Monthly Archives: May 2009

I wanted to do my Surgery clerkship early during my third year, but my lottery picks never seemed to align with this goal. It is the largest domain within medicine with which I had no familiarity prior to this year, and so I wanted some early exposure to determine whether or not it would be on my list of interests. Now, as my last rotation during my third year of medical school (which, by this point, has become rather old in appeal), it would be very much a “Hail Mary” pass if I suddenly fell in love with this field.

Nonetheless, I can understand the appeal and have discovered as much during my General Surgery month: it is action-oriented, the Operating Room tends to run with a degree of speed and efficiency not always found in other parts of the hospital, and there is a degree of satisfaction that comes with using your hands and metal tools to accomplish unnatural feats (connecting two pieces of small bowel, peering into the chest or abdominal cavity with a camera, sealing off perforations, stopping bleeding vessels from the inside, and opening and closing the body as it if were merely a well-read book).

However, I also find that there are so many sacrifices made to pursue this life. Several of my residents whom I adore and respect have repeatedly canceled, delayed, or missed dates, family engagements, and other priorities in life due to emergency surgeries. As for myself, I wake up at 4 AM in the morning and leave work between 7-10pm at night, leaving me only an hour or two to eat and catch up with my fiancée on the phone, let alone study for the written and oral exams I will soon face on this clerkship. I prefer speaking to my closest friends and family on the phone or spending time with them in person, but that has not happened since I started this rotation three weeks ago and is unlikely to happen during the next five weeks as I move on to more time-intensive specialty services (Neurosurgery and Cardiothoracic/Vascular Surgery). Furthermore, the environment within which I have been working is very high-stress, combative (with two recent arguments nearly evolving from verbal threats to physical blows), and unsupportive (colleagues are more likely to criticize and make fun of one another than utter a supportive compliment). Some training surgeons seem to buckle under this pressure and are unable to handle multiple responsibilities, possibly jeopardizing the care of their patients on a routine basis. All of which begs the question: is it worth it? How does a third year medical student fall in love with Surgery and, if they have other priorities in life, how do they convince themselves the price is worth the reward? Many of my classmates have arrived at the answer “Yes,” and it may take some time for me to understand why.

The stage is set for major health policy reform, but there is no clear solution in sight. Part of the problem is that there is no one issue that explains all of the failings of America’s health care system: it is described as a “systems problem” exacerbated by malpractice litigation, decreasing health insurance coverage, decreased incentives for physicians to enter primary care, increased utilization of emergency resources, and many other factors. Having completed my Family Medicine (primary care) and Internal Medicine (hospitalist medicine) clerkships, I’m more aware now of the considerable ideological differences between primary care physicians and specialists. For example, the way physicians handle scientific evidence varies greatly. Many physicians in academic centers and hospitals are willing to change their practice of medicine based on a single, well-designed ground-breaking study. However, primary care physicians are much more conservative in their changes: while it may seem that they are “outdated,” they ideally focus on making changes based on a broad base of evidence (many studies over several years) to minimize costs and maximize effectiveness. In other words, PCPs don’t care as much about “expert opinions” and new discoveries and instead focus on what appears to be repeatedly proven truths.

There are great merits to both schools of thought, and American medicine benefits from having this dichotomy. It is clear that there is a problem with primary care in this country, and most people consider it to be a shortage of primary care physicians. However, I’m discouraged by the proposals that varies policymakers, physicians, and others make in an effort to solve this problem. For example, some propose increasing primary care payments at the expense of specialist payments. While this seems honorable to reassert the value of “cognitive” specialties (e.g. medical care based on actually knowing your patients and individualizing their care rather than medical care based on delivering specific treatments), it doesn’t seem sensible to “lower” the value of specialist care: after all, it’s the specialists that drive discovery and research (developing new and better treatments, discovering new knowledge on how to better treat diseases, etc.). Furthermore, there’s a shortage of specialists in many areas of the country (i.e. distribution is an issue). Others propose requiring medical graduates to do a year or two of primary care before starting their residencies. This proposal makes very little sense to me: what happened to the notion of “continuity of care?” It would not necessarily help patients to inject a fresh supply of young and inexperienced medical graduates into communities only to have them leave a year or two later (after seeing their patients maybe 3-5 times). Lastly, the AAMC is requesting medical schools to increase their enrollment of students by as much as 30% with hopes that this will increase the total number of physicians that can enter primary care specialties and practice in underserved areas. While this will likely help to some degree, this doesn’t change the incentives contributing to the current problems.

Some people seem to be bothered by President Obama’s focus on health information technology as an initial centerpiece of health care reform during his term, but this I do not see this as a fault. If anything, health information technology is low-hanging fruit: the lack of interoperability between electronic medical record systems and the continued reliance on paper documentation is a frustratingly backwater problem (e.g. reliance on fax machines, errors made based on poor handwriting, time wasted in documentation, etc.). There are many hospitals and communities in which electronic systems are very functional and useful, while there are also many others where it has been poorly implemented. Laying the groundwork for a more functional, national intranet makes sense with respect to reducing the long-term costs of overutilization: much the way medicine is practiced (e.g. ordering tests and interventions) revolves around finding information (that may already be available in older records and is not volunteered or remembered by the patient). While eventually all of the other issues will need to be addressed, I don’t think it is a problem starting with a relatively more straightforward issue.

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