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Monthly Archives: June 2007

Most doctors, like most people, rely heavily on first impressions to guide their assessments, choices, and opinions. I have always been very critical of this dependence: I see it as a great and common weakness that prevents most people from reaching their true potential (with respect to analysis and comprehension). While trusting first impressions may offer speed, it does not necessarily guarantee accuracy or even efficiency (because of mistakes made, and the time it takes to make corrections). I think this is particularly troubling for doctors because many who deal with large patient volumes develop an ability to achieve decent or even excellent accuracy in diagnosis and treatment, and sometimes, a very inflated ego (about their ability). However, while some physicians often perform highly intellectual and complicated analyses (e.g. mostly likely those in academic medical centers and large hospitals), many practices mostly see their “bread and butter” standard profiles of patients. In other words, most cases fit common templates. These cases may not be particularly complicated, and that’s part of the reason why PCPs and FPs are grumbling about being replaced by nurse practitioners, physician’s assistants, and other “health care providers” who don’t cost as much (and might handle relatively simple cases just as well).

While some medical cases may be relatively easy to solve, public matters may not be as facile to comprehend to a meaningful degree: they may require more than a two-minute examination. This is my main problem with the medical blogosphere: there are a lot of people (including me) who think they know what they’re talking about, but more likely than not, they don’t. In many instances, it is clear that the people who are blogging have not taken a closer look at the issues they are writing about.

Fortunately for me, I’m just a medical student, so I have a fair amount of spare time to actually read multiple perspectives (including many I tend to disagree with) and incorporate information from multiple sources. I don’t have the ego-issues that would prevent me from deigning to do some background research and learn new concepts. If I’m wrong, it ’s relatively easy for me to admit it since I have little at stake, while that would be much harder for others. (It’s great, too, to be going through this educational process with fellow bloggers and friends with which to debate and discuss various issues.) For me, blogging is part of my education: it’s a learning experience and an exercise in reflection.

For many other medical bloggers, however, it’s a way to exert influence and a way to express their frustrations (perhaps with hopes of instigating or stopping change). Much of this is inspired by the very poor quality and integrity of health care reporting in the popular media: some doctors seek to better educate their colleagues and the public in the face of sensationalized, muckraker journalism. However, are bloggers any better than the reporters and editorialists they might otherwise replace?

Medical bloggers seem to work in a few different ways. Some do this through their own writing of their opinions and experiences, sometimes from the soapbox and sometimes through a creative anecdote. Others exert their influence and perspectives by posting links. I find these to be very much like a convenience store: you can get what you’re offered, but chances are you’ll find something better and less pricey (i.e. fewer ads, fewer sponsors, and no/less spin) if you do your own search. (i.e. “I’ll post up this link for you to read, but you can tell a lot about what I think and how I’d like to present the issue by the text surrounding the blockquote.”). As one who has been making websites and surfing the web since about 1996, I’m pretty old-school in my principles: if you’re an individual (i.e. not a business) with credibility and integrity, you don’t clutter your site with ads.

Other medical bloggers seem to take a more reflective and personal route, often blogging about other aspects of their personal lives such as family, hobbies, and more. While I’m not sure how interested I am in taking a voyeuristic look into some stranger’s life, some of these blogs do give off the aura of being more well-rounded in their views (like the best of physicians).

At this point (almost a year into the life of my blog), I’m feeling particularly critical about this medium and the way it is used. Blogging does not benefit from the experience, wisdom, and filtering capabilities of editors. Bloggers cross-link their posts and are encouraged to post in 250-word sound bytes (to “hold the attention of their readers”), and thus have little room (or impetus) to actually think about what they are saying and try to build a sound argument. Instead of reading a self-contained, well-researched and cited argument, readers are forced to follow blog writers as they ramble along a rant through a series of posts (or scores of mini-posts): some blog writers are more like talk show hosts interviewing themselves than thoughtful, talented essayists.

Does medicine, as a profession that prides itself on having more integrity than others, have room for a wildly undisciplined medium for public discourse? As the medical blogosphere experiences its growing pains, I wonder if the only public blog writers that remain after a number of years will be those who take the time to think about what they’re trying to say rather than those who just post on a whim.

As much as contemporary conservatives would like to decry all change as the end of Medicine, it is highly unlikely that an institution with as much value as the medical profession will find itself completely disenfranchised at the expense of patients. As during the past few hundred years of American history, physicians in the U.S. will endure many difficulties during times of transition, but as must all survivors, physicians will have to adapt to short term changes (even if through staunch resistance) and evolve to match the needs of a growing society. (That is, if you believe in evolution. Those who don’t can complain all they want, sit on their thumbs, and wait to see what happens.) If we are worried that the general public will not find value in our services as compared to those of potential competitors (independent nurse practitioners, alternative medicine practitioners, etc.), then we must show the public the value in the services we offer. During the next few decades, there will have to be a system-wide change in the approach of physicians to patient care so that our service remains in its proper position: as leaders, coordinators, and decision makers in teams of health care workers, and as the final joint arbiter in care decisions with patients.

Fearful, Footloose, and Fancy-free

We live in a society that places great value in life and its preservation. This is one of America’s greatest assets: protection of the pursuit of life, liberty, and happiness. This is rarely protected nearly as effectively or vigorously elsewhere in the world (although the current presidential administration has weakened the perception and execution of these protections). However, this emphasis on life places the notion of death in an awkward spot: Americans don’t know how to die. We try to hold onto life until the very end, whether our lives, those of our family members, or those of our patients. Many have talked at length about how this attitude is costly with respect to health care finances: end-of-life care (intensive care or nursing home care) is very expensive and is sometimes reimbursed poorly by health insurance companies.

However, while there is much talk about how we conduct ourselves and make decisions at the end of our lives, there is less meaningful discussion about how we arrived at that point in the first place. The endemic fear of death not only affects our decisions in our final days, but it also affects how we manage our daily lives and lifestyle habits. As we gain more knowledge as to what might cause disease, we are inundated with this information and have difficulty processing and prioritizing each concern. Many people are so flustered and overwhelmed as to believe that “everything causes cancer,” and it is sometimes difficult for those of us who have a more precise, nuanced view to dispel that notion. This flood of information is numbing, and it makes people want to ignore everything: all of the “if you don’t stop this it’ll kill you” proclamations, and all of the small but significant measures that they could take to avoid pain, suffering, and premature death. People want to be live care-free, but they end up being careless.

Things to Change:

Instead of inundating our patients and our communities with more of the same type of mind-numbing information, we as physicians need to adjust our approach: we need to be concise and effective. While patient autonomy is paramount, patient care decisions are jointly made by the physician and the patient: there must be agreement, else the care provided is ineffective and the patient receives fewer benefits from the relationship. As such, the knowledge we provide can and should strongly influence the behaviors of our patients: problems of compliance should be related to forgetfulness, not disagreement, disbelief, or disgruntled feelings. There is much (conflicting) information out there: we need to help patients cut through the noise and find the correct path.

Condoning Ignorance

While being concise, we shouldn’t be too short in our explanations or too cynical about the intellectual abilities of our patients. Our society not only values life, but it also places a great value on intelligence: this is why physicians hold a professional and social status above other “health care providers”, as physicians have undergone many more years of training and learning, engaged in more complex activities, and held greater responsibility. Nonetheless, training does not necessarily equate with raw intelligence, and we as physicians should not lord over our patients or our team members (nurses, physician assistants, technicians, etc.) in a condescending manner. We should lead, but lead through skill and confidence as opposed to mandate (via degree).

Similarly, while our patients seek our knowledge and perspective, this does not mean that patients will not understand complex ideas. Instead of resorting to sensationalism, we should aim for effectiveness and clearness. For example, a physician might tell a patient: “If you keep smoking, you will die of lung cancer.” This may be true: lung cancer is the leading killer among cancers, and cancer is the #2 killer nationally and worldwide. However, a patient might then respond: “Well, I’m going to die of something anyways. It might as well be lung cancer.” This is not the message that patients should be getting. Instead, we need to help him/her develop more perspective: “About 25% of regular smokers die in their 40’s and 50’s, and it isn’t a ‘peaceful death in your sleep.’ Also, lung cancer and ‘dying’ isn’t the only problem. Almost 100% of cases of COPD are caused by smoking. Getting COPD means that you will gradually lose function in your lungs over time: you won’t be able to breathe and do all the physical activities you would like to do because of not being able to breathe. This isn’t a fun way to spend the last twenty or thirty years of your life.”

On a related note, why do kids know more about dinosaurs than their own bodies? Why are “health” classes in grade schools taught by gym teachers who have no teaching or health care qualifications?

Things to Change:

Knowledge is power, if you know how to use it. Too much knowledge can be a bad thing, or knowledge can be misinterpreted. We as physicians need to fight ignorance, not condone it. We need to be excellent debaters and effectively and efficiently convince our patients, not lecture to them. At the same time, we need to fight against misinformation from opponents of health care (those who stand to lose from better knowledge conveyance because their products are harmful to health), such as the tobacco industry.

King of the Hill

Physicians are at the top of the chain of health care providers. The term “health care providers” is an item of contention: some physicians say that it is a scheme to reduce the perception of the value of care provided by physicians while inflating the value of care provided by independent nurse practitioners, physician assistants, etc. While this may be the case, I think that there is much posturing that can be attenuated. Wherever physicians go, there are wanna-bes and don’t-wanna-bes: people who admire physicians and want to be as respected and influential, and people who hate the pomposity and arrogance of some physicians and want to show that they can be equally effective as health care providers. There is fault on all sides for this inane social and work environment, but I think that physicians, at their best, rise above this by openly praising and using the value provided by each of their team members while giving their teams reason to have confidence in their leadership and direction.

Things to Change:

Some skills are best provided by other health care team members. Procedures or machine operations might be better performed by technicians. Around-the-clock, personalized care is best provided by nurses. Physicians need to understand the value in all of these, and be thankful for them. Physicians have received the longest and most rigorous training, but that doesn’t meant that we can do everything effectively and efficiently alone. Physicians should be team leaders, not divas. Physicians, like good quarterbacks, pass the ball and make successful plays happen. The team cannot win without them, but they also don’t run every time.

A New Direction

Providing knowledge more effectively and being better team leaders may make a substantial difference in providing much better medical care to our patients while also developing stronger connections between physicians, health care team members, and patients. However, how will we accomplish these goals? Here are a few benchmarks to aim for:

1. Be comfortable with non-absolute knowledge.

And share this attitude with others. We practice medicine in an evidence-based manner, but at the same time, new evidence may refute old evidence with studies that are larger and better powered statistically. Instead of becoming cynical about knowledge acquisition, we should encourage in ourselves and others the drive to seek the truth: this is the science in medicine, what makes medicine better than charlatanry. In the meantime, we all need to work with what we know rather than be paralyzed without the confidence of definitiveness.

Attributed to General George S. Patton: “A good plan, violently executed now, is better than a perfect plan next week.”

2. Find balance in our approach.

We want to care for people and help them out of ruts, but at the same time not be so soft as to provide no firmness in our guidance. Instead of simply providing medical care, we should strive to lead people toward changing the way they approach their own health. Each person is individually responsible for his own health care, but he cannot do this without the guidance of a physician. Instead of just guaranteeing health care access, we need to also push our patients to seek health care in the right way at the right time rather than give up on the hope of a health care system better than the status quo.

Attributed to Confucius: “Give a hungry person a fish, he eats for a day. Teach a hungry person to fish, he eats for a lifetime.”

Each day I learn a little bit more about many fields in medicine, and I walk a few more steps along the path to becoming a physician. Though I have flatly ruled out few possibilities, I have grown much more interested in some disciplines and much less interested in others.

I am currently of the opinion that I probably don’t want to join a front-line specialty: Family Medicine, Emergency Medicine, Pediatrics, etc. While there is some truth to the notion that these fields contribute the valuable skill of differentiating between life-threatening conditions and the usual background noise of non-urgent problems, I don’t think that I would necessarily find this task as intellectually interesting twenty years from now than I currently do (not having this skill yet). I may be wrong in my perception, but this task essentially is a high-precision form of triaging: determining the severity of a problem, determining whether or not I can solve the problem with my current skill set and available resources, and if necessary, refer the patient to a specialist or send them to the operating room or intensive care unit if I cannot solve the problem myself. In Emergency Medicine, this skill has to be particularly refined and quick, and it seems that there is less of an emphasis on being definitive in one’s diagnosis: the goal is to stabilize, and then either discharge or send the patients to the appropriate department. Though I have learned much from my handful of EM experiences so far, I don’t think that this relatively young field has built-in measures of satisfaction that suit me. The time spent with each patient is too small with the lack of follow-up, and I wonder if the constant, high-volume triaging would eventually numb my motivation and compassion. Family Medicine and Pediatrics theoretically enjoy more time spent with each patient due to the development of long-term relationships and multiple visits, but they have a lower probability of turning up intellectually interesting conditions or urgent care needs. There is satisfaction in developing long-term relationships and seeing improvement or maintenance of good health over long periods of time, but I might find the lack of urgency boring.

On the topic of urgency, I think I may have in mind one notion that partly explains why “proceduralists” (interventional specialties, surgeons, and emergency medicine physicians) are paid much more than “cognitive” physicians (physicians that don’t do procedures but instead focus on taking histories, doing physical examinations, and prescribing medications and lifestyle changes). That notion is time. Not the time that physicians spend with patients, but rather, the time that a patient has left to live. Many procedures (surgeries, angioplasties, bronchoscopies, etc.) serve as interventions that dramatically reduce morbidity (suffering and disability from a disease or condition) or save the life of a patient who would otherwise die in a short time. One reason why cardiologists try to convince patients with myocardial infarctions (heart attacks) to have a cardiac catheterization (i.e. balloon angioplasty, stent insertion) instead of taking medication to resolve the coronary artery blockages is because “time is muscle.” In other words, the longer it takes to open the coronary artery blockages, the more damage the heart muscle takes (i.e. more heart muscle cells die, and these cannot be regenerated), and the patient, although still likely to survive, will be much more severely disabled than if he/she had the blockages opened quickly with a balloon angioplasty. By contrast, physicians in cognitive specialties theoretically have more time to deal with a patient’s problem since they are usually addressing non-urgent acute conditions or the long-term management of chronic diseases. This does not mean that these health problems are less important, economically or with respect to the burden of disease, but our society places a great value on time because time is a limited resource. Time is money, and in medicine, many procedures serve as rapid interventions to acute problems that cannot be resolved by cognitive physicians. For some time, I wondered whether this differential payment was a result of the sensationalism of “saving a life” as opposed to less dramatic long-term management of disease. I think that beneath that sensationalism lies the truth: that we value time, and when you are sliding down a steep slope with little time left, only proceduralists can save you and give you a fighting chance at continuing to live a decent life. Not all procedures are immediately life-saving, but they still require extra skills to learn. The system may allow for proceduralists who lack the cognitive skills of cognitive physicians, but I doubt that these physicians are less intelligent: the best proceduralists I’ve met and worked with use both cognition and procedure in an equal balance (especially using cognitive techniques to guide the use of procedures). (In fact, the interventional cardiologist I shadowed frequently took on the role of an internist and picked up the slack for primary care physicians.) While I believe that there will always be a place for family medicine and other cognitive specialties in American health care and that these should be well-reimbursed, I don’t think that these physicians should necessarily receive the same compensation or better than proceduralists (interventional cardiologists, pulmonologists, gastroenterologists, surgeons, emergency medicine physicians, etc.) as some would like to dream.

At this time, I’m leaning toward Pulmonary and Critical Care Medicine and Interventional Cardiology. Both of these involve a mixture of cognitive medicine and procedural medicine. Furthermore, both may involve commanding a section of the hospital: pulmonologists typically direct intensive care units, and interventional cardiologists lead teams in catherization labs. I like the idea of being in command of one’s own ship (to some degree) rather than being a nomad in various wards. Neither are front-line specialties, and that’s fine by me: I would like my batting average to reflect that I could do something both tangible and meaningful for most of my patients.

Being an intensivist would have its own unique challenges, though, including the growing debate as to how people should die and to what extent the medical profession should attempt to prolong the transition between life and death. Medical bloggers (and other people in health care) like to pick on the ICU as being one symbol of what is wrong with our health care system: it is the most expensive unit in most hospitals, and it generates horrifying images of barely-brain-alive patients powered by machines and stories from patients’ family members who would plead on behalf of their dying loved ones to just let them die. At this point in time, I am sympathetic to both the perspectives of many physicians and patients who want to die: I would want to work as hard as I can to stabilize patients and help them substantially recover a chance at living a decent life (with medical support, yes, but not necessarily a miserable one), but I also have respect for the desires of patients and an ear to their reasons for wanting to die (by being taken off life support). It’s a matter of balance, and given that seeking balance is a core value of mine, I wonder if this would be an ideal profession for me. Although others might find the ICU depressing because of the high mortality rate (as much as 20%), I think that I might find some satisfaction in helping guide patients through their transition: back to a stable life (disabled, perhaps, but with reason to live) or toward a less painful and less sudden end.

Anyways, these are just some of my early musings. I have recently come to realize that while my choice in discipline is important for finding personal satisfaction in my career (as there are many differences in style between various fields), it is also important for me to realize that this is a long journey, and the journey is half of the fun. In some ways, picking a long journey with fixed, incremental endpoints (unlike graduate school) gives me a vast variety of experiences at a good pace that few others will ever encounter: from medical school, to residency, to fellowship, to practice, to research, to teaching, and so on. I am happy that I have picked a profession that can allow me to do so many different things, and I even if I may not be as interested in some things now, I may be more interested and more involved in the future (e.g. almost all of my lab instructors for Anatomy were former surgeons; I would love to spend my venerable years teaching students instead of sitting around in retirement and having nothing meaningful to do). With that in mind, I realize that it’s important to enjoy each stage and find value in each one rather than constantly looking toward the days when I can practice independently. Sure, each stage will have its frustrations and annoyances, but there’s also something unique and good about each as well. Rather than focusing on inadequacies, why not focus on what I can do and be? There are many milestones, and I’m happy to be what I am now: a kick-ass medical student that can do whatever I set my mind to.

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