Throwing Money Away and other Medical Topics

(I confess, what with the feasting, shopping, caroling, and wassailing of the holidays I cannot collect my thoughts to write anything coherent longer than a couple of paragraphs. My apologies. -PB)

Taking Leave of our Common Sense

In a previous article I mentioned that politically, health care reform was not a big issue for me and I was instead more concerned about national defense and killing terrorists. I reiterate that from a purely utilitarian point of view, building, equipping, and manning a Carrier Battle Group is a better way to spend our national treasure than attempting to guarantee free health care for all. I know that as physicians we’re supposed to believe in medical care like foxes believe in chickens but there are more important things in life most of the time, for most people, most of whom don’t need that much medical care except on infrequent occasions. It is more the fear of not getting medical care that is driving the current electoral panic rather than any real risk that anbody is going to be left outside the door of the hospital for lack of insurance. While it is true that there is a small subset of the population who have no medical insurance, this doesn’t mean that the majority of them have no access. We act as if access can only be had if somebody else pays the bill but large numbers of the uninsured could afford major medical insurance and their own primary care (which is not expensive) except that they have other priorities. There is nothing preventing their access to medical care except their reluctance to divert money from other, more important discretionary spending.

That and a lack of primary care physicians but that’s not a problem that can be solved by giving everybody free health care. Even the insured have difficulty finding a doctor and waving a magic wand, declaring that the unwashed now have access, and even throwing a bunch of money at the problem is not going to materialize a couple hundred thousand primary care physicians out of nowhere.

The real question is whether somebody who doesn’t care about their health should get free health care courtesy of the public treasury. A pack of cigarettes costs around five bucks in my neck of the woods. That’s 150 bucks a month, to which we can add another couple hundred for booze and other irregular pleasures. With this kind of money changing hands even among the Holy Underserved, it is inexplicable why you or I should be asked to finance their routine health care except through some sort of quasi-extortion where the usual suspects pushing We-Swear-It’s-Not-Socialized-Medicine hold a gun to the patient’s head and threaten us with higher costs down the road if we don’t cough up some money now. Or look at it like a mugging where, to avoid getting hurt, we’re supposed to hand over our wallet without making any trouble.

The key concept is that primary care is not expensive and, under the care of a physician who has the time to think about a patient, it can be extremely effective in keeping chronic conditions stable or at least delaying the inevitable expensive interventions significantly. But only if the patients give a crap about their health which no amount of free health care will do a thing to encourage. In other words, a good predictor of how much or little expensive medical care you will eventually need during your life is the amount you care about your own health. If you care, you will pay for the occasional doctor visit even if you have no insurance and both take your medications (which are hopefully inexpensive generics) as well as take steps to modify your lifestyle. If you don’t care then you will ignore your doctor, decide that personal watercraft are more important than your blood pressure medication, and despite getting all the free primary care in the world you will still end up dying the death of a thousand interventions as you decompose slowly in the medical triangle trade. (Nursing home to Emergency Department to Intensive Care Unit.)

To smoke a pack a day in the face of severe emphysema or to choose booze over your antibiotics is to demonstrate that you don’t give a rat’s ass about your health. If you don’t, why should anybody else except because of the previously mentioned blackmail mentality?

Throwing Money Away

Primary care is dying in this country, largely because the the government which sets both the amount that doctors are reimbursed for their time as well as pattern by which private insurance reimburses, has decided that cognitive skills are less valuable than throwing a lot of procedures at the patient. Most of this is a lack of trust by parsimonious bureaucrats who reflect the general American character trait of preferring action to deliberation. A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.

The motherfucker didn’t even order any tests.

On the other hand if he presents to the Emergency Department and is loaded to the gills with intravenous contrast dye and then assaulted with every possible test and invasive procedure imaginable, the typical patient or his family will settle complacently into their happy zone convinced that now, finally, they are getting their money’s worth. Doesn’t matter that much of what is done is unnecessary or at least could have been replaced with a little bit of sound clinical judgement, nobody’s happy until they see some action.

This is not to say that people don’t want to spend a lot of time with their doctor, just that they don’t feel they should have to pay more than a couple of bucks for the privilege. Thinking is easy, after all. It’s not like the doctor had to do anything. The government has picked up on this philosophy and has subsequently come up with the perfect formula to save money which, as is typical when people who are qualified for nothing else but government come up with a plan, has resulted in large amounts of money being thrown away.

Consider the typical internist or family physician trying to keep the lights on in his practice. The amount that Medicare or Medicaid (and private insurance as they typically take their reimbursement guidance from the government) pays the doctor for his cognitive skills; the traditional history, physical exam, and clinical judgment, is so small in relation to both his expenses and his completely reasonable desire to make as least as much as a decent auto mechanic that he is forced to run a high volume practice. Of course, not every patient requires a long visit and certainly a more complicated patient can be given a little more time but when you are seeing thirty patients a day, you can see that it is impossible to give the truly sick and the multiply co-morbid the time that they need.

The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

The Ticking Time Bomb

Having patients followed on a routine basis by a cadre of specialists is not only wasteful but dangerous. Under the team-based health care delivery philosophy, physicians are supposed to communicate with each other but, as talking to other doctors is generally non-reimbursable time, communication suffers for the same reason every other poorly-reimbursed activity suffers. The danger is that patients who are being followed by a disorganized squad of specialists will receive dangerous interventions and studies seemingly willy-nilly and, most importantly, are placed on long lists of medications, the interactions of which cannot possibly be fathomed except that someone has the time to sit down and spend an expensive half hour doing it. I regularly see patients with one-page medication lists taking three or four medications of the same class as well as medications that seemingly act at cross-purposes, not to mention having the potential for dangerous interactions.

I know perfectly well that many patients require this kind of complexity but after you see enough unexplainable altered mental status, coumadin levels (INR, I mean) through the roof, as well as the effects of everybody’s favorite loaded gun, digoxin, you sometimes wonder if anybody has ever taken the time to verify that yer’ demented granny really needs to be on 20 different pills.

Now, and I’m just thinking out loud here, what cardioprotective effects are we getting by keeping an 89-year-old woman on a beta-blocker, a statin, and an ACE inhibitor that are not completely offset by the possibility of side-effects and dangerous interactions with her other medications? It is this and other questions that need to be addressed and decisively answered by one doctor who has the time, via adequate reimbursement, to do it. The alternative is highly fragmented and slipshod care.

And no, it is not enough to expect the patient to keep track of these things. Some can of course, but it is very common for the multiply comorbid patient to know nothing more about his medications than their colors and shapes or that one is a water pill and another is for his “gouch.” In an ideal world, the only variable would be the compliance of the patient, not the confusion that results from trying to coordinate the care of various specialists.

Happy New Year

Another one has come and gone. One day, as the memory of medical school and residency fades and I have to devote most of my free time to moonlighting at Taco Bell to make ends meet under whatever silly health care reform comes out of the trailer parks, ghettos, universities, and other islands of provinciality and entitlement in America, I may grow tired of this blog. As I am, however, still going strong, I appreciate your taking the time to spend your time reading and I hope I can continue to provide you with a good reason for doing it. As always I appreciate all comments even the ones I have to delete.

Hey, we have rules on this blog. I had to go to a moderated comment format because of a few people with bad manners and I hope this hasn’t been too much of a burden. Not to mention that my spam filter catches about a thousand spam comments a day which leads me to this question: What on earth has Britney Spears done to deserve this kind of attention? Fully half of all the spam comments I receive promise to link me to naked pictures of her in all kinds of situations. I’m just not that interested. In fact, my interest in Paris Hilton, Anna Nichole Smith, and Anglina Jolie, the other members of the internet Gang of Four, is about a 0.001 on the ten-point pain scale.

Throwing Money Away and other Medical Topics

The Brazen Cage and other Medical Thoughts

(I get a lot of questions and comments by email and I thought I’d share some of them with you folks. -PB)

Hey Panda, who are you going to vote for in the 2008 Presidential election?

Good Lord, is it already time for another election? It seems like I have only just recovered from the horrors of the last one although I do remember with great fondness when the Bush National Guard Letter turned out to be an obvious and amateurish forgery which lead to the subsequent collapse of the Kerry campaign’s raison d’etre.

Good times.

Seriously though, I have not really been following the campaign. I will say that Health Care is not that big of an issue with me, at least not in the sense that I burn with a holy fire to insure the uninsured. I know too many of them to really buy into the notion that they have some kind of inalienable right to my labor. I believe in charity so I have no trouble with the idea of providing aid and comfort to the poor but come on now. Except that there is very little incentive to do it, most people, most of the time, can afford most of their medical care if they got their priorities straight. Best Buy, for example, was packed on the day before Christmas, absolutely packed, with people going into debt for useless consumer electronics. A couple of video games, a Wii, an iPod.  Pretty soon we’re talking serious money that people will not, repeat not, even dream of spending for something as useless a visit to the doctor.

Can’t spend money on that shit. Oh no. Everybody knows that medical care just flows effortlessly out of hospitals like water out of a tap.

So like I said, I’m not excited about health care reform as a national issue. Not to mention that giving it away for free, about the only kind of “reform” that is going to be able to run the guantlet of lawyers and other special interests, will do nothing to solve any of the structural problems that make our system so expensive.

My big issue is national defense and fighting the islamofascists so despite being a social conservative, I’m probably going to back Rudy Giuliani. I’m not looking for perfection, you understand, just someone whose heart is in the right place when it comes to killing terrorists. All the other issues? Just fluff mostly. Or schemes to transfer more of the personal wealth of those who earned it to those who not only haven’t but feel entitled to it. That’s what most of politics in the Western world has come down to unfortunately, although the United States is probably one of the last of the Western Democracies where people will get excited about something other than extending cradle-to-grave social benefits.

I’d certainly rather see my tax money going to build and operate a Carrier Battle Group than to enable somebody to get their asthma medications for free rather than having the cost eat into their cigarette money. Aircraft Carrier? Useful in its own right as well as being the modern equivalent of a cathedral if you can stretch your mind around that concept. Free asthma medication? Useful, of course, but unlike national defense, protecting citizens from the consequences of their bad decisions maybe shouldn’t be federal policy. I favor health care reform to take away free medical care from as many people as can pay for it themselves while continuing to support the people who obviously can’t. At the very minimum most people, most of the time, should be expected to pay for most of their primary care while reserving health insurance for catastrophic events. That’s the kind of market force to intoduce into the system, the only kind that will work which is for people to realize that going to the Emergency Department with a chief complaint of “My butt is sweating” is not a good use for their own money. Funny how nobody cares about money if they’re spending somebody else’s.

So I haven’t exactly caught Ron Paul fever. I like the guy, of couse, and he would be a perfectly acceptable candidate despite his opposition to the war in Iraq, but we need a gunslinger in the White House, not a doctor. Naturally, as I am a Broken Glass, Yellow Dog Republican (I’ll crawl through broken glass to vote for the Republican candidate even if he’s a Yellow Dog) I’ll vote for whomever the Republican Party nominates. I think Vice President Cheney is probably the best man for the job but he’s not running, more’s the pity.

So Panda, do you think it’s worth it…medical school and residency I mean?

God, I hope so. I really hope so. But every now and then I have some doubts, doubts that are probably just the residuum of almost seven years of medical school and residency with nothing to show for it but debt, financial ruin, and the sure knowledge that it is this or nothing. I mean, on an intellectual level I know it is probably going to be all right. I have less than 18 months left of residency and I can just about see the faint glimmer of light at the end of the tunnel which represents a time when we can start chipping away at our massive debt and maybe putting some black on the old family balance sheet. But it is eighteen months in the permanent temporal-financial crisis known as medical training which paradoxically seems like either an eternity or the blink of an eye depending on whether you are dreading either another year of debt or the all too imminent end of your ability to hide behind your training status as an excuse for not knowing something.

It’s a hot and cold, love and hate kind of thing. I like being an Emergency Medicine resident but I hate being a resident. I like having the support and guidance of my attendings but I hate that I have close to 12 years of higher education and am making about what I made as a starting Civil Engineer almost fifteen years ago. I worry about the future but on the other hand, as my wife points out, we are in it (and in it good) with no choice but to make a success out of it because there is no other option now. We have burned every bridge, played-out every strike, staked the farm, mortaged our souls, and robbed (no, mugged) Peter to pay Paul. We are in a cage and only time will tell if the bars are gold or common brass.

And no, I wouldn’t do it again if I knew back then what I know now. Don’t get me wrong, medicine is a pretty good job. For my part, I see a fairly broad range of patients, most of whom I like, with every possible complaint you can think of, from the ridiculously pedestrian to the spine-chillngly grim. We also get plenty of respect as physicians, even as residents, so no complaints there. I like it just fine but there is just so damned much of it. I occasionally get a normal weekend off and it is amazing to think that I once took this kind of thing for granted, not having to do anything and more importantly, not worrying about things. You see, I used to be a Structural Engineer and felt pretty good about it most of the time, especially as I was self-employed and within the confines of the need to produce work for my customers did entirely as I pleased.

As to how it feels to practice medicine past residency I can only profess ignorance and remain mute. But medical training is tyranny, a necessary condition for the most part but still tyranny and while I’m glad I did it and look with optimism to the future, I am, in fact, almost done. If I had known nine years ago when I first got the idea in my head to go to medical school (and believe me it seemed like a crazy idea at the time) what it was going to be like I would have laughed and forgotten about it in short order.

“I’d like to go into Emergency Medicine but I don’t think I’d like all of those patients who aren’t really sick. What do you think?”

Grow up. While I’m sure that there may be some physicians whose entire day is spent managing patients on the knife-edge of disaster, where every decision they make is fraught with peril and only made after the ramifications are weighed in their lightning-fast minds, most of us spend a lot of time with patients who are either not very sick or so chronically sick that you have a little bit of time to make decisions. Everything is not an emergency, in other words, even in the Emergency Department. This is not to say that we don’t see a lot of really sick patients but the idea of having residency training is to make even the incredible so mundane that one day you arrive at the point where, when confronted with a dialysis patient in florid congestive heart failure and respiratory distress from cocaine use, you yawn, take the appropriate steps, and wonder if you have what it takes to handle a really complicated patient.

But apart from the obvious abusers of Emergency Services, you are going to see a lot of colds and vague abdominal pains that turn out, after the five-thousand dollar work-up, to have been nothing. You just have to deal with it. It is the steady parade of minor complaints made possible by that Mac Daddy of unfunded mandates, EMTALA, which keeps the doors open and the lights on for the twenty percent of patients who really have medical emergencies. In other words, if it wasn’t for the minor complaints most Emergency Departments would be sleepy little affairs where most of the employees spent most of their time sitting on their hands except, of course, when something big came in. But the four or five big traumas we see every shift or the ten or so bona fide medical emergencies that need immediate management will not keep the doors open at the current levels of staffing. If we turned away the minor complaints (which we could do in theory under EMTALA) or quickly admitted the ones who were really sick but didn’t need any acute intervention, Emergency Medicine as a specialty would be like pediatrics, that is, it would be filled with people for whom the specialty was a special calling and who did it even though it didn’t pay that well.

I rise in support, therefore, of the minor complaint. Chronic pain? Fibromyalgia? Mild asthma exacerbation? Lips tingled a little after eating shrimp but feeling better now? Upon this sturdy foundation is our specialty built and it is the demand for Emergency Physicians, doctors who can handle everything from a common cold to a traumatic evisceration, that keeps salaries at their current level. Like every other specialty, Emergency Medicine is a volume business and the volume has to come from somewhere.

It also helps to keep in mind that most people are fairly rational and, while you may have the occasional patient who makes you scratch your head and wonder how they manage to breath and wipe their ass at the same time, most people will not sit in the waiting room at two in the morning waiting for several hours to be seen if they weren’t concerned about something. In other words, something about their vague chest pain worried them enough to call the ambulance or drive through the snow to see you. If you keep this in the back of your mind you will avoid the dangerous tempation to minimize your patient’s complaints. I can’t tell you the number of times the chief complaint and initial presentation masked a terrifying condition that made me glad and relieved that I not only hadn’t missed it but may have had a part in saving the patient’s life.

A lot of times the big level one trauma coming in turns out to be nothing. It’s the quiet little lady in the distant corner of the department who may be bleeding internally and require your complete attention.

The Brazen Cage and other Medical Thoughts

The Paper Jungle and other Medical Questions from Real Readers

A reader writes: “Is there a solution to inefficient paperwork? With such great technological advancement, do you foresee any computerized forms of paperwork to make it less inefficient?”

Sure. We have a great electronic record system at one of our departments (the T-System) which makes documentation and order writing a lot easier than previously. The problem is the temptation to document more simply because we can. Not to mention that so long as there are bureaucrats, there will always be new ways to waste time and, unless it is aggresively cut back like creeping kudzu, paperwork will always spread into every available niche.

In other words, despite great technological advances in information technology, there has been no decrease in the amount of paperwork involved in medicine. The converse is true unfortunately as every year seems to find some new asinine JHACO compliance chore sucking up somebody’s otherwise valuable time. Now, to be fair, most of this stuff is what I call “automatic paperwork” meaning that they put a form in front of you, you sign it, and it vanishes into the mouldering realm of medical records where the evidence of your compliance with the hospital’s ass-wiping policy will be entombed forever. It’s not too bad I suppose but it is somewhat annoying and, just as a vigorous mongol warrior may easily ride down a few peasants here and there until you throw enough of them into his path to seriously impede his attack, so too is the modern doctor’s attempt to secure the medical equivalent of the goats and slave girls severely hampered by the reams of innocuous paperwork between him and his objective.

This is not even taking into account the tangled labyrinth of forms, regulations, and coding required to be compensated for your work in a system where nobody wants to pay anybody for anything and most of the bureaucracy is actively engaged in either deflecting invoices and delaying payments or in trying to get somebody else who isn’t involved, the so-called “third party,” to pay.

It all stems from a complete lack of trust at all levels of both medicine and society in general, a lack of trust engendered or at least encouraged by the legal profession against which most paperwork is directed. The hospital doesn’t trust its employees therefore they are required to complete endless forms foreswearing infractions of things that used to be common sense or to give fealty to their overlords in the diversity theocracy. Doctors don’t trust their patients not to sue so every discharge instruction includes the usual reams of boilerplate instructing the patient on differentiating their ass from a hole in the ground. Doctors don’t even trust other doctors and document in an attempt to drag as many people into the stew as possible under the theory that it’s a lot more fun to fry if you do it as a group. The hospital takes the opposite approach and, to minimize their liability, structure their paperwork to identify the one guy who can take the fall for everybody.

Insurance companies and the government don’t trust anybody on general principle.

The two things that have surprised me the most about medicine? Number one is the severity and number of illnesses people can collect and still grimly cling to their mortal coil. Number two is the absolutely astounding volume of paper generated in a hospital, the great bulk of which is completely useless except that the bureaucrats believe it to have talismanic powers against the legal vampires. That and it supplies work to countless people employed in tending it.

But as far as technology simplifying things, we have a long way to go. I still get a kick when patients from out of town or who frequent some other hospital airily dismiss my attempts to garner a past medical history or a medication list with a casual, “Oh, it’s all on the computer.”

Lady, at 3AM your primary care doctor’s electronic medical records might as well be on Neptune for all the good they can do you.

What do you think about the USMLE Step 3?

I took Step 3 today, or rather finished it, because it is a two-day test. I won’t elaborate on the questions so as not to subvert the exam but I will say that it is obviously slanted towards both primary care and, surprisingly enough, Emergency Medicine. It just seems to me that a surgery resident would have to study for it harder than a Family Medicine resident because I have a fairly good idea that most surgery residents rapidly forget all the primary care they ever knew. Sure, they know how to treat a lot of things tbut they may have forgotten how to handle some of the routine cases that are second nature to a Family Medicine intern who has the various preventative medicine guidlelines beaten into his head every day.

Confess. How many of you surgery residents know what to do with a pap smear?

An unusual feature for those of you working your way up the Steps are the interactive cases, nine of them, on the second day of the exam. Definitely do the practice cases provided by the USMLE before taking the real test because the interface, while easy to use, is not intuitive and you need to know how to handle the mechanics of the computer simulation. If you’re going to screw it up its best to do it honestly and not because you clicked the wrong button at the wrong time.

Since the practice cases are available publicly, I don’t think I’m giving anything away by describing how this section of the test, a section that I rather enjoyed, works. The first thing is to relax. You have been doing this since third year and the only difference now is that you don’t actually have a patient in front of you. After being presented with the history, you are free to write orders, ask for physical exam components as needed by system (which are given to you for the asking), and transfer the patient to any area of the simulated medical center in which you are working. A case might begin in the clinic, for example, and if by history and physical exam you realize that your patient is having a heart attack it’s time to transfer them to the Emergency Department where you continue your management. You manage the patient by writing orders asking for labs, studies, and consults. Some cases seemed (seemed) pretty simple and required simple management with some discharge instruction here and there to stop smoking and lose weight but on one I transferred the patient from the clinic to the Emergency Department to the ICU before my time was up.

You have 20 minutes of “real time” per case plus five minutes at the end to finalize orders and provide a diagnosis. The diagnosis, as I understand from the tutorial, is not part of your grade but can serve to clarify what in the hell you were thinking. The case may span more than 20 minutes of “simulation time.” Within the limits of the “real time” (that is, the limit allowed by the test) you can advance the clock in whatever increment you desire. Sometimes you write your orders and then, with nothing to do, you need to advance the clock to a time when the next lab or study results are available. At other times you advance it to a follow-up appointment that may be the next day or later as you would do in a real clinic when presented with a non-emergent case. One of the practice cases, for example, is a guy with Giardia. I sent him home with lomotil pending the results of his giardia antigen assay and then on the follow-up visit, when it was positive, started him on Metronidazole. I guess this was the correct “play” because on advancing the clock the computer told me that he was feeling better and then abruptly ended the case.

That’s the disconcerting thing, however. You can be tooling along writing orders, managing like a big dog, kicking medical ass and taking health care names when the case, with time still on the clock, will suddenly and without warning come to an end. Naturally this can come as a shock because there may be no feedback. Did I cure him? Did I screw it up? Supposedly the case can end early if you handle it well but some hint would be appreciated. On one case I had no idea what was wrong with the patient and after shotgunning a whole bunch of labs and venturing some treatments just kept advancing the clock until I either killed the motherfucker or the computer decided I was an idiot and put me out of my miseries.

Without boring you with the mechanics, the program recognizes a couple thousand common orders for common studies, medications, and interventions. (I wrote an order to “intubate” and, mirabile dictu, a little window popped up saying that the patient was intubated and on the vent with the appropriate settings without any complications.) It is not necessary to know dosages of drugs but only the name (trade or generic) and the route of administration (PO, IM, IV, etc.). You don’t have to get that detailed with the orders so relax and don’t worry about the esoterica like vent settings and specifying everything you need for an Incision and Debridement. You do, however, need to order the stuff that most Emergency Medicine residents take for granted like intravenous access and cardiac monitors. In the computer simulation world, the nurses still dress like porn stars and don’t do a thing until explicitly told to do so by a doctor.

I guess the object is to show that you know how to manage efficiently and economically. Apparently some of the cases seem simple because they are simple and it is not necessary to admit every upper respiratory tract infection to the ICU. I imagine whoever or whatever grades the test takes points off for over-reacting, maybe putting Emergency Medicine residents at a disadvantage because I often found myself looking for the button labled “Indiscriminantly CT Everything.”

Other than that, all I can say is that like Step 1 and Step 2, knowing “what is the next step” is big. That is, knowing the diagnosis is not as important as knowing what to do about it and when. I don’t think anything came out of left field. Even the things I didn’t know I knew that I should have known. In other words, I knew what the question meant and what I was supposed to know even if I couldn’t exactly remember the details. Some of the answers seemed so obvious that I marked them for review and came back to them just to make sure they weren’t trick questions. You find yourself doubting if those massive ST elevations in the anterior leads are really pertinent to the answer and if the test is really asking you for some subtle, psychosocial management strategy.

Many of the questions are on ethics. Again, I will not subvert the test by giving you specific examples but I think we all know that “Taser the Patient” is probably an answer you can eliminate right off the bat. That and advising your Hispanic patient that “she needs to learn English.” I wasn’t so comfortable taking the test that I could afford to screw around so I voted the straight diversity party line like a good boy.

The Paper Jungle and other Medical Questions from Real Readers

Pandorama Randomorama

Sweet, Sweet Chronic Back Pain

An extremely busy shift last night. Not necessarily by volume (because I actually saw relatively few patients) but certainly by acuity. Almost everyone was legitimately sick and required real, honest-to-gosh admissions for bona fide medical complaints. And three of them were admitted to the ICU, two of them intubated. In fact, the admissions were so strong that I was even spared the usual complaints from the admitting physicians, one of whom even said, “Wow, that sounds pretty bad…let me have his nurse so I can give some orders.”

So around eight o’clock as my shift was drawing to a close I was starting to feel a little worn-out when I picked up the next patient.

“What’s this guy here for,” I asked.

“Oh, he’s a regular,” said his nurse as I walked towards his room,”Chronic back pain looking for some narcotics.”

“Thank God.”

A Confession

I don’t want to work in a busy urban trauma center when I get done with residency. Our program gives us pretty good exposure to both this kind of department as well as the smaller, community type and I prefer the latter which has a mix of minor complaints, major medical complaints, some critical patients, and the occasional trauma. Just a personal preference. I can’t believe anyone will have the bad manners to castigate me in the comments section. Not that I don’t like the typical urban indigent and uninsured knife-and-gun-club patient but I can see how I’d like a little variety as well as the occasional uneventful day now and then. I find that three busy 12-hour shifts in a row sort of wear me out.

“Are you a good doctor?”

One of my readers asked me, by email, if I thought I was a good doctor to which I must reply that I believe myself to be an average to slightly-below-average Emergency Medicine resident. I am certainly not even close to the best resident you will encounter just as I am probably not the worst. I try hard, of course, and I have an excellent work ethic but I am not one of those residents who seems to know everything all the time. I try to keep up with my reading but it seems like none of it really sticks and the only way I can really learn something is if I see it a few times or really screw it up; for example how I learned that there is no need to bury the needle when looking for the internal jugular vein to place a central line. (Good lord, if you’re more than an inch or so in you’ve probably missed it.) Part of residency is to be criticised constantly. In good programs, and mine is an excellent program, this criticism is constructive and a legitimate method of teaching. Naturally it wears one out to be continuously under supervision but that’s why we have residency training and why any old Joe Blow just out of medical school is not qualified to be an Emergency Medicine Physician.

So, like I said, I’m working hard at it and graduation and eventual board certification will be an honor that I hope to have earned and for which I hope I am qualified.

With this in mind, I just want to remind attendings everywhere that if, on occasion, your resident asks you a question about a subject that technically he should know (assuming he remembers everything about the lecture you gave three months ago and everything he read in Tintinalli) rolling your eyes and looking at him as if he is worthless scum who will unfortunately soon be polluting the Emergency Medicine pond is not exactly going to encourage him to ask questions in the future.

Which may be your plan and I can certainly understand not wanting to answer a lot of questions.

But when the resident beats a retreat mumbling his heartfelt apologies and promising to “look it up,” please don’t call him back and pimp him on the same subject in front of the nurses and techs. People don’t believe me when I say this but in the Marines, an organization that I am fond of comparing to medical training, we were taught not only to never belittle our subordinates but to never criticise them publically. (Criticise in private, praise in public) If I didn’t know the answer to the question when I asked it I certainly didn’t learn it in the interval between the asking and the pimping and your frustration that I didn’t know it, as well as my rapid transition into the karmic solace of a humble “I don’t know” as I went into full subservience mode did nothing to dredge up information that just wasn’t there.

What can I say? I didn’t know. I do now.

For Fifty Bucks I Want You Naked, Damnit! Naked!

So there’s this guy with a horny parrot. To skip to the punch line and thus spare you the totally superfluous details of the joke, he pays fifty dollars for a female parrot and, after hearing her shrieking, rushes back into the room to find the horny parrot on top of the female pulling out her feathers and squawking, “For fifty bucks I want you naked, damnit! Naked!”

I learned a lesson a few months ago about exposing patients. You all know how it works. The patient is taken to a room for some horrific-sounding complaint and when you see them they are sitting in their bed fully clothed, socks and shoes on, or with maybe just their shirt off under the hospital gown. While I understand the reluctance of patients to disrobe in a curtained alcove in a busy Emergency Department, because a good physical exam is impossible to perform on a fully-clothed patient they need to strip at least to their boxers under the gown. It is particularly difficult, for example, to listen to heart and lung sounds through the kind of winter layering that is common up here in Yankee-land and it seems awkward reaching a stethoscope under somebody’s blouse. Sort of feels like groping.

I had a patient the other day with all the symptoms of Diabetic Ketoacidosis (DKA) and it was down this primose path that I was lead. He kept his shirt and pants on and there was nothing in the clothed physical exam to suggest anything else was amiss. He was a rather large fellow and as he was breathing pretty hard it would have obviously involved a major effort on his part to take off his clothes. When the laboratory studies started coming back my initial suspicions were confirmed and I sort of settled into the DKA autopilot mode, the only unusual thing about the patient being that he was a Type II diabetic (but insulin dependent, you understand) and they aren’t supposed to get DKA, at least not a commonly as Type I diabetics.

After a little while, his white count came back fairly elevated. It wasn’t incredibly elevated so the value wasn’t flagged for immediate attention and I didn’t notice it for an hour or so (not to mention that sometimes the lab is painfully slow). My attending directed me to a disrobed exam whereupon I saw extensive, well developed cellulitis (a skin infection) on both legs from about mid-thigh to just above the cuff of his pants. A couple of abcesses too, just for good measure. Diabetic keotacidosis can be precipitated by infections as well as quite a few other things so now the presentation was entirely clear and we started him on the appropriate antibiotics before calling his doctor for an admission.

“But Panda,” you say, “The patient didn’t tell you about the cellulitis, how could you have been expected to know?”

Well, look. When you weigh close to 500 pounds your daily activities are a little different than most of ours. It’s quite possible that my patient, otherwise a very pleasant man who answered all questions appropriately and cooperated for the exam and our treatments, had not had his pants off in several days. Therefore when I asked him if he had any skin rashes his answer of “no” was entirely truthful.

The point is that you need to get your patients stripped down for all but the most trivial of complaints. Imagine if this fellow had gone to the floor and his cellulitis had not been discovered until, despite clearing all of the markers for DKA, he continued to be dyspneic and hypotensive and somebody more intelligent than me slapped his head and said, “Good Golly, this patient is septic.” The idea is to start antibiotics and your Early Goal Directed Therapy…well…early. Not late.

For ten thousand bucks (or whatever his admission cost the taxpayer), I want him naked, damnit! Naked!

A Quarter of a Million

This blog is two years old and over the last fourteen months of it (when I started counting) I have had over 250,000 unique visits. I get some regular visitors and I have the accidently-dropped-by-after-looking-for-stuffed-panda-bears-on-Google-market absolutely sewn up. Whoever you are, I want to thank you for their continued interest in my humble blog. I hope you continue to read and your comments and criticisms are welcome.

Except, that is, for those of you who comment that my articles are too long. I know your lips get tired reading anything longer than a brief paragraph on your way to naked pictures of Britney Spears but maybe you could read until they cramped, mark the spot, and come back to continue later. This is just not that kind of blog. I think even my most rabid critics will agree that there are few medical blogs with as much content on them as mine.

Pandorama Randomorama

Putting Granny Down and Other Health Care Conundrums

(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)

Bread and Circuses

This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.

The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.

The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.

Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.

It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?

No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.

In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.

The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.

Things Cost What They Cost

I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.

Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.

Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.

He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.

Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.

This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.

It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.

You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.

Throwing Good Money After Bad

I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..

For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.

My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.

Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.

Putting Granny Down and Other Health Care Conundrums

Avoiding the Cringe Factor: Writing the Great Personal Statement For Medical School Admission

(As those of you applying to medical school know, the personal statement on the AMCAS application is, at least by conventional wisdom, one of the most imporant parts of your application. It doesn’t seem fair when you think about it, that all of your effort to get good grades and to position yourself with extracurricular activities can be undone by a few lines of prose, but that’s just how it is. Here are some general rules that might help you get started.-PB)

You Are Not Applying For A Position In Management

Every generation has its peculiar bureaucratic vernacular. In the nineteen-fifties it was the breezy patter of the Madison Avenue ad men. In the sixties it was vacuous leftist duckspeak. Today it is the stilted jargon of the diversity Mafia with which the timid writer protects himself from the one true sin of diversity, that is, to have an original idea. In fact, if you can’t write a decent-sized page without mentioning “diversity,” “inclusiveness,” “open-mindedness,” or any of the other shibboleths of the ossified Pharisees who protect the academic temple from blasphemy, you’re not trying hard enough to write an interesting personal statement.

Even the bureacrats who will read your essay must tire of yet another anthem to diversity, improving access, or your efforts to bridge the gaps between different peoples. It’s like describing dirt to a farmer. They get it. The modern academic bureaucrat eats, sleeps, and breathes diversity. It’s their religion in whose teachings they derive mindless comfort even though if pressed, they’d have a difficult time explaining why diversity is better than conformity.

You are, in fact, gilding the proverbial lily every time you mention your efforts to enhance diversity or “bring diversity to the table.” Everybody says this. It’s sort of a baseline. Nobody (with the exception of your Uncle Panda) is ever critical of diversity so what is your point going to be except that you wasted a couple paragraphs of your finite allocation of words on the literary equivalent of wall-paper? Completely unoriginal and unnecessary.

You Don’t Have Any Original Ideas

Say! Here’s an idea. Volunteer in the inner-city for a couple of months teaching kids how to read and then crow about it in your personal statement. They’ll never see that one coming and I’m sure you will hold your reader in thrall. The fact is that there is nothing new under the sun. Medical school admission is a highly formalized dance not unlike the compulsaries in Olympic pairs skating. Everybody has the same moves and a certain level of technical skill. That you only taught inner-city children how to read to buff up your application goes without saying. You know it and the person reading your personal statement knows it even though it was a good impulse and no harm came of it. Surely there are worse ways to spend your free time than doing some low-level, ineffectual community service. Do not, however, make a mountain out of a molehill or a religious experience out of handing out clean needles to drug addicts. I know people who were sentenced to the same kind of community service and they never talk about it.

Look at it this way: did volunteering amongst the great unwashed in any way change your decision to apply to medical school? Of course not. You were going to apply before you volunteered and nothing you saw or did dissuaded you. Ergo, volunteering is useless as a predictor of fitness for a medical career. I know it, you know it, and the admission committee knows it. With this in mind, rather than bragging about how you “facilitated this” or “enabled that” why not pick one person or event that either interested or affected you and write about it? And the kicker is to only loosly connect it with your life-long, thought-of-nothing-else-since-first-grade dreams of medicine. In other words, describe but do not use the suffering you witnessed as a vehicle for self-aggrandizement.

It is also not necessary to commit to a life of selfless dedication to the underserved. Talk is cheap and even you must know that where pre-meds become outraged at the plight of the poor, residents become outraged at their own plight, working as they do long hours for little pay in the service of the same poor who take them completely for granted, viewing as the poor are wont to do the complicated logistics of health care delivery with the same indifference as they view water or cable television.

You are a Terrible Writer

Admit it, love it, embrace it. Hell, I’m a terrible writer myself. I regularly abandon wonderful ideas for articles because I don’t have the skill to do them justice. I’m not proud of this but at least I recognize my limitations. Sure, I can sometimes bang out a servicable paragraph or two but I have a blog upon which I have been practicing for the last two years. You however, with the exception of a couple of cut-and-past term papers which weren’t even graded critically on style or grammar, have probably never had to string together even a couple of paragraphs of coherent ideas. There is no shame in this but you have to realize that you are not up to the task of creating something original and beautiful. You need to instead strive for servicability. Just say what you want to say and the more stilted phrases, wandering metaphors, and over-blown rhetoric you can eliminate the better (for you and your reader).

If you aren’t much of a writer, start with a simple subject-predicate sentence structure. “I went to Darfur in my senior year to work at a refugee camp” just sounds bettter than, “To actualize my life-long commitement to serving the underserved, something about which I have been passionate since the third grade, I decided to devote my free time working to facilitate the delivery of basic health care to the refugees in Darfur.” Through which sentence would you rather wade? Both sentences say essentially the same thing but the first assumes that the reader can put two and two together while the second doesn’t trust the reader to wipe his own ass, much less recognize your superior altrusim.

Give the reader some credit. Keep your prose simple, your sentences coherent, and he will follow along until the end when everything will be explained. Flight of ideas, flashbacks, and other literary devices are dangerous weapons in the hands of amateurs and you need to leave them alone unless you have some training in their use. Stick to the basics. State a theme, develop it modestly, and end it. You can go back later and embellish the stupid thing if you can’t resist the urge to put lipstick on a pig.

Avoid humor, by the way, unless you can pull it off which you can’t. You are not funny. You say some funny things occasionally, we all do, but that doesn’t make you a comedian. This doesn’t mean that your style needs to be ponderous but, as we mentioned, you don’t actually have a style per se. Humor is a difficult style and you have to work up to it.

Brevity, Sweet, Sweet Brevity

Be merciful to your reader. Unlike my blog which no one is obliged to read, to faithfully discharge his duties the medical school admission officer must read your entire personal statement, potentially all 5300 hundred characters of it. This is a lot of reading especially if the writer is a hack. I have read quite a few personal statements and I sometimes have to make a couple of attempts at them, not only to get clear of the sticky morass of stilted language and ponderous prose but also to appreciate the vastness of the writer’s accomplishments in his short, 24-year-old life. Good Lord. I am regularly amazed that I got into medical school because I have done absolutely nothing in life of any use to anybody. Compared to the typical medical school applicant, my life has been a vast wasteland of watching television, playing frisbee with my dog, and other activities that do nothing but prove my unfitness for a medical career.

Give it a rest. Few of us are interesting enough to fill a paragraph with our accomplishments let alone a whole page unless it were to relate every little thing we ever did in some mad paroxysm of achievement inflation. You can leave some things out. Pick one or two things about which you are justifiably proud and write about them. Once again, give your reader some credit. You are either a bona fide saint or a shameless opportunist but packing your personal statement with a catalogue of everything you did to polish you credientials since high school will neither expose nor conceal this.

You don’t have to use all of your alloted characters either. Use succinct paragraphs (with a decent space between them) and consider making your personal statement short. While I wrote the typical cringe-inducing AMCAS personal statement, when I re-applied for the Emergency Medicine match my ERAS personal statement was two brief paragraphs for a total of about 500 characters. Maybe I didn’t get an interview or two because of it but I still have my self-respect.

Avoiding the Cringe Factor: Writing the Great Personal Statement For Medical School Admission

Complementary and Alternative Medicine Month: Finale (Reposted from 12/6/06)

(No, we’re not in re-runs here at Panda Bear, MD. I was asked to repost this article by a few of you and even though it is in the catagorized archives, I thought I’d just run it again as a finale to CAM month. Enjoy and I swear I will have a new post up tomorrow. -PB)

Keep an Open Mind

So they asked me a lot, when I was interviewing for medical school, what I thought about complementary and alternative medicine particularly the use of traditional practices as adjuncts to Western Medicine.

I’m all for it. There are a lot of traditional practices I’d like to see become a part of modern medicine. Like snake handling. For my money snake handling has everything you’d ever need in an alternative therapy. You’ve got your snakes representing nature, you’ve got your mystical religious overtones, and you’ve got scads of anecdotal evidence and testimonials in prestigious religious journals attesting to it’s efficacy.

For those of you who don’t know, snake handling has flourished in the folkways of the southern United States for more than a hundred years and is a time-honored method of casting out the demons that cause most sickness, at least those that cannot be ascribed to qi or bad karma. I understand that the NIH offers a fellowship that will equip anyone interested for an expedition to the wilds of Louisiana in which strange and magical land they may sit at the feet of ancient masters of this art and learn the secrets of the serpents.

And don’t forget to try Uncle Skeeter’s Gator-Taffy if your expedition passes through Lafayette.

I also would like to see more faith healing employed in the modern clinic. I’ve personally seen the lame walk, the blind see, and the gaseous find relief all from the “laying on of hands” as the technique is described by the learned shaman who practice it. For those of you who are lacking in cultural competence, the faith healer’s art is practiced in tents or, more lately, air-conditioned football ashrams where a large crowd can direct their good karma (or “prayerful thoughts” as it is often roughly translated) towards the patient. The patient, under the power of both suggestion and an Ayurvedic being named “Jaysus,” has his bad chakra forcefully removed, some would say driven, from his body with a precisely placed blow to the forehead.

The Shaman often yells “Come out!” but this is just showmanship, not unlike the way we yell “stat” in the Emergency Department even though we know that we’ll be lucky to get the labs by next Tuesday.

There is some debate whether faith-healing owes it’s effectiveness to the so-called “placebo effect” rather than any demonstrable physiological process but the debate is ridiculous and anybody who challenges this ancient traditional practice is a close-minded bigot. It’s not like they’re sticking needles into people or something lame like that. We’re talking bona-fide healing here, often before a television audience of millions. It would be highly unlikely that something like this could be faked in front of so many highly intelligent television viewers.

I have also heard of another traditional mind-body therapy for psychiatric problems, this one practiced in the deep hearts of our ancient cities. Basically, the patient dials a talismanic number, usually preceded by the mystical “900″ or any other Number of Power and ceremoniously asks to speak with a priestess whose name is usually Yolanda or Mistress Debbie. The priestess then diagnosis all kinds of psychiatric and sexual dysfunctions, often times correctly pointing out that somebody close to you is cheating on somebody else close to you and “he needs to show you love, girlfriend…and you are so not fat…besides, he digs big women.”

Sometimes they throw in the winning lottery numbers.

Anyways, with all of my patients, the “P” in SIG E CAPS is “Psychic Hot-line.” I understand medicaid will reimburse for it. It’s not as if we’re asking them to pay for something ridiculous like a visit to the chiropractor.

Finally, for my money, nothing can compare to the healing powers of a good old-fashioned poultice like the kind my grandma used to make out of chicken droppings and mustard greens. It was the sovereign cure for a variety of ailments from lumbago to dropsy. Through years of experimentation, traditional practitioners have developed a wide spectrum of salves and rubs that are pushing the boundaries of our understanding of medicine. Our so-called “evidence based medicine” has nothing to compare to alternating layers of gumbo clay, sassafras bark, and chicken bile covered with brown paper and tied to the offending limb with common twine. It’s so good it’s almost magical. For fever, pepper is often added as it is a hot spice. For chills, it’s not uncommon to add the musk of a nutria as everybody knows this hardy animal can gnaw it’s way through the ice that forms every fifty years or so on the bayou. Beaver semen will do, I suppose, but there is no good evidence to support its substitution and I wouldn’t have that kind of quackery in my practice.

Besides, there’s no room to stock it as my shelves are crammed with homeopathic remedies.

Complementary and Alternative Medicine Month: Finale (Reposted from 12/6/06)

More Medical School Admission Advice: Addressing the Diversity Puzzle (Real Questions from Real Readers)

(Once again I dig deep into the archives to answer questions about the medical school admissions process-PB)

Dear Panda,

In order to take advantage of affirmative action, I lied about my race. Good move or not?


Plain Vanilla Pre-med

(Eating a Baloney Sandwich, on White Bread, With Mayonaise, somewhere in Minnesota)

Dear Vanilla,

I also lied about my race. I said I was black. At first my interviewers didn’t want to believe me because not only am I actually Greek but my ancestors are Macedonian Greeks, i.e. the Swiss of the Hellenic world.

So we went around and around. I’d give some proof, they’d refute it. I tried busting a rhyme, they cited Vanilla Ice. I railed against “the Man,” they yawned as every white liberal does this. I even tried a few break dance moves but despite my baggy pants, apparently MC Hammer sold out and is now considered a white man.

Finally, I dropped the big one. Let’s just say that they didn’t call him “Alexander the Great” for nothing.

But generally you need to leave this kind of thing alone unless you can produce the goods.


P. Bear, MD

No Moussaka, No Peace

Dear Uncle Panda,

During the admission interview I was trying to be conversational and asked my interviewer how their medical school reconciled their primary care rural setting with their research goals. As they also have a homogenous, rural population, I asked how they increase student’s exposure to diverse patient populations. My point was not to be intense or to show intellectual superiority but to ask about genuine issues that the school faces. I think I threw my interviewer for a loop because he ended the interview shortly thereafter. Were these not appropriate questions?


Trepidatious in Tacoma

Dear Trepidatious,

Sweet smiling baby Jesus. I admit it. I must come from a different planet than a lot of you guys. Who actually thinks like that? Or cares about that kind of crap anyways? Diversity is a totally meaningless concept. I know it has become something of a growth industry and sucks hospital resources from important things like patient care and paying the residents a little more but if there is one thing you are going to learn, despite all of the “Sprit Catches You and You Fall Down,” the diversity seminars, the multi-cultural gestapo, and the linking of hands to sing Kumbayah, efforts to promote diversity only serve to drive a wedge between people, particularly Americans, who should be striving for a little more conformity.

(Ah…Sweet, sweet conformity. What a great society it would be if we all stopped whining about our past and looked to the future. A society where we could put away the emphasis on our differences and strive to live like Americans, embodying as this does our best traits as a people which include enterprise, courage, self-reliance, generosity, and an abhorrence of being perceived by our fellow citizens as a whiner.)

Come on. ‘fess up. If they offer you a spot you’ll still have the freshly opened acceptance envelope in your sweaty hands when you call and say, “Thank you, I will certainly come.” All of that crap you mention above (and it is meaningless, irrelevant crap) won’t matter a bit.

I weep for the youth of today. When I was in my early twenties I did normal things like chase girls, drink too much, and get in minor scrapes here and there. Somebody please tell your Uncle Panda that you kids still know how to do these kinds of things.

Sorrowfully Yours,

P. Bear, MD

Dear Dr. Bear,

I secured an interview at a prestigious Eastern medical school and everything was going fine at the interviews until my interviewer asked me if I had any questions. Now, to be honest, they had done a pretty good job during the tour answering our questions. To be even more honest I really want to attend this school and would accept admission there even if a pre-requisite was having a nest of rabid weasels lighted on fire and packed in my ass. I’m afraid I blurted out the first thing that came to mind which was, “What qualities are important for your graduates to possess?”

Did I blow it?


Depressed in Dallas

Dear Depressed,

Man. Must everyone be a tool all the time. How do you expect them to answer that?

“Gee, buddy, if we can get them to stop yelling racial epithets and molesting the patients by the time they graduate we put ‘em in the ‘win’ column.”

I repeat, it is not necessary to be a tool all the time. It’s all right to make small talk and perfectly acceptable to ask, “So, how’s the nightlife around here?”

I think you blew your shot at that medical school. Sorry.


P. Bear, MD

More Medical School Admission Advice: Addressing the Diversity Puzzle (Real Questions from Real Readers)