Always a good sign

I chuckled when I got this e-mail. 

After speaking with several fourth year students and Dr. [X]... several of us felt it imperative to inform you all that there is NO box to check or area to denote any form of mental illness or having ever received counseling of any sort on the residency application. You tell a residency program if you have received counseling for or suffer from depression, anxiety, burnout, etc. AFTER you have matched. It will be the paperwork you fill out for the specific program like any other job you have had.
We bring this up because students fear seeking help from counseling services on and off campus. This is unnecessary as you will not be asked about such information when applying for residency during fourth year through ERAS. Please, PLEASE seek help if you need it. We have amazing resources available to us!

This is an old link from KevinMD, but it's relevant: Medical schools need to better recognize mental illness in students. 

Physicians have traditionally experienced higher rates of suicide than the general population – 40% higher for male doctors and a whopping 130% for female doctors. Students who enter medical school with a relatively “normal” mental health profile, in the end, suffer a higher rate of burnout, depression and other mental illnesses. In fact, over the course of med school, up to a quarter of students may suffer from depression and over half from burnout.

This is a friendly reminder that burnout, depression, anxiety, etc. are all a depressingly normal part of medical school. Please get treatment if you need it. To my knowledge nobody will know outside of your school's student health department, or whichever physician or counselor whom you see. Mental health issues are common and highly treatable.

I'm not surprised that one of the main hindrances to seeking help for mental health issues at my school appears to be "What if people find out?" I would like to think doctors and healthcare workers are more enlightened about mental health issues than other people, but I'm not sure the data really bears that out. My anecdotal experience sure doesn't.

So I wonder to what extent should medical students (or residents, or doctors) suffering from mental illness speak out. If you're in a stigmatized group, how much responsibility do you have to other people in the same boat?

Maybe that's the final step in getting better. Where you've reached the point where you aren't afraid to talk about it. Or maybe that has nothing to do with healing at all but rather with where you are in your career.

Step One fun, plus a tiny news roundup

It's nearly Step One time! Which is to say that in about two months' time, I will be tested on anything or everything that I've learned in the first 2 years of medical school. I will then almost certainly forget half of it within one week or so.

So, the part of my brain that isn't re-learning which special bacteria requires chocolate agar (Hemophilus influenza and Neissiria meningitidis, if you're keeping track) or what a PAS stain is checking for (glycogen, Whipple disease) has been reading through the news looking desperately for an interesting story. So far it looks pretty grim. Some guy in Nevada owes the federal government a lot of money. A dude I've never heard of who owns a basketball team made some dumb comments. A missing plane is still, uh, missing.

Instead of talking about those awesome topics, I instead am linking an article by Andrew Sullivan at the Dish, regarding John Kerry's remarks about Israel. If you missed it (and I forgive you if you have) John Kerry stated that Israel was in danger of becoming an "apartheid state" along the lines of South Africa. As far as I can tell, this is pretty basic stuff: unless Israel persuades a whole lot more Jewish people to immigrate, and fast, demographics are going to turn it into a Jewish-minority state.

Nothing about that is particularly controversial, in my opinion. Jeffrey Goldberg, who has written extensively about Israel's present and future, concurs.

By 2020, the Israeli demographer Sergio Della Pergola has predicted, Jews will make up less than forty-seven per cent of the population. If a self-sustaining Palestinian state -- one that is territorially contiguous within the West Bank -- does not emerge, the Jews of Israel will be faced with two choices: a binational state with an Arab majority, which would be the end of the idea of Zionism, or an apartheid state, in which the Arab majority would be ruled by a Jewish minority.

Which is all to say, I clearly don't understand the politics of the situation very well. Unless Israel's demographers have gone mad, the Arab population is going to become the majority group within Israel fairly soon. So if you are inclined to believe that the Jewish people deserve their own state, the only rational future seems to me for Israel to accept a second state. Waiting for demographics to force the issue seems like poor planning, and jumping on John Kerry for pointing this out seems quite frankly counterproductive.

Of course, I do assume people want a reality-based solution and not fantasy (Maybe Palestinians will be abducted by aliens! Maybe ten million Jewish people will immigrate overnight!) so I may be over-thinking things.

Finally, for a well-informed take that is more critical of Israel than I am, Juan Cole provides some good insights.

Galveston's uninsured, physician satisfaction, and concierge medicine

This is an old article, but it's one that's fairly important to me for obvious reasons - I live in Texas, and more specifically in Galveston.

http://www.texasobserver.org/a-galveston-med-student-describes-life-and-death-in-the-safety-net/

If you recall, the island was hit by Hurricane Ike in 2008, and this devastated large parts of Galveston Island. UTMB, the major healthcare provider and employer in the region, was nearly bankrupted in the aftermath, and the solution at the time was to begin cutting services to patients lacking health insurance, or patients covered by programs like Medicaid which are notorious for poorly reimbursing doctors and hospitals.

From another article in the Texas Observer, UTMB went from turning away 35% of uninsured people seeking care to 91% as of 2011.

As a result, the estimated 21.5% of Galveston County's residents who are uninsured suddenly have a lot fewer options. One choice is the student-and-volunteer-run free clinic of St. Vincent's House, which sees patients on Tuesdays, Thursdays and Saturdays. The physicians who oversee patient care are strictly volunteers. Poorer patients may rely on donations of medication from the stores of dead former patients, and access to some basic drugs like antibiotics for simple infections is difficult (a 7-day course with some of those may cost well over $100, which is outside the financial reach of many of those coming to a student clinic).

Luckily, a major resource that the clinic can afford its patients is time. Because medical student education is a goal (and the physicians are not getting paid for their time), the initial patient interviews are conducted by medical students who can listen for longer than the 5-to-10 minute window of a typical doctor visit in the US. This is fairly rewarding, both for the students involved and (usually) the patient. There is little financial pressure cutting the visit short. More important, it is how many medical students envision patient care: you spent a lot of time listening to the patient's health complaints, and then try to come up with a plan to treat them. The relaxed pace of the interview means that you have time to learn about the patient outside of their hypertension or diabetes.

I bring this up because I read an article in the Guardian by one physician who is deeply dissatisfied with the medical care he is giving:

The same "reward and punishment" that is the hallmark of the American free market system has rewarded physicians for seeing more patients (no different than hourly billing rewards for lawyers) and doing more to patients (such as surgical procedures and other interventions). Consequently, physicians have been pressured to see more and more patients in the same amount of time. It should be no surprise that such encounters have become more like business transactions rather than what they should be: rich and intensely human interactions potentially resulting in tremendous fulfillment for both parties.

 He is getting at what I believe is a fundamental part of medicine: the idea that it is not merely a job like many others, but a chance to connect with people on a very deep level. Some of this may be conceit: it is pretty ambitious to view your profession as a "calling", a term I've commonly seen in reference to medicine. But many physicians do enjoy talking to and connecting with their patients. The main reward for primary care isn't financial but being able to build a long-term relationship with patients and their families, if you're lucky.

I find it darkly amusing that this style of medicine has been pushed out of many hospitals and doctors' practices, but is still thriving at a clinic run by medical students for Galveston's poorest. Even with excellent insurance you may not be able to develop this kind of long-term relationship with a physician.

Maybe patient satisfaction scores were highest back in the days when doctors had no medical option but to listen. Surely there must be some way to reconcile the tremendous advances in medicine and technology with an approach that does not dehumanize patient and physician alike. Is it concierge medicine? Will healthcare reform help or hinder this process?

Physicians are too bright to allow office visits to become merely a commercial transaction. I hope.

Concierge medicine is one solution to this problem, but the problem remains how to make this kind of care cost-effective for more Americans. I don't think too many of the patients at St. Vincent's could afford a physician retainer, no matter how excellent their care would be. How can we bring that kind of quality long-term relationship care to more/poorer patients? Is it economically possible?

KevinMD: The Primary Care Crisis Has Been Legislated

http://www.kevinmd.com/blog/2013/09/primary-care-crisis-legislated.html?utm_source=buffer&utm_campaign=Buffer&utm_content=buffer39a5a&utm_medium=twitter

So, if you're in healthcare and living under a rock, you might not be aware of this, but primary care in the US is in a state of "crisis" right now. Fewer and fewer medical students are choosing primary care and opting for more-lucrative specialties like dermatology, radiology, and anesthesiology. The traditional doctor-patient relationship is doomed, as the ten remaining primary care doctors in the US will be replaced by physician assistants and nurse practitioners.

A solution, at my school among others, has been for doctors to "talk up" and encourage students to go into primary care. It's like sacrificing oneself for the greater good; you are going into a lower-paying but demanding field for the good of the US and your other fellow physicians. If primary care goes, what is next? Psychiatry? Well, that's kind of a spooky field anyway. What about anesthesia, though? Or God forbid, surgery? Nervous laughter.

So it looks like a lot of medical students have taken this call to serve seriously. From the most recent data available, an increasing number of medical students entered primary care this past year for the fourth year in a row. http://www.usatoday.com/story/news/nation/2013/03/15/doctors-medicine-match-residents/1990549/ Despite the hassles involved with primary care, which are very real, a lot of medical students are forfeiting millions of dollars in potential lifetime income to serve on the traditional first line of defense against illness, and prevent encroachment on the field from NPs and PAs. Except... why are NPs and PAs replacing doctors?

PCPs simply do not have enough time to perform their job well. Period. As a 2012 paper notes:

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. The average US panel size is about 2,300. http://www.annfammed.org/content/10/5/396.full

 So, really, maybe this crisis could be averted if existing primary care doctors just worked 21.7 hours per day. Or maybe we legitimately need healthcare professionals with enough time to actually take a damn physical exam, let alone a history. Maybe patients appreciate being listened to; I suspect that's a reason NPs outscore physicians with regard to patient satisfaction (http://www.clinicaladvisor.com/nurse-practitioners-outscore-physicians-in-patient-satisfaction-survey/article/206090/).

Maybe doctors need time to help heal their patients. This might not always be true; a broken bone is just a broken bone. (A cigar is sometimes just a cigar!) But what about patients suffering from chronic diseases, like lower back pain, depression, hypertension, or diabetes? Maybe part of their treatment therapy could be a healthcare provider's time... regardless of whether it is a NP, PA or MD.

Breaking bad news - relevant link for yesterday

http://www.kevinmd.com/blog/2013/09/delivering-bad-news-vast-divide-doctor-patient.html?utm_content=buffer45f85&utm_source=buffer&utm_medium=twitter&utm_campaign=Buffer

There is (a) vast divide between the physician sharing a hard reality and the person receiving it.  As much as the doctor works to imagine what it must be like, he or she is not the one whose life is changing.  The physician moves on to the next patient, while the patient now lives in a new world.

I read this after posting last night; the bulk of the post is about the poster's own autistic son, and how different it is to give versus receive bad news. Neither my spouse or I personally enjoy great health, so I'm hoping I can rely on that to not completely suck at giving patients unpleasant news.

It's kind of funny, I think, that we have an actual class session next semester dedicated to breaking bad news. One other student will meet with a standardized patient (an actor) and pretend to give bad news to him or her, and a group of us will watch a video and critique how the student could have demonstrated more empathy, etc.

I predict it's going to be awkward as hell for that student. But based on my own experiences and those of many people close to me, doctors are often terrible communicators. Your test results are X, Y, Z. Come back in 6 months. On to the next patient. But the patient is still sitting there in the room and the doctor just walked out because he's triple-booked and well it's damn hard to keep to a schedule. No other professional is scheduled the way that doctors are. You don't meet with your attorney for a 6 minute talk, after which he finishes your will. You don't meet with a counselor for 15 minutes and suddenly your anxiety is better. People often need time for healing, and few physicians have it to give.

Ultimately, the problem is not that doctors are terrible communicators (although some are) but the amount of time allotted to break bad news... well, that's time spent not seeing other patients, or performing procedures. You're losing money for your employer if you spend too much time with a grieving patient. You'd hate to get fired, right?

First death (in a manner of speaking)

I had my first experience with patient death last week.

Let me clarify. I'm a medical student, not a care provider, and I am in no way permitted to make any changes, suggestions, prescriptions, or even offer friendly advice to patients. The patient is even, for the moment, alive and well enough. But Crohn's is a nasty illness, and sooner rather than later it is going to claim her.

She was younger than me, which was unusual. Most medical students start out at 22-23 and graduate four years after that. Unless you're in Pediatrics, you shouldn't be seeing too many young patients, period. A large number of people live fairly illness-free lives until the inexorable diseases of hypertension, diabetes and back pain start to kick in during middle age. I am not one of those people, but more importantly neither was my patient for the day.

She had Crohn's Disease, and she had the worst case I've ever seen for her age. Crohn's isn't an autoimmune disease, exactly, but it's very similar to them. Your immune system is in a constant inflammatory war with bacteria, food, and your own bowels. There are a lot of drugs that can delay the progression by decades, to the point where the average life expectancy with Crohn's is only 2-3 years shorter than if you never had it. It's unpleasant, but it's not typically lethal.

My patient was not typical, however. She had three tubes in her draining a collection of feces, blood, pus and God knows what else. Her list of antibiotics filled half a page. If she hadn't had Crohn's, it would still be no wonder she had no appetite. She'd been in the hospital for several weeks, with no end in sight. She was leaking onto her hospital bed and taken over by opportunistic infections that were happy to make a new home in her body. When I talked to her, she was scared and wanted to know when she was going home. Well, what could I say? I wasn't a doctor, and I wasn't even working on the medical service (that is to say, with her main team of doctors.) My job was to evaluate her mental state, empathize, and get out. I had no access to her records at the time that quietly noted hospice care might be necessary soon. Neither did she, of course.

She asked me: what is my long-term plan? When will I get out of here? I had no idea. Her doctors had no idea. Given the severity of her infections, she might be leaving via the basement. Or the heavy-duty antibiotics might clear her infections and she might live several more decades. Nobody could say.

About three patients into my fledgling medical career, and I feel like I really failed already. I have absolutely no doubt her medical care was technically excellent. The doctors I rounded with clearly empathized with her, and the pain consult was trying its best to ease her suffering. But the patient had no idea how serious her illness was. I asked my resident: who will tell her? Well, that's the job of the medical service. We were consultants, and if medical hadn't mentioned hospice care yet, there was no way he or I was going to do that. It wasn't my place, and what if we were wrong? He was not an internal medicine doctor, and I was a medical student, for goodness' sake. We just had to wait.

So, as far as I know, my young patient is still in the hospital still waiting for someone to break the news that this infection isn't like the others so far, and she might not be leaving the hospital. She will continue to receive technically excellent medical care. I hope she recovers, although I don't believe she will. If not, I hope that she is able to spend her remaining time as she wishes, instead of waiting for news from her doctor that might never arrive. We will see.