Money (that’s what they want)

I’ve rounded the corner of my third year of medical school, where students have to start thinking about their future since we will begin applying for residency this summer/fall.  3rd year is a chance to try out a lot of the specialties, and hopefully find your niche.  You decide what you like or dislike about each area (internal medicine, surgery, pediatrics, neurology, etc) and decide how that fits into your needs or desires.

Some students are lucky – they knew, for example, that they wanted to be a neurologist right from the beginning of med school, they were fortunate to love it during their 3rd year rotation, and can now focus on arranging their 4th year electives to reflect this choice.  Maybe they weren’t sure what they wanted to do, but they loved pediatrics and can’t imagine doing anything else.

Other students thought they knew what they wanted to do, rotated in the specialty and hated it, and are now completely clueless and a bit panicked as to how they will approach their last year of medical school. (a lot of my future-surgeon friends seem to fall into this category)

Then there are students such as the one currently rotating with me on pediatrics.  Read the rest of this entry »

Advertisements

When you wish patients would die

I haven’t blogged in quite a while, and my husband was harassing me to post something new.  I’m currently in my third year of medical school rotating through various specialties in the hospital.  It’s not that I’m too busy to blog (though I’m quite busy between hospital scut work and studying), it’s just that this year feels like such a whirlwind of emotions sometimes that it’s hard to put them out into the blogosphere without feeling a little exposed.  But maybe those are the types of topics that make for the most interesting read.  So I give you a topic that reflects what was going through my mind a few days ago: when you wish patients would die.

Try not to read too much into that – I don’t want to harm or kill my patients.  But sometimes you see people who have been suffering for so long, that you wish for an end to their suffering.  Unfortunately for some people, the only end that would provide this is death.

Read the rest of this entry »

More than one problem? Make another appointment

So I’m currently rotating through an outpatient medical clinic, and despite all the hand-holding, kumbaya-ing, and “the patient is a person” mentality, beneath the surface an insidious beast lurks. This “beast” is the closely held belief that the patient is only allowed one complaint for each scheduled appointment. You made your appointment to get your blood-pressure meds refilled but you also have seasonal allergy concerns? Too bad, make another appointment so we can discuss the issue on a separate occasion.

Just recently I was (politely) scolded by my resident because I presented a 7-week-old baby whose mother had 3 concerns – the child had been throwing up his milk at each feeding for the past few weeks, he had a rash across his entire body for the same amount of time, and she was concerned that he might also have an umbilical hernia. “Try to keep them to one complaint” my resident told me. But the rash and difficulty feeding were likely related (milk-allergy), and the hernia concern arose because she was a new mother and didn’t realize kids usually outgrow those things – it took 2 seconds to say “oh, that’s normal and he’ll probably outgrow it. don’t worry.”

I have difficultly understanding where this idea, that we can only allow the patient one problem per visit, comes from. I understand that the appointments are booked closely together, generally with 15-20 minutes per patient (which includes the time it takes to fill out any necessary paperwork), but have these doctors lost their minds? Do they not realize that people who come into their clinics must take off work to get there, rearrange child-care schedules, etc? Even if they are retired or stay at home to take care of their children, they still have lives and would prefer not to spend most of it at the doctors office waiting in boring stimulus-free rooms.

I have to believe that if we actually had a free-market health care system many of these problems wouldn’t exist. Our society is accustomed to getting it all done at once – this is why stores such as WalMart or Target have achieved their level of success – you can get your grocery shopping done and stock up on anything else you need in one trip. People expect the same thing from their doctors, and I’m siding with the patients on this one. There is no reason why our system couldn’t adjust to accommodate the person who has a couple different medical problems going on. A more market-based approach would simply charge a bit more for the larger amount of doctor’s time the visit uses. As it sits right now the system is too rigid to adjust to these demands – everything must fit neatly into a 4-5 digit “code” for what the visit accomplished, and the doctor is paid according to that code. I understand doctors don’t like it when a visit they thought would take 15 minutes all of a sudden takes 45 because the patient has a lot of issues to bring up, but if you took your car to the mechanic to get the oil changed and they found a problem with your engine, wouldn’t they offer to fix it on the spot while you waited? Wouldn’t you be pissed if the mechanic told you to make another appointment (which would be at least 2-4 weeks from now) to get your engine fixed, and that in the meantime you would just need to deal with it and keep your fingers crossed while hoping that your car doesn’t break down? I would be pissed. No wonder people don’t like going to the doctor.

~ Lily

3rd year medical student extraordinaire (at least in my mind)

Ethics in medicine – real life experiences

I haven’t been posting very regularly on this blog since starting my third year of medical school because I’ve been a bit busy adjusting to the new routine of seeing patients every day. I must say that although the hours required during the clinical years of med school are worse than the classroom years (overnight calls, long shifts of standing, etc), it is also much more interesting seeing patients every day and applying everything we’ve learned up to this point (hello steep learning curve!). With this intense clinical exposure comes a lot of scrutiny of my future colleagues – I look at each of the doctors I work with and see traits I would like to possess, and also those I do not. While I can say that most of the doctor’s I’ve worked with have been fantastic both with their patients and with their interest in teaching us students, a few have been downright awful and possibly unethical. Here is a sample of the worst that I’ve encountered these past few months:

The first is a doctor that takes no interest in the students and barely listens to what we have to say after we interview her patient and give a report before she examines them. I have to wonder why someone like this doc is working for a teaching hospital if she obviously despises the students. To make matters worse, a few of the students who have worked with her more frequently have commented on how she treats patients differently depending on their race. While I haven’t witnessed this first-hand (I’ve only been with her on a few occasions), I can’t say it would come as much surprise…I understand everyone has personal biases, but when you care for such a diverse patient population as ours it is necessary to work extra hard not to let your biases influence care. I hope I don’t turn out like her.

The second involved a primary care physician who was treating a morbidly obese patient with osteoarthritis of both knees. This patient’s insurance would not cover a particular injection the doctor wanted to give to alleviate the pain/inflammation of her joints, so the doctor was in the process of setting up a situation where she would order the injection for another patient whose insurance would pay for it, but give it to the first patient. I’m pretty sure that counts as some form of insurance fraud, but my guess is a lot of people would look the other way because of the general public perception of the “evil insurance company.” While I certainly sympathized with the pain this patient must be going through with her knees and the impact it has on her quality of life, I couldn’t help but think that if she would lose even a little weight she would feel a lot better all around. Perhaps the insurance company wouldn’t cover the shot because it likely wouldn’t make much difference given the severity of her obesity and arthritis. But what do I know?

The third doctor was a specialist performing an endoscopy-type procedure on a middle-aged woman. If you’re not familiar with how those procedures work, you are basically putting the patient under partial anesthesia so that they are awake but heavily sedated. Most people don’t remember much afterwards, though their eyes are open and they can talk a bit throughout the entire thing. This doc was chatting with his fellow nurses and technicians when politics came up. I was always raised never to bring up “religion and politics” while at work, but I figured since these people worked together for so long they must be comfortable discussing their views. The doctor was a republican, while most of his coworkers in the room were democrats…to be honest I think they were all a bit stupid when it came to understanding federal policy, as none of them sounded very educated on the issues (but I digress…). Of course Barack Obama comes up, to which the doctor makes some remark about how “Obama’s a muslim, and I just don’t think it’s right to have a muslim in office with terrorism being such a issue” etc. I’m probably wording things a bit more eloquently than what came out of this guy’s mouth. I am not an Obama fan for various reasons, but I couldn’t stand by quietly while this doc was spouting lies. I made some comment about how Obama is actually a christian, but how some keep trying to spread the rumor that he is a muslim because they think it will deter people from voting for him. Then the doc starts rambling about muslims, saying what essentially amounts to “muslim = terrorist”. Suddenly he becomes aware of what he’s saying, and he looks down at the patient and asks, “are you a muslim, ma’am?”. This poor woman, in her drugged state shakes her head “yes” and says something unintelligible. The doc’s face loses a bit of color, and then he turns to one of his nurses and asks if she would please administer more of the drug that produces amnesia (so the patient won’t be able to remember the offensive things he said). The nurse looks at him thinking he’s joking, but the doc is entirely serious, so she administers more of the drug. Would the extra dose of this drug harm the patient? Probably not, though it is still plausible that it might have. I guess “first do no harm” goes out the window for this guy when you say something offensive to your patient who is completely incapacitated. It made me really sick to my stomach to witness the entire thing, and I hope I’m never paired with this doctor in the future.

I still think most doctors are good people, and this has been confirmed numerous times for me in the past couple of months as I’ve worked with a variety of different practitioners, but it’s hard to look at them the same way when there are a few rotten apples spoiling the perception. I may not know what kind of doctor I want to be at this point, but I’m starting to get a good idea of what kind I don’t want to be. From your perspective, what are traits that make a doctor good or bad? Any comments are appreciated!

~Lily

Why you should avoid hospitals during the month of July

I haven’t posted in awhile, mostly because I’ve been so busy studying for (and hopefully passing) Step 1 of the US medical licensing exam. But I thought this would be a good time to write a post – for one, I have the day and weekend entirely free, and two, I start rotations in the various clinical specialties next week and am not sure how much free time I will actually have at that point.

So, why should you avoid hospitals during the month of July? To avoid run-ins with new interns and 3rd year medical students like me! No, I’m not trying to be self-deprecating…just realistic. Interns started at the beginning of this week – these are students who just graduated medical school and are starting the first year of their residency. Many of them are at new hospitals in a new part of the country, and have not had to assume a whole lot of responsibility up to this point. They’re nervous and still learning the ropes, and it will take time for them to feel comfortable with the situation.

Then there are 3rd year medical students like myself – we’ve had limited patient contact up to this point, but now we are thrust into the hospital and assigned patients to follow as we rotate between specialties like surgery, medicine, pediatrics, etc. We have limited clinical skills, but are expected to hone them as we complete the year (this includes things involving needles and patients – such as inserting IV’s and drawing blood…scary thought). We may not have much say (read: almost none) in what happens to the patients, but since we are new to the hospital we inevitably don’t know much about what’s going on and will slow the well-oiled machine down.

These factors contribute to longer stays and higher rates of mortality during the month of July (http://www.nber.org/papers/w11182). Just another reason to be careful this July 4 holiday.

~ Lily

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

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

Who gets to make end of life decisions?

This is currently being debated by our neighbors to the north, where a situation is unfolding involving the family of an 84 year old man on a ventilator and the hospital/medical staff currently treating him.

Background:

Samuel Golubchuk is an 84 year old Orthodox Jew who suffered brain injury and multi-organ failure, and was at some point admitted to the hospital and hooked up to a ventilator. Many times when we imagine a brain-injured person hooked up to such a machine, we (as a lay person) assume that they can’t breathe on their own – note that this is certainly not always the case, and that mechanical ventilation is often provided to people who are merely having difficulty breathing and need some assistance until they get better. Sometimes people can be removed from ventilators, and sometimes they are so sick that it is one of the only things keeping them alive. Before the advent of mechanical ventilators, death was usually based upon the heart – when your heart stopped beating, you were dead. But now we have so many ways of keeping the body alive, that death (from a medical point of view) is based upon brain function – you are dead when you no longer have meaningful brain activity. It all gets confusing when you add the various terminology including vegetative state, persistent vegetative state, etc where a person’s body appears alive, but clinically/medically they are defined as “dead.” For simplification, it is enough to know that Mr. Golubchuk is not (based on what I’ve read) clinically brain dead – he is merely very sick, and at the age of 84 this is never a good sign. He may not die immediately, but certainly the odds are not in favor of his living for much longer.

Now, enter into this picture the Canadian health system, and the doctors it employs. The hospital treating Mr. Golubchuk, having decided the prognosis is not favorable, wants to remove his ventilator and “hasten his death.” Though not stated directly, we must look at this as a case of resource rationing – the system only has so many ventilators available, and it would be a more efficient use of resources to give the ventilator to someone who has better odds of surviving (e.g. a younger patient).

Enter Mr. Golubchuk’s family – they argue that his condition has been improving, and that he has even regained consciousness. As Orthodox Jews, it is against their religious beliefs to remove the ventilator – plus the patient had signed an advance directive specifically saying that he wants to be kept alive. Says Prof. Shimon Glick, a leading Israeli medical ethics expert:

“From a halachic point of view, removing a feeding tube from a patient who has any brain function is active euthanasia, equivalent to murder… But here, in addition, unless the patient has specifically indicated by advance directive that such is his desire, one has a violation of the patient’s autonomy, as well.”

Alright, so enough background – what do you think should be done in this situation? If you were paying taxes to support such a system, is it fair for your money to be spent on someone who has a small chance of recovery at the expense of other people who might benefit more? If you were in that situation, would it be fair to have your beliefs and specific wishes (as indicated on a legal document) trumped by a physician who has decided the plug should be pulled?

There is no easy answer in this case, given the public funding of the health care system. Many people (in the US at least) seem to think that a national health care system would solve all of our problems, but it really should be seen as a trade-off. Some people gain access into a system that was previously unaffordable, but in the process you lose a (significant) degree of liberty. For me, a libertarian, this is unacceptable. I do not want a doctor, hospital, or government official dictating my health care choices. I don’t want to be “rationed” according to someone else’s belief system. In fact, this quote from Dr. Jeff Blackmer (executive director, office of ethics, for the Canadian Medical Association) scares the bejeezus out of me:

“Our viewpoint is that we want to make sure that clinical decisions are left to physicians and not judges…These decisions are not made lightly and they’re not made in haste, and they’re not made with anything except the best interest of that individual patient at heart.”

The only person who has the patient’s best interests at heart is the patient! And if the patient is incapacitated, as in the case of Mr. Golubchuk, it should defer to his legal wishes or immediate family.  From the standpoint of an American hospital, this situation is baffling. Certainly we have end-of-life issues as well, but rarely of this sort. From the perspective of the Canadian health system, however, the case may be rare but is unlikely to be unique (particularly when you consider our rapidly aging population). How many times each day must difficult decisions be made within such a system as to who gets what test/procedure/equipment, and who doesn’t? I’m not saying the US system is perfect (far from it!), but our way of”rationing” is very different. Americans who favor a single-payer national health system need to think carefully about situations such as these. How much of your individual decision-making abilities are you willing to hand over to a stranger? It will be interesting to see what the Canadian judge decides in this case (I believe it is scheduled for sometime this week).

~Lily

Sources:

Insure Blog – “A troubling conundrum

Jewish Post (1/7/07) – “Canadian judge to rule on Jew facing euthanasia

Retuers (UK – 12/14/07) – “Canadian life-support case pits religion vs. science

Prohibition doesn’t work (health care edition)

Normally when I say prohibition doesn’t work, I’m referring to current drug and alcohol laws which punish people who use responsibly and do nothing to stop the people who abuse or put others at risk. This time, however, I refer to a Missouri law (courtesy of the Baltimore Sun) that makes it illegal for a certified midwife to deliver babies. According to the article:

“A state lawmaker whose wife was aided by a midwife pushed through legislation this year that would allow midwives to practice freely in the state”

In round 1 of midwives vs. the medical establishment, the midwives won – the new law was passed and subsequently signed by current MO Governor Matt Blunt. But the medical establishment, who “argue that home births without physicians are perilous ventures”, couldn’t let it rest and fought to overturn the law. In round 2, the medical establishment won, and the law is currently awaiting its turn in front of the Missouri Supreme Court.

Do you really think the medical establishment (of which I will soon be a member) are arguing against this law because they believe home birth is “perilous”? No – they argue against it (or rather, a lobbying group that claims to represent their views argues against it) because it hurts their pocket books. Every woman who gives birth at home is a woman not paying for a hospital bed, nurse, obstetrician, anesthesiologist, laboratory technician, etc. And, surprise – most of them do just fine giving birth at home. It’s not like women have been giving birth without doctors for 200,000 years…oh wait…they have. I’m not saying there aren’t risks involved when giving birth at home – things can and will go wrong from time to time during labor and delivery. Mom can be hypertensive, baby can be breech or have the umbilical cord wrapped around, blood is lost – these may range from minor to very serious. They occur in the hospital setting as well, though in that setting there is a team in place to respond immediately (something which cannot be said about a home birth). Of course I would also argue that a lot of the procedures done in a hospital setting may put the mother at more risk than a natural birth (anesthesia always carries a risk, and cesarean sections are invasive and thus probably increase the risk of infection or serious bleeding).

Still, pregnant women are adults who can decide risks for themselves. It’s obviously very important to many of these women to give birth at home – not only are they choosing a midwife over a hospital physician, but they are willing to break the law and risk arrest in order to get what they want, and in the process are effectively creating a home-delivery black market. If these “medical establishment” groups really cared about the safety of the women, they would listen to their reasons for choosing a midwife or home-delivery, and they would try and compete:

“Kerr of suburban St. Louis said she had an easy time finding a midwife through friends. She said many women choose home births with midwives to limit hospital pressure to use drugs for pain or to have a Caesarean; to have a more intimate, controlled and personal birth; or because of religious beliefs that keep them away from hospitals. “

Hospitals are noisy and offer little privacy, and there probably is pressure from certain doctors to use drugs for pain even after the woman has made it clear she intends to go without. Bottom line – let the woman decide who she wants to deliver her baby, and in what manner she wants it done. The only time the law should intervene is if someone is masquerading as a health care provider – i.e. a person pretending to be a certified midwife or physician. These women are adults capable of making adult decisions, including evaluating the risks and benefits of each alternative. We should not force our values onto them, even if we strongly believe we are correct; we should not use the force of law to get these women back into hospitals (it hasn’t worked yet, and in fact only succeeded in creating an illegal market for midwives) – instead we should try and create alternatives within the hospital or physician setting in order win back their trust and create an environment where they would enjoy giving birth.

~ Lily

Impending doctor shortage?

Courtesy of Reuters comes an article that discusses the coming retirement and career changes of physicians between the ages of 50 and 65. That group represents about 1/3 of all doctors in this country, and according to a survey conducted a fourth are planning on leaving the profession in the next few years:

Specifically, 14 percent said they were planning on retiring, 7 percent said they were looking for a medical job in a non-patient care setting, and 3 percent said they were seeking a job in a non-medical field.

It’s not really news to see that 14% of older physicians are planning to retire – a lot of people in that age range are nearing their retirement. The survey finding I did find interesting was this:

When asked about the work ethic of physicians entering practice today, 68 percent of the respondents said that these younger doctors are not as dedicated or as hard working as physicians who entered practice 20 to 30 years ago.

Ha! Granted I’m only a medical student and not a physician, but it’s quite funny to me that they don’t think I’m as hard-working as they are. Many people don’t know what it’s like to be in medical school, but it pretty much takes up you’re entire life. We study all the time, and when I say all the time I don’t mean a 40-50 hour week. I mean you wake up, go to class, maybe take a break for lunch, study, take a break for dinner, and study more. Weekends are usually filled with some degree of more studying. We don’t study this much because we want to, but because that’s what it takes to pass exams, and more importantly, prepare to pass the licensing exams (USMLE). I’m not as bad as some of my classmates, but I definitely have a few friends who literally study from 8 am to 10 or 11 pm, and then spend almost their entire weekend in the library. Medical students don’t really go out and party (at least at my school), unless it’s the day after an exam when we get a brief break. It’s just funny to me that older docs don’t think we work as hard, especially given that a lot of the material we have to learn now was not taught when they were in medical school because the medications didn’t exist or the disease mechanism wasn’t well understood. Our professors have to update their lectures every year to reflect all of the advances made in medicine. I will say that I doubt this generational view is specific to physicians – I’d bet that if you surveyed any older professionals about their younger peers, they would say the youngsters don’t work as hard. Another finding of the survey, which was a bit sad to me, is this:

Fifty-seven percent of older physicians said they would not recommend medicine as a career to their own children. Similarly, 44 percent said they would not select medicine as career if they were starting out today.

I understand that sentiment – it’s not that they don’t like treating patients, but is likely due to the fact that the medical field has significantly changed from when they started out. Paperwork is a nightmare, and you really don’t get to spend a lot of time with each patient. Patient’s definitely don’t like this, but neither do a lot of doctors! They want to spend more time with each patient, but if you saw all of the paperwork that must be filled out and all of the phone calls that must be made (regardless of whether it is private insurance or through a government system like the VA), you’d see that a huge chunk of their day is taken up in those less-than-desirable activities. Plus reimbursement is always an issue. Obviously they make a good living, but payment incentives tend to lie more with performing procedures rather than talking with the patient to understand all of the factors that are contributing to their illness.

The major concern, with older physicians leaving the profession, is whether the country will face a doctor shortage. The truth is, who knows? A lot of studies now point to both a doctor and nursing shortage in the near future. But, not too long ago a lot of studies predicted a surplus, to which the industry responded by restricting entry into the profession. The problem with the surplus studies is that they were made based on the assumption that our entire country would be under managed-care by now…a prediction that has since proved false. I think there is a good chance that there will be a doctor/nurse shortage – fortunately some actions are being taken to alleviate this, but unfortunately some are contributing further to the problem. First, the good – many medical and nursing schools are adding positions to their classes, and new schools are opening up. This is great, and in the next 5-10 years we should (hopefully) see a noticeable increase in health care providers. The bad news, is that lobbying groups and regulatory agencies continue to put restrictions in place to limit supply. Mostly this is done to ensure that these groups’ constituents continue to earn high wages (supply vs. demand), though they lobby under the pretense that they’re “ensuring quality” or something to that effect. Consider, for instance, that the medical licensing board has continually raised the minimum passing score. An intelligent person would say it’s great if 97-99% of medical students pass their licensing exam – it means that the schools are preparing them and covering all of the important material, and that the students are really working hard. But this group wants to maintain the pass rate at around 94% – so every time it starts to creep up, they raise the minimum pass score or make the exam harder (I don’t pay $40,000 a year and work my ass off to fail an exam). It’s great to increase the overall quality of the profession, but do those measures actually increase quality in the areas patients most desire? Doubtful – the best way to increase quality in areas that are important is to let the patient decide, not a licensing board or lobbying group. All they manage to accomplish is a further increase in their wages, which makes the medical care they provide expensive and unattainable for a significant portion of our population.

If we’re really serious about health-care – and given all of the attention it gets during election time I’m assuming we are – then we should deregulate some of this stuff. Lessen the licensing requirements and let the market pick quality physicians (they’d probably be less socially-inept bookworm and more warm-caring physician). Remove restrictions that physician-lobbying groups place on other health care providers – let nurses, physician-assistants, optometrists, physical therapists, etc occupy their rightful place in our health-care system. They’re capable of a lot more than we’re allowing, and it’s insulting and stupid to waste all of that talent and manpower (seriously…be skeptical every time you hear these lobbying groups tout “quality” as their motivation to place further restrictions on another group). Not only would this lower prices of care, it would open up the system to people who are currently shut-out. These regulations don’t ensure quality as much as they ensure that an increasingly larger share of people cannot afford the most basic care. That’s tragic, and completely unnecessary…it really doesn’t have to be this way, and there are better solutions to increase access that don’t involve a Hillary Clinton-styled single-payer system.

~ Lily

Walk-in “Quick Clinics” controversial

There’s a good (short) article via Reuters discussing the use of these walk-in clinics, which are usually found at grocery stores or pharmacies. To some people they’re controversial, and perhaps it’s no surprise that one of the groups concerned with the use of the clinics is the American Medical Association. Ah, yes…the AMA.

The article mentions the AMA passing resolution a few months ago “asking state and federal authorities to investigate whether there was a conflict of interest in drug-store chains that both write and fill prescriptions.” Now, I have no problem with investigating conflicts of interest, but it’s a bit ironic that a group such as the AMA is pointing their fingers at walk-in clinics and not themselves. What better example of a potential conflict of interest than a physician who receives undisclosed perks from drug companies and then prescribes those drugs? To be honest, I don’t have strong feelings regarding whether physicians should be allowed to receive food/(small)freebies/etc from drug companies so long as they are honest and disclose these things. I should also take this moment to point out that the AMA doesn’t represent all, or even most physicians – only about 25-30% of physicians are members of the group.

Still, I checked out what their website had to say about these walk-in clinics, and there’s some entertaining stuff (well, actually it’s kind of sad…but I prefer to laugh at the absurdity rather than cry). For example, the AMA says that:

“Store-based health clinics must use standardized medical protocols derived from evidence-based practice guidelines to insure patient safety and quality of care.”

Now, you might not think this is laughable, but it is when one considers that many doctors do not adhere to so called “standardized medical protocols derived from evidence-based practice.” There will always be patients who do not benefit from such standards, because every patient is unique. However most patients do benefit from such standards which is why they are “standards”, but again – why point the finger only at the quick clinics and not also at the physicians they represent? From the AMA website:

“Store-based health clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community.”

Have regular health clinics and hospitals ensured continuity of care yet? Didn’t think so. Again, says the AMA:

“Store-based health clinics must establish appropriate sanitation and hygienic guidelines and facilities to insure the safety of patients.”

This one seems so obvious that it’s a bit silly they feel the need to point it out. Or is it? Maybe not when one considers the research that estimated about 2 million patients a year acquire an infection from their hospital stay, and up to 90,000 will die as a result. Bottom line – I don’t have a problem with the AMA recommendations per se, but it’s a bit like the pot calling the kettle black. To me it comes across as the AMA only looking out for their own interests (and by that I mean the salaries of their members) instead of what is in the best interest of the patient. They’ve also lobbied hard to get these clinics under the supervision of a physician, which defeats the affordable part of the experience. I have no problem with leaving Registered Nurses in charge – I’ve had clinical visits with RN’s on a few occasions, and they are certainly competent to deliver the level of care required by many people visiting these clinics. If they can’t provide the care needed, they refer out to a physician. My guess is that if for some reason a person visiting this clinic didn’t feel like they were receiving appropriate care, they would stop going and instead find another clinical setting where their needs are met. But considering the success these clinics have achieved thus far, they seem to be operating appropriately.

Reuters article on walk-in clinics “Clinics in US retail stores bring controversy

AMA website excerpt

Pharmaceutical companies and the doctors who work for them

Dr. Ed of Abducens Nucleus has posted Part 2 of his series “Sick, Sicker, and Sicko,” this time discussing some of the problems in the British NHS. There’s some good points over there, including how fewer Brits see medicine as a good career choice, hence the country is relying very heavily on foreign graduates (which can be dangerous for the health care of the countries from which they’re borrowing, in addition to their own system which depends on the constant influx of foreigners). Dr. Ed then goes on to discuss medical innovation in the US, and includes the following:

Sicko also fails to mention the name of Dr. Maurice Hilleman, an American whom we should all know about. He invented 8 of the 14 vaccines routinely given to young children that save about 8 million lives per year. His measles, mumps, and rubella (MMR) vaccine protects children against three diseases with a devastating legacy. Ironically, his death came less than one month after the Centers for Disease Control and Prevention announced that rubella had been eliminated as a health threat in the U.S.

Perhaps the reason the public doesn’t hear much about Dr. Hillman is because he spent most of his career at pharmaceutical giant Merck where he was able to convert his research into life saving products that benefit children world-wide. And to acknowledge Dr. Hillman’s achievements would be acknowledging the contributions of his employer to world health.

This brings up an interesting part of the health profession, specifically the general distrust many physicians (and often the public) have for pharmaceutical companies. I frequently hear the argument that drug companies can’t be trusted, because all they care about is making a profit…that they would sacrifice patient safety if it meant a few extra dollars in their pocket. I’m not here to say drug companies are perfect, as there have been heavily publicized incidences where they failed to disclose certain side effects from their products, but to say they would put profit above safety seems a bit far-fetched. It doesn’t take a genius to realize that if they injured or killed all of their customers, they wouldn’t have anyone left to purchase their goods. Or if you prefer to view them as profit-hungry bastards, if they injure a few people the public generally hears about it and the company’s stocks and sales fall…hence it is in their best financial interest to help, not hurt, people.

Dr. Hillman is a perfect example of the public good that comes from these companies, and it’s a shame few know of him. As Dr. Ed says, to acknowledge his achievements would mean you would have to admit that drug companies (and the docs that work for them) actually contribute greatly to our health – something many health professionals hesitate to admit.

Part 2 of “Sick, Sicker, and Sicko”

Doctors + Govt. Database = potential for misuse

Sed quis custodiet ipsos custodes?

But who will watch the watchmen?

The NY Times has an article today about Sen. Charles E. Grassley (R, Iowa) and his proposal to require “drug makers to disclose the payments they make to doctors for services like consulting, lectures and attendance at seminars.” Any doctor who collects payments for Medicaid/Medicare – aka almost all doctors – would be subject to this requirement, and the information would go into a national database.

I have several problems with this proposal, but let me start with what I think is right. I think doctors should disclose the payments they receive from drug companies. I think it’s in the best interest of patients, the consumers, to have this form of transparency in the system. It’s good to know whether your physician is prescribing a particular medicine because he thinks it’s the best, and not because the company who makes the drug paid him a hefty sum last year to speak at their conferences. Of course I also understand that just because the doctor received payments from a drug company doesn’t mean that that drug is bad (it may in fact be the best drug available).

Here is where I have a problem:

1) There is a big difference between “should” and “must.” Doctors should disclose their pharmaceutical ties, but I don’t think they should be forced to. This is a moot point in our current health care system, because patients don’t get the opportunity to really shop around, so to speak, for their care. In an ideal system the patient would have an incentive to choose a physician that meets criteria they consider most important – for one patient it may be the stellar reputation of the doctor, for another it might be the proximity of the clinic, etc. In this system there would likely be consumers that reward physicians (by choosing them to provide services) who disclose their dug company ties. I think some patients want this info, but there would probably be some who could care less.

2) A national database, run by the government, is just screaming potential for misuse. It may start as a mere collection of drug company payments, but what other information would they collect (NSA phone database)? If they don’t like what they see, what types of legislation will they write to regulate pharmaceutical companies, doctors, or health care in general? How safe will that info be? The government, after all, has a bad track record when it comes to protecting the databases they currently run (Veterans Affairs ring a bell?).

Given the government’s poor track record, and the knowledge that there are other ways to get doctors to disclose pharma ties that don’t involve force or coercion, I think this legislation is a terrible idea.

Somewhat related – for a good article about the problems with a national medical-records database, click here.