tag:blogger.com,1999:blog-36212332049391342532024-03-17T23:03:11.301-04:00Primary Dxangienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.comBlogger90125tag:blogger.com,1999:blog-3621233204939134253.post-77974084149897435262014-02-08T19:14:00.001-05:002014-02-08T20:02:40.356-05:00It's not About the Money: Why Monetary Carrots-and-Sticks are Detrimental to HealthcareIn describing why Cooper Union, a unique college that offers absolutely free education to students, would effectively die if it starts charging tuition, Kevin Slavin wrote:<br />
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<i>"For many of us, Cooper wasn't even the cheapest way to go to school...So the question is: why did we go? We went not because of the financial value of free--that is, zero tuition--but rather, because of the </i>academic <i>value of free. At Cooper Union I was paid poorly, and I was proud of it. I would have worked all day just to be able to teach at Cooper Union at night. I would never have done that in an institution that charged their students. Because "free" affects far more than a fiscal bottom line. It affects the intentions, behavior, ambition, and performance of everyone in the system. In other words, it determines the </i>academic quality."<br />
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Kevin Slavin, an alumni and a teacher of Cooper Union, understood that money affects human motivation, and not in a good way. The phenomenon he describes is equally true in medicine.<br />
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Let me give you an example. I work in an academic hospital, one so large that it was impossible to survive financially without succumbing to the craze of monetary carrots-and-sticks that is sweeping the nation, such as Physician Quality Reporting System (PQRS), a Center for Medicare and Medicaid Services (CMS) initiative to promote better health outcomes through incentive payments/penalties.* Unfortunately, the actual outcomes are not what was intended, and the road to hell is truly paved with good intentions.<br />
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As a geriatrician caring for older adults, I would be remiss if I do not engage my patients in advanced care planning - helping them pick health care proxies in the event that they cannot make decisions for themselves, explaining the details of mechanical intubation, guiding them through the conversations of how to obtain a good death. These are difficult conversations - taxing, uncomfortable, time-consuming. But, I often stay late at work, skipping meals and foregoing sleep, to make sure I give these conversations the time and sensitivity that they deserve.<br />
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Why did I stay late? I sure was not paid overtime, not that overtime would make me stay longer. I was not paid by the number of health care proxy forms that I filled. Money does not drive me, and doctors should not be reduced to horses that live for a carrot on a stick. I helped my patients plan for the future because I care that their wishes regarding their life and health are followed, because it matters to me that I do a good job.<br />
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Sure, it makes sense that doctors are driven by altruism, but how is money as motivation detrimental?<br />
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Here's how: in an attempt to succeed in the age of carrots-and-sticks, my outpatient geriatric clinic created a competition in which the clinic provider with the most documented health care proxy forms filled wins a $100. It did not matter how many health care proxy forms were actually completed in reality, because that number was never used to determine the winner - only health care proxy forms recorded in the right slot on electronic medical records count, because those are the ones our clinic will get paid for. It was never said but one notion was undeniably true - the most important and direct purpose of this effort was to get the clinic paid. Having care plans for our patients was a side event.<br />
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Because advanced care planning slots in the electronic medical records were inadequate, undescriptive and user-unfriendly, I recorded my patients' wishes in free text. To reflexively participate in our clinic's proxy-form sweep stake, I would spend time transferring my free-text work into slots of electronic zeros and ones that count for money. That time cannot be spent on something else, like caring for patients or educating myself to become a better doctor, because time is limited, and knowing this I refused to participate in this shenanigan. I refused to be reduced to a primitive horse.<br />
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Once upon a time I happened upon a CMS policy maker and commented to her that incentive payments are not effective in achieving desirable outcomes in healthcare.<br />
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"What do you mean? Of course money motivates people. You don't think doctors' behaviors are motivated by money?" she interrupted the conversation, incredulous.<br />
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I replied, disillusioned by what I was hearing, "I hope not." I hoped, then and always, that doctors do what we do because our job is a calling.<br />
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"Well, maybe <i>individual</i> doctors are not motivated by money, but our healthcare system should be. Research studies have shown consistently that money can motivate behavior change," she was convinced.<br />
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I was convinced, too. "Sure, money can change behaviors, but are they behaviors that we want?"<br />
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She had no answer.<br />
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*Of note, monetary incentives are used by many parties in the healthcare system, both private and public, at a variety of levels. Using PQRS as an example was not an attempt to target or comment on current government efforts on healthcare reform.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-12131053976592563542013-07-27T20:50:00.000-04:002013-07-27T21:25:48.829-04:00Dash and IDash was sweet, but feisty. He was polite, but always refused to give up. He was eighty, but he was lean, full of strength. I sat by his bed and watched, letting my heart break with every word.<br />
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"Bbbbut...I...dooon't...understand!" We came back to this sentence over and over, as I tried to comprehend the anger, the vibrant possibility contained within this husk of an extensive left hemiparesis. Everything I took for granted was monumental to Dash, every day since his third stroke put him in a nursing home. Every word was a marathon, every shower a hike over Mount Everest.<br />
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"Ttthhey...leeefft...me...heere...to...die!" Dash shouted in heart-wrenching fragments, and all I could offer was a touch on his right arm. I had nothing better, and it was humiliating. Dash was moved to the long-term care unit when he could not make enough progress to go home. We took care of him, because his family would not. Dash would die here - I could not have put it better myself.<br />
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Dash was a fighter, and he was ready. He would concede anything to get better, to regain function, to go home. Everyday I saw him he would ask why the physical therapists no longer came by, why no one gave him a chance to leave. I would tell him that Medicare would not pay, because this husk, on this generic, impersonal hospital bed, was the new Dash, was all that Dash would ever be now. It was the truth, and the truth was awful. I had no answer for him, so I sat there, sad and defeated, holding his right hand. I tried to understand what it was like, to lie in this bed as a prisoner, to lose the basic independence of showering without someone staring at you, and I couldn't. I wish no human being had to, but here we are, Dash and I, holding each other's hands, a pair among millions of elderly residents in nursing homes and their doctors.<br />
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Dash looked away, a tear dropped on his pillow, and my heart broke. I wanted to help Dash, help him cope with this new life, but I had no right. Dash had to take this journey on his own, this path to acceptance, because no one should have the audacity to say this is OK, other than Dash. Until then, I held his right hand, and Dash squeezed back.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-47031710538300444852013-05-04T18:20:00.002-04:002013-05-04T18:20:42.303-04:00Learning to be a Caregiver in the Midst of HardshipI am honored to post a story from Cameron, a reader who would like to share his experience taking care of loved ones with difficult medical conditions, which is becoming more common for all of us - elderly parents, children with cancer, relatives with addiction. Please share your experiences or leave questions for Cameron in the comment section.<br />
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<b><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">Learning to be a Caregiver in the Midst of
Hardship</span></b><span style="font-family: Times, serif; font-size: 13.5pt;"><br />
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</span><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">November of 2005 found
my wife, Heather, and I confronted with the worst news of our lives. This
news came at a time when we were just enjoying being brand new parents to our
lovely three-month-old daughter, Lily. But on the fated day of November
21st, Heather was diagnosed with malignant pleural <a href="http://www.mesothelioma.com/">mesothelioma</a>. When we received the
diagnosis we were in shock at what we would do next. As I felt my life
begin to rapidly change in front of me, I knew immediately that I had to take
on the role of caregiver to ensure that my wife received everything she needed
to fight the disease.</span><span style="font-family: Times, serif; font-size: 13.5pt;"><br />
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</span><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">We had three choices for
Heather’s treatment, one of which included going to an experienced doctor who
specialized in mesothelioma in Boston. This doctor’s name was Doctor
Sugarbaker, and while we also had other options that were closer to home, we
chose Doctor Sugarbaker due to the extensive experience he had with this
particular type of disease. I knew that in order to survive this, my wife would
need the best care possible.</span><span style="font-family: Times, serif; font-size: 13.5pt;"><br />
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</span><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">After going into
caregiver mode and deciding upon a treatment plan for Heather, I started having
occasions where I felt overwhelmed with the disease we faced and the overload
of my schedule. One time, I simply collapsed and cried on the kitchen
floor, afraid of what the future might bring.
I could only picture the worst case scenario, Heather passing away and
leaving me to raise our daughter on my own. However, even with these
moments of weakness I never let Heather see my fears. I knew she needed me to be strong, no matter
what I was going through on the inside.</span><span style="font-family: Times, serif; font-size: 13.5pt;"><br />
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</span><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">Being a caregiver is not
an easy task, especially when you are providing nearly round-the-clock care for
someone you love. One piece of advice I have for anyone who is faced with
being a caregiver is to accept help when it is offered. I really do not
know how Heather and I would have made it through her ordeal if it had not been
for the loving and supportive help of her parents and many other people in our
community. <o:p></o:p></span></div>
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<span style="font-family: Arial, sans-serif; font-size: 11.5pt;">Over the following
months, Heather would undergo difficult treatment, involving <a href="http://www.mesothelioma.com/treatment/conventional/chemotherapy/">mesothelioma
chemotherapy</a>, surgery, and radiation.
Despite the odds against her, she eventually came through her treatment
cancer free, and remains so to this day, over seven years after her diagnosis. <o:p></o:p></span></div>
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<span style="font-family: Arial, sans-serif; font-size: 11.5pt;">I am so thankful that my
wife will be okay, and our lives are in the process of returning to normal and
getting back on a productive track. Providing non-stop care for Heather
taught me many things. I learned the importance of finding balance and
maintaining priorities at all time. We now hope that by sharing some of
our experiences, we can help others currently battling through their own cancer
journeys today.</span></div>
angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-20318703999554617872013-01-09T23:43:00.001-05:002013-01-10T00:27:47.578-05:00How to Train Your DoctorsBack in the day, legend has it that when space programs were just developed, NASA soon discovered that ball-point pens will not write in zero-gravity. Unfazed, NASA spent a large amount of money developing pens that will work in space, while the Russians simply used pencils.<br />
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It turns out that this legend is only half true(1), but the lesson remains - sometimes, we get bogged down trying to solve a problem within its existing framework. Sometimes, it's better to wipe the slate clean and start from scratch.</div>
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The problem I propose is residency, how our future doctors are trained. Imagine a shearing shed. On one end stands a line of plump, happy, fluffy sheep - metaphorically these are bright-eyed medical students, healthy, well-rested from the last year of light coursework in medical school, excited to finally be at the forefront of medical care. After 3 or more years in the residency, the shearing shed spits out a scrawny, shivering ghost of a bald sheep - these are your doctors. They are burnt out, fatigued, unhealthy graduating medical residents usually without the same self-esteem, optimism or hunger for knowledge they used to have. This generalization has truth in it - poems(2), books(3), other forms of media(4) have tried to describe this gruesome experience. I, for one, have never heard anyone said that they would want to do residency for the rest of their life, as a real job, because they love it so much and they never want to quit. </div>
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Maybe that is too much to ask - not every job in the world creates that kind of enthusiasm. But, considering the importance of the task at hand, should we not attempt to train doctors in a way that by the end, the sheep remain plump, happy, fluffy and, most importantly, medically smarter than before the shearing?</div>
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I propose that we build this alternative training program from scratch, so we can dream bigger without the constraints in the current system of what can and cannot be. My proposal assumes happy, fluffy sheep - meaning caring, upstanding medical students looking to learn real medicine so that they can provide the best care for patients on the job - this is not always true but that's the topic for another day. With that assumption, a better training program will have the following characteristics:</div>
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1. Autonomy: Learners should be able to dictate the content and the manner in which they want to learn medicine. </div>
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1.1 Content: Not every medical student wants to be a pulmonologist, so why does every medical resident in the same program need to do the same amount of ICU time? Learners should tailor the type and duration of rotations to fit their career goals. </div>
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1.2 Manner: How many current residents, laboring in the trenches, work with ACGME on work hour regulations? I am going to tempt fate here and guess zero, or at least a very small minority if that, because there simply is not enough time in the day. So why are people sitting in an office far removed from residency deciding when a bunch of grown-up adults should take a nap, go home, come to work? Shouldn't 25-something future doctors know when they're at their best learning and when they need to take a break? If your future doctors need to rely on someone else to manage their work day, would you really want them to be your doctor, especially out after training when there is no one and nothing telling them when to take a nap, go home, come to work? The new work hour regulation is really misguided and quite a shame, because being able to follow patient progression over a 28-hour call is priceless - I wrote more about work hour regulations <a href="http://angienadia.blogspot.com/2011/05/new-acgme-work-hour-regulations-for.html" target="_blank">here</a>.</div>
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2. Service vs Education: there is a time for service in every doctor's life, but residency should not be one of them. Medical students may have as little as 1 year to learn *everything* they need to know to be able to treat you on their own without supervision. None of that time should be spent learning the computer system or filling out paperwork, because many people can fill out paperwork without spending 4 years in medical school - it is low-yield. Progressive medical clinics hire scribes to write notes, enter orders, fill out paperwork, so doctors can focus on patients, look at them during conversation and treat them like respectable human beings. The diversity of cases is also important, which is why many reputable programs have medical admitting residents scouting for cases with educational values. There will be time to take care of patients admitted for pain control or alcohol withdrawal in the real world, but if a full-fledged doctor has never seen a case of pituitary adenoma during their training, would you trust him/her to care for you if you have one?</div>
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3. Evaluation: To become a full-fledged doctor, which is the goal of residency, you only need to spend a certain amount of time among a number of required rotations, and pass a multiple choice test. Failing other types of evaluations beyond these do not necessarily stop one from becoming a doctor. Other qualitative evaluations are performed mostly by doctors, a few by nurses, none (in my program) by patients, which seems backwards to me. It is important to know what your colleagues think, but isn't it more valuable to see if your customers are satisfied? I don't know of other thriving service industry where close to 0% of evaluations come from customers. </div>
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4. Equality: Residency is a monopoly, where medical students cannot become doctors without going through it. As a result, residents usually get the short end of the stick in everything that they do: slower computers, fewer medical assistants, more rectal exams. Being treated as a second class citizen should never be a rite of passage. Equality means respect, and the hidden curriculum in residency currently teaches us that it is acceptable to treat those with less experience without respect.<br />
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5. Add yours here. Wipe the slate clean and dream about how you want to make your doctors. One day, someone might actually listen and make your dreams come true.</div>
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(1) http://en.wikipedia.org/wiki/Space_Pen</div>
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(2) Farrago, Douglas. "Stages of the physician." The Placebo Chronicles. New York: Broadway Books, 2005. 5.</div>
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(3) Not the least of which is the infamous House of God, written by psychiatrist Stephen Bergman</div>
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(4) http://www.youtube.com/watch?v=VUd-JMPhgK4</div>
angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com4tag:blogger.com,1999:blog-3621233204939134253.post-4472070012555493622012-08-26T21:44:00.001-04:002012-08-27T20:34:10.792-04:00The only thing I had to do was to help Jerry and I failedI have failed Jerry, and now I'm replaying every word I ever said in my head, over and over, the whole exercise consuming my being.<br />
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Jerry was not old. He just turned sixty, a good few decades of retirement awaiting him. Then, he was diagnosed with stage 4 esophageal cancer. It seemed that he had spent his entire life working up to that moment, only to be stolen away unjustly, by a cancer that drowned him slowly in his own oral secretions. Jerry had been in the hospital for months, battling recurrent aspiration pneumonia that caused nasty sepsis. He frequented the intensive care unit, had a feeding tube placed along with a stent in his esophagus to remedy a fistula to his trachea, a communication caused by a large tumor burden in his chest.<br />
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I met Jerry the day before he died. Jerry was in bed under a tangle of wires, breathing quickly, gasping for air with every available muscle in his chest. He was distressed, decompensating from another ravaging aspiration pneumonia, blood pressure non-existent. I was supposed to help Jerry, as a responder from the intensive care unit. The only thing I had to do was to help Jerry and I failed.<br />
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I asked for labs and a stat chest X-ray. I was told by his inpatient doctor that Jerry was full code, meaning Jerry wanted anything and everything done, including a tube down his throat and compressions that would break his ribs, interventions that were becoming more and more realistic for Jerry. I waded through a throng of nurses poking for veins and grabbed his hand. I asked for his wishes, again, wanting to make sure I knew what he wanted for himself. I asked Jerry if he would want to be intubated - he shook his head and said no, with the perplexity of a schoolboy who was offered a rotten piece of Jello that he had already refused. Jerry seemed to have given extensive thought to this piece of Jello, and after multiple rounds decided that he would not want Jello for himself.<br />
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Still, I was not sure if Jerry was thinking clearly in his severe illness. I asked if he would want his wife to make decisions for him, seeing that Jerry was already working so hard to keep himself oxygenated. He nodded, with immense fatigue, then went back to focus on his breathing, his staying alive. I found his wife, crying and beside herself. I felt cruel when I asked her what Jerry would have wanted - what a burden I placed on her. The word unfair was an understatement. How can she agree to the tube if Jerry hates it? How can she refuse the tube if it's the only thing that will keep the love of her life breathing longer?<br />
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She produced a piece of paper - Jerry's living will. It said that Jerry did not want artificial respiration, cardiopulmonary resuscitation, artificial nutrition that would prolong his life. It said so in capital letters. The last sentence read, "these decisions are made when I am sound of mind." He signed it on February 20, 2012 - 6 months ago.<br />
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I was relieved. I thanked Jerry he made a living will. I could guide Jerry's wife through this difficult process, having an idea of what he wanted. I was angry. If Jerry coded before I found this piece of paper, I would have done everything that Jerry did not want. The covering inpatient doctor did not know why his living will was not found or discussed on admission.<br />
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Jerry's wife was broken, in despair. Her daughter asked her to keep Jerry alive while rushing in to the hospital. She pulled at her hair. She heavily sobbed. She begged me, begged the world and Jerry, not to make her choose. I sat her on a chair, hoping to provide some comfort, and told her that we would not intubate or perform chest compressions on Jerry - the medical team changed his code status to DNR/DNI. Luckily, even though Jerry was breathing quickly, his oxygen saturation was holding. For now an optimist could hope that Jerry would not require intubation. Jerry did not discuss pressors on his living will - most people do not. Pressors would keep Jerry's blood pressure up in the setting of sepsis, but a central line required to administer pressors is poked through the neck, a procedure with its own set of risks and discomfort. I talked to Jerry, his wife talked to Jerry, and we agreed that Jerry wanted pressors. Jerry came with me to the intensive care unit.<br />
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The next few hours was wrong, was when I failed Jerry. He maxed out on levophed, tiring out from tachypnea, secretions building up and drowning him. Jerry was actively dying. His daughter, now at bedside, asked about intubation. She said Jerry had been intubated before, despite his living will. I asked how, and she was not sure if the living will was discussed with his doctors then. I said I did not know where Jerry would land if he were intubated, avoiding projections with my limited experience, but I said there was a good chance that once placed, the tube would not be successfully removed. Jerry might be stuck on the ventilator - a horrible way to die for someone who specifically stated, when he was sound of mind, that he would not want to die on the tube. Jerry's wife agreed, while his daughter looked on, not saying a word, tired and holding her tongue. I told them my critical care attending was coming in - he could discuss intubation in more details with them.<br />
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By the time the attending stepped in, Jerry was out cold, no longer conscious but struggling to breathe all the same. Maybe out of experience, maybe out of comfort with aggressive medical care, maybe out of sympathy for his wife, imagining how heart-breaking it must be to watch her love drown, my attending offered intubation to the family. We can always back off, he said. It was the only tangible hope in a sea of despair and the family took it. I wondered if they took it for Jerry or for themselves, but who can fault family members, regardless of what they choose? His wife loved Jerry and wanted the best for him. She was deciding the only way she knew how, making earth-shattering choices for the first time in her life for Jerry, without Jerry.<br />
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The gamble did not pay off, for anyone. No one could know in a few hours Jerry would max out on 3 pressors, now with a breathing tube that did not do anything for him. Jerry was dead, had been dead long before the time when his heart would eventually stop. The Jerry that the world knew was dead. The-accomplished-pharmacist-who-regularly-hugs-his-wife-Jerry had left the world. The body on the hospital bed accepted breaths initiated by the ventilator, but once his heart and lungs finally gave out, chest compressions and electrical shock would not fix the sepsis within. Jerry would eventually die. He could not be saved.<br />
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And I have failed. I failed to save Jerry from the breathing tube, even though he told me clearly what to do. I failed to save his wife from the guilt that she may ruminate on, increasingly over time, wondering if she made the right choice for Jerry, and there would be no resolutions to that doubt because we would never know what happened if Jerry was not intubated. My only hope for her was that Jerry would know every decision was made out of love, that there was no blame, that he understood and loved her all the same. In the end the sepsis overwhelmed Jerry and there were no more pressors to give. The breathing tube was never withdrawn.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com5tag:blogger.com,1999:blog-3621233204939134253.post-85500874291667542922012-08-22T23:15:00.000-04:002012-08-23T00:58:34.835-04:00How We Die<br />
It was another day in the intensive care unit. The night was clean and calm, ventilators beeping their expected melody, and the laborers of medicine went about their night shifts uneventfully, including me sitting with the obnoxious admission pager attached to my hip. The smoothness of it all shattered when the beeper started screaming - I picked up the phone and soon the emergency room physician was on the line.<br />
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"We have an old lady with potential sepsis for you - fluids are going right now," the voice said.<br />
"What's her blood pressure?" I asked reflexively.<br />
"80/50 and still unstable - you should come see her soon," the urgency in that voice was unmistakable.<br />
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I scoured the patient's information quickly from the chart before heading to the emergency room, as I usually do, and registered a repeated past medical history of an abdominal aneurysm that had never been fixed. Her name was Dorothy, a name that is endearing today and would have been very fashionable in the 1920's. Dorothy lived in a nursing home for the past few years, with multiple hospital admissions becoming increasingly frequent in the recent months. Her stage 4 pressure ulcer was unrelenting, undermined by severe malnutrition demonstrated by an albumin level of 1.5. Her white blood cell count was not elevated, but infected older patients do not always present with leukocytosis. From the chart I braced myself for the harsh reality I was about to encounter, knowing her chance of leaving the hospital alive was poor, and with a heavy heart went to find Dorothy.<br />
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I pulled the curtain aside as I stepped into the room and the commotion around Dorothy was jarring. The monitor was unhappy with a blood pressure of 80/50 and it made its discontent known, loudly. Nurses ran in and out, starting new intravenous access, hanging more fluids, everyone fumbling all around except Dorothy. She was in a hospital gown but the blanket had fallen by the bedside, revealing her lower naked half with a foley bag lying nearby, draining not a drop of urine. Her arms and legs were skin on bones, her face gaunt with wispy hair, all combined to make her the life-sized version of a skeletal crypt keeper from horror movies, except the only horror in that moment was in Dorothy's eyes, staring blankly at the ceiling. She was agitated, scared perhaps, confused most certainly, her arms flailing wildly for something invisible that may save her life. She moaned, yelped, then screamed a cacophony of unsettling fear and panic. I grabbed her grasping hands and soothed her, uttering something vague like it's OK - not so much to say that life was there to stay but more to acknowledge that it was perfectly normal, expected even, to be scared. I searched for a family member, someone more adept at calming Dorothy than me, but I found no one.<br />
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Then something horrible happened. Dorothy's blood pressure started plummeting right in front of our eyes, systolic down to 70, then to 50, blood surely pouring out of her aorta into abdominal compartments. It became clear that her aneurysm had ruptured, catastrophically, life literally seeping out into her abdomen. The family, informed prior of what believed to be sepsis in Dorothy, mistakenly thought that they would have time to come visit her in the morning. They were promptly called again, this time notified that Dorothy was actively dying, a surgical repair of her aneurysm unlikely to be successful considering her frail baseline. Everyone was thankful that her family decided to stop all interventions knowing they were futile. Her son said he was rushing in then hung up the phone.<br />
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But Dorothy was already dying - I knew none of her family members would make it in time. I looked at Dorothy, left in the wake of the ravenous medical efforts aiming at postponing death, and there was not an ounce of dignity left in her being. Her gown was pulled aside, revealing a stomach dirtied with gel used for the bedside ultrasound. The foley hung lifeless between her bent legs, IV kits and needles strewn around like candy wrappings, wires attached to EKG leads tethering her soul. Dorothy was no longer flailing, her body now without the necessary blood to fuel the bodily expression of the fear within. I picked up her left hand and held it, making a mental note to stop in that moment for Dorothy and witness her death, in an attempt to add what little dignity I could to this horrible chain of events. My intern looked at me, then proceeded to hold Dorothy's other hand. Everyone else, the emergency room physicians and nurses, moved on out of necessity to other sick patients, all but one who returned with clean sheets to cover Dorothy, hopefully leaving her presentable to family members.<br />
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As Dorothy's heart slowed down and I held her lifeless hand, I could not recall a more horrible death other than a trauma case in medical school, a 12-year-old girl crushed by a school bus bleeding out every orifice. No one can predict death, but looking at Dorothy's chart one would guess that death was near - odds are that a malnutritious, demented, immobile body ravaged by stage 4 pressure ulcers would not survive increasingly frequent hospital admissions. I wondered if anyone ever mentioned to Dorothy or her family members that death was coming, that they should prepare for it, sooner rather than later.<br />
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Sometimes fear of death is so blinding that we forget to think about how we want to die. Other than certain suicides, we have no control over when we die, even though postponing the moment of death is what medical care is focused on. The only aspect of death we mortals could dictate, given enough thought and preparation, is how death will take us. The spectrum ranges from Dorothy to a peaceful death at home surrounded by love and familiarity, expected and prepared for. I remember reading a survey reporting that most people wish to die at home, although in reality only the minority of people do. I wonder if it is because we become so afraid and occupied, speculating how to fend off death, that we forget death is certain, a natural twin of life, something that can only be fended off for so long. I wonder if people know that hospitals are a horrible place, that once you enter it can be difficult to leave through the front door. I wonder if people know that Do Not Hospitalize is an option. I wonder if people know how to plan for death at home - I certainly do not. Of all the wishes in our lives, the wish for how we die seems as important as any, something to plan for deliberately and carefully.<br />
<br />
The line on the monitor went flat and still Dorothy was alone, two strangers holding her hands. The nurse stared at me expectantly - I pronounced the time of death as she left to gather paperwork. I wanted to stay and find out where people go after they die in the hospital. Who pick up the body? Are they put in a body bag? Where is the morgue? I wonder if other doctors know the answers - patients stop being ours once they are dead, even though they remain as human as ever - before and after, especially during death. How we die should never be taken lightly.<br />
<br />angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com5tag:blogger.com,1999:blog-3621233204939134253.post-49845457097913204902012-03-18T18:02:00.000-04:002012-03-18T18:02:50.855-04:00If people want to die, heroic measures won't get in their wayI was working in the Intensive Care Unit (ICU) the other day and as I counted, I found that more than half of the patients there, for lack of a better term, brought the condition upon themselves.<br />
<br />
I sound harsh, but there was no better way to put it. I was taking care of Mrs. B, a 60-year-old lady with COPD who called EMS for shortness of breath. As EMS readied to take her to the hospital, she said, "you all are gonna have to wait until I finish my cigarette." She has been intubated many times for COPD exacerbation, visited the ICU a hundred more times. She said if she got out, the first thing she would do would be to smoke a cigarette, but she did not believe she would make it this time. After multiple weeks on continuous BIPAP with spurts of intubations in between, she told us to quit and let her die.<br />
<br />
Looking around the ICU that day, there were multiple stories like her - a cirrhotic who was actively drinking despite his varices bleeding to death after 30 units of various blood products that turned out to be futile, a 20-year-old diabetic with recurrent admission for diabetic ketoacidosis who left against medical advice the minute he found out he would not get any intravenous dilaudid, a gentleman admitted with pulmonary edema every 3 days because he refused to go to dialysis.<br />
<br />
As days passed, I realized that these patients were common - I was being trained to undo what these people did to themselves, so that they can leave the hospital to do it some more. Some has hurt themselves so many times it could not be undone, despite many resources wasted and much money spent. I watched 30 units of blood passed through one end of our patient only to flow right out another, and I wondered if there was not someone else out there who would not undo our efforts, our blood products, our precious resources.<br />
<br />
More importantly, I wondered if we could ever draw a line, where we say enough is enough, where we say you do not get a second chance at life so that you can just kill yourself in the end, where we say there comes a point when heroic measures cannot cure how people want to live their lives. Before medical school I always thought that medicine was made to promote health, but in the light of reality I have learned that my job in the ICU today is really to prolong death, so that in the end people can crash and burn a bigger flame, taking much needed resources with them.<br />
<br />
Mrs. B knew in her heart that smoking would be her death, yet smoking was the one thing she pined for. I wanted to tell Mrs. B that if she wanted to die, I was in no place to stop her. I might have had a shot as her primary care doctor before she picked up her first cigarette, but that time is long passed. In the end when the BIPAP came off, she became unconscious and passed away peacefully. I wanted to ask if we should have stopped sooner, maybe two intubations ago, but I will never know.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com2tag:blogger.com,1999:blog-3621233204939134253.post-37458341893155586222011-09-12T19:09:00.002-04:002011-09-25T11:17:18.610-04:00More medical care is bad for youI recently admitted a patient with a pulmonary embolism. Before heparin drip was started, my attending ordered a hoard of eccentric, non-indicated hypercoagulable workup in the hope of avoiding the effect of heparin on these test results, including phosphatidylserine antibody and methylenetetrahydrofolate reductase DNA. I watched in horror as the nurse drew out approximately 13 tubes of blood, since each test needs its own tube.<br />
<br />
On rounds, the attending of course pimped us about all the possible tests you could draw on a patient who comes in with a clot. I zoned out in my head since I know that regardless of the test results, pulmonary embolism is life-threatening enough that this patient will need life-long anticoagulation - the tests will not change anything. Even if the patient tested positive for genetic clotting diseases, there is no point screening family members or even considering anticoagulation in them unless they develop clots themselves. We went on a long and useless thought experiment. What bothers me the most is that we get a pat on the back when we try to draw these tests just because they are vaguely related to hypercoagulability, but when you actually stop to ask yourself what you would do if the tests come back positive, the answer is usually a shoulder shrug . Imagine the phosphatidylserine antibody came back positive - what does that even mean? and do we even care? I personally do not as the patient is going home with anticoagulation no matter what.<br />
<br />
Useless thought experiments, unindicated lab tests and interventions happen on a regular basis, both in my medical school and residency program. We transfuse blood when there is no good evidence that it improves any outcome, just because doctors are nervous that patients will have heart damage from demand ischemia. Consulting surgeons would like to follow Lipase level in my patients with pancreatitis, and my attendings let them even though there is no evidence that its correlates with symptoms just because we don't want to get in a fight. I was told to perform extensive workup in a patient with acidemia, when the obvious cause of kidney failure stares us right in the face - I couldn't convince my attending to wait until the kidney failure resolves to see if the acidemia goes away, at which point no workup will be needed. We looked for zebras even though we know it's a horse, only because my attending "didn't want to miss anything."<br />
<br />
In my opinion, most of what we do in medicine is not backed up by good evidence. A lot of the guidelines are biased by group interests and potential profits. This is part of the reasons why some of the tests/procedures that used to be indicated are no longer. Mammogram used to be recommended every year, but now yearly screening may lead to unnecessary breast procedures and once US Preventive Services Task Force tried to recommend increased screening interval, the backlash from groups that stand to profit from mammograms and breast procedures was overwhelming.<br />
<br />
But a lot of it stems from how we are trained in medical school and residency. If we get a pat on the back every time we draw useless tests, we will continue to perform unindicated workup when we become attendings. If we are deemed unknowledgeable every time we refuse to do extensive lab work because we have a good explanation of what the abnormality is, we will spend more money without improved outcomes, which is happening in the US as we speak.<br />
<br />
I wonder if my patient knew that the test for phosphatidylserine antibody costs $194 at our hospital, and that in the end the test will leave her with nothing better than less blood in her veins.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com2tag:blogger.com,1999:blog-3621233204939134253.post-73688771409214507502011-06-30T03:52:00.007-04:002011-06-30T03:57:56.396-04:00From the brink of hospice to awaiting a reading machine<!--[if gte mso 9]><xml> <w:worddocument> <w:view>Normal</w:View> <w:zoom>0</w:Zoom> <w:trackmoves/> <w:trackformatting/> <w:punctuationkerning/> <w:validateagainstschemas/> <w:saveifxmlinvalid>false</w:SaveIfXMLInvalid> <w:ignoremixedcontent>false</w:IgnoreMixedContent> <w:alwaysshowplaceholdertext>false</w:AlwaysShowPlaceholderText> <w:donotpromoteqf/> <w:lidthemeother>EN-US</w:LidThemeOther> <w:lidthemeasian>X-NONE</w:LidThemeAsian> <w:lidthemecomplexscript>TH</w:LidThemeComplexScript> <w:compatibility> <w:breakwrappedtables/> 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mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; mso-bidi-font-size:14.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Cordia New"; mso-bidi-theme-font:minor-bidi;} </style> <![endif]--> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">It was a beautiful Monday morning in May. Yawning uncontrollably, I hopped into a Ford Hybrid with my attending and drove off to visit a patient who lived two hours away from our hospital. I woke up especially early that morning since we knew the commute would take many hours. We drove past open fields and a few cows before pulling into a driveway of a lovely house with a cute garden behind it. A middle-aged lady peered through the screen door and waved. My attending waved back as we clambered out of the car. She opened the front door and hugged my attending like a long lost friend, which she practically was, as they caught up over a short conversation before moving on to discuss her brother, Mr. R.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">Mr. R was blind. He could not and had not left his one-windowed bedroom for many years. When my attending was called about Mr. R a few years ago, it was a consult for home visit evaluation for hospice - Mr. R had such severe COPD that his prior provider thought that there was nothing more medicine could do for him. When my attending first met Mr. R, he was in bad shape - he was bound by yards of oxygen tubes connected to a tank, however not quite long enough to reach anywhere but his bathroom across the hall from the bedroom. That did not matter much, since getting up from bed was a huge feat causing severe shortness of breath. The blindness did not help either.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">My attending agreed to see him under special circumstances. Mr. R lived outside the usual range of home care visits provided by our hospital - she was hoping to set him up for hospice during a one-time visit. However, as she looked at Mr. R more closely, she realized that his COPD was not yet optimized and that medicine deserved a fighting chance. She set to work as his new primary care doctor, driving out to his house over the years to provide medical care - if Mr. R could not get up from bed without gasping hopelessly for air, there was no hope of traveling to the clinic for him.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">I looked at Mr. R with a hidden surprise, watching him grin as my attending entered the room. He was thin with a well-kept white beard, looking incredibly full of life for someone previously considered for hospice. I felt his firm handshake and observed in quiet wonder - Mr. R was breathing normally, speaking in full sentences, on 2Liters of oxygen. He reported that he was doing very well, taking inhalers as prescribed and finishing the last of his prednisone taper, which allowed him to titrate his oxygen down to 2Liters. He could get up from bed and make it to the bathroom, although still short of breath by the end of his journey. He appreciated the visit by the good people at the blind rehabilitation center, who helped him cope with blindness and promised him a reading machine.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">I stuck a pulse-oximeter on his finger, which beeped after a few seconds showing 94% oxygen saturation and a heart rate of 80 - his vitals were much better than my guesstimate. His lungs were a bit wheezy, although with good air movement. We drew his blood for testing and decided to adjust medication by phone after results came back. We concluded the visit - my attending gave him a hug and promised to follow up on his reading machine. As I asked Mr. R for a trash can to dump a piece of used gauze, a weird sense of humility hit me - suddenly I did not know where things were and was at the mercy of my patients, I could not go into other rooms or touch anything unless permitted by Mr. R - is this what patients feel like on our turf in clinic?</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">My attending talked with his sister in the hallway afterwards regarding the plans of care for Mr. R, and she thanked us profusely for making the trip out to her house - a familiar happening during a home-care visit. I took my last look at Mr. R facing the one window in his room, as if he was staring through it, and thought about how far he has come - from the brink of hospice to awaiting a reading machine. I turned around and climbed back into our vehicle, driving a long drive back to the city.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;mso-bidi-font-size:11.0pt;font-family: "Georgia","serif";mso-fareast-font-family:"Times New Roman";mso-bidi-font-family: "Times New Roman";color:black;mso-bidi-language:TH">In this day and age when our population is growing older and fewer people have the time or resources to go to doctor's appointments, home care visits by doctors have become increasingly valuable and life-saving. Home-bound population is greatly underserved, and capacity for home-care visits is limited, most of all by time and distance. Doctors can only travel to so many patient destinations in a day. </span><span style="font-size:12.0pt;font-family:"Times New Roman","serif"; mso-fareast-font-family:"Times New Roman";mso-bidi-language:TH"></span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">With the increasing popularization of mobile technology, a new model for home care visits emerged - one that could save time, expand home-care capacity and utilize community-based health care. I amateurly dubbed it, "The Home-Care Node System."</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">The Home-Care Node System consists of two major nodes: a single physician node in the center at the hospital interacting with multiple allied health nodes situated in the patient's neighborhood. In the node system, physicians make the first home-care visit along with a team of allied health professionals (who live near the patient) to perform initial intake together - the team can perform physical exams first-hand to document an agreed baseline on the patient. For subsequent follow-up visits, allied health professionals become the eyes and hands for physicians. They go out to patient's home, easily since they live nearby, equipped with a video-ready device (maybe an iPad, maybe a laptop, fill in your own blank here). Video conference is linked to the physicians at the central node, allowing them to take history, maybe take a look at a rash on the patient's foot, and listen to reports from allied health professionals who can answer any questions that video footage or patient's account cannot answer. Allied health professionals can take vital signs or draw labs if needed.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">The only missing ingredient is the ability to repeat physical exams by the physicians in person, but I argue that this is not extremely important. Allied health professionals can perform the physical exam and share their findings with the physicians. Most physical findings that matter do not require MD training to recognize. If a wheeze is too tiny for an untrained ear to hear, then the lungs are practically moving good air on the grand scheme of things. If a wheeze is prominent and diffuse, a medical student will hear it and so will a physician attending. If there is any doubt, a physician can make a special trip to the patient's house to investigate further, but for all other non-subtle findings, allied health professionals in the area can free physicians to take care of more patients in wider areas of service. There is also much to be said about community-based health care - local allied health professionals understand the environment that the patient lives in and have invested interest in improving the health of their community.</span></p> <p class="MsoNormal" style="margin-bottom:0in;margin-bottom:.0001pt;line-height: normal"><span style="font-size:9.5pt;font-family:"Georgia","serif";mso-fareast-font-family: "Times New Roman";mso-bidi-font-family:"Times New Roman";color:black; mso-bidi-language:TH">The Home-Care Nodes will not be easy to set up in our maze of a health care system, but a lot of great inventions sprout from what-ifs that were given a try. As I sat down to write my home-care visit note for Mr. R and pondered about how far he has come, I daydreamed of a day when home-bound patients are adequately and efficiently served. But then again, daydreaming is a powerful thing – as long as we act on it.</span></p> <p class="MsoNormal"> </p>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-7128135826320200292011-06-28T02:02:00.007-04:002011-06-28T03:47:50.265-04:00Why is medical education so demoralizing?My first year of residency training has ended. As I sit awaiting the start of a new year and new responsibilities that come with being a senior resident, the accomplishments of last year and the excitement of what comes next are overwhelmed by dread - I am not excited and cannot wait for residency to end.<div><br /></div><div>I look around me in the health care sphere and most of what I see is negativity. Exacerbated by the failure of our health care systems, sure, but that is not the brunt of it. As I take leave from medical training and step outside to work on my personal projects in non-health care related fields during vacation, I realized I fear returning to work, to medical training, like a little kid fearing a trip to the dentists.</div><div><br /></div><div>I look back over my training this past year and realize that everyday is a beating- from my colleagues and never from patients. Every day on rounds, we residents put ourselves up to mean scrutiny - we give presentations on patients we admitted to hospitals, we devise a plan on how to help them feel better - and, of course, we take great pride in what we do and pour a lot of thoughts and heart into these presentations. What we get in return from most attendings and senior residents are often agreements, sometimes additions to the plan, other times harsh criticisms on systematic failures attributed to individual's carelessness (which is seldom true - when things fall through the cracks in hospitals, it is usually due to a systematic flaw bigger than one person), but rarely an acknowledgement that creates a positive work environment. The focus seems to be on what is not perfect, and hardly on what was done well - strides are rarely celebrated in medical education.</div><div><br /></div><div>There are many instances when residents are "pimped" by attendings - that is, being asked questions to see how much we know. The original intention of pimping (I hope) is to teach, but nowadays I would say that goal is rarely accomplished. Most clinician educators take less than a few seconds to wait for answers while pimping - when do residents have time to think and formulate their responses? A question answered correctly is rarely followed by a pat on the back, only harder questions, some so vague and uneducational most residents don't bother learning answers to. Many times residents are pimped tactlessly in front of patients, whose trusts and confidence are needed for us to do our jobs. I wonder why I feel that the goal of pimping is to embarrass and make us feel stupid.</div><div><br /></div><div>Last but not least, I feel that my time is not valued. There are many instances when I sit around without any responsibility, waiting just to be let out at 5PM like a 5-year-old because that is when my attendings deem appropriate - I look at people who have autonomy over their own time (like Google employees) and wonder why we are not treated like adults, who can make our own decisions regarding which activities are useful in our training and which are not. There are many occasions when I try to eat lunch in 5 minutes, when I miss a meal completely, when I do not go to the bathroom for 10 hours, when I sleep 4 hours a night, when I work 21 days in a row - and I look at people in other jobs, sometimes nurses, who have a real lunch break, who have real weekends, and I wonder what kind of existence I was living. </div><div><br /></div><div>On a Southwest plane during my vacation, I read a Southwest magazine featuring its 40th anniversary in business, and a heart-warming theme throughout the whole magazine was how thankful the company was to its employees, how each one of them takes great pride in what Southwest offers and how each one of them was excellent in what they do. Most successful companies have the right idea - the funny thing about humans is if you tell them they are excellent, they become excellent, and compliments and appreciation are rare in medical training. </div><div><br /></div><div>I can already foresee comments telling me to tough it up and stop whining, but I look at great companies in other industries and employee's morale is never allowed to be quite as low with such daily beatings and abuse. Talk to a resident, and what you will most likely hear are complaints - about long hours, about mean attendings/senior residents, about inefficiency in their workplace. If residency is a long-term job that you can keep until 60, most doctors will not stick with it or want to return to it. </div><div><br /></div><div>If I could do it all over, I would still pick residency, because my patients made everything worth it, but really, does medical education have to be so demoralizing? Why do we teach people by making them feel small instead of empowered? Does adequate medical training have to come at the price of 10 hours without urination? I challenge us to do better, to build a system where self-esteem is high and residents are well-rested. If Southwest can do it, so can we!</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com5tag:blogger.com,1999:blog-3621233204939134253.post-67392672423106543392011-05-05T17:54:00.000-04:002011-05-05T17:55:24.820-04:00New ACGME work hour regulations for interns: friend or foe?<span class="Apple-style-span" style="color: rgb(17, 17, 17); font-family: Arial, 'Helvetica Neue', Helvetica, sans-serif; font-size: 14px; line-height: 22px; "><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">On the night of October 4, 1984, a young girl named Libby Zion was admitted to New York Hospital in Manhattan for fever, agitation and strange jerking movements. No one knew that her death the next morning would, 27 years later, drastically change the quality of physician training, for better or worse.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">When Libby was evaluated in the emergency room that night, neither the ER physician nor her family physician Dr. Raymond Sherman, consulted by phone, were able to make a definitive diagnosis of what was going on with Libby.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; "><span id="more-52883" style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "></span></p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">They decided to admit her for hydration and observation. When an intern Dr. Luise Weinstein and a resident Dr. Gregg Stone evaluated her for the admission, they also were not sure of Libby’s cause of illness – Dr. Stone termed it “a viral syndrome with hysterical symptoms,” suggesting that Libby may be overreacting to a benign viral syndrome. They prescribed her Meperidine to control shaking, and Dr. Sherman approved the plan by phone without evaluating the patient. Dr. Weinstein went on to care for 40 other patients in the hospital that day, while Dr. Stone went to sleep in the next building, to be reached by beeper if needed.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">Later on that night, the nurse contacted Weinstein when Libby became more agitated and started pulling out her intravenous lines. Weinstein ordered restraints and Haldol, a medication used for agitation, without re-evaluating the patient. She also did not notify Stone or Sherman. Libby finally calmed down later that morning, until 630 AM when a vital sign check showed that Libby had a dangerously high fever to 107. Measures were taken to reduce her temperature, but Libby soon suffered cardiac arrest and died.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">On careful review, it was discovered that Libby was taking an antidepressant named Phenelzine. Combined with Meperidine given to her in the hospital, Phenelzine can cause fatal serotonin syndrome, symptoms of which include hyperthermia resulting in cardiac arrest.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">What follow were outraged parents, a high-profile court trial and the image of the bedraggled, unsupervised intern wreaking damage in hospitals featured in the pages of the <em style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Washington Post</em>, the <em style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">New York Times</em> and <em style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Newsweek</em>. Libby’s parents believed that her death was caused by inadequate supervision and fatigue from long work hours. This sparked <a title="Will the new resident duty hour rules improve patient safety?" href="http://www.kevinmd.com/blog/2010/08/resident-duty-hour-rules-improve-patient-safety.html" style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; text-decoration: underline; color: rgb(125, 0, 0); ">work hour regulations</a> for residents and interns, which continued to evolve even 27 years later. In 2010, the Accreditation Council for Graduate Medical Education (ACGME) announced stricter work hour regulations, from 30-hour shifts in 2003 to 16-hour shifts to take effect in July 2011. It also stipulated that residents must have 8-10 hours off between shifts, with total work hours/week not exceeding 80 hours.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">I have the distinct fortune of being the intern during this monumental transition – I am the only group of interns who during my first year of training have the opportunity to work 30-hour shifts while also transitioning to the 16-hour calls. As I keep my head above ground while my residency program goes through multiple trials of work hour changes to meet the new standards, I often ponder (despite lack of time) about what happened to Libby.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">Looking carefully at the story, Libby did not die simply because interns were taking 30-hour calls. When Libby presented, multiple physicians missed her diagnosis, including the more experienced ER doctor and the Zion’s family physician, who should know that his patient Libby was taking Phenelzine before she came to the hospital. The decision to give her Meperidine was not made by the residents alone – it was approved by the well-seasoned, board-certified family physician Dr. Raymond Sherman. When Weinstein decided to give Libby restraints and Haldol, she was probably tired, but more importantly she was BUSY – she did not re-evaluate Libby or call for help, not because she was sleeping, but because she was covering 40 other patients.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">Libby highlighted what was and is wrong with medicine today. Private physicians cannot and should not be allowed to manage patients who are sick enough to be admitted by phone – Experienced physicians need to evaluate patients in person and should not rely solely on residents’ accounts. Medication reconciliation and prevention of medication cross-reactions should not be left vulnerable to human errors and information technology needs to be effectively used.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">Most importantly, from personal experience, I can testify that as an intern, I am more likely to make medical errors because I have to take care of an absurd number of patients, not because I am tired, and cutting calls from 30 to 16 hours will only exacerbate the situation. As my call hours are cut to sixteen, I am still forced to admit the same overwhelming number of patients I usually do on a 30-hour shift. As I struggle to get out at the 16th hour, there were numerous orders that I simply did not have time to execute, and the fate of the patients are left to the residents who stay overnight for 28-hour calls but remain overwhelmingly overworked. As I lose post-overnight call resting hours and accumulate more commute time from not being able to stay in the hospital, I end up spending MORE time working and less time sleeping. As I become more tired and take care of more patients in shorter periods of time, my learning has greatly diminished – I spend less time processing my patients and more time cramming 30-hour worth of paperwork into 16-hour shifts.</p><p style="padding-top: 0px; padding-right: 0px; padding-bottom: 0px; padding-left: 0px; margin-top: 0px; margin-right: 0px; margin-bottom: 1.571em; margin-left: 0px; ">The solution stares us in the eye – interns need a stricter cap on the number of patients they can admit or care for at one time. Patient care can be improved and medical errors can be avoided if providers simply have more time – thorough assessments can be made and comprehensive plans can be formed. Sixteen-hour shift is not the answer – it only aggravates the actual source of the problem</p></span>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com4tag:blogger.com,1999:blog-3621233204939134253.post-41379814822966869682010-09-01T21:47:00.005-04:002010-09-20T23:54:38.598-04:00Medical care and airlines - should there be a difference?A recent <a href="http://www.nytimes.com/2010/08/26/health/26pauline-chen.html?_r=2&partner=rss&emc=rss">article</a> by Pauline Chen features a group of primary care physicians at Tufts Medical Center in Boston, who have created a concierge practice that funnels income into the traditional general medical practice that sees less-advantaged patients. Surveys (performed by the medical center itself) found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff. According to the medical director, analogous to airline services providing both first class and coach services, the parallel practice gets patients to the same destination - some eating peanuts, others eating caviar. <div><br /></div><div>I believe this is an intelligent hybrid that may have successfully reacted to our broken medical system, but the ends does not justify the means. Differing services based on the ability to pay is discrimination - it is demoralizing for coach flyers, but morally wrong for economically-disadvantaged patients. This is because medical care is not the same type of services as airlines - people will not die if they cannot fly to places, but they will die without medical care. </div><div><br /></div><div>In a civilized society, its members should have equal access to life-saving services regardless of the ability to pay. Just like the fire department, medical care should be provided as a societal safety net so that, instead of worrying whether our house will burn down while we're off at work or whether a catastrophic illness will take away everything we've worked hard to earn, we can focus on higher pursuits like being a productive member of society. </div><div><div><br /></div><div>Differences in health outcomes between two groups remain unclear. If they are unequal, then there is discrimination based on the ability to pay. If they are equal, then first-class patients pay more money without justifiable returns other than convenience and a more pleasant office staff, which I argue should not be different in any circumstances - I'd like to believe that medical professionals treat fellow human beings in sickness with utmost compassion at all times, regardless of payment scheme. </div><div><br /></div><div>Either way, segregating patient care leaves a bad taste in my mouth. As a doctor, we ask patients to trust us with personal life stories that they may never share with their parents or their significant others. Such level of trust can hardly be established in the settings of discrimination.</div></div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com5tag:blogger.com,1999:blog-3621233204939134253.post-42632100887005073702010-08-24T22:21:00.002-04:002010-08-24T22:32:22.461-04:00Deep-fried snickers barsToday I went to a lecture where a cardiologist showed us photos of disgusting food sold across America. The purpose was to convince all the cardiologists in the room that despite decreasing incidence of heart attacks from 2000-2007, cardiologists can rest assured that these fattening food items will keep them in business, and this is true only because America pay based on volume regardless of outcome. It makes me sad to think that cardiologists are happy when people eat deep-fried snickers bars.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-25920740559710245192010-08-09T21:45:00.019-04:002010-08-13T00:15:45.180-04:00Why do we use carrots and sticks if humans are not horses?<p class="MsoNormal"><span class="Apple-style-span" style="font-size: 13px; ">It was 6PM and I was still at the clinic. My last patient, Mr. R, had left over an hour ago and as far as the rules go, I could be home by then, eating dinner and taking a shower. But as I perused Mr. R's medication list over and over, I couldn't get myself to leave. He was taking over 15 medications and the pill burden was overwhelming. Since he recently lost Visiting Nurse Services and had to fill the pillbox on his own, he was exhausted from taking medications. I thought of how all the puzzle games I used to play had prepared me for this day as I went through different combinations of medications to arrive at the smallest possible number of pill counts for Mr. R. I continued to think of his case on my drive home trying to figure out a way to get a better control of his raging diabetes.</span></p><p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">As I sat down and stuck a fork into the piece of chicken that was my dinner, the clock read 730PM and I thought about why I didn't leave earlier. Why did I spend time trying to fix the life of a stranger instead of feeding myself? What motivates us as doctors to stay late and perform a thorough task instead of clocking out on time and leaving the fate of our patients to other forces in the health care system?</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">And this is a pivotal question, because as our nation tries to make sense of why health care cost is spiraling out of control, the new system will be rebuilt based on what motivates health care workers to do a good job of caring for patients. </span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">Many fresh carrots on newly-minted sticks have already been instituted in various areas of the medical system as part of the new health care legislation in an attempt to motivate health professionals to do the right thing, including programs like Medicare's Physician Quality Reporting Initiative (PQRI). According to the legislation, PQRI asks physicians to report how the care they furnish aligns with evidence-based clinical guidelines for a variety of medical conditions, such as diabetes or heart disease (1). In 2010, physicians who successfully report these measures will receive a 2% bonus on charges received from Medicare. The bonus tapers down to 1% in 2011 and 0.5% from 2012-2014. However, starting in 2015, physicians who fail to report these measures will receive a penalty of 1.5 percent deduction from their Medicare revenue from that year, increasing to 2% penalty in 2016 and each subsequent year. </span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">But before we march forward to the trial and error of this new measure designed to induce higher performance, it is important to step back and ask ourselves: what motivates us as human beings?</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">According to Daniel Pink's book <i>Drive </i>based on numerous researches replicated in various settings over time, humans are motivated by three intrinsic drives: autonomy, mastery and purpose.</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">In a book by Deci et al published in 1985 (2), multiple researches on school children randomized to autonomy-supporting versus controlling teachers conclude that autonomy-supporting environment correlates with more creativity as well as enhanced intrinsic motivation and self-esteem. The concept of autonomy is replicated in the real world today by a successful Australian software company called Atlassian (3). Inspired by FedEx's promise to deliver a package in 24 hours, Atlassian instituted "FedEx day," when, once in each quarter, software developers are allowed 24 hours to work on anything they want, enjoying full autonomy. Results are brilliant bug fixes and new innovative features that otherwise would not be explored as successfully.</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">Another landmark article in 1959 (4) by Robert White, a professor emeritus in clinical psychology at <st1:place st="on"><st1:placename st="on">Harvard</st1:placename> <st1:placetype st="on">University</st1:placetype></st1:place>, proposed that the inherent satisfaction in exercising and extending one's capabilities is a strong motivator. It later inspired numerous experiments on mastery motivation which show multiple positive effects on performance, from leading test subjects to spend more of their free time on tasks (5) to increasing cognitive development in children (6). The 21st century example of these validated experiments can be found on Youtube, where there are millions of videos on the how-to of everything, from using make-up to writing computer programs, made by folks who enjoy the subjects in their free time, free of charge.</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">An interesting study by Adam Grant at Wharton demonstrates the power of purpose as a motivator (7). The study shows that employees working in a call center at a university fundraising organization who were given stories of how the money they raised affected the lives of beneficiaries earned more than twice the amount of donation compared to before the intervention. Volunteers exemplify the power of purpose in the real world, where people from all walks of life are driven, not by the extrinsic motivation of money, but by the intrinsic motivation of being part of a cause. </span><span style="font-size:13.5pt; color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">Interestingly, within decades of social studies research on motivation, the most surprising finding of all is that monetary rewards actually lead to poorer performance for cognitive tasks. The pervasive belief that higher monetary rewards lead to higher performance only applies to straight-forward, mechanical tasks – as soon as the job requires even the least amount of rudimentary cognition, monetary rewards produce negative effects on performance. This finding has been shown in works by numerous researchers, including Dan Ariely (a professor of behavioral economics at MIT)(8) and Dr. Bernd Irlenbusch (a lecturer at the <st1:city st="on"><st1:place st="on">London</st1:place></st1:city> School of Economics) (9). </span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">Despite the repeatedly validated science of intrinsic motivations, managers and organizations continue to use money to motivate workers for the more and more complicated cognitive tasks of the 21st century, the Medicare's Physician Quality Reporting Initiative (PQRI) included. The monetary penalties of PQRI will narrow physicians’ minds onto the goal of mechanically completing reports, eliminate autonomy and distract away from mastery and purpose. It sends the message that physicians should do a good job, not because our work has a higher purpose of keeping other human beings healthy, but because we will earn more money for it. In a way, it views physicians as rudimentary horses easily lured by rudimentary carrots, when in reality I would like to believe that physicians are human beings driven by the ability to direct our own fate, the desire to be good at what we do, and the heart to be part of something bigger than ourselves.</span><span style="font-size:13.5pt;color:black"><br /><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">On my drive home after another hard day's work, listening to the repeating lyrics of the wise singers of "The Lox," I reflected back on our motivation as physicians as the radio crooned, "It's the key to life. Money, Power and Respect." Autonomy is power, and mastery brings respect, but the Lox was wrong about the last key to life. In the end, life is never about money - it is all about purpose.</span></p><p class="MsoNormal"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(1) </span><span style="font-size:13.5pt;color:black"><a href="http://www.acponline.org/advocacy/where_we_stand/access/int_prac_guide.pdf"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:#000099">http://www.acponline.org/advocacy/where_we_stand/access/int_prac_guide.pdf</span></a><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(2) Intrinsic motivation and self-determination in human behavior By Edward L. Deci, Richard M. Ryan</span><span style="font-size:13.5pt;color:black"><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(3) </span><span style="font-size:13.5pt;color:black"><a href="http://www.atlassian.com/about/Atlassian_Media_Kit.pdf"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:#000099">http://www.atlassian.com/about/Atlassian_Media_Kit.pdf</span></a><a href="http://eresources.library.mssm.edu:2346/stable/1128130?seq=7"></a><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(4) R. White. Motivation Reconsidered: The Concept of Competence. <i>Psychological Review. </i>Vol. 66, No.5, 1959.</span><span style="font-size:13.5pt; color:black"><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(5) S. Harter. Developmental Differences in the Manifestation of Mastery Motivation on Problem-solving Tasks. <i>Child Development. </i>Vol. 46, No. 2 (Jun., 1975) pp. 370-378.</span><span style="font-size:13.5pt;color:black"><a href="http://eresources.library.mssm.edu:2344/journals/rev/66/5/297.pdf"></a><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(6) K. Jennings et al. Exploratory Play as an Index of Mastery Motivation: Relationships to Persistence, Cognitive Functioning, and Environmental Measures. <i>Developmental Psychology. </i>Vol. 10, No. 4, 386-394</span><span style="font-size:13.5pt;color:black"><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(7)</span><span style="font-size:13.5pt;color:black"><a href="http://www.management.wharton.upenn.edu/grant/Grant_JAP2008b_TaskSignificance.pdf"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:#000099">http://www.management.wharton.upenn.edu/grant/Grant_JAP2008b_TaskSignificance.pdf</span></a><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(8) D. Ariely, U. Gneezy, G. Lowenstein, &N. Mazar, Federal Reserve Bank of Boston Working Paper No. 05-11, July 2005; NY Times, 20 Nov. 08</span><span style="font-size:13.5pt;color:black"><br /></span><span style="font-size:10.0pt;font-family:"Georgia","serif";color:black">(9)</span><span style="font-size:13.5pt;color:black"><span style="font-size:10.0pt;font-family:"Georgia","serif";color:#000099"><a href="http://www2.lse.ac.uk/newsAndMedia/news/archives/2009/06/performancepay.aspx">http://www2.lse.ac.uk/newsAndMedia/news/archives/2009/06/performancepay.aspx</a></span></span></p>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-11423111649512985642010-08-08T00:03:00.007-04:002010-08-08T17:23:44.814-04:00Can entropy be reversed?For those with an android phone, I'd like to introduce you to Edwin, one of the most amazing applications out there for android users that really puts the future in perspective. It is a speech-to-speech personal assistant program that lets you asks any questions, from what is the meaning of life to where is the nearest coffee shop, and it will give you the answers (which by the way are 42 and dunkin donuts on chapel street). It links to wolfram alpha, google translate, and other incredible computational programs that vastly increase Edwin's ability to assist, including calculations, word spelling/definitions, language translation, map/navigation - the list goes on. Below are just some of the quirkier responses you can play around with if you're bored:<div><br /></div><div>Input: I love you</div><div>Response: Sadly, I was not designed to love, but if I were, I would love you</div><div><br /></div><div>Input: I hate you</div><div>Response: I'm sorry you feel that way. Maybe with a later update, you will change your mind.</div><div><br /></div><div>Input: Where is my car?</div><div>Response: Not sure, but wherever you find it, that's where it is.</div><div><br /></div><div>Input: Why are you awesome?</div><div>Response: If I have computed more, it is by standing on the shoulder of giants (plus a lot of hard work - with all due respect to Sir Isaac Newton).</div><div><br /></div><div>Input: Do you have a brain?</div><div>Response: I am capable of universal computation; that I can say.</div><div><br /></div><div>All fun aside, Edwin just shows that all the fancy technology we ever imagined in sci-fi novels/movies will become reality only in a matter of time. Edwin seems to be a primitive ancestor of Multivax, the all-knowing AI in the famous short story "The Last Question" by Isaac Asimov. With more computational power and programmed responses, Edwin will maybe one day tells us how entropy can be reversed. Until then, the next game-changing discovery will be something we have never ever imagined, sensed or comprehended in human history - a completely separate dimension that will change everything and how we operate. In a way I feel like we are ants, unaware of the human world above us. When Armageddon comes we wouldn't understand why, when in reality God just spilled a bag of skittles on us. </div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-44047732545901460132010-06-20T21:45:00.003-04:002010-09-22T19:12:41.560-04:00Extra Hour in the SunAs a new intern at a well-endowed medical institution, I was disappointed despite the flurry of excitement that comes with orientation. I was disappointed despite the brand new privilege to save lives and relieve human sufferings. And the disappointment was made clear to me over the past two days.<br /><br />What has happened in the past two days? As I will be working at two separate hospitals, for the past two days I have sat through training for at least 5 different EMR systems, none of which are similar or produced by the same company, all of which are designed to do the exact same things as hundreds of other EMR systems used in other parts of the country.<br /><br />What really drove this home, as I zoned out during training for the 4th EMR system of the day, was the fact that in the mix, I didn't receive access for one of the EMR systems. The technician at the training center instructed me to call help desk when I got home. At home on the phone with the help desk specialist, I was told that the issue unfortunately could not be solved on the phone and I would have to return to the training center. As I hung up the phone, I thought how nice it would have been if I had found this out 15 minutes ago when I was still at the training center.<br /><br />But I wasn't told that stopping by the help desk was an option. I wasn't informed that the help desk was in the same building as the training center. I didn't know that there was a possibility that this issue could not be solved on the phone.<br /><br />Could this whole ordeal have been foreseen? Could it even be possible that I'm not the first person who fell through this trap? Very likely. But this is only one of the possible failings in our highly fragmented, variable medical system. With 5 different EMR systems in only two hospitals, how could a human being possibly plan for all the possible shortcomings these non-uniform processes create?<br /><br />It's not a matter of inconvenience that new providers have to learn 5 new computer systems in two days - it is a matter of patient safety. I continue to be amazed that despite all our advances, we as a country have not reconciled our differences and agreed on a uniform EMR across most, if not all, medical institutions. The benefits are many, including the ability to consolidate fragmented/repetitive medical information, better coordinate care and reduce possible mishaps created by each separate system. The waste that goes into reinventing the wheel, retraining medical professionals, troubleshooting hundreds of different EMR systems nationwide is likely enormous. <div><br /></div><div>I believe that amidst the effort to reform health care, the time is ripe for us as a country to put our self-interests aside and work together so that future medical professionals and patients do not have to settle for this substandard, fragmented medical system. But until then, I am walking back to the training center to tell Jim, my computer trainer, what had happened to me so that future interns can have an extra hour in the sun instead of spending time at a computer training center. </div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-58456996425304561362010-05-26T16:38:00.007-04:002010-05-26T17:08:20.427-04:00Tricky questions about the DMV and car insurance<div>DMV</div><div>Q: What is the difference between Title and Registration?</div><div>A: Title confers ownership of the car, while registration allows you to operate the vehicle regardless of ownership. Usually the two processes are completed together by the dealer when you buy a car, but they can be done separately at any time. Read more <a href="http://www.nydmv.state.ny.us/broch/c19.htm">here</a>.</div><div><br /></div><div>Q: How do you transfer license from other states?</div><div>A: The processes are usually detailed on that state DMV website, but basically until you have a real license in hand, starting a transfer process means starting everything over (you'll have to redo the eye test, knowledge test, road test, pay for another 8-hour pre-licensing course). This is true for both learner's permit and interim license. </div><div><br /></div><div>Auto insurance</div><div><div>Q: How can I get great prices and coverage on car insurance?</div><div>A: Edmunds.com has a good article explaining everything in detail <a href="http://www.edmunds.com/advice/insurance/articles/89618/article.html">here</a>.</div></div><div><br /></div><div>Q: Can you get insurance on a car that is not registered/titled to you?</div><div>A; Yes. Title and registration do not mean much - it is the car insurance and the coverage that really matter. If you need to drive someone else's car and would like to buy insurance to cover you and your friend's car in case you wreck it, you can certainly do so. Read more <a href="http://www.carinsurancecomparison.com/how-do-you-get-insurance-on-a-car-not-registered-to-you">here</a>. </div><div><br /></div><div>Q: Do I get car insurance based on the state of registration, the state where I live, or the state where I drive the car?</div><div>A: Car insurance is based on the state in which you drive the car, basically where the garage is. Every state has different requirements and you can check the above link from Edmunds.com to see what they are.</div><div><br /></div><div>Q: If I'm a new driver, can I get a cheaper insurance if I add another experienced driver on the policy?</div><div>A: I tried this while soliciting online quotes and discovered that the more drivers you add to the car, the higher the premium, regardless of their driving records, impeccable or not.</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-65001226870887349782010-05-26T15:28:00.006-04:002010-05-26T17:09:20.701-04:00How to deal with car dealersI recently bought a 2010 Honda Fit Base Automatic in silver with security system installed for $16,002.36 as a base price, $17,707.07 out the door with NY sales tax and registration (sales tax $1420.21, registration fees $197 ($214 with sales tax - dealer only charged $212), title fee $50, inspection fee $10, tire tax $12.50 for 5 tires). I believe it was a good price and I wanted to share my experience with you so that you can get the best deal on your future cars!<br /><br />First, I read <a href="http://www.edmunds.com/advice/buying/articles/78386/article.html">these tips</a> on buying new cars on Edmunds.com. It gives a good, step-by-step overview of how to navigate through the whole process, most importantly how to not get scammed by dealers. After perusing the article, I went through the following process.<br /><br />- I went on <a href="http://www.truecar.com/index.html">www.truecar.com</a>, which is a great website that updates true cost to dealers (how much it actually costs the dealers to sell you the car) and true market value (the average of how much everyone is paying for this car) of your new car more regularly than Edmunds. According to truecar.com, the true cost to dealers of a new 2010 Honda Fit Base Automatic without the security system installed is $15,740. A great price is less than $15,912, good price is less than $16,343, and $16,344 or more is overpriced. These figures include destination fee (what dealers pay to get cars from factories to the lot) and regional ad fees. With these figures in mind, I have an idea of how much I should be paying for the car<br /><br />- Truecar.com provides a list of dealers with the lowest prices in your area, so I solicited quotes from the internet departments of the 3 cheapest dealers. To save yourself some time, make sure to solicit out-the-door price through internet transactions only - beware of dealers trying to get you to come in for a test drive with unrealistically cheap base price for the car. Once you make a trip out to the dealer for a test drive wasting many hours of your day, they will add on ridiculous fees here and there so that in the end, you end up overpaying for the car. As a result, you want to negotiate based on the total price you will be paying, all fees included. I solicited quotes from both CT and NY, because even though I lived in NYC at that time, I was about to move to CT and could get the car at either place.<br /><br />- I lucked out and got a ridiculously cheap quotes from a dealer in CT: $16,967 out the door, security system installed, including CT sales tax 6% - that's $15,847 base price with security system included. Considering the fact that true cost to dealer was $15,740 and the security system is worth at least $165 or so without the installation fee, this price was too good to be true. They were probably hoping that I will make a trip to CT so that they could force on ridiculous fees when I'm stuck there, but it did not matter.<br /><br />- With this ridiculous quote in hand, the next thing I did was checking out the inventory of potential car dealers in the area. Dealers do not want to keep cars on their lot, so if you are willing to take cars that dealers already have on hand, they will be more eager to sell it to you, probably at a cheaper price just to get rid of the car. We searched for dealers with a lot of Honda Fit on hand and said to them, "if you could beat this quote, I will take the car off your lot today." This got many dealers squirming for business.<br /><br />- I landed at a big dealer in Queens with the cheapest out-the-door price of $17,707.07. Base price with installed security system was about $16,000 like I mentioned above, and I made sure that all the other fees were not bogus. Sales tax is easy to check and is based on the state in which you register the car (it does not matter where you buy the car - you pay sales tax based on the state of registration). Registration fee varies, but you can use <a href="https://harmonia.dmv.state.ny.us/RegFeeCalc/rrorEnterVehInfo.cfm">the DMV dealer's registration fee calculator</a> to see if the dealer is overcharging you for registration. Title fee and inspection fee are standard and are always listed on the DMV website. Tire tax applies at least in NYC where the government charges tax for recycling your tires.<div><br /></div><div>- People usually think that buying a car with a full cash amount up front will get you a better deal, but this is untrue. Dealers either do not care or would prefer that you finance the car, so that they can sell your debt to outside banks and make more profit on the deal.<br /><br />Beware of the following dealer tricks:<br />- Some of them will make you sign a price offer, stating that if the dealer could match your price, you automatically have to buy the car. Do not sign this form - so that should you come upon a cheaper quote from another dealer, you can easily switch without your hands tied.<br />- If you decide to get extra options for your car, after you have agreed on a price, dealers will try to make you switch from OEM (original equipment manufacturer) options to other non-authentic options made by some random companies. They will say the non-authentic options are basically the same, but have better features, so as to persuade you to switch, but do not fall for this trick. Obviously, OEM options are worth more and will get you a better price for your car when you trade it in later on.<br />- Even though you have agreed on a price, dealers will try to sell you random extras while you're signing the contract - do not agree to buy unless you have thought carefully and decided you really want these options - most of them are junk. If you feel like you might be intimidated in the dealer's office and fall for these tricks, you can try to have dealers come by your house or fax the contracts over, but I found that dealers rarely agree to do this. Remember to be strong and do not buy anything because you feel bad or pressured.<div><br /></div><div>More on tricky DMV questions in the next post!</div></div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com21tag:blogger.com,1999:blog-3621233204939134253.post-67719577895502137952010-04-22T16:00:00.008-04:002010-04-23T01:10:36.730-04:00Testing out PDSA - RoughageWith too much time on my hands, I'm taking free online courses on <a href="http://www.ihi.org/">the Institute for Healthcare Improvement website</a>, currently on quality improvement. The IHI chose the PDSA cycle as its weapon of choice, and in the spirit of self education, I'm creating a self-improvement project using the PDSA method. Follow me as I stumble through the path towards more roughage!<div><br /></div><div><b>PDSA1</b></div><div>The three fundamental questions of the model for improvement:</div><div>1. Aim (How much? and By when?): <span class="Apple-style-span" style="color:#FF6600;">I will consume at least 1 serving of fruits/vegetables with every meal eaten by the next month</span></div><div>2. Measures (How will we know a change is an improvement?):</div><div>- Outcome measures (How is the system performing?): <span class="Apple-style-span" style="color:#FF6600;">Percentage = number of times successfully consuming AT LEAST 1 serving of fruits OR vegetables per meal eaten/total meals eaten. Data will be collected manually when eating real food only (not counting desserts/snacks). Baseline measurements will be excluded for convenience.</span></div><div>- Process measures (Are parts in the system performing reliably as planned?): <span class="Apple-style-span" style="color:#FF6600;">The number of days with at least 2 servings of fruits/vegetables in house, the percentage of successfully getting a salad when eating food without roughage.</span></div><div>- Balancing measures (Did the changes we made to improve one part of the system mess up other parts?): <span class="Apple-style-span" style="color:#FF6600;">One month after successfully eating at least 1 serving of fruits/vegetables per meal, I should not gain more than 10% of my baseline weight as a result of trying to eat more roughage. This data will be collected before and after 30 consecutive days of achieving the outcome measure. I don't have a scale so we'll have to skip this one.</span></div><div>3. Changes (What changes can we make that will result in improvement?):</div><div><span class="Apple-style-span" style="color:#FF6600;">- Keep at least 2 servings of fruits/vegetables in house at all times</span></div><div><span class="Apple-style-span" style="color:#FF6600;">- If there is no roughage accompanying the food I order when eating out, I must get a serving of salad with my food.</span></div><div><span class="Apple-style-span" style="color:#FF6600;"><br /></span></div><div>Plan:</div><div>- Objective: increase roughage consumption</div><div>- Question/prediction: Will keeping roughage in house and ordering salads when eating out increase roughage consumption?</div><div>- Plan: For the next week I will keep at least 2 servings of fruits/vegetables in house at all times, and if there is no roughage accompanying the food I order when eating out, I must get a serving of salad with my food.</div><div><br /></div><div>Do:</div><div>- Problems: Cherry tomatoes go bad quickly and I can't shop that often, must find longer-lasting roughage!</div><div>- Unexpected observation:</div><div><br /></div><div>Study:</div><div>- Results:</div><div><br /></div><div>Act:</div><div>- Plan for next cycle: keep a bag of salad vegetables and Japanese salad dressing in house at all times? (yum!)</div><div><span class="Apple-style-span" style="color:#FF6600;"><br /></span></div><div>Track my progress <a href="https://spreadsheets.google.com/ccc?key=0AuUO7ibq7SsWdFhvS2lVdVZSaU1TTS03UFd5WmtWakE&hl=en">here</a>!</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-38093567015172312492010-03-27T16:06:00.005-04:002010-03-28T06:22:14.439-04:00Why do primary care doctors deserve more money?Today I had an interesting conversation with a few friends regarding the new health care reform that just passed. One future specialist asked me why primary care doctors should receive more money than they have in the past. <div><br /></div><div>And this is an important question that I think sheds light on the whole mess of health care that we are in. It's important to specialists because there is only one pie - if primary care doctors start taking bigger cuts, specialists will have to take smaller pieces of income home. But more importantly, this question is compelling because really, what do primary care doctors do that make them deserve more money than what they are already earning (which is some of the lowest among the medical profession)? </div><div><br /></div><div>I think the general notion is that primary care doctors manage various medical issues that are not complicated enough to be passed on to specialists. And so my specialist friend asked, why can't primary care doctors be replaced by less-trained health care professionals (nurse practitioners or physician assistants), if they are only managing basic medical issues? And if so, why do we need to pay primary care doctors more money if we can just hire non-doctors to do the same job?</div><div><br /></div><div>I think that our job in primary care cannot be replaced any more than in other fields like surgery or anesthesiology. In every field of medicine, there are simple patients that can be taken care of by lower level health care workers, even in specialized fields, and then there are more complicated patients that need to be cared for by physicians with a deeper understanding of medicine. For example, in the field of anesthesiology, nurse anesthesiologists can do many things that MD anesthesiologists can do, but they serve as a simpler clone of that physician so that he/she can anesthetize a few patients at one time. In the field of OB/GYN, midwives play a very important role in non-complicated deliveries, while leaving trained obstetricians to care for complicated pregnancies. </div><div><br /></div><div>I'd like to argue that in the field of primary care we specialize in coordinating care for the patient as a whole person - a manager for your health care - which I think is one of the hardest jobs in this complicated health care maze. Doctors in traditional medicine do not usually view this as a real or worthy specialization, but more and more people start to realize that this is a complex field of specialization that requires a smart physician with a thorough understanding of all other medical fields. </div><div><br /></div><div>A good analogy I've heard is to think of primary care doctors as air traffic control . Specialists only see the problems within their field, just like a pilot in a single plane. They are important, but it's impossible to expect them to take in the big picture of the whole airport with hundreds other diseases in it, all interacting with one another. Primary care doctors step back and integrate all information to make sure that all treatments work together synergistically and that the airport as a whole functions optimally. </div><div><br /></div><div>And this is why health care reform is focusing more and more on attracting talents to primary care. Since we're the managers, we make the decisions on when patients need tests or a trip to the specialists. If the managers suck, costs go up without increased outcomes, and specialists can't get good referrals without a good gatekeeper. Sure, for a young healthy person, their care can be coordinated by a nurse practitioner, but for a 70 year old patient with multiple comorbidities, that job gets complicated and it needs to be handled by a good primary care physician. </div><div><br /></div><div>I have high hopes for primary care, and even though I obviously did not choose this field for the money (because there is none), I do hope that we get higher reimbursements in the future so that we can attract better talents (than me) that will turn our failing system around and keep our nation healthy.</div><div><br /></div><div><br /></div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com8tag:blogger.com,1999:blog-3621233204939134253.post-35643690225215266392010-03-26T05:36:00.002-04:002010-03-26T19:17:53.547-04:00Humans vs AlgorithmsSince the conception of the first computer operating on algorithms, there has been a struggle between humans and machines – when will computers get so good at doing our job that they should replace humans?<br /><br />Two most interesting articles shed light on this question. One was written by Garry Kasparov<sup>1</sup>, the chess grandmaster who battled the famous Deep Blue, a supercomputer programmed by a full team of humans to play chess. Kasparov’s career spans a pivotal period when computers progressed from a weak chess player to an unbeatable one. But the most interesting finding of all was the fact that when weak human players team up with a few average computers, they are superior to chess grandmasters or the best supercomputers alone.<br /><br />The second article by Kahneman<sup>2</sup> explains why this is by characterizing how human intuitions work. First, good intuitions take years to attain – a study by Chase et al<sup>3</sup> showed that chess players take 10 years of dedicated study and competition to possess a good mental collection of board patterns that allow players to identify a good move without calculating all possibilities.<br /><br />Second, intuitions are easily affected by biases or the way information is presented. One example is the anchoring phenomenon. When people are asked “Is the average price of German cars more or less than $100,000?” before giving an estimate of the average price of German cars, participants will “anchor” around Mercedes and high-end cars when estimating. On the contrary, when another group of respondents are asked a different anchoring question “Is the average price of German cars more or less than $30,000?” they anchor around cheaper cars and give a lower estimate.<br /><br />Third, human intuitions are inconsistent. A study by Goldberg<sup>4</sup> created simple diagnostic algorithms based on the criteria used by 29 psychologists to distinguish neurotic from psychotic patients. These 29 psychologists then compete with algorithms built from their knowledge to distinguish new sets of patients. Researchers found that algorithms differentiated neurotic from psychotic patients more accurately than psychologists from whom the models were derived. Kahneman believed that this is because human judgments are inconsistent.<br /><br />Last and most importantly, intuitions only work in a limited environment that provides good cues and rapid feedback. This explains how a team of weak human players and average computers becomes so powerful. In this setup, humans use accurate cues and rapid feedback provided by computer calculations to make decisions. The key is a good process with humans and computers playing to each other’s strengths – computers are better at processing information, while humans are better at strategic planning.<br /><br />The advancement of computers creates an impending shift in how we practice medicine. As we strive to limit human errors and stretch limited resources to expand health care access to underserved areas, computers and their algorithms play an important role. To reduce medical errors, evidence-based guidelines can help physicians concentrate on strategic thinking instead of recalling medical knowledge from memory. To increase access to care, we can rely on a team of health workers aided by computer algorithms for simpler medical problems, while referring to human physicians and their intuition to override preformed models for more complicated cases.<br /><br />Overall, considering the fact that common medical conditions are common, the role of physician experts will change as we rely more on evidence-based algorithms and mid-level health professionals. This shift should free doctors to fulfill a bigger, more complicated role in health care that has yet to be determined. Until then, it is important to recognize that intuitions are limited. Using algorithms to aid in diagnosis is not just an option – it is a must to improve patient care.<br /><br />References<br /><br />1 Kasparov G. The Chess Master and the Computer. The New York Review of Books. 2010:57:2<br /><br />2 Kahneman D, Klein G. Conditions for intuitive expertise: A failure to disagree. American Psychologist. 2009:64:515-26<br /><br />3 Chase. The mind’s eye in chess. In: Chase WG. Visual information processing. New York: Academic Press, 1973:215–81.<br /><br />4 Goldberg LR. Man versus model of man: A rationale, plus some evidence, for a method of improving on clinical inferences. Psychological Bulletin. 1970: 422-32.angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-55857674351465947842010-03-25T03:01:00.002-04:002010-03-25T03:48:03.696-04:00Doctors are only as good as the environment around themMaggie Mahar digested a new <a href="http://www.healthbeatblog.com/2010/03/a-culture-of-fear-and-intimidation-reforming-medical-education.html">report</a> on the abusive, unprofessional state of current medical education. She used the word shocking, but reading the quoted examples I could not feel more at home - for every outrageous finding that was mentioned, I have a personal anecdote for it. <div><br /></div><div>Health care really is a weird, alternate universe where people can do nasty things that will never be ok out on the streets and get away with it. Surgeons often throw sharp instruments in the OR out of anger, many times at other human beings - can you imagine a mechanic throwing a wrench at their colleagues out of anger? Sadly, the former example fails to raise any eyebrows, and the most interesting phenomenon I've ever witnessed is how fast the foul mood trickles down in an OR. The pecking order goes from surgeons --> scrub nurses --> medical students, and soon enough everyone makes mistake out of fear and anger. </div><div><br /></div><div>Under abusive environment, I notice I fail to accomplish tasks that I have previously mastered, and under nurturing environment, I can complete procedures I've never even seen. Doctors, like any worker in other industries, are really as good as the environment around them, and when people's lives are at stake, it is so important that health care professionals learn to be nice to one another. Instead of criticizing others for stupid consults, we can educate them when consults are warranted. Instead of labeling patients as non-compliant, we can try to sympathize with the myriad of reasons why people continue to be overweight and diabetic in this country. </div><div><br /></div><div>For readers in the health care profession, I know this is old news, but let's make it not so. </div><div><br /></div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-49195362928370707842010-03-22T01:04:00.003-04:002010-03-22T01:44:14.949-04:00Today we made historyDespite all the complaints I have in a prior post regarding joining the medical profession, I must admit there isn't a more exciting time in medicine than now, especially in the field of primary care which I dearly believe in. Today will be written down in history as the day that our society decided to move forward and become truly civilized - health care reform has passed. Just like slavery and other outrageously unfair practices we inflicted on our fellow human beings, pre-existing condition is a now a thing of the past. <div><br /></div><div>After match day last week, I have encountered much skepticism from friends and family members when I told them I chose primary care. Is that still internal medicine? Can you still do GI/cardiology? Are you sure that's not family medicine?!?</div><div><br /></div><div>Primary care at this point in time gets you no glory or money - I believe that will change, and health care reform has proven it. Even though we won't be earning significantly more in the near future, our values are recognized when the legislation included a provision that primary care doctors will be paid 100% of Medicare rates when caring for Medicaid patients (doctors should not be paid less when caring for poorer patients!). People in business know that managers have to be one of the smartest people in any organization, and this provision recognizes our value as managers and gatekeepers of your medical care.</div><div><br /></div><div>Having an independent board consisting of medical professionals determining Medicare payments also holds a dear place in my heart. As an economics major and a QI enthusiast, I always struggle between being a good, comprehensive medical student ordering every test that's remotely relevant, and timidly presenting my superiors with evidence that the tests they wanted are unnecessary and harmful. After this provision, along with bundling of medical reimbursements, hopefully this struggle will lessen.</div><div><br /></div><div>This monumental legislation has renewed my faith in health care - I am so honored to be able to share in its glory as I enter the next phase of my medical career in the same year it was passed. I can already see myself telling my grandkids about it - "Back in my days when I graduated from medical school, it was the year when Obama passed health care reform, and it's the last time anyone ever heard of pre-existing conditions!"</div><div><br /></div><div>Check out a good summary of its benefits <a href="http://www.healthbeatblog.com/2010/03/highlights-from-the-reconciliation-bill-and-maggies-comments-on-the-changes.html">here</a>. To all readers who are angry/skeptical, please have compassion for your fellow men and give this legislation time to prove itself. I definitely think it's a start of many great things to come.</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1tag:blogger.com,1999:blog-3621233204939134253.post-25347305997470073172010-03-16T00:00:00.004-04:002010-03-16T00:18:48.123-04:00Stepping stoneI've lost my passion in medicine. It is match week and I cannot care less. I see people excited about residency and I do not share their sentiment. <div><br /></div><div>I still love the science of medicine itself but the field as a profession holds no excitement for me, because I know practicing alone won't make a good enough dent in the life of my patients if the system as a whole does not improve, if doctors can't even agree to put their greed aside and put the interests of the patients first and foremost. One of the things I hate the most in life is a bad team, and going into medicine I know I can't control who my team members are. There are so many things wrong with medicine that I can't wait to walk away and start over - I'm distracted by the glitter of creating something that is my own and hand-picking my own team, knowing that if I fail, I will have failed with the best and it will be a great learning experience. Comparing my twitter columns, one in health care and one in social entrepreneurship, the grass is definitely greener on the other side. </div><div><br /></div><div>It seems I have fulfilled the prediction that most medical students will have burned out by the time they graduate, but I do think I definitely crashed and burned harder than others. Deep down I hope I didn't match so that I could go into health consulting and learn something pertinent to my current passion. It doesn't look like an exciting 3 years from here, but at least I'll know how to save lives - a girl could always use that.</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com0tag:blogger.com,1999:blog-3621233204939134253.post-74425656390824395412010-03-07T05:25:00.000-05:002010-03-07T05:26:19.274-05:00The vicious cycle of finding the right volunteer opportunity<div>I went on Idealist.org today looking for a volunteer manager. They list a total number of entries in each category as if to boast their success, but I beg to differ and argue that volume is their downfall. There are way too many listings entered without a preset, uniform standard that orients people to the similarities and differences between entries. I could not find anything and was tempted to list my request instead of doing a manual search, but found that many people have resorted to that method without success, resulting in even more entries sitting around on the server adding more work to people combing through search results.</div><div><br /></div><div>Not sure why they do not use a Google-powered search engine, but only strings of keywords can be used - they do not accommodate syntax for advanced search (for example, cannot use " " to signify that you only want search terms in this exact format). </div><div><br /></div><div>In the end, I came back empty-handed and frustrated. If you know a volunteer manager, please let me know.</div>angienadiahttp://www.blogger.com/profile/12919624755675825187noreply@blogger.com1