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Monthly Archives: April 2008

It has been a long time coming: the AAMC has finally taken a strong stance against the distribution of free gifts (from pens and bags to food, travel expenses, vacations, ghost-written papers, etc.) to physicians, medical school staff members, and students by pharmaceutical and medical device companies (reference). The AAMC is not a ruling body for medical schools, but it does provide guidelines and directives that most medical schools choose to follow. Responding to the growing efforts of companies to influence the medical decisions of doctors, the AAMC has proposed an all-out ban, no strings attached.

Surprisingly, several executives from major pharmaceutical companies including Amgen, Eli Lilly, and Pfizer were on the task force, although it seems their dissenting opinions were overruled by the majority. One of the Amgen representatives expressed conditional support for the AAMC’s report “because we have a different view about the accuracy concerning representations about the motives of the participants.” This is not entirely untrue, but it illustrates the subversive nature of the tactics many companies have used to influence prescription writing, device usage, and product endorsement behavior of physicians. Various studies have consistently demonstrated that physicians who accept gifts underestimate their susceptibility to influence by the drug and device makers over their medical practice decisions. Most physicians do not perceive their acceptance of free gifts as prostituting themselves to these companies, when in reality, they are allowing these companies to take advantage of their sense of entitlement (something often developed in medical school).

Some members of my generation of physicians-in-training might complain: “Our predecessors received free gifts and tens of thousands of dollars in speaking fees; why shouldn’t we?” My response: suck it up. How hard is it to buy your own pens and lunch? The movement within the field to expose financial conflicts of interest has done a reasonable job of revealing the extent of potential influence of drug and device makers over medical practice, but it is now our job to take a stand and say “no.” 

Today’s New York Times featured an article discussing the tendency for a number of states to raise tobacco taxes in order to make up for deficits in the budget, particularly with respect to financing health care reform and medical research. Interestingly, the tobacco companies, unhappy about the rising taxes, gave this argument in response:

The tobacco industry counters that smokers already bear an unfair tax burden and that increases encourage cross-border purchases and bootlegging. Cigarette manufacturers also argue that tobacco taxes make for an unstable revenue source because of declining sales. An analysis of recent tobacco tax increases conducted by Altria, the parent company of Philip Morris USA Inc., concluded that three-fourths of them had raised less money than projected.

The first argument is amusing at best. When did tobacco companies start caring about the well-being of their customers? I suppose they care about the financial well-being of their customers but not their health. As long as the tobacco companies can make a profit from tobacco sales, they will be happy; otherwise, they could simply lower tobacco product prices to compensate for the tax increases. Given their benevolence and concern for their customers, will tobacco companies do this? Not likely! The second argument is spurious. It is improbable for any analysis or study by a tobacco company to be scientifically sound and unbiased, but nonetheless, the conclusion is of interest. However, does it matter if the money raised is lower than expected? Tobacco taxes have been very successful in the past at raising some money for medical research in states such as Louisiana, but perhaps they shouldn’t be depended on as a sole method of covering deficits.

The many societal (e.g. anti-smoking laws) and financial (e.g. taxes) barriers to smoking seem to function well as preventive measures for starting the habit of smoking, and they similarly might help the medical profession set the stage for patients to quit smoking (since we now have more effective medications/patches and counseling methods). That is, people would rather quit or taper their smoking habits than pay the taxes (e.g. being “financially burdened” by the new taxes). People adjust. Tobacco companies might not. Even if the tobacco taxes do not raise as much money as expected, is there any harm done except to an industry that feeds off the anxiety and fatigue of its consumers (to the detriment of their health)? I say tax away.

Leading into my third year clinical clerkships, I predict that my posts will become increasingly shorter in length (which is probably a good thing) as I will have less free time to myself and more time to commit to my patients and team members. Nonetheless, reflecting on my experiences through writing is a personal commitment and a powerful learning tool for me as I seek to continue developing the self-awareness and self-assessment skills required of a good physician. Here is a short reflection on developing thoughts.

I believe that in the liminal spaces of sickness and healing, there are few words said that lack a deeper meaning. We, as physicians, must be careful and conscientious of the words we choose to convey our instructions, encouragement, and bad news. Our partners in this relationship, our patients, do the same, though perhaps with less premeditation. For the first time, an inpatient, encouraging me and a team member during our early stages of medical training, spoke these words to me: “God gave you the power to heal.” In those words, I find not only encouragement but also the desire to assign meaning and order to his tortuous path. With the will of God breathing a purpose into each action and interaction, it is possible to move forwards through each hardship with a peaceful mind and connect to those who would help or test you along the path.

I am not a religious person, and I am uncertain as to whether or not I ever will be. However, I do believe in a greater order connecting each person and living being and a meaning behind every occurrence. For me, believing that there is a greater order and reason serves to assure me that not all events and outcomes are in my control. On the other hand, believing that the power of healing is a gift from God reminds me that I have a responsibility to use my abilities (however nascent at this time) to serve the well-being of all people, all who are connected by this greater order and reason. The former prevents the anguish and the tendency to cast and misplace blame that arises from the failure of a patient to recover as expected. The latter marks the commitment needed to always do everything in my power (within reason) to help and understand he or she who suffers. I believe that those who enter medicine with a prior connection to God through religion have an advantage in this area: they are more likely to quickly develop the range of behavior and systems of rationalization that are appropriate and helpful in the care of patients. That is, they may be more humble than others in their perceptions of their effect on patient outcomes and more likely to recover from the trauma of poor patient outcomes, while also being more committed to using the gift of healing given to them. Religions may not always promote the values we support as practitioners of medicine (equality, compassion, tolerance), but most do. Accordingly, I hope that physicians-in-training with religious beliefs and commitments always find a place to speak with other students, and patients, about their faiths and their intersections with medicine and patient care. Not all in medicine fits within the purview of science: much revolves around how we connect to another person, and how we see that connection.

A few images of my places in New Orleans:

My class is finally approaching the end of our second year coursework. Although the true climactic conclusion will be the successful completion of the USMLE Step 1 licensing examination (national standard exam, for which there are three “steps”), it feels as though we have already come a long way since August 2006. Since then, I’ve collected a number of impressions and suggestions regarding the preclinical education of medical students at my school and others:

Gross Anatomy – My coursework was exceptional, largely due to the educational vision of Sandor Vigh and the excellence of his current/ex-surgeon laboratory instructors. Many schools seem to skimp on this course as they seek to revise and shorten their M1/M2 curricula, and some schools minimize the dissection time requirements for students. While I understand this tendency and the relatively “low-yield” nature of the subject with respect to the USMLE Step 1, I think that the course encompassed some of my most important first year experiences: my classmates and I were forced to mature into a professional attitude and manner uncharacteristic of most jobs, became familiar with death, and developed trust and respect for one another. The “grueling,” physical, and time-consuming nature of the course encouraged teamwork and inspired many of us to become more solid and hardy. With the team-oriented activity of dissections, when else do medical students get a chance to take responsibility and work together as equals during the first two years? PBLs (problem-based learning sessions) do not provide the same experience (at least at my school) since there is typically too much reliance on one or two students in each group.

Exam Protocol – One of my greatest frustrations has been the reluctance of my school’s faculty to provide digital copies of exams and answer keys for later review. My understanding is that faculty members may reuse questions and have a few reservations. Worried that some students may have an unfair advantage over others? Provide past exams and answer keys on a central site accessible to all. My college (Harvard) did this, and it worked very well in providing all students in certain courses with extra preparatory material. Worried that students will “score too well” on the exams and find them too easy? This, to me, is a trivial concern. If exam questions are well-structured, then they should be either 1) easy to alter to present the same concept in a different case setting (and thus easily produce a “different” question), or 2) be straightforward enough such that it wouldn’t matter if the question has been seen by the student prior to the exam (e.g. the question would reflect the lecturer’s material, not an obscure fact not emphasized by the instructor). My primary interest in having access to my exam and the answer key is to be able to learn from them: much of medicine involves learning from one’s mistakes (whether through shame and embarrassment or simply the desire to do better). By limiting access to this material after each exam, instructors may simply be trying to limit their own work: writing good exam questions that match lectured material.

Lecture Relevance – I think one of the most common questions running through a medical student’s mind is, “Do I really need to know this?” Many students have some strong feelings about particular fields they like or dislike during their preclinical years: it is then easy to question the relevance of any given lecture outside one’s area of interest and easy to justify the “binge and purge” learning style encouraged by contemporary medical education. I think there are two excellent ways for instructors to overcome this obstacle. First, patients are incredibly valuable assets in inspiring medical students: three of the patients that have visited my classes that I will never forget include a woman with Parkinson’s disease, a toddler with phenylketonuria, and a preteen with tuberous sclerosis. Their stories and words convey stories that a more straightforward lecture cannot: personal stories of hardship, suffering, and recovery, with the help of a knowing physician. Some of the patients had good prognoses and were “model cases.” Others were not, and sometimes had to live from one day to the next without a clear picture of the future. Either way, they easily make the case for future physicians to be familiar with their diseases. Secondly (and I’m sure many students would disagree), I think that lecturers should present current research alongside most of the subjects they teach, even and especially if that research is their own. Many students complain that some lecturers will talk only about their own research – I feel the same way. However, connecting current research (and expressing excitement about the relevance of one’s own research) to each topic can greatly assist students in understanding the context and importance of each disease or concept to many people. A good balance is needed.

A shorter M2 – Many schools are implementing potentially drastic alterations to the lengths of the preclinical curriculum, shortening it by one month, two months, or in the case of Duke, an entire year (replaced with a year for other medical opportunities such as research, service, etc.). My fiancée is a second year medical student at Harvard Medical School, where the administration implemented a new rendition of “New Pathways” that includes two fewer months of preclinical curricula. Her class will be entering their clinical rotations alongside a previous class of third year medical students, doubling the number of medical students on the wards in May and June. Columbia Medical School and Tulane University School of Medicine are also following suit with similar shortenings. Do these changes make sense? The second year of medical school seems to be considered by many to be the lowest point of morale in medical training since it involves learning massive amounts of material in order to have a basic foundation of knowledge when entering the wards. Will students with abbreviated preclinical curricula have the medical knowledge to be prepared for their clinical rotations? A lot of learning takes place during the third and fourth years (perhaps the majority of knowledge that will be needed to function and perform well in a clinical setting), but how much harder will it be for students with a smaller foundation of knowledge when they arrive? In many places, it is popular for instructors to encourage “self-directed studying” as a method of incorporating more material into a course without actually having to teach the material. This unfortunately may encourage laziness on the part of instructors with respect to their core responsibility: to ensure that their students are prepared well for the next stage in their training. Only time will tell if these reforms are wise. At this point in time, I would not be unhappy to have a shorter M2 year, as long as the remaining time is used well to prepare second year medical students for their clinical rotations (not to simply throw the students into the wards prematurely).

Problem-Based Learning – is a problem. I have had great PBL sessions, and I have had abysmal, useless sessions. Group dynamic is certainly an important contributor to good experiences, but the structure of the PBL system is largely inadequate at my school. As mentioned before, there is little responsibility given to each PBL attendee except attendance: one or two students, perhaps simply wanting to get the session over with quickly, will take charge and blaze through the material at the fastest speed the faculty facilitators will allow. The case material quality depends on the writer and can easily make discussions needlessly complex or confused. The best PBL sessions I have attended were designed by Sandor Vigh as part of his Anatomy course: the PBLs were digital (integrated with imaging studies such as x-rays, CT scans, angiograms, and MRIs) and sometimes involved standardized patients. The SPs were an important component: they gave us an opportunity to interact in a simulation setting to interpret data, develop a plan, and build a doctor-patient relationship. I would love to see traditional PBLs (groups of students with a faculty facilitator and paper-based cases) abolished entirely in favor of integrated standardized patient PBL sessions: a small group of 4-6 students could work with a clinical facilitator to solve a case presented by an SP. This would work very well with systems-based curricula, the current trend in medical education reform.

Standardized Patients and Simulation – Making frequent use of a standardized patient program has been both boon and bane to my class: we were on the cusp of reform in this program and were given twice the amount of instruction received by any other class. As a result, the basic sessions where we learned physical exam maneuvers were repetitive. Additionally, while some SPs are amazingly knowledgeable and helpful, others may be excessively didactic in their teaching approach. Lastly, it is impossible to develop any confidence in certain physical exam maneuvers without access to true “pathology”: how do you know you are performing the thyroid exam correctly if you usually cannot feel a person’s normal thyroid? As much as the coordinators of the SP program laud the development of an advanced program at my school, the program cannot fulfill its true potential without further collaboration between the SP program and clinical instructors or course directors. Having the program run in isolation from the rest of the curriculum makes it feel less relevant (even though developing good clinical physical exam and interviewing skills is an obvious requirement to practicing good medicine). Our new medical school dean, Benjamin Sachs, is developing a new simulation center and hopes to fight the old medical establishment’s dogma of training medical students, residents, and practicing physicians (e.g. surgical procedures) on real patients: with the right resources and technology, it is a great hope to be able to improve patient safety further by ensuring that all medical professionals will have some competency in each skill before they apply it to a patient. For medical students, our primary patient-oriented skill development revolves around patient interviews and physical exams through our interactions with standardized patients and real patients while working with clinical preceptors. As such, would it not make sense to use the SP program as much as possible to hone these skills in the context of the learning taking place in the lecture hall and classroom? In the “Clinical Diagnosis” course taught by physician Jeff Wiese, our second examination was a “clinical problem solving session” simulating the interview, examination, and medical management of a single (standardized) patient. This session seems to have been well-liked by all students I have spoken to, and many have suggested, “Wouldn’t it be great if we had many more of these sessions throughout the year?” I think such an exercise in the use of clinical skills, clinical reasoning, and medical knowledge can be used as an amazingly useful, routine method of teaching material. For example, this clinical problem solving session could follow the paper-based course exams during each systems block (e.g. one or two patients with a GI problem, a neurological problem, etc.). 

Clinical Experience – I have been extremely lucky in my assignment to clinical preceptors: both my first year interventional cardiologist and my second year Internal Medicine/Infectious Disease preceptors have been amazing instructors and clinicians. During the first year, I had six 3-4 hour shadowing sessions with my preceptor, and this year, I had ten 3-5 hour sessions with my preceptor. In my view, this is not enough. In the absence of greater integration of standardized patients and/or simulation into the core curriculum (e.g. pathology, physiology, etc.), preclinical medical students need to spend more time in the clinic with actual responsibilities. During my first year, I was merely shadowing. This year, my preceptor gave my team the opportunity to interview her patients with and without her supervision. While it was still primarily a learning experience with patients she had already seen, it gave us the opportunity to provide an additional set of eyes and minds to the clinical cases at hand. For example, in one case, I discovered that a morbidly obese patient with asthma had been given oral corticosteroids for multiple years and had subsequently gained a lot of weight, leading her to discontinue using the medication that was helping control her asthma (I spoke with the patient about inhaled corticosteroids and how they tend to not have the same systemic effect of weight gain and recommended a new outpatient treatment regimen to my preceptor). Furthermore, at least in my experience, I never learn better than when I am working with real patients in the hospital. Regardless of the accuracy or feasibility of simulation or standardized patient components of medical education, there is nothing as powerful as a true story and a real interaction with a patient and his or her condition. Not long ago, I had difficulty remembering and conceptualizing thyroid diseases. Then, I met a woman during one of my preceptor sessions who was remarkably agitated and hypertensive: she had hyperthyroidism, and in working through the diagnosis and management of her case, I learned lessons that will never leave me. The third and fourth years of medical school are designed to expose students to a variety of medical cases as well as introduce them to their newfound responsibilities, but if medical educators want students to be more prepared when they enter the wards, it makes little sense to either 1) keep the preclinical and clinical years isolated from one another, or 2) shorten the preclinical years without integrating substantial amounts of clinical experiences and ward preparation curricula into the first two years.

Today, my preceptor group had its last of ten sessions together. I have had the great fortune of working with an amazingly thoughtful, intelligent, and patient preceptor as well as three hardworking, clever, and insightful classmates. It is amazing looking back at my previous admission notes (e.g. patient write-ups on admission) and seeing how far my preceptor has guided me along my developmental path. I have previously kept a brief record of my clinical experiences on this journal, but I unfortunately lost that information prior to my weblog’s migration to a new server and address. Nonetheless, I would like to chart my progress on this journey thus far: one of the most convincing and meaningful arguments for the length of medical training for physicians is the importance of exposure. When you have examined and worked with a patient with a particular condition, asked a particular question, or performed a particular physical exam maneuver once, the intricate web tying the patient, pathology, social circumstances, examination, and treatment is forever burned in one’s memory. And so, as a quick self-reminder, anonymous and indistinguishable to all but me:

Cases

1. A 55-year-old man with several ulcerated, discharging skin lesions behind his left shoulder and deep pain in the shoulder. Diagnosis: osteomyelitis of the left shoulder and a potential recurrence of lung cancer. The lung cancer may have exhibited local spread to the shoulder, triggering the deep tissue infection.

2. A 68-year-old woman unable to lift her right leg. She felt “pins-and-needles” in her right leg, then felt it was “heavy as lead,” and then felt “jabbing” pains in her right knee and neck. Diagnosis: spinal stenosis.

3. A 36-year-old nurse with vomiting, nausea, “churning” abdominal pain, and 10 pounds of weight loss in the past month. He was HIV+ with AIDS. Diagnosis: HIVAN (HIV-associated nephropathy).

4. A 57-year-old with a one-week history of incapacitating weakness, coughing, fever, productive cough, and shortness of breath. Diagnosis: CAP (community-acquired pneumonia).

5. A man with very painful periorbital headaches of short duration. He was HIV+ with AIDS and slowed mentation. Diagnosis: cryptococcal meningitis and HIV dementia.

6. A 26-year-old man with severe, persistent pain in his inner thighs, tea-colored urine, and a highly elevated CK (creatinine kinase). He reported no trauma, excess alcohol use, street drug use, or medication use. Diagnosis: rhabdomyolysis (of unknown etiology).

7. An 84-year-old woman with shortness of breath and a productive cough unrelieved by use of her asthma inhaler. Diagnosis: atopic asthma (exacerbation) and CAP (community-acquired pneumonia).

8. A 54-year-old man coughing up blood clots without mucus, “stabbing” epigastric pain, unspecified weight loss, and a rapid onset of full-body non-pruritic red macular rash. He reported a 2-month history of a “flu”-like illness. Diagnosis: secondary tuberculosis, syphilis (latent), chronic HCV, polysubstance abuse, bipolar disorder.

9. A 60-year-old woman with a 2-month history of difficulty breathing (shortness of breath, dyspnea, and orthopnea), “flu,” “diarrhea,” and weight loss and a recent traumatic fall. She was very restless and irritable during the interview and did not tolerate a full physical exam. Diagnosis: congestive heart failure, with hyperthyroidism as the likely etiology.

10. A man with prominent scleral and sublingual icterus.

Statistics and Observations

• Used my diagnostic set (ophthalmoscope and otoscope) during 4 out of 9 physical exams. Used the ophthalmoscope 3 times to rule out papilledema (my ophthalmological skills need significant improvement, but I can now regularly examine the optic disk using a coaxial head in a lit or unlit hospital room). Used the otoscope with specula once to examine nasal passages (e.g. atopic asthma with severe sinus congestion – hold your breath!).

• Entered respiratory isolation at least 3 times using N-95 masks where patients were suspected of having tuberculosis. Performed two patient interviews and physical exams wearing N-95 masks (obstrusive, but necessary).

•  Using my Littman Master Classic II stethoscope was at first difficult due to the tendency of the rubber tubing to brush against skin and impede efficient and effective auscultation of the heart. I have since found ways of stabilizing the tubing to prevent this from occurring, but I still question my choice of stethoscopes.

• I have yet to use my 256 Hz tuning fork or reflex hammer when examining an inpatient. I have not been carrying these with me, but this may change during my third and fourth year clinical clerkships. On the other hand, my stethoscope and penlight are always used.

• Practiced writing admission notes, admit orders, and outpatient prescriptions.

• Found many of the experiences very challenging and difficult, but I feel much more prepared for inpatient clinical care now.

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