Thanksgiving

So today is the day after thanksgiving. It is a a really welcome break from all the madness that is medical school. I am so happy not to have to wake up at 6am in the morning everyday! Unfortunately, that is all coming to an end on Monday, but at least for the moment there is nothing for me to do or worry about.

So, Courtney and I had a very good holiday, probably as good as it could be considering we are 3,000 miles from our family on the #1 family holiday of the year. I spent the morning completing some surprisingly long computer based training so I can begin working at the VA Hospital next month. Once Courtney and Drac finally roused from their night's slept, Courtney and I went to the Ronald McDonald House to volunteer for the 1st part of the afternoon. We helped cook dinner for the 16 or so families that are staying there this holiday because they have a sick child at the hospital. We were in charge of the mashed potatoes :) We didn't get to meet many of the families, it turns out that the zoo was giving free admission on Thanksgiving so most of the families were taking advantage of the distraction. However, we did get to see some rambunctious kids running around and it felt nice to do something for someone else on the holiday.

After making the dinner, and coming home briefly to decompress, we went out to dinner at a restaurant around the corner called 3 Square Grill. It was absolutely delicious! We had our turkey, of course, but we also had two different stuffings (corn bread and oyster) as well as delicious potatoes, cranberry relish and a wonderful ginger cake for desert. Courtney said she never ate so much in her life! Well, she paid for it later with a tummy ache that is still hanging on today. Oh well, I guess that is the price you have to pay sometimes.

Anyway, hope that your holidays went well. I am steeling myself for the last few weeks of school before holiday break. The new class is brutal. Just had an exam on Wednesday, and the class average was a 75. That is where I was (I seem to always get the class average!) after studying for it for 5 days. Just doesn't seem right, no? Anyway, we have another exam in this class before xmas break and that is it for a while. I have to start keeping a journal again starting next week, so be on the lookout for some more "healthcare themed" blogs coming your way.

Random Thoughts

I just got back from a conference in Vegas. Honestly, I don't think I ever thought I would attend a conference in Vegas, but there I was! Anyway, it was very good. I represented OHSU at an information session and also took part in a pharmfree conference. It was fun and energizing, although I personally have no taste for Vegas. It feels like a soulless place to me.

We have our first test in our new course, Cell Structure and Function, this Wednesday...the day before Thanksgiving. I am not sure how I will handle integrating this week's lectures before the exam, but I guess I have no choice. I am looking forward to the mini-vacation that will follow the exam.

That's all. It is late and I need my rest. All free time is dedicated to studying until Wednesday's test is over (except for brief mind recovery periods, like this one, so I can be more efficient.) I will post something next weekend that is a bit more fleshed out, I promise!

Stem Cells

We are learning about stem cells in class right now. From what I understand, it looks like you could take a person, plop them into a vat of some solvent so that all of their cells melt away, and leave their connective tissue behind. Then, if you just added some of their stem cells you had saved, VIOLA! You have a brand new version of the same person! Perhaps that is a bit of an oversimplification, but that is what it seems like.

Healthcare Reform

Barrack won! Now we will all be able to afford our healthcare right? Maybe not.

Do we all get universal coverage? Not so fast. Beyond the obvious labeling of our government socialist by people who are in opposition, just take a second to think about the ramifications. According to data we saw in class the other day, about 25% (give or take) of your hospital bill is spent on administrative fees, that means this money is going to someone. Medicare has a much lower overhead, somewhere south of 10%. So if 25-10=15, than that 15 has to go somewhere (and not just into some rich CEO's pocket.) That extra 15% is going to support people who work at Blue Cross/Blue Shield, Aetna, etc. It is also going towards keeping the extra administrative staff at the hospital and doctor's office employed. So, the biggest ramification of socializing the system is that it would have the immediate effect of putting a whole bunch of people out of work. That is not such a good idea, especially in the middle of a recession.

One of the other big problems we have is cost. By now, most people have heard that most of medical expenses are spent on critical care during the last two years of life. So, what would the option be? Deny grandma an medical treatment once a doctor deems that she is not worth it? You can just imagine the uproar. But perhaps that is too harsh of an assessment. Maybe grandma doesn't really need to see so many specialists at her age. There was a landmark study done by Dartmouth a couple of years back comparing outcomes at top teaching hospitals in the US. It looked at what they spent on the last two years of a person's life. There were some big differences between Mayo Clinic and Mass General, specifically. They were on the order of hundreds of thousands of dollars per patient. To top it off, the outcomes were no better at Mass General (who spent much more) than at Mayo.

Personally, I feel like I am seeing this in action right now as I work with my urologist out in Oregon. He is very sensitive to the practical considerations of whether it is advisable to treat a patient given their age. If someone is 85 years old and appears with prostate cancer, it is not something he is concerned about. That might sound cold, but the reality is that they are not likely to die from that disease until the are about 105. Would other doctors treat this patient? I am almost positive they would. Should they?

Finally, the last part of this problem that is on my mind is the purpose of the healthcare system in the US. A lecturer we had discussed the "mission statement" of the US healthcare system. He went on to say that if the mission is to generate profit, than we are succeeding marvelously. However, if it is meant to provide for the public health, than it is an utter disaster. I think that this is a discussion that needs to happen. For comparison, we don't have for-profit fire fighters. We used to. If you go to look around olde city in Philadelphia, you will notice that there are some placards on the front of the townhouses. These placards were purchased from local fire companies and, if your house was on fire, they looked for the placard. If there was no placard, they let your house burn down. This is how the healthcare system is working today. If you have a raging inferno, than they will treat you in the Emergency Room, but they might bankrupt you as a result. If you have a slow fire burning, say a cancer, they are not forced to treat you at all. Addressing this mindset is key to reforming healthcare in the US in my opinion.

So basically, there needs to be: a solid plan in place to prevent not send millions of people to unemployment, a serious study of various health systems (both in the US and internationally) to learn how to handle costs, and some hard discussions about idealology and purpose. If these things actually happen, then I will be hopeful.

Sex for Octagenarians

**disclaimer, this is not an actual patient account, but a collage of various experiences with names and specifics changed to protect health information.

As many of you know, I have been spending the past two months working with an urologist here at school. This has been a surprisingly rewarding experience for me, and I am a bit sad that it is coming to an end soon. Most of our cases that come to the office involve urinary tract infections, kidney stones, prostate and bladder cancer, or various "itises" that are only inflammations but are presenting themselves as if they maybe a more serious affair. In addition to these cases, we also get our fair share of erectile dysfunction. Now, it is one thing when the patient presenting with erectile dysfunction in their fifties, however, when they are well into their eighties, it is pretty amazing to me.

There is so much in the news today about therapies, pills and exercise programs that we can do in order to live longer lives. However, when I see a many of these older patients, it becomes crystal clear to me that a longer life is not better than a quality life. After a day of seeing a number of elderly patients in poor health, the urologist I work with asked me, "So, how old do you want to live to be?"

You see, most of the people who show up at the office who are in their eighties are not thinking about having sex with their husbands or wives (or girlfriends/boyfriends, for that matter!) These people are generally concerned with trying to be generally free of pain and discomfort, or are really just trying to stay alive. Some people, when asked about their sex life, haven't had one for years, even though they are still married. In addition, a good percentage of these patients are not as sharp mentally as they used to be, so the physicians are really just trying to patch things together and trying not to make a bad situation worse. Now, to be almost ninety, be of pretty sound mind and body, and to have erectile dysfunction as your chief complaint? That is something that many of us can only hope for.

And that is where the 80-something year old guy comes in, let's call him Mr. Jones. My hat is off to him. Mr. Jones is basically of both sound mind and body (more or less). On top of that, he is still able to maintain an intimate relationship with his spouse (in this case, a re-marriage going on twenty years). What a life! His quote to me? "Sometimes the wife still likes to play around." It is a cute way to say it, but I feel like it was very sweet. Maybe like the x-rated version of the feeling you get when you see the older couple going for a walk and still holding hands.

My answer to the urologist about how long I wanted to live? To live as long, but also as well, as Mr. Jones. That is clearly the way to go.

Take an Acting Class

Ok, so anyone who knows me understands that I always like to shake things up. I don't know if OHSU was really aware of that when they decided to offer me a seat in their incoming medical school class, but here I am! My latest gripe has to do with how we are being taught to interact with patients, get their histories, and show empathy. It is not that I think we are being taught bad or incorrect things, I just feel that the class structure is putting the horse before the cart. And I think that this is problematic.

The latest criticism of mine is centered around a technique we are learning which is called the BATHE technique. BATHE stands for: Background, Affect, Trouble, Handling, and Empathy. This is a simple acronym that we are keeping in our heads to help us elicit a better history from our patients and better get to the root of some of their problems, particularly problems that are presenting themselves physically but have a psychological root (stress, anxiety, depression, etc.) This is a really good thing! If more physicians had the time and capability to implement this strategy, I'm sure that many patients would be helped.

Now, our teachers have of course pointed out that this is a rather simplistic and robotic way to interact with people. If you followed along these steps exactly, you are likely to sound more like a robot than like a physician. And this is what gets to the root of my problem. This "checklist" is, I think, the second step in the conversation, not the first. Maybe it is my theater background rearing its head, but I believe that it would be more helpful to start with an actual workshop on listening. This is a key first step in improvisation acting, which is what we are doing in a sense when we are interacting with our patients.

Now, we did start the semester by talking about the importance of listening to our patients. But, the thing is, we never truly worked on it. We never had an instructor (in this case, I would argue the instructor should be an acting coach, not a doctor) insert us into situations and have us work on listening and reacting appropriately. When you are truly listening, your thinking is different, your being is different, your physical presence is different. To say to yourself that you will listen does not mean that you are. Every half decent actor knows how to listen, but I am not convinced yet that most doctors do, and I believe that most Americans can agree with me on this one.

I feel like our classes are trying to get to this place, but it isn't there yet. We do "play act" with each other, but it does not remotely compare to the intensity of the real thing. If we don't all learn what it truly means to listen to our patients (and to each other) than taking part in something like the BATHE technique will just be window dressing, and the patient will see it for that. Learning these skills are hard, and I think that the time needs to be devoted to these fundamentals. We all could use the practice.

Pharm Free

Next week in National Pharm Free week, and I just found out a few days ago that I will be the coordinator for the activities at OHSU. It is a little crazy, but it looks like we are going to pull it off.

Let me start by saying that "Pharm Free" is a terrible name. It implies that you would like to treat all of your patients without the aid of pharmaceuticals. Obviously, this is not the case (would make being in med school pretty hard, no?) Pharm Free is all about reducing the influence of marketing on the physician/patient relationship in an effort to bring down the costs of pharmaceuticals (and healthcare in general) while also working to restore some of the physician/patient trust that has eroded over the years through the "business-ification" of medicine.

"What is wrong with business and making money?" you might ask. Well, nothing really. However, the relationship between physician and patient is supposed to be about something more, from what I both understand (and am taught weekly in my PCM course) and what I aspire towards. People come to a doctor's office, often in a very vulnerable state. They share with their physician some of the most intimate details of their lives...heck, they are already sharing these details with me and I've only been a medical student for a month and a half! As a result, I feel, and I am constantly being taught that, a physician's role is supposed to be to "Do good" not to "Do well."

In society today, we are constantly exposed to images that go against this basic premise. This serves to undermine this delicate and all important trust. TV reality shows are full of doctors anymore who are seeking both glory and a fat paycheck. The media latches onto stories about irresponsible and sensational doctors (e.g., "Patient sues doctor after he cuts off man's penis!") And our expensive medical bills cause all of us to wonder why some doctors are making over $500k a year, while their patients are filing for bankruptcy. Also, the current role of pharmaceutical companies in patient care is a constant specter hanging over the state of medical care in the US. All of these problems are substantial and eat away at that basic trust that must exist between a doctor and a patient in order for medical care to be effective.

Pharm Free Week, is simple but profound grassroots initiative that addresses one of these problems. We will be working during the week to have medical students sign the Pharm Free Pledge (http://www.amsa.org/prof/pledge.cfm). This simple pledge will plant the seed in the minds of future physicians that it might not be in their patient's best interest to accept that free lunch, golf trip, or conference in the Bahamas, from a Pharma company. I believe that most, average people see these perks for what they are: bribes. That is unfortunate. That eats away at the physician/patient relationship. That helps to reduce the effectiveness of medical care in this country.

In addition to taking the pledge, we will also be handing out stickers so we can "liberate" the drug pens that so many healthcare workers use to do their work. While it might not be like your doctor walking into the examination room with a big "Prozac" sweatshirt and cap on, simply using a pen with that same drug name implies something. The patient needs to know that the doctor is 100% on their side, and not prescribing them a certain drug because they will get a "kick back" as a result.

Anyway, that is enough of me standing on the soapbox for today. Here is the Pharm Free website if any of you out there are interested and want to make a change in your own small, grassroots way (http://www.amsa.org/prof/pharmfree.cfm).