It’s the lifestyle, stupid!

I was reading a NY Times article discussing the top residency choices for this year’s match (which I think is today – the day when graduating medical students find out where they will be going for the next 3-5 years of their training). The article follows a married couple from Harvard hoping to get into a dermatology residency, which, along with plastic surgery and ENT are easily the most competitive spots to snag.

Call me cynical, but the quotes from the med students about why they chose derm sound more like BS spouted within their personal statements and along the interview trail rather than what’s really motivating them. Consider this gem:

Ms. Singh said she initially planned to emulate her mother, a physician who focuses on treating major adult diseases.

A lecture on skin-pigment conditions like vitiligo changed her mind.

“Nobody can see if you have hypertension or asthma, but everybody knows if you have a pigmentary disorder and these changes are a lot more obvious and devastating to patients with skin of color,” Ms. Singh said.

I’ll tell you what changed her mind – she survived medical school and is probably graduating at the top of her class with multiple research publications. This means she can have her choice of specialty…add onto that the fact that she already has 2 young children – why in the world would she go into general surgery or family practice, when she can work 35-40 hours a week (or less!) and make good money? (let’s not forget she has six-figures worth of student loans to pay off) Unless she absolutely loved some other specialty, she would have to be a little crazy not to consider dermatology. I’m not trying to downplay the importance of dermatologists – appearance is obviously very important in our society even if it isn’t life-threatening, and they definitely treat people with more “serious” conditions like skin cancer. But there is no reason for dermatology to need all of our best and brightest, other than the fact that it is the epitome of a lifestyle specialty.

What I also find amusing, which is not discussed within this article, concerns forthcoming physician shortages. You would think that a specialty as lucrative and competitive as dermatology would see no shortage amongst its ranks – after all, they more or less have their choice of any medical student available and should have no problem keeping up with demand. Yet even dermatologists are facing similar shortages as other areas of medicine. It can take weeks or months to get a referral to a dermatologist. This is not the NHS, where such waits would be expected because of the role of the British government to cap spending – this is the US, with a supposed “free-market” healthcare system. And then you begin to realize (if you haven’t already) that we’re not a free-market health care system. The reason for physician shortages are due in large part to licensing restrictions (the MD monopoly, or “medical cartel” as it’s sometimes affectionately called)…medical schools keep their class-sizes low (though many are finally starting to expand), and lucrative residencies keep their available spaces artificially low. Doctors of those “chosen” specialties like derm get to work as much or as little as they want, and make some serious money. Specialists get their big houses, fancy cars, and afternoons free to play golf, while the regular folks get longer waits and higher prices (which means higher insurance premiums, which inevitably results in more uninsured folks because they can no longer afford to pay the high premiums). See how this all starts to fit together? You should start to ask yourself why physician groups oppose or place restrictions on other non-physician health care providers (“Minute Clinics” with nurse practitioners, chiropractors, optometrists, etc)…are they really only looking out for your best interests, or could it be possible that they are also concerned with their own pocketbooks and lifestyle? Just sayin…

~ Lily

Those drug reps are good! (or…er…bad?)

I shadowed an internal medicine specialist last week, and as I was trailing behind him like a lost puppy (ah…the joys of being a clueless medical student) someone who appeared to be his buddy joined us as we reviewed charts and examined some imaging studies that had been ordered. The doctor and his buddy (who I presumed to be another doctor given that he was wearing a pair of blue scrubs) talked about their plans for the weekend, what topics should be presented at an upcoming conference, and then started discussing the pros/cons of various procedures and new techniques that might be helpful.

It was at this point that I got a closer look at the “buddy”, and noticed something inscribed on his scrubs that was neither his name nor the name of the hospital…it was the name of a drug company! Eek! I had been fooled! He was handsome, charming, and seemed to know the medical lingo (perhaps his good looks and perfect hair should have been the first clue?). He followed this doc around for a good 3 hours (maybe even more since I had to leave), including being present for a procedure on a patient, which seemed entirely unnecessary given that there was no “product” being used on this particular person. Drug reps definitely know which doctors respond to their attention, so the doc I was shadowing must have been a huge fan of their products.

It was weird to see the close relationship the two had, but did the patients know the physician was getting followed around all day like that? That he was getting paid to speak at conferences on behalf of this company? I don’t have a problem with drug reps per se…I understand products need to be marketed and sold, and I’m all in favor of competition…but if you publish a paper in a journal, you have to disclose all of your financial ties to show any potential bias you might have. Shouldn’t you do the same for your patients?

I’ve set a goal for myself for next year (my 3rd year of medical school, when I start rotations in the different specialties) – I’m going to see how long I can last without taking a single thing from a drug rep. No pens, no free lunches, no little gadgets…nothing. It’s mostly because I want to force myself to be aware of all the different ways the drug companies woo doctors/nurses/students…and because I like a good challenge. If I last a week, I’ll be proud…if I last a month, I’ll be amazed (free food is really hard to pass up when you’re poor and in a hurry). I’ll try and update the blog with all of the cool stuff I’m passing up, as well as how long it takes before I succumb to peer pressure. It’ll be fun! 😉

~ Lily

In the Foxhole

The Washington Post reports:

A soldier claimed Wednesday that his promotion was blocked because he had claimed in a lawsuit that the Army was violating his right to be an atheist.

I’m sure you’re all shocked. I found my own thoughts being expressed eloquently by one of the plaintiff’s supporters:

Mikey Weinstein, president and founder of the religious freedom foundation, said the lawsuit would show the “almost incomprehensible national security risks to America” posed by the military’s pattern of violating the religious freedom of those in uniform.

“It is beyond despicable, indeed wholly unlawful, that the United States Army is actively attempting to destroy the professional career of one of its decorated young fighting soldiers, with two completed combat tours in Iraq, simply because he had the rare courage to stand up for his constitutional rights,” Weinstein said in a statement.

How can we be opposing religious fascism in Iraq and the Middle East when our military is actively promoting it here?

~Fox

 

Thoughts on the John Ritter case

I was perusing my blog feed this morning and came across a CNN article discussing the wrongful-death lawsuit against doctors who treated the actor John Ritter. Ritter was treated for a heart attack, when in fact he was actually suffering from a “torn aorta” as the article puts it, which in more technical terms is an “aortic dissection.”

It’s tragic that he (or anyone for that matter) has to die at such a relatively young age – 54 is much to early to go. But for me the significance of the case is to serve as a great reminder of how non-scientific medicine can be. Don’t get me wrong – there’s a lot of science to medicine, and a lot of treatments are prescribed because of solid evidence and many years of research comparing different treatments with outcomes. You’d think by now we’d be experts at treating someone who comes to the emergency room complaining of “chest pain”, until you realize how many different problems can present themselves under that single descriptive term. We’re taught in medicine to come up with a list of possible diseases each time a patient complains of a certain ailment – we call this the “differential diagnosis” and it includes both what we think is likely to have occurred as well as a list of long-shots. For instance, if someone came to the hospital with “chest pain” a doctor would consider serious problems such as heart attack, pulmonary embolism (blood clot to the lung), aortic dissection (torn aorta), pneumothorax (collapsed lung), and cardiac tamponade (blood around the heart that limits its pumping ability)…but would also consider benign problems such as indigestion, esophageal spasm, etc. They then go through their list and try to target their questions to rule in/out the various conditions, focusing on the more serious ones first since those pose the most immediate threat. In the case of John Ritter, his family history of heart problems may have come into play. Medications, alcohol/tobacco use, or previous medical ailments might also influence which diagnosis you lean towards.

I should add at this point that I’m not a doctor, let alone a cardiologist – I’m a medical student with a very introductory understanding of how this process works. Most emergency room doctors would have probably considered the various problems listed above, taken a detailed history of the patient, and then decide which course to pursue. If they suspected a heart problem, they would probably obtain a chest x-ray as well as an EKG to look for electrical abnormalities that might indicate a heart attack (and call the cardiologist to come down and examine the patient). But this is where it starts to get tricky – an EKG is a great tool, but will not always show electrical changes even if someone has had a heart attack or is on the verge of a heart attack. Thus if the patient’s history strongly suggests heart attack but is not confirmed by an EKG, the doctor might still treat as if it were so. I have no idea what happened in the case of John Ritter, but perhaps that is one possibility of what took place. The classic presentation of aortic dissection is sudden onset chest pain that migrates…if Ritter’s pain wasn’t radiating (or if the doctor didn’t ask whether it was radiating) that diagnosis might be missed – that doctor would not have ordered a CT scan to look for tearing of the aortic wall, and might go on to treat as if the patient had something else.

Even if it is caught, aortic dissection is a terrible diagnosis with a very high death rate – surgery is required to immediately fix the tear before it occludes blood flow to vital organs and causes permanent damage/death.

In summary, I’m not writing this post to make excuses for the doctors involved in the case – I have no idea as to the specifics involved and what was or wasn’t considered. I’m merely trying to provide insight into how this whole medical process works, since most people outside the system are entirely clueless. Medicine is a wonderful tool with the potential to have huge impacts on our health and quality of life…but it is a mix of science and art, with the two frequently so intertwined that it may be difficult to distinguish where one stops and the next begins. Fancy tests only tell you so much, and are generally meaningless without a thorough history of the patient (I wonder how much money we could save by simply providing more time for talking with the patient, which may then allow us to avoid having to use the fancy high-tech toys at our disposal). Regardless of whether John Ritter’s death was the result of a medical mistake or an inevitable outcome, it’s tragic that he had to die at a young age. Hopefully medicine will evolve to provide more accurate distinctions between the various types of “chest pain” so that such tragedies may be avoided in the future.

~Lily

CNN article

Perfect vs. Good – Round 1

The Baltimore Sun reports today that Vermont is considering lowering the legal drinking age in the state.  This is a good idea.  A better idea would be to eliminate drinking age requirements entirely, but I am a firm believer that we usually ought not let the perfect stand in the way of the good, so I would gladly support such a measure.

Of course, since it’s been brought up, it seems worth it to ask how we got in the present situation, with uniform nationwide drinking age laws, in the first place.  The Constitution does not grant the federal government the authority to legislate on such matters.  We once recognized this which is why the original proponents of nationwide alcohol restrictions had to pass an amendment to see their plans implemented.  Of course, we all know how poorly prohibition turned out then, and that the amendment was itself amended and revoked in short order.  So what happened next?  Well, in 1984 congress passed the National Minimum Drinking Age Act which extorted state compliance with the threat of withholding federal transportation funds.  Somehow the Supreme Court found that the legislature could require indirectly what they once could not demand explicitly.   It truly boggles the mind.

My favorite quote from the Sun piece came from John McCardell, the former college president leading the movement to lower the drinking age, “If Congress would grant a waiver, the states would be willing to try something, and at least then we could get some evidence and see whether things are better or worse.”  What a sad commentary on our present condition that states must petition the federal government for permission to participate in federalism.

~Fox