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Archive for August, 2010

Tuesday, August 31st 2010

The Most Important Profession

I don’t think there is anything nobler than being a physician. In it’s most prime form it is service to life’s most basic needs.

Certainly there are professions and lives with similar dedication. But lawyers and journalist I can’t reasonably place amongst them. This from someone who favors liberty and transparency in society above most else; certainly things that lawyers and journalists can help foster.

And yet, for all the respect thrown towards physicians by society, even amongst the access crisis and the accusations of greed, you can’t help but get the sense that some people are delusional. I take this from a speech by Gerry Spence,

“[Lawyers] are the most important people in America,” Spence said. “There is no other profession in America that fights for freedom, that fights for what America is about, that fights for justice for ordinary people.”

[...]

“I want to ask you which would be more important: If all of the doctors in the country somehow disappeared or all the trial lawyers in America somehow disappeared?” he asked. “We can live without medical care, but we cannot live without justice.”

Spence was a prominent trial lawyer, a near celebrity trial lawyer, who may be prone to such hyperbole. But the reality is no American will ever need a lawyer quite like they need an operation for a perforated bowel. Not even if facing criminal charges to potentially include execution as punishment, if for no other reason than the difference in acuity amongst the two examples.

To claim the legal profession as more important than the practice of medicine borders on delusional.

So does the next quote,

“Journalism is not brain surgery; it’s more difficult than that,” said Andrew Cline, an assistant professor of journalism at Missouri State University, who has written on the perception of bias in news coverage.

The blogosphere jumped on this quote, as it appeared in an Ombudsman’s article in the New York Times. See Kevin, MD or The Happy Hospitalist or Pursuing Holiness.

There are people who do great things with their lives, on par with any healing effort. But a trial lawyer and a mainstream journalist cannot claim their importance to society as such. And the fact people exist who think such shows that, for all the respect it is granted, there may still not be quite enough for exactly what physicians do.

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Monday, August 30th 2010

Service

The scripture yesterday in service was Matthew 25:31-46,

31 “When the Son of Man comes in his glory, and all the angels with him, he will sit on his throne in heavenly glory. 32 All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats. 33He will put the sheep on his right and the goats on his left.

34 “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’

37 “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? 38 When did we see you a stranger and invite you in, or needing clothes and clothe you? 39 When did we see you sick or in prison and go to visit you?’

40 “The King will reply, ‘I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.’

41″Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels. 42 For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, 43 I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me.’

44 “They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’

45 “He will reply, ‘I tell you the truth, whatever you did not do for one of the least of these, you did not do for me.’

46 “Then they will go away to eternal punishment, but the righteous to eternal life.”

It was important for me to hear. Not the message of judgment necessarily, but the reminder of our obligation to serve.

Empathy is such an important part of medicine. It is favored in the medical school application process. And yet the decline in it as students and residents progress through training is well documented.

In part there’s a sense of inevitability with such. Familiarity weighs on such. Everything from callousing oneself to suffering to feelings that there is a lack of gratitude for your efforts to being tired to blaming patients for their illnesses. It all wears away the idealism and dedication to service that I think most medical students sincerely enter the profession with.

I’m guilty of it as most. And so it was good to be at church on Sunday.

I’m incredibly blessed. Not least because I am in a position to serve everyday. And I hate losing sight of that. I hate sitting in the call room at 2 am and getting a flood of pages from the ER. Those phone calls are a medical record number and some demographics and my annoyance at having more heaped onto my plate to do that night. All because some guy or gal got into their car after having too much to drink or fell off a bar stool or got into a fist fight.

There’s nothing to those judgments and my annoyance. These are people in the end who need my help. However they got to my care, here they are and I have the potential to do them great service and maybe affect their life for the better.

I want service to be central to me being a doctor. This isn’t just a job. These aren’t just hoops I have to jump through to complete training. These aren’t just operations.

These are chances to change lives; to serve.

Now just to take a deep breath late into my call nights and remember such.

Sunday, August 29th 2010

Harvey Cushing’s Collection

If a single characteristic makes a good surgeon, or physician in general, I think it is meticulousness. An astute observer, who pays careful attention to the details of a patient’s symptoms, to an operation, to a diagnosis.

Such might be the best short description of Harvey Cushing. His meticulousness extended to the documentation of the care he provided. And his collection at Yale University. The Cushing Center has been recently endowed and set up, displaying Cushing’s incredible collection of gross specimens, anatomical drawings and medical records.

In June 2010, after a colossal effort to clean and organize the material — 500 of 650 jars have been restored — the brains found their final resting place behind glass cases around the perimeter of the Cushing Center, a room designed solely for them.

These chunks of brains floating in formaldehyde bring to life a dramatic chapter in American medical history. They exemplify the rise of neurosurgery and the evolution of 20th-century American medicine — from a slipshod trial-and-error trade to a prominent, highly organized profession.

These patients had operations during the early days of brain surgery, when doctors had no imaging tools to locate a tumor or proper lighting to illuminate the surgical field; when anesthesia was rudimentary and sometimes not used at all; when antibiotics did not exist to fend off potential infections. Some patients survived the procedure — more often if Dr. Cushing was by their side.

Dr. Cushing was an incredible figure. Few specialties within medicine can so articulatly draw their origins to a single, or group of figures, as neurosurgery can to Harvey Cushing. Michael Bliss’ Harvey Cushing has become a kind’ve definitive biography and well worth the read if you have any interest in the history of medicine. And a visit to the Cushing Center is probably well worth the trip.

Wednesday, August 25th 2010

God Complex

I just wrote a lengthy piece on, essentially, why I deserve to be paid more. Despite that, I swear my head isn’t getting big.

God forbid something happens and I never attain “neurosurgeon status,” say I can’t pass my boards or something, and all of this in hindsight looks like bluster. The point is, no matter what I was aspiring to I think my arguments for the pay gap stand and have little to do with what ego I have.

Tuesday, August 24th 2010

Contextual Error

er·ror
   /ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.

A mistake. That’s how I think of an error.

Here’s how we’re to think of contextual errors apparently,

A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.

I like the idea; I think it raises important considerations.

I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.

Here is how a Huffington Post blog summarized the study from the Annals,

He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)

In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”

A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.

Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.

I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,

That error rate is unacceptable.

Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.

Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.

Monday, August 23rd 2010

The Future of the Pay Gap

The primary care-specialist pay gap is a popular target for those eager for reform. The gap is hailed independently as an example of and a cause of the lack of focus on primary care and prevention in the United States.

There is no doubt that the United States treats primary care, preventative care and triage much differently than most of the rest of the developed world. The distribution of primary care to specialists, especially procedure based specialists, favors the specialists much more here than in any other health care system, at least that I’m familiar with.

But I’ve expressed serious doubts about how payment reform might reshape the distribution of primary care versus specialists considering the per capita primary care population has grown just as fast that of the specialist, if for no other reason than the ever increasing influx of foreign medical graduates. FMGs who have picked up whatever slack was left by U.S. doctor’s perceived abandonment of primary care. We haven’t lost ground on primary care, in terms of the numbers, as the inequality between the earnings of the general practitioner and the specialist have grown.

My point, articulated better elsewhere on this blog, is that there is no doubt that a redistribution of physicians towards primary care would benefit population health in this country but revolutionary payment reform is unlikely to achieve that redistribution alone.

And amongst the editorials and blog posts that focus on leveling the pay scale, sometimes, the very reasons originally articulated for paying more for a CABG as compared to an office visit are ignored.

And so I want to make the argument for why the orthopaedist, the cardiologist, the neurosurgeon deserves to earn more, and considerably more, than the primary care physician. And to make the argument that maybe we’re not so far off the mark with out current reimbursement structure.

I would lay out the argument for the specialist’s pay like this: the training is longer and more difficult, there is a disparity in early earnings and the assumed risk is something much more.

I’m going into a specialty with better earning potential than just about anything else in medicine. I’m also perhaps more intimately aware of differences in training amongst the specialties than most. I’m currently a neurosurgical resident, previously I started a general surgery residency, I watched my mother go through a pediatrics residency and a critical care fellowship as a single parent, and I’ve watched my fiancee through her internal medicine training at two different programs. Not bad breadth and more familiar and substantial than just observation of the day to day doings of various residents, in various specialties that anyone at a teaching hospital sees. Enough to speak on I feel.

My residency training is as long as it gets. The seven years I will put in are more than double what a family medicine resident will. More importantly, and controversially, I would argue that it’s more difficult as well. Even in the age of work hour restrictions, I would argue wholeheartedly that each 80 hour work week is not created equally.

Now to be fair, there is much intraspecialty variation. I’m sure if I was training somewhere else my work load would be something different. Even so, I am daring to argue that on the average a surgical subspecialists training will be more work, hour for hour, than a general practitioners. Sometimes substantially more.

This year, through 2 months, is poised to be exceptionally more work than my time in general surgery and, I will say, at my own peril with my family, exceptionally more work than what I’ve seen of medicine or pediatrics training. And I face seven years of such.

Granted, there are some reprieves in terms of the rotations (bless you neurology) but I would argue, as a percentage of my training, those “good” months are less than what is generally found in primary care training.

Specialists are poised to do, in my case, more than twice the years of training of primary care physicians and those years promise to be more difficult; even if it all adds up to 80 every week.

And, ignoring the questions of variability and reliability that surround physician income surveys, the median income in my specialty is somewhere between 2-3 times that of a family medicine physician. That doesn’t seem too unreasonable to me.

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Monday, August 16th 2010

Yet, Yet More HIV as Assault

The trial of Nadja Benaissa has begun. She is a German based pop-singer who is accused of having unprotected sex with multiple partners while knowing she was HIV+ and not disclosing that fact. At least one partner claims to have been infected by her.

I’ve commented on this ‘trend’ before, of criminalizing risky behavior. Despite my earlier post on the issue, I’m pretty adamant that this shouldn’t be a criminal matter. It’s not that I’m concerned with the shadowing consequences such a trial and potential verdict will have on those who are HIV+, it is merely that there is shared responsibility here enough. Unless the trial brings to light some form of actual deceit, for instance if she lied about her HIV status, then I’m not sure unprotected sex with a person of unknown HIV status in the modern risk environment doesn’t exculpate the accuse somewhat.

But there should be penalties and if not in a criminal court then in civil opportunities for those she’s put at risk. I guess we’ll see just how aggressive this German court wants to be over the coming weeks.

Sunday, August 15th 2010

The Problem for Psychiatry

Psychiatry has always had an image problem. And it isn’t just the stigma of mental illness or jackass Tom Cruise acting crazy and not making sense.

Having to draw the line of what qualifies as pathology is an issue for psychiatrists as it is for no other physicians. Diabetes is not “normal,” a brain tumor is not “normal,” coronary artery disease is not “normal.” Beyond that they all have comparatively well vetted treatments for things like improved long term survival and decreased major morbidity.

But beyond the psychotic disorders psychiatry has no such certainty. What qualifies as “normal” amongst our thoughts and emotions and behaviors is something not so cut and dry. Nor are the treatments particularly well proven when compared to much of what the rest of medicine might called evidence based.

True, other specialties have their share of poorly defined diseases whose pathologicization has been tied at times to the cost to treat. Anecdotally I can think of restless leg syndrome. But the rest of medicine doesn’t have to hold a vote on what to call “normal” and what to call pathology. Consider a new change to the next edition of the Diagnostic and Statistical Manual of Mental Disorders,

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.

This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have.

It makes pscyhiatry, fairly I would argue, prone to questions of the validity of some of the places it dares to tread. Can psychiatry ever aspire to be a science as say, nephrology or oncology?

Depression is a good example of the problem this makes. A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure. Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease? Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection? Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning? If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them. Peter Kramer, in “Against Depression” (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously. It was the depression talking, she told him, not her.

The diagnosis and treatment of non-psychotic psychiatric disorders has sky rocketed since the 1980s. Whether that reflects legitimate outreach or the unnecessary medicalization of the “normal” or some combination of both needs to be seriously looked at by psychiatry. To be fair my experience with psychiatry is limited to my time as a medical student and I’m hardly the first or the most prominent or the last to question the validity of some mental health diagnoses. But the unique position of psychiatry as a medical specialty necessitates that organized psychiatry address questions and concerns about the medicalization of the “normal” with a more social campaign and with more self awareness about just what the future of psychiatry is.

Sunday, August 15th 2010

Final Fantasy Opera

I thought I’d start my return to posting with something completely off topic and geeky.

I am a huge fan of Nobuo Uemtasu, a Japanese composer who has turned compositions for video games into an art form. Time magazine named him an innovator for the coming century several years ago and his work on the Final Fantasy series has spawned a number of concert tours. Above is a group of professional performers and the Royal Stockholm Symphony Orchestra performing an act for an opera which Uematsu wrote for an early Final Fantasy game.