What am I to You?

As the final months of medical school approach, it surprises me how much my role has changed in the lives of my patients, my classmates and school mates, my family, and the physicians with whom I work. As a third year medical student, I at times lamented our sorry state of existence: we served as scut monkeys for the interns, lightning rods for upper-level residents and attendings who needed fodder for making an example or simply a transient and “safe” target for displacement, irritating space invaders and time wasters to the nurses, and inadequate messengers for demanding patients and their family members who wanted an occluded IV infusion alarm turned off, or a second breakfast, or quite legitimately, a realistic estimate as to when the doctor would come visit. More often than not, however, I remember having a more positive influence:

• as an assist to the interns and residents who could be trusted with obtaining key information, examining and interviewing patients accurately, discussing issues with consult physicians, and even writing orders (or the equivalent in the Operating Room: cutting and suturing).

• as an ally to the nurses who could rely on us to help with everyday tasks and ensure that important observations were brought to the attention of the residents and attendings (usually translating into new written orders or order modifications).

• as a proxy for the physicians when they otherwise didn’t have the time or opportunity to counsel and educate patients (including one time when a rather belligerent patient “fired” the rest of the medical team). My fiancée, currently on her Medicine subinternship (a fourth year clinical rotation where the medical student has similar responsibilities to a first year resident), recently counseled a patient who had many questions about her complicated medical condition and the tough decisions being made, and when the resident came in to see and counsel the patient, the patient told him, “That’s ok, she (my fiancée, the medical student) already explained everything to me and answered my questions.”

• as the consistent “doctor” to patients who otherwise are visited by a dozen different residents, specialists, nurses, and therapists each day (who have many more patients to see than me). Some of my attendings said, “I’ll know you’re a good medical student if I ask the patient ‘Who’s your doctor?’ and he points to you.”

• as an enthusiastic student to the attendings who sometimes depends on us to ask good questions, stimulate discussion, or simply remind the medical team that we are working in an educational institution and that we have a mission to preserve and expand the fund of medical knowledge and use this knowledge to the benefit of mankind.

• as an equal practitioner of certain aspects of the “art” of medicine: empathizing with the patient’s suffering and anxiety, equilibrating to the moods and attitudes of the patient and her family, knowing when to smile or frown or laugh, using physical contact in the right ways and at the right times to strengthen the doctor-patient connection, maintaining an appropriate demeanor and veneer, expertly managing the giving and receiving of knowledge with the right tempo and cadence, knowing and expressing what you can and cannot do for the patient, and showing constancy in providing hope and guidance through the most difficult of times.

All of these are potential roles for the third year medical student. I have happily assumed all of the more positive roles, and I reluctantly find minimal value in the more negative positions if only to be able to show the red badge of courage to the naturally cynical and more senior generation of physicians who believe that today’s young doctors are too soft and pampered. My disclaimer and proclamation: I survived the Charity Hospital system.

Now, as a fourth year medical student, I have shed some of the less desirable roles and gained a few others: marginally more experienced teacher to third year medical students, cautious and suddenly more aware health advisor to family members, potential future colleague to residents, and potential trainee and employee to attendings and residency programs. From this vantage point, I’m starting to glimpse the coming transition to physician status, one which is commonly reported by first year residents to be hardly a noticeable transition in personal qualities at all – only a transition in personal responsibilities. Accordingly, I plan to use these final seven months to brace for the next new role: doctor (without quotations).

Filed under: Apollo's Experiences, Medical School

Finding a New Home

Like many of my classmates, I am entering the interview stage of my final year in medical school. I just completed a one month away rotation (or exchange clerkship) at one of the programs I am very interested in: it was nice to have the opportunity to have an extended look at the inner workings of the training program, the work environment and culture, and the attitudes and styles of practicing medicine of the residents and attending physicians.

A few pieces of advice given to me by the faculty and residents at this program have resonated strongly with me:

• First, don’t feel that you have to prove anything when you visit programs to interview. If you have been given an invitation, you have already met their qualifications, at the very least on paper. Instead, they will be doing their best to sell their programs to you.

• Secondly, perhaps the most important thing you can do on the day of your interviews is to get a sense about who the people are, especially the residents. Most of the learning during residency comes from your senior residents and colleagues. Furthermore, after three years, you’ll probably be a lot more like them in thinking, attitudes, and personalities.

Good luck, everyone!

Filed under: Apollo's Experiences, Medical School

A Wealth of Information

There has been a lot of talk about health care reform over the past month: much of the information has been repetitive, not based in fact, or purely sensationalist. However, there have been some well-written and meaningful pieces that have emerged above the din. I’d like to highlight a few of them here:

August 9, 2009 – NY Times – Robert Pear and David Herszenhorn – “A Primer on the Details of Health Care Reform”

This is a relatively concise and unbiased article covering some of the main issues of the Congressional health care reform proposals. It might be slightly outdated, but it’s hard to tell what real changes, if any, have been made since Congress is currently on recess. Various pundits and politicians can spread rumors about changes until they’re blue in the face, but it won’t mean much until the paperwork is presented again.

August 23, 2009 – Washington Post – T.R. Reid – Five Myths About Health Care Around the World

This article was passed along to me by a friend of mine who is much more internationally aware and better traveled than I am. It provides a brief education about some of the most common misconceptions about health care systems in other developed nations including the prevalence of socialized medicine and the overall quality of American health care compared to other systems. There are, in fact, several systems based entirely on (regulated) private insurance that have better health outcomes than the U.S.

One point I have stated previously and am always glad to reiterate is that many people in America fail to distinguish between medical care and health care: the U.S. likely has the best medical training, technology, and physicians (at least, on average, the best trained), but medical care is only one component of health care. Health care incorporates medical care, nursing care, rehabilitation, social work and case management, payment and insurance, drug and biotechnology development, hospital and systems administration, and perhaps most importantly, patient involvement and responsibility. In general, it appears that liberals seem to find fault in everything but patient responsibility, while conservatives find fault in nothing else but patient responsibility.

August 26, 2009 – Blog “Mind, Soul, and Body” – Repost: Medical Care, right or privilege?

One of my fellow bloggers reposted a piece he wrote last year. Although I don’t agree with everything in the post, there was a passage that I felt was particularly meaningful:

There is a certain basic concept that we are beginning to forget in our society, the concept of common wealth. Way back in the days of print media, communities would pool their resources to build a collection of books we call a library. This was because information and education was felt to be mutually beneficial if shared. The poor can only benefit from learning. We all can gain more as a group, enriching the whole, than any of us can individually. This is a way the group can protect resources from individuals who would devour or horde them. It turns out that together we have much more than any of us could ever hope to acquire individually. This is the thinking behind public museums, national parks. These are something different than commodities. They are actual sources of well being. This is our true wealth, and it is shared.

The common wealth of America are habitats, ecosystems, languages, cultures, science, technology, schools, social and political systems, democracy. These are things often so basic we sometimes forget how much we have. They are things we all value together and are well worth fighting for. So is medicine a right, or a commodity dependant on resources and wealth? My answer has to be an unqualified yes, it’s both.

I believe, sincerely in the depths of my soul, our commonwealth has to include medicine. We need to protect it, not exploit it. I doubt any of us could calculate what exactly any of these things would cost on the open market. I think it is safe to say that taken together our common wealth’s value exceeds all we could ever own privately.

August 7, 2009 – Kaiser Family Foundation – Side-By-Side Comparison of Major Health Care Reform Proposals

Finally, if you want to actually be truly informed about the proposals being proposed by various sectors of Congress, here is a consolidation of the information currently available as collected by the Kaiser Family Foundation, a nonpartisan health information group. One thing you will note is that President Barack Obama has not proposed a health care reform plan: in many ways, it is very silly for people to keep referring to a single health care reform proposal as “ObamaCare.” It is definitely a worthy argument that President Obama could, or perhaps should, take a stronger role in directing health care reform, and a few members of Congress have asserted this. On the other hand, there are multiple plans currently being proposed, all of which have various advantages and disadvantages, benefits and flaws. Instead of reading a thousand pages of triple-spaced legal-ese (the Dingell-House Democrat bill H.R. 3200), this table is 44 pages long. A shorter version provides details on the Senate HELP committee and House Tri-committee proposals, the main proposals being debated currently. Educate yourself. “Fight the stupids.” – Maple Street Bookstore Bumper Sticker

Filed under: Apollo's Experiences, Medical School, News Analysis