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.

Today, I'm going to write about something that came up on my infectious diseases rotation this month.

The Infectious Diseases Society of America (IDSA) just published new guidelines for treating intra-abdominal infections. They came out at the beginning January. Apparently, there's been some debate in the ID world over whether these guidelines have too much industry influence. Several of the authors of the guidelines have connections with drug companies, and several of those drug companies happen to have recently come out with some very broad-spectrum, very expensive new antibiotics. These new antibiotics are part of the guidelines, and they are listed as options to treat intra-abdominal infections while some older, generic antibiotics were excluded because of concerns about resistance.

So there is debate and controversy over these new guidelines. The issue becomes a bit more complicated when you look at it from the hospital's perspective. We try to practice evidence-based medicine, as much as possible, and guidelines from major organizations like the IDSA are important tools in doing that, since they are essentially literature reviews. At a hospital like UM, the hospital's guidelines and policies might be based on the IDSA guidelines.

The question then becomes, if you are responsible for creating your hospital's antibiotic policies, what do you do with these guidelines? If you think there's too much industry bias, do you still base hospital policy on them? Do you ignore them? Do you just take the parts you think are unbiased and ignore the rest? And if you have to go through and figure out which parts are biased and which are not, how is that different than creating your own guidelines and ignoring the IDSA ones?

And if you have a patient with an intra-abdominal infection, and they die, and the patient's family thinks you should have used one of these newer, broad-spectrum antibiotics, then what? The patient's family/lawyers can point to the guidelines and say, look, here are national guidelines that say you could have used this drug. Why didn't you? Then you are left defending the tenuous position that national guidelines don't constitute standard of care.

And yet, if you really think that using the newer antibiotics will unnecessarily increase resistance and cost, you are ethically (and financially) obligated to restrict them.

It's a balance that each hospital has to find on its own. I think a big part of the answer is to look at resistance levels at your hospital, and to decide whether the older antibiotics will work in most cases or not. Cost, as always, is important as well.

In the end, guidelines are just that - guidelines. They shouldn't dictate policy on their own; there should be a significant amount of thought put into the value of the guidelines and of policy changes at a given hospital. That's why there are infectious disease specialty physicians and pharmacists.

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.

Today's doctors are many things, but teaching or teacher aren't words generally associated with them (except perhaps in academic medicine). The word "doctor" invokes a particular set of images in popular culture - white coat, scrubs, stethoscopes, always doing something - but the word may not so often invoke the more unglamorous image of patient education. It's my belief that every med student and resident chooses to become their own unique "kind" of doctor, their own way of interpreting the art and the science. Thus it's my belief, and my choice, that doctors should be teachers.

During my one-year foray into public health, one of the greatest experiences of my life was teaching several discussion sections of the undergrad intro to genetics course, alongside other grad student instructors (GSIs, also called teacher's assistants or TAs elsewhere) and the professors of the course. Standing by the blackboard in front of a room of 20-30 undergrad students kept me on my toes (figuratively and literally) and oddly energized. Here I was, imparting knowledge onto students, clarifying concepts and facts, elucidating materials from lecture more in depth, intently watching for the wheels in their minds to turn. Everything I said mattered, mistakes and incorrect knowledge could backlash with great fury, so I had to be sure and confident of what I said. At the end of the day, I hoped that I had sparked that interest in someone to take the knowledge they learned from me and do something great with it.

In my opinion, medicine (particularly primary care) isn't so different. Doctors impart health knowledge onto patients, clarify misconceptions on health issues, answer questions, recommend medication and treatment plans, and hope the patients comply and carry through because they understand and trust their doctors. At the end of a visit, I would hope a patient would take the knowledge he/she learned and do something great with it - keep themselves healthy, improve their health, or even educate others. I feel many students go into medicine because it's a decisive field - you're sure (or at least act sure) of the medicine or treatment you give your patients. Truth be told, you'll never know if your patients actually take their medication or follow through with your recommendations after they leave your sight. And so proper education, communication, and trust are vital.

Already I've had a couple experiences in med school that can attest to the role of doctors as teachers. About a month ago I went to a nearby high school with another M1 med student. We were to give a presentation on obesity and diabetes to a 10th grade health class. My love of teaching instantly rushed back. At the end of the presentation there was still 5-7 minutes left before the end of the class, so we opened it up for the students to ask us any question. One student asked me, "What do you want to do after med school?" Which I initially thought was an odd question, so I answered, "Umm . . . become a doctor." He continued with something like, "Do you want to keep doing stuff like this? Coming into classrooms and teaching about health?"

That struck me. Of course I would love to go to a high school a few times a year into a health class and give a talk on some health topic. I would love that kind of community interaction as a practicing physician. I then realized how uncommon it must be for doctors to take a day or half-day off work and go into the community and do just what I did as a med student. I couldn't recall in all my years of primary education of seeing a doctor come in and give us students a health presentation. There's definitely a role, and sometimes perhaps a need, for doctors to go into the community, talk to a group of people, and educate them on some common health issue. This is certainly one role of doctors within public health.

This isn't to discount the important and integral role of the one-on-one patient-physician relationship. A couple weeks ago while volunteering as a "patient educator" at a free clinic, I saw a late middle-aged gentleman who wanted to discuss smoking cessation and depression. It was a wonderful opportunity for me to interact with patients outside of the rigid "medical interview, physical exam, diagnosis, and treatment" template. We talked rather freely as I asked him questions about what he's done, his personal and social environment, and how we can "tailor" a way to help him with these two issues that works with his life situation rather than against. I felt that to a certain degree, a more relaxed medium of communication between physicians and patients may yield better adherence to medical/health advice, as opposed to a more didactic approach commonly found in medicine. Then again, I've certainly no research to support this.

Lastly, a doctor is a life-long student and teacher. The field of medicine changes so rapidly it's mind-spinning. It can take a lot of work just to keep up and learn the newest updates, and at the same time relay this information to colleagues and patients. But it's a challenge we signed up for the moment we set foot in med school. As future doctors, I believe it's our duty to educate our patients so they may make the best and healthiest decisions for themselves.

Image from: http://www.gettyimages.com/detail/200542888-001/Photodisc

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.

It is always interesting to experience something from two sides.

In my one-year foray in grad school working towards my Master's in Public Health (Hospital & Molecular Epidemiology program), I've had the pleasure of taking courses focusing on the emergent importance of genetics in medicine and public health. Since the sequencing of the human genome there has been the scramble to identify the function and relationship of every gene in the human genome in hopes of pinpointing risks of various diseases, of developing gene therapy, and ultimately of creating "personalized medicine" where each person's treatment is tailored to his/her own genome. The field of genetics is advancing almost exponentially from year to year. Physicians and public health officials are often left in the wake as they try to keep up with the implications of new research.

In my public health courses that discussed genetics, we covered the genetic components of diseases (e.g. in cancers), the role of genetics in public health policy and ethics, how to design genetic epidemiological studies (e.g. genome-wide association studies), how to communicate genetics to the general public, and how to teach genetics to (mainly primary care) physicians and med students. For this post I will focus on the last point: teaching genetics to med students.

In some of my public health genetics courses we had discussed briefly on what to teach med students so that they are aware of the importance of genetics and so they may use that knowledge as a foundation for understanding more advanced concepts in genetics. Because genetics is an ever-changing field, what do we want med students - at a minimum - to know? How can it be taught in a way that's engaging and useful?

First, what's (more often than not) the current situation? Because med school curricula have always been packed with information, there is not a lot of time to create a new course without detracting from already existing courses. In many places, a month or less is dedicated to medical genetics. Most of the genetics one eventually encounters in med school is interspersed throughout other courses such as biochem and pathology. Entering M1 med students have very diverse backgrounds and many people have never taken any genetics beyond what little was presented in an intro biology course in undergrad.

Second, what're some of the challenges of a medical genetics course? Genetics is a complex field that interweaves between multiple disciplines, and often requires at least some basic knowledge in other disciplines such as biochem (for molecular genetics) and statistics (for population genetics). Medical genetics must also be taught in a way that's directly applicable in medicine, and much of this also requires knowledge outside of "strictly" genetics such as pathology for disease etiology and progression. Thus such a course must be basic enough that it doesn't require too much outside knowledge, but advanced enough to be actually useful.

Third, what's the purpose of a medical genetics course? This course should serve to introduce genetics to med students and give them an appreciation of its ever-increasing involvement in diseases and research. It should serve as a primer to be aware of the role of genetics in other disciplines. And finally, it should teach med students some basic utilities of genetics (e.g. pedigrees and when to suspect genetic conditions).

Let's summarize the above: 1. there is limited time to teach medical genetics, 2. genetics draws from many disciplines and must be taught in a careful and balanced way, 3. medical genetics should serve to prime and sensitize med students to the role of genetics in medicine and to make them aware of its importance. From my experience (and the experiences of some of my peers at other med schools), medical genetics is poorly taught and often used as a sort of hodge-podge "class fodder" to insert aspects of biochem and human development (embryology) to serve as introductions to those courses instead. As a result many, if not most, med students end up hating and cursing medical genetics because they can't see its utility.

So now I'll touch on the content that needs to be taught in a medical genetics course. Some of this is from discussions held in my public health courses and some of this is due to reflections from my own recent experience with the course. Some content should include:

- brief overview of mitosis and meiosis

- brief overview of replication, transcription, and translation

- brief overview of Mendelian genetics

- brief intro to non-Mendelian genetics (co-dominance, incomplete dominance, X-linked, variable expressivity, penetrance, etc)

- discussion of multifactorial genetics (e.g. additive traits, quantitative genetics)

- highlight genetic diseases to above cement concepts (e.g. sickle-cell anemia, cystic fibrosis, Huntington's corea)

- how to take a pedigree and pedigree analysis

- intro into genetic counseling and the role of genetic counselors

- intro to cancer genetics, with some basic pathology of cancer

- highlight genetic cancers to reinforce concepts (e.g. BRCA1/2 for breast cancer, FAP and HNPCC for colorectal cancer)

- brief discussion of genetics in public health (e.g. GWAS studies, linkage analysis)

- discussion of ELSI (ethical, legal, & social implication) issues in genetics and genetics research

There are likely more aspects of genetics that can be included in a medical genetics course, but the above is what I and many of my peers would have liked to see. Some topics (e.g. mitosis, meiosis, replication, transcription, and translation) were covered in more detail than necessary whereas other topics (e.g. epigenetics and cancer genetics) were briefly mentioned and some weren't even discussed (e.g. genetic counseling, multifactorial genetics, ELSI issues). The suggested content above looks daunting, but it is doable - it is possible to include most of it in a month's worth of medical genetics.

With the current state of medical genetics courses (in general) in the standard medical curricula consisting of basic science courses in the M1 & M2 years and clinical rotations in the M3 & M4 years, there is a real danger of medical education being unable to keep pace with the great strides in genetics - a fear that today's physicians will become overwhelmed with the promises and prospects of genetics, that tomorrow's physicians won't be able to properly synthesize and recognize the role of genetics in their practice.

Then again, my viewpoint might be highly biased due to my interests in genetics.