900

It scares me that I'm 6 months shy of an MD. In 6 months, there will be an expectation that I know something, that in the event of childbirth, a car accident, a natural disaster, I will spring into action and make things right. If a flight attendant asks, I will be expected to stride to the front of the plane with confidence and resuscitate a peanut anaphylaxis or reverse a choking hazard. There will be a responsibility in 6 months that I act not out of self-interest but on the behalf of others, some of whom may be unable to advocate for themselves. In 6 months, my signature will no longer need a co-signature; it will have the force of an "order" and the gravity of a legal document. I will need to know when to ask for help, when to have someone double check my work, things that will not happen automatically. In 6 months, I will be responsible for a medical student in the same place I'm at now. Where will I be in 6 months? Will I be ready?

Conversations

One of the great things about interviewing for residency is the conversations with other applicants and interviewers. Talking to others allows me to gauge a nationwide opinion on medicine in general and anesthesia in particular. Most of my classmates applying into anesthesia are like me, looking to do fellowships, excited about research, interested in academic positions. But talking to those from other schools on the applicant trail introduces me to a wide array of other career goals, equally important and valid. Some are interested in private practice high efficiency anesthesia, others are interested in outpatient pain clinics, yet others are interested in regional techniques for local anesthetic blocks. Some applicants emphasize their leadership skills because of the increasing role of oversight of certified registered nurse anesthetists; others focus on their interest for one-on-one patient contact in high acuity surgeries. The other wonderful thing is getting a sense of where people think medicine and anesthesia are heading. Talking to peers, residents, and faculty from other institutions, geographical areas, and backgrounds is intensely enlightening. How do Kaiser doctors feel about the uninsured? How do county doctors think health care reform will change what they see? How do applicants feel about the programs at their home schools? Where do people think anesthesia will be in 10 years? Interviews, though exhausting, provide great opportunities for fascinating intellectually stimulating conversations.

Hand Film

I think this picture is fantastic. It's a print of one of the first X-rays, taken by Wilhelm Rontgen. The hand belongs to his wife Anna and was taken in 1895 and presented at the Physik Institut, University of Freiburg. Although the image itself might not be all that impressive, I'm astounded that just over a century later, we've transformed this into a critical medical field with rapidly changing technology and greater and greater precision. Image is in the public domain, taken from Wikipedia.

Medicare and Residency

Interestingly, Medicare also pays for residency education. Residents are the poorly paid workhorses that do the day-to-day work in hospitals and clinics. Although governmental subsidy of post-graduate training is not unexpected, the fact that Medicare covers it surprises me. Taxes collected for Medicare pay residency programs to train future generations of physicians. In 2008, 2.7 billion dollars were paid as resident salary and benefits, and 5.7 billion dollars were paid to teaching hospitals for indirect costs. Because funding has remained fairly constant, the number of residents trained is constant. However, we're reaching a point where there aren't enough doctors; patients are getting older, health insurance is expanding, but there simply aren't enough providers to see everyone. Furthermore, we can't increase the supply of doctors because Medicare doesn't have the money to do so. Even if medical schools increase enrollment (which they are), the physician supply will be limited by residency spots which, in turn, is limited by Medicare's budget. This is a strange and perhaps unwieldy system, but it seems to be here to stay.

Medicare and Money

Medicare, which provides health insurance to Americans 65 and older, will face a financial crisis. In the 2008 report to Congress, the Board of Trustees estimated that the program's hospital insurance trust fund could run out of money by 2017. This is a problem. Despite the health care legislation being discussed right now, it's not clear that government health insurance can remain solvent in the near future. Any new health care bill must account for long-term planning. Where is our money going to come from? How can we keep costs down? Can we guarantee that this major health care overhaul will remain stable in the future?

I feel that a solution to health care must encompass wide-reaching policies in different fields. For example, to keep Americans healthier and control costs, we need to target chronic diseases that are rising in prevalence like diabetes and obesity. To make headway on problems like that, we need to step out of the health care box and push for policies in other arenas. For example, how much does the government subsidize commodity food products like corn? Food companies have a huge incentive to produce corn products including high fructose corn syrup because the infrastructure and government favors this. But high fructose corn syrup products, fast food, soda, indestructible sugar-laden foods are all responsible for driving up our health care costs and increasing the prevalence of obesity and diabetes in children. If government is to take a stance on health care costs and if we are leaning towards a role of bigger government influence, then it needs to subsidize fruits and vegetables, not candy and chips. We need to favor local small markets rather than multinational corporations.

In the same way, we need to figure out how to prevent people from starting to smoke; prevention is a lot easier than intervention, and cheaper. There is a fair amount of research and a number of medications that help people quit tobacco, but what we need is research figuring out how we can stop people from starting in the first place. If we want to keep health care costs down and people out of the hospital, we need investigate how people make those personal choices.

We don't want to tell people what to eat or how much to exercise or whether they can smoke or not. We don't want to interfere with their personal decisions and free will. But if we're serious about taking on the responsibility of health care and if our funding is not inexhaustible, we need to put pressure on people to stay healthy.

How much money do we spend on mammograms and prostate cancer screening? How much money do we spend on getting kids to eat vegetables and exercise? Which, in the long run, is most cost-effective at increasing health? I don't know what the answer is, but I want to suggest that if we take a stronger stance on prevention, even if it means more government, we can get people to be healthier and perhaps save on our health care costs.

Art II

Why write? For me, writing provides a necessary outlet to organize in my head and express the complex emotions, unfamiliar situations, and difficult moments that are inherent to medical school and taking care of sick people. Blogging every day, even if it is not directly about my day-to-day experiences, allows me to decompress about the faults in medicine and brainstorm on ways to fix it. More and more, reflection is seeping into medical education, but I am not sure it should be universalized. Reflective writing works for me, but that doesn't necessarily apply to everyone. By now, most students know how they deal best with stress; writing is only one of many ways to let that out.

But stories and poetry are also more than that. Narratives are how we describe the world. No matter how hard science tries to sterilize or objectify medicine, it remains in a world of human experience. Each patient and her illness unfolds as a story over time. Each patient will tell a unique story, if only we listen. Stories are a dynamic, probing, and interactive art form. They challenge readers, create worlds, stimulate imagination, and confront human emotion. Underlying each different perspective is some unifying shared human experience, allowing great stories to speak universally.

In any case, art is important. What we create in this world lasts. Why do doctors take care of the sick, prevent patients from dying, try to extend quality of life? So those people can live and create and love. We are not an end in ourselves. We exist to support those human activities that create art, build community, push the frontiers of discovery, and celebrate humanity.

Art I

What happened to art? I used to play the viola and read voraciously. At one time, I studied philosophy, loved history, enjoyed musicals and plays. Now, I surround myself with textbooks and charts and Internet follies. For the last four years, medical school has dominated my life, and now I'm trying to push back. I think the path of the medical student funnels us into greater and greater specialization until we lose perspective of what's important in this world. For some students, residents, and attendings, medicine is what they do; they have precious little beyond that. But I refuse to fall into that trap; I fight to keep writing blogs and stories and poems. Before bed, I read for fun. The dance group I'm in reconstructs historic dances from the Victorian and Ragtime eras, complete with costuming. My nightstand has novels stacked on them; some even have bookmarks at a respectable distance into the book.

Here's the problem. There's a considerable amount to learn to become competent in medicine. The premed curriculum gets larger each year. Medical knowledge is expanding at an exponential pace; textbooks are being constantly revised, and by the time one edition is published, it's already out of date. There's an infinite amount of information to learn, and for those interested, an infinite number of questions to be investigated. Medicine is a black hole of erudition to which great clinicians and academics disappear. It's wonderful, it's fascinating. I signed up for a life of learning and I love it.

But what about everything else? How much of our lives outside medicine do we sacrifice? I have a dozen ongoing projects and ideas for a dozen more. Here is one project that has been on indefinite hold. I first started learning to code in elementary school on the operating system Turbo BASIC (sixth grade) and moved onto coding on the TI-83 graphing calculator (ninth grade; calculators were perfect because your math teacher just thought you were working) to C++ (junior year of high school) to Java (senior year of college). I love programming; I love thinking of cool applications to write and putting them into action. I could have easily gone into computer science. I still have a ton of ideas to try, and I tell myself when things get less busy, I'll open up the old compilier. But up until now, things have just been too hectic. Perhaps this year, with the flexibility of fourth year scheduling, I can start again. It takes a little impetus, but it's important. "But at my back I always hear / Time's winged chariot hurrying near." That, of course, is from Andrew Marvell's "To His Coy Mistress", and tomorrow's post will be on poetry and writing.

Medical Education

It seems to me that medical education research is a fairly new field, but it's very interesting. We have to learn a little about how to teach small group sessions so I've been reading some articles. Although these articles are older, they appear to be expert opinion. Only recently has medical education trended towards evidence-based research, but I really don't know much about how medical education research works. Nevertheless, it seems that medical schools are moving towards small group problem based or case based learning. Indeed, when I was applying to medical school, that was the big difference between medical school curricula; some would be "traditional" lecture heavy environments while others encouraged student teaching in a smaller setting. Personally, I think different students have different learning styles and no single model of teaching works for everyone.

In interactive case-based sessions, students work through a hypothetical patient case to discuss diagnosis, pathogenesis, epidemiology, and treatment of a disease. It's great because students see how information is applied to clinical medicine. What's interesting to me is that pre-clinical curricula are emphasizing this style of learning, but clinical didactics still remain lecture-based. In my third year rotations, nearly all my teaching was done by lectures even though third year of medical school is about learning to think through patient cases. I'm not sure why that is. Perhaps lectures complement the case-based learning we're already doing, or perhaps, medical school education changes are trickling down and will soon reach third year didactics. To tell the truth, my favorite third year teaching sessions involved cases where my classmates would present a case and we would discuss how we would manage those cases. Because of our greater clinical knowledge as third year clerks, those discussions tended to be much richer, more thoughtful, and more educational than a passive lecture (especially since third year rotations are so tiring).

Teaching

I'm actually teaching for the next month. Fourth year is quite flexible and we have opportunities to teach, do research, or go abroad. I will spend a total of two months teaching; right now I'm a small group leader for the first year medical student cardiovascular block. It's fun. I feel that attempting to teach something helps me know how well I understand things. Today, I spent the entire day (from 9:30 to 7pm) teaching an EKG lab. We went through the basic science of electrical dipoles, vector math, and Einthoven's law, and then we took EKGs on students. Leading multiple sessions really helped me recognize various ways to effectively teach difficult concepts and work with the range of student learning styles. I also try to get the first year students to teach each other since I think that is a very important skill to learn. I'm a small group leader for physiology, pharmacology, and medicine. Not only is it fun to review stuff I've forgotten (all those channels creating the action potentials) but it is a great opportunity to work on leadership, presentation, and communication skills. We get very good training and preparation sessions from the session coordinators. I'm really looking forward to it.

Anesthesia in Rhyme

Perhaps I'm seeing things, but I notice anesthesia references everywhere, from early 20th century poets to contemporary rock bands.

"Let us go then, you and I, / When the evening is spread out against the sky / Like a patient etherised upon a table" - T.S. Eliot, "The Love Song of J. Alfred Prufrock."

"And well, he's on the table / And he's going to code / And I don't think anyone knows." - Third Eye Blind, "Jumper"