Status: Post-Step 1

During a lesson in my third year of medical school in Italy a professor told us “as doctors, you won’t be able to have hobbies, you will have to study all the time.” I remember how I marked him off as an exaggerating Italian who thought too highly of himself and his profession. Recently however, I came to realize that perhaps he wasn’t the only one in the medical profession to share this opinion.

Since my plan is to practice medicine in the U.S, I had to take the USMLE step 1 exam just two days ago. I studied for four whole months. Towards the date of the exam I stopped cooking food for myself because I was too stressed out. I reduced my runs and gym sessions to a minimum, completely changed my schedule from yoga at 6:00 am to solving online questions at 1:00 am and stopped attending some excellent lectures at Yale University. So yes, now I know that collagen is composed mainly of proline and glycine, and that the symptoms of Kartagener’s syndrome include situs inversus, but in the process of memorizing those soon-to-be-forgotten facts I missed my girlfriend’s 30^th birthday. I couldn’t be with my brother (and best friend) who was having a nervous breakdown after breaking up with his fiancee. Even now, after the exam, I can’t relax and enjoy life because I worry that I failed and probably ruined any opportunity for a future career in the states.

It seems that, worldwide, the medical profession is considered to be, and even worse- expected to be, the most noble and tough profession. If you are a medical student, whether in Taiwan, USA, Italy or Israel, you are expected to be smart, serious, hard working and always always stressed out and overwhelmed with classes and clinical work. Why is that? Why, if studying medicine is like drinking out of a fire hose, are medical students expected to work all the time, be always busy and memorize lists upon lists of differentials by the right order of frequency?

Lately, there are increasing complaints regarding the inhumanity of physicians, their lack of sympathy and compassion, but can one really blame them? The medical student is expected to spend hundreds of hours studying diseases he will never encounter, so he remains with very few hours to read a simple book, relax and just enjoy life for a little while. He is trained to be efficient, rational, and is measured mainly according to his dry textbook-knowledge, but no one teaches him how to be a better human being, a happier one.

It seems that only when a medical student finishes his residency, he allows himself to stop and think about himself and his life (maybe). What if it’s not good enough for me? What if I don’t want to suspend my life and the life of my future family just so I can practice medicine? What if I am approaching the limit of the extent to which I am ready to sacrifice everything else in my life? Does that mean I shouldn’t be a doctor? Does that mean I could never be a good doctor? I don’t know, and I don’t have the time to think about it - neurology begins in three weeks…

Author: Zohar Lederman
zoharlederman@gmail.com

Improving the readability of scientific articles

In the Dec. 28 issue of JAMA Robert Brook MD, ScD (1) points out that the language in which scientific articles are written lack the passion and emotion that often are contained in the personal essay sections which lack he argues decreases their readability and their capacity to engage physicians’ interest.
He offers as two good examples A Piece of My Mind which appears in JAMA and On Being a Doctor which appears in the Annals of Internal Medicine.
Probably many physicians, especially those who are not directly involved in research or teaching would agree with him. Scientific prose is dry and convoluted. Although as a resident I would read the scientific articles without too much difficulty in understanding them, my ability to do so over the years and my interest have unceasingly been on the decline.
He offers as a remedy the use of personal language that would add an emotional factor to the articles and also mentioned the addition of “cartoons, pictures, or emotional images”.
It is hard to say whether doing so would engage more readers. Certainly it would at least catch their eyes but the long term effects only time would tell. And for most new science that is being, there probably is little room for the kind of personal language he desires.
But the readability of scientific articles for the average physician could be improved if authors used more simple words and used shorter sentences and wrote paragraphs that were coherent and focused. Scientific writing by its nature is complicated but it doesn’t have to be pedantic and convoluted.
Readability and understandability can be achieved perhaps more easily in scientific article by following these simple suggestions than by introducing personal and emotional language, cartoons, or pictures.

1. Brook RH. A physician=emotion+passion+ science. JAMA. 2010;304(22):2528-2529.

Will large medical groups kill off small medical practices?

In the Dec. 22/23 JAMA Arnold Relman MD (1) proposes that physician-managed groups sharing global payments to hospitals may offer the best prospects for controlling costs. Theoretically, this makes sense at least from a financial point of view. But there are other things to consider’

Generally speaking whether doctors will work in large independent multispecialty groups or in hospital owned groups, something will have been lost from the practice of medicine. When physicians join large groups the doctor-patient relationship inevitably changes as does the doctor-doctor relationship. Why? Because large groups constantly have to battle the ever increasing costs of new technology, updating computers, and increased liability costs to name just a few. And it will be an exceptional group of individuals who can work together and not fight over issues of compensation or resent who gets what piece of the global payment pie.

Primary care doctors in particular still are unhappy over what they consider to be gross underpayment for their services and a relentless increase of the drudgery work that is heaped upon them. Although the so-called medical home is supposed to correct some of the deficiencies that make primary care the most undesirable of medical careers, most primary care physicians believe that their workload will increase greatly, and any increase in their compensation will quickly go to pay for ancillary office help in the form of midlevel providers, office staff, and electronic record keeping. Most suffer in silence and grimly accept the dilemma they have been handed.

Additionally, doctors who work in large groups will find that their freedom to speak out on abuses within the system is seriously curtailed as internal pressures to control costs become greater. If one broaches this subject with doctors employed by hospitals or large medical groups it is apparent that working in the financial confines of a large organization of necessity bring with it a restriction of personal freedom and a silencing of physicians’ voices.

It is commonly said that small businesses are the backbone of the economy. I would add that small independent medical practices are the backbone of medicine. It is in them that the soul of medicine will be kept alive and in them that the principles of medicine will find their greatest protection against the financial and political forces aligned against them. Everything must be done to protect them and assure that they prevail.

1. Relman AS. Could physicians take the lead in health reform? JAMA.2010; 304(24):2740-2741.

Private organizations' Intrusion into medical practice

In the December 22/29 issue of JAMA, Sessions and Detsky (1) made a very good point by emphasizing that though the U.S. has fought off government intervention in health care more than other countries, private groups have assumed powers and are acting more like government bodies than free market agents.They warn that it is just as important to keep on eye on private agencies as it is government ones since both can overly influence the practice of medicine.
But, besides actual medical care, there are other ways in which private organizations negatively impact the ways doctors practice and the way they interact with patients.
One is the way in which the various medical boards cause rivalries caused among physicians. There are 24 medical boards and over a hundred subspecialties. Each fights fiercely to protect its fiefdom. This prevents physicians from political unity and is one of the chief reasons why outside forces have so successfully exploited and controlled physicians.
Another area where private agencies have exploited physicians is in the area of continuing medical education (CME). CME has become an independent and profit-oriented business that exerts an inordinate influence over doctors’ lives. CME has become expensive and time-consuming and is often is wrongly touted as a proxy for competence. This is perhaps best exemplified by the American Board of Medical Specialties (ABMS) recertification process. The methods and legitimacy of the ABMS have increasingly come under scrutiny by physicians. Many of them have no confidence in its testing philosophy which they consider incomplete and impractical. Worse, some look upon it as an exploitive organization, undeserving of its position as high arbiter of physician competence; and serving more its private goals for economic gain and control over physicians than anything else.
Thus, the authors were correct to point out that it is illusory to believe that some private organizations are less controlling and less self-serving than government.
Someone said that eternal vigilance is the price of freedom. I would add that vigilance needs participation. And it is through physicians’ active participation in their state medical societies whose collective strength culminates in the American Medical Association that their freedoms and health reform have the strongest advocates against control and exploitation.


1. Sessions SY, Detsky AS. The “shadow government” in health care. JAMA. 2010; 304:2742-2743.

Ed Volpintesta

Nurses and Primary Care

December 15, 2010
JAMA

Bridget M. Kuehn (1) mentions the Institute of Medicine’s (IOM) espousal of allowing nurses to play a more independent role in health care delivery.

In primary care, which is the more hotly contested area where nurses’ roles are being introduced, the use of nurses makes sense. Over the past few decades the role of the primary care physician has taken on more the role of health care coordinator. The immeasurable amount of administrative work that is required of primary care doctors, whether for better or worse has changed their roles greatly. Much of the primary care work that physicians do can be safely done by properly trained nurses.

It might be said that in today’s world many primary care doctors are “overtrained” for what the real world demands of them. For example the most of them have little use for the organic chemistry, physics, and calculus they labored through in medical school.

The Kreb’s Citric Acid Cycle, as elegant as it may have been in biochemistry class is useless when caring for the elderly patients with hypertension who are also plagued by loneliness and concerns for who will care for them if they become seriously ill.

I disagree with those who say that doctors should maintain a supervisory role and care for the sickest patients, leaving the “routine” illnesses to the nurses.

As a primary care doctor I use the time spent treating “routine” illnesses to cement my relationship with my patients. It gives me a chance to get to know them better and earn their trust. It is the part of my day that is fun and relaxing. If all I did was treat “serious” illness, I would be less a general practitioner.

1.Kuehn BM. IOM:Boost nurses’ role in health care. JAMA.2010; 304(21):2345-2346.

training the future primary care workforce

December 14, 2010
JAMA

In her article about training primary care doctors for the future Rebecca Voelker(1) mentions how limiting primary care doctors’ training to the hospital experience does not prepare them adequately for the real world they will face when they graduate. The article points out how new methods are needed, more practical ones that take place in ambulatory venues.

It is interesting that when Abraham Flexner one hundred years ago published his famous Report, several doctors, most notably Sir William Osler disagreed with his ideas. While Osler wanted a two-tiered system, one of which would train research doctors in institutes and another which would train practical doctors in hospitals by doctors in private practice, Flexner wanted full-time clinical professors and wanted all medical education to take place in a university-connected medical school and hospital. Because he had the powerful backing of the Carnegie Foundation for the Advancement of Learning and the Rockefeller Foundation behind him, Flexner easily dispelled Osler’s opposition and the future of medical education has ever since borne the stamp of Flexner’s ideals.

Although the curricular changes that Flexner instituted helped advance medical science immensely, the downside was that too little emphasis was placed on the training of primary care doctors.
It is good that medical educators are taking a second look at the direction of medical educations and correcting some of the unintended consequences of Flexner’s ideas.

The words of Michael Barr, MD, MBA and senior vice president of the ACP sum up the current crisis in medical education concisely. He said “The current education system doesn’t value the kind of training we’re talking about”.

1. Voelker R. Medical education meets health reform: New models are needed for patient-centered care.JAMA. 2010;304(21):2349.

Diagnosing diagnostic errors

December 14, 2010
Amednews.com

To the Editor,

Re “Diagnostic errors: Why they happen” (by Kevin B.O’Reilly, posted Dec. 6,2010): The author mentions that the majority of diagnostic errors are not caused because of lack of knowledge but because of other factors such as poor communication, over-confidence, and ignoring new evidence.
Most experienced doctors would agree.
But the author omitted to mention that having to sort through the numerous tests and scans that doctors order strains their powers of concentration and their ability to synthesize data. Sometimes too much information makes diagnoses murky and retards their treatment. Arguably, the pressure by insurers to move patients out of the hospital sooner drives doctors to order an excessive numbers of tests.
And for medical residents, particularly those in primary care, the pressure to move patients out of the hospital quickly, may give a too-narrow opinion of the realities which they will face in the real world. Indeed, for them the hospital may be losing its effectiveness as a teaching institution. Perhaps they would be better trained in community health centers.
Another cause of diagnostic errors is the “incidentaloma” that frequently shows up on CAT scans and other imaging studies. These gremlins obfuscate more than they clarify and often lead to unnecessary tests.
Finally, not being able to schedule patients for outpatient studies and consultations quickly also can lead to diagnostic error, or at least diagnostic tardiness. This is particularly problematical when working up patients who have cancer and need to be staged. Waiting while tests and consultations are scheduled can cause patients and their doctors unnecessary suspense and anxiety.
Perhaps these patients are better served by hospitalizing them to complete their work-ups even though insurers consider it an economic sin?
Clearly, the reasons for diagnostic errors may be more complicated than they seem at first.
Both doctors and their patients would benefit if more thought were given to this subject.

Ed Volpintesta MD

Of dog bites and barks

December 12, 2010
The New York Times


Re “Risks: Hospital Admissions for Dog Bites Are on the Rise” (Vital Signs, Dec. 10): As a primary care doctor I have seen a fair number of patients over the past thirty-five years with dog bites. Most have been minor but a few were large and necessitated suturing. One consulted a psychiatrist to control the anxiety she was left with.

But there are other problems besides bites that some dog owners overlook. It not unusual for walkers out to enjoy the fresh air or joggers out for exercise to be barked at and chased. This disrupts their peace of mind and can be a frightening experience. And parents may shy away from taking small children for a walk because of hostile dogs in the neighborhood.

Dogs can be an important source of comfort and protection for their owners. But owners have a responsibility to ensure that they are not a source of fear or danger to passersby.

Ed Volpintesta MD

doctor-patient rapport

December 12, 2010

USATODAY
Letter to the Editor

Your front page article by Elizabeth Weise (”Doctor-patient rapport lacking” Dec.6) raises an important issue. Effective and sincere communication between doctors and their patients is critical. Although some education in communication may help doctors to achieve a more satisfactory performance, my experience is that the doctors who are especially good at it (whether they are specialists or primary care doctors) owe their ability more to natural inclination more than anything else.

Perhaps medical schools would do well to ensure that the students they accept have, in addition to abilities in the sciences, a natural interest in the humanitarian aspects of medicine as well.

You mentioned the Schwartz Center for Compassionate Care at Massachusetts General Hospital. It should be mentioned further that some hospitals have Schwartz Rounds, named for attorney Kenneth B.Schwartz, a patient who as he underwent treatment for a cancerous condition realized the importance of compassionate communication with his caregivers. Schwartz Rounds provide doctors with an opportunity to discuss not only the benefits of effective communication, but some of its challenges as well. Additionally they give doctors the opportunity to share and look for solutions to the stresses and doubts they frequently undergo, watching a patient slowly slip away with a terminal illness.

Ed Volpintesta MD

Call Me A Luddite

I have a very good friend, a fellow physician, who right in the middle of a medical meeting recently called me a “Luddite”.
The origin of the word is interesting. There are conflicting opinions as to whether the person from which the name is taken ever actually existed. According to English folklore in the early 1800s a man named Ned Ludd believed that labor-saving equipment diminished employment opportunities for textile workers. To protest this encroachment of technology on his ability to make a living he destroyed a knitting loom.
Today the term is used to describe anyone who is opposed to technology in general.
I am not opposed to all technology. After all, I am writing this essay on a computer and several years ago when my appendix burst, modern surgical technique (I had a great surgeon) and new antibiotics saved my life. So I am okay with technology.
So why did my good friend call me a Luddite? As many patients already know, medicine has become so complicated that the amount of paper work that accumulates is overwhelming. When patients go to their doctors, they are used to seeing them strumming the pages of their charts and grumbling as they look for a blood test or an X-ray. I do it often.
So computer experts designed programs called electronic health records, called EHR for short. The idea is to put all of a patient’s records on the computer so they can be retrieved easily and even sent to other doctors or to hospitals. Of course this means that all the information has to be typed in first.
The nice thing is that the notes are easily readable. I confess that sometimes I have trouble reading my own notes but no one has suffered so far.
But typing in the notes can be difficult. Not everyone has the same degree of hand-eye coordination. Besides, typing in the notes can cause a temporary disconnect with patients, something that they complain about. It is a well-known fact that the most common criticism that patients have is that their doctors don’t spend enough time talking to them. And it is hard to listen and talk and typewrite at the same time. I have a hard enough time just typing. I think that if I had to type in front of my patients, something important will have been lost from the visit.
It seems that technology should have evolved by now so that doctors can record information by using their voices and not typing. This way, the doctor and patient do not become disconnected. Eye contact will not have been broken and patients will not feel that they have lost their doctors’ attention.
Clearly, the office visit can become easily depersonalized if a doctor’s attention is divided between his patient and his keyboard.
Of course, having patients’ records legible and available is a good idea. And when all the doctors’ offices are connected with each other and with the hospital, transmitting information will be easy and fast.
But after 35 years of practice I have not had major problems with my hand-written notes. Maybe that is because I have only one partner and we both know each others’ patients pretty well enough to respond to most of their needs.
My biggest worry about electronic records is that every patient I see and every one of their diagnoses and treatments will be readily retrievable by insurers. They will see which doctors are following the rules set up by insurers on how to treat patients. And which ones aren’t.
Physicians who adhere to their guidelines will receive bonuses and those who don’t will be penalized. Needless to say, I don’t see too many bonuses coming my way. Electronic health records will become insurers’ ultimate weapon of controlling the treatment that I and other doctors give to our patients.
When physicians are forced to base their judgment on insurance companies’ rules, the risk is great that patients will not receive the care that their doctors believe is best suited for them. He doctor-patient relationship will be reduced to a commercial transaction. Almost, like buying groceries.
Be this as it may I know that the pressure to use electronic records in one form or another will only get greater. But until all of the safeguards are in place that will prevent doctors’ records from being used to control the way patients are treated, I cannot accept the electronic records with open arms.
By the way, in a medical meeting the other day, a colleague admitted that he was a Luddite too. It’s nice knowing that I am not alone.

Ed Volpintesta MD

Increasing the number of primary care residences ignores other factors that need tending to

December 8, 2010
Amednews.com

To the Editor

Re “Primary care work force: Grants target perennial pleas for more residencies” by Carolyne Krupa posted on Dec. 6, 2010:

Increasing the number of primary care residencies should help to expand the primary care workforce. But, there are other ways that should also be considered.

Specifically, if the college and medical school years were shortened by a total of two or three years, competent primary care doctors could be turned out in eight or nine years (depending on individual ability) instead of the customary eleven years.

For residents who desire, a fourth year of residency could be added.

The point is that most primary care doctors have little need to know the intricacies of organic chemistry, physics, and calculus to take care of their patients. They have little use for covalent bonds and molality in taking care of elderly patients whose concerns are often more social and psychological than medical.

It should not be too difficult to design courses that teach primary care doctors the basics of medical science while leaving the more detailed aspects for those interested in pursing research careers. After all their role is to be practicing physicians, not medical scientists.

Finally, perhaps medical students should be give psychological tests to see where their natural aptitudes lie. Some may be more suited for a career in a specialty than in primary care.

Be this all as it may, medical educators need to broaden their ideas on how to increase the primary care workforce.

Simply increasing the number of residencies will not cure primary care’s malaise.

Ed Volpintesta MD

Two Girls in the Fall

Two Girls in the Fall

I was waiting for the bus to take me to the medical school, but not unexpectedly it was taking longer than usual. It was a pleasant autumn morning, however, and I rejoiced in the fresh air. While I was looking for the bus, a young woman of, let's say 48, came swinging along, and she looked so exuberant even at a distance that I waved cheerily. She stopped, took off a glove, we shook hands, greeted each other like friends, she donned her glove and went on her way. I did not know her, but I felt happier.

A few minutes later a younger woman came by, let's say 24 years old. She too was smiling, and I imagined for a moment that smile was for me until I glimpsed the white buds blooming from her ears that told me that her attention roamed far away.. I am sure that she too was happy, but "What care I how fair she be, so she be not fair to me." She went on, in the silent cocoon that young people now enfold themselves, the island that John Donne did not recognize.

So who cares? Who lost? The first woman looked half my age, the second a quarter, but what a difference in the way the two generations react. The older woman met a stranger for just a moment, an old man she could have hurried by, like my young passerby, a comet sufficient to herself. Did anyone lose? Or gain?

As I age into oblivion, I find myself more often chatting up strangers in what I take to be a hope that a friendly word helps to make us all brothers and sisters. Did my greeting to the first woman make any difference? Should I have ignored the second’s earphones? I sound like old TS.’s Prufrock.

But I listen to the sounds of the street and inhale its smells as I gaze avidly around. Wordsworth's "One impulse from a vernal wood can teach you more of man, or moral evil and of good, than all the sages can." may be carrying it too far, but meandering along the New Haven streets I delight to loll in that “free-floating attention” mode that goes where it will.

A while back , James Collins in the New York Times confessed that he rarely remembered the details of what he had read, but a neuroscientist assured him that much is retained in the internal networks of the brain. He found that comforting, and so do I. Once read, any residue that remains has changed me in some way.Those networks must be, I suppose, much like the “clouds” in which, experts tell me, are stored my electronic data and my memories.

Just so, the relaxed mode of the flaneur strolling through the streets, paying little attention to specifics passively taking things in , must refresh the mind. much like dreams are said to do. Can a fuzzy gaze refresh the mind with a benefit absent from the sharper focus on more important issues? I hope so.

At 86 accomplishment past, I am free to wander and wonder, before senility or death takes me away. At the medical school where I worked so long -- and certainly in the general society around us- matters have so speeded up that there is little time for relaxation, time only for what has been scripted. Gossip, exchanging stories and jokes, talking about "great" patients, long ago disappeared from the medical school. How can it be brought back?

Do I suggest that play is important? I would not have thought so 20 years ago. But I am glad now that young woman did not stop to shake my hand or I would not have this pleasant daydream.

More in the life of Ari Goldberg, pseudonym

Another visit to the Cancer Center and another positron emission tomography. My oncologist showed me the scan next to the previous one where there is less lighting up, particularly where there had been bony mets. He reserved final interpretation until the radiologist saw the pictures. The Tarceva is doing its job.

A week later a visit for my monthly Zometa infusion. While waiting to be called, a young couple and a boy sat down a few rows away. The boy, about 10, was the patient. The parents looked like they were in their late twenties or early thirties. I couldn't hear what they were saying, but the pantomime was clear. A kid who would rather be outside playing was soon going to be stuck with needles, and have injections for his pet scan and/or CT. These needles don't bother me- I've given more than I've received in my life-but I'm sure they bother that boy.

I couldn't imagine what these parents were going through. It's one of those things you can't fully understand unless you have been there yourself. They will never be at ease with their boy's illness and never free of worry. I hope he has a treatable leukemia and not a glioblastoma.

When there are so many bad guys in the world, you wonder why he is in a cancer center. He didn't take over a plane and fly it into a building killing people whose only risk was coming to work that day. He didn't blow up a pizza place crowded with children, and he didn't run a financial company that stole life-savings from the unwary. It doesn't seem like a loving and merciful god is in charge.

I've been unable to get him and his parents out of my mind. There must be one sleepless night after another for his parents. If there are other kids in the family, they will have to give up some attention from their parents while they tend to the boy's appointments and the rest of his required program.

Then to my infusion by another great nurse that they have at Smilow. No problems and they even gave me lunch while the IV was running. Home and to bed later, but waking up at 3:00 AM thinking about that kid and his family. It's almost enough to make a grown man cry.

NB: To those who have written to me: These remarks are NOT from Howard Spiro, who just facilitates their presentation.