Cheers!

This image of flaming cocktails is shown under Creative Commons Attribution 2.5 License, from Wikipedia.

Literature on Death and Dying

"Tell me frankly, I appeal to you - answer me: Imagine that it is you yourself who are erecting the edifice of human destiny with the aim of making men happy in the end, of giving them peace and contentment at last, but that to do that it is absolutely necessary, and indeed quite inevitable, to torture to death one tiny little girl who beat her breast with her little fist, and to found the edifice on her unavenged tears - Would you consent to be the architect under those conditions. Tell me and do not lie!" - Dostoevsky, Brothers Karamazov.

For centuries, literature and philosophy have been asking questions that medicine has only started to raise in the last few decades. Is it permissible to let one person die because the cost-benefit ratio is so unfavorable that diverting resources to other endeavors would benefit more people? Are we obligated to do so, say in a purely economic fashion? Should we not pursue the greatest benefit from the limited resources we have?

I'm not going to try to address this topic in this blog (to read previous posts, you can look for blogs labeled "death" and/or "philosophy and ethics"). But I would like to bring up the fact that books, stories, philosophy treatises, essays, plays, and poems have been grappling with these topics of contention for years. True, some may argue that the vagaries of fiction and the theory of philosophy cannot apply directly to real life clinical situations, but I think they can contribute to our knowledge, understanding, and way of thinking. Those of us who think of these issues should welcome the contributions other disciplines can offer in our understanding of the human experience.

Aviation and Medicine

Over the last decade, comparisons have been drawn between the healthcare and aviation industries in an attempt to improve patient safety. Beginning with the often-quoted Institute of Medicine's groundbreaking report "To Err is Human" in November 1999 stating that 44,000-98,000 people die in any given year from medical errors, researchers, hospital administrators, and policy makers have been trying to address medical errors on a systems wide level. Learning from the aviation industry, hospitals are moving towards checklists, multiple back-up mechanisms, standardized protocols, and simulation training. For example, each surgery must begin with a "time-out" to verify the patient, procedure, location of procedure, and other simple questions to prevent easily identifiable errors. We're finally starting to learn from other industries to improve health care delivery to patients. That's not new news, and later I'll review a book about medical errors in health care.

Today, I wanted to raise a parallel idea; can what we've learned in medicine help the aviation industry? Recently, the news has been focused on an attempted terrorist plot by a man flying to Detroit, Michigan on Christmas day. There has been a lot of flurry over airport security, both in why the explosive device was not detected and in how to ratchet up security measures in the future.

For me, this draws some parallels with preventive medicine. One aspect of preventive medicine is preventing cancer and identifying it when it can be cured. Like a terrorist plot, we cannot predict when, where, and who will get cancer, but the outcome is so terrifying and unacceptable that we want our cancer and terrorism incidents to be zero. We have rudimentary methods of detecting the two; X-ray machines, metal detectors, mammograms, and PSA blood tests are standard but imperfect. There's always talk that newer tests or procedures may catch cancer earlier, but cost and patient discomfort are always considerations. In the same way, Homeland Security and the Transportation Security Administration are now trying to figure out how to increase detection without breaking the bank or halting transportation.

So what have we learned from cancer screening that can cross-over to airport security? Well, you can't catch everything. The American public wants and expects the administration to eliminate all terrorist threats, but I don't think that's a reasonable expectation. We simply cannot anticipate and protect against every possible terrorist plot. And despite these scares, plane travel is actually quite safe. The balance is between increasing sensitivity (the likelihood that if there is a threat, it will be detected) and cost or inconvenience. We can increase sensitivity by doing strip searches of everyone, but the cost and inconvenience of that makes it impractical. Consider the idea that we must remove our shoes before passing through the X-ray scanner. This is a minor inconvenience that we've become accustomed to. But has it increased the sensitivity of detection? That is, have shoe bombs been averted because of this procedure? I don't know the answer to that, but if they haven't, then there's no point in forcing us to take off our shoes; we should spend our time and money in looking at other methods of detection. (I realize a weakness of this argument is that in forcing people to remove their shoes, you're preventing development of terrorist plots that involve shoes).

In any case, aviation and healthcare have a lot of parallels. Research and policy in one area should be considered in corresponding fields. I think that medicine is no longer a closed silo, and that we can learn from advances in a myriad of unrelated fields.

Poem: I Thought I Knew Cold

This poem is fairly confused; as I was writing it, it sprouted half a dozen directions. Now, I'm not sure where it's going but I'm trying my best not to get in the way.
-
I Thought I Knew Cold

i lived twenty-five years of my life
without knowing the cold;
only met in passing
midnight in december
over the semi-feral charles
the howls whipping up waves
lashing across cheeks
forehead pained to wrinkles
but i didn't know cold
until i saw the look on your face

i had a cold patient once
26 degrees centigrade
his heart beating a nippy day
his brain an ambient room
blankets piled on
fluids in, fluids out;
after we toasted him
and revived his alcoholic mind
he threw shiners at anyone
who'd get close enough
i thought i knew cold

we tied him down
trussed like a turkey
and only the nurses knew
how to free him;
i had to cut through the knots
when he started seizing
trying to swim up from bed
to disengage those anchors
and i had thought that was cold

a week in intensive care
and another month
and you had our benediction
hospital volunteers rustled
up a retired coat;
that's how i recognized you
by your coat, not your face
but seeing that foreign face of cold
i pelted fast as i could
only to watch you hurl oblong
into that good night.

Universal Health Care

With the recent passage of the Senate legislation, we are at a momentous possibility of dramatic health care reform. One of the primary goals of health care reform is to expand coverage to insure those who currently have no health insurance. Like most other medical students, I believe that health care is as fundamental a right as life, liberty, and the pursuit of happiness. Anyone who needs care from a physician should get it. This is a patient-centered approach, but I also believe the flip side is true as well. Providers should provide for anyone. Students love working at the county hospital and at homeless clinics not only because we believe in universal access to health care, but also because we want to take care of diverse patients. We feel obligated to care for the poor and underserved. I think both of these ideas are central to the expansion of health care coverage. We are broadening the insured, and we need doctors to take care of them. Luckily, I think most of the medical students and physicians I know have a commitment to taking care of anyone who walks through the door. We need everyone to contribute to the care of these patients, rather than retreating to the profit-drive "concierge" practice of taking care of only the wealthy. Even those who have primarily practices that care for the wealthy and working can still contribute their time by volunteering at free clinics or through international medical missions. All people deserve medical care. All physicians by virtue of being such have an obligation to care for the underserved.

Happy Holidays

With warmest regards this holiday season, Craig.

Image is titled "Rime in Black Forest, Germany" from Wikipedia, in the public domain.

Interviews III

Here are ten suggestions of how I would change interview days to be better for applicants.
1. Often programs offer dinner the night before the interview to meet residents. West coast programs should schedule an earlier dinner (to accommodate those coming from the east coast) and east coast programs should schedule a later dinner (but not too late as applicants want time to wind down in the evening). I realize they have to be timed so that residents can make it. Dinners should accent the flavors and diversity of the city. Residents should intersperse themselves among applicants, and the dinners should not drag on forever. Cuisine should not leave strong odors in applicants' clothing, since everything goes back in the suitcase.
2. Residents obviously cannot be censored in what they say, and it's easy for applicants to tell if they're being candid. However, if the first thing a resident says is, "I love the hours and the pay," then the program is going to attract those people that are interested in hours and pay.
3. The interview day should not start at 6:30am (especially east coast interviews - the equivalent is 3:30am).
4. Program administrative staff should meet applicants as they arrive. At one place, applicants just showed up in a room and waited for the program director to arrive; we never knew who the faceless person behind the emails was.
5. Program directors should have applicants introduce themselves. This decreases the awkwardness of being among foreign suits. Plus, we run into the same people on the interview trail and they may be our future colleagues, so it's good to get us to mingle. Any talks given by the program director should be made available in the packet given to applicants.
6. Tours are a problem. On the one hand, they're expected and standard. On the other hand, all hospitals look pretty much the same. Tours stand out if the hospital is new or innovative or if they incorporate history. But most of the time, they're bland. Tours turn out to be a good time for questions with residents, and residents should know that.
7. The interview schedule should anticipate that interviews will run over time and applicants must ferry from place to place. Interviewers should have time between meetings to jot down impressions.
8. Lunch is usually provided. The food should be appropriate to be eaten in a suit. Spaghetti sauces are dangerous.
9. Some interviews, especially medicine interviews, have applicants attend teaching sessions like morning report or noon conference. I like this! Other applicants might not care, but I like learning something. That being said, make sure the teaching sessions are good. I saw a morning report taught at a third year medical student level; that doesn't reflect well on the program.
10. Reuse name badges. At the end of this whole process I'll have about 20 name badges that I won't use again. Be green. (Some programs have alternatively changed to name stickers - I don't like these as much; the adhesive comes off and they simply don't look as professional).

Interviews II

Someone asked me how I would change the interview process if I were a program director some day. I think I'd have interviewers attend a training session by human resources recruitment managers. The problem is simply that doctors are not trained in interviewing and hiring people, but they often think they can do it. Management science and engineering is a budding field and I think residency programs need to harness the knowledge and resources it offers. I was just reading an article about college admissions officers, and I learned that many of them have little training in recruitment practices yet they make one of the most critical decisions in anyone's life. Since residency recruitment is akin to employee recruitment, interviewers should get some training from professional interviewers.

I would have around four interviews of half an hour each; as an interviewee, I found that two interviews felt too limited and more than five was definitely fatiguing. One or two of the interviewers would be given no information about the applicant prior to the interview; one or two would only be given the CV and personal statement; and one or two would have the entire file. The interviewers with less information go in without preconceptions and primarily assess personality and "fit." UCSF medical school interviews followed this idea with "closed file" interviews, and I really enjoyed it. The interviewers with more information primarily ask more in depth about questions or issues raised in the application. If I chose to set up interviews like this, I would let applicants know the purpose; otherwise, faculty who have not reviewed the applicant's file would simply appear unprepared.

The best interviews I've had involved conversations that go beyond easily anticipated questions. For example, a research faculty and I brainstormed further experiments I could have done with my research project and a chief of the medical service and I discussed the ongoing health care reform. During these interviews, I did not feel like I was being assessed; rather, I felt like we were actually trying to work out problems together. It was definitely more fun that way.

The last issue is that of geography. It is well known that one of the most important factors in determining where someone goes for residency is geographical location. As a result, a lot of interviewers have asked me whether I would be willing to move to the East Coast, move to Southern California, or stay in the Bay Area. This is one of the most annoying questions to me, mostly because I would not interview somewhere if I didn't have the intention to go there. This is especially true given the costs of flying to the East Coast and finding lodging. Indeed, I've canceled half a dozen interviews simply because I don't think I want to live in that geographic location. However, it is an important thing for programs to gauge, so I would propose that programs designate one interviewer to ask that question so the applicant does not get bombarded with the same thing with each person he talks to.

Interviews I

I'm back from half a dozen interviews in the last two weeks. Although it is fun to visit new cities, meet other applicants, and see various programs, all the accompanying accoutrement - the cost of flights, the sleep toll of time zones, the stress of braving public transportation - can be really wearying. I'm glad to be nearing the end.

What is the goal of the interview? At the bare minimum, it allows programs to ensure that I am the person advertised. It allows applicants to ask any questions of the program and gauge the fit with faculty. But the range of interviews is quite tremendous; at some preliminary programs there is one meeting with a chief resident whereas at some derm programs have twelve 20-minute interviews in a row with faculty. I can't imagine doing that; that would make my head spin.

The types of interviews vary considerably. Most applicants dread the "stress" interview where applicants are put in an uncomfortable situation to see how they react. Those are rare these days, mostly because applicants don't want to go to programs that employ that technique, and it may not be all that revealing. Likewise, I have not yet been asked any "content" questions, that is, quizzing an applicant on a specific disease or EKG or biochemical pathway. Classic questions like "What's the rate-limiting step of the Krebs cycle?" have fallen out of favor, and I think this is the right direction to go. Certainly, applicants have test scores that represent normalized comparisons to peers in controlled settings, and an interview that focuses on assessing fund of knowledge would hardly be better than the standardized exam.

The bulk of questions I've experienced have fallen under several umbrella categories. The easiest have to do with things I mention in my application or personal statement. "Tell me about your research" and "how did you get interested in anesthesia" are straightforward questions as long as I've put a little thought into my application and residency decision. Other interviewers ask me what I'm looking for in a program or what my favorite clerkship was or where I see myself in ten years.

Even harder questions involve fundamentally important events and ideas such as: "how do you think health reform is going to affect anesthesiology?" "What is the role of anesthesia-extenders like nurse anesthetists?" But the hardest questions I've had are "behavioral interview questions." Adapted from interview techniques in the business realm, these questions are becoming more popular because they cannot be easily anticipated, and apparently, answers reflect how a candidate may act in future situations. Examples of these questions include: "Describe a situation in which you stood up to someone." "Give me an example of a time in which you had to make a split second decision." "Give me an example of a time when you tried something and failed." These are very tricky, and I personally dread them.

One Week Vacation

Hello. I hope the recent posts have been interesting, thought provoking, and possibly controversial. Unfortunately, December is packed with back-to-back interviews on both coasts. I have been pre-writing a lot of blogs to ameliorate delays and missed days of writing. Nevertheless, I am going to take one week vacations from my two blogs in order to focus on interviews and then enjoy the holidays. So there will be no new blogs here this week (12/13-12/19), and no new cases of the day next week. Thanks for understanding!

Against Standardized Exams II

The clinical skills portion of the USMLE licensing exam attempts to gauge one's interpersonal skills. The exam is only administered at five cities in the U.S., and the cost to applicants is very high, perhaps as much as $1500 to take the test (registration, flight, hotel). 97% of applicants from U.S. medical schools passed in 2007-2008; applicants who don't pass can retake the exam.

Here's my problem with Step 2 Clinical Skills. With a 97% pass rate, the number needed to test is 33.3, and at $1500 per person, it costs about $50,000 to identify one applicant who fails. But the pass rate for repeaters is 92% (2007-2008). Therefore, the number needed to retest is12.5. Since the cost of finding a retester is $50,000, then the cost to identify an applicant who fails twice is $625,000.

That's a lot of money. The cost is borne collectively by applicants so its effect is diffuse. But I don't think it is cost-effective to spend over half a million dollars to identify a medical student who fails twice at the clinical skills portion of the licensing exam. Thus, I don't think it is reasonable to mandate USMLE Step 2 CS testing for all U.S. medical students.

I do think assessing interpersonal and patient communication skills is important. But I think it should be the responsibility of the medical school to make sure all the students they graduate can take a history and physical and treat a patient nicely. And they should already have mechanisms in place to do that. Indeed, all eight California medical schools have already instituted a clinical performance examination (CPX) designed by a consortium of clinical and medical educators. Our examination involving standardized patient interactions is taped and graded; we are evaluated on our interpersonal skills. It acts as a preparation for the Step 2 CS testing. I think it should replace the required Step 2 CS test. Furthermore, it's more useful than the USMLE because we watch our videos to generate feedback on our performance. This should be sufficient to ensure that our interpersonal communication skills are adequate.

Even more than that, I think the best assessment of patient-doctor skills is to ask patients. We never ask patients how students do. I think it would be appropriate and useful to survey patients or their families after a medical student interaction, both looking for alarm signs and general impressions. "Did the student introduce him or herself? Did he or she wash hands before examining you? Did you feel respected?" While certainly you will occasionally run into a disgruntled patient who doesn't give honest or useful feedback, I think overall it may work. Furthermore, we always tell patients that they are helping train a new generation of doctors; soliciting feedback really involves them in this process.

USMLE Step 2 CS is a financial burden on medical students. It is not a cost-effective test. It gauges a skill set that should fall under the responsibility of the medical school, and it can be assessed as well if not better by medical schools rather than a regulatory agency.

Against Standardized Exams I

The path to become a doctor is fraught with standardized exams. From premedical courses to preparing for the MCAT to tests in the first two years of medical school to shelf exams during the clinical years to USMLE licensing exams, we keep the number 2 pencil business (and now the computerized testing industry) alive. In fact, selecting for doctors is akin to selecting for good test-takers, a skill set that is necessary for being a physician but has little real life application.

I don't think standardized exams accomplish what they're supposed to do; a person who does well on them may be a terrible a doctor, and a person who does poorly on them may turn out to be a fantastic physician. In other words, the sensitivity and specificity of standardized tests in determining whether someone should be a doctor is poor. They are neither necessary nor sufficient for establishing that someone has the skill set to take care of patients.

Fund of knowledge is important, but I think people overemphasize its centrality in clinical medicine. A certain proficiency in the basics is necessary, but when things get complex, doctors look it up or consult a specialist. There's no shame in turning to a textbook or the Internet; in fact, medicine changes so much that looking up references may yield newer findings that one didn't originally know. Standardized tests assess fund of knowledge well, but they must be calibrated to determining whether someone has the foundation to be a physician rather than how much esoteria one knows. Furthermore, standardized tests lack the ability to discriminate problem solving ability and clinical reasoning.

First Principles and Anesthesia

Everyone who studies philosophy reads Rene Descartes' Meditations on First Philosophy; I read it in five separate classes (and wrote a paper in each). This seminal work established the foundation for philosophy of mind and metaphysics. The premise of Meditations is to build from scratch a framework with which to view the world; he begins by doubting every single belief he has, and the rest of the meditations struggle to rebuild those beliefs. Hence, he derives from first principles those beliefs which have merit. Indeed, he even doubts himself until in the treatise, he writes, "I am, I exist" which has since then been colloquialized "I think, therefore I am."

But how does this relate to anesthesia? Anesthesia, unlike medicine, relies strongly on first principles, and I love that. The physiology and to some extent the pharmacology of anesthesia build upon simple laws of physics, chemistry, and biology. EKGs can be represented through Kirchoff's law, hemodynamics through Ohm's law. The administration of anesthesia follows the gas laws and Dalton's law of partial pressure. The action of drugs follow chemical laws of pharmacokinetics and pharmacodynamics (remember Lineweaver-Burke plots?). Much of the basics of anesthesiology can be reasoned out with a thorough understanding of the first principles - the basic sciences.

On the other hand, medicine cannot easily be derived from first principles. Vesicular lesions on the lip with a positive Tzanck test imply herpes simplex 1 infection; shortness of breath, fatigue, and swelling in a person with a history of heart attacks implies congestive heart failure; hyperpigmented skin in combination with fatigue, dizziness, weakness, hyponatremia, and hyperkalemia imply Addison's disease. Although some aspects of these diseases can be derived from known principles (Tzanck cells are multinucleated giant cells seen with herpesviruses, heart failure manifests if blood cannot be effectively pumped forward, and aldosterone is key to sodium and potassium homeostasis), there's some aspect of pattern recognition and memorization.

I really like medicine and the subtleties of differential diagnosis. But I think my background in philosophy and my demand for rigorous proof lend itself to thinking from first principles, whether in terms of philosophy or physiology.

Journal Watch

I've realized textbooks are no longer the most efficient way for me to learn. Reading a textbook can be low yield because some of it is out of date and other information has already been taught in lectures. During my clerkships, I turned to UpToDate which has the latest peer-reviewed evidence. But over the rotations, it's common to read the same UpToDate articles multiple times. To keep learning new medicine, we are encouraged to read core journals, but that is so hard to do as a trainee; the volume of information is overwhelming, I have not yet winnowed down my area of interest, and the material is pretty dense. So I'd like to put in a plug for Journal Watch, electronic newsletters compiled by the editors of the New England Journal of Medicine. Daily emails update me on key research articles in core journals or important current events such as the status of novel H1N1 "swine" influenza, and weekly emails cover topics from general medicine, hospital medicine, women's health, pediatrics, and a number of subspecialties. Even though I'm not going into those fields, I still find most synopses in Journal Watch to be interesting, educational, relevant, and understandable at my level of knowledge. For topics that seem particularly useful or fascinating, I can always look up the primary source. So I'd encourage those of us who've cast aside textbooks to go beyond UpToDate and subscribe to Journal Watch to get the latest relevant research.

Revision: Galileo, Galileo

Galileo, Galileo

I hoped I'd never get this page:
Your patient jumped out the window.
They are resuscitating him downstairs.

By downstairs, anon meant sidewalk
flecked with gum, shining like mica
blood like thrown art
where a Zeus dethroned learned
clouds are less dense
and sidewalks denser
than flesh.

In fifth grade science, we made homes for five story eggs.
We made omelets on the sidewalk.

I had just talked to him.
He combed his scraggly beard
and asked for an apple.
I forgot to tell the nurse
or dietician, or cafeteria.

Five children, that's what struck me.
In the debriefing, the piano tie said
sometimes five children
is five too many.

Galileo, Galileo.
He tossed the chair first
then became the chaser.
Arms spread eagle, his roommate said,
hair in long ropes ascending
hospital gown parachute.

Why didn't you stop him? I ask.
The roommate shrugs
and my voice cracks.

Wish I noticed something the day we met,
Wish he had mentioned a chorus of voices
or had a loaded gun.
How could it be? Like fate like gravity
any response of apology or guilt wanting.

You wrestle my pager from me,
tell me to go home.

Galileo, Galileo.
Good night.

Trainees II

This is a continuation of yesterday's post (below).

There might be a socioeconomic disparity among patients seen by medical students. For example, homeless clinics are common in many medical schools. They are positive and wonderful entities, providing free care to those who do not have access, giving back to a community, and advancing the education of first and second year medical students. However, I think it is a little disconcerting that we are "learning" on those with low socioeconomic status. The care we deliver is good care so I don't think we're learning at the expense of these patients, but it is interesting that in our health care system, those who fall through the cracks get picked up by trainees.

Similarly, rotations at county hospitals often offer medical students more opportunities to do "hands-on" procedures, and this is sometimes attributed to the patient population. Those with less education may not understand the difference between student, resident, fellow, and attending and have a higher likelihood of having procedures done by a medical student. In my experience, patients who decline having a medical student care for them are better educated and understand the system.

In the vast majority of clinical situations, having a medical student does not lead to suboptimal care; in fact, academic teaching hospitals deliver better care to their patients. But there is a health care disparity that those who have a lower socioeconomic status are more likely to have greater medical student involvement. I'm not sure if this is a problem, but it is something to think about.

My own experience as a student has greatly influenced my attitude as a patient. The more I realize how much I have learned and gained from patients, the stronger I feel that when I am a patient, I want to encourage medical students taking care of me to do more. I have taken care of patients who are physicians or retired physicians, and they often are the ones that teach me the most. Medical students often feel "entitled" to care without trainees, but I would like to encourage my peers to let that nursing student place the IV or the pharmacy student give the vaccine because we understand best how educational and necessary such experiences are.

Trainees I

Imagine you are a hospital inpatient. The person who walks into the room, young and apprehensive, identifies herself as a student. You let her take a history and do a physical exam, and then she asks if it's alright for her to put in the IV or perform a lumbar puncture or deliver a baby. What do you do?

Trainees are an essential part of the culture and backbone of academic medicine. Of course, I'm biased, being one myself. Most patients I've encountered accept the fact that students "come with the territory." Some will welcome students, especially VA patients who understand an environment of learning and hierarchy. Almost all patients I know will allow a student to do a basic history and physical exam, including asking about "sensitive" information like drug use or sexual activity.

But sometimes a problem arises when it comes to invasive procedures. "How many times have you done this?" you ask. The student, without making eye contact, replies, "Well, umm..." None, she thinks to herself.

No one wants to be the first person that a student attempts a procedure on. Yet every practitioner has a first for every procedure. For some procedures like phlebotomy (blood draws) and IV placement, the problem is ameliorated by having students learn on each other. For others like suturing or gynecologic exams, there may be suitable substitutes like tying knots on pig skin or hiring patient educators who are willing to have a speculum exam done. But for some "bigger" procedures - paracentesis, thoracentesis, lumbar puncture, chest tubes, incisions and drainage - the first time someone learns to do it, they're doing it on a patient. There's really no way around it.

This is a scary topic to broach in a blog read by the general public. But there are several things I'd like to say. First, you always have the right to decline care. However, I would encourage you not to do that. It's not that bad. While we are medical students who may be doing something for the first time, we will be adequately supervised. We will be adequately trained for what we're doing. No one is going to let a medical student do something they can't do completely successfully, and no medical student should allow themselves to do something they don't feel comfortable doing.

Cool Molecule

I stumbled across the molecular structure for eptifibatide, a glycoprotein IIb/IIIa inhibitor derived from the venom of the southeastern pygmy rattlesnake. I think the cyclic heptapeptide looks super cool.

Image is in the public domain, from Wikipedia.

Simulation

This week, I have been facilitating a patient simulator experience for the first year medical students. Patient simulators are interactive mannequins that can demonstrate various physiological and clinical states. The students encounter a clinical scenario, interact with the model to learn the history and perform a physical exam, and interpret data on the monitors (which can be as simple as pulse oximeter and blood pressure to as complex as ventilator management). After determining and instituting appropriate therapy, they can see the physiological effects of their interventions. I think simulators are most useful in teaching response to rare, acute, life-threatening events, and they are often used in anesthesia to prepare someone for events like anaphylaxis and malignant hyperthermia. Although at some levels, the experience feels contrived, it can actually be really fun and educational. After the simulator experience, I walk the students through a chalk talk on the clinical situation. It's really fun for me since it's a topic I really enjoy, and I think the students are able to reinforce what they learn through lecture. UCSF's Kanbar Simulation Center is a fabulous, innovative, and interactive teaching tool.

Image is in the public domain, taken from Wikipedia.

Rationing

The latest recommendations to decrease screening of breast and cervical cancer and the introduction of a health care bill that seeks to expand care without costing more has created a fear that we will end up rationing care. We're afraid that medicine will put a dollar value on a person's life and if saving them is too expensive, we won't do it. American society is terrified of rationing. We want to believe that modern medicine will go to any extremes to take care of our health.

I argue that this is a moot point. We are rationing. We have always been rationing and we will always continue to ration care. Resources are finite, and possibilities are endless. By deciding how many doctors to train, how many hospitals to build, how many clinics to fund, how many public health measures to support, and what research to underwrite, the government is rationing resources. By deciding how many patients to see a day, when to go home, how much overnight call to take, a physician also rations his care. We would love to have hour long doctor's visits, same day appointments, immediate access to world-renown specialists, clinics and emergency departments within 5 miles, free medications, and cures for every disease, but we recognize that such ideals are simply not possible. Our system now rations care. True, it is far more indirect than telling someone they can't get a test because it's too expensive, but the principle is the same.

If it would cost taxpayers a million dollars to extend someone's life an additional month, some of us might not choose to break the bank. There's some limit to what's reasonable or not. But how do we finesse that balance? I think that if we educate physicians to be socially conscious, that will be sufficient to control costs without plunging into the dreaded nightmare of "rationed care." Physicians make a commitment to care for a patient and they will do right for that patient until that competing interest of social or economic feasibility balances it out. In medical ethics terms, there's always a competition between beneficence - doing what's best for a particular patient - and justice - equitable distribution of resources. I believe we can train physicians in these ethical principles so that they do what is appropriate and right.

But on a systems level, who should make the calls? Should hospital CEOs decide what tests need prior authorization because of the expense? Should public health officials decide how to distribute a limited supply of vaccines? Should academic department chairs decide what research to focus on? Should the government issue blanket statements like "routine mammograms between 40-49 are not recommended?" These are much harder questions, and I don't have answers. However, I do want to point out that the mammogram recommendation was based completely on an assessment of risks and benefits to the patient rather than a cost-effectiveness analysis, and as a result, is not an example of rationed care but rather rational care.

In the end, I believe the ethical competing interests of beneficence and justice exist on a dynamic and evolving spectrum. The question of how to ration care is very real, and we need people from all backgrounds: patients, ethicists, public policy makers, and physicians to weigh in their input so we do what's sustainable for our system and what's best for each individual person.

Enshrouded

One of the very fun things about interviewing is seeing a host of different cities. Nevertheless, each time I return to San Francisco, I'm stunned by the beauty of the bay. Though I've lived here for several years, I don't think I appreciate it enough. Here is a gorgeous picture, and though I sometimes complain about the fog and cold, I can't imagine many big cities as breathtaking.

Image shown under Creative Commons Attribution ShareAlike 3.0 License, from Wikipedia.

Revision: About Suffering They Were Never Wrong

About Suffering They Were Never Wrong

One half of the room curt and drawn, diagrams
across parchment, labeled strings to ants
warbling into seashells and the echoing ocean,
cataloged cones of conifers, pelts of beach-strewn animals,
feathers and feathers, some plastered with glue,
hourglasses and spectacles and units of measurement.
The other side, a half-made bed, feathers spewed
from pillowcases, a doll with eyes blooming in cataracts,
an etched stool and desk, marbles scattering a phalanx
of toy soldiers, shield and spear discarded. On the sill
two small footprints where they jumped. Tell me,
could the blind prophet have known that curse?

The Financial Woes of the University of California

The economic downturn has affected everyone, but the University of California took a big hit to an already strained budget. Budget cuts always seem to affect health care (especially mental health and services for children), education (though higher education often skirts by), and corrections facilities. This year, state funding for the University of California was cut by $637 million, a 20% reduction. Furthermore, certain mandatory costs like health benefits, unfunded enrollment, utility costs, and inflation are increasing without compensation by the state. Further cuts may still be in the future as the state is projecting a $7-8 billion budget deficit for 2010-11.

This has sent University officials into a flurry. All employees have a mandated furlough averaging an 8% pay cut, and many may be laid off. However, what has really struck students is a mid-year fee increase; mine are a 24% increase. Overall, the Board of Regents voted to increase undergraduate fees by 32% next fall. Moreover, students are feeling a crunch in terms of educational services such as reduced library hours. Even doing my teaching rotation this month, I've heard how resources that we had in the past are no longer available due to the budget crisis.

I fully appreciate that this is reality and the state cannot run a budget deficit. And since I'm graduating, I'm pretty much out of the woods in terms of tuition and fees. But I cannot help but worry about the effects of this belt tightening on education. I chose UCSF for medical school because of its outstanding educational opportunities, but with the professor furloughs, the decreased student services, the lack of resources, and the overall demoralization of the University, I don't know if the quality of education which has made this place so good is sustainable. I don't have any solutions unfortunately, though I've heard proposals from online courses to dismantling research at other campuses to accepting more out-of-state students who pay more. But the state government must not forget that higher education is a responsibility whose effects are vast and life-changing. The state government must not forget that the University of California is a long term commitment and hamstringing it now for a short term benefit will lead to long term consequences that may be hard to repair.

Thanksgiving

Today, I am thankful for my education. I have been in school for 80% of my life, a remarkable investment of time, money, and labor by my parents, the public school system, a private college, a public medical school, countless teachers, professors, and teaching assistants, peers, and patients. I gripe as much as anyone else, but the persistent encouragement of my mentors has really helped me through those doors afforded by education. Very few people are as lucky as I am. Some fortunate confluence of societal, social, and circumstantial factors have gotten me to where I am now. In understanding disparities in our society today, education plays such a fundamental role. We need to advocate for those who can't advocate for themselves. Improving educational disparities is as much a part of improving health care in America as research, expanded coverage, more primary care, preventive medicine, and any of the other major health care reform concepts. Education both directly and indirectly empowers patients to take control of their lives, medical decisions, and illnesses. I am thankful for my education. Happy Thanksgiving everyone!

Behind the Scenes in Teaching

One of the other things I've realized during my teaching month is the amount of work that happens behind the scenes. As a student, I showed up to lecture and small groups and labs without any thought to the construction of the curriculum and the preparation for each session. I only had a vague idea that faculty were volunteering their time to teach, that they had many other clinical, research, and administrative responsibilities. But now I get to see the other side. All the instructors and small group facilitators get together before each small group and spend hours debating the problem sets. We have clinical faculty, basic science researchers, pharmacists, and medical students, and all of us argue over the clarity of the clinical cases, the best way to teach something, potential questions, and anticipated quagmires. The sessions are tiring but really educational. I've also gotten to see a little about the organizational side of things, and it's crazy. From scheduling a dozen rooms to keeping track of a dozen instructors all with different schedules to fielding questions on the message boards to dreaded committee meetings, the course administrators have their hands full. This has really helped me appreciate the tremendous amount of work that goes into education.

Teaching

Over the last few weeks, I've been leading small group sessions for first year medical students and teaching labs. You don't realize how much you don't know (or how much is unanswered) until you try to teach something. Furthermore, there are certain concepts like EKG axis that make a lot of intuitive sense to people with a strong math or physics background, but my challenge as an instructor is to figure out how to explain it to someone who doesn't think mathematically. I think there is an advantage to being a fourth year instructor in that I understand what background first year medical students have and I remember the kinds of explanations that worked for me. And I think the students I'm teaching have responded really well to my enthusiasm and trouble-shooting for difficult topics.

But more than that, I've been learning a whole new skill set for small group facilitation. Thrust into a leadership role, I have to figure out group dynamics, time management, communication skills, and how to cater to different learning styles. As small group leaders, we're not supposed to lecture, but instead, we're supposed to facilitate a dialogue of teaching and learning between the students. I think this is a lot harder. Some groups are dominated by that one loud person; other groups get sidetracked easily; other groups are less prepared. But the best way to learn leadership is to do it, and I think this teaching experience is really fantastic to my preparation to become a resident.

Poem: Astronaut Love Triangle

I once took a creative writing class from a short story writer of the bizarre, Adam Johnson (Parasites Like Us, Emporium). One of our prompts was to find a tabloid heading for a title; the inspiration was Robert Olen Butler's "Jealous Husband Returns in Form of Parrot." It was fantastic; I still remember writing "Aging Burglar Robs Own House." When I came across this news title, I couldn't help but scribble the phrase down, and flying to Seattle for an interview today, I got a moment to make it a poem.
-
Astronaut Love Triangle

You can't say I didn't warn you.
My FAQ had this situation:
"What to do with an astronaut love triangle"
right below "When robots take over."

Somewhere between Earth and stars
hovers that maiden of fantasy.
You send men out there to harvest moon rocks,
build satellites or talk to Martians
and soon they'll realize the only pull
in space comes from themselves.

A year and they come to know the shuttle hull
pretty well, the air lock between now and after.
Astronaut love triangle:
it doesn't follow any of the laws of our world,
doesn't obey our sublunary flails in fetters and ideals. No--
up here, strip men of jobs, clothes, families, pets,
first loves, last loves, nationalities, alcohol,
and what could be purer? Here,
in the absence of money and guns
and locations more romantic than the infirmary,
here in the absence of poetry, the undiluted
emotions perspire. Envy, obsession, infatuation, hatred--
what else could there be
in a world with only Saturn's iridescent
rings, Jupiter's hot spot, all the stars you can imagine.

The House of God

The House of God by Samuel Shem is a classic medical satire and a must-read for all medical students and residents. Written by a doctor who did his internship at Beth Israel Deaconess in Boston, it captures amazingly the brutal callousness and coping mechanisms of intern year. When I first read it prior to medical school, I was taken aback by the gallows humor, the coarse views about patients and patient care, and the ridiculous situations encountered. But after third year of medical school, I've realized that though the medical system has become much more humane since the 1970s (when the book is set), much of the underlying themes ring true. It has become a fiendishly bare yet funny expose of the medical training system.

The main themes of the book can be summarized by the Laws of the House of God as given by the Fat Man, a brilliant nonchalant resident who guides the interns through their harrowing year. Law #5 ("Placement comes first") describes how the intern's goal is to figure out how to make his service smaller and turf patients to other teams; Law #4 ("The patient is the one with the disease") describes how interns cope with the horrors of dying patients; Law #3 ("At a cardiac arrest, the first procedure is to take your own pulse") teaches interns how to approach emergencies; Law #10 ("If you don't take a temperature, you can't find a fever") warns against unnecessary tests and procedures ("Law #13: The delivery of good medical care is to do as much nothing as possible."); Law #7 ("Age+BUN = Lasix dose") captures some of the randomness of medical care.

The book captures beautifully the psychological impact this year has on the main character; with the long call nights, the dreaded patient population ("gomers" - the elderly with complicated but uninspiring medical conditions), and the oppressive hierarchy, the main characters turn to coping mechanisms like sex. They soon find their personal relationships falling apart. The book hits upon so many details of the hospital experience: minorities, the intensive care unit, needle stick accidents, autopsies, relationships with nurses and staff, clinic, medical mistakes, euthanasia, and the "lifestyle specialties" (rays, gas, path, derm, ophtho, psych).

I highly recommend this book to anyone in the medical field with a cautionary grain of salt; it portrays not the idealistic white coats that we would like our doctors to be but the filth they have to wade through in their training. Though extreme, moments ring true and that authenticity, often veiled in humor, rings a chord in me. The writing style isn't the best and the plot gets bogged down in the latter half, but it is still a worthwhile read.

Image is shown under fair use, from Amazon.com.

The Novel H1N1 Vaccine

"Swine flu" or the novel H1N1 influenza this year has created an interesting mix of reactions. Since the first outbreak in March/April of this year to the declaration of a pandemic in June to the development of a vaccine, some have become terrified of this disease and others have become terrified of the vaccine. Should we vaccinate? Is the lack of widespread equitable distribution of the vaccine a failure on the part of the government?

The vaccine is created similarly to seasonal influenza vaccine, and side effects are expected to be similar. Several trials looking at dosing of vaccine and antibody titer response have shown that getting the vaccine effectively induces an immune response against those antigens. The hope is that this will prevent transmission of the influenza virus from an infected host to an immunized individual.

However, we don't have any data that this works. The theory is sound, but there are no studies on whether the H1N1 vaccine prevents infection. Indeed, it'd be hard to design a study; you'd have to randomize people to getting vaccine and placebo and see if they make it through the flu season without getting sick. So do you believe in evidence based medicine? If you do, you have to concede that all this hullabaloo over vaccination can't really be supported by numbers. We think it works, but we simply don't know.

I fully support getting the H1N1 vaccine; I believe in the biology and immunology, and I think it works. But not having numbers bothers me. What if the vaccine isn't all that good and only prevents 10% of infections? Are we spending our money wisely? Are we rationally weighing risks and benefits? That being said, there is a study modeling the cost-effectiveness of vaccination that suggests that vaccinating 40% of a large U.S. city with a 75% effective vaccine would avert 1468 deaths and save $302 million. This would require 3.3 million vaccine doses (if one dose is effective for an adult). I'm always iffy about modeling studies, but that's the best evidence we have so far.

Breast Cancer Screening II

The meta-analysis conducted by the U.S. Preventive Services Task Force result in these numbers: the relative risk reduction of screening mammography on breast cancer death in women 40-49 is 0.85 (CI 0.75-0.96; 8 trials). Due to the lower incidence of breast cancer in this age group, the number of people needed to invite for a screening mammogram to prevent 1 breast cancer death is 1904.

Therein lies the rub. Are we, as a society, willing to do 1904 mammograms to prevent one breast cancer death? Mammograms aren't completely benign. False-positive results are very common and lead to unnecessary invasive procedures and undue anxiety. This is not trivial; biopsies and surgeries as a result of false positive tests can be extremely costly and entail their own consequences. Other issues include discomfort of the procedure, overdiagnosis, and dangers of radiation exposure.

The problem is this: any woman would rather face the anxiety of a false positive test than have cancer. Furthermore, of the 1904 women screened, if you're the one with the actual cancer, then screening matters. But this kind of reasoning leads to a slippery slope. Why don't we mammogram women 30-39? They get breast cancer too. We'd have to do more mammograms to prevent a single death, but there are potential lives to save.

Where do you set the cut-off? If we do screening mammograms on women 40-49, we pay $190,400 to save one life (based on average cost of mammogram $100). Is that worth it?

Think of how many swine flu vaccines we could buy with that amount of money. (Don't worry, my opinion on the novel H1N1 vaccine is coming soon). My opinion doesn't really matter as I'm not going into primary care. But in looking at the numbers, I think it's reasonable to be ambivalent, and either side can be defended. For me, given a patient from age 40-49, I would assess her risk factors, and absent any red flags, I'd reassure her and schedule her for a mammography when she turns 50.

Breast Cancer Screening I

Recently, the U.S. Preventive Services Task Force (USPSTF) revised breast cancer screening guidelines to recommend against routine screening mammography in women age 40-49. This is a landmark change. Previously in 2002 the recommendation was routine screening mammography every 1-2 years for women 40 and older. The USPSTF is an independent panel of experts in primary care and prevention (not including oncologists) that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. This change in recommendation has garnered quite a bit of press and criticism from patients and providers alike. It is not clear-cut; the American Cancer Society and other expert panels argue against this change.

I think this is a great moment for several reasons. First, it is a bold move for the task force; how can you recommend against looking for something that kills so many people each year? Indeed, the USPSTF has remained neutral on many cancer-screening recommendations; they conclude there is insufficient evidence to recommend for or against screening for skin cancer, prostate cancer, or lung cancer. (I'm not even that ambivalent; I reviewed the literature on CT for lung cancer screening and concluded it is neither effective nor cost-effective.) But here, the USPSTF has taken a bold move, changing a previous recommendation to screen to one against it. Millions of women 40-49 have faced the discomfort of mammogram; many have had abnormal results; some have had cancers detected that otherwise would have been missed. Now, the USPSTF is simply saying stop. Don't do it. It's not worth it.

This is also a great moment because it shows that evidence is dynamic and recommendations evolve. What we learned as dogma (I'm certain this appeared on my Board examinations) changes. This is real life medicine. Nothing is certain; nothing is set in stone. As we learn more, we change what we do. Good doctors must be skeptical; they must challenge what is foisted upon them, and if new ideas persevere through those challenges, they must learn to adopt them. Research, and understanding the principles of solid research are fundamental to the practice of good medicine.

I'm going to reserve my opinion on the change for tomorrow's post. But I want to encourage you to look at the evidence. Why did they change their recommendation? Do you believe their reasons are valid? This is what I did as an undergraduate philosophy major. It doesn't matter to me what you conclude, only that you can support your reasoning. Don't use anecdote (we've all seen that unfortunate 45 year old who has metastatic breast cancer); don't use a gut feeling. Use real data. As much as you need to convince yourself. What will make someone a good doctor has nothing to do with whether they mammogram their patients 40-49; rather, a good doctor will think independently, use guidelines as guidelines, apply research to individual patients as best they can, educate the patient, and decide in a patient-doctor partnership.

Poem: Portland, 2009

Portland, 2009

Rain racing down eaves of the bus
like hair winding its way behind your ears,
and the chatter of droplets cast
white blurs over the faces - this
is what transparency is,
a city stirring and groaning
under the pressure of decompressing clouds,
weep and weep again, droplets
that sheer with acceleration
throwing motes of rainbow
through the windshield. A woman
stumbles on board, and the driver
does not press for a transfer.
Here, it is warm; the rumbling of womb
over bridge, the plumes of fog,
the soothing greens. Here, buses stop
for the biker, wheels leaving a wake,
water water everywhere.

You were never perfect,
and that's why I stayed.

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"

Poem: Buenos Aires, 2005

Here's another 31 word poem, written on the plane.
-
Buenos Aires, 2005

The gaucho entwined your leg over
mine in a manner that seemed
anatomically impossible.
Like wind over roses, you dipped another
two inches. Cowboys stamping
heartbeats as you let go.

Scary

Happy Halloween! The venomous lizard shown above is the Gila monster which has an interesting place in the history of medicine. One of the newer medications for Type II diabetes, exenatide, was derived from a hormone found in the saliva of the Gila monster. This molecule is similar to a human protein that regulates glucose metabolism but the version found in the Gila monster lasts a lot longer. Although now exenatide is made directly through chemical synthesis, it demonstrates how new drugs can be found in nature. Indeed, a great example of this is premarin, estrogens derived from horse urine (the name comes from pregnant mare urine). Perhaps sometimes, it is better not to know where our medicines come from.

Image is in the public domain, from Wikipedia.

Learning

Knowledge, it seems, occurs in ebbs and flows. By the end of college, we are overflowing with facts and formulas; we can demonstrate the right hand rule, navigate the photosynthetic transformation of light into chemical energy, and describe the Wittig reaction (aldehyde + triphenyl phosphonium ylide = alkene + triphenylphosphine oxide). Then we reach medical school and realize all that memorization must be neatly stored away in file cabinets labeled "foundation." We spend the first two years of medical school filling our heads with new facts until we are brimming with eponyms and images of cells and names of drugs we've never seen. Flying through exams, we imagine we cannot possibly learn more, and no more knowledge could possibly exist. Indeed, looking at multiple choice vignettes, we see the world as clear cut and distinct; medicine is easy, we say.

Then, we shed our backpacks and don our white coats to enter the clinical realm. The third year of medical school comprises of learning a new kind of practical knowledge. How do we interact with nurses, pharmacists, clerks, therapists, and ancillary staff? How do we call primary physicians, and how do we present real people with complex diseases in several minutes? Oh, certainly in college, we understood the chemical structure of bicarbonate, and in early medical school, we learned its use and toxicity, but now, only now, do we face a blank order sheet and realize we have no idea how to write the order. We learn how to learn, where to get information, how to teach ourselves, how to glean what we can to help those we serve.

And in the last few months, I encountered the turn of the fourth year. As a sub-intern responsible for patients, I realized how little we know. Sure, I know the mechanics of diseases and the treatments. But why do two patients with the same disease have different outcomes? Why are we so unsure how long a patient with a terminal illness will live? Why are there first line and second line drugs; what causes one treatment to fail and how can we prevent that? Why do medical mistakes happen? How can we miss such devastating diagnoses as domestic violence or child or elder abuse? How do we approach ethical dilemmas in practice? How do our subconscious biases affect our thinking? How can we anticipate unanticipated outcomes and unforeseen events?

The more I learn, the less I know. If real life were textbook, we would be healthier, medicine would be cheaper, and the vagaries of judgment and instinct would no longer persist. But textbooks hardly encompass all of medicine. When applied to the real world, theory can be flimsy and our fund of knowledge a dearth of practicality. This is why research is critical. To remain stagnant is to concede that we don't know what is always the best for our patient and we aren't trying to find out. A doctor who doesn't ask questions cannot remain at the forefront of his field and does not avail himself of the toolbox that medical school has given him. This is what I've learned in medical school: learning is lifelong and there will be a point in time when we have to teach ourselves; we investigate, we think, we learn, and we teach. Research is not for everyone, but to forget its place in medicine is to lose the humility that makes good physicians good.

Back

I'm back to blogging regularly now. In the last week, I took both parts of the Step 2 licensing exam and went to my first interview at UCLA for anesthesiology. It was quite a tiring week. The clinical portion of the exam involved 12 patient encounters with patient actors; we had to do a history and physical and write a brief note. I felt that UCSF prepared us well for this exam as interspersed through the curriculum, we had standardized patient encounters simulating common chief complaints. Nevertheless, seeing twelve patients was exhausting; it felt like a long clinic day. The fund of knowledge exam was also quite involved, but I am glad to be finished.

Going on interviews is both exciting and tiring; the logistics of travel, navigating a new place, dealing with sleep deprivation, and at the same time learning about programs and interviewing well is challenging. But I am really looking forward to seeing different programs, their emphases, their strengths, and their styles of training. I won't blog specifically about any programs, mostly because it would not be a prudent decision. The residency selection process (which will probably earn itself a blog sometime) involves a somewhat obscure and precarious match (though the match was implemented to improve clarity and equality). The mechanics behind it are such that publicly formalizing my opinions about each program would hinder me. Furthermore, as I learned on the medical school interview trail, rumors about every program abound. I don't find them useful and would not want to start or perpetuate anything. Lastly, the word "match" really describes the process well; each program and applicant has its personality and style and no program is for every applicant; it really is about finding the best fit for oneself.

Michelangelo

This was sent out as an advertisement for an anesthesia research project by the Bickler lab at UCSF. I am very amused by it. Shown under fair use, from Paul Au.

I am going to take a one week break from this blog for Step 2 preparation. USMLE Step 2 is the second of the three-part licensing exam and involves a two-day test including a practical portion and a fund of knowledge portion. I'll return to blogging in a week.

Health Policy II

From the California HealthCare Foundation, health care was 16.2% of the GDP in 2007, $7421 per capita. 31% was spent on hospital care, 21% on physician and clinical services, 10% on dental and other professionals, and 10% on prescription drugs. Only 7% was spent on administration.

Who pays this? Private insurance covers 34.6%, out-of-pocket payments cover 12%, and other private monies cover 7.2%. The federal government foots the bill in 33.7% of payments (19.1% Medicare, 8.3% Medicaid) and states and local governments fill in the last 12.6%.

This is a problem. Though in recent years, we've tried to curb costs and spending, health care still outpaces inflation; growth rates of the consumer price index are consistently several points below national health spending growth rates. Our costs are out of control.

Cost containment fails, I think, because we're Americans. Our consumers demand. We resist limited choices, we love the power of industries (device manufacturers and drug companies), our political system acts as a glacier. But we need to control costs; there's no alternative. Each dollar that's spent on health care is a dollar less from schools or the environment or jobs. Without cost containment, we can't insure more people; without cost containment, people will still find themselves bankrupt from emergency appendicitis. Yet our system hangs around because it seems "good enough"; too many special interests groups exist that are afraid that change will hurt them so they stick with what we have now.

Things will change; they may be at the brink of change now. But what I've come to understand is that our system now is unjustifiable and unsustainable. With medicine's focus on evidence-based practice, where is the evidence here? We're spending all this money, and our outcomes are not very good. What went wrong? Can we fix it?

Health Policy I

By the usual standards, the United States does poorly in health outcomes; we rank 19-25 among OECD in infant mortality, maternal mortality, and life expectancy from birth (but we do a lot better with life expectancy after age 65). Many reasons have been proposed to explain these differences such as the heterogeneous population in the U.S. or the prevalence of resuscitation of premature infants, but the hard outcomes still trouble me. Furthermore, race-stratified outcomes are even worse; African American men have very poor life expectancy compared to Caucasians or women. Many of our gains in life expectancy are in upper socioeconomic status groups (and many from decline in tobacco use). While we're making improvements, these are not equitably distributed.

Yet the costs of our medical care is stunning. Our health expenditures were 16.2% of the GDP in 2007 (California HealthCare Foundation); with the recent economic recession, the % of GDP is even higher since healthcare is more insulated than other industries to recession. Projections for healthcare % of GDP are hard to make but uniformly, estimates suggest larger and larger proportions of the GDP will be spent on health without clear benefits (since our outcomes haven't changed much). Indeed, compared to other nations, our expenditures are staggering.

Why do things cost so much? We seem to have much more specialists, but not more doctors. Perhaps our payment valuations (fee for service) are wildly unreasonable. Compared to other countries, our doctors are paid more; there's a larger gap between physician and non-physician salary in the United States. From a hospital standpoint, we have more ICU beds, expensive procedures, and technology even though hospital stays are shorter.

Costs vary a lot; states like Minnesota spend the least on health care while states like Florida spend a staggering amount. We have a good bit of administrative overhead, but estimates seem to hover around 14% of health care expenditures, suggesting that increased efficiency would save some but not a whole lot of money. Many doctors claim defensive medicine (especially with imaging) drives up costs. You'll also hear practitioners complain about the aging population, but other countries have an aging population as well. Economists will cite lack of cost competition and market forces; I really don't know enough to comment. The government will claim it is a lack of investment in information technology.

Costs are tied to everything. Nearly all students favor universal health care, but I heard a recent insightful comment. We can't even pay for Medicare for those who have it now; how can we talk about expanding Medicare to everyone? Things aren't even working now, without universal health coverage; how do we expect to get universal health care to work?

Revision: Hangman

Hangman

I remember when it was black and white,
you were living or you were dead, and the in-between
belonged to Michael Jackson music videos
and occulteers in dark alleys, when
there was no controversy; if you had a knife in your head
or the cough of consumption, we dragged in the box;
not this ridiculous business, shining lights at pupils,
insulin pumps clicking like the return of a typewriter,
an octopus sprouting from a dead man's mouth.

I remember when you'd kill a man
and he'd be dead; it was civilized that way,
but now diverted in transit, they end up
on my chopping block, in my glass coffins,
more machine than man in each of these rooms.
I make my executioner rounds every day
and the culling is always the same,
euphemized as family discussion for goals of care.

I don't want to kill them, but
they're already dead, I tell myself.
My hair falls out in clumps.

The white coats, we pat ourselves on the back since
this is the closest we've gotten to resurrection itself.
I tried rolling in a three-day boulder
but the nutritionist stopped me, said
"You can't do that, we need to give him tube feeds."

He never came back, this gentleman,
we didn't think he was Jesus anyway.
I filled out the paperwork, scheduled a time,
1600, as if death were too busy in the hospital
to come without an appointment.
Even though he aspirated at 1400,
a blooming pneumonia, an old man's friend
we continued full steam for another two hours
until morphine came waving down the caboose.

Pediatric Skills Session

I went to an open pediatric skills lab run by one of the pediatric ICU attendings, and it was a lot of fun. I spent most of my time practicing intubation on pediatric mannequins. I found it especially useful to try different laryngoscope blades just to see the practical differences with size and Mac vs. Miller blades. I had a lot of time to just troubleshoot with the models. I also practiced phlebotomy, IVs, and arterial lines on the pediatric models. It was very productive and worthwhile.

Image is in the public domain, from Wikipedia.

Trepanation

This is a fascinating skull from ~3500BC from a female girl who survived trepanation, shown at the Natural History Museum, Lausanne. Trepanation is the practice of drilling a hole into the skull, presumably to relieve pressure. Evidence of trepanation has been found in prehistoric human remains, possibly to cure seizures, migraines, and head trauma. Furthermore, there is evidence that people to whom this has been done survived the procedure. Who knew one of the oldest surgical practices would involve the skull?

Image shown under CeCILL license, from Wikipedia.

Frequent Flyer

Some patients are known as frequent fliers to the emergency department. The ones I've seen come in regularly for drug-related problems: alcohol intoxication, alcohol withdrawal, cocaine, amphetamines, opiate withdrawal. As an idealistic medical student, I try my best to persuade them to change their habits knowing it takes more than a scolding. We send them out, and they come back, pretty much the same.

When I was on my ICU rotation, I took care of a patient who stroked from cocaine hypertension. Looking at her past ED records and discharge summaries, I gathered that she had been to the emergency department a dozen times, admitted several times, and each episode was due to cocaine. All the discharge summaries emphasized the substance-use counseling given and the importance of quitting. Yet she kept on coming back, until her latest admission for a severe hemorrhagic brain bleed landed her in the ICU. She had several kids, all under 10. None of us thought she was likely to recover, but because of her family, we pushed on.

This is frustrating. What can we do to prevent frequent fliers from coming back to the emergency department? Although some patients have exacerbations of asthma or congestive heart failure, most of the frequent fliers I've seen have been due to drugs and alcohol. The nonchalance they have scares me, and the power of addiction they face controls them. One of these days, they won't be lucky enough to leave the emergency department to get another drink or high. So each time I see someone like this, no matter how futile the situation, I do my best to get him to change.

Information Economy

One of the ideas that Freakonomics touches upon is that of an information economy. For the most part, doctors deal in an information economy. When a patient goes to their physician, they want to know what is causing their rash or cough or fatigue. The doctor, a veritable repository of facts, deduces from the history, physical exam, imaging, and laboratory tests an answer, and they can proceed to treatment. We go to four years of medical school and three to eight years of residency to develop such a fund of knowledge as well as the tools to know how to ferret up knowledge we don't have. The "thinkers" in medicine such as internal medicine doctors deal with this information economy.

This is changing. The Internet is here to stay. Patients google their symptoms, peruse websites, post on message boards, and find support groups online. The vast information gap between physician and patient is closing, at least for the educated patient. Frequently, I see patients who have already done their research and come up with conclusions.

What does this mean for medicine? I'm not sure. Patient empowerment is a good thing, but we will have to see how empowering the Internet will be for consumer understanding of medicine. Information gleaned from the Internet may be biased, out-of-date, incomplete, false, esoteric, or too complex but this may not be readily apparent to the general public. Doctors will have to struggle with convincing patients that they know better, or on the other spectrum of things, conceding that they know less than the well-researching patient. This is somewhat disconcerting. The information economy of medicine is crumbling, and doctors that I have spoken to vary a lot in their reactions. Some don't like it. Others welcome it. Most adapt.

Patient / Doctor

One of my close friends from college who is also a medical student recently had surgery. Talking to him about his hospital stay was enlightening. You would think that being in medical school would cushion the experience as a patient. But he said that though he walked the same halls with confidence in his white coat, when the roles were reversed, he found it a scary and foreign experience. From the pre-operative clinic visits to the surgery to an ICU stay to the floor, he was never comfortable, never at ease. Despite understanding more medicine than most, he still found everything emotionally challenging and frightening. The role of the patient comes with undeniable vulnerability, no matter how prepared one is. Perhaps knowing more about the medical system makes the experience even harder. Those of us in the medical field know that the system is hardly perfect, that unforeseen events and errors happen, that some complications may not be avoidable. We're all very grateful that he made it through his eight hour surgery safely and well.

What is it like to be a patient? What is it like not to speak English, not to understand medical vocabulary, not to know what each pill is for, not to know what a surgery or procedure entails? What is it like not to know who your doctor is, or how the system works, or the plan for the day? What is it like to wonder whether you'll make it out of the hospital?

I underestimate how scary the hospital is. It's foreign, mechanical, imposing, gray. The patient experience of illness and health extends far beyond the medicine he takes or the doctor he sees for fifteen minutes each day. The patient experience encompasses emotion and fatigue, physical and spiritual challenge, an eclipsed understanding, a willingness to trust that things will be better. Relinquishing that self-determination, giving one's free will to a surgeon, hospital, institution, that's what makes being a patient hard. Unfortunately, I feel that no matter how much I try to understand this feeling, I won't fully know it until I find myself fully immersed in it as a patient.