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.