Every time a homeless person is admitted to the hospital, an angel gets his wings

November 27, 2007 at 4:53 pm (Clinical rotations)

As part of the med school admissions process, applicants must write a personal statement in which they confess their undying love for humanity and their willingness to join the medical field for the sole desire to help others. Applicants come up with pretty unique ways of demonstrating their humility with everything from the mundane such as serving lunch to the homeless to extremes such as trips abroad to teach Third Worlders about sanitation and vaccines. When I applied, I had to prove that medicine was my life’s calling. I don’t know why medical schools purposefully force pre-meds to pretend that through divine will they chose medicine as if they were entering the convent and becoming a monk for the rest of their lives.

Part of this humility involves the willingness to treat all people regardless of race, religion, or ability to pay. Although a noble cause, medical schools try to coerce students into this feel-good attitude about treating a variety of patients including criminals, the insane, the criminally insane, and even the stinky. At my own urban hospital, we play host to numerous homeless persons who drop by for everything from getting a drug fix by mentioning vague 10/10 abdominal pain, to those hungry few who couldn’t convince the residents outside to donate a dollar to get a meal—so they show up at the emergency department demanding turkey samiches.

The emergency department serves at a gateway into the rest of the hospital. Its doctors serve as the primary care physicians for a variety of non-tax payers who think that healthcare is free anyway. Our hospital sees drug seekers, samiche seekers, and even skirt chasers. I’ve had quite a few Casanovas call out to nurses, “Hey baby doll, bring me some water and come on over here.” While these pseudo patients with no medical issues are taken through triage, a good physician can stop them there. Unfortunately, a few attendings still believe the personal statement story they wrote many years earlier.

I’ve seen sickle cell patients claim 10/10 diffuse body pain and demand round-the-clock dilaudid, only to fall asleep during the interview because they already had so much morphine on board. For this particular patient, I had to use a sternal rub to wake him up—at which point he slurred his words to say that he was still in 10/10 pain and required more powerful narcotics. I wanted to send him home and tried to plead my case for my attending. My boss said that we could not judge the patient’s level of pain and wrote for a patient-controlled dilaudid pump that would deliver enough drugs every 10 minutes that would send an average man into a coma. This patient was an average man. Nurses found him unresponsive and had to call a code to resuscitate him. When the patient regained consciousness, he stated that he was still experiencing 10/10 pain and requested cinnamon-coated apples for lunch.

Similarly, my current attending wants all patients to remain in-house for complaints that could be handled as an outpatient. I have one gentleman who has been waiting for the results of his biopsy during the past week. Keep in mind that we aren’t actually doing anything for him other than waiting for the test result to come back. When I asked the physician in charge why we’re holding onto the patient for so long, she replied that he may not return to clinic given that he’s homeless. We throw around phrases such as “lost to follow up” to describe patients who miss outpatient appointments. Some of these people are homeless; all of them are uninsured. So instead of losing $400 with the biopsy and clinic visit, the hospital is now losing $10,000 a week just to have the patient sleep in one of our mechanical beds.

The worst patients are the homeless individuals who show up with multiple friends and family members. For the homeless, getting admitted to the hospital is like winning the lottery. They get free meals, a warm bed, and a nurse offers a sponge bath every morning. One patient had six friends show up and demand beds of their own—because in their kindness, they wanted to take care of their buddy.

Instead of charging tax payers the extra expense of hospitalization, let’s send the bill to the attending who hides behind the label of loss to follow up. If nothing more, let’s have med schools cut their nonsense about helping others and admit only students who clearly have a business sense and a wariness to discharge patients when the hospital fails to provide added benefit over outpatient care. Now that’s a personal statement worth reading.

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1-800-IDEA-MAN: Eliminating the first two years

November 20, 2007 at 6:20 pm (1-800-IDEA-MAN, 1st and 2nd year)

After having been on the wards for a while now, I’ve seen the importance of having a strong background in the basic sciences before moving on to seeing patients. While many students and physicians alike bemoan learning the mechanisms of action and half-lives of medications, this information is important in creating a useful drug regiment for treating disease.

The traditional med school curriculum uses two years of lectures and classwork to teach the basic sciences, followed by two additional years of clinical experience. The thought is that students need a firm foundation in book knowledge before applying that information to patients. Occasionally, universities get students into the hospital to practice on patients. At my school, we have a course called Physicianship Training that teaches students necessary skills for clinical encounters. The school throws us this bone to keep us interested in continuing the lectures that drag on for those first two years. The only problem is that medical school costs about $30,000 a year for those lectures.

I’ve come to realize that the first two years of med school were largely a combination of wasted time in lecture and physicianship training exercises. I’ve noticed that my school charged $60,000 for students to teach themselves from textbooks for two years. Many of my readers who are already in medical school or are doctors are all too familiar with the self-teaching that occurs. Professors are notoriously bad at teaching about mitochondria and the brachial plexus, leaving the student with the task of clarifying the material later.

Given that the students are already self-teaching, I propose that we eliminate the first two years and leave the basic sciences up to the textbook authors. We’ll make the Shelf and Step exams the determining factor of who gets into medical school. The top 17,000 scores get in, while everyone else has to re-take Step I. Naturally, research experience and rec letters will play a role in admissions, but this method will bring in a steady supply of doctors with a strong basic science background.

Some critics will claim that Step I’s 350 questions do not cover enough information to fully assess a person’s ability to become a doctor. My first response is to point out that Step I is already used as the primary indicator of knowledge from the first years. Second, we can extend the exam to cover two days and double the number of questions if there is any concern that the test is not an adequate measure of science comprehension.

Companies such as Kaplan will emerge with their own medical schools to prepare people for these exams. Critics will claim that test prep groups teach to the test and not to the material. While there is some credibility to this argument, I certainly won’t miss out on all of the surgery lectures I saw where the surgeon shows before and after pictures of his work. Further, I am sure that Kaplan would hire better lecturers, would be more efficient at teaching, and would be cheaper. Similar to a cell phone contract, at $30,000 a year I’m currently locked into my school where the professors have a monopoly on my education. Under my plan, when universities are forced to compete against each other, the quality of lectures would improve drastically. Then, after Step I, future doctors could move onto the wards—and the real two years of medical school.

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Ask the Half MD: Are there any jobs for M.D.’s that don’t want to practice medicine?

November 11, 2007 at 11:29 pm (Ask the Half MD)

Every year about this time, medical students at all levels of their training begin questioning if they’ve made the right decision in life by pursuing an M.D. Whether this issue arises as a result of the first bad grade received on an exam or it comes from looming uncertainty of becoming a clinician for 20+ years, many students will eventually wonder if they can pursue careers outside of medicine.

Unfortunately, I can’t imagine many reasons for employers to seek physicians on any other grounds other than their medical acumen. While the C.I.A. is looking for health analysts, similar jobs are hard to come by. By its very nature, medical school is designed to give professional training for a occupation with a narrow focus. If it trained any more broadly, we’d call it business school and give everyone an M.B.A.

Sure, we can point to famous physicians such as Sanjay Gupta, Michael Crichton, and Howard Dean, but none of them really needed a medical degree to pursue their current careers. Gupta is merely a reporter; Crichton is a science fiction writer; and Dean long gave up anything remotely related to health or science. If anything, these men took on needless amounts of debt and schooling only to keep someone else from that spot in the applicant pool from becoming a real clinician.

Some readers will bring up the idea of health managers—hospital and health plan directors who don’t see patients, but still need some amount of medical knowledge before setting up shop. My answer to this objection is to look at the ages and resumes of these administrators. Many of the M.D.’s started off in practice and gained experience before transitioning over to leadership roles. Further, the field is full of managers with no firsthand healthcare skills. Duke University offers a degree in health sector management without any requirements of prior medical training. You don’t necessarily need to be a doctor to know how to lead other physicians. And given how poorly medical schools and residency programs are already run, I’m glad that others realize that having doctors in charge is a bad idea.

I realize that the thought of seeing sick patients for the rest of your life can seem unflattering. I also realize that there are warrant fears of getting sued, getting sick, or losing out on family time. However, anyone thinking of applying to medical school needs to understand what this life entails. The blogosphere is full of horror stories of medical training and practice simply because many of the things we experience are so painful. If you’re still in the pre-med phase, take a while to evaluate what an M.D. really means to you. You can certainly find other ways to gain money and respect without taking this route. If you’re already in medical school or residency, things get trickier. While Hoover was willing to leave, others may not be willing to make the same move so early. I’ve already seen so many classmates regret the choices they made in coming to medical school. Getting accepted is difficult enough; being able to admit to such a mistake is even harder.

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Lies that attendings tell

November 4, 2007 at 11:53 pm (Clinical rotations)

As a medical student, you’ll hear lots of one-line clich‚s that attendings tell to break you into the system. Unfortunately, all of these pearls are lies. Here are just some of the half-truths I’ve run across this year:

“The hierarchy in medicine is just like the military” — Always stated by someone who never served in the armed forces, this lie is meant to justify the way attendings and residents treat students. Apparently, watching the media depiction of boot camp is enough to make physicians tell others, “You’re going to kill someone one day if you don’t pay attention enough,” and other clever insults.

“Pimping is a good way to learn” — Apparently, using the Socratic method is a great way to teach. According to this time-honored tradition, a resident or attending will pommel a student with questions repeatedly until the student finally answers something incorrectly or states, “I don’t know.” Then, the teacher will proceed to humiliate the student further until the day’s lesson is presented. I was once asked during a surgical case about the cause of a woman’s liver adhesions. The attending berated me for having not studied gynecology. Considering that surgery was my first rotation, I don’t know why he would have expected me to know that STD’s cause a sticky liver.

The reason why this statement about pimping is so untrue is that the very purpose of teaching is violated. In order to learn something, you must first be ignorant. If a student shows up to rounds not knowing something, he’s going to get his ass handed to him by the residents. To shine on rounds, the student will instead have to learn on his own and then present that knowledge on the following day’s pimp session. In effect, the teaching session is therefore redundant and not necessary since the student will already know the answers to the question.

Another variation on this statement is “Pimping leads to the knowledge gap.” I have one professor who is fond of telling us that by harassing us with questions, he knows where to pick up the day’s lesson.

“I’ve got an opportunity for you that no one else will receive” — You’ll never get opportunities during third year, only grief. This phrase is meant for attending to force a student into some task that isn’t related to learning medicine at all. My opportunity this week is to sit in on a hospitalist meeting where we discuss patient safety goals and how we can prevent medication errors. My guess would be to have pharmacy techs draw up all of the day’s medications, put them in a plastic bag with the patient’s name and dispense time on the outside, and then drop them off at the nurses’ station. That way, nurses will merely have to pick up Mr. Jones’ 5pm bag of Flomax and bring it directly to his room at the appropriate time. Unfortunately, medical students don’t speak at these meetings, our job is to learn about the process of meetings. Other opportunities that have no bearing on your future abilities as a physician include grand rounds, resident report, and morbidity and mortality conferences.

Feel free to share some of the lies that you’ve heard around the hospital.

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