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Caribbean medical schools: It’s not all palm tress and sunsets
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Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That’s a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores.

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

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A victim of sexual harassment as a medical student
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When I was a third-year medical student, I was a victim of sexual harassment.

I had a patient (I no longer remember his name, so let’s call him Mr. X) who was in his eighties and I had to do a rectal exam on him. I had been on the team taking care of Mr. X for a while, and I was fine doing the rectal exam and checking for blood in the stool.  These type of things often fall on the medical student as the low person on the totem pole.  Mr. X repeatedly asked me where I was from and even though I answered California, he was not happy with my answer.  He had served in the war.  Korean? Vietnam? I no longer remember.  He thought I was from Japan.  I’m not.  He called me “sweetheart” and did not address me appropriately as a member of his medical team.

Granted, most patients are confused about the medical system.  Most patients don’t understand the hierarchy at a teaching hospital.  And some patients assume that if you’re female that you’re the nurse or nursing student.  Mr. X would treat me appropriately when there were other members in the room.  When I went to check on him on my own, he was sexist in his answers and made me uncomfortable.  I didn’t report him.  I was overheard by my (all male) team talking about what happened.  My attending asked if I would attend a hospital meeting about sexual harassment.  Again I felt uncomfortable, but I thought that I should attend because it was a teaching session for other people.  I thought it was a good thing that the hospital wanted to make sure that we were being treated fairly.

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What a burned out physician looks like will surprise you
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I was very saddened to learn this past week of another physician who died by suicide.  This, the untimely death of a young and brilliant mother of two, is a horrifying tragedy.

I do not write this to pretend I know anything about this recent tragedy.  I write this as a sort of case report on myself.  I was an at risk physician at one point.

I’ll start where the problems most obviously began.  For me, that was progressing through a highly competitive residency in a surgery subspecialty.

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Once upon a time, being a doctor was great. Not anymore.
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Gather round kids! Let Grandpa Doctor Leap tell you a few things about the old days of doctoring in the emergency room:

Back in the good old days, medicine was what we liked to call “fun.” Not because it was fun to see people get sick or hurt or die, but because we were supposed to do our best and people didn’t wring their hands all the time about rules and lawyers. Sometimes, old Grandpa Leap and his friends felt like cowboys, trying new things in the ER whether we had done them before or not. Yessiree, it was a time. We didn’t live by a long list of letters and rules — we knew what was important. And we were trusted to use our time well, without being tracked like Caribou with electronic badges. Those were the salad days.

When I was a young pup of a doctor, we took notes with pen and paper and wrote orders on the same. It wasn’t perfect, and it wasn’t always fast. But it didn’t enslave us to the clipboard. We didn’t log-into the clipboard or spend twenty minutes trying to figure out how to write discharge instructions and a prescription. We learned in grade school. EMR has brought great things in information capture and storage, but it isn’t the same — or necessarily as safe — as the way humans conveyed information for hundreds, nay thousands of years.

 

Back then, kids, the hospital was a family! Oh yes, and we took care of one another. A nurse would come to a doctor and say, “I fell down the other day, and my ankle is killing me! Can you check it out?” And the doctor would call the X-ray tech, and an X-ray would get done and reviewed. The doctor might put a splint on it or something, and no money changed hands.

In those days, a doctor would say to the nurse, “I feel terrible, I think I have a stomach bug!” And she’d say, “Let me get you something for that.” And she’d go to a drawer and pull out some medicine (it wasn’t under lock and key) and say, “Why don’t you go lie down? The patients can take a break for a few minutes.” And she’d cover you for 30 minutes until you felt better.

We physicians? There was a great thing called “professional courtesy,” whereby we helped one another out — often for free. Nowadays, of course, everybody would get fired for that sort of thing because the people who run the show didn’t make any money on the transaction. And when you have a lot of presidents, vice-presidents, chief this and chief thats — it gets expensive!

When medicine was fun, a nurse would go ahead and numb that wound for you at night — policy or not. And then they’d put in an order while you were busy without saying, “I can’t do anything until you say it’s OK, or I’ll lose my license. Do you mind if I give some Tylenol and put on an ACE? Can you put the order in first? And go ahead and order an IV so I won’t be accused of practicing medicine?” Yep, we were a team.

There was a time, children, when doctors knew their patients and didn’t need $10,000 in lab work to admit them. “Oh, he has chest pain all the time, and he’s had a full work-up. Send him home, and I’ll see him tomorrow,” they might say. And it was glorious to know that. Or I might ask, “Hey friend, I’m really overwhelmed, can you just come and see this guy and take care of him? He has to be admitted!” And because they thought medicine was fun too, they came and did it.

In those sweet days of clear air and high hopes, you could look up your own labs on the computer and not be fired for violating your own privacy. (Yes, it can happen.) You could talk to the ER doc across town about that patient seeking drugs and they would say, “Yep, he’s here all the time. I wouldn’t give him anything.” And it wasn’t a HIPAA violation — it was good sense.

Once upon a time, we laughed and we worked hard. Back then, we put up holiday decorations, and they weren’t considered fire hazards. We kept food and drink at our desks, and nobody said it was somehow a violation of some ridiculous joint commission rule. Because it was often too busy to get a break, we sustained ourselves at the place we worked with snacks and endless caffeine, heedless of the apparent danger that diseases might contaminate our food. We had already been breathing diseases all day long and wearing them on our clothes. Thus well fed and profoundly immune — we pressed on.

In those golden days of medicine, sick people got admitted whether or not they met particular “criteria,” because we had the feeling there was something wrong. We believed one another. Treatment decisions didn’t trump our gut instincts. And “social admissions” were not that unusual. The 95-year-old lady who fell but didn’t have a broken bone and didn’t have family and was hurting too much to go home? We all knew we had to keep her for a day or two, and it was just the lay of the land.

I remember the time when we could see a patient in the ER and, because my partners and I were owners of our group, we could discount their bill in part or entirely. We would fill out a little orange slip and write the amount of the discount. Then, of course, the insurers insisted on the same discount. And then nobody got a discount because the hospital was in charge and everyone got a huge bill, without consideration of their situation. The situation we knew, since we lived in their town.

Back when, drug reps left a magical thing called “samples.” Do you remember them, young Jedi? Maybe not. Young doctors have been taught that drug companies, drug reps and all the rest are Satan’s minions, and any association with them should be cause for excommunication from the company of good doctors. But when we had samples, poor people could get free antibiotics, or antihypertensives, or all kinds of things, to get them through in the short run. And we got nice lunches now and then, too, and could flirt with the nice reps! That was until academia decided that it was fatal to our decision-making to take a sandwich or a pen. Of course, big corporations and big government agencies can still do this sort of thing with political donations to representatives. But rules are for little people.

When the world was young, there was the drunk tank. And although mistakes were made, nobody pretended that the 19-year-old who chose to a) go to the ER over b) go to jail, really needed to be treated. We understood the disruptive nature of dangerously intoxicated people. Now we have to scale their pain and pretend to take them seriously as they pretend to listen to our admonitions. They are, after all, customers. Right?

These days, we are perhaps more divided than ever. Sure, back in Grandpa Doctor Leap’s time, we were divided by specialty and by practice location; a bit. But now there’s a line between inpatient doctors and outpatient doctors, between academics and those who work in the community, between women and men, minorities and majorities, urban and rural, foreign and native-born and every other demographic. As in politics, these divisions hurt medicine and make us into so many tiny tribes at work against one another.

And finally, before Grandpa has to take his evening rest, he remembers when hospitals valued groups of doctors — especially those who had been in the same community and same hospital for decades. They were invested in the community and trusted by their patients and were valuable. Now? A better bid on a contract, and any doctor is as good as any other. Make more money for the hospital? In you go and out go the “old guys,” who were committed to their jobs for ages.

Of course, little children, everything changes. And often for the better. We’re more careful about mistakes, and we don’t kick people to the curb who can’t pay. We don’t broadcast their information on the Internet carelessly. We have good tools to help us make good decisions. But progress isn’t all positive. And I just wanted to leave a little record for you of how it was, and how it could be again if we could pull together and push back against stupid rules and small-minded people.

Now, Grandpa will go to bed. And if you other oldies out there have some thoughts on this, please send them my way! I’d love to hear what you think we’ve lost as the times have changed in medicine.

Love,

Grandpa Doctor Leap

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan.  

Image credit: Shutterstock.com

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The most important thing you’re not discussing with your doctor
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Politicians and policymakers are discussing what parts of the Affordable Care Act to change and what to keep. While most of us have little control over those discussions, there is one health care topic that we can control: what we talk about with our doctor.

The Institute of Medicine (IOM) released the landmark publication Crossing the Quality Chasm 15 years ago. The report proposed six aims for improvement in the U.S. health system, identifying that health care should be patient-centered, safe, effective, timely, efficient and equitable.

The idea that health care should be patient-centered sounds obvious, but what does that mean? The IOM defines it as care that is “respectful of and responsive to individual patient preferences, needs, and values” and that ensures “patient values guide all clinical decisions.”

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Why the physician workforce needs to be rejuvenated
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U.S. physicians continue to struggle to maintain morale levels, adapt to changing delivery and payment models, and provide patients with reasonable access to care. This finding from our biennial physician survey reverberated amongst the members of the Physicians Foundation. But what amazed us the most were the over 10,000 physicians who took the additional time to provide written comment on the concerns they felt most passionate about. That act alone demonstrates how strongly physicians feel about what is happening today to the practice of medicine. Here’s what they had to say:

“This would be the greatest profession in the world only if the government would not be involved.”

“My comments here in general fall on deaf ears. Health care delivery needs to be a free flowing process devoid of external influences that interrupt good care. The process has become so corrupt that none of us can truly practice medicine.”

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4 reasons why being a doctor is worth it
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2016 closed around a continued effort to “salvage” the medical profession’s reputation, but the notion that it’s broken continues to be counterproductive.

The brightest students, for example, question the long journey and delayed gratification being a physician entails. They do the math and continue to engage in other professions that are medical but not specifically Medical Doctorate degrees or Doctor of Osteopathic degrees. These same students conclude there is no longer a reason to choose to be a doctor because the culture seems to regard doctors less. And on top of that, the financial and physical debt incurred is harder to pay back.

Pre-medical students, already feeling wary of a long and stressful road ahead, question the sanity of pursuing a medical degree. This is the logical conclusion of watching all of the turbulence and frustration from the establishment.

Discussion groups amongst doctors entertain the question: ”Would I choose to be a doctor again?” What a daring and provocative question to ask!

We must be vigilant to avoid souring the future of medicine for prospects, and we need to address problems within the medical field. Let’s prevent the burgeoning ideology of young professionals that being a doctor isn’t worth it.

Here are four reasons why being a doctor is:

1. Becoming a doctor has long been an esteemed honor. As experts in science, biology, wholeness and wellness, doctors remain influential members of society. And they will continue to be the foremost authority on health and wellness for a long time.

2. Doctors invite themselves to experience other’s vulnerability. It’s an honor to be so intimately involved and dedicated to the exploration of creating well-being.

3. A doctor not only experiences the health and wellness of their patients but their sickness and ultimate death. This glimpse at mortality and the fragility of life that hone efforts to sanctify life and progress society. This awareness allows doctors to influence society for the better.

4. Doctors are part of a community which fosters support and creates social awareness that, indeed, doctors need rest just like anyone else.

Medical students need our reassurance that they will be rewarded and regarded. They need our efforts to secure their commitments with meaning. They also need our reflections on the incredible and very honorable role we serve to our society. Such an honor and promise of mastery and lifetime productivity and trusted intimacy is no small feat for the weak. It is for the exemplary students with the biggest hearts. It is for wisest and most compassionate that we hope are attracted to our profession.

Would you select medicine again? Would you advise the brightest students to our order?

Be an instrument of changes as much as you are a tool of inspiration, lest we all suffer without guidance and care and the best on our side.

Jean Robey is a nephrologist who blogs at ethosofmedicine.

Image credit: Shutterstock.com

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The untold story of Match Day emotion
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It’s Match Day.  Standing with my medical school class in the lobby of our medical education center, there is a palpable energy. It had been a long journey. After reluctantly leaving CA for NY I had finally completed four grueling years. The entire time I was laser focused on doing well enough to make it back to California. The four years came and went in a flash, and without hesitation, I will say that the last two years had been some of the most rewarding and fun years of my life. Working hard in the hospital and playing even harder in the city had made for an interesting work life balance.

So here I am standing in the lobby of my medical school waiting to be handed a piece of paper that will bind me to a residency program. I had done well enough in school, well enough on my boards, did some research, did well enough on my interviews, and had a stacked rank list of the best ER programs in the country. During the interview season, I received an interview offer letter from a program in Denver. How the hell did I get this? This is one of the original ED programs. There is no way they should have wanted to interview me. Did they mistake me for some other Indian guy? Whatever. I booked the interview, go there, and I was amazed at how awesome the program is.

So back to the lobby.  The dean starts speaking: “The class of 2009 did spectacularly this year matching at top residency programs across the country.” He specifically mentions how three people had matched at the California program I was expecting to match to. My heart starts pounding even faster. I am so excited. They continue to spout off some other statistics and finally at noon they say that we can go to a table to pick up our match letters.

All around me people are opening envelopes. People are starting to cheer as they receive news that they are going to his/her top choice. Off in the corner, I see one of my classmates crying. She must not have matched where she wanted to. This is so weird; there is such a mix of emotions from complete elation to utter dejection.

I’m handed my letter. The first line reads congratulations …blah blah blah. My heart is pounding, and I scan the next line. Wait a minute that didn’t register. The state reads CO. My eyes must be playing a trick on me. I keep reading CO expecting it to be CA. CO … CO, not CA … is there a typo? Did they mean to write CA instead of CO? I’m so confused. Then it starts to register and settle. This is so weird. I can’t believe it; I somehow matched to Denver.

And just like that my fate is sealed. I am to shipped off to Denver. No ifs ands or buts. I am to pack up my New York life and move to Denver. Even if I wanted to move back to California, that is no longer an option. At this point, I must go straight to Colorado. Do not pass go. Do not collect $200. Is this how NFL football prospects feel on draft day?

Is this normal? Is it normal that people who have invested so much time and have so much education are forced to move in what seems like such a random act? What if I had a family and kids? What kind of conversation would I be having with them? “Sorry dear … So it turns out we have to move away from family and friends to a place where we know no one because the computer matched me there.”

You would think that going through four years of undergraduate education and four years of medical school would put you in a position that you could essentially pick where you want to be.   But I start to realize that there is one more hoop to jump through.

My heart skips. I am so confused. So excited to be going to one of the best programs but so conflicted that I won’t be in California. I’m approached by other EM bound residents: “Holy crap how did you match there?” We head outside to celebrate. Champagne bottles are popping off. And after a short while, we get on a party bus ready to paint NYC red with our recent successes and for my good news.

Zahir Basrai is an emergency physician who blogs at the Physician Grind.

Image credit: Shutterstock.com

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Doctors revived after suicide tells all
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In this podcast, I share insights from a doc who barely survived his suicide attempt plus simple ways to prevent the next suicide. Listen in. You may save a life.

Dear Pamela,

I’ve never been so happy to fail at something in my life. Four weeks ago today I died. Cardiopulmonary arrest in jail. Why was I in jail? My wife alerted the police. Sheriff deputies were upset when I did not pull over to talk to them after overdosing. After boxing me in, they threw me from my truck into the slushy street and tased me. After charging me with a felony and two misdemeanors, they nearly provided the perfect assist to my suicide. Through a series of miracles, I was brought back. I am missing four days of my life including three on life support, but I am alive. I have to repair almost every relationship I treasure from the betrayal of my weakness, a chore I will perform with as much love and patience as I can muster. I may never practice my specialty again, but I am alive. My family has a husband, father, son, and brother.

My wife once asked how we do it in the ER, to be there for everybody’s worst day and also for their best. My worst day was almost my last. Funny thing is I was as happy as I had ever been in my personal life. My decision to end it all was 100 percent work related.

I had just lost a young girl in the ER a few weeks before. Influenza. I followed proper protocol, gave her a couple of treatments and she felt better, so I discharged her home with appropriate warnings. Thirty hours later she came back, in respiratory arrest. She ended up on life support with family refusing to withdraw care. They, of course, blamed me. And, of course, complained.

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Let’s stop therapies that hurt kids
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We do many things in medicine to patients that are either not helpful or have the potential to harm. If you take the long view of medical history, this should not be surprising. After all less than a century ago, physicians were still giving toxic mercury compounds to people in the form of calomel. And a century before that, physicians were bleeding people because they thought that was a good thing to do for serious illness. The dawn of scientific medicine in the late 19th century began the process of putting medicine on a scientific basis, that is, of demanding proof that a particular therapy works — and why. But we still have many, many things we do in medicine that have never been studied rigorously and are done more because of tradition than anything else. I have been encouraged over the past decade or so to see more and more of the accepted practices, therapies that have never been shown to be helpful, are being questioned. Treatment of respiratory syncytial virus (RSV) infection is a good example of this. We now follow fairly specific guidelines regarding what to do, guidelines which are based on actual evidence rather than tradition. Traditions die hard, though, and I still see some of my colleagues clinging to the older approach that has been shown not to help. We need to keep the stuff that works and discard that which doesn’t.

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The jurors who evaluate physicians’ testimony in court
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Two doctors I work with were recently asked to testify in court. I knew it was a case involving domestic violence and I knew I wanted to see what it was like to testify: One day I’d like to work with families in the foster care system, and that will likely mean having to testify in court. So I asked my clerkship director, and with her support, the clerkship coordinator went above and beyond rearranging my duties so that I could attend the court case.

One the day of the case, I was to meet my two attendings in front of the courthouse before the case started at 1:45 p.m. Shortly after 1:30, we realized that the case was being tried in another city, and we rushed back to the car to drive north. When we finally arrived, I walked into the courthouse and felt as if I had stepped into a television show. The jurors were a diverse group and one of the ladies in the second row was asleep. The defendant, a balding middle-aged man, sat looking at his expensive watch. The defense attorney had polished leather shoes. The district attorney was double-checking her notes. Everyone turned to stare at me. It was a public trial, and I was the only member of the public to show up.

I sat from my squeaky seat in the back of the courtroom as first one doctor testified and then another was cross-examined by the district attorney and the defense attorney. The case was rather clear-cut. A woman was being treated for kidney cancer when she reached out to her doctor to report that her husband had assaulted her. The doctor was out of town and arranged for her to see a colleague for medical evaluation. At that time, she had large bruises on numerous parts of her body. Her story and her physical exam findings were consistent with abuse. A CT scan done two days earlier for her kidney cancer showed no broken ribs. A repeat CT two months later, also for her cancer, showed that she had a healing fracture in one of her ribs, exactly where her large painful bruise was.

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Should patients order their own lab tests?
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Knowledge is power. Increasingly, patients are demanding and receiving access to levers in the medical machine that would have been unthinkable a generation ago. The informed consent process, which I support, can overwhelm ordinary patients and families with conflicting and bewildering options.

Television and the airwaves routinely advertise prescription drugs directly to the public. Consider the strategy of direct-to-consumer drug marketing when millions of dollars are spent advertising a drug that viewers are not permitted to purchase themselves. The public can now with a few clicks on a laptop, research individual physicians and hospitals to compare them to competitors. The Sunshine Act publicizes payments to physicians and hospitals by pharmaceutical companies and other manufacturers.

Every physician today has the experience of patients coming to the office presenting their internet search on their symptoms for the doctor’s consideration. “Yes, Mrs. Johnson, although it is true that malaria can cause an upset stomach, I just don’t think this should be our first priority.”

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My patient was right: I was awful when she had a miscarriage
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On a busy day in the office, a patient was added to my schedule for “bleeding, early pregnancy.” She was one of my partner’s patients, but he was not in the office that day. We talked for a minute, then I examined her and did an ultrasound. As I expected, she was in the process of a miscarriage. Unfortunately, I, who wasn’t her regular doctor, had to give her this news. We discussed the option of a dilation and curettage (D&C) or letting nature take its course. She was unsure and wanted time to decide. After we had talked, I left the room for her to dress and check out. About a month later, I received a letter from her describing how insensitive I was, and how in that awful moment for her, I did not care for her emotional needs. She suggested even just a small gesture of offering her a quiet place to call her husband or walking her to the check-out would have been helpful. It hit me to the core. I was embarrassed. I thought I was a more sensitive person than that. But she was right. I missed the opportunity to comfort her in her moment of need. Thank goodness for her courage and honesty, despite her pain, to send me this note. She opened my eyes to my impact and how I needed to change, to be more empathic and aware of my patients’ needs especially in the midst of a crisis. Despite working in a busy office, taking an extra moment with her would not have impacted my other patients, but it would have made a world a difference to her.

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How much are patients to blame for ER overuse?
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The U.S. rings the bell on health care spending, and some point fingers at patients themselves.

But why do patients choose the paths they choose? Just about every shift, I and my coworkers shake our heads, and wonder what may be driving our patients’ decisions. Parents who haven’t yet tried a drop of acetaminophen bring kids in at 2 a.m. with fevers. Patients show up with nose bleeds that have already stopped bleeding out in the car. Sprained ankles roll in by ambulance.

ER old timers (I guess me too now) can often be heard saying “when I was a kid there’s no way my parents would’ve taken me in for that.” It’s easy to blame patients. However, I suspect more forces are in play.

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Politicians can’t fix our health care system
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Health care costs are out-of-control, and many patients can no longer afford medical treatment. The system is broken, but no real fixes are visible on the horizon. Sure, politicians debate the road health care should take and act like they are very concerned about the health of Americans. Truthfully, however, they are driven by political agendas corporate influence. Little discussion is given to what it would take to fix the system. Rather, fingers at pointed and legislation touted as failures.

America leads the world in medical innovation and technology. Scientists in our country make the world’s medical discoveries. It is an atrocity that many Americans are being priced out of the system. The fact that the U.S. is the only country on the globe that allows its citizens to go bankrupt because of medical expenses is an outrage. And it is the middle class that is being squeezed the hardest.

When I discussed this in the past, I was criticized for not recognizing the fact that “someone has to pay for it.” Yes, this is true, and the fact that it is unaffordable doesn’t mean it should be free. It is not an either-or situation. What we need to do is make health care affordable for everyone. Now many will say that single payer government-run systems are the solution. Do we really want the government in charge if the entire system when we see how the ACA (Affordable Care Act) failed?

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My promising patient tormented by disease and drugs
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When I first met Jason, I was a third-year medical student halfway through my psychiatry rotation, and he was a newly admitted patient halfway through a nasty comedown from crystal meth.

He sat slumped in his chair scowling with his face hidden by a baseball cap and black hooded sweatshirt and growling responses to my interview questions.

“Why do I have to do this? I hate this crap. I’ve answered these bullshit questions a million times. I’ve been in the psych ward a million times, and it’s never done anything for me.”

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Why it’s important to protect Roe vs. Wade at the state level
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G1P0 or Gravida 1, Para 0. Well, turns out that’s me. It’s very common in the medical field to use this phrase to describe women who have been pregnant but do not have any living children. This could have been due to miscarriage or worse yet, intrauterine fetal demise at later staged pregnancies. Or it could be due to an elective termination. For me, it was the latter.

I had never been pregnant, and the idea of having a child was very far from my mind. Having just started my surgical residency, I simply could not be pregnant. Lo and behold three pregnancy tests I took while at work told me otherwise. My husband and I were then faced with a decision. Both of us as newly minted physicians faced an incredible amount of student debt and several years of 80-hour work weeks ahead of us. We could not possibly be parents — not now. Sleep deprived from an overnight call shift and feeling tremendously financially insecure with my four-digit savings account, I panicked, cried and then began my search for an OB/GYN who was licensed to perform abortions in my city.

My search did not take too long. A few seconds of online searching directed me to a 24-hour hotline for reproductive health services in New York City. It was only a few minutes later that I had an appointment within two days for an abortion.

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Here’s what’s really scary about Trump’s health care
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It has come to pass: President Donald J. Trump. Are you scared? Are you planning to “resist” the policies you imagine President Trump will pursue by tweeting furiously with clever hashtags galore? Would you prefer to move my fastidious quotation marks from “resist” to “President”? This is, after all, the first President in a very long time to take office without the blessings and financial support of established “world order” leaders. It must be rather disconcerting to proceed without clear guidance from our betters, especially seeing how well they served us over the last decades, and particularly when it comes to the affordability of health care in America.

Are you binge-watching the Obamacare drama playing on America’s center stage these days? Are you tweeting and retweeting every shred of information that proves Obamacare is a huge success, and its repeal will mean certain death for millions? Or are you busy proclaiming your faith in free markets, the (undemocratic) government of Singapore or the charitable nature of Americans in general and doctors in particular? Is President Obama your tragic hero or your shifty villain? Is President Trump your great liberator (although he promised not to do anything you really want), or the Grinch who will steal health care (although he promised to preserve everything you really like)? Are you not entertained? Pass the bread, please.

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Who hates taxes? The answer isn’t what you think.
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I was raised in a family that hates taxes. Not hates taxes as in, “Gosh, it’s too bad such a high percentage of my paycheck goes to the government.” More like: “How dare the government steal my hard-earned money and give it to undeserving moochers?” (Is there such a thing as a deserving moocher? Sorry, I digress.)

The origins of this anti-tax sentiment are deeply ideological, steeped in a frothy mix of conservative and libertarian principles. My family loves freedom, property rights and the Protestant work ethic (even though they are Catholic). Their attitudes towards taxes spring forth from their deepest moral values. It’s not just the taxes that bother my parents and siblings, but the thought that income is being redistributed to unworthy people.

Or so it seems. Evidence is now accumulating that people’s attitudes toward topics like taxes and income redistribution are more fragile than many of us think, and that sometimes our desires –for social status, and for income we may or may not have earned–take hold on us, forcing us, unconsciously, to later embrace political ideologies that coincide with our preceding desires. When it comes to our attitudes toward taxes, we feel first and think later.

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3 things to say to a suicidal physician
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This week, a resident asked, “What do you say to suicidal physicians?”

1. I don’t say anything. I listen without judgment. Our culture doesn’t support physicians asking for help — or revealing their suffering. As a result, physicians fear sharing suicidal thoughts with friends and family because we’re the ones that others rely on for help. Physicians fear speaking to their program directors or employers because of professional retaliation and loss of licensure. Physicians fear sharing mental health struggles with colleagues due to shame, stigma and loss of their confidentiality. If employers are notified, docs may face potential job loss or be mandated to attend Physician Health Programs (which are essentially 12-step programs for substance abuse that have turned into a dumping ground for any doc with mental health conditions). Physicians need to be able to speak confidentially to other physicians who understand their pain. So that’s what I do. I listen. Confidentially. Without judgment. For as long as they need to talk. For free. As a healer and a friend.

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Physicians are not robots
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Physicians are not robots.

The health care system (and the corporate world in general) turns idealistic students into jaded and cynical professionals. They become small pieces in a profit-obsessed machine. They count down the days until retirement.

We have to beat this system. And to do that, we must protect at all costs our humanity and creativity. We have to challenge the notion of how a doctor “should” be by embracing the things that make us unique.

If we want to recreate health care, don’t we need some creativity?

(Thank you to everyone who is featured in this video.)

Jamie Katuna is a medical student.  She can be reached on Facebook.

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What Tom Price doesn’t know about prostate cancer screening
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Dr. Tom Price may become the first medical doctor to lead the U.S. Department of Health and Human Services in 24 years. One might think that having completed medical school and practiced orthopedic surgery before entering politics might give him some extra insight into what works and what doesn’t in medicine. But judging by a letter to then-HHS Secretary Kathleen Sebelius that he signed in 2011 objecting to the U.S. Preventive Services Task Force’s draft recommendations on prostate cancer screening, Dr. Price either failed to learn anything in evidence-based medicine class or forgot everything he learned.

Price and colleagues wrote: “Since the [prostate-specific antigen] PSA test came into widespread use for cancer detection in the mid-1990s, the rate of deaths due to cancer has fallen by 40 percent.” This statement reflects an association, not causation, and there is a serious problem with positing the latter based on the natural history of PSA-detected prostate cancers. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), the only trial to conclude that PSA screening reduced deaths from prostate cancer, it took 9 years to observe any difference in prostate cancer deaths between the screening and control groups. But not only was the prostate cancer death rate falling in the U.S. long before any possible screening effect could have occurred, it was also falling in other countries (such as the United Kingdom) that were not employing PSA as a screening test.

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My child has a concussion. What should I do?
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A concussion is a brain injury. A mild one, yes, but one that can lead to longstanding symptoms. What you do after a concussion, immediately and in the weeks that follow, can make a big difference in how your child recovers.

Though it’s a mild injury — there’s nothing to see on a CT, X-ray, or MRI — the effects of a concussion can be significant and uncomfortable for a child and family. Headaches, dizziness, trouble sleeping, and problems with concentration and mood are all common. And the average length of symptoms is three weeks. Many people experience symptoms for longer; some for much longer. What’s the best way to ensure that your child recovers as quickly as possible?

Two recent studies help clarify the best steps to take. The first, from August 2016, looked at the immediate response to a concussion. The authors compared teenage athletes who had a concussion, looking at a group that was immediately taken out of the game versus a group that continued playing. The risk of having prolonged symptoms was about nine times as high among athletes who kept playing after concussion. Bottom line: the first thing to do after even a suspected concussion is to take the player out of the game.

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3 reasons why health care IT will always be terrible
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One of the topics I write most about and have also done a considerable amount of consulting work on is improving and optimizing health care information technology. I hate to say it, but after a few years of doing this, I’m starting to despair a little from what I’m seeing. It’s a question I never thought I’d ask: But will health care IT ever really get to where it should be? Improvement is desperately needed — even small tweaks can be made to our electronic medical record (EMR) systems to help improve workflow for doctors. Information technology in its current format is the number one frustration for doctors and nurses across the United States. And it’s responsible for much misery on the front lines of medicine as an unacceptably large amount of time is spent navigating them.

Here are three reasons why improvement is uniquely difficult:

1. Wrong customer: administrator not end-user. After attending many events and networking meetings in health care IT, one thing has become abundantly clear to me: We (meaning doctors) are not the people that health care IT folks are catering to. It’s the hospital administrations. Can you imagine if great companies like Apple totally disregarded the end-user experience like that? This is one of the prime reasons we find ourselves in this absurd situation. As an example, I recently used the latest version of Siri on an Apple device. And how brilliant it was — far, far superior to any voice recognition software I’ve used in health care and designed with the user in mind.

2. It’s a monopoly once installed. Once health care organizations have spent millions of dollars on a particular EMR, the IT vendor is truly “in.” The organization is stuck with it no matter what and can’t just switch to another one if they don’t like it. Therefore, what incentive is there for the IT system to really get better?

3. Lack of strong voice. I was talking to a very intelligent doctor who was bemoaning how he was spending the vast majority of his day at a computer screen. Certainly not why he went to medical school. He said something very thought-provoking: “I’m surprised that the medical profession has allowed themselves to be so quickly turned into data-entry clerks without making a fuss.” So true. What happened to the public perception of a doctor — the fierce patient advocate who always stood up for good medicine? Why is there not a strong national movement to improve health care IT?

Even the most hardened technophobe doctor would acknowledge that technology represents the future in all aspects of our lives. But we want good technology that is fast, efficient and seamless enabling us to be doctors. We don’t want reams of garbled data that transform our patients’ stories into tick boxes. We want fast, mobile order-entry systems. We also want an acknowledgment that the medical profession has to remain a social and personable profession—not one where the frontline heroes are turned into “type-and-click bots.”

When I meet health care IT folk, it often seems that we are in two separate worlds. I’m quite an optimist by nature and hope I’m proved wrong about this never improving.

Suneel Dhand is an internal medicine physician and author of three books, including Thomas Jefferson: Lessons from a Secret Buddha. He is the founder and director, HealthITImprove, and blogs at his self-titled site, Suneel Dhand.

Image credit: Shutterstock.com

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The blame game: It’s not alright to blame the patient
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Most of the lawsuits I deal with have more than one named defendant. For example, the plaintiff (typically a deceased patient’s next of kin) might sue a hospital, a nursing home, and the attending physician at each facility. Sometimes they go a bit further and may even include the administrator, the director of nursing, and individual HCPs, such as the wound care nurse or the registered dietitian nutritionist.

When a lawsuit has multiple defendants, one of the main tasks is determining how much responsibility for the outcome to assign to each party. Responsibility is a nice word for blame, because that is really what we are talking about. Each defendant’s attorney will argue that their client is not to blame, which is obviously their job. What is not so obvious is that this means the attorney must deflect the blame to one of the other parties. It is truly every defendant for himself or herself.

The right to refuse treatment

While the intricacies and machinations of lawsuit settlement are eye opening to watch, the more important question is what if the patient is (even partly) to blame for his or her own dire situation? Where does patient responsibility fall in all this?

Every day patients with diabetes chose not to follow diet recommendations and suffer the resultant elevated A1c levels. They then question why their diabetic foot ulcer is not healing. Patients with sacral pressure injuries refuse to allow staff to turn them to a different position and stay lying flat hour after hour. Every day in doctor’s offices, clinics, hospitals, and post-acute care centers, patients refuse advice and do not follow doctor’s orders. Clearly, it is a legal liability when HCPs do not follow doctor’s orders, but when the patient does not, it is a much touchier subject.

As Americans, we all have the right to refuse treatment unless we are declared mentally incompetent and are assigned a court-ordered guardian or medical proxy. In long-term care, recent efforts for a culture change have encouraged a more participatory, home-like environment. In today’s world, the facility’s residents have free choice about many matters affecting their lives. These are rights we all cherish, no matter what the care setting. The problem begins when we like our rights, but then don’t like the outcome from exercising those rights. In our litigious society where suing medical professionals has become commonplace, this opens a very expensive can of worms without getting to the root of the problem.

Fostering better communication

One of the keys to this problem is better communication with patients. Every day patients relay stories about how they were rushed, did not fully understand what they were told, did not get the results of tests, and were generally dissatisfied with their medical care. With this lack of satisfaction and by extension, trust, it is easy to understand why patients choose not to follow medical advice.

I recently conducted a survey on implementing basic nutrition interventions for wound healing. The majority of respondents said they did not follow nutritional advice because they did not believe it would have any effect on their wound. This was a gut-wrenching finding because nutrition seems so fundamental to wound healing. Obviously, this is not well communicated to patients, so we need to go back to the drawing board and rethink how to impart this message. The takeaway is that changes are needed to get patients on board with their own treatments.

Steps to improve communication

Here are four concrete steps to begin practicing today.

1. One of the most common complaints of patients is that HCPs did not listen to them. Nowadays, many HCPs are typing away in the electronic medical record, rather than actively listening to the patient. Are you are doing this?

2. Simplify medical terms. Talk in a language that the patient can easily understand.

3. Use a teach-back method of education. Ask the patient to repeat back to you what you have told them to make sure they understand.

4. Understand the patient experience. Most patients are scared, in pain, frustrated, tired, and angry or some combination of these emotions and more. Show that you care. If you are burned out and have lost your empathy, evaluate yourself honestly. Is it is time for you to take a break or go in a new direction?

Most of the time in litigation, blaming the patient is not a successful tactic. A better tactic is to have happy patients who feel the medical community served them well and who do not feel the need to consult an attorney. If you want patients to follow your instructions, they must trust you and your advice. Open, honest, effective two-way communication is the place to start. I would love to hear your thoughts on the blame game.

Nancy Collins is a registered dietitian with expertise in wound care, malnutrition, and medico-legal issues. She can be reached at her self-titled site, Dr. Nancy Collins.

Image credit: Shutterstock.com

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