A note from the other side of the doctor-patient relationship

April 26, 2008 at 3:40 pm (Uncategorized)

  

A few months ago I was involved in a car accident.  My vehicle was T-boned at an intersection by an elderly man who was driving an SUV.  I was thrown into a railing and was pinned inside of my car.  I needed a few seconds to realize what had just happened.  I had enough mental faculty remaining that I could pull out my phone and dial 911.  I remember that there was blood quickly dripping from my head, as well as shouts from nearby pedestrians who were trying to see if I needed help.

Paramedics arrived almost instantly but were helpless to do anything because my car was pinned between the SUV and the rails.  Because of the impact, the doors in my car were sealed shut and could not be opened.  Firefighters had to push back the SUV, breakthrough my windows, and then saw through my passenger side door to get me out.

My neck was a little stiff, my hip hurt like hell, and I was still bleeding from several spots on my face and head despite all of the pressure I had been putting on them with a paper towel.  The paramedics successfully got me out, put a C-collar on me, and tied me down to a backboard.  I told the lieutenant that I was a medical student and I wanted to go to my university’s hospital.  I figured that if the paramedics let the attendings know that I was a student, I would get quicker service.  I reminded the paramedics again on the trip to the emergency department that I was a student at  the approaching hospital and that they needed to let the physicians there know.  Otherwise, I was probably going to have to wait several hours before being seen, despite having just been pulled from a totaled car.  One of the EMTs laughed it off and try to assure me that anyone who comes in from a motor vehicle collision would be seen instantly, regardless of his educational status.

I’ve mentioned before on this website that my university’s affiliated hospital is an urban medical center that caters to a largely uninsured population.  Its emergency department sees over a thousand new patients every day, effectively triages them, and provides care to whoever needs it.  The dedicated physicians and nurses do all of this despite the numerous abuses of the system by the patients who come here.  Unfortunately, due to all of these visits, the time between walking in the door and getting a physician’s ear for five minutes can take up to three hours.  I warned the paramedics that I was going to be in for a wait if they didn’t alert the staff there that I was a medical student.

In the past, whenever my classmates have needed emergent care, they simply pull out their student ID and precede to instantly seeing the attending.  Unfortunately, I had been hit on a Saturday night and did not have my ID with me.  The paramedics never did tell the physicians that I was a medical student.  And I ended up staying in triage—tied to a backboard—for over two hours before finally being seen.  Since I had so much free time on my hands, not being able to move and all, I used the stopwatch feature on my wrist watch to see just how long I would wait.  I was right; the paramedics were wrong.  I was there for a very long time.  So long, in fact, that a police officer was able to arrive from the scene, take a statement, and then issue a ticket with the other person’s insurance information available.  The only person from the hospital who came to talk to me during that time was from finance.  She only wanted my insurance card.  I told her that I was a medical student only to have her brush it off by saying, “They will take care of it.”

During the wait, I really felt as if I needed to use the restroom.  I tried to flag down the nurses to let them know that I had to pee.  No one was paying any attention.  As people in scrubs walked by, I would say, “Excuse me, miss, could you help…” and then watched as the person ambled by without so much as looking at me.  I thought about all the times I had ignored patients in the emergency department who try to get my attention for food, water, a trip to the bathroom, or whatever else was on their mind.  I always ignored them, too, because I assumed that they were psychotic.  And here I was, receiving the same treatment.

When I finally did get to see the physician, he was greatly annoyed that I had to stay out in triage for so long.  Our hospital’s rule is that medical students and residents get seen instantly.  He was frustrated to learn that no one had bothered to talk to me from the medical side in the entire time that I was held to the backboard.  In the end, I didn’t suffer any broken bones.  I didn’t even need stitches.  I couldn’t receive them anyway.  So much time had passed that I was ineligible for any kind of suturing.  Luckily, the bleeding had stopped anyway.  I was sore for the next few weeks, had a little difficulty walking because my hip was in so much pain, and now have several prominent scars on my head and face from where broken glass cut me during the collision.

I saw life as our patients see it: scared, wondering when I would be seen, and greatly annoyed that finance got to me before anyone in healthcare did.

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How do they find us?

April 22, 2008 at 11:03 pm (Clinical rotations)

Despite working in a private practice family medicine clinic, today I managed to land all of my neighborhood’s psychotic patients who came in seeking primary care.

1. Lady with borderline personality disorder came in asking for a steroid injection into her knee. Her regular doctor was out of town and she demanded that we perform the procedure. As I tried to take her vitals, take a history, and even find out what medications she was on, she kept angrily replying, “All that information should be in my chart! Just give me the shot.” On physical exam, I noticed that she had multiple linear scars on her arms pointing in different directions, a sign that she had been cutting herself for a very long time. She tried to explain the scars by saying, “I have a lot of cats.” We sent her home with a prescription for tramadol and told her she would not be getting a steroid injection from us.

2. Schizophrenic diabetic man came in with peripheral neuropathy of his lower legs. Essentially, that means that his blood sugar has been uncontrolled for such a long time that now the nerves in his legs are severely damaged. The man can barely feel his feet, and what sensation he does have left he describes as constant burning and tingling. He even lost the hair on his legs because his diabetes had gone on for so long. When I asked him how he checks his sugar at home, he replied, “That machine is just too damn complicated to work. I’m so fucking frustrated with how hard it is because I’m a genius. No seriously, I’m a genius.” He then went on to tell me how he had witnessed UFOs and how aliens had been healing his friends of their illnesses. He was wondering when the little men would be paying his home a visit to take care of his illness. We gave him a prescription to Lyrica, which he then forgot on his way out. He never did come back.

3. A couple in their 70s presented for a routine checkup. The man had been diagnosed with OCD previously and had minor anxiety attacks with everything I told him. Since he was about 24 years overdue on getting a colonoscopy, I told him that he would need the procedure to look for any signs of colon cancer. He just about had a heart attack. The wife—who is now on husband number 3—consistently yelled at him to shut up while the doctor was talking. They’re a solid example of marriage as a failed institution.

I surely have lots of respect for you primary care doctors. With the awful payment structure that is bestowed upon generalists, I just don’t see how you guys do this day-in and day-out. Outpatient medicine really is the seventh layer of hell for me. (Layer number six is general surgery.)

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How to be a drug rep

April 20, 2008 at 3:04 pm (Uncategorized)

How many of you have watched TV in the past month? Chances are if you sat in front of a television for more than 30 minutes, you’ve come across a commercial hocking any number of prescription medications. For example, Pfizer states that it can give great erections, Merck will cure your depression, and everybody has a treatment for restless leg syndrome.

These commercials do a lot of damage to physicians. Patients show up all the time feigning symptoms to obtain the latest medication. Probably the most disgusting is the commercial for Abilify, an antipsychotic medication used to treat schizophrenia. From what I can gather by watching the commercials, the manufacturer is telling people that Abilify can treat memory loss. What’s worse is that Abilify cost nearly $300 a month. I don’t know a single schizophrenic who has the income necessary to pay for this drug.

But if you’re ready to sell your soul and start hocking the goods to doctors directly, consider becoming a drug rep. These company reps make a ton of money simply by distributing free samples to physicians and then obtaining their signatures. From the intelligence I’ve gathered by talking to reps, a talented employee can make more than a pediatrician. They get loads of free gifts from their bosses, and can sometimes go on trips at the company’s expense. But before you start asking where to sign up, realize that there are several necessary qualifications that must be possessed before joining.

First, you must be a gorgeous female under the age of 30 who is blonde, willing to wear short skirts to show off perfect legs, and be able to convince male physicians that you are considering going out with them if they continue to take your free samples. The best reps can flirt as if they are at a nightclub and trying to pick up strangers for the evening. They will provide a private two-hour lunch to the doctor that causes him to run very late in seeing his afternoon patients.

Notice, I said nothing about education or medical experience. Most drug reps graduate from college with a liberal arts degree and find themselves at the age of 22 with no redeemable skills in the business world. Eventually, they turn to the pharmaceutical industry and take a six-week course on hocking Lipitor. They learn to say the right buzzwords like “randomized controlled trial,” “statistically significant,” and “This medication is on most insurance companies’ formularies.” If you become a drug rap, realize that you’re a salesman first and foremost. Any knowledge you have about pharmacology comes secondary to your ability to communicate with others. Think of the used car salesman. How many of them even know what a catalytic converter is, much less where to find it on the particular model that they’re selling?

The absolute worst drug reps are the ones who try to make everything professional, or worse still, become defensive when their profession is attacked. Earlier this week, I saw drug rap hanging around the patient waiting area. Spotting a drug rep is easy: they are always wearing business suits or dresses, and are carrying a significant load in a luggage cart. To any casual observer, they look as if they are about to board an airplane. But I know better. They are here to sell.

I saw this person, approached him, and said, “Are you a drug rep?” To which he replied, “I’m not just any rep. I’m the best! Would you like some information on…”

I cut him off and said, “No, I just want a free pen. I will also take free textbooks, medical equipment, or trips to Colorado.” At this point he became irate and said, “Do you know anyone who is gotten a free trip to Colorado?”

“No.”

“So you’re just saying that. My company has never given me or anyone else that I know a free trip.”

Cool it, mister. I’ll gladly show you the door if you’re going to get annoying. We’ve got a dozen drug reps visiting this office every afternoon. There is certainly no shortage of people jumping all over themselves to get a two-minute opportunity to talk to the physician. And you can ditch the speech about how your company’s randomized controlled trial of pitting your drug against your major competitor is statistically significant to a p value of .07. I don’t want to hear it. Neither does my attending. So give me the free stuff and be on your way.

And if you really want to piss off a physician, just try teaching him pharmacology. If you pimp me, I’ll school your ass very quickly on how the body works. You’re here is a marketing liaison, not as a medical school professor.

So remember: breasts, thighs, and a nice smile deliver medications. Leave the attitude and the book learning to me.

Edit: a reader alerted me to this article from the Public Library of Science about drug reps and their tactics.

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How to behave on an interview: advice for the tour guides

April 14, 2008 at 11:32 pm (Applying to med school)

Previously, I’ve written on this blog tales of bad behavior by interview applicants. Examples include asking about the student:body ratio in the anatomy lab, challenging people about the school’s current ranking, and trying to lead the tour as a pre-med. This time I want to address those medical students who volunteer their time to serve as tour guides and lunch hosts: don’t be a jackass either.

I’ve taken a step back from giving tours due to time constraints in third year. I still try to meet with the applicants on a regular basis to discuss my experience here at the university and to answer any questions they may have about life as a student here. I always try to answer their questions honestly such as mentioning that we do a poor job of preparing students for the boards, that we waste a lot of time in Physicianship Training learning about things such as medical informatics and Medicare billing structure, and that while many opportunities abound at this university, students are generally left on their own to make use of those opportunities. I try to answer the applicant’s questions by highlighting both the positives and negatives so that they have a good generalized picture of what to expect should they matriculate.

You can imagine my frustrations then when I see medical students selling our campus as if it’s some kind of used car. I’ve seen numerous people say, “Our school lets students have lots of hands-on experience starting within their first month. You won’t find that if you go to Harvard or Yale, where you’ll just stand in the back of the room and not be allowed to touch the patient.” First, unless you’ve actually attended Harvard or Yale, don’t ever make a comparison between your institution and someplace else. Second, making these comparisons makes it seem as if you are trying to compensate for something. I am reasonably sure that the tour guides at Harvard are not going around saying, “Don’t go to State University because you won’t get the same kind of experience as you’ll receive here.” I don’t think that there is a person alive who would choose our school over Harvard if given the choice.

I also hate it when students feel the need to say that our school is a noncompetitive environment and that attending any other university will only be met with constant fighting with classmates. I repeatedly hear “I hear from my friends at other universities that students hide books in the library so that other people can’t study.” To this day, I have never met a medical student at another university who can confirm these rumors. Without exception, every one of my friends at other institutions has stated that their classmates are generally friendly and will freely provide their notes to the rest of the student body. I really don’t see what makes our students so special. I’m pretty sure that attending any medical school will result in the same experiences and the same knowledge.

Finally, don’t cuss in front of the applicants. I watched in horror as a graduating fourth year medical student dropped the F-bomb four times during an applicant lunch. He tried to present himself as some kind of jock or frat boy, but came across as a royal a-hole. I wouldn’t be surprised if none of those people end up coming here due to his disrespectful attitude.

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A lecture worth giving

April 8, 2008 at 10:42 pm (Clinical rotations)

As part of the family medicine rotation, all students must prepare a lecture on a selected topic of disease that is commonly seen in the outpatient setting. Our speeches are supposed to be given such that a lay audience can understand material, though we’re really just talking to our classmates. We also have to create pamphlets similar to what is given out in a doctor’s office to sufferers of these pervasive illness is. You’ve probably encountered the trifold pamphlets that have a title along the lines of “Have you had your cholesterol checked recently?” The professionally created note then goes on to list all the dangers of high cholesterol, before finally telling you that you need a particular drug (as prescribed by your doctor of course). These tracts—which look eerily similar to religious pamphlets—are usually created by drug companies as a marketing tool under the guise that they are somehow educating patients.

I have been assigned the topic of vaginitis, inflammation of the vagina that is usually caused by infection. I’ve decided to throw caution to the wind and present a lecture worth giving. I imagine that it would go something like this…

The lights dim, Yanni starts playing, I light a candle and say something classy to the women in the audience like, “You look great. Have you lost weight? I’ve got a talk today that’s just for the ladies.”

(PowerPoint goes to the opening slide)

VAGINITIS

I’ll then give a definition of vaginitis and describe some of its features: erythema, burning sensation, and discharge. “Red, hot, and juicy? That sounds more like an advertisement for the Steak and Ale than it does a serious disease.”

Next, I’ll have to discuss how women get it. “Most cases of vaginitis are caused by bacteria. Women get infected with bacteria ‘down there’ by committing sin. So remember, preventative medicine is key: go to church and stay away from doctors.”

Finally, I’ll wrap up with the treatment section. To treat vaginitis doctors have to go after the most common causes. Therefore, they typically use metronidazole because it kills most of the organisms that can cause this disease. Treatment decisions are usually empirically based without confirming the presence of the microorganism. Gynecologists are handing out metronidazole like it’s Halloween candy. Like they’re donating Thanksgiving turkeys at the homeless shelter. Like they’re Oprah and giving out freebies. “You get Flagyl! You get Flagyl! You’re all getting Flagyl!”

Now that’s a lecture worth seeing.

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The new rankings are out; patients continue to get quality care

April 6, 2008 at 8:37 pm (Applying to med school)

The pop-culture magazine U.S. News & World Report recently released its latest edition of the university rankings. This list—published on or around April 1 each year—attempts to tell readers which colleges are the best in the country. A look at this year’s rankings reveals that Harvard and Johns Hopkins University are once again the top two medical schools in the country. The magazine then goes on to record 60 other names in sequential order as if going to medical school at #10 somehow produces a better doctor than #20. While I’m glad to see that my school is named amongst these ranked universities, I wonder if these numbers mean anything. Besides, who’s ever heard of Washington University (#3) anyway?

Each medical school goes through a rigorous accreditation process and is forced to turn out some of the world’s best physicians. I’ve looked at the match list for several universities this year and noticed that medical students can land top residencies no matter where they get their initial training.

Further, patients really don’t care where their doctors have gone to school. There is no shortage of people waiting to get treatment from my university’s attendings. As much as I like to rail against the inefficiency of my medical school, our alumni fare well after graduating. They can enter any specialty imaginable, have published tons of papers on various diseases, and can do a pretty good job of taking care of patients, too.

To this day I have never heard of physicians say that finding a job is difficult. A quick glance at any set of classified ads for doctors will reveal that there is a huge demand for our services, regardless of where we did our training. Heck, I even had one psych patient asked me if I had gone to Yale, Harvard, or Princeton for medical school. He was shocked to find out that my program even existed. My own personal internist went to a Caribbean medical school. But if his American residency program believe that he was good enough to become an internist, I’m certainly willing to continue seeing him.

The take-home message is that the ranking system does more to inflate the egos of people who are applying to medical school than it does to instill confidence with patients. I don’t know why med school applicants put so much stock into these numbers.

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