For what purpose do we practice medicine? For ourselves (i.e. to improve ourselves or out of interest) or for others? Trick question: it's both. Keep this in mind throughout this post.

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On Monday, I went to the HIV/AIDS Awareness Night event organized by one of the student groups. I was pleasantly surprised to see the ID (infectious disease) physician I shadowed, Dr. P, at the event. I also recognized one of the HIV patients on the patient panel, who I saw while shadowing Dr. P.

While we got our dinner, the event began with a 20-minute clip of interviews of two young men living with HIV. Then Dr. P introduced himself as the panel moderator. Each of the 4 HIV patients introduced themselves as well as another ID physician. The remaining hour-and-a-half was devoted to the panel Q&A.

To hear what these patients went through - and still go through - was strangely motivating. It was incredible to hear their stories, their ups and downs, their will to keep moving forward. Two of the patients were diagnosed with HIV in the 1980s and the other two were diagnosed recently (within the last 10 years), so we heard about how things were different then compared to now . . . and how some things regrettably haven't changed.

Each patient recounted how they found out about their diagnosis, and I can't forget the last patient's (an African-American male) experience. He had divorced his wife in the 1980s and was raising their kids as a single parent. His doctor, a white male, thinking himself a savior (the patient's words, not mine) came to the patient's door and gave him the diagnosis. In front of the patient's kids. ::facepalms:: It simply shocked us in the room that a doctor would have the lack of common sense and the audacity to do such a thing.

Throughout the panel discussion, I'm sure a singular thought echoed in the minds of all the med students in the room: "How can we be better? How can we do better? How can we make things better for patients like you?" I learned a lot from this 2-hour event. I admire the patients' courage for coming in and speaking to us, and I admire how Dr. P is there for his patients (I think the 4 patients were all his) and the relationship he developed with each of them. There were a few instances where I felt almost moved to tears.

Dr. P said something I don't think I'll soon forget: "Even today, even though things are better, there's perhaps no other disease that still carries with it the kind of stigma that HIV does." It's true. Even health professionals - health professionals - sometimes react abhorrently (and unjustifiably so) when hearing that a patient in front of them has HIV.

After the event ended, I went down and talked to Dr. P to tell him how much I appreciated him being there and how highly I thought of the event and the patients. I also spoke with the other ID physician. We got talking on public health and the research being done on developing a vaccine or cure against HIV. Talking about the vaccine trial and the "test and treat" model being proposed to "treat away the HIV epidemic" was refreshing. It was invigorating to speak almost on par with an ID physician on such things. He called ID as being "primary care on steroids." I'd agree with that. :-P

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On Wednesday, I went to a lunch talk organized by another student group. A speaker with Tourette's syndrome and Hirschsprung's disease came to give the talk. He told us about his life experiences with these two diseases as he tic'd away (verbal and physical tics). He was a very charismatic speaker and he had aspirations to become a pediatric surgeon (in the footsteps of his pediatric surgeon who saved his life), until he took a year off after undergrad and realized he could probably help more people by doing what he currently does - that is, giving inspirational/motivational talks.

He also said some things that I won't soon forget. There are things that doctors probably should do that med school doesn't prepare for. Med school doesn't adequately prepare students to care for people as whole people. Almost every class we have in the M1 and M2 years are "basic science" classes - anatomy, biochem, physiology, neuroscience, pathology, microbiology, pharmacology, etc - but few classes prepare us for all the other "non-medical" things that definitely impact a patient's health. Med school doesn't prepare us on how to break the bad news of a HIV diagnosis or on how to counsel a HIV patient through stages of depression. It doesn't prepare us on how to help a middle-schooler with Tourette's make friends or on how to talk to other people about having Tourette's. Too often we're taught - either implicitly or explicitly - how to break patients down into symptoms and pathologies, even while being told the whole time that patients are not "HIV' or "Tourette's." Easier said than done.

The speaker left us with an acronym he invented: HAATS. Humor. Acceptance. Advocacy. Tolerance. Support. Humor helps one cope in a healthy way - to laugh at oneself and at others. Acceptance of oneself with a condition or some difference. Advocacy for oneself and for others; many times patients don't have an advocate for themselves, and so the doctor must fulfill this role. Tolerance of others, that not everyone can or will understand - and that's okay. Support from family, friends, medical staff, etc are critically important.

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After reading the 2 accounts above, I ask again: for what purpose do we practice medicine - for oneself or for others? The answer's still true now as it was at the beginning. But I think it's worth remembering the latter purpose. And that's not just for health professionals, but for all of us.

If you want to read more about the Tourette's speaker, you can go to his website at: www.whatmakesyoutic.com.

I very recently read the following article in the Los Angeles Times, The doctor is in -- but not for long. It reports a decrease in physician work hours from an average of 55 hours/week to 51 hours/week between 1977 to 2007. The study can be found for free here: Trends in the Work Hours of Physicians in the United States by Staiger et al. in the Journal of the American Medical Association (JAMA).

Now, both articles above interpret this decrease in physician work hours as somewhat troubling, the LA Times almost "blaming" doctors for their newfound laziness (compared to teaching, law, and journalism). The study reports the decrease to be most prominent in younger physicians (defined as 45 or younger). The study concludes that this 5.7% decrease in physician work hours averaged over the 630,000 or so doctors in the 2007 workforce translates to losing about 36,000 doctors. That's pretty dramatic. 630,000 doctors to take care of over 300 million Americans is quite some feat.

I suppose I'm the devil's advocate as I find it irritating that the study concludes the decrease in physician work hours to be worrisome for the US health care. To me, it's overdue and about time for this decrease in work hours.

Let's put the hours into perspective. Assuming a 5-day workweek, 55 hours/week translates to 11 hours/day. That would be like getting to work at 6am and not leaving until 5pm, or getting to work at 7am and not leaving until 6pm, etc. Again assuming a 5-day workweek, 51 hours/week translates to just over 10 hours/day; so 6am until 4pm, or 7am until 5pm, etc. If you haven't noticed, that's still a lot of time spent in the office, and that's not including time spent commuting to/from work. The study also doesn't take into account all the paperwork and other aspects of being a doctor that are often done outside the office or from home. I believe that younger physicians are more tech-savvy and are more likely to utilize online resources and such from home.

The study correlates the decreased work hours with lower reimbursement rates in urban areas compared to rural areas. Let's address this. In urban areas there's often a "saturation" of primary care physicians. In more than one lunch or dinner panel with residents, some of them mentioned their concern over being (potentially) unable to find a job in an urban setting, and so sometimes decide to specialize. When you have more doctors in an area for a given population, each doctor sees fewer patients . . . and so likely works fewer hours. In contrast, rural areas have fewer doctors because fewer doctors want to practice there. And because there are fewer doctors, there's a greater need for them; thus, they work longer hours out of necessity to their patients and they well deserve to be reimbursed more for their increased work.

A point briefly mentioned in the study was the thought that younger physicians wish to have a more balanced lifestyle. As if that's a crime? . . . Is there something wrong to want to have time to spend with one's family and go to their children's events? Is there something wrong with wanting to take a vacation every now and then? Refer to the first point I made - that even with the reduction in work hours on average, it's still a lot of time at work. Times have changed since the 1970s. The rise of the two wage-earner family means that each wage-earner can afford to work fewer hours to support the family.

I remember reading a blog post on EverythingHealth by Dr. Toni Brayer called New Doctors - New Culture that hits at many of the points I've made. That post was written in 2008 and it continues to ring truer and truer every day. One of the top concerns of many of my female classmates is how to balance work with family - how can a doctor work so much and still be there for his/her kids? Something has to give.

So I ask: should the health of others be held above one's own health? Above the time one spends with one's own family and friends? Aren't doctors humans as well with very human needs and limits?

I think it's easy to forget that doctors are people too, that we're not all-knowing and unfeeling automatons. The reduction in work hours shouldn't be maligned, they should be welcomed as being more reasonable and more conducive to having a life outside the office. But certainly something has to be done to compensate those lost hours. The variables affecting the production of new doctors are complex and many (and I won't go into them here). But it all begins with a better health care system than currently exists in the US.

A middle-aged Chinese woman came to the clinic who spoke little English. As the only med student on staff that morning who could speak Mandarin Chinese, I was asked to help with the medical interview. While I wasn't obligated to offer translation help, it was a unique opportunity I couldn't pass up. As a result I've realized a few things:

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Despite being fluent in (conversational) Mandarin, there were many questions I was unable to ask the patient directly. I knew how to say many common medical terms (e.g. hypertension, high cholesterol, diabetes), but there were many more that I was simply unable to recall (e.g. cancer) even though I know the words. Furthermore, because I have no training in medical Chinese, there were many things I had to ask in a roundabout way - such as asking the patient if her condition worsened at particular times during her menstrual cycle (that was super awkward).

The work-up on that one patient took about 3 hours. Everything is at least doubled in time due to need to work through a translator (me). If I hadn't been available and willing, there was a translation service over the phone - but that might've been much worse, at least time-wise.

Because we live in an ever-increasingly global world, and particularly in the US as a very diverse country, the value of knowing multiple languages is indispensable, especially in the health care fields. Language still remains as a major barrier in delivering optimal medical care. A second language offers more than simply the ability to translate, as languages are almost invariable tied to cultures. As such, a language may offer some insight into cultural values that may prove very useful when treating a diverse patient population.

When there is a language barrier, the translator is potentially more important than the doctor. The patient looks to you, the translator, as the doctor's words. While a patient may give respectful deference to the doctor, they really look at you to speak the doctor's words and serve as his/her proxy in a sense. Therefore the demeanor and attitude of the translator is critical to ensure open and honest communication.

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While ideally both doctor and patient speak the same language(s), this is not always possible (indeed, it rarely is). Heck, even if they do speak the same language(s) there may still be communication issues. It is equally unrealistic to require entering medical students to be proficient in more than one language. As such, the role of translators - preferably professional - is critical and often necessary.

As the health care bill is being debated in the US Senate, it's a good time for us going into/already in the health field to think about the next steps in US health care. I'd like to talk about 2 topics in this post: evidence-based medicine (EBM) and electronic medical records (EMR).

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What is EBM? My personal definition of EBM is the application of science to the practice of clinical medicine. Sounds intuitive and obvious enough, and it sounds like all of medicine does/should operate this way, right? Apparently not.

To elaborate, EBM is the utilization of epidemiological studies (the study of disease patterns) and biostatistics to help physicians make more informed decisions when deciding on treatment or between two treatments, whether they be drugs, surgical intervention, or whatnot. Also, EBM allows for the ability to understand and critique the literature of medical studies in order for each physician to come to his/her own conclusions on the studies.

Arguably, a class on EBM is one of the most important courses a med student will take. It is also a class many med students loathe to take for various reasons - from their dislike of statistics, to the dry nature of the material, to the impersonal and "cold" methodology of analyzing data from many "anonymized" patients. This is perhaps best highlighted with the recent brouhaha in the news over changes in screening guidelines for breast cancer and Pap smears:

These revisions were generated in part by looking at and analyzing the current epidemiological data on those cancers. There is indeed a culture clash highlighted with these revisions - between those who dislike EBM and those who champion it. In my opinion, it would be wise to withhold final judgment on the new guidelines until one has read the study itself and decided if it's applicable to his/her practice.

Now, of course with all epidemiological studies the data is on pooling together a population (or populations) rather than focusing on a given individual. So while there is no "average patient," it's probably a good starting point. The guidelines don't apply to women with an above average risk of breast cancer or cervical cancer, i.e. a strong family history of breast cancer or testing positive for a BRCA1/2 allele variant.

Medicine is moving more and more towards EBM, as it should be. The more data we have, the more scientific knowledge we possess, the better we can develop guidelines and starting points when treating patients. But it should be noted that individuals are not a population, nor does a population represent an individual. EBM is a tool, and a very valuable one at that, but it shouldn't be the sole tool for a clinician.

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There has been much excitement and distress over implementing EMR systems across hospitals in the US. Certainly EMRs have their advantages, but also less know are their current disadvantages. Suffice to say, EMR systems in the US are still nascent and may not quite ready for prime time.

The advantages of an EMR system are manifold. EMR reduces the amount of paperwork (save some trees!) which could aid in decreasing the possibility of paperwork becoming lost in the process. EMR has the advantage of being more easily organizable, such as creating tabs for "Medications," "Allergies," "Surgical History," "Family History," etc. Ultimately, EMR systems will be searchable (i.e. search for "allergy to penicillin") and more readily transferable between hospitals. So if I moved from Michigan to Wisconsin, a doctor in Wisconsin would be able to pull up my health records via EMR from Michigan once I've authorized it, rather than asking the hospital/clinic in Michigan for my health records to be faxed/sent over.

However, there are currently many obstacles to the final vision of EMR systems. My friend, Alicia, a genetic counseling student, went to their conference recently. And at their conference, there was a representative from a company that creates an EMR system. The representative painted a rather pessimistic outlook on EMRs.

One of the primary obstacles is that every hospital that uses EMRs use a different EMR system. Therefore these EMR systems aren't compatible with each other. So if a doctor in Wisconsin were to request my health records by EMR, his system has to first be compatible with the EMR system used in that hospital/clinic in Michigan. There's currently no communication between EMR systems and there appears to be little (if any) communication between the companies that design these systems - logically so, as they're competitors.

Another obstacle is the transition from paper to EMR. Someone has to either manually enter all the data into the EMR or scan the paperwork into the system. Both require considerable time and money. Paperwork can be easily buried, lost, or forgotten in the transition to EMR, potentially with devastating outcomes.

Lastly, there is some difficulty in making EMRs searchable. The cumulative medical/health data of a single individual from birth to death is enormous. EMRs would require a massive amount of storing capacity, and to design a search function that can find just what you want within that massive pile of data is currently out of reach. And a physician doesn't have the time (nor the patience probably) to look through a person's entire EMR to find that one relevant nugget of info.

So does this all mean that EMRs are doomed to fail? Not necessarily. There are obstacles, yes, but not insurmountable. If there was an incentive (perhaps from the federal government) for companies designing EMRs to communicate and collaborate, it's possible that a basic package that's compatible with all systems could be achieved. More specialized functions and widgets could be added on that need not necessarily be compatible with other EMR systems. There is also potentially a market niche in developing compatibility software that allows data from one EMR system to be accessed in another. The transition from paper to EMR is unavoidable, and it's just something that will have to take time and be toughed through (unless someone comes up with an ingenious method). And I've full confidence in the progress of technology to one day make EMRs searchable. I mean, look how far computers have advanced within the last 20 years!! But for the near future, making tabs for different clusters of data is probably the next best thing.

A nation-wide EMR system is currently a dream, and probably not something achievable within the next 20 years. But if there's a will there's a way, and being an optimist, I could see the potential and possibility of a nation-wide EMR system being in full use within the next 5-10 years. Where there's a will there's a way.

Back from Thanksgiving Break... *yawn*... everyone eat well? :)

Let me share an idea from a lecturer who came to my reproductive health class.

Think of the following as a "Wouldn't it be nice if this was carried out?" type of suggestion.

(In other words, gently ignore plausibility issues)

Problem: Regular check-ups are not as common as health care providers would hope for.

Solution: When the patients do come in for something, whatever that may be, screen/counsel for everything else while you're at it, and if appropriate connect with another facility that can treat for new diagnoses that you can't handle.

Example: Patient comes into a gynecological clinic for a pelvic examination...also check for cardiovascular conditions, diabetes, respiratory infections, etc. Provide medications, treatment, and schedule follow-up visits as necessary.

In other words, maximize on the opportunities that you can find in patients' regular care-seeking profiles. Everyone has their own individual pattern of seeking health care and screening and it may well be that they have many reasons why it's difficult to change it to better resemble state or federal guidelines.

So providers, take an all-encompassing approach. Open the door to more complete health outreach. Patients show up for a particular concern or a specific type of routine examination, providers can add other check-up procedures to that visit.

..........(contemplating barriers and limitations).........$$$

Okay, maybe I wouldn't be happy as the patient if I came in to be treated for bronchitis and ended up having to go through a multitude of other unrelated screening procedures and lengthy counseling for diseases not immediately on the horizon. But by having a conversation with my provider, risk can be assessed with prevention of disease as the goal, so I may be willing to sit through extra counseling if not extra procedures.

If this attitude became the general accepted norm (a tall hurdle), such a system may work out.

Although, surveillance for reportable diseases might get messy.

But from a public health standpoint, wouldn't that be nice if this was possible?

We'd be able to catch so many symptoms before they ballooned into serious ailments.

An idea is but an idea...until someone can pave a path for it...

Money, dollars, bills - those green pieces of paper with numbers and faces on them, are what's on everyone's mind these days, especially in the healthcare field. With the so-called economic crisis, resources are scarce in the medical community. I've heard many stories concerning the use of the emergency room as a way for patients to get over-the-counter meds, but I have never experienced it myself until my clinical preceptorships at the ED (emergency department). Now I realize how hard it is to be non-judgemental.

Many times I would see patients come in for conditions such as a common cold and ask to be prescribed tylenol or motrin. They would wait many hours in the waiting room with a fever and a cough, and use up not only medical resources but also their own precious time. When doing social histories, I'd ask patients whether they smoke or use alcohol. Oftentimes the answer to both is yes. With a pack of cigarettes costing $4 and alcohol being on a range of prices, people can end up spending a lot on these two amenities many consider essential in life. Being a non-smoker myself, I sometimes find it hard to be non-judgemental, for patients would spend on cigarettes yet not for medication for their condition.

After many such encounters, I talked with one of my preceptors about the situation. He responded that I can't be judgmental; if I grew up in similar situations as the patients, then the patient might be the 2nd-year medical student and I could be the smoker and alcoholic. I realized the importance of education, and what "don't judge the book by its cover" truly meant. With the healthcare in great need of reform, more attention should be placed on implementing earlier education in schools. Instead of the majority of attention being focused on where funds should be allocated or how to better manage the ED, funding should be placed in sexual education, health courses, and lifestyle-related courses in middle and high schools.

I don't know if what I'm advising is doable or valid, but I feel like it would be a step in the right direction in solving the healthcare crisis we are facing. Although this is easier said than done, with more attention placed in this field, perhaps we can shift our attention to better, more feasbile, and smarter methods in solving the education crisis.

My first rotation, in August, was supposed to be about pharmacy compounding. As it turns out, though, compounding pharmacies tend to do a LOT of alternative medicine, herbal medicine, supplements, weird off-label uses of drugs with no evidence to support them...whatever you want to call it. This one, in particular, also had a clinic where "alternative medicine" doctors came to see patients.

I won't get into how unhappy I was about my situation, or how ethically compromised I felt. What I do want to talk about is one of the first questions that came to mind. Most of our patients were from Ann Arbor, and they were fairly homogenous. They were well-educated, upper middle class, and typically (though not always) women in their 40s and 50s. And so I wondered. What was it that made these people come to us? What made them turn from their doctors and from normal medical practice? Why were they more willing to trust someone who charged $200 for a consultation than someone they could see for a $15 copay?

The inevitable conclusion was that these were people who, for one reason or another, had lost faith in the medical system. They all had PCPs, who they were disillusioned with. They all had medical problems that could not be or had not been solved. They were intelligent, well-educated, independent people and you knew that they had thought, well, if my doctor can't

fix me, maybe someone else can. One of the most common questions we got was, why couldn't my doctor diagnose this? Why didn't they know about this (weird, alternative) diagnosis?

As a healthcare provider, this disturbed me very much. All the good we do is based on the assumption that our patients trust us. If they don't trust us, they won't come back for followup appointments, they won't take their meds, and they won't do the things necessary for staying healthy.

So what is the problem here? Why didn't these patients trust their doctors? Three points come to mind.

1. We don't spend enough time with our patients. This goes for both doctors and pharmacists, and probably other providers as well. Our days are busy- we see lots of patients and we deal with a seemingly endless stream of paperwork and insurance issues. It's sometimes easier to just tell the patient, this is what you have and this is what you need to do, and not spend any time explaining why, or going through the risks and benefits of treatment (or no treatment).

We had a patient, in the compounding pharmacy, who came to us because she had been having some generalized symptoms- headache, fatigue, lack of energy, etc, and also had some weird rash/dermal thing on her foot. When the pharmacist asked her if she'd seen a dermatologist, the patient said, "well, no, that's just it. My doctor didn't even look at it! She just told me to go see a dermatologist." That was probably a reasonable reaction on the part of the doctor- if the patient described this rash thing, it probably would have sounded like something outside the realm of a PCP. And if any specialty work were to be done on it, she would have to go see a dermatologist anyway. But all the patient heard was that the doctor was brushing her off, or didn't have time for her, or didn't care about her. If the doctor had taken the time to stop and look at this rash, or to explain to the patient that she wasn't really trained to deal with this sort of thing, and that a dermatologist might be better able to help her, then maybe our patient wouldn't have abandoned the entire medical system.

Those consultations were a full hour for new patients, or half an hour for repeat patients. How many normal doctors have time to spend more than 15 minutes talking with a patient? How many pharmacists have time to spend more than 15 seconds talking with a patient?

2. Educated patients like to have some say in their care. In the pharmacy world (and probably in the medical world as well) we call this "patient autonomy." If you give patients options, discuss treatments, discuss disease states and let the patient decide that treatment is necessary, they are more likely to follow through with it. Not to mention that in most cases the patient does have a right to have some input into what their treatment will be.

And if your patient has done some Internet research and has come up with some alternative treatment, it then becomes necessary to acknowledge that treatment and explain why it is unlikely that it will work, rather than just brushing it off.

We had a case where a women came to us for hormone replacement therapy (HRT) after her doctor put her on estrogen alone, and the patient thought that this was the wrong decision. As it turns out, she was right to an extent- using estrogen alone, without progesterone, can increase your risk of breast cancer. Now, progesterone itself has side effects, and without knowing the details of the patient's history and family history I can't say whether it was the right decision or not. But our patient came to us because she felt that she didn't have any say in her treatment.

3. We don't communicate clear expectations for patients of what medical treatment has to offer. The classic case is the patient taking an anti-depressant, which can take up to 6-8 weeks to reach its full effect, who stops taking the medication after a week because it's not helping. Many of our patients at the compounding pharmacy had been put on antidepressants for those general physical symptoms, depressed mood, and lack of energy. Only very rarely did these patients stay with the antidepressants for more than a few weeks. Maybe it would have helped, maybe not- but no one ever told these patients that we wouldn't know for a while.

In the end, like some many things, it comes down to communication. We in the healthcare world have a responsibility to communicate with our patients, to tell them what we are doing and why, and what they should do and why. Equally, our patients have a responsibility to come to us when they have questions, or problems, or side effects, or treatment failures. This is one of the best ways in which we can build trust in ourselves, our patients, and the medical system in general.