Banned at work

November 15, 2008 at 2:59 pm (Uncategorized)

I tried to log into my website this week from a nursing floor only to discover that my hospital has blocked access to halfmd.com, saying that it is “inappropriate for the workplace.” I wonder how they came to that conclusion.

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Ask the Half M.D.: what is the fourth year of medical school like?

November 5, 2008 at 8:22 am (Ask the Half MD)

Over the past few weeks, several medical students in the first through third-year classes have been asking me what the final year of medical school is like. I’ll be the first to confirm that the fourth year is indeed the promised land of your medical education. After working nearly 80 hours a week as a third-year medical student, you can look forward to the warm light at the end of the tunnel that is your fourth year.

Whenever I encounter residents or attendings and tell them that I’m a fourth year student, they tilt their heads to the side, stare off into space for a few seconds, and release a nostalgic sigh as they remember the joys of their own fourth year. A typical conversation might go something like this:

Senior resident: You’re late. Where have you been?
Me: I’m a fourth-year medical student.
Senior resident: Oh, in that case you don’t even have to be here. Would you like to go home?

The final year for medical school can roughly be divided into two domains: getting into residency and vacation. You’ll certainly have to do some work this year as you will travel the country on externships in an attempt to impress various programs where you might want to enter residency later. During these externships you’ll serve as a star student reliving the 80-hour work weeks that you grew to hate so much during third year. You will study hard, work hard, arrived early, leave late, and introduce yourself to every faculty member in the department in the hopes that you can get a favorable review when the time comes to apply for residency.

Fourth-year is also filled with lots of administrative headaches such as tracking down grades, securing rec letters, meeting with deans, applying through ERAS, setting up interviews, booking flights, and voting in the presidential election. But after your you have finished all of those tasks, you are ready to enjoy the next six months.

Whereas the third years are required to take courses in surgery and obstetrics where they invariably get yelled at for not knowing everything on the first day, fourth years get away with courses such as nuclear medicine and geriatrics. Typically, the day starts at 9:00 a.m. when I come in and meet my resident to obtain his signature on my attendance form. I then go home at 9:05. Thanks to the accreditation board which requires that we attempt to learn something during this glorious year, clerkships hold afternoon lectures which usually revolve around having an attending show up late, tell us how wonderful fourth-year is, give out the answers to the final exam, and then end class early.

That’s not to say that all medical students take fourth-year so lightheartedly. There are a few scabs at could never let go of being a gunner for the previous three years and for some reason, feel the need to study and work away their last year of freedom. These students will take clerkships in the intensive care unit and hematology/oncology service where they will work to the point of exhaustion while the rest of us play drinking games during the presidential debates. As for me, I started brewing my own beer and I’ve been working my way through all of John Grisham’s novels. As far as I’m concerned, those are the only sorts of activities that fourth-year medical students should be involved in.

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Ask the Half M.D.: Is there a best medical school?

October 21, 2008 at 8:17 pm (Ask the Half MD)

A reader posted the following comment on another article:

Hi, I was just wondering how large a factor what medical school plays into getting a residency and job where you want. I realize getting into Harvard Med is a bigger deal than say Oakland University. But when you say apply to as many school as possible, is it simply the money issue that would prevent you from doing that, or is getting into a below average medical school that bad of a thing.

I’ll summarize it by saying, “Is there a best medical school?”

The U.S. News & World Report rankings would have you think that there is a vast difference in the quality of medical schools here in the United States. Pre-meds, parents, and the media play into this frenzy of believing that certain schools are vastly superior to others. I’ve written in an earlier post on my feelings about the ranking methodology. Instead, I will use today to discuss whether or not there is any validity to these rankings.

First, consider performance on the licensing exams. All universities, on average, have a 95% pass rate for their students. That also means that there is, on average, a 5% failure rate. Both Harvard and Drexel each have students perform at the top of the bell curve as well as those who fail outright. While there are differences in the average score, your performance on the test is based solely upon your own preparation, and not any magical instruction given by the school.

Here are the match lists for Johns Hopkins University (currently ranked #2), Brown University (currently ranked #31), and Albert Einstein College of Medicine (not ranked). You will notice that people from all three universities have matched in noncompetitive specialties such as pediatrics as well as competitive specialties such as ophthalmology.

I also found a list of people who have matched into plastic surgery in 2007 and neurosurgery in 2008. Take a moment to go through the names of all of the schools. You’ll notice a variety of universities are listed, including rank and unranked programs.

That’s not to say that where you go to medical school is completely meaningless. Residency program directors certainly take it into consideration. For example, if a senior resident from State University is doing well at a particular residency, the program director is likely to look favorably upon medical students applying from that university. The converse is true. If a resident who is an alum of your university is performing poorly, the program director might unconsciously think that you will struggle as well.

Some research has been performed on the subject as to what program directors are looking for. Several years ago the journal Academic Emergency Medicine published an article ranking the most important factors of an application. They are:

1. Emergency medicine rotation grades
2. Interview
3. Clinical grades
4. Other
5. Recommendations
6. Grades (overall)
7. Elective at the program director’s institution
8. Board scores (overall)
9. USMLE step II
10. Interest expressed
11. USMLE step I
12. Awards/achievements
13. AOA status
14. Medical school attended
15. Extracurricular activities
16. Basic science grades
17. Publications
18. Personal statement

You will notice that “medical school attended” falls behind “other” and “interest expressed.” So maybe it does play a role after all.

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The angry resident. You will meet this person

October 15, 2008 at 8:35 pm (Clinical rotations)

Just look at this census. Many of these patients have been here over 2 weeks. Good lord! This guy has been here for 34 days. Just what is his deal? What’s that? You say that these are burn patients? Well if they’re just going to lie in bed all day and drink Ensure, they can do it at home.

Why do these patients’ families want constant updates? Good God, cut the umbilical cord already! Your 40-year-old daughter can deal with her subarachnoid hemorrhage just fine. If there’s ever a real emergency, I’ll give you a call.

Don’t these patients have anywhere better to go? Just look at the waiting room in the emergency department. Half of them are here just because they want a turkey sandwich and a bus token. They’ve got no real health issues. Maybe if they would go out and get a job, they wouldn’t have to constantly exploit the system. Hey, I see that guy wearing a gold chain. He had better not tell me he doesn’t have insurance.

Why the hell hasn’t the orthopedics resident returned my page yet? I’ve called him twice in the past 10 minutes. The last time I had to get a hold of them, they use some excuse about being in the OR for a trauma case. Don’t give me your mass casualty nonsense. If a busload of schoolchildren just happens to flip over while driving down the highway, there are certainly plenty of other hospitals that people can go to. But there should always be at least one person to answer my page.

There goes the psychiatry resident talking to himself again.

What does this attending think he’s doing, cutting in front of me in the cafeteria line? I’ve got to be at clinic in 15 minutes. And although he supposed to be there, too, he certainly won’t be seeing as many patients as I will. I hope he chokes on his chocolate cake. That was the big slice meant for me.

Why is this med student following so closely behind me? I know it’s his first day as a third-year, but does he really have to be my shadow? I think I’m going to have to run in a zigzag pattern and then duck behind a corner to lose him. Stop asking if “there is anything that you can do” already! I’m not the one who writes your evaluation. But if I did, I would say that you’re creepy and you know nothing about medicine.

Oh look, the nurses on the fifth floor are calling me again. I wonder what they want this time. I wish they would just learn to read my handwriting already and stop asking me stuff like, “What do you mean here?” I mean, give the patient his pain medication and stop pestering me.

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The unnecessary vilification of greed

October 9, 2008 at 8:28 pm (Uncategorized)

In the movie It’s a Wonderful Life we learned that every time a bell rings, an angel gets his wings. This simple chime of a bell can somehow confer morphological changes to a mystical being. The opposite seems to hold true for politicians. Whenever Barack Obama begins to speak of insurance companies, a little bit of truth dies. In the most recent debate I heard him say that insurance companies are greedy as if to imply they are unethical and have the sole purpose of trying to make Americans’ lives miserable. This rhetoric of greed as applied to Wall Street, insurance companies, big businesses, hospitals, and doctors is a bit off the mark.

Greed is a good thing. The knowledge that harder work leads to more money causes men to put in more hours and complete more goals. Obtaining more wealth is a seemingly reachable prize that can be obtained by creating better products, by developing more efficient methods, and by taking new risks. Greed is the invisible hand that runs the United States. Its roots span back as far as the Declaration of Independence. Our forefathers were not seeking religious freedoms when they broke away from Britain; they wanted lower taxes. It’s the reason the Spanish-American war was fought. It’s the reason Henry Ford developed the Model T. And it’s the reason that doctors are willing to work 80 hours a week.

Whenever an applicant applies for medical school he has to come up with a convoluted explanation as to why he wishes to become a physician. Many of the personal statements I have read in recent years center on helping other people, delivering health care to those in need, and providing access to those who cannot reach. In reality, many people are seeking a $200,000 a year job. An applicant who can say, “There’s no way I would do this for $30,000,” is much more honest. And yes, while there are some people who would deliver healthcare for free out of the goodness of their hearts, enrollment in medical schools would significantly drop, and the number of physicians in the nation would be at a critical shortage if greed were taken out of the equation.

Greed is a wonderful thing. We should embrace it and get people to work harder and more efficiently by dangling this prize in front of them. I know what you’re thinking. “Have you bothered to read the news, Half MD? The whole reason we’re in this economic mess is because of the predatory lenders and the greedy people on Wall Street!” I would counter that by saying the whole reason we’re in this mess is because of unethical behavior and stupidity. Greed did not cause banks to dole out $300,000 mortgage loans to persons making $40,000 a year—but stupidity did. Greed did not cause banks to sell unfunded insurance plans to each other—but unethical behavior did. On the other hand, when greed is contained within ethical boundaries and wise decision-making, it can be a force for good and for change.

Medicare could use its dollars to influence physician behavior for the better. It could offer higher payouts to those doctors that use a centralized electronic medical record system. It could grant bonus money to the lowest 20% of hospitals with nosocomial infection rates. Someone will counter by saying, “But then greedy hospitals will simply not report their nosocomial infection rates so that they can earn bonus money.” And I will respond by saying, “No, unethical hospitals will not report such embarrassing data.” A greedy, honest hospital will develop more safety barriers to prevent the spread of infection.

The next time someone says to you, “Those insurance companies sure are greedy,” usually counter back with, “I hope they are.”

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The Life Raft for psychiatry

September 29, 2008 at 7:21 pm (Life Raft)

Few fields of medicine are as unique and exciting at psychiatry.  Where else are you going to find a 34-year-old man talking to his penis and telling it secrets?  At the end of your shift you will come home wanting nothing more than to tell all of your friends and neighbors about all of the interesting people you’ve met throughout the day.  Don’t go breaking HIPPA and other codes of decency just yet.  There are several important rules of etiquette that apply more so to psychiatry than to any other specialty.

First off, never say that a patient is “crazy,” “bizarre,” or even “psychotic.”  These terms stigmatize mental disease and place blame on the patient for a neurochemical disorder that could just as easily affect any one of us.  Instead used terms like “inappropriate behavior” or better yet, cite specific examples of things that the patient does, such as “responding to internal stimuli.”

Second, never say that a psychiatry resident is “crazy,” “bizarre,” or “psychotic.”  For whatever reason, the strangest people in medical school generally end up as shrinks.  And as the book Mount Misery tells us, psychiatrists will specialize in their defects.  There are many stigmas against the field both within medicine and among the lay public.  And you certainly don’t need to contribute to them.

Television shows such as Dr. Phil leave us believing that anyone can treat mental disease and has turned us into a nation of armchair therapists.  Encroachment on the field by social workers, life counselors, and a variety of psychologists who use any title such as “school psychologist” make the specialty seem easy to enter.

Among other physicians, psychiatrists are seen as being helpless to treat medical conditions.  I wanted to apologize to our consultants every time we had to call them because our residents could not manage blood pressures of 150/90.  Whenever a patient attempted suicide by cutting his wrist and then presenting to the psychiatric hospital, he was immediately deferred to another physician to suture the wound closed.  The other specialists were generally greatly annoyed that anyone with a title of “M.D.” could be unable to manage mild hypertension or mildly elevated blood sugars.

What you need to know to succeed on your clerkship:

1.  Drugs, drugs, drugs.  With the exception of electroconvulsive therapy, there are no procedures to master in this rotation (as if you’ll even see ECT during this rotation).  The sole method of treating mental disease amongst psychiatrists is to use an armory of medication in the hopes that the various neurotransmitters are put back into proper balance.  I suggest that you either find or make a list of various psychotropic medications, their mechanisms of action, their indications for use, and the side effects specific to each drug.  Such a list of drug names would not be very long, but should contain a detailed amount of information.  For example, clozapine  is a very effective medication against schizophrenia.  However, its most dangerous side effect is agranulocytosis.  I can guarantee you that you will be asked about this drug at least once.

2.  DSM criteria for diagnosis.  In psychiatry, the majority of diagnoses are made solely upon history.  There is no physical exam, and anyone who tells you otherwise is lying to himself.  There are however a battery of paper-based scoring test that are used in the management of a patient’s condition.  Rarely are labs ordered.  If they are, look to order electrolytes, a thyroid panel, vitamin B1, vitamin B12, urine toxicology screen, and an RPR to test for syphilis.

Several months ago I posted my stories about psychiatry on this website.  They generated quite a bit of discussion amongst my readers.  Here are my previous posts.  I hope that they can create new conversations amongst all of you.

You won’t believe the stuff I saw today
Everyone gets a diagnosis and a prescription
Psychiatrists as shams
You won’t believe the stuff I saw today (part 2)
The fake doctors
Leap Day
How’s that for a can of whoop ass?
You won’t believe the stuff I saw today (part 3)
You won’t believe the stuff I saw today (part 4)

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What if the restaurant business followed the medical mindset, part 2

September 21, 2008 at 1:55 pm (Uncategorized)

I’m sitting here at Tino’s restaurant wondering how much longer my food is going to take. I’ve been here for at least 20 minutes already and no one has taken my order. A waitress has passed by me twice without giving me my meal. In fact, she’s avoiding eye contact because she knows it’s her job and she just doesn’t want to do it.

I had to start coming here because my old restaurant, Great Papa’s, has become too expensive. I can no longer afford my prior chef. He kept raising his rates citing nonsense like overhead and food poisoning insurance. I’m pretty sure that he just wants more money so he can join a country club. We all know how greedy chefs are.

Christ, how long is this going to take? Is he out playing golf somewhere? Just where is my chef? My waitress mentioned something about a kitchen fire. My last chef tried to use the emergency excuse whenever he wanted free time to surf the Internet, too.

Doesn’t he know that food is a basic right? I can’t go on if these meals become too expensive. Why does he keep raising the rates? There needs to be some kind of intervention. A system where food can be given to the good citizens of this nation so that we can eat and know that our bellies will not starve. On top of that, I need everything on the menu, right now, and for free. And I don’t care how many times they tell me that the food won’t mix well together. Don’t let laziness be an excuse.

I don’t trust the chefs and chef assistants anyway. They’re always making mistakes. There needs to be more oversight of their assistants, the food prepares. Lord knows I don’t want them messing up my food. Just last week my friend Joanna got food poisoning from eating the shrimp. She stayed up the whole night vomiting. That crazy ER doctor that she went to see tried to pawn it off on my friend by saying she was throwing up because she had been drinking too much whiskey. I’m pretty sure that the doctor was in cahoots with the chef.

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Introducing the EBM calculator

September 20, 2008 at 2:38 pm (Uncategorized)

I recently began working on a calculator for biostatistics and evidenced-based medicine. While there are certainly valid complaints about the field—I’ll let others be the complainers—EBM has pulled medicine out of the dark ages into a more scientific discipline. To help with calculations regarding diagnostic procedures, I’ve put together this Excel chart that can give sensitivity, specificity, predictive values, likelihood ratios, 95% confidence intervals, and a graph of the pre-test vs post-test probabilities.

Simply enter the appropriate information into the 2×2 table and the program will take care of the rest. If you wish to print the form, only print the first page. The rest of the chart contains a series of calculations.

In the future I plan to continually add to the EBM calculator to include exposures.

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Ted Newley, running for Congress

September 15, 2008 at 4:57 pm (Uncategorized)

Hello, my name is Ted Newley, and I am running for Congress as a representative of the Enchanted Forest.  I want to represent all woodland creatures such as elves and dwarves.  In short, I want your vote.  I’m a reformer among reformers and I think that I can do the best job for the Forest.  Let me share with you my platform.

I have big plans for the little citizens of this area.  My major goal is to reform health care with the following actions:

1.  Extend Medicare’s drug plan to include magical potions.  Far too long western medicine has come in with its mass-produced medicines that do nothing but cause rashes and diarrhea.  I would force the federal government to open up its coffers to the healing power of the eye of newt and wing of bat.

2.  Allow benefits for trips to gypsies and fairies.  American physicians may have many years of training, but they still don’t know how to properly predict the future or heal a broken heart.  Through the power of tarot cards and palm reading, a soothsayer can accurately tell you when you’re going to die.  Further, there is no pain like that from a broken heart.  A fairy should be able to enchant your heart and find your one true love.  Once you have that, there is not much more that can harm you.

3.  During the Great Depression the chant was “a chicken in every pot.”  I advocate for pot of gold at the end of every rainbow.  We need to ensure that healthcare provides a holistic healing for the patient.  What better way to do that and to provide the necessary funds for getting a taxi ride, hiring a babysitter, and purchasing pet food?

If you agree with me on my plans for the future, vote for me this November.  You can meet me in person on October 8.  Food will be supplied by the Keeblers.

Ted Newley

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Doctors, the smartest and dumbest people alive

September 2, 2008 at 6:59 pm (Uncategorized)

The public seems to have this dual perception of physicians as if we are the smartest, yet stupidest people in existence. For instance, there is a certain infallibility that doctors are expected to have when it comes to medical care. You didn’t diagnose a rare presentation of a disease? You’re going to get sued. You failed to order a CAT scan on a person with a chief complaint of “mild headache,” yet has no fever, no neck stiffness, no focal neurological findings, and is perfectly awake and oriented, only to later find out that the person has a hemorrhage? Time to hand in your license. That non-smoking, white collar worker has a cough and you didn’t bother to check for mesothelioma? I want you to meet my two friends Cohen and Cohen.

At the same time, however, the public has a perception that physicians are easily swayed by marketing gimmicks. Somehow if a drug rep gives me a free pen with the word Seroquel written on the side, I’m going to start prescribing the product to everyone that has a chief complaint of “feeling happy.” Those shining members of ethical practice known as Congress have decided that come January, drug reps can no longer supply free gifts to doctors. The thought is that physicians are too easily swayed by the cheap gifts given out by drug reps. Meals are still fair game because “they can be educational.” Textbooks, on the other hand, are no longer allowed because they are considered big ticket items. Somehow, a fancy dinner that costs $100 is considered more appropriate than a book with the same price.

How do doctors to get this dual reputation of being the most educated yet easily persuaded members of society? And where am I going to start getting my pens?

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