Tuesday, June 24, 2014

Disparity in Doctors. Reflection on Washington Post Blog " The Outrageous cost of working in Medicine."

"The journey to and through medical school was challenging and expensive. " - Me

I grew up in a middle class family in New York City. My father was a civil engineer for the NYC department of transportation. He worked hard and gave us a humble and honorable upbringing. We had everything we needed in life. Everyone in my family made certain sacrifices to sustain our middle class life.
     Despite a New York City public school system that often gets criticism, I managed to get into a competitive exam based science high school. I never had extra tutoring or took a review course and therefore feel lucky to have gotten accepted. Today these high schools are extremely competitive and many students are paying significant amounts of money for tutoring and review courses to augment their opportunities.
     I also never had a job in high school and had time to focus on my studies. Fortunately I got into an excellent, albeit expensive university. In addition to loans, my parents luckily had the ability to stretch their budget to pay for my tuition. I also participated in the work-study program for 2 years until the mounting pressures of the pre-med life forced me to quit. I was able to focus on my MCAT's and had the financial means to pay for an expensive review course. The review course definitely helped a lot.
     I didn't get into a medical school right away and applied for 3 years. It was a process that cost me close to $10,000. Once again, my family was there to support this expense while I had a low paying research position. I persevered, got into medical school and finally was able to bear the entire brunt of my educational expenses in the form of loans in excess of $250,000. I'm recounting my educational journey through the financial lens to highlight that even starting in high school the journey has been an expensive one. This is a journey many students cannot afford to make.
    The Washington Post article highlights several critical issues facing healthcare today. The cost of medical school is immense and has been looked at as a key reason why medical students are opting for higher paying specialties instead of primary care.  I think this makes absolute sense. But interestingly, the article also highlights a very important separate issue. The fact is that only 3% of medical students come from families in the lowest 20% incomes and 60% of students come from the top 20% incomes. This reality directly correlates with the paucity of minorities (especially African American and Latinos) entering medical school and our physician workforce.
     The article argues that the cost of medical school is a reason why minorities veer away from medicine. I agree there is some truth to this. But it's a lot more than that. Getting into medicine is a series of hurdles scattered over many years. Broken public school systems, social and financial pressures make these hurdles significantly greater for students in lower socioeconomic groups. To optimize academic opportunities there are many added costs that only students and families with financial security can better handle. This includes tutoring, review courses, books and a myriad of extracurricular activities. This makes the gauntlet to medical school  immensely challenging for students in the lower socioeconomic strata. Even for middle class families, this process is a huge struggle. This is a key reason why 60% of the medical students come from families in the top 20% of incomes.
    This also brings us back to the question about why students are choosing higher paying specialties instead of primary care. There's no doubt the enormous cost of medical school is a big reason. But logically, you'd think if 60% of the students are coming from the top 20% of earners, they might have less medical school debt and therefore be more apt to choose lower paying specialties. But the reality is, one of the great motivators in human behavior is the fear of loss. In this case, if you're coming from a higher socioeconomic group, why would you pursue career paths that threatens that?
     I'm not criticizing successful successful parents who give their children every opportunity to succeed in life. Nor am I criticizing students for choosing career tracks that best suits them. But the current construct of our educational systems are not set up to solve some of the critical problems in healthcare.We have struggling primary and secondary education systems followed by woefully expensive undergraduate, graduate and medical schools. We don't have enough medical schools or enough residency spots.The people that do take those few spots are not doing primary care (the foundation of a successful healthcare system). We live in a diverse multi-ethnic country yet several key minorities are underrepresented in our healthcare system.
       This highlights just another one of the several systematic problems in our healthcare system that is self perpetuating with no end in sight.

Here's a link to the Washington Post piece.
The outrageous cost of working in medicine


Tuesday, June 10, 2014

The Calm before the storm. Tips for New Interns

It's June kids.
Time to ditch the short white coat, grab the long one and start being a doctor.

There's lots of helpful tips written by residents out there.
Here's a quick list of tips from the perspective of an Attending in Internal Medicine who primarily does outpatient work.

1: Focus on the "WHAT" and the "HOW?" 
For the short term, focus less on the "WHY."
    As a new intern, your job essentially is to get things done. So constantly ask your resident/attending/nurses "What do I need to do?". Keep an organized list.
   Since you're  in a new hospital, also ask "How do I do this?". If you don't know how to get it done, don't wait to figure it out. Ask right away and get it done.
   As you get more comfortable and efficient, then you'll be able to ask the WHY questions.

2: Be humble.
    Yes, you're extremely smart, you're an MD/DO now and you've crammed your heads with tons of esoteric medical stuff which most people (even residents and attendings) have forgotten. But realize, you may know a lot of medicine, but taking care of patients is completely different. Humility will leave your mind and days open to learning and endless possibilities.

3: Try and have fun!
Don't get me wrong. This isn't going to be easy and there will be moments and days where your patience will be tested. There will be moments where that polaroid smile while seem like an insurmountable task.Nevertheless, try to see the glass half full and find the joy and humor in the craziness that is Internship.  Have fun for your own sanity, the sanity of your team and most importantly for your patients. If you enjoy what you do, patients will sense it and believe in you!

4: You are an incredibly important person in the team.
    Sometimes it may seem like your presence isn't that important and you're simply a cog in the machine. But to that very ill patient (in hospital or in clinic) you are critically important. You are the physician that's going to spend the most time with the patient. You are the first contact when things go bad. You are the eyes and ears for the senior resident and attending.

5: Residency is a PIT STOP in your life
Life is like a Nascar (or Formula 1) car race. It's a long race, hundreds of miles, it's relentless and it goes fast.  Residency is just a small fraction of your life. It's like a pit stop in automotive racing. The race may last a few hours but cars spend only a few minutes in a pit stop.

But if you know anything about car racing, teams work tirelessly to make those pit stops perfect. In fact, races are often won and lost in the pit stop.
You should approach residency the same way. Realize it's just a small part of your life, but strive to make it perfect, and work tirelessly at it to win the bigger race.

6:You are being evaluated by everyone
    This is the era of 360 evaluations which means everyone has a say on how you are doing. I can't tell you how many times I've seen excellent interns and residents rotation get derailed (Despite being an excellent doctor) by negative evaluations by medical students, nurses, residents, sub-specialists etc. Be a professional towards everyone!


That's all I've got for now. Hope this helps.

Good luck to all the new interns! You've made a great career choice and it's only going to get better!

Monday, June 2, 2014

Fast Food Medicine

"Would you like fries with that?” 
"Would you like to upgrade to a large soda instead of a medium?"
“Would you also like an additional blood test for Lyme disease?”

Sure why not? I love fries!
And a larger drink? Heck yeah, if it's only a few cents more.
I'll also take that Lyme disease test, just to be on the safe side!

The above sounds like a great fulfilling experience.
You get delicious inexpensive food, served by very pleasant and efficient people that were also willing to cater to whatever you want. You also get a doctor who seems to really care and thorough by ordering a battery of tests. It's the kind of experience and place that anyone would want to keep coming back to, again and again.

This is not the typical experience many patients (consumers?!?) have when they interface with our general healthcare system. Healthcare is not inexpensive, not convenient at all and the quality of the product is variable. And in many cases the experience is very unpleasant.

"Necessity is the mother of all invention."

What started out as filling a void for overcrowded emergency rooms and unavailable primary care physicians, urgent centers have been flourishing. It's simple supply and demand. Supply of primary care doctors are dwindling and the demand for more convenient patient care is increasing. Now in any of your neighborhoods, you can get coffee, fast food and some "healthcare" rather quickly and merrily. 

I've gotten used to counseling my patients on the dangers of obesity and its association to fast food. Lately, I've had to start counseling my patients on the dangers of fast food medicine. Although I recognize their need and why they appeal to patients (consumers!?!), I have serious concerns about the impact Urgent Care centers have on healthcare at large. Just in the past few years, these are the types of issues I've noticed from care provided by such places.

Over prescription of antibiotics
Unnecessary use of broad antibiotics
Shot gun blood work with spurious findings
Recommendations to pursue unnecessary advanced imaging
Unnecessary recommendations to see specialists
Patient expectations for over treatment and extensive work ups

These are just broad generalizations but after a years, my patient sample size is growing.

I'm not a business man, but in the "for-profit" world" you do things that get you paid (x-rays, blood work?) and you give the consumer what they want to ensure return business. These are dangerous business concepts when applied to healthcare and urgent care centers are rapidly becoming the prime example of this. 

As the cost of our healthcare approaches 20% of our GDP and medical educators at all levels preach value and cost, urgent care centers, retail clinics and their profit incentives threaten to undermine this entire movement.

I'm not the only one that is worried about this.

The link below comes from a blog post on Kevinmd.com echoing similar sentiments. 

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Reflection from Spring APDIM 2014

    A little late, but this is a small piece of my Spring APDIM experience that I forgot to publish.

      For the second time, I had the privilege of attending an APDIM conference.  For spring 2014 it was held in Nashville, Tennessee. And just like Fall APDIM 2013 in New Orleans, the streets were filled merriment, music and food while the conference halls were filled with bright minds, ideas and tokens of inspiration for medical educators like me. 
     This was essential my first trip to a "southern city" (Florida doesn't count). True to southern tradition, hospitality was abundant. Though diverse in its population, the southern twang was prominent and enjoyable for a Yankee New Yorker like me. Downtown was lined with bars and restaurants all staged with talented musicians raucously playing traditional country, rock and honky tonk into the late hours as locals and tourists danced with each other in small smoke filled venues. Add to this, jubilant fans of the UCONN huskies women's basketball team emptied Bridgestone arena into downtown one night. "Nash-Vegas" as my taxi driver called it, was kicking. 
     It was this same taxi driver who on my first night in Nashville brought me back to my physician roots and reminded me why I was there in the first place. As a primary care physician, I love stories. It is the story of each life, whether it is drama, tragedy or comedy and its successful completion under our watch that makes this a gratifying career choice. It was his successful story that makes our field an important part of the fabric of American society.
     As we drove to downtown Nashville, he told me he was from Acapulco Mexico. He immigrated to the USA in hopes for a better life 25 years ago. He started in Texas and left despite the large Mexican community. He took a chance on Nashville. He worked nights driving a taxi so that he could purchase a home for his family. Eventually he turned his 1st house over for a profit and built a dream home.  He was quick to tell me his home would cost millions in New York. Along the way, he fell in love with a nurse, raised two kids who currently attend top rated colleges. His story doesn't end there. He continues to work nights to save up to start his own business. He wants to create a Latino southern themed department store to cater to immigrant populations that are homesick and struggling to find their own American dream. I never asked what medical problems he had or what role his doctor played in fulfilling this life. But I know every day when I see patients in my office, whether it's through prevention or managing chronic illness, my mission is to ensure illness doesn't derail a story like his. And if illness does catch a gentleman like him, we as primary care physicians treat and guide them so that his story has a happy ending.