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Demystifying Medicine One Month at a Time

Category: medical education (page 2 of 14)

Match Day 2017

Click on the link below to see an essay from NPR on learning from and working with foreign medical graduates.

All in honor of St. Patrick’s Day, which this year is also Match Day — when medical students learn where they will match for residency — the next chapter in their training.

Medical Revolution(s)?

9780465050642This week an essay in the New England Journal of Medicine asks if our collective learning to handle uncertainty should be ‘the next medical revolution.’ It caught my eye because many of the medical educators I follow on social networks were abuzz about it.

Coincidentally, I’m reading a fuller-length exploration of medical uncertainty, a book called “Snowball in a Blizzard,” by Steven Hatch, an infectious diseases doc at UMass.

Both the essay and the book remind us to have humility: though medical technology and scientific knowledge have leapt ahead and continue to hurtle forward, our profession’s abilities to diagnose, treat, or predict future health outcomes with precision remain stubbornly elusive.

The metaphor of the ‘snowball in a blizzard’ comes from the world of radiology–in particular mammograms. That’s what radiologists who read mammograms are looking for on the images they see. It’s challenging and inexact work. Often they miss tumors that are cancerous; to correct for this, it’s natural that radiologists need to be extra cautious and have women with anything even remotely suspicious follow up for more images and possibly biopsies. [With negative biopsies, such mammograms become known as ‘false positives.’]

I agree with the thesis that we should all become more comfortable with uncertainty. But it will be challenging.

As patients, we want our doctors and scientists to be able to give us predictions that are accurate.

  • Is this the right diagnosis?
  • Will this treatment work?
  • How long have I got?

As doctors, we wish we had greater ability to answer these questions.

As ‘consumers,’ we are fed an unending stream of media that tell us what we ‘should’ do, what we ‘need’ to be healthy, and what will make us live longer. Much of it never offers the necessary caveats about the inexactness of the science. This will be an uphill battle.

I was pleased to see a chapter in Hatch’s book devoted to health media, featuring Gary Schwitzer and his website HealthNewsReview.org. Gary has devoted his latter career to debunking medical hype. His site is well worth perusing.

The Evolution of Hospitals

I-love-Lucy-assembly-line-300x223Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really — if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get one ‘bundled’ payment for the whole hospitalization based on the patient’s diagnosis. Average length of stay for hospitalized patients went from thirty days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay — depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

‘Throughput’ became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than four days. (Of course, for mothers with normal births, this is even less — about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now — can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there’s a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

Column Laurel

Good news dept:

2016-Column-Contest-560x469Dear loyal GlassHospital readers–

GlassHospital was recently recognized by the National Society of Newspaper Columnists as a finalist for columnist of the year in the Online, Blog, and Multimedia Category with >100,000 readers. This is for work published on the world’s best health care site, NPR’s Shots blog [to which I attribute such high readership — you loyalists on this site are in much more select company].

I was awarded third place, behind a Reuters columnist who works to bring broader understanding of Islam to a large general readership, and a columnist from The Street who writes frequently to expose scams and complicated investment schemes that over-promise and under-deliver. Given all that’s going on in the news cycles of late, I think this makes perfect cosmic sense.

I do my best to share NPR work on this site to attract you over there, but if you’re interested in the columns for which I won the award, links to them are below.

  1. From August 2015 — Suicide: not a natural cause of death
  2. From April 2015 — How should we educate 21st century doctors?
  3. From September 2015 — For older folks, pruning back prescriptions can bring better health

Thanks for reading!

Berkeley’s Budget Blues

berkeleycampusLisa Aliferis of KQED wrote a nice explainer on the budgetary threat to a niche program that trains California students in both medicine and public health.

Known simply as ‘The Joint Medical Program,’ and founded in 1971, it’s a combined effort between the University of California’s flagship campus in Berkeley, and the prestigious medical school across the bay at the University of California San Francisco.

The program accepts 16 students per year, and half of the graduates over the years reportedly enter primary care fields like Family Medicine or Internal Medicine.

With the national rate of medical school graduates entering primary care fields hovering near 10%, a program that offers dual degrees (such as MPH or MBA on top of the MD) and still churns out practitioners and scientists committed to primary care is noteworthy.

Now the Joint Program is threatened with closure. Due to budget deficits, the university’s Chancellor has decreed that all campus programs must be examined top-to-bottom for savings. Some programs will be cut or consolidated, and the Joint Program is one such program as deemed by the administration of Berkeley’s School of Public Health.

Students and alumni are upset by the program’s threatened closure, and an online petition to save the program has started.

As a primary care physician, it saddens me to think that a program producing dually-degreed doctors interested in systems (public health, organization, business, etc.) beyond ‘just’ direct patient care is under threat. It seems that the Joint Program is valuable and has a successful track record in producing physician leaders.

On the other hand, now in the role of a full time campus administrator facing severe budget cuts, I also empathize with the Berkeley executives who are in a no-win situation.

Aliferis’ article stated the School of Public Health needs to cut $900,000 from its budget — which is why the Joint Program is such a ripe target.

Is there a Silicon Valley donor willing to step in to save (or even grow!) the program?

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