My reader take on kevinmd.com

July 28, 2008 at 9:06 am (Uncategorized)

I posted a reader take on kevinmd this weekend. With a fake story about witch doctors and socialized medicine, how can you go wrong?

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Short post: Japanese are a bunch of pussies

July 14, 2008 at 11:48 pm (Uncategorized)

I was sent this article about workers in Japan. I’d like to see them work American residency hours. What’s more, I’d love to see if anyone outside of medicine cares if a resident dies from “overwork.”

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This old white coat

June 17, 2008 at 10:19 pm (Uncategorized)

I’m sitting here at my desk looking at my old white coat. I’ve worn this jacket almost every day over the past year. It’s a reminder of the power and trust that physicians instantly hold with all patients. It’s the universal symbol of healing and knowledge. And yet when it comes right down to it, it is barely more than a glorified bed sheet with buttons and pockets.

It is covered with stains from various bodily fluids, food from the cafeteria, and a mysterious orange color that I have yet to identify. Although I’ve washed it regularly it will continue to be synonymous in my mind transference of infections from one patient to another.

This past year will certainly be memorable to me for a very long time. People talk about medicine as if it’s a calling. At no point have I ever felt as if God or any other deity was telling me to become a physician. But I do know that this is the field for me. Nothing else gets me up in the morning so early and so eager as medicine does.

Unfortunately, not everyone feels the same. So many of my classmates have gotten this far only to realize that they have made a very expensive mistake. I know of at least two people who now openly admit that they dislike medicine. Unfortunately, they are now more than $150,000 in debt and cannot leave the profession. They are now stuck in this job field for no other reason than economics. I think that many physicians are similarly trapped because so few other specialties have a high enough payout to clear the necessary debt that comes with this education. So to all of my pre-med readers out there: know what you’re getting into. This is an 80 hour a week job that comes with high emotional strain, abuse from attendings, abuse from patients, threats of litigation, inability to predict whether or not you will be paid, and a constant worry that maybe you didn’t make the right decision with that last patient. But if you like science, are good with people, and enjoy solving puzzles, then maybe you should consider a career in medicine.

Now that third year is over, I’m amazed by the amount of material that I have learned. I wonder why college took so long. If I were to employ the same model of education to my undergraduate degree that I have to med school, I would have earned my bachelors in about nine months. Despite all I have learned, I feel woefully unprepared to start practicing on my own. I started medical school with the realization that there was a gap in knowledge that needed to be filled before I could become a physician. With each rotation I see that there is no knowledge gap. It is a never ending abyss from which I don’t know if I can ever truly master. I have more training than a physician’s assistant, yet the medical community rightfully recognizes that I should not treat patients on my own. And despite similar realizations from physicians at all levels of training, the government and lobbying organizations continue to push for such asinine developments as “doctor of nurse practitioner.”

I look at this old white coat and realize that I have closed the chapter of one of the hardest years of my life. I look at it with a smile knowing that I don’t have to take a shelf exam ever again. I look at it with a frown knowing that one day my signature will be on the prescription pad or the order form—and that I’ll be the one who’s held accountable. I look at it and wonder where the last year has gone.

Prior to third year I used to exercise for a minimum of one hour a day. I was in such good shape that I had a resting heart rate of just over 50 beats per minute. The Air Force even recognized my athletic abilities when I was at officer training. And now, all that has gone away. When I was studying for STEP I, I gave up exercising so that I can free up more time to prepare for the exam. And then I continued not to work out. Due to the time constraints of this past year, I never got a chance to get back into shape. I also took the easy way out with regard to eating and began choosing fast food and microwavable meals over home cooking.

I tried running this week for the first time in almost 14 months. Once I hit the road I knew in less than 20 minutes at the past year has not been good to me. I gained 10 pounds since the start of third year—which is remarkable given that I’ve weighed the same for the previous decade. I started using a new notch on my belt, my blood pressure has risen by almost 20 points, my resting heart rate is up by 30 beats per minute, and there’s no telling where my cholesterol has gone.

I look at this old white coat knowing that I’m going to have to throw it away. It has simply become too filthy with all of the stains I’ve picked up here to continue its usefulness. And yet I hesitate to throw it away. I feel like there should be some kind of ceremony. A funeral. Simply tossing it into the garbage would be akin to shooting a member of the family in the backyard who has outlived his usefulness. And so there it continues to hang by the door where it has greeted me every morning over the previous year.

I look at this old white coat knowing that my training is almost finished. I look at this old white coat and know that I am about to embark upon the next journey—whether it be as a flight surgeon or in some other specialty. And whether medicine is a calling or simply an interesting job, I look at this old white coat knowing that one day soon I’m going to be a doctor.

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The unnecessary cost of technology

June 2, 2008 at 10:51 pm (Uncategorized)

Few professions can be as economically wasteful as medicine. Sure, we all love to bitch about politicians, but medicine really should take the award for financial pissing. We build wonderful technologies that can look at the inside of a person’s heart, check the electrical activity of the brain, read any component in a person’s blood, and even watch a baby move inside of the womb. However, all of these devices are made unnecessarily expensive by using non-standardized equipment and are being produced as new models that do nothing to bring down the cost of older versions.

Let’s take a look at the EKG. Any complaints of chest pain or a sensation like the heart is about to leap out of the chest will instantly be met with the EKG. This machine records the electrical activity through the heart and can be used in the diagnosis of arrhythmias, heart attacks, enlarge areas of the heart, and even certain electrolyte deficiencies. At its core, this device is simply comprised of 10 wires that are connected to an oscilloscope (a fancy voltmeter that you probably saw in college physics). I did some searching online and found that an oscilloscope can be had for about $150. The rest of the equipment needed to build an EKG can be found at Radio Shack for pocket change. In the real world, purchasing a new EKG machine runs about $2,000. What’s worse, this device will only print out the tracings of the heart as a snapshot. Getting a machine that uses a screen to show real-time activity of the heart cost even more. Then, once you have this paper-based tracing, you’ll have to insert it into the patient’s paper chart. The only way to get the same result into an electronic medical record is to buy a more expensive upgrade that can connect to a computer. Currently, the total package runs for about $4,500. The end result is that the physician will carry this charge to the patient for about $100 per EKG ($10 after insurance reimbursement). I imagine that an entrepreneur could build an EKG machine that connects directly into the computer’s USB port-complete with interpretation software-for less than $50. The computer’s monitor would serve as the oscilloscope; and a standard laser printer could print out the tracing on paper if desired.

Another unnecessarily expensive piece of medical equipment is the ultrasound. A solid high-resolution machine runs for almost $100,000. That’s a pretty hefty sum for a computer that merely interprets sound waves. One company has released a USB-based ultrasound probe that connects directly into the computer. According to press releases, it sells for just under $4,000. However, looking over these probes I’m concerned about the quality of the images. But the end result is the same: medical equipment can be produced at a cheap cost. The current system does nothing to reward us for developing innovative, cost-effective devices. Instead, we continue to throw away money on machines that can be produced by hobbyists for 1/100 of the cost.

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Price gouging the insured

May 19, 2008 at 12:43 am (Uncategorized)

The United States currently has about 47 million uninsured people.  Every year politicians, social groups, political commentators, ethical theorists, and medical student organizations try to come up with relief to the so-called “problem” by claiming that we need socialized medicine, higher taxes on the wealthy, a reduction in the amount of healthcare that is given, or any number of other scams that closely resemble Canada in price and England in quality. 

My own hospital caters to a large uninsured population.  Every day we provide numerous CT scans, x-rays, surgical procedures, intravenous immunoglobulin, radiation therapy, chemotherapy, and all manners of treatments that are given free of charge to our patients while inching us ever closer to bankruptcy.  Like most places, my hospital has taken to overcharging the insured to make up for the any losses incurred by caring for low-income people.  For example, merely walking in to the gyn emergency room immediately racks up a charge of $1000.  Once the ultrasound and blood tests are ordered, the bill quickly rises from there.  This charge is lobbied against everyone, regardless of their ability to pay.  We know full well that many of our patients—especially the ones seeking pregnancy tests—will never pay the bill.  Therefore, we are forced to charge exorbitant amounts to other people so that their insurance company will cover the difference.

Case in point: let’s consider my hospital’s trauma center.  After a car accident or gunshot, paramedics will quickly mobilize to bring the patient to a trauma center where a team of surgeons will run through the ABC’s of trauma, stabilize the patient, run him to the CT scanner, and take him to surgery if necessary. The cost for the initial evaluation is $29,000.  That price does not include surgery, hospital admission, or any critical care expenses.  Naturally, insurance companies realize what a scam this is and will only pay half of the price.  The patient is then left with a bill for $15,000—an impossible sum for most Americans.  The end result—even for an insured patient—is that the bill is left unpaid.  My hospital has become so fed up with not receiving reimbursements for its services that it immediately sends its bills to a collection agency without bothering to contact the patient for payment.  The hospital tries to explain its actions of double charging the insured by stating that it needs a method to cover the expenses of the poor.  I call this practice something else: price gouging.

In most states charging double for a good or service is illegal.  I would love to see an investigation into the practice of overcharging the insured.  Most consumers would be ashamed if they knew what healthcare really cost.

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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 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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Fixing healthcare

March 23, 2008 at 7:15 pm (Uncategorized)

I recently stumbled upon the blog Stuff White People. Although not medically related, it’s very funny in that it touches upon many aspects of white culture and things that White people claim to love, such as coffee, Asian women, soccer, and Barak Obama. Using that site for inspiration, I wrote this piece about White people’s need to fix healthcare in America. I tried contacting the owner of the website to see if he wanted publishing rights. He never wrote back.

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Fixing healthcare

White people are always trying to collectively fix the nation’s woes. They figure that with all of their genius and talent, they should be able to come together as a group and clear any one of the country’s problems, usually as a result of what they’ve seen on the evening news.

In the past White people have tackled airline safety, rebuilding New Orleans, and Terri Schiavo. This year White people have decided to take on healthcare. They like to throw around words like “health disparities” and “47 million uninsured Americans.” Never press a White person for further clarification as to what a disparity is or why having uninsured Americans is so bad. You’ll only create problems for yourself. Instead, simply nod your head and say, “We’re the only industrialized nation that doesn’t have a national health plan.”

While White people are eager to increase access to physicians for other people, they are wary of the black magic and side effects that result from using Western medicine. They are quick to point out that herbal remedies can be used to treat depression, lower blood pressure, and cure cancer, all without any of the side effects that prescription drugs cause. If you would like to open an herbal remedy store and make lots of money from a White person, be sure to use a least two of the following buzzwords:

All natural
Holistic
Native American
Eastern
Clinically proven
Endorsed by Chuck Norris

Occasionally, a White person might demand more information about a particular remedy you’re suggesting. In that case, be prepared to print out an article from Wikipedia, as it usually has all the answers. White people never bother to look farther than that.

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Happy birthday to Half M.D.

March 19, 2008 at 10:02 pm (Uncategorized)

I started this blog one year ago today with the hope that I could share some insight with life as a medical student. I wanted to cover everything from admissions to medical school, to funny patient encounters, to all the asinine hoops that we have to jump through to get an M.D.

I’ve written over 70 articles, have had more than 32,000 visitors, and have been cited by several respectable names in the medical field. I’ve also had quite a bizarre list of searches end up on my doorstep. The host of this blog, WordPress, can track what users are searching for online who eventually stumble upon my website. Below are some of the real phrases that people type into Google and somehow find this place:

death to men
i’m a nurse how do i date this MD
My first enema (three times!)
when a cna spread rumors about you
hobo christmas
medical students with nice breasts
can men take correctol
quick boner pills
running long distance with a catheter
i’m half assing my clinical rotations
sexist men (twice)
sake compared to other alcohol

I’m shocked. People must think that I’m a sexist man who is handing out dating advice while inserting catheters into athletes, giving enemas, and rating the best sake in town.

It’s been a great year—and I’m hoping that the next 12 months are equally enjoyable. I started family medicine this week and have already had one person suffer a transient ischemic attack (a mini stroke), a psychosomatic woman who walked into the office and asked for a handicapped parking decal, and multiple cold sufferers who think that we can magically cure their illness while at the same time they get pissy because they have to sit in the waiting room. I’m already cooking up some new stories.

Also of note is that tomorrow is Match day for civilian medical students. I want to wish everyone good luck in landing the residency of their dreams. Who am I kidding? All of the fourth year medical students are too busy celebrating right now to read this blog.

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Bankrupting the country through medical care

February 27, 2008 at 7:44 pm (Uncategorized)

The Democrats are in full swing this election season with promises of healthcare for everyone. They make it seem as if a magical fairy will sprinkle greater access and shorter waiting times upon the entire country, all the while keeping our taxes at the same level. What they don’t bother to mention is that the true cost of health care—$2 trillion—rivals the federal budget. In essence, to pay for everything we would have to nearly double the tax rate just to keep things the way they are now. What politicians also fail to mention are the further economic consequences of going to a single-payer system. Consider all of the men and women currently employed by the multitude of insurance companies. The moment we enter a single-payer system all of those people are going to be unemployed. Such a massive wave of people losing their jobs will lead to an immediate decline in government revenues and an increased burden on the welfare system.

While Hillary Clinton is trying to convince us to use evidence-based medicine as a way of deciding which medications and procedures get reimbursed, I wonder what standard would be used to uncover which parts of medicine are truly evidence-based. Using such a system would mean that all sections of complementary and alternative medicine could not be paid for. Many common surgical procedures such as the Whipple would also have to disappear. And even some of our medications—we aren’t sure of the mechanism of action for some of them—would cease to exist. Further, given the ever changing nature of medicine, how quickly will the government respond to new evidence? Just this week an article came out in PLoS Medicine stating that antidepressants are ineffective in patients with mild or moderate depression. If we were to use Mrs. Clinton’s principles of evidence-based medicine, would physicians have to rate a person’s depression in order to get a prescription to Prozac covered?

Also, now that healthcare is now “free,” will there be any limit to the amount of services that a person can use? Can a person with a headache demand an MRI just to rule out the one in a million chance that there is an intracranial bleed? Will over-the-counter medications now be covered? How many ultrasounds will a pregnant woman be allowed to have? I foresee physicians’ offices getting overloaded with very minor complaints: everything from an ingrown toenail to sunburns. And why stop at primary care? So long as we’re getting everything for free, let’s not even bother with setting an appointment. Let’s just go straight to the emergency department for any complaint that we want to get seen that day. My own hospital has loads of uninsured patients showing up to use the department as fast access primary care. I can’t imagine the time delay that will occur once millions more start to take advantage of this system.

Probably the greatest bite in the ass is that the American Medical Association—the group that is supposed to be protecting doctors’ interests—is the very organization that is stabbing us in the back with regard to health insurance. The AMA has recently begun airing commercials called Voice for the Uninsured in an attempt to shame us for having medical coverage. When I was a first-year medical student, many of my classmates joined the AMA by signing on for the $40 annual fee. I didn’t sign on back then and I have no plans of joining now. Yet somehow, I continue to receive postcards from the AMA on an almost weekly basis urging me to sign up for their program.

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