411~1January-February~2008-57~Reviews~Should We Think Like Doctors?~Rote learning doesn’t make the physician~Andrea Wershof Schwartz~How med students should think~When will it happen? At what moment will the memorized facts, bullet points and multiple-choice questions coalesce into a body of knowledge to guide us as we solve clinical problems, diagnose disease and help our patients? Not soon enough, claims Harvard Medical School’s Dr. Jerome Groopman, and maybe never at all. An education system based soley on charts and graphs cannot create sophisticated and compassionate diagnosticians, he writes in How Doctors Think (Houghton Mifflin, $26), a book aimed primarily at patients but with plenty of lessons for physicians-in-training.


Groopman, a renowned researcher and hematologist-oncologist, neither disparages medical education nor criticizes hard-working doctors. Rather, he strives to pinpoint how errors creep into their thinking, leading to missed or mistaken diagnoses. While he acknowledges the value of pre-set clinical algorithms that lead doctors to diagnoses, Groopman weaves his moving stories around the premise that these algorithms smother creativity and disrupt independent thinking. “Instead of expanding a doctor’s thinking,” he writes, “they can constrain it.”


This is not the latest pulp collection of medical errors, terrifying both patients and their future physicians with tales of poorly written prescriptions or wrong-site surgeries. How Doctors Think presents the lay reader and the health care worker alike with specifics on where medical thinking breaks down and how cognitive errors lead the diagnostician astray. These problems in thought process then result in misdiagnoses, bad advice and, ultimately, unnecessary patient suffering.


The inclusion of experts in cognitive theory and peer-reviewed evidence lend weight to the book and utility to medical student readers. Groopman uses them to explore the errors of thought common in medical settings, such as radiologists overreading diagnostic images after they were sued for previously missing a malignancy. He examines how our preconceptions about a patient’s personality or values can color, if not cloud, medical judgment. Errors of attribution, when physicians rule out a possible diagnosis too quickly because a patient fits a “negative stereotype,” are also illustrated by Groopman through specific cases: A fit hiker complaining of chest pain is sent home from the ER because he doesn’t fit the typical picture of a “heart attack patient.” He returns the next day, presenting with an acute MI.


But perhaps the book’s strongest point is the author’s honesty. He shares his personal experience with cognitive error as a physician treating patients with serious illnesses, as a parent with a sick child and as a patient caught in a frustrating quest for a diagnosis. These candid reflections make the book engaging and even disarming, suggesting that no one is immune to error, either its root or its result.


In the epilogue, Groopman emphasizes the importance of partnership between patients and physicians. He reminds readers that while some medical problems have simple, straightforward solutions, sometimes the facts are not enough. The doctor must then rethink the case, starting from new angles and a new sense of openness and humility. The message for students: Master the knowledge, but strive for the insight into the thought process that makes a good doctor.


Andrea Wershof Schwartz is a third-year at Mount Sinai School of Medicine.



A Colorful Look at Complex Systems

by Katherine Ellington


Medical students augmenting their official textbooks have plenty of options. There are multiple review series available, but the scope and quality of the books can vary, even within a series.


The 23-title Crash Course series, by Mosby, uses an illustrative approach with diagrams, charts and tables to summarize key concepts.


Crash Course: Cardiovascular System (Mosby, $29.95) makes a good guide for students beginning to study cardiovascular physiology, a companion for those approaching USMLE Step 1, and may keep its place on the shelf during clinical rotations. This review text, like most in the series, is divided into two parts: basic medical science and clinical assessment. Cardiovascular System offers a unique integrated review of the anatomy, embryology, physiology and pathology of the cardiovascular system. The human heart’s vasculature and blood flow comprise an amazing web of relationships that this text reveals in a variety of high-yield illustrations. Modified concept maps, flow diagrams, and the usual graphs and charts illuminate complex structures, while pithy explanations cover radiography, angiography, CTs, MRIs and nuclear imaging.


Like all the books in the series, Cardiovascular System highlights key material and presents questions for review at the end of each chapter. It would help if these review questions were all in one place, perhaps on the Web site. However, there are 50 USMLE-type questions available to book purchasers at www.studentconsult.com with comprehensive explanations for each answer.


A section on the investigation of cardiovascular function covers electrocardiography, echocardiography and cardiac catheterization, and characterizes routine investigations, like clinical chemistry in hematology.


Crash Course: Gastrointestinal System (Mosby, $29.95) has more relevance for those studying basic and clinical gastroenterology material, like residents in radiology or internal medicine. The clinical assessment includes common presentations of gastrointestinal disease with extensive flow charts that help with differential diagnoses.


This text is broad rather than in-depth. Medical students would already have this material on their bookshelves from course work in physiology and anatomy, but the clinical approach and the basic review questions at the end of each chapter offer some value.


Katherine Ellington is a second-year at St. George’s University School of Medicine.
~~~~~Humanistic Medicine,Medical Education,Physician Patient Relationship,Practice of Medicine,Student Life and Well-Being~
413~1January-February~2008-57~Feature~SPOTLIGHT: Google Medicine~How to Make the New Doctor–Patient Relationship Work~Linda Childers~As the Web gives patients another conduit to health information, the doctor–patient relationship is changing. How can you help parse fact from fiction and turn the DIY health care trend to the advantage of both your future practice and your future patients? Plus: Solid health sites you can recommend.~Empowered by the World Wide Web, the average American has entered domains once the feudal territory of professionals. These self-helpers have become their own accountants, car salesmen, bank tellers and even attorneys. But now, the surfing citizen wants to be the informed patient of the future.


Dr. Steve Regwan, a third-year medical resident and Air Force officer, has become familiar with the patient trend referred to as “Google medicine.” During his residency at Lackland Air Force Base’s Wilford Hall Medical Center in San Antonio, Texas, Regwan witnessed a rise in patients who self-diagnose via the Internet, arriving at their appointments armed with numerous suggestions and questions for their providers. And as more patients turn to search engines for health information, the dynamics of the doctor–patient relationship are rapidly changing.


“Rather than having the doctor dictate the appointment, a lot of patients are now using appointments to question their doctor on symptoms or remedies they have read about online,” Regwan says. “The doctor–patient relationship has changed from one that pits a passive patient against a paternalistic doctor to more of an active collaboration, with patients becoming more proactive about their health care.”


It’s a trend unlikely to abate. According to a survey released by Harris Interactive in July, more than 160 million Americans have searched for health information online, a 37 percent increase from 2005.


Dr. Tiffany Barnett, a third-year family medicine resident at the University of Nevada, Reno, has also witnessed a tremendous increase in the frequency of patients who self-diagnose using online information.


“The Internet has created a generation of patients who are better informed and feel comfortable researching their specific medications and conditions,” Barnett says. “Patients are no longer afraid to bring in stacks of Internet articles related to their perceived health issues.”


With a click of their mouse, patients can access a wealth of health information, including disease-specific support groups. Organizations ranging from the American Cancer Society and the National Multiple Sclerosis Society to startups including organized wisdom.com and dailystrength.org offer a new generation of interactive Web sites to potential patients. These sites provide expert medical content while also connecting patients to each other through disease-specific online communities, virtual support groups, real-time Web chats and other features, allowing patients to share experiences and advice, and even rate doctors.


Yet Regwan cautions patients not to believe everything they read online, and to consult their doctors before trading in their prescription medications for anothor remedy just because they saw it on the Web. In a study commissioned by the Department of Health and Human Services last year, the Pew Internet and American Life Project found that just 2 percent of popular health sites display the source and date of information, and only 25 percent of consumers polled check the sourcing
of their online health information “always” or “most of the time.”


“While there is a lot of health-related information available on the Web, some of the information may be out-of-date, inaccurate or pushing a particular product for commercial reasons,” Regwan says.


On the other hand, many reputable health Web sites, like WebMD, encourage patients to share information they obtain online with their doctors. The site, which attracts more than 30 million consumers each month, offers a symptom checker and health articles, all reviewed by physicians.


When Information Becomes a Problem


The trend of surfing the Internet for health information can become problematic for the patients health experts have dubbed “cyberchondriacs.”


While a little information can be a good thing, Googling health concerns can promote anxiety in patients, who have vague symptoms that could be caused by any number of ailments.


“While the Internet has created a generation of better-informed patients who are not afraid to research their specific medications and conditions, it’s also raised the possibility of patients buying into information that is inaccurate,” Barnett says.


A survey conducted last June by
the Opinion Research Corporation showed that most adults polled followed health and nutrition advice found on the Internet whether they believed the information to be accurate or not: Only 62 percent of respondents who sought health information online believed in its accuracy. Still, 89 percent of the group followed the advice that they found.


Dr. Jennifer Griffin, who just completed her first year of practice in the Department of Obstetrics and Gynecology at the University of Nebraska Medical Center in Omaha, points out that the Internet can also be a breeding ground for medical rumor.


“A lot of urban legends exist around obstetrical practice,” says Griffin. Among the Internet hoaxes, chain e-mails and tall tales that circulate online are claims that specific restaurant meals can induce labor and that tampons contain asbestos.


“We caution patients about taking everything they read online as fact and trying crazy methods of inducing labor,” she notes.


“I’ve found it helps to listen to patients and find out where their fears are coming from,” Regwan says. “Patients are usually fearful for a reason. Perhaps they recently lost a loved one to cancer or are going through a particularly stressful time in their life.”


When patients make numerous visits and continue to worry about serious illnesses despite having undergone a physical and family history assessment, Regwan gently recommends a referral to a mental health professional.


“I acknowledge that their perceived medical problem appears to be causing them a great deal of stress,” he adds. “And then I suggest it might help to talk to someone about their anxiety.”


Putting Google Medicine to Good Use


Turning the drawbacks of the Internet-ready patient into advantages takes some finesse, but it is possible.


“Patients try to manage their health care and sometimes find information online that makes them question their doctor’s orders,” Regwan says. “I try to listen to each patient’s concerns and help them to interpret the information they’ve found. But sometimes that’s hard given the time constraints of appointments.”


So how can future physicians successfully work with patients arriving for appointments armed with stacks of information and questions they’ve gathered online?


When faced with questions about unproven treatments or remedies that his patients have discovered on the Web, Regwan explains the practice of evidence-based medicine and tells patients how physicians strive to combine clinical expertise with evidence from systematic research.


“If I prescribe a cholesterol-lowering drug to a patient, I explain how it’s FDA-approved and monitored and how it’s gone through years of clinical trials; the same can’t be said of most herbal remedies,” Regwan says.


“Building a strong physician– patient relationship today involves validating the patient’s health concerns and then providing sound medical advice regarding their specific health issues,” Barnett says. She has found it helps to steer patients to reputable medical Web sites like www.mayoclinic.com.


The Internet can also prove to be a useful source of health-related information for residents and doctors, but unlike many consumers, they rely on Web sites maintained by federal government agencies, large professional organizations and medical schools.


“For my practice, I often direct patients to www.acog.org, which has a special patient information section,” Griffin says. “My staff frequently prints patient information sheets from www.emedicine. com, which also has good overviews on certain medical problems.”


Online health Web sites can also provide doctors and other health care providers with pertinent information that might not be found elsewhere. Last year, doctors at the Princess Alexandra Hospital in Brisbane, Australia, identified 26 diagnostic cases presented in the New England Journal of Medicine during 2005. They included conditions such as Cushing’s syndrome and Creutzfeldt-Jakob’s disease.


Using three to five search terms from each case record, they performed Google searches and documented the three most prominent diagnoses that fit the symptoms. Searches found the correct diagnosis in 15 cases, or 58 percent of the time.


Doctors such as Griffin have found positive ways to use Internet information to engage patients in a conversation about their health concerns.


“When patients Google their symptoms, it can help expedite counseling with [those] who have a pre-existing condition,” she says. “It is possible to use the information as an opportunity to educate patients about their health and help them make more informed decisions.”
~Resources

The Medical Library Association’s Web site offers a list of the Top 10 most useful sites for health consumers.
www.mlanet.org


The Health on the Net Foundation, based in Switzerland, certifies health-related Web sites. Their criteria include clearly distinguishable advertising, attribution of sources and information intended to complement, not replace, the doctor–patient relationship.
www.hon.ch


SearchMedica offers a search engine for medical professionals.
www.searchmedica.com


Health Ratings, a joint project of Consumer Reports Webwatch and the Health Improvement Institute, rates the top health, diet and pharmacy Web sites.
www.healthratings.org


OrganizedWisdom is a search engine for patients, directing them to multiple health-related Web sites.
organizedwisdom.com


DailyStrength offers support groups and networking for patients with a wide variety of conditions.
dailystrength.org


eMedicineHealth includes first-aid and emergency care information for patients, as well as information on consumer health.
www.emedicinehealth.com
~~~Linda Childers is a freelance writer in Martinez, California. Direct comments on this articles to tnp@amsa.org.~Learning Tools and Technology,Physician Patient Relationship,Practice of Medicine~
414~1January-February~2008-57~Feature~Primary Preview: 2008 Election Guide~~Pete Thomson~It may be January, but health’s hot in the 2008 presidential election season. The first primary is only days away, so we’ve put together a roundup of the platform planks affecting future physicians.~Election Preview (PDF)


Last September, The New Physician brought you opinions on the future of medicine and health care. The truth is, the decisions are happening right now about where we—providers and patients—are headed as a nation in terms of our health and care. And the country is paying attention.


In poll results released by the Associated Press in December, health care and the war in Iraq were the big issues: Voters seem to see the moral and financial questions in both. In the past, health care has been bumped from political discussion by topics more suitable to sound bites and wedge issues intended to polarize voters.


For several 2008 candidates, however, health care coverage itself is a loaded issue. Sen. Hillary Clinton (D-N.Y.) carries the weight of the doomed plan she developed for her husband’s administration more than 10 years ago. Republican candidate Mitt Romney must face critics on both sides of the debate as a former governor of the first state to deploy a health care coverage mandate; some critics cite his support for the Massachusetts plan while others say he didn’t go far enough in its implementation. Rep. Ron Paul (R-Texas), a retired OB-Gyn, practiced for more than 30 years in Texas. Democratic candidate and Rep. Dennis Kucinich (D-Ohio) has long pushed for a single-payer national health care program. Former Health and Human Services Secretary Tommy Thompson bowed out of the race in September. John Edwards was himself a high-profile lawyer in North Carolina.


Clearly, both physicians and physicians-in-training will be watching—and voting—for how the system in which they work will be shaped. They will also be keeping an eye on candidates’ platforms for medical liability reform.


For medical students—and especially premeds—there is more at stake than health care, malpractice and financing: Higher education and student loan policy will affect their future significantly. Ongoing efforts to achieve diversity in medicine will also be impacted by the tone set by a new president. Medical residents should note that the funding for their positions could be altered by any significant change in Medicare’s direction.


With these interests in mind, TNP has prepared a guide to this year’s elections. Iowa caucuses kick off this year’s primary season on the 3rd of this month. By the time Nov. 4—election day—rolls around, the people will face a simpler choice. If future-physician voters want to get into the details of what this country’s health care and medical education will look like for the next four years—and probably beyond—the time for discussion is now, not in the fall.
~~~~~Health Policy~
415~1January-February~2008-57~Feature~Politics vs. Public Health~The surgeon general’s high wire act~April Fulton~Testy testimony surrounding the president’s latest nominee is only part of a long back-and-forth between surgeons general and the administrations they serve. In recent years, however, the nation’s doctor has really been pushed into a corner. Is this the end of an independent voice for public health?~Joking that rappelling from helicopters might not set a good example for safety, President George W. Bush presented America with his choice for a post-9/11 surgeon general, Dr. Richard Carmona. Returning to his nominee’s record, Bush mentioned the doctor’s military, SWAT, community health and emergency medicine experience.


Carmona, who retired from the post in 2006 when his term expired, would later charge that in the wake of Hurricane Katrina, political appointees blocked reports on global health, mental health and emergency health care despite his background.


The surgeon general of the United States is expected to wear many hats: doctor, teacher, scientist, health expert and public speaker extraordinaire. But must he or she wear the hat of a politician? Does the surgeon general have an obligation to promote the politics of the administration he or she serves?


Former surgeons general, former assistants and deputies, and other public health advocates say the surgeon general should promote science, not politics. Yet they all acknowledge doing so is challenging, and has become even harder under the current administration.


“The job of surgeon general is to be ‘the doctor of the nation’—not ‘the doctor of a political party,’” Carmona testified before the House Committee on Oversight and Government Reform in July 2007.



Concerns about the independence of the surgeon general from public health and political corners alike are prompting Congress to take a closer look at the Office of the Surgeon General, its responsibilities and duties to the American public, with an eye toward ensuring the “nation’s doctor” has the independence and the authority to speak to the science, regardless of politics. The potential of the office to administer health on a nationwide scale is unparalleled, but it takes a person willing to be a singular figure in the public eye.


“The position of surgeon general is a revered post in our government. Fixing what’s wrong and making the office work again should be a bipartisan priority,” said House Oversight Committee Chairman Henry Waxman (D-Calif.), at the hearing. Waxman introduced a bill in August which he hopes will do just that.


At the hearing, Carmona testified that he was invited to meetings that he considered “political pep rallies” and was instructed to include Bush’s name several times in his speeches.


He says he was blocked from speaking in his official capacity as surgeon general at an event for a group helping the intellectually disabled for fear it could appear to support the interests of a prominent Democratic political family—the Kennedys.


He said he was left out of meetings on the impact of global warming after he took issue with administration officials’ views at one meeting.


The Bush administration denies it interfered with Carmona’s work, but other former surgeons general echoed his concerns that the political climate is getting worse.


“Over the years since I left office, I have observed a worrisome trend of less-than-ideal treatment of the surgeon general, including undermining his authority at times when his role and function seemed abundantly clear,” testified Dr. C. Everett Koop, former surgeon general, who served under President Reagan.


“I think it is OK for the White House or the Congress to disagree with the surgeon general on issues, because the American people look to the surgeon general for the best available science,” testified former Surgeon General David Satcher, who served under Presidents Clinton and George W. Bush. “I don’t think it is OK for the White House or the Congress to dictate the messages of the surgeon general, and that is our concern.”


Long-time observers of the surgeon general’s office agree. “It’s a fact that political appointees in certain administrations have been on shorter leashes than others,” says Dr. Georges C. Benjamin, executive director of the American Public Health Association (APHA) and a former secretary of
the Maryland Department of Health and Mental Hygiene. “That doesn’t mean a surgeon general can’t support the agenda of an administration, but the science has to be pure.”


A Historic Mission Altered


The surgeon general is America’s chief spokesperson on public health issues and oversees the operations of the 6,000-member Commissioned Corps of the U.S. Public Health Service (PHS).


Appointed by the president and confirmed by the Senate for a four-year term, the surgeon general reports to the assistant secretary for health (ASH), who is the principal adviser to the secretary of the Department of Health and Human Services (HHS) on public health and science.


But it wasn’t always so. Several times in the long history of the surgeon general’s office, the positions of surgeon general and ASH have been combined, and their authorities over U.S. public health have shifted.


The PHS is a “jewel that the public really doesn’t know about,” says Benjamin. It is composed of various medical professionals and charged with rapid response to public health needs in a crisis and the general advancement of public health science.


Congress established the PHS’ predecessor, the U.S. Marine Hospital Service, in 1798 to care for sick and injured merchant seamen. In 1870, the service was reorganized as a national hospital system under the direction of the supervising surgeon, who later became the surgeon general.


Until 1968, the surgeon general headed the PHS and enjoyed administrative and financial management authority, reporting directly to the secretary of Health, Education, and Welfare.


Then, in 1968, President Lyndon Johnson reorganized the office and designated responsibility for PHS to the ASH, and required the surgeon general to report to the ASH rather than to the secretary directly.


In 1972, President Nixon reversed course, requiring the surgeon general again to advise the secretary directly. In 1977, the positions of ASH and surgeon general were combined; in 1981, they were separated again, according to the surgeon general’s office.


Dr. Samuel “Woodie” Kessel, a recently retired assistant surgeon general who has worked with every surgeon general since the 1970s, recalls that under President Carter, Dr. Julius B. Richmond served as both ASH and surgeon general. “As a consequence, I think it was a challenge for Julius to manage as well as be a spokesperson,” says Kessel, a pediatrician who now teaches at the University of Maryland.


When Koop took over after Richmond in 1981, Kessel says, the job was split again, giving ASH the primary responsibility for the PHS’ Commissioned Corps and the health budget.


“The policy implication was very important at that point,” Kessel says. “The ASH really had all of the responsibilities for all of the resources. The surgeon general, as I recall the organizational chart…, reported to the ASH for health but did not have all of those assets,” he says.


Perhaps because of all the changes—particularly the lack of budget authority—the surgeon general position in recent years has been reduced to a “figurehead position with potential,” says Dr. Fitzhugh Mullan, a former assistant surgeon general from 1990–1995 and a 23-year veteran of the PHS.


Mullan is currently a joint
professor of medicine and policy in George Washington University’s Department of Health Policy. As the author of the 1989 book Plagues and Politics: The Story of the United States Public Health Service, Mullan acknowledges that there has always been political pressure in public health in one form or another, although he says the “handcuffs that were on Dr. Carmona were as tight as any I’ve observed.”


However, the sheer force of personality has a lot to do with the success of a surgeon general, and many observers point to Koop as the primary example.


Feats of Daring


We might still be smoking on airplanes or driving drunk without the efforts of Koop in the 1980s and Reagan’s essentially hands-off policy toward him.

If Koop had been impeded in his duties, reports on smoking and health, tobacco addiction, the toll of drunk driving, and the state of the nation’s nutrition might never have been released, he said, among many other efforts.


Koop’s outspokenness on the emerging AIDS epidemic has since become a public health touchstone, even leading to a parody on “Saturday Night Live.”


“The Koop period was quite an extraordinary period,” says Mullan. Koop enjoyed recognition and credibility because of both his personality and his ability to speak with relative freedom about the hot health topics of the day.


“By the time Reagan’s aides realized Koop had become a phenomenon, championing these issues, his horse was already out of the barn,” recalls Mullan.


Koop testified at the committee hearing that he knows Reagan was under pressure every day to fire him and credits then-HHS Secretary Otis Bowen for supporting him in getting information about AIDS out to the public.


“If we had followed the protocol, and every word was scrutinized, these reports, because of their nature and plain speaking, I am sure, would not have seen the light of day,” Koop said.


But Koop wasn’t always so revered. In fact, leading Democrats, including Waxman and Sen. Edward Kennedy (D-Mass.), opposed his nomination during extremely contentious confirmation hearings because he was unapologetically anti-abortion.


He vowed to focus his job on science rather than his personal beliefs, was confirmed by the Senate, and by all accounts, kept his word.


It remains to be seen whether the current surgeon general nominee, Dr. James Holsinger Jr., will be given the opportunity to prove he can do the same. Holsinger has been under fire from congressional Democrats for a paper he wrote in 1991 that argued homosexuality is not natural or healthy. Senate Democrats kept the Senate in session over a scheduled fall break to prevent Bush from making Holsinger a recess appointment. As of press time, the same tactic was planned for their winter break.


There has always been a significant amount of vetting of a surgeon general’s work within the administration, says Kessel, and that’s to be expected. But the danger is when the vetting process strays from reviewing the science.


Many previous surgeons general acknowledge they have experienced political pressures.


Satcher testified at the House Oversight Committee hearing that he was hampered from finalizing his report “Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior” by both the Clinton and Bush administrations, forcing Satcher to release it without official signature in 2001, his final year of service.


“The president and the secretary did not support that report, and they did not support it because of obviously both its political and religious implications,” Satcher said.


The Future of the Nation’s Doctor


All three former surgeons general
who testified at the House Oversight Committee hearing say the office needs its own budget and greater independence from the administration under which it serves.


“The surgeon general’s office would benefit tremendously from being more independent with well-defined resources for carrying out the duties of that office. It is clear that the American people value the Office of the Surgeon General, and that the global community has tremendous respect and appreciation for the office,” said Satcher at the hearing.


“The security of a four-year appointment doesn’t mean much if you can be easily denied the resources you need to do your job,” added Koop.


Waxman’s bill, the Surgeon General Independence Act, H.R. 3447, would create a more prominent role for the PHS Commissioned Corps in the nomination of a surgeon general, require the surgeon general to submit an annual budget and report directly to the HHS secretary, and release an annual report that can only be blocked by the secretary.


The bill was referred last summer to the House Energy and Commerce Committee, which has jurisdiction over the surgeon general’s office.


Mullan, who has consulted with various congressional aides on potential legislation, says the future surgeon general can play a key role as the nation’s doctor, but added: “That role will not be played out and will not be effective if the person is seen as an agent of the political administration.”


Koop went so far as to suggest that a panel of the Commissioned Corps vet future surgeon general nominees.


“I believe that the surgeon general should not be a political appointment,” he said at the hearing.


APHA’s Benjamin is not willing to go that far. “Let’s not fool ourselves by thinking if you take away the political appointment, the politics are not there,” he says.


“These [surgeons general] all have to be strong leaders, good doctors, and they have to have a political sense,” he says, but adds that they need the independence to speak and the budget to back them up.


“We have to have a White House that is supportive of [independence],” says Benjamin. “I doubt anything will happen before the next administration.”
~~~~April Fulton is a freelance writer in the Washington, D.C., area.
Direct comments about this article to tnp@amsa.org.~Community and Public Health,Health Policy,Legislative Action~
418~2March~2008-57~On the Wards~Only One Patient~Making or breaking a doctor’s day~Katrina S. Firlik, M.D.~The patient that defines the day~A bowl of cereal ruined one day in recent memory. Another was compromised specifically by a bagel with cream cheese. The nurse on the other end of the line always feels obligated to tell me exactly what my patient ate for breakfast when he was supposed to have nothing by mouth after midnight in preparation for surgery. For whatever reason, it’s not enough for her to say, “Dr. Firlik, we have to put your case on hold for three hours. Mr. So-and-so had something to eat.” At least then I wouldn’t have to hear that it was Grape-Nuts or a sesame bagel. Such finer details could be left to my imagination as I sit in the surgeon’s lounge in my scrubs, staring at the television bolted to the wall and contemplating my wasted morning.


One breakfast transgression by one patient shifts my whole day and threatens to land me at home late. I wonder whether my friends in business or law are ever paralyzed by something so humble as a bowl of shredded wheat. It would be unfair to blame the patient, so I don’t. So many patients these days are elderly and forgetful and live alone. Regardless, mornings like this reinforce my belief in the adage familiar to all physicians: It only takes one patient to ruin your day. A physician may see 20 patients in a given day, but only one is required to take up those extra hours and make us miss a dinner engagement, or keep us in the hospital on Thanksgiving, or even, as a bonus, reward us with a frivolous lawsuit. But this is what I signed up for when I decided to become a surgeon.


On occasion, my day is hobbled by just one patient with just one simple request, typically while I’m out for dinner or a movie and typically on a Friday evening. The patient is in excruciating pain—the worst pain of her life, in fact. She demands that the hospital operator page me because she suddenly finds herself out of Percocet after regular working hours. She needs more. She offers one of the following reasons, in a groan: A) her handbag, containing the full bottle of pills, was stolen; B) the pills accidentally got flushed down the toilet, or—a common variant—her boyfriend flushed them down on purpose; C) her teenage son stole them out of the bathroom cabinet; or D) she accidentally left them behind in a hotel room.


Those are the stories, in descending order of popularity, I hear from patients who assume I’ve never heard those stories before. Sometimes the patient will have me paged again, even after I’ve explained our no-refills-after-hours policy. Some will even go so far as to call me back directly, once they’ve captured my cell phone number. At that point, I have to decide how long I’ll endure the soliloquy before I hang up. As I said, it only takes one patient and, often, it only takes one little thing. A bowl of cereal. A bottle of narcotics.


Just as often, though, it only takes one patient, and one little thing, to make my day. I took care of a woman who had seriously injured both frontal lobes in a fall. Her husband visited her every day, and I often saw him at the bedside during my evening rounds. He tried his best to engage her in conversation despite the profound lobotomy-like apathy that her swollen frontal lobes returned to him. It was torture for him—and me—to watch. One evening, I eavesdropped on their “conversation” while I worked at the back of her head to remove a few sutures. While he held her hand, he spoke softly and patiently of his day at work, the weather and current events. “What a great guy,” I thought to myself. “What a strong marriage.”


Then he mentioned to her how he arrived home alone the other night and decided to clean out her purse. “Just the way you like to do,” he told her. “I got rid of all the gum wrappers at the bottom.” It was his mention of the gum wrappers that really got to me. I had to excuse myself. Standing out in the hallway, I dabbed my eyes and took a deep breath before going back in the room. It was the simple gum wrappers.


Not long ago, I saw an elderly woman as a consult in the hospital. Her internist ordered a brain scan to evaluate her rapid decline in memory and speech. She already had mild Alzheimer’s, but this was something more. I took one look at the scan and knew the answer: malignant brain tumor. Sure, I explained to her internist, we can be fooled on rare occasion. Sometimes it turns out to be something else, like an abscess or a more benign type of tumor. That’s why we usually recommend at least a needle biopsy. Otherwise, we can’t offer any treatment.


I went through this thinking with the patient and her daughter. They asked me for some time to think about it. A few hours later, I received a phone call from the daughter. They appreciated my advice but they decided to leave things be. “She’s had a full life,” her daughter explained.


Although I had nothing left to offer, I stopped by her room again on my evening rounds. The patient’s entire family was there, and her daughter was pouring champagne.


“We’re toasting to her life!” the daughter told me. The patient laughed. She was the happiest patient I had seen all day, despite being the closest to death. She smiled and offered me a glass.
~~~~Dr. Katrina Firlik is a neurosurgeon at Greenwich Hospital in Greenwich, Connecticut, and the author of Another Day in the Frontal Lobe: A Brain Surgeon Exposes Life on the Inside.~Physician Patient Relationship,Practice of Medicine~
419~2March~2008-57~Well-being~On Call, 168 Hours a Week~Parenthood brings new perspective to PGY-3~ Andrew W. Seefeld, M.D.~Resident parents have more fun on less sleep~Jolted awake three times already, I was finally able to seek refuge in my bed, imagining the gift of at least a few hours of sleep. As a physician-in-training, I have endured years of being suddenly and brutally rousted from a peaceful sleep by seemingly endless pages from nurses and fellow physicians. During my internship, I would often lay in my on-call room, unable to sleep, waiting for my “wake-up call,” though this wouldn’t come with complimentary breakfast and coffee or even a stale croissant. Thirty–hour shifts, usually every three to four nights for a year, were rough on the body as well as the mind, but I survived.


Tonight was different. Instead of being roused by my 8-oz. pager’s intrusive beep, it was an 8-pound newborn’s piercing shriek. My “new” pager, like my medical pager, could go off at any moment. Having weathered my medical internship year and started a “pager-free” residency in emergency medicine, I figured my sleepless nights were now behind me. Wow, was I wrong. My beautiful daughter is so small, but she is also extremely demanding. I am having a difficult time deciding which is harder: internship or fresh fatherhood. Tonight, I’m thinking fatherhood. Turning off a pager takes a push of a button. Stopping a newborn from screeching requires much, much more.


Though I made it through four years of medical school, a year of internship and now a year-and-a-half of residency training in emergency medicine, nothing prepared me for being a father. Without a doubt, parenthood requires a great deal of commitment, patience and most importantly compassion—the same attributes that characterize a well-rounded physician. However, fatherhood has given me a profoundly different perspective on life. With every diaper I change, every bottle I mix and every bath I give, I hear my own mother silently saying, “Just you wait.” Of course, she is referring to the changes that will take place in my life while raising my child.


Meanwhile, my priorities are changing, my interests shifting. A tough day of work in the emergency department (ED) can easily be softened by a simple glimpse of my daughter or the sound of her jabbering. A day off is better spent at the beach drawing pictures in the sand rather than being slumped over a medical book for endless hours. In order to care for my child’s needs while still staying current with my studies, fatherhood has made me a master of efficiency. With every smile from the beautiful child we were so fortunate to bring into the world, I am reminded what a small sacrifice it has been to defer activities on which I used to spend my free time.

Though the demands of my internship training have been challenging, often bordering on inhumane, new fatherhood sometimes makes my training look like a walk in the park.



The blending of my roles as physician and father has also produced an unexpected paradox: Despite my medical knowledge, I question myself when the patient is my daughter. The slightest cough makes me turn to my medical books, when, in reality, it is simply a result from overfeeding or gas. I often hear myself asking my wife, “Do you think she is OK?” Or, “Should I call one of my colleagues for advice?” Truth be told, there have even been times when I’ve called my mother for advice and reassurance! What’s going on here? I don’t feel this insecurity when dealing with patients in the ED. Why do my clinical knowledge and intense medical training appear to be useless when it comes to dealing with my own child? Perhaps the answer is quite simple: When I cannot remain completely objective, my knowledge and experience, rather than being assets, become liabilities that impair my ability to realistically evaluate probabilities. Since my wife is not in the medical field, she is unaware of the vast range of potentially debilitating medical illnesses that “may” be associated with seemingly benign symptoms. This is fortunate for me. Call it mother’s intuition or anything you’d like, but it quells my concerns and brings me back to reality when she turns to me and says, “The baby’s fine.”


During the pregnancy, my wife and I spent hours reading books about parenting, but nothing could have prepared us for the real thing. These last few months have depleted my strength more than any time in the hospital during my training. Instead of “Baby on Board,” the sign on our car should read, “Exhausted Father on Board.” Though the demands of my internship training have been challenging, often bordering on inhumane, new fatherhood sometimes makes my training look like a walk in the park. And no, I never thought I would ever make such a statement either.
~~~~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.
Direct comments about this topic to tnp@amsa.org.
~Residency,Student Life and Well-Being~
421~2March~2008-57~Feature~Breaking Into the Boys’ Club~Why do gender gaps persist in surgical subspecialties?~Beth Rogers~For longer than a decade, more than 40 percent of medical graduates
have been women. Female physicians have reached parity in some
specialties and even outnumber men in some others. But they’ve made few inroads into a few subspecialties: notably orthopedic surgery and neurosurgery. What’s keeping the numbers from evening out?~In many respects, this is a wonderful time to be a woman in America. Women have gained entry to just about every profession under the sun. Their numbers have grown in the upper echelon of the corporate world. There is a serious female contender for president of the United States. However, in the medical arena, while women have made inroads and are represented at almost every level, some subspecialties are still overwhelmingly male. At issue is whether this is by design or default.


According to the Association of American Medical Colleges, 49 percent of first-year medical students and 44 percent of residents were women in the 2006–2007 academic year. But in the not-too-distant past, female physicians were an anomaly and female surgeons were even more rare.


The road to the present has been paved by people like Dr. Frances Conley who, in 1966, became the first woman to pursue a surgical internship at Stanford University Hospital. Eleven years later, she became the fifth woman to be certified by the American Board of Neurological Surgery, and in 1988 she became the first woman to be appointed to a tenured full professorship of neurosurgery at Stanford University School of Medicine.


It was not always easy for medicine’s female pioneers. “In medical school, more often, as women, we were ignored, even if we had the right answer,” Conley said in an interview with the National Institutes of Health for an exhibit honoring women in medicine. “The women in my class learned to deflect a few of the insistent, almost daily insults, but we absorbed many more offensive slights that had little to do with bad performance and everything to do with fortune of birth.”


It wasn’t uncommon, noted Conley, for them be addressed by their male colleagues as “honey” rather than “doctor,” or even to be groped after they had scrubbed for surgery and could not use their hands to resist.


Although males and females have essentially reached parity in medical school, a few subspecialties are markedly filled by men, most notably neurological, orthopedic and thoracic surgery.


Relatively speaking, the numbers of women in these specialties are growing exponentially, but they’re still low, which has caused many to analyze the reasons for this disparity. Though a certain amount of discrimination remains, experts and female physicians in these specialties point to concerns trainees hold about time commitments, lifestyle and lingering misinformation about their capacity to fulfill the duties of particular subspecialists. One overarching thread is the dearth of role models beckoning them into these fields.


Dr. Deborah Benzil, a neurosurgeon with Westchester Spine and Brain Surgery in Hartsdale, N.Y., is only one of about 200 board-certified female neurosurgeons nationwide, and Dr. Kim Templeton, an orthopedic oncologist in the department of orthopedic surgery at the University of Kansas Medical Center, is one of fewer than 400 board-certified female orthopedic surgeons.


Asking the lifestyle
question


Dr. Monica Zangwill, who edits CME materials in Boston, notes that self-selection often starts with residency. The length of the residencies required for surgical subspecialties may intimidate, Zangwill says. “A lot of women, if they want to be able to have kids, start thinking, ‘Maybe this is not going to give me enough flexibility.’”


The biggest concern that Templeton hears from women who are contemplating orthopedic surgery is the busy lifestyle will keep them from having a family. “Once you’re out in practice, your lifestyle is as busy as you want to make it.” The vast majority of female orthopedic surgeons Templeton knows are married with children. “I hate to think that’s the only thing that would keep people out of ortho,” she says, “because if you look at other medical subspecialties, like OB-Gyn, the hours are actually worse than…orthopedics, yet over half the people in that specialty are female. So it can’t just be the hours issue.”


Benzil and Templeton firmly believe that lifestyle concerns should not be a deterrent to pursuing surgery. Benzil says, “One of my mentors told me, ‘Everyone has choices and the only thing you can control is whether you make them actively or passively.’” Benzil has two children and will be celebrating her 20th anniversary this May. She has family dinners at least four times a week—a schedule more determined by her teenage kids than her own workload. She ticks off all the things she is able to do: work out regularly, vacation annually, publish papers, serve as an officer in several national organizations, travel around the world to lecture and participate in neurosurgery programs—all while maintaining a successful private practice. “I would love to be able to travel more, to read more, to help more patients, publish more,” Benzil admits, “but I do a little bit of all of the things that are really important to me.” She adds that most of her female colleagues have spouses and children.


When asked if there was something about neurosurgery inherently off-putting to women, Benzil replies, “It’s not always easy to step into an arena where you’re going to be a distinct minority: the quote-unquote ‘boys’ school.’” And neurosurgery suffers from the same time-intensive schedule as orthopedic surgery. “Even after you finish your training, the hours are long and surgeries are physically demanding, so I think there were a lot of women who maybe just felt that it wasn’t what they were looking for.”


Nonetheless, Benzil was able to get married and have two children during her residency—without missing a single call.


Finding a muse


A significant source—and opportunity for improvement—of female underrepresentation in certain specialties is a lack of student exposure to those specialties. Benzil notes that exposure in medical school to neurosurgery is a key to attracting more people to the profession, regardless of gender. “I wasn’t headed into neurosurgery like some people who know when they’re 12 years old,” she says. “I had a rotation on neurosurgery and I just fell in love with it and couldn’t see myself doing anything else.” But, she adds, less than 10 percent of medical schools require clinical exposure to neurosurgery.


Lack of exposure, agrees Templeton, is a big reason why women aren’t entering orthopedics: “Not all medical students are exposed to the topic of musculoskeletal health during their medical school training…so they don’t necessarily get to see orthopedic surgeons [and] they don’t get the opportunity to look at this as a professional career option.”


Once they get the exposure, women don’t always see other female role models. Not seeing women in a profession sends a message that they aren’t welcome or it isn’t attainable.


One of the primary conclusions of a recent study, published in the November issue of the Journal of the American College of Surgeons, is the importance of mentoring. “Mentorship is something that is immensely important, perhaps not even in a way that is so measurable,” says Dr. Sharon Weber, a surgical oncologist at the University of Wisconsin and co-author of the study. “I can tell you of multiple examples of students who think they can’t do surgery because they have partnered and have kids. They just need to see that it’s possible. If you don’t see someone doing it successfully, you don’t think it’s possible for you to do it.”


The study found that of the medical students who identified a mentor, about 70 percent went into the same field as their mentor. Change could be effected, authors imply, by setting up mentors in undergraduate or medical schools.


“Without a lot of women in orthopedics—and therefore not a lot of women in academic orthopedics—the students who come through don’t see a lot of women as mentors or role models,” Templeton says. “Not that female students have to have a female mentor, but at least from a role model standpoint, it helps to see that there are women out there in the field and know that there is somebody you can talk to.” Without solid role models, she says, a lot of students hear stories about orthopedics, which may or may not be correct.


When Kim Bishop decided she wanted to go to medical school, she was initially interested in orthopedic surgery. However, Bishop recalls, “When I met with an orthopedic surgeon, I was told that I was too small to physically do the job, and in general women are too weak to be able to physically meet the demands of an orthopedic surgeon.” Bishop is now a first-year at Southwest College of Naturopathic Medicine and plans on being a family practitioner. She says her decision was made, in part, by that comment.


Templeton is familiar with anecdotes like Bishop’s. Women who apply to the residency program at the University of Kansas often have concerns about their physical ability due to comments from advisers or people outside the orthopedic world. However, she points out, “Things have changed quite a bit as far as the strength required. We have a lot more instruments that we can use, a lot more power tools, and other than in a very few instances within orthopedics, you really don’t have to be all that strong to do it…. Yes, there are a lot of things that we do that require a lot of brute strength. [But you] get somebody to help you as a lot of the guys do…. There are a lot of small guys who do orthopedics.”


That being said, Templeton recalls that as the first female orthopedic surgery resident at Rush-Presbyterian-St. Luke’s Medical Center in Chicago, early on in her training, she was doing a difficult trauma case that did require a lot of brute strength, and her attending looked at her and said, “I always wondered what it would be like to see a woman have to do something like this.” As more women enter professions and demonstrate their competence, stereotypes are broken down.


Templeton admits that there have been many missed opportunities to recruit women into orthopedics. “When you ask people why they want to go into orthopedics, a vast majority go into it because of a background in sports,” she says. Templeton, who played collegiate tennis and had a lot of injuries, was drawn to the field for those reasons.


However, she continues, there has been a gender-based difference in how that interest is nurtured. When Templeton interviews medical students for her residency program, many men tell her they got interested after an injury when their orthopedists encouraged them to get into the field. But she never heard about any female medical students who were encouraged by their doctors until this year. “I was shocked and quite pleasantly surprised. I think the tide is turning.”


Given how few women there are in certain specialties, should they only mentor other women? “I think there’s a natural fit in terms of personality,” responds Weber. “In general, people seek out what they need, and so I will bet that most women surgeons mentor more women and have conversations about family life…than men do. Probably a lot of women would never ask that of [male] surgeons.” However, Weber notes, women who mentor men can help to further break down stereotypes.


Women’s medical societies help highlight role models and create networking and mentoring opportunities. Benzil was among a group that founded Women in Neurosurgery (WINS) in 1989, and she makes herself available to female medical students, who call her from all over the country.


For the past 12 years, Benzil has been a full-time faculty member at New York Medical College (NYMC). Whenever she teaches a course, she says, “I always include a few things about being a woman neurosurgeon, even if I’m lecturing on cerebrospinal fluid, cerebrovascular disease, or brachial plexus.” She thinks that she has inspired five or six women at NYMC to enter neurosurgery.


Templeton didn’t have a mentor during her training. “That is one of the reasons why I try to work with women as much as I can because I know what it’s like to try to do it on your own.” She intensively mentors one or two students each year and tries to talk with each female student she interviews to see if they have any issues she can help resolve. She is also a member of the Ruth Jackson Orthopaedic Society, named after the first board-certified female orthopedic surgeon.


Striking balance


Because for the most part women still shoulder the brunt of child care and certainly all the responsibility of child-bearing, it’s no wonder that women in Weber’s study deemed lifestyle as being more important (69 percent) than men (43 percent). “Chairs of surgery are recognizing that lifestyle is a huge issue for getting people into the surgical field,” Weber says. “That is true for men as well as women.” Weber’s study also stresses the importance of surgeons promoting and modeling a balanced lifestyle.


Another interesting finding of Weber’s survey is that 80 percent of female surgeons have a spouse who works full time versus 26 percent of men. With society slow to embrace men as stay-at-home dads or endorse them as less than primary breadwinners, coupled with women shouldering a majority of household duties, Weber notes that everyone needs to prioritize and abandon tasks they don’t need to do. “We’re lucky we have money as surgeons. You can hire a housekeeper [or] nanny, which is a great way of decompressing the amount of household work.”


Today women are heavily clustered into five major specialties: primary care, pediatrics, psychiatry, internal medicine and OB-Gyn. In pediatrics and OB-Gyn residencies, women are now the clear majority. While some point to this as a reflection of a perceived better lifestyle, or at minimum shorter residencies, Templeton would again like to dispel the assumption that pursuing OB-Gyn is an easier track. She admits that the orthopedic residency is longer, but feels, hands down, that after residency, orthopedics has the same or fewer hours with more handsome financial rewards.


When Dr. Peter Klemin, a first-year resident in the Department of Obstetrics and Gynecology at the University of Wisconsin Hospital, was interviewing for residency programs, there would typically be 10 to 15 people at the interview site, of which two or three would be male. He speculates that women are drawn to the specialty because it focuses on women’s health care. He also notes that today more women in general are in medicine—his medical school class was 55 percent to 60 percent female.


As the trend continues for specialties like OB-Gyn to become more female-dominated, Klemin says there may be hesitancy for some males to go into those programs, “just because gender commonality isn’t there…but I don’t ever think there will come a time when a male OB-Gyn wouldn’t be welcome or wouldn’t be able to find employment somewhere just because of his gender or patient preference.”


Like a snowball rolling downhill, women in surgical subspecialties are slowly gaining mass and momentum. Women, says Benzil, now represent 10 percent to 15 percent of each residency class and almost 5 percent of all neurosurgeons, growth she considers to be a “huge leap.” When Benzil completed her residency in 1994, she was one of about 50 women in neurosurgery. Less than 15 years later, those numbers have quadrupled.


Organized neurosurgery, says Benzil, recognizes that attracting women to the field is important, and it has begun an outreach working with WINS to help identify barriers. “It’s well known that diversity in the workplace fosters greater creativity, greater ingenuity…and the ability to look at things from different angles,” she says. “Neurosurgery traditionally wanted to attract the best and the brightest, and currently 50 percent of all medical students are women…. If neurosurgery isn’t attractive to women, it’s not necessarily attracting the best and the brightest moving forward.”


Templeton echoes Benzil, saying, “We don’t have to have 50 percent of orthopedic surgeons being women, but they at least need to know that the career is out there, and we need to remove roadblocks to allow them to pursue the career if they’re interested.”


The days when men could get away with acting like troglodytes seem to be mercifully in the past, but there still appears to be subtle discrimination and stereotyping. Randomized, controlled studies indicate that both women and men evaluate female job applicants lower than men and still look to men as more effective leaders.


Benzil says she would be lying if she said she never encountered sexism, but adds, “I think very little was intentional. I think most of it was that they didn’t recognize the kinds of things they were saying and doing were offensive or uncomfortable for me. Because when you’re used to being around guys and only having guys around, you might say and do certain things.”


From a practical standpoint, Benzil notes that many operating rooms she encountered 20 years ago had a nurse’s locker room and a physician’s locker room. “I was always put into the nurse’s locker room and, in many cases, the surgeon’s lounge was actually physically inside the male locker room, which meant that it was impossible for me to sit and socialize and do rounds with the people on my team.” Today, Benzil says, most hospitals have a separate surgeon’s lounge. “But, believe it or not, there are still some hospitals I go to where the surgeon’s lounge is inside the male locker room.”


General surgery, Benzil points out, went through a difficult time when applications “really plummeted,” forcing it to go through a process of self-examination. Today 30 percent of the applicants to general surgery are women, and a fair number of surgery chairs around the country are headed by women. “They really decided to jumpstart the process, and they really turned things around in five to 10 years,” notes Benzil. “It really takes an active effort on the part of a specialty to say, ‘We’re not doing a good job with this. We are going to dedicate ourselves to promoting change,’ and then I think it’s fairly attainable in a relatively short period of time.”


The wheels of change are turning, slowly. As more women enter more professions, it will hopefully effect a tipping point. One study indicates that a ratio of approximately one-third women in a group is needed to change the culture of the group.


And there are some distinct advantages to being a woman in an overwhelmingly male specialty. Benzil still has patients who are surprised when they encounter a woman, but there are many female patients who strongly prefer female physicians. That leads many females to be inundated with patients.


Benzil’s grandmother, one of the few family members to encourage her decision to become a neurosurgeon, reminded her it was far better to work 80 hours at a job she loved than 40 hours at a job she hated.


“Most of the issues aren’t as big as people think,” Templeton says. “If this is a profession that you love and you want to get into it, then there really shouldn’t be anything stopping you. Size shouldn’t be a factor. Potential lifestyle issues shouldn’t be a factor. Everything can be accommodated.”
~RESOURCES


~~~Beth Rogers is a freelance writer based in Bethesda, Maryland. Direct comments about this article to tnp@amsa.org.~Career Development,Medical Education,Residency,Women in Medicine~
422~2March~2008-57~Feature~To Err Is Human. To Report it Is Another Matter~For future physicians, reporting mistakes made or witnessed is an important, if painful, move~Avery Hurt~Physicians want to report mistakes. Studies show that doctors—and trainees—believe that they should tell their institutions and patients about errors they have made or witnessed. But a number far less actually do
so when a mistake happens. The holdup may lie with error-reporting
systems, like hotlines and mountains of forms. Or it might be an
unwillingness to admit mistakes, even to themselves. Plus: The categories of error.~Since the 1999 Institute of Medicine report “To Err Is Human,” the medical community, and increasingly the public, has been aware of the urgency of the problem of medical errors. And a spate of recent studies has shown that physicians and other health care providers overwhelmingly agree that medical errors should be reported—and overwhelmingly admit that they rarely report them.


A survey of U.S. physicians, published in the Jan. 14 Archives of Internal Medicine, found that while 92 percent of the physicians surveyed agreed that reporting errors, near misses and other adverse events improves patient care and would likely report a hypothetical error, only 17.8 percent had actually reported a minor error, and a meager 3.8 percent had reported a major error. This was more or less consistent with a larger study by the Institute of Medicine (IOM), published in the Dec. 4, 2007, Annals of Internal Medicine, which found that 46 percent of doctors failed to report obvious errors on at least one occasion.


Most studies of error-reporting among physicians over the past few years have had similar findings, though not all have been consistent. A survey of U.S. physicians, published in the January–February issue of the journal Health Affairs, found again that the vast majority of physicians believe reporting errors can improve patient safety, but in this survey, a surprising 83 percent said they had used at least one type of reporting mechanism, such as filing an incident report, reporting the incident to risk management, or reporting to a patient safety program. Increasingly, hospitals and medical centers are implementing systems for safe and anonymous reporting, such as hotlines and patient safety boards. The seeming discrepancy between the studies’ findings could be due to the way the questions were phrased: “not reporting on at least one occasion,” as opposed to “having reported on at least one occasion,” or because the study listed several methods of reporting.


In any case, no matter how the questions are parsed or the numbers crunched, the trend is the same: Physicians do not report adverse events as consistently as they report their belief that they should report adverse events. And one point the Archives study and the Health Affairs study did agree on was that roughly half of all physicians do not know how to report errors, or in the case of the Health Affairs study, don’t know even if there is a mechanism for reporting errors in their institutions intended to improve patient safety. Even fewer—39 percent in the Archives study—were clear about what kinds of errors they should report.


If a lack of user-friendly systems for reporting errors and confusion about what to report is indeed the crux of the problem, the fix should be easy. Tweaking the reporting systems, making physicians more aware of those mechanisms, and educating them about what needs reporting should result in immediate improvement. Indeed, as more and more medical centers and hospitals implement error reporting systems and training programs, the problem should be on its way out. However, as the odd and inconsistent data suggests, self-reported survey questions about such emotionally loaded issues aren’t likely to tell the whole tale. Most of those who have carefully studied this issue think the problem is much deeper and more subtle than inefficient reporting mechanisms. “The issue is more difficult because of the human nature of the problem,” says Dr. Stephanie Fein, who studies the topic. “Essentially it is a personal difficulty.”


See One, Do One, Screw One Up


If making errors is a particularly human thing, as the proverb tells us, then we shouldn’t be surprised that other equally human traits come into play when it comes to owning up to them. The psychology of physicians and the culture in which they work are as important, if not more, than the mechanisms for reporting.


Two aspects of medicine make the issue of responding to mistakes particularly problematic. First, there is the strong sense of personal responsibility characteristic of most, if not all, doctors. No matter how aware a physician might be that he or she is a part of a team and could not do the job without the rest of the team, the relationship between the physician and the patient is an individual relationship. When something goes wrong, a good physician takes responsibility—even if there were many factors, or even many individuals, involved in the incident. That’s part of what being responsible is about, and may explain yet another odd finding, this one in the Archives study: Few physicians said they reported errors to the institution where they worked, but a far greater number—41 percent—said they had reported a minor error to a patient.


Dr. Lauris Kaldjian, director of the Program in Biomedical Ethics and Medical Humanities at the University of Iowa College of Medicine and lead investigator on the study, wasn’t surprised that doctors are more likely to report errors (at least minor ones) to patients than to colleagues or institutions. “When doctors deal with patients, they know that communication is a key part of the job. Moreover, it is a sign of respect for the patient,” says Kaldjian. “This [communication of errors to the patient] is of immediate value and benefit to the physician in a way that anonymous reporting to an institution is not.” Paradoxically, this relationship with the patient might be what makes doctors more willing to tell the patient when they are aware of a mistake, but perhaps less able to admit, even to themselves, when they have made mistakes. “If I am to be honest,” Kaldjian says from his personal experience, “I must say that if I am involved in a clinical situation when something doesn’t go right, my natural inclination is to justify myself.” In this way, perhaps doctors aren’t reporting mistakes because they don’t realize they are making them.


The second aspect of medical culture that interferes with consistent event reporting is the tremendous pressure in medicine to get things right. “Recall the old saying in medical training: ‘See one, do one, teach one,’”
says Dr. Spencer Nabors, a fourth-year resident in emergency and internal medicine at SUNY Downstate/Kings County Hospital. “That’s see one, do one, teach one,” Nabors emphasizes. “You were told once, so you should know. In no other career is that kind of thing expected. There is a powerful group norming in medicine that says you have to get it right from the very start,” he says. Mistakes are simply not a part of the program. This is especially difficult for students and residents, who are still learning and, in any other profession, would be expected to make mistakes.


Don’t Tattle?


Sometimes, of course, crises of “to report or not to report” involve mistakes made by others. This is especially true for trainees, who probably are more likely to make mistakes, but whose mistakes are usually caught and dealt with by superiors. But what happens when a student witnesses a mistake that no one else seems to acknowledge?


Heather Finlay-Morreale is a second-year at the University of Cincinnati College of Medicine. She sees a great deal of subtlety in the issue. “There are a lot of things seen by medical students that might be interpreted as [errors] when, in fact, they aren’t. When I see something questionable, I try to stop and think if I am sure that I have the answers and the knowledge to evaluate the situation. I don’t run off and tattle.”


Fein, a UCLA medical school researcher who has been looking into this issue for many years, understands exactly what Finlay-Morreale means. “In the beginning we don’t think we know anything,” Fein says. “There is a huge amount of uncertainly. But looking back, I don’t think we ‘don’t know’ as much as we think we ‘don’t know’ when we are starting out. Lack of knowledge can be a handy reason not to speak up. Ideally, a student will have someone he or she trusts to go to and ask about what has happened,” she says.


But as important as it is to have trusted advisers, they are not a substitute for a clear policy on dealing with errors or suspected errors. “Someone at orientation should say, ‘If there is an error, here’s what you do,’” says Fein. “The procedure should be clear. And fortunately this is done routinely now—not that long ago, it wasn’t done at all.”


Not Blame but Opportunity


We all make mistakes, but convincing doctors of that might be a losing battle. On the other hand, a better understanding of the nature of mistakes might do a world of good.


The sense of responsibility, as well
as a presumption of infallibility, might blind medical professionals to what is really going on when mistakes happen. Experts who study medical errors agree that medical errors are rarely the mistake of one individual. “Mistakes are best seen as the result of a confluence of failures in multiple systems,” says Dr. Chris Landrigan, research director of the Inpatient Pediatrics Service at Children’s Hospital Boston, who has worked on issues relating to patient safety and medical errors, especially in regard to medical students, residents and sleep deprivation.


Fein points out that coming to grips with errors by spreading the blame is easier in theory than in practice. She sees the issue, at least in part, as an emotional one. “It is my personal belief that the relationship between the doctor and the patient is an intimate relationship; this makes mistakes even more difficult to cope with—it becomes a personal difficulty, letting someone down,” she says.


However, seeing the mistake as an individual failure, regardless of how natural or noble that may seem, doesn’t do much to prevent future mistakes, if indeed they are the result of a complex web of systems failures. If errors are a function of multiple malfunctions, reducing errors and protecting patient safety will require carefully analyzing those errors, and obviously in order to do that, we have to have records of them. And seeing them as systems failures may also be the best way to get more of them reported. “Reporting an error is not the same as assigning blame,” says Nabors. “It is better to see reporting as pointing out an opportunity for change.”


Landrigan agrees that a culture change is needed if errors are to be more consistently reported. But in addition, we must have “safe, anonymous reporting systems that offer adequate protection, especially for junior folk, and we must make an effort to engage students in the issue of patient safety,” he says. “It is a complex issue with no simple solutions. Things will change, but change will be slow.”


Fein shares the view that change is coming. “The issue of informed consent used to be like this,” Fein says. “Surgical patients were not routinely told about the risks of the procedures. Disclosure of errors may be moving in the direction of informed consent, which seems so obvious now, it’s hard to imagine that it wasn’t always routine. I think that is a good sign for reporting errors.”
~Errors, Adverse Events, Near Misses—they are several terms to refer to similar things, and they are often used a bit loosely. Here are the definitions used in the original IOM report “To Err Is Human: Building a Safer Health System,” and further defined in the Health Affairs study.


ADVERSE EVENT: An injury that was caused by medical management rather than the patient’s underlying disease.


MEDICAL ERROR: The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim; medical errors include serious errors, minor errors and near misses.


Serious Error: An error that causes permanent injury or transient but potentially life-threatening harm.


Minor Error: An error that causes harm that is neither permanent nor potentially life-threatening.


Near Miss: An error that could have caused harm but did not, either by chance or because of timely intervention.

~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.
Send us your comments or share your experiences with us at tnp@amsa.org.~Career Development,Ethics,Medical Education,Medical Research,Physician Patient Relationship,Practice of Medicine~
425~3April~2008-57~Perspectives~Good Friday~A new physician gives thanks for her life~Carina Grassman Baird, M.D.~Ten years from a close call~Ten years ago, April 10 was a Friday. Good Friday, in fact. And it was a good Friday, the Friday of a high-school senior’s spring break, before four years of undergrad and four years of medical school. My first memory of that day is meeting up with a group of eight friends, piling into two cars for an hour’s drive to Huntington Beach to enjoy the day together. My next memory is turning right onto the Pacific Coast Highway (PCH), the sun shining onto my blue Jeep Grand Cherokee and a cool wind blowing through the car.


Then, calamity: warm blood all over me, the steering wheel and the crumpled dashboard. Through crushed glass I saw the smashed front end of another vehicle, that of a wrong-way driver who had plowed his car into my own.


No—please no. Please no. Oh my God. I screamed it repeatedly: Oh my God. Utter disbelief, utter helplessness. And complete fear.


I caught a glimpse of my left leg—with my broken shin bone protruding through bloodied flesh. I felt a pain in my face so severe that my mind must have decided it was too much to bear. It shut down nearly immediately; I hold no memory of the Jaws of Life, of the ambulance transport, of the emergency department. Only the voice of my longtime best friend, who was the passenger in the front seat of my car, remains in my mind: “Carina, it is OK. It is OK. It is OK.”


But is it? I remember there were two passengers in the back seat of my car. What happened to them? I do not hear their voices.


April 10, 1998, was a good Friday gone wrong, the wrong way indeed. Bits and pieces of my hospital stay punctuate my memory like the shards of broken windshield: my parents, grief-stricken yet amazingly strong, telling me what happened when I awoke later that evening; the white hospital walls juxtaposed in my memory with the bloody interior of my car; feeling a row of teeth along the middle of my tongue and being told, to my horror, that it was a result of my broken jaw; noticing the taste of bloody gums where other teeth used to be; realizing I was breathing through a tube in my neck—and learning that I had broken nearly every bone in my face.


Yet the nightmare of awakening in the car after the crash was still blurry in my mind, and I lacked any real concept of the magnitude of the accident. Silenced by the tracheotomy, I asked my questions with a pen and paper. “How is my car?” I naively wrote. “Will I still be able to be in the school dance team parade?”


As the reality of what had happened began to formulate, I began to think of questions I was terrified to ask: Where were my friends? I started to cry, thinking the worst. I assumed they had died and no one wanted to tell me. But they were alive, all of them, in the only good news of the day. Though my condition was the most serious, they all sustained significant injuries. My parents reassured me, though, that they were receiving good care and were going to be fine. Still, I felt horrible, and wrote the only words I could think of: “I’m sorry. I’m so sorry.” I was told repeatedly that it was not my fault; the wrong-way driver was going twice my speed and I had no time to react. Then I remembered: the driver. What happened to the other driver? Ever so gently, my mother informed me that he died. He died? A lump rose in my throat, and I cried for this person whom I had never known but had so tragically affected our lives—and lost his own. I later learned he had no drugs or alcohol in his system at the time of the accident, and there was no apparent reason for why he was headed south on the northbound side of the PCH. It is an unknown I’d have to live with, but that was OK with me, I decided: I was alive.


That night, I underwent repair of my open tibia-fibula break and Lisfranc fracture of my left foot. Five days later, when my facial swelling had subsided sufficiently, I was again wheeled to the OR, this time for 15 hours of facial reconstructive surgery. About 30 titanium plates and 10 screws rebuilt its supportive infrastructure, producing a result that closely matched that of my “before” photos posted around the room to guide the surgeons. From that point on, everything in my life became implicitly categorized as “after.”


The “after” involved an extended hospital stay, months of physical therapy, and multiple oral surgeries. But it also meant the beginning of my journey of healing. The traumatic memories of waking up in the car as well as my hospitalization still affect me to this day, but the realization of how fortunate I was has changed my perspective of everyday life. I am now thankful for what is so often taken for granted: the chance to live a normal life. It is never apparent from looking at me that I have lived through such physical trauma. The only obvious scar is that of my tracheotomy. Colleagues and physicians at my medical school often attribute it to thyroid surgery, not believing that a young, healthy woman like me could have been trached in an ICU like many of their own ailing patients. Yet this scar reminds me of how close I came to not being here, not making it, not becoming a doctor myself. It reminds me of the simple joy of living a life unaffected by permanent injuries, such as to my brain or spinal cord, which could have easily occurred. It is the freedom of health.


I was awakened last April 10 by a kiss from my husband and a long embrace as we listened to the soft breathing of our 3-week-old son. My life is blessed with a wonderful family and a fulfilling career, 10 years after the accident that almost ended it in 1998. This is not to claim that life is now perfect, or that I maintain a staunchly optimistic perspective, or that I don’t get bogged down by the everyday trials that permeate life. It is to say that these things are normal—and that is precisely what I find worth celebrating. The fact that I am able to live the life I’d always imagined is what makes this day, and every day, a good day.
~~~~Dr. Carina Grassman Baird graduated from the University of California, San Francisco, School of Medicine in 2007 and will begin a residency in pediatrics this fall.~~
426~3April~2008-57~Reviews~The Stories We Tell~Deriving lessons from our patients’ narratives~Himali Weerahandi~Thinking through the stories~While on my family medicine rotation, my preceptor lent me The Man With the Iron Tattoo and Other True Tales of Uncommon Wisdom (BenBella Books, $11.20 paperback). The authors, Drs. John E. Castaldo and Lawrence P. Levitt, held a reading at a conference my preceptor had attended, and she was so moved by the stories they shared that she felt compelled to buy the book to lend out to her students as they rotated through her clinic. She prescribed reading a story or two from the book each evening, even though she knew that, as a medical student, I had enough reading already. I took a crack at it that night and was drawn in. I read it in a weekend. It was engrossing and touching, and I can’t recommend it highly enough.


The stories are paired by loose themes, and the overarching theme is wisdom learned from patients. On a deeper level, it questions the way physicians approach clinical problems. It touches on errors in judgment—that despite our medical training and experience, we’re still fallible. In some ways, it reminded me of the popular book How Doctors Think, by Jerome Groopman, reviewed in TNP’s January–February issue. In his work, Groopman painted with broad strokes; the stories he shared were just glimpses at the practices of various physicians he had interviewed.


“Many medical students and doctors are surprisingly incurious about human narrative, to which they have almost unparalleled access,” wrote David Brown in his review of How Doctors Think in the Washington Post. As future physicians, we have a greater opportunity in these illustrations.


In The Man With the Iron Tattoo, each chapter focuses on the tales of a specific patient and how it impacted the physician writer. In detailing these experiences, Castaldo and Levitt demonstrate how valuable these narratives can be, meditating on the lessons they have learned by listening to their patients.


In one chapter, “Listening to Eva,” Levitt writes about how relationships bring others’ health into a physician’s focus; in this case, he writes about his relationship with his own wife, Eva, and the wife of Stan, his patient. “Finally I realized what was really bothering me—that I’d ignored Eva’s and Susan’s intuition about Stan’s injury. Both of them had forcefully communicated their doubts to me, yet I’d brushed them off. What could they know?


“Because neither Eva nor Susan had any formal training, I simply didn’t take their concerns seriously. Yet it was Stan and I—experienced doctors—who had missed the crucial clues. Our wives had not. When I thought more about it, I realized that Eva had long been deeply attuned to matters of illness and health in our family—in truth, more so than I was.”


In acknowledging his error, he learned a valuable lesson. It can often be difficult to discern how seriously to take a given symptom, but knowing people as people and not as “Disease X” can aid with clinical decision making. In these lessons learned, we also learn the importance of humility: that medicine isn’t just about “playing God” as some like to say.


I’m touched and grateful that my preceptor bought this book for her medical students. The Man With the Iron Tattoo is a portrait of the way medical practice should be. Clinical knowledge is something we must learn to become good clinicians. But compassion, humility and empathy truly make a doctor. The themes depicted by Castaldo and Levitt are so much more effective for their simplicity and elegance. The stories are
personal and focused, and, above all, inspiring.


Himali Weerahandi is a third-year at Temple University School of Medicine.



Letters From Home

by Elizabeth Drucker


Though fewer and fewer future physicians are receiving a stream of traditional letters, some direction is better given through that intimate medium rather than an overcrowded
e-mail inbox. Through Dr. Perri Klass’ Treatment Kind and Fair: Letters to a Young Doctor (Basic Books, $24.95 hardcover), the reader gets an idea of what it takes to do strong work in pediatrics while struggling in murky social, ethical and professional spheres.


The book, organized as a series of letters to her son Orlando, a premedical student about to enter the world of medicine himself, provides specific insights on the issues that physicians grapple with, such as surviving residency and making mistakes, as well as absorbing death and dying.


Klass’ book displays a keen ability to define the areas where medicine and people meet. She describes the transformative quality medicine has on the people who become doctors and upon their relationships with other people. Simple ways of communicating with other people change when one has reached the clinical sphere.


The book describes the harsh realities of going through medical school, residencies and the other milestones of being a physician. The book’s personal style and letter format give it a personal feel and add to its readability. The reader feels as if she is actually hearing the clinical stories from someone trusted, rather than merely scanning them in a dispassionate journal.


As a whole, the book is a mélange of different topics. Klass describes the competitive nature of medical school admissions. She asks important questions about the medical school curriculum, such as when the first patient care experience should take place. Klass describes working during residency when she was also a young mother herself.


Still, she notes that among all the good things medicine has brought her patients, there are errors and mistakes as well. Her candid admission that she—an experienced physician long in practice—has not always been perfect or made the right decision is exactly what future physicians sometimes need to hear.


Elizabeth Drucker is a premedical student at the University of Arizona.
~~~~~~
427~3April~2008-57~On the Wards~Parting Irony~A tragic first night on call~Hadley Leggett~A first night foretold~“Beware of the 5 a.m. page.” Those were the words of an experienced pediatrician, warning me to prepare for the worst before my first night on call as a fourth-year medical student in the pediatric emergency department (ED). At the time, I didn’t pay much attention to his words of caution. I knew that he was referring to sudden infant death syndrome, but I felt insulated by the reassuring improbability of such a tragic occurrence marking this first night in the ED.


Even so, when the angry buzz of the trauma pager sounded at 4:24 the following morning, I awoke from my fitful, uncomfortable sleep with a deep sense of dread. My senior resident had been resting on the cot beside me in the tiny call room, and she, too, sat up with a start, grabbing reflexively for the pager at the bedside table. I heard her fumbling groggily in the dark, and then I saw her silhouetted by the pale green glow of the message screen. As soon as she registered the meaning of the page, she leapt into action, all traces of sleep erased by the adrenaline that suddenly coursed through her veins—and mine. I had fallen asleep with my stethoscope and ID badge still around my neck; as we raced out of the room, I fought with the tangled cords that seemed to be trying to choke me.


“Four-month old female, PEA on arrival, no evidence of trauma,” the senior resident whispered to me in the elevator. In my foggy, sleep-deprived state, I had to think for several seconds before I understood. PEA. Pulseless electrical activity. So the baby had arrived in the ED without a pulse, but at least her heart was making an effort to beat. No trauma. Baby arrived at 4:24 a.m. The realization broke over me like a cold sweat. We were dealing with exactly what my attending had warned me of the night before: This was likely sudden infant death. I shuddered with the cruel irony of his casual warning.


Then, before I had time to rehearse the appropriate resuscitation sequence in my head, the elevator doors sprang open, and I sprinted down the hall on the heels of my resident. I followed her through the corridors, racing past a disheveled young woman with bits of black charcoal dribbling from her mouth and past an elderly man, obviously drunk, shouting nonsense from his gurney in the hall. We slowed down as we arrived in Zone One: the trauma zone, reserved for only the sickest and most desperately injured patients. A small crowd of doctors, nurses and technicians had already gathered outside the curtain of room four. The group parted a bit to let the senior resident through. I followed close behind, hoping I could offer some service despite my inexperience.


I felt my stomach lurch at my first glimpse of the scene. I could no longer breathe. Before me, lying flat and motionless on the operating table, was a baby girl. She hardly looked real, she was so unnaturally still, her torso and limbs ashen white but her face a deep, horrible purple. Tiny rivulets of blood crusted around her swollen lips, parted to allow a thick breathing tube down her throat. I cringed at the sight of another large tube jutting out from her right calf, a sign that IV access had been attempted through an intraosseous line–someone had plunged a needle straight down to her bone marrow in a last-ditch effort to administer fluids and medicine.


A flurry of activity surrounded the baby: One scrubs-clad resident stood above her head and manually forced oxygen into her lungs while another performed rhythmic chest compressions, a single hand sufficient to artificially pump her tiny heart. My senior resident stepped in to help, but I stood riveted in place, unable to tear my eyes from our patient. I watched as the emergency medicine team continued their carefully choreographed dance, one that probably seemed routine to them but was still frighteningly new to me. Someone called for epinephrine, then atropine, medicines that will sometimes jumpstart a failing heart. I am not sure how long I stood there, waiting for that baby girl to wake up—the seconds blurred together into minutes—and yet, still no pulse, and nothing but a flat line on the monitor screen.


“Time of death, 4:57 a.m.” The attending physician’s words were confident and unemotional, generating a wave of sudden stillness that washed over the room. No more oxygen, no more chest compressions, only the harsh reality of the dead child before us. For a second, everyone in the room stood frozen. Then the motion began again, orderly and businesslike as always. Monitors and lines were gently removed, caked blood was carefully wiped away, and the baby was swaddled in a blanket.


Leaving the ED later that morning—though it seemed years later—I stepped out through the double doors into garish, blinding, too-bright sunlight. Walking numbly toward my bus stop, I felt shocked to see the fresh, smiling faces of well-dressed professionals on their way to work. A classmate waved; I flinched and looked quickly away. How can these people not see that the world has changed? A life is over before it even began. My ears still echoed with the anguished, desperate cries of the baby’s mother, as she cursed God for his cruelty. I could only imagine the depths of her sorrow and the long grieving process that now stretched out bleak before her. As I settled wearily into my seat on the bus, I pressed my eyes closed and said a tiny prayer for healing, love and that beautiful baby.
~~~~Hadley Leggett is a fourth-year at the University of California, San Francisco, School of Medicine.~~
429~3April~2008-57~Feature~Your 15 Minutes~Learning to love the system you’re (stuck) with~Barbara A. Gabriel~The 15-minute patient interview didn’t get its name because you only got that much training in the technique, but chances are you may not have had a lot. Practicing physicians aren’t even that good at it. How did we wind up with such a tiny window of opportunity, and how can you make the most of it? Plus: Practice makes perfect.~
“If we could improve the interviewing skills of all physicians across the United States by 10 to 15 percent, we could change the face of American medicine.”



That’s the claim of Richard Frankel, a health services and qualitative researcher at the Regenstrief Institute in Indianapolis, who has spent the past 30 years studying clinician–patient relationships.


Sound a bit too easy? Not according to Frankel, who holds a Ph.D. in sociology. His research suggests that it is not so much the amount of time clinicians spend with their patients in the exam room that leads to positive outcomes, but rather how that time is spent.


But how did physicians end up with only 15 minutes to interview and diagnose each of the 30 or so patients who come into their exam rooms? Why are Frankel and his colleagues dedicating so much of their time to teaching physicians to maximize the use of those interviews, rather than trying to open the window even wider?


In a word, money.


“In the U.S., we have decided that health care is a marketplace commodity rather than a social good, and we’ve made that fundamental decision as a nation time and time again,” says Dr. Christine Cassel, president and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation.


“It’s the recognition that time is money,” adds Frankel, who recalls the rapid growth of health maintenance organizations (HMOs) in the late ’80s and early ’90s. HMOs promised to be a force of equity in health care delivery, enhancing its efficiency and eliminating waste, and many physicians welcomed them.


And we all know how that turned out. Physicians who optimistically embraced HMOs two decades ago now decry it as the Evil Empire that continually impedes equal access to quality health care while reaping record profits for their stockholders. The federal government, in the form of Medicare and Medicaid, lowers reimbursement rates each year, and HMOs follow their lead, Frankel points out. And this downward trend is hitting primary care physicians on the front lines of health care delivery in this country the hardest.


“If you’re spending an hour with each patient, and you’re only getting reimbursed $23 per patient, or if you’re in an HMO, which gives you a certain amount of money per patient per month, and you’re spending a lot of time with those patients, in the end you’re going to wind up losing money,” says Frankel.


No wonder our primary care physician shortage is reaching crisis levels in many parts of the country. No wonder fewer and fewer medical students each year decide to specialize in primary care. No wonder record numbers of primary care docs are taking early retirement. They’re burnt out, frustrated and disillusioned. A survey conducted by Physicians Practice magazine last year asked primary care physicians nationwide how they felt about their initial decision to practice family medicine. Just 39.5 percent said they would follow the same career track; 38.7 percent said they would have chosen to become surgical or diagnostic specialists; and 21.8 percent replied that they wouldn’t have gone into medicine at all.


Sobering indeed.


Cassel blames some of this disillusion on medical education itself, which she characterizes as “very efficiently beating out of students within four years the values that they enter medical school with.


“I don’t want to be too cynical about it,” she says, “because I believe that many physicians still respect those values or feel they have some connection to them, but it can lead to great cynicism and disillusionment to feel that you’re not living up to those
values.”


An academic disconnect


Dr. Emily Durkin, a fourth-year general surgery resident, says that since
her graduation from Michigan State University College of Human Medicine in 2004, she’s realized how much of a “disconnect” there is between the way she was trained to conduct patient interviews and how they are conducted in the “real world.”


Durkin says Michigan State dedicated an entire class through her first two years of medical school to teaching students how to conduct patient interviews. She says there was no emphasis on limiting the time students had with the standardized patients they examined; rather, classes focused on eliciting patients’ stories and ensuring students knew the “real issues” each patient presented. Durkin says the process typically took one hour.


But when rotating through private practices, Durkin says the experience was quite different. “Those physicians have a time schedule that they obviously have to keep to, and oftentimes as
the day got later and time pressures increased, they’ll just have the student observe what they do.”


Dr. Terence McAllister, a pediatrician in solo practice in Plymouth, Massachusetts, underwent training different from that of most medical students. After attending Tufts University School of Medicine on a military scholarship and graduating in 2000, McAllister served his residency at a busy Air Force base. He says his patient interviews typically lasted 15 minutes or less.


McAllister maintains that he would not have been able to run a clinic based on back-to-back 15-minute visits if he did not have considerable staff to back him up. His medical technicians gave him just enough information to know the patient’s chief complaint before McAllister walked into the exam room. “I had to be really strict in focusing on that one complaint,” he says. “If another issue came up, I was forced to tell the patient to make another appointment…. What everybody’s taught in medical school, and what I think is really true, is that you make your diagnosis through the history that the patient gives you. Asking [follow-up] questions gives you more information and confirms things, but the most important part of the patient encounter is getting that history and finding out from the patient—or, since it’s pediatrics, the family—exactly what’s going on and really understand what the issues are and what the problem is.” When technicians handed him hastily written, incomplete histories, McAllister knew he was not giving his patients the attention they deserved.


But McAllister says what he resented most from his lack of adequate patient time was the reason he went into medicine in the first place: the solid foundation of the doctor–patient relationship on which to base his diagnoses and treatments. “That’s what I hated about it,” he says. “It really was a very rigid relationship that I had to have with the patients that really interfered with forming the type of bond [they needed to] feel comfortable coming back with some of the more complicated and more important issues that might be going on in their lives.”


A couple years ago, McAllister completed his military obligation and established his own solo practice in which he now calls his own shots, keeping his overhead low so he can schedule half-hour to hour-long visits when he feels they are necessary. He can now lay the foundation for long-term patient relationships with the babies, children and teenagers he sees. And he says his patients notice the difference. They value the easy accessibility they have to their pediatrician, he says, and the majority of his new patients are referrals from existing ones.


That doesn’t surprise Cassel. She says one of the top complaints Americans voice about their experience with our health care system is that their physicians don’t spend enough time with them.


“The physician is really kind of stuck,” she says, “because the profession comes from a history and a tradition of putting the patients’ interests first and foremost always, no matter what. And yet the world is telling you that you are a businessperson, and the rules of business are caveat emptor. It’s buyer beware. The patient can take it or leave it.”


Working the system


It seems that for the foreseeable future, most patient visits will follow the 15-minute model, and nothing less than a significant overhaul of our entire health care system could change that. So, assuming that the current marketplace model of health care delivery isn’t going anywhere soon, how can physicians make the most of the patient interactions they do have?


Dr. Dave Davis, a Toronto family physician who recently retired after 40 years of medical practice to join the Association of American Medical Colleges as a continuing medical education and educational quality consultant, doesn’t buy the too-little-time, too-many-patients theory. Rather, he thinks physicians fail to deliver optimal care when they are less than fully present during the time they do have with patients.


In his practice, Davis says he typically saw between 32 and 40 patients per day, and sometimes more. Such visits, he says, usually lasted 15 minutes or less. But Davis doesn’t think lengthier visits would have meant better visits.


“Some of us believe that professionalism cannot exist in the culture of 10-minute visits or in a managed-care environment, when in fact the two are not incompatible at all,” Davis maintains. “Time is not a factor in forgetting the principles of professionalism like respect, compassion and integrity. Those are all innate to us, and we can operate in a 15-minute or even a five-minute time span while adhering to them.”


Davis says he has a 90-second secret that helped him make the most of his time-constrained patient visits. He consciously cultivated his listening skills and began each office visit by asking his patient, “What do you think is going on?”


Davis says this technique can save both the patient and the physician a significant amount of time in the long run: “Spending that extra 60 seconds to ask the patient what they think the problem is will help you get to know the patient a little bit in a professional sense and can also avert unnecessary testing or repeat office visits.” Davis advises physicians to give their patients the opportunity to set the agenda for the remainder of the visit themselves: “Tell them, ‘We’ve got 15 minutes today; how do you think I can help you most?’”


Patients may list five or six items they want to address, so Davis advises physicians to give patients the opportunity to rank the importance of those items by candidly informing them that time constraints will not allow for addressing everything that day. Patients will typically choose the items that are also of most concern to the physician, says Davis. Once you’ve established with your patients your goals for a specific visit, Davis recommends politely asking them to make another appointment for less pressing concerns. He says that cultivating these communication techniques, which he maintains typically take less than 90 seconds, establishes
a mutually agreeable template from which physicians can deliver targeted, quality care.


Really?


Frankel at the Regenstrief Institute thinks so: Davis is basically following an approach to physician–patient encounters that Frankel and his fellow researchers formulated a decade ago popularly known as “the four habits of highly effective physicians.”


In a nutshell, those habits are: 1) invest in the beginning of the visit, which is about greeting patients and negotiating the visit’s agenda with them; 2) eliciting the patient’s story; 3) demonstrating empathy; and 4) investing in the end of the visit. Of course, there are specific skills connected to each of these four habits, several of which Davis outlined in his own approach.


“We know from research that patients are typically interrupted by their physicians 18 seconds into the visit,” says Frankel. “Once interrupted, they very infrequently will raise additional concerns at the beginning of the visit, but they will raise them at the very end of the visit when you have your hand on the door and are saying, ‘You don’t have any more concerns, do you?’ And the patient says, ‘Uh, I’ve been feeling sort of sad and blue lately….’ You are probably already running a couple minutes late, and now you have to make the decision if this issue is worth taking an extra 10 minutes to assess the patient’s potential for suicide, et cetera.”


Frankel’s subsequent research has convinced him of the efficacy of this model. “The average American physician conducts between 140,000 to 160,000 medical visits in their practice lifetime,” he says. “That’s a heck of a lot of doing anything, and it does involve developing habitual ways of thinking, habitual ways of doing things. If we could improve physician interviewing skills, we could have quite an impact on patient satisfaction and outcomes in this country.” ~The Learning Curve


Richard Frankel likens the way students learn to conduct time-efficient patient interviews to the gradual learning curve of beginning to understand how to use a stethoscope.


“If you are a medical student or resident and you are just learning these skills, it is unlikely that it will feel efficient,” says Frankel, who has researched physician–patient relationships for decades. “Just like anything else, if you ask medical students or residents or practicing physicians, ‘The first time that you listened to the heart, how many of you heard heart sounds?’ only about two-thirds of the people will raise their hand…. So listening for heart sounds is a skill that you develop over time, and you develop it by practicing it over and over and over again. Similarly, with interviewing skills, they don’t come immediately—these are skills you have to learn, just like listening to the heart.”


So hang in there to get the hang of it. “Don’t expect at the beginning when you ask a patient about emotion to be able to be entirely efficient,” he adds. “But over time you will become more and more
efficient as you inculcate effective interview methods.” —B.G.
~~~Barbara A. Gabriel is a freelance writer and editor based in Tampa, Florida.~~
430~3April~2008-57~Feature~Embracing Our "Place in the Universe"~Medical centers must find ways to reduce their environmental impact, and medical students can help~Pete Thomson~By Earth Day 2008, environmentalism has come a long way since John Muir’s writings. But it hasn’t gotten that far in the health care world. As the environment weighs on health, and the health care industry weighs on the environment, where do medical students fit in the cycle? Plus: Some specifics to get you started.~On a crisp February morning, a box truck idles perpendicularly to the curb at the northeast corner of Weill Cornell Medical Center in Manhattan. Just up the street, another box truck and an unhitched tractor trailer are parked in a bay. All three are emblazoned with appropriate stickers and badged with codes from the federal departments of environmental protection and transportation.


The trucks, loaded with waste bound for an offsite disposal facility, hold only a small portion of medicine’s leftovers, the scraps and drips and casks too dangerous or complex for the hospital to incinerate, or thought too costly to reuse. A hospital’s business is healing; that mission is difficult enough. Anything tangential is often left unconsidered, but the amount of waste output and energy consumption by the industry of health is staggering.


But, as more and more medical centers are coming to realize, there are advantages in both health and cost savings to reducing their environmental footprint. For other facilities, it might take their trainees to show them the way.


In fact, above the bay where the trucks sit is Weill Cornell’s new cogeneration plant, which generates power while warming the building with
otherwise wasted heat. The plant, completed last year, is expected to save the facility $5 million a year, and was
partially financed through $1 million in state grants for improvements to energy efficiency.


An environmental imperative?


“Are physicians—and especially hospitals—being environmentally irresponsible by the kinds of products they buy and the waste they generate and its disposal?” asks Dr. William Ruddick, a professor of philosophy at New York University (NYU). “By in large, I think that is not a subject that most physicians or hospital administrators have given much thought to.”


Ruddick holds an M.D., but turned to the study of philosophy and ethics during a break from medical school; he chose to pursue that path rather than a residency. He now heads a new program at NYU that combines bioethics with environmental ethics, two disciplines that developed in similar arcs, though separately. The program, currently one of a kind, hopes to attract medical students who can take time away from their studies to consider some of these questions. Its inaugural class of 11 includes one medical student, a few researchers and a few nurse practitioners. Some of the participants hope this line of study could help them with work on institutional review boards or give them knowledge to weigh the ethical considerations of individual patient cases.


The ethical ties between health and the environment are numerous, and sometimes conflicting. There can be conflicts, say, between the development of a treatment and its environmental cost, which are more complex to solve than they seem: If a cancer drug, like Taxol, would literally consume an entire species of tree in its production, is it a question of weighing one species against another? But what about future generations of patients left without the resources to make the drug for themselves, Ruddick presses. Despite an American insistence on a solution to every problem, many trade-offs are difficult if not impossible to solve. (In the case of Taxol, which has been highly effective in the treatment of several types of cancer, production of one dose required the bark of nearly an entire Pacific Yew tree. However, researchers found a process to convert a related compound into the drug, allowing them to harvest from a more-common cousin of the rare Pacific Yew. But
this isn’t necessarily the answer to Ruddick’s riddle.)


The relationship between health and the environment, though, can be far more obvious. Global climate change threatens health in a number of ways, its prognosticators say, through potential natural disaster, changing disease patterns or the spread of famine. Such a change is primarily linked to atmospheric levels of CO2, a byproduct of power generation and industry. Recently, energy consumption and resulting climate change has risen to the top of environmental concerns for health advocates—especially as the health care industry is one of the highest consumers of energy in the United States: The Department of Energy says health care ranks second only to food service as an industrial energy consumer, spending $5.3 billion on energy annually.


“The big problem of health care is its scale. There is just so much of it, and so much of it is controversial. The
energy costs are huge,” says Andrew Jameton, a professor at the University of Nebraska’s College of Public Health.


“If you are going to add environmental cost as an additional criterion for the cost of health care, you are going to basically raise the cost,” he says. “And [hospitals are] going to have to…do things much more efficiently, and/or you are going to have to cut down on what you provide. And people recommend both.”


The Ethics of Environmentally Responsible Health Care, a book that Jameton wrote with Jessica Pierce, is considered a significant introduction to the impact hospitals can have on the environment, and his ideas were part of the inspiration for the creation of NYU’s new program. Jameton himself holds a Ph.D. in philosophy.


On a functional level, hospitals can be an environmental nightmare, but one almost out of necessity.


“They generally operate 24 hours a day, they demand good lighting, and a lot of equipment requires a lot of electricity,” Jameton points out. “You want a stable temperature, and you want good filtration on the air.” Those elements add up to significant power consumption.


Toxicity has long been an environmental concern associated with health care due not only to medication, but including chemicals for the lab, developing agents for X-ray films, lead in testing equipment and especially the agents for disinfection.


“You want a high level of capacity to poison germs and things like that in a hospital,” Jameton says. “So how on earth do you design something that kills the right things in the right places, without being harmful when you dispose of it or misuse it or when the workers who use it are exposed to it?”


But Jameton notes that though toxicity as a concern predates discussion over the energy consumption at hospitals, the latter looms larger now due to concerns over climate change.


“Energy conservation, energy
materials from different sources, and efficiency are suddenly weighing in very heavily, and a lot of us are having trouble shifting our priorities here,” Jameton says of those in the green hospitals movement.


And, unfortunately, reducing toxicity and increasing energy efficiency do not necessarily go hand in hand. “To make things pure and safe and to get the toxic materials out takes a lot of energy,” Jameton explains. It is a conundrum not easily solved—especially without adjusting the third factor: cost.


“To add an additional criteria to a product—it needs to be safe to patients, it needs to be effective—and then you add, ‘Oh, by the way, it also has to be environmentally sound,’ it is inevitably going to raise the cost,” he says. “And since health care is already costly, I think many people worry about making it even more costly. And I think that is a legitimate concern.”


In an article for the journal Synthesis/Regeneration (S/R), Jameton commented on whether it would be possible to reduce the energy usage of health care by as much as 80 percent. Intended only as speculative opinion, his estimates included a 50 percent reduction in health care usage and reducing the use of physical health care facilities. Any dedicated structures or equipment—including the kinds that don’t need to be plugged in—have an environmental consequence. But one element of health care that does not is staff. Any model that uses more staff but less facility is a step in the right direction: More home health care, more non-dedicated outpatient clinics and more nursing care facilities would be a start in the direction of a serious reduction in health care energy use.


This does not include the “upstream” complications of manufacturing pharmaceuticals and equipment that are used to care for patients. Some pharmaceutical companies are examining practices to reduce their impact, as they fall under scrutiny through the Toxic Release Index. But beyond the industry itself, little research has examined the environmental impact of any given treatment, and there aren’t enough National Institutes of Health funds to do so, even through the National Institute of Environmental Health Sciences.


And herbal medicines aren’t necessarily any better: If they were used on the scale of conventional medicine, they could require vast areas of land and farming practices to produce, Jameton points out. And in his S/R paper, he writes that any remedy that isn’t as efficient as possible is wasteful.


Designing Efficient Buildings


But there are ideas to improve health care’s footprint that are increasingly falling into place, at least in terms of energy usage.


Buildings of all types can be certified against a score sheet of environmentally responsible elements and given a value
in the Leadership in Energy and
Environmental Design (LEED) Green Building Rating System. Until recently, that certification did not have a branch specifically tailored to hospitals, but it was a starting point. Now, there is the Green Guide to Health Care (GGHC), a scoring system for the physical structures of hospitals that was patterned after the LEED concept. The document itself is nearly 400 pages in length, and it is intended for use by architects, engineers and institutional planning more so than those who will practice in the building.


Elements of GGHC certification include plumbing efficiencies, nontoxic building materials, the use of daylight and sustainability of the ecosystem around the building. Some of the architectural elements, the organization notes in their materials, also have a directly positive impact on patients, like views of nature and natural illumination.


The ideas behind LEED certification and green building practices certainly are not alien to the industry.


“Those things are out there, and they’re being applied,” Jameton says. “They’ve certainly come to Omaha, where new university buildings are now required to be green.”


But those certifications do not necessarily solve problems with toxicity or establish best procedures for cleaning or recycling of a hospital’s waste, though the GGHC does include checklists for procedures. Also, some design elements can reduce the need for cleaners. Jameton notes that given the chance, one physician pointed out an inefficient air flow in a building design that would offer an opportunity for infectious agents to collect in the heating and cooling system. After a redesign, less disinfecting agents would be needed.


Building Efficient Systems


But it remains that the bulk of procedural inefficiencies and waste reduction must be tackled by another type of change agent, one that must often be established by the institution itself.


Kai Abelkis, a former political aide and environmental activist, found his way to Boulder Community Hospital (BCH) in Boulder, Colorado. One of the hospital’s campuses, its latest, was the first hospital to be LEED-certified in the world. Abelkis serves as the
hospital’s environmental coordinator. Though that job was once perhaps closer to being a walking conscience of sorts, Abelkis says the center’s staff and the community around the hospital have found environmental awareness to be their own second nature. That attitude has helped them move beyond the physical design of their building to establishing purchasing and waste management procedures to lessen their impact on the environment.


“It is a cultural shift,” Abelkis says. “Most of the time, we as hospital employees think that we are here to purchase and dispose, without really an awareness of what’s the implication of purchasing whatever product and disposing whatever product. And bringing that awareness leads to decisions.”


Now, he says, these issues are raised in planning meetings—even when he’s not there. “It is now just how we do business.”


And business is good. Abelkis estimates the hospital has realized $500,000 a year in cost avoidance and cost savings due to measures intended to increase energy efficiency and reduce waste.


One of the steps that has led to both savings and a reduction in environmental consequence was a waste audit.


“And that came about because we looked at our waste, and we segregated through it; we did a waste audit,” Abelkis says, “and it provided us with a way to look beyond just waste reduction, but really understand where the waste comes from and do something about it.”


During the audit, BCH’s waste processing manager noticed how much blue wrap was going into the landfill. He took his observation to the administration and convinced them to purchase special reusable hard containers for medical equipment. The initial investment was significant—around $100,000—but the savings over the disposable blue wrap were close to $120,000 beyond their investment, and Abelkis points out that those savings were in the materials themselves, not including the savings in soft costs, like hauling the excess waste away.


And the audit led to the leveraging of suppliers. Stryker, from whom BCH was purchasing expensive artificial hip components, was convinced to design a new container for the products they were delivering so BCH would not have to wrap them any longer.


But there are many challenges, Abelkis says. Reprocessing—reusing materials like tubing or instruments that could otherwise be treated as disposable—presents problems on both technical and cultural levels. “I see it as a way to reduce waste and save money. Others—the manufacturers of these products—see a kink in their finances because we’re reusing a product, so they’ll do everything they possibly can to thwart it.” And some see potential infection control issues, too.


A guide put together by a group of experts and published by Bristol-Myers-Squibb discusses the trade-offs of reprocessing certain products. The only way to weigh infection control through thorough cleaning and disinfection against the impact of discarding used materials is on a product-by-product basis. Their guidebook includes such alternatives as using reusable feeding bottles, disinfecting thermometers with alcohol instead of using disposable sleeves and using non-PVC blood bags. In Germany, according to the guide, the re-use of Redon bottles, thorax bottles and suction systems saved facilities almost 50 percent of costs over the disposable versions.

An economy has sprung up around such reprocessing, and there can be
savings, both monetary and environmental.


But all of these movements, from building design to cultural change to waste audits, came from an organization of people. “It’s politics. Maybe it is not capital-P politics,” Abelkis says, “but you have to work within a system. And if you are a change agent, you have to understand how one goes about…finding the folks that support you, getting the budget…, making things relevant to people.”


And that ground level is where students can come in. Lauren Zajac, a representative for Student Physicians for Social Responsibility and a coordinator of the Medical Alliance to Stop Global Warming, came to medicine from an environmental activist background. Her studies for a master’s in public health focused on environmental impact. Her experience has led her to be involved both on a nationwide scale and at Mount Sinai School of Medicine in New York, where she is a second-year. And she has advice for other medical students looking first at their own medical center’s footprint.


Every institution has unique environmental challenges, she says. Some medical centers have recycling efforts in place; some are struggling with using greener cleaning products. Others might seek to produce less cafeteria waste. And many have no efforts implemented at all. Any of these situations offer students an opportunity to get involved, either raising questions, raising awareness, suggesting solutions or forming coalitions to start change.


Forming coalitions with others at the medical center has been useful at Mount Sinai, Zajac says, and works just as well at other institutions. Doctors, staff, faculty and administration are not only useful groups to work with; they are often necessary.


And, at least at her institution, she has found people—students, faculty
and administration—to be increasingly interested in the concept of environmental stewardship as central to public health.


“There have been a couple of construction projects at Sinai that have been some level of LEED, which we consider a huge victory,” she says. “So I think it is slowly kind of breaking into the mainstream; I don’t think quickly enough, but resistance, in my opinion, is lessening.”


Still, environmental change at huge and complex institutions involves much more than the erosion of barriers. There are many legitimate operational concerns held by administrators and staff that must be addressed before moving forward.


“People always want to hear the bottom line: Is it cost-effective?” she adds. “Unfortunately, a lot of these things might cost X number of dollars up front, but eventually save money in the long run.”


Compact fluorescent light bulbs, a product being pushed even by Wal-Mart and other chain stores, are a good example. “For an institution to switch, they are going to have to make that up-front commitment, even though within a year they are going to end up saving money,” Zajac says. “And that’s in all aspects of our society, unfortunately. A lot of people are unwilling to invest, even if it’s going to pay off in the future. It’s all about short-term returns.”


The disconnect between environmental ethics and public health appears again. “Unfortunately, they are often looked at as separate, when, in fact, they are very deeply linked,” Zajac says. “So I’m trying to make it relevant to some of the students who, maybe, have never thought of environmental issues and climate change as a public health issue.”
~Your Corner of the Campus

Physicians, other students and even hospital administrators are increasingly open to green ideas, and here are some that students can initiate, thanks to the Medical Alliance to Stop Global Warming. At www.amsa.org/tnp, you can find links to the complete PDF put together by Mount Sinai School of Medicine second-year Lauren Zajac.


~~~Pete Thomson is editor of The New Physician.~~
433~4May-June~2008-57~Well-being~Comfort Food~A resident weighs a stressful life~Zachary D. Jacobs, M.D.~Eating through stress~Nathan is 18. His mother brought him to the general pediatrics clinic because she is concerned about his weight. The young man looks down at his shoelaces; he doesn’t want to talk about it. He played basketball and was relatively fit until last year, when he stopped the sport to focus on his grades. He is feeling the pressure of applying to college, and often stays up into the wee hours of the night writing papers for numerous Advanced Placement courses. His mother can’t believe her son’s course load and says that she didn’t have anything comparable until she was in law school. His parents know the problem is eating: the late-night fast food and early morning microwave meals that keep him going. He’s too busy to exercise. There are more important things to do than that.


What can I, a pediatrics resident, say to this young man? Who am I to say anything? History has shown me that I would do no better in his situation.


During my sophomore year of college, I realized I had become a monstrosity, a beast capable of downing a large pepperoni pizza at one sitting, ordering two value meals for one lunch and inhaling a large bag of barbecue potato chips just for fun. I could not walk up stairs without becoming winded. At times I imagined myself a beached whale, attracting gawking crowds as I thrashed about in the sand.


One morning, I decided I was tired of all the “glamour” of being overweight, bathed in the attention of the gawkers, and decided to do away with the excess baggage. I began running every day. My first run was really more of a stumbling saunter, and I heard it from the horns of passing cars. Clearly, my pain was their pleasure. But I got stronger, and I got faster. My diet became strictly regimented, consisting mostly of deli turkey and green beans. Over the next nine months I lost 55 pounds. People I had not seen for a while failed to recognize the slim, healthy new me who had replaced the overweight, fatigued sloth.


But college ended up being some of the least stressful years of my life: It’s easy to lose weight and stay healthy when one only has to go to class a few hours a day. With medical school, long sleepless nights of studying for exams the first two years were followed by long sleepless nights as the junior medical student on call. I learned that when sleep is the most precious commodity in one’s life, the quality of one’s diet and the desire to exercise falls drastically in the hierarchy of needs. The ritual became eat what I could when I could, sleep as long as I could when I could. I didn’t fret when I had to wolf down a burger on the way home, as my neurons were devoted to other things at that moment, such as not driving off the road in a call-induced fog. My saving grace was the drawstring on my scrubs, for without that I would have had to look myself in the mirror and acknowledge I no longer had pants that buttoned. My medical school actually offered an evening course in reducing stress, but who would have time for that?


Then came the glorious fourth year of medical school, a year of set clinic hours, free weekends and no exams. I proposed to my girlfriend, Melissa, and life was good. I rediscovered exercise and was running six miles a day by the end of the year. Melissa and I created weekly menus to maximize nutritional value. We would relax and have a glass of wine at the end of a long—but not too long—day. I resolved to continue my new habits throughout my pediatrics residency.


In the first month, however, I found myself in the neonatal intensive care unit, up all night every fourth night. Sleep became a precious commodity again. When I did drift off, I would hear in my dreams the buzzing and dings of continuous monitoring and mechanical ventilation. The emotional range of the year was broad: I saw a baby die of spinal muscular atrophy, and I saw children who were at the brink of death make full recoveries from bacterial meningitis. As my emotions went from one extreme to the other, so did my weight. At the most stressful points, my waistline would swell, and then I would work like mad to get those pants to fit again when assigned to the rare clinic-based rotation.


I know healthy eating and exercise are imperative to health, yet when I am stressed, I still go to what is easy. When I am in the call room in the middle of the night, my body doesn’t tell me to have an apple. It tells me to warm up a burrito.


The relationship between stress and poor dietary choices has been well established by numerous studies. What has not been established is a way to get around it. How can an intern in the intensive care unit reduce stress? Is he to go to a meditation session after a 30-hour call? It’s easy to say, “Reduce stress”; it is much harder to actually accomplish it. As physicians-in-training, we know this, and we should never say to a patient, “All you need to do is cut out stress.” Because for a great number in our profession, we breathe in the very stress we are counseling people to avoid.


I sat down across from Nathan, the young man struggling to balance school and health. I told him frankly that his situation is difficult, and that I have the same problem. It is an excruciating battle with oneself, and it will most likely go on every day for the rest of his, and my, life. When stressed, I make poor eating decisions, I said. I’m keenly aware of this, and despite that knowledge, I still do it. I discussed healthy dietary decisions and exercise with him. I went over ways of reducing stress, if only for a few minutes a day. I shared my setbacks and my triumphs. Be a better man than me, I said. I wished him luck and sent him back into the environment that brought him to me in the first place, struggling for a better solution.
~~~~Dr. Zachary D. Jacobs is a pediatrics resident at the University of Missouri Children’s Hospital.~Student Life and Well-Being~
434~4May-June~2008-57~Perspectives~Clarity on Gift Giving~Using the right arguments against marketing~Benson S. Hsu, M.D.~Time for a new argument~The practice of pharmaceutical gift giving has been under intense scrutiny in recent years. From the American Medical Association to the universities of Stanford and Yale, multiple institutions have implemented policies against aspects of this practice. Countless publications have also documented physicians, medical associations, ethicists and consumers opposed to this marketing technique. It is clear to me, a resident in pediatrics, that this is a heated and often emotional debate.


However, a review of the literature reveals primarily a lopsided argument. Personally, I oppose pharmaceutical gift giving on ethical grounds, but I am alarmed that some common arguments against this practice—those based on patient harm and financial impact—rest on misguided rationale.


The data-based argument contends that patient health is negatively impacted by pharmaceutical gift giving. In other words, patients receive suboptimal care as a result of their physicians receiving gifts. This argument builds on an overwhelming number of studies detailing undeniable changes in physician prescribing practices resulting from exposure to pharmaceutical gifts and sales representatives. However, the causal link between changes in prescribing practices and negative patient outcomes is generally assumed without scientific evidence.


Specifically, this presumed effect arises from two lines of thought: one, patients are hurt by improperly tested medications, like Vioxx, the use of which has been encouraged by gift giving; and two, physicians, influenced by gifts, prescribe medications that are no more effective or even less effective and with greater side-effective profiles than current treatment modalities. For example, a compromised physician prescribes third-generation cephalosporins instead of amoxicillin for treatment of acute otitis media.


The real culprit in the first line of thought, rather than the practice of gift giving, is a lack of proper testing and appropriate approval process for medications; this shortfall alone is a topic rife with complexities. The noted negative impact on patients is more specific to the existence of the unsafe medications than the marketing tactics used to sell them. If this erroneous reasoning holds, then any benefits from marketing safe medications will also be negated from a decrease in gift giving. The pivotal aspect of this argument is actually the safety and efficacy of the medication in question and not the practice of gift giving.


The second line of thought is an implied causality not supported by the literature. An extensive review of the literature through PubMed shows no studies that have established pharmaceutical gift giving directly causing negative patient outcomes. Instead, the available research focuses on changes in prescribing practice and infers patient harm. As Dr. Ashley Wazana wrote in a January 2000 issue of the Journal of the American Medical Association, “Physicians and the Pharmaceutical Industry: Is a Gift Ever Just a Gift?”—the most-often cited review article looking at physician behavior in response to gift gifting—no studies used patient outcome data.


In order to substantiate causality, scientific studies would need to demonstrate measurable negative patient health impact of prescribing certain medications—for example, Prilosec over Tums for gastric reflux or Zyrtec over Benadryl for allergic rhinitis. Furthermore, the use of medications supported by gift giving must be a deviation from accepted practice. Until a study occurs that fits these criteria, no one can contend with certainty that any health effect on patients, positive or negative, results from marketing tactics including pharmaceutical gift giving, direct-to-consumer marketing or even medical journal advertising.


Arguments against gift giving also frequently reference increasing health care costs and characterize the impact that gift giving has on health care expenditures. The national health care expenditure in 2005 was $1.99 trillion, and spending on prescriptions topped $200 billion, as noted by the Department of Health and Human Services. In comparison, IMS Health, a leading health care consulting firm, characterized the costs of marketing to physicians at $6.8 billion. This equals to 0.34 percent of national health care expenditure and 3.4 percent of total prescription expenditure.


Moreover, direct-to-physician marketing decreased $0.56 billion in 2005, compared to 2004. Total prescription cost rose by $11 billion, and national health care expenditure increased another $129 billion in the same time frame. Although causality cannot be inferred from these figures, it does give pause that a 7 percent decrease in physician marketing occurred in the same year that spending on prescriptions and national health care increased by almost 8 percent and 10 percent, respectively.


To contend that gift giving contributes to health care costs means that decreasing gift giving should similarly decrease health care spending. For this to occur, pharmaceutical companies would have to willingly shift current funds spent on gifts to directly offsetting the cost of prescriptions. Thus, a decrease in health care spending from decreasing gift giving will only occur if pharmaceutical companies are willing to cut prices on prescriptions while facing decreasing sales and pressure on their profit margins. This argument is counterintuitive.


The practice of pharmaceutical gift giving to physicians should not occur. Physicians have already more than sufficient justification against this practice based on ethical arguments alone. The negative impact pharmaceutical gift giving has on patient trust is monumental and, by itself, should end this practice.


However, it is imperative that the discussion on the impact of gift giving should not deteriorate to a set of rationalizations that, although seemingly valid, withers under scrutiny. This would only further weaken public trust in
the health care system and, more specifically, patient trust in physicians. Instead, physicians should take the first step to addressing this issue with our strengths—a detailed, methodical, logical analysis based on scientific research and real facts.
~~~~Dr. Benson S. Hsu is a pediatrics resident at the University of Wisconsin School of Medicine and Public Health. Direct comments to tnp@amsa.org.~~
436~4May-June~2008-57~Feature~Road Trip~After four years, no graduation in sight for Step 2 CS~Avery Hurt~Four years after Step 2 CS was implemented, we don’t know any more about how well it works. But it’s still expensive and inconvenient. And that may add up to an even greater cost for medical education. Plus: Oh, the places you’ll go.~It’s the test medical students love to hate. Now four years old, this Step 2 component evaluates students’ hands-on ability to perform a clinical examination. It’s expensive, inconvenient and time-consuming—and there is no evidence that it aids in producing better doctors or makes a difference in patient outcomes. So why, again, are you taking it?


It’s hard to find someone in the medical community who doesn’t agree with the need to teach and test clinical skills. However, students and doctors alike seem to have many problems with the Clinical Skills (CS) portion of the USMLE Step 2 as it now exists. And those problems can at times—especially testing times—arouse passions. It has been called “absurd,” “utter bullshit” and “evil.” Dr. Jason Etheredge, director of the American Medical Association’s (AMA) National Clinical Skills Evaluation Initiative and a first-year psychiatry resident at the University of Kansas School of Medicine, has heard all this and more. He recently finished a national survey, to be presented in June and published later this year, gauging the perceptions of students about this test. Etheredge says 4,000 medical students responded to a Web-based survey publicized by the AMA’s Medical Student Section, the American Medical Student Association and the Association of American Medical Colleges’ Office of Student Representatives. “Some students are just pissed—nobody wants to take a test, especially an expensive one,” says Etheredge. “But some have well-reasoned, legitimate complaints.”


When you get past pissed-off comments about this absurd, evil, bullshit test, what do you have? There are several oft-heard complaints, but one is heard more often and much louder than the others: cost. As of 2008, the exam itself costs $1,025, and because it is given in only five locations nationwide, most students have to travel and stay in hotels in order to take the exam. And review books run $70 a pop.


International medical graduates (IMGs) have to pay an extra $200 to take the test. IMGs register for the exam with the Educational Commission for Foreign Medical Graduates (ECFMG). The ECFMG is responsible for assessing the readiness of IMGs to pursue postgraduate training in the United States, and provides many of the services for IMGs that dean’s offices provide for students who train in the United States. The ECFMG also provides online and telephone support, accounting for the extra cost. Nonetheless, students wonder if their money is well spent.


Several organizations, including the American Academy of Family Physicians (AAFP) and the AMA opposed the test from the beginning, largely because of the cost. “With medical student debt already alarmingly high, it is not an insignificant expense,” says Dr. Perry Pugno, director of the AAFP’s Division of Education.


Dr. Ann Jobe of the National Board of Medical Examiners’ (NBME) Clinical Skills Collaboration Evaluation, however, doesn’t see the test’s relative cost as so significant. “Most students spend $2,000 or less for everything, including travel and lodging. Students spend more going to residency interviews than taking this test,” she points out. “And it is an educational expense and can be folded into loans.”


But an amount that may seem insignificant to Jobe doesn’t seem so to everyone. “When you’re talking about taking out loans for $20,000 or $30,000 a year, it begins to sounds like Monopoly money sometimes. That’s an amount of money so far beyond normal life that it’s hard to even think about sometimes,” says Amy McGaha, assistant director of medical education for the AAFP. “But it is real debt—and a lot of it—that these people have to pay back.”


Despite the shouts and groans about the money, many students are almost as troubled by the inconvenience. “Scheduling the test is the biggest problem,” says Dr. Ann Lebeck, an intern at Grant Medical Center in Columbus, Ohio. Especially during fourth year, when many students are traveling on rotations or doing overseas projects, coordinating the Step 2 CS with an already crazy schedule can be a major headache.


If (you don’t know if)
it ain’t broke...


Despite the grumbling, most people do acknowledge the need for some kind of standardized evaluation of clinical skills. “I believe some observational tests are necessary. As a person who trains residents, I have noticed a lack of examining skills in some students,” says Dr. Bruce Vanderhoff, assistant dean for medical education at the Ohio State University College of Medicine.


“Early in the history of the NBME,” explains Jobe, “there was a clinical skills exam. The examinee went to a bedside with a physician to test the student’s clinical skills. This early version of the test was stopped because it was too inconsistent. With many different physicians administering the exam in many different circumstances, it was not a fair way of testing students’ skills.”


However, the desire for a reliable means of testing students’ abilities to perform a clinical exam did not go away. The medical community was—and is—in agreement that learning and refining clinical skills is a key part of medical training. And so is the public.


The new version of the test, added in 2004 to the current round of licensure qualifying exams, was brought about, says Jobe, largely in an effort to address the issue of patient complaints filed with state licensing boards, and the fact that most lawsuits against physicians result from problems having to do with clinical skills.


Even students see the need. “[The CS] is a very important step,” says Lebeck. “Much of what we do is the clinical, and there is really no way other than testing to ensure students are learning this. I just think a one-day exam might not be the best way to determine this.”


McGaha of the AAFP agrees. “We can understand the need for standardization, but we do question the process,” she says. “We have no way of knowing whether the test is accurately measuring skills.” And that seems to be the crux of complaints, really. If students are going to spend all this money, time and effort to take yet another test, it would be nice to know that it works.


Some preliminary research funded by the Robert Wood Johnson Foundation and based on analyses of prototype tests has indicated that the CS portion of Step 2 might be a good indication of performance in internships. However, other research suggests that the nature of the exam may lead to inconsistent results. In any case, the published research is both minimal and preliminary. At four years old, the exam is too new for any meaningful evaluation. “The test is so amorphous, it is hard to put your finger on [whether] it is making a difference. Lacking outcomes data, we can’t really say anything about its effectiveness,” says Etheredge, “and the NBME is keeping what data it has close to its chest. Results will be available only in a dozen or so years when a sufficient number of people who have taken the test have been in practice a sufficient number of years, and complaints may or may not start to drop.” That is, a dozen years and many, many dollars that may or may not have been wasted.


Jobe agrees that it is far too early for useful evaluation of the test. She does point out, however, that some data from Canada, where they have had a similar test for longer, indicates that high scores correlate with lower complaints. Meanwhile, in the United States, we’ll just have to wait and see.


Don’t think, though, that lack of outcomes poses any serious obstacle to the test, however. “The prevailing sentiment at the NBME is that this is a growing pain that has to be worked through,” says Etheredge. “The NBME has a lab where they are doing research on the best ways to test these kinds of things—how to quantify the unquantifiable,” he says.


Even if the NBME is so far quiet about what it has learned over four years, you can be sure that it is keeping the data. The NBME put years of work into pilot programs before launching the national test, says Jobe. And Etheredge says that while he doubts there will be large changes due to the need for consistency, the NBME occasionally makes small tweaks to the test.


A few of those tweaks have come in response to pressure from student groups. Etheredge says that after an early round of feedback showed how strict testing centers were being with breaks, his group spoke with the NBME and some policy changes were made.


Teaching to the test


There may not be any data yet on the exam’s impact on patient care, but those who keep an eye on the test say there is one good result of adding the CS to Step 2. When the USMLE first added the CS portion, less than half of medical schools tested clinical skills, says Etheredge. Now virtually all of them do. This is, according to Etheredge, the best thing this test has done.


Jobe also appreciates this result. “Thanks to this test, medical schools realized the need to have this in the curriculum and started to add it,” she says. That may be a small comfort to medical students who are struggling to schedule and prepare for the test.


But if nothing else, the goal of the test is the same as the goal of everyone in this enterprise: to do what’s best for patients. “We’re working with the NBME to hold them to that professed goal,” says Etheredge, “to make the test the best it can be. We’ve taken them to task several times, and they’ve responded well,” he says.


~TOO MANY MYTHS

As with most things controversial, Step 2 CS has attracted its share of misinformation. Here are a few of the myths and rumors surrounding this test that can be put to rest.


It’s easy.


A lot of students seem to think that if you are a good student, all you have to do is show up and remain awake. According to Dr. Jason Etheredge, that’s not a good strategy for passing the test. Etheredge, himself a psychiatry resident, is also director of the American Medical Association’s National Clinical Skills Evaluation Initiative.


“At the end of the day, it’s a high stakes exam,” he says. “There are a lot of little things that can trip you up: not draping the patient properly, not introducing yourself to the patient, not washing your hands.” No matter how good you are at medicine, remember that the purpose of this test is to prepare doctors to deal with patients in a way that reduces complaints and lawsuits. “Things that make the patient uncomfortable and don’t foster trust in the patient aren’t going to get you far.”


The NBME is in cahoots with test prep mills, getting kickbacks and making a fortune off of desperate students.
This one is persistent, but probably as silly as it sounds. Both Etheredge and Dr. Ann Jobe, of the NBME, agree that the NBME does not endorse or give information to any test preparation company. In fact, Jobe herself advises students that there is no evidence that spending money on test prep classes helps. It’s best, she says, to just go back over your notes.


The NBME, or at least somebody somewhere, is getting rich off the exam.
In one online discussion, a medical student “did the math”: 16,000 medical students each year at $1,025 a head for a total of $16 million. The student suggested that there was “no way” that a nonprofit organization needed $16 million a year to administer this test. The NBME is not giving out details on where the money goes, but even among those most opposed to the test, there is no serious suspicion of financial malfeasance. Maintaining the centers, training the actors who pose as patients, and providing the infrastructure for the test, as well as doing the statistical research to design the test are costly enterprises. “The NBME doesn’t make any money on this,” Etheredge says definitively.


The test is on the way out.
Nope. “It’s not going anywhere,” says Jobe. Get used to it.
~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.~~
437~4May-June~2008-57~Feature~Diverse Decisions~Tough choices face underserved patients and their physicians~Linda Childers~Will your patients look like you? What do underserved patients look for in their physicians? Research shows that minority physicians are more likely to reach out to underserved populations. But have we turned this into an expectation?~Sonja Boone was in junior high school when she first became interested in medicine. While some of her fellow students were repulsed at the thought of dissecting frogs, Boone was intrigued. She soon found a role model in her family doctor who shared both Boone’s African-American heritage and passion for medicine.


“Minority physicians are often the mentors and catalysts who help recruit future minority physicians as well as patients,” says Boone, now a doctor herself who serves as medical director of physician recruitment and director of diversity at Northwestern Memorial Hospital (NMH) in Chicago. “My own family doctor showed me the need for physicians of color and encouraged me to pursue my dream of becoming a doctor.”


While blacks, Hispanics and Native Americans combined make up just under a quarter of the U.S. population and are expected to make up more than a third by 2030, the Association of American Medical Colleges (AAMC) says that only 6 percent of currently practicing physicians are from one of these minority groups. And based on current medical school enrollment, those numbers will change only slowly.


The goal of increasing diversity among medical school students is often linked to research showing underserved patients may be better reached by physicians from ostensibly similar backgrounds. But for some students, that connection implies an obligation—or at least expectation—for their career track.


To increase the number of physicians of color, organizations including the AAMC have begun outreach efforts to encourage more students from underrepresented minorities to choose medicine as a career. Hospitals and universities, including Northwestern, are hiring medical professionals such as Boone, who implemented the Medical Staff Diversity Initiative for NMH in 1999 and helped increase the minority medical staff at the hospital by 81 percent.


Two years ago, the AAMC launched AspiringDocs.org to provide undergraduate minority students with support, information and guidance. “There is also a large body of research that shows that when patients have the opportunity to select a health care professional,” says the AAMC’s Nicole Buckley, “they are more likely to choose people of their own racial or ethnic background and are generally more satisfied with the care they receive.”


A Commonwealth Fund–supported study conducted in 2004 supports this research showing that patients in race-concordant relationships with their physicians rated their physicians’ decision-making styles as significantly more participatory and their care more satisfactory overall than patients in race-discordant relationships. Another study, published in the Journal of Health and Social Behavior in 2002, found that when patients were given a choice, they were more likely to choose a doctor of the same race or ethnic background, and they were more likely to be satisfied with their care.


Physicians of color say their own experiences reflect these findings.


“I have a real connection with my African-American patients,” Boone says. “I can relate to them on a cultural basis, and there is a certain amount of inherent trust. As a result, my patients are more likely to share critical health information which translates into better communication and positive patient outcomes.”


In fact, a study published in the July-August 2000 issue of the journal Health Affairs found that black and Latino patients sought care from physicians of their own race because of personal preference and language, not solely because of geographic accessibility. And a 2005 study in the March/April issue of the Annals of Family Medicine found that “Among African-Americans, stronger beliefs about racial discrimination in health care were associated with preferring an African-American physician.”


April Inniss, a third-year medical student at the University of Massachusetts Medical School in Worcester and the only African-American in her medical school class, says that while her interactions with minority patients have been limited, they have all been extremely positive.


“While I haven’t seen many patients of color, the ones I have seen are happy to see me,” Inniss says. “I think it helps to even the physician–patient power dynamic when a physician looks like their patient. Most patients want a doctor who respects them and is interested in hearing what they have to say.”


Her own experiences led Inniss and several of her colleagues to begin a health disparities interest group to encourage more students of color to consider careers in medicine. In addition, the group hopes to support the cultural competency preparedness of residents and students, and to expand current models for student research focusing on issues of minority health and health disparities.


Inniss also credits having strong women of color as mentors with helping her to succeed in medical school.


“I am so grateful to have several supportive mentors, including Dr. Alice Coombs of the Massachusetts Medical Society,” she says. “If it wasn’t for her support and guidance, I don’t know that I would have made it this far in medical school.”


Choosing to Serve
the Underserved


When Dr. Lynne Holden heard there might be federal budget cuts to programs directed at increasing students of color in medicine, she decided to take matters into her own hands. After nearly eight years of informally mentoring students of color, Holden, an emergency medicine physician at Montefiore Medical Center in the Bronx, New York, founded the nonprofit group Mentoring in Medicine in 2006.


Many of the students in Holden’s group have never met a physician of color. Others have been discouraged when they mention they want to pursue a career in medicine. Some are already in medical school and have to continually convince patients they are training to be a doctor rather than a nurse. Holden hopes her group will empower students while also addressing what she sees as an alarming lack of diversity among the nation’s health care professionals.


“Given the fact that the population is almost 25 percent African-American and Hispanic, it’s a gross shortage when you calculate the numbers,” Holden says.


Groups such as the American Medical Association (AMA) say that increasing diversity in medicine is important not simply for its own sake, but for the patients since many minority populations continue to be in poorer health, compounded by limited access to medical care.


Other groups, including the Robert Graham Center in Washington, D.C., which studies primary care, cite studies that show minority physicians are more likely to return to their communities and provide care for minority and underserved populations.


“I think minority medical students tend to naturally gravitate toward the communities they are familiar with and have supported them through their journey,” Holden says. “Learning about the imbalances in health care and prevalence of potentially preventable and controllable diseases naturally empower these students to want to take action and improve the situation.”


A study conducted by researchers at the Charles R. Drew University of Medicine and Science in Los Angeles and published in the September 2006 issue of the Journal of the National Medical Association reported the results of a Web-based survey of 668 fourth-year medical students from 32 medical schools across the country. The study found those interested in primary care reported an increased likelihood of working with underserved populations when compared with other specialties.


But that doesn’t mean those students don’t have a choice.


“Generally speaking, significant pressures are placed on minority students to care for patients belonging to underserved racial and ethnic populations and to select careers in primary care,” says Leah Bennett, an M.D./M.P.H. candidate at the University of Arizona and chair of the Race, Ethnicity and Culture in Health committee for the American Medical Student Association (AMSA).


“The idea that patients are better served by physicians who look like them is often cited as a reason why diversifying the physician workforce is necessary,” Bennett adds. “Whether or not this idea is true—and I believe in many cases it is—it places a significant burden on students of color from the moment they enter medical school to follow a career path in which they care for underserved racial and ethnic populations as primary care providers.”


Bennett is also careful to point out that not all minority medical students come from underserved communities.


“While this may be true in some cases, many minority medical students come from economically and educationally privileged backgrounds,” she says. “A student of color from a privileged background may have little more in common with patients from the underserved racial and ethnic communities than a privileged white student would have.”


Both Bennett and Holden feel that medical students should be encouraged to pursue their own goals rather than feel an obligation to return to their communities to practice.


“While some medical students may initially feel an obligation to return to their community to practice, they often find a different passion in medical school,” Holden says. “Minority students are often encouraged to fill the void in their communities by pursuing a primary care specialty, but they should be encouraged instead to follow their passion.”


Bennett agrees. “Students who truly come from underserved racial or ethnic groups feel institutional pressure to serve their population that is compounded by family and community pressures to do the same,” she says. “Students of color should feel the same freedom as any other medical student to select the specialty and career path that will most fulfill them.”


Minding the Gap


Since today’s medical schools don’t always look like a cross-section of the United States, some schools are considering creative ways to increase the number of physicians who care for underserved populations.


Last year, the U.S. Census estimated the Latino population at 44.3 million people, making this group the nation’s largest ethnic or race minority. In California, one-third of the population is Latino, a number to increase to more than 40 percent by 2025. At the same time, Latinos make up only 5 percent of California physicians.


These demographics make it imperative to increase the number of physicians who can treat Latino patients in a linguistically and culturally sensitive manner.


A few California medical schools are taking a unique approach to addressing the physician shortage.


At the University of California, Irvine, School of Medicine’s Program in Medical Education, the PRIME-LC program trains future physicians of all ethnicities to address the distinct health care needs of the Latino community. Students who are admitted to the five-year program receive both a medical degree and a master’s degree in public health, policy or business. Not only do all students need to meet all medical school entrance requirements, they must also be proficient in Spanish, demonstrate a commitment to public service, and express a strong desire to serve underserved Latinos after graduation.


At the UCLA International Medical Graduates program in Los Angeles, physicians who have graduated from medical schools in Latin American countries are given assistance in competing for primary care residency training positions.


Even hospitals in urban areas face challenges in luring new physicians to work with underserved and diverse patient populations. In the San Francisco Bay Area, long known for
its ethnic and cultural diversity, the high cost of living still makes it challenging to recruit a diverse physician base.


Dr. Sharon Levine, associate executive director of the Permanente Medical Group for Kaiser Permanente in Northern California, said the organization’s physician group was composed of more than 50 percent whites, 36 percent Asians or Indians, 7 percent Latinos and 5 percent blacks. She adds that Kaiser is committed to increasing those numbers and improving diversity through residency and mentoring programs and outreach efforts that attempt to interest minority junior high and high-school students in pursuing medical careers.


“We want to ensure we have a group of employees who share the races and cultures of our members,” Levine says. “All of our physicians take part in cultural competency training, which teaches them how to appreciate differences in regards to race, ethnicity and gender identification.”


Levine says cultural competency training is very important in that it recognizes that being a physician means not only having clinical expertise but an understanding that people from different cultures may experience and express pain or other aspects of their health in different ways.


“Diversifying the physician workforce is a big priority,” admits Dr. Harvey Cohen, a pediatrician and former chief of staff at Lucile Packard Children’s Hospital at Stanford in Palo Alto, California. “Our physicians work with a diverse patient base, including many medically indigent patients who come to Packard from throughout California for specialized services.”


Cohen says that all physicians at Packard are required to complete cultural competency training, as well as to become immersed in a variety of cultures by completing work in some of Packard’s outreach clinics.


“Families often bring a whole culture when they bring their ill child to us for medical care,” Cohen says. “It’s important for physicians to be cognizant that one size doesn’t fit all with our patient population.”


For the most part, Cohen says most patients at Packard choose doctors based on competence rather than race or gender.


“Since many patients travel a great distance to Packard, families are typically more concerned with their doctor’s unique area of expertise and are searching for the medical team that can best treat their child,” Cohen says.


And cultural competency extends beyond physicians, AMSA’s Bennett points out. When a person of color is seeking medical care, his perceptions may extend beyond the exam room.


“If a patient feels disrespected by the receptionist when they check in at her doctor’s clinic or mistreated by the institution where the doctor works, it is unlikely that patient will trust her doctor as much as she otherwise would, regardless of how the physician treats her,” she says.


The curriculum for cultural competency can vary among medical schools and is one of the issues that is currently being addressed by AMSA.


“There is a great deal of variation from school to school in the amount of time spent focused on cultural competency and the types of issues that are covered,” Bennett says. “At most schools, didactic education on cultural competency occurs primarily during the preclinical years, and training on caring for racial and ethnic minorities during clerkships and electives depends almost entirely on the particular faculty a student works with.”


Bennett adds that one of AMSA’s four strategic priorities is “Enriching Medicine Through Diversity,” and the group is carrying out actions and advocating for policies that make it easier for students from underrepresented racial and ethnic groups to get into medical school and to succeed. Her committee, formerly titled the Minority Health Action Committee, carried out a survey last year on cultural competency curricula and is in the process of evaluating the data in order to develop recommendations for medical schools as to what model curricula on cultural competency would include and how it would be carried out.


“Few schools teach students about contentious subjects such as institutionalized racism in health care or the historical abuses that physicians and members of the medical community have perpetuated on racial and ethnic minority patients,” Bennett says. “Race seems to be a subject that our culture is very uncomfortable discussing openly, and this discomfort leads to an avoidance that is also seen in medical education. We hope to change this.”
~RESOURCES


  • The AAMC’s Aspiring Doctors program offers tools and information for minority students considering medicine.
    aspiringdocs.org

  • The Mentoring in Medicine program
    in New York City encourages
    economically and socially disadvantaged students to consider medicine as
    early as elementary school.
    medicalmentor.org

  • The University of California-Irvine’s PRIME-LC program offers combined M.P.H. and M.B.A. programs for
    premeds who are dedicated to working in Latino communities.
    www.ucihs.uci.edu/PRIMELC

  • AMSA’s Race, Ethnicity and Culture
    in Health committee offers a support network and resources to medical
    students and premeds.
    www.amsa.org/minority
    ~~~Linda Childers is a freelance writer based in Martinez, California.~~
    440~5July-August~2008-57~Letter from Afield~Summers of Strength~Lessons on illness for campers and counselors~Lizbeth Dalaza~Summer-camp lessons~For four years before I started medical school, I spent my summers as activity coordinator and camp counselor at Camp Boggy Creek, a medical camp for chronically ill children. I learned about Camp Boggy through Boston College’s premedical program. I loved working with kids, and the camp was in my home state of Florida.


    With its Olympic-sized swimming pool, theater, dining hall and archery range, Camp Boggy looks like any normal camp. The campers ranged in age from 5 to 16, and filled their days with arts and crafts, horseback riding, boating and fishing. But there was also an on-site hospital, known as the “Patch,” complete with round-the-clock registered nurses and physicians, not to mention premedical student staffers like myself. During rest time and before bedtime, children would come to the Patch to receive chemotherapy, dialysis, medications and more.


    Each camp week was divided by disease: The first week was called ROCK camp, for Reaching Out to Cancer Kids; other weeks were designated for children with asthma, AIDS, epilepsy, hemophilia and sickle cell disease. During my four-summer tenure, I met more than 3,000 children with these illnesses. Through the experience, I witnessed the human side of medicine, and I have not forgotten it.


    These children, for the first time, were with other children who shared their disease, and they could all just be kids. Often accustomed to the confines of a hospital, children at Camp Boggy were no longer singled out because of large scars across their chests, a lack of hair due to chemotherapy or lesions visible on their skin. At camp, prescriptions were not for medications, but for hugs and laughter.


    My role as activity coordinator and camp counselor was to make sure that laughter happened. We made music videos, and I supervised mock talk shows. We put on the Camp Boggy VH1 Music Awards with my dad’s camcorder, my laptop full of songs and the children’s imagination. I’ll never forget Jared, a blind child known as the shy kid in the group; he broke out of his shell to the tune of Michael Jackson’s “Beat It,” using his own rendition of the Moon Walk. He even decided to show off his talent at the camp-wide talent show later that week.


    But even usual children’s games could have stark differences there. I was playing cards with a group of kids about 12 years old, all with cancer. I don’t remember their names, but I can recall their faces even at this moment. Usually young girls at that age should be talking about boys and clothes, but they were comparing medications and hospitalizations. They discussed with each other their determination to become either registered nurses or physicians—if their cancer remained in remission long enough.


    Then they turned to me and asked what kind of cancer I had as a child. A handful of the camp counselors and activity coordinators were survivors of one disease or another, but I was not one of them. Mary, a counselor, survived leukemia and spoke about it with the children all the time. But for the first time, I tried to put myself in these campers’ shoes. If I was 12 and had a horrible disease, would I be candid enough to speak about it? Would I even want to leave home and my parents?


    Yet there were people, even among the counselors, who could not em¬pathize. I recall Sean, a fellow counselor who was terrified of the children who came for AIDS week. “I want to wrap myself in Saran Wrap and hide,” he jokingly said during our weekly orientation. Throughout the remainder of the week, he didn’t really interact with the children. Physicians trained us to be cautious, and use bodily substance isolation, but by no means were we supposed to hold back affection.


    The camp was a learning and growth experience for counselors and campers alike. I was helping a young boy cast his fishing line when, suddenly, the friend next to him was struck by a grand mal seizure and fell into the water.


    As the on-site doctor and nurse helped the boy out of the lake, the other children panicked, and some wondered what had happened. They ran up to me asking, “Do I have that? Did I ever do that?” Some children did not even know they had epilepsy. Their parents had withheld that information hoping the kids would find out about their condition in a supportive environment with other children who shared the disease.


    Late one night, Tia, a 6-year-old, had a sickle cell crisis and was in so much pain. Older kids had told me that these crises felt like a million stabbing knives. Tia was screaming and crying, and the other counselors woke to keep the cabin’s other kids calm. Tia was so debilitated that I had to carry her all the way to the Patch. As a premed sophomore, I had learned about the basis of sickle cell disease. Now I was a witness to what it can do to a child.


    As future physicians, we must not forget our humanity. We must listen, understand and be savvy with openness. I try to reflect on my experiences at Camp Boggy through all of my studying, med school exams and third-year clinical clerkships.


    “Be bold and be humble,” former Health and Human Services Secretary Tommy Thompson told Boston College graduates during the 2001 commencement. “Go out, grab hold of the world and make a difference. And in doing so, take care to touch gently the face of your fellow man.” I was bold to bring my childhood back for these children, and humble to step back and watch them live their own. I will carry their faces in my mind as I work through those third-year clerkships, apply to residency and train to be a physician in service of her patients.
    ~~~~Lizbeth Dalaza is a third-year at the University of New England College of Osteopathic Medicine.
    Names of campers and counselors have been changed to protect their identities.
    ~~
    441~5July-August~2008-57~Perspectives~No Home, No Second Thought~The economic axis of culture~Katrina Leonard~A culture without borders~Simple things I had taken for granted like eating and showering became difficult. I never got used to it. My passenger window was busted when someone broke into my car. With little money to eat, I had even less money to put toward repairing it. I covered it with a trash bag when it rained, but the thin plastic couldn’t stop the water from coming in when it was driven by the wind. The moisture left my ’88 Hyundai Excel with a constant mildew scent.


    I never realized how suspicious people get when there is a “foreign” car parked in their neighborhood. I awoke often to a flashlight beam and a tap on the glass, a police car parked behind my “house.” The conversation usually started with, “Ma’am, we received a call about you being parked out here. You can’t sleep here.” I would scramble for an excuse for why I was parked in such a nice neighborhood with such a beat-up car. The conversation always ended with me thanking the officer and being followed out of the neighborhood.


    To be homeless is to be a part of a distinct culture to which there is a harsh acclimation. When I prepared to travel abroad, I was able to read about the area into which I was traveling. When I went to Guatemala, I found books on the country, the language, the traditions and the history. These are aspects of the culture. But these resources don’t exist for the homeless culture. The majority of what we know of the homeless culture is from the media and from watching through our driver’s side window. It is extremely difficult to know what it is like to be homeless without being homeless.


    That statement can be applied across the board for various ethnic, socioeconomic and social groups, but the one aspect that makes the homeless stand out from other cultures is that if you ever had a home, you never get used to being without one. One can get used to living in America, speaking Spanish, playing sports, or drinking alcohol every day. Being homeless can become tolerable, but you never get used to it. That it never “grows on you” gives great insight into the beliefs, behaviors and norms of the homeless culture and brings a new component to cultural competence.


    When thinking of cultural competence, it is almost reflexive to think of ethnicities. For me, cultural competence used to conjure up images of the different ethnic groups that I had taken care of in the past and their subtle differences in attitudes toward health care. I thought of the Middle Eastern patients I cared for who wanted same-sex caregivers. I thought of my Hispanic patients who had their entire family around them when they were very sick or about to die. I thought of the Asian patients who often had their children at the bedside, assisting in care giving. It was my previous experience with different ethnic groups that gave me insight into various cultural beliefs, practices and preferences.


    However, previous experience with the economically disadvantaged gave me little insight into their cultural beliefs and norms. I literally had to be in their shoes to understand. A series by social policy expert King Davis on the subject defines cultural competence as “the integration and transformation of knowledge about individuals and groups into specific standards, policies, practices and attitudes used in appropriate cultural settings to increase the quality of health care….” This definition does not restrict cultural competence to ethnicities.


    While we frequently learn about cultural sensitivity and competence with regard to diverse patient populations, the diversity almost never encompasses the homeless or impoverished. These two cultures made up the majority of my patient population when I worked as an emergency room nurse on the southwest side of Houston, but I did not learn about them during my mandatory cultural competence class during orientation.


    In the emergency room, there was always a high incidence of unconscious homeless patients who frequently smelled of alcohol. When working in Austin, I had a higher incidence of un¬conscious college students who smelled of alcohol. I noticed that the staff would treat each patient population differently. Those who were homeless were given an intravenous line and a liter of fluid. As soon as the patient would show an inkling of arousal, they would be discharged back to the streets. The college students were also given an intravenous line and a liter of fluid but often received blankets and a dark room in which to sleep. They were allowed to stay until they were fully awake and ambulatory without assistance. The doctors would often leave the discharge to the nurses, writing “Discharge when sober” on the chart. “Sober” was frequently left to personal interpretation.


    While we have made strides in the training of health care professionals by incorporating cultural competence into health professions school curricula, we have yet to incorporate one of the largest growing cultures: the homeless and the impoverished. I still find that some of my peers assume that all homeless people are drunks, drug abusers, psych patients that have fallen through the cracks, or people too lazy to do things for themselves.


    The difficulty arises in training. The knowledge required to provide the best health outcomes for the two populations usually comes from hands-on experience. While it is not practical to have every health professions student shadow a homeless patient or a patient living below the poverty line, it is essential that students are exposed to these patient populations either through interviews or clinical experience.


    This exposure is possible in just about any area in the country, both rural and urban. It is difficult to exercise cultural competency across socioeconomic cultures as it differs among individuals within each group. However, there are standard practices that can be applied regardless of the patient’s classification. Examples include not prescribing the most expensive medication when a cheaper one will work just as well, writing for generics instead of brand names whenever possible, taking your patient’s transportation means into account when scheduling referrals, and referring your patients to pharmacies that fill prescriptions at a reasonable cost without insurance.


    While these are practices that can be implemented across the board regardless of the patients’ economic status, they are sensitive to the patients’ finances and take their economic well-being into consideration. Things become slightly more complex with the homeless population but, again, there are standard practices that can be applied. As a nurse, I found that my patients were more receptive when they weren’t hungry. Providing a sandwich or snack was a simple intervention. With regard to medication access, we frequently had to contact the social worker to obtain “charity” medications that the patient did not have to pay for. The hospital pharmacy would fill the prescription, and the patient would take the medications with them at discharge.


    These are culturally sensitive interventions that allow us to provide better care. As health care professionals, we have a responsibility to provide the best care possible. We face the challenge of treating the whole patient, which means taking into account anything that may adversely affect health outcomes. In order to be truly culturally competent, we must not limit our definition of culture to ethnicity. We must be aware that there are many subcultures that our patients may be a part of: the drug
    culture, homeless culture, the culture of poverty or one of many other such categories. To be culturally competent, we must change our attitudes and recognize that the challenges our patients face aren’t always “in the book” and that we may often need to rely on empathy and compassion to help us find a feasible solution.
    ~~~~Katrina Leonard is a third-year at the University of Texas Medical Branch at Galveston.~~
    443~5July-August~2008-57~Feature~Pulling Rank~Picking the right programs for your Match list~Pete Thomson (editor)~Where will you go for residency? No matter how often we say it’s up to the Match, it’s really up to you. Through tips from current residents and past student leaders, we’ll help you clarify your choices, tackle your rank list, and take charge of your future.~Your residency wish list has little to do with naughty or nice.


    Decisions on both specialty selection and residency programs are highly personal and individual ones. Despite being a highly dedicated and motivated bunch, medical students in their third or fourth years face the most significant decision of their budding careers.


    As for the National Resident Matching Program (NRMP), the algorithm may make the Match feel beyond your control, but you’ve set the tone for your career path all along. Why stop now? Take care in picking the programs for your rank list. Though you may feel like leaving the selection up to the winds of fate, you should stack the deck in your favor.


    Sure, there are strategies for the Match itself. But how do you decide which programs should make your list in the first place? We’ve pulled together some starting points and questions you should ask yourself and others when it’s time to make your wish.


    Since 1979, the American Medical Student Association (AMSA) has made available the Student Guide to the Appraisal and Selection of House¬staff Training Programs. The guide has been revised and updated by several generations of AMSA leaders since 1979. What follows are selections from their collective wisdom.


    Your Choices, Your Timing


    The more goal-oriented students begin consideration of residency choice well before beginning their fourth year of medical school. These students are likely to proceed in a fairly rational manner: to weigh the pros and cons of each program and, after visiting the hospitals under consideration, rate each one on a sound basis. Others have procrastinated in taking action on this decision until they are forced to do so by Match deadlines.


    The typical student has little or no conception of the complexities of the postdoctoral training program selection process until the middle of their third year. Suddenly the student realizes another life decision is approaching and that this is the most important round yet. The selection of a postdoctoral training program will have a far greater effect on the applicant’s future career than the choice of either an undergraduate institution or a medical school.


    Medical education in the United States is often incorrectly presumed to be uniform, but the content and conduct of many programs vary widely. The educational background of some students may not have been geared to prepare them for some types of postdoctoral training. Although this should never rule out consideration of a program, it is a factor that should be added to the data used in making a final decision.


    The First Step: Specialty Selection


    Most students are not well prepared for deciding on a career choice or on the type of setting in which to take their postgraduate training. They may approach this decision with the same doubts and fears they experienced when applying for medical school.


    Other students are unsure of the branch of medicine they should pursue. On occasion, an influential factor in determining a career choice has been a student’s exposure to the physicians on a particular medical school rotation. On the other hand, areas of medicine that have been rejected because of the inadequacies of a particular service may become appealing again when experienced in another institution with different instructors.


    Picking a Setting


    One decision that will steer your early choices is the choice between university and community hospital settings. Much of that choice will ride on what setting you want to practice in later in your career.


    Excellent research programs exist outside university centers. If you want to enter private practice, the decision is easier. You can take training in either type of institution. For those who are interested in academic medicine, either teaching or research, however, it may be wiser to receive training within a university setting.


    The basics of patient care are available in the community and university hospital. University programs, however, tend to have more patients with unique or complex disease processes than community hospitals.


    The fourth-year medical student determining the hospital of her choice for postgraduate medical education is poorly qualified to evaluate the training program offered by the community hospital. Neither the student nor the faculty advisers usually know any medical environment other than the university setting and are not in a good position to relate the training program to the practice of clinical medicine outside the walls of the university.


    Knowing Who You Know


    At graduation or soon thereafter, most medical schools publish in their alumni bulletins a list of the graduating class and where they will be going to residency training. If this publication is available, it will be helpful to look through the last several years to see if anyone from your medical school went to a residency program in which you are now interested. A personal resource for information can be extremely helpful in finding out information that might not be apparent on paper or in the interview process itself.


    It is also useful to know whether anyone—at your medical school or in the community—trained at a particular program. This information is sometimes harder to locate, yet it can be worth the effort.


    Your Personal Statement


    This should be brief, not more than a page in length. Say why you want to go into the specialty and what you intend to do during your career in that specialty; make those two sections. Then, in one brief section, talk about other aspects of your life, like sports, family, your community activities. You may be able to draw parallels between those lifestyle elements and your career track, but avoid potentially controversial topics like religion and politics. Be honest about your strengths—don’t be afraid to blow your own horn, but don’t do it in an offensive way.


    Asking the Right Questions


    When evaluating residencies, there are a number of questions to pose about programs, either to interviewers or with residents currently in a program you are considering. Many can be answered online as well. Take a look at these questions selected from the program selection guide and start thinking about other details you’ll want to know.


    On the ER





    On the Patients





    On the Population




    On the Residents





    On the Attendings





    On the System






    On Your Allies





    On Scut




    On Learning Beyond the Wards






    On the Current Crew



    ~Resident Expert:

    Amanda Meulenberg, M.D.


    The biggest thing you need to know is the stability of the program. Programs have been closing at an alarming rate; you need to know if you will still have a job in a year or two.


    You also need to know how committed to the program the chairperson and program director are. You need to have someone in charge who is committed to your education and will look out for you. If the chair or program director leaves, this can be detrimental to the program. If the chairperson and program director are really committed, the residents would know that and talk freely of it. I interviewed at a few programs where the residents raved about their chairs and program directors. I didn’t take them too seriously but realize now that this was an important issue and should have been factored into my rank list.


    Finally, you need to know how well the residents get along with each other and if they work well as a team and support each other. Residency is going to be hard and trying no matter where you go. You need to be sure that the people who you are working with will pull their weight and have your back.


    Dr. Meulenberg is a PGY-4 resident at New York Downtown Hospital’s Department of Obstetrics and Gynecology.

    Tip:
    Remember: the longer,
    the better.


    National Resident Matching Program data consistently shows that the best predictor of your chance at getting into a program is the number of programs on your rank list. The more you have, the better chance you’ve got. This is no surprise, but use it as motivation to go the extra mile.


    Resident Expert:

    Liz Kwon, M.D., M.P.H.


    Here are a few tidbits that I found helpful while making my residency decisions:




    Tip:
    Pre-interview checklist:





    Resources:


    For updated Match schedules, the Electronic Residency Application Service or an explanation of the algorithm itself, visit nrmp.org.


    AMSA’s Student Guide to the Appraisal and Selection of Housestaff Training Programs, excerpted here, is a pocket-ready volume with tips and questions for you as you pick out your programs.


    The Council on Teaching Hospitals and Health Systems (COTH) publishes a listing of the hundreds of member teaching hospitals. The guide lists the types of residencies offered at each, along with the number of residents. You can find their directory at www.aamc.org/coth.


    Getting Into a Residency: A Guide for Medical Students, by Kenneth Iserson, M.D., contains comprehensive information on both specialty choice and residency selection.


    Opinions and input on particular programs abound on StudentDoctor.net, as do suggestions and feedback on programs’ interview processes. Just gauge each anonymous post carefully.
    ~~~~Career Development,Residency~
    446~6September~2008-57~On the Wards~Explaining the Inexplicable~Facing the family after a difficult death~Andrew W. Seefeld, M.D.~Informing the family~“What do you know so far?” I asked the family of a 30-year-old man I had just pronounced dead after a prolonged cardiac arrest. They thought he might have had a seizure but knew adamantly that “he was going to be OK.” Unfortunately, the reality was far from OK. The situation was awful any way you look at it. My stomach was twisting, the lump in my throat expanding. I felt like running away, avoiding the horrible truth I was going to have to disclose.


    I informed the family that despite our best efforts and aggressive medical resuscitation, their loved one had suffered irreversible heart and brain damage and had died.


    Upon hearing the news, the patient’s fiancée dove desperately at my leg, hysterically demanding that I tell her that I was mistaken. She was frantically seeking an answer that I would not be able to give. After about five minutes, she slumped to the ground, tears streaming down her face. There was emptiness in her eyes, her face frozen in anguish. At this point, I, too, was emotionally exhausted; I placed a hand on her shoulder and offered her a chair. Over and over again, I continuously reiterated that the family did everything right and in no way were they at fault. After what seemed like an eternity, I led the family into the room where the patient’s lifeless body was located. His mottled skin and rigid extremities were further testament to the devastating situation. Before leaving the room, I notified the hospital chaplain to come and spend time with the family.


    It had been a typical winter night in the emergency department (ED): coughs, colds and flu-like symptoms. Around 10 o’clock, a radio call came in detailing a young male in nontraumatic cardiac arrest. Nontraumatic cardiac arrest in a young man? Really? It happens, but it is extremely rare unless there is a significant medical history. When the paramedics arrived, CPR was being conducted appropriately, and an endotracheal tube had been placed to secure the airway. Apparently, the patient was on the bumper cars at a fun park when he suddenly stiffened and slumped over the wheel of his cart.


    When paramedics arrived, they found him in cardiac arrest. By the time I received the patient in the resuscitation room in the ED, his heart rhythm was in asystole. This almost always leads to death, and often there is very little that can be done at this point. We continued CPR and administered additional medications, but after being in cardiac arrest for over an hour, I had to make the call. If this were an 80-year-old patient with significant medical problems, the decision to cease further intervention would have been a bit easier. But this was a young man with no significant medical history who was now dead, his fiancée and loving family in the waiting room. Adding to my despair was the fact that I didn’t know the cause of death.


    I knew what I had to do. Telling anyone that their loved one has passed away is awful. Doing it under these circumstances borders on unbearable. As a resident physician, I had only given this talk a few times, and it certainly does not seem to be getting easier. Moreover, I had never had such a young patient die in this manner. While at the bedside of the deceased patient, his father looked at me. “My son was such a good kid. He had so much promise,” the father said. “He was supposed to bury me, not the other way around.” At that point, I almost lost it. I thought of my baby daughter. I thought of my own father. What if I was lying on the bed and my father was saying this to a physician about me?


    As a physician, there is an underlying need to be stoic, to be able to give news like this and not feel the emotion. My attending and I spoke at length about the young man’s death and his family’s heartbreak. She reminded me that it is OK to feel—and even show—emotion.


    This death hit me hard, and I would hope it would do the same to all of my colleagues. The cornerstone of medicine is humanism, and this experience underscores this value. I had never met these people before, but I could feel their torment and their despair. As physicians, our world is a coupling of science and compassion. Without this inseparable bond, medicine would fail at treating the whole patient. Medical illnesses may be biological in origin, but the process by which we provide patient care is often personal and requires empathy and understanding. We see people at their most vulnerable times, often their darkest moments. Patients look to us as miracle workers, and when we cannot provide the “miracle,” it can be devastating. This is a large burden to carry, especially as a physician-in-training. I will be forever indebted to my attending that night. With her true dedication to teaching, she helped me give the feared “death talk.”


    In my experience, though limited, there seem to be three key points to this talk: reassurance, listening and compassion. No matter the circumstances, always provide reassurance to the family and friends. Let them know that they did everything right, and that their actions in no way led to the current situation. This is not a time to pass judgment, even if it is justified. Details surrounding the actual cause of death can be handled later. Furthermore, assure the family that everything medically possible was done to save the patient’s life.


    Second, it is important to listen. It’s a skill that physicians tend to undervalue, but this is the time to avoid old habits. Listen carefully and answer all questions that the family and friends have, even if you can’t give definitive answers. The patient’s family is devastated and will reach out to you for understanding. Aid them in this endeavor the best you can.


    Finally, offer your compassion. Put yourself in the shoes of the family and friends; try to feel what they are experiencing. During these times, physicians need to express their humanistic qualities. We are not robots; we are human beings first and physicians second. It’s OK to feel real emotion, especially for patients and their families and friends during such a crisis.


    Though physicians must give the talk, we aren’t alone in working with the bereaved. While the discussion is taking place, nurses and technicians in the ED remove unnecessary lines and tubes from the body. The hospital’s chaplain, or the family’s own spiritual adviser, is a professional trained to deal with these situations and can have an enormously positive impact on the stunned survivors.


    For me, driving home the next morning, all I could think about was what caused such a young man to die. He was healthy; no known medical problems, yet now he lay in a morgue awaiting autopsy. His future had been promising. He had a new job, a fiancée that loved him, a desire to have children. But now his family has suffered an enormous and tragic loss. As an ED resident, I see death often, sometimes on a daily basis, but for some reason, this case still plagues me. Perhaps it was not knowing the cause of death. In medicine, we always search for the diagnosis and rarely stop until we are satisfied.


    However, physicians, at times, must realize that there may not always be an immediate answer. It is during these instances that we must step back and concentrate on what is most important. Be there for the family; offer as much support as you can. Set the science aside for a second and immerse yourself in sympathy and compassion.
    ~~~~Dr. Andrew W. Seefeld is an emergency medicine resident at the University of California, Los Angeles/Olive View program.~Ethics,Humanistic Medicine,Physician Patient Relationship,Practice of Medicine,Residency~
    466~8November~2008-57~Feature~M.D. or Else~Family Pressure Leaves Its Mark on Future Physicians~Steve Woo~When parents see medicine as their child’s only career option, pressure can lead to stress, conflict or both. Some students, however, thrive under the established structure. And underrepesented groups could see gains from encouragement.~In 2006, Ophelia Young won an award for feature writing from the Society of Professional Journalists. Her path to that moment had been difficult, but finally she was given the recognition lacking in her life: Her parents, first generation immigrants from Burma, finally understood that there could be a successful career for their daughter outside medicine.


    For most premedical students, securing a spot in medical school is a dream come true. But in some families, that dream belongs instead to their parents. Their children are encouraged from infancy to become physicians. All through school and at home, they are told medicine is the only career they can pursue. Period.


    While many medical students say they have no regrets and even appreciated the parental pressure to become doctors, others felt forced into the decision. For some students, the pressure does not stop even after getting into med school. Their parents often choose which specialties they can pursue. Some parents go so far as to tell their children what courses to take. Many children and, often more visibly, children of immigrants have to bear the weight of their parents’ expectations of success. These parents want their children to have what they never had: the chance to achieve the “American Dream.” For some, it is about their children having social status or money. Other parents want to keep up with the family down the street.


    Children coming from a family of doctors may be expected to eventually take over the family practice or at least follow in the family’s footsteps. Tanyaporn Wansom, a fourth-year in an M.D./M.P.P. program at the Uni¬versity of Michigan Medical School, felt the weight of family history.


    “My family said I was going to be a doctor or they would disown me,” says Wansom, who is also national chair of AMSA’s Committee on Global Health. “When I told my mother I might want to get a Ph.D. in the sciences, she didn’t talk to me for six months.” Her mother said she could be anything she wanted—as long as she went to medical school.


    For other parents, the philosophy of choosing a career is just a financial decision. “Work is not something to be enjoyed, but is only something to gain money,” Vivian Huang recounts her father telling her. Huang is a second-year resident in internal medi¬cine at Long Island Jewish Medical Center. Her father told her she could pursue other interests after work.


    To Huang and others, pursuing dreams of a creative career, such as being a writer, artist or musician are forbidden.


    Some specialties are also off-limits. For example, many are pushed away from psychiatry, which Huang wanted to pursue. Her father didn’t consider psychiatrists “real doctors,” she says.


    For those who resist the pressure, choose their own careers or drop out of medical school, they may face some serious consequences, and not just from family. Students who choose a new career after several years of medical school can face overwhelming debt. And then they have to pursue a career in medicine just to pay the bills. There’s no going back.


    Culture, Status and Money


    Family pressure to become a physician doesn’t manifest itself just in Asian families, but it’s a prominent stereotype that often rings true, experts say. Many families mandate that their children must have a lucrative career with high social status. Many immigrant parents live a life of sacrifice, often working multiple and menial jobs with the goal that their children will succeed. Their children are expected to follow along.


    Becoming a doctor offers the prestige that Asian parents seek, says one Korean-American woman, who tutors underprivileged Asian children. In speaking with TNP, she asked to remain unnamed, explaining that her views may not reflect the stance of her organization.


    Many Asian parents believe that the ability to heal the sick offers a level of status not offered in other careers, she says. She offers insight in speaking about her own Korean background.


    “A lot of the time the parents of our youth think that being a doctor or a lawyer is the ideal level of prestige of a profession,” she says. “It signals an entry into a social status and that automatically indicates a level of education received by the students.”


    An assumption exists among Asian parents that their children must exceed, or at least equal, their own achievements, she explains. Many parents live vicariously through their children. One facet is living up to family expectations so parents can tell their friends how successful their child is to be a doctor, she adds.


    Ever since Huang was young, her parents told her she was going to be a doctor. As she went through school, she did what was necessary to achieve this goal, like getting good grades. Bringing home a report card with strong marks became a goal in its own right. But eventually, Huang questioned her career path.


    “In college, I had a quarter-life crisis and said I didn’t know if I wanted to be a doctor,” Huang says. “I liked the humanities.” But witnessing the work of physicians at Bellevue Hospital in her sophomore year of college renewed her passion for medicine. Her father, though, nixed her choice of specializing in psychiatry.


    Huang has no regrets about becoming a doctor, now pursuing internal medicine, but she does regret that she couldn’t pursue her desired specialty. “Some days are OK, and some days I think psychiatry is more suited to my personality.” She may find a way to pursue that passion later in her career, she says.


    “My father probably wants a better life for me,” Huang says. “It was probably out of love for me and to not have to see me struggle as they had.”


    But Huang says that as children become assimilated into American culture and live in the United States for several generations, career pressures may ease. Huang says if she has children, she would not force them into a certain career. “I would want to make sure they were happy in whatever they chose.”


    Opting Out


    Some are brave enough and have the strength to resist the pressure. Young was also pressured to be a doctor. Coming from an immigrant family, her career path, too, was decided in childhood.


    “They said that they brought me here to become a doctor,” Young says of coming to the United States from Burma. In her family’s home country, a doctor can be akin to a spiritual leader.


    Facing this pressure was not easy, but eventually her parents understood her decision to say no. Young found her passion as a journalist. She even wrote about her choice in her college newspaper. After earning her journalism degree from the University of Cali¬fornia at Irvine, she is starting her career in broadcast journalism. It took time for her parents to understand. But her national journalism award helped.


    One of Young’s inspirations to follow her own career dream came from an English instructor she had at the University of California at Riverside. The instructor decided to leave medical school one year shy of graduation, Young explains.


    Others decide against practicing medicine, but find they can use their medical degrees for related careers. Donald Matsuda, a fourth-year at Stan¬ford University School of Medicine, says that he wants to pursue a career in health administration. His parents are fourth-generation Japanese Americans, and they didn’t push him. He struggled in medical school to find a purpose in what he was doing and eventually said he was so close to finishing, he might as well do so.


    Going Too Far


    Some families and children can find acceptance in career choices. When it doesn’t happen, the pressure and strife can lead to a crisis. Huang, who is Chinese, remembers Korean classmates who were pushed even harder and “dropped out of high school and disappeared for a while.” Others have had to forget medical careers because their grades or test scores were not good enough to get into med school.


    For 11 years, Jennifer Tyner served as assistant vice president and then president for student life at La Sierra University, the former undergraduate campus for Loma Linda University. She witnessed firsthand the pressures some students faced from family to become doctors. One of the worst days in her life, she says, was when a student was found dead in his car just outside campus. “He had shot himself in the head after receiving his MCAT scores,” Tyner says. “At the funeral, it became very clear what type of pressure he was under from his family.”


    Madeline Levine has seen intense parental pressure far too often—especially in affluent families. The psychologist authored a book on the subject titled The Price of Privilege: How Parental Pressure and Material Advantage Are Creating a Gen¬eration of Disconnected and Unhappy Kids.


    Levine says these kids lose their childhoods studying for a career they may not want. As doctors forced into the profession, many realize when they get older that they are not living an authentic life, and they can become depressed, she says. “By middle age, they say, ‘What did I do?’”


    “Medicine is a very demanding mistress, and if you are not happy every day, you get the feeling that your life has been robbed,” Levine says, “because it’s not like a part-time job or something you can do indifferently so you can get along to doing what you want to do.”


    In the process, something much more important can be destroyed, she says. It can tear a family apart, destroy trust and inflict emotional wounds that potentially could take a lifetime to heal.


    A Family Resistant


    However, in some underrepresented communities more parental involvement is needed, says Dr. Sampson Davis, who grew up in an impoverished area. Children from poor areas are often told from an early age that they cannot be doctors. In inner-city and rural areas, children need educational support, whether from family, mentors or supportive friends, he says.


    “I do think we should increase the encouragement for students in poorer communities to do well, and take a page from more affluent communities where children are expected to go to college and to do well and make something of their lives,” Davis says.


    Davis found his support through an agreement with two friends who grew up in the same neighborhood and who also were determined to succeed.


    “We made a promise to one another to become doctors,” Davis says, “and we became the backbone to hold ourselves accountable.”


    Davis, an African-American, grew up in inner-city Newark, New Jersey. He was the first in his family to attend college, Seton Hall University, and earned his medical degree from Robert Wood Johnson Medical School. He completed his residency in emergency medicine at the hospital where he was born, Newark Beth Israel Medical Center. He is now an emergency medicine physician at several Newark area hospitals. He was also the assistant medical director of the emergency department at one of those hospitals, Raritan Bay Medical Center.


    His rise from poverty has been chronicled in The Pact and The Bond, books he wrote with the two friends. Since then, the three have formed a foundation to help inner-city children believe in themselves and even foster their dreams to be doctors.


    He doesn’t know if there is a template for success to follow, whether to adopt the parenting style of ultra-demanding parents or otherwise. But in underserved, underrepresented communities, parents need to give their children the encouragement they need to be successful in any career, he says.


    “All I wanted was someone to believe in me so I could have a chance,” Davis says. “And for everyone in our family now, I want it to be our tradition to go to college.”


    The Right Choice


    Young has found joy in choosing journalism over medicine and felt that writing about her experience was important.


    “I definitely have no regrets,” Young says. “When that article came out, my mom said she was disappointed that I had to write about it, but for us, we don’t have any regrets.”


    Some people are born with certain passions, Young says. For them, “they watch shows about doctors, and they grow up wanting to be a doctor. And I never wanted to be a doctor.”


    Young insists that her choice wasn’t about intentionally going against her parents’ wishes. “I was kind of saying yes to my own dream,” she says, “rather than saying no to my parents’ dream.”
    ~~~~Steve Woo is associate editor of The New Physician. For comments or to tell us about your own experiences related to this topic, e-mail tnp@amsa.org.~Career Development,Premedical Education,Student Life and Well-Being~
    467~8November~2008-57~Feature~Give Me Health Care, or Give Me Death~This election season, the people have called for a reformed health care system, but details remain shrouded in semantics.~Jacqueline M. Duda~Separating signal from noise is difficult in the debate over the potential future of U.S. health care. Public, private—fact, fiction: Experts and advocates explain what we need to cover our nation.~Past demand for health care reform ebbed and flowed with the rise of each election. But concerns about gas prices, national security and floundering banks devour the fervor and shove health care to the background like a neglected stepchild. But that tide is slowly turning.


    In a March press release issued by the Physicians for a National Health Program (PNHP), 59 percent of 2,193 physicians surveyed across the United States last year supported government legislation to establish national health insurance (NHI), 32 percent were opposed, and 9 percent were neutral. The study, conducted by the Center for Health Policy and Professionalism Research (CHPPR) and published in the Annals of Internal Medicine, reflects a 10-percentage-point increase since 2002, in physician support for NHI. The strongest support comes from psychiatrists, pediatric subspecialists, emergency medicine physicians, general pediatricians and internists, and family physicians.


    “Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy,” says Dr. Ronald Ackermann, associate director of the CHPPR at Indiana University School of Medicine, and co-author of the study.


    Mary Carol Jennings, Jack Rutledge legislative director for the American Medical Student Association (AMSA), says that “universal health care” snags the greatest number of hits on the organization’s Web site, bringing in droves of respondents that keep AMSA’s e-mail lists jumping. “The lack of access to medical care is one of our most engaging and mobilizing issues,” says Jennings. Most medical students are passionate about eliminating inequalities in our current system, she explains. It’s rationed health care based on who can pay without regard to who needs it; insurance companies that dictate medical care rather than respect a patient–doctor decision; and people dying by the thousands in a first-world country from preventable diseases because they can’t access health care.


    Reality check: “socialized medicine”


    The knee jerk reaction that health care for all will ring the death knell of “socialized” medicine dissuades real movement toward reform, says Stan Dorn, senior research associate at the Urban Institute in Washington, D.C., a clearinghouse of information, research and education regarding social and economic issues. Dorn’s April report, “Are We Heading Toward Socialized Medicine?” concludes that the core issue in health care reform is not the role of the government, but which policies will yield the best results by addressing the number of people with health coverage, quality and access to necessary health care, cost growth and consumers’ ability to make choices about their care and coverage. Likening U.S. health care reform efforts to socialized medicine simply derails action regarding the real issues, Dorn insists.


    Jennings says the assumption that the United States has a predominantly private health care system is misleading. Annually, at least $1.2 trillion in U.S. health care expenses are paid by tax dollars. Medicare, Medicaid and SCHIP are prime examples. Dorn says that no serious reform proposal of which he is aware would result in either a purely government-run system or a pure free market.


    The high cost of doing nothing


    Studies show that failing to enact reform is far more costly to society, says Dr. Robert Crittenden, a professor at the University of Washington School
    of Medicine, chief of Family Medicine Services at Harborview Medical Center and director of the Herndon Alliance, a nonpartisan health care coalition based in Seattle.


    Proponents of health care reform cite savings rather than losses. A 2007 analysis of an Illinois health care reform proposal, issued by Ken Thorpe, health policy and management professor and chair at the Rollins School of Public Health at Emory University, describes how the state’s proposal to reduce health insurance premium growth would produce $15.6 billion in savings for Illinois families and businesses in just four years. After taking into account the cost of financing the reform, the state would realize a net savings of nearly $9 billion from 2008 to 2011.


    The money for upfront costs might already be hidden in the system. Covering the uninsured will require such upfront costs unless the new coverage is accompanied by built-in cost controls, says Alan Sager, director of the Health Reform Program at Boston University School of Public Health. “But if building in cost controls is not politically popular, coverage for everyone doesn’t have to increase spending after the transition period, because half of today’s health care spending is wasted,” Sager explains. The challenge will be to make care durably affordable for all Americans by squeezing out some of the waste, says Sager, in ways that will protect all needed hospitals, doctors and other caregivers.


    “We spend 16 percent of our gross national product on health care,” says Dr. Oliver Fein, president-elect of PNHP and professor of clinical public health at the Weill Medical College of Cornell University, arguing that the United States can rid itself of bureaucracy and waste, and use the savings to cover the uninsured.


    “People say we are spending too much, but my immediate question is, how much should we spend?” asks Michael Miller, policy director for Community Catalyst, a national health care advocacy group based in Boston. “Who’s to say we shouldn’t spend 15 [percent] or 20 percent of our GNP if the spending results in good health care value?” The system needs to weed out low value procedures and requires more comparative effectiveness studies. “Medicine is part science, part art,” Miller says, adding that the United States has to invest in learning more about what works.


    “Cost control can’t be done with a scalpel,” says Sager. Cost control in health care is a retail job where doctors should make decisions patient by patient and can refrain from ordering tests just to protect themselves from being sued. “Ultimately, we haven’t negotiated a peace treaty with doctors and addressed these concerns,” he says.


    Single payer versus public/private integrated systems


    Fein supports a single-payer approach similar to Medicare that covers the entire population—a single, public financing agency, where hospitals remain privately owned, and physician reimbursement procedures stay the same. He argues that universal coverage through an extension of private health plans brings with it expensive overhead and administrative costs. Medicare overhead costs, on the other hand, make up a meager 3 percent of the program’s expenditures. Like Fein, AMSA favors a single, comprehensive, publicly funded, privately delivered system—a less than dramatic shift from the current system, Jennings insists, and more efficient. A single-payer system, Fein says, offers maximum potential for choice and would make the marketplace more interesting. “The competition would be based on quality and service, rather than price,” he explains.


    The American Medical Association’s “Voice for the Uninsured” campaign supports a public/private proposal that builds on the strengths of the current system and will provide financial assistance subsidies to purchase health insurance and choices of health plans, along with individual responsi¬bility and protections for high-risk patients. “We have overuse and underuse of health care systems throughout the country,” insists Robert Zirkelbach, strategic communications director with America’s Health Insurance Plans (AHIP), a Washington, D.C., trade association representing nearly 1,300 insurers. Consumers prefer a public/private approach, he says. The belief that the only way to achieve health care reform is for the government to take over is the biggest myth of all. “To improve quality and safety and reduce rising costs, we need a uniquely American approach that builds on what’s working in the U.S. and shores up where we’re falling through the cracks,” he explains. “We need a system in this country that shows what works best and delivers
    this information to providers and consumers so they can make the decisions.”


    Miller recommends reform that will move the United States in the right direction without getting stuck on “it’s my way or the highway.”


    Is the doctor in?


    In-country examples of reform already exist, and some of the potential problems have become apparent. The 2006 Massachusetts health care overhaul created a waiting list nightmare, especially in primary care, Fein says. However, national public systems like Medicare and SCHIP rank high in customer
    satisfaction and access, he notes. Crittenden says that increased demand is only part of the problem. A huge system change must occur concurrently with raising primary care numbers, he insists. “We have to start growing our own primary care doctors,” says Dan Hawkins, senior vice president of policy and programs with the National Association of Community Health Centers (NACHC) in Washington, D.C. NACHC is partnering with the School of Osteopathic Medicine in Arizona to revive anemic numbers. “Students experience primary care at its finest before entering residency. Most will become family doctors or pediatricians,” Hawkins explains.


    Publicly financed medical education that sends physicians into underserved areas as a service payback is another solution. In lieu of mandates, Hawkins suggests the National Health Service Corps, which has assisted medical, dental and nursing students with their education costs and placed them in underserved communities to “pay back” the assistance in service. “There are five to 10 times as many applicants as the Corps can help right now,” says Hawkins.


    AMSA is paying close attention to states that are implementing systems of health care for everyone. “We see the movement growing,” says Jennings. Despite the nagging access problems in Massachusetts, says Miller, an unexpected dynamic emerged. Workers being rationed out of health care because of their inability to pay, he says, are one thing. But now the upper and middle class are feeling the pain. And that may be a potent remedy for health care problems, moving reform up on the agenda.
    ~RESOURCES

    ~~~Jacqueline M. Duda is a freelance health journalist in Washington, D.C.~Health Policy,Universal Health Care~
    470~9December~2008-57~Feature~Port On Call~The high seas provide a far-reaching training opportunity~Jesse Wright~The USNS Mercy delivers care to patients and unique training opportunities to medical students. Jesse Wright joins the crew of this floating hospital on its Pacific tour.~





    Deep inside the USNS Mercy, Chae Kim and Bridgett Payne were scrubbed in for surgery. The operating room’s hum came from the medical machinery, rather than the whine of a ship’s engines. The Mercy is a hospital first, then a Navy boat. On the table is a 38-year-old mother of one. Kim and Payne, buried up to their eyes in scrubs and gowns, hold out their wet hands and wait for a towel.


    The patient is East Timorese, one of the hundreds of patients from the Southeast Asian island of Timor now on board the American hospital ship idling in the harbor of East Timor’s capital city of Dili. Before anesthetic, the patient was nervous. She had never been on a hospital ship, and her experience with Western medicine was patchy. This removal of uterine cysts would be her first OB-Gyn procedure, and she didn’t know what to expect.


    East Timor is a tiny nation of about 1 million people just below the equator, northeast of Australia. In 2006, four years after being granted independence from Indonesia, the nation was rocked by a yearlong civil conflict. The president and prime minister were both targets of assassination attempts. One of the poorest countries in Asia, East Timor is struggling to develop its health sector, and there is still much to be done.


    For Kim and Payne, first-years at the time, it would also be their first OB-Gyn surgery. They dry their hands, slip into their gloves and take their places next to senior naval surgeons.


    As civilian students on board the Navy’s traveling hospital ship, the two are getting a unique opportunity to observe and learn their craft up close and personal in faraway places—and years before their classmates.


    Prior to their stint on the Mercy last summer, neither Kim nor Payne, now second-years at the University of California, San Diego, School of Medi¬cine (UCSD), had been in surgery. By the time they arrived in East Timor in mid-July—a month into their trip—they had helped out with plastic surgeries as well as gall bladder and thyroid removals. Now they would help with the uterine cysts.


    Both of the woman’s ovaries had become infected with “chocolate” cysts. The safest measure was to simply remove both ovaries to reduce the chance of recurrence. But in East Timor, having one child is rarely enough. The patient asked the doctors to try to save at least one ovary. Although the doctors were forced to remove one ovary, the second ovary—and the woman’s fertility—was saved.


    After the operation wrapped up, Payne said she felt lucky to be able to scrub in on so many surgeries, considering most of her first-year class had not yet seen any.


    “We’re learning a different type of thing,” she said later. “[On the Mercy] we’re learning practical skills. In pharmacology class we learned the different names of the drugs, but here we see how they’re used and sometimes we help the anesthesiologist administer them.”


    Sonia Chen, then a second-year at UCSD, wanted to travel, learn more medicine and have a few adventures before her August return to school. But Chen didn’t have many options. Her fellow students were volunteering at the UCSD free clinic or doing lab research at school, but she’d already volunteered at the clinic and wasn’t interested in research. She considered going to Zimbabwe, but as the unrest during Mugabe’s president election intensified, the country’s stability seemed increasingly precarious. Besides, most of the overseas programs she researched all had high program fees that she could not afford.


    “I really wanted to do something international this year,” Chen said during her two-week stop in East Timor. “I really wanted to travel internationally because I have an interest in international health.”


    Then, last April, she received an
    e-mail from UCSD’s dental director and adviser, Dr. Irvin Silverstein. The UCSD Pre-Dental Society was working with the U.S. Navy to fill spaces on the Mercy, one of only two hospital ships—the other is the USNS Comfort—used for humanitarian missions.


    Last summer, the Mercy embarked on its Pacific Partnership Program, an annual tour of impoverished countries around the Asia Pacific region. Sil¬verstein’s e-mail was an open offer to any student, dental or not, with an interest in summer travel, adventure and learning. Although there is no permanent Navy medical staff on the Mercy—they rotate on and off, not unlike the medical students—many of the Navy medical personnel are reservists. Prior to embarking with the Mercy, none of the students had given the Navy much thought, but after a summer spent with the crew, the students said they would consider it as a career option.


    Like Chen, Kim and Payne signed up with Silverstein’s program because they were eager to have a different service experience than the average medical student.


    “We just finished our first year and after your first year, it’s the last summer you’ll have free,” Payne said. “Seventy-five percent of the other students are doing research at med school, so we’d probably be doing that or we’d be on our last summer vacation until the end of med school. Maybe we’d volunteer at a clinic, but this is much more exciting.”


    Before Chen embarked with the program, she did a bit of research and discovered it had no admission fee, and room and board was included. If she could pay for the flight to Singapore, Chen could join the Navy’s medical crew on board the Mercy for two months. She had a month to decide. It wasn’t much time, but it wasn’t a difficult decision.


    Among 28 other medical and dental students, hundreds of Navy medical personnel and sailors lived on the ship as it sailed the Pacific, stopping in some of the region’s poorest and most remote ports of call. In those months, she worked as long as 14 hours a day helping Western and local doctors treat indigenous patients. She put into practice everything she’d learned over the past two years in school and more, as she saw cases unlike anything she’d seen outside her textbooks.


    “It sticks in your brain when you see a patient with a heart murmur, and you go over the diagnosis with a doctor,” Chen said. “It’s amazing.”


    Part of the novelty was the independence she felt as she learned to diagnose patients on their symptoms and her skills alone, she said. The Mercy is a fully equipped hospital, but while the most serious cases, such as those that require surgery, are treated on board, Navy doctors see hundreds of patients on land.


    In East Timor, Western medicine still competes with traditional healers, and many Timorese see Western drugs as a last resort after traditional medicine fails. But even getting access to Western medicine can be tough. Most villages have a basic clinic, and only a handful of hospitals are scattered across the country.


    Chen spent her time off the boat in small neighborhood clinics—one of which was a battered elementary school jury-rigged as a clinic for the week. Few of these clinics had electricity, let alone diagnostic equipment.


    “The medicine we practice [in the clinics] is more hands-on because we only have a certain list of drugs to choose from, and we don’t have CT scans,” Chen said. “You have to have your clinical skills a lot sharper here. You have to be a good clinician here because you can’t depend on a lot of technology.”


    During her time at the elementary school-turned-clinic in Dili, Chen saw about 30 patients a day, with a Navy doctor supervising her.


    The lack of care means that some patients must live with conditions for years before being treated, making for some unique experiences for Chen and her colleagues.


    “The patients we have here have a lot more pathology that’s textbook, in that their diseases appear in the most severe form because they go untreated for so long,” Chen said. “The other day at the Dili medical site, someone came in with clubbing, and we usually don’t see that in the States because the symptoms are usually treated before clubbing occurs.”


    Kim and Payne, on board since the Mercy left its San Diego port in June, also saw plenty of unusual cases firsthand.


    “We saw a lot of burn cases in Vietnam,” said Kim. One man in his mid-20s came to the clinic with scar tissue on his right shoulder from a cooking accident as a child. “He couldn’t even lift his arm. The plastic surgeon removed the scar tissue and removed the skin from his thigh and then did a skin graft.”


    “At first, when we saw him, he couldn’t move his arm at all, and then, after we went to check up on him, as we were leaving, he was waving,” said Payne.


    Although intense learning experiences and work take up the students’ days while in port, there is down time. Between aid stops, the ship pulls into developed ports to restock. There, the medical students are given about five days of leave. After Vietnam, the ship docked in Singapore and after East Timor, the Mercy spent time in Australia before it traveled to Papua New Guinea and Micronesia.


    For some future physicians, even the breaks offered learning opportunities.


    “I’m a dork. I went to Singapore General Hospital to see how they do things there,” said Matt Chenoweth, a UCSD doctoral student and premed. “I got a tour of the facility.”


    In transit, life on the Mercy isn’t dull. At night the mess hall might host pizza dinners or poker games. There are movies and, between the helicopters on the flight deck, opportunities for stargazing.


    “The time in transit is usually slow, but there’s always something to do,” Chenoweth said. He explained that one night he and the medical students offered to serve food in the mess hall along with the regular Navy crew. “We volunteered, and they were glad to have the extra hands.


    “Everybody works together, though there is a hierarchy. Everyone is collegial, and everyone is very good at what they do.”~All Hands on Deck


    Anyone interested in getting aboard the USNS Mercy in 2009 should act now.


    “The sooner people contact me for the 2009 partnership, the better,” says University of California, San Diego (UCSD), dental director Dr. Irvin Silverstein. “The Navy is starting to plan now for several 2009 humanitarian missions.”


    Although the placements are through the UCSD Dental Society, spots are open
    to non-dental students too, including physicians, dentists, pharmacists, medical
    students, pharmacy students and preprofessional students.


    2009 will be Silverstein’s fourth year involved with the USNS Mercy, and he says the student response has been positive.


    “This is a unique project in the U.S., and we’ve been recognized with numerous awards,” Silverstein says. “My students who go on these trips aren’t the normal pre-dental students. Many have had several years of hands-on clinical experience and giving back to society. This trip just exposes them to a higher level of need. It makes them feel they need to think on a worldwide level.”


    For more information about the project, visit the UCSD Pre-Dental Society Web site at fdc-pds.ucsd.edu.
    ~~~Jesse Wright is a journalist in East Timor.~International Health,Military/VA Medicine~
    471~9December~2008-57~Feature~Health Care Elsewhere~How Health Care Works in Other Countries~Steve Woo~We always hear how much better and cheaper health care can be outside our borders. But how do these systems work? TNP looks at four models of care different than our own.~The United States spends by far the most for health care in the world, yet produces some of the worst health outcomes of any industrialized nation. For years, a host of countries have produced much better results for a fraction of the cost.


    For all our country spends, about 47 million of our citizens remain uninsured. Last year, health care costs took 16 percent of our gross domestic product (GDP), or $2.3 trillion. Studies project that dollar figure may nearly double in the next decade.


    In health care systems research, the United States, compared to other developed countries, consistently scores low or at the bottom on common benchmarks of effectiveness: average life expectancy, quality of care, number of uninsured, access to and cost of care, and national health care spending. Americans polled are generally unhappy with the health care system. One third of them want the whole system scrapped, and half say fundamental changes need to be made, according to a Harris Interactive poll released this past summer.


    We’ve chosen to profile the health care systems of four countries that offer more highly touted care and whose citizens, according to the Harris poll, say they are much more satisfied with their coverage: Canada, France, the Netherlands and the United Kingdom (U.K.).


    Each country administers care differently, but in each, no one goes uninsured. These systems cover all citizens. Care is provided by the government or, in the case of the Netherlands, by insurance companies that are legally required to accept all applicants. No one is denied care if they can’t pay.


    So how do these systems work?


    Canada


    As a neighboring country, the U.S. health system is often compared to Canada’s. While the country’s system is not as highly rated as many in Europe, it still produces better results than the United States, according to research by the Commonwealth Fund and others. On the measure of average life expectancy, Canadians live 80.2 years compared to 77.8 years in the United States. Access to care is also not a problem.


    “Canada has a couple of things that clearly are better than the U.S.,” says Dr. Robert Ouellet, president of the Canadian Medical Association. “It has coverage for the entire population.”


    Contrary to popular understanding, Canada has a single-payer rather than a federal system. The government pays for all of the care from a single fund, but uses private doctors to administer care. Patients can choose where, and from whom, they get their care. Each province and territory has differences in their respective systems, but the national government oversees and regulates each.


    Canada publicly funds 70 percent of care through national income and employer and payroll taxes; the remaining 30 percent is covered privately through insurance companies. Health care spending is much lower than in the United States, having accounted for 9.9 percent of Canada’s GDP in 2004.


    The Canadian system covers services such as primary care, physical therapy, occupational therapy and speech therapy. Psychiatric services are covered, but services outside hospitals or community-based mental health clinics are usually not. Chiropractic services and alternative medicine are covered in some cases.


    Dental and vision care are not included and are covered through private insurance.


    Critics of the Canadian system cite long waits for care, including elective procedures such as knee replacements. Patients may, at worst, have to wait months to be seen. Those who disparage the system joke that Canadians “die in line waiting for care,” as Ouellet puts it. But if conditions worsen, or a patient needs immediate care, such as emergency room care, patients can be seen much sooner.


    France


    France is frequently mentioned in the top tiers of health care. Life expectancy there is 80.3 years. Experts say the country offers some of the finest, most comprehensive coverage in the world, and even covers illegal immigrants. In 2000, the World Health Organization (WHO) ranked the country first in overall care. The United States was ranked 37th,
    one step ahead of Slovenia. The WHO has since stopped its rankings after concerns about research methods, including missing data for many countries. Regardless, France is still first in many surveys, such as one by the London School of Hygiene and Tropical Medi¬cine earlier this year.


    The system’s advantages include offering patients quality care without long lines, and plenty of choice of doctors and specialists, says Paul Dutton,
    a historian at Northern Arizona Uni¬versity. He is the author of Differential Diagnoses: A Comparative History of Health Care Problems and Solutions in the United States and France.


    “The French would never stand for socialized medicine,” Dutton says. “They would say, ‘That’s the U.K. system.’ They want choice.”


    But fundamental differences in cultural philosophy create barriers to U.S. adoption of other countries’ systems.


    “A big difference is because of society,” says Maggie Mahar, a health care expert and fellow at The Century Foun¬dation, a public policy research group. “Nothing is too good for a fellow French¬man. They are socially obli¬gated. In America, they say, ‘It’s me and my family.’”


    France’s care does not come without a price. The French and the three other countries studied have significantly higher taxes. But citizens of these countries accept it as a necessity. They realize someone has to pay for it, Ouellet says of Canadians. “It’s a societal choice. This is a sacred principle.”


    French care is funded mostly through payroll and income taxes. The government regulates hospital fees and keeps costs down. The most ill get the most coverage, and the government pays entirely for long-term treatment and expensive procedures. In 2004, France’s health care spending was 10.5 percent of GDP.


    Physicians in France are self-employed, and the government pays them on a “fee-for-service” model. Pay rates are negotiated with the government and medical unions.


    No waiting lists exist for elective procedures, and patients do not need preauthorization to see a specialist, as in the U.K.


    The French system isn’t without its problems. As in the rest of the world, national health care spending continues to increase. France’s costs have led to budget deficits of several billion dollars, one that may even threaten to bankrupt the system, experts say. As in the United States, the number of physicians is dwindling compared to the increasing size of its population in the near future. Concerns exist that paying for health care through employment taxes discourages employers from hiring. France is now turning toward broad taxes on earned and unearned income to pay for health care.


    The Netherlands


    Rivaling France for the title of best health care in the world is the Netherlands. Since Jan. 1, 2006, it has required every citizen to buy health insurance. But there, insurance companies are government regulated. They can neither deny coverage to anyone for any reason, nor can they charge exorbitant rates.


    Citizens pay a single rate to the insurance company. Seemingly every type of medical procedure is covered, including primary care, maternity care, speech therapy, mental health care, and dental and vision care. People choose among insurers, which compete on premiums. In addition, they can purchase supplementary insurance to cover alternative medical treatments, such as acupuncture.


    This sharply contrasts with U.S. insurance companies, which determine whether to offer coverage based on factors such as chronic illnesses, pre-existing conditions and conditions that are expensive to treat.


    Compared to the loopholes in U.S. insurance, insurers in the Netherlands do not offer “Swiss cheese” policies, Mahar says, because the government regulates and requires everyone to sign up. Insurers can make a profit, but they can’t cherry pick.


    Care is delivered through private health care providers, from general practitioners to specialists, whom the insurance companies pay. The country’s national health care cost was 9.2 percent of GDP. As with the other countries studied, a regulatory body monitors care quality, patient rights and other concerns.


    Critics note that the Netherlands is facing a shortage of general practitioners, a dilemma faced by countries worldwide. Also, Dutch physicians are generally hesitant to prescribe medicine unless clearly necessary. The philosophy is that the body is best left to heal itself. For supplementary coverage, insurers can turn away customers, or boost premiums based on the applicant’s medical history, Mahar says.


    The United Kingdom


    The United Kingdom offers a true national health system. The National Health Service (NHS) offers comprehensive care, from primary care to dentistry to treatment for learning disabilities. The government administrates the care, owns the hospitals and employs the doctors. But citizens can choose which doctors they want to see and where to receive care. Private supplementary health care and insurance exist for those who want more privacy and comfort than is offered in the public system, shorter lines for elective surgery and other benefits.


    The NHS pays the bulk of the cost of prescription drugs, and the remaining co-pay is low. Those exempt from co-pays are a host of people, from those under 16 years of age to pregnant women to the elderly. Even transportation to and from the health care facility is covered for those with low income.


    NHS patients must see a general practitioner (GP) first before they can see specialists.


    GPs are paid through primary care trusts, which encompass a mix of salary, flat-rate fees for any services and separate service fees. GPs get financial rewards for reaching clinical and other performance goals.


    Private general practitioners set their own rates and generally are not reimbursed by the public system. The NHS is financed mainly through general taxation. In 2004, the U.K.’s national health expenditure was 8.1 percent.


    To ensure quality care, regulatory bodies monitor and assess the quality of service by public and private providers. Criticisms include long waits for elective surgery and difficulty seeing GPs after hours. The U.K. also has some of the longest wait times, with 15 percent having to wait more than six months for elective treatment. Canada is second to last, at 14 percent. The Netherlands is the best, at 2 percent, according to a 2007 Commonwealth Fund study.


    What stands in our way?


    Each country has some form of universal care. While adopting aspects of such a system sounds like a good solution, implementing it in the United States would be far from easy, says Dr. Richard Reece, editor-in-chief of the newsletter Physician Practice Options.


    In the United States, he says, universal care will not be put in place entirely, not everywhere and not anytime soon. Clashing political and cultural ideologies stand in the way, not to mention the multibillion-dollar insurance industry and those who demonize universal care as “socialized medicine.”


    Health care for all is considered a right in the other countries studied. In the United States, public services like electricity, education, and police and fire departments are considered essential and are funded through tax dollars. Other countries consider health care just as essential, Mahar says.


    Adopting universal care would most likely mean a significant increase in taxes, a serious barrier since Americans, and especially politicians, generally abhor tax increases.


    Health care in the United States is not without its strengths. It leads the world in health research and innovation, with many of the world’s best doctors, specialists and technology. Foreign physicians routinely visit the United States to learn. But, ironically, high costs and poor access have left us lagging. The number of uninsured is staggering.


    “The main difference is that you have 47 million people uninsured, and the facilities are top-notch,” Ouellet says of the United States.


    Change entails enormous practical concers as well. The U.S. population is more than 300 million, about 20 times the size of the Netherlands, which has a population of about 16.5 million. France is the most populous nation in our comparison, with about 64 million citizens. Furthermore, the United States is much more ethnically and socially diverse than those other countries, Reece points out.


    Mahar says another major barrier to change is that health care is a for-profit enterprise in the United States, and that people are making money off of people being sick. Financial contributions to politicians are a hindrance as well.


    “We have chosen to put health care into an unregulated, for-profit enterprise, and you end up with a lot of corrup¬tion,” she says. “Political power and money are tremendous players and will continue to be huge players in health care.”


    But Mahar believes that change is possible. “Government is the single largest provider of care in the U.S.,” she says, “so government has tremendous power as a payer to improve the care delivered.”~~~~Steve Woo is associate editor of The New Physician.~International Health,Universal Health Care~
    475~9December~2008-57~Med Rx~The Hot Seat~A primer for residency interviews~Daniel V. Schidlow, M.D.~An interviewer speaks~The origin of the word “interview,” the French entrevue, means “to see one another.” Residency interviews are based on a common need. The interviewer is “seeing” if the candidate is a good fit for the program, and the candidate is finding out if the job—the location, facilities and residency program itself—is what she wants or needs.


    The season to don the dark suit and start traveling is upon us. In 30-some years of conducting interviews, I have witnessed the gamut of human behaviors ranging from autonomic storms—causing hiccups and sweating—to awkward seating positions and lack of eye contact. Through those experiences, I have developed some thoughts and biases that I wish to share with you, and I hope that my suggestions will help you as you set off on the fourth-year’s traditional winter interview tour.



    Personal aspects of your life need to be factored into your choices. Happy people make happy residents, and happy residents are a blessing.~~~~Dr. Daniel V. Schidlow is Chair of Pediatrics at Drexel University College of Medicine and Physician in Chief at St. Christopher’s Hospital for Children in Philadelphia.~Career Development,Medical Education,Residency~
    476~9December~2008-57~On the Wards~A Shattered Mind~An older vet demonstrates challenges ahead~Jeffrey Jenks~The scars of soldiers~I met Rich for the first time on the fourth floor of the hospital, in the psychiatric unit. The police brought him in the night before; they had found him walking around in traffic without a shirt or shoes on, yelling expletives at passengers in the cars zooming around him.


    Rich’s first stop was the emergency department (ED), where he was clearly highly agitated. Rich would pace around the room, shadow boxing some imaginary competitor and yelling incoherently. He was rude to the ED physicians and other hospital staff. They couldn’t wait to get rid of him, and he eventually made his way up to our unit.


    Rich was 57 years old, the spitting image of Doc Brown from “Back to the Future.” He had long, white hair that almost reached his shoulders. It didn’t fall naturally as most hair does, but was a fuzzy mess that rose straight and stiff off his scalp. He had sideburns that reached halfway down his face, and a scruffy stubble around his chin. I was half expecting Rich to exclaim, in an excited voice, “Marty, 1.21 gigawatts? Great Scott!”


    Not surprisingly, there were no one-liners from “Back to the Future” spoken by Rich, and he was not happy to be in the hospital. He was agitated and uncooperative, and spoke like someone who had to get someplace very soon, as if there was very important business left unattended. His speech was rapid and rambling, and very difficult to follow. To make matters worse, Rich had misplaced his dentures somewhere between his house, the intersection where he was found by the police, and the emergency room. This not only added to his misery, but also made Rich almost completely incoherent.


    As his story began to unfold, we were able to verify through other area hospitals that Rich was indeed a schizophrenic. Although his presence at this particular hospital was new, he was familiar to many other hospitals around the city. The pieces of his puzzle began to fall into place, and a picture of a long history of schizophrenia with frequent episodes of decompensation began to take form.


    After adjusting Rich’s medications, we hoped that he would get a good night’s sleep and reassured him that we were determined to help him through this latest crisis. He began to improve over the next few days.


    A few mornings after meeting him for the first time, I walked into Rich’s room to check in. I sat down. His room was bare, with only a small wooden bed and the chair I was sitting in. Outside, beyond the barred windows, the sky was a magnificent orange, with the sun just beginning to rise for a beautiful July summer morning.


    I gauged how Rich was doing after a few days in the hospital. He was improving dramatically, especially after having the new medication in his system for a few days. As I was finishing our discussion, I remembered something we had briefly talked about the other day, his service in the Marines.


    “Were you ever deployed overseas?” I asked.


    “I was in the Marines for four years, from 1967 to 1971,” Rich responded proudly, “and was deployed to Cambodia during the Vietnam War.”


    “What was that like?” I said, attempting to ask an open-ended question, but I knew it could be a loaded one nevertheless.


    The smile left his face. He looked at me intently, with greater clarity than I had seen in him previously.


    “It was hell,” he told me. “Pure hell. I wanted to go to Vietnam, but they sent me to Cambodia instead. I don’t like to talk much about what happened over there. Most vets don’t talk about it.”


    Of course, the wars in Cambodia and Vietnam aren’t unique in the numbers of veterans who return with serious mental health issues. I was hoping Rich could shed some light on how his experiences in Cambodia had transformed him into the person who sat before me that morning.


    Tears began to well up in his eyes, and he seemed lost in his own memories. “The Vietnam War was hell. I guess most wars are, in their own way.”


    As I put the pieces of his story together, I began to learn more about Rich’s story and his history. He had been only 17 when he signed up for the Marines. After four years and a deployment to Cambodia, he was honorably discharged. Unfortunately, Rich would never be the same after returning from Cambodia.


    The night of his admission to the psychiatric unit, I had called Rich’s mother to verify some of his information. She had told me that he was just an ordinary young man before he went to Cambodia, but when he came back, his mental health problems began.
    Like many schizophrenic war veterans, Rich’s break probably occurred sometime while he was away at war. To what degree his experiences in Cambodia contributed to his eventual break we will never fully know or understand, but to someone who is already at risk for schizophrenia, the brutality of war can play a significant factor in his downward spiral into the depths of the disease and other mental illness. I could only imagine what sort of horrors Rich experienced while he was so far away from home.


    One of the most cruel aspects of war is that soldiers can carry the scars from it throughout their entire lives. Rich had left home as a 17-year-old boy and came back from the Vietnam War with an intact body but a shattered mind. Forty years later, he is still paying for his experiences, and probably will the rest of his life.


    I didn’t ask Rich any more questions that morning. I would have loved to hear more about his experiences in Cambodia. It would have helped me better understand what sort of trauma could cause someone to lose control of his mind in such a dramatic way. But that would not have been fair to Rich, and I would have never knowingly put him through any more suffering than he had already experienced.


    As I prepared to bid Rich farewell, I couldn’t help but think about all the soldiers—men and women, some still boys and girls—who are presently coming home from fighting the wars in Iraq and Afghanistan, and the horrors many of them are inevitably facing and what their lives will be like upon their return.


    I hope and wish that none of them will suffer as Rich has suffered, but know that this hope will never come true.~~~~Jeffrey Jenks is a fourth-year M.D.-M.P.H. candidate at Wright State University Boonshoft School of Medicine.~Humanistic Medicine,Military/VA Medicine,Physician Patient Relationship~
    477~9December~2008-57~Perspectives~Think Small~A rural home for medical education~William G. Cloud, M.D.~Fresh ground for academia~When the rich learning environment of prolonged inpatient stays in a university hospital is completely plowed under by “managed care,” what will take its place? Where can students be exposed to the clinical decision-making process completely and transparently? The remaining habitat of this hidden curriculum is the small community practice.


    Formerly a 14-year member of an urban community-based teaching faculty in general surgery, I have been at the crossroads of two well-developed trends. The first is an erosion of the teaching experience for mentor and learner wrought by managed care. The effects on education of shorter patient stays are well described. More patients are receiving outpatient community care. Academic medical centers are concerned that the community-based experience has serious educational limitations. There is no nearby clinical and basic research, no academic culture for clinical conferences and Grand Rounds, and no faculty “village” for consultation, as a 2003 Institute of Medicine report on academic health centers noted.


    Dr. Kenneth Ludmerer, who studies trends in medical education, has written that academic centers may begin to look more like community practices as revenue considerations drive faculty to focus on clinical productivity but dilute teaching and research. The addition of regulatory restrictions on hours and liability issues concerning resident independence make decision-making experience tough to get.


    I have experienced another phenomenon, as a solo private practitioner of general surgery in Morganton, a town of 17,000 in rural North Carolina. For the past seven years, I have witnessed the disappearance of the general surgery work force. This shortage of primary and specialty physicians in rural settings has been well documented. The majority of surgical residents are going on to subspecialty fellowships, and the numbers are increasing. A late-’90s report from the American Board of Surgery showed how the scope of practice for general surgeons in urban areas is limited by this excess supply of subspecialist surgeons.


    The other effect of the rural surgeon shortage is a considerable dearth of clinical experience, including endoscopy. These small communities cannot support subspecialty practices.


    This confluence of factors results in a unique opportunity for academic medical centers, rural surgeons, students and residents: a wonderful environment in which to experience the clinical decision-making process. The process, from patient presentation to the development of a putative differential diagnosis, workup and creation of a treatment plan, is immediate. The close personal observation of the evolution and implementation of the diagnosis and treatment plan is clear and seamless, even though mostly in outpatient settings. The experience of surgery and postoperative course is intimate.


    This model offers the opportunity for the establishment of a continuum of competency. The creation of an extended and integrated system of education can connect students to residents to alumni in practice. This aligns with initiatives being undertaken by the Committee on the Health Professions Education Summit.


    The small community-based practice can be an extension of the academic medical center without a huge investment on the part of either. With information technology resources, which are readily available and relatively cheap, the scope of the academic medical center can be extended. E-mail, text messaging, Web-conferencing and podcasts can make specialty consultation, conferences, lectures, and assessment of teaching and learning successful at a distance.


    With existing electronic medical records and programming resources within academic electronic engineering programs, surely an interface can be created that allows exchange of medical records compliant with the Health Insurance Portability and Accountability Act.


    This model will require two important developments: Community-based physicians must be committed to the educational process, and academic faculty and administration must be committed to increased flexibility. It should not require massive increases in financing. As students with much to gain or lose by change or continuation of the status quo, you have much to add to the discussion.~~~~Dr. William G. Cloud is a general surgeon in Morganton, North Carolina.~Community and Public Health,Health Disparities,Learning Tools and Technology,Medical Education~
    447~6September~2008-57~Reviews~Trumping Technology~Better performance, better system?~Himali Weerahandi~Performance above all~In his previous book, Complications, Dr. Atul Gawande discussed issues we in the medical field already knew about—mistakes in medicine. In Better (Metropolitan, $14), he continues on the same tack and takes it further. Gawande, a general surgeon, argues that errors—along with other problems in medicine—can be addressed by fixing the system in which care is delivered, and focusing on performance rather than simply technology. Surprisingly personal at times, Gawande asks himself the same questions he asks of others. Perhaps this security stems from the fact that he’s on faculty at one of the most prestigious institutions in the country, not to mention a well-established writer. Nevertheless, it’s refreshing.


    Better is divided into three sets of pieces that he’s grouped under the headings “Diligence,” “Doing Right” and “Ingenuity.” Though these headings may not completely fit with the corresponding essays, he argues his central thesis quite effectively. Thoroughly researched and organized, his journalistic skills are enviable. The pieces he’s woven together are not dense, academic literature, but rather engaging narratives from which the reader comes away thinking that perhaps there is a way to fix our broken health care system, if only we could reflect upon the achievements we’ve already made and apply them to other areas of deficiency.


    Gawande doesn’t discuss the health care delivery system in such explicit terms, but his arguments about performance and improving the system we work in can easily be extended to it.


    “To be sure, we need innovations to expand our knowledge and therapies,” Gawande writes. “But we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we’ve made a science of performance, however..., thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine—an effort that at present gets only a miniscule portion of scientific budgets—can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines and all the other laboratory work we hear about in the news.”


    Medicine has made leaps and bounds in scientific discoveries—pharmacological interventions, imaging, procedures—which together can extend lives and perform feats that decades earlier would’ve been considered just short of miracles. Yet our health care system is fraught with problems, and it’s far from being considered the best in the world. It’s not lack of technology which is holding us back. Rather more mundane and basic things can make a difference in the quality, efficiency and even quantity of care delivered.


    As the system we work in becomes larger and increasingly fragmented, it becomes imperative that that system is well-tuned. As it stands now, while medical technology has advanced, the way it’s delivered has not. It remains entrenched in the past with its growing stacks of paper and mazes of red tape, almost negating the progress that technology has made, because the people who need it aren’t able to access it.
    ~~~~Himali Weerahandi is a fourth-year at Temple University School of Medicine.~Learning Tools and Technology,Practice of Medicine~
    448~6September~2008-57~Perspectives~Patients’ Education~Self-reflection, alliances lead to responsible care~Margot Brown~Letting patients teach~Shoving the last of a Rice Krispies treat into my mouth on my way to speak to a patient group, I thought about the day’s presentation, my summer plans and that evening’s dinner. I was not thinking about the fully functioning beta cells in my pancreas, or about the insulin soon to be released into my bloodstream. I am oblivious to the harmonic convergence of my perfect digestion: the release of enzymes, the contraction of smooth muscle, the efficient utilization of insulin receptors—all parts working together in concert to keep my blood sugar within normal range.


    I opened the meeting room door to a group of people who hadn’t been so lucky. They all had diabetes, and the last time they thought about their blood sugar was probably two minutes ago. As the health educator for this weekly diabetes group, I was expected to deliver pertinent information in an accessible manner.


    This particular day, we were talking about diabetic complications. “The point of today’s discussion,” I announced in an enthusiastic voice, “is not to scare you about the complications of diabetes, but to highlight the importance of self-management. Lowering your risk of these complications is within your control.” The group of diabetics I worked with every week looked up at me; some stared blankly, some nodded their heads in agreement and others avoided eye contact.


    The youngest group member, a Type I diabetic named Julie, spoke up. “It is easy for providers to say, ‘Manage your disease,’ but what does that really mean? It means I need to take my blood sugar every day, measure and administer my insulin, watch what I eat and live with the fear that I could go into a coma again.”


    Her comment ended my enthusiastic delivery. Beyond being correct, she reminded me of my health status in this room of diabetics. I was thinking about dinner, eating a sugary snack, and daydreaming about a summer of possibilities while everyone else in the group was checking their blood sugar. How can I possibly understand what it is like to live with a chronic disease?


    Although this is changing, medical providers today are disproportionately wealthy, white and capable of making the same assumption that I did: that their patients share their reality. This can be detrimental to care. Telling a patient to eat more vegetables can mean very little if they lack the income to buy fresh food. Giving out health education materials is disempowering to a patient who can’t read, and advising a patient to walk around her neighborhood for exercise overlooks the fact that some people live in dangerous areas.


    During my junior year of college, I—a financially secure, educated white woman—acted as the health educator for a school in West Oakland, California, predominately made up of students of color in a low-income neighborhood. At that time, the school had no health education program, so it was my responsibility to develop and implement one. I chose to focus on sex education. I figured that sex ed was my biggest need in high school, so why wouldn’t it be the same in West Oakland? After three months, my curriculum was up and running, and the students seemed to be enjoying and learning from the presentations.


    Then the first wake-up call came. During a sex ed session with 11th graders, I was explaining that about 30 percent of men get prostate cancer in their lifetime but, because of slow growth, most die of something else first. A male student then asked, “What would they die of first—getting shot?” I was taken aback by his comment. Addressing homicide as a primary cause of death is something that would have never crossed my mind.


    About a month later, a shooting on school grounds punctuated the distinction between my uninformed perception and their reality. There was no school assembly, no outreach or grief counseling and a general attitude among the school administration that the students could cope because it “happens all the time.” Though I was outraged by the lack of response, the truth was that violence was ever-present: The homicides in Oakland numbered 148 in 2006, with 47 percent of the victims under age 25. Students at the clinic shared heart-wrenching tales with their doctors, counselors and, over time, with me, about being raped, abused or losing a sibling.


    In Oakland, I began to understand the invaluable role that self-reflection and awareness play in the delivery of health care. I had come into this school, this clinic and this neighborhood with an agenda to help the youth make better choices.


    The logic seemed easy enough: Tell the students how to take care of themselves and they would do it. I was basing these assumptions on my personal experience growing up. When I learned how to better take care of myself, I did it because I could. I had access to necessary medical services, a supportive and financially secure family and, most importantly, I felt safe.


    These youth did not have access to the same tools I did when I was their age. This compromised my effectiveness as a health educator; I had very little to offer the students until I understood where they were coming from. I had to start over.


    Violence was the pertinent issue for West Oakland youth, so I began to work outside my comfort zone and focus on violence prevention. I also needed to examine my social location and role as an educator. Talking about violence and working to prevent it meant having open conversations about race, racism, oppression and power imbalances in society. Who was I to present on these topics? They were the experts and I was the amateur. It was not appropriate for me to take on a leadership position, so I stepped out of the spotlight and asked the students to assume that role.


    Immediately, I noticed a difference in the reception of the presentations. Youth leaders were talking candidly with their peers about their real-life experiences. Youth were able to talk about difficult issues from their perspective, and not that of an outsider. What’s more, by acting as a support person, and not a leader, I gave the students a chance to build community in the classroom, empower one another and strategize collaboratively to combat violence in their neighborhood.


    This is when I first realized the concept of alliance: the ability to join forces with others in pursuit of a common goal. In this case, the goal was violence prevention. For someone with a significant amount of privilege, the best thing I could do was back off and let those who may not have had a voice take a leadership role. But what happens in cases where there is little choice in the relationship? Doctors, for example, cannot allow patients to diagnose and treat themselves. In clinical situations, as with the diabetes group I worked with, the concept of alliance can mean something else entirely.


    Delivering good medical care is a constant interplay between self and others, a chance to scrutinize assumptions and act from a place of understanding and respect.


    In educating diabetics, high-school students or any other patient group about their health, we must constantly ask ourselves, “How can I teach this population?” I can by incorporating open conversation and peer teaching into the curriculum whenever possible, truly valuing the abilities and experiences of group members, and giving them the chance to educate each other. This is the best health education we can offer.
    ~~~~Margot Brown is working at the Prevention Institute and applying to medical school.~Community and Public Health,Physician Patient Relationship,Practice of Medicine~
    450~6September~2008-57~Feature~Student Debt and the Physician Workforce~Peeling back the layers of a multifaceted problem~Jacqueline M. Duda~You already know that debt is going to be part of your life for a long time, but medical student debt also affects the entire health care system. Here’s how.~The financial desert left behind by flailing government funding and a weakening economy casts a cloud of uncertainty over medical students’ choices. And the forecast seems bleak. Tuition costs continue to march upward; recently lowered income limits quash hopes for overworked and stressed-out residents to obtain interest-free loan deferments. Minority students avoid the profession entirely, fearing they’ll never be able to tame the massive student loan debt.


    Hard evidence is nonexistent, but there’s plenty of anecdotal commentary from the trenches to suggest that debt plays more than a minor role in career choice. Vocal opinions on all sides identify a variety of factors, but debt is the one variable that keeps reappearing.


    Separate reports from the American Medical Association, the Center for Health Workforce Studies, the Ameri¬can College of Physicians (ACP) and the Association of American Medical Colleges each warn of an impending crisis in the primary care physician workforce, citing skyrocketing medical school debt. Excessive administrative burdens, large patient loads and declining revenues for practicing primary care physicians are reasons more students are choosing to specialize. Peer-reviewed studies indicate that high debt levels drive students away from primary care and hammer students from underrepresented minority groups, discouraging them from entering medicine or practicing in underserved areas.


    Some fear that internal medicine is becoming a less competitive “fallback” option rather than a viable career choice, worrisome at a time when the need for general internists to manage and coordinate patient care is rising along with the numbers of an aging U.S. population.


    Looming debt overshadows primary care


    Flavio Casoy, a fourth-year at Brown University Medical School and former national debt coordinator for the American Medical Student Association, insists that the impact of debt on practice choice is hard to gauge, citing the lack of long-term studies that could identify a definitive correlation. He cautions, however, that anecdotal evidence in primary care shows that high debt levels and relatively low remuneration rates are nudging more students toward higher-paying specialties.


    Recent years have witnessed student debt rising higher than the earnings of a primary care physician, even when adjusted for inflation, says Dr. Candice Chen, assistant professor of general pediatrics at George Wash¬ington University (GWU) Medical Center. Some of the literature, she says, indicates that the debt level is becoming a larger issue when students make career choices.


    Harvard Medical School fourth-year and chair of the ACP’s Council of Student Members, Maya Babu, agrees. She adds that students entering medical school with tag-along debt from undergraduate education face a double whammy—piling debt upon debt. “Debt influences practice choice, but it’s not as simple as saying, ‘I have lots of debt, so I’m going to specialize,’” Babu explains. Recent years have expanded existing options in medicine—research, academia and the private sector. “It’s more about thinking about your career,” she says, “and trying to piece it all together according to what’s most important to you.”


    The issue is complex, says Dr. Doug Campos-Outcalt, associate chair for the department of family and community medicine at the University of Arizona, Phoenix. “Why people say they do something, and why they really do it, are sometimes entirely different. People tend to rationalize why they do certain things,” he explains. Underlying reasons, such as simply wanting to make more money, can influence choice.


    However, Campos-Outcalt concedes that income differentials and insurance reimbursement rates contribute to an overall devaluation of primary care. The earnings are less, and the system doesn’t encourage patients to take ordinary problems to primary care doctors. Some insurance plans allow patients to bypass primary care physicians and go directly to specialists. “I think that’s what some students are responding to by moving away from primary care,” he says.


    Dr. Lawrence Ward, associate director of the Internal Medicine Residency Program at Temple University School of Medicine, says that general medicine is the ultimate challenge. He explains that some students worry that they won’t feel like experts if they choose primary care. “Debt is the final nail in the coffin for many who view primary care as unsatisfying or lacking in prestige,” says Ward.


    Juggling the load


    Students have at least a rudimentary understanding of how swiftly debt will hit once they graduate. This awareness depends on the school and its financial aid office. “The financial aid policy in general is wonderful, but it’s like a slot machine,” says Leon Johnson, president and CEO of Education Association Services Group, a Florida firm that partners with professional associations and schools to provide higher education financial advice to students and families. Student loans might feel like easy money with no immediate financial strings attached.


    “Not all debt is bad,” Johnson insists. Debt is sometimes necessary to build wealth. The key is being able to manage it, he says. A new physician typically goes into practice with more than $100,000 in debt. For Ward and his wife, Stephanie, also a family practitioner at Temple, debt will plague them for years—till Ward turns 61. “We owe about $300,000 between the two of us. We could have picked any specialty we wanted, but we went into general medicine because we love it,” he says.


    Johnson says that primary care physicians can manage debt with a little sacrifice and financial savvy. But living below one’s means is hard to do. “Especially in a culture where spending is the only social addiction that everyone smiles about,” he admits. And, Chen says, if economic times worsen, it can spell trouble for primary care physicians already strapped with monumental loans.


    Ward admits their decision may not have been as financially rewarding when compared to peers who chose to specialize, or dove into careers that didn’t require seven to 10 years additional training. “Sure, I’d like a bigger house, or more vacations, but that’s not what we chose to do,” he says.


    “The idea of managing debt depends on how you define rich, and what the individual considers to be an asset,” says Johnson. It’s part behavioral and part societal.


    Debt impedes diversity


    A vast majority of medical students come from affluent or upper-middle- class backgrounds. Debt and skyrocketing costs are believed to create a barrier to working-class undergrads and underrepresented racial minorities, particularly black men. “It’s a big topic these days,” says Chen, who is working with Dr. Fitzhugh Mullan at the GWU School of Public Health and Health Services on the Medical Education Futures Study. The study, led by the Robert Graham Center, seeks to identify ways to develop a socially responsible physician workforce and is examining primary care, underserved areas, minorities in medicine, and the degree to which debt affects practice choices and the numbers of physicians in underserved areas.


    Johnson says it helps when students and families understand that debt can become an asset, and how interest accrues and repayment options work. But there’s no guarantee that the mounting debt will ensure success. “You can go all the way and still not finish medical school,” says Campos-Outcalt. The gamble is risky.


    And while affluent undergrads engage in research and community involvement to increase their chances of gaining entry into the medical school of their choice, students from economically disadvantaged backgrounds are working retail or other jobs to help pay their way through college. Even when schools seek out minority applicants, says Babu, many are unable to bring previous academic and community experience to the table to help boost their chances for medical school.


    When students with limited financial resources overcome the barriers and become practicing physicians, it doesn’t make sense for them to return to treat the underserved in their communities, Babu says. In addition to being hamstrung by debt and low Medicaid reimbursement rates, physicians in community health centers face persistent structural issues that include high staff turnover and instability. These factors can drive away the most altruistic family practitioner. Ward says, “They [new physicians] can’t afford to minister to their community.”


    A bleak outlook for primary care


    Johnson refers to the situation as collateral damage—an unintended consequence of laying debt on people’s future incomes. It encumbers their options and limits what they are able to do as they go forward.


    Harvard and several other schools are responding, Babu says, by designing programs to forgive loans for those going into primary care. Ward says that additional financial loan forgiveness and scholarship programs are needed, combined with improved repayment options, particularly for students going into primary care. “Whether it’s an expansion of the National Health Service Corps, or state programs,” he says, “we need more incentives to entice students to choose primary care.”


    “Physicians are clearly in the upper echelons of income, there’s no question about it,” Ward says. But this is a question of debt and the amount that primary care doctors are paid. “It influences career choices. And everyone should be concerned, because we’re losing primary care physicians.”
    ~~~~Jacqueline M. Duda is a freelance writer based in Monrovia, Maryland.
    To comment or share your own experiences on this subject, e-mail tnp@amsa.org.~Diversity in Medicine,Medical Student Debt~
    451~6September~2008-57~Feature~Fighting the Depths~Depression—and its consequences—among physicians-in-training~Beth Rogers~Many medical students who suffer from depression won’t seek help for fear that they’ll be labeled by their peers or even their professors. Add in the high rate of successful suicides among practicing physicians, and the extreme risk to providers is clear. Plus: looking out for yourself and others.~Fishing, logging and mining are occupations known for their high fatality rates. Anecdotally, doctors also belong to a profession with a high death rate. This rate, however, is not necessarily due to the inherent risk of on-the-job accidents, but rather to physicians’ elevated risk of purposefully ending their own lives. The phenomenon was observed as far back as the mid-19th century when English physicians noted that members of their profession killed themselves at a greater rate than that of the general population. Sadly, that trend continues today. Male physicians are 70 percent more likely to die by suicide than males in the general public, and female physicians are 250 percent to 400 percent more likely to die by suicide than other women.


    Physician suicide, experts say, owes its grim numbers to the practitioner’s mastery of the human body—their attempts are much more successful than the general public’s—and the underlying challenges of untreated depression among doctors and physicians-in-training.


    An estimated 400 doctors commit suicide each year, the equivalent of a few medical schools’ graduating classes—but beyond these tragic losses, patients can be affected. Depressed physicians are much more likely to make medication errors and other mistakes than those who aren’t depressed. And beyond patient impact, future physicians under the stress of training deserve the right to seek mental health care without the threat of labeling from peers.


    The emotions of medicine


    Dr. Paula Clayton, medical director of the American Foundation for Suicide Prevention (AFSP), believes that physicians of both genders are no more depressed than the general public, but have higher suicide rates because they have the means and the knowledge to be more successful in their attempts. This mathematical relationship has particularly lethal consequences for female physicians: Women in the general population attempt suicide as often as men but are one-fourth as successful because they tend not to use firearms or other highly effective methods. Since 2002, the AFSP has been operating a special project focused on bringing awareness to physician suicide and depression. The potential for depression and suicide in physicians may have its roots in the physicians of the future: medical students.


    “Students come into medical school with similar rates of depression [and] anxiety as their age-matched nonmedical school cohort. And by the end of the second year, that rate of symptoms of depression doubles and triples,” notes Dr. Christine Moutier, assistant dean for student affairs and associate professor of psychiatry at the University of California, San Diego (UCSD), School of Medi¬cine. While no one has recently tracked completed suicides in medical students, small studies asking them about suicidal thoughts reveal that between 11 percent and 35 percent admit to experiencing such thoughts in the preceding year.


    Despite the high suicide rate, Clayton says there’s no data supporting the idea that physicians have more stress than other people. “I think it’s presumptuous to suggest that the job of a physician is more stressful than that of an attorney.” She does note, though, that depressed people tend to be more sensitive in general, which may draw them to healing professions like medicine to begin with.


    However, some data implies that medical students are more depressed than their age cohort. “We need more study of the issue,” says Dr. Charles F. Reynolds III, senior associate dean and professor of psychiatry at the University of Pittsburgh (Pitt). “Medical school, and then residency, is a high-stress period. I have seen figures as high as 25 [percent] to 30 percent rates of depression among residents.”


    Medical students are exposed to death and suffering. Further, Moutier says, premed students are accustomed to being the best and the brightest in their classes—that’s what got them into med school—but in med school they’re with other high achievers. All of a sudden their accomplishments don’t look so stellar. Down the road, rotations tend to highlight deficiencies rather than indicate progress.


    This pressure cooker environment can lead to depression. “Nita,” a Wayne State University third-year who asked that her real name not be published, took a leave of absence to address her depression. She notes that as an undergraduate, she was a top student who aced every subject with little effort. Then, when she got to medical school, “I studied my butt off and still failed exams. That’s a huge shock when you go from being a straight-A student to failing all your exams.”


    But ultimately, says Reynolds, untreated mood disorders like depression or bipolar disorders—often ac¬companied by substance abuse—in¬crease the risk for suicide. “The role of life stressors is much less clear.”


    Laura Kenkel, a fourth-year at Ohio State University (OSU) medical school, felt the onset of depression in graduate school. She had a strong family history of anxiety and depression. Attending college and graduate school on full academic scholarships, she had a lot of self-imposed academic stress. Those factors, she believes, coupled with family tragedies, triggered her depression. She realized she had problems when anxiety kept her from falling asleep. In the morning she was so poorly rested she had trouble waking up. She got to a point of fantasizing about hurting herself “just to stop the anxiety,” which eventually progressed to more suicidal ideation. She couldn’t even share her feelings with her longtime boyfriend.


    If existing mood disorders are to blame, why are the very physicians responsible for treating the public so reluctant to seek help themselves?


    Silence and the stigma


    It’s common for people with depression to deny that they have a problem, notes Moutier, but medical students, and physicians particularly, want to see themselves as strong and able to help their patients. “[It’s] even more of a mental leap for them to accept the fact that they’re fully human, that they have vulnerabilities that are common to the entire human race. That includes mental health vulnerabilities.”


    Stigmatization of mental health issues is considered to be one of the key reasons why people don’t get help. Even though UCSD has mental health services, not enough students use them, admits Moutier. Lack of time, perceptions of academic jeopardy, confidentiality concerns and cost all keep students from seeking help, she says. UCSD has been working hard to dismantle those concerns through holistic programs such as a peer-mentoring group and seminars on coping with stress.


    “Students often feel so pressured for time that they’re reluctant to carve out time for themselves, whether it’s to get help for depression or to lead a more balanced life,” Reynolds explains. “[But] treating depression…doesn’t have to involve a great deal of time.” Most students, in Reynolds’ experience, don’t need a leave of absence or inpatient treatment.


    Students may cite cost as a reason not to seek treatment, not realizing that many of their health services are free. As Moutier points out, most students have pretty good medical insurance that covers mental health benefits. In fact, those benefits often exceed the coverage they can get as interns or physicians.


    Students are also afraid of repercussions or sanctions that would adversely affect their academic standing or chance of competing for a good residency slot. Mental health disorders, says Reynolds firmly, are not reported to the dean. Although in some states physicians are sanctioned for revealing they have mental health issues, medical students will not be punished or disadvantaged if they come forward and admit they need help, Reynolds says. In addition, the AFSP and groups like the American Medical Association are trying to address such state sanctions.


    Part of the disease of depression, notes Moutier, is the individual’s skewed perception of how they’re being perceived. The depressed person’s fear of being viewed negatively can be “so far out of proportion to what their actual co-workers and families are thinking.” Since seeking treatment, Kenkel has been open about depression and says she’s never had anything but positive feedback. Her fears of being treated like damaged goods never came to fruition. Today, she’s comfortable talking about depression, and the OSU administration has been incredibly supportive, asking her to speak to other class members. She has received numerous e-mails from people thanking her for sharing her story.


    However, not all students are convinced about claims of confidentiality. Nita was highly fearful that any information about her mental health would go on her record. She didn’t use the counseling services at Wayne State, noting that work-study students often get tasked with pulling and filing records. “You don’t want your peers to know all that stuff.” She wasn’t totally sure she could trust her school’s assertions of confidentiality. “You have a counselor on campus that you speak to, but they’re always jotting stuff down and keeping a file on you,” she says. “They say that that file is separate,” Nita adds, “[but] whether it goes on the record or not, these are people who know things about you.”


    Maybe because it can’t be felt like swollen lymph nodes or seen like a fracture on an X-ray, it’s still too easy to stigmatize depression in our culture. “Look at what we call doctors who work on mental health,” says Nita. “We call them ‘shrinks.’ It’s [seen as] a very negative thing to have to go see someone about your mental health.” No one thinks less of a diabetic for having to take insulin, Nita points out, but when depressed people get treated with serotonins, “because it’s with your head, there’s so much more of a stigma associated with it.”


    And Nita isn’t convinced that depression isn’t seen as a liability by others. “No one wants to deal with anything extra,” she laments. “No one wants to deal with psychiatric issues.”


    Fighting the stigma, finding the solutions


    Most medical schools are interested in the mental health of their students, says Moutier, and are dealing with it in a very proactive way. Because medical school class sizes are small, she adds, it’s relatively easy to monitor students. However, she admits, it’s not always intuitive to medical educators how to draw the line between students who are academically at risk and those who are emotionally at risk.


    The AFSP and Moutier point to Pitt as a leader in medical student health issues. For more than 20 years, Reynolds says, Pitt has tried to make seeking mental health services something that’s OK to do. “We talk openly with the students about the fact that stress and depression are common among medical students, and we encourage help-seeking.” Students can take advantage of talk therapy and antidepressant medications, and all the services are free and confidential. “What we’ve tried to do, in essence, is remove as many barriers as we can to appropriate help-seeking by medical students,” he explains. “We try to de-stigmatize the topic of depression; we try to remove the barrier of finances, the barriers related to confidentiality and fear of adverse effects of help-seeking. And we provide a combination of services ranging from counseling to psychiatric backup.”


    Part of demystifying and de-stigmatizing depression entails encouraging more people to come forward and talk about their own experiences. At Pitt, a former medical student Reynolds used to treat for depression is now on faculty, and she has talked with students about what it was like to be diagnosed and treated. “That is the kind of story that needs to be told because it will give people hope,” notes Reynolds.


    Even though OSU has counseling services, Kenkel initially worried, like Nita, about confidentiality. Kenkel was afraid that if her peers and professors knew she was depressed, “I wouldn’t be seen as capable…. I was afraid people would regret ever having admitted me.” At first, she went outside the school for help. Today, as she has gotten to know the OSU counselors, she realizes that her fears were unfounded.


    After getting help, Kenkel decided to start a support group for fellow students in her second year of medical school. With encouragement from the school, she sent out a school-wide e-mail and wound up with a group of five or six students who met each week to share their experiences, frustrations and solutions. The group went on hiatus during her third year, but Kenkel plans to resume it this semester.


    Nita acknowledges that schools offering free medical services on campus “at least show that the school is recognizing the need,” but says that at Wayne State there is only one counselor for each class of about 300 students.


    Kenkel says schools need to do more outreach and create an environment of trust to make sure students feel safe coming forward for help. Most universities’ counseling programs, Kenkel points out, “don’t have connections with the college, and they’re well-trained in confidentiality and dealing with the issues that all students have in common.” OSU contracts with an independent counseling firm to further inspire confidence in confidentiality. At Pitt, the counselor’s office is located off the medical school campus.


    However, schools must be very explicit in explaining to students exactly what goes into academic records, Kenkel says. For example, there should be a protocol in place discussing who gets informed if a student is hospitalized.


    Nita wants to feel reassured that “anonymity is the number one concern,” and suggests using electronic files or numbers instead of names to ensure complete anonymity.


    But can reaching out to medical students impact suicide rates in physicians? “Depression often begins earlier in life, sometimes by the second or third decade,” Reynolds says. “By earlier diagnosis and treatment, we may be able to prevent some of the long-term complications of depression, which include recurrence…, inadequate performance in professional roles, problems in marriage, self-medication, poor compliance with medical treatment for coexisting problems such as high blood pressure, and ultimately an increased rate of death by suicide.”


    When she becomes a physician, Kenkel notes, she has no plans to conceal or ignore any mental health issues. “If I need help, I’m going to have to get help. Maybe I feel somewhat defiant, but just like any other medical problem, if I had cancer, I would take time to get the chemotherapy.” Kenkel is planning on a residency in psychiatry and will definitely note her experience with depression and the OSU support group in her application, saying that it shows leadership, and it is something that she is very proud of.


    Nita notes that her experiences can only make her a better physician, and she is currently reaching out to her peers. Ultimately, the means and the knowledge that make physicians so effective at terminating their own lives can be used to more positive ends by teaching students how to better recognize depression in themselves and their classmates, and by helping doctors recognize depression in their patients and colleagues.


    It’s too soon to tell what effect reaching out to medical students will have on mitigating depression and suicide among physicians. Moutier thinks that the solution to reversing this trend is to remind students, residents and physicians that they are not infallible and, as part of the human condition, they will all have different vulnerabilities at different times in their lives. “They must view self-care as part
    of their professional responsibility,” Moutier says. “There’s enough data out there that show that when depression and burnout are a factor for a physician or a resident, that medical errors go up and empathy goes down. It’s very reasonable to say that taking care of oneself has to be a part of that duty that we sign on to in terms of doing right by our patients.”
    ~Signs of Depression and Where to Go for Help


    “Nita,” a Wayne State University medical student who asked that her name be withheld, diagnosed her own depression when she lost 25 pounds, couldn’t sleep, and her hair started falling out. “I had a textbook case,” she says.


    However, says Dr. Christine Moutier, assistant dean for student affairs at the University of California, San Diego, School of Medicine, medical students seldom diagnose their own depression, although they are better equipped to identify depression in their peers. Regardless of how depression is diagnosed, notes University of Pittsburgh senior associate medical school dean Dr. Charles F. Reynolds III, it’s definitely not a good idea to treat oneself.


    Laura Kenkel, a fourth-year at Ohio State University, says questionnaires are a good way to get started in diagnosing and measuring depression. One of the most helpful and widely used screening instruments, says Reynolds, is the nine-item patient health questionnaire, or PHQ-9, which lists the nine cardinal signs and symptoms of clinical depression. “We tell the students how to use it as a screening instrument. It’s available on the Web and is very good for recognizing different levels of clinical depression.” Pitt is also piloting an online stress and depression screening tool in conjunction with American Foundation for Suicide Prevention, whereby students can fill out a password-protected questionnaire and have a clinician make an assessment for further treatment.


    The warning signs of depression include self-doubt, sadness, a sense of being overwhelmed, poor grades, trouble sleeping, persistent fatigue and not enjoying being around friends. Moutier says that typically she starts to see students address depression when they can’t concentrate and are having sleep problems.


    Students who think they are depressed should visit their student health service and inquire about the availability of mental health counseling services. Most services are free and promise confidentiality.


    Resources


    These sites and offices offer help and resources. Many have 24-hour hotlines, numbers of local psychiatrists and psychologists and links to online support and discussion groups.


    ~~~Beth Rogers is a freelance writer based in Bethesda, Maryland. Direct comments about this article to tnp@amsa.org.~Disabilities in Medicine,Medical Education,Student Life and Well-Being~
    452~6September~2008-57~Feature~Getting to know your CMS~~Steve Woo~Medicare, Medicaid—what’s the difference, and who cares? You should, and we’ll explain why in our at-a-glance guide to these huge federal programs. Plus: Looking for a proxy fight? ~As a medical student, you might not think learning about Medicare and
    Medicaid would be of much importance until you start practicing.
    You might want to think again.
    The massive Centers for Medicare & Medicaid Services (CMS) pay the
    medical bills for about 100 million Americans, including seniors and
    those with low incomes or disabilities. The programs each cost about
    $700 billion to fund annually and help finance residency slots for medical
    graduates.


    Reimbursement rates will affect how much you’ll get paid once you become
    a doctor. The federal government is attempting to cut Medicare and Medicaid
    rates, often already lower than what doctors normally charge for the same services.


    Because of this, some doctors are even choosing not to take patients on
    either program. The number of baby boomers eligible, especially for Medicare,
    will skyrocket in the next decade, placing a massive burden on the existing system.
    With fewer taxpayer dollars to fund Medicare, the program is widely expected
    to become insolvent by 2019.
    Here, TNP presents a short overview of these huge programs, complete with
    numbers and a guide to what Medicare and Medicaid mean to you.


    Read more...~~~~~Community and Public Health,Health Disparities,Health Policy~
    453~7October~2008-57~Feature~No Fresh Start~Providing health care to immigrants amid a broken health care system~Avery Hurt~Caring for immigrant communities hasn’t come easily in the United States, despite our history as a nation of newcomers. In an overburdened health care system, where do these populations find help?~If you are white, of European descent, and were born in the United States, you may think of yourself as standard-issue “American,” with everyone else a member of one minority or another. If so, you’ll soon need to revise your definition. Cur¬rently, though some 80 percent of the U.S. popu¬lation is non-Hispanic white, one in eight is an immigrant, and that share is growing.


    Despite our view of ourselves as simply American, we have always been a nation mostly of immigrants—and have always been somewhat ambivalent about that fact. As the
    old joke goes, “We have always had problems with immigration; ask any American Indian.” And when it comes to providing health care, both the social and economic problems are magnified.


    If current trends continue, by the year 2050 non-Hispanic whites will be in the minority, representing only 47 percent of the total population, according to projections of the Pew Research Center. The bulk of the increase will be Hispanics, mostly of Mexican descent. While this may seem like no more than an interesting bit of demographic trivia, it has profound implications for the health care community. As with so many social issues, the health care community is, like it or not, on the front lines of immigration—a topic fraught with both controversy and practical challenges. If we can’t seem to find the resources to get health care right for the population we have now, how are we going to deal with the projected 113 million new immigrants?


    Presenting Symptoms


    Often when immigrants come to this country, they arrive with nothing more than the clothes on their backs—and the illnesses in their bodies. For the most part, immigrants have the same health issues as the native-born population. “We see a lot of diabetes, GERD, hypertension, high lipids,” says Lina Meng, a fourth-year Pharm.D. student at the University of California, San Diego (UCSD), Skaggs School of Pharmacy and Pharmaceutical Sciences. Asthma is also quite common, she says. Meng works at one of UCSD’s many free clinics that serve immigrants, mostly Hispanics.


    Despite the list of the usual ailments, first generation immigrants are typically in better health (both mental and physical) than the native-born population, though this advantage seems to deteriorate rather quickly after arrival. In fact, the length of time an immigrant spends in the United States positively correlates with their rates of heart disease, cancer, diabetes, low-birth-weight babies, anxiety, depression and mortality generally.


    This is known as the “healthy migrant effect” and is the basis of much speculation and study. The phenomenon is particularly fascinating because the majority of immigrants come from countries with higher rates of poverty and lower standards of living than the United States, making it difficult to understand why they are healthier than we are when they get here. The factor that gets most of the blame in the popular press is the notoriously poor U.S. diet. An immigrant’s “home” diet may be a far better nutritional bet than a fast-food burger or the overly processed fare that appears routinely in so many U. S. kitchens. However, diet is certainly not the only factor involved, and may not be the most significant one.


    The most obvious reason for better health upon arrival is that one has to be in good health to make the trip in the first place. Immigrants tend to represent the younger and healthier members of their native populations. This still doesn’t totally explain the phenomenon, however. By far the largest group of immigrants currently coming to the United States are from Mexico, a country where, according to the World Bank, half the population lives in poverty and one-fifth in “extreme” poverty, defined as less than $1 a day. The healthy migrant effect suggests that poverty in immigrants’ home countries might have a less detrimental effect on one’s health than poverty in the United States.


    Recent research has indicated that poverty is detrimental to health only up to a certain level. According to Michael Marmot, the British epidemiologist at the forefront of this research, at income levels greater than $5,000 per capita, social conditions seem to matter far more than economic ones. As counterintuitive as it may seem, poverty in a rich country is far more detrimental to health than poverty in a poor one. Once immigrants settle here and adopt not only our diets and hurried lifestyles, but our values and stresses as well, their health begins to match ours: not so great.


    The healthy migrant effect is made even more complicated by what is known as the “Hispanic paradox.” Hispanic immigrants typically have more diabetes, are more likely to be overweight, and have a worse lipid profile than U.S.-born residents—all risk factors for heart disease—but they, in fact, have less heart disease, says Dr. Michael Criqui, professor of medicine at UCSD and lead investigator on a six-year study of Latino health. Criqui points out that the data is confusing and, in some cases, conflicting. In one study, adjusting for smoking seemed to blunt the so-called Hispanic paradox. However, in a larger, national study focusing on several groups of immigrants from Spanish-speaking countries, the paradox is holding up.


    Patchwork


    Though the diseases immigrants develop once they’ve settled in, and to a lesser degree, the diseases they arrive with, are familiar ones, providing good health care to an immigrant community poses an array of challenges, especially economic ones. More than 80 percent of immigrants have at least one full-time worker in the family, roughly the same as low-income native families. But more than half of immigrants, both documented and undocumented, are uninsured, according to data compiled by a Kaiser Commission on Medicaid and the Uninsured report. That ratio contrasts sharply with the 15 percent of native-born citizens who are uninsured.


    The problem of providing care to immigrants was only worsened by welfare reform and other restrictions imposed in recent years on eligibility for various public programs. “Denying care to people who are already here was a big step in the wrong direction,” says Nicholas Freudenberg, distinguished professor of public health at Hunter College, City University of New York. Freudenberg, who holds a doctorate in public health, has studied health trends in immigrant populations for three decades.


    Even people who support restrictions on immigration don’t believe that denying health care services to recent immigrants does much to lessen the demand for health care services. “Unskilled legal immigrants have a high rate of non-insurance as well,” points out Steven A. Camarota, director of research at the Center for Im¬migration Studies, an organization dedicated to reducing illegal immigration. “It may slightly increase the chances that [immigrants] will go back home, but doesn’t reduce the incoming much at all,” he explains.


    Many states have stepped in to try to fill the gaps left by federal programs. Measures include expanding eligibility for the State Children’s Health In¬surance Program and enrolling both documented and undocumented immigrants in various state-funded health care assistance plans and making efforts to reduce language barriers. This has been some help, but it is doubtful how long this piecemeal approach can last, since most states are dealing with increasingly severe financial challenges.


    Putting more emphasis on preventive care is one approach that may help. “Hospitals can’t turn away people with life-threatening problems, but they can turn away everybody else,” Freudenberg points out. “I’m not suggesting that we not treat people in life-threatening circumstances, but that putting more emphasis on prevention is both the right thing to do and is cost-effective,” he says.


    Finding the means to provide health care to immigrants is just one facet of our ongoing national health care crisis, and it is unlikely that any solution
    can be found independent of the larger problem. “None of the country’s health care problems can be solved until we have national health care,” says Freudenberg. “Meanwhile, everything is patchwork.”


    Building Bridges


    While economic problems get the most attention, they are by no means the only barriers for immigrant care. Language barriers and subtle cultural differences pose challenges of their own. People who migrate to this country bring with them an array of beliefs and attitudes about the causes of disease, how health care should be managed, and the role of health care providers.


    Sometimes, the cultural gap is relatively small. Dealing with it may call for little more than fluency in the language or good translation that allows for clear communication. Other times, cultural problems can be all but insurmountable, as with a family of Hmong, an ethnic group from Southern China, described by Anne Fadiman in her 1997 book, The Spirit Catches You and You Fall Down. Despite the efforts of many concerned experts, including medical sociologists, the world of the Hmong family and the world of Western medicine never managed to meet.


    Even with Spanish-speaking immigrants, for whom comparatively more communications opportunities exist, cultural differences can complicate health care decisions. In a joint survey by the Pew Hispanic Center and the Robert Wood Johnson Foundation, 13 percent of Hispanics say the reason they do not have a regular health care provider is that they prefer to treat themselves. This is not an acceptable practice in mainstream U.S. medicine. “My take on alternative medicine and folk remedies is that many are quite effective—digitalis was once a folk remedy, for example—but some are dangerous. [These treatments] can only be tested by clinical trials,” says Criqui.


    And if Western medicine does not look kindly on traditional healers and their pharmacopoeia, neither is it likely that any clinical trials, even if they were to be done, would convince a newly arrived immigrant to choose Western medications over the familiar ones of home. In communities with a strong preference for traditional healing methods, it might be a good idea to combine practices. Having a traditional healer or herbalist at the clinic might be useful. “The early neighborhood clinics back in the ’60s would often have a herbal healer working alongside an allopathic doctor. This might be a good way to bridge the cultures,” says Freudenberg.


    Deciding how to treat may be the easy part. In some cases, convincing patients that they even need treatment is the challenge. For example, both Asian and Hispanic cultures have strong stigmas against mental illnesses.


    Dr. David Folsom, a professor at UCSD who has both a family medicine practice and a psychiatry practice, has seen this among the Hispanics who come to the free clinic where he practices. “Often patients come to me as a family medicine doc to discuss issues related to depression, but when I suggest that we could have more time to discuss things if they would come to see me during my psychiatry hours, they refuse. ‘I don’t need to see a psychiatrist,’ they say, ‘I’m not crazy.’” In many Asian languages, there is no word for depression. The problem is written off as “being tired,” or having “low chi.” Mental illness doesn’t seem to even make the radar screen, yet Asian-Americans have a relatively high suicide rate.


    Lacking deep immersion in the cultures, care for immigrant communities is best accomplished through a liaison. Meng’s clinic employs a Hispanic person as a liaison between the clinic and the community. “You can sense that [the Hispanic patients] don’t fully trust us. Having someone from their own community as a part of the medical clinic helps a lot,” she says.


    Though Freudenberg agrees that bridges to the community are a good idea, he adds that they work best when the communication is two-way. It’s not only helpful to have someone explain to patients what doctors are trying to get across, but helpful for someone in the community to explain to doctors what community members are thinking. “Two-way communication can help medical practices make changes so that they can better reach their communities,” says Freudenberg. Listening is as important as talking, he points out.


    Alternate Route


    Most, if not all, health care professionals would much prefer if they could simply focus on caring for their patients—whoever they are and wherever they come from—without having to deal with the intricacies of politics. Unfor¬tunately, it is impossible to ignore the intersection of health care and immigration policy. “You either select immigrants [who] don’t need much health care, or you provide health care for anyone who comes. There is no middle ground,” Camarota says. Though it might be hard to “select for” immigrants who won’t need much health care since the health of immigrants seems to deteriorate only after they arrive, the cost of providing health care certainly factors into deciding how many, if not which ones, to accept. “Every dollar you spend on health care is a dollar you can’t spend on something else—education, infrastructure—and every health care dollar you spend on one person is a health care dollar you can’t spend on someone else,” Camarota adds.


    Few people would disagree with that statement on its face, or with the obligation to provide health care to those who need it. But the situation may not be the Gordian knot Camarota makes it seem. If there is no middle ground, perhaps there is an alternate route. “The United States is espousing policies that say that money, goods, services can move around the world without barriers,” Freudenberg says. “If so, then people should be able to move freely as well. We can’t have free trade without also allowing free movement of people…. If you want fewer people to come in to the United States, you must have policies that give people opportunities for economic [advancement and security] in their own countries.”


    On the topic of immigration, the health care system is coping with stresses and problems that go far beyond anything having to do with medicine. These larger issues will need to be addressed before anything significant can be done to relieve the burden on both the immigrants and the system that attempts to care for them. Meanwhile, doctors continue to do their best to stitch and patch.
    ~TOO MANY MYTHS


    Often, attempts to address the problems of providing health care to immigrants get sidetracked by discussions of documented and undocumented immigrants. While the designation can be important in determining what benefits a person does and does not qualify for, it is rarely as much of an issue in the clinic as it is in the immigration office. Nonetheless, myths abound. Here are some facts compiled by the Urban Institute about the differences between documented and undocumented immigrants.




    RESOURCES


    ~~~Avery Hurt is a freelance writer based in Birmingham, Alabama.
    Direct comments about this topic or your own experiences with this subject to tnp@amsa.org.~Community and Public Health,Diversity in Medicine,Health Disparities,Health Policy~
    456~7October~2008-57~Folk Tales~Congressional Treatment~Trading practice for political medicine~Steve Woo~Declining coverage for the greater good~After three decades as a practicing physician, Rep. Steve Kagen, M.D., (D-Wis.) knows the importance of having health insurance. So when the time came to sign up for the congressional health plan upon entering office two years ago, the answer was obvious.


    He said no.


    With 47 million people uninsured in this country, the freshman congressman, up for re-election next month, had a strong feeling about declining that generous coverage.


    “I didn’t run for public office to get a benefit,” says Kagen. “It’s about public service. It’s about giving back. It just didn’t feel right to take a benefit that wasn’t offered to everyone else.”


    Granted, as a successful doctor whose family has coverage through work or school, Kagen may have an easier time paying for doctor visits than others do. But his decision drew at least a little attention to a health care system that needs a lot of fixing.


    Kagen represents the 8th Congressional District in northern Wisconsin, an area that includes Appleton and Green Bay. In 1966, his dermatologist father ran unsuccessfully for the same congressional seat Kagen occupies now. That experience was a major factor in the younger Kagen’s political aspirations. For years, politics was a common dinner-table topic, and he spoke off and on about running for office, he recalls. Then, 40 years to the day of his father’s failed attempt, Kagen was elected.


    A University of Wisconsin medical school grad, Kagen comes from a family with seven generations in health care. Continuing in the family vocation, his son is in medical school and his daughter is in nursing school.


    In an interview with TNP, the allergist and immunologist who had owned a string of medical clinics spoke about his health care initiatives, medical education and other national concerns he supported during his past term.


    The lawmaker had to give up practicing medicine upon entering Congress. “I miss it every day,” he says. He is one of 11 physicians in the House, according to the Office of the House Historian. There are two in the Senate.


    In Congress, Kagen has used his medical background to call for health care reform. As a first-term congressman, Kagen’s major health initiatives could be summed up in the No Discrimination in Health Care Act of 2008. Introduced by Kagen last February, the bill—H.R. 5449—focuses on improving health care based on Kagen’s “No Patient Left Behind” principles. It would require insurance companies to openly disclose health care prices; end health plan exclusions for pre-existing conditions; establish standard prices for health care products and services, regardless of the patient’s insurance coverage; set deductibles at 3 percent of household federal taxable income; and have the government cover overhead costs of providing health care to low-income people. The bill garnered 18 co-sponsors and was referred to the House Subcommittee on Health. It’s now up to the committee how the legislation proceeds, Kagen’s spokesman says.


    The current health insurance model is discriminatory, especially denying coverage for pre-existing conditions, Kagen explains. His goal has been to make health insurance affordable and available for everyone. “Simply put, if you’re a citizen, you’re in.”


    He also emphasizes the importance of replacing varying state insurance regulations with a federal standard.


    His advice to future physicians is simple: You don’t need to be a financial wizard to run a doctor’s office. “You shouldn’t be entering medical school thinking about an M.B.A.,” he says.


    Students must consider debt in a new way. Kagen says to “be a lumper,” which means thinking about debts in the long-term—over years, rather than months. Focus on why you want to become a doctor, rather than the dollars it takes to become one, he says. “Over your career, you are going to do just fine.”


    Nonetheless, Kagen has supported legislation to reduce higher education costs. He voted for the College Cost Reduction and Access Act in 2007, which is now law. It increases college aid by $20 billion over five years by cutting some loan interest rates, increasing Pell Grant awards and other measures.


    In 2008, Kagen voted for the Ensuring Continued Access to Student Loans Act, also now law, which was developed in response the housing crisis’ effect on student loans. He also supported the 21st Century GI Bill of Rights Act of 2007, which expands the education benefits veterans receive under the GI Bill to restore full, four-year college educations for veterans who served overseas after Sept. 11, including Iraq and Afghanistan. The bill was referred to the House Sub¬committee on Military Personnel.


    In terms of the country’s health care shortages, the congressman says the number of student slots at medical schools must increase due to the shortage of physicians in coming years. In 2007, he co-sponsored H.R. 410, the United States Physician Shortage Elimination Act, which would increase the number of doctors entering primary care, especially in underserved rural and inner-city communities. The legislation would reauthorize the National Health Service Corps loan repayment and scholarship programs, increasing funding to $300 million per year through 2011. Ten percent of those funds would be set aside for medical school scholarships. The bill would also reauthorize the Centers of Excellence program and the Health Careers Opportunity Program. These programs increase minority and disadvantaged student representation in health professions through outreach to K-12 students and college students, mentoring and support for enrolled students, and expanded residency training programs and primary care services offered by community health centers. The legislation was referred to the House Sub¬committee on Health.


    As a physician, Kagen has found himself legislating on changing medical technology and ethics. In 2007, Kagen joined a bipartisan group of lawmakers to advance stem cell therapy. Kagen voted for legislation to extend funding for stem cell research and institute strict ethical guidelines for stem cell work conducted under the National Insti¬tutes of Health.


    In testimony for the bill on the House floor, he referred to himself as “Pro-Cure”—stating the efforts may assist in advancing treatment for Alzheimer’s disease, juvenile diabetes, spinal cord injuries and other conditions.


    “Saying no to stem cell progress would be unkind to patients who will benefit from new treatments and potential cures,” he told fellow lawmakers. “If one truly cares for life, then one should say yes to stem cell progress. Be not afraid to take this step forward.”


    Kagen has voted for bills to bring American troops home from Iraq, improve the economy and protect the environment. The legislation that may have had the most significant impact in his term was the Gas Price Relief for Consumers Act of 2008. The House approved Kagen’s act 324-84 in May. The bill allows the United States to sue any foreign country that limits oil production or engages in price fixing to affect competition.


    For Kagen to continue to present his ideas for health care reform and other issues, he must first win re-election.


    Supporters say the process will be bruising. His district has historically been conservative. The congressional seat was originally vacated in 2006 when Republican lawmaker Mark Green, after four terms, decided to run for governor. (Green lost to Democrat incumbent Jim Doyle.)


    This election will feature a rematch between Kagen and his nemesis John Gard, whom he narrowly beat in 2006 to win the House seat. Gard, a Republican, served in the state assembly from 1987 to 2007, the last four years as assembly speaker. Kagen defeated Gard 51 percent to 49 percent, a margin of merely 6,000 votes.


    Neither Kagen’s nor Gard’s offices would comment on the coming election for this story, but the race between the two is most likely to be as tight as it was the first time around, said Jeremy Levin, the Wisconsin Medical Society’s government relations specialist.


    “It will be an interesting fall for sure.”
    ~~~~Steve Woo is associate editor of The New Physician.~Advocacy,Career Development,Health Policy,Legislative Action~
    457~7October~2008-57~Well-being~Differential Diagnosis~For family, setting aside the clinical mask~Yasmin Ahmedi~Being the daughter~As a third-year, I explained the following: The patient is 80 years old with chronic medical problems. He presented with mental confusion and a new onset tonic-clonic seizure three days ago. He was brought to the ER where he was given anti-seizure medication. An EKG and cardiac labs showed that he had a heart attack. He was stabilized in the ER and transferred to the ICU where he continued to have seizures and mental confusion. The working diagnoses for his altered mental status are CNS infection, new onset seizures or secondary to medication. Workup includes an MRI/MRA. Current therapy includes antiviral, anti-seizure and antipsychotic medications. His heart condition is stable.


    I looked up to a crowd of blank faces. One of the faces looked puzzled. “But, is he OK?” they wondered out loud. I’d given my presentation not to a group of attendings, residents and interns, but to my family. I had no idea what else to say or do.


    When I got the call from the ER that my father was in the hospital, I went into medical student mode. I put together a differential diagnosis in my head of new onset seizures in the elderly and reported this to the ER physician. “But, what is his story?” the doctor asked. He wanted to know about my dad’s life, medical problems and environment. When I met the admitting internist, he looked at me and said, “You must be the medical student.” I shrugged off the question and asked him for a report. I wanted to know labs, tests and medications. I asked to look at the chart.


    The physician left me staring intently at my father’s hospital records. I noticed they had done an LP and started antibiotics, and I needed to make sure that they did this in the proper sequence. Did they think of meningitis? Did they check for TB? I sat down and started to expand my differential diagnosis.


    When I finally went in to see my father, the first thing I did was look at his vital signs, IV drips and Foley catheter. I called the nurse immediately to ask what my dad’s blood sugar was running due to his diabetes. I wanted to make sure that he had insulin on board. I spent the night watching his telemetry and waiting for an abnormal rhythm so that I could alert the internist.


    In the morning, the neurologist and cardiologist came to see him. They looked like a superhero duo from a comic book, medicine as a daytime cover job. I began my presentation: “He is an 80-year-old with chronic....”


    “But, how is he doing?” they interrupted in unison. I explained that he continued to have altered mental status and was being maintained on antibiotics and antivirals, and was scheduled for an MRI/MRA today. They left without any comment.


    The new internist, a stocky gentleman, entered the room. He smiled. “I heard that you are a medical student.” I took a breath and began my thoughts for the day. I questioned the first MRI that was taken. It may not have been adequate due to my father’s agitation during the procedure. My thought was that it should be repeated.


    The internist stopped his exam and looked at me with wide eyes. He lowered his head for what seemed like minutes. I thought he was contemplating my idea for repeating the MRI when, suddenly, his eyes met mine and he started laughing. “Be the daughter,” he said, with a subtle intensity in his voice. He pivoted and left the room. I followed after him, half wanting to continue my questions and half wanting to run away from the hospital.


    I thought better of both and returned to my father’s room. Walking to the side of the bed, I noticed his disheveled hair and the flecks of dried blood on his chest. Deep, dark bruises covered his face. He was awkwardly twisted in the hospital bed with one pillow barely holding up his head. He looked sick. I knelt down and just looked at him. Then, for the first time, I took his hand. I swear that he opened his eyes as soon as I did so. I believe that he saw me before he went back to sleep. Maybe he was comforted that I was by his side. I held his hand for hours.


    Later, a nurse tried to wake him, as if to make sure my father was still alive. He looked at the nurse and instinctively extended his arm in one quick motion. “I’m not here to draw blood or anything,” she reported. My father shrugged his shoulders and winked to nobody in particular. If he could have spoken, his body language would have translated to “Nurses and doctors usually only come in when they want something. So if you don’t want anything, then please leave me alone.” My father’s condescending gesture was comforting to me. Underneath all of the confusion, my dad was still there. When my family walked into the room, they asked me how my father was doing. I held my dad’s hand a little tighter and said softly, “He is better.” Turning around, I caught the expressions on their faces: They, too, looked comforted.


    If I could do it all again, I would walk straight into my father’s hospital room and hold his hand. I realize now that the advice of that wise internist was the most important. My father was in the care of very skilled physicians; he did not need a medical student during this time. What he needed was a daughter.


    About a week after his initial presentation, my father was transferred to a rehabilitation facility. I visited him there in the afternoons after mornings at his apartment, getting it ready for his return. My sisters and I were trying to make his place perfect with new pictures and decorations. I anticipated his return home to be quite fast. In fact, he improved greatly over the next three days. He started walking and even engaged in a few of the facility’s social activities. Visits from friends and loved ones occupied his time, and he wanted me to comb his hair as he sat in bed to receive guests.


    Now that he was getting better, we could laugh at the stories that resulted from his confusion while in the ICU, like when he thought his commode was a wheelchair and asked the nurse when the ride would begin. Everyone laughed and my father remarked, “This seizure thing is bad; it is so hard to recover from. It just throws you off of your feet.” I was upset by his comment. Didn’t he realize how lucky he was that it was just a seizure and that he was recovering? What if he had a brain tumor?


    Although it was difficult, I tried to remain more of a daughter than a medical student. I still asked about his meds and tests daily, but I stayed out of decisions regarding the medications chosen and tests ordered. My father had his doctors. This role lasted until my dad took a turn in his rehabilitation. He started getting weaker, had acquired an infection, and stayed in bed for about two days. One afternoon, he didn’t appear to be his normal self. I asked him if he knew my name, which he answered correctly, but strangely. It was hard to tell if he was being sarcastic, so I asked him if he knew where he was. When he told me he was in Santa Fe, far from our hometown of Seattle, I ran outside and called for the paramedics.


    The next day, my sister and I transferred him to the hospital. I spoke with the internist, as well as a nephrologist, who explained that my father’s kidney labs were poor. He had suffered from chronic renal failure for years and had managed to avoid dialysis until now. The nephrologist wanted to wait another 48 hours to see if treating my father’s infection and dehydration would help improve his kidney status. I felt positive that the nephrologist didn’t feel the immediate need for dialysis. “All you have to do is get your kidneys to work, and I can take you home,” I told my dad.


    Many of our family members visited with my father. Always the socialite, he loved the company. But it was obvious that he was tired and even having some trouble breathing, so the nurse politely sent us all out. I watched my father bid goodbye to my sister as I stood by the door, ushering her out as quickly as I could. I wanted to get home so badly that it was the first time I did not even say goodbye to my dad. I knew that I had a lot to do the next day, from checking his kidney labs to following up on his heart status, so I asked another of my four sisters to tell him good night and that I would see him early in the morning.


    My father passed away that night. They said that I was with him for four hours after he died. I don’t remember any of it. All I remember are the days that followed, as I tried to come up with a reason for why he left me. Was it rehab facility neglect, medical error or God’s will? This was a differential diagnosis out of my realm.


    There was no great epiphany, only the hopelessness of a daughter wishing that she could do anything to get her father back. Was there anything I could have done, either as a daughter or as a medical student? If only I had looked at every lab, spoken to every doctor. I will always have the guilt of feeling like I could have saved my dad. I miss him more than anything in the world. We each get one person in the world who truly understands our heart and soul. He was my one person: a wise, intelligent, pure-hearted, glorious man. My father. May God grant him peace and eternal health.
    ~~~~Yasmin Ahmedi is a fourth-year at the University of Washington School of Medicine.
    Direct comments about this topic or your own experiences to tnp@amsa.org.~Creative Expressions,Humanistic Medicine,Physician Patient Relationship,Student Life and Well-Being~
    462~8November~2008-57~Perspectives~Care, Not Coverage~The physician’s role in cost containment~Cain McClary and Gus Crothers~Technology, cost and the physician~
    pullquote (w/ art): Every political effort to extend health insurance coverage has been stymied by rising costs. Physicians are caught in the middle of this push and pull, and have seen their vocation change drastically in a short period of time.



    The current abundance of political discussion concerned with finding coverage for America’s 40 million uninsured may be energy misspent. Politicians’ plans for extending health coverage to the uninsured are as varied as they are numerous, but each ignores one fundamental point: Coverage does not equal care. Already, many insured Americans find themselves unable to keep up with rising medical bills. With current insurance industry trends, “affordable coverage” is only affordable for those who stay away from the doctor. Who is to blame? Insurance companies for offering an incomplete product to the public? Employers and families for purchasing that same product when they know that its coverage is inadequate? Politicians for encouraging more or less government regulation? Clearly, playing the blame game with an issue this complex is unsuccessful.


    The common obstacle shared by all parties involved in health care is the insurmountable cost of medical care itself. Costs range from the bandage for a laceration to the latest expensive fad, such as personalized genome sequencing. The many dysfunctions of America’s health care system are symptoms of an underlying disease: uncontrolled costs. It’s time we shift the focus of our treatment.


    Although Washington, D.C., has been widely unsuccessful in its attempts to contain health care costs, there is another avenue for change: physicians. As the point-of-care decision makers, physicians are in a unique position to contribute to health care cost control in the United States. In fact, some could argue that they are the only ones who are in any position at all.


    It is not recognized widely enough that rising medical costs have caused the erosion of the current American health insurance model. Seemingly unreasonable insurance premiums are understandable when one considers the swiftly rising price of health care in America. This price increase has rapidly outpaced growth of our gross domestic product and wages, according to Department of Labor statistics and health spending projections by researcher J.A. Poisal and others.


    Faced with these price hikes, employers opt for cheaper plans that shift the burden of cost to individuals. America has seen a directly correlated rise in popularity of health savings accounts (HSAs) and catastrophic coverage models of insurance. Such plans are detrimental to the health of individuals and the insurance market alike. For individuals, stingy coverage encourages insured individuals to adopt the same unhealthy behavior as the uninsured: namely, avoiding inconveniently expensive routine medical care until problems become more serious and, as research has shown, more expensive. For the insurance market, this only adds to the crippling cost-of-care burden while reducing the shared-risk pool because of the low up-front premium costs of “affordable coverage plans” and HSAs. The cyclical nature of this problem is obvious.


    Unfortunately, political plans, both Democratic and Republican alike, aim to add to the cycle by increasing the popularity of bare-bones coverage without addressing the underlying problem of uncontrolled cost. In effect, they are looking to unrealistically increase the demand without addressing the expense-limited supply. Cost control must become a real priority.


    In the exam room, physicians have the power to include economics in their consideration and presentation of treatment options to their patients. Tra¬ditionally, the existence of a third-party payer allowed both physicians and their patients to ignore these considerations, but times have changed. It is time for physicians to realize that the economics of health care is no longer an inconvenient thorn in the side of an otherwise desirable profession, but rather a major piece of the health care puzzle that is as important to patient health as the traditional practice of medicine.


    Admittedly, physicians are not trained economists, and the examining room is no place for physicians to play penny pincher. Rather than putting an additional burden on precious examining room time, we should encourage physicians to take an active role outside of the examining room in shaping the medical landscape as it changes around them. Every year hundreds of new technologies enter the realm of U.S. health care, and this trend plays a significant role in the rise of medical spending.


    U.S. medicine thrives on innovation, and there is tremendous public pressure on physicians to practice the newest, most advanced techniques. Unfortunately, the costs associated with developing and using these techniques is choking off the public’s access to health care, bringing into question the continued arrival and adoption of these technologies to the marketplace. Tech¬nology assessment is a field of paramount importance to public health, but physicians widely ignore it. The average physician might argue that she does not have the economic tools necessary for thorough technology assessment, and to a certain extent this is true.


    Nevertheless, physicians’ knowledge of the disease process and familiarity with the benefits and shortcomings, both medical and economic, of current medical technologies makes their input on any new medical technology invaluable. Genetic medicine, for example, is a growing area in need of physician analysis. Its promises for the future of medicine are extravagant and exciting, but are its benefits realistic and cost-effective?


    The life science industry is spending hundreds of millions of dollars trying to develop and popularize technology for rapid, personal genome sequencing in the hopes of making this technology commonplace in medical practice, according to an interview, published in Science, with Francis Collins, former director of the National Human Genome Research Institute.


    While the utility of this technology in detecting certain rare genetic disorders is unassailable, physicians must seriously consider the implications of its widespread use. Ethically, personalized genome sequencing threatens to strip away much of the profound element of what it is to be human, while economically, genome sequencing promises the introduction of an expensive new technology into the health care marketplace without the promise of improved health outcomes.


    Obviously, there are hundreds of diseases with directly traceable genetic etiologies, and for many of these conditions, genetic screening at birth is already commonplace. Why attempt to popularize genetic sequencing for adults when the window for most genetic diseases to appear has already passed? Regrettably, genetic screening can add little to the health outcome. Despite 30 years of trials, there have been few breakthroughs in gene therapy of any utility. With the current trends in health care costs, physicians must advocate against spending valuable health care dollars on expensive diagnostic screening techniques that do not contribute to their ability to treat the diagnosed patient.


    Proponents of individual genetic screening argue that its utility is not in diagnosing specific rare diseases but, instead, in uncovering predispositions to more common conditions like hypertension, heart disease and diabetes. But another diagnostic screening technique already accomplishes the same goal at much lesser cost: a detailed history and exam. Though a patient’s knowledge of a genetic predilection might ease the counseling of a healthier lifestyle, this counseling should be given to all, not just those who can afford the latest and most expensive diagnostic screen.


    Modern medicine already knows the cure for America’s deadliest diseases: preventive medicine and lifestyle counseling one cigarette, one Big Mac and one TV episode at a time. Often, irresponsible lifestyle choices are at the core of a disease process, and modern culture tends to minimize the patient’s individual responsibility.


    An unfortunate corollary of this cultural phenomenon is the commonplace misconception that modern medicine can provide convenient cures whenever problems arise, thereby freeing the public from the inconveniences of a healthy preventive lifestyle. Physi¬cians are quite familiar with this problem and should know that popularizing new, expensive medical technologies only adds to it.


    Personalized genome sequencing also raises ethical issues. Widespread genetic screening threatens to corner individuals into a predestined death. Accurate predictions of a patient’s lifetime disease profile may seem attractive to some, but to others it threatens to remove some of the enigmatic uncertainties in life that make us human. Personalized genetic profiles would only give insurance companies more information with which to raise rates and deny coverage. Despite the genetic anti-discrimination bill just signed into law—woven with loopholes—commonplace genetic sequencing still threatens to make health care a privilege for not merely the rich, but also the genetically blessed.


    Although genetic sequencing pro¬mises outstanding returns on some fronts, it does not take a degree in economics to see that the widespread application of this technology in the current health care landscape would create more problems than it would fix.


    Every political effort to extend health insurance coverage has been stymied by rising costs. Physicians are caught in the middle of this push and pull, and have seen their vocation change drastically in a short period of time. Rather than waiting in the examining room for their analysis, however, physicians must influence the direction of new technology development in order to prevent inappropriate technologies from becoming commonplace and worsening the cost of care. We must conduct just this sort of analysis on a regular basis and use our unique and powerful position in the health care industry to improve the health of our patients, careers and the country as a whole.
    ~~~~Cain McClary and Gus Crothers are medical students at Tulane University and Tufts University, respectively.~Health Policy,Learning Tools and Technology,Physician Patient Relationship,Practice of Medicine~
    463~8November~2008-57~On the Wards~A Handshake~Reaching a patient from the sidelines~Joseph Freeman~Reaching out from the corner~The unspoken agreement: If I took the jobs no one wanted, I was allowed to watch the trauma team perform.


    So I emptied towel bins saturated with vomit and congealed blood. I took gurneys to the decontamination room and hosed off the previous occupant’s fluid. I counted rolls of gauze, stacked alcohol swabs in short piles and ran vials to the lab.


    But I never let those tasks occupy too much of my attention, always listening for the scratchy voice of the central dispatcher alerting the department to an imminent arrival. I watched for the extra shuffle in the attending’s steps, the disguised hint of panic in the residents as they followed in tow. These were the clues alerting me that the battle of someone’s life was about to begin.


    After the subtle signals, I scurried to place myself in position: hidden in the corner and out of the way. I looked on at the mass of people as they entered the room. They communicated only with a smile or simple head nod. A subtle quiet would slowly rise above the raucous white noise of the emergency department (ED). I would hear the approaching helicopter outside.


    The scene was the same, night after night: the doors bursting open, a gurney with some unknown person lying on it shoved into the room, accompanied by flight nurses wearing blue and gray jumpers. They would yell the vitals, the procedures they already performed, drugs they already pushed. The medical personnel would spill onto the floor, each pursuing an individual purpose. And I would stretch to see over their shoulders from the safety of my corner, involuntarily clench my jaw, and watch.


    One night, the doors failed to swing open with their regular crispness. “Pedestrian versus car,” the resident called out to the room. “Full impact. Approximately 50 miles per hour. Male. John Doe.”


    The team swarmed John Doe so quickly, all I saw were his erratic flailing arms through fleeting gaps between personnel surrounding his gurney. Cloth restraints were tied onto his violently convulsing body that was now streaked with drying blood. The attending charged with starting the IV in John Doe’s left arm called for help. Two sturdy male ED nurses joined his side, one straining to pin the patient’s left forearm against the bed, the other fighting to contain the upper arm. As the attending and nurses struggled, I watched from my corner. Gasps of air traveled past John Doe’s fatigued vocal cords, producing a squeal that could no longer express his pain.


    I saw his left hand pumping and squeezing at emptiness. His right hand was pumping and squeezing like his left, but not at emptiness. It was reaching for something. My eyes watched the movement in shock. Without warning, my body lurched forward and extended my own hand through the crowd. John Doe grasped my hand so tight that I froze in place. My objectivity was instantly stripped away. I was no longer shielded from the helplessness of watching this human being suffering in terrible pain, and the room blurred into the background as my only focus became his grip.


    The shock of my actions did not register until the two residents on either side of me slowly stepped back. Disbelief showed on their faces as I followed their eyes from me to the attending. “Whatever you did,” the attending said, “don’t stop.” Numb, I followed the attending’s gaze down before I realized that John Doe’s body had stopped its violent convulsions.


    It was then that I looked up to his face. I saw a boy who could not have been older than 12, clenching his entire body in an unspeakable pain. His agony shut out the world, except for the single remaining connection we had formed. I hope I never feel the desperate energy that was in that handshake again. As IV sedatives and diuretics were infused to relieve the building pressure in his brain, John Doe’s grip began to lighten.


    His story unfolded over the next half hour: A paramedic brought in his shoes, found within a few feet of where he was hit by the car; 25 feet from the blood stains where his body made first contact with the concrete. John Doe’s grip lightened more. A police officer from the scene informed us it was a hit-and-run just outside of downtown. None of the witnesses knew who John Doe was. No one could identify the driver. The social worker informed everyone in the room that with no identification or documents, it would be nearly impossible for us to find his parents. John Doe’s grip let go as I felt his identity slip away.


    The room had long since cleared when the attending came up to me and touched my shoulder, letting me know it was all right to release John Doe’s hand. I gently placed his hand across his chest in a room that had become filled with an echoing silence.


    I drove home that night with the music turned down to an inaudible level. I went outside and sat in a chair. Wrapped in a blanket, I watched the sun climb above the horizon and touch the grass beneath my feet before I went inside and fell asleep.


    John Doe never regained consciousness and passed away three days later. The team was unable to locate his parents before his death. A year later, while driving down the highway, a tear unexpectedly ran down my cheek. I pulled off the road as tears flooded my face over the injustice of life.
    ~~~~Joseph Freeman is a fourth-year at the University of Washington School of Medicine.
    Have an experience of your own to share? Send it to tnp@amsa.org.~Creative Expressions,Humanistic Medicine,Physician Patient Relationship~
    464~8November~2008-57~Reviews~An Intern in Full~A postgraduate memoir rings true~Monya De, M.D.~A memoir for us~The title of Dr. Sandeep Jauhar’s doctor’s confessional, Intern, is misleading. The book sprawls across the years from the author’s premed inklings all the way to the beginning of his fellowship, chronicling an unusually tortured path. The more appropriate title may be “Doubt.” Unlike many other “I-went-to-med-school” tomes, Intern (Farrar, Straus and Giroux, $25) is for us. Jauhar, while he does rhapsodize about the mechanics of the heart and pathology of various diseases for his lay audience, focuses on a taboo topic: not wanting to be a doctor.


    Born to immigrant Indian parents, Jauhar has a charismatic older brother who delights his parents by keeping his nose to the grindstone through medical school and residency. So the pressure to succeed, already guaranteed by the author’s culture, intensifies. He opens his abbreviated autobiography with a portrait of himself as a young intellectual, aimless in eventual goals but fascinated by his estimable graduate studies in physics at University of California-Berkeley. While in school, Jauhar displays some characteristics of a slightly rebellious child; he cavorts with white girls and takes drugs (yes, many Indian parents consider them equally bad). He dreams of forever being a student, pondering problems without actually having to solve them, of beers on Fridays with lab mates, of having just enough money from the government to live on.


    But soon the call to medicine comes, and Jauhar is suddenly wearing a white coat. Part of the impetus is his experience of a white girlfriend’s battle with lupus, but his description of this is surprisingly unemotional. Jauhar wants to get right to the meat of things: med school and residency. After detailing his initial forays into journalism, Jauhar details exhaustively (sometimes exhaustingly) medical student adventures like formulating a differential diagnosis, doing a spinal tap and doing a Mini-Mental Status Exam. Lists abound, such as the list of items he puts in his pockets on his first day of residency. In these moments, we feel Jauhar is holding us at arm’s length, hiding in the details.


    But the protagonist is not infallible. Jauhar is at his strongest when he reveals the most painful moments of residency, those that most of us would soon like to forget. We are naked with him as he mutely stands by during a code—tragically, he is supposed to be the code team leader. We feel the humiliation of being cut down by an attending for misinterpreting a chest X-ray or spilling ascitic fluid all over the floor. He takes a leave of absence. These moments are meant for us, the med students, residents and attendings. He explains some medical terminology but not all, probably leaving lay readers a little confused but telling a story to those “in the club.” But now, we believe Jauhar when he reiterates what is laced all through the book: that his entire medical career was fraught with career doubt.


    While his illustrations of career-related arguments with his conservative Indian parents are memorable, his accounts of his flirtation and eventual marriage to—who else?—a female Indian doctor seem sanitized. Sonia is painted as a sort of adoring, perpetually cheery Tinkerbell to Jauhar’s moody fish out of water. We wish to see more of her reactions to his ever-changing mind, to get a window into the kind of love that can carry a depressed, conflicted resident to hard-won success. That would make this story of redemption even more meaningful for the thousands of residents who walk into the hospital each day with utter dread.
    ~~~~Dr. Monya De is a physician and journalist in Los Angeles.~Medical Education,Student Life and Well-Being~