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In the midst of preparations for the USMLE Step 1, we (medical students) sometimes resort to mnemonic devices and memory tricks to help us remember details on subjects with which we feel less comfortable. Some of these devices involve acronyms that stand for items in a series (e.g. microorganisms susceptible to a particular antibiotic); others might be pictures or stories. During our Human Behavior (Psychiatry) block, one of our professors had the excellent idea of illustrating personality disorders with movie characters; unfortunately, many people were not that familiar with the references to older films and plays (e.g. Vivien Leigh as the histrionic Blanche DuBois in A Streetcar Named Desire).

Here is my more contemporary comparison of fictional characters to personality disorders: the colorful inhabitants of the world of J. K. Rowling’s Harry Potter. 

**Warning: Minor spoilers below! (for those who have not read the Harry Potter series or seen the movies, however few of you there are out there)**

Cluster A Personality Disorders
Paranoid [distrustful, skeptical, expecting betrayal] = Cornelius Fudge - irrationally fears that Albus Dumbledore is trying to overthrow him as the Minister of Magic
Schizoid [voluntarily withdrawn, seeks isolation, reserved in expressing emotion] = Severus Snape - rarely expresses emotions and usually stays in his office or in the Potions chamber, away from the company of others
Schizotypal [odd appearance, magical thinking, awkward in social settings] = Sybill Trelawney - a very eccentric Divination instructor

Cluster B Personality Disorders
Antisocial [criminal behavior, disregards well-being of others, believes rules don't apply to him/her] = Voldemort aka Tom Riddle – the classic model of a conduct disorder case growing into a full-fledged antisocial
Borderline [dramatic mood swings, impulsive, unstable, feels empty] = Moaning Myrtle - technically she is too young to have a Personality Disorder diagnosis (these are not applied until behaviors stabilize in adulthood), but her expressed feelings of loneliness and abandonment mixed with the occasionally warm approach to frequent visitors is strongly reminiscent of this disorder
Histrionic [dramatic expressions of emotion, seeks attention] = Bellatrix Lestrange – the theatrical right-hand woman of the Death Eaters craves the approval and appreciation of her master
Narcissistic [feels entitled, grandiose self-perception] = Gilderoy Lockhart - self-indulgent and always expecting admiration and adoration, even where lacking

Cluster C Personality Disorders
Avoidant [socially awkward but desires company, fearful of rejection] = Rubeus Hagrid - although he develops strong relationships with several characters in the series, Hagrid’s half-giant background and shameful exits from Hogwarts make him very sensitive to the opinions of others
Obsessive-compulsive [overly concerned with perfection and control] = Dolores Umbridge - the temporary Headmistress and Inquisitor of Hogwarts upon Dumbledore’s disappearance is the perfect picture of obsessiveness and rigidity
Dependent [lacks self-confidence or assertiveness, passive, needs to be cared for] = Peter Pettigrew - the once friend of James Potter, Harry’s father, shifts the target of his submissive behavior from James and his friends to Voldemort and the Death Eaters

Impressively, J. K. Rowling has done a wonderful job of creating characters with many different personality profiles, including debilitating and self-compromising flaws.

After a short holiday after my Shelf exams, I am once again embarking on a long road of studying in preparation for the USMLE Step 1. For multiple reasons I feel a bit impatient: I would very much like to have this examination over with so that I can move on to the next stage of my training and life. Fifteen hundred miles away, my fiancée has already started her third year clinical rotations in an auspicious and exciting fashion: although she had little prior interest in surgery, her Surgery clerkship has hit the ground running. She remarked to me that she felt that she had learned more on the first day of her rotations than she did during the past two years. As I am climbing toward the peak of my knowledge and performance with respect to the preclinical curriculum and as I am starting to feel as though I might actually be a doctor someday, her discovery places my challenge in an entirely different context. As hard as I strive toward perfection now, preclinical knowledge is only one attribute that must be trained and constantly improved upon in order to perform well as a physician. I am terribly excited about that prospect: though my academic ability has improved considerably over the past few years, I do not see my strengths in the books or in the test setting. I chose this professional pathway to be with people, work with people, and rise to the emotional and intellectual challenge posed by human suffering and disease, not to sit in front of books and lecturers and computer screens.

Nonetheless, although my classes and course exams of the second year are over, I still have three more weeks of preparation left until I can officially leave this part of my life behind. For a while, I felt apprehensive of the notion of the third year of medical school: will I miss the unstructured time outside of lectures? Will I miss the leisurely lunch breaks and study breaks? Will I miss the relative lack of responsibility and expectation? At some point, I thought I might, but now I don’t think I will miss them very much. At least, I don’t think I will miss them any more than I miss my years as a child or a teenager in high school. Those times, these times had their joys and pains, ups and downs, and now it’s almost time for something new and better fitting for who I am and who I am becoming. I think that medicine must be a very unpleasant career for someone who cannot find pleasure in the journey: the long and winding road through training and hard commitments. Indeed, this is a reminder to myself: here, in this challenge, you have the opportunity to prove your mettle, show what this choice of school and path has given to you, and provide some measure on how far you have come. This time is the evening before game day, the climb before the summit celebration. It has to be done, and there’s only one person who can do it as well as you.

I watch this presidential race, apprehensive about its implications on national politics and health care. After Hillary Clinton’s narrow win in the Indiana Democratic primary and Barack Obama’s solid win in North Carolina, it appears that Clinton’s campaign aides are doubling their efforts to have Michigan and Florida included in the final delegate count in a last ditch effort to help Clinton win the nomination. The two states have been excluded because they held their primaries at an early date in defiance of rules set by the Democratic National Party; furthermore, Michigan’s ballot did not even list Barack Obama as a candidate. Considering the problems the state caused in the 2000 election, I find it ironic that Florida is one of the states involved in this controversy. Do we really want to nominate a presidential candidate who is as willing to bend and break rules to win as our current President?

My primary concerns, nonetheless, are with the health care policies touted by the three current contenders: Senator Hillary Clinton, Senator John McCain, and Senator Barack Obama.

On Clinton

I’m very worried and concerned about the extent to which Hillary Clinton intends to reform health care. Granted, as one news writer pointed out, health care reform legislation ultimately will be written by Congress (or lobbyists). However, the next President will play an important role in setting the tone for the nature of the reform to come. My political leanings tend to be toward the progressive and the left which would make me more sympathetic to Clinton’s calls for universal health care. Notably, neither Clinton nor Obama are advocating for a single payer system of health care financing (in which a single entity, usually the government, would manage and pay for all health care insurance and expenses). However, according to health08.org’s comparison of the health plans proposed by the current three contenders, Clinton’s plan does have a few cryptic proposals:

1. Individuals must have health insurance coverage. – The most distinct difference in the health reform plans offered by Clinton and Obama is that Clinton’s plan establishes a mandate requiring all individuals to have health care coverage (e.g. insurance) while Obama’s plan requires all children to have health care coverage. Obama’s plan essentially seems to be an enhanced extension of SCHIP (which covers uninsured families with children who are not eligible for Medicaid) and Medicaid: it would be a relatively modest step to ensuring that all children in the U.S. have health care coverage, not unlike present laws requiring children to receive grade school education. The attitude of American society toward children is relatively favorable, and it is widely believed and accepted that all children should be given equal opportunities before the onset of adulthood. However, Clinton’s mandate for all individuals to have insurance is a more complicated and larger task. There is certainly a considerable population of individuals who choose not to purchase health care insurance, although their attitudes and reasons may vary (based on considerations of cost and benefits, perceived need, ignorance, etc.). A larger portion of uninsured Americans would probably prefer to have health insurance coverage but are unable to afford it on their own as private plans are usually prohibitively expensive. At this time, Massachusetts is the first state to have a mandate requiring all individuals to have health care coverage (or face a fine). Thus far, the plan has been successful in reducing the number of uninsured individuals. However, the plan has also put severe strain on the health care infrastructure and financing systems, requiring the state to take extra measures to raise funds for the government subsidization of individual health plans. My question is this: if such a mandate is straining the health care system in Massachusetts, a relatively wealthy state, how successful would such a mandate be on a national scale? How would it fare in a state as poor as my own home state of Louisiana?

2. Cost Containment: A “paperless” health information technology system. – As mentioned in a previous post, I am very much in favor of digitizing medical records if the transition occurs in a sensible and balanced manner. A national standard for electronic medical records that interfaced with patient-accessible personal health records would be a wonderful advancement in health care. However, as expressed in my concerns for my hospital’s EMR system, who would be responsible for managing, fixing, and updating this system? Would it be a consortium of government agencies and private companies? Or perhaps a network of different EMR systems that were forced to communicate with one another? Either way, the startup cost of the software development and hardware replacement would be considerable, and the system could easily fall apart without a strong central authority with a clear responsibility to manage it.

3. Cost Containment: Linking medical error disclosure with physician liability protection. - Of all the details listed of Clinton’s plan, this is the one that worries me the most. What does this ambiguous and undiscussed clause mean? In a worse case scenario, it sounds as though Clinton would like to see a system in which physicians who “make mistakes” lose their malpractice insurance coverage (e.g. perhaps as a “three strikes, you’re out” type of policy). Considering that most medical errors are “system” errors rather than individual errors, how can one appropriately determine which is which? This clause is listed under “cost containment,” and it is difficult to view it as anything but a penalizing system for physicians that would likely exacerbate the current malpractice crisis. Which again makes me wonder: what snooty premed spurned Hillary Clinton in her younger days to make her hate doctors so?

On McCain

Medical blogger Shadowfax recently wrote an intriguing review of McCain’s recently exposed health care plan: essentially, his plan promises to completely destroy the current methods that most Americans can acquire health care insurance (through employment) while exacerbating the major problems facing medicine and health care today (e.g. the least amount of health insurance coverage or no coverage for the sickest and poorest patients). Originally, when McCain had not revealed detailed of his plan, I considered his superficial approach (e.g. “ignore reforming health care because it is a Democratic platform issue”) to be less threatening than that of Hillary Clinton, whose “grab-health-care-by-the-balls” approach seems as though it may cause more harm than good. However, while Clinton’s plan might harm health care providers and health care infrastructure (and in turn, indirectly pass on the damage to patients and consumers), McCain’s plan will directly affect the American people adversely. Paraphrasing part of Shadowfax’s argument, McCain’s plan aims to remove employer tax benefits and thus the incentives for employers to provide health care insurance to their employees, forcing individuals to purchase their own plans. This may be useful if health insurance plans were affordable. However:

McCain’s plan does the opposite by deregulating the insurance industry. That’s not what they call it, of course. Rather, conservatives claim that state regulations are so onerous that they drive up the cost of insurance. Their proposal is to allow insurance products to be marketed across state lines. The consequence of this will be that large insurers will domicile themselves in whichever state has the least level of regulation and the most pliable legislature. States which have robust consumer protections in place — guaranteed issue, prudent layperson legislation, bans on pre-existing condition exclusions, minimum benefit levels, etc — will find that their insurance products are more expensive because they cover more benefits (and sicker people). The states which allow the most aggressive anti-consumer policies will have cheaper costs and the lowest common denominator will become the de facto national standard.

On Obama

I am currently most in favor of Obama as a candidate based primarily on his health care policies, his no-political-BS approach, and his ability to evoke images of a better leadership for a better America. With respect to his health care plan, it essentially is a leaner, less confrontational Democratic plan with some of the same approaches as Hillary Clinton. However, his plan is more balanced and more likely to draw support from both patient-consumers, physicians, and the industries that support health care:

1. Require all children to have health insurance. – No one can argue with this, or they would just look callous and heartless.

2. Create a new public plan so that small businesses and individuals without access to other public programs or employer-based coverage could purchase insurance. Plan coverage would offer comprehensive benefits similar to those available through FEHBP. Coverage under the new public plan would be portable. – Both Clinton and Obama have plans suggesting the creation of new public/government health care insurance plans or the expansion of preexisting plans. However, at this time, I haven’t yet found information in Clinton’s plan about provisions to allow health care insurance to be portable. Allowing insurance to be portable gives patients the ability to have more control over their health care by allowing them to select and access physicians of their choice. McCain’s plan does have provisions for portability, but his plan focuses on “allowing the free market” to provide competition between health care plans in order to theoretically provide patients with affordable options. McCain’s idea would seem reasonable if he actually had strong measures in place (along the lines of Hillary Clinton’s reform policies) to reel in the influence of the health insurance industry, but this is not the case.

3. Prevent insurers from abusing monopoly power through unjustified price increases. Require health plans to disclose the percentage of their premiums that actually goes to paying for patient care as opposed to administrative costs. In market areas where there is not enough competition, require insurers to pay out a “reasonable share” of premiums on patient care benefits. – Obama’s plan unfortunately does not explain in detail what these clauses mean. However, it offers some promise that as a President, he would be interested in breaking apart the health care insurance monopolies currently in place that prevent any meaningful competition between companies.

4. Reform medical malpractice while preserving patient rights by strengthening antitrust laws and promoting new models for addressing physician errors. – Where Clinton’s plan fails to inspire confidence, Obama’s plan shines here. In this single clause, Obama reveals his nature as a moderate candidate that is willing to work with many parties and is willing to see issues in the degree of complexity that they exist. Clinton, as an executive, would likely not hesitate to try and bulldoze over any opposition she faces, especially opposition from physicians as a group. However, Obama’s policy reads in such way that seems to offer concessions to all parties involved while aiming to address the central issue (acknowledging that there is no one party at fault).

At the end of the day, this is all still speculation on early glimpses of health care reform plans that may change significantly over the next few years. However, at this time, I suspect that Obama offers the best hope toward encouraging positive reform in health care while both Clinton and McCain seem to offer great risk for catastrophe.

Like many second year medical students, I have sometimes (or perhaps often) questioned the importance of learning about exceedingly rare or obscure diseases. With a Pathology curriculum based on a combination of the Robbins and Cotran Pathologic Basis of Disease text and “self-directed learning,” it is not difficult to find oneself buried in an incredibly dense and detailed textbook, hoping to absorb relevant details without knowing what “relevant” truly means. Relevant to the treatment of patients? Relevant to pass the course exam? Relevant to do well on the USMLE Step 1? It seems that there is little standardization in the defining of relevance for medical students: it is a subjective task that encompasses each individual’s perception of the core principles of the medical field and each individual’s biases and preferences toward or against subfields.

Nonetheless, I found myself very impressed by the compelling case presented by my Genetics course faculty, their patients, and the families of their patients: that as physicians, it can make an enormous difference to simply be able to recognize a rare disorder as being rare and something to be considered. During the two week course, we had visits from five different patients from very different backgrounds, with very different diseases, and with varying degrees of management and severity of prognosis. Their message was uniform and clear. In one case, a child with a metabolic disorder requiring strict dietary restriction called phenylketonuria (PKU), the parents lived in a small town, and their family’s longtime pediatrician had no knowledge of how to manage a PKU patient. After receiving the first positive result suggesting PKU on a routine test shortly after the child’s birth, the doctor went so far as to tell the parents not to worry and that the child did not have PKU because “no one gets this disease.” The parents still bring their child to this pediatrician to manage everything besides the child’s PKU, but the doctor is still unfamiliar with the disease and how to manage basic illnesses that may be much more severe in a PKU patient. Would it not be a small price to pay to spend some time learning a little bit more about a patient’s rare disease to improve his or her health management, or moreover, learn a little bit about as many rare diseases as possible to be able to recognize those patients should the statistically unlikely occur?

For a medical student, it seems to be a daunting task to learn about every disease known to man, especially those for which there have only been a handful of cases reported and recorded. Reading about these diseases in a textbook or hearing about these diseases in a lecture (from a non-expert in these specific diseases) seems to do little to encourage the formation of permanent memories. However, assigning a face to a rare disease, shaking someone’s hand, asking her questions, and hearing her story in her own words and voice is a powerful experience that is forever fixated in one’s mind. I will likely forget their names, but I will not forget the stories of individual patients who suffer from tuberous sclerosis, Fabry disease, phenylketonuria, and Down syndrome.

My suggestion to medical school instructors is this: if you want to teach your students about an uncommon condition and you have a patient who has it and is willing to speak about it, please bring him or her to the class. Few tools of instruction are as profound and lasting for the student, not to mention that it also gives the patient a chance to take ownership of his or her condition and help others who suffer the same.

Today, I had my first real intimate look at one of the electronic medical record systems used by one of the hospitals in which I will rotate during my third and fourth years of medical school. Although I am generally in favor of the idea of digitizing medical records, I was thoroughly unimpressed by the system for which I received training today. A few points made by many medical writers before me with a few of my thoughts interspersed:

1. Many electronic medical record systems are very poorly designed from the perspective of those who use them. – This is a common complaint of doctors and nurses. EMR systems are generally not designed with the user in mind: they are designed solely toward achieving the goal of preventing errors. As such, they are sometimes built in ways that impede the ability to search for and access information in an intuitive manner. Why isn’t there a national standard EMR designed with a joint consortium of physicians, nurses, programmers, and legal consultants? Instead, we have dozens of expensive, cumbersome and antiquated systems that do not cross-talk and sometimes cause more medical errors.

2. Information technology administrators hate medical students. - At least, they seem to want to make our lives as difficult as possible. This is perhaps an unfair way of putting it, but I was left with the distinct impression that some information systems administrators see medical students only in their capacity to screw things up. It might have had something to do with the administrators repetitive statements of “This measure is put in place so that you cannot screw up the system” and “You are at the bottom of the food chain, so you don’t have access to this.”

A few questions I have:

Q1: What sense does it make for medical students to not have access to the radiology records (e.g. x-rays, CT scans, MRIs, etc.)?

My preceptor (e.g. attending physician) specifically told my team that a good medical student might improve his or her skills and demonstrate the desire to learn by evaluating the imaging studies on his or her patients and then reviewing them with the intern or resident on the team. How can a student effectively learn without having to bother his or her team members for access?

Q2: What sense does it make for a medical student to not have the ability to access records outside his or her assigned service?

For example, a medical student on a Medicine rotation cannot access information on a patient coming from the Emergency Room to the medicine ward until someone else enters a digital request for a consult for the patient. Considering that medical students in our system cannot edit or modify electronic medical records at all, what is the purpose of this “safety measure?”

Thoughts for later consideration:

In the midst of my Shelf exam and USMLE Step 1 preparation, I have looked toward the third year of medical school with excitement and anticipation: at last, my classmates and I might have the opportunity to have some responsibility, however small. Through the inspiring teachings of clinician-educators such as Dr. Jeff Wiese, I have discovered that many academic physicians see medical students as viable and integral members of a medical team: we are the ones who spend the most time with our patients and can truly become “experts” on the patient’s story, if not the patient’s medical condition and management. The patient’s history and story/context are extremely valuable pieces of information, usually providing up to 90-95% of the information needed to obtain the correct diagnosis (according to Dr. Wiese). Furthermore, medical students play an important role in building relationships with patients and helping them adjust to their stay in the hospital. Medical students also keep the rest of the team on their toes: for example, asking questions about clinical, laboratory, or imaging findings (which might not be as feasible with restrictions on imaging access). If anything, it seems that many attendings and their teams of residents and interns would prefer to give more responsibility to medical students: they want to see us demonstrate our mettle, very much in the tradition of a mentor passing on duties to a rapidly learning apprentice with guidance and supervision.

However, there is an opposing force: the system of administrators and “safety experts” whose concern is not with the medical student but with the patient. Their objective is to keep patients safe, not to help medical students learn. If anything, these administrators most likely see medical students as walking liabilities. I wonder if this opposing force (and the medical teams that make little use of their eager medical students) are doing a disservice to medicine and healthcare by stunting the growth of medical learning on the part of third year medical students and constantly fencing them into an “observing” role. Notably, the learning curve during the third year of medical school is very steep, and there have been a number of studies that show that physical examination skills are rarely improved after the learning taking place during the third year (e.g. listening to and identifying heart murmurs, differentiating between various diseases showing findings on a chest x-ray). Don’t misunderstand: I personally believe the role of safety experts is extremely important. Nonetheless, how do you balance the need for safety with the need to train physicians as well as possible?

My concern is that there is too much focus on methods of “correction” (and punishment) rather than methods of “improving performance” (and providing incentives for better performance). Perhaps if the safety systems (such as those impairing the usability of electronic medical records) were built in a smarter manner with a concomitant improvement in mechanisms to encourage better performance (on the parts of medical teams), electronic medical records would be more readily welcomed by physicians.

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