Capitation

In primary care, we discussed the idea of capitation which is often used by managed care organizations to control costs. In capitation, a fixed amount of money is paid to the provider per patient per year. Thus, the financial burden of excessive testing is transferred to the physician, not the managed care organization. That is, a physician will be paid the same whether or not he does a needless X-ray or blood draw. There's a financial disincentive against doing unnecessary costly procedures. There is also an incentive in keeping people healthy, in preventative medicine, so such costly procedures aren't necessary.

In some respects, capitation makes sense; a general pediatrician sees many, many well children a year, and the reimbursement for seeing a well child should be straightforward to calculate: the physician's time, health education, vaccinations, vision and hearing exams, routine laboratory tests, overhead, a little more to cover expected sick visits, etc.

But capitation also has disadvantages. For example, teenagers rarely go to the doctor. Capitation favors practices that recruit teenagers; they'll get paid each year for each teenager, but can double book teenagers expecting that they won't show up. On the other end of the spectrum, very sick children such as those with genetic or chronic diseases will be costly for physicians to take. If reimbursements are the same for a healthy child and a sick child, this is a disincentive to caring for those who need it the most.

Poem: Under

Under

Resisting gas-mask theriac
plunging this pool of honey
faces quivering like reflections in a pebble-battered
pond of honey
viscous struggle, filling ears and eyes and mouth and nose
dancing into my brain

A daffodil sees itself calm
among lakes of gold
idling away petals
a sick-saccharine breeze-

dreamlike, this painted town where
lovers try positions they can't handle
lanterns trickle through the streets
that radiant face
that scented glow
clouds can hardly conceal

Up down in out
paddling through amalgam river
quicksilver and longing
to wake up again.

-
Image is of Narcissus by Caravaggio, 1597-1599, oil on canvas, Galleria Nazionale d'Arte Antica, taken from Wikipedia, in the public domain.

San Francisco

Image is of the gay rights flag at the corner of Market, Castro, and 17th, from Wikipedia, shown under Creative Commons Attribution License.

Airplane Medicine

I went to a Graduate Medical Education Grand Rounds on airplane medicine, which was really interesting. What do you do when an attendant asks whether there is a physician on the plane? What things are you likely to see? What equipment do you have?

First, there is a paucity of research, data, and information on this sort of situation; we don't even have accurate numbers on how common "in-flight consults" are. Common "emergencies" include neurologic problems (fainting, strokes), exacerbation of cardiovascular or pulmonary disease, and gastrointestinal symptoms. About 10% of the calls are for kids (often having seizures). Unfortunately, medical kits aboard U.S. planes are often woefully incomplete. The stethoscope (and blood pressure cuff) are limited by the loud ambient noise (imagine listening for wheezes over the noise of the engines). Equipment for an IV line is available, but the only bag to hang is 500cc of normal saline, hardly enough to do a resuscitation. Needles are present, but due to safety fears, scalpels are not. For pulmonary problems, there are oral and nasal airways along with a generic bag-valve-mask and oxygen. All planes carry an AED (defibrillator to shock the heart in case of a life-threatening rhythm) which can be used as a monitor and rudimentary EKG. The drugs on board are frighteningly limited: epinephrine, nitroglycerin, 1 amp of D50, diphenhydramine, atropine, and perhaps one or two more medicines.

Physician volunteers act as a consultant to the pilot. They can have the pilot do several things: continue the course, drop to a lower altitude (useful to increase the partial pressure of oxygen and decrease expansion of gases in a closed space), or divert. Diversions, as you would expect, are extremely expensive and still take a substantial amount of time. They're also limited; a transatlantic flight doesn't have that option. Planes often consult with ground medical staff who are familiar with the resources on the plane.

Legally, responders on a plane are protected by Good Samaritan laws. I think it's important to respond in such emergencies. It's scary, and the resources are limited, but as physicians, we carry our knowledge, skills, and responsibilities into different and strange settings.

Image is in the public domain.

Primary Care Pediatrics II

Although the overwhelming majority of kids I saw were healthy, I did see a few children with chronic diseases. I saw a newborn with a striking hypopigmented periorbital rash which turned out to be neonatal lupus. I also met an incredibly loving and supportive family of a nine year old boy with Down syndrome. I learned a lot about what it's like to have a chronic disease in childhood and the impact it has on family and friends. Medically, I was able to review the clinical features of Down syndrome and its implications on future health. Similarly, I learned quite a bit when I met a child with sickle cell anemia.

I was talking to one of my classmates who was less enchanted about primary care pediatrics. One question that was brought up was whether these visits were important or necessary. For the most part, these kids are healthy, thriving, and happy. Many of them are only here for vaccinations. Yet they take up a decent amount of health care resources; the clinic is always overflowing and physician time is precious. Do kids who get routine pediatric care do better than kids who do not? I'm not sure, and I actually think it's an interesting and worthwhile question. Certainly, we would like to think that people plugged into the health care system do better, but given a population which is so healthy in general, what is the cost-benefit analysis?

Primary Care Pediatrics I

My week in primary care pediatrics was great. Nearly all the visits were well child checks (interspersed with follow-ups from hospital or emergency department visits). Most of the children were 2 weeks to 4 years (once they get their Kindergarten vaccinations, visits are less regular). I learned a lot about developmental stages, nutrition, anticipatory guidance, and vaccinations. But most of all, I enjoyed playing with the patients. I love four-month-olds who are beginning to interact with people around them, adorable and fun, tracking, laughing, and trying to roll. I also love four-year-olds who will answer questions and try to balance on one foot and copy drawings. One four year old patient told me her favorite animal was a "T-rex" and another told me she wanted to be a psychiatrist when she grew up (where she learned the word, I don't know). These kids are bursting with imagination, creativity, and energy. It makes me really happy to be around this patient population.

Pediatrics

My last rotation as a third year medical student is pediatrics at the main UCSF teaching hospital. The rotation is divided into one week of primary care, two weeks of urgent care, one week of nursery, and two weeks of inpatient pediatrics. While it is meant to give us the breadth of the specialty, we sacrifice exploring each aspect in depth. Pediatrics is fun; children are really a unique population. Pediatric attendings, attuned to development, understand the medical student plight of being very early in our developmental stages. I don't remember pediatrics well, even though I had formal lectures on it a year ago in the Life Cycles block. I did get some pediatrics in family medicine, but that was ten months ago. So I'm going into this block with a little apprehension but expecting to play and learn a lot.

This rotation has less formal didactics than other rotations; we have one afternoon for laid-back case discussions. But we join the residents for morning report and noon conference, and most of the learning is on the job.

Poem: Questions of Travel

I love Elizabeth Bishop's poem "Questions of Travel."
-

Questions of Travel

The doctor surprised me,
young, no-nonsense, hair in a bun,
black steel and angled.
She did not blink.
Her questions carve
turkey for Thanksgiving dinner.
This woman could take call like Scheherazade,
live in a hospital and crave nothing else.

I needed vaccinations for Egypt,
a land of hieroglyphics, Nefertiti,
and pharaohs in sealed tombs, as if
the country produced nothing but history and historians.
Oh, how it surprised me when I saw
cars rather than camels traveled the roads
and hotels were not shaped like clay pyramids.
How it surprised me when I asked
the doctor Questions of Travel
instead of the sterile and rehearsed,
she recited Elizabeth Bishop's poem,
eyes closed, lips deliberate in rapture, anticipation.

Match Day

Yesterday was match day, the culmination of residency applications for fourth year medical students. The whole ritual is a bizarre process which I will probably describe next year as I go through it. But match day is the exciting time when graduating students find out where they're going to be (stuck) for the next 3+ years. In a strange coincidence, this past week has also been the kindergarten match. I'm on pediatrics now (blogs to come) and all the parents are very excited (or dismayed) to report the kindergarten their kids got into; apparently, you can list up to 7 and it's very competitive. Good preparation for college, I suppose.

Anesthesia and Perioperative Medicine

The rotation as a whole was great; I loved the hands on procedures, seeing the surgeries from the other side of the curtain, and thinking about physiology and pharmacology. My first experience at the VA and their population of patients was education and fun. I reaffirmed a lot that I knew about anesthesia and learned a lot about the immense planning, preparation, anticipation, and thinking that anesthesia involves. Although the perioperative period is short, I realized anesthesia involves a lot of patient care and family contact. The teaching was fantastic, and I really had a fun time.

I've always been somewhat interested in anesthesia given my past experiences. As an undergraduate, I serendipitously stumbled upon a seminar taught by anesthesiologist Dr. Rosenthal, an emeritus professor at Stanford. Since then, I have worked with anesthesiologists in clinical and research settings. I like the combination of procedures and medicine, the focus on one patient at a time, the defined length of care. My personality fits anesthesia well; I like being organized, planning, anticipating problems, and instant gratification. I enjoy the OR setting. If I went into anesthesia, I would further train in critical care or cardiac anesthesia because I like complexity and difficulty. I think after this rotation, anesthesia remains high on my list of possible specialties, but I know there are things I'd miss about medicine if I only did anesthesia.

Simulator Session

Along with the usual lectures on sedation, acute pain management, preoperative evaluation, etc., we had a session with a simulator. These high tech mannequins act like a real patient in the OR and are controlled by a faculty member behind the scenes. The patient talks, breathes, and acts like a real person. We draw up drugs, induce anesthesia, watch the vital signs and monitors, and intubate the patient. The simulator session is a good teaching tool to train us in thinking independently. We had two cases, one involving hypoxia and one involving hypotension. When we watch our residents or attendings handle these situations in the OR, things seem smooth, under control, and manageable. But in the simulator session, I felt anxious, tense, and apprehensive as our "patient" began to crash. When we are responsible, it's a lot harder to remember all the steps of intubation or decide which drugs and what dosage to push or even evaluate the clinical situation. It was a great experience in teaching us how to handle these stressful situations and not to take a resident or attending's composure for granted.

Cardiac Anesthesia

I wanted to write a short post about cardiac anesthesia, the most exciting, stressful, and fun experience I had on my rotation. The cardiac cases are long, intense stressors on patients who can be fairly sick. During the anesthesia pre-operative visit, we spend a long time getting to know the patient, ordering tests, and preparing a plan. The montoring is complex; one case had two arterial lines (femoral and radial), two IVs, a pulmonary artery catheter through a central line, a trans-esophageal echocardiogram, and a bispectral index (neurological monitor). We prepare over a dozen medications, infusions, and emergency resuscitation drugs. We check and recheck everything. During the case, we manage everything tightly, titrating blood pressure medications, anesthetics, analgesics, antiarrhythmics. We follow arterial blood gases closely, optimizing the patient for bypass. After bypass, we pace the patient's heart and support the rhythm with medications. It requires working closely with the surgeon, perfusionist, and the OR team. Along with vigilance, cardiac anesthesia requires constant reappraisal of the clinical situation.

Anesthesia Analogies

I've heard anesthesiology described as "hours of boredom punctuated by moments of sheer terror." There are many analogies that exist to describe anesthesia. Some liken it to piloting; the take-off and landing are stressful, intense, high-risk times, but the duration in between is usually smooth sailing. Indeed, many of the innovations of the airline industry transfer well to anesthesia: multiple back-up systems, double check mechanisms, root cause analysis of errors.

But I've been convinced that the lay public, and even most doctors have no idea what anesthesia involves. We spend our time behind the blue curtain, projecting a confident smile, but behind the scenes, anesthesiologists do an amazing amount. Surgeons sometimes complain that "all the patient sees after the four hour operation is the dressing." Anesthesia is the same. The best you can do is what is expected, for the patient to wake up with her original baseline function. None of the stuff that anesthesiologists do is ever seen by patients or other doctors.

Anesthesia is the practice of vigilance. Most surgeries go as planned, without complications. But the anesthesiologist must be prepared to deal with anything. One attending compared it to driving a car. There are so many things to attend to that it's surprisingly difficult at first. I have my eye on the heart rate and blood pressure, and all of a sudden the attending points out the IV bag is empty or the patient might be moving or the surgeons are having more blood loss. As I'm putting in the IV, I have trouble listening to the beep of the heart rate or keeping an eye on the monitors. My attending reassured me that like driving a car, things are overwhelming when you start. But after a while, you can pay attention to the road, know the cars around you, gauge your speed, watch your gas, adjust the temperature, listen to the radio, navigate, and (with a hands-free device) talk on the phone. I can see how anesthesia is similar.

Poem: The Ides of March

The Ides of March

Unaccustomed to the civilities of high tea
we picked at our three tiered sandwiches
and let our conversation wander to the named days:
Pi Day, preceding the Ides of March.
Gone are the days of cryptic soothsayers;
now we have scientific hypotheses, cause and effect,
domino by domino, clacking down train tracks.
Nevermore will Oedipus and Jocasta sin,
no longer will we call on Odin's fury.
No - life now consists of Earl Grey
and double Devonshire clotted cream,
organic and sustainable, scientifically justifiable.
The Ides of March have come and gone.

Surgeries

Another interesting aspect of anesthesia is seeing the wide range of surgical operations. General surgery involved typical cases like hernia repair and laparotomies. I saw a handful of orthopedic surgeries; we did hip replacements under spinal anesthesia and knee surgeries with regional nerve blocks. I saw a cataract surgery (anesthesia is simple sedation), a robotic prostatectomy done by the Da Vinci system, and cystoscopies.

However, the most amazing surgeries I saw were the heart surgeries. I saw two bypass surgeries (CABG) and one aortic root repair for an aortic aneurysm. At the beginning of the surgery, the resident begins harvesting the bypass vein (saphenous for both of the surgeries I saw) while the attending does a median sternotomy. This vertical midline incision involves sawing through the sternum or breastbone. We adjust our ventilation settings to allow the surgeon to work in the chest cavity and dissect out the pericardium to examine the heart.

Seeing the heart is beautiful. I love seeing the dynamic pumping, the anatomy, and the pathology. All the surgeries I saw were done on cardiopulmonary bypass where they stop the heart, remove blood from the body to oxygenate it and remove waste products, and return the blood to the body. In order to do so, they have to cannulate the aorta and superior vena cava. We bring down the blood pressures to allow the surgeon to cut into the aorta, put in a tube, and suture it down. We then heparanize the patient to thin the blood for bypass.

Finally, the perfusionist starts the cardiopulmonary bypass, and the surgeon cross-clamps the aorta. The heart is stopped with ice and medications. I always feel apprehensive watching the heart bathed in ice and watching the EKG show hypothermia, then arrhythmias, then asystole. After the heart is still and empty of blood, the surgeon can begin the procedure, sewing the graft onto the heart in the CABGs or sewing an artificial mesh into the aortic root repair. After the repair, we take the patient off bypass, reverse the heparin with protamine, and watch tensely to see if the heart regains function. In some surgeries, I've seen the heart go into ventricular tachycardia and then fibrillation, a life threatening condition. While the surgeons shock the heart directly, we gave resuscitation medications. I unfortunately also saw an intraoperative myocardial infarction ("heart attack"), all risks with such large procedures. The surgeons finally insert chest tubes to prevent cardiac tamponade and wire the sternum together.

Image is in the public domain, from Wikipedia.

Procedures

Anesthesia is great because it lets us get our hands dirty. I've gotten to start IVs, draw up and administer medication, set up monitors, ventilate a patient with a mask, intubate, and generally help out with the set-up prior to a surgery. Intubation itself is a fun procedure, sedating and paralyzing a patient, visualizing the vocal cords with a laryngoscope, and then sliding a tube through. And I got to see a whole host of other intubation techniques including fiber optic intubation and awake intubation. The awake intubation was the most taxing one. We weren't sure whether we could adequately ventilate the patient if we induced anesthesia and could not secure an airway; furthermore, his anatomy and pathology (large thyroid mass) disturbed anatomic landmarks. As a result, we sedated him, anesthetized his airway with lidocaine spray, and intubated him with fiber optics. The entire episode was very difficult and took almost two hours.

I've also gotten to do a few other cool things. I got to insert a spinal needle, do some regional blocks (femoral nerve and sciatic nerve), and thread a Swan-Ganz catheter from the superior vena cava into the pulmonary artery. For shorter cases, I get to put in a laryngeal mask airway or nasal airway; to empty the stomach, I put in orogastric or nasogastric tubes. All these hands on things are pretty fun, but make me realize that preparation is the key to success.

Image is in the public domain, from Wikipedia.

VA

I really like the Veterans Administration. Fort Miley is located at the northwest corner of San Francisco and has an absolutely beautiful view of the Pacific Ocean. It's really a pleasure to drive there each day (though with the time change, mornings have been pitch black), and I'm often tempted to take the scenic route along the beach home. The patients, most of whom are older Caucasian or African American men, are incredibly friendly to students. For the most part, they really enjoy having us as part of their care and encourage us to involve ourselves as much as we can. I think this has a little to do with their military experience; they understand what it's like to be a trainee and work in a hierarchical system. Listening to them is really inspiring; they have amazing stories of their time in the service. Unfortunately, most of the patients I see have heart disease, hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and prostate cancer. It's a unique and wonderful population but also a narrow one.

Anesthesia 110

I am in the second week of my anesthesia rotation at the Veterans Administration. I love it. It's interesting, fun, but busy. Anesthesia is the care of the perioperative patient. We assess patients prior to their surgery, noting relevant medical conditions, selecting our anesthetic agents, and deciding on the monitoring necessary. Depending on the surgery, we may do local, regional (spinal or epidural), or general anesthesia, from sedation to knocking someone out completely. Anesthesiologists maintain the airway and are concerned primarily with the cardiovascular system during the stress of the surgery.

On this rotation, our primary objectives are to learn the role of the anesthesiologist, the prepartion of a patient for a surgery, and basics of airway management, sedation, and pain control. We are encouraged to do as much hands-on stuff as we can, especially putting in IVs and intubating (putting a tube in the trachea or windpipe so that a ventilator can help someone breathe). We learn a bit about making an anesthetic plan, interpreting data, and anticipating problems. It's just a two week rotation, but there's a good mix of didactics and clinical operating room experience; as a result, I'm having little time to blog.

Poem: Dostoevsky, to his Brother

Dostoevsky was arrested and imprisoned in 1849 for being part of the liberal intellectual group, the Petrashevsky Circle. In November, he was sentenced to death and faced a mock execution. His sentence was commuted to four years exile in Siberia. This poem is modeled after a poem written by my friend Taylor Altman who recently published her first collection, Swimming Back.
-
Dostoevsky, to his Brother

Russia's never warm any time of year
but my other option was hell
I was blindfolded, back against the wall
ready for the tolling of the bell

Someday I might write a book
one of the pastimes of exile
a writer emerging from imprisonment?
will never go out of style.

700

Some people love food. They try new restaurants, create new recipes, discuss culinary treats of all sorts. Other people love traveling. They backpack across continents, mingle with the locals, sight see cathedral and canyon. Yet others like wine. They frequent Sonoma, buy expensive bottles, taste with their sensitive palate. Or perhaps adventure: these people skydive, white water raft, swim with sharks.

I love stories. I love reading fiction, listening to people's lives, writing. In medicine, I enjoy patient narratives, learning about who they are, even thinking about the evolution of their diseases. I like drunk speeches, bedtime stories, historical accounts, philosophical arguments. I can't converse about sports figures or movie stars, but I like talking about authors. Instead of collecting souvenirs from worldly travels or fine wines, I have a folder with my favorite short fiction and a collection of my favorite poems. I rarely talk about food; instead, I talk about the conversation held over dinner. Everyone has their thing; stories are mine.

Biostatistics Primer

Comic drawn by Randall Munroe, from xkcd.com, shown under Fair Use.

Admissions III

It seems to me that medical schools are trying to attract two different types of people. We have our standard potential doctors who intend to practice medicine, pediatrics, radiology, neurosurgery. Their premedical education would be best served by the current system: cookie cutter science courses, a bit of clinical experience, a decent MCAT, etc. But UCSF seems to try to recruit a different type of doctor: the academic researcher, community leader, global health specialist, medical educator. Highly academic institutions like Harvard or Johns Hopkins like to create physician leaders, the best in the fields they pursue. These doctors don't do full time clinical practice. I think that recruiting them out of the same pool of applicants as the bread-and-butter doctor and training them in the same way isn't optimal. I would add another year of medical school training to this track of student; UCSF has a Joint Medical Program with Berkeley that grants an MD and masters. I would look for applicants who demonstrate passion, perseverence, creativity, and excellence in any field, and actively recruit them. Instead of looking among people who've been trying to impress medical schools, admissions offices should find those who are amazing at what they do and see whether they could become medical leaders.

Admissions II

What kind of criteria should medical schools use for admissions? I'm not sure, but I'm not convinced the current system makes sense. Dr. Lewis Thomas (1913-1993), a physician-essayist who served as Dean of Yale Medical School, Dean of New York University School of Medicine, and President of the Memorial Sloan-Kettering Institute wrote a fascinating essay in his collection Medusa and the Snail on premedical training. He claimed that if admissions policies to medical school are not changed, "all the joy of going to college will have been destroyed." He is a proponent of the broadly educated liberal arts curriculum: history, literature, English, philosophy, art, political science. I love his essay; here is an excerpt:

"There is still some talk in medical deans' offices about the need for general culture, but nobody really means it, and certainly the premedical students don't believe it. They concentrate on science.

They concentrate on science with a fury, and they live for grades. [...] The atmosphere of the liberal-arts college is being poisoned by premedical students. It is not the fault of the students, who do not start out as a necessarily bad lot. They behave as they do in the firm belief that if they behave any otherwise they won't get into medical school.

[There ought to be] some central, core discipline, universal within the curricula of all the colleges, which could be used for evaluating the free range of a student's mind, his tenacity and resolve, his innate capacity for the understanding of human beings, and his affection for the human condition. For this purpose, I propose that classical Greek be restored as the centerpiece of undergraduate education. The loss of Homeric and Attic Greek from American college life was one of this century's disasters. Putting it back where it once was would quickly make up for the dispiriting impact which generations of spotty Greek in translation have inflicted on modern thought. The capacity to read Homer's language closely enough to sense the terrifying poetry in some of the lines could serve as a shrewd test for the qualities of mind and character needed in a physician."

Admissions I

I don't know much about admissions for medical school other than what I learned going through it. By any measure, it's a harrowing process. It begins early in the undergraduate years when one has to commit to this career, taking a series of required courses. A prospective medical student has to volunteer early, try out research, do something "clinical." The vast cohort of premedical students doesn't create camaraderie; rather, it engenders competition, stress, even underhanded deception, backstabbing, and undercutting. The premedical life can be miserable; students get ulcers and nightmares, relationships fall apart, passion is lost. People forget why they're doing what they're doing, and many never find out or change course. Looking back, I wonder why so many students go down that path at all.

One of the things we are supposed to do as an undergraduate is get clinical experience, most likely through volunteering. I volunteered my time at a VA, providing social support to long-term patients in the psychiatric facility there. Now that I am actually in medical school, I realize that experience gave me no clue what most of clinical medicine was about. Yet so many of us premeds diligently put in our time, and it was questionable whether the driving force was a resume or true compassion. There seem to be so many things in life that we shoot for, not knowing really what it is we're getting ourselves into. We're asked to jump through hoops, and most of those hoops aren't even oriented in the right direction.

Poem: Two Roads Diverged in a Wood

Two Roads Diverged in a Wood

Clearly, Robert Frost had not been schooled
in the mechanics of quantum mechanics
when he wrote "The Road Not Taken."
If he had, he might have instead written
"The Electron Takes Both Roads" or
"The Road that Vanishes if We Watch" or
"Poetic License Allows Me to Characterize
The Road Not Taken, though Such Phenomena
Only Occur at a Macroscopic Level."

Thank God Schrodinger did not stroll past
Frost's New Hampshire farm; Thank God
Frost did not down a few pints with Planck.
Imagine, we might not have this ridiculous
American poem - we might not have anything to say
at graduation speeches or best man toasts
if Frost had attempted a marriage
between poetry and physics, the cutest couple
I may or may not have ever known.