Better to Best: Thoughts on Global Health Care Systems

Sorry for the extra-long hiatus.

Posted in Medical School (General), PharmFree by reshmagar on April 15, 2012

This year has been something else. It’s been fun, devastating, satisfying, frustrating, and more all at once. I can safely say that I am confident I chose the right career path. As sad as this may sound, I really love working at the hospital. I love saying hello and good morning and smiling to everyone who walks by and talking to patients who most of the time think I’m in high school. I love working with the whole team to figure out what’s going on with our patients. I even love the cafeteria…especially now because post-call, chocolate chip pancakes really hit the spot. So all in all, that’s good. I’m pretty relieved about all of this. Hopefully, this love will be reciprocated and my patients one day will enjoy having me as their provider.

Anyhow, I’ve neglected this blog for way too long. It’s been a very busy year and during my free time, when I had hoped to update this, I instead decided to sleep, catch up with friends, or do non-productive things like watching way too much television on my computer or go to websites like this.

But I’ll be back in two weeks. I will be officially done with third year and taking a couple years off to serve as the American Medical Students Association PharmFree Fellow and then go to grad school. I’ll definitely be updating this with various things I’m working on or the many articles/emails in my inbox that I’ve archived for later. 

In the meantime, see how your medical school did on the 2011-2012 PharmFree Scorecard in terms of their conflict of interest policies.

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Difficult Patients.

Posted in Doctoring, Medical School (General) by reshmagar on August 30, 2011

A few weeks ago for my family medicine rotation, we were asked to write about a difficult patient encounter. I’ll share with you all what I wrote as this pretty much sums up how I feel on a daily basis on this rotation.

During my first few days at my site, I have not had an extremely difficult patient or interaction that has stuck out in my mind more than others. In fact, almost all of my patient visits have been a bit difficult in a strikingly similar way. None have been difficult because the patients have complex, multi-systemic illnesses or because they were extremely abrasive. Most of the patients have a trusting relationship with my mentors and get along with them well, regardless of their condition. Instead, I found the patients regardless of their age or background to be difficult not because of their presentation but because of what my mentor and I couldn’t do for them.

From one patient to another, I’ve seen a pretty similar problem list – high blood pressure, high cholesterol, and prediabetes/diabetes. Many also are overweight or obese. Many others used tobacco. The age of the patients ranged from elderly women who were now afflicted with COPD and other chronic conditions to teenagers just entering middle school. The blood pressure and diabetes were easy to manage by either titrating up their medication, refilling current prescriptions, or adding another to their daily cocktail when what they were already taking wasn’t cutting it. While my mentor and I were in the back discussing the patient and grabbing any samples they might need, my mentor would lean over to me and say, “Now comes the hard part. We have to talk to them about their weight/smoking.”

We always left the best for last, jokingly bringing up the smell of cigarettes we noticed as soon as we stepped into the exam room or asking them if they remembered what the doctor had discussed with them the last time (this usually was their cue to say “You told me I needed to lose weight…” and smile sheepishly). It was almost like watching a play where different patients played the same character repeating the same lines over and over again. My mentor reminds them of their promise to lose weight or stop smoking from the last visit. The patient would look away while my mentor reads out their weight changes or tells them again that they were at risk for COPD. Often times, the patient will then say, “I know, I know. I’m trying to but it’s just not working.” End scene.

Maybe it’s the comfort of knowing that the patient will return within a few weeks or months. Maybe it’s past experience of having patient after patient who comes in with increasing weight or no change in their smoking habits. Maybe it’s a mixture of both but this would be the point where my mentors give vague suggestions about how to lose weight or stop smoking – eat more fruits and vegetables, less carbohydrates and junk food, start exercising, stop eating out, stop smoking, do you want the patch, do you want Chantix, do you want gum. The patient nods along, answers appropriately before agreeing with the doctor that yes, things should change.

I find these encounters the most difficult. I always make it a point when talking to the patient about their treatment plan try to give them a concrete goal to achieve by the next visit that more often than not, surprises them, as they cannot give their usual responses. Instead, they now have to reserve to responses my mentor and I don’t like such as “no” or “I don’t know” or “maybe next time”. One patient came in for a routine follow-up exam was surprised to hear she had gained weight within the last month. I asked her further about eating and activity habits and found out that during the summer, she wasn’t working and instead sitting at home more. Additionally, although her portions at meals had become smaller, she was still eating a lot of starch-heavy foods and soda. When I told her about programs in her community that offered free group exercise classes as well as websites with recipes, she was startled and sputtered out “no” saying she could not see herself exercising in front of others. I instead tried to tailor some exercise around walking her dog and received a vague “I’ll try” to that. I left the room feeling frustrated and voiced my concerns to my mentor who nodded in commiseration and responded, “You did what you could do. She’s hopeless.”

This happened again the next day with a 17-year-old girl who reported smoking a pack-per-day since she was 13 years old. I was later shocked to find out that her mother had a similar history and now was suffering from severe COPD. I asked the girl if she would like to quit smoking to which she said she would but didn’t know how. I told her of the various options and suggested maybe trying to cut down on the number of cigarettes over the next few weeks before we saw her again. I set the goal as a half-pack per day and offered the patch. She nodded and said, “yeah, okay we’ll see.” I tried other tactics – bringing up her mother’s history and telling her that while her mother’s condition was irreversible, hers wasn’t. I also did a lung exam on her that showed decreased breath sounds and wheezing. She told me that she noticed she lost her breath often to which I responded that it was possible for her to not feel like that anymore by not smoking. At the end of the visit, despite the positive responses I had received from her, I got the feeling that she would return as she was today – looking older than she is and reeking of cigarette smoke. I could only hope that she would at least try this month and that my shpiel would be repeated again.

I tell myself I should be patient and that in time, there will be some patients who change and some who don’t. It’s difficult though to watch them walk out the door and wait for the next time they would come. It’s difficult to think that they will often walk out the door and my mentor will either wait till the next time or just give up somewhere down the line in order to preserve their relationship with the patient. I understand the reasoning behind this but I wish I could do more…or at least do something.

If only this was the perfect solution…

Posted in Medical School (General), Patient Quality and Safety by reshmagar on August 9, 2011

A while ago, many of my friends in med school posted this article from the The New York Times Health Blog – lauding the innovative method the doctor used to counsel her patient about their medications. To summarize the article, the author, a physician had a visit with one of her usual elderly patients who was chronically ill with diabetes, hypertension, and high cholesterol. Like many who are chronically ill, the patient had over time been prescribed a slew of medications which he brought to the visit and was confused as to when to take each of them. Turns out he was unable to read the pill bottles as well as the directions the doctor had written out for him the visit before. To solve this dilemma, the author worked painstakingly on a new set of directions;

Mr. M and I opened up his pill bottles. We extracted a pill from each and taped it onto a piece of paper. I drew a sun next to the ones that needed to be taken in the morning, and a moon next to the ones for nighttime. He left my office with sheet of brightly colored pills, a rainbowlike guide that I hoped would offer him access to the quality medical care he surely deserved.

I first came across this article posted on Facebook by some of my friends stating that this would be a great way to tackle non-compliance amongst patients. From my last rotations in psychiatry and Ob/Gyn, I frequently see patients struggle to take their medications at appropriate times for a variety of reasons – sometimes they just don’t like the way the medicines make them feel or feel like they don’t need them or other times, they are unable to access them due to loss of insurance or funds. I read the article hoping to find new insight into this topic only to find an interesting anecdote on patient health literacy and a good method for the patient described in the article.

Regardless, I do agree with the author’s approach to her patient in that she actually spent time to explain the medication regimen. During my first year of medical school, I worked with an Urgent Care Center physician who taught me from day one the importance of not only writing out instructions for the patient and explaining the treatment plan to them but also the need to spend time asking the patient what they understood the regimen to be. In the hospital setting and in other clinics, time is precious and often, patients leave with a stack of discharge instructions with paragraphs regarding their condition and medications as well as prescriptions they have to pick up on their own time. We often at our hospital triage see repeat patients who failed to follow-up with us as directed or pick up their medications causing their medical condition to exacerbate. They return often more sick than necessary and a new treatment plan has to be created. Some are even admitted.

In looking at the problem of health literacy, there are certain pragmatic factors to take into consideration to ensure that patients upon leaving the hospital understand their treatment. For many doctors, time is a limiting factor. In most medical practices including primary care practices, follow-up appointments last approximately 15 minutes. In this time, not only does the doctor have to address any immediate concerns that the patient has, but they also have to ask questions to ensure that they are no other health issues going on the patient may be unaware of as well as a modified physical exam. Usually, the physician also spends a minute or less going over any results and their recommendations.

Additionally, physicians often schedule patients back-to-back which means that any additional time taken with one patient going over medications takes away time from subsequent patients. With the impending shortage of primary care doctors, it is not possible right now to take on less patients. The Affordable Care Act will provide much-needed health care to millions of new patients who will all require a primary care doctor. In line with this, however, there are provisions to build more community health centers but no clear provisions to increase the number of primary care doctors. Until there are more students going into primary care and more incentives to do so such as a salaried position or less overhead costs in a private practice, doctors will probably not be able to spend an extra 15-20 minutes with patients who have complex chronic diseases along with other social issues such as being illiterate. At least, not on a regular day.

During gynecology, one of my attendings set aside one day per week for a chronic pelvic pain clinic where she tailored care for each patient that included long sessions with each person along with regular emails and phone calls. Perhaps, this is the solution in primary care we need. A day set aside for the most complex patients to spend longer amounts of time to construct a comprehensive plan. Rather than being sent to a chronic care specialist, patients who see their primary care doctor more often will get regular check-ins to ensure they understand the plan completely.

Another solution proposed has been to hire a nurse or other practitioner who after each visit will sit down with the patient to go over their treatment plan and check-in with them. This, I also do not see as realistic. With rising overhead costs from the lightbulbs and toilet paper in the practice to paying the billing specialists and receptionists and more and more primary care doctors closing their practice due to these costs, it seems unlikely that hiring someone else to sit down with patients after their visit is a sustainable solution.

Today, I start family medicine. I have no idea where I am going to be placed but I do wonder if I will encounter a similar situation to the one detailed in the New York Times health blog. I would like to think that I will spent the extra time needed but what if my attending expects me to finish the visit within a certain period of time (which has happened) before moving onto the next patient? Then what solution will work then? Will I allow the patient to walk away with a confused look on their face and a statement along the lines of “Well, if you have any questions, feel free to call or email. Okay?” That makes me uncomfortable especially after recently realizing that I am more at peace immediately constructing a flowchart plan and wanting to actively try the best algorithm as soon as possible. I am not comfortable with expectant management usually…but I guess, we’ll see what happens with this rotation.

Does anyone know of solutions to this that have worked that they’ve seen implemented? Any input on this would be much appreciated.

The State of Pharmaceuticals (in pictures!)

Posted in Medical School (General), PharmFree by reshmagar on June 19, 2011

Last week, I was sent this awesome infographic via AMSA PharmFree regarding the incentives that doctors receive from drug companies to prescribe expensive brand-name drugs. I agree with the first statement here that drug costs were not really brought up during the healthcare reform debate. In fact, when Dr. Ezekiel Emanuel came to Brown this past year to talk about how healthcare reform would impact our current system in terms of costs, he glossed over the issue of rising brand-name drug costs and the newly (and sneakily) added evergreening legislation that extend patents for brand-name biologics stalling the entry of cheaper generics into the market. When asked further about this, Dr. Emanuel called the legislation “unfortunate”. Womp womp.

Needless to say, it is true that doctors do have the power to decide what to prescribe to their patients. Working in the psychiatry unit, this was very apparent as there was a Walmart $4 prescription list available throughout. We had one patient who was prescribed brand-name antipsychotics by his PCP. The patient was on Medicare and when he went to the pharmacy, he was told that the medication was not covered and he would have to pay a full price of around $1000. Needless to say, after a month the patient stopped taking his medications, became again psychotic and was admitted. Now he’s on the $4 brand but suffers from some motor side effects. On the list, there’s only one anti-psychotic available so we didn’t really have a choice in the matter and can only hope that his outpatient provider will keep an eye on him to see that these side effects don’t get worse. We wondered why his outpatient provider prescribed him this brand-name medication, especially as it was the most expensive one available. Perhaps, they just didn’t realize he was on Medicare…or perhaps, they were getting some nifty kickbacks from Big Pharma. While there have been laws passed banning pharmaceutical companies from even giving out pads and pens to doctors, we see them in offices all the time. The incentives are still there and unfortunately, there’s little to no regulation of them.

In JAMA this past week, an article was printed stating that while two-thirds of medical students think that drug companies’ educational materials are biased, at least one-third find the information used and half or more would like to receive ADDITIONAL materials from manufacturers. The most shocking finding, I think, is that as medical students advance from their preclinical to clinical years, they are more likely to find the incentives from pharmaceutical companies to be “ethically permissible”. Seriously? Yikes.

Clearly, this shows that these incentives and the biases of doctors as a result are not just a policy issue but also a cultural one. So long as medical schools in their curriculum and practice do not preach or practice to their students the importance of being independent and unbiased in their prescription practices and have a discussion about the impact their decisions will have on drug costs and in turn, the healthcare system, this issue will continue in the eyes of many students to be ethically ambiguous.

Medical Students’ Paradox: Drug Company Materials Biased Yet Helpful, They Say

Rebecca Voelker

Medical students appear to be a paradoxical lot in their views of pharmaceutical companies. A new review shows that at least two-thirds of students surveyed think the companies’ educational materials are biased. But at least one-third say the information is helpful, and half or more would like to receive additional materials from drug makers (Austad KE et al. PLoS Med. 2011;8[5]:e1001037). The findings also show that as medical students advance from preclinical to clinical training, they are more likely to view gifts from pharmaceutical manufacturers as ethically permissible.

The study’s authors say they conducted the review in response to ongoing controversies about the role of pharmaceutical companies in undergraduate medical education. With an understanding of how physicians’ attitudes toward the pharmaceutical industry develop during their training, the researchers say, medical schools would be better equipped to teach students about interactions with pharmaceutical companies and to develop institutional policies on industry contact with students.

The review is based on 32 studies of 9850 students at 76 medical schools in the United States, Canada, Australia, Russia, and several countries in Europe and the Middle East. The data show that by the time medical students reach their clinical training years, up to 90% have received some form of educational materials from pharmaceutical companies. Students who had contact with pharmaceutical sales representatives were more likely than those who did not to have positive perceptions of industry marketing practices. Students exposed to more marketing were less likely to view promotions as inappropriate or an attempt to influence prescribing patterns.

“Interventions that decrease students’ contact with industry and eliminate gifts may have a positive effect on building the ‘healthy skepticism’ that evidence-based medical practice requires,” the authors wrote.

From children to adults.

Posted in Medical School (General) by reshmagar on June 13, 2011

Two weeks ago, I finished my 3 week stint in child psychiatry. I found myself feeling very sad to leave the adolescents, even the ones who had just been admitted and wondering how they were going to do afterwards. During the following weekend, I would think of some of my patients and the questions I wanted to ask them on Monday before realizing that I wouldn’t be seeing them anymore. I’m sure that the next set of students that rotate through will do a wonderful job but on Friday at 5 pm, I couldn’t help but think about all the notes I had written about a particular patient and how much of a rapport I had built with them and whether or not the next student would be able to do the same. It’s funny how when we find ourselves really invested in something, we think that when we step away, it’ll fall apart when in reality, it just goes on fine without us. Everything in the end has a strange way of working out.

From the rotation, I did determine a few things. First off, I am not emotionally capable of being a child psychiatrist. I really enjoyed working with the adolescents who came through the unit and found myself able to connect with them well. Maybe it was because I had lots of shared interests with them such as drawing, comic books, sports, television shows and also almost infinite time to talk to them about anything and everything, but regardless I was able to provide some pertinent clinical information to my team that would help create a better treatment plan. I was, however, unable to not think about them after I left the unit. At night, I would come up with more questions to ask them and mull over the stories they told me. Seeing some of the kids who came to the unit to escape being at home killed me – they were willing to stay in a hospital with strangers who asked them invasive, personal questions rather than being at home with their “loved” ones. Some of the kids never wanted to leave or thought life outside would never get better. Those cases left me feeling helpless at times. I don’t think I would be able to handle having that feeling for more than 3 weeks.

Secondly, we were never really only treating the patient. We were dealing with their families and more often than not, the families usually contributed to why the patient was admitted to the hospital in the first place. I saw mothers leave their children in the unit, not visit them over the weeks they were admitted, and instead, go on vacation. Everyday I saw our team’s social workers struggle to contact the patient’s caregivers, schools, and therapists only to get frustrated by a lack of response or caring. They did amazing work, coordinating all the family meetings and packaging together the patient’s discharge plan with not only the psychiatric component but also the educational plan, family plan, and sometimes even providing afterschool activities the patient might be interested in. The social workers were definitely overworked in the unit each handling around 10 cases at once. The doctors were also overworked often having other responsibilities outside of the inpatient unit including outpatient services. There were so many pieces that needed to be fit together and often, we had to compromise to make sure the patient would be even safe. Other times, we let the patient go in hope that they might even be readmitted so that they and their families would confront the reality of the situation.

Now I am working fulltime with adults in an inpatient unit. At first when I walked in, nothing seemed too familiar. The unit was a drab white unlike the yellow, blue and green of the adolescent unit. There was no psychologist on staff to do psych testing or run groups. Patients were cramped into smaller common areas. Private spaces for doctors to meet with patients were limited. Most of our patients also had previous diagnoses and were alone. Many were alone – not having any visitors, single, and having very unsupportive families who did not want to take care of them. Later on though during interviews, I realized that my adult patients were very much like my child patients in the ways they handle situations and the lack of insight into their condition. It struck me how much my adult patients had reverted back to their childlike defenses in light of their mental illness or social situation. Patients would often pick their favorite staff in terms of how much the staff gave them what they wanted. If a staff member was stern with them, the patient would immediately paint them to be an enemy and tell other staff members sometimes even dishonest things about the “evil” staff member who had wronged them. They threw temper tantrums launching food, their fists, or even all of themselves at people or at walls. The doctors in the unit of course treat them as they act, taking away items they “rented” such as radios or pencils, speaking them to calmly and slowly, and sometimes just ignoring them and isolating them from other patients.

In the adult unit, I was still left with the same feeling as when I was with adolescents. We would ensure they were safe, give them medications, and send them to a long-term provider for them to get help for the underlying issue that brought them to the hospital. It’s an unsatisfying feeling…watching a patient walk away and wondering what will happen to them, wondering if we had made a difference, and wondering if they would be okay.

I’m not sure yet if this feeling is more pronounced or specific to working in an inpatient psychiatric unit. I’m not sure if the feeling will ever go away either.

Child Psych Week 1

Posted in Medical School (General) by reshmagar on May 18, 2011

I have now completed my first of six weeks of my psychiatry rotation. Half of the time I’m at a hospital that specializes in Child and Adolescent Psychiatry and the rest of the time I’ll be in an inpatient unit in an adult hospital. For my first three weeks, I’m in the Adolescent Inpatient Unit where teenage kids are admitted usually from the ED for suicide ideation, self injurious behavior, or trying to commit suicide. Coming into the rotation, I was told by my fellow fourth years that it would be a light, fun experience where I would get to play with kids, interview them, and work with my attendings to help manage their medications and therapy. While it has been fun sometimes, it definitely has not been a light experience.

Before coming into the rotation, we had the option of expressing our interest in child psychiatry or not. I chose to as I really love working with kids (and as evidenced by my strange habit of taking pictures of them running around although now in New Jersey, I can’t do that anymore or else I’ll be arrested…). During our psychiatry block, we had a few sessions on child psychiatry but most of the material was geared towards adults and I was interested to see how the physicians would work with the family to manage the care of children. To be honest, while I love kids, I was a bit apprehensive about working with teens as they’re toeing the line of trying really hard to grow up fast and be recognized as older and still staying a kid. Also, my child psychiatric viewpoints especially in the realms of teens were shaped by Law and Order: Special Victims Unit and not so much actual academic material. From that show, I did know that there were a lot of players in the management of children other than their parents – there were their teachers, school counselors, social workers, outpatient therapists and depending on what their diagnoses were, a whole host of other people specialized in those individual areas such as learning disabilities and specific types of therapy. In the AIU, I constantly see the interplay of all these people and how complicated it can be. Many of the teens that come through have seen a slew of providers and depending on their own preferences, their parents’ preferences, their insurance, and sometimes even their age, they jump from one person to another. Cohesive continuity of care is essential for these kids.

While the kids have been great to work with and sometimes fun, I find my heart breaking for them a little everyday. These kids are coming in for acute treatment in order to ensure they do not harm themselves and figure out coping mechanisms to deal with the stressors in their life. Unfortunately, most of them come from homes that are either abusive (physically, verbally, emotionally, and/or sexually), burdened by the parents’ own mental health issues, and sometimes on the lower end of the socioeconomic totem pole. During talk rounds in the morning, there is an insurance representative present to inform the doctors when the last day of their stay in the unit will be covered. I have seen patients come in and leave in less than 3 days due to lack of coverage. The doctors and social workers have to coordinate together to ensure family meetings as quickly as possible as well as the most effective strategy for the kids to not harm themselves and to receive outpatient treatment. I have yet to see a child who has been fully treated once they leave the unit. Many of them return to stressful homes and relationships and consider being at the hospital a small vacation from the real world. They become behind in school for weeks, months, and even years and many are second or third time returners.

This rotation has been particularly trying for me in some ways. When talking to the kids and hearing their sad story, I immediately feel sympathetic. When one teen tells me about their mother and the horrible things they say or do to them, I want nothing more than to make sure that the parent does not harm the child again. Afterwards, when reporting this interview to my attending or the social workers, I find out often that the teen has either lied or exaggerated the story, which shocks and scares me at times. Sometimes it’s pretty elaborate and I marvel at the creativity of these young kids. Other times, their story is true and their parents have a completely different take on the situation. Sometimes the parents even exaggerate or misconstrue situations for their own ends. Sometimes, the kids rather stay in the unit than go home and are forced to due to lack of insurance or other reasons. In the adolescent unit, the patient is never treated alone.

I often have to fight the urge to say something placating to the kids or even offer advice. The things they bring up in their lives remind me of when I was a teenager struggling with similar issues. I have to refrain from doing so and instead ask “why?”. I have to remind myself that even though they’re in the unit and are patients, they like I was as a teenager loved telling people, “You don’t know me.” Advice to me as a teen was never much appreciated and as their physician, dishing out advice for their school or family issues as someone who is not trained to do so is bad idea. Plus, they don’t want that. They want someone to really listen and help them with their underlying problem that got them admitted. Some want to just do enough to get out.

The worst and most devastating to see are the kids who don’t think they need to be hospitalized after trying to harm themselves or threatening to harm others. They are adamant they don’t need help and after a while, the doctors are powerless to do anything especially if the parents agree with the teens. Watching them leave is horrible – it’s as if we’ve strapped a ticking time bomb to someone without any idea when it’ll go off. Most of the staff predicts that they’ll be back soon. Most of the time, they turn out right.

‘Glass ceiling’ exists for women surgeons – Surprise, surprise?

Posted in Medical School (General), Uncategorized by reshmagar on February 24, 2011

‘Glass ceiling’ exists for women surgeons | Research News @ Vanderbilt | Vanderbilt University.

On its face, the statistics look good. The number of women graduating from medical schools has nearly doubled since 1979, and those moving on to become surgical residents and surgeons have nearly quadrupled since 1970.

But a closer look reveals a persistent glass ceiling for female surgeons looking to attain full professorship at medical institutions across the country. In fact, women make up less than a third of the surgeons who advance to senior ranks.

While nearly 35 percent of male surgeons earn full professorships, just more than 10 percent of women do so.

This according to new research by Colleen Brophy, professor of surgery in the Division of Vascular Surgery at Vanderbilt. In a paper that will be presented this spring at the annual meeting of the Association of American Program Directors of Surgery, Brophy points to the disproportionate rate of female full professors in surgery, compared to the rate for men.

Potential causes
One common theory has it that fewer women are entering the field. But Brophy’s study suggests that other unknown variables are at play since the number of women in the surgical pipeline is, in fact, growing.

One possible variable links the role of productivity to promotion. But again, Brophy’s research shows no difference in the number of publications men and women attain throughout their careers.

In gathering her findings, Brophy pulled data through 2009 from the American Association of Medical Colleges (AAMC). She has been studying leadership in academic medicine for more than 10 years.

“How we cultivate good leaders, both male and female, is obviously critical in any industry,” said Brophy. “But if leaders in business make a mistake, they lose money, profit-share. If we surgeons make a mistake, someone can lose a limb or his life. How we lead matters,” she said.

Listening for solutions
To address surgical leadership, R. Daniel Beauchamp, chair of the Section of Surgical Sciences, meets quarterly with female surgeons. The group discusses issues relevant to career development, work-life balance, gender bias, perceptions and other issues of importance to faculty members. They also discuss how to recruit, promote and retain more female surgeons.

“Of all the leadership activities in which I am engaged, I see none more important than my involvement with our outstanding women faculty members,” Beauchamp said.

“They have made me much more aware of the issues that are most important to them, and to the unconscious bias that exists in our profession.

“Because many of the most talented medical school graduates are women and because we need to have women represented at every level of academic surgery and surgical leadership, I am committed to increasing the presence of talented women on our faculty and to the development of their careers as leaders in academic surgery,” Beauchamp said.

Can we teach good bedside manner?

Posted in Doctoring, Medical School (General) by reshmagar on April 19, 2010

Prior to this past week, I have not been to a primary care physician in years. Yes, years. Not that I haven’t needed to. Instead of finding one in the city I am studying in, I’ve resorted myself to going to my university’s health services when desperately sick or the hospital emergency room. It’s something very easy to put off especially when you don’t have a car to take you. After telling my mother about some strange symptoms I’ve been experiencing over the past months, she insisted that I finally get a primary care physician here. My roommate made sure I did this too. With a car this year and a possible illness, I had run out of excuses.

According to my insurance company, finding a doctor in Providence, RI was impossible. Instead, I had to head to Massachusetts. Since I had to drive regardless, I decided to look up where these doctors went to medical school and residency and pick the best based on that. I finally found one and set an appointment with the receptionist in a month and a half. To save time at the office, they sent me the necessary paperwork I would have to fill out as a new patient in the mail and told me to bring it to the office. New Doc: 1-0.

So while I have not seen a primary care physician in a while, I had managed to see a dermatologist over the past years (clearly I have my priorities straight.). I had one at home since high school who I saw occasionally when I went back for college breaks. However, as I have been going home less and less and as she does not practice on the weekends, it was time to find a new dermatologist in the area. And since I was on a doctor roll, I decided to look for a new dermatologist. I found one who had a practice also in Massachusetts and surprisingly, was able to set an appointment within the following week.

My dermatologist at home has an immaculate practice with a spa and licensed facialists along with it. Large waiting room always filled with people and cool brochures of the latest dermatological treatments to make your skin tighter, whiter, tanner, clearer, etc. Upon stepping into my new dermatologist’s office in Massachusetts (after getting lost for a half hour), I was greeted by a dreary, small empty waiting room. Then when asked to pay upfront for the visit, I was shocked. I was accustomed to always paying at the end of the visit after being walked out by the doctor to the reception area.

This would have all been okay had I been satisfied with my visit. My visit lasted around 5 to 10 minutes with no past medical history taken and no real questions asked. I was given literature about new medications and procedures and told to come back in a month. I then found out the dermatologist had multiple practices and there was one in Providence. I was told I could go there and see another doctor on that visit. I decided as it was more convenient to opt to doing that.

My next visit with the dermatologist actually came up right before my first primary care visit. I went again to another dreary office and was again told to pay upfront. I paid and then waited in the examination room for the doctor. After 5 minutes, I heard a knock at the door and he walked in, introducing himself hurriedly and stuttering. He did not ask my name, my age, what I did for a living, or much else. He read the chart and saw what the other doctor in the practice had written. He avoided eye contact the entire time and stood over me making me uncomfortable. The visit here also lasted 5 minutes with the conclusion being that he didn’t agree with the other doctor and that I should come back in a month. I became frustrated having paid a copay of $45 for nothing and with the very limited funds I had, this was not okay. He simply shrugged his shoulders when I told him this and told me to again come back in a month. I doubt I’ll go back.

Two days later, I went to my primary care physician. Her office was quite the opposite. Large and bright with staff that greeted you with a smile and worried about the copayment after the visit. The doctor also had electronic medical records and was very good about maintaining eye contact and a camaraderie with me while typing away at her computer. She addressed every concern I had with not only genuine concern but also professionalism. The visit wasn’t too long here either but I left feeling taken care of. I’ll be going back to see her in 6 weeks.

Seeing both of these doctors back to back made me wonder how people will perceive me as a physician. I began to wonder how I come across to patients even now. I noticed that in my assessment of my doctors that I had focused on even the little things they did – did they shake my hand? Did they ask my name? Did they try to pronounce it at all? Did they sit down when they addressed me?

It became apparent to me that I have to now be extremely self-aware of myself especially in front of patients. If one day I wanted to open my own practice, this is what would ensure that I stayed in business. But not only that- whether or not I would get sued. A study from the Wood Institute showed that surgeons that expressed personality traits of being more friendly, more sympathetic, and more caring had less medical malpractice cases than others that were lacking in these traits.

Are these traits that can be taught in medical school? Is good bedside manner an acquired skill that will come with years of practice? Or is it something innate within medical students that can be seen in their 15-30 minute interview? Also, is it a necessary requirement for a good medical school student? If so, what about the students who go into specialities with limited patient contact like radiology and pathology? Are they not good students? These are things I wonder about. I do know that I want to be considered as a doctor with not just good, but great bedside manner, who can make patients feel comfortable and cared for and who can give them the best treatment and not just medically.

Health Care Reform = No unemployment for me.

Posted in Healthcare Reform, Medical School (General) by reshmagar on April 13, 2010

Massachusetts which has almost universal healthcare is facing this problem now – a doctor shortage. Especially a primary healthcare physician shortage. Imagine that on a national level:

Medical Schools Can’t Keep Up
As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years

The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won’t be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.

Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.

Doctors’ groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn’t make it into the final bill.

“It will probably take 10 years to even make a dent into the number of doctors that we need out there,” said Atul Grover, the AAMC’s chief advocacy officer.

While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.

One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.

Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.

In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.

“We’ve tried to make sure the attitude of students going into primary care has changed,” said Dr. Wheeler. “To make sure primary care is a respected specialty to go into.”

Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York’s Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore’s department of family and social medicine.

One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that “primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens.”

In light of this frightening prediction, there are three major things I think need to be done to ensure that there is no doctor shortage in 15 years AND that universal healthcare becomes a reality, not just words in a bill.

1. Lower medical school tuition.
2. Pay primary healthcare providers more money.
3. Create more family medicine residency programs at academic institutions and prevent them from canceling already existing ones.

See? Not that hard…

New Year Resolution

Posted in Doctoring, Medical School (General) by reshmagar on January 28, 2010

Throughout my first semester of medical school, I have spent it primarily in a lecture hall. I sit with 94 other students learning about things I might see one day in a clinical setting. Sometimes, my classmates and I have the opportunity to see what we learn in class when we go to Doctoring with our mentor and talk to patients. For me, those are the moments where I am most excited and happy to be in medical school. Those are the moments where what I thought was crazy cool in class becomes real. Those are the moments where a disease, syndrome, or a symptom becomes a person instead.

As the year goes on, I’ve been thinking about what it means to be a medical student. Academically, it means I along with my classmates and many others will have to go through four years of training, two in a classroom, two in the clinic. Even in the hospital, I’ll be going from one clerkship to another and my role will be similar to that of the one I have now in the classroom. I will be expected to learn as much as possible, take an exam, and then move on to the next set of training. Even though we see ourselves as apprentices in this field, patients see us as much more. When I wear my white coat and stethoscope in my Doctoring mentor’s office, patients see me as their future doctor.

In our medical school, I’ve had the opportunity to take an amazing elective called “Healthcare in America” where we learn about another major component of medicine- the system in which I will be practicing in. Many of the speakers have spoke to our class about what we can do as medical students in terms of issues like healthcare reform such as calling our lawmakers, making testimonies, or even something as simple as wearing our white coat to a rally. Not all medical students are in favor of healthcare reform. Nor do all medical students share similar views on implementing healthcare reform. There is a reform movement, however, that is independent of all this and is purely for the good of our patients and our medical integrity. A reform movement we are firsthand witnesses to when we step into a clinic or hospital. But to become true players of this movement, there is a new role I along with my other future physicians must undertake. This is my New Year Resolution – I will become a positive deviant.

If anyone has read Atul Gawande’s book Better, he speaks of this role and gives suggestions on becoming a positive deviant. I am going to take that concept and apply it to myself and possibly other medical students right now and not the doctor I will be years later.

SUGGESTION 1: Ask an unscripted question.

In my Doctoring course, I have learned a series of questions to get a History of Present Illness, Past Medical History, Family Medical History, Social History, Nutritional History, Sexual History, Review of Systems, etc. We get tested on remembering all of these questions and are expected to practice asking these questions in our Doctoring sites. I have noticed though when I ask a patient about something else instead, the atmosphere completely changes. During one of my mentoring sessions, I was going to assist my mentor in removing a foreign body from someone’s eye. The patient sat patiently with their reddened eye watering as my mentor went to go get the tools necessary to do the procedure. I started talking to him about what he did for a living and soon found out that he had been in the Army and now was working odd jobs. He also used to live in my hometown and shared a similar disappointment in our basketball team. He even smiled.

I will also try to do this with not only patients, but the other people in my mentor’s office such as the nurses, the physician assistant, the receptionist, anyone and everyone. Doctors are team players, not the one at the top of the totem pole. The other people in the office matter just as much and sometimes, if not more than the physician to the patient.

SUGGESTION 2: Don’t complain.

Our biochemistry block was not the greatest taught block. The lectures were dry. The lecturers were not organized and sometimes even avoided pertinent questions. Half of the class began to not attend class. After one such terrible lecture, a group of us walked out in the hallway. For the next half hour, we reamed the lecture and lecturer. It didn’t help. It didn’t make anything better. It left us drained if anything.

After each block, we have evaluations to fill out. Evaluations that are actually read by the administration and sometimes even lead to change in the curriculum. Filling out these was a much better use of my time. Talking to the head of the course about the problems and possible solutions also was a much better use. Next year, students hopefully won’t have to experience the same discontent with the block. Complaining only doesn’t make people listen – giving concrete ideas for positive change does.

SUGGESTION 3: Count something.

For our Doctoring course, we are required to fill out data regarding how many patients we saw, whether or not it was supervised or unsupervised interaction, and if we got feedback. This year, I will add a new category. I work in an Urgent Care Center and can make a list of what’s routine there. How many people come in with head and neck problems? How many people injure themselves at work? How many people above age 65 come into the clinic?

This was how the Safe Surgery Checklist was started. Someone asked how many patients were getting harmed during surgery, how many times something was left behind in their body, and how many times a timeout was done. A pattern was found, a project was formed, and now lives can be saved. In doing this, I hope to learn something too.

SUGGESTION 4: Write something.

This blog is my effort to write something. I hope that in writing that I can put everything in perspective, that I can consolidate my own personal feelings with what I’m learning and what I aspire to be. My classmates often put up something that happened at school that was awesome (like removing the brain from our cadavers) as their Facebook status. We also have to write field notes for class to give reflections on things we do. This is how we keep sane and let people we care about know what we do.

I know, I slacked off in January. But I’ll keep it up, promise.

SUGGESTION 5: Change.

In terms of healthcare and healthcare reform, the one constant has been the reiteration of rankings and statistics. Yes, there’s always room for improvement. But what kind of improvement? Medicine is constantly evolving both clinically and politically but it will always be our duty as physicians to give the best possible care in our power. And to do this, we should be able to change and adapt to the shifts in medicine and the system. I want to be apart of this change, this flux towards better quality, better care. I can’t say right now I know exactly what to do. But I know that I want to change myself at least for the better…and maybe even one day, the best.