I was mistaken for a drug rep this afternoon.

I was walking to my car, wearing my long black coat and heavy bag, walking towards two heavyset, well-dressed men in long black coats with heavy bags. One, with aviators and a shiny tie, asked me expectantly, "Is there still room on the list for us?" I stared at them for a minute, having no idea who they were or what they wanted, and finally I said, "I'm not sure what you mean. You'll have to ask someone smarter than me. I'm just a med student." Ohhhhhhhh, they grinned together, and went inside. Then I realized that they were drug reps, and they thought I was one of their tribe. That would be the only reason why a girl in heels and a long coat would be leaving a low-slung dull-bricks & fluorescent-tube-lit suburban family clinic whose nearest neighbors are a liquor store and a SuperAmerica.

I was leaving early so that I could attend a special bioethics committee meeting at which the author of the above-linked article was going to discuss the hopeless enmeshment of the drug industry with our institution. My previous day at this clinic, the doctors were talking about which days they would and would not have lunch catered by Merck, or Pfizer, or AstraZeneca. "How often do you have lunch?" I asked. That single question was enough to get Dr. B to launch into a long and practiced speech about how no amount of pizza would get him to change his prescribing habits and how his patients were helped by the well-stocked sample cupboard that Aviators and friends refill on their twice-weekly visits, and how much he learned from their educational education. I nodded, thinking that if this level of defense was provoked by such an innocuous question, I'd better leave the topic the hell alone. We rotate sporadically through these clinics. We are their guests and not their moral or Freudian provocateurs. "I'm hearing a lot of hostile feelings. Do you think we could explore that?"

At the meeting, surrounded by the committee members - chaplain, ICU nurse, community leader, pediatrician, risk lawyer - Dr. Elliott details a number of scandalous cases involving our faculty's ethical transgressions. Describing one, he mentions my brand-new psych department advisor, who does indeed accept drug company study money, by name. I feel oddly guilty by association. Stories of wrongdoing and lawsuits flow forth, familiar and still incredibly gross. Rants and raves ensue, a general depression descends over the room. I discuss my clinic predicament with Joy and Dr. Elliott. I ask, what is the best course of action for the conscientious objector? No one knows.

Today, mercifully, there was no drug lunch. People came and went from the back room between phone calls, eating their lunches in the narrow space left between appointments. Dr. A said that she listens to the New England Journal on podcast while she makes dinner. There is never any time to spare, only overbooking and lateness, and this makes visits from pretty salespeople carrying literature and pitching new drugs in 30-second increments attractive.

Not long after lunch, a man staggers into the clinic and collapses on the front desk. He is having an asthma attack so intense that he can barely speak. "How long has this been going on?" we ask, wide-eyed, and he holds up three shaky fingers instead of trying to explain. It turns out that he had been at the clinic with his wife that morning, and when he had an attack a few hours later, oxygen deprivation told him to walk a mile in the cold back to the clinic. It is not his clinic. We have no idea what his name is until we read it off his asthma inhaler's pharmacy label. His surprise appearance derails the schedule significantly. Dr. A and Dr. C both try to hand off Mr. Wheezy to each other, but Dr. A wins because of her next patient. "Would you rather tell Ms. K that she has breast cancer?" Dr. C admits that she would prefer the wheezes. "I like asthmatics," she says, and goes to listen to him wheeze some more. I am useless. No one wants a med student around when they find out they have cancer, and Mr. Wheezy is too sick to tell me what happened to him. I listen with my steth to his sad huffing-honking sounds and pretty soon he has a syringe of epi in his arm and a puffing nebulizer strapped to his head, and pretty soon some crabby paramedics are hauling him to the ER. The wasted drops of epi that swelled and fell from Dr. C's needle dry up on the workroom counter, while I read about chemotherapy. Kool 108, the favored radio station of this clinic, begins playing "Stayin' Alive."

Things the dwell inside our rectums and other medical school hazing rituals

No one reads our blog so I don't feel embarrassed in the least to announce that I will be culturing my fecal matter in the very near future.  It's quite a procedure really and it will involve a hopefully sterile swab being inserted into at least the most exterior portion of my rectum. I will perform this daring procedure myself during class time and this is all going to be done in the name of science and me passing my infectious disease class. Up until this point I haven't thought much about my rectum and I'm sure you nonexistent readers haven't either until I sort of shoved it in your face by making this announcement. Let's just take this moment to be glad we all have rectums even if they are crawling with E. Coli and Shigella and Cholera and all those other bugs because without them where would we be?  We'd be in big trouble, with a nice little problem called rectal atresia. Anyway, I'm on a rectal tangent. I'll end it there.  

Why Primary Care is Sexier than Dermatology

In his book, Better, Atul Gawande recounts the moment he was offered his first job as a fully licensed physician after years of grueling preparation. The head of the department asked him what he wanted to be paid. Gawande didn’t know how much would be reasonable, let alone how much he wanted. It’s a problem we all face in medicine, though perhaps in a more subtle way, when we pick our specialty. We are not supposed to be "in this for the money," but let’s face it: most of us hope our dream specialty--the thing that gets us out of bed in the morning, ready to heal the sick and comfort the dying--also has a nice paycheck and doesn’t require excessive amounts of overtime to boot. Why not? We’ve worked hard for a long, long time (longer than any other professional degree course) and are burdened with excessive levels of debt that overshadow those of any other profession. William Weeks of Dartmouth has found that working hours for physicians are longer than for any other profession, and that the payoff in terms of educational investment is poorer in medicine than in law and business. It is largely the motivations of salary and working hours which have dramatically restructured the dynamics of specialty competition and thus the availability of healthcare across the spectrum of specialties.
This March the New York Times published an article examining the popularity of dermatology residency programs. It is undeniable that dermatology is currently among the most competitive specialty choices for young doctors. Only 61% of fourth years applying to dermatology residency in the US last year matched in that specialty, compared to 98% of internal medicine applicants. The numbers show another trend: the best and the brightest students, in terms of academic honors, board scores, and research experience, are heading towards dermatology. But, it wasn’t always that way. Several decades ago general surgery and internal medicine attracted the best and brightest medical students while dermatology drew few.
Dr. Eric C. Parlette, a dermatologist in Chestnut Hill, MA, attempts to explain this trend in the article: “It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time.” Certainly the procedure-based emphasis of our current reimbursement scheme is a major factor in the rising popularity of dermatology and other specialties like plastic surgery, which are low on preventative care and big on procedural therapy. Moreover, an additional factor heightens the appeal of these specialties: cosmetic procedures, paid in full without insurance middlemen. The 40-hour average workweek for dermatologists also adds to the appeal of the specialty, making it the crown jewel in the young doctor’s ROAD to success--an acronym for the well-known lifestyle specialties of radiology, otolaryngology, anesthesiology, and dermatology. The acronym is passed along like a mantra for success in the hallways of American medical schools, and it is very clear to students where the payoff lies. Less work and more pay is an obvious choice for many students when faced with the reality that in 2000 the average family practitioner saw 122.9 patients per week and made $144,700 before taxes, while the average procedure-performing cardiologist saw 92.4 patients per week and took home $315,500 before taxes, according to the American Medical Association Physician Socioeconomic Statistics (2003).
Certainly we need dermatologists. Many of them are passionate about unappealing but important diseases like skin cancer and contact dermatitis. However, the problem with the inordinate popularity of specialties like dermatology and plastic surgery is that it comes at the expense of other specialties, those relied upon for the treatment of widespread, life-threatening diseases. Primary care specialties are the neglected siblings of those that line the procedure-based ROAD. The skewed specialty distribution has ramifications for the health of our patients, who may find it difficult in the coming years to gain access to life-saving but un-flashy preventative care for diseases like heart disease and diabetes.
Beyond the effects on healthcare delivery to individuals, there are major systemic reasons why a healthcare system based on primary care is best. In February of this year an American Journal of Medicine study showed that as the proportion of physicians in primary care practice increases, healthcare costs decrease. Last year we spent $2.3 trillion on healthcare, according to the National Coalition on Healthcare. The money was used to sustain a decidedly inefficient and wasteful system. If increasing access to primary care could help make our ailing system significantly more efficient, it’s certainly worth a try. Furthermore, according to a 2001 study in the Journal of American Family Practice, we could have better detection of breast cancer and reduced incidence and mortality caused by colon and cervical cancer, as well as improved health outcomes for a list of a dozen other major killers of Americans. A 1992 study in JAMA found that we could have to fewer tests, higher patient satisfaction, less medication use and lower care-related costs. Finally, in 2001 a study in the American Journal of Public Health found that strong primary care would lead to reduced health care disparities, particularly for areas with higher economic inequality. This list of benefits reads like a laundry list for a utopian health care system. In the mangled words of John Lennon, imagine a world with less use of emergency rooms and hospitals, and better preventative care.

We have no choice but to look for solutions to the systemic issue of physician supply and demand in order to provide both individual patients and society with the best possible care. The most obvious solution is to find a better way to reimburse doctors so that pay for educating patients about disease processes would be at least on par with providing liposuction and Botox. A prototype exists in New York State, where the infamous Eliot Spitzer proposed a program called Doctors across New York that would compensate general practitioners with an aggressive loan repayment program and increased salaries. We need to change the incentives for careers in primary care so that all doctors can afford to make career decisions based on patients rather than profits.

"For Top Medical Students, An Attractive Field" was published on March 19, 2008 Fashion & Style Section of the New York Times.

Tell HHS It's Not Right to Deprive Patients of Reproductive Rights and Informed Medical Decision-Making

Here's Mike Leavitt, the Secretary of the Department of Health and Human Services. He looks so I-coach-soccer-on-the-weekends, doesn't he? Turns out he has a blog, in which he describes his works and travels. He certainly seems to care about his job and the people he visited in his summer trip to Africa - it's a shame that although he promotes PEPFAR and enjoys being crowned an honorary tribal chief, he doesn't have a problem with the Global Gag Rule and doesn't mind that his administration's policies tie the hands of health care workers trying to fight the AIDS epidemic. Anyway.

Here on his official blog he muses on the reasons why he's in favor of a proposed HHS rule strengthening "conscientious objection" to providing any services (e.g. emergency contraception) that is at odds with a provider's religious affiliation - to the point of threatening the rights of patients, and the rights of non-objecting physicians. This has been well covered elsewhere, but I learned about it today - and there's still time to comment! I was at a lecture today given by Lois Uttley, who testified before the Prez' Council on Bioethics last week about the proposed rule.

Our Bodies, Our Blog wrote about this when it first came out. Hillary Clinton & Cecile Richards published an NYT op-ed a few days ago. You can Google your way

Here's the official story - here's where you tell HHS that physicians are hampered and patient-centered care damaged by such a rule.

Getting going...on the Evil Hidden Dangers of Strep Throat

We did not intend this blog to be (entirely) devoted to John Kerry's Boston shopping habits. And so, with second year fully in progress, I'll get started with a little cautionary tale.

This week's Diagnosis in the New York Times Magazine (a weekly feature that, lately, my medical parents have taken to leaving clipped out for me as some kind of boards-prep quiz...) is about a disease - a phenomenon - that I learned about last year. (Read it now if you want to be surprised.)


The clinical vignette is about a case of Lemierre's syndrome. I first learned about this last year, when I heard an alarming story about a friend of a friend, a field organizer during the 2006 elections, who, run down after months of endless work and no sleep, came down with a nasty strep throat - just after the elections. Healthy and in her early 20's, she ended up in a coma for over a week, septic and near death, because of Lemierre's. She made a complete recovery, but, I did a little reading about Lemierre's at the time and made a mental note not to underestimate strep. In this case, the 17-year old patient died, which was probably avoidable, if the diagnosis had been made earlier - and his doctor describes breaking down and crying with guilt.

And this perfectly illustrates the increasingly frustrating - and scary - paradox of use and abuse of antibiotics in the current system, where MRSA is always on the rise and antibiotic development lags behind bacterial adaptation. Concerned about antibiotic resistance, doctors prescribe less potent antibiotics for strep, have young children cry through their ear infections rather than pump them through the courses of antibiotics that I took as a kid (and loved 'em - because the pain I endured without them was unbearable) - and cases like this can be the result. The article notes that Lemierre's is on the rise because of the decrease in penicillin use for strep. Yet, in an essay earlier this week in the NYT, Sandeep Jauhar starts out his castigation of "pay for performance" schemes with a case in which an elderly man was started on IV antibiotics as part of the hospital's anti-pneumonia initiative, didn't get pneumonia, but did get a severe case of C. diff diarrhea - a common, debilitating, expensive consequence of antibiotic use and overuse. Two sides of the same coin - which makes appropriately conservative, exquisitely tailored, sensible standards of care all the more important. So, what about Lemierre's? Follow-up cultures for everyone? Back to penicillin?

Tuesday night rondevu at Whole Foods

By popular request, meaning Amanda, I've been asked to post the story of my late night rondevu with one tall, dark, ex-democratic presidential nominee. He's taller than you'd think from tv, a full foot taller than the notoriously sky scraping Clinton. I don't know why I was surprised  about the whole business since we've lived within spitting distance for years and it's kind of amazing it hasn't happened sooner.  We collided at the sliding glass doors of the whole foods entrance.  He elbowed me aside with his long, hooky arm and then before I'd connected his recognizable face with the full famousness of who he was, my internal monologue began, "oh that John Kerry, elbowing me aside to make it to his overpriced foods first......". A beat passed, "Oh, that's the actual John Kerry". I guess I'm sometimes amazed to see the famouses in the flesh; that they have flesh and don't exist purely as television phantoms, haunting us in ad campaigns and political stump speeches over the years. I know they are flawed with afflictions such as verbal diarrhea in the case of Kerry, but it's strange to see them in their suits after work with the rest of us, elbowing past to get to the deli first. Guess it's nice to know he gets cranky and hungry like the rest of us. 

It is the summer after my first year of medical school, and it is time to start the blog, in which I and my dear friend Kate will attempt to understand/put in perspective/gripe about/provide commentary on issues surrounding the med school experience and the medical world in general. We take advice and comments and we don't take ourselves too seriously. Or try not to.