s situation, and upon examination, the doctor found that the discs were indeed raised, though mildly. As we remained silent, he began to explain about optic nerve drusin, and how sometimes they can hide beneath the surface of the nerve. Buried drusin is simply deposits of hyaline bodies—highly refractile calcium or other unknown material deposits found in and around the optic nerve head. Some people develop drusin later in life as a result of age-related physiological changes in the eye.
But he had seen no drusin. So he began to explain about pseudo-tumors. My mind went back to my internship, and the one middle-aged female patient I’d seen with such a problem. I remember prescribing Diamox, which was the doctor’s next word before moving on to the possibility of space-occupying lesions.


Being an oncologist and dealing with percentages all day long, I asked what my son’s chances were of having a space-occupying lesion. The doctor simply responded that if he was going to Las Vegas, he “would not bet on it,” but it does happen on occasion.


Now the seed was planted and began to grow in my worried mind. He went on to tell us of a required lumbar puncture, under anesthesia, that would be necessary if the MRI was negative for a brain tumor. If my son’s cerebrospinal fluid pressure was high (>10-20 mm Hg in young children), then we would use the Diamox for an undetermined amount of time.


But at no time was there a discussion about what we were going to experience over the next 18 hours while waiting for the results of the MRI, scheduled for the next morning.
That night, I was awakened at 3:00 a.m. by my own worries. Although I know too much already, I made the mistake of Googling “increased intracranial pressure.”


I did not like what I saw—85 percent of the information had to do with cancers, and in the brain, all tumors act malignant even if they are benign. I read about optic pathway tumors, oligodendrogliomas, gliomatosis cerebri, and the more common glioblastoma multiforme and anaplastic astrocytomas. I envisioned the upcoming chemotherapy, radiation treatments and possible surgery.


I saw my 6-year-old son with a port-a-cath, receiving multiple injections, developing hair loss and being full of questions as to why this was happening to him.
As I write this, I know I have to deal with my own demons. But maybe some true eye contact would have helped to reassure me that things would be OK. The doctor lost a valuable opportunity to bring peace in the face of a potentially life-threatening situation. It was lost because of a 50-patient day.


His attitude is one reason I decided, well before my son’s illness, to move from my busy oncology practice to one where the pace is more human; where I can look my patients in the eye and shake their hands before I sit down to listen. It is a place where I have time to review the chart before I walk into the exam room, giving me the freedom to look at the patient and others with whom I am sharing space and experiences. I can get a better feel for where my patients and their family members are coming from, and where their minds may be taking them. Then I can do my best to reassure them.


It seems strange when patients tell you, just after you’ve broken the news about their stage IV lung cancer and what that means, that they feel better after talking to you. I believe it’s because they’ve found a way to walk away with at least a little hope.
~~~~John Inzerillo is a medical oncologist at the Marion L. Shepard Cancer Center in Washington, North Carolina.~Ethics,Humanistic Medicine,Practice of Medicine~
334~9December~2006-55~Reviews~Call Companions~Helpful volumes for the wards~Monya De, M.D.~Survival manuals~It’s hard enough being a resident on call without the various sinking feelings: that you will get more patients than you can handle, that no one is there to help you, and the most awful of all—that moment when you realize that you are the only psychiatrist/neurologist/ophthalmologist/plastic surgeon on call for the entire hospital, and your training consists of third-year medical school with some biochemistry and fluffy away rotations thrown in.


Fear not—at least those of you on psychiatry and pediatrics rotations—the good people who put out the On Call series have published new pocket buddies, including the third editions of On Call: Psychiatry (Elsevier/Saunders, $34.95) and On Call: Pediatrics (Elsevier/Saunders, $36.95).


There are plenty of medical textbooks that rhapsodize for pages about rare diseases and exhaustive patient workups. Thankfully, for those of us who actually practice medicine, this series of concise, practical handbooks shepherds the hapless resident through those long nights.


The senior editor of On Call: Psychiatry, Dr. Carol A. Bernstein, is a residency program director who has wisely enlisted several resident contributors. The result is an incredibly useful collection of gems that should have been put together a long time ago.



The authors prep the pitiable resident on call by setting a few things straight, including how to prioritize one’s time seeing psychiatry consults, how to triage, and how to manage difficult patients and constant restraint orders from nurses. They emphasize being prepared for what the patient will unleash on you so you can avoid getting flustered. You can practically hear the voices of the contributing residents piping up with lessons learned the hard way; as an internship survivor, I can attest that they are right on the money.


Different patient presentations, from “anxious” to “rape victim” to “violent,” are discussed concisely. All of the On Call books are a little wordy at the beginning, but this one does a decent job of using lists to make the pages more visually digestible for tired eyes. I loved the inclusion of common medications and dosages, like a built-in Pharmacopeia. The authors didn’t ignore medical cases, either, with good attention to management of questionable situations that may have psychiatric or medical roots. On Call: Psychiatry is a definite buy for the shrink on call.


On Call: Pediatrics is also a particularly good offering within the series. It is chock-full of good practical information, with fluff kept to a minimum.


Wisely, pediatricians Dr. James Nocton and Dr. Rainer Gedeit begin this butt-pocket-sized volume with a primer on communication for the hospital resident. Advice on tense situations, such as middle-of-the-night encounters with scared parents, is matter-of-fact and unambiguous. The lessons are easily digestible and easy to remember. Particular emphasis is given to documentation—especially important given the rash of medical errors publicized in recent years as doctors get busier and busier with more tests to order and more drugs to dispense.



Chapters are divided by chief complaint rather than organ system, another practical decision. The chapters are appropriately brief and informative for the sleepy resident, and include more diagrams than in other On Call books. Explanations of key calculations, such as the A-a gradient, are given, as well as instructions for various procedures and normal values for a variety of indices, such as blood pressure in children. Colored headings are used to quickly guide the reader to the appropriate treatment for vomiting, for example.


If I was in a family medicine or ER setting, I would certainly want to have this book on hand to guide me with pediatric patients. When you can’t have a senior resident with you, a good reference is the next best thing.


Monya De is an alumna of the University of California, Irvine, College of Medicine.



Putting Disability In Its Place


by Leroy Trombetta, M.D.


Since antiquity, humans have been faced with how to deal with those individuals who are “different,” “abnormal” or “disabled.” Society’s response to its outliers has included segregation, elimination, abuse, exploitation and acceptance. In Cultural Locations of Disability (The University of Chicago Press, $19 paperback), authors Sharon L. Snyder and David T. Mitchell explore the position that people with disabilities hold within society, and how mainstream medicine and politics have helped define that position.


The authors begin their analysis in the 19th century by defining how society viewed the mentally and physically impaired. Using the literary works of Herman Melville and others to exemplify the conscious and subconscious attitudes held by persons in that era, Snyder and Mitchell make it possible for the reader, in a sense, to revert back to the early 19th-century thought paradigm. They present this in a readable manner, but seemingly overemphasize Melville’s The Confidence-Man in their examples, a novel with which most casual readers are unfamiliar.


Snyder and Mitchell then explore the eugenics movement of the early 1900s. Although most of the book focuses on those with mental disabilities, the authors show how the place of minorities, people with physical disabilities and homosexuals is also defined by the teachings of eugenics, a social program of shaping human evolution through intervention.


Most striking is the role that mainstream medicine is shown to play in defining the location of outliers within society at large. The initial segregation of the disabled for the purpose of correcting the disability and returning them to society gave way to permanent isolation via institutionalization. The reader then learns how this slippery-slope eugenics philosophy fostered what would now be considered unethical research conducted on the institutionalized. This culminates in
the extrapolation of the eugenics philosophy to all those seen as “abnormal,” facilitating the Nazi atrocities in the 1930s.


Snyder and Mitchell take a close look at institutionalization, using examples of training and education strategy employed within these centers. They present an entertaining, embarrassing and borderline farcical description of how those with disabilities are trained to assimilate into “normal” society. The authors explore the often co-dependent relationship between the disabled and therapist, inmate and warden. A major strength of this book is the authors’ ability to relate how the medical field, especially psychiatry, shapes and reinforces where society at large places people with disabilities.



The authors then attempt to define the location of disability in today’s society, employing contemporary literature, cinema and research in their efforts. While the times of imprisoning people based on biologic deviance have likely passed, Snyder and Mitchell do an excellent job of pointing out our collective unconscious attitudes toward people with disabilities and how those attitudes manifest in our daily lives.


Today, we are barraged with constant reinforcements of what “normal” should be, leading to a thought paradigm that makes it easy for us to isolate or ignore those with disabilities. The authors emphasize this phenomenon—brought forth in media, cinema and literature—as being a major obstacle to including people with disabilities in mainstream daily life.


Realizing that even as a physician, my mind is cluttered with prejudice. I found this book a fascinating sociologic journey. Upon further thought, I realized that most of the prejudices toward those with disabilities are unfounded, reactionary results to a perceived threat to “normalcy.”


Compassion alone is not enough to erase those prejudices, but Cultural Locations provides the reader with an understanding of the history behind these prejudices, allowing analysis outside our current thought paradigm.


Leroy Trombetta is a general surgeon at Brooke Army Medical Center in San Antonio, Texas.
~~~~~Learning Tools and Technology,Medical Education,Residency~