July 1st

Tomorrow is July 1st, a rather momentous day for those involved in medical education.

Every July 1st, a new class of interns and residents (and even medical students) begin working in hospitals around the country. For those entering their 3rd year of medical school, the clinical rotations begin, and you leave the books behind and begin working with real flesh and blood patients (literally). For the med school grads, you trade your short student coat for a full-length lab coat; you are no longer cocooned in your relatively safe student status, but are now full fledged MD's. It is often a rather daunting prospect.

At the beginning of my junior year of med school, my first rotation at Charity Hospital was in Pediatrics. I somehow ended up in the Newborn ICU, absolutely lost mentally and geographically (the hospital was huge, and loomed nightmarishly large to me); I was pretty convinced that I was going to be responsible for the demise of some poor premature infant through my ineptitude. The physician I was assigned to seemed just as lost as I was (I think she was entering her 2nd year, but somehow it was her first experience at Charity), and on top of it all, I was scheduled to be on call that very night. I was convinced that the cosmos had coalesced into some horrible, fate filled configuration. I remember watching my classmates happily skipping out of the unit at about 5 pm, and there I was gazing longingly at them like some little kid stuck in his room, unable to go out and play. I muddled through the next few hours, assigned to the menial, "scut" tasks that med students are doomed to forever perform, a growing sense of despair creeping over me. At one point, I remember looking up through my funk, and seeing Rich Manthey (a classmate of mine) bringing me a bag of chips, "something to get you through the night, man," he said. I somehow made it through the night without any loss of life.

I was, and will always be eternally grateful for that bag of chips.

Two years later, I began my first rotation in residency. For some reason, my memory is less distinct about that night, I think partly because I was even more terrified than
the medical student of two years before. I think I was on call that first night also. You don't really sleep; the beeper goes off throughout the night, paging you for different tasks and "scut" work that is the bane of every intern--check somebody's blood pressure on the floor, rush down to L&D for a delivery, work-up an admission in the ER, etc. I can look back on it with some fondness and laughter, but going through it was a different story. All of your fears of being competent, about not knowing what to do, about wanting to do the right thing because doing the wrong thing might cost someone their life--it's all right there, in your face. Somehow we get through it; I do remember clearly finally heading home around 7 the next evening, completely engulfed in relief and fatigue.

So, tonight, somewhere, some poor med student, some shaking intern is trying to not to get too freaked out, trying real hard not to turn into some drooling idiot, and trying hardest of all to remember every last thing that he or she has learned in the last 4 years. EVERY LAST THING.

So, a request, and some advice.

My request--pray for that poor student.

My advice--stay out of the hospital for the next few weeks. There's a lot of learning going on.

Dissatisfaction in Medicine

I ran across this story from the New York Times earlier this week. It's not really news; doctors have been dissatisfied with the state of medical practice for years now, for a variety of reasons. But . . .

I asked when his work usually got done.
“It is never done,” he replied, shaking his head. “See this pile?”
He pointed to five large manila packages on a shelf above his desk. “These are reports I still have to finish.”

Wait a second. Is this guy dissatisfied with medicine, or is he just overworked--by his own choice? These are reports I am assuming the doctor has generated himself. The way reimbursement works is you have to document in some fashion (like a "report") what you have done, say, to diagnose or treat a patient. These reports weren't assigned to him. He has to complete them in order to get paid; actually, the hospital and clinic he works out of won't get paid either until they get done. Is he griping because he has too many? Why is this guy then working so hard? Does he have too?

I liked this quote, too:

“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

Now this guy is an internist, but I will still bet that the 'scrips he was called on were those he had written for new drugs that had just been released and that cost a lot of money to fill--money that comes from somewhere, either the patient's pocketbook, or the insurance company's funds. I'll bet he had no idea how much the prescription cost. Most of us in practice are woefully naive as to the specifics of how much our patient's drugs cost. But he's upset because the insurance provider wanted him to find a less expensive, equally effective drug. Is that a bad thing?

Then there's the MRI issue. An MRI is a great technique for imaging structures inside the body, but it is not always the best way to look at different areas. It probably doesn't need to be ordered on a patient who is already hospitalized, as it is more often indicated as an outpatient diagnostic tool (for inpatients, a CT scan is more likely to help a doctor make a timely diagnosis, and is far cheaper). As a gynecologist, I am often referred patients from other physicians in other specialties who have diagnosed a patient using MRI. An ultrasound is much more useful in imaging pelvic structures, and again costs hundreds of dollars less. I don't know--maybe this guy doesn't know much about how insurance utilization and reimbursement works.

There was a "Golden Age" of medical practice, somewhere back in the 60's and 70's, when you as a physician could hospitalize patients whenever you wanted to, for whatever reason ("nervous exhaustion," etc.). You did a cataract extraction, or a hysterectomy, and sent the charges in to the insurance company, and were promptly paid for the work you had done. But as medical costs began to soar, the insurance providers began to wake up and hold physicians accountable for the costs attributable to them. Utilization review became the fashion, and suddenly, almost every facet of medical practice became subject to scrutiny and approval--hospitalizations, surgeries, prescriptions--all things thought to solely be the doctor's sole private prerogative. Although the review process is less extensive these days, it is still around.

I never practiced in anything but a managed care setting, so maybe that's the only thing I am used to; it doesn't bother me as much as it does some of my colleagues. In some ways it's bad; it truly is hard to try and explain to some coding clerk why your patient is not stable enough to go home. In some ways, however, it provides some needed oversight for medical practice. I suspect that the "Golden Age" was perhaps not so "golden" after all.

There are a lot of areas of medical practice that need reforming and retooling. If you decide, however, that you want to work your butt off, then get busy. You can only kvetch at yourself.

Kitten

Here's a picture of the little kitten we recently acquir---I mean, that recently acquired us. I think she's already appeared on Anya's blog. Her name is Gypsy, or sometimes Bat, or sometimes OUCHHEYCUTITOUT as she crawls up your bare leg.

A little change from my rantings, so enjoy.

Schools, crisis, and critical thinking

As I've noted in a previous post, I am not happy with the idea of teaching Intelligent Design or creationism in our science classes. I believe it is important for our kids to get the best possible education that they can, and especially when it comes to science class, we need to teach kids critical thinking, and how scientists reach the conclusions about how the world around us works, namely through the scientific method. It is the inability to think critically that allows for people to believe that the AIDS virus was created to infect certain groups of people, or that the government dynamited the levees in New Orleans to destroy the black community there. The inability to think critically certainly leads to stories like this one.

So, I am concerned about the bill about to become law here in Louisiana that would allow for the teaching of ID in the classroom. There are folks out there who are convinced it means that Louisiana is doomed. Indeed, the feeling among some is that the mere mention of ID in class spells the end of the world as we know it (and I feel fine. . . sorry . . .)

But, I ran across these stories over the last day or two:

--17 girls are pregnant in one high school in Massachusetts, apparently as part of some kind of pact they made to all get pregnant so they could raise their babies together.
--the Pledge of Allegiance was banned at a 5th grade graduation ceremony in Oregon because the principal felt that the words "under God" were offensive---TO MUSLIMS!
--Obama recently praised an experimental high school in Colorado that was able to turn a 50% drop out rate into a 100% graduation rate. He seemed particularly impressed with the Afrocentric nature of the curriculum:" . . . the theme that year, they called it "Passages." And it was all about the African American experience. And so they incorporated music, you know, ah tracing sort of the history of African music through blues through jazz to modern times, along with history, along with literature . . ." (Is it just me, or does Obama seem less than articulate at times?)

Yeah, I'm not too thrilled with the idea of ID in the classroom. But I think there are a lot of bigger issues out there, that spell DOOM a lot more clearly than what is happening here in LA.

Al Gore's Kilowatt Nightmare

I love this post about the Gore mansion. He got busted last year for being an energy glutton, and vowed to revamp his digs to be more energy efficient. The inconvenient truth is that he still doesn't get it.

As I've said before, when the doomsayers begin behaving like it's a serious problem, then they may have a better chance of being believed.

They told me if Bush were elected . . .

. . . there would be discrimination against Muslims at political rallies . . . and they were right!

With apologies to Instapundit, who is famous for doing this kind of thing.

Iowa and New Orleans

I'm sure that a lot of people have been watching the disaster as it unfolds in Iowa. I read where 83 out of the state's 99 counties have been declared disaster areas. The pictures are pretty shocking--lots of water where roads and houses should be. People in boats. Aerial shots of cities underwater (like this one).

There are some things I'm not seeing, though.

No looters.

No people shooting at the cops.

No burned out buildings.

No rescue workers ducking gunshots as they try to evacuate hospitals.

Hmmm.

Okay let's be fair--I realize that this flood is not the same as Katrina. I know we are looking at two different areas of the country. Two different kinds of disasters (sort of). Two vastly different geographic and cultural settings (Iowa could be on the other side of the galaxy as far as New Orleans is concerned). Two vastly different groups of people in terms of socioeconomic status, level of education, types of jobs, and a host of other factors, including race. Still, there are some basic similarities--vast areas of inundation, mass displacement, economic disruption, all in the face of a natural disaster.

But why are things turning out so completely and utterly different? I think there a few reasons.

Take leadership. It's not really about FEMA or evil Bush/Cheney, because they're all still there. Did the feds muck things up in N.O.? Without a doubt; they don't necessarily get a pass here. But the same administration, the same FEMA was in the neighboring state of Mississippi in September of 2005--and look how different things turned out in that state.

Why? You know whose pictures I'm not seeing from Iowa? Blanco's. And Nagin's. Do I need to say more?

But just as important is New Orleans itself. I love my hometown. There isn't any other place like it anywhere. But it's almost like the place was rotten on the inside, a flimsy, termite ridden facade that Katrina unroofed like some scab, so we could see all of the disease and decay within. I was ashamed at what happened there 3 years ago. I was ashamed at our so-called leaders, like Bill Jefferson commandeering rescue vehicles so he could get to his house and rescue his freezer-bound cash. I was ashamed at the "citizens," black and white, looting and "finding" with abandon. I was ashamed of the law officers abandoning their posts, or worse, helping themselves to the new car lot in New Orleans East.

To be sure, there were countless acts of selflessness and heroism and sacrifice by all involved. There is no doubt that there were (and are) good people in that city, and that they rose above it all to help strangers just as unfortunate as they were. But there seemed to be some sort of underlying current of darkness and desperation and savagery that flowed through that city--that somehow doesn't seem to be flowing through the streets of Iowa City.