337~1January-February~2007-56~On the Wards~Nightmare on Elmo Street~Facing the dreaded peds clinic~N. Abimbola Sunmonu~The rug-rat rotation~I was unsure of what to expect on the first day of Student Continuity Practice (SCP), a program at my medical school that places students into local clinics one afternoon a week from the beginning of the first year all the way through the third. It is a way the University of Connecticut School of Medicine gets students to really practice medicine—not just shadow a physician—and to follow patients long term.


I was initially dismayed to learn I’d been assigned to a pediatrician, Dr. Neil Stein, in West Hartford. The first thing I thought of was how much I disliked pediatrics. If only I had opted for internal medicine or family medicine instead! I did not realize just how much I preferred working with adults until I was told that I had to work with children. That Stein occasionally saw adults with congenital issues did not assuage my apprehension. In my mind’s eye, those three years of SCP stretched into an eternity of torture. I even tried to get reassigned, but the program director was having none of it. I wondered if I would make it out intact or scarred for life.


Walking into the good doctor’s office on my first day, I pushed that thought to the back of my mind, determined to make the experience useful, if not enjoyable. Suddenly, I wished I had fortified myself with a few bars of chocolate before arriving. My clammy hands did not bode well for the afternoon ahead.


Stein, as it turned out, was just my kind of doctor: relaxed, approachable and knowledgeable without that condescending, arrogant air that infects some doctors like a bad case of head lice. I appreciated his warmth and humor, and his readiness to say “I don’t know” in the same breath as a promise to investigate. Maybe this whole peds thing was not so bad, after all.


But wait! Were those really children I saw in the waiting room—those little hobbits in midget-sized outfits reminiscent of Britney Spears? Who knew they made them that small? Ditto for the kids.


Our first patient was a screamer in all his 10-month-old glory. I could barely hear above the din. It was a wonder Stein was able to conduct himself in a professional manner while simultaneously carrying on a civilized conversation with the boy’s mother. There was no sense in me trying to hold the baby still—he had the strength of an elephant. I tried to focus on the arrangements for the boy’s care while sweat bullets sprung from my temples. Yet Stein ignored his antics as he gave the flu shot, then spoke with the mother about asthma medications.


I walked out of the consulting room both enlightened and terrified of the future. Images of countless irritable, noisy toddlers swarmed in my head, and I took a moment to steady myself by the doorway. To my credit, I had a ready smile for the doctor and a quick “Great!” when he asked how things were going so far. What a skilled liar I was becoming.


That day, we saw patients ranging in age from the 10-month-old to a 40-ish man with spina bifida, a congenital condition in which the neural tube fails to close properly during fetal development. I did not even notice when the 6:30 p.m. closing time came around, or that I had not sat down for a second since arriving at the clinic.


I was fascinated by all I had seen and learned that day. Stein had spent the few minutes he could grab between patients filling me in on their histories, answering my questions and discussing everything from Big Pharm to federal health guidelines.


The biggest surprise for me was just how many American children are diagnosed with asthma. All but two of our patients that day had the disease. I also learned that it is hereditary—I had always thought it had everything to do with environment. What an eye-opener. One of the children we’d seen had asthma in her entire family: sister, baby brother and parents. A 6-year-old boy had lost his father to the disease last year, and his was already serious.


I liked Stein’s way of practicing. He always had fun with the kids, but was not so playful that he diluted the import of what he had to do. Think Patch Adams without the clown outfit, and on a lot less sugar. He seemed to do many extra things that I do not remember other pediatricians—even mine—doing. For instance, when examining a patient’s genitals, he would always pause before starting and explain to the child that the only reason it was OK was because the parent was in the room, and that if anyone else ever looked at or touched the child in the same way, he or she should always tell the parents, even if the person told them it was a secret. I found that a powerful testament to the ways he goes beyond the textbook and guidelines to care for his patients in every way, not just physically.


Now that I’ve completed my SCP assignment, I still know for sure that I do not want to enter pediatrics. But I enjoyed the opportunity to learn from this special population. Did I wish I were seeing adult patients? Every day. Did I force myself to stifle a blood-curdling scream every time I saw yet another ear infection? You betcha. Would I have liked to ask my patient a question directly instead of his/her mother? Of course! At some point I would have liked to take a CC, HPI, PH, FH and SH of someone who could actually control a bowel movement in my presence and knew more than two colors.


But I am proud to say that in retrospect, my initial apprehension, nervousness, lack of interest and aloofness regarding the pediatric population have gradually given way to curiosity, interest, knowledge and—dare I say it—enjoyment. I still prefer to work primarily with adults, but at least I have opened myself to the great possibilities that pediatric patients present.


Today, I am still amazed when something I learned at SCP comes up in class, or when I see a patient with manifestations of a disease we discussed in class and I have the opportunity to find out how it has personally affected him or her. Those “aha!” moments truly cement my commitment to medicine.
~~~~N. Abimbola Sunmonu is a second-year in the University of Connecticut School of Medicine’s M.D.-Ph.D. program.~Medical Education,Practice of Medicine~
338~1January-February~2007-56~Perspectives~Back Pain? Big Deal!~Suffering medicine’s most boring complaint~Michael D. Burg, M.D.~On being a boring patient~My back hurts. It has been hurting since the morning of April 24, 2006. The day before, I’d done my usual workout: stretching and sit-ups first, then 20 minutes on the stair climber and 45 on the treadmill. Light weights followed—lat pulls, curls, triceps extensions—but nothing too challenging. No sense pushing it. I’ll never have huge arms; not with a herniated cervical disk, but that’s another story.


Afterward, I had my usual shower, spa and sauna, and went to bed that night feeling fine. The next morning, however, I awoke with an intense low backache—fierce, as though someone had grabbed hard and squeezed. The juice from the central cramp ran down both legs, largely bypassing my thighs, but pooling in my calves and feet, which felt leaden. It hurt to stand. It hurt to sit. It hurt to kneel or squat or lie supine or prone. It hurt before two extra-strength Tylenol and three aspirin, a hot shower and rest, and it hurt just as much after.


I’m a doctor in the emergency department of a large teaching hospital, working with physicians-in-training. There is supposedly a teaching moment in every case we see, and it’s my job to find that moment and expound upon it. But back pain bores every doctor I know. It’s as common as white bread and just as dull. Were I cloned and became my personal physician, even my own back pain wouldn’t interest me.


Back pain is the mechanical equivalent of the common cold. If you don’t see a doctor, your symptoms will drag on for an entire week. If you do see a doctor, he’ll clear it up in just seven days. Likewise, the natural history of a back-pain bout is resolution. Usually it’s unclear what causes it and unclear why it goes away—which is fine because, mostly, treatment doesn’t matter. Rest or activity. Heating pads or cold packs. Massage or immobility. Pain medications? Sure, just pick your poison—there’s no difference in outcomes, although some drugs are notable for their unpleasant side effects like dysphoria, itching, gastrointestinal distress and constipation, not to mention narcotic tolerance and dependence.


Then so on and so forth, through muscle relaxants, yoga, imagery, curative spirits and voodoo. Relief eventually occurs in 80 percent to 90 percent of patients regardless of treatment protocol, offering no challenge or satisfaction for the professional healer.


Yet certain presentations of back pain can elevate it from tedious to intriguing. For example, fever and back pain is one fascinating combination, since it may imply that serious, even life-threatening, pathology lurks. More than likely, it’s just a kidney infection, but the possibility of something enthralling does suggest itself. Back pain in a cancer patient is never good, but it is attention-grabbing. So is back pain with concomitant abdominal pain; leg weakness; constitutional symptoms like weight loss, anorexia and fatigue; bowel or bladder dysfunction; progressive symptoms; or in any patient over 55.


I carried none of this exotic baggage, which was nice for me, but not so entertaining for my doctor. About six weeks into my ordeal, after trying everything myself and finding no relief, I called him for an appointment, and he reluctantly squeezed me in. Even the tone of his voice gave away his deep sense of ennui at having to see me. But I had reached my personal desperation point, and didn’t care if I was boring.


I get the sense that even without having to face me, my doctor leads a pretty dull existence, so I always try to spice up his day with stories or humor. But during the exam, as he monotonously ran down the standard list of questions—“How long has it been there? Where does it hurt? What have you tried to make it better? Do you have fasciculations, weakness, incontinence, blah, blah, blah?”—I had nothing electrifying to offer him. When he was through poking and prodding, forcing me to jump and bend, and banging on my spine, he sat back and hmmmmd. That’s when I took the opportunity to jump in with, “Did I mention my cyclical fevers to 103?”


He wheeled around so fast I thought he’d topple from his stool. When I had his undivided attention, I added, “Just kidding.”


Many physicians believe an MRI can help diagnose the cause of back pain, and while this is true in a select few cases, it’s false in most. Most back-pain patients have no discernable abnormalities on imaging, and alternatively, many individuals getting CT scans, X-rays and MRIs for other reasons reveal hideously disordered backs, chock full of bulging disks and collapsed vertebrae, but no back pain.


I myself question what I will do with the imaging information. If I have bulging disks, will I consent to surgery and two months of postoperative pain added to the discomfort I’ve already endured? Besides, the stats on lumbar disk surgery are grim: Only half of patients have sustained relief following surgery; the other half continue to have pain, as bad or worse. But I want the MRI because I want answers. I’m not entirely sure why I do, but I do.


In the end, my doctor agreed to do the MRI, grudgingly. “The insurance company will have issues with this,” he grumbled. I’m sure they will. They will (rightly) question the decision to do an expensive test to possibly diagnose a self-limited process, and I don’t care. Maybe, though, they’ll find cancer or some other unexpected treat on the MRI. That’ll be interesting!


But I predict there’ll be minimal to insignificant findings, and my back pain will simply go away in time. In short, a resolution boring to most doctors, but not to me—not anymore!


As I now await my MRI date, I am aware that it has been almost two months since I awoke in pain, and my back hurts just as much as it did on day one—sometimes worse. But now I appreciate why people seek attention from me in the emergency department for their mind-numbing low-back pain. There’s a certain desperation that takes hold after awhile. If the long, relentless search for diagnosis, relief and cure crescendos at 2:00 a.m. on Sunday, then they find me and plead for relief and answers. I understand that anguish now.
~~~~Michael D. Burg is an emergency physician at the University of California-San Francisco Fresno Medical Center. He can be contacted at michael.burg@fresno.ucsf.edu.~~
341~1January-February~2007-56~Specialty Close-up~Geriatrics~Confronting a patient explosion~Pete Thomson~Geriatrics~This month, The New Physician inaugurates a new regular department, “Specialty Close-up.” In each issue, we will examine a medical specialty in depth to give readers facts and perspectives as they weigh their specialty choices.


Geriatrics at a glance




Over the next 20 years, a tsunami of aging baby boomers will sweep the United States, and it’s an event for which our medical system may not be prepared. Geriatricians say that, like it or not, all physicians will have to incorporate more care for elderly patients into their practices, and more specialties will likely add certifications in geriatric care.


And while the over-65 population is about to explode, the supply of geriatricians isn’t growing much at all—in 2004, fewer than 300 physicians entered geriatric medicine fellowships, a number that has remained virtually unchanged for years. Over half of the fellows were international medical graduates, and the number of fellowship slots remaining unfilled hovered around 31 percent, according to a workforce study by the Association of Directors of Geriatric Academic Programs.


The number of geriatric psychiatry fellows is actually declining: There were just 79 in 2004–05, down 16 percent from three years earlier.


Most geriatricians have internal or family medicine backgrounds. They either serve as the primary care physician for patients over 65, or consult as a specialist when another physician has found that age has made a case too complex. Some geriatricians travel around several assisted living facilities or nursing homes to see patients.


Though the current pathway to board certification in geriatrics leads through either a family or internal medicine residency, followed by a one-year fellowship, geriatrics isn’t necessarily just family practice for the elderly. Other specialties may soon be picking up the certificate as well.


Dr. Germaine Odenheimer is both a geriatrician and neurologist, a twist the Oklahoma City academic physician believes we’ll see a lot more of in the coming years. A geriatrics certificate for neurologists might be available in the next year or two, she believes. Odenheimer spends about one-third of her time doing clinical work, primarily seeing patients with dementia.


At Dr. Wayne Chen’s private practice in Southern California, around 70 percent of patients are seniors. His other job as director of the University of Southern California’s Home Visit Program takes him into the community to treat hundreds of home-bound elderly. The care is far more involved than treating acute conditions, he explains. “For new patients, I’ll try to assess what their social support system is.” For example, a patient might need help taking medications.


Though some of the home-bound patients live with family, many are alone, and some are seniors taking care of even older people. Chen mentions a household with a 100-year-old woman living with her daughter and granddaughter—all of whom are seniors.


He follows up with patients about once a month, depending on their particular needs. His work also requires coordinating a network of home-based medical services such as equipment suppliers and caregivers.


Such home visit programs help keep hospitalizations of seniors and associated costs down. Providers can also keep an eye out for Medicare fraud—or elder abuse.


There’s also plenty of research opportunities for improving the care of a delicate patient population. “As I went through my residency, I found out that the people I liked taking care of, the sorts of issues that I liked dealing with, were the complex [ones],” says Dr. Jacob Blumenthal, a geriatrician who spends most of his time doing research at a federal Geriatric Research Education and Clinical Center in Baltimore, Maryland, one of 21 developed by the Veterans Health Administration. Geriatrics is full of complex patients, so the choice was a “no-brainer” for Blumenthal. His fellowship consisted of one clinical year and two in research. “There are lots of unanswered questions that someone like me can break into.”


Currently, his work focuses on fat tissue as an endocrine organ. “The cocktail-party answer is that we’re finding now that fat isn’t just a repository for excess energy; it is also an organ that secretes mediators,” he explains. On top of the possibility that the fat’s specific region affects those mediators, the age of the patient may also play a role.


Harvard Medical School second-year Elizabeth Kwo cites her grandparents as stimulating her interest in geriatrics; the broader social issues of aging also appeal to her.


“This country is very youth-focused, and I feel like the elderly are often overlooked. And oftentimes, I think this idea of aging seems to scare a lot of people,” she says. “I could really see myself helping people to embrace aging to a point where...they look at it like a natural process, rather than a process to avoid.”

Kwo hopes to set up a concierge-style practice that will help finance her work in the community. She is developing an idea she calls an “aged manpower bank,” in which seniors take their skills and experience to the community, such as in a library, while also staying active.


Though no one has discouraged her plans to follow an internal medicine residency with a career in geriatrics, many of her peers are surprised. Her classmates say things like, “That’s very admirable.”

“Geriatrics is just not the glamorous, sexy fellowship that people talk about,” she says. “But [that] has never been a deterrent.”


One concern voiced by students interested in geriatrics is the compensation, which is more comparable to family practice than surgery. The median salary for an internal-medicine-trained geriatrician was $155,000 in 2003, up 2.3 percent from 2000. Meanwhile, the median salary for a urologist was up 14 percent over the same period, to $344,000.


“I’m sure my classmates will be making about twice as much as I will going into primary care. I do think about that, but ultimately I can’t see myself doing anything else,” Kwo says.


Which is probably a good thing: According to workforce studies, the number of geriatricians needs to start climbing, and soon—the wave of aging baby boomers is on its way, and people aren’t dying any younger.


Simha Ravven, on a one-year research fellowship at the University of Iowa between her second and third years at Tulane University School of Medicine, is concerned about funding for geriatrics training, and whether there will be enough fellowship slots. Currently, there are—but only because they aren’t being filled.


The American Geriatrics Society’s May 2006 position paper for the American Board of Medical Specialties outlined potential changes to training requirements for a specialty that, according to Census projections, may have 70 million patients in its demographic in just over two decades. The authors could not reach a consensus on whether to keep the one-year fellowship model, or extend it to a required two years and risk losing recruits even while improving the quality of training.


Ravven points out that some medical schools have started incorporating geriatrics into the curriculum during the first two years. “That engenders an interest in it,” she says.


Odenheimer agrees, and from personal experience. In addition to seeing patients, she teaches at the University of Oklahoma Health Sciences Center, the first school to require geriatrics training. During the second year, for example, students learn about the personal challenges of aging by wearing diapers during a two-hour session. Some are given “arthritis,” and everybody has to count pills at the pill station. And they have the pleasure of “paying” for it all at the bill station when they are done. Even for those students who might not be driven to the specialty by the experience, there is a tangible benefit.


“One of the things that I see, from my perspective, is the need for geriatrics to become part of lots of other specialties,” Odenheimer says. “I think a lot of students may or may not think of doing geriatrics up front, but clearly the population demographics are going to absolutely demand geriatricians.... Whether people go into geriatrics directly, or whether they go into it through another specialty, I think that most physicians are going to have to have a substantial amount of geriatric training in the next 10 years or so.”
~~~~Pete Thomson is associate editor of The New Physician.~Career Development,Medical Education,Residency~
342~1January-February~2007-56~Feature~Deeper Healing~Inside osteopathic medicine’s parallel world~Avery Hurt~Osteopathic medicine is attracting a growing number of students who appreciate its hands-on healing and primary care focus. Workforce watchers hope this influx of new D.O.s will help fill the current shortage of generalist physicians, but not all graduates see primary care—or even manipulative medicine—in their future. Also: M.D.s seek manual medicine skills.~
“To find health should be the object of the doctor. Anyone can find disease.” —A. T. Still


Like a well-worn comic book plot, the practice of medicine most Americans are familiar with has an alternate universe—a parallel world with its own history and philosophy. It is a world where physicians train in alternate institutions, belong to alternate professional organizations and sport an alternate degree: D.O. (doctor of osteopathy) rather than M.D.


In actual practice, the variations between the two types of physicians are often so slight as to be unnoticeable to patients, and a day in the life of each can appear indistinguishable. But the differences are there, subtle but deep.


Osteopathic medicine was conceived in 1892 in Kirksville, Missouri, by Andrew Taylor Still, M.D. Disappointed with the limitations of traditional allopathic medicine, he set out to devise an alternative. At that time, just before 20th-century medicine began to blossom with modern pharmacology and surgical techniques, M.D.s could offer few sure-fire treatments for injury and disease, so alternative ideas in healing, like chiropractic and homeopathy, were sprouting up all over.


Still called his therapy “osteopathy”—from the Greek osteo, meaning “bone,” and pathos, meaning disease or suffering. He believed that manipulation of the spine could improve the flow of blood and other fluids throughout the body, and was the best means of treating almost any ailment. And while other nontraditional therapies of the time were ultimately relegated to the sidelines of alternative medicine, osteopathy developed and evolved into osteopathic medicine. One hundred and fifteen years later, more than 50,000 D.O.s practice in the United States, and that number is growing.


What started as a form of practice centering on one therapy has become much more expansive and generalized. Osteopathic physicians are licensed to do everything an M.D. does, although they receive additional training in a modality known as osteopathic manipulative medicine (OMM). Otherwise, the differences in practice between the two can be so subtle that patients commonly don’t realize their family physician is a D.O. rather than an M.D. “Osteopathic medicine used to be radical; it is not so radical anymore,” says Kenneth Veit, D.O., dean of the Philadelphia College of Osteopathic Medicine.


Marty Knott, a fourth-year at Texas College of Osteopathic Medicine and national president of the Student Osteopathic Medical Association (SOMA), says that the differences are blurred further by the fact that “allopathic physicians are doing more holistic therapy, and osteopathic physicians are getting more into evidence-based medicine. Some merging is going on.”


When describing how their approach does differ from the allopathic, D.O.s are likely to characterize their practice as holistic, people-oriented, and focused on prevention and wellness rather than disease. They will tell you they see body, mind and spirit as a unified structure wherein dysfunction in one area affects the smooth operation of the others. Many M.D.s will take issue with this—not because they disagree with its basic truth, but because they reject the notion that this approach is the purview of osteopathic medicine only.


Yet despite allopathic medicine’s growing embrace of holistic therapies, perceptions persist that it is more focused on illness than on health; more interested in diseases than in people. These are fair claims, says Joel Howell, M.D., who teaches the history of both allopathic and osteopathic medicine at the University of Michigan Medical School. “These criticisms can be true of allopathic medicine.”


Certainly, osteopathic medicine centers on a commitment to treat “the whole person.” Purists believe that the body has a natural tendency toward homeostasis, or balance; that it “wants” to heal; and that if given the right conditions, will heal itself. The osteopathic philosophy is as much about enabling the body’s wellness as curing its ills. “All bodily systems need to function well together at an optimum level to fight off disease, infections and so forth,” explains Kevin D. Treffer, D.O., associate professor of family medicine at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine. “This is what we call health.”


Still’s primary innovation, OMM, uses physical manipulation of the musculoskeletal system to restore the body to its natural homeostasis. As one might expect, it’s most commonly used for musculoskeletal complaints such as low-back pain. But it can also be used for lymphatic drainage to reduce congestion, asthma and labor pains, and even induce or speed up labor, explains Jay Bhatt, president of the American Medical Student Association (AMSA) and its first osteopathic student to fill that role.



Separate But Equal


Osteopathic medicine is taught in a network of osteopathic medical schools on 23 campuses around the country. These schools are independent and distinct from allopathic medical schools, and are accredited by the Bureau of Professional Education of the American Osteopathic Association (AOA), which in turn is recognized by the Department of Education and the Council on Postsecondary Education. To be admitted to an osteopathic medical school, applicants submit transcripts, recommendations and MCAT scores. For the academic year 2005-2006, 13,406 students were enrolled in U.S. osteopathic medical schools.



The osteopathic curriculum is much like the allopathic: two years of basic sciences and two years of clinical study. Courses cover the same material as allopathic schools and often use the same textbooks. Graduation is followed by a one-year rotating internship and then a residency. Primary care is heavily emphasized during a D.O.’s training, and 60 percent choose to specialize in family practice, internal medicine, OB-Gyn or pediatrics. However, all specialties and subspecialties are open to D.O.s. AOA certification programs are available in 18 specialties, including anesthesiology, neurology and pathology.



D.O.s can also apply to programs certified by the Accreditation Council for Graduate Medical Education (ACGME). According to Veit, orthopedics and physiatry are particularly attractive to D.O.s, and their musculoskeletal training makes them particularly well suited to these specialties.



Just like M.D.s, D.O.s must pass state boards in order to practice. Each state has its own licensing requirements; some states administer the same tests to M.D.s and D.O.s, while others have separate exams for each. Passing the boards certifies D.O.s as full physicians, trained and licensed to provide all the care that M.D.s provide. They can prescribe medicine, perform surgery, make and accept referrals, and battle with insurance companies, Medicare and all the rest of the red tape.




That Healing Feeling


The distinguishing feature of osteopathic study—OMM—is threaded through almost every lesson and clinical rotation. Training begins on the first day of medical school, and can amount to, over four years, 400 to 500 extra hours of course work. “OMM training is important, even if a student enters a specialty where OMM is not a dominant part of the practice,” explains Veit. The knowledge and skills learned in the OMM curriculum will make a person “a slightly different physician for the rest of his or her life.”



This difference includes a thorough understanding of the musculoskeletal system, as well as the knowledge that “it is OK to use your hands; OK to touch people,” says Veit. “Manipulative medicine gives the patient a sense of satisfaction. Something magical happens in OMM.”


Something magical happens to the student as well, it seems. Veit points out that while it takes a long time to become good at OMM, some level of proficiency can be achieved very quickly. “Early in their training, students learn techniques that they can try out on their boyfriends or girlfriends, friends and family. Right away, students can gain the feeling that they are healers.” This is a feeling that allopathic students may have to wait years to know.


But like so many great ideas that launched movements, OMM may wield more influence as a theory and a unifying principle than a practical tool. It is often misunderstood—even occasionally reviled. A perusal of Internet medical forums discussing the practice reveal that in some quarters, manipulative medicine is held in the same regard as chelation therapy and colonic irrigation. The more charitable of skeptics class it with acupuncture or massage.


The bias even extends, on occasion, to D.O.s themselves. One patient who asked his D.O. to use manipulative therapy to treat a musculoskeletal problem was referred to a chiropractor. Surveys of osteopathic physicians indicate that use of OMM is declining, especially among D.O.s who did their residencies in ACGME-accredited programs. And as more D.O.s are choosing specialties other than primary care and completing ACGME-accredited residencies, some worry that the therapy may slip even further out of mainstream osteopathic practice.



The decline in OMM use is not due to a loss of faith in the procedure, however: Lack of opportunity, equipment and time, plus problems with reimbursement, are the most common reasons cited in surveys.


Those who do use OMM find it soundly beneficial, even if just as a framework for thinking about patient care. “When I see patients after surgery, and they complain of aches and pains,” says Knott, who currently is applying to surgical residency programs, “I think about how they are positioned and how that may be affecting their comfort. Even if you don’t use OMM, you think about it every day.”


The move toward evidence-based care has also been a problem for OMM. “We don’t teach that by treating a patient with OMM you can cure diabetes,” explains Treffer.


No, but what claims do D.O.s make for it, and how well supported are those claims?


“Currently we are trying to validate with research and clinical trials what is largely anecdotal and observational evidence,” says Knott. Much research has been funded from within the profession by the AOA and the Osteopathic Heritage Center. But lately, more grants are coming from the National Institutes of Health and the National Center for Complementary and Alternative Medicine (NCCAM).


“NCCAM has been really good at funding research,” says Knott, who himself has been involved with the center, researching the mechanisms of OMM. Using manipulative medicine to treat ear infections in children, pneumonia in adults and, of course, for back pain, has shown promise in studies. “If we can demonstrate that there is a scientific method [to OMM], and if it is shown to be better and safer than traditional medications, then it will become the standard of care,” says Knott.


Meanwhile, those who do use it keep at it because their patients say it works. “[They] keep coming back. The important thing is helping patients,” says Treffer, whose practice is “99 percent OMM.”



Growing Appeal


According to Bhatt, osteopathic medicine tends to appeal to those with a sense of social responsibility; its emphasis on primary care attracts those with a community focus.


Lauren Sachs, a third-year at the Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, had never even heard of osteopathic medicine until she went to college in Kirksville, the birthplace of the field. “As soon as I learned about [it], I knew that the overall osteopathic philosophy was exactly in line with the kind of medicine I wanted to practice.”


For Sachs, OMM is “a tool I have in my tool belt that I will use when appropriate,” but it was not the main reason she chose an osteopathic school—although she does enjoy OMM, and her family is always eager for her to practice on them when she comes home for a visit.


The past few years have seen a substantial increase in osteopathic education. In 2005, 8,255 students applied to osteopathic schools, up from 6,324 in 2002. One reason for the jump is that several osteopathic schools have opened branch campuses to accommodate more enrollees. According to the American Medical Association’s American Medical News, forecasters are expecting an additional 2,000 to 2,500 osteopathic students to enroll over the next decade.



Much of this increase has been stimulated by calls for academic medicine to produce more primary care physicians. But like M.D.s, D.O.s often choose other specialties for economic reasons—educational debt and the perception of low pay in primary care. Still, says Stephen Shannon, D.O., president of the American Association of Colleges of Osteopathic Medicine, family practice offers many benefits that appeal to today’s osteopathic students: the sense of having more control over their lives, closer relationships with patients and the option of working part time. The latter is a significant benefit to women who want to balance family and career; half of all osteopathic medical students are female.


Significantly, osteopathic students tend to be older than allopathic students and have more life experience, says. Shannon. The attraction works both ways: Osteopathic schools seek out a certain type of student, he says. “We look for mature individuals who are sure what their path in life will be. Many…are coming to medicine as a career change. They are often former high-school teachers or people with previous experience in the health professions—EMTs, physician’s assistants, former military medics.”


Many become members of AMSA, which embraces allopathic and osteopathic students equally. “Osteopathic students have always been a big part of AMSA,” says Bhatt. “Other professional organizations don’t give such a warm welcome.” Currently, AMSA is launching an osteopathic medicine awareness campaign that will feature education in the community, visits to undergraduate schools by osteopathic deans and AMSA and SOMA members, and a lot of bridge-building between the two worlds of medicine. Recently, a group of AMSA members were invited to present to the AOA board in closed session, an almost unheard-of honor. “AMSA and the AOA believe in a lot of the same things,” says Bhatt.


Unfortunately, the perception lingers that many people attend osteopathic schools because they were unable to get into allopathic schools. In fact, the entrance requirements are fairly similar. Osteopathic schools do place less emphasis on numbers (MCAT scores and GPAs) than allopathic schools, says Shannon, but they place more emphasis on personal characteristics and other attributes.


For some people, it may actually be harder to get into an osteopathic medical school. “That it is easier to get in
is a common slam [on osteopathic schools], but the data don’t really support that,” says medical historian and M.D. Howell.


In any case, the differences in this respect are as minor as any between the two worlds. The two types of education really are, says Knott, just different paths to a common end: practicing medicine. And despite occasional cracks about the shortage of evidence for manipulative medicine, or insinuations about the lack of patient focus in allopathic medicine, there is really not much acrimony between the two worlds. And there seems to be less and less as time goes on.


As allopathic medicine, urged on by groups such as AMSA, takes a more holistic and socially responsible approach to health care, and as osteopathic medicine puts more time and energy into research to support its approaches, the few differences between the worlds will continue to dissolve.


[Editor's note: The online version of this story has been corrected to clarify some of the uses of osteopathic manipulative medicine.]~The Lure of Manipulation


Although fewer and fewer D.O.s are using osteopathic manipulative medicine (OMM) routinely in their practices, more allopathic physicians are interested in learning this therapy.


A survey in the December 2005 Journal of the American Osteopathic Association found that more than 70 percent of allopathic physicians indicated some interest in learning OMM. “We always have lots of D.O.s at [American Medical Student Association] meetings,” says Lauren Sachs, a third-year at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine. “The allopathic students want us to show them OMM.”

And this fascination isn’t limited to students: “Every five or six years,” says Kevin D. Treffer, D.O., associate professor of family medicine at the school, “the American Academy of Family Physicians has its national resident and student conference in Kansas City. We do OMM workshops for them, and they always fill up. They say that they want to learn more about the musculoskeletal system—things they didn’t learn in their curriculum.” —A.H.



Boning Up on the Numbers

~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~Medical Education,Osteopathic Medicine~
344~1January-February~2007-56~Feature~SPOTLIGHT: The First Cut~The surgical rotation can be both surreal and sublime~Anthony C. Hall~A medical student’s earliest experiences in the OR can be scary, surreal and often mesmerizing. Watching a living body taken apart and put back together is an electrifying experience that often seals surgery as a career choice.~His suturing was as perfect as it could possibly be. He did his work slowly, not only because there was plenty of time, but because he was so profoundly moved by the task assigned to him.


As a medical student, Dr. Darshak Sanghavi, now a pediatric cardiologist and an assistant professor at the University of Massachusetts Medical School, had been asked to close the incision in the chest of a brain-dead teenager whose heart had just been removed for transplant. The care he took and the reverence he felt for the families involved is characteristic of many students’ initial experiences in
the operating room. Here, third- and fourth-years are confronted with extraordinary and sometimes surreal moments that blend the spiritual, psychological and scientific parts of their lives. It can be a dizzying catharsis that sets them on an unswerving path toward a surgical career.


Chirag Patel, a second-year at the University of Arizona College of Medicine, remembers the day he held a patient’s cold heart in his hand while the attending told him, “Whatever you do, don’t move.” He didn’t move, but the patient’s heart did, picking up a pulse as he held it, warming as it surged back to life. “I was just as happy as I’ve ever been. It was spiritual. I thought, ‘Wow, doctors have so much power,’ if you will, in that they can completely change someone’s life,” Patel says.


Of course, it’s a long route from “don’t move,” to the mastery of a scalpel, but even with the sleepless purgatory of residency around the corner, not one of the surgery-bound students interviewed for this article doubts that he or she is on the right path.


John Braca, a third-year at the New York Medical College who is planning a career in neurosurgery, phrased it this way: “I don’t regret choosing something bigger than myself.”


Theater of the Absurd


To a medical student, an operating room is one part sterile-field sanctuary and one part chrome-bedecked coliseum populated with green-smocked gladiators. And it’s a place where reality can actually change shape. Steel nerves or not, the first time witnessing a surgeon drill through a patient’s skull, or a baby being born, requires a new way of comprehending what’s happening right in front of your eyes.


Take, for example, the hallucinatory experience of watching a maxillary osteotomy. The surgeon begins by disconnecting the patient’s upper jaw so the mid-face slides forward, “like a drawer in a bureau,” says Dr. Jeffrey Lewis, who performs the procedure frequently in his plastic surgery practice in Ithaca, New York. Once the upper jaw is detached, the very shape of this person’s face is in the hands of the surgeon. Almost like a Halloween mask, the skin follows as the surgeon slides the bone forward, and one of the tenets of normalcy—faces aren’t supposed to do that!—dissolves right in front of you.


And then, whoosh—another med student slumps to the floor.


“The first time, I just about lost it,” Lewis says. So in preparation for the second time, he studied up, reading everything he could about the operation “so I could wrap my brain around the concept.” And then it came to him in a stirring flash. The same operation became “so cool. I knew I had to learn how to do that,” he says.

Helping his surgeon father repair an infant’s cleft palate was an unforgettable moment for Jon Black, a fourth-year at the University of Nebraska College of Medicine, who had decided some months before to become the third consecutive generation in his family to take up plastic surgery. During the operation—one of the first he’d ever seen—Black was struck by the enormity of his father’s skill and the swift completion of a procedure that would allow the child to drink without drowning and click her tongue on the roof of her mouth.


“That was probably the surgery that had the most profound effect on me,” Black says. “Because I saw the surgery, I immediately saw the results of the surgery, and then I saw the effect it had on the patient’s family.” And, he says, he saw his father “completely differently” from that day on.


For Braca, a pterional craniotomy was about as good as it gets. Neurosurgery called to him like a trumpet calling to a young Miles Davis. At the moment he watched surgeons remove the front quarter of a patient’s skull, Braca recalls, “I realized that all the things I had been learning and all the things I did in med school all led to this moment.”


That jolt, he said, was accompanied with “amazement that technology and knowledge even allowed such a thing [as neurosurgery] to exist,” and the sense that he had, “in a way, become a part of it…. It was the realization of one of my dreams and the realization that I was ready to go forward,” he says.


Derek Jenkins, a fourth-year at Dartmouth Medical School, says he feels so engrossed and “in the moment” on the surgery ward that an 80-hour workweek doesn’t even register as work at all.


Jenkins was, in fact, studying engineering at Dartmouth when he witnessed the surgery that changed his life. “Here I am, 19 or 20 years old, an engineering student faced with going into the OR,” Jenkins recalls, “and I remember being in awe of Hitchcock [Medical Center], this huge hospital.”



As a member of an engineering lab team that was researching how to improve artificial knees, he had been invited to attend a bilateral knee replacement performed by Dr. Michael B. Mayor, a professor of surgery and an adjunct professor of engineering at Dartmouth, who is now retired.


Jenkins did not scrub. He was told to stand against the wall. It was requested that if he felt faint, he not collapse in the sterile field. But far from passing out, he became enthralled with the procedure. He was most impressed by the way Mayor and his team, which included a second surgeon for the second knee, an anesthesiologist, residents, nurses and students, all worked in orchestrated unison, communicating with eyebrows, small touches and minimal words.


Mystery Dance


“It’s a lot like a dance,” Jenkins says, referring to surgery’s nonverbal communication that takes place with subtle touches, much like leading a waltz partner with one hand held high and one hand on the small of her back.


The patient aside, surgery is “a physically intimate kind of thing,” says New York Medical College fourth-year Jennifer Dore. “Attendings or residents will put out a hand, and someone knows what they want and they give it to them. If things go right, there’s that chemistry, and there’ll be no word spoken at all. It’s really cool, that in itself. It’s one of the reasons I love being in the operating room.”


But for a student exposed to the OR for the first time, the choreographic nuances can be mystifying. You want to participate in the dance, but you don’t know how to act, what to say, where to stand or how to scrub. You don’t know your logical place in the room, but you suspect—and you’re right—that you rank even lower than the observing medical device sales rep, because at least the only mistake he can make is to talk out of turn.


And the student is keenly aware that in the OR, calamity waits in every corner. It happened on University of Nebraska fourth-year Matt Gawart’s third surgical rotation. An aorta that ruptured on the operating table brought on the collective realization that the patient, who had walked unaided into the emergency room less than an hour before, was now, suddenly, dead. And, while no one was blamed, the feeling that there were “a million things we could have done differently” churned in Gawart’s brain, he says, for the better part of a week.


Yet for every guilt-inducing loss, there are emergency surgeries that miraculously foil death. But it is still a tough blow, Gawart says, when a life ends in front of your eyes.


A Delicate Balance


Keeping a healthy perspective on life and death is a balancing act that
challenges every would-be surgeon. “Moving on, so it doesn’t affect the rest of your surgeries that day” is a necessity that comes with the territory, Gawart says. The next surgery could bring a patient back to her feet, pain-free for the first time in months. The one after that could disclose a body rife with too many tumors to count or to curse. Yet, “As soon as you depersonalize, you’re not doing everything you can,” says third-year Milton Little of the University of Michigan Medical School, who is following his grandfather’s footsteps into the noble profession. “Without that emotional attachment [to the patient], I feel like I’d be cheating myself,” he says.


This balance of attachment and detachment can be seen in the darkly humorous stories surgeons commonly share with each other. Remember that time, someone might say, when a junior resident noticed that the Teflon replacement for a clogged artery, en route from the middle abdomen to a leg, had inadvertently tunneled right out of a fold in an obese patient’s belly and back into his body again, unobserved by one and all?


That wasn’t even the funny part, says the established surgeon telling this tale (and who happened to be the former junior resident in question). It was the 15-minute debate on who would have to go tell the temperamental surgeon, who had already left the room, that the patient, who was waking up on a gurney while they argued, had a tube exiting and re-entering two folds of his abdomen.


Who eventually told the surgeon? That would be the lowest-ranking (i.e. the most expendable) person in the room, of course. With visions of his career ending almost before it began, the junior resident fetched the surgeon with the vague confession that “something went wrong.”


At that, the surgeon returned to the OR and leaned over the patient for a full minute. He then uttered something quite memorable:


“I hate it when I do that,” the surgeon said.
~~~~Anthony C. Hall is a freelance writer in Dryden, New York.~Career Development,Medical Education~
345~2March~2007-56~Feature~SPOTLIGHT: Thinking Differently~Students, schools and board exams contend with hidden disabilities~Pete Thomson~With more medical students coming forward to acknowledge their learning disabilities, is the stigma of accepting special accommodations finally disappearing?~When Lisa Pappas addressed her "greatest challenge" in a medical school application essay, she wrote about the Medical College Admission Test (MCAT). The test undoubtedly is a challenge for most applicants, but it was particularly so for Pappas.


As an undergraduate at the University of Michigan, she struggled with a learning disability that made arithmetic and reading difficult. Because of this and an additional diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), the school provided accommodations for her test-taking. However, when it was time to take the MCAT, her request for extra time was denied. So Pappas devised her own strategy for taking the test, one that involved skimming the questions and 'skipping some of the reading. She explained this system in her essay.


During a subsequent admissions interview, one member of the panel went off the record. "I was specifically told I shouldn't have [revealed my disabilities in the essay], just because of the stigma," Pappas says. "It's not what they wanted to hear."


Pappas is now in the middle of a yearlong dermatology research fellowship between her third and fourth years at Wayne State University School of Medicine (WSU). At school, she requested and receives extra time and a semi-private room during exams. "I would have failed out if I hadnÕt [pursued accommodations]," she explains. "The thing is, I made sure only to ask for the things I really needed and not the things that might feel nice but aren't necessary."


Accommodation for all types of disabilities is related to 1990's Americans with Disabilities Act (ADA) and the earlier Rehabilitation Act of 1973. Among other stipulations, the laws mandate that educational institutions receiving federal funding cannot exclude students solely on the basis of their disabilities, and must accommodate disabilities within reasonable limits. Though the letter of the law is a bit vague, the courts have hashed out some of its meaning, and medical schools and their legal counsels have created departments and procedures for accommodating students' needs.


At most medical schools, students with learning disabilities or attention disorders must apply for accommodations. Medical schools need not-and generally do not-approach the student. Disability services departments consider a studentÕs application for accommodations and the documentation supplied by the student to support his or her claim, and then work with faculty to implement the accommodations. One of the department's considerations is how to stay within the purview of the school's own curriculum and standards.


"The purpose of accommodation is to level the playing fieldÉso [students with disabilities] are given the same opportunities to succeed or fail on their merits as anybody else," says Helene Horwitz, associate dean for student affairs at the University of Minnesota Medical School (UMMS). "I think sometimes students think the accommodation is there to help them pass, which is a little oversimplified."

Though Pappas had no trouble with her decision to pursue accommodations in undergraduate and medical school, she had resisted them in her early high-school years for one reason: "Pride. Because there is a stigma [about] asking for accommodations," she explains. "I didnÕt really want to go through it if I didnÕt have to."


Even now, she doesn't go out of her way to tell classmates about the extra time she is given on tests or the quieter classroom in which she takes them. "It is easier at a larger school," Pappas says, "because people say, 'Oh, I'll see you at the exam.' I would never say, 'Oh, I take it in a separate room,' unless I knew them really well."


"Students worry about that pretty frequently, and one of my jobs is to reassure them that no judgment will be given to them," says Robyn Gandy, ADA coordinator at the University of Toledo Health Science Campus in Ohio. "No one should be making commentsÑand that is the law." When accommodated students wonder what their classmates are going to say if they donÕt report to the exam room at the same time, she tells them that with two classrooms-worth of exam takers, hardly anyone would notice anyway. "I see the flip side, where their classmates are supportive and nurturing," she says.


In any event, Pappas hasn't felt any friction from classmates over her accommodations, but at times she has felt somehow marked. "I think it is more myself, how I felt, getting different treatment than other peopleÉ. The whole purpose of accommodations is to be on an equal footing. And so by telling other people that things are different, it makes you feel different."


But Pappas has had at least one conflict with a faculty member over her accommodations. A professor was reluctant to provide extra time at each station of an exam. When Pappas pressed him on the issue, he offered her more time after visiting all of the lab stations to finish up her answers. The solution wasn't helpful to her, but she didn't pursue the matter, instead taking the test without accommodation. It has so far been an isolated incident of resistance.


Otherwise, WSU has been great, she says, and a 3-year-old group there, the Student Team Enabling Peers (STEP), also lends support. Out of Pappas' class of around 250 students, about six take their exams in the same reduced-distraction setting. At first, however, they all sat at a single table. The STEP group convinced the school to provide individual desks instead. And the group, composed mostly of students receiving accommodations, provides a good place to vent.



INCREASING THE ACCOMMODATED


The number of students applying for accommodations for learning disabilities and attention disorders is increasing, due in part to larger numbers of such students being accommodated through their undergraduate years, an increased awareness of their rights, and a somewhat more accepting environment in the often-competitive world of medical education.


Students with learning disabilities have become savvy consumers now, Gandy says. Through the ADA, people have become more familiar with learning disabilities and the need to accommodate students who have them. "If we go back 20 years ago," she says, "it wasn't common knowledge."


Broadly speaking, learning disabilities, distinct from attention disorders, are signaled by a significant difference between intelligence and achievement. Learning disabilities can include information processing and number problems, dyslexia and difficulties moving information from short-term to long-term memory.


Gandy says a standard deviation of two between the score on an intelligence test, such as Wechler's, against an achievement test, like the Nelson-Denny Reading Test, is her school's diagnostic standard for learning disabilities.


Attention disorders are not related to the processing of information, but to how well a student focuses on tasks, especially during tests and lectures. The University of Toledo looks at such instruments as the Connors Rating Scale and other such indicators, as well as self-reported symptoms and input from families and significant others.


But in order to be accommodated, students must first know where to go for help, and when. During orientation, Gandy administers a personality test to all new students and uses the opportunity to talk about the services her office provides, including accommodations applications. Her office also offers free tutoring to all students, up to 10 hours a week, and word-of-mouth brings students to her door.


"My name is very much out there, and faculty have been very supportive of my office," she says.


But the University of Toledo, like many schools, does not administer its own tests to gauge learning disabilities or attention disorders. Neither does Dartmouth Medical School, says Kalindi Trietley, director of learning and disability services there. To do so might be a conflict of interest, or at least be perceived as such. If there are ever questions about why a student did not receive a particular accommodation, the documentation would be from outside the school's walls.


At both Dartmouth and the University of Toledo, like many other schools, medical students must schedule and fund their own testing and documentation. When Trietley refers a student to a local counseling service for testing, the student can often recoup some of his or her costs from health insurance. Otherwise, students are free to seek documentation from any specialist meeting Dartmouth's criteria.


Gandy's office tries to put students on the right track if they suspect they may have an impairment. A cognitive psychologist by training, she used to administer such tests prior to joining the school's ADA compliance office.


"We try and look at other things that could be playing into poor academic performance," she says. She employs a preliminary screening tool that has proven to be fairly accurate before referring students to outside specialists for testing.


Medical schools tailor accommodations to a student's particular needs. Students with difficulty reading might get as much as twice the time on exams, to compensate for their impaired reading rate. A student with ADHD might be allowed to take tests in a distraction-reduced classroom, with just a handful of people. Otherwise, Gandy says, they might be in a room with 150 others.


Trietley grants students accommodations on a temporary basis. A committee composed of faculty members and legal counsel meets quarterly to review her arrangements and approve them. This gives the faculty a voice in how accommodations fit into Dartmouth's curriculum, and Trietley says this helps reduce their resistance to working with students who need to compensate for disabilities.


ON YOUR RECORD


In Gandy's office at the University of Toledo, the heaviest traffic comes when the United States Medical Licensing Examination (USMLE) is on the horizon. A large number of students come in when the test is almost too close for accommodations to be approved by the National Board of Medical Examiners (NBME), which administers it.


If a student receives accommodations from the University of Toledo, his or her application for accommodations on the boards needs Gandy's signature. And some students who haven't previously sought accommodations-whether they've been using their own compensatory techniques to overcome their disability and stay below the radar or are panicking in the face of the boards-will show up with questions. Gandy suggests students start their USMLE accommodations process early, preferably in November for Step I, to get through all the paperwork.


At the NBME, an examinee's application is initially reviewed internally for completeness. If there's insufficient documentation, the applicant is sent a detailed letter to that effect. Once the NBME has all the documents it needs-formal letters from physicians, proof of previous accommodation in schools or on the boards, diagnostic test results-the consideration process can proceed, says Catherine Farmer, manager of the NBME's Disability Services department. At that point, most applications are reviewed by outside experts who consider the documentation and decide what accommodations to provide. Though applicants may request specific help, such as extra time or additional breaks over one or both days of the exam, the board has the final say on what students actually receive.


Receiving accommodations on Step I does not automatically mean accommodations will be granted on Step II, but it may simplify the approval process, Farmer says. If a student's disability waxes or wanes, for instance, some re-evaluation may be necessary.


Pappas was granted extra time and a reduced-distraction room for Step I. When she showed up on the first test day, however, the on-site proctor was reluctant to provide them. Pappas contacted the NBME, which she says was extremely helpful in seeing that the accommodations were implemented.


What makes the USMLE an important touchstone for students with learning disabilities, besides being the multiple-choice gateway to medicine, is that it's the point at which students' accommodations go on their records. For certain types of help, such as extra time, the NBME places an annotation on the test-taker's score report indicating that the test was taken under nonstandard conditions, Farmer says.


LEVELING THE WARDS


But the classroom and the clinic aren't the same, and accommodations that work in one may not in the other. And what is needed on a written exam might not be necessary in the patient exam room.


At UMMS, the process for deciding what accommodations students with learning disabilities need on the wards is the same as the classroom decision, but the accommodations can vary. The call schedule has been modified for some students, and the occasional student receives direct and explicit feedback forms, Horwitz says. UMMS has roughly five students per class receiving accommodations out of third- and fourth-year classes of about 220 students each. Her office also helps students with organization and time management-skills she says most students have to work to master.


Clinical faculty are informed of their role in a studentÕs approved accommodations by a chain of communication that spans UMMS' multiple training sites. "We have a series of guidelines, if you will: responsibilities on the part of the student, responsibilities on the part of the course director and responsibilities on the part of the director of clinical education," Horwitz says.


Though many clinical faculty havenÕt worked with a student who needs an accommodation, Horwitz says they tend to be fairly receptive. ÒAt this point in time, weÕve moved beyond [the attitude of] Ôeverybody ought to be able to do this.
~~~~Pete Thomson is associate editor at The New Physician.~Disabilities in Medicine,Medical Education,Student Life and Well-Being~
348~2March~2007-56~Resident Rx~Knowledge Held Hostage~Locked-up information kills patients~Jason Ryan, M.D.~The paper trap~When I first see Betty Kearns, I don’t think she will survive until morning. It is 20 minutes to midnight and I am hungry, sweaty and craving sleep. As senior resident in the ICU, I have spent the last four hours placing central lines, resuscitating arrest victims and meeting with a family about their dying father. I am in no mood for more. But one look at Betty and I have to accept that relief isn’t coming anytime soon.


She looks like a corpse when the paramedics wheel her gurney into the ICU. She has long, gray hair matted against her pillow. She is unconscious; her mouth hangs open with a breathing tube jutting out and trickles drool onto her bile-green gown. One of the EMTs squeezes an ambu bag, making her chest rise and fall. She is little more than a skeleton, her wrinkled skin hanging helplessly over bones.


“Paperwork for you, doc,” one of the EMTs says, handing me a manila envelope. I sit down in a high swivel chair while the nurses settle Betty into her bed.

Four hours ago, another hospital called my attending, requesting to transfer Betty. They said she was in her late 80s with a complicated medical history. Admitted there two days ago with respiratory failure, she had steadily deteriorated in the ICU. Now opening the envelope, I hope to learn more.


But I do not learn more. As is so often the case with patient transfers, the other institution sent little information. There is an ER nurse’s note, two days old, documenting her initial complaint (“shortness of breath”). There is a scribbled list of medications she is on. Other than that, and a few sheets of demographic information, there is nothing.


Sighing, I pick up the phone to call the other hospital. As I dial, I know what’s coming next. The transferring doctor will not be there, and the staff who knew Betty will have left for the day. At best I’ll find a helpful nurse manager who will try to dig up some records. At worst I’ll get nothing and have to completely start over.


It is then that I think to myself, medical information could save Betty’s life.


Betty is not new to the medical system. Over the years she has seen scores of doctors, pharmacists, hospitals and clinics. She has been examined hundreds of times and given her medical history many more. Enough blood has been drawn from her veins to fill gallon jugs. Her body has been scanned by ultrasound beams and X-rays, the images reconstructed by the most modern computers.


Yet none of this information is available to me now. A computer sits at the nurses’ station next to me—a computer with an Internet connection able to communicate with Web sites around the globe. Although I can instantly learn the weather across the country, I cannot access Betty’s allergy list from her pharmacy 50 miles away. Although I can read newspaper articles from the past 10 years, I cannot learn the results of Betty’s blood work from this morning.


Patient medical information is a resource shackled to a former age, mired in the pen-and-paper era. While industries around the globe have leapt forward technologically, medicine has merely inched ahead. Its move to computers has been sluggish and chaotic. Much information is still imprisoned on paper, and the few computer systems that exist cannot communicate with each other.


As the phone rings at the other hospital, I think of all the ways medical information could benefit Betty. The first and most obvious way is to tell me her medical history—something she is unable to do in her present state. In addition to revealing the last two days of her care, it could tell me about allergies, past medical problems and risk factors for myriad diseases. I could make informed decisions about her care and avert the pitfalls of her previous doctors. I could avoid repeating tests—something that may put Betty at unnecessary risk and cost the health-care system dearly. In essence, I could be more informed as I try to save her life.


But that is only the beginning. Personal medical information, like Betty’s medical records, and scientific medical information, like the thousands of clinical trials published annually, exist in isolation from one another. A doctor’s primary focus throughout the day must be the patient. As my call night in the ICU illustrates, keeping up with the medical literature is often brushed aside in favor of patient-related chores like placing orders, performing procedures and documenting in charts. But why must these things be separate?


If medicine was truly an integrated information industry, Betty’s personal medical record could be woven into the fabric of medical science. I could order tests and treatments for her that would be instantly checked against current national guidelines. I could be alerted to new scientific publications pertaining to her medical problems. My treatment of her sepsis, respiratory failure or stroke would not be limited to my own recollections, but instead integrated with the latest clinical trials. I could be warned of emerging antibiotic resistance in the community. I could be prompted to recommend proven preventive measures like vaccinations, aspirin and healthy diet.


Then my performance in all these areas could be catalogued, telling me how I compare with my peers across the country. I could treat Betty not as a solo practitioner, but as a member of a global health-care team, bringing the brunt of cutting-edge medical knowledge to bear against the diseases that threaten her life.


After several rings, a pleasant, polite nurse answers the phone. She apologizes profusely for the lack of records. She offers to find Betty’s chart and fax it to me. After thanking her, I hang up the phone and walk into Betty’s room.


Standing at her bedside, still tired and hungry, I do the best I can with the information I have.
~~~~Jason Ryan is a clinical fellow in the Division of Cardiology at Beth Israel Deaconess Medical Center in Boston. His essay received first place in a recent writing competition sponsored by Elsevier.~Health Policy,Physician Patient Relationship,Practice of Medicine~
349~2March~2007-56~Perspectives~Indiscriminate Hands~Care should be as blind as justice~James A. Feinstein~Lives in the balance~“All rise,” a booming voice thundered throughout the room.


I wiped my face with the back of my sleeve, trying to remove the evidence as swarms of people returned to their places in the courtroom.


My eyes remained fixed on the young man who stood so near to me, but a few feet closer to the judge’s podium. We wore identical khakis, similar button-downs and the same serious expressions. Only a mahogany railing separated us; with just a few steps, I could easily have changed places with the young man.


But I knew he would never have the option of moving those few feet backward to the other side of the railing where people with hopes and dreams and viable futures sat watching.


A stodgy-looking old man stood next to the defendant, repeatedly glancing down at the yellow legal pad in his hands, as if searching for a clue on how to proceed. The paper was sparsely covered with lines of illegible script, indicating that the lawyer probably would not find what he looked for there; it appeared he had carelessly scribbled down those few sentences on his way to the courtroom that morning. He finally decided on some combination of thoughts and stood to address the court, his absence of enthusiasm immediately apparent in the drone of his voice. Anyone would have surmised that not even the defendant’s lawyer believed his client’s plea of innocence.


As if anticipating the lawyer’s canned comments, the judge stopped him mid-sentence and requested that the defendant stand to address the court himself. “You, the defendant, are being tried for the charge of child abuse,” the judge intoned. “If convicted, you could serve up to 25 years in prison. Do you understand these charges?”


The young man appeared visibly shaken; his voice quivered as he responded that he did understand. While he spoke, I bit at my lip, realizing that the duration of the possible sentence probably exceeded the defendant’s young age. Nevertheless, I wanted to hate him, feeling as though each moment of sympathy I experienced somehow slighted the injustices he had committed against his child.


Just a few weeks earlier—the first time I’d felt the tears—I would have instantly tossed aside any feelings of sympathy. At that point, I’d had only a few days of experience working with the city’s child-abuse team. But in that short time, I had already developed strong feelings against people who hurt their children, although I felt oddly unsettled by harboring such powerful negative emotions. Until that point in my life, I could argue that I had never actually experienced hate. For me, the word held the same dirty connotations associated with other four-letter words. I used the term sparingly and when I did, it was still only something I thought I knew about from reading historical accounts of crimes against humanity.


But this changed the moment I set eyes on a bloody, puffy infant that lay cocooned beneath layers of plaster and gauze. There, leaning against the cold steel railing of the hospital crib, I felt hate. The sensation caught me by surprise as it oozed into my veins and coursed throughout my body, boiling over into clenched fists and grinding teeth.


The father’s hands had beaten without discrimination, breaking his baby son’s leg, crushing his ribs and bruising his face. The X-rays revealed old, healing rib fractures. This time the mother had summoned enough courage to bring her child to the hospital, although her inability (however understandable) to indict the father for his wrongdoings made me seethe with anger.


I remember walking out of that hospital room hoping that the child would never have to see his father again. I wanted to imagine the father behind bars in a small prison cell, miserable and remorseful over what he had done.


A few moments after answering the judge, the defendant spoke again. “Judge…judge?” As he stammered, most pairs of eyes in the courtroom focused on the young man, waiting to see how the judge would punish this unsolicited outburst. Before the judge could react, however, the defendant teetered to the side and slumped against his unsteady lawyer, who provided even less physical support than he did legal support. Caught off guard, the lawyer fell to the ground with a thump, followed soon after by the sound of his client’s limp body crumpling onto the floor.


In an entire courtroom full of people, only a single person sprang into motion. In one fluid movement, the physician sitting next to me—the same one who was to testify against the defendant—traversed those few feet of space, lifting himself over the mahogany railing and landing squarely next to the defendant’s body. Without hesitation, he instructed the court deputy to call an ambulance while he placed his ear close to the defendant’s mouth, listening for breath sounds, and his hand across the defendant’s neck, feeling for a pulse. He found both and within a few short moments, the defendant’s eyes opened, signaling that he had come to.


After a bit of questioning, the physician ascertained that the defendant had not eaten a real meal in the past 24 hours. He continued to ask the defendant about his medical history, concerned there might be some other underlying condition. All the while, the physician held the man’s hand for the primary reason of monitoring his pulse, but perhaps also to provide reassurance to the scared, almost childlike man who had likely fainted from raw fear of his bleak future. The physician made it known in those few, brief moments that the defendant was not alone; not every person in that courtroom hated him.


Aside from the physician and the young man lying on the ground, the rest of the courtroom carried on with surprising normalcy. The judge retired to his chambers, the district attorney used the time to study his notes, and the courtroom audience turned their discussion to the latest tabloid news. The court deputy rolled in a tray of food and soda, slowing only to maneuver the cart around the defendant’s body, and made his way toward the judge’s chambers. The defendant’s own lawyer sat in a chair, shaking his head, as if he had just endured some grave injustice. Under his breath, he vowed to file a claim for any damages he incurred in his fall.


Perhaps most unsettling, as everyone busily tended to their own needs, was how the physician continued waiting for someone to bring the defendant a glass of cold water. No one had thought to offer a can of soda or juice. In fact, once the defendant had opened his eyes, no one seemed to think much of anything about the young man. Blatant contempt had quickly replaced the fleeting sympathy he had commanded in his moments as a patient.


Finally securing a glass of water and a damp towel, the physician dabbed the defendant’s head with a knowing touch and continued to monitor his pulse, waiting for the ambulance to arrive.


For the third time this month, and for reasons unique from the first two, I again felt the salty tang against my lips. I experienced a profound sadness, not out of sorrow for the abandoned defendant, nor simply for the grave injustice of a beaten baby, but because of the realization that humanity could not straddle those two extremes. A rare few can shelter both an abused child and the abusive parent in their arms.


The attitudes apparent in the courtroom—from the stark indifference of the court to my own inability to reconcile my emotions—revealed how hard most of us struggle with the idea that people who abuse children require just as much help as the children they hurt. Most of us.


Except, of course, for those charmed people who touch the world with unprejudiced hands, stroking the foreheads of both a black-and-blue baby and a devastated child abuser.


Perhaps that’s the true reason I wept—the world had just let me in on its little secret: They really do exist, those people with indiscriminate hands and unconditionally accepting hearts. I promise.
~~~~James A. Feinstein is a fourth-year at the University of Pennsylvania School of Medicine. This is a fictionalized account of true events; all identifying material has been changed or removed.~Ethics,Physician Patient Relationship,Practice of Medicine~
351~2March~2007-56~Feature~The Wards Less Traveled~Practicing medicine off the beaten path~Martha Frase-Blunt~There’s more to medical practice than sterile scrubs and packed waiting rooms. Some future physicians are combining their professional aspirations with dreams of travel, adventure, or getting down to the gritty basics of the street. We look at some of medicine’s most unique practice settings.~SEA SICKNESS


Believe it or not, positions for cruise ship physicians are readily available to those with the right training and the willingness to be cut off from traditional medical facilities for weeks at a time. “You don’t want to be practicing on a cruise ship if you don’t have confidence in your skills, because you are really isolated,” says Dr. Robert Wheeler, member and former chair of the American College of Emergency Physicians (ACEP) Section for Cruise Ship and Maritime Medicine. “There are no specialists down the hall to consult with, so you have to be willing to deal with problems on your own.”


Cruise medicine has come a long way just since 1996, when the ACEP formed the first organized body to set quality guidelines for this type of practice. Before that, the international cruise industry was “pretty disorganized” in its standards for providing on-board medical services, Wheeler says. Cruise ship physicians once came from a variety of specialties, from pediatrics to dermatology. Nowadays, most have backgrounds in emergency or internal medicine, and the ACEP recommends that they have three years of training beyond medical school graduation and be board-certified in their specialty. “It’s not always possible [for cruise lines] to require board certification, since many countries do not have the same formal training or certification systems,” he adds.


Another very important qualification for a cruise ship physician is to be comfortable socializing with passengers. “There is a very social aspect to the job,” says Wheeler. “You wear a uniform and are very visible—some people don’t like that.”


For many cruise physicians, the job is a temporary junket, often coming between residency and a permanent practice. “Some want to do a bit of traveling before starting their career,” Wheeler explains. Although the pay varies by cruise line, it’s not too shabby, considering food and board are taken care of. “On larger lines it can reach $8,000 to $10,000 per month.” Doctors are independent contractors with contracts lasting from two weeks to four months. “A full-time position is working eight months a year.”


Wheeler, an emergency physician in Amherst, New Hampshire, cruised part time as a ship’s doctor for 20 years while still maintaining his land-based practice. “I’d save up my vacation time and go out for two to four weeks.” But it’s nothing like a vacation, he adds. “It can be very tiresome—it’s a seven-day-a-week business, and on smaller ships you may be the only doctor on board. But for the most part, it’s a reasonable tour of duty. You meet a lot of interesting people, and there is usually time to enjoy the travel.”


But the ship’s medical ward can be as busy as any family medicine clinic. On a typical cruise, about 1 percent of all people on board will visit the doctor each day. So on a voyage with 2,000 passengers and 1,000 crew, that’s 30 patients a day, every day. Fortunately, Wheeler says, “About 80 percent to 90 percent will be nonemergent,” presenting with sore throats, chest colds and so forth. But because they are on vacation, “they really want to get better, and they do—very quickly!”


Another 10 percent to 15 percent have minor emergencies, such as broken bones or lacerations, and the remainder are “really sick,” he says, with conditions like heart attacks, stroke or intestinal bleeding. “They consume a lot of your time, but overall we can treat 99 percent of patients without disembarking them.”


Most physicians come on board with no experience at all in this type of medicine. Medical student and resident experiences are scarce, because most cruise lines can’t provide teaching because of lack of space. One exception is an elective co-sponsored by the ACEP and Yale University School of Medicine’s emergency medicine department. The four-week elective is available to fourth-year residents in U.S. or Canadian emergency medicine programs, and some third-years who have completed two years in the ER. It is administered through Vanter Ventures, which also recruits medical personnel to the cruise industry.


The elective provides experience in managing minor and major cases in the medically isolated environment of a cruise ship under the supervision of the senior medical officer and the back-up of a telemedicine consultant on the Yale Emergency Medicine faculty. The rotation also exposes new physicians to the issue of prevention and early detection of communicable disease outbreaks like the norovirus, which has become a high-profile concern among cruise passengers.


Physicians interested in cruise ship medicine might be concerned about norovirus, but the illness needs to be put into perspective, says Wheeler. “Certainly, in the past few years we have seen more [norovirus] than ever all over the world. The feeling is that the virus is mutating and becoming more infectious.” And yet, the media doesn’t often cover shore-side outbreaks, which are far more common. “Look at it this way: About 1 in 12 people get this every year generally, compared to 1 in 3,000 who contract it on a cruise ship.” And the virus moves so quickly through the body, most people suffer only for a day or two. In any case, cruise ship doctors log every person who comes to the infirmary with gastrointestinal distress, “so we can catch every one of these people.”


Intrigued by shipboard medicine? Wheeler says that jobs are plentiful. “The cruise industry has grown 8 percent to 9 percent annually in recent years, so if [you] are qualified, there’s a good possibility of getting these assignments.”


INTO THE WILD


Far from the world of all-you-can-eat buffets is the world of freeze-dried MREs (Meals, Ready-to-Eat) and wilderness medicine. Practicing in the wild can encompass everything from snakebites and heat exhaustion to altitude sickness and diving-related disorders—but it’s always an emergency.


One of the most established programs is found at Stanford University School of Medicine, which in 2003 founded the world’s first fellowship in wilderness medicine, designed for physicians who have completed residency in emergency medicine. A primary goal of the fellowship is to promote research leading to a better understanding and prevention of wilderness-associated diseases, and to improve clinical care, rescue techniques and injury prevention.


Fellows also have the opportunity to pursue a wilderness experience through such organizations as the Himalayan Rescue Association in Nepal and the National Geographic Society in Belize.


Stanford’s Division of Emergency Medicine also offers one of the few electives in wilderness medicine for medical students. It is offered during the spring semester and includes didactic sessions, outdoor hands-on skill-building workshops and field trips.


Wilderness medicine specifically addresses the physiology and pathophysiology of humans as they encounter environments that are considered to be “wildernesses.” In these varied environments—from the desert to the tundra to the bottom of the ocean—health professionals encounter rarely seen medical problems like high-altitude pulmonary edema, wild animal attacks and even sea snake envenomation.


But can you make a career of it? “Wilderness medicine is more of an avocation than a vocation,” remarks Dr. Eric Weiss, director of the Stanford fellowship program. “People get into it because it combines their passion—their love for the outdoors—with a profession.” That love could focus on skiing, mountain climbing, scuba diving, hunting, rafting, or any number of outdoor sports.


It also appeals to students and physicians who love the challenge of practicing medicine in an austere environment, “whether at an Everest base camp or volunteering in a remote village with Medecins Sans Frontieres,” But it’s not a full-time living, Weiss points out. Even those providing emergency care in national parks will have a regular hospital or primary care practice.


Most of those in the field have emergency medicine or primary care backgrounds, “which can be a natural segue into wilderness medicine because they need to know a lot about other specialties. They will be called to handle wounds, eye injuries—even pregnancy complications,” says Weiss.


There seems to be no limit to the kinds of assignments a wilderness physician could pursue. Recently, Weiss was asked to serve as the physician for a major film production company filming a movie in the Sahara desert. Although he had to decline, he says it’s an example of how in-demand these services are. “Anyone working outdoors more than one hour from medical care needs [access to] this expertise,” he asserts.


Much of the demand for these skills is for posts that aren’t as sexy as being an expedition doctor, but “the expertise is extremely helpful in working overseas in refugee camps where there is a modicum of equipment. You have to know something about travel medicine and be able to be comfortable living in austere environments,” Weiss notes.


For the more exotic wilderness medicine assignments, getting in the door requires some proactivity. “A lot of it is word of mouth, knowing people in the community and networking,” says Weiss. He recommends that interested students or physicians attend conferences, especially the annual National Conference on Wilderness Medicine. He also suggests networking through the Explorers Club and the National Geographic Society.


In the meantime, students can take classes in such topics as Wilderness Advanced Life Support to hone their skills. “Certification isn’t required to practice, but such classes are very helpful to learn the fundamental principles,” he says.


A wilderness medicine elective can also be a refreshing break from a grueling medical school course load—and a lot of fun, in the experience of Dr. Jordan Safirstein, who completed a one-month program during his fourth year at the University of Utah School of Medicine. He initially chose it for “the opportunity to ski and learn some cool medicine,” but ended up finding “an amazing opportunity to use medical knowledge for something other than tests and patient management. We were taught to use practical medical knowledge for our own benefit and the benefit of others who might be on outdoor excursions with you.” The course, he says, highlighted major injuries and ailments encountered in the field, and also went over major climbing-associated injuries and how to deal with them in the wild.


Although Safirstein is currently doing a fellowship in interventional cardiology, he still considers wilderness medicine a developmental aspect of his training, and daydreams about using it again, some day, some way. “Perhaps [the experience] would enable me to gain more training so that I could eventually do something like base-camp physician at Everest.” He says he “would 100 percent recommend this to others. And it was also a wonderful chance to visit and learn about Utah—and ski the heck out of it!”


STREET BEAT


It may seem like a stretch from a mountaintop to a homeless camp under an urban bridge, but wilderness medicine and street medicine do overlap. Both require physicians to provide care on the spot, often outside, and without the immediate security and comfort of a hospital staff and high-tech equipment.


Providing structured care to the unsheltered homeless is a fairly new innovation that can be traced to the vision of Dr. Jim Withers of Pittsburgh, Pennsylvania. In 1992, Withers, an internal medicine physician, began providing medical care to the homeless directly on the city’s streets. Partnering with formerly homeless individuals, and initially dressing as a homeless person, he gradually earned the trust of this transient and wary patient group as he made nighttime rounds in alleys and under bridges. More clinical volunteers soon joined in—medical students, residents, nurses, mental health professionals and others—and Operation Safety Net (OSN) became one of the nation’s first targeted, full-time street medicine programs, inspiring imitation all over the United States and abroad.


Withers’ purpose wasn’t simply to provide for the homeless—he had medical education firmly in mind. “I wanted to create an example for students of how to step over the boundaries of medical practice and care delivery to meet the needs of a group that is not user-friendly or well-served, and to see them in the context of their reality.”


Through the department of Medicine at Pittsburgh’s Mercy Hospital, OSN operates clerkships for fourth-year medical students, as well as rotations for primary care residents, some of whom have gone on to pursue street medicine full time.


Two of those graduates are Dr. Patrick Perri and Dr. Elizabeth Cuevas, who both chose the University of Pittsburgh because of its many service medicine opportunities. They became involved with Withers and OSN, and later matched in internal medicine at Massachusetts Medical Center to work with Dr. Jim O’Connell at Boston Health Care for the Homeless—“a mecca” for street medicine, Perri says.


The husband-and-wife team are now part of a full-time roster of 15 physicians, more than 30 mid-level health professionals and more than 60 nurses working for the organization. When not on the streets, Perri and Cuevas spend much of their time teaching students and volunteers the ropes.


“Teaching is a core part of the mission, and an unwritten rule [of this type of practice],” Perri says. “We are trying to target folks going into primary care or other careers with diverse patients, because they are going to encounter homeless and at-risk patients.”


“These kinds of service-learning programs are springing up all over the place,” Withers says, “and really need to be a component of medical education generally.” He believes that street medicine can teach every future physician—whether planning to go into a service career or not—how to be flexible and “live in the patient’s shoes.”


One newer medical-school-based program that emulates the OSN model is MUSHROOM—Multidisciplinary Unsheltered Homeless Relief Outreach of Morgantown. Established in West Virginia’s capital just over two years ago, “it was an entirely student-driven initiative,” says faculty adviser Dr. David Deci, who is also assistant professor and vice chair of West Virginia University School of Medicine’s Department of Family Medicine. “Students in our Family Medicine Interest Group wanted to take medicine to the city’s most marginalized residents.”


The most important part of orienting to this way of practicing “is that the whole goal is to develop trust among the homeless—it’s our greatest therapeutic tool.” Most are marginalized from mainstream care because of mental health problems or family dysfunction, which are commonly superimposed on drug and alcohol issues. They don’t trust the system—including the medical system—and many of them have been abused or degraded by people in authority. “That’s why we have to begin by developing relationships of trust.”


Many volunteers “think we will rush out there and start detecting diabetes or hypertension in the field, but most of our work is sitting around talking and being present, building their self-worth as human beings,” notes Deci. And while most clinic doctors have just 15 to 30 minutes to spend with each patient, “street rounds are open-ended. We take as much time as the individual requires.”



Street-care providers don’t just dispense medicine: Teams bring food, beverages, clothing, tarps and any other materials needed to support life on the street. “Interestingly, the ticket into the [physician–patient] relationship is often clean, dry socks,” he says, which are in more demand even than food.


MUSHROOM sends out two teams each day, including three or four medical students as part of a varying multidisciplinary cohort that also includes licensed physicians, social workers, clinical psychologists, nurses and even occupational therapists. Rounds take place on a regular schedule and in predictable places. “The homeless get into the habit of looking for us at certain times and in certain locations,” Deci explains. In Morgantown, those locations may be a main storm drain, abandoned buildings, under bridges and in riverfront camps. Still, the population is very migratory and will move around depending on the weather, police activity and individual needs. So the teams work with formerly homeless partners “who help us locate people.”


On rounds, volunteers carry medical equipment in backpacks and a large rolling cart, “which is like a tool chest on wheels,” Deci says. Most of the medical interventions are minor and can be handled with suture kits, saline and bandages. “It’s like making a house call, except the ‘house’ is a space behind a dumpster.”


But every once in awhile, a team will come across an acute medical crisis, so everyone carries cell phones to alert 911. Deci remembers one man he discovered behind an abandoned house suffering from end-stage liver failure and just hours from death. “The good thing is that we knew this man; we had been seeing him on the street and he trusted us. He allowed us to call an ambulance to transport him to the hospital, where the staff knew us as well.” One MUSHROOM team member was a hospice nurse, and arranged to enroll the man into a program providing a visiting hospice nurse to the homeless shelter where he was settled. “He got better and stayed sober; he’s told us he feels better than he has in years.”


Another man was discovered in a schizophrenic crisis. The team was able to contact local mental health services and get him an inpatient bed for treatment. “Our program has a lot of connections throughout the medical community in Morgantown, which has been essential to our success with this population,” Deci asserts.


Even if they practice on the street for just a few months, students learn lessons that can last throughout their careers. First- and second-years with experience in the program get to teach the third- and fourth-year newcomers, and the team works collaboratively in a way not seen in an academic health center, according to Deci.


“My goal is to provide them with structured and life-changing experiences. When they go on to work in an ER or hospital ward, they will be able to relate to poor and homeless patients, and not see ‘just another bum.’”
~RESOURCES


Cruise Ship Medicine



Wilderness Medicine



Street Medicine

~~~Martha Frase-Blunt is editor of The New Physician.~Career Development,Community and Public Health,Medical Education,Practice of Medicine,Residency~
352~2March~2007-56~Feature~Medicine Behind Bars~More new physicians are being drawn to the nation’s prisons by the promise of exciting cases and epidemiological challenges.~Anthony C. Hall~Care for the incarcerated is improving under stricter guidelines and a higher quality of medical professionals entering the field. We take a look at patient care behind prison walls. Also: The troublesome matter of physician-assisted executions.~When Lauren Gillory, a third-year at the University of Texas Medical Branch (UTMB), spoke of her internal medicine rotation recently, the conversation veered, almost by default, to the subject of tattoos. Many of her patients are covered with them—human canvases silently seeking expression.


She recalled one patient in particular: 25 years old and emaciated by Crohn’s disease, he had faces drawn on the back of each hand—one with fangs dripping down two of his fingers that revealed themselves when he balled up his fist. He had tattoos on his arms, chest, neck and face. Teardrops were permanently inked on his cheeks. And when he closed his eyes, two smiley faces appeared on his eyelids.


Third-year David Keelen, on the same rotation team with Gillory, was struck by how his ward once filled up with patients whose symptoms seemed exacerbated by the telecast of the World Series. One, a patient with cystic fibrosis, presented with normal O2 stats that did not match up with the level of complaint. It turned out that many of his patients’ “symptoms”—and subsequent inpatient stays—could probably have been resolved by easier access to a television.


The common denominator for Gillory and Keelen’s patients is that they were both wards of the correctional system of the state of Texas, and both were seen at the Texas Department of Criminal Justice (TDCJ) Hospital in Galveston, which includes—besides television sets in every room—a warden, prison guards and numerous security checkpoints. The inpatients, of course, find the hospital more comfortable than their normal environs, but for any trip to the operating or exam room—even for women inmates about to give birth—shackles are required for transport.


GETTING INSIDE


Nationwide, very few medical schools offer rotations in correctional institutions, although several use prisons for elective course work. New York University School of Medicine, for example, has a popular elective in psychiatry at Bellevue Hospital’s prisoners’ ward. But rarely are opportunities in correctional health as accessible as at UTMB, where the state’s prison hospital, built to keep sick prisoners inside the penitentiary walls in as many situations as possible, sits on the medical school campus. This allows students rotations in a setting adequately described by one correctional health administrator as “the nexus between ethical, legal and medical issues.”


At rare times, correctional health might require a physician to preside over a hunger strike. More commonly, he or she might have to decide whether to report a violent guard to the prison warden. And prescribing medicine to a population that is 74 percent drug- or alcohol-dependent presents a constant challenge. Even a relatively benign pharmaceutical like the HIV drug efavarenz (Sustiva), which can cause intense dreaming, has a black-market value in a penitentiary.


Do you recommend an operation, even a critical one, if the healing time exceeds the patient’s maximum sentence? Do you see a patient with a head cold if the warden wants him in solitary confinement for participating in a violent altercation? Or do you protest such a punishment if a patient—no matter what he or she has done—is suffering from serious depression?


The challenges of correctional medicine are ironically felt: The only population guaranteed health care in this country is the same population that society prefers to ignore. As such, conditions in prison clinics can range from state-of-the-art to resembling those found in the developing world, says Scott Chavez, vice president of the National Commission on Correctional Health Care (NCCHC), which sets the standards on prison medical services for 25 percent of the incarcerated population in the United States. “I’ve seen good and bad.”


GOOD BEHAVIOR


One thing holds true: The first time the doors close behind you in a county jail or a state or federal prison, the sound of the steel door clanging shut is hard to forget. Students at UTMB sometimes feel overwhelmed and intimidated the first trip down the long, elevated corridor that connects the so-called “free world” with the prison hospital. But soon they forget the feeling of menace or the prejudices they assumed would cloud their medical judgment.


Patients are patients, no matter that they wear jumpsuits. In fact, prisoners seeking health care tend to be cooperative and polite, according to those interviewed for this article. “They’re like the perfect patients,” Gillory says, referring to prisoners’ tendencies to explain their symptoms cooperatively and to show gratitude for the care they receive. Keelen says he witnessed a patient who had been partially paralyzed for six months wiggle his toes after a medication adjustment reduced the swelling around his spine. By the next morning, the patient insisted on using a bedpan by himself and was refusing help to sit up, hoisting himself up instead by an overhead bar.


“They size you up quickly, and they won’t respect you if you give them everything,” says Dr. John Barnett, associate chief medical officer and acting regional medical director for privately owned Prison Health Services (PHS) in Virginia, who has spent much of his career in correctional health. “But nor would I let them leave the office without their serious needs taken care of.”


“We, by nature and by training, want to help reduce people from suffering and pain,” says Dr. Sylvia McQueen, Alabama Medical Director for PHS, which operates services in 28 states. It’s not difficult for correctional health-care workers to leave their personal judgments in the parking lot, she says, but protocol is important. “I don’t let [prisoners] call me Sylvia, but I have asked the guards permission to give an inmate a hug, and we’ve cried together many times.”


“Your patients are generally very grateful, because you’re the only person who gives a damn about them as a person,” says Dr. David Thomas, chair of the departments of Surgery and Correctional Medicine at Nova Southeastern University College of Osteopathic Medicine (NSUCOM) in Ft. Lauderdale. “Most everyone else in a correctional setting simply wants them to sit down, shut up, behave and do what they’re told, and has no other interest in them at all other than conforming to the rules,” he asserts.


Thomas, who once served as chief medical officer overseeing more than 85,000 Florida inmates, says that “some of the pathology I saw in…corrections was profoundly more difficult, esoteric and fascinating than at a tertiary care medical center, partly because inmates [often] don’t get medical care [before entering prison]. Secondly, it’s the only environment where you can follow the natural history of the disease.” Indeed, doctors say correctional medicine is a clinical utopia for its wide variety of medical conditions that are rarely seen in a free setting, and because patients, once diagnosed, don’t disappear if they don’t like their doctor.


Another professional challenge for prison physicians is the pervasiveness of chronic disease. HIV/AIDS is five times more prevalent in incarcerated adults than in the U.S. population as a whole. In 1996, almost 500,000 of the nation’s 1.3 to 1.4 million inmates and former inmates in the nation’s jails and prisons were infected with hepatitis B or C, according to an overview of prison health services presented to Congress by the NCCHC. That is a figure that grows, step by step, along with the inmate population as a whole, which is now said to top 2 million.


Their health care, provided by approximately 4,000 physicians across the country, is frequently the stuff of unfortunate press coverage and rarely praised, even as a career in correctional health appears to be growing in prestige and popularity. Two-year fellowship programs combining clinical and administrative course work are now available at UTMB, NSUCOM and the University of Massachusetts Medical School.


The field is growing most quickly among young female physicians. “Women are actually the fastest-growing type of doctor and midlevel [health practitioner] in our system, because the hours are good, the challenges clinically are good…. You can have a life outside of your practice. So here they can get kind of the best of both worlds,” says UTMB’s assistant vice president of Community Health Services Owen Murray, who oversees correctional care programs serving 80 percent of Texas’ incarcerated population. His oversight includes responsibility for 100 prison facilities and the TDCJ Hospital on UTMB’s campus.


“A lot of older folks who got into correction not by choice, but because it was their only opportunity, are gone,” he says. “Now you get a lot of younger, board-certified doctors who do it because they enjoy it and they find it challenging.”


The pay, he adds, is usually competitive, but not always great. Doctors in correctional health, however, don’t need medical liability insurance, nor do they hassle with insurance forms at all. And the hours can be sustainable, in part because prisons have a tendency to reduce on-call assignments, since rowdy behavior is mostly limited to daylight hours. “That takes away some of that anxiety that a lot of good docs have,” Murray says. Paradoxically, the lack of hassles with insurance companies, the steady hours, the monopoly on patients and the interesting work add up to a lifestyle that is less stressful for a physician than many a suburban practice, he adds.


"CALLOUS" SYSTEM?


This is not to say correctional health is worry-free. Doctors working in prisons don’t run out of patients, but they don’t seem to run out of headlines, either. The Los Angeles Times, the New York Times and the Detroit Free Press have all published stories of negligence leading to tragedies in recent months, including the case of Lloyd Byron Martell, whose untreated colon cancer was diagnosed during a one- to four-year stretch in a Michigan prison for driving with a suspended license and fleeing from police who tried to pull him over for a cracked car window.


His case was called a “de facto death penalty,” not only by the Detroit Free Press, but by U.S. District Judge Richard Enslen, who ruled in December 2006 that Michigan’s correctional health-care system was “callous and dysfunctional.” After hearing testimony of another inmate with blood in his urine who had to wait 40 days for tests to be done, and testimony about Timothy Joe Souders, a 21-year-old mentally ill inmate who died of hypothermia and dehydration after spending four days bound and naked in his cell during a heat wave in Jackson, Michigan, Enslen ordered the state to fill immediately
all medical staffing vacancies and authorized a monitoring agency to look after the state’s correctional health program.


The case was hailed a victory by the American Civil Liberties Union, whose National Prison Project brings suits on behalf of inmates for many issues. Medical cases, however, comprise more than one-quarter of the Prison Project’s docket, according to the project’s public policy coordinator Jody Kent. “Certainly, correctional health care would benefit from having young and energetic doctors who are coming out of med school who are interested in doing work in fields that expose you not only to a variety of health issues, but larger societal issues,” she says. “[But] it’s at the point right now where [correctional health] really is a nationwide crisis.”


PRIVATE PRACTICE


Not everyone pushes the sentiment that far, but many point to the privatization of prison health services beginning in 1976 as the start of a shift toward profit-engineered health service contracts, which have eroded the public’s confidence.


The almost-unanimous U.S. Supreme Court decision in 1976’s Gamble v. Estelle declared that inadequate health care in prisons was “cruel and unusual punishment.” It put government-run prison health-care services on notice and paved the way for private, profit-oriented firms, which now oversee 40 percent of the country’s health-care needs for inmates. Its chief flaw, many say, is the mandate of state and county governments to accept contracts from the lowest bidder, creating a propensity to cut back on services. “I’ve seen it work and work very well, but in other places it doesn’t,” Chavez says. “It depends on individuals and the ability to meet the needs of patients and the inmates. But privatization is here to stay. I don’t see it going away, and it has advantages in areas where government can’t provide adequately for the inmates.”


Good doctors, however, can make or break a clinic in any setting, whether inside or outside the bars, and incarceration settings may be too exceptional to make an apples-to-apples comparison anyway. Incarcerated patients are often smokers, and often in the throes of alcohol or drug withdrawal; the population includes “some of the sickest people in the country,” Chavez says.


Besides HIV/AIDS and hepatitis, tuberculosis and sexually transmitted diseases are all overrepresented in prisons, as are major depression, bipolar disorder and various forms of psychosis. One patient Keelen remembers well in the TDCJ Hospital was missing both legs and one arm due to diabetes and the fact that he was prone to self-mutilation. Leprosy was recently diagnosed in a Texas prison, Murray says. And a story in a January 2007 New England Journal of Medicine concluded that within the first two weeks of their release, former inmates were almost 13 times more likely than other populations to die from violence, heart failure, drug overdoses and suicide.


While some doctors might flee, “I got into medicine to serve the underserved,” says Dr. Lynn Sander, who graduated from Boston University School of Medicine in 1975, then moved to Baylor College of Medicine to complete an internal medicine residency with the city’s community health system. Later, a simple job transfer brought Sander into correctional health, which she believes was a natural transition: “Correctional medicine is the best job in the world,” she says.


Barnett, with PHS—a large firm hounded by bad publicity in recent years—is also proud of his long career in correctional health, which started years ago when he volunteered one day a week at a county jail.


During one of his first visits there, he diagnosed a man who had been arrested for DWI the night before as, in fact, a sober diabetic who had gone
into cardiac arrest. The man’s gratitude cemented Barnett’s appreciation for correctional health.



Then there was the woman he arrranged to have sent home to South America, even though she was awaiting trial in the United States on drug charges. She spoke only Spanish and her lawyer, he says, spoke only English; in fact, the two had never met. But Barnett does speak fluent Spanish, and he also recognized that the prisoner’s stomach cancer was certainly beyond hope of recovery. So as her physician, he did the best that he could do. He picked up her file and took it to the local courthouse, where he engineered a quick release for his patient. She then went home, Barnett said, to die surrounded by children and friends.
~PHYSICIAN-ASSISTED EXECUTION


If there was ever a year of contradictions on the U.S. Supreme Court, 1976 would be it.


In November of that year, America’s highest court decided in Gamble v. Estelle that it was “cruel and unusual punishment” for incarcerated persons to be held without adequate health care. The case involved a Texas inmate who hurt his back during a work detail. The decision meant that health care for inmates was constitutionally guaranteed.


But 1976 was also the year the highest court, after a decade-long moratorium, reinstated the death penalty. The very next year, Oklahoma became the first state to adopt lethal injection as a means of execution, but it was five years later—Dec. 7, 1982—that Texas became the first state to use lethal injection on a death row prisoner: Charles Brooks, a hitchhiker who murdered two men who had picked him up on the road.


Lethal injection, however, moved the method of killing closer to medical procedure, and the ethical question of doctor-assisted executions suddenly became a hands-on dilemma for physicians.


Of the 38 states with death penalty statutes, 35 allow physicians to attend executions and 17 require it, according to a March 2006 article in the New England Journal
of Medicine by Dr. Atul Gawande. The issue, however, moved to front and center in February 2006, when a U.S. District Court ordered California to have physicians—specifically anesthesiologists—supervise lethal injection executions.


Ostensibly, the reason was a good one: to eliminate pain before proceeding with an injection of 120 to 240 mEq of potassium, which is intended to bring about almost immediate cardiac arrest. The California Medical Association, the American Medical Association (AMA), and the American Society of Anesthesiologists, however, quickly reaffirmed their positions on doctors assisting in executions. Doctors, according to the AMA, for example, can issue a death certificate after someone else has pronounced the prisoner dead. Any actions that bring a physician into play before or during an execution are deemed unethical.


The Society of Correctional Physicians, the National Commission on Correctional Health Care and the American Nurses Association also adamantly oppose doctors participating in executions. However, the American Pharmaceutical Association allows for pharmacists to supply the sodium thiopental, pancuronium and potassium—called the Deutsch protocol after its inventor, Dr. Stanley Deutsch of Oklahoma—which is commonly used for executions.


Physicians, usually with airtight anonymity, have participated to varying degrees in many lethal injection executions—numbering more than 850—that have taken place since 1976. But in California, two anesthesiologists who signed on to attend the execution of murderer Michael Morales on Feb. 21, 2006, backed out a day before the execution when they learned they would be required to administer additional painkillers to the prisoner if the first batch appeared not to work.


The action forced a stay of execution for Morales, and his situation is now a test case to see if the court can force physicians to participate in his execution as a guarantee to the public it will be painless when he dies. —A.C.H.
~~~Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.~Career Development,Community and Public Health,Practice of Medicine~
353~2March~2007-56~Specialty Close-up~Anesthesiology~Is the gas always greener?~Pete Thomson~Anesthesiology~

Anesthesiology at a glance



Resource: The American Society of Anesthesiologists hosts a wealth of information for students considering the specialty. www.asahq.org



One of the defining characteristics of modern medicine is its focus on pain. Though suffering certainly remains, the alleviation of pain and even consciousness during medical procedures is de facto. Anesthesia interfaces with nearly every specialty, and as the number of surgical procedures climbs, so does the need for someone to champion patients’ sensations.


For those choosing a specialty, anesthesiology is fast-paced and hands-on, but carries the lifestyle advantage of manageable and relatively predictable hours. It is the content of those hours that is unpredictable, and thus exciting, anesthesiologists say.


When Duane Ellsworth volunteered at Utah Valley Regional Medical Center as an undergrad, he noticed that patients were more complimentary of the anesthesiologists than anyone else. Ellsworth, who is now a second-year at the Arizona College of Osteopathic Medicine (AZCOM) and strongly considering the specialty, believes this has a lot to do with lifestyle. “I believe they were happy doctors and, in turn, uplifted the nurses and patients who they were involved with.”


According to physician salary surveys, anesthesiologists earn an average of just over $330,000 a year, though salaries range widely by experience. But beyond money, the practice setting is often the main appeal. “I absolutely love the OR, and I love physiology and pharmacology,” says Dr. Adam Cotton, an intern in a private hospital in Oklahoma City. “I don’t much care for clinics or rounding or long-term care. So the choice was really pretty easy for me.”


Dr. Josh Atkins, a PGY-4 anesthesiology resident at the University of Pennsylvania Medical Center, says this is a specialty for dynamic people who like to respond quickly and put their hands on patients—not for those who like to take time deliberating over cases. “Almost all of what we do, especially in the operating room…is very unpredictable,” he says. “You really need to thrive on the idea that what is happening now may be completely different than the situation you’re managing 10 minutes later.”


That flexibility also leads to a wide variation in the number of patients an anesthesiologist might see daily. In a cardiac rotation, residents might see only two cases a day, Atkins says. In an outpatient setting, they might be involved in five or six surgeries. The maximum number of patients would probably be eight or nine in a pain clinic.


“It also helps if you are the kind of person who really likes a constantly changing interpersonal dynamic,” Atkins adds. In a day, an anesthesiologist may work directly with a constant parade of surgeons, residents and nurses. “You need to enjoy and be able to operate in a complex social infrastructure.”


Once out of residency, anesthesiologists in private practice may oversee certified registered nurse anesthetists (CRNA), stepping in to monitor the critical junctures of an operation. In an academic setting, they’ll work with residents who monitor the patient’s condition minute by minute.


Most anesthesiologists enter private practice, but Atkins plans to join Penn’s faculty, spending about 75 percent of his time on clinical work doing most types of anesthesia, save cardiac or pediatric, which tend to be limited to those who’ve completed the appropriate fellowship. Atkins, who also holds a Ph.D. in organic chemistry, hopes to research genetic variation and response to anesthetics in patients.


Lifestyle is a common draw for students considering anesthesia. Though anesthesia is not shift work, Atkins says, its schedule is somewhat predictable. Practicing in a team-care model, the anesthesiologist is not the only person responsible for the patient, and is generally relieved by another physician when working hours are done. “You might work a little later, but in that sense… you can usually plan your schedule,” Atkins says.


There are about 160 anesthesiology residency programs in the United States, according to the American Society of Anesthesiologists (ASA). The average has about eight residents per postgraduate year.


There were 1,283 anesthesiology positions available in the 2005 Match, with 965 U.S. applicants seeking them, according to National Resident Matching Program data. Another 544 applicants included osteopathic students and international medical graduates.


Anesthesiology residency takes at least four years, but the first, the clinical base year, can—for now—be spent in a different specialty or institution. Many programs, according to the Accreditation Council for Graduate Medical Education (ACGME) and the ASA, are moving toward incorporating the clinical base year into a complete package with the other three years, the clinical anesthesiology years. In the meantime, interns can spend their year in a transitional internship or in another specialty, including surgery and pediatrics.


Residents do four- to eight-week rotations through subspecialties, generally starting off with “straightforward” general anesthesia in the OR with relatively healthy patients, according to Atkins. Eventually, residents rotate through pediatrics, obstetrics, neurosurgery and cardiac surgery.


“The day-to-day in the OR is very similar for all those different rotations. It is just that the patients and the complexity and the specific issues of the day change,” Atkins says.


Residents learn what types of anesthesia to use in outpatient settings, when their patients might be walking around later that day.


In the OR, anesthesiologists may work with strong personalities in a high-stakes environment, and that can factor into selection. The characteristic of getting along with fellow residents is much the same as inter-specialty diplomacy, says Heather Ebbs, anesthesiology residency coordinator at Oklahoma University (OU) Health Sciences Center. “I expect my guys to be able to get along and play well with others…. This is the big sandbox, right?”


OU’s program is four years. Residents train at the medical center during their three clinical anesthesiology years, but their first year is multidisciplinary, spent at a private hospital across town. Ebbs says this is a good experience for them. “We’ve been told that we have one of the best clinical base years in the country.”


Certifying fellowships are available in cardiology, pain management, critical care and pediatrics. Other fellowships in obstetrics, neuroanesthesia and regional anesthesia are also available.


Though the role of the anesthesiologist may seem constant and necessary, it may be entering a period of flux. Just as the ACGME training requirements are changing, so too are some of the theaters of practice.


With the explosion of outpatient procedures like colonoscopies and biopsies, anesthesiology has been stretched, and other specialties have been filling the gap.


“There is increasing encroachment on this area by gastroenterologists, emergency physicians and plastic surgeons,” Atkins says. “There is a lot of debate right now about whether anesthesiologists should be the only ones who are able to do deep sedation with certain types of anesthetic drugs.”


The role of the anesthesiologist outside of the complicated operating cases may be changing, and it’s not clear exactly what’s in the future, he says. Someone entering anesthesia to work outpatient cases at a surgery center, for example, may find those opportunities less available in five or 10 years.


There is a general shortage of anesthesiologists—about 37,000 are currently practicing outside of residency, according to workforce studies—so CRNAs provide a large number of anesthetics. In some programs, you work side by side with them, Atkins says. Eventually, you may oversee their work in a private practice setting.


Atkins adds that there is a movement to position anesthesiologists as a complete perioperative physician, not only taking care of an unconscious patient during operations, but perhaps consulting days or months in advance and following up with patients several hours after procedures for the lingering effects of anesthesia.


On the technological side, regional anesthesia—using highly targeted blocks to speed postoperative recovery time—are becoming increasingly sophisticated and more common, Atkins says. The military has been making significant strides in the technique, which is useful in combat conditions.


Chronic pain management and palliative care are also growing areas for anesthesiologists, ones they share with other specialists.


There are a lot of opportunities in the field, and picking a focus doesn’t lead to being pigeonholed. “With some certainty,” Atkins says, “you can be sure that one day is going to be completely different from the next.”
~~~~Pete Thomson is associate editor of The New Physician.~Career Development,Medical Education,Practice of Medicine,Residency~
355~3April~2007-56~Feature~Brain Matters~Spanning Psychiatry’s Mind–Body Divide~Martha Frase-Blunt~Students considering a career in psychiatry may find themselves subject to dismissive comments and narrow-minded notions about whether psychiatry is “real medicine.” But this doesn’t deter the dedicated from their commitment to this multifaceted, rapidly advancing, one-of-a-kind specialty.~Most in the medical field found it hard to take Tom Cruise seriously as he faced off against the “Today” show’s Matt Lauer last year, railing against the evils of psychiatry. But there are doubtless many in the patient community who do.


The field of psychiatry has come under much criticism and debate, Cruise’s public antics notwithstanding. The increasing use of psychiatric medications and fewer psychiatrists doing traditional psychotherapy have created a stereotypic image of a medical specialty in the pockets of Big Pharm, diagnosing new disorders as fast as potential treatments for them become available.


Disparagement of the profession is nothing new. Abuses of early psychiatry—from the imprisoning of the poor and mentally ill in asylums to its use as a tool of political control—in Nazi Germany, the Soviet Union and apartheid South Africa—have not been forgotten. “Shrink” jokes still abound, and virulent anti-psychiatry movements are gaining media attention.


HAZING


On a much more subtle scale, medical students considering a career in the field often face bias from their own peers, hearing such comments as: “It’s not real medicine.” “Patients are difficult and incurable.” “All you will do is prescribe.” “There is no biology involved—it’s a pseudoscience.”


When Dr. Christopher Stanley was a fourth-year at the Medical University of South Carolina (MUSC), pondering his future, psychiatry was at the top of the list. In an article for The New Physician, he reported “mental hazing that comes with the stigma that is attached to psychiatry as a career choice.” He continued: “Attendings in other specialties are just part of the problem. I faced much more relentless attacks from family, friends and even classmates.” On every rotation, it seemed, “I was hit with pleas from classmates and other residents to stop considering psychiatry so that I would not ‘waste my medical degree.’”


Three years on, Stanley is a third-year psychiatry resident at the University of Kentucky Medical Center (UK) who teaches students daily and is involved in residency recruiting. He still sees the stigma to some extent, “but it’s different,” he says. Right now, the school is revamping its rotation requirements, and psychiatry may be compressed from two months to one, “because it’s seen as a less significant rotation. Now I am fighting to make sure students have access to us.”


That said, Stanley doesn’t sense the same negativity from students and physicians in other specialties that he felt in medical school. One reason, he believes, is that at UK, psychiatry residents are active and accessible in the emergency room, compared to MUSC, where they had no required call. “Students see us working just as hard and staying awake just as long as everyone else, and they gain a better understanding of what we do.”


Sunny Aslam, a fourth-year at Saba University School of Medicine, saw some of this stigma on his own rotations. He thinks the main issue for those unfamiliar with psychiatry “is that they think they don’t have the patience to sit and listen to patients whining on.”


Brian Hurley, a fourth-year at the Keck School of Medicine of the University of Southern California, says that while he has not heard any overt disparagement of his chosen profession, “there is an honest recognition by other students that you are going into something different—that you are not ‘in the fold.’” He and his peers who plan to enter the specialty often talk about the need to be “willing to give up the white coat” that is the symbol of a practitioner of physical medicine.


Psychiatry isn’t seen to have the same physiological underpinnings as other specialties, Hurley continues. Part of the disconnect for uninitiated students, he thinks, is a “hidden curriculum” transmitted through medical education that separates biological from psychiatric medicine.


Dr. Chris Ballas, a practicing psychiatrist for the University of Pennsylvania Health System, works with medical students and residents on the wards, and also blogs as “The Last Psychiatrist,” offering his sometimes controversial views on his profession. In six years as an attending, he’s seen his share of students “forced into the required psychiatry rotation” who demonstrate a definite skepticism about the field.


“Their attitudes are: ‘I don’t like it’; ‘It’s a silly specialty’; ‘Why do I have to learn this?’ These are typically students who are planning careers in surgery or other technical fields like radiology or cardiology, with more procedures.”


And while they don’t dismiss the instruction outright—they typically act professionally, he says—“you see it when they present their cases; when they say a patient has a ‘major depressive disorder,’ you can tell they are regurgitating what they have read and don’t really believe in the diagnosis.”


It is particularly telling, he says, when students go further “and use the word ‘disease’ rather than ‘disorder,’ thinking it is the psychiatry ‘party line,’” he says. “They don’t know me, and they assume I am just the attending psychiatrist and have no skepticism, even though I don’t believe [every mental illness] is a ‘disease’ either.”


Many are intimidated by the inpatients. “They don’t know if someone is going to assault [them], so there is a lot of tension and worry” about patient encounters, says Aslam. But in his experience, “Some of my patients are very, very ill, yet they are some of the sweetest patients you would ever meet. Sure, they have episodes of mania and can be noncompliant,” he says, but he tells of patients who have made handmade gifts for his daughter, whose picture he wears on the back of his ID badge. “One woman would ask about my daughter often.” From her questions and comments, he says, “I could tell how she was doing that day.” Attachments develop on both sides of the physician–patient relationship, he explains.


Hurley agrees wholeheartedly. In psychiatry, you come to know the patient on a deeper level, he explains. “While a family practitioner gets to know your whole body—even those of your entire family—a psychiatrist gets to know your hopes, dreams and fears,” which is very satisfying, he says.


BODY OR SOUL?


Despite the vocal anti-psychiatry movement—promulgated primarily by the Church of Scientology in various disguises—Ballas hasn’t seen a significant rise in student skepticism in the years he has been teaching. “It’s just that the language is different. When I was a resident, the key question was whether psychiatry was biology or psychodynamics; now they see it as either biology or bunk. The rhetoric is a lot sharper now.”


In fact, preconceptions about a career in psychiatry can be found at two extremes: among the most skeptical and the most committed, Ballas says. “A good 70 percent” of the third- and fourth-year medical students in his rotations have dismissed any notion of going into the field. The remainder are divided; half are interested in the specialty and really want to learn the basics, and the other half are already committed to this career. But paradoxically, it’s the mildly interested group “who are most able to learn,” he believes. “Many who have made up their minds are already biased. They think they know exactly what [psychiatry] is.”


The others—those who discover psychiatry after a particularly satisfying exposure in medical school—often dream of having a practice that allows them to holistically balance pharmacotherapy and psychotherapy. Ballas has to break it to them: Practicing both medication management and therapy is difficult, because insurers don’t want to pay for hour-long talk sessions with an expensive M.D. or D.O. “Students start out wanting to be able to do whatever modality they wish,” but by the fourth year of residency, he says, “they are looking at community mental health or hospital consulting. Reality sets in—they can’t do therapy at $250 an hour.”


And one can’t blame the payers for not wanting to reimburse board-certified physicians for work that can be done as effectively at lower rates by psychologists, clinical social workers and other health professionals with intensive training in cognitive and behavioral therapy.


NP "PRINCE OF TIDES"


Ballas himself says he has “a therapy bias” and “always wanted to be an analyst,” which is why he so enjoys his work with seriously ill inpatients. “But so many students don’t want to work with the inpatient population; they have images of the homeless and schizophrenics. But these are the same people they will see in a clinic; it’s just that [inpatients] have committed some act—setting a trash can on fire or something—so they ended up hospitalized.” Many students and residents “think the hospital experience is not realistic—they expect their practice to look more like ‘The Prince of Tides,’ but as psychiatrists, [the very ill] are the people they will see most.”


And almost all of the patients new psychiatrists will encounter—inpatient and outpatient—will be treated with psychiatric medications. This reality particularly agitates the anti-psychiatry crowd, and even much of the lay public, who often see new diagnoses like social anxiety disorder as lifestyle, rather than psychiatric, concerns. But the first question one should ask, says Ballas, “is, do these medications work? Many times, yes. But the second question is, just because the pills work, does that make it a disease worthy of treatment? Are insurance companies obligated to pay for it?”


As for the strong emphasis on drugs today, he says, “Everyone blames Big Pharm, but the unfortunate reality is that psychiatry has structured itself to define everything as disease [needing treatment by a physician] so it can justify itself as a medical specialty. It’s not that these medications don’t work, but do we need an M.D. to prescribe them? Do you really need four years of medical school to write a prescription?”


Increasingly, the answer is no, as nurse practitioners and Ph.D.s have won the right to prescribe medicine in many states. The American Medical Association and the American Psychiatric Association (APA) continue to fight this trend, but their efforts may be futile, since non-physician practitioners “are defining psychiatric medicine for the coming years,” says Ballas.


MORE THAN MED-CHECKS


James Knowles Rustad, a fourth-year at the University of Vermont College of Medicine (UVM), plans to enter psychiatry because he is passionate about the work, the patients and the professionals in the field.


“I love working with psychiatrists—they are a wonderful group. The profession is full of intelligent, nice people.” In addition, he finds the field “intellectually interesting, with a huge amount of research in high-growth areas like Alzheimer’s, schizophrenia and neurobiology.” He adds that he also finds gratification in the way patients “rapidly improve” with appropriate treatment, which often includes medication.


Rustad says he has long been interested in human behavior, and developed an interest in the biological sciences as a zoology major at the University of Florida. Before medical school, he frequently worked with psychiatric patients as a nurse’s aide in a local hospital, and was hooked. “I really like the mix of social and biological sciences in the field of psychiatry.”


When asked about the biological aspects of the specialty—something that many medical students aiming for other specialties cite as lacking in psychiatry—Rustad says this: “Just like any other field of medicine, patients come in with signs or symptoms. You take a thorough history and physical in order to tease out what’s going on. You start broadly, with a wide differential and just narrow it down.”


In clinical settings, Rustad has frequently observed the biological basis of psychiatric symptoms. “I recently did a rotation in neurosurgery, where I saw that patients with brain tumors and metastatic cancers can present with behavioral alterations. And I can’t begin to tell you how often depression turns out to be caused by an underactive thyroid.”


The physician’s role, he believes, “is to make the patient as comfortable as possible and alleviate symptoms. It’s not to be a magician who can instantly get rid of a chronic disease process, and in that way, [psychiatry] is no different from neurology or internal medicine.”


In medical school, he notes, the psychiatric curriculum trains the students to look at the body of scientific research like in any other field of medicine. “At UVM, we have excellent lectures with psychiatrists such as Dr. G. Scott Waterman that emphasize the biological underpinnings and clinical manifestations of bipolar affective disorder and other disorders. We learn about the effectiveness of medications in specific situations. We are always encouraged to do our own evidence-based medicine and keep the perspective of a scientist. You can’t let what’s emanating from pop culture affect your pursuit of knowledge—that would be foolish.”


And while it is too early for Rustad to decide on an area of practice or a subspecialty, he says he welcomes “the opportunity to work with patients whose lives are coming off the tracks, and get them back on the tracks—that’s the goal of any physician.”


In addition, he says the ability to practice in a variety of areas concurrently is one of the most compelling aspects of the specialty. “I know a lot of people who do everything. My adviser, Dr. Paul Newhouse, runs the Clinical Neuroscience Research Center at UVM, has a geriatric practice, and works with students and residents.”


Aslam agrees, and says that he “can’t see how any other type of training prepares you to treat people in so many different systems, and also the most seriously ill.” The field, he explains, delves into neurological testing, brain imaging, working in the court system, studying the pathology of the body, and exploring organic disease, genetics and pharmacology. “The explosion in the biological aspect of mental health is huge,” he asserts. “The future is in DNA, and targeting drugs so specifically to patients that we can look at how their genetic makeup allows them to break down chemicals.”


THE COMING CRISIS


Aslam, who will become the 17th generation of physicians in his family, first thought he wanted to be a surgeon like his father in Maine, but on his second rotation in January 2006—pediatrics—he had his first experiences with children with behavioral problems. “Primary care physicians treat these patients a lot because there are so few child psychiatrists out there.” The pediatrician he worked with, who cared for a number of very disturbed children, “made it very clear he felt he could deal with these problems as best he could, but when he was out of his depth, he would turn to psychiatrists and the community mental health system.”


After Aslam’s next rotation—six weeks of inpatient and adolescent psychiatry—he began seriously considering the field of child psychiatry. “It was a well-rounded program, and I enjoyed learning the stories of [patients’] lives.” Plus, he found the psychopharmacology fascinating.


And even with the legacy of surgeons in his filial history, he says his family has been very supportive. “They see how much I want to do this and how invested I am. I am talking about it all the time.”


As for the dichotomy between medication management and therapy, Aslam wants to do both, but understands it will be a financial tradeoff. During his recent interview at SUNY Upstate Medical University, where he hopes to do his residency, he brought the issue up with the department chair. He came away with the realization that “I can get paid to do therapy, but not as much as only doing med checks. But I want to do what’s best for the whole patient. I want to combine both, so I can follow patients over time.” Whether that will prove a reality, he doesn’t yet know.


Is Aslam worried about the encroachment of non-physicians into the areas of therapy and pharmacology? Not at all, he says. “I see a lot of resentment among physicians about the involvement of mid-level practitioners, and them causing salaries to drop,
but I am fairly supportive.” There
are not nearly enough mental health practitioners out there, he believes. “Everywhere I’ve gone to interview, I’ve seen a huge shortage. I see kids having to wait six to eight weeks to get help at a community mental health center.”


He points out that “there are only about 7,000 child psychiatrists in the whole country. With so many foster children in the United States—so many moving stories of deprivation—there really is a need. All [students] want to feel like we are making a difference.”


Rustad, too, is concerned about patient needs going unmet. “The World Health Organization is forecasting that by 2020, depression will be the second-most frequent cause of disability and death in the world,” he notes. “It is important to recruit as many people as possible to go into mental health, especially psychiatry.”


To this end, he serves as a regional coordinator for PsychSIGN, the Psychiatry Student Interest Group Network, a new organization that works to foster the involvement, organization and implementation of student psychiatry interest groups at individual medical schools. The group functions as a central hub for the exchange of ideas, information and resources for student coalitions in psychiatry. It also promotes discussion of psychiatric education in the medical school community, and for advocacy and justice in mental health as an integral part of health overall.


The group meets annually alongside the APA’s national meeting, and also holds regional conferences and speaker series around the country with a goal to eliminate misconceptions and promote the positive aspects of the profession.


“I really don’t know why there aren’t more of us,” ponders Rustad. “I have found the training extremely fascinating. The field represents a wide range of opportunities—a lot of directions you can take your career. The future is wide open and poised for high growth. And there is a great deal of satisfaction involved in helping these patients.”


Aslam agrees: “To me, psychiatry [training] is the gold standard. I wouldn’t change my choice for anything. I feel prepared to jump right in and get involved right away.”
~RESOURCES

~~~Martha Frase-Blunt is editor of The New Physician.~Career Development,Medical Education,Practice of Medicine,Residency~
365~4May-June~2007-56~Reviews~Brushing Up on Basics~Systematic review for the USMLE and clinical years~Katherine Ellington~Crash courses~Students hitting the boards and the wards need systematic review texts and books offering compact clinical overviews. The Crash Course series from Mosby/Elsevier strives to be both.


Each of the 23 titles in the series offers an illustrative approach using diagrams, charts and tables to summarize key concepts. The concise format is not exhaustive, but conveys user-friendly basic-sciences material for first- and second-year medical students, and the series allows you to keep some of the most important basic-sciences topics within your immediate grasp. Overall, the books are a solid review of essential knowledge, replete as study guides or companions for more exhaustive texts.


Crash Course: Endocrine and Reproductive Systems (Mosby, $29.95) provides the fundamentals from embryonic development to endocrine organ structure and function, with each section covering the anatomy, microstructure, development and hormones of the gland. Later chapters cover the female and male reproductive systems.


Clear charts and diagrams are helpful study guides, and the review questions at the end of each chapter and online give ample opportunity to build on your expertise: “Describe jet lag from an endocrine point of view,” for example. While not exhaustive, the questions do prevent lethargy from the repetition required for competence. (Hint: Think about circadian rhythms and melatonin.)


The overlap and integration of different systems is glossed over by the text, but keeping it simple allows students to build from a sound foundation. The complexity in learning the endocrine and reproductive systems is easily compounded by emerging new concepts and breakthroughs in molecular biology and genetics. Newer findings, like the role of the hormone leptin, are introduced, but it would have been better also to include a section on adipose tissue as an endocrine gland. Still, this makes for a solid review text, especially if you need to strengthen your core understanding of the endocrine and reproductive systems.



Crash Course: Neurology (Mosby, $29.95) centers on the patient, with consideration of numerous neurological disorders. The first part of the book includes sections that describe disorders and disturbances most likely to challenge you in the clinical setting, such as headache, visual impairment, dizziness and vertigo. The content strategy for this book centers on epidemiological data for the prevalence of neurological conditions. History, examination and common investigations are covered in four chapters, which can be handy for clinical settings. Conditions like dementia, epilepsy, Parkinson’s disease, myelopathy and radiculopathy are approached with background information and management plans, but anatomy is sparse. This makes the book more of an introductory clinical guide than a basic-sciences review text. The absence of embryonic development or discussions on cellular structure and function, like axonal transport or excitable properties of neurons, will leave those looking for board-review material disappointed, and there are no review questions at the end of the sections.


Still, the diagrams and charts that are available sufficiently summarize the details, and the complexity does not seem overwhelming. This one may make a good pocket guide for clinical rotations.
~~~~Katherine Ellington, a second-year at St. George’s University School of Medicine, is currently working with the Program in Narrative Medicine at the Columbia University Medical Center in New York City.~Learning Tools and Technology,Medical Education~
407~9December~2007-56~Feature~Altruism or Tourism~Hidden Ethics of Overseas Electives~Avery Hurt~More and more medical students go abroad each year for rotations or other clinical experiences; a quarter of recent medical school grads have an overseas elective on their transcripts. These students no doubt learn important lessons about the wider world and the practice of medicine, but what do the patients get from the relationship? Plus: How to choose a mutually beneficial program. Also: Checking out better health systems.~
Call it the Albert Schweitzer syndrome. It affects the brightest and best—the most caring and compassionate of both present and future physicians. And it can have real health consequences.



According to data collected by the Association of American Medical Colleges, 27 percent of medical school graduates had some international experience during their four years of medical school. Twenty years ago, the number was closer to 6 percent. And the trend doesn’t seem to be letting up. Sangeetha Reddy, a second-year at the University of California, Los Angeles, School of Medicine, coordinates med students who want to work with LIGA International, a group of volunteer physicians and medical students who make monthly trips to clinics in Mexico to provide medical services and supplies. According to Reddy, this year she had places for 36 medical student volunteers—and twice as many applicants.


Médecins Sans Frontières’ receipt of the 1999 Nobel Peace Prize may have added a little cachet to global health care, as has publicity of work like Dr. Paul Farmer’s in Haiti and elsewhere. Literature such as John le Carré’s novel, The Constant Gardener, has fueled many a romantic notion. And even now, the image of Dr. Albert Schweitzer devoting himself to the patients in his African clinic is as powerful as ever. But when it comes down to it, the impulse to go overseas, to take one’s nascent skills and use them in some small way to make the world a better place can be seen simply as the impulse to practice medicine in its purest form.


Or it can be seen as a way to build an impressive résumé and a reputation as an international adventurer. Not everyone is Schweitzer at heart.


To be fair, students’ motivations seem most often to be genuine compassion, and the students who choose overseas rotations, or do volunteer work in their off-time, gain more than medical experience and exposure to foreign cultures. “Students come away [from international volunteer experiences] excited by the broadening of their views,” says
Mary Terrell White, director of the Division of Medical Humanities at Wright State University’s Boonshoft School of Medicine. Dr. Marc Kahn, professor of medicine and a dean at Tulane University School of Medicine, goes so far as to say that the experience is “life changing” for the students who participate. Much of the change, no doubt, is personal and immeasurable.


Newly inspired career choices, however, can be tracked. Child Family Health International (CFHI), an organization that provides volunteer opportunities in global health care to medical students, has begun surveying its former volunteers to see what kind of effect the experience has on them. This research is still in its early days, but so far 38 percent of volunteers have replied that working overseas with CFHI influenced their choice of medical specialty, presumably leading them into primary care, pediatrics, tropical medicine or another field that will allow them to work with underserved populations in developing nations.


When Bad Things Happen to Good Intentions


The experience is life changing for the students, but what about the communities and individuals they go to serve? Does visiting another country with the intent of sharing medical knowledge and services always do more good than harm for the intended beneficiaries? Not all experts are sure that it does. The ethics of this kind of medical altruism are anything but straightforward. In the “Personal Views” section of an April 2000 issue of the British Medical Journal, Drs. Rachel Bishop and James Litch, co-directors of the Kunde Hospital in Nepal, write:


It is inappropriate arrogance to assume that anything that a Western doctor has to offer his less developed neighbor is progress.… [Visiting Western physicians] frequently don’t understand local illness presentation, culture or language. They often offer inappropriate treatment because they think they “must give something.” The consultations are often one off, with little possibility for follow-up, and the local health providers are left to pick up the pieces with no record of the consultation. If an unregistered Nepali doctor on holiday in the United Kingdom offered general medical consultations in a shopping centre, there would be a public and professional outcry. The problem is extended when applied to nurses, paramedical staff and medical students.


This complaint is not an isolated one. And physicians on the ground in underserved areas aren’t the only ones who are concerned.


Rachel True, program director of CFHI, sees similar problems with students eager to volunteer in under-served communities on the other side of the planet. “We have a challenge in shaping students’ expectations,” says True. “Some students think they’ll go overseas and try out clinical skills they can’t use here in the United States,” she explains, “when more often they go as observers on a learning mission.”


The ethical problems that arise are not always the result of unrealistic expectations, however. When medical care of any kind is scarce, students are often asked to do things they aren’t qualified to do or aren’t comfortable doing, such as suturing wounds or delivering babies. As much as one wants to help, and believes that any care is better than none, students should never feel pressured to do things they aren’t comfortable and prepared to do, says White.


“Programs can actually be a burden on a community if they are not set up correctly,” she says. Dropping in for
a few weeks with humanitarian gestures might help a few, but the long-term effects are not so obvious. A visiting doctor cannot provide ongoing care, and those who are left behind after the volunteers have departed may have to deal with more problems than they had before “help” arrived. For example, local health workers may not know what drugs were given by the volunteers. Local health care providers may be using traditional treatments that are effective on their own but interfere with the medications given by visiting physicians.


More likely, though, problems arise when volunteers simply do not understand the cultural and political complexities of the areas they visit. In most cases, health problems in underserved areas, including those in the United States, are so complex that providing a few weeks of medication and consultation will be of relatively little benefit even if it causes no direct harm.


In a recent editorial in the New York Times, Uzodinma Iweala, an American novelist whose parents are from Nigeria and who spent his childhood in both Nigeria and the United States, criticizes the approach, if not the intent, of much American aid to Africa. “There is not an African, myself included, who does not appreciate the help of the wider world, but we do question whether aid is genuine or given in the spirit of affirming one’s cultural superiority,” Iweala writes. “Africans, real people though we may be, are used as props in the West’s fantasy of itself.” He goes on to explain that in our zeal to do good and to feel good about doing good, the West often ignores the work Africans themselves have done to fix their problems. The ethical complexities, many obvious, others subtle, of playing Schweitzer is enough to give the most dedicated do-gooder pause. And pause they should.


Getting It Right


Arrogance, cultural ignorance, and that American tendency to barge right in and “do something even if it is wrong” is not a reason to turn away from the world’s health crises. It is a reason to do it right. “The burgeoning interest in global health is very positive for heath care as a whole,” says White. Problems can be avoided, she says, by thorough preparation and a knowledge of your limits.


“I went on an [international health care] program as an undergraduate with the best intentions,” recalls Alexis Armenakis, a fourth-year at the University of California, San Francisco, School of Medicine, who is spending a year as the global health intern at CFHI. “I soon learned that it is more important to sit back and learn than to think that [the local people] will benefit from what you have to offer,” she says. For those still in the preclinical years, that is the best attitude. Being a sensitive, strong listener is essential, White says. Even though an area may be lacking health care services and technologies, they are not necessarily lacking knowledge and tradition. Listening to and learning from the locals can be as important as sharing the information and supplies that you have brought, she adds.


What students can actually do is very situation-specific. “Some students have had nursing experience, EMT experience, or some other kind of clinical experience at home,” White explains, “and they will obviously be able to do more.”


Reddy points out that in her first trip to the San Blas clinic in Mexico, she worked as a translator for some of the doctors who spoke little or no Spanish. Other students, further along in their training, were able to assist with surgeries. “Be sure that you go with a clear idea of what your limits are, [and] what you will and will not do,” says White.


Avoiding the more subtle ethical dilemmas is a bit trickier. But again, preparation is key. Gaining a better cultural perspective is one of the benefits of this kind of experience, says Tulane’s Kahn. White agrees, but stresses that you shouldn’t wait until you get there to start learning. She offers advice familiar to medical students: Do your homework. Most experts recommend spending at least six months studying the culture and politics of the area you are planning to visit. A year is even better. If you don’t already know the language, learn at least some, urges True.


It is also crucial to choose a good program (see “Checklist: Picking a Program,” p. 15). Flying in with a few skills, a box of medicines and flying out a few days or weeks later does little or no lasting good. A good program has close ties with the people in the communities they are serving and offers continuity of care. Even if many of the workers are there for only a short time, there are others who stay long-term, and local people are ultimately in charge. Building relationships with the communities CFHI serves is essential to the group. “We try very hard to be socially responsible and financially just,” says True. “We feel that it is important that the hosts be compensated for their time and effort [in teaching students].” In addition, when students take supplies, CFHI takes care to make sure the materials are necessary for that particular community. This kind of care is only possible when a program is based on a long-term relationship with the local community. For example, the LIGA program, of which UCLA is one of many partners, makes monthly weekend trips to three clinics in Mexico. The clinics are open only when the U.S. doctors are there. At worst, this sounds like medical tourism and, at best, like weekend warrior training missions for students who can’t afford the time for a longer program. On the ground, however, the program is well organized and staffed by a consistent group of doctors, says Reddy. They are able to give follow-up care to the patients they see, and local residents can come to one of the three clinics for ongoing treatment of chronic illnesses and elective surgeries, knowing that they will get continuity of care by physicians who know their medical history. Evaluating a program requires paying close attention to this kind of detail.


But perhaps the key to successful global health care is as much a matter of having the right attitude as having the right system. “When they go on these trips,” says White, “students are ambassadors of Western nations, Western medicine, Western people.” And, as such, there is much more than giving vaccinations that needs to be done.


“We can make an impact by not being so aggressive, by listening, forming relationships, being collaborative and humble,” says Armenakis. Being collaborative and
humble, in particular, are not traits that come easy to most physicians here in the United States. But it is essential that we develop these skills if our humanitarian impulses are to do more good than harm.


And we must get it right, because the ultimate ethical issue is our responsibility to the rest of the world, a responsibility White believes stems from our drain on their resources. “We owe these underserved nations something,” White says. “We must pay them back for what we’ve taken.” When viewed that way, humility quickly replaces arrogance.
~Checklist: Picking a Program

Here are a few things the experts agree should be on your list of things to ask about a program before signing up.



Not Always Underserved


While overseas rotations in underserved areas or developing nations raise serious ethical questions, it is important to note that not all international rotations are to places that need help. Many programs, such as the ones that Dr. Marc Kahn facilitates at Tulane University, often take students to places that arguably have health care superior to our own, such as Japan or France, to learn what other developed nations are doing. Before anyone can benefit from our health care expertise, we need to realize that we also have a lot to learn. The fact that the United States ranks among the lowest developed nations on many indicators of health, including life expectancy and infant mortality, should deflate our remaining arrogance and encourage us to reach out to nations that have a lot to teach us as well as countries that need help. —A.H.
~~~Avery Hurt is a freelance writer in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~~
356~3April~2007-56~Feature~Practicing to Practice~Medical simulation breathes life into physician training~Anthony C. Hall~Making a mistake during your first surgery at-bat could have unpleasant consequences for your patient—unless he happens to be made of rubber and microchips. Sophisticated medical simulators are having a major impact on how today’s physicians-in-training learn hands-on skills.~When Joshua Franczyk has to go to work, he often pretends he is sick. It is right there in his job description: “Pretend to be sick.” Gasp for breath; cry out in pain; call for a doctor; cough directly into the microphone.


Some days he suffers from appendicitis; some days it’s acute anemia. As a skilled patient–actor, he’s had assignments become even more exotic lately.


Around the country, trained medical actors like Franczyk verse themselves in the symptoms of leaking aortas. They show signs of developing avian flu. They complain about hot flashes and fainting spells. They feign aching joints, headaches, insomnia and shortness of breath—or maybe even mimic the subtleties of Gorlin syndrome or Kugelberg–Welander disease.


The third-year medical students attending to the “patient” with the raspy voice or the swollen knee are on videotape too, playing out the patient encounter at the University of Pittsburgh’s Peter M. Winter Institute for Simulation, Education and Research (WISER). Cameras whirl to capture the scene—the moments of indecision or screw ups, as well as the triumphs.


Franczyk is a bona fide simulation specialist: one part performer, six parts systems engineer and a former anesthesia technician. He joined the staff of WISER two years ago and has helped its SimMedical Department run 10,000 medical encounters with a variety of simulation techniques, including programmed mannequins. He often works with equipment—high-tech and low—to help professors create real-time scenarios for medical students in as accurate a setting as they can produce.


On the low-tech end, live actors, called “standardized human sim-
ulators” or standardized patients, help pace students through outpatient examinations. Suturing pads are used for practicing with
needle and thread.


On the other end of the tech spectrum, computers in a control room create an array of symptoms in highly sophisticated mannequins. From the control room, like the man behind the curtain in “The Wizard of Oz.” Franczyk will cough, wheeze, or say, “Ouch, that hurts!”


And, of course, in one of the distorted realities of this brave new world of medical education, part of his job entails keeping the mannequins “alive.”


In the forms of “SimMan,” “Stan D. Ardman,” “Noelle,” “SimBaby” and “Harvey,” medical mannequins have shot into the modern age with anatomical and physiological structures brought to life by electro-mechanical innards that push as far as technology and creativity allow. Such simulation began in 1960 with Resuci-Anne, the legend of CPR training, first introduced by Norwegian doll maker Asmund S. Laerdal and modeled after the late 19th century death mask of an unnamed drowning victim, known as “the girl from the River Seine.” Since then, mannequins in medical schools have been ailing on the job with increasing fervor and at a more rapid pace.


The modern medical simulation era began, some say, when Dr. David Gaba, now the associate dean for immersive and simulation-based learning, and professor of anesthesia at Stanford University School of Medicine, read Charles Perrow’s 1984 book about the Three Mile Island nuclear power plant disaster Normal Accidents: Living with High-Risk Technologies,” and thought, he said recently, “This is just like anesthesiology.”


Medical errors, Gaba felt, could be viewed as a case of systems breakdown, rather than individual error. Simulation was an opportunity to practice and perfect a team approach to medical education; one that could put failsafe mechanisms in place, with nurses, technicians and doctors all more aware of what the other was doing. A team, he reasoned, could reduce mistakes in hospitals.


In 1986, he put together what he called “a virtual pseudo-instrument,” which could produce blood pressure data without using real patients. In his second try, Gaba used “mostly off-the-shelf stuff” inside the shell of a mannequin. These efforts evolved into ever more sophisticated medical dummies, and ultimately he licensed the technology to CAE-Link, a division of the company that produced the original Link Trainer for aviation simulation.


The bar on simulation thus raised, mannequins began to proliferate. With the Institute of Medicine’s 2000 report, “To Err Is Human: Building a Safer Health System,” which chronicled medical accidents as one of the leading causes of preventable deaths in the United States (estimated at 44,000 to 98,000 per year), the race to create patients who refuse to die—mannequins, in other words—was on for real.


INTENSITY


At WISER, high-tech dolls, which can run as high as $200,000, are often addressed with the generic endearment, “Mr. Smith.” At Stanford—which has four simulation centers and a new one in the works—mannequins are named after Grateful Dead songs. Gaba is quite pleased that Johnny Goode, August West and the Doo-dah Man will suffer a variety of illnesses at the flip of a switch.


At the University of Michigan Health Systems (UMHS), Clinical Simulation Center director Pamela Andreatta says the mannequins are so real, “there’s a level of intensity that you would see in the same way that you would see in a clinic.”


Students anthropomorphize the mannequins, she says. “People try to comfort them.” She herself confesses that “when I’m doing a tour and the mannequins are out, I go over and stroke their heads.” In fact, one unsubstantiated report claims that a nursing student was so distraught when her mannequin died that she went to grief counseling.


Reality is one way to go. But the push for new training techniques extends beyond whole-body mannequins to “task-trainers” that allow students to practice a specific surgical skill, including laparoscopic procedures. At UMHS, students use “box trainers” that allow them to get the feel of handling endoscopic surgical equipment. Using an endo-stitch tool, for example, students can practice cutting up a sponge or, if they prefer, “removing the skin from a tangerine,” Andreatta says.


Simulation is getting wilder and weirder, too. With more innovators reaching to create training environments that imitate everything but the pain and the dying parts of medicine, the gloves are off. A handful of Cave Automatic Virtual Environment (CAVE) structures around the country now allow medical students to practice in a room with projections on three walls that put them into real-life scenarios. At UMHS, the CAVE has five walls, and participants wear goggles to create a 3-D effect.


Gaba, once happy with a computerized blood pressure cuff, now dreams of a “virtual hospital,” with medical students, nursing students and residents playing the professional parts and mannequins filling in as patients. Literally and virtually, the sky is the limit.


GRAND ILLUSIONS


Behind it all, however, is a central question: Can simulators replace traditional methods of hands-on teaching? “It wasn’t long ago, about 15 years ago, when, as a medical student, you were simply monitored by a more senior physician and, when [he or she] felt you were good enough to go, and you had put in the requisite number of hours, you were on your own,” says Mark Scerbo, co-director of Eastern Virginia Medical School’s National Center for Collaboration in Medical Modeling and Simulations, and professor of psychology at Old Dominion University, where he works with and tests simulators.


That follow-the-doctor-around approach, commonly called “see-one, do-one, teach-one,” is not going away overnight. Nevertheless, Scerbo says, “What the world of training in educational medicine will look like five years from now is going to be so totally different than it was 15 or 20 years ago, [yet] it is hard to believe that they haven’t been doing this all along. They will never go back to the old way again.”


There is a race to create more realistic, more believable simulation techniques—on computer, with live actors, with mannequins. But as the push for realism goes on, Scerbo worries that some of the simpler, more subtle skills might be skimmed over. One phlebotomy simulator that he evaluated missed the mark by asking students to apply a tourniquet by simply clicking the computer’s mouse. “So you never learned how to actually put a tourniquet on at the correct level of tension for a given patient,” he says. “Every simulation system that is out there, from the Cadillac down to the least expensive, is deficient in some degree of physical and functional fidelity,” he claims.


Clearly, success of the illusion is one thing; success of the procedural training is another. Scraping the tissue, carving the bone and tying the knots are certainly the first order of business in an operating room, but the planned procedure is generally not where mistakes are made. By watching a master surgeon, proficiency is enhanced, but when a serious emergency occurs, “the senior people take over and bump the junior people out of the way, which is great for the patient,” Gaba says. “But you aren’t learning how to make decisions. And how are you going to learn that if you never get to practice it?”


Practicing one procedure without losing a patient is a universally applauded idea. Practicing 50 times with the same idealistic results is better still. But practice isn’t just about perfection: “It allows the learning to come to a higher dimension,” says Andreatta.


Like tying shoes or driving a car, once the skills are in place, a person can perform complicated tasks without giving them much thought. In a car, for example, you learn by first concentrating on the ignition, the brakes and how the windshield wipers work, she says. Next you learn how to navigate. After a while, however, you can drive effortlessly, aware of your surroundings, but without much brainpower in play. You can, in time, drive around while writing a term paper in your head.


You can imagine, then, who shows up in CAVE scenarios at UMHS. Distraught family members can be seen screaming in the background when the door to the virtual operating room opens up. Three-dimensional images of technicians come and go. Announcements and sirens blare. The idea is to practice a technique so many times that even in the chaos of real urgency, the technique becomes automated, Andreatta says.


“Any time in a medical situation, there’s a lot to remember. One of the kinds of things we can do is automate as much of that response as we possibly can, so that when the physician or the nurse or the technician is in the field or in an applied environment of any context, it allows them to focus their cognitive resources and their energies toward the specifics of that scenario,” she says.


Administrators are happy to point to another forward leap in medical training that simulation provides: consistency. This breakthrough has had a ripple effect: The Food and Drug Administration now considers simulation training de rigueur for practicing carotid stent procedures, and the American Medical Association cites one study finding that simulation training results in six times fewer errors in laparoscopic cholecytectomies, and another finding 30 percent faster surgeries dissecting the gallbladder from the liver bed.


If that’s not convincing, how about a discount on physicians’ liability insurance? With simulation training among other points on a résumé, CRICO Risk Management Foundation, which insures Harvard medical affiliates, has knocked off 10 percent from obstetricians’ $61,130 annual insurance bill; anesthesiologists with simulation training are allowed a 5 percent discount. Other insurers are following suit.


No dead patients—check. Consistency, teamwork, decision making—check. Practice before you embarrass yourself in front of your patients—check. Funny names for your mannequins—check. The benefits are enormous and the potential perhaps larger than that. Ten years since it seriously took hold, the medical field has yet to spend $100 million on simulation-based training, Scerbo calculates, while the Federal Aviation Agency, he notes, spends $800 million per year on this type of training alone.


The aviation business has a saying: that the pilots are always the first ones to the scene of an accident—a sentiment appreciated by third-year Stanford medical student Dora Casteneda. “I take the training very seriously,” she says. “As a student, I don’t want my first experience with trauma to be a real-life trauma.”


She adds with conviction, “It’s great to practice practicing medicine, and nobody gets hurt.”
~~~~Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.~Learning Tools and Technology,Medical Education~
372~4May-June~2007-56~Feature~Rude Medicine~Are hazing, harassment and abuse an inevitable part of training?~Martha Frase-Blunt and Anthony C. Hall~Most medical students suffer varying levels of discomfort at the hands of their preceptors—from mild invectives to outright harassment—during the course of their education. Is this just the price of pursuing the noble profession, or a dangerous cultural holdover that affects the quality of patient care? And when does mistreatment cross the line into genuine abuse?~Bullying surgeons. Power-pimping attendings. Boorish residents. Medical students are warned at the outset that these characters are fact, not fiction, on the wards, and trainees need to grow thick skins. Bad-mannered behavior seems more accepted in the medical education community than in other forms of professional training, and hazing so ingrained that it has become part of the didactic experience. But is it really necessary to strip down student egos to create tough, capable physicians? To a point, yes, say both
students and their teachers.


PIMP CULTURE


Take the tradition of pimping, described in British medical literature as early as 1628. The rapid-fire questions posed by attendings to catch interns or students off-guard were termed “Puempfrage” in 1889 by German surgeon Dr. Walter Karl Koch, who loved to use the technique on his rounds in Heidelberg. Dr. Abraham Flexner, on his visit to Johns Hopkins University in 1916, wrote admiringly of rounding with the famed Dr. William Osler, who “riddles house officers with questions. Like a Gatling gun…. [S]tudents call it ‘pimping.’ Delightful.”


But today, the concept of pimping often carries connotations of a fearful and humiliating, if necessary, rite of passage for physicians-in-training. In his now-legendary 1989 tongue-in-cheek essay, “The Art of Pimping,” published in the Journal of the American Medical Association, Dr. Frederick L. Brancati wrote: “On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem…. Pimping welds the hierarchy of academics in place, so the edifice of medicine may be erected securely, generation upon generation. Of course, being hammered, wrought and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning.”


While “unpleasant” perhaps, pimping is typically harmless, and is recognized by students as an important element of pedagogy and of “the socialization process into the medical community,” according to researchers in the department of behavioral sciences at Northeastern Ohio Universities College of Medicine. Their interviews with a cohort of fourth-year medical students in 2005 revealed that students note the hierarchical nature of pimping, viewing it as a tool for attendings or residents to assess students’ levels of knowledge. Although some respondents experienced so-called “malignant pimping”—humiliation by incessant questioning or questions inappropriate to their level of training—students in the sample were overwhelmingly positive about the practice and its effectiveness as a teaching tool.


“In my experience, even the most brutal pimping experience was not unjust in the information that was being requested, only in the method of delivery,” says Victoria Wong, a fourth-year at the John A. Burns School of Medicine, University of Hawaii at Manoa. “As for the psychological effects of such sessions, I must say that they toughened my skin, and I have often been grateful for such character building because it comes in handy when dealing with patients who are bullies.”


Still, overbearing behaviors commonly cross over into the darker territory of belittlement and harassment, according to students responding anonymously to the Association of American Medical Colleges’ (AAMC) annual Graduation Questionnaire (GQ). The AAMC has been asking graduates about experiences of mistreatment for the past several years. In its 2006 GQ, more than two-thirds of respondents (68 percent) said they had been mistreated by hospital clinical faculty, and more than 70 percent by interns and residents. Only 36 percent reported these incidents to their schools, however. Those who kept quiet often did so because the incident “did not seem serious enough to report” (40.7 percent), they did not know what to do about it (20.9 percent) or they were afraid of reprisals (54.2 percent). See chart below.





Interestingly, the GQ has shown that far more students today are saying they have experienced mistreatment than just a few years ago: In 1998, only 31.8 percent said they had been mistreated by hospital clinical faculty, and only 33.5 by interns or residents.


So are incidents on the rise, or are today’s students just a more sensitive bunch?


Dr. Jordan Safirstein, an interventional cardiology fellow at Saint Vincent’s Medical Center in New York City and editor-in-chief of the online housestaff community www.StopPaging Me.com, thinks it’s the latter: Most medical students today “are cry babies,” he says. “For the most part—and I am speaking in massive generalities and from personal experience—most of them have never played team sports or been subjected to authoritative figures other than their parents. Whenever I’ve heard residents repetitively complaining about their superiors’ behavior, it was usually as much the fault of the complainant. Sometimes interns and juniors need to know that they are not doing things well or well enough. And not everyone delivers teaching in a hold-your-hand way.”


A SUCK-IT-UP STATE OF MIND


Undoubtedly for many medical students, enduring humiliation or mistreatment—from verbal insults to running menial personal errands for residents—is just the price of pursuing a demanding career. Whenever specific claims of superiors going over the line come up on student discussion forums and listservs, complainants are inevitably bombarded with exhortations to suck it up and stop whining. Didn’t they know what they were in for when they signed up for the exalted calling of medicine?


More general forum discussions of medical student abuse prompt plenty of dismissive comments as well, like these from the Student Doctor Network: “In no way are students the victims; they knew what they were getting into when they signed up”; and, “Perhaps [it is] because this is a job that an immature, wimpy little brat won’t be able to handle…. So, the hazing is sort of like a boot camp to prepare you for what is ahead.”


And this comment, from a teaching resident: “You only get harassed if you let yourself get harassed. Treat everyone in a forthright manner, look them in the eye, and be respectful without being obsequious and nobody is going to harass you.”


After four years of medical school, Wong’s perspective is this: “I believe it is a myth that medical students are belittled or mistreated by those who are teaching them. Certainly, having to ‘suck it up’ is a common part of a medical student’s education. In fact, it is a perpetual state of mind, rather than intermittent endurance of specific occurrences of injustice and annoyance. The obstacles of the medical student…have more to do with physician egos and scut work, rather than outright mistreatment. It is difficult to determine what behaviors of superiors are uncalled for.”


Certainly, defining what constitutes real abuse is challenging, since it deals in the gray areas of individual behaviors and perceptions. Both victims and tormentors may subscribe to the imprecise notion that “I know it when I see it.”


Determining if a student has been mistreated “is a very fuzzy line, because it’s in the eye of the beholder,” says Dr. Leslie Kahl, professor of medicine and associate dean of student affairs at Washington University School of Medicine in St. Louis (WUSL). Her office is in charge of handling incidents of student abuse, but she notes that she receives very few formal complaints. “Occasionally a student reports that a line has been crossed and we investigate, then get five other stories from five other people who were present.”


This is understandable, she says, because these incidents typically occur in a stressful, fast-moving setting. “Someone gets shoved, but to other observers, the person was just being moved out of the way.”


Although WUSL takes student mistreatment very seriously, publishing a detailed policy on its Web site defining medical student abuse and channels for reporting it, Kahl still encourages students to handle all but the most egregious incidents themselves before involving administrators. “We advise our students during orientation that often the best way to deal with it is [to talk to the offender] right at the time, making sure to deal with the facts and their own feelings, and not to attribute emotions or motivations to the person who offended them—not to pass judgment.”


This approach “almost always leads to immediate resolution,” she notes. But when students don’t feel comfortable dealing directly with the individual involved, “we tell them they can talk to that person’s supervisor, and so on up the line, all the way to me. We offer many pathways, since different situations require different responses. So we try to be flexible in our response.”


Consequently, her office rarely gets involved, she says. “They usually deal with their feelings by talking it out with their friends or resolving it directly with the transgressor or a superior.”


Kahl does acknowledge how shocking it can be for a student the first time he or she is sharply criticized or knocked aside during a procedure. “It may sound stereotypical, but the way [physicians] behave differs from rotation to rotation, which can be difficult for the novice student. He or she may have just come from pediatrics and into surgery where expectations and behaviors are different. As a senior clinician, I know this, but students can be caught off-guard.”


THE REAL DEAL


But for one medical student, an attending’s role-playing lesson in dealing with unpredictable psychiatric patients suddenly turned into a terrifying threat. “Basically, my attending…pulled a Bowie knife on me.” Another student, also speaking anonymously, says that when she politely and repeatedly declined her attending’s efforts to get her into a residency program he favored, he angrily spit on her.


As these and many other documented instances show, serious medical student abuse can and does occur, and educators agree it should not be tolerated.


The Liaison Committee on Medical Education, which accredits medical schools, leaves it to institutions themselves to establish standards of conduct “in the teacher–learner experience” and how infractions will be handled. However, the American Medical Women’s Association offers more specific guidance for members in a detailed position statement delineating examples of abuse. They include:



Mistreatment of students can become institutionalized, says Kahl, and occurs when a malignant training culture has been accepted for too long. Typically, “the more senior offenders are simply left alone” with no consequences, and the tradition marches on.


According to the American College of Physician Executives’ 2004 physician behavior survey, more than 95 percent of responding members said they encountered disruptive and even dangerous physician behaviors on a regular basis.


The operating room is where some of the worst offenders can be found, ruling military-style, and commonly acting on the assumption—sometimes accurately—that doing something wrong or too slow is not an option.


“In surgery, there’s a culture where a surgeon is in charge and that culture exists for a lot of reasons,” says Brian Hurley, a fourth-year at the University of Southern California Keck School of Medicine and vice president of the American Medical Student Association. “Sometimes surgeons will run their OR like a king would run a kingdom.”


One surgeon he worked with recently was generally “mild-mannered” through every facet of his demanding day—patient visits, student interactions, policy meetings. But when he stepped into the glare of an operating room, Mr. Hyde turned into Dr. Jekyll. “It was just a stream of negative; anything he saw that was wrong, he would be very vocal about,” Hurley says. “Feelings didn’t matter.”



THE PRICE OF ARROGANCE


So, what’s the big deal if a student’s or nurse’s feelings get bruised by a particular physician with a perpetually sour attitude?


“It is patient safety,” says Hedy Cohen, vice president of the Institute for Safe Medication Practices, a nonprofit organization that reviews and provides education on medication errors and adverse events for the health-care industry. A constantly prickly physician is less easily approached than a friendly one. And without open communication, patient safety is compromised.


“If you have a nurse or pharmacist or another physician who gets an order or sees something they want to discuss with [someone who] is consistently rude or doesn’t listen,” she points out, then he or she might attempt to bypass the physician, and errors occur. The argument for team-oriented medicine was never more clearly asserted than in the Institute of Medicine’s 1999 report, “To Err Is Human: Building a Safer Health System,” which listed medical accidents as one of the leading causes of preventable deaths in the United States, estimated at 44,000 to 98,000 per year.


Indeed, agrees Dr. Luis T. Sanchez, director of Physician Health Services for the Massachusetts Medical Society, what is the point of having qualified students, nurses, technicians and residents around if you intimidate them into not speaking freely? “We probably need to be often authoritative, but we should never be authoritarian,” he says.


Optimists about the future of medical education point to hopeful shifts toward teaching a team approach to care. Old-school docs, initiated by their own hazing rotations years ago, now have patients who research their illnesses on the Internet and are sometimes better informed than they are. Physicians are now on care teams that include “the nurse, the secretary, the janitor,” Sanchez jokes. “We have to get along with the parking attendants, the licensing boards, [and] managed-care people.” He adds, “From my point of view, equally important as learning about cardiac exams and how to treat a broken leg is to learn how to behave correctly when under stress.”


At the University of Southern California, for example, “teamwork is a big push,” Hurley says. In many classes, “students get together in teams instead of learning by lecture, so you’re taught in an integrated manner.” Still, “business schools are head and shoulders above medical schools” in teaching teamwork and leadership, adds Hurley, who also holds a business degree.


INTERVENTION


Pamela Rowland, director of the office of professional development at Dartmouth Medical School, has been rescuing doctors from themselves for almost 20 years. She might get a call from a licensing review board, an attorney, the American College of Physicians or a hospital administrator looking for help for a doctor who has lost it too many times. “I go into some difficult situations, where somebody is on their last chance. In other words, if I can’t turn it around, they’re in real trouble,” she says.


Rowland is part of a heightened response to behavioral issues in medicine that includes hotlines for medical students; coordinated responses from nurses to rise up and help, rather than combat the physician who acts out of line; and wellness programs for difficult doctors themselves.


The good news is that when physicians turn their intelligence, goal-setting and other inherent powers toward self-improvement, the results are almost always successful, she says. The bad news is that they usually won’t make the first appointment unless given a serious nudge.


And that nudge may be coming more readily: In April, the Joint Commission on Accreditation of Healthcare Organizations approved a new standard on physician behavior that will require hospitals to bring professionalism policies up to code, including what to do when someone crosses the line.


Kahl has found that there is a lot schools can do to protect the student– preceptor relationship. “One thing institutions can do is to specifically define the expectations teachers and learners have for each other.” Another is to have a method for identifying problem preceptors and then either weed them out or ensure they adapt their behaviors.


She recommends that schools “have an evaluation process that allows students to give feedback about specific individuals they had trouble with. Repeated citations of the same person will show a clear pattern, so that it should be possible for a course director to address the problem, or lay it at the feet of the department head.” The problem physician might then “get a talking-to, or undergo sensitivity training, or just no longer have students assigned to him or her.”


Kahl notes that while students want the process to be completely anonymous, faculty members don’t, and she doesn’t blame them. “The stakes are very high for the accused,” she says. But one school she knows of came up with a “very clever solution”: It started having students at the end of each rotation complete the portion of the AAMC’s GQ that deals with mistreatment. The data were collected over a period and then shared with faculty and section heads. “[Physicians] are a very data-driven group, so when they gathered [information] over time, they could identify the outliers; it wasn’t a matter of we-said-they-said.” And once everyone had the data in front of them, “the problems self-corrected very quickly.”


Still, for most medical students, offensive remarks or harsh criticism at the hands of rude residents or impatient physicians won’t be remediated by administrators, so the only comfort they can take comes from those who have been there before them: “The concept of ‘sucking it up’ while in training is a necessity in any field,” says Wong. “It just seems more prevalent in medical education because the learning curve is steeper, the expectations are higher and the learning is endless.”


Safirstein agrees: “Sometimes [in life] you have to work with people you don’t like, and you don’t have a choice about it. Put your head down, read your medicine, open your ears and close your mouth. The best way to shut someone up is know more than them.”
~~~~Martha Frase-Blunt is editor of The New Physician. Anthony C. Hall is a freelance writer in Dryden, New York. Direct comments about this article to tnp@amsa.org.~Ethics,Medical Education,Residency,Student Life and Well-Being~
383~6September~2007-56~Well-being~Walking the “Thin” Line~To gain control, I had to give it up~Brooks Brodrick~Starving for control~As I stare out the window of the Lincoln Town Car, I knead the rock in my hand hoping it will provide me with courage. Once again, fear rips through my body, not unlike six weeks earlier when this same car dropped me off at the Renfrew Center, a residential eating disorder treatment facility in Coconut Creek, Florida. But before, I was petrified of what Renfrew would be like, and I was embarrassed that I couldn’t recover from anorexia nervosa on my own.


Committing myself to a treatment facility was the hardest thing I have ever done and, conversely, the best thing I have ever done for myself. Even the act of admitting I had an eating disorder was easier because I erroneously believed that if I confessed to being anorexic, I could maintain control. What I failed to realize was I had lost control long ago. The eating disorder had taken over my life. It isolated me from my friends and family, it forced me to lie, and it jeopardized my future.


My anorexic behaviors began during my first year of medical school when I felt as if my life was spinning out of control. I could not memorize all the material that was being thrown at me. All those obsessive-compulsive study habits I had so meticulously perfected during my undergraduate years were not helping, but instead were hindering me. Inevitably, my evenings would end with me on the floor in tears surrounded by review books.


Consumed with studying, I opted out of social events. And embarrassed that I didn’t know more of the material, I refused to study with others, which resulted in feeling isolated and depressed. The only time I allotted for myself was the hour I spent at the gym, swearing not to gain the “freshman 15” like I did during my first year of college. Ultimately that one hour would evolve into two and then three hours, as exercise became my escape from my insecurities about becoming a skilled and compassionate physician.


I watched helplessly as my relationship fell apart, partially due to the stresses of two first-year medical students attempting to maintain a long-distance bond, and partially due to my inability to share my vulnerabilities.


Although I did survive the first year academically, I had lost 20 pounds, and I did not feel prepared to handle the additional pressures of the second year. Anorexia was my warning flare, signaling to others I needed assistance since I was ashamed and afraid to ask for it myself. When two of my classmates approached me with concern about my weight loss, I was relieved to finally have help, but I was not prepared for the battle I would face in the recovery process.


Thus began a four-year roller coaster ride in outpatient treatment with some of the best physicians, nutritionists and therapists. Their support enabled me to go back and complete my second year of medical school along with USMLE Step 1, but it was not enough to prevent me from relapsing. Renfrew was my last resort.


At Renfrew, I surrendered physical control of my world. My mornings began with a 5:30 wake-up call for weights and vitals. All meals were eaten as a group and were supervised to ensure they were completed.


Group therapy occupied the majority of the day, and attendance was taken at each session. Curling irons, nail files, scissors or anything that might be used to hurt oneself (an estimated half of those with eating disorders also self-harm) had to be checked out from the office. There were surprise room inspections for nonpermitted items, such as gum or anything containing alcohol—even hairspray or perfume. The one 8-ounce Styrofoam cup of coffee we were allowed after each meal was no replacement for my venti latte. I was miserable, but I refused to show how difficult it was for me.


It wasn’t until my third week I was at Renfrew that I finally broke down. And that was when the healing process really began. I began to realize that my treatment team was tremendously knowledgeable and highly proficient in helping people recover from eating disorders. With their guidance and support, I learned to surrender all control—only then could I rebuild my life on a stronger, more flexible foundation.


People often ask me if life at Renfrew was really like it was portrayed in the HBO documentary “Thin.” But I compare my experience more with “Indiana Jones and the Last Crusade.” I barely avoided being crushed by many boulders. I felt as if the ground beneath me was crumbling. I had to have faith that if I stepped off the ledge, a bridge would appear beneath my feet. Like Indy, I was in pursuit of the Holy Grail, except mine was not the fountain of youth; it was my recovery from anorexia. To get there, I had to ask for support from my friends and family, I had to face many of my fears, and I had to have faith that recovery was possible when at times it seemed as if there were far too many obstacles in my path.


Now, as I sit in the Town Car, a nervous excitement pulses through my veins. This is my opportunity to utilize the coping skills I had practiced and refined within the safe and nurturing environment of Renfrew. Now I have to do it on my own.


Before leaving, I had shared with the counselors my anxieties and concerns about what my fellow classmates and supervising physicians would think of me having been in a treatment facility. One simply replied, “If it were easy to recover, then places like Renfrew wouldn’t exist. Seeking help is not something you should be ashamed of; it is something you should be proud of.”


In the palm of my hand is a rock with two stick figures painted on it, and the word “connect.” It was a gift to me from my movement therapist during the “healing garden” ritual—a weekly custom in which each new arrival picks a rock from the basket, and departing patients hand off their own inspirational rocks.


My challenge now is to break down the fake façade I created to mask my insecurities, and to accept my imperfections along with my talents. To use my newfound voice, and not the anorexia, to ask for support.
~~~~Brooks Broderick is a fifth-year M.D./ Ph.D. candidate at the University of Virginia School of Medicine.~Student Life and Well-Being,Women in Medicine~
385~6September~2007-56~Feature~What Lies Ahead for Health Care?~Forecasting the biggest changes in medicine over the next decades~Martha J. Frase and Pete Thomson (editors)~Interviews with dozens of policy-makers and health leaders yielded a rich tapestry of opinion on what will be the biggest change to hit health care in the next 10 to 15 years. We share their various conclusions.~Download this article


For the past several months, The New Physician has been gathering comments from a wide swath of the medical community seeking an answer to the question, “What will be the greatest change in health care over the next 10 to 15 years?” The diversity of answers we received reflects the current state of health care—in constant flux, evolving rapidly and with plenty of problems that must be solved by the time today’s premeds finish up their residencies.


SEN. HILLARY RODHAM CLINTON (D-N.Y.)

2008 presidential candidate


“Advances in genetic testing will change the ability to predict illness, an advancement that will overwhelm our insurance system and place millions of individuals at risk for being denied coverage.


“At the same time, stem cell research, nanotechnology and other medical advances will lead to more effective treatments than we ever dreamed possible. These advances will not occur in isolation. In three decades, the number of Medicare beneficiaries will double. We will have to change how we finance health care in order to maximize the impact of our medical advances and meet the growing demand for health care without bankrupting our system. I believe the solution will be guaranteed, affordable health-care coverage for all.”


SUSAN F. WOOD

Research Professor, The George Washington University School of Public Health and Health Services, and former director of the Office of Women’s Health, Food and Drug Administration


“I hope that the regulation of pharmaceuticals moves along a path that strengthens both the use of the science and the decisions being made, with the priority on public health and benefiting patients. FDA is at a turning point now, and we have to turn it back toward a very strong and independent FDA. That’s going to take resources, competence and skill—and it’s going to take leadership. If we have all of those elements, we’ll have an agency that regulates the pharmaceutical industry fairly but rigorously...with the public as its first priority.


“There are many, many issues that FDA has to deal with right now, even limited to just pharmaceuticals. We have to be both creative and innovative in our thinking about drug safety, comparative benefit of products, and honest communication with both patients and physicians. We have to grapple with all of that and more. I hope we come out of this experience moving in that direction. But because there is a great deal at stake and a great number of players, I can’t predict. I’m either feeling optimistic or pessimistic at any given moment.”


DR. SIDNEY M. WOLFE

Director, Public Citizen’s Health Research Group


“The following uniquely American scenarios will force the necessary changes in our so-called health-care system: 45 million uninsured and at least another 55 million underinsured; about one-third of the population without adequate insurance; medical bankruptcy caused by inadequate health insurance being one of the most common causes of personal bankruptcy; and (support our troops) 1.8 million American veterans without health insurance or access to the VA health system. This is the only country with most care delivered by or through for-profit entities such as insurance companies, HMOs, nursing homes and dialysis centers, [with] annual excess administrative costs and waste of more than $350 billion a year because of multiple payers and a system that employs tens of thousands of people to specialize in denying care: non-health-care professional private-sector bureaucrats.


“Common to all presidential ‘plans’ to solve this problem is the retention of the major cause of the problem, the health insurance industry. A single-payer system eliminates these middle men and uses the freed-up funds to provide health care and, as articulated by the [U.S.] Labor Party, Just Health Care.”


BIOTECHNOLOGY



GREGOR F. BENNETT

President, American Academy of Physician Assistants


“I think that, in the next 15 to 20 years, the face of health care as we know it is going to change drastically. We are presently at the dawn of the Genomic Era, poised to enter a time when truly dramatic changes in the way we view health care will be unfolding at an exponential rate. We will soon begin to have understandings of diseases and of human response to disease states that will radically alter our approach from one of pure treatment of pathology to the prevention of life-altering events. As this evolves, we will undergo a paradigm shift in the economics of health that will place far more emphasis on stopping illnesses before they appear than on treating them after they do. I think that it is going to be the most exciting time in medicine since the advent of germ theory.”


PATIENT CARE



DR. RICK KELLERMAN

President, American Academy of Family Physicians


“If we look out 15 years from now, we have to consider the aging of baby boomers and what that’s going to mean to the health-care system in a number of ways. No. 1, they’ll have more chronic disease, which will put a tremendous burden on a health-care system that is already not functioning well. We have a very costly system that under-performs in terms of the quality it provides. We also have patients and physicians who are not happy. And we need to start asking ourselves the questions of how to realign health care to meet the needs of the American population in five, 10 and 15 years. That will probably be painful. It won’t be business as usual.


“For family physicians in particular, there is a new understanding of the role of primary care: providing prevention, management of chronic illness, cost-effective acute care, and end-of-life care. This new role of primary care has been called the patient-centered medical home, a concept where patients have a personal physician who provides coordination of and access to care using health information technology to better manage individual patient problems and also improve the overall quality of care patients receive.”



DR. RUTH L. KIRSCHSTEIN

Acting Director, National Center for Complementary and Alternative Medicine, National Institutes of Health


“Large numbers of American consumers are using complementary and alternative medicine (CAM) in an effort to pre-empt disease and disability or to promote health and a sense of well-being. Driven largely by this demand for CAM, integrative medicine is rapidly becoming a major force shaping health-care systems in the United States and around the world. [Our] mission
is to support rigorous research intended to fill the CAM knowledge gap,
and to disseminate information regarding CAM’s effectiveness and safety to the public and to health-care professionals.”


DR. BRIAN F. KEATON

Department of Emergency
Medicine, Summa Health System, Akron, Ohio, and President, American College of Emergency Physicians


“The future of health care in our country will be shaped by the competing forces of demand and capacity. Advances in pharmacology, technology and medical research, combined with the graying of the “baby boomers,” are creating demand for medical services that far outstrip our capacity to provide them.


“In many parts of the country, the tension is reaching crisis stage as evidenced by hospital closures, ambulance diversions, ER crowding and 45 million uninsured in a nation that spends over 16 percent of GDP on health care. As we look to the future, it is certain that the status quo is not an option. These trends are simply not sustainable. While there is no question that we will provide health care in the future, it is certain that the care we provide will look very different from the care we provide today. It is up to all of us to work to ensure that this transformation results in a system that is fair, equitable, efficient, patient-centered, evidence-based and available to all Americans.”


PUBLIC HEALTH



DR. GLORIA WILDERBRATHWAITE

President and CEO, Core Health


“We are soon to become a nation of the disabled and dependent. Progressive nations are marching into the 21st century resolved to define social justice in practical terms and to provide a fair opportunity for their citizens to live a well life without creating dependency on charity or good will. I do not believe our nation’s leaders have a genuine interest in health and wellness. The hope lies in the fact that most Americans still do; most of us dream of a well life and are willing for our neighbors to have the same. The promise lies in the new generation of health-care providers and leaders who are willing to make professional sacrifices to resuscitate a dying health-care system.


THOMAS J. VAN COVERDEN

President and CEO, National Association of Community
Health Centers


“Exciting things are happening in community health. The focus in health care has turned to primary care and prevention. The nation has come to recognize the value of a community health system that can expand access, reduce disparities, and generate savings in health and prevention.


“Community health centers are reaching out to millions of uninsured and medically underserved. Our programs in chronic disease management, prevention and culturally competent care are publicly cited as models of primary care practice. Moreover, enhanced partnership with the public/private sectors is spurring initiatives to address a multitude of problems from substance abuse to child obesity, hepatitis C and HIV/AIDS.


“For community health providers, the opportunities to improve the delivery of health care have never been greater. Yet, challenges remain, and foremost is the shortage of primary care physicians. Today, we are collaborating with medical schools, governments and communities to develop strategies that will ensure an adequate workforce into the future. We believe health centers will be successful. Community health is the future of our nation’s health.”


QUALITY



DR. JEFFREY SEGAL

Neurosurgeon and Founder and CEO, Medical Justice Services, Inc.


“I hope as a physician, a patient, a husband and father that the future of medicine will go beyond new medications and new treatments. Medicine will be transformed into a team sport where reimbursement will be based on what happens—outcomes—and not on what is done. Excellence will stand out and be rewarded. Further, if patient safety is ever to be taken seriously, those who identify system-wide problems will be rewarded and not punished, as they currently are. The biggest change to health care over the next 10 to 15 years will be physicians leading the way to true reform.”


DR. JAMES MANDELL

President and CEO, Children’s Hospital, Boston, and Chair, Conference of Boston Teaching Hospitals


“Many leaders of academic health-care systems believe that there will be significant changes in the next 10 to 15 years. Many [changes] will be the result of an enhanced ability to measure and report quality and outcomes in a more accurate and timely manner than ever before. Armed with information on outcomes, public and private payers will directly link payment with performance and place a greater emphasis on identifying and eliminating racial and ethnic disparities in health care. Other changes could include a mandated or standardized health coverage system where much of the care will be delivered in large, integrated primary care networks at the expense of small and independent group practices.”


JEANETTE LANCASTER

Dean, University of Virginia School of Nursing, and President, American Association of Colleges of Nursing


“Health-care providers today rely on advanced practice nurses for many front-line services, such as primary and preventive care, managing chronic conditions and teaching patients to navigate the health-care system. Mounting studies show that the quality of care provided by nurse practitioners and other specialists is equal to and at times better suited to the needs of patients and their families than comparable services provided by physicians. As we move toward increased doctoral preparation for nurses engaged in advanced practice, the primary care provided by nurses will promote further advances in patient safety and quality. This care brings the added benefit of being both high quality and cost-effective.”


WORKFORCE



DR. FITZHUGH MULLAN

Murdock Head Professor of Medicine and Health Policy, The George Washington University School of Public Health and Health Services


“The current pressure to open more medical schools will result in major new opportunities in medicine for many more young people than in the past. Medical education will remain expensive, but more “community service” options such as the National Health Service Corps will be funded by governments at the state and local levels. More government-mandated planning in types of training programs will result in less choice for students and residents but a far better balanced and more efficient medical workforce.


“One of the most important aspects of this may well be the training of adequate numbers of physicians for the service needs of the United States rather than the current situation where we train only three-quarters of the physicians we need in medical school and then import one-quarter more at the GME level. More self-sufficiency in medical training will in turn result in a diminished brain drain from developing countries. This will be a huge benefit to countries that desperately need stability in their workforce to deal with the
devastated condition of their health
sectors.”


DR. REGINA GAN-CARDEN

Chair, Women in Medicine Subcommittee, Maryland Chapter of American College of Physicians


“I think the biggest change in health care or medicine in the next decade and a half will be the increasing number of women physicians who are also the primary caretakers of their families, the need for health-care reform and flexible work options, and the loss of physicians going into or continuing in primary care due to burdensome practice regulations and increasing unpaid activities associated with patient care.”


DR. BEN GALPER

Immediate Past Chair, American Medical Association-Medical Student Section, and PGY-1, internal medicine, Columbia-Presbyterian Medical Center


“We need more physicians. The older portion of the population is growing. Every year we need more doctors to take care of them, particularly in underserved areas and lower socioeconomic classes. We need more primary care physicians, and we need to motivate people to go into primary care through funding measures like the National Health Service Corps. We need to entice more people from lower socioeconomic classes to become physicians through programs like Title 7 funding—which both AMSA and the AMA-MSS have worked for—to increase the number of physicians from lower socioeconomic classes and minority [groups]. It takes about 10 years to make a new doctor, so we have to start now, recruiting students in high school and college to go into medicine.”


EDUCATION AND TRAINING



DR. MICHAEL EHLERT

President, American Medical Student Association


“Health care is in a crisis in this country, and medical education has done little to prepare us for the future. My hope is that in the coming years, students will take on the leadership roles as practicing clinicians and be the instruments of change we so desperately need. There will come a tipping point where the medical–industrial complex can no longer squeeze doctors any more, and there will be a revolt for independence. The trend of lower wages, increased debt, growing uninsured rates and centralized control of services underscores the need for active leadership. AMSA provides these opportunities to grow and develop among our peers and strengthens that fiduciary culture toward our patients and our profession.”


DR. SIMON AHTARIDIS

President, Committee of Interns and Residents


“Over the next decade, resident physician training programs will be confronted by two challenges. [One] is finding an appropriate balance between the service and educational aspects of graduate medical education.


“With the exponential growth of medical information and constantly updated guidelines, the burden of education has grown considerably over the past few decades. To continue to produce highly trained, competent physicians able to fully implement the advances that new technologies give us, residency will need to focus more on streamlining and organizing the educational experience into something more rational than the current haphazard apprenticeship model.


“For this to happen, resident training will need to meet a second challenge: adequate funding. Over the past decade, graduate medical education funding has come under attack. Most of graduate medical education is funded by public programs such as Medicare, a program that has survived a number of cuts but faces more. Furthermore, hospitals are seeing diminishing revenue streams amid increased costs. The money that hospitals receive for graduate medical education makes a tempting source of revenue to fund services unrelated to graduate medical education.


“If improving the quality of our doctors is a priority, our elected officials should focus both on improving funding and holding hospitals accountable for graduate medical education dollars.”


DR. STEPHEN SHANNON

President and CEO, American Association of Colleges of Osteopathic Medicine


“In osteopathic medical education in the next 10 to 15 years, the influence and impact of our profession on the greater health-care needs of our country will become more evident than it has been in the past. I believe that some of the qualities that are part of osteopathic education will be increasingly recognized and sought after in allopathic medicine, and that there will be increasing integration of osteopathic medicine with allopathic medicine and the other health professions in our health-care system. In the next 15 years, colleges of osteopathic medicine will double the number of their graduates.


“One of the things we’re focusing on is trying to deal with the development of documentation regarding best practices in osteopathic medical education for everybody’s information, and to be cognizant of the public health needs that are out there.


“Given what is currently happening regarding research, graduate medical education and health-care system changes, there will be greater integration, and osteopathic and allopathic medicine, in many ways, will look more similar. Osteopathic medicine has a basic philosophy that includes patient-centered, holistic care. That philosophy is not exclusive to osteopathic medicine, but I think allopathic medicine has embraced it to a larger degree because of our influence. While we are a separate profession in some ways, with a separate medical education system in some aspects, we are all trying to do the same thing—train the best physicians for tomorrow’s health-care system.


“If you are a student today, getting ready to enter an osteopathic medical school, there is real opportunity to be part of a transition and a change that is very exciting. It is a very optimistic time, because there is almost an unlimited future there, assuming this country can ever figure out the health-care system under which we should be operating.”


DR. DARRELL KIRCH

President and CEO, Association of American Medical Colleges


“The way we’ve viewed the training of a physician, it’s been in discrete compartments. You finished your premed training, then moved into medical school, took a whole series of tests and received your M.D. degree. You then were off to separate residency specialty training, and when you finished that, you could become board certified. Once you were in practice, your education was essentially left to you. But the notion of being finished at any point during this process, I think, is proving to be fairly naïve. In fact, becoming a physician means developing increasing levels of mastery and specific competencies over a lifetime.


“The change I see happening is we are beginning to think about this continuum in a much more holistic way, and we are beginning to think about the assessment of competence in a different way. That means we all have to give up our concept of different organizations owning different parts of the continuum, and we need to take an approach of common shared accountability for the whole continuum.


“I’ve been very encouraged that there are active discussions going on at the national level about the ways in which we might do this, and I think it will be of great benefit to physicians and patients. Physicians will have the satisfaction of proving their real-world competence, as opposed to relying on abstract tests to do that. And I know it will be a benefit to patients, because what patients care most about is not what their doctor knows, but how their doctor applies what they know to them.”


FINANCING



DR. DAVID MELTZER

Associate Professor, Department of Medicine, Department of Economics and Harris School
of Public Policy Studies, University of Chicago


“The next 15 years may challenge many medical specialties and the organizations that organize them. At least two forces may drive this. First, the imperative for cost control in the United States seems likely to increase reliance on capitated —as opposed to fee-for-service—medicine. This will mean payment of physicians by salary rather than fee-for-service and greater incentives for health-care systems to pair highly paid specialists with lower-cost providers who can extend their work and ultimately drive down compensation. Second, federal budget pressures will drive down physician compensation, and the hardest hit will be highly paid specialties.”


DR. OLIVER FEIN

Associate Dean, Affiliations, and Professor, Clinical Medicine and Public Health, Weill Medical College of Cornell University


“We are, in the United States, approaching a critical fork in the road
of health-care delivery, and the most significant thing would be the achievement of a single-payer national health insurance program…. And I think there is a real possibility that we could do that. We have the resources and, really, the ability to do it. And that would be transformative in many respects, in terms of who has access to care and what indeed we can offer people in care.


“However, the other fork in the road is the possibility of returning to the pre-health-insurance era during which individuals were responsible for their own health insurance. This is kind of the way things were prior to the 1930s, and I think that could be a disaster for the health-care system, a system in which your wealth really shapes your access to health care.”


CYNTHIA A. BROWN

Director, Division of Advocacy and Health Policy, American College of Surgeons


“Health-care stakeholders are realizing that price controls do not constrain total health-care spending. New technology, complicated financial incentives for patients and providers, uneven resource distribution, increased specialization and other factors combine to create a health-care labyrinth rather than a health-care system. No one is happy with the result, and physicians are caught in the middle.


“Remarkably, all stakeholders seem to grasp the problem at once, and they are collaborating in unprecedented ways to develop a new model that focuses more on which services are purchased during an entire episode of care, rather than on what price is paid for individual services during a specific patient encounter. Expanded use of health information technology and new payment methods will make this possible. Those physicians and hospitals providing comprehensive, evidence-based, cost-effective care will succeed. But, physicians must be involved in the development and design of this new model, or patients will confront an entirely new set of problems.”


GLOBAL HEALTH



DR. PAUL ZEITZ

Co-founder and Executive Director, Global AIDS Alliance


“We are the first generation in human history that can practically achieve major progress toward realizing the vision of global health equity. We have the medical and development technologies as well as the information, communication and transportation technologies to actualize a new paradigm. Stakeholders around the world are galvanizing themselves in an unprecedented, focused mobilization of political will, resources and actions toward achieving the health-related Millennium Development Goals by the end of 2015. We can halt the spread of AIDS, TB and malaria. We can dramatically reduce the millions of preventable deaths and enslaving morbidity afflicting children and families. Victory in our time!”


DR. DOUGLAS HAMILTON

Epidemic Intelligence Service,
Centers for Disease Control and Prevention


“The change in medicine that will probably have the biggest impact on us is the growing globalization of health and public health. We’ve recently all seen the international impact of a single case of tuberculosis, where the patient traveled between several countries, and I think as air travel continues to get easier and borders easier to cross, we will be faced with public-health challenges created by the rapid movement of people around the world. If we’re not adequately prepared, that’s going to be a major problem.


“In terms of disease threats, the big kahuna that everyone is afraid of is the re-emergence of pan flu. In general, I don’t think people really are aware of the huge impact that pandemic influenza can have. If you just look at the 1918 pandemic, the estimates of the number of people that died worldwide are as high as 50 million. I also think there is a real potential problem with the re-emergence of some old diseases that are drug resistant. Drug resistance can result from inadequate treatment in many parts of the world, and the growing number of people who are immunocompromised—look at the rise ofTB and its relationship to HIV infection—and drug resistance can also be promoted by the overuse of antibiotics in things like animal feed and agriculture. All of these things have led to an environment that is providing us with more examples of drug resistance, which is another big threat.”


HEALTH INFORMATION



BRYON PICKARD

Director of Operations, Vanderbilt Medical Group, and President, American Health Information Management Association


“Empowering citizens to take greater control over their own physical and mental well-being must be a goal for the 21st century. Health care is a global commodity, and decisions to improve health and health care at a sustainable cost will require global solutions. Advances in health IT and managing health information offer a very credible approach to solving the future’s health-care challenges. Putting the right information in the hands of those who need it, when they need it and in the amount they want will be advantageous to both providers and consumers alike.”


DR. CHANTELLE PAYDARFAR

Family physician, Research Triangle, North Carolina


“I predict that many patients, including the elderly and those who suffer from chronic illnesses will begin to solve a lot of their own health problems or be less dependent on their doctors for a number of reasons, including advanced technology such as the Internet, better education about diet and lifestyle, and self-made attempts to lower individual health-care expenses.”
~~~~~Advocacy,Health Policy,Medical Education,Practice of Medicine,Universal Health Care~
386~6September~2007-56~Feature~The Future of the Future Physician~Medical students look for innovations both simple and space-age~Martha J. Frase and Pete Thomson (editors)~Students also weighed in on what they think their practice world will look like in the next decade and beyond. Most see positive, even extraordinary developments, but others fear that current dilemmas—the influence of Big Pharm, health inequities, the strain on certain specialties—will persist, or degrade further.~In speculating about the health-care world where they will practice in 10 to 15 years, students and residents anticipate wide-ranging change. And being a characteristically optimistic bunch, most predict improvements on our current system, from better experiences of health equity to the ability to cure disease through nanotechnology. But a few see little hope for untangling today’s complex problems. Still, it’s clear that today’s learners are looking forward with expectation—and a little awe.


“In the future of medicine, the challenge will not be discovery of therapies, but the delivery and access of therapies to everyone. It will not be about innovations, but about equity.”

JOUBIN AFSHAR

premed, American River College




“We will see a significant drop of incidence in diabetes, heart disease, cancer and obesity due to the widespread implementation of health promotion initiatives. Medical schools will lead by example with health standards and objectives for students that promote stress management and proper diet and exercise that future physicians will continue throughout their lives.”

ROBERT JAMES CROMLEY

premed, Ohio State University




“With the onset of the baby boomer generation quickly stepping into retirement, there will be a growing need for geriatric care and the pharmaceuticals to support it.”

ALISON ZACHRY

second-year, St. George’s University School of Medicine




“The physician of the future will have to traverse a balance between Western medicine, Shamanic medicine, mind– body medicine, Eastern medicine and quantum medicine. Cross-cultural ideas of medicine will merge, yielding unique treatment modalities and novel ways of perceiving a patient’s physical-psycho-spiritual state and how it fits into the larger health of the global community.”

CHRIS HOLDER

fifth-year, Bastyr University




“The United States will have a centralized electronic record system that vastly improves the efficiency of our system and the management of patients who are seen in multiple settings.”

JULIA SKAPIK

fourth-year, Johns Hopkins University School of Medicine




“The biggest change we’ll see…is a fundamental rethinking of what it means to be a physician. Care is increasingly delivered in teams and by allied providers. The physician can’t continue to be the one guy who knows everything; we’re going to have to learn to be managers and coordinators of our patients’ care teams.”

ALIK WIDGE

third-year, University of Pittsburgh School of Medicine




“[Cures] for medical mysteries and newfound diagnoses never thought of will come to pass. [We’ll gain] a whole new insight about the biology/immunology of the body and how foreign bodies attack our system as a whole, and how they will and can be counteracted through the ideas of new and upcoming creative minds of medicine.”

ANDREA JENKINS

premed, University of New Mexico




“We will work in a world even more saturated with me-too drugs and pharmaceutical-created medical conditions.... We will probably have drugs for things like ‘happiness disorder’ and ‘pre-pre-pre-PMS syndrome,’ while the majority of those in the world with malaria and HIV/AIDS will continue to be without medicines for their conditions.”

ANTHONY FLEG

fourth-year, UNC at Chapel Hill School of Medicine




“With interventional radiologists running wires into the brain, I wonder how viable neurosurgery is going to be in 15 years. With nurse practitioners and pharmacists pushing for more and more rights, I don’t think I have to wonder what’s going to happen to GPs in 15 years.”

JARED G. DOVERS

first-year, University of Alabama School of Medicine




“Electronic medical records combined with epidemiological and geographic database analysis have the potential to revolutionize the way we practice medicine in the near future. Imagine watching an influenza outbreak in real time as each patient that presents at a hospital or doctor’s office has their case (anonymously, of course) uploaded to the national database.”

CHRISTOPHER GRIGGS

third-year, Emory University
School of Medicine




“Hopefully, the biggest change will be a national electronic patient health record and data system along with a national insurance system that covers everyone and makes huge improvements in the access to and quality of health care available in the United States. If we’re lucky, this will be accompanied by incentives to make primary and preventive care available to all by putting a more appropriate value on this type of health care and slightly less emphasis on heroic measures and high-tech.”

CINTHIA ELKINS

M.D./Ph.D. candidate,
University of Illinois College of Medicine at Urbana-Champaign




“I envision a healthy universal health-care system promoting [and] empowering patient–physician teamwork, prevention, integrative medicine, cultural awareness and compassion.”

ILANA SEIDEL

second-year, University of Pittsburgh School of Medicine




“I expect…an even greater emphasis on research in medicine. In light of the emergence of new diseases and metamorphosis of existing ones, research in all fields will become more relevant to the practice of medicine.”

GRIGORY OSTROVSKIY

first-year, Weill Cornell Medical College in Qatar




“The most significant change will be technological, in the form of outsourcing patient genomic data to private enterprise producing genome-specific remedies from the gene patents they hold.”

JASON HIGGINS

post-baccalaureate premed,
San Francisco State University




“Two words: translational research. The cutting-edge medical technology and scientific tools bequeathed by the current generation will allow a flourishing of novel insights by emerging physician-scientists, eventually leading to cures for diseases previously considered untreatable”

JOHN GILBERT

first-year, Yale University
School of Medicine




“I believe that within the next 10 years, the United States will finally have universal health care that provides a basic level of care to each and every American. If not, I may be living in Europe in 10 years.”

JULIANA “JEWEL” KLING

third-year, University of Arizona College of Medicine




“I hope that physicians will begin to integrate complementary therapies like acupuncture and homeopathy into their practices to better treat chronic diseases.”

JULIE NUSBAUM

first-year, Mount Sinai
School of Medicine




“The next decade will see the rise of individualized medicine, where a patient’s treatment will be tailored to his or her genetic makeup. The use of faster and more affordable genetic profiling methods will allow physicians to “divine” an individual’s response to available interventions and design the course of therapy most effective for that patient.”

MY-LINH NGUYEN

first-year, Harvard Medical School




“The battle between individual freedom and public health will continue as the government issues ration coupons for fats and sugars as a means of controlling the obesity epidemic.”

DR. KURT MICELI

PGY-5, University of Virginia
Health System




“I am strongly considering a cash practice because I do not want to deal with the red tape and paperwork of insurance companies. However, I don’t want to limit my practice to only those who can afford it, so I may have a sliding payment scale and will consider taking a certain percentage of Medicare and Medicaid patients. I plan to use a significant amount of osteopathic manipulation in the family practice setting, which I think will cut down on other office procedures and their associated costs. If many of my colleagues are thinking along these same lines, then I predict that private health insurance usage will decrease, and hopefully the funds will be redirected toward reasonable federal health insurance coverage, but I’m not holding my breath.”

MARTHA GILMAN

third-year, University of New England College of Osteopathic Medicine




“I see medicine as an integrated field where people will have informed choices of different systems of medicine, and physicians will rise above their selfish interests and strive toward one common goal: health and wellness of the community they serve.”

DR. NAINI KOHLI

Advance standing student,
University of Bridgeport College of Naturopathic Medicine




“The prejudice toward mental health care in America will continue to lessen—a good thing for our patients with mental illness, but worrisome as well. As more people seek mental health services, without more psychiatrists being trained, people will turn to other sources for their mental health care resulting in unpredictable and likely poor outcomes.”

DR. PAUL O’LEARY

PGY-3, Department of Psychiatry, University of Alabama at
Birmingham




“The greatest thing will be the discovery of a vaccine for AIDS.”

MOZHGAN SEPEHRIMANESH

Mazandaran University of
Medical Sciences, Sari, Iran




“Psychiatry is a field that’s often forgotten or looked down upon, as was highlighted in The New Physician’s April 2007 issue. I believe psychiatrists as well as drug companies will be less focused on medication and more focused on holistic, behavioral and spiritual approaches. There is room for healing on a higher level than medicine, and I anticipate this transformation in the future.”

NATOSHA D. SMITH

third-year, St. George’s University School of Medicine




“The health-care system in the United States will be one centered on disease prevention, global health and perhaps even universal health care. Whether we like it or not, our health-care system is so intertwined with the topics of concern today—environmental policy, infectious disease, the global economy and health—that we will be forced to change current policy either before we self-destruct or in response to a medical/public health disaster.”

PRIYA JOSHI

fourth-year, Chicago Medical School




“The future of medicine will be a highly controlled environment dictated by profit-oriented bureaucracy in which physicians can no longer practice medicine in the true sense of the meaning, but rather are left only to follow protocols set forth by researchers of conglomerates with strong political lobbying power.”

RARES ION COCIOBA

third-year, New York College of Osteopathic Medicine




“Going on the current trend, I forsee a shortage of committed minority doctors simply because of the greater compounding obstacles of socioeconomic disparities in this country’s educational system.”

PHILIPPE FABRE

Ross University
School of Medicine




“There will be a tremendous increase in medical tourism. Rising insurance costs will drive patients to Asian countries for expensive surgical procedures. And as a prospective surgical resident, I find it very disturbing.”

RAHUL GLADWIN

second-year, University of Health Sciences, Antigua, West Indies




“I think the most significant change in medicine will be the employment of nanotechnology. Also, I believe more patients will want to know their individual risk factors for a disease based on their genes.”

RACHEL E. GENGLER

premed, University of South Dakota




“Paper medical charts will have their own exhibition in a museum.”

SALINA LAI

first-year, Sophie Davis
School of Biomedical Education/
CUNY Medical School




“It is not a question of will be or may be. The most significant change in health care has to be achieving universal access to quality, affordable and evidence-based health care.”

ROHAN RADHAKRISHNA

third-year, University of California, San Francisco/Berkeley
Joint Medical Program




“Progress is being made slowly, but I see medicine becoming more open to discussions of problems unique to disenfranchised populations—in terms of both patients and providers—particularly lesbian, gay, bisexual and transgendered individuals and individuals living with disabilities.”

SCOTT NASS

third-year, David Geffen School of Medicine at UCLA




“The health-care environment is dynamic and has already reformed significantly. The future medical school curriculum will realize this and educate students on other vital perspectives in medicine including managing a business; law and medicine; handling debt; medical economics; prevention; the public’s health on a local, national and international level; and how to be a patient advocate.”

SAYONE THIHALOLIPAVAN

fourth-year, New York University School of Medicine




“I think the most
significant and clearly necessary change in health care will be the transition to a single-payer, nationalized health-care plan. Otherwise, the cost of health insurance to corporations will simply be too great to be competitive in a global economy.”

DR. SHIRLEY LIU

PGY-4, California Pacific
Medical Center




“By 2020, medicine will add to its regimen biologic therapies such as stem cells and nanotherapeutics, especially for the treatment of cancer. We will also be using the data from the Human Genome Project to develop and effectively deliver treatment specific to populations.”

STEVE KUPERBERG

third-year, Ross University School of Medicine


~~~~~Advocacy,Career Development,Health Policy,Medical Education,Practice of Medicine,Universal Health Care~
387~6September~2007-56~Feature~Ectopic Brain~How PDAs are changing the clinic and classroom~Avery Hurt~The now-ubiquitous PDA puts an entire medical education—updated almost daily—in the palm of your hand. How are these portable-knowledge-machines changing the way medicine is taught in the classroom and delivered at the bedside? Also: The winning entry in our “What’s in Your White Coat Pocket” Photo Essay Contest~When Star Trek’s Dr. “Bones” McCoy was faced with a sick crew member or the occasional ailing alien, he waved a small handheld diagnostic device over the patient. His gadget looked eerily like today’s PDA (Personal Digital Assistant) without the weird sci-fi beeps and whistles. When McCoy brandished his magical tool, he was likely to get instant answers, and often a cure.


PDAs aren’t that good—yet. But for the thousands of physicians and medical students who’ve come to rely on them, these devices do make the practice of medicine more efficient. Still, they are not without their downsides. And according to some, their niche in the medical world may be a temporary one.


In today’s technology-saturated society, where grade-schoolers have cell phones and “BlackBerry thumb” is a recognized ailment, it is not surprising that more physicians are getting jacked in every day. According to a 2006 study in the Journal of General Internal Medicine, 50 percent of practicing physicians, and between 60 percent and 70 percent of medical students, use PDAs—defined by the researchers as any pocket-sized handheld computer that typically combines information storage, computing and communications technologies—on a regular basis.


An increasing number of medical schools are requiring students to use PDAs, offering technical support—and sometimes financial support—to facilitate their use. Other schools that do not require PDAs strongly encourage students to buy the portable devices, and learners come to depend on them, especially in the clinical years.


In 2002, Ohio State University School of Medicine (OSU) was one of the first to require PDAs, and now provides all medical students with free Palm handhelds beginning in the third year. [See “The Basics,” p. 36.] Incoming residents are given the units as well.


According to Dr. Andrew Thomas, assistant dean for graduate medical education at OSU, “Students are generally embracing this technology; residents, less so.”


This may be simply a matter of age and habit, says Allan Platt, senior associate professor of family medicine at Emory University School of Medicine and author of Evidence-based Medicine: Using Personal Digital Assistants, due out this fall from Bartlett and Jones. “In our program we have a diverse age range,” he says. “The younger people seem very comfortable with technology; it is second nature to them. The older students have more trouble.”


But today’s PDAs, which combine many of the functions of a laptop computer, cell phone and personal secretary, can be useful enough to make even old dogs learn some new tricks. After all, there has to be some reason half of all practicing physicians—a number that necessarily includes many who trained in the days when computers stayed obediently on desktops—are carrying around a pocket device McCoy might have envied.


Library in a Box


If you aren’t already using a PDA, you may wonder what all the fuss is about. And if you are still walking around with a pocket stuffed to the seams with little plastic reference cards, you’ll soon know.


Among other things, a PDA is a library in a box.
A variety of medical reference programs, such as Epocrates (pharmaceutical and disease databases, updated regularly), the Merck Manual and many electronic textbooks, are available for PDAs. Programs like MedMath and MedCalc make chores like calculating dosages and determining due dates for OB patients quick, easy and less error-prone. A PDA that can also access the Internet (and most can) puts virtually limitless resources in the pocket of your white coat.


“If I see a patient who has a list of 15 meds he is taking, I can do an immediate check for interactions,” says Denise Taylor, a third-year physician assistant student at Emory. “Being able to immediately look things up cuts down on mistakes, especially in dosages of medicines.” She adds that PDAs also provide a quick and handy way to keep logs of patients seen, tests ordered and so on.


Dr. Brad Crotty, a recent graduate of Harvard Medical School currently interning in general medicine at Beth Israel Deaconess Medical Center in Boston, prefers to use a Palm Treo, a PDA that combines cell phone and
e-mail functions alongside typical medical programs. “The best feature of my Palm phone,” says Crotty, “is the calendar, which beeps to remind me of appointments and keeps logs of the hours I’ve worked and procedures I’ve done. It’s more of a personal secretary in a busy world.”


Thomas at OSU agrees that many of the most popular features aren’t necessarily medical. “Everyone appreciates the calendar,” he says. As cell phones get more sophisticated—the new iPhone, for example—there are lots of ways to integrate information and use the new technologies coming out, he adds.


PDAs are invaluable in the clinical setting, but they have their uses in the preclinical years as well. “Continuing Medical Education articles come in every time you synchronize your PDA,” says Taylor. If you have your PDA in your pocket, you can read them in your spare time.”


Platt uses PDAs in the classroom in several ways. “One of the beauties of the Epocrates program is the differential diagnosis generator. It’s great for new students who haven’t had time to memorize much yet.”


In one of his courses, students feign particular diseases that they have thoroughly researched, while others try to make a diagnosis. After taking a history, the students who are diagnosing take what Platt calls a “beeper break.” They get to say, “Oh, that’s my beeper; excuse me, I have to take this call,” step out into the hall and look things up on their PDAs. “The students have a blast with this,” he says.


Another advantage of the PDA for study and classroom use is that it offers immediate feedback. That’s especially helpful when using self-study programs, many of which offer quizzes and learning games to help with basic sciences courses such as anatomy and physiology, as well as prepare for boards.


Stanford Medical School pioneered the classroom use of PDAs. Its entire curriculum is downloadable from the Internet to the PDA, including streaming video of lectures. This capability allows students to keep up with and review course work any place, any time—as long as they have their PDAs handy and enough charge in the battery.


Brain Strain


Throw in a digital camera and an MP3 player (available as add-ons to the fancier models) and what’s not to love? A lot, actually. Even those who have no serious criticism of the units are quick to point out their limitations. Nathan Morrell, a fourth-year at Stanford, got his PDA as a first-year, but says he is still getting used to it. Though he finds it helpful for getting drug information and logging patient data, many of its capabilities are wasted on Morrell. “Time is always an issue,” he says. “No one shows me how to use the programs; I have to figure them out for myself, and I can’t spend much time on it. I tend to use only the ones that are self-explanatory.”


The most common complaint, however, is screen size. “The old television ad where someone holds up a Palm Pilot with a CAT scan on it is unrealistic,” says Thomas. “You can’t see that much detail.”


Scott Clarke, a student just beginning clinical rotations in the physician assistant program at Emory, agrees. “The reality,” he says, “is that PDAs do a lot, but are limited by their screen size. I have lots of small reference books that I still carry around. I am a techno-junkie, but I love to read. It’s sort of a love/hate relationship.”


Some students, as well as teachers, wonder if relying on a pocket computer, no matter what the screen size, will make them lazy, less inclined to use their intuition and dependent on the information available in their pockets. Of course, as Taylor points out, being able to keep up with evidence-based medicine is one of the advantages to using PDAs, yet she believes that some caution is necessary. “Instinct in medicine is extremely important,” she says. “You have to listen to your gut.” Still, she advises, “Check out anything your gut tells you”—an operation that can be done, in part, on your PDA.


For some, the only complaint is when PDAs don’t work. Dr. Zack Berger, a first-year resident in primary care at NYU Bellevue Hospital, had recently suffered the catastrophe of a dead battery in his PDA. “I’m suffering from withdrawal,” he says.


Future of Pocket Medicine


This year’s indispensable gadget is next year’s recycling problem; information technology is fickle, and in medicine it will surely evolve beyond handhelds. Crotty sees PDAs as more transition than revolution. “The hopes for medicine switching to [PDAs], and everyone having [one] to sync information to each other are fading,” he notes. “Personal computers are being installed at every hospital desk, and even on roller carts for rounds. PCs are more powerful for researching information, tracking patients and entering orders. Likely, a small version of a tablet PC will come out that will allow quick data entry and quick information retrieval, but is that a PC or a PDA? It’s probably a PC.”


Even leading-edge OSU knew that the romance wouldn’t necessarily last forever. “We didn’t do this to solve all our problems,” says Thomas. “We already had in place a digitized ordering system for labs, etc. [when we started using PDAs]. Now we have 200 rolling laptops around the hospital.” With laptops getting cheaper, smaller and more ubiquitous in hospitals, they may reduce the need for handheld computers. “PDAs just don’t cut the mustard in many ways—mainly screen size,” says Thomas.


Taylor, however, thinks that any reports of their imminent demise are very premature. “PDAs won’t be replaced by laptops on carts or at stations. PDAs fit in your coat pocket, go wherever you go, and can be personalized with the programs you like to use and information you frequently need,” she points out. And until we get our hands on whatever McCoy was using, they’ll just have to do.


~THE BASICS


Schools requiring PDAs will either provide one for you or give you the specs you need to choose one yourself. But if you are out there on your own, deciding which device to buy can seem more challenging than organic chemistry. First, a little terminology: PDA is a (very) generic term. The two platforms that support medical programs are the Palm Operating System (OS) and the Pocket PC (Windows). It is generally agreed that Palm has fewer technical problems and much more available software. At this point, Palm is ahead of Windows by 7 to 1, according to Allan Platt at Emory University School of Medicine. Windows Pocket PCs have, at least according to some, more memory, better graphics and better processing speed, but lose out when it comes to battery life.


Find out if your school recommends a format, or offers technical support for one platform rather than the other. If that is not a factor, decide which format you are more comfortable using. Then take a look at the available programs, decide which ones you think you’ll need and make sure the device you choose runs those programs. Online sites can be very helpful when making these decisions. For products geared toward medical use, go to www.cent.com for product comparisons and reviews, www.handango.com for software, and www.pdamd.com for a little
of both.
~~~Avery Hurt is a freelance writer in Birmingham, Alabama.~Learning Tools and Technology,Medical Education,Practice of Medicine,Residency~
390~7October~2007-56~Feature~Dr. Executive~Taking the Healing Arts from Bedside to Boardroom~Avery Hurt~Choosing to combine your medical and business skills to become a physician executive doesn’t mean giving up your aspirations to help patients and cure disease—it allows you to do so on the largest scale.~Define the following terms: Decarboxylase. Macrophagic myofascitis. Radiculopathy. Arteriole.


Good. Now try these: Amortization. Floating rate. Uncertainty analysis. Vertical market. Impaired capital.


Not medical terms? Don’t be so sure. You already know English, and are pretty fluent in medical nomenclature, but it may be useful to learn one other language before you graduate: business-speak.


If your image of a physician is someone in a white coat moving resolutely from exam room to exam room, listening to patients, ordering tests and making clinical decisions, you have only part of the picture. In today’s health-care world, many physicians wear power suits (without stethoscopes), attend lots of meetings and rarely, if ever, see patients.


At the root of most students’ reasons for choosing medicine is the desire to help people—to cure disease, to relieve pain, to prolong healthy lives. At first pass, it may seem that a “desk job” might not fill that need. But there is more than one way to ease suffering and promote wellness: “The chief appeal [of an executive career] is one of scope,” says Brian Hurley, a 2008 M.D./M.B.A. candidate at the University of Southern California’s Keck School of Medicine and Marshall School of Business. “As a physician in an exam room, you see one patient at a time. As a physician executive, you can influence hundreds to thousands of patients with a single project.”


Mergers


The role of physician executive now goes well beyond managing a practice or overseeing housestaff, having become a specialty of sorts in itself. Once, doctors took care of the clinical work and “suits” saw to management—an arrangement that made sense in simpler times. But as health care has grown more complex, the line has blurred. Physicians who think they can practice without concerning themselves with administration are quickly disabused of that notion when they find that a patient’s insurance won’t pay for the medicine that’s best for his or her condition, or when a new diagnostic technology that would save lives is too expensive, or when the amount of time they spend with each patient is regulated by nonphysicians for reasons completely unrelated to the interests of the patient.


Things aren’t any more straightforward in health care’s corporate and public-sector offices, where insurance executives try to learn the nuances of medical procedures in order to decide which to cover, pharmaceutical administrators struggle to evaluate the merits of a clinical trial protocol and policy-makers mull over conflicting evidence about mandatory vaccines.


Clearly, there are many jobs in today’s health-care industry for which the ideal candidate has both medical and management expertise. “A physician’s primary concern is, and should be, getting needed medical services for their patients, says Dr. Maria Chandler, faculty adviser for the M.D./M.B.A. program at the University of California, Irvine. “But physicians have been accused of not understanding the financial necessities of health care.”


For example, Chandler says, in a hospital budget meeting, a physician might be quick to insist that “we can’t cut that program; it saves lives,” but be unable to suggest ways to pay for the program. A better understanding of the financial realities of medicine would help in situations like this.


And on the other side of the boardroom table are administrative officers who have to tell M.D.s that they must do without a valuable diagnostic tool or preventive medicine program because it is too costly or will divert resources from other programs—the kind of broad corporate thinking not usually found in day-to-day patient care.


Physicians are more willing to listen if the hard news comes from their medical peers, believes Dr. Barbara Linney, director of career development at the American College of Physician Executives (ACPE). “Executives have to influence physicians and sometimes change how they practice,” she asserts. “We need M.D.s in [these] positions.” Having a physician at both ends of the equation makes sense, since “a physician won’t be able to say to another physician, ‘You don’t know what it is like on the ground.’”


The idea of mixing business with medicine appeals to many physicians-in-training, but envisioning how such a career would look can be difficult, especially when your experience has been limited to the clinic. Heading an HMO or running a group practice may spring to mind, but these jobs are just the tip of the iceberg. Like clinical practice, executive career options vary enormously, running the gamut from procurement to policy-making.


“The challenges of an executive career involve asking strategic as well as medical questions,” says Dr. Amrit Ray, who has made his career in the pharmaceutical industry and also holds an M.B.A. “People are often surprised to find out that there are several hundred thousand physicians [in executive positions], and they do many different things.”


Ray is vice president of medical safety assessment for Bristol-Myers Squibb—just one direction a physician can go in that industry, where other options include working in clinical trials, research, marketing, education and strategic planning.


Not all physician executive positions require the skill set of an M.B.A. though. “In some careers, medical skills are more pertinent; in others an M.D./Ph.D. might be better suited to the job at hand,” Ray notes. “The set of opportunities has evolved very much in the past 10 to 20 years.”


Both Linney and Chandler agree that the field is booming right now. But, Linney warns, “the competition is fierce.”


Fixers


In the nonmedical world, graduates choosing business careers are about as normal as it gets. Your parents will be proud, and no one will ask awkward questions about why you are doing this. But a medical student deciding to take this route still raises a few eyebrows. Why would anyone want to spend eight or more years learning medicine just to don a suit and tie and shuffle papers? And how can you know if it’s really right for you?


“In my experience,” says Hurley, “some students enter medical school already set on the notion of becoming a physician executive, but most tend to gravitate toward it as they progress in their medical education. During my first and second years, I took a hard look at the injustices I was fighting as a local student group leader, and recognized that the solution required change driven by executive leaders, not simply by rank-and-file physicians.”


Katherine Chiu, a 2009 M.D./ M.B.A. candidate at the University of California, Irvine, School of Medicine (UCI) and the Paul Merage School of Business, knew this was the path for her in the fall of her first year of medical school. “As an undergraduate, I had been exposed to lots of business education, and I have always been interested in the politics of medicine,” she recalls. As she began her medical training, Chiu witnessed medical directors and chiefs of staff “trying to be advocates for
their patients and having to fight with insurance companies.” She saw her role clearly.


Hurley’s and Chiu’s approach—exploring the business path during their educational years—is the way to go, believes Linney. “Often, people get into medical practice and find that it’s not what they expected. They look around and think, ‘Maybe I’ll try management.’” This is not the way to step into a physician-executive career, she says. “You can’t do this because you’re running from clinical practice. You have to have a passion for this kind of work.” Chandler agrees: The right person will be someone who “has the urge to fix the health-care system,” she believes.


In addition, you have to be a problem-solver, a team player and a good communicator. The ideal candidate will “behave well and work well with others,” says Linney, in her best imitation of a kindergarten teacher. “Screamers and throwers don’t make it here,” she says.


Earning Your Pinstripes


So once you’ve decided that this is for you, what’s next? Looking over the course listings for medical school, you’ll probably notice that there aren’t very many (if any) courses on the business of medicine. The obvious solution, of course, is to take the road Chiu, Hurley and others are on: getting a dual M.D./M.B.A. degree. It is becoming more common for medical and business schools to align programs for students to pursue these dual degrees. In 1993, fewer than 10 universities in the United States and Canada offered M.D./M.B.A. degrees; now more than 50 have such programs. Each school has its own method of including all the course work, but typically the dual degree takes an extra year (and costs roughly the equivalent of an extra year’s tuition), making for five years before residency training. The M.B.A. work can be done between the third and fourth years or in segments during the last two years of medical school—the course work cannot be done simultaneously.


That’s not all there is to it, though. “Education is not the ticket in, as it is with clinical practice,” says Linney. “Most recruiters [for management positions] are looking for someone who is board certified, has practiced clinically for at least five years, and has some management experience.”


But you don’t have to wait until you complete your residency and start practicing to begin building a résumé that will ultimately land you a good management position. “There is a lot you can do at the medical school level to get you started,” says Linney. She recommends taking on a variety of leadership roles, particularly those having to do with finance. If potential employers see that you’ve had management experience, particularly supervising people and handling money, you’ll be ahead of the game, she says.


Bill Rietkerk, a 2008 M.D./M.B.A. candidate at UCI, is taking this approach: “I’ve been using my M.B.A. training to advance a personal project developed here at UCI. It’s called the Joel Myers Melanoma Awareness Project. We teach junior-high and high-school students about sun health and melanoma. I have been able to use my training to secure an endowment that has allowed us to continue the project far into the future, and I have used training about process organization to streamline and reorganize how we recruit volunteers and schools so we can increase the amount of children we reach.”


Of course, as Ray at Bristol-Myers Squibb has pointed out, an M.B.A. is not always necessary in order to become a physician executive. The ACPE was formed as a response to the growing need for physicians in health-care management positions. Rather than promote M.D./M.B.A. programs, however, the ACPE designed its own certification program using a mix of live training, online training and distance education. The association also provides networking and assistance with job searches. But while there are many routes one can take to prepare for a career as a physician executive, everyone agrees that the first step is taking on leadership roles as early and as often as you can.


In some respects, careers in the business of medicine and in the practice of it are not vastly different. Physician executives can make more money than family practitioners or pediatricians, but rarely approach the incomes of cardiologists or orthopedists. The hours can be long, but there is rarely evening and weekend call.


A “day in the life” will be different, though. A physician executive will spend little time with patients (sometimes none), and lots of time in meetings. He or she will work closely with other physicians, executives and sometimes government officials. Paperwork will overtake lab work, and negotiation will often trump independent decision-making. The goals and satisfactions are much the same, however. Whether you are in the clinic or the business office, you are working to impact the health of individuals.


In the end, the important questions are not “Am I suited for this?” or “How do I pull it off?” but, “Is this the life for me? Is this what I want from medicine? Is this what I want to contribute to medicine?”


For Ray, the answer is a resounding yes. “As a resident, I was very engaged with patient care. I…would sometimes see 20 to 30 people a day. You can miss that sometimes,” he says. “But there were many limitations as well. Therapies were not available or not accessible, or economic constraints kept the patient from getting what was needed. It was troublesome. I looked at the Hippocratic oath and wondered if we were doing all we could. I began to look at where these problems are solved…and that brought me to the pharmaceutical industry.”


For similar reasons, Chiu hopes to work in a nonprofit or at a health policy institute, helping to design a better system for future patients. Rietkerk hopes to run a group private practice and eventually become a department head in an academic setting. Hurley is already using his administrative skills as national vice president of the American Medical Student Association. And all are figuring out unique and challenging ways to put their medical training to use helping patients on a large scale, changing the outcome not only for a select group of people but for all of society. “It [will] be an incredibly rewarding career,” assures Ray.
~Resources


Check out these organizations for more information about combining a medical and business career.

~~~Avery Hurt is a freelance writer in Birmingham, Alabama. Direct comments about this article to tnp@amsa.org.~Career Development,Health Policy,Practice of Medicine~
358~3April~2007-56~Reviews~Making a Date With Death~A day in the life of legal assisted suicide~Jason Cheng~Final exit~Marianne, a volunteer “escort” who helps her clients navigate the emotion and bureaucracy of dying, listens to her answering machine: The first message is from a client who talks about his schedule for the day of his planned death. Another needs someone to talk to. The last message is from a man who has decided to set a date.


The Swiss organization EXIT helps terminal patients in that country die legally, and the documentary film “EXIT: The Right to Die” (First Run/Icarus Films, $440 on DVD, $125 rental) follows the group’s staff as they interview candidates, evaluate their judgment, and ultimately support clients through the process of making the decision to die, choosing a date and finally drinking a deadly barbiturate cocktail.


As the title implies, the documentary does not question the organization’s viewpoint. The scenes support assisted suicide and EXIT’s guidelines, and clients frame their decision to die, not as a matter of want, but of need, due to unbearable suffering.


The English-subtitled film teaches us about EXIT without formal interviews. All rules and procedures are explained in the context of phone conversations, speeches at meetings or escort-client interactions. A speech given by the group’s president, Dr. Jerome Sobel, and the cocktail-hour conversations that follow, serve to inform the viewer about EXIT’s policies and ongoing efforts in the assisted suicide movement across Europe.


Long pauses during conversations between escort and client allow the viewer to join in processing the enormity of the clients’ final acts. This technique effectively draws the viewer into the organization’s mission, but throws the spontaneity of the action and the sincerity of dialogue into question. Sometimes the camera changes angles in mid-scene, reminding us that the film is edited to provide the best portrayal of EXIT.


Leaving aside larger questions, the film simply assumes the propriety of EXIT’s work, and instead probes deeper into other issues of caregiver stress and protocol. In a team meeting, some escorts say they cannot take any more cases because they are overwhelmed with assignments as it is.


Marianne and a new escort walk through a foggy Swiss countryside, talking about the way clients affirm their humanity in the face of death. One woman insisted on repairing the shutters and clearing out the refrigerator before going. In this way, “Right to Die” argues not about morality, but about death as a part of life. The two escorts settle together on a fallen tree and discuss facing and accepting death. This acceptance is necessary for them to sit with their patients emotionally and spiritually.


Medical personnel everywhere may benefit from seeing this particular perspective of dealing with terminal patients. Unfortunately, the price of the film likely restricts purchase to organizations rather than individuals.


As Sobel makes a final drive to a client’s house, his eyes dart between the road and the rearview mirror, allowing us to imagine what he is thinking. At the house, he carefully confirms the client’s wishes, and then he helps her to sit up. As we look on from behind, he sits on the bed next to her, handing her the cocktail. For a few moments, before she starts feeling dizzy, the client, the doctor and the viewer are all looking in the same direction. Seemingly everyone is on the same page.
~~~~Jason Cheng is a third-year at the University of Michigan Medical School. Second-year William Cederquist provided editorial assistance.~Advocacy,Ethics,Physician Patient Relationship~
359~3April~2007-56~On the Wards~Doctor Legs~The confidence to be feminine~Emily Watters, M.D.~Skirt as status symbol~I have spent most of today looking at her legs. She wears a short skirt every day, no exception. Her hair always hangs loose against her shoulders. She wears sandals, and she knows it’s against the dress code. Her legs stick out from under her white coat, and from the back, it looks like she could be wearing nothing under it. Her legs just hang there, browned and silky, like a commercial.


When she leans in toward a patient, she lets her skirt pull part way up her leg, and I can see the little crease in her thigh that tells me she’s in shape.


Her patient today asks her how she copes with seeing so many patients with brain tumors. She laughs and says, “I go swimming.” That must be how she got the crease.


Last week, a patient asked her, frowning, “Aren’t you a bit young to be a doctor?”


“I’ve been practicing for 15 years,” she says smoothly, “but thanks. It’s good to look young, right? You are complimenting me, you know.” She smiles flatly, and he is the one left shifting in his seat.


I sit in the corner chair of her office. I have a long white coat now, but little else has changed since medical school. My fellow interns are frenzied and gasping for air on the medical wards. Not me; I’m sitting and saying nothing, trying to muck together an education by listening—although we all agree that no one can really learn this way.


The head neurologist had told me that it would help my career in psychiatry if I spent a week here in the neuro-oncology clinic. I’d sighed inwardly, knowing this inevitably would mean more time with her legs, and with the personality that enables those legs to feel the fresh air.


My own legs are wrapped up in long black slacks and long black socks, ending in black shoes that are a little like clumps of coal. You would never know what color my toenail polish is, or that I have legs so milky that people used to ask me if I was wearing white pantyhose. Even at the beach.


There is an old part of me that is relieved by the suggested dress code. The part of me that dreads swimsuits and the beach—a place where guys used to smile at my browned friends and then, glancing down the line of us, would tell me they hoped I was wearing sunscreen. My legs are hidden in these pants, and hers are some of the only bare legs I have seen in the hospital butted up to a white coat, possibly ever.


She looks at her patient and frowns. “Why didn’t you taper off the steroids?” she snaps. “That’s what we discussed last time, is it not? Did you have some reason for that? Well?” He shrugs and says he didn’t really know why he didn’t, and was she sure that was the plan?


Oh, she is sure. She raises an eyebrow to confirm. He looks down at his feet. I watch his eyes to see if they ever graze over her legs. And they don’t.


I have spent all of medical school, and now these first few weeks of residency, hiding my skin. Wearing something just short of a turtleneck. Some part of me has even given thought to…a tie. After all, my male friends wear ties and never have any of them been mistaken for a nurse. Fear of being the target of that mistake is part of what keeps us women doctors stern and fully garbed. It is what I was told counts as “professional.” I do feel just a little bit professional as I watch her lean in and laugh. She turns to me and says, “He’s a joker, isn’t he?”


I can’t remember the last time I let myself really laugh when I talked to a patient. Certainly there were times I wanted to laugh, when funny things were said. But I was told not to do that a long time ago. That it made me look silly and school-girlish.


But she laughs with a full mouth, and if I didn’t know better, I’d say she was flirting. If I came to work dressed like that and laughing like that, I’d have 20 phone numbers by the end of the day, and maybe a print on my ass from all the playful slappings.


But her patients do not take her the wrong way even for a second. They shower her with praise. “You are a wonderful doctor,” they tell her. “I trust you. Dr. So-and-so sent me here because he said that you’d tell it to me straight.”


Old ladies tell me I am wonderful every once in awhile. Or they will say I’m going to be wonderful. That I seem angelic—that sort of thing. Never have they meant anything other than I am awfully nice. Her patients do not think she is just plain nice. They think she is brilliant.


She pulls up his MRI slides. “See?” she says. “There has been no tumor progression. These slides are virtually identical. Your tumor was fully resected, and the spot here has been stable for some time. I want you to taper off the steroids. There is no need for them now. They were given to you initially because you had an enormous mass effect from your tumor. That means your tumor was pushing on everything. There was swelling too. The steroids controlled that. There is no need for the steroids now. There is nothing for you to worry about.”


My eyes have drifted to her legs again. They seem even more of a status symbol than her diplomas on the wall; than any of her awards hanging beside them; than that entire file cabinet full of papers authored by her. Those legs tell you—she’s made it. She has earned what women can spend a lifetime slaving toward and never achieve: She has earned respect.


I know there is a lesson here. She is an accomplished woman. She has done the work. She has studied in her field extensively. She has done research. She has that no-nonsense thing about her too—that high-strung, snappy thing.


What I don’t want the lesson to be is that I have to go all out—that I have to study through to my skin in a way that my male counterparts will never do, just so that I can dress like a woman, and be viewed as a woman, without my male patients deciding that this is their lucky day, and they had better let me know just how beautiful I am.


I resent having to do all that work. So the alternative is to look as little like a woman as possible. To pull my hair back tight, hard to my head. Maybe even slick it in a k.d. lang style. Wear a high-cut shirt that doesn’t show an inch of skin that a man doesn’t have. If I have done my job, it will be completely unclear to the casual observer whether I even own a pair of breasts. To add, I will follow in the generation of Laura Ingalls Wilder and consider it poor taste to even show my ankles.


There. Now that I have made it abundantly clear to my patients that I am not available, that I am not showing anything off in an attempt to attract a mate, that I am not even obviously a woman, for that matter, I can go ahead and be completely average in my studies and knowledge.


On my current daily route on the wards, my legs will never see the inside of a hospital. They will see nothing but black all day and every day. Not a single person in the hospital will ever know that I have a birthmark on the back of my calf or that my veins are just starting to peek through my pale skin in that old lady sort of way. That is my secret, and in some ways, my shame: my failure to go all out and get that final trophy, a skirt. An actual woman skirt.
~~~~Dr. Emily Watters is a second-year resident in psychiatry at the Feinberg School of Medicine at Northwestern University.~Residency,Women in Medicine~
360~3April~2007-56~Perspectives~Knowing Cody~Putting a face on the dissection debate~Nahal Rose Lalefar~Cutting out cadavers?~He was the first person to teach me about the human body. Yet, he never spoke a word. He was the first person who taught me how to interact with patients. Yet, I never even knew his real name. He was the anonymous donor who generously had decided in life to donate his body in death so that I could learn to become a doctor.


My anatomy group named him Cody, and for 10 weeks, he taught me about the intricacies of the human body while forcing me daily to come face to face—literally—with death.


Cody was an integral part of my first year of medical school. But I worry that future classes will not have the chance to work with their own “Cody.”


Medical education is changing. One such change that has been stirring up controversy, but has yet to reach its full effect, is the abandonment of traditional dissection in anatomy class in favor of alternative approaches such as prosection or computer imaging.


The dissection versus prosection debate has a long history, and today U.S. medical students have aspects of both in their curricula. In the view of many, prosection should be the preferred method, since dissection is a slow and meticulous process. You must peel back the layers of skin, fascia and fat, and manipulate your way through a labyrinth of tissue to get a glimpse of what lies underneath.


Using prosections—pre-dissected specimens—students do not have to take time cutting, or even thinking about how to cut. They do not have to worry about finding and then dissecting out that brachial plexus, or wondering if it is an anatomic variation when they do finally locate that thyrocervical trunk. When you think about it, a lot of dissection time is spent on a preserved cadaver that does not fully resemble a living human.


The prosection program has been shown to be more efficient and time-sparing, freeing up more time for students to do independent study or pursue other activities. Studies have shown that students who learn through a prosection program perform similarly on practical tests as students who learn via dissection. In fact, prosection students may have better recall ability several years down the line.


Another strong argument in favor of prosection is that it presents less emotional strain for medical students than dissection. One study showed that 7 percent of dissection students reported recurring images of cadavers, and 2 percent had insomnia after commencing dissection. For some of us, gross anatomy was the first time we dealt with death, and that can be a difficult adjustment for some to make.


Yet faculty and students alike still find it hard to let go of cadaver dissection, no matter how inefficient and time-consuming it might be. It is a process that teaches us about teamwork as we spend long hours with our fellow students and teachers, dissecting and studying the cadaver. And it is a process of discovery, where the time spent searching is just as meaningful as what we find at the end.


Gross anatomy dissection also teaches us about professionalism. Each encounter with the cadaver must be treated as an interaction with a patient. We must be respectful in the words we use and the actions we take. That means covering the body appropriately, cutting and not slashing, and speaking as if a donor family member is standing nearby. Despite the scientific purpose in our dissection of his entire body, we never lost sight of the fact that Cody was once someone’s son, father, brother, partner or friend.


And finally, with dissection, you put a human face to death and learn how to deal with it. For me, that was the hardest but most important lesson to learn. Cody’s face remained covered with a cloth and bag until the last third of the anatomy course. When it came time to uncover it, I was terrified. My heart immediately started palpitating, and my throat became dry. And when I finally saw his face, my initial thoughts were how long his eyelashes were, and that he must have had beautiful doe eyes. However, I took a deep breath, composed myself and commenced the dissection.


I eventually learned to detach myself from the man Cody without sacrificing my compassion and mindfulness. After all, I like to think those are the qualities that drew me into medicine in the first place. Had I not gone through that experience in my first year, I do not know how I would have handled patient mortality when I got to the wards in my third year.


Without being too cliché, gross anatomy was a life-altering experience for me. I am sure many other students would agree. Although I can see gross anatomy evolving into something that is a blend and balance of dissection, prosection and radiology, I hope we have yet to see the end of traditional dissection. It is a rite of passage for the medical student. After all, dissection and human anatomy have gone hand-in-hand since the times of ancient Greece, and the use of cadavers has been a mainstay since the 15th century.


I think you would be hard pressed to find a physician who does not vividly recall his or her medical student dissection experiences. How often does one have the chance to open and look inside the human body? Is it time-consuming? Yes. Do you learn anything unique from the act of dissecting? Maybe not. Can it have a weird psychological effect to uncover the face of a cadaver, only to dissect it minutes later? Probably. Would I trade that learning experience for anything? Absolutely not.


At the end of those 10 weeks spent with Cody, I thanked him and said my goodbyes. We left a single lavender orchid on his chest, and with that, he was taken to be cremated. At our body donor memorial service several months later, I made a speech to the donors’ loved ones with reference to Cody. I referred to him not as the cadaver that we dissected in anatomy class, but as the body donor who had given us a gift from which we could learn.


Because of him, I said, I will become a better doctor. I hope future generations of medical students will be given the opportunity to say the same.
~~~~Nahal Rose Lalefar is a third-year at the University of California, Davis, School of Medicine.~Humanistic Medicine,Learning Tools and Technology,Medical Education~
361~3April~2007-56~Specialty Close-up~Pathology~The “physician’s physician” slips the lab~Pete Thomson~Pathology~The puzzle of disease, presented in dispassionate cells and tissue samples, is the trade of the pathologist. Increasingly, their stains and markers help treat that disease, taking a practice—once relegated to hospital basements and considered limited in scope—beyond its diagnostic walls.


“I think once people get to know pathologists and their departments...they’ll see we’re not really scary trolls,” says Anthony Sireci, a fourth-year at Johns Hopkins University School of Medicine. “We may be in the basement on occasion, but I think it’s a misconception that the pathologist...is only interested in esoteric medical minutia and [not] patient care.”


Early in medical school, Sireci held that view too. But by this past March, he was hoping to match into a pathology program. For the time being, he’s interested in pursuing an academic career in gynecological or general urinary pathology, particularly working in cervical cancer or prostate cancer.


In truth, the field is tremendously broad. The “physician’s physician”—as many call the pathologist—handles the intricate testing of samples generated by nearly every other specialty, and its numerous subspecialties run the gamut from backing up nearly every test in a rural hospital to running blood banks to tackling crime.


Anatomic pathology—examining tissue and considering anatomy in diagnosis, and clinical pathology—testing samples in a laboratory—are the two major arms of pathology training. While some residency programs allow students to stick to one arm or the other, most pathologists—around 90 percent—train in both.


Still, most pathologists follow residency with a specialized fellowship—nearly 74 percent in 2004, according to the Intersociety Council for Pathology Information. Ten percent entered academic medicine, and another 9 percent started practice. Of the 2004 crop, 51 percent were women, and 43 percent were international medical graduates (IMGs).


Most, though not all, open residency slots are filled every year, says Dr. Mark Sobel, executive officer of the American Society for Investigative Pathology, but the field is becoming more competitive. Every year, a higher percentage of slots fill, and more are occupied by U.S. medical graduates. Indeed, National Resident Matching Program data show that 91 percent of 525 slots were filled in the 2006 Match—60 percent by U.S. graduates. In 2002, by contrast, only 83 percent of 398 slots were filled, more than half by IMGs.


According to the College of American Pathologists (CAP), roughly half of pathologists work in a group setting, with the other half working solo—in an academic setting, independent laboratories or as medical examiners. Their workweek is around 49 hours, just shy of the overall physician average of 55.


But those are just averages, and with such a broad field, lifestyles can be all over the place. If you want to find a 9-to-5 pathology job, it’s out there, says Dr. Thomas Sodeman, CAP president. So is everything else, including positions requiring call.


The perception of pathology as a “lifestyle specialty” frustrates Sireci. “As a residency, it is seen as this very cushy, 9-to-5 type deal, and nothing could be further from the truth,” he says. “I’m so amazed when people say that.... You work hard, and you have to learn a lot. The learning curve is incredible.”


Sireci came into medical school thinking about primary care. Pathology first entered his mind as he did some research work after his first year. “It was something that, first of all, I was good at,” he says, “and second of all, I enjoyed doing.” After an elective in pathology during his third year, he’d made up his mind. “That’s what medicine is for me: a basic understanding of disease at the level of the organism, at the level of the cell, then going one step further and still including that knowledge of management and therapeutics.”


The sheer knowledge required for pathology also appealed to him. He is impressed by pathologists’ mastery of modern therapies, literature and ability to talk intelligently about pathophysiology—things that slip the minds of students once they’re past second or third year and getting knee deep in patient interaction.


But for some students, that interaction is what pathology is missing. “You can’t mind having to be in the background, as far as the patient is concerned,” Sireci says. “Patients are never going to go up and thank their pathologist. At least I’ve never heard of that.”


While Sireci, Sobel and Sodeman all emphasize that being a pathologist does not necessarily mean a complete divorce from patient contact—in fact, Sodeman says, direct patient interaction with pathologists is on the rise—most simply work with little pieces of patients, and Sireci says that’s something students considering pathology should think about.


“Am I going to miss that kind of intimacy? There is no level of intimacy greater than what a clinician has with his patient, I think…. It is a little addictive,” Sireci admits. “I’m planning on deriving my satisfaction in interpersonal relations from being a consultant for other clinicians…. To me, that’s just as fulfilling, being able to affect patient care by consultation.”


“Pathologists are one of the last of the general practitioners, if you really think about it,” Sodeman says. “A pathologist in the hospital receives specimens from every discipline.”


A pathologist in a small, rural hospital sees and does it all, says Sobel. Those in an urban environment would probably gravitate toward running the particular tests at which they are skilled. One might specialize in samples of the liver, another in breast tissue. But even in that setting, they would all have the expertise to cover each other’s territory.


Working with other physicians isn’t the only chance for human interaction. Forensic pathologists, beyond their deceased patients, are actively involved in community health, Sodeman explains. “Most of the seatbelt laws we see across the country are the result of the efforts of forensic pathologists in their community and nationally, because they understood the cause of death.” They know and work among police and with the legal system, not to mention relatives of crime victims.


For those who want both pathology and patient contact, there are options. Pathologists serve on tumor boards and with diagnostic units for breast cancer. Some might do fine-needle aspirations.


More such opportunities may also arise as the pace of technology and science quickens.


“The application of molecular testing is expanding and increasing and is being mainstreamed,” Sobel says, “so it is becoming more and more important for pathologists to at least understand what’s out there.” These tests form an area of specialization, but some of the more common molecular tests might be performed by general pathologists.


Increasing understanding and application of molecular markers of disease is changing the specialty, but what’s really significant, Sodeman says, are the markers that predict treatment outcomes. “All of that is opening up an incredible opportunity in this profession to really become involved in a more extensive look...at predicting disease, and then... determining whether a patient will be responsive to therapy.”


But with growth comes pain. Like so many specialties, pathology faces a workforce crunch. Sodeman cites Association of American Medical Colleges workforce data showing that 45 percent of active pathologists are over 55 years of age, so more than 6,000 may retire over the next decade. Residency programs are only turning out 500 a year.


And there’s friction over reimbursement. Unlike physicians holding a stethoscope to a patient’s chest, when it comes to pathology, the public just doesn’t get it.


“In general, legislative bodies and regulatory agencies disregard the cost of doing a test, so third-party payers are basically squeezing the laboratories,” Sobel says. “There is a constant battle out there for getting fair compensation.” It might be a matter of public relations, but pathologists have to make clear to patients at large that the pathologist is necessary, even if invisible. “Sight unseen, you don’t understand the value of what the pathologist is doing. And the public’s lack of understanding is mirrored by their representatives and the regulatory agencies and the legislature,” Sobel notes.


But inside the hospital, there’s respect for a critical role without a lot of glory, Sireci says.


“Everyone is coming down to the pathologist, and oftentimes it comes down to ‘What’s the diagnosis?’ ‘What does the tissue say?’” Sireci says. “And the only person who can really say that is a pathologist.”
~
Pathology at a glance



The College of American Pathologists debunks “myths” and provides an
“Ask a Pathologist” e-mail link.


The Intersociety Council for Pathology Information brings you background information on residency and links to numerous pathology member organizations.
~~~Pete Thomson is associate editor of The New Physician.~Career Development,Medical Education,Practice of Medicine,Residency~
366~4May-June~2007-56~Folk Tales~Raising the Bar~A nontraditional student finds balance~Pete Thomson~Carry that weight~Surrounded by screaming, red-faced teammates and coaches in a crowded convention hall ballroom, Edward Dudley-Robey slides under the barbell at the American Powerlifting Federation (APF) California State Championship for his first bench press of the meet. Flanked by three spotters, he lowers the bar to his chest, struggling to focus his nervous energy on lifting it back up without any unnecessary movement that would disqualify him. On the judge’s command, he pushes the bar smoothly off his chest.


Dudley-Robey, a fourth-year medical student with an eager, polite demeanor seemingly at odds with the high-octane sport of powerlifting, has two busy months ahead of him. He’ll graduate from medical school, take Step 1 and head to Daytona Beach, Florida, for the APF Senior Nationals. And then comes the challenge of applying for residency—and matching—as an older international medical graduate (IMG).


That February morning at the state meet, Dudley-Robey wound up with both a medal and his proud coach’s monstrous arm around his neck. He hopes it isn’t the only success of his year.


At 33, Dudley-Robey comes from the “Emergency!” generation of future physicians. The TV program initially piqued his interest in pre-hospital emergency care. “They’d defibrillate someone every week, even if the patient only had a hangover,” he remembers.


While still in high school, he became involved with the Los Angeles Police Department Explorers, a co-ed pre-professional program, and volunteered to train others in CPR. After receiving basic nursing training in the Army, Dudley-Robey worked in Los Angeles-area ERs. After being licensed as a naturopath, he decided he also needed a strong allopathic background to succeed in medicine.


Dudley-Robey graduates next month from the University of Science, Arts and Technology, a Caribbean school on the tiny island of Montserrat. The school began instructing students in 2003, according to the Educational Commission for Foreign Medical Graduates’ database of foreign schools.


Most of his preclinical course work took place on the island, but he has pursued most of his clinical training in the United States. In March, he rotated in the preventive medicine department at Griffin Hospital in Connecticut, and he has completed many other clerkships in the Los Angeles area.


Those L.A. rotations have been convenient for his powerlifting training at FIT gym in nearby Sherman Oaks. “Anyone will tell you you need distraction from medical school or you’ll go nuts,” he says. “And this is perfect.”


It does seem that way. His practice schedule includes only two three-hour sessions a week, since recovery is a big part of the training model, he explains. For their practice lifts, he and his teammates “put up” weights close to their maximum capability with very few repetitions. They stick to the events they’d face in a powerlifting competition: bench press, squat and the dead lift.


It is in this regard that powerlifting differs from competitive Olympic-style weightlifting. The latter consists of two events, and lifting involves complex motions to hoist the bar from the floor. Powerlifting, on the other hand, involves more isolated movements using stationary equipment like you’d find at your local YMCA—only with a lot more weight on heavier bars.


Unlike recreational weightlifting, however, there are very specific rules. In bench press, for instance, the bar must be stationary until the judge commands the lifter to start—no bouncing off the rib cage for that extra pop. The bar must remain level during the lift, the legs must not move, and the competitor must “lock out” their elbows at the top, again bringing the bar to a stop.


Scot Mendelson, who Dudley-Robey frequently calls “the strongest bencher on Earth,” is the APF’s demigod and Dudley-Robey’s coach. Mendelson is known for being the first man to bench press more than 1,000 lbs., and the feat makes him a frequent reference point throughout the fragmented powerlifting scene, which is divided into principalities delineated mostly on what you can wear when you compete.


The APF, for instance, allows the use of bench shirts made of denim or canvas, stiff fabrics that help an experienced lifter pop the bar off his chest at the bottom of the lift. Other leagues allow no such shirts, or restrict the use of joint wrapping. There are distinctions in drug testing as well. The APF does not require testing except in its amateur division.


Dudley-Robey thinks of his federation as the big leagues. “The APF is where most of the records are set,” he explains.


His winning bench press in his class was 275 lbs., perhaps not outside the range of many recreational lifters. But the lift was enough to win the competition, and he was nursing a wrist injury at the time. His personal best bench press was 507, but in powerlifting, it’s all about the moment, not about the max. The true competition comes in how lifters, under the pressure of the competition and amid the noise, use their three chances to lift the bar to the satisfaction of the judges.


“In football, if you make a bad play,” he notes, “you have four quarters to make it up.” Not so in this three-chance sport.


Strategy—adapting to your performance—is also part of the equation. Lifters have only one minute between lifts to tell the judge what their next weight will be. Some competitors open with their most ambitious weight. Others need to shake off the jitters out of the gate with an easy start.


Sometimes, nervous energy drives that first try—and sometimes nerves ruin the lift.


“In the gym,” he says of practice, “even with your coach yelling and screaming at you, it’s different.” The unknown, he says, is the adrenaline and the stress. Dudley-Robey won the state meet on his first lift.


Already, his mind is on the nationals in the middle of June. The state meet was his first, and the nationals might be his last, opportunity to be competitive. Though his medical school schedule has permitted him the time to train, residency probably won’t.


He plans on vying for an internal medicine spot in the 2008 Match. His ultimate interest is sports medicine, but he’s realistic about his prospects for becoming an NFL team doctor or anything flashy. “There aren’t that many of those jobs out there, and there are a lot of really good guys doing them,” he explains. Instead, he’d be happy practicing in primary care, with an emphasis on athletes. “I can relate to athletes a little differently than someone who hasn’t been one.” That population, he says, often hides injuries and speaks a different language than most physicians.


Beyond his interest in athletics, he is also concerned about public health at large. Just look at this society’s obesity rates, he implores. “Sports has got to become a larger part of the U.S. lifestyle.”


Assuming he matches next year, he’ll be 37 or 38 by the time he’s done with his medical training, and probably with his powerlifting career. “For every athlete who competes through older ages, there are dozens who can’t do that,” he says. “This really is probably my last competitive year.”


Beyond nationals and boards, Dudley-Robey’s mind is also on residency interviews, and he’s trying to secure every advantage he can for that application. U.S.-born IMGs had a 50-50 chance of matching this year, with graduates of stateside allopathic medical schools filling 56 percent of internal medicine positions, according to National Resident Matching Program data. And unlike powerlifting—“the weight is the weight,” he says, “either you lift it or you don’t”—program directors’ judgments are subjective. Interviews are “nerve-wracking,” he says, and he thinks his age might be seen as a disadvantage.


After his boards and nationals, he’ll pick up some nursing shifts in the ER to earn a living, and work on finding a residency spot. “I’m hoping that I’m a good enough person,” he says of his candidacy, “and a good enough student.”
~~~Photo by Steve Tamerius~Pete Thomson is associate editor of The New Physician.~Student Life and Well-Being~
367~4May-June~2007-56~On the Wards~Playing Doctor~Who was that masked man? Me.~Benjamin Silverberg~Dress-up doctor~My first day to play dress-up doctor actually coincided with Halloween. It wasn’t the first time I had donned the garb of a physician, however. I had made my premiere in the fabled white coat (size 44) last year, just prior to taking the Hippocratic oath with my classmates.


Soon after, I purchased a blue Littmann Cardiology III stethoscope, and presto! I was a doctor. Or, at least, I looked the part. Besides the cliché of wanting to help people feel better, there was little substantive knowledge behind the costume. Regardless, there must have been some change, for even when I stripped off the white coat to work at my pediatric clinic assignment, I was still, incorrectly, called “doctor.”


Children and their parents let down their guard and exposed themselves to me, both with their honesty and with their flesh. With only a piece of rubber tubing around my neck, what was it that elevated me to an expert, even when it had clearly been stated that I was only a student? Though this was part of my training, and I had been privy to some difficult situations, our encounters were still make-believe. It was an eerie parallel that my first day seeing patients in a hospital coincided with one defined by costumes and playing pretend.


Yet, my access card to patients at Connecticut Children’s Medical Center was not a white coat. The cloth specter would have scared the kids—something I had learned in my outpatient pediatrics clinic. My credentials were subtly announced by a thin adhesive badge listing only my name and the designation “hospitalist.”


Again, I had been given a small white article that would serve as a magic key to open up doors and, potentially, other people. As my classmates and I followed the multicolored hallway, we noticed the “H” in the word “hospitalist” had been misprinted. Laughing, we penned in a stroke to correct the letter on each other’s nametags. I quietly mused on the significance of only having part of the word show up properly: Were we going somewhere without knowing where we had started? Were we running around with our heads cut off? More optimistically, I equated it with the feeling that I had earned the first half of the “M” in “M.D.,” having completed my first year of medical school. Three more to go.


Sitting down with my fellow students in a conference room near the cafeteria, I could barely contain my excitement. I was already thinking that maybe I could do a residency in pediatrics. I felt comfortable interacting with kids, and the green dinosaurs and other figures painted on the hospital walls made the whole setting feel a little less serious. It was a hospital, yes, but its lack of bland sterility made me temporarily forget where I was.


Dr. Jung, a young physician dressed as Little Red Riding Hood, walked in, handing us guides for our upcoming oral presentations on the patients upstairs. Indeed, the photocopied papers were like maps to get us through the woods—the rows of bedridden kids eating candy in their hospital rooms, locked away from Halloween on the street.


An unexpected wave of nervousness flushed through me as we readied to meet our assigned patients. Jealous that my fellow student Diego had been given a Spanish-speaking patient, I volunteered to go with him. I must admit, with some embarrassment, that I enjoy surprising people with my ability to speak other languages.


Upstairs were more costumes: nurses dressed as ladybugs, doctors in Egyptian robes and children in hospital gowns. But one lucky patient was healthy enough to put on overalls and stuff her pockets with golden straw. Her thin frame made her a perfect scarecrow, but as she stepped out from the shadow of her room into the fluorescent-lit hallway, her frailness became apparent. Angling myself to peer into another room, I saw a teenager curled up in his bed, coughing from a genetic disorder that filled his lungs with mucus. My eyes were wide with sad curiosity. I had read about cystic fibrosis, but to see its effects 10 feet away certainly was very different. I realized this was the first time I had been witness to truly sick kids.


As the other students peeled away one by one to interview their patients, Diego and I arrived at a closed door. Soledad, a 4-year-old girl, waited inside with her mother and father. Hypervigilant to the prospect of communicable disease, the hospital staff had put her on “droplet precautions.” A red cart outside her room contained disposable blue plastic smocks and yellow facemasks. Ah! My costume!


Unwrapping and untangling the hospital couture, Diego and I opened the door and introduced ourselves from the hallway. I slipped the textured plastic over my head, covering my orange tie and black pants, and entered the room, immediately crouching down to be at Soledad’s level. With my mouth covered, it was nearly impossible to show her I was smiling, let alone get
her to give one in return. I hoped my eyes, at least, were expressing friendly warmth.


I tried to give her a high-five, but despite her mother’s encouragement, she stared at me blankly. My small bag of tricks already used up, I shifted my attention back to Diego, who had been interviewing the father. Diego’s crisp words contrasted mine: He was serious and efficient; I stumbled over my Spanish and got lost in the chronology of Soledad’s illness. Despite my desire to interact with the patient and make her feel more at ease, I recognized the utility of Diego’s approach. Grudgingly, I gave up on getting Soledad to smile and focused my attention on her father.


This was the fourth time Soledad had been in the hospital: the first being her premature birth, then for a rare form of liver cancer and now, twice in the last month, for pneumonia. Though she had vomited last night in the emergency room, Soledad wasn’t in pain—she was just bored. Silently, she squirmed on the bed, positioning herself to get a better view of a telenovela on Univision.


In examining her, I was surprised to find that her lungs sounded clear. Soledad was completely apathetic to us revealing the scar on her abdomen, even though Diego tried to garner some rapport by noting he had a similar scar. Apart from the hospital location, the history and physical exam were like any other I had done before. The difference was just that we were invading the patient’s space, rather than her entering our office.


The exam over, I felt a sense of accomplishment as Diego and I escaped the hot plastic outfits, washed our hands and thanked the family for their time. Outside the room, we looked briefly at Soledad’s chart, confirming the vitals we had taken were accurate and recording the ones we hadn’t taken. I wondered then how I might have responded had she been “sicker,” like the young man with cystic fibrosis.


After reorganizing our notes, we prepared to give an oral presentation to Dr. Jung. Despite having had some practice with this in my pediatrics outpatient clinic, I felt some stage fright. No option, I thought, but to just jump into it. Indeed, I had to trust in my skills and not psych myself out. As I spoke, I took solace in the fact that both Dr. Jung and Alexa, our fourth-year student mentor, were nodding in agreement. Once everyone had presented his and her patients, our game of playing doctor came to a close.


On our way out of the hospital, we removed our sticky badges. One of my classmates had folded hers over so that her name and “hospitalist” were on opposite sides, leaving one identity to be shown and the other to be hidden. It finally occurred to me that I didn’t know what “hospitalist” meant.


Later, reflecting on the symbology of the day—in other words, the symbolism and the rituals associated with it—I looked up the suffix “-ist.” Though “biologist” was an easily accessible example of its usage, I could not quite define “hospitalist.” I found myself idly wishing the word was actually “hospitalitis”—inflammation of the hospital. Shaking my head amusedly at the thought, I suddenly found the answer: “-ist,” one who is engaged in, or one who believes in.


Ah, so a “hospitalist” is someone who believes in the institution of a hospital.


Diction, like a mask that covers only part of my face, or my white coat, is another small part of my costume. But my future career is not something I can take off. I am primed like Clark Kent: When I need to, I can revert to my alter ego and leap into action. To comic book readers, Superman was the costume and Clark was the person. But to Superman, that was his true identity: Clark Kent was the cover-up.


So that begs the question: Which
is my costume and which is me? Superman or Clark Kent?
~~~Photo by Julie Fanning~Benjamin Silverberg is a second-year at the University of Connecticut School of Medicine.~Medical Education,Physician Patient Relationship,Student Life and Well-Being~
368~4May-June~2007-56~Resident Rx~The Perfect Turf~Dodging a case is sometimes a matter of survival~Andrew W. Seefeld, M.D.~Turf wars~It was 1:00 in the morning; I was lying on my bunk bed in my on-call room, on the eighth floor of the hospital, staring at the ceiling and trying desperately to fall asleep as so many nights before. The bed linens were always too stiff and the mattress never thick enough. The water faucet had a slow, rhythmic leak, like some kind of torture tactic. In the distance, a cacophony of alarms began chiming away, each with its own rhythm—a reminder that hearts were still beating and patients still breathing.


I knew the page was going to come; it was just a matter of time. I had one more bed to fill on my service, and I was praying for an easy admission. Or better yet, an admission that I could turf to another service. If I turfed the patient, I would still get credit for the admission and then sleep the rest of the night knowing that I wouldn’t be bothered again.


You may be wondering, what is the definition of “turf”? In the medical context, turfing is taking a patient who is supposed to be admitted to one service, like general surgery, and redirecting that admission to another service, like internal medicine. But why would a physician even think of doing such a thing?


Ask yourself this: When was the last time you worked 30 straight hours without sleep, especially in a field that is so intimately associated with life and death? Moreover, when did you last repeat this process every third day for months on end?


Like clockwork, my pager went off, and the operator told me we had an admission from the emergency department: a trauma patient with multiple injuries after a car accident. Calling the ER directly, I inquired why the patient was coming to my general internal medicine service and not going to the surgical one. They informed me that, although the patient had a liver laceration and a broken femur, he also had a complicated medical history, including hypertension, chronic lung disease and diabetes, which the surgeons claimed they wouldn’t be able to take care of.


I had to give it to them. A perfect turf, I thought to myself with animosity glazed with admiration. What could I say? I had been beaten. The orthopedic surgeons would fix the broken bone, the general surgeons would repair the liver injury, and I would manage the rest. Could I really expect a general surgeon to handle a medical problem that doesn’t involve a scalpel, or an orthopedic surgeon, a drill? Now the question was not what orders needed to be written or what procedures needed to be completed to stabilize the patient, but rather, how I could still turf this patient off of my service to another.


Maybe the patient was too sick to be on a regular medicine floor. Could I send him to the ICU? But his blood pressure and heart rate were normal in the ER, which would not suggest shock or the need for close monitoring, lots of intravenous fluids or even lifesaving medications.


What if his liver started to bleed more, or his femur fracture got displaced further? But the laceration was small, and the femur was only partially fractured, so this was unlikely to cause any major complication. It looks like I would have to take this one. Those surgeons may not be so lucky next time!


The institution of turfing is not a product of laziness, or a lack of compassion or interest in patient care, but a result of the long hours and the unyielding demands, both physically and mentally, that physicians are exposed to during their careers, particularly in residency training.


In July of 2003, the Accreditation Council for Graduate Medical Education instituted a resident duty hours standard, which states that physicians-in-training—residents—are to be limited to no more than 30 straight hours in the hospital at one time, and no more than 80 hours a week averaged over a one-month period. The goal of such guidelines is to improve both patient and resident safety.


Ironically, patient errors are still being made and resident safety is still at risk, despite these attempts at regulating work hours. Personally I have seen countless violations of these work-hours regulations and the repercussions that have resulted. Residents have been told since the beginning of medical school to go the distance; to work the long hours, and the rewards in the end will be infinite. But I don’t see the rewards in falling asleep while driving home, or injuring a patient because of extreme fatigue and lack of mental clarity.


It is disturbing that any human being, particularly a physician, needs a work-hours regulation that limits him or her to an 80-hour work week. What ever happened to the 40-hour work week? Physicians are the people on whom you depend in times of illness, distress and crisis. Can you think of another profession that carries the same weight or the same consequences if mistakes occur? If your broker chooses the wrong stock, you may lose your money. If your physician falters, you may lose your life. Which risk would you rather take?


So now I hope you are beginning to understand the origin, and thus the nature, of the turf. It is a form of self-preservation that physicians-in-training have been using for years to protect themselves from making devastating mistakes. If turfing a patient, even just for a night, as the surgeons had done, meant that there would be a little more sleep, better decisions in terms of medical management and, even more importantly, getting home safely, it was worth it.


I went into the medical profession to do my best at healing individuals with medical illnesses. The last thing I expected when I chose this calling was that I would be making errors and compromising patient care, along with my own well-being, because I am working too long with not enough time off for both mental and physical recuperation. In the end, physicians and patients are human beings, made of the same organic molecules. If your physicians are not healthy, then how can you expect them to ensure the same for you?


With these ideas rattling around in my head, I sluggishly got into my car after spending the entire night examining the new patient who had been turfed by the surgeons, writing orders for the nurses and preparing for morning rounds with the attending physician, my boss. Fumbling for my keys, I started the car and began driving the 30 miles home, hammered by extreme fatigue. My eyelids felt like they weighed 50 pounds, my legs and feet ached, my brain felt like a pile of mush and I was on a freeway driving 60 miles an hour with the morning rush-hour traffic beginning to build. The highway was riddled with cars filled with children going to school and men and women heading to their offices. I vaguely remember my eyes slowly closing, and then silence.


A sudden jerk of the wheel prevented me from hitting the freeway barrier and causing what could have been a devastating traffic accident. I was lucky this instance, but what about next time?


Maybe I will be the next patient to be turfed.
~~~~Dr. Andrew W. Seefeld is a second-year
resident at the UCLA Medical Center Department of Emergency Medicine.~Ethics,Medical Education,Physician Patient Relationship,Residency~
370~4May-June~2007-56~Specialty Close-up~Physiatry~Restoring health and hope~Martha Frase-Blunt~Physiatry~
Physiatry at a glance



Directory of PM&R Residency Training Programs


The Medical Student’s Guide to Physical Medicine and Rehabilitation




For medical students with little exposure to the field, physiatry is just a game-winning Scrabble word. In fact, it’s one of the fastest growing and diverse medical specialties of the 21st century.


Also called physical medicine and rehabilitation (PM&R), physiatry focuses on helping patients with disabling conditions—from simple mobility issues to complex cognitive impairment—reach their maximum level of function. Physiatrists are trained to treat any disability—arising from either disease or injury—involving any organ system. They practice in major rehabilitation centers, acute care hospitals and outpatient settings.


Those having some familiarity with the specialty may write it off as simply advanced physical therapy. “That’s a common misconception,” says Dr. Laura Hobart, an osteopathic resident in her second year at the University of Arkansas for Medical Sciences. “In fact, we are the team captains, coordinating occupational therapists, physical therapists, social workers, psychologists and everyone else involved in the care of a patient in rehab. When a patient has problems urinating and his therapist doesn’t know what to do, we are the go-to guys.”


One aspect of the specialty that practitioners love is its variety. Today, physiatrists treat an extensive range of conditions, including arthritis, stroke, neurological disorders, musculoskeletal conditions, traumatic injuries—including brain and spinal cord injuries—chronic pain, work and sports injuries, and chronic diseases. Patients can range in age from infants to the elderly. Physiatry also employs some of the most exciting new medical technologies coming onto the market in the areas of electrodiagnostics and state-of-the-art adaptive equipment.


It’s not hard for physiatrists-in-training to find one or more facets of the field to get very excited about. “My absolute favorite patients are those with brain injury,” says Hobart. “Some will come onto your service unable to speak or communicate at all, except by blinking an eye to let you know someone is in there. But when they leave, they are walking and talking. It’s like watching a child grow up, or a flower bloom. It’s the most amazing experience a physician can have.”


Hobart came to the field through her experiences in osteopathic manual medicine. “I wanted to see the allopathic approach to some of these techniques, and in PM&R I realized there was so much more involved. It is about helping people get through difficult times in their lives, and making the most of what they have.”


Physiatry began to develop as a specialty in the 1930s when doctors began to treat musculoskeletal and neurological problems, and gained prominence soon after when disabled veterans returning from World War II sought help to regain productive lives. It was certified by the American Board of Medical Specialties in 1947. At that time there were 91 physiatrists practicing in the United States; today there are almost 8,000. Practitioners have increased by more than 35 percent in the last decade, yet physiatry is one of the few medical specialties where there is a relative workforce shortage. Medical education simply can’t keep up with the patient population boom.


According to the National Center for Health Statistics, 34.3 million people (12 percent of the U.S. population) are physically limited in their usual activities due to a chronic condition. More than 7 million use assistive technology—canes, walkers and wheelchairs—for mobility impairments, and more than 4 million use assistive devices such as back braces and artificial limbs to compensate for musculoskeletal impairments. Then there are those with acute conditions like low-back pain, shoulder pain or neck pain. Ten percent of all visits to physicians’ offices in the United States involve musculoskeletal conditions, and these figures are expected to increase as the baby-boom generation ages.


“One of the best things about this field is that it’s wide open, and you can create your own niche,” says Dr. Christopher Taylor, a fourth-year resident in the department of PM&R at Froedtert Memorial Hospital at the Medical College of Wisconsin. “I have seen the gamut of what the field involves, and have been able to pick apart my interests. This is a specialty where you can do what you want to do, where you want to do it, and how.”


Taylor plans to do a fellowship focusing on both sports medicine and spine care. The training will involve interventional pain management—a passionate area of interest for him. “Pain medicine has really been dominated by the anesthesiology field, but PM&R is now getting much more involved in doing procedures,” typically treatments using injections, he notes.


Like many of his peers, Taylor arrived at his career choice in a roundabout way. In medical school, he knew little about physiatry, but with an interest in sports medicine, was considering orthopedics. After failing to match in that highly competitive field, he began a program in general surgery, but soon “developed a picture of surgery I was not happy with. I couldn’t see myself doing just that, and I felt like burnout was a real possibility,” he says.


While doing a burn medicine rotation in Washington, D.C., he worked with physiatrists at the National Rehabilitation Hospital. “The doctors there opened my eyes to the field. For me, my interest came out of working with burn patients—it was mind-blowing that I could [work with just these patients].” After completing a year of research in burn rehabilitation, he was accepted to the PM&R program at Wisconsin.


Taylor has observed that many come into physiatry motivated by the experiences of friends, family members or themselves who needed rehab. Once in training, students soon realize that the medical model is very different from other specialties. “It’s not the pathology model—the focus is not treatment; it’s to return or regain function, which can come in many forms. The goal may be to get the patient to walk again, or just to gain better positioning in a wheelchair,” which can really improve quality of life, he explains. “The fruits of our labor come in a different form.”


Physiatrists can also enjoy long-term patient relationships, providing primary care to people with long-term disabilities. “Our job is to manage all aspects of their health, like their skin, bladder and bowel, and spasticity,” Taylor says. “For spinal-cord injured and chronic stroke patients, even if they have a cold, we see them first.”


Postgraduate education requires one year of internship and three years of residency training. Typically, the intern year is spent in a transitional year program, and residents match in PGY-2, but a few programs are now offering a combined four-year residency. In 2006, according to the National Resident Matching Program, 78 PGY-1 slots were offered and 95-percent filled, and 274 PGY-2 slots were offered and 94-percent filled. Just over half of all slots were filled by U.S. medical graduates.


Residents typically study internal medicine, orthopedics and neurology, and many go on to serve one or more fellowships in such areas as electrodiagnostics, pain management, spinal cord injury or brain injury. The American Board of Physical Medicine and Rehabilitation has agreements with the boards of pediatrics, internal medicine, neurology and psychiatry in which a five-year combined training program leads to dual certifications in PM&R and one of the affiliated specialties.


The work/life balance of a physiatrist is reasonable, particularly for those who work in an outpatient setting. Even in hospitals, the schedule is relatively predictable. “Rehab call is a lot different,” says Hobart. “There are no admissions to your service, since patients are already at the hospital. You still get emergencies as you would on a medicine floor—we recently had one patient who contracted appendicitis—but you can somewhat control when patients come onto your service.”


Hobart plans to do some type of fellowship when she completes her residency, but that time “seems pretty far away for me.” She is considering pediatric rehab, seeing it as a particularly rewarding area. “Children don’t view themselves as ‘broken’ like adults do. They see their wheelchairs as extensions of their own bodies, so they have a lot more potential to recover than adults, both physically and emotionally.”


Indeed, physiatrists’ patients often recover very slowly, so it’s a specialty not suited for those who like the instant gratification of fixing traumatic injuries or removing tumors. “You really need to be patient,” says Taylor. “The work we do can be very subtle, so you have to keep an open mind, and be open to different and creative ways of benefiting your patients.”
~~~~Martha Frase-Blunt is editor of The New Physician.~Career Development,Medical Education,Practice of Medicine,Residency~
373~4May-June~2007-56~Feature~HIPAA: Does Privacy Have to Be So Painful?~~Avery Hurt~Fours years after the Health Insurance Portability and Accountability Act went into effect, providers are still trying to integrate its seemingly contradictory goals of keeping patient data both confidential and accessible.~Now that federal health-care privacy legislation has been in force for a few years, it’s time to ask: Is it working? And is it worth it?


As with so many complex, overwhelming projects, it started out as a very simple idea. In 1996, the federal Health Insurance Portability and Accountability Act (HIPAA) was passed to ensure that when people lost their jobs for whatever reason, they wouldn’t lose their ability to get insurance coverage. Simple enough. However, at the same time, increased use of computerized medical records, the Internet and e-mail was creating concerns about the privacy of personal medical information. So HIPAA was crafted to include provisions for the secure transfer of electronic medical data as well.


As often happens in Washington, D.C., one thing led to another, and now HIPAA comprises more than 1,000 pages of legislation—the executive summary of the
Privacy Rule section alone stretches to 22 pages of very tedious reading. These dense, often confusing regulations essentially stipulate what patient information can be gathered and how that information can be used, stored and shared.


HIPAA regulations went into effect in 2003; four years later, health administrators are complaining about implementation costs, researchers are complaining about difficulty accessing medical data, medical students on rotation are complaining about redundant training, clinicians are complaining about their inability to get patient records from other physicians, and most patients still don’t have a clue what HIPAA is or how it is supposed to protect them.


Nevertheless, almost everyone seems to agree that it really is a good idea. Protecting patient privacy is worth a lot of trouble—as long as the benefits outweigh the problems.



WHO GETS THE BILL?


HIPAA is what is known in the legislative world as an “unfunded mandate,” meaning that the government makes you do it, but doesn’t offer to help pay for it. And the costs can be surprisingly high in a system that is in a state of constant flux in the way information is handled. Installing electronic records systems—which is still in the planning stages for many health-care institutions—is obviously expensive, but HIPAA compliance entails costs that don’t come readily to mind.


For example, all employees who have any patient contact whatsoever must be trained in protecting patient privacy, and this typically requires printed materials, videos or computer programs, and time. In hospitals and larger practices, highly specialized experts are hired specifically to ensure HIPAA compliance. In addition, there are forms to be printed and kept on file; new computer programs—with secure data-transfer protocols and systems for
storing password-protected data—to purchase, install and learn to use; and a considerable amount of worker time spent reorganizing files and creating new systems for securely managing patient records. No one knows exactly how much this is costing, but everyone agrees that it isn’t cheap. Estimates range from $3 million to $7 million per hospital just to meet basic compliance requirements.


“Eventually, [HIPAA compliance] should actually cut down cost, mostly thanks to electronic records and a more efficient system of collecting and sharing information,” says Brenda Hart, HIPAA compliance officer at Baylor College of Medicine, “but right now it’s very expensive.”


TRAIN AND RETRAIN


Since HIPAA is as much about behavioral practices as rules for record-keeping, training is crucial. But as with funding, there are federal regulations but no federal system for training.


Each health-care provider, from large multi-site medical centers to small physician-owned practices, must take care of its own training. This is prob-ably not much of a problem for employees who take one job and stay there for years, but it can be a true challenge for medical students, who at times rotate from one facility to another on a monthly basis.


Students often find themselves undergoing repeated training, says Dr. Dennis Boulware, associate dean of education at the University of Alabama School of Medicine in Birmingham. “VA [Veterans Affairs] hospitals are particularly reluctant to accept training [students gain] from other institutions,” he says.


The solution, Boulware suggests, is a competency-based assessment. “There [should] be a national, standardized test that everyone takes to demonstrate an understanding of HIPAA regulations.” Such a system would not only save money and time, but would also ensure that the quality of training is uniform from institution to institution, he explains.


Understanding and putting HIPAA into practice requires more than simply a day or two of training and passing a quiz, however. HIPAA is in no small measure a new way of life in day-to-day medicine. “HIPAA has changed the way hospital culture operates,” says Todd Theman, a third-year at Harvard Medical School. “We don’t talk about patients in elevators, or discuss cases over lunch. Everyone is very HIPAA-aware.”


Simple (or maybe not-so-simple) changes in routine, such as placing charts face-in on examining room doors, using white-noise machines to ensure conversations can’t be heard in the hall, and blacking out identifiers before taking case materials home to study are all part of the post-HIPAA lifestyle for physicians-in-training.


And yet, these familiar bricks-and-mortar settings, rather than the more ethereal computer networks, may be where most of the violations take place. “When I give talks about HIPAA, I have to remind people that laptops can be stolen; that a piece of paper that you put in the recycle bin might next be seen flying down the freeway off the back of a truck,” says Hart. “I tell people to think of a patient’s medical information as if it were your money. Don’t leave it lying around.”


And leaving things lying around is all too easy. Julia Skapik, an M.D./Ph.D. candidate at Johns Hopkins University, once brought a patient in an AIDS clinic into the exam room only to find that the labs of the previous patient were visible on the room’s computer screen. Skapik did not report the violation. “I wouldn’t even know who to report it to, and I wonder if anyone would take it seriously if I did,” she says.


Though employees—and medical students particularly—may be uncomfortable reporting violations, they probably shouldn’t be. “I do weekly HIPAA audits when I walk around the medical center to see how things are working,” says Hart. “When I see a violation, people usually say, ‘oh gosh, we need to address this.’ Their hearts are in it.” So she advises students to always report any violations they see.


“It would be great if you could go to your direct supervisor, but this is not always comfortable,” she notes. “Most institutions have a HIPAA hotline. If not, get in touch with the HIPAA compliance officer. These reports will be kept confidential and used to address the problem so that it won’t happen again.”



WHY ARE WE DOING THIS AGAIN?


In the midst of training, reorganizing and paying for it all, it’s easy to forget the reason for doing this in the first place. HIPAA is a lot of things, but the heart of the legislation is the privacy rule, and the privacy we are at such pains to protect is that of the patient. When it comes right down to it, no matter how carefully providers implement the regulations, no matter how well-trained and careful the staff, if HIPAA doesn’t work for the patient, it doesn’t work.


“Patients have to read papers and sign forms, but do they really understand what this is all about? Probably not,” says Skapik. The typical HIPAA form that patients sign, explaining how the provider can and cannot use and share information, is almost as tedious to read as the executive summary, if a great deal shorter. And most people aren’t feeling well when they read it. But even if they do read it closely and fully understand it, they still probably don’t fully appreciate its implications; the typical form doesn’t really explain that.


“I shadow a primary care physician every week,” says Theman. “Many of the patients see other providers, and we often end up repeating lab tests and other diagnostic procedures because we can’t get the information quickly from the other doctors. This increases the cost, the time and often exposure to X-rays and so on for the patient.”


Cinthia Elkins, an M.D./Ph.D. candidate at the University of Illinois College of Medicine at Urbana-Champaign, also sees this as the main flaw in HIPAA. “The problem I’ve seen is getting information between institutions and getting a patient’s history in a timely manner. For this, we need a national, computerized medical information system, such as the VA has, so you can get records from other sites with just a click of the button and without having to use unsecured and slow methods like faxing.”


Theman agrees. “The problem with HIPAA is that we got the cart before the horse. We have ended up with just the privacy part and no infrastructure for dealing with it. We need to stop thinking of privacy as an end in itself. There is an inherent conflict between smooth communication and protecting privacy. We can protect patients’ privacy, but we need to balance that with being able to provide efficient care,” he says.


But this might yet be possible. The next phase of HIPAA, moving to a unified and secure system of electronic medical records, is still on the drawing table, but the institutions that already use such systems find that they are working well. Elkins mentioned the
VA, and Theman says that Partners HealthCare System in Boston, which serves Brigham and Women’s and Massachusetts General hospitals, has an efficient electronic records system that protects patient privacy while allowing physicians to access medical records and case notes for any physician in the system easily and quickly. The problem for most institutions at the moment, says Hart, is that everybody is on a different computer system, making communicating among institutions difficult.


A nationalized system would solve this problem. However, some patients are very uncomfortable with the idea of electronic records even in a local doctor’s office, much less on a nationwide database. But as protections go hand-in-hand with improved communications, the bugs may still be worked out and the balance maintained between privacy and efficiency.


Despite the complaints, most health-care professionals agree that HIPAA is great in spirit, if occasionally awkward in practice. “HIPAA just legalizes and codifies what we should have been doing anyway,” says Boulware, “and I always felt we were doing a pretty good job. Protecting a patient’s privacy is just good medicine—and good manners.”
~~~~Avery Hurt is a freelance writer in Birmingham, Alabama.~Ethics,Health Policy,Legislative Action,Physician Patient Relationship~
376~5July-August~2007-56~Letter from Afield~Blinded by Bureaucracy~Useful health access is about more than money~Tanyaporn Wansom~Holes in Thailand’s safety net~I’d just finished a routine Pap smear and pelvic exam at a reproductive health clinic in Northern Thailand when a nurse came to the back room and asked for me. “I know you mostly see patients with HIV at the hospital,” she said, “and there’s a case here for HIV counseling that I’d like you to talk to with me. You have to see her eyes.”


I was surprised and flattered that one of the nurses thought I might be able to help. A rising fourth-year, I had completed a year of clinical training in the United States and was spending one abroad focusing on clinical research at Chiang Mai University Hospital. I also wanted more community involvement, which brought me to the reproductive health clinic.


Located in a nondescript building, the clinic provided affordable examinations, contraception, STD screening, HIV testing or medical abortions to about 50 patients a day. Although I was mostly put to work doing Pap and pelvic exams, I occasionally participated in HIV and abortion counseling. In these capacities, I saw many women wandering aimlessly through a health-care system intended to benefit them, but often leaving them bewildered and isolated.


As you would expect in a primary care outpatient setting, most of the patients I saw were not very sick. Unfortunately, the girl the nurse wanted me to see was an exception. I was immediately taken aback by her small stature; she looked much younger than her stated age of 16. She was blind in one eye and had a crusted eye patch over the other. Her older sister, who was about 20, did the talking; the patient deferred completely to the sister, and clung to her.


Their parents had both passed away, likely due to HIV/AIDS, and the girl had been transferred to the local university hospital from their home city of Chiang Rai when she began to go blind. Hospitalized for almost a month, she received surgery and medications for her eye problems, caused by herpes zoster and cytomegalovirus infections. The doctors also found abscesses in one ear. They told the older sister—now head of the family—that the girl had tested positive for HIV.


The sister told us this was the first time they’d known about the girl’s HIV status, and wanted the reproductive health clinic to retest her just to be sure. They were frustrated with the large university hospital, and had missed an appointment the previous day with HIV doctors because they had been charged for the hospital’s care after an earlier visit and were afraid they would have to pay out of pocket again.


Thailand’s national health-care system should not have required them to pay for any care due to their status as orphans, and I shared the sisters’ frustration. Without an advocate, or simply someone to explain the system to them, they had gotten lost in the health-care bureaucracy.


The nurse and I talked to the sisters about their next step and how to transfer care back to Chiang Rai. I had served as an HIV counselor in Bangkok prior to medical school, so I spoke to them about what having HIV meant, answered their questions and stressed the importance of taking antiretroviral therapy (ARV) consistently. After an hour-long conversation, the older sister thanked us for our help, said she understood HIV much better and led her younger sister, who could barely see shadows, out of the clinic.


Later, the nurse told me she would follow up with the older sister and try to find out exactly what happened later at the hospital. Though this made me feel better, their visit evoked strong emotions for me. The Thai government provides ARV treatment without cost to everyone who qualifies clinically. This girl—and her family—was entitled to services, including counseling and medication, that she did not appear to have received.


Sometimes it’s difficult to talk about HIV/AIDS with minors, but I found it hard to believe that nobody had sat down with this patient to discuss the disease, treatment or the transferal of care when I knew these services—and dedicated people to provide them—were available at the hospital.


It was, however, not a total failure of the system. Had the sisters not skipped their appointment the day before, they may have learned more then.


Still, it’s easy to see how the sisters didn’t understand the importance of that visit—one more turn in the maze of a patient’s care. For lost patients like these, so much work remains, not just in treating diseases like HIV, but in educating all of those affected, including concerned family members.


Although I rarely see people as sick as that one patient, her blindness and hesitancy reminded me of many patients I saw at the clinic on other days. These are the patients who are generally healthy, but have come to the clinic to seek an abortion. They are often young, and accompanied by unhappy parents, close friends and, at times, their partner in the pregnancy. They are not in touch with their own bodies and do not feel comfortable talking about reproductive health, contraception or risky sexual behavior. They rarely ask questions, and the clinic staff do not ask many of their own.


Abortions are illegal in Thailand under current law, unless the mother’s life is in danger. Many women attempt to self-induce abortions using readily available over-the-counter emergency contraception, or paying unqualified people to perform a procedure. A few clinics across the country provide safe abortions by a certified OB-Gyn, albeit illegally.


When I started helping out at the clinic, I asked the director if I could look at some records, wondering about the demographics of the women who had sought abortions there. He was thrilled that someone was going to look at the data, as no one had the time to do it before.


Unfortunately, patient data sheets were destroyed every six months to preserve confidentiality and protect the clinic, and what records remained were mostly incomplete and didn’t capture a lot of useful information. With the director’s encouragement, I wrote up a new form for the nurses to implement among patients seeking abortions at the clinic. The data collected would then be used to identify the clinic’s target population and help the clinic determine priorities, such as post-abortion contraception. Although it’s not what I had originally envisioned as clinical research, it was an important and necessary part of helping a community-based clinic identify the population it’s treating and the issues that population faces.


For patients like the two sisters and other bewildered young women who turn to the clinic, the need for education and health literacy stands out to me, especially in a complex, if potentially beneficial, health-care system.


As they left the clinic, the younger sister seemed so small, as if she was trying not to look like a burden. The older sister tried to provide comfort as she guided the sightless girl out of the clinic’s open entranceway, hugging her and whispering in her good ear.
~




Seen here with nurses, the author (center) sought more community involvement by counseling patients during a year of clinical research in Chiang Mai, Thailand.

Public health stations like this one are in almost every nonurban Thai community. The stations function as community health centers, providing a variety of services including drop-in clinics, exercise classes and health education. The author helped a mobile clinic see 100 women at this station, located in Vieng Pa Pao, Thailand.
~~~Tanyaporn Wansom, a fourth-year at the University of Michigan Medical School, recently returned from a yearlong Fogarty/ Ellison fellowship in Chiang Mai, Thailand.~Community and Public Health,Health Disparities,International Health~
377~5July-August~2007-56~Specialty Close-up~Thoracic Surgery~Cracking chest medicine~Martha J. Frase~Thoracic surgery~The life of a thoracic surgeon is “rigorous, pressure-filled and demanding,” says Dr. Brett Sheridan, assistant professor in the division of cardiothoracic surgery at the University of North Carolina at Chapel Hill. The reward, he says, is the ability to make a positive impact on a life-threatening disease process. “It’s not subtle; you give [patients] a better quality of life, a longer life, and they are immensely grateful.”
That is why many medical students choose surgical subspecialties—so many that experts have long lamented the drain of surgery on the primary care workforce. But the long and strenuous training period, stressful work and concern about future job prospects have meant fewer applicants are vying for entry into this particular discipline.
In 2006, only 84 of 126 available thoracic surgery fellowships were filled, leaving one-third of the positions vacant. This continues a downward trend that began in 1995 when there were 200 applicants.
The reason, believes Sheridan, is that prospective thoracic surgeons are concerned that the work of chest surgery is diminishing, thanks to the recent explosion in nonsurgical cardiac interventions—in a word, stents. These procedures are the purview of the interventional cardiologist, and thoracic surgeons who rely on steady demand for coronary artery bypass grafting (CABG) are finding their volumes decreasing.
Coronary angioplasty was first performed in Zurich in 1977. With further technological evolution, the opportunity to apply catheter-based interventions has increased dramatically. Patients have a considerably less-invasive—and often less-expensive—alternative to CABG. Blocked arteries can be opened by threading a catheter into the artery through the thigh and inserting a balloon and a permanent stent—the latest models coated with clot-busting drugs—with no cracking of the chest required. According to the Agency for Healthcare Research and Quality, the number of CABG procedures declined 28 percent from 1997 to 2004, while percutaneous coronary interventions rose 36 percent in that period.
“This monumental shift in therapy for multivessel coronary artery disease is a great controversy in heart disease, and has been the hottest topic outside of universal health care,” Sheridan says. The public has embraced this procedure because it is seemingly safer, the recovery is extremely swift, and it is perceived as an equal alternative to open-heart surgery.
“But as data have accrued,” Sheridan notes, “we’ve seen that for [disease] involving multiple vessels, [angioplasty] is not as reliable or safe as surgery. [CABG] really is the most life-preserving treatment for many patients. But we have a difficult time convincing cardiologists that surgery on the front end has improved outcomes, especially for sicker patients. It seems counterintuitive that CABG would be safer and more durable in sicker patients [than angioplasty], but the published data are consistent. The reality is that the surgical treatment of heart disease is going to make a strong rebound.”
Meanwhile, there are dozens of other procedures that thoracic surgeons can sink their scalpels into. Sheridan performs heart and lung transplants, implants artificial hearts, corrects arrhythmias, and treats the killer cancers of the lung and esophagus. Many thoracic surgeons choose to specialize in either the heart or the lung; others practice a mixture of both.
Training covers the operative, perioperative and critical care of patients with pathologic conditions within the chest. This requires substantial knowledge of cardiorespiratory physiology, vascular biology and oncology, as well as skills in heart-assist devices, management of abnormal heart rhythms, drainage of the chest cavity, endoscopy, and invasive and noninvasive diagnostic techniques.
Typically, residents complete a full program in general surgery, followed by a two- or three-year thoracic surgery fellowship. A second pathway is under development by the Thoracic Surgery Directors Association involving an integrated six-year thoracic surgery residency that will be available through a small number of schools. During the fellowship years, students can train to practice general thoracic surgery or adult cardiac surgery, or to further subspecialize in pediatric cardiac surgery.
After seven to eight years of postgraduate training, thoracic surgeons can expect to go into the field making more than $300,000 annually. Of course, there is a lifestyle trade-off. Sheridan estimates his colleagues work an average of 50 to 60 hours a week, just slightly less than notoriously overworked neurosurgeons. “And I take call every other night.” Still, Sheridan says, most nights pass without an emergency page.
So what’s the attraction to this specialty? Practitioners “love the challenge,” says Dr. Andrew Chang, assistant professor at the University of Michigan Medical School, who shepherds medical students through thoracic surgery clinical rotations and anatomy labs. At the end of a decade of training, “the reward is that we are getting to do what we trained for.”
One might assume this discipline is a young person’s game, but the fact is, “Practicing thoracic surgeons have stuck around,” says Dr. Atul Grover, associate director of the Association of American Medical Colleges’ Center for Workforce Studies, which is researching the future thoracic surgeon workforce. While about 20 percent of all U.S. physicians are 55 or older, more than half of the 4,800 board-certified thoracic surgeons active today are in this bracket. Approximately 70 percent are expected to retire in the next 13 years, dramatically shrinking the provider pool and leading to what certainly will be a critical workforce shortage hitting just at the time a swell of aging baby boomers will need their services.
Sheridan predicts a major comeback for CABG among these older patients: “Demand will explode, and
the field will become more attractive to medical students,” he believes.
Still, Grover’s research predicts that by 2025, the number of thoracic surgeons will be 1,000 to 2,000 short of what’s needed, even if residency programs add positions. “What’s also going on is that we can’t see how the future looks,” he says. “Stent technology was deployed so rapidly and is changing all the time.”
For its part, the Society of Thoracic Surgeons has lobbied Congress to add a provision to H.R. 609—the College Access Opportunity Act of 2006—that will remove barriers to medical school graduates choosing subspecialties requiring the longest training, including thoracic surgery, by forgiving some of their federal student loans. “They are trying to unencumber people who are thinking about choosing this difficult and challenging career,” says Sheridan.
Chang feels that it is becoming more difficult to introduce medical students to the field, “because surgical rotations tend to be less student-friendly. It’s a vicious cycle—the challenging environment exposes students to more negative feedback, so they pull away from these rotations. We can’t bend over backwards to make learning easier, but we do try to make it more attractive. It is up to us [teachers] to be better mentors and role models for our students.”
Chang’s department is looking into resolving such issues through its training model. Instead of a student having to wait a prescribed period of time before trying a procedure, “we are interested in ‘graded responsibility.’ There is no reason teaching should be driven by how many years one has been in medical school [instead of] competency. We are trying to make that a reality.”
But in the end, you can’t entice someone to go into thoracic surgery. It takes a particular work ethic and enthusiasm for battling the top killers of Americans—heart disease and lung cancer. The one thing aspirants have in common, Sheridan says—and he notes that as many women as men are entering the field—is their determination to change lives for the better.
“Their passion for these diseases is what sets them apart,” he observes. “These are students who are comfortable in acute and intensive care…. Their future opportunities will be wide open.”
~Thoracic surgery at a glance



RESOURCES
~~~Martha J. Frase is editor of The New Physician.~Career Development,Medical Education,Practice of Medicine,Residency~
380~5July-August~2007-56~Feature~When the “Doctor” Is Not a Doctor~Teaming with nonphysician clinicians~Avery Hurt~From the moment students enter the wards, they will encounter a variety of nonphysician clinicians taking on a number of roles, from lending a gloved hand in surgery to providing high-level case management and clinical know-how. Tapping into and respecting the unique expertise of all members of the care team will benefit your patients—and make you a better physician. Also: “Playing a Team Sport.”~They are called by many names—nonphysician clinicians, allied health professionals, physician extenders—and they have many different titles, specializations and competencies. But when it comes to patient care, they are no less than central to the clinical team. Working effectively with these professionals is essential to keeping the system afloat.


Health care today is dizzy with changes. One of the most striking is that when a patient sees “the doctor,” that person may not be a licensed physician at all. Nurse practitioners (NPs), physician assistants (PAs), physical therapists, certified nurse anesthetists and midwives, medical technologists and a host of other professionals are shouldering more of the day-to-day duties of patient care. Their roles are constantly evolving, and getting all those masked heroes working together in the most efficient, patient-friendly manner can sometimes be a challenge. It’s a challenge that must be met, however, because these folks are here to stay.


According to a 2005 report by the Robert Wood Johnson Foundation (RWJF), the number of nonphysician clinicians (NPCs) in the United States increased by two-thirds in the preceding decade, and shows no sign of slowing.


This is due at least in part to a projected shortage of physicians. Although their numbers are increasing slightly, the growth will not keep up with projected demand. An aging population, and with it, an alarming increase in high-maintenance chronic diseases like diabetes, will add additional strain to an already stressed system in the coming years. On top of that, U.S. physicians themselves are aging: More than 20 percent are over age 55. At the same time, newly minted practitioners are demanding less grueling, more family-friendly lifestyles than their mentors had, which means cutting back on the time available for patient care. And under financial pressure from large payers like private insurers and Medicare, a physician is fortunate to spend more than a few minutes with each patient.


It’s one of the defining characteristics of medicine in today’s world, says Dr. Andrew W. Seefeld, a third-year resident in emergency medicine at UCLA Medical Center: “Too many patients, not enough staff.” One solution to this dilemma, he believes, is NPCs. “I think they are invaluable. They are helping to increase the quality of care patients are getting. I wish we had more.”


So what do NPCs bring to the exam table and bedside? The most immediate resource is time. “Physicians are typically with a patient for 15 minutes. Allied health professionals may spend hours with a patient,” says Deborah Larsen, associate dean of Ohio State University College of Medicine and director of the School of Allied Medical Professions. But just as importantly, NPCs often develop a body of knowledge that M.D.s don’t have. For example, a physician can diagnose and treat Type 2 diabetes and stress the importance of a careful diet in the management of the disease. But when it comes to designing a particular diet for a patient and ensuring compliance, a registered dietician (RD) is better for the job. No medical school curriculum has room to include in-depth training in nutrition, and it doesn’t need to—that’s what RDs train to do.


But where NPCs are most immediately valuable is right there in the clinic or the ER: NPs and PAs are trained and qualified to take histories, order diagnostic tests and, in many cases, treat and manage illnesses independently, saving the physician precious time that can now be spent more productively with the patient, or with others who require more intensive treatment. “NPCs…can make clinical decisions based on their knowledge and experience, and come to us if they have problems, or the patient needs care that they cannot provide,” explains Seefeld.


Family Squabbles


Still, the rapidly changing roles of NPCs can make it difficult to get a feel for exactly what they do, particularly as the degree of responsibility and autonomy awarded them varies enormously from specialty to specialty and state to state. And regulations are changing even as The New Physician goes to press. Several states have pending legislation concerning the scope of practice for various nonphysician disciplines.


Nonetheless, one thing is clear: NPCs working alongside physicians in a team effort is becoming an accepted norm. A 2003 study from the New England Journal of Medicine showed that demand for NPC care often comes from the patients themselves, and that insured, middle- to high-income patients with some college education are those most likely to avail themselves of nonphysician care.


The study also put to rest fears that a proliferation of nonphysician providers might constitute unwanted competition for physicians. The study found that physicians are likely to refer patients to NPCs, and the two typically work side by side in the same clinic or hospital. All the same, the authors of the study did raise a concern that the use of several providers might result in fragmented care. But in a commentary that accompanied the study, Linda Aiken, a registered nurse and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, noted, “Many studies of nurse practitioners and nurse midwives, for example, provide solid evidence that the excellent outcomes of care they provide are due in part to their central roles as case managers and coordinators of care.” It turns out that having an allied health professional coordinate patient care might be more beneficial than having a slew of physician specialists.


Of course, some tension has always existed between physicians and, well, everyone else in the room. The paradigm of the physician as God and everyone else, no matter how skilled or well-trained, as landing somewhere much lower down the hierarchy is a stereotype with years of medical culture to support it.


While NPCs have been complaining for years that they don’t get enough respect from physicians, hard evidence of mistreatment—beyond gossip and anecdotes—isn’t readily available. Nevertheless, off-the-record reports of surgeons demeaning their intelligence or ignoring their recommendations—even when the NPCs are in a better position to make the call—are legion. Careful reading of studies and reports prepared by doctors often gives clues to what is going on beneath the surface. For example, one passage in the RWJF report reads: “Although the principle that [NPCs] can deliver high-quality care is unequivocally true, more research is needed to test this principle under conditions of greater clinical complexity and autonomy.”


In other words, the “unequivocal truth” that NPCs deliver high-quality care is, in the opinion of some physician policy-makers, not enough to grant them the authority to do just that. The problem, it seems, is not so much a lack of evidence demonstrating their competency as a lack of respect for their skills.


When asked what message she would like to send from allied health professionals to physicians, Larsen replies, “We’d like you to have respect for the body of knowledge and experience that we bring to [health care]. It is OK to ask questions of us.”


Jeff Pepin, now a third-year at St. George’s University School of Medicine, was a paramedic before starting medical school. “Walking through the doors of the ER as a paramedic and attempting to communicate with physicians was often a nerve-racking experience,” he says. “I believe that [many] physicians have a lack of understanding as to how allied health professionals are trained and how they can be more effectively utilized…. In my experience, more often than not, multidisciplinary health-care teams have not worked as well as their administrators would have liked.”


But the culture of medicine is always changing, and Pepin’s experience may not be the norm for long. “The concept of a medical team is much broader than it used to be,” says Larsen. “[Medical school] graduates in the ’50s, ’60s and ’70s had less training in the ‘team concept.’ Today it is often not a physician, but another health professional, who runs team meetings.”


Catherine Jones, an M.D./M.P.H. candidate at Tulane University School of Medicine, has found this to be true. “After Katrina, I took eight months off and worked at Common Ground Health Clinic in New Orleans,” she says. “The clinic was run by a nurse practitioner. Doctors were not dictating the care on a daily basis.”


And this kind of experience is helping to influence a change in the larger culture of medicine. “My experience [at Common Ground] will definitely have an impact on how I practice medicine,” Jones adds. “The idea of being disrespectful of an allied health professional is alien to me.”


Twenty-first Century Teaming


If you say it enough times, the word “teamwork” begins to sound like business jargon. But in fact, it is the key to making the contribution of nonclinical professionals a valuable part of medicine. In fact, teamwork is one of the fundamentals taught to NPCs.


Alison Williams, a student in the surgical assistant program at Virginia College in Birmingham, Alabama, says that in her experience, “a surgeon couldn’t do his or her job without the rest of the team doing theirs.” And according to Williams, most of the surgeons she has worked with (and in the Virginia College program, students take part in two or three surgeries a week) understand this. “They can occasionally be rude or even mean,” she says, “but when they are, they usually apologize after. They know that they couldn’t do it without their teams.”


Today’s health-care environment is making this a lesson worth learning. Larsen believes that the diversity of health-care professionals will work better together in the real world if they also train together.


“We are looking into co-teaching [medical students and allied health students] so that it will be easier for them to work together when they are out of school,” she notes. And Pepin suggests, “As part of problem-based learning in the clinical skills block of the basic-sciences course, medical students should learn how to delegate to allied health practitioners.”


Training together is not the only approach. At many schools, NPCs themselves take part in teaching. And why not? They are extensively trained in their particular areas of specialty and can take the time to share this knowledge with medical students. “When I was on OB rotation,” recalls Jones, “one of my instructors was a surgical PA. He was an amazing teacher—very knowledgeable.” Jones was also taught by a nurse anesthetist on the same rotation.


Focusing on this kind of teamwork early in the study of medicine might keep medical students from making common “rookie” mistakes—everything from assuming that all nurses are female to believing that all NPCs are low-level assistants with token training. While such mistakes mostly occur in matters of courtesy and respect, at least some will have a negative impact on patient care. According to Larsen, the most common error medical students make when dealing with allied health professionals is “failing to ask for information from other members of the team—they don’t want to look like they don’t know something, so they don’t ask. Often medical students are unfamiliar with the educational preparation and knowledge of allied health professionals and, therefore, fail to recognize [them] as a source of information, or in some instances the need to relinquish control of the situation to the other professional.” When the other professionals are their teachers, this mistake is far less likely to happen.


If “teamwork” sounds like business-speak, Williams has another word for it: “It’s really like a family,” she says. “Everyone has a role to play and a job to do.” With a little practice, health-care teams might become that rare breed: a functional family.
~WHO'S WHO


Future physicians will encounter a diversity of nonphysician clinicians on the wards. Here’s a primer on some of the most common, and what they typically do, although authority and responsibilities vary from state to state:





FIRST PERSON:
Playing a Team Sport

By Andrew W. Seefeld, M.D.



“Doctor, there is a new patient in room 15 with a systolic blood pressure of 60, pulse in the 130s and a hemoglobin of 4.6!”


Wow! How this man walked into the emergency department (ED) coherent, with a blood count at this level, was a mystery to me. Evidently the patient is a known GI bleeder who left the hospital yesterday after an unsuccessful endoscopy. However, at this point it didn’t matter why the patient had signed out against medical advice. What did matter is that we had a group of health-care professionals who understood the unstable nature of the patient’s current condition.


Entering the room, I, the emergency medicine resident, stood back for a second and watched. On the bed lay a middle-aged male, markedly pale, profusely diaphoretic, in significant distress. To his right, a nurse was skillfully putting in a large-bore IV; on the left, a technician was placing the patient on oxygen and a cardiac monitor, and was beginning to obtain an EKG as well as baseline vital signs.


As I began gathering the patient’s history and conducting the physical exam, I couldn’t help but notice how well we were all working together. In the ED this is vital, especially for critical patients. Blood needed to be drawn, IV fluid needed to be infused, a nasogastric (NG) tube needed to be placed, and consults needed to be paged. In fact, our ability to care appropriately for this patient was directly proportional to our capacity to work together. Leaving the room, having completed my physical exam and written orders, I felt confident that my colleagues were managing him well.


I finished writing up the chart and was heading to see another patient when a nurse informed me that they were having difficulty passing the NG tube. But it was imperative to prove to the gastroenterologists that there was active bleeding in the stomach so they would prioritize this extremely unstable patient. Entering the room, I informed the nurses that I would try to place the NG tube. They smiled, and almost laughed. The idea of a doctor being able to perform such a task was both humorous and extremely unlikely.


Little did they know, I had spent a year prior to medical school working as a technician in an ED, placing IVs and NG tubes and doing all sorts of procedures that the nurses had taught me. With some assistance, the tube was placed, and we were on our way to lavaging the stomach.


My eagerness to help with the procedure seemed refreshing to my nursing colleagues. However, it also provided another example of how success in emergency medicine is team-dependent. It didn’t matter whether or not I was the physician in charge of this case—a procedure was needed, and I had the ability to do it, thanks to the training I had received as an ED technician.


With the tube in the stomach, we suctioned out a significant amount of bright red blood, indicating that the patient did indeed have an active bleed and would need an emergent endoscopy. Walking back to the central workstation, I asked for the gastroenterologist on call to be paged. After explaining the story, she agreed that the patient would need the procedure, confirmed that we were transfusing packed red blood cells and providing the appropriate medications, and stated she would be heading into the hospital.


Success! Quality patient care had been achieved through the power of a team approach. Watching the patient being wheeled out of the ED, I was pleased. Not only had we excelled as a team, but we had also proved that this type of unified approach in emergency medicine, in terms of efficiency and delivering quality care, is almost always a victory. This achievement was the product of a group of people willing to work together toward a common goal, independent of level of training, degree or title. There is certainly no place here for arrogance and egotistic individualism. Everyone, from administrative assistants and technicians to nurses and physicians, plays an integral role on the patient-care team .


Dr. Andrew W. Seefeld is currently completing his residency training in emergency medicine at the University of California, Los Angeles/Olive View Program in Los Angeles, California.
~~~Avery Hurt is a freelance writer in Birmingham, Alabama.~Diversity in Medicine,Medical Education,Practice of Medicine~
391~7October~2007-56~On the Wards~The Other Patient~The man at the bedside was suffering too~Gary Schooler~The patient at the bedside~There were two: one lying on a hospital bed, the other standing by his side.


I had the good fortune of meeting both on my second night on call for the medicine service at the VA medical center in Oklahoma City. I had spent what felt like 24 hours in the ER, but in reality, I had only been there around two and a half. I was tired. Everyone was tired. Patients appeared to be everywhere—some sitting in wheelchairs, some lying on gurneys, all trying to stay out of the way of the busy shuffle. It seemed the addition of one more patient would surely be a violation of the fire code.


After I got the call to see Mr. F., I found my way to his glassed-in bay and peered through the slit between the curtains. While I stood there, I contemplated what my resident had told me about him: “67-year-old white male with a history of multiple myeloma who is here for nausea, vomiting and diarrhea.” After spending the better part of two or three minutes striving to remember the details of the pathophysiology of multiple myeloma, I pushed back the curtain and entered his bay.


He looked uncomfortable. He was lying on his left side, neck flexed, head almost off the pillow and eyes staring into space. I introduced myself in the usual fashion, indicating that I was a student and that I would like to visit for a while and hear about what had brought him to the ER on this particular occasion. Having earlier read the brief note written by the ER physician, I was well aware that getting my 101 questions answered in the full detail I had come to expect would be more of a chore than usual, as my new patient had suffered a stroke that had affected his “word finding” ability.


I shook my new patient’s hand, then turned and introduced myself to the other man in the room. When he replied, his eyes gave away their relationship more so than any of the words he spoke: He was the patient’s brother.


My questions and our conversation eventually allowed me to learn a significant amount about my new patient. He lived alone in Oklahoma City and had done so his entire life. Because of his stroke, he had been placed on full disability and could no longer program computers as he once had.


With careful attention to his medical history, I learned the cancer was bad. It had spread throughout his entire vertebral column. In the previous year, he had undergone a stem cell transplant and received chemotherapeutic drugs I could not even pronounce. Throughout his tribulations, his brother had been by his side, close enough for security but far enough to offer a sense of independence. He checked on his brother daily, and on bad days, such as the one being suffered today, he took extra time and helped him get to the doctor.


My exam had to be performed with careful detail. I needed to correlate a five-day history of fever, nausea, vomiting, neck pain and headache with physical findings to arrive at some conclusion about what was causing my new patient his obvious discomfort. Possible diagnoses raced through my mind with each exam finding.


Pain was a recurring theme. Barely moving at all, my new patient winced in discomfort while he searched for the words to tell me what he was feeling. Often, no words came at all. As I scrutinized from head to toe, the patient’s brother stood by the bedside as a spectator. His hands rested on the bed rails. After every maneuver, he looked at me and his eyes asked, “What does that mean?” I did my best to explain what I was seeing with each palpation, percussion and auscultation. When I finished, I thanked them both for their patience and willingness to share their problems with me.


As I began to walk out of the room, it was evident by the apprehension worn on his face that my new patient’s brother was worried. He forced a smile and stood there with his hands tucked into the front pockets of his jeans. He did not say a word. In the brief awkwardness of the moment, I thought, “How could I, as a third-year medical student, bring any comfort to a man who had seen his loved one suffer more in the last four years than many do in a lifetime?” My skills as a young physician were novice at best.


I was not sure of any diagnosis. Nor was I certain in what direction the treatment plan was going to go. But I realized that what I could do was listen to his questions, keep him informed, and do my best to explain to him in simple terms what would come next for his brother.


And this is exactly what he wanted. He didn’t expect any Oslerian feats of medicine to be performed right there in the ER bay. Rather, he wanted someone to recognize that while his brother was aching from disease, he was aching with an immense amount of empathy for his closest companion.


My brief career had been filled up to that point with countless lessons in medicine that emphasized pathophysiology, treatment and prognosis. I realized that night that there is sometimes more than one patient, and being a compassionate doctor is truly about good “patient care” for all of them.
~~~~Gary Schooler is a fourth-year at Oklahoma University Health Sciences Center.
Have an interesting story about an experience you had while on the wards? Let us know. Send it to us at tnp@amsa.org.
~Medical Education,Physician Patient Relationship,Practice of Medicine~
392~7October~2007-56~Specialty Close-up~Radiology~Out of the darkness~Martha J. Frase~Radiology~As a first-year medical student, Dr. Adam Talenfeld remembers overhearing one fourth-year tell another, “There are three things you can do on a daily basis as a doctor: You can hold clinic and talk with patients, you can diagnose disease, and you can treat and do procedures. In most specialties you’ll spend most of your time doing two of these, so you just have to pick which two you like best.” But Talenfeld ultimately discovered a specialty that, for him, offers a taste of all three.


Radiology is usually thought of as a diagnostic specialty, but advances in its fastest-growing practice area—interventional radiology—allow radiologists to treat disease through minimally invasive, image-guided surgery, which comes with a significant amount of patient contact.


“I really like radiology’s emphasis on diagnosis, and I like that by specializing in imaging, I continue to learn about every organ system and almost every other specialty,” says Talenfeld, now in his fifth year of residency at Mount Sinai Medical Center in New York City. “But radiology [also] offers many opportunities for image-guided procedures/therapy.” And with his eye on an interventional radiology practice, “I also look forward to performing problem-focused consults and post-intervention follow-up visits as part of an office-based practice, as would any other surgical or procedural specialist.”


The stereotype of the pale, solitary doctor reading endless stacks of films in a dark, windowless room has been shattered by radiology’s progressive technologies. The advent of PACS—picture archiving and communication systems—has made reading film quick and efficient; meanwhile, innovations in molecular imaging are enabling radiologists to go beyond visualizing anatomy toward perceiving molecular changes in the body. “It’s a very interesting field—challenging and intellectually stimulating; You continually have to keep up,” says Dr. Martha Mainiero, professor of diagnostic imaging and director of Brown Medical School’s radiology residency program.


It’s also one of the most diverse specialties. Almost all radiology residents subspecialize, concentrating perhaps on specific organ systems—cardio, gastrointestinal, genitourinary, neuro—or on body regions, like abdominal, breast, musculoskeletal, or head and neck. Others subspecialize in the types of patients they treat, like pediatric, women’s or emergency. Most become experts in more than one area.


That’s one reason Dr. Matt Davenport, a PGY-3 at the University of Michigan, was attracted to the specialty: “It offers the best opportunity to become a master in a particular field. One of the nicer things about radiology is that, although you are already a resident, you still have many options in front of you. For instance, you can select a heavily procedural fellowship—e.g., interventional radiology—or something less so—e.g., emergency radiology.” Davenport adds that “although the bulk of your time is spent interpreting diagnostic images, radiology is at its core a procedural specialty. From conducting biopsies to performing cerebral angiograms, radiologists have ample opportunity to be as much or as little involved [with patients] as they wish.”


Residency training in radiology takes five years, with a minimum of four spent in diagnostic radiology. A minimum of six months must be spent in nuclear radiology, and a full year must be spent doing clinical training in internal medicine, pediatrics, surgery, OB-Gyn, neurology, family practice, emergency medicine, or some combination of these. This clinical year will usually be the first postgraduate year. In their fellowship year, radiology residents can explore neuroradiology, nuclear radiology, pediatric radiology or vascular and interventional radiology. (Radiation oncology is treated as a specialty distinct from radiology, having its own five-year residency track.)


Radiologists tend to work in group practices, most of which have hospital and outpatient components, although some practices focus on one setting or the other. The lifestyle is considered desirable and well-compensated. “Radiologists are fortunate,” Mainiero says, “in that they can get a job anywhere they like. And it’s a pretty controlled lifestyle, with some weekend or night call, but since it’s usually shared among a group practice, it’s not so burdensome.”


Radiologists can also adjust their schedule freely. “You have the capacity to work part time, or to work different shifts,” she adds. “Some people I know hire themselves out to do night call for other groups.”


But earning extra cash isn’t typically a problem for established practitioners; radiology is among the highest-paid medical careers. According to the American Medical Group Association’s 2006 compensation survey, those
performing interventional radiology earned a median salary of $424,992—an increase of 3.59 over 2005 and the sixth highest among the 108 specialties included in the survey. Noninterventional diagnostic radiologists ranked eighth overall, with a median of $400,000—an increase of 9.62 percent over the previous year.


But can the gravy train keep chugging? Medical students worry that the field is too competitive, and the growing use of nonphysician clinicians (NPCs) and “super technologists” to do imaging will further erode job availability. But Mainiero is reassuring: “The field has actually been projecting a shortage for a few years, so jobs are plentiful and easy to get.” And although training slots are necessarily limited by Medicaid funding and hospital staffing constraints—the 2007 Match filled all 141 PGY-1 slots in diagnostic radiology and 98 percent of the 902 PGY-2 slots—she notes that the number of positions offered has stayed stable or climbed slightly in recent years.


“The Match is competitive, but there are so many different kinds of programs, most people can usually find a fit. You don’t have to be at the top of your class,” says Mainiero.


As for NPCs, she reports, “Radiologists are starting to use physician assistants and X-ray techs to perform some of the procedures, but at this point there is so much to be done, [NPCs] are seen not as a threat but as an advantage. More imaging is being done, with more applications, and it has become central to the practice of medicine.”


Indeed, Davenport is stimulated by the number and range of cases he sees: “Every complicated patient makes his or her way down to the department at least once, if not a few dozen times,” he notes. “Every specialty uses our services and every specialty in some way or another relies on our advice. Therefore, as a radiologist, you are in a position to make significant alterations in the course of clinical care across nearly every medical specialty.”


The exciting pace of change and the multiplicity of patients may be one reason radiologists tend to stay in their jobs longer than most physicians. A study in the December 2006 issue of the American Journal of Roentgenology reported that more than half of practitioners over age 65 are still active in the field.


But no one seems to know exactly why the field remains so male-dominated. The latest study on gender gaps from the Radiological Society of North America failed to yield “a conclusive answer” as to why women, who make up almost half of all medical students, represent only one-quarter of diagnostic radiology residents.


“Women are much underrepresented in radiology,” Mainiero acknowledges. “We would like to see that change.” Anecdotally, women usually give the reason that there is not enough patient contact, or it’s too technology-centered, she explains. “But the reality is that we need all kinds of radiologists—the computer-savvy engineer technophile, as well as those who are patient-oriented and barely got through physics in high school.”


The specialty should appeal to anyone “who loves the intensely cerebral diagnostic exercise of medicine,” says Davenport. “Each day is spent making literally hundreds of decisions regarding benign and pathologic processes. You have the opportunity to know and be familiar with all the rarest diseases that you never thought you’d have to memorize—and even get to learn hundreds more you never knew existed! Not to mention the fact that radiology has become the hub of the hospital framework.”
~Radiology at a glance




Resources

~~~Martha J. Frase is editor of The New Physician.~Career Development,Medical Student Debt,Residency~
394~7October~2007-56~Feature~SPOTLIGHT: Intimate Details~Schools shy away from sexuality training~Yvonne K. Fulbright~Think you know a lot about sex? Then just try and speak candidly about it to your patients. Without instruction on communicating sensitive sexual topics, new physicians miss key opportunities to diagnose disease and transmit healthy behaviors.~Will any of your future patients need advice on the function of the clitoris, the timing of ovulation, the etiology of sexual dysfunction or the safety of coitus in late pregnancy? It’s highly likely. But will you have the answers—or be able to help them ask the questions?


Sadly enough, Cosmopolitan may prove to be a better sex-information resource than your average physician-in-training. For more than four decades, studies have found sexual ignorance running amuck in medical schools worldwide, with information beyond the biological rarely given proper time and attention.


Sexual function is a major quality-of-life factor, and sexual health impacts one’s physical, emotional and psychological well-being. Yet most medical schools are failing to train future physicians adequately, despite the modern-day doctor’s role as health educator, counselor and resource.


Sorely Lacking “Sexpertise”


“It surprised me that many of my colleagues didn’t have a background in sex ed,” shares Dustin Costescu, a fourth-year at University of Western Ontario School of Medicine & Dentistry. “Many of them have the same questions patients do. They don’t have more than public knowledge.”


Bias, anxiety, gaps in knowledge, misconceptions and discomfort with the subject are some reasons many physicians are ill-equipped and deficient in providing sex information and counseling to their patients. “In terms of sexuality [information], we’re not producing capable physicians,” states S. Michael Plaut, associate professor of psychiatry at the University of Maryland School of Medicine. “We need to, for example, think about who we conceive of as a sexual person beyond young, heterosexual people who can reproduce. If you’re over a certain age, or with chronic illness, disabilities, mental retardation…nobody wants to talk about that—and these people do have sexual issues.”


Not surprisingly, medical students find it difficult to develop comfort and the ability to discuss sexuality with patients, as New York-based sex counselor Eric Garrison can attest: “One thing that strikes me is how heterosexist medical students are,” he says. “I also find their knowledge of reproductive anatomy appalling, despite physiology classes. They confuse vagina with vulva all the time.” In his work training medical students and clinicians, Garrison often hears students ask why taking a sexual history is so important, and wonder aloud why patients won’t just volunteer what’s wrong. “They don’t get it,” he asserts.


He also finds that students can be very judgmental in the area of sex. “You can see it in their facial expressions—they can’t say herpes or HPV without cringing. I actually had a female medical student ask a patient, ‘You do what?’—and it all ended right there.”


A 2001 study among Harvard and University of Massachusetts medical students found that only 6 percent were “very comfortable” taking a sexual history of patients 55 years and older. Also, students were more comfortable discussing male erectile dysfunction than loss of libido or vaginal dryness in postmenopausal women. And there was a marked difference in students’ comfort levels in taking a sexual history from heterosexual versus homosexual patients, with the majority of respondents feeling unprepared to provide sexual counseling to the group not sharing their orientation. Based on the study’s findings, Harvard went on to create a sexual health awareness elective in 2005.


Thanks to mass media and the Internet, patients are becoming more sexually savvy. A better informed—and often misinformed—public now sees sex as suitable for discussion, is more concerned about sexual performance and is more willing to get help for sexual problems. Michael W. Ross, lead author of the book Sexual Health Concerns: Interviewing and History Taking for Health Practitioners, highlights the dilemma: “Because the physician is the first point of contact and referral, patients expect physicians to know about sex and to have a basic level of competence. We discovered this when Viagra came on the market. Doctors were shocked by the number of men who came in with erectile dysfunction, demonstrating how many physicians aren’t talking about it. [They] can’t talk about it or don’t want to raise the issue.”


A major consequence of this silence is that the sexual history is not taken often enough. Among the reasons physicians cite for not doing this are concerns over patient discomfort, belief that a sexual history is irrelevant to the chief complaint, inadequate training or knowledge about what to do with information collected, and their own personal embarrassment. Yet the need to take a sexual history is great, regardless of a physician’s specialization, for reasons like:




Ultimately, the goal of a physician should be to integrate sexual health care into patients’ general care. If this is omitted, a major aspect gets overlooked, significantly reducing the clues to diagnosis and basic treatment.


Until about 1956, medical schools found it all too easy to ignore completely the subject of human sexuality, laden as it was with misinformation based on scientific ignorance and contradictory emotional, cultural, religious, moral, ethical, political and social messages. But along came Dr. Mary Calderone, medical director for the Planned Parenthood Federation during the ’50s and early ’60s. She is credited with integrating the study of family planning into U.S. medical school curricula, and was among the first to point out the disturbing lack of birth control information in four of the major obstetrical textbooks.


Yet by 1960, only three medical schools offered formal sexuality instruction, despite research indicating that doctors were using questionable sources of information and personal values in counseling patients. Faculty resisted on moral grounds, and few were trained adequately to teach such subjects.


It was not until 1968, backed by the sex research of Dr. William Masters and psychologist Virginia Johnson, that larger numbers of medical schools started offering sexuality programs. Medical education finally had sound scientific knowledge based on reproducible lab evidence. Coupled with the sexuality explosion of the time, and increased expectations that primary care doctors be willing and able to handle patient sexuality concerns, medical school courses of the 1970s often included two- to five-day explicit multimedia presentations, large and small group discussions, lectures, counseling demonstrations, panel discussions, workshops and written exams. The goal was to demythologize sexual behavior, desensitize overreaction to stimuli, re-sensitize one in the direction of human and professional understanding, develop tolerance, and understand one’s own sexuality and that of others.


Almost all U.S. medical schools were involved in teaching human sexuality by 1975, thanks in large part to Dr. Harold Lief, who championed comprehensive sex education through his work with the Center for the Study of Sex Education in Medicine at the University of Pennsylvania. By 1977, 81 percent of American medical schools offered such instruction, but only 45 percent offered organized courses and only 42 percent had required courses.


But by the 1980s, efforts were diminishing. Even the program at the University of California, San Francisco, School of Medicine, considered a national model with its thriving sex therapy clinic, slowly died out. In 1995, Barnaby B. Barratt, of the American Association of Sex Educators, Counselors, and Therapists, reported that 90 percent of medical schools are doing essentially nothing in the realm of human sexuality. “What [is] significant is that since the mid-’80s, sex education in medical schools had definitely dropped off. Some schools dropped their sex class to pick up an HIV course, which can make what is taught more negative.”


Out of the Brown Bag


Dealing with a subject often framed by infectious diseases or “deviant” behaviors, medical schools have struggled with delivering adequate sexuality and sensitive-communication training, with few success stories today. Students identify many curricular gaps in areas like sexual assault, abortion, lesbian-gay-bisexual-transgender health and HIV, with some schools simply handling matters over a brown-bag lunch. Others, however, are taking matters more seriously.


Hailed as an extremely sophisticated program, Quebec’s Université de Sherbrooke Faculty of Medicine’s four-day, required “Human Sexuality Camp” is led by a clinical sexologist and urologist, and involves an intensive self-examination of attitudes and sensitivities toward various aspects of sexuality.


The University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School hosts a required “Sex Week” for second-years. Based on the belief that physicians should be well-rounded people first, the program goes beyond facts to delve into ethics, values, beliefs and attitudes. Within the 40-hour, five-day human sexuality course, student “sexpertise” is cultivated through films and slides, lectures, small group interactions, testimonials and panel discussions.


The University of Minnesota’s flagship Program in Human Sexuality is respected for its knowledgeable faculty, leadership and curriculum. It hosts a sexuality course for first-year medical students, equipping them with the knowledge needed for the primary care of patients’ sexual concerns.


Apart from these recognized standouts, it is difficult to really evaluate who else is doing what well, given that there are no curricular standards for sex education. Data collected from 73 medical schools by the Association of American Medical Colleges exemplifies this lack of structure, with courses covering a mishmash of sexual development, sexual abuse, gender disorders, sex and culture, sex and spirituality, with some programs seemingly more active than others.


Complicating matters further is just how little sexuality is covered within more general courses. Barratt stresses, “Human sexuality gets continually squeezed out of medical education. In comprehensive curricula, it gets integrated, but it is an orphan topic, along with domestic abuse, cross-cultural issues, drug and alcohol treatment…depending on faculty.”


The most recent assessment of the 125 U.S. and 16 Canadian medical schools of how they prepare physicians to diagnose and treat sexual issues was a 2003 study from the Medical College of Georgia. It recommended that an “expansion of human sexuality education in medical schools may be necessary to meet the public demand of an informed health provider,” based on the following findings:



More than one-quarter of schools did not respond to the survey at all.


Interestingly, Canadian schools devoted more time to exploring attitudes and beliefs related to sexuality, whereas American schools appeared to stress facts more.


The findings are a far cry from what students like Costescu want: “A good program involves a motivated professor who can speak to issues, and faculty that support progressive medical education. They have not only medical facts, but psychological information, like risk factors for teen pregnancy.”


For many students, “sex education is very much self-directed,” he adds. “You need to find people doing research, find articles and read up on it.”


To create their own learning experiences, students should shoot for activities that nurture a knowledge base and skills building, recognizing that challenges for student-initiated electives include securing funding, finding administrative support and guaranteeing sustainability. Among the strategies students can use for molding sex education initiatives at their school are: inviting outside experts to speak; talking to students at other schools to find out what’s working on their campuses; encouraging premedical students to take human sexuality courses; hosting events that take a formative, student-centered approach in pursuing active learning techniques; and working with sexuality organizations in drafting enticing curricula, backed by faculty and a plan of implementation with which to woo deans into action.


“Medical education does not incorporate the kind of curriculum with standards and expectations as it relates to sexual education,” holds Jay Bhatt, immediate past president of the American Medical Student Association. “The content students and schools can develop in this area will help the next generation of physician-leaders adequately deal with issues of sexual orientation, environment and pathology in a way that is sensitive and appropriate.”
~~~~Yvonne K. Fulbright, Ph.D., is a sex
educator, consultant and author of several books. Her Web site is www.sexuality source.com. Direct comments about this article to tnp@amsa.org.
~Learning Tools and Technology,Medical Education,Physician Patient Relationship,Practice of Medicine~
397~8November~2007-56~Resident Rx~Cut and Run~Why I quit surgical residency~Charity Thoman, M.D.~Throwing in the scalpel~It’s painful for me to write this. I’ve never loved anything more than surgery. Even now, a full year after resigning, answering the question of “Why?” hits a tender spot.


This is a raw confessional for medical students ready to take the plunge. My goal is not to discourage you from entering surgery, but to speak to those like me: someone who had all the signs of a star surgeon in training, yet was doomed at the outset.


As a fourth-year at a prestigious private medical school, I was a surgery nut. My fourth-year “Pig Surgery” elective found me staying up all night, poring over The Atlas of Surgery. When I successfully completed an open left nephrectomy on that poor pig, I celebrated by buying myself Sabiston to start reading for residency. Operating was the ultimate high.


After matching at my No. 1 choice, I started my intern year full of energy and high hopes. Every operation was fascinating. But as the year drew on, a more sinister side of this work became evident. I began to notice that while the interns were exhausted, and the junior residents miserable, the senior residents had a residing bitterness that permeated every corner of their lives. They snapped at the floor nurses, spoke of deteriorating marriages and even harbored anger toward the guy who served their lattes every morning. But that was not me…not yet.


During my first month, I posted an article in the residents’ lounge about Médecins Sans Frontières pleading for surgical residency graduates to fill volunteer spots in the war-torn regions of Africa, and describing the shortage of surgeons in particularly needy areas. I found it both interesting and relevant to our careers. The next day I was shocked to read a new message scrawled across the article: “Inappropriate. Get back to work.”


Where did the surgical residents learn this cynicism? From the attendings, of course. It was modeled for us every day in the operating room.


Our attending used to enter the OR asking me what the interns had screwed up today on his service. He would yell at the scrub nurse for not prepping in his particular style and ask the anesthesiologist demeaningly what med student had taught him how to insert lines. By the end of one particular appendectomy, my nerves were so shot from the constant barrage of insults and having my hand repeatedly slapped—literally—that it was no wonder I screwed up my subcutaneous stitch a few times.


And like the good students we were, we modeled the behavior that was modeled for us. Raymond, one of the chiefs, replicated the attending’s insulting style later that day when he berated the junior resident over his choice of antibiotics for a post-op patient. Hours later, I was on the receiving end when the same junior resident laid into me over the type of tape I had used to dress the wound. I went home and took it out on my loving dog.


By halfway through the year, the junior residents had become proficient in the art of abuse. In horror, I watched people whom I deeply admired evolve into replicas of the malignant attendings. The progression was subtle, but inevitable. To justify my guilt over tolerating the abuse, I fooled myself into believing that I would somehow be different.


Then one evening in the doctors’ lounge, the director of the hospital’s medical staff approached me. I assumed he was going to congratulate me on getting the highest ABSITE score in my class. Instead, he whispered in a husky voice, “You’re lucky I’m a married man. If I were 20 years younger, and single, you’d be in trouble.”


My silence was less one of intimidation than of shock. Still, as a female—and a blonde one at that—I had accepted that I would face challenges my male colleagues would not. I stand by that statement even now: The sexual harassment and uncomfortable attention I received was not what made me throw in the towel. But it didn’t help.


Then there was the problem of reproduction. (“What do you plan to do with that uterus of yours?” a surgical director asked me in one of my residency interviews.) During my first few days as an intern, Shannon, my chief on GI surgery, gave our entire team a lecture on how critical it was that women wait to bear children until their careers are well established. Later, and privately, I asked her why she had such strict policies on something so personal. “You would be abandoning the program,” she replied vehemently. “You want to be a surgeon, don’t you?”


Over the year, I also began to understand how my attendings lived. One morning at 2:00, we were waiting for the on-call surgeon to finish his last appendectomy so we could do a rectal abscess drainage. As he shuffled into the OR, his shoulders drooped in exhaustion. “Don’t you want the billing sheet?” the circulator asked him. “For what?” the surgeon grumbled. “You really think this guy’s got insurance?” He later explained to me that 30 percent of his on-call work was done for free.


Imagine any other professional working for free almost one-third of the time. I began to grasp the private surgeon’s dilemma as reimbursements continue to fall and more Americans are without insurance. Veteran surgeons, who labored through residency before the mandatory work-hours restrictions, are still working like dogs. And unlike us, their hours have no compulsory limit. At the end of this difficult yellow brick road, there is no Emerald City. In fact, there is just more of the same, stretching as far as the eye can see.


Everything became clear for me one warm Sunday morning. Exhausted from a rigorous call night, I plopped myself onto the deck in my scrubs. I cracked open a beer and lit up a cigarette, still fuming over my fellow intern’s mistake that had earned me a good whipping on morning rounds. My fiancé came down and frowned at the cigarette. “Aren’t you going to church for Easter?” he asked.


Easter? I gave him a blank look. Then it hit me. There I was, downing a beer, smoking a cigarette and calculating my revenge on a fellow resident—on Easter Sunday. The day of the year that I held as sacred and holy. Never, even during the throes of medical school, had I neglected to honor the holiday, much less forget it all together. My faith had always been the central pillar of my character, and without recognizing it, I’d traded that in.


Over the next month, I took an inventory of my own character. In place of the vibrant, tender spirit who had started surgical residency was a deflated cynic. I dissected all the aspects of my chosen career, from the challenges I would face as a woman and mother to the fatigue I’d seen in older surgeons. This analysis led to the very difficult decision to leave my passion, surgery, to pursue a kinder field of medicine.


Maybe it is throwing in the towel, or maybe it is succumbing to surgery’s scheme to weed out the weak. Either way, I accept my fellow residents’ criticism, and I accept that I will never again get to operate. But I see myself as the winning player in this game. After all, I ended up happy. Will my former peers feel the same?


The hard-core surgical residents reading this will dismiss me as a softie. The veteran surgeons may sigh and reminisce about times when the pot at the end of the rainbow was, in fact, full of gold. But medical students seeking to avoid becoming an intern with a fate like mine will listen.


I want to tell you some things I wish someone had told me: Know what you’re in for. Program directors who sugarcoat the lifestyle may be misleading you. For women who want to “have it all,” don’t assume the genders are equal in this profession. You will be asked to choose between being a great mother and a great surgeon. Finally, be prepared to tolerate an abusive environment in silence. Humanitarians with a strong sense of justice may deteriorate emotionally, as I did, from the chronic mistreatment.


The greatest risk you will face is losing the compassion and integrity that drove you into medicine in the first place. Thankfully, I have not.
~~~~Dr. Charity Thoman is a first-year internal medicine resident in Southern California.


Send comments about this article to tnp@amsa.org.
~Ethics,Residency,Student Life and Well-Being~
399~8November~2007-56~Feature~Night Classes~Dream interpretation for first-time healers~Jeremy Spiegel, M.D.~The raw material generated in just a few hours of slumberous dreaming can reveal fascinating insights about your unconscious conflicts and desires. Dream interpretation is an especially appealing method of self-discovery that can be pursued wherever you can find a pillow.~Since dreaming is correlated with intense study, you as a medical student can be expected to dream more than individuals outside academia—that is, if you can get enough sleep.


Learning to decipher your dreams can reveal unconscious conflicts you face in medical school and the nature of your true self, and can help transform medical school “nightmares” into positive, profession-affirming experiences.


When interpreting a dream, first look at how it unfolds, noting its contents. You will likely discover some of the “special effects” Dr. Sigmund Freud describes in The Interpretation of Dreams, especially condensation, displacement, repetition and wish fulfillment.


Condensation is a distillation of two or more beings or ideas from waking life into one image, frequently manifesting as a composite human being. Displacement occurs when dream content is oriented toward a feature or action unrelated to the dreamer’s waking focus of attention. Repetition entails a dream element appearing more than once—either in the same dream or in recurring dreams—in formats such as imagery, language and wordplay. Wish fulfillment discloses a wish that the dreamer unconsciously wants fulfilled. The fulfillment is sometimes expressed overtly; other times in subtle imagery.


If disregarded, these elements can lure you into psychic tumult or leave you with disturbing sensations long after awakening. Over time, these experiences are absorbed while their meaning remains unconscious, provoking self-defeating attitudes or actions, as well as unhappiness as you shuffle disagreeably from patient to patient.


But practicing dream interpretation can help you access and reinforce your true self, increasing self-awareness. And the greater your self-awareness, the better your ability to function as a confident medical student, mindful of, rather than ruled by, the hidden agenda of your unconscious.


Ultimately, you can learn to dispel the anxiety found in disturbing dreams and use the passion of exhilarating dreams to enhance your waking energy, slipping it into your scrubs pocket like a golden nugget and taking it with you on your rounds.


Unraveling the Unconscious


Ted, a fourth-year who had just completed an infectious disease elective, had this disturbing dream:


“I’m in a treatment room with the attending, and there’s a patient wearing a loose-fitting gown. Something is horribly wrong with this poor man: He has straw-like gunk in his eye sockets, completely covering his eyeballs. Sweating, he grunts intermittently, his speech basically unintelligible…. Knowing immediately what to do, I take a sponge and soapy water and scrub his back for him.


“The man is at once a patient and my paternal grandfather. I look toward the attending physician, whom I now realize is actually my father-in-law, a doctor in real life, and he nods in approval of what I am doing for this patient. Suddenly discovering that I have not been using gloves, I pull on a pair and quickly return to the work of scrubbing. Now I see that the patient is infected with some kind of parasite. As I scrub vigorously, he says, ‘That feels good.’ His words make me feel good, too.


“But when I begin washing up, feelings of fear, resentment and rage come over me, and I ask the doctor if the patient is infectious. ‘I suppose so,’ he says. As I pull a couple of brown paper towels from the dispenser, my most horrible fears are realized. There, on my right glove, I spot a little wormlike thing with a bifurcated head standing on its hindquarters and undulating slowly from side to side. The word fluke comes to mind, and I instantly see a bunch of flukes attached to my arms. Now I realize that I will become like this patient, only I will die and my family will suffer. ‘What a horrible mistake. Why didn’t somebody warn me?’ I say to myself, feeling a nauseating sensation in my gut.”


This dream’s evocative contents yielded numerous insights into Ted’s conflicting anxieties and passions. It contains two examples of condensa-tion: The attending doubles as Ted’s father–in-law. The patient combines with Ted’s paternal grandfather, who died prematurely of congestive heart failure and chronic obstructive pulmonary disease. In effect, the condensations embody themes relating to family relationships and vulnerability to illness and death.


The essential action in the dream— scrubbing the patient’s back while tragically overlooking the need to protect himself with gloves—is a display of altruism gone wrong: The “son” cares for the grandfather under the guidance of an ineffectual, neglectful attending (or father-in-law), who leaves him vulnerable. In the dream, Ted revealed, he is less concerned about transmission of illness than about looking helpful in front of his superiors, and further explained that on his clinical rotations he often felt vulnerable himself as he cared for others, especially older men who should be protecting him. The dream illuminates Ted’s emotional nakedness—the true cause of his psychic distress.


Further, Ted’s dream contains the element of repetition—multiple meanings of the word fluke. He admitted that his lack of confidence has sometimes made him wonder if he got into medical school “by some ‘fluke,”’ and would say that very word to himself.


The unconscious wish in Ted’s dream—his desire for an inner sense of goodness and productivity—is fulfilled in the washing of the patient. The positive feelings this act evokes reflect Ted’s exhilaration at helping others as a physician. To him, a true healer involves being in physical contact with a diseased body and overseeing the patient’s course of treatment, both of which are represented in his dream.


Through dream interpretation, Ted has become more cognizant of his reactions to older men and gradually has gained a healthy sense of self-protection, trust in his own judgment and the ability to take cues from his true self.


Collecting Shells


Immediately focusing on a dream’s revelations helps prevent you from forgetting them in the controlled chaos around you. Here are some guidelines for learning from your night visions:


1. Place a pen and paper near your bed before going to sleep, whether you are at home or on call in the hospital. When you wake up from a dream, write down the content as you remember it in a quick, linear way before it fades into the ether like a helium-filled thought-balloon whose string slips gently from your weakening grip.


2. Next, list the important people, objects and actions in the dream, even if you do not yet recognize their symbolic meanings.


3. Look for condensations, displacements, repetitions and wish fulfillments in the dream content, enjoying the creations of your unconscious mind as you search for the insights they provide.


4. Free-associate to the dream imagery, noting the first thought or image triggered by elements of the dream, no matter how irrelevant it may seem. For example, dreaming of a plastic speculum behind a glass showcase may at first remind you of the day you, as an art student, were asked to visually analyze a speculum as an art object, bypassing its functional aspect. This experience in turn triggers memories of your elementary school art class, rife with rubber cement “boogers” and feelings of being small, messy and uncomfortable in a smock. Then with a sudden insight that causes you to fast-forward to the present, you see a connection between the art smock and a surgical gown, concluding that the gnawing feelings you have had lately relate to apprehensions about abandoning creativity for medicine’s methodical approach.


5. Finally, ask yourself which elements, themes and resulting insights you want to hold in your waking life to strengthen your true self—which shells collected from your psychic sea you wish to keep as you see your next patient or do your next procedure.


Nightmare Do-over


Just as you can keep positive aspects from your dreams to enrich your true self, you can also dispense with elements that detract from the vision of who you would like to be. The “nightmare rehearsal technique” is a means for revisioning a frightening or unpleasant dream, weakening its power to cause anxiety or other psychic distress.


Imagine that two weeks before your OB-Gyn rotation, you have the following dream: You are in a hospital near the elevators with a group of your fellow medical students. Suddenly, a succession of large-bodied people in physical pain are wheeled quickly in their hospital beds to the center of this open area where they crash into one another. As this happens, the elevator opens and you dash inside, but when you push the black “tongue” along the side of the door to keep it open for your classmates, it cracks apart, reminding you of an unhealthy placenta.


The door then closes abruptly, pinching your stethoscope and ripping your white coat pocket, out of which falls a small address book with a disturbing image on the front: a baby with mongoloid features emerging from a birth canal, and the faces of the horrified parents. You realize you are personally responsible for this tragedy and experience self-loathing. You conclude that the birth of this child with Down’s syndrome to ill-prepared parents is somehow linked to your poor practice.


This dream recurs several times during your OB-Gyn rotation, forcing you to experience yourself as a klutz with a reverse Midas touch—holding a position of responsibility but contributing to a disastrous outcome.


To work with this dream, first implement the steps outlined earlier to determine its meaning. Then use the nightmare rehearsal technique, revising the dream positively by going back in time to the patient’s prenatal care and seeing yourself as the practitioner who performs the amniocentesis and receives the karyotyping results. You could envision finding that the chromosomes are normal and there is no Down’s syndrome, or see yourself discovering the abnormality and helping the parents cope by explaining their options.


After revising the dream in your imagination, “rehearse” the new dream sequence in your mind before bed. The new, emotionally nourishing content reflecting your conscious wish fulfillment as a physician will become absorbed into your mind, simultaneously decreasing your anxiety and enabling confidence to spring from your true self by envisioning the type of physician and healer you wish to be.


As you record and explore the possible meanings of your dreams, you’ll become aware that they are not simply visions that restore exhausted medical students until their pagers beep them back to awareness. Rather, dreams are useful tools for understanding hidden conflicts and desires, and for activating and nourishing the true self.


Dreaming of patients, hearing patients’ own dreams, or both, may draw you closer to this self.
~~~~Adapted from the forthcoming book The Mindful Medical Student: A Psychiatrist’s Guide to Staying Who You Are While Becoming Who You Want to Be. Dr. Jeremy Spiegel is a psychiatrist in Portland, Maine. His Web site is www.mindful medicalstudent.com.~Student Life and Well-Being~
400~8November~2007-56~Feature~Orientation~Understanding the needs of your LGBT patients~Avery Hurt~Your patients will include lesbian, gay, bisexual and transgender people living secretly or openly. To provide them the best health care, new physicians must learn and practice the skills of communicating about sexuality sensitively, yet frankly, with all patients.~Elderly patients may react differently to certain medications than do younger patients. Blacks are at higher risk for stroke than whites. Children require a whole series of immunizations just for childhood diseases.


Understanding the special needs of different patient populations is a part of good clinical care and good medical training. When it comes to the needs of patients who are lesbian, gay, bisexual or transgender (LGBT), however, awareness and sensitivity to these special needs are often lacking, both because training is absent and, all too often, clinicians aren’t aware which of their patients are part of this population. And that means that LGBT patients are not getting optimal care.


Unfortunately, the subject of LGBT health care often launches with a discussion of STDs, but that is only a small part of the picture. Of course, gay men and men who have sex with men are at higher risk for a variety of sexually transmitted diseases, including HIV/AIDS, hepatitis and anal papilloma. And although lesbians are generally not considered at high risk for most STDs, HPV and genital herpes are easily transmitted between women during sex, and many contract bacterial vaginosis, especially those under age 30. But the LGBT population has more to worry about than just STDs.


Rates of substance abuse (alcohol, tobacco and other drugs) are higher in the LGBT community than in the general population. Depression also takes a particularly harsh toll among LGBT people, especially adolescents, those who are still in the closet and those who do not have a good social support network.


Violence, too, affects this population disproportionately. According to the National Coalition for LGBT Health, 47 percent of lesbians have experienced repeated acts of domestic violence, and two in every five gay and bisexual men experience abuse with an intimate partner, about the same as domestic violence rates for heterosexual women. A survey from the National Coalition of Anti-Violence Programs (NCAVP) found that 50 percent of transgender individuals had been raped or assaulted by a romantic partner.


And, of course, the violence is not always domestic. The NCAVP’s 2007 annual report documented 1,440 violent anti-LGBT incidents nationwide in 2006.


Research also shows that breast and ovarian cancer are more prevalent in lesbians, though it is not clear why, and transgender individuals are at higher-than-average risk from reproductive cancers, at least in part because they have difficulty accessing care and early detection, and because they often feel discomfort with routine procedures involving reproductive health.


Even workaday wellness issues such as diet and fitness require a unique emphasis in the LGBT community. Lesbians, on average, have a higher body mass index than heterosexual women, putting them at greater risk for heart disease, cancers and diabetes. Gay men are more likely to have problems with body image than straight men, which can lead to abuse of steroids. Eating disorders are also more common in gay than straight men, leading to a spectrum of related health problems.


Handling these specific needs is not terribly tricky from a clinical perspective, although some, like depression and eating disorders, can be difficult to identify and may require a team approach to treatment, and social issues, such as domestic violence, can require a high degree of sensitivity. But in order to start to address these health concerns, the physician has to know the patient. And that, with regard to LGBT patients, is most definitely the rub.


“Discussions of sexual health and sexual orientation are essential to understanding the needs of all patients,” explains Dr. Henry Ng, lead physician at Cleveland’s MetroHealth Medical Center’s PRIDE Clinic, a comprehensive primary care medical home for LGBT patients. All too many physicians are poorly trained, uncomfortable or simply unaware of their own presumptions when it comes to taking a sexual history or otherwise discussing sexuality with their patients, Ng asserts. But getting this right goes beyond being culturally sensitive: “This is a standard of care, but it is often neglected—or worse yet, performed poorly with heterosexual bias.” But why do otherwise caring and competent physicians get this so wrong?


Don’t Ask, and They
Might Not Tell


The short answer is that many physicians just aren’t comfortable taking a sexual history. In fact, just like many nonphysicians, they can be uneasy with LGBT people and do not really want to talk about it. And fearing a negative response from the physician, patients can feel awkward, too. But getting past this little dance of discomfort is absolutely essential for good health care for LGBT patients.


Dr. Nelson F. Sanchez, a third-year resident in internal medicine at New York University, is lead author of a study, published in the January 2006 issue of Family Medicine, gauging medical students’ ability to care for LGBT patients. His research found that the more clinical exposure students had to these individuals, the more likely they were to get a comprehensive history, have good attitudes toward the patients and have adequate knowledge of the attendant health-care issues. That familiarity is key to taking a thorough and useful history.


However, even the students with high self-reported comfort levels did not always take a comprehensive history, and even in the group of students with prior exposure to LGBT patients, only 49 percent routinely asked about an intimate partner, and 81 percent never or rarely asked patients’ permission to document sexual history in their charts—an important and often overlooked option, according to Sanchez.


“Sometimes it’s just a matter of invisibility,” says Dr. Ken Haller, past president of the Gay and Lesbian Medical Association (GLMA) and associate professor of pediatrics at Saint Louis University School of Medicine. “It just doesn’t occur to people. Straight doctors just don’t think to ask.”


But they should, Ng insists. “Providers should routinely ask about sexual orientation, sexual behaviors and domestic violence, just as they ask parents about their children’s development or ask their adult patients about signs and symptoms of heart disease.”


Set the Right Tone


It’s one matter to agree that physicians need to ask the questions; it’s another to know how to go about asking.


“Thus far, there is no standardized manner to obtain [an LGBT] history,” says Ng. One potential tool is the intake form, he suggests. Forms that include gender-neutral terms and offer more than two choices for gender and sexual orientation “can signify that [these] issues are important to that provider and practice.”


Dr. Stephen Smith, professor of family medicine at the Warren Alpert Medical School of Brown University, agrees. “Putting sexual preference on patient questionnaires would be a good thing, as would changing ‘sex’ options to more than just male/female so as to include transgender persons,” says Smith. But conversation is still key. “When talking with patients, I ask if they are sexually active with men, women, or both. I believe this lets them know that I am sensitive and open to the issues and would encourage them to be open with me. I think this is a better approach than specifically asking them ‘Are you straight or gay?’ which puts the patient on the spot without yet knowing how you, the doctor, will react to the answer,” Smith adds.


Getting the tone right when asking the questions is essential as well. “It is important for the physician to always come from a nonjudgmental place during the medical history,” believes Rob McDonald, a fourth-year at the University of Alabama at Birmingham School of Medicine (UAB). “Being nonjudgmental comes through in an intangible but perceptible way during conversation, and that facilitates a good relationship and an optimal assessment,” he says.


Haller agrees: “It is important for physicians to understand how much power they have in validating patients’ issues. Having [the right questions] on the intake forms normalizes [the patient’s sexuality],” he says, and discussing it openly helps create a comfortable relationship between the doctor and the patient.


Of course, talking about sexuality—any kind of sexuality—rarely is a simple matter. One gay student at a Northeastern medical school who asked not to be named says it’s not easy for him, either. But he does offer some advice to straight doctors who are struggling with this. “It is important,” he says, “not to equate homosexuality in men, for instance, with anal sex and/or HIV. To be gay means more than just the sexual geometry or how things fit together—or not. I hope that the new generation of physicians knows that sexuality is more than just sex. There’s a whole culture and set of ideals behind it. The important thing is not to assume anything. If the patient isn’t backed into a corner by imposition of a given sexual orientation or assumptions about a particular lifestyle, then the interview will be more comfortable for both.”


Running Interference


Just as LGBT people often are called a community, medical people operate within a community as well, and it includes a host of professionals, from clinical specialists to psychologists, nurses and social workers. Very often, the primary care physician who has made an effort to establish an open and understanding relationship with his LGBT patients will have to be an advocate for these patients in the larger medical community.


Liz Galst, a lesbian and the birth mother of two young children, had an almost ideal situation with the OB/Gyn practice that delivered her babies. “The practice is very gay-friendly,” says Galst. “The hospital staff were great, too, but they were a little confused.” In New York, where Galst and her family live, her partner was able to adopt the children in what is known as a “second-parent adoption.” However, the adoption is not completed until after the baby is born, and the birth-certificate form lists only two options: single and married. When their second child was born, since Galst had not named a father on the birth certificate, the hospital staff listed her as a single mother and assigned a social worker to the case, even though she was not single at all, and her partner was with her throughout the birth.


Situations like these, of course, do not have an impact on physical health (although conceivably could contribute to gays’ and lesbians’
higher rates of depression), but they are areas in which a sensitive, supportive physician can help by, as Galst puts it, “running interference” for your patients in the larger medical community.


You may also need to intervene in your own education. In most medical schools, the curriculum won’t be much help. When Smith was in medical school from 1968 to 1972, “there was no discussion of sexual preference and almost no discussion of sex, period,” he says. Smith developed a sensitivity to these issues after he got out of medical school by attending workshops developed by the American Medical Student Association. Education about LGBT issues still varies wildly from school to school; there is no curricular requirement from the Association of American Medical Colleges on this one. “There is a mandate in most medical schools to be ‘culturally competent,’ but this can be interpreted in many ways,” says Haller.


Dr. Ricky Y. Choi got his medical degree in Charleston, South Carolina, a conservative community with a school having what Choi calls a “frankly homophobic staff.” He became acquainted with LGBT people only during his residency at the University of California, San Francisco (UCSF). “While I did have some LGBT patients [at UCSF], interestingly, I had more kids with LGBT parents. I also had LGBT co-residents, some of whom had young families of their own. I can’t say that it changed the way I practiced, but it did help me see LGBT families as part of regular society—an important and valuable part of society, where children can thrive,” he says.


Not all schools totally drop the ball on this one, though. McDonald says that his school, UAB, “does a reasonable job of teaching LGBT issues. Particularly on World AIDS Day, [when] speakers make special efforts to convey to students that there are additional health risks associated with being homosexual, including substance abuse and psychiatric issues related to the difficulties of not being accepted by ‘mainstream’ society.”


Alison Reid, a third-year at Johns Hopkins University School of Medicine, has a “pretty high comfort level” with LGBT patients. Hopkins, says Reid, offers a unit on sexuality in which LGBT issues are briefly but nicely covered. “There was a very good lecture on transgender communication. For the most part, those who wanted to got a lot out of it.”


Most of Reid’s training came outside the classroom, however. She worked as an HIV counselor in a clinic where 80 percent of her patients were gay, and she was trained in taking a sexual history for this job. The training included small group sessions and role-playing, she says.


If your school does not offer resources for learning about LGBT health care, you might have to take matters into your own hands. “If you are in an area without clinics that target the LGBT population,” Sanchez says, “schools should offer scripted encounters to give students practice.” And when schools don’t, students should speak up and ask for it.


“You have to make a strong argument to effect change,” he asserts. “Get in touch with gay and lesbian groups on campus. Find out what other schools are doing and see if you can mimic it. Gather evidence and look for faculty support. Get deans and professors on your side. You’ll have to find someone willing to teach it.” Sanchez adds, “In some places, students teach each other.”


Getting the training and exposure you need to provide high-quality health care to LGBT patients may take a little effort. But it is worth it. Knowledge and experience will make you comfortable, and, says Reid, “If the provider is comfortable, the patient will be, too.” Having patients you are at ease with treating and who are relaxed and open with you can help nourish your joy in medicine. After all, you got into this field because you wanted to help people—and there is a rich variety of people out there.
~RESOURCES


If you find yourself low on the LGBT learning curve, these resources might offer some insight:


~~~Avery Hurt is a freelance writer in Birmingham, Alabama.
Direct comments about this article to tnp@amsa.org.
~LGBTPM~
401~8November~2007-56~Feature~On the Trail of Rare Disease~Investigators and advocates hunt for collaboration and smart funding~Pete Thomson~How researchers, medical schools and the NIH make sure that uncommon diseases affecting few patients don’t get lost in the hype afforded to bigger and flashier cures.~Patients coping with a chronic condition their doctors may never have seen before can feel isolated and discouraged about the future. Similar is the frustration of that disease’s larger community—the few researchers and physicians fixated on finding treatments and cures for some of the rarest of human disorders.


The National Institutes of Health (NIH) and other federal agencies classify a disease or disorder as “rare” if it affects fewer than 200,000 Americans directly. But having a rare disease isn’t uncommon at all: NIH estimates that 25 million Americans have some type
of rare disorder: Hamman-Rich syndrome, Sandhoff disease or one of thousands more known but highly exceptional medical conditions.


Piece of the pie


A late-1980s survey by NIH of its own rare disease research efforts found that 15 percent to 18 percent of the overall research budget went toward the study of rare diseases. Stephen Groft, who heads the NIH’s Office of Rare Diseases (ORD), thinks that percentage is still about the same.


“It’s a fair amount of research,” he notes. “The problem is, with over 7,000 diseases, many times you don’t have a lot of research projects going on with any particular rare disease, and that’s why it is important to generate that interest in rare disease [generally] within the research community.”


Disease research funding is a complex system that is not always equitable or proportionate. The system is influenced by advocacy groups pushing for their piece of the pie or taking the funding fight into their own hands. But it’s increasingly clear that rare disease research is dependent on partnerships between government, industry and philanthropic groups—as well as among research centers themselves.


In fact, the ORD fills gaps between other NIH institutes, focusing on activities that benefit all of them in the collective pursuit of rare cures. This includes coordinating and administrating the relatively new Rare Diseases Clinical Research Network (RDCRN), mandated by Congress in 2002.


Lost in translation


Industry—mostly pharmaceutical researchers and manufacturers, but also device and equipment makers—is paying for most of the medical research in the United States. It spends nearly $65 billion a year—though critics note that pharmaceutical R&D budgets often include money spent on marketing—bringing new drugs to market or
doing basic research to find a starting point for cures, according to estimates put together by Research!America, a collection of research institutions and interested parties.


Though by far the biggest game in town, private industry is joined by many branches of the federal government in medical research funding. Aside from well-known agencies like the NIH, the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, there are some other interesting players: NASA and the departments of Defense and Agriculture, for example. But NIH is the health research destination for the biggest portion of the tax dollar, and for better or worse, the institutes also have the corner on the basic science market.


“The federal government is the biggest supporter of basic scientific research,” explains Bill Leinweber, Research!America’s executive vice president. “Industry supports basic research, clinical research and translational research. The government does all of those as well, but the biggest piece of the pie in the government is for basic research.” Meanwhile, private industry excels at translating that basic research into clinical applications.


“It was NIH, for example, that discovered the growth factors in blood cells, and it was the industry that went forward and developed erythropoietin into a new biologic,” notes Abbey Meyers, president of the National Organization for Rare Disorders (NORD), an umbrella for disease-specific patient advocacy groups.


But translational research is currently the weak spot in studying rare disease. Funding has been hard to come by due to NIH’s focus on basic research, and industry has been the main player in translation, Meyers says. The NIH is responding to criticism by focusing more on translational research of its own, but more is needed.


Most of the NIH’s budget goes into extramural research done at medical schools and universities, as opposed to intramural research done at NIH headquarters in Bethesda, Maryland. The extramural research system is highly dependent on researchers applying for NIH grants, and the level of their interest in particular diseases can sway the mix of research. For lack of interested researchers, disease Z may go uninvestigated, while disease Y’s titillation of physician scientists may draw disproportionate funding.


Patients need interested physicians to step up and apply for funding to translate basic research pertinent to the patient’s rare condition. “If you are studying a rare bone disease, for example, you are learning about all of the basic research discoveries that have to do with bone,” Meyers posits. “In your mind, you say, ‘How can I apply this to the patients that I am seeing?’” And that’s where the responsibility for moving basic research onto the wards lies.


The evolution of advocacy


The most significant dynamic in the history of rare disease research has been the rise of vocal patient advocates. From often-humble beginnings, many groups develop a knack for building attention for their disease, either through legislation or their own fund-raising efforts.


It’s tempting for those considering the funding of research to look at the money NIH and others spend on researching a disease, and divide that dollar amount by the number of patients affected. This may seem like a great way to compare the relative value of disease study. But Meyers explains that it’s a lot more complex.


“You really can’t analyze it, and NIH knows that,” she says. “And that’s why they cannot report to the public and to Congress and say, ‘We’re spending this amount of dollars on this disease.’ Because so much of the basic research dollar can be applied to each one of those diseases.”


When there was a sudden push for funding HIV/AIDS research, for example, a fair amount of the NIH’s research budget went into studying the basics of the immune system. Though that money was technically spent on the study of AIDS, the knowledge was broadly applicable, benefiting the study of other autoimmune disorders under the purview of the National Institute of Arthritis and Musculoskeletal and Skin Diseases.


“You have to understand, a lot of these [rare disease] groups start with members of a family where somebody got sick, and they start on somebody’s kitchen table,” Meyers says. “It takes them a long time to get that organization up and going, and become advanced enough to understand the importance of advocacy in Washington.”


But once they do, their influence can be significant, although, Meyers says, it hasn’t always been helpful. In pushing Congress to earmark certain NIH funds for particular diseases, those funds become unavailable to other institutes—even if funds go unused because there aren’t enough researchers interested in taking a piece of the pie for that particular disease.


Also, advocacy groups for diseases both common and rare have occasionally lobbied to create a new institute at NIH—a very costly endeavor, Meyers says. She explains that a significant portion of the funding to a new institute gets lost to administrative costs, and having yet another subdivision of science can confound those who are trying to apply for grant funding.


Nowadays, savvy patient advocacy groups lobby for language that compels NIH to hold symposiums on a disease or set progress goals for the next few years. In this way, their efforts don’t tie up money, but their cause doesn’t get left behind. The ORD has held weekend seminars for the executive and research directors of such patient
advocacy groups, familiarizing them with the way the institutes work, how the research funding process functions and where the groups themselves can fit in.


“They will be the main source of information about the clinical studies that are ongoing; they’ll be asked about the value of participating in clinical studies,” Groft says. “So we try to explain to them so they have a good understanding of research.”


There is another key role for advocacy groups in addition to providing voice, support and a knowledge base for patients: “The bottom line is, they have to be out there raising money to fund research. These support groups, they have to fund research to get the doctors interested in that disease so they’ll study it,” Meyers says. “And a lot of the organizations have realized that’s what they need to do.”


And there is an interested next generation of niche researchers among medical students. Aaron Viny, now in his fourth year at Case Western Reserve University’s five-year M.D. program, spent his research year as a Howard Hughes fellow. He worked on the genetic study of large granular lymphocyte (LGL) leukemia, one of several rare bone marrow failure syndromes studied in that lab. Through the additional funding for his fellowship, he was able to work with whole-genome array “snip chips”—massive collections of genetic data for comparison—looking for a complex causation for the disease.


“One of the hardest parts of studying a rare disease is that you have a small sample size inherently. It’s a rare disease. You don’t have a lot of cases. So your statistical power goes down,” he says. Other challenges include getting published, as major journals try to appeal to a broad audience of physicians. But the lab’s work led to identifying a cluster of genes that could put patients at risk of LGL leukemia, which mostly affects adults. “We’ll have to see how it pans out as we do some testing, but it’s certainly exciting thus far.”


Several patients in Viny’s program formed their own advocacy group and raised enough money to fund a postdoctoral fellowship to help out with the lab’s bone marrow failure research.


Fishing for industry funds


Common conditions like high cholesterol have proved a cash cow for pharmaceutical companies. Their efforts to develop and push popular drugs have led to further development in those areas—and controversy. But as the largest funder of translational research, their role is unavoidable.


“The reality is, as a profit-making sector, industry has shareholders to respond to,” says Research!America’s Leinweber, whose consortium includes industry partners. “That’s not a negative; that’s the reality of capitalism. And as such, the focus of their efforts is, in large part, on diseases and disabilities that impact large populations.”


Drugs that could be used for rare diseases were long considered by private industry as a dead end, and virtually ignored. However, in 1983, through lobbying efforts by NORD and other groups, Congress passed the Orphan Drug Act (ODA), providing incentives like tax credits, windows of exclusivity and application fee waivers to drug companies that continue with research that may lead only to a handful of customers, and help make those drugs available to those with rare disorders.


The ODA incentives are administered by the FDA’s Office of Orphan Products Development, which also has a small budget for providing grants to spur rare disease research.


To be designated as an orphan drug, the manufacturer must demonstrate that the treatment is for a condition affecting less than 200,000 people—or, if the drug will be administered to more than that number, that there is no reasonable expectation that the costs of drug development will be recovered. In essence, they have to show that the drug’s development flies in the face of a profit-making enterprise.


According to Meyers, the process works, and there are about 320 approved orphan drugs now on the market and another 1,400 in the research pipeline. “Some of the rarest diseases...for example, lysosomal storage diseases that each affect fewer than 5,000 patients in the United States [are being treated by] enzyme replacement therapies on the market now.”


After working to get ODA through Congress, NORD began monitoring the act’s implementation and lobbying for research funding at large. Drugs for rare diseases are very expensive, so NORD also helps patients afford their unusual medicines through payment assistance programs, Meyers explains. “It’s a long process from encouraging the research to encouraging the development of the treatment to making sure that the patients have access.”


In some ways, the pharmaceutical companies’ research programs offer a model for federal rare disease efforts, and that’s where the ORD’s new clinical research network, the RDCRN, fits in.


“We draw multiple research sites together in a way that we can conduct common protocols,” Groft explains. “Industry does this very successfully for their own studies, and I think that the realization is that, with the rare diseases, you have to do that even more.” The
lab in which Viny worked is part of one of the RDCRN’s nine consortia, and works with other labs at other institutions toward a common, if rare, goal.


Despite some challenges, the study of a rare disease offers opportunity, Viny notes. “Because so few people have looked at it, because there are so few cases, the potential to make a big discovery is that much greater, particularly when you have some of the new tools that are being focused more on common diseases.”


Groft agrees: “The individuals in training are looking for something different.… This is one of the benefits of the rare disease. You are able to pick a disease that no one has done a lot with in many respects.”


Viny, along with the director of the bone marrow failure lab, worked with a statistician to devise new ways of dealing with small sample sizes in their genomic studies. Viny presented their findings at an ORD-sponsored conference in September so other rare disease researchers would benefit.


That kind of exchange, between researchers working on different disorders and med students and mentors, is what Groft, ORD and the millions of Americans with an uncommon condition count on to keep rare disease research alive.


For now, Viny is back on the wards, but wants to make the study of immunologic and hematological disorders part of an academic career, a track that presents challenges of its own. “There is pressure to see more patients, and it’s harder and harder to get protected research time,” he says of teaching hospitals. “But if you’re studying a rare disease...it’s a better opportunity to have that kind of a career. And that’s what I'm looking for.”
~~~~Pete Thomson is a freelance writer in New York City.~Ethics,Health Policy,Medical Research,Pharmaceutical Industry~
404~9December~2007-56~Letter from Afield~A Single Patient, Writ Large~Effecting change as a physician-journalist~Leana S. Wen, M.D.~Saving patients with stories~Children ran after us, bright plastic clogs slapping behind them as we drove through the lush rolling hills.


“Muzungu!” they shouted—white person—a comment I’d rarely heard directed at me, a Chinese-American. Men pushed bikes flanked by heavy bottles of water. Women wearing patterned skirts and wraps sauntered by, bunches of bananas effortlessly balanced on their heads. Straw huts and clay houses lined the roads, framed by plots of banana trees, cassava leaves and coffee plants. The streets were so clean and colors so vibrant, it was hard to believe that eight of 10 people here made less than $2 a day. As if anticipating the question, our driver remarked, “People are poor, but we are proud. We make it a point to present our best to each other and the world.”


This, my second trip to Rwanda, was the prize for Win-a-Trip, a contest organized by New York Times columnist Nick Kristof. For the contest’s second year, Nick chose a teacher and a student to accompany him on a journey through Rwanda, Burundi and the Democratic Republic of the Congo (DRC), making daily blog entries and videos for the New York Times. I was the student. After finishing medical school in May, I traveled to Central and East Africa with Nick, high-school teacher Will Okun and op-ed videographer Naka Nathaniel.


I had applied for the trip because I wanted to effect change by telling stories. Doctors are natural storytellers. We have the privilege of hearing, seeing and experiencing the lives of our patients, but along with that privilege comes the responsibility of advocating on their behalf. Nick, a Pulitzer Prize winner, believed in practicing journalism as activism, and I wanted to learn from him how storytelling could educate and motivate the public.


Journalists are supposed to watch, listen, ask and interact, but not shape the events that are unfolding. Yet physician-journalists cannot abdicate their duty to safeguard life. We were going to be in war zones and poverty-stricken regions where famine and injury persisted, and people went their entire lives without ever seeing a doctor. How would I balance telling the stories as a journalist and responding to the people as a physician?


I quickly realized that finding stories was the easy part. Every day we heard far more stories than we could process and write. In Rwanda and Burundi, we heard of hope and success, a welcome change from the horrors so typically associated with the continent of Africa. Rwanda is emerging from a gruesome era, punctuated by the massacre of 100,000 people in 100 days during the genocide of 1994. Now, Rwanda’s government is stable and its economy is improving. While it is still very poor and lacks needed resources, the country has a system in place to provide universal health care to all of its inhabitants, reflecting values to which even the United States has not committed.


In 2003, a conflict in neighboring Burundi ended, and that country remains the poorest in the world, according to the World Bank. But Burundi also exhibits significant signs of progress. Several projects, like the World Food Programme’s school feeding efforts
and microfinance programs through CARE International and Women for Women, have proven both sustainable and vital to the population’s ongoing recovery.


But our trip also led us to witness bleaker futures. Unlike the hope and optimism brimming in Rwanda and Burundi, the Congo was filled with despair. It is in the midst of a war that has already claimed at least 4 million lives. Tragic stories abound. We were interviewing villagers about their health conditions in the town of Malehe, an hour away from Goma, when a group came toward us with what appeared to be a skeleton wrapped in rags. This was Yohanita Nyiahabimana, who weighed no more than 50 pounds and looked far older than her 41 years. Yohanita was completely emaciated and extremely ill. Her heart rate was in the 130s. She was taking deep, raspy breaths, and though she felt warm to touch, she was shivering. On her groin and buttocks were multiple oozing bedsores, all of them to the bone, all of them teeming with flies.


Her family told us that the war had driven them out of their village. Soldiers came to abduct, kill, rape and steal, and the family was among the lucky ones who escaped. When they came back to the village, they found all their crops destroyed and houses gone. There had been no time to replant crops, and the family had been living on bananas alone. A few months ago, Yohanita fell out of a tree and probably sustained a pelvic fracture, but her family had no money to bring her to a hospital. Her current condition was likely due to immobility, infection and malnutrition. She was now dying in front of us.


At that moment, I realized that there would be no conflict for me between practicing journalism and medicine. What I needed to do was clear. I would tell Yohanita’s story later, but at that moment, she needed medical attention, and I needed to help provide it. I explained the situation to her family: Yohanita was very sick and would die unless she got care from a hospital. The family said that they could not afford it and had no way of taking her to the nearest hospital, which was more than 60 km away. After some discussion, we found a way to transport her to Goma, and Nick and the New York Times agreed to pay for her medical bills, which would total around $100. A few hours later, Yohanita arrived at HEAL Africa and began receiving fluids, antibiotics and food.


Health care workers volunteered day and night at the HEAL Africa hospital in Goma to do what they could to correct the gruesome aftermath of war. Their ranks included physicians specializing in the treatment of gynecologic fistulas, which thousands of women had developed after soldiers and militants used weapons to rape them.


After visiting villages decimated by fighting, interviewing dozens of rape victims, and witnessing the endless streams of refugees, all of whom had had family members killed, we met with rebel leader Gen. Laurent Nkunda. Nkunda was not the only person leading the killing and destruction in the Congo—other rebel groups and even government troops are implicated—but he was a renegade warlord indicted for mass murders and rapes. To hear his claims about being a faithful Christian and pastor called into question my own beliefs: How is it possible that the people at HEAL Africa and Nkunda’s troops are all acting in the name of God?


In my blog, I wrote about Yohanita and about how she represented the human cost of the war in the Congo: When we think about the consequences of war, we typically picture people killed in the line of fire, but the human cost extends to disease and starvation that directly result from conflict. There are thousands more who die silently in their villages. Most readers understood my point, but some responded with incredulity that we would spend money and time to help Yohanita, when the problem was much larger than her. Was it fair to help her and not the rest of the people in the community? Was it a good use of resources to help one person, when many thousands or millions were also dying in the Congo?


My answer is yes. We didn’t go to the village to “save” someone, but we could not have, in good conscience, walked away from a dying person. As a public health-oriented doctor, I cannot agree more that there are larger issues to address: ending the war, and providing food, health care and education to everyone. But we don’t need to have global reform before contributing our best effort to the patient in front of us. Ultimately, we should aim to do what we can to help. In this case, what I could do was to help one person; perhaps, in telling her story, I can inspire others to help more people and improve the overall system.


Storytelling is a powerful way to draw in the audience and illustrate a policy perspective. Readers react to stories and individuals more than they do to dry statistics. Every time we take a patient’s history, physicians are, in fact, practicing journalism: asking the relevant questions to put together the puzzle of someone’s life.


Still, the role of the physician-journalist is complex. I may have worn the hat of a journalist, but I will always have the heart and soul of a physician. I continue to seek answers to big-picture questions and continue to aim for global change—but I will always keep in mind that my primary duty is helping the patient in front of me.
~


Fun and finance: The author dances with participants in a CARE International project that provides loans so Burundian women can launch their own businesses.


Arriving with a patient at a DRC hospital, the author (with stethoscope) faces the challenges of being both a physician and a journalist.

~~~Dr. Leana S. Wen, a recent graduate of Washington University School of Medicine and former president of the American Medical Student Association, now studies at the University of Oxford as a Rhodes Scholar.~~
406~9December~2007-56~On the Wards~No Place to Cry~Tracing the patient’s bridge to ability~Benjamin Silverberg~An unseen chapter revealed~I didn’t expect much from my visit to Gaylord Hospital in Wallingford, Connecticut. Then a second-year, I was driving south along country roads from the University of Connecticut School of Medicine to tour a facility dedicated to rehabilitation, the next step for some of our patients. Unlike my school’s John Dempsey Hospital, there was no striking monolith on the horizon to guide me or clarify my impressions.


I envisioned what amounted to a nursing home on steroids. Somehow the concept of rehabilitation, rather than abbreviated transition, was lost on me.


At the entrance, the blank expression and outstretched leg of a man in a wheelchair didn’t do much to reverse my expectations. Only when I walked into the warmth of the hospital from the sunshine outside did I whisper, “Wow.” The place was considerably more positive than I had expected it to be.


From my previous experiences in primary care and emergency medicine, the epilogue to a hospital stay was often unknown to me. Certainly there were other hospitals, but in my myopic view, they were all acute-care facilities, serving to fix a life-threatening problem or allow some recovery following surgery; regaining strength and ability was a personal task left for the home.


I would need to create a new classification in my head: an amalgam of trained health care workers and hospital beds, summer camp activities to pass the time, and busy gymnasiums mixing physical therapy and preparation for daily life, nursery school revisited. Though it was easy to smile at the pretend supermarket shelves and plastic produce, hidden behind the counter lay the painful efforts of countless patients to regain the cognitive and physical capacity to go grocery shopping. To me, the empty cardboard boxes represented childhood games of pretend. For the patients, the boxes represented challenges, pain and memories of a former life.


Nonetheless, the hospital was not a place to dwell on one’s disabilities. I was struck that very few of the patients could actually be found in their rooms. With wide doors to accommodate wheelchairs, handrails along the walls and ramps throughout, nearly the whole facility was easily accessible for most patients. They filled the in- and outpatient gymnasiums, sat in small groups in hallway alcoves for speech therapy, discussed their progress individually with health care providers or listened intently to instructions on how to paddle a kayak in the hospital’s swimming pool. Even the patients who chose to paint or sketch between scheduled sessions were focused on creation rather than limitation. All of this served to rebuild the spirit, a vital ingredient in one’s path to recovery.


On the one hand, I felt guilty to breeze through the halls as a walking, talking young man. But one patient privately explained that no comparisons were drawn between those who could and those who could not. It was an individual journey, with individual milestones, and the hospital’s staff served to facilitate this.


This patient-mentor, a 60-year-old man with malignant glioma, told me that once he overcame his self-pity, he became obstinate in his efforts to function independently. Only if he emerged from his room with a shirt stuck around his neck and his arm in the air would he ask for help dressing himself. Following him to his physical therapy appointment at the pool, I awkwardly tried not to offer help unless asked. It was hard not to instinctively give him a boost as he moved from his wheelchair to the seat that would lower him into the water, but he needed the chance to take ownership of his body. Neither his left-sided hemiplegia nor an upcoming third round of chemotherapy robbed him of his ability to go into town with some of the other patients or prepare dinner with them.


The hospital’s mission statement spoke of preserving or even enhancing health and function. Behind this ideal, however, was a business. Gaylord had to market itself to discharge coordinators at Yale and other Connecticut hospitals. Despite our health center’s own financial woes, I had never superimposed the idea of a “business” on the institution of a hospital: People just went when they were sick; no marketing was involved. This hospital’s goal was clearly to better health, but in the countryside, it needed to reach out to stay alive. The physiatrists at Gaylord were keenly aware of what was needed to maintain hospital licensure and keep the facility growing.


Hospital stays—as dictated by licensure rather than insurance companies—ranged between 14 and 25 days, so patients’ conditions must be neither immediately correctable nor impossible to solve. Only through misdiagnosis would a patient stay long-term. The time frame encouraged the admission of stroke and brain injury patients or those with pulmonary problems over those with musculoskeletal complaints better suited to outpatient care.


After a few previous episodes of cerebral hemorrhage, my patient-mentor was quite familiar with Gaylord and the premise of recovery. He praised the staff for their attention and optimism, citing that this stay left him feeling better than before his last crisis. He lived in the “cottage house,” a co-op dormitory that meant greater independence but ostensibly less privacy from the other residents. His only complaint: There was nowhere to just sit down and cry. Despite this, having a body of others supporting him, without making comparisons to themselves or others, makes a substantial contribution to the healing process. The collective group body could do everything, even when his own could not.


The hospital was a new beginning for some and a continuation of care for others, but never was it an end point. There was life after rehab. You just had to rise up and greet it.
~~~~Benjamin Silverberg is a third-year at the University of Connecticut School of Medicine.~~
408~9December~2007-56~Feature~The Disease of War~Surviving the intentional disruption of public health~Pete Thomson~Conflict strikes most often in countries already strapped for health care, adding grim new burdens to the population. Though each clash is unique, the response of local and international aid organizations can make the difference between a hopeful future and continued misery. What must these groups do to repair the damages of war?~In October 1993, Melchior Ndadaye, president of Burundi, was killed during an attempted military coup. Politicians stirred tribal divides in the small Central African nation for their own ends, and Hutu and Tutsi populations began a clash that would last a decade and cost 200,000 lives in Burundi alone.


The fighting stayed just beyond the edge of the world’s perspective, apparently lacking the journalistic impact of the genocide in neighboring Rwanda, which had itself been sparked by Burundi’s civil war. But the killings in Burundi were happening, just more measured. Slower. A village razed here, a school destroyed weeks later, children still inside.


The next year, Deogratias Niyizonkiza escaped the country and the fighting at the age of 23, though he didn’t escape the violence: Contacting family members in Burundi was difficult at best, and impossible for a time.


The conflict did not fully subside until 2005. Now, the factions exhausted, peace has settled in, as have the health consequences of a decade of tribal war, indistinguishably meshed with the difficulties faced by an already resource-poor nation.


Setting medical school aside after two years of class in the United States, Niyizonkiza has chosen to tackle the reminders of war by forming a clinic in rural Burundi, working with U.S. colleagues and Burundian community members.


Niyizonkiza’s clinic, Village Health Works, formally opens this month. The president of Burundi will attend the ceremony. Already, the project has had fruits: Former enemies worked side by side to build the physical facility.


Conflict exacerbates the health challenges of already stressed regions, and the web of interested parties can become complex. When treating peoples marred by war or even their own governments, today’s international aid organizations and their physicians have to do much more than address the immediate trauma and lasting disease. To be counted as successful, these agents must leave a network of effective local providers in their wake, just as war and poverty may have swept them up.


“The system was there, mostly, during the conflict,” Niyizonkiza says of Burundian hospitals and health care. “But now we have more people who are so dirt poor because of the conflict…. They lost their land; they lost everything.”


The effects of war on public health vary by the nature of the conflict and the international response, or lack thereof. But poverty, hunger and disease are the obvious commonalities—all combined with fear.


“A conflict can be either 24 hours, or four days or a week, but the repercussions last,” says Dr. Jill John-Kall, who has worked in multiple conflict areas in Africa. “Even if the conflict is over, people are still deadly scared to go back [home].”


When John-Kall went to India to attend medical school, the sight of abject poverty shocked her. After residency, she decided to practice where her skills would be most tangible. In June 2004, she left on her first mission, with Médicins Sans Frontières, to Uganda. Afterward, joining the International Medical Corps (IMC), John-Kall worked in southern Sudan, Chad and Sudan’s Darfur region. The latter mission was supposed to last six months, but it became 18.


“If you are living in a rural village, you don’t usually have adequate health care to begin with,” she says. “On top of that, whatever you do have might be destroyed, or the regular people who could offer health care have now run away or been killed.”


Or perhaps lured away by other regional efforts. “Nowadays, most of the physicians that were in Burundi are working in Rwanda because Rwanda is getting so much help from the international community,” Niyizonkiza says. “But in Burundi, nothing.”


Though the response to conflict often involves a similar network of
aid organizations as natural disaster response, war can tear down even the most meager of infrastructure and order. After the 2006 earthquake in Pakistan, the Pakistani army helped organize and assist the responding NGOs and multilateral agencies.


In a civil war scenario, however, those groups may find military forces pitted against their efforts. In any circumstance, the citizenship of those affected bears heavily on their outcomes.


Internally displaced persons (IDPs) have lost their homes but stayed within their home country’s borders, while refugees have crossed national lines into an often-reluctant host country.


The host country usually wants as little to do as possible with the refugees. They are sequestered in camps away from cities, lest they settle permanently, even though many conflicted regions have national borders arbitrary at best, and the populations may share common language, culture and even ancestry.


John-Kall found working in Chad with refugees displaced from neighboring Sudan easier than working with the internally displaced Sudanese. Because the Chadian government steered clear of responsibility, aid workers and NGOs were able to operate with great autonomy.


At the same time, the care received by refugees—or those internally displaced—can cause significant resentment among the local population, as John-Kall saw in Chad. “The refugees were getting all kinds of services, where the actual Chadian population had almost nothing,” she says. “We tackled that through mobile clinics, which are definitely in and of themselves a temporary measure. They are not sustainable, but at least it decreased the tensions.”


By August of this year, the U.N.’s Office for the Coordination of Humanitarian Affairs (OCHA)—an important player in conflict and disaster relief efforts—tallied 2.2 million IDPs in the Darfur region. On the whole, Sudan has the highest number of IDPs in the world, thanks to multiple vicious conflicts in its borders. As recently as September, aerial bombardment, attacks by militia and fighting between government and opposition groups continued to drive Sudanese from their homes. The U.N. has reported the deaths of five aid workers in Darfur during 2007 alone, the wounding of several others and the carjacking of dozens of official vehicles.


Conflict isn’t always outright war between two factions, leaving an opening for aid groups to set up their system. Sometimes the conflict comes in the form of massive governmental oppression.


The Burmese government has been trying to overtake land held by an ethnic minority population along its eastern border for 30 years. Just across the line, in Thailand, the usual soup of intergovernmental agencies tend to camps for refugees. But people still within Burma’s borders have to rely on help from their own ranks. The Planet Care/Global Health Access Program (GHAP), organized by U.S. physicians in the 1990s, trains Burmese medics in Thailand. Those medics return to their villages to provide care, while GHAP lends them technical support and helps supply them. Most of their medics are trained at the Mae Tao Clinic, where they spend a six-month to two-year internship.


“In an active conflict, where international institutions can’t reach you because you are in a conflict zone…, health care is best provided by people from that region,” says Emily Whichard, who has worked with GHAP for two and a half years. “That kind of organizing around health care is really important [to rebuilding] community during crisis-ridden times.”


The conflict in Burma, Whichard says, is characterized more by human rights violations and limitations on movement than by perpetual active combat. This doesn’t lessen its immediate impact, however. The Burmese military still makes use of landmines. When the roving military depletes local food stores—a common practice—villagers are forced to seek sustenance outside the confines of their town. And that’s where the mines are.


Burma illustrates another difficulty in the politics of conflict: health information. Studies from data gathered by medics working in Burma show infant and maternal mortality rates in Eastern Burma comparable to the highest rates in the world. “Those numbers differ significantly from the published data from the Burmese government, obviously, because they are certainly not collecting data in the areas [in which] they are fighting,” Whichard says. “That’s a huge component of conflict and health: the kind of health information you are able to glean and how you can plan appropriately.”


Even without deliberate interference, reliable numbers amid the disruption of war can be a tremendous blind spot. “Even today, no one really knows what the rate of HIV is in Burundi,” Niyizonkiza says. The World Health Organization (WHO) and the government have some figures to hand out. “These numbers have been around since the mid-’80s.” Village Health Works will conduct an independent survey of health needs in their region of Burundi as part of their initial effort.


Even in areas where war has ceased, there are needs that some would consider a luxury to those in such extreme circumstances, like mental health services, which has added utility in the healing of ephemeral wounds.


“There are so many parents who lost their children or lost everything, and they feel that they…are no longer useful,” Niyizonkiza says. “And they take their life, and that is the end of it. And this is a country that has not a single psychiatrist…. It’s really frightening. People are so desensitized.”


THE WEB OF CONFLICT RELIEF


Though conflict compounds health problems, dramatic coverage can bring world attention and, hopefully, aid and assistance.


By October, U.S. government funding alone in Sudan totaled $687 million for the 2007 fiscal year. Roughly half of that money was provided to groups working in Darfur, and $90 million to those working in neighboring Chad.


Most U.S. spending is distributed by offices under USAID, like the Office
for Foreign Disaster Assistance (OFDA). The State Department also chips in, as relief in conflict areas also serves diplomatic and political purposes.


On the ground, coordination between aid groups and funding bodies
is often provided by OCHA. Each
“sector” of the effort, like sanitation, medical care or food provenance, is led by groups recognized for their expertise in that area. The WHO, for instance, often coordinates health care while the World Food Programme might lead feeding efforts.


OCHA brings these leading groups together at sector-level meetings for a look at the bigger picture. Down the line, the sector-leaders direct NGOs and the actual workers on the ground, providing a level of interconnection among groups that might otherwise be thought of as competitors.


The groups can coordinate the movement of workers and supplies around the region, or respond to changes in migration, health or safety.


Funders set the tone for how the NGOs respond to crises. By placing requirements on their grant applicants, they can influence the methods and efficiency of the NGOs on the ground. OFDA, for example, has a set of best practices they require grant recipients to use. One of those best practices, and current buzzwords, is capacity building.


HEALING THE SYSTEM


Training Burmese medics to treat malaria, tuberculosis and landmine injuries, GHAP focuses exclusively on capacity building: It provides no direct care, instead establishing a base of knowledge and experience in the local community to sustain it once international aid has subsided.


IMC, which operates in dozens of countries, uses a two-pronged approach: emergency response plus capacity building. “Eventually, when we leave, we want to hand over these programs to the national staff, so these programs are sustainable,” John-Kall says.


“Even if they burn down your clinic, nobody can take away the knowledge that you’ve imparted to another human being,” she says. “So all you have to do is rebuild that [physical] clinic, and all of the players are still in place to run that program.”


What constitutes capacity building depends on what the country’s baseline needs are. “In Chad, we were basically looking at more clinical teaching because that’s what they needed,” John-Kall explains, “whereas in Darfur, they had the clinical basics because their programs were so much bigger.”


Many of the “national” staff used in Darfur had been recruited from Khartoum, which had a medical education infrastructure. In that setting, national staff members were sent for more sophisticated training. One member went to Nairobi to learn about a malaria program while another headed for Bangladesh to learn about controlling cholera.


After her year and a half in Darfur, John-Kall took a break this past fall, pursuing a master’s in tropical medicine and international health in London. “It does change you. It changes your view on what you can do, what you can’t do,” she says. “It is frustrating…and you pay a very emotional price, even though you don’t really know it.”


GHAP’s Whichard is now a first-year at the University of California, San Francisco, School of Medicine, but she plans on working with trainees on
the Thailand-Burma border next summer.


Although the extent of disease and the toll of Burundi’s war is not yet known, Niyizonkiza is notably positive in discussing the trajectory of the beleaguered country. The people’s exhaustion with fighting gives him hope that the conflict is really over.


“They’ve learned a lesson the hard way,” he says. “They just need help to rebuild their own lives, and say, ‘never again.’”
~~~~Pete Thomson is editor of The New Physician.~Health Disparities,International Health~