Health Care Reform: Medicine vs Surgery

Lost within the political debate over healthcare reform, is a battle currently going on within medicine itself. Although most if not all doctors agree that there needs to be significant changes to the health care system, there is significant debate as to what exacty this should entail. Before I get too far ahead of myself, let's go back to the opening salvos...



In response to this statement the American College of Surgeons released the following letter, which goes on to decry the gross exaggeration of what a surgeon makes on a given operation. In addition it states that misinformation regarding healthcare does nothing to further the debate, adn that the surgeon patient relationship could be damaged as a result. Also, interesting is the many surgical subspecialties that signed on to the letter. This was not just the American College of Surgeons (ACS), but it also included everything from the American College of Obstetricians and Gynecologists to most if not all of the surgical specialties (Urology, Orthopedics, ENT etc.).

More recently the American Medical Association (AMA) has come out in support of the current legislation that passed in the house relating to health care reform. In a letter to Speaker Pelosi, the AMA applauded many of the proposed changes that the bill would enact--specifically they stated that the bill would expand coverage, reform the insurance industry, and protect patient-physician decision making.

Not long afterwards the ACS shot back with this letter to the senate, cosigned by 21 other specialty organizations. It rebutted several of the points made by the AMA and focused on several key issues that it had with the bill.

Additionally they reaffirmed the need for Tort reform in this statement:

CHICAGO: The American College of Surgeons applauds Democrats – led by House Majority Leader Steny Hoyer (D-MD) – for recognizing the need for Congress to address medical liability reform as part of the overall health care reform bill currently under consideration. Over the past few weeks, we have been encouraged to have heard Democrats and Republicans across the country talking with constituents at town hall meetings about the need to address this important bipartisan issue.

The current climate in this country is one in which surgeons and other physicians are forced to practice in an environment of defensive medicine, sometimes ordering additional and possibly unnecessary tests in order to avoid lawsuits. Addressing medical liability reform as part of the overall health care reform bill will help to stem the tide of rising health care costs.

The American College of Surgeons urges President Obama to make medical liability reform a more central component of his call for overall health care reform. Further, we urge the leadership of both the House of Representatives and the Senate to include this important issue in the bills that they will take up in the coming weeks.

Here is President Obama speaking to the AMA regarding Tort reform.


Recently, the ACS has released a side by side chart of the House and Senate bills, along with what they view as some of the drawbacks.

The battle lines seem to have been drawn, with the AMA standing with the president and the majority of the Democrats (except Tort reform), while the ACS and most Republicans stand in opposition (although both groups support repealing the Sustainable Growth Rate provision--something opposed be most Republicans and some Democrats). It's interesting to me how this has happened, I wonder if the average surgeon would describe themselves as being right-leaning politically and the average medicine doctor would say they are left-leaning, or whether this is just how the chips fell in this one instance.

Surgery - The Start of Third Year (Part 1)

After two days of ortientation both to the hospital and the surgury rotation in general we were finally able to start getting our hands dirty learning the basics of general surgery. I was both extremely nervous and very excited, nervous that I would make some glaring mistake, nervous that I would ask stupid questions and be thought of as a student not deserving of the trust that was placed in me, nervous that I would not be able handle the long hours associated with the surgical rotation, but most of all just nervous that maybe I was not going to be able to cut it as a clinical medical student. At the same time I was also very...

Excited. Excited that I never again would spend days on end studying for a (mostly worthless) biochemistry test. Elated that I was now going to be working with real patients. Overjoyed that I was going to play some small role on a team that was working to help heal patients. Needless to say it was a time marked by dramatic mood swings.

Before I get too far, I should give a little more background.

The surgical rotation that I am on does mostly common general surgical procedures, for instance gall bladder removals, appendectomies, thyroid and parathyroid surgeries, some melanoma removal and emergent surgical cases.

The service that I am on is specifically a trauma service, so over the course of the next 6 weeks I'll be helping to take care of a lot of patients who have been in a car accident, or fallen and broken bones, or patients that require an emergency appendectomy or other urgent procedure.

I found all this out during the first two days of orientation, but nothing that they tell you during orientation could prepare you for the experiences and emotions that you will feel as you walk into the hospital on your first day of work.

Immediately I met the chief of the service--for the unindoctrinated, the chief of the service is a doctor who is in the final year of their residency, in general surgery this means that they have been out of medical school for 5 years. In my situation the chief resident had been a doctor for 6 years as she had taken a year to do a fellowship in critical care.

Also on the trauma team was a first year resident, aka an intern. At many hospitals, about half of the interns are on a track to become general surgeons while the other half are either in a year-long "preliminary surgery" program or are in a "transition year". For the most part, those in those in the "preliminary surgery" program are either US or international students that didn't match into the surgical specialty they wanted to (ortho, ENT, general surgery, etc). Students in a transition year have already been accepted into other programs, but as part of their training they rotate through different specialties for their first year. For the first month we had a transition year student who was accepted into the Radiation Oncology program, and the second month we had a Preliminary Surgery resident.

I was very fortunate in that I was on a relatively small team for my surgery rotation. In other hospitals, 4 medical students would be assigned to teams of 10 residents. The major difference between our 3 person team and the larger teams seen at other hospitals was the lack of mid-level residents on our team. In other words the 10 person team would have a number of 2nd, 3rd, and 4th year residents sharing the workload. The downside to a small team is that when there are 40 patients on the rounding list for a Saturday you only have the three of you to see them all. The upside is that many times in the OR it was just me, the attending and the chief resident doing a case. Which for me was the most interesting.

Start of a New Chapter

A week ago I started a new chapter in my medical life; 3rd year rotations. It has been a huge adjustment, but a very fulfilling one at the same time. No more speding days on end with my nose buried in a book. From now on the majority of my learning will be hands on.

When I have the time I'm going to be writing about the experiences that I have while on rotations so that I can someday look back and remember what it felt like to be just starting out.

For my first two months I am rotating through surgery (which I first saw as a curse but am now really enjoying) at one of the busiest surgical centers in the country (in terms of # of surgeries at this hospitals three sites).

Drag Me to USMLE Step 1

I'm stuck in a never-ending Step 1 studying, phase of life, I'll post some more once I emerge.

Secrets of Happiness

A Harvard study of which has been running from the 1960s to the present found that there were seven characteristics common to the happiest of the men studied. The characteristics were: mature adaptations (chosing altruism, humor etc in response to difficult situations), education, stable marriage, not smoking, not abusing alcohol, some exercise, and healthy weight.

The complete article can be found here.

Here is an exerpt from the article taken from The Atlantic:

What happened to you?

You grew up in a kind of fairy tale, in a big-city brownstone with 11 rooms and three baths. Your father practiced medicine and made a mint. When you were a college sophomore, you described him as thoughtful, funny, and patient. “Once in awhile his children get his goat,” you wrote, “but he never gets sore without a cause.” Your mother painted and served on prominent boards. You called her “artistic” and civic-minded.

As a child, you played all the sports, were good to your two sisters, and loved church. You and some other boys from Sunday school—it met at your house—used to study the families in your neighborhood, choosing one every year to present with Christmas baskets. When the garbageman’s wife found out you had polio, she cried. But you recovered fully, that was your way. “I could discover no problems of importance,” the study’s social worker concluded after seeing your family. “The atmosphere of the home is one of happiness and harmony.”

At Harvard, you continued to shine. “Perhaps more than any other boy who has been in the Grant Study,” the staff noted about you, “the following participant exemplifies the qualities of a superior personality: stability, intelligence, good judgment, health, high purpose, and ideals.” Basically, they were in a swoon. They described you as especially likely to achieve “both external and internal satisfactions.” And you seemed well on your way. After a stint in the Air Force—“the whole thing was like a game,” you said—you studied for work in a helping profession. “Our lives are like the talents in the parable of the three stewards,” you wrote. “It is something that has been given to us for the time being and we have the opportunity and privilege of doing our best with this precious gift.”

And then what happened? You married, and took a posting overseas. You started smoking and drinking. In 1951—you were 31—you wrote, “I think the most important element that has emerged in my own psychic picture is a fuller realization of my own hostilities. In early years I used to pride myself on not having any. This was probably because they were too deeply buried and I unwilling and afraid to face them.” By your mid-30s, you had basically dropped out of sight. You stopped returning questionnaires. “Please, please … let us hear from you,” Dr. Vaillant wrote you in 1967. You wrote to say you’d come see him in Cambridge, and that you’d return the last survey, but the next thing the study heard of you, you had died of a sudden disease.

Dr. Vaillant tracked down your therapist. You seemed unable to grow up, the therapist said. You had an affair with a girl he considered psychotic. You looked steadily more disheveled. You had come to see your father as overpowering and distant, your mother as overbearing. She made you feel like a black sheep in your illustrious family. Your parents had split up, it turns out.

In your last days, you “could not settle down,” a friend told Dr. Vaillant. You “just sort of wandered,” sometimes offering ad hoc therapy groups, often sitting in peace protests. You broke out spontaneously into Greek and Latin poetry. You lived on a houseboat. You smoked dope. But you still had a beautiful sense of humor. “One of the most perplexing and charming people I have ever met in my life,” your friend said. Your obituary made you sound like a hell of a man—a war hero, a peace activist, a baseball fan.

Don’t!

Here's an interesting article on delayed gratification, something I'm sure most medical and pre-med students are all too aware of:

Dept. of Science: Don’t!: Reporting & Essays: The New Yorker

Valuable Orthopedic Websites

Here are a couple of valuable websites that I've looked at:

Orthopedic basics from the AAOS:
http://orthoinfo.aaos.org/topic.cfm?topic=A00274&return_link=0

A listing of all orthopedic programs in the US:
http://www.orthosurg.net/orthopedic-residency/programs.asp

A site of everything otheropedics, that I haven't used much myself but that other's have recommended:
http://www.orthogate.org/

Questions to Ask While Interviewing for Orthopedic Residencies

A little preparation can go a long way to showing your interest, this was provided by one of the fourth year students:


General Questions
What is the structure of didactic curriculum?
Is there time allotted for electives?
Do the residents have a high operative volume?
How busy is the ER? Level 1 trauma center? What types of trauma?
Do residents attend national conferences? Is it funded?
Where do the graduating residents go?

Questions for Residents
What are the strengths/weaknesses?
Did you ever consider leaving the program?
How many facilities do you cover? How do you like that? A lot of driving? Any required rotations in different cities?
Do fellows take away from learning experience?
What is call schedule like? How are the call rooms? Do you sleep while on call?
Do you have ample time to read?
How is the balance between autonomy and supervision?
How is ancillary staff? Are they helpful and pleasant to work with?
Is there a lot of scut work?
How is your relationship with the staff?
How do the residents get along? Do you hang-out outside of work? Are there any sports teams that you play on?
Do the residents get along with other residents in the hospital?
How do you like the city?
How are the benefits? Parking? Meals paid for?
Do you have moonlighting opportunities?

Questions for Chairman/PD/Attendings
What are your plans for the future?
How do you see the program changing in size or structure over the next five years?
How long have you been here? Do you plan on staying at this program for the next 5 years?
What is the status of the programs accreditation?
How highly do you emphasize resident education?
How do you feel the relationship is between the staff and the residents?
What are the research opportunities like? Is it required? How is it funded?
How are the residents evaluated?
How do the residents perform on OITE? Boards?
What do you look for in a candidate? How many people do you rank?

Some Tips From the 4th Year Students on Getting Into Orthopedics

Some notes from our 4th year panel last night:

1) Ways to get around your school's limits on away rotations
a) Do a “research” month somewhere you want to go
b) Use weeks off to get a feel for the program, just contact the people at the program beforehand

2) Get a blackberry, iPhone or other smartphone. When it comes time for interviews, hospitals will send out an email to 100 students, the first 80 students to schedule an email will be interviewed the rest won’t

3) How do you have a chance to match out west/east etc (a region where you aren't in medical school)?
a) Rotate in the region
b) Better chances if you are from out there
c) “I like the weather” is a bad answer if they ask why you want to come here

4) Be prepared for crazy questions on interviews
a) Tell us a joke
b) Do puzzles while answering questions

7) Letters of recommendation
a) Most places only want to look at ortho letters

8) Step 1 advice
a) Average nationwide is 231 for those who matched
b) People from have matched with a 217 on Step 1…and a 250 on Step 2, can use the Step 2 to make up for a low Step 1
c) Vastly different views on how to prepare, do what’s best for you
One just read = 256
One did all questions = 255
d) Once you get an interview, all the scores go out the window and everyone is on an even playing field

9) Interview trail
a) Rank all programs that you would rather go to than sit around for a year if you don’t match
b) Don’t rank multiple specialties unless you would be happy doing either, there are lot’s of miserable radiologists that really only wanted to do ortho
c) Be ready to answer the question, “What would you do if you didn’t match this year?”

10) Your school's alumni
a) Contact people for free places to stay, i.e. many doctors will put you up for a month in another town for free during your rotations, the school has a directory

Med School Videos From the School of Hard Knocks

...warning, some use of profanity...

Book Review: Hot Lights, Cold Steel

Although I've mentioned this book in prior posts, I thought it only fitting that one of my all time favorite medical books is given a post all to itself. First I'll include a summary, followed by my review and a link to where you can buy it off of Amazon.

Hot Lights, Cold Steel: Life, Death, and Sleepless Nights in a Surgeon's First Years
by Dr. Michael J Collins

"If he didn't feel overwhelmed before the Mayo Clinic senior orthopedic surgery resident lobbed a beeper at him with the nonchalant order, "Cover for me," 29-year-old ex-cabdriver, ex-construction worker, and, at the time, brand-new resident Collins certainly did then. It was his first day on the job, and
instantly he began fielding calls from staff nurses requesting orders for patients he hadn't laid eyes on. If it hadn't been for his innate sense of humor--brilliantly demonstrated in this memoir of his Mayo residency--and a sense of perspective derived from that experience, he might have failed. He didn't, and here he honors those who helped him along the way and those whom he helped. As a man who recognizes that he, too, makes his living with his hands, Collins anguishes over the options available to a carpenter who had severed four fingers. After assisting at a young cancer patient's leg amputation, only to learn later that she had died within months, anyway, he agonizes over what drew him to his profession in the first place and what could possibly keep him on course. "I wanted to be the guy who confronted the arbitrariness of life and strangled the unfairness out of it." Instead, while honing his craft, he learned from a Vietnam vet that the main thing patients deserve is compassion. If Collins' scalpel is as sharp as his pen, his patients are in capable hands, indeed."

Hot Lights, Cold Steele is a firsthand account of what it is like to be an orthopedic resident at one of the busiest and best hospitals in the nation. For the unindoctrinated, the Mayo Clinic is generally thought of as the best program to get into in terms of the training experience for orthopedic residents. I've heard that getting in is so difficult, that medical students who scored below a 240 on the USMLE need not apply because they will not even look at your application (a 240 and above includes only the upper 4% of test takers or so). In other words, aside from being a very interesting story in its own right, it shows what it is like at the best orthopedic training hospital in the country.

Interwoven through Dr. Collins story is the theme of choices. The story opens with a dilema as to whether he should try to save the arm of a boy who nearly had it ripped from his body when it became intangled in a combine, or amputate the arm immediately. The choice to moonlight at another hospital, or get some extra sleep. The choice to go to church with his family, or use that extra time to relax.

At once both lighthearted and introspective, Hot Lights, Cold Steel challenges the reader the reader to put themselves in the shoes of an orthopedic surgeon (which is why I loved it). It tells the story of one of the most loved patients he saw, a patient who all the nurses talked about and kept tabs on once she left the hospital, and you can't help but experience the hurt when he later finds out that she died a few months later.

During the lighter times, I found myself laughing at the similarities to my own life. When he talks about going from one clunker to the next, I'm reminded of my own experiences with cars (I've been getting in the passenger door and climbing over for the past 10 months). When he talks about making choices between medicine and family or medicine and faith, I think of all the similar choices I've had to make.

In summary, this is a book that will make you laugh and make you cry, and I don't think that you have to be a medical student, or a budding orthopedic surgeon to love it.

Discussion on Orthopedics and What it Takes to Get Into an Orthopedic Residency

Here's a video discussion about orthopedics in general and what it takes to get into an orthopedic residency program.

How To Do Well in Your 3rd Year Surgical Clerkship

Here is a form on the internet from Vanderbilt University detailing how students
are scored on their surgical clerkship.

My Lecture May Be Awful, But At Least I Have Travel Pictures To Show

Have you ever noticed that some of the dryest presenters put pictures of all their travels in their presentation. It always seems to be the dermatology people--it's like they want to rub it in your face that they have tons of free time and are making money hand-over-fist.

Advice on Getting An Orthopedic Residency

Here's a bit of advice I got from an Orthopedic Surgeon on what are the important things to consider when trying to get into an orthopedic residency, it's valuable because it speaks to things other than just the typical "get good Step 1 scores, do lots of research etc.":

"I would tell you that scores on tests are important, but that they would a given, that I would expect excellent scores. There is no doubt that a recommendation by a friend known to me would count highly, but a rotation at the program would count the most. That has always been the case. So, if you spend a month at a program and are knowledgeable, tireless, eager, nice but not an obvious brown nose, competent at procedures, first to arrive and the last to leave, can quote articles from JBJS, you will be a shoo-in."

First Year Haiku

Anatomy
Welcome to Med School!
Did you buy your scalpel yet?
Dead bodies are here

Clinical Medicine
Your first real patients
Except they are just actors
They think they're great

Tests
Gauge how good you'll be
Life is multiple choices
Oh wait that's not right

Specialty Choices
Most are rational
Except the bug-eyed, creepy guy
Loves pediatrics

Email Listservs
Some department fights
Are best disseminated
To all four classes

Biochemistry
You won't need this again
Continue the illusion
Undergrad mattered

Physiology
How many times can we
Tell students about GFR
Before they go crazy

Pretending to be Interested in OB/GYN To Get Free Food (or An IUD at an OB/GYN Party)

Sorry about the dearth of posts in the past few months, second year is much more time consuming than first year, especially once you get closer to Step 1 season. (This is going to be a very "rusty" post)

A couple of days ago I received an email saying that there was going to be an OB/GYN interest group meeting and that there would be some free food involved. I was starving, so I decided to see if people interested in OB/GYN were actually human.

I walked down to the conference room where the meeting was being held, and the first thing that I noticed was that there was one of the staff members guarding the door to make sure that nobody came in, grabbed food, and left. Clearly they knew that there wasn't going to be a lot of interest in OB/GYN today.

So I put on my best "I can't wait to deliver babies for the rest of my life" face and confidently walked past the food police to sit down at the conference table, as if I didn't even come for the free food. And it must have worked because all of the other OB/GYNites seemed to accept me as one of their own.

As I began to look around at what kind of people would actually want to go into OB/GYN, I was struck by the fact that they seemed normal, on the outside at least. (I was also struck by the fact that they didn't have any food). Clearly, I was the only second year student at the meeting, but I did my best to act like a first year while deftly avoiding their conversations about the neuroanatomy test that they had coming up.

The food finally arrived (baked potatoes, chili and broccoli--not great but better than going hungry) and I took as many of the chocolate chip cookies that I could reasonably fit on my plate, which didn't seem to bother any of the other 8 obstetrics lovers, their stock was rising.

So what kind of people go to an OB/GYN meeting? One was a mother, the other women couldn't wait to be, and the two guys that were there seemed to be a little to excited to be around this many women (as evidenced by their laughing at anything that was said). Needless to say, the topic of conversation was babies--which I love, but I don't need to spend lunchtime for the rest of my life discussing every bit of infant minutia.

When the doctor finally arrived who was heading up the meeting, everyone quieted down and waited for him to begin. But before I continue, a brief quiz:

Which of the following is a group of OB/GYNs and which is a group of orthopedists?

A)












(don't let their smiles fool you, they're miserable on the inside)

B)











Back to the story, so the OB/GYN doctor talks about his life in medicine, how he came to be doing what he's currently doing etc. There really wasn't anything especially interesting or unique to his story, aside from the fact that he mentioned he worked in rural Arkansas for a few years after finishing his residency, and though I hate to admit it, he actually seemed pretty normal.

Then came the questions, someone asked, "I heard that OB/GYN is awful and getting worse" or something to that effect.

To which he responded that things weren't necessarily getting worse, but that those who had spent a lot of time in practice were noticing that OB/GYN had changed dramatically from what it was when they started as doctors; less individuals, more groups, doctors who were more concerned about lifestyle than just seeing a lot of patients.

Someone else asked a question about malpractice (OB/GYN's have to pay for malpractice insurance 18 years after they're done practicing!), and then a few questions later and it was over.

As I walked out, I was struck by the fact that those interested in OB/GYN are actually quite normal, as long as by normal you mean that they enjoy the thought of putting thousands of dollars towards paying malpractice and talking about children and women's reproductive organs 24/7.