One of the benefits of my current rotation, cardiology, is that it's not at my university hospital.

There's only one cardio rotation at University Hospital, so because cardiology was lower on my list of Most Wanted Rotations, I got sent out to Smaller Hospital 40 minutes away, which has a big cardiology department. (It's not a small hospital, exactly - their CCU alone has 17 beds. It's just smaller than most I've been to.)

So I'm a bit out of my comfort zone, because I don't know the hospital or their computer systems or the way they practice pharmacy. When I got there, I found that there are a number of other students from another nearby pharmacy school who do all of their rotations at Smaller Hospital. They, of course, know the system very well, and they were happy to show me around.

But it's interesting to see how pharmacy is practiced differently. For example, at this hospital, the pharmacy (the staff pharmacists, not the clinical pharmacists) is responsible for doing about half the Coumadin and antibiotic dosing. As such, they routinely write orders for certain antibiotics, INRs, and antibiotic levels. Their stewardship program consists of monitoring all the restricted antibiotics (and then not being able to do anything about it unless they're consulted. It's a pretty ineffective stewardship program). Another thing I've noticed is that they're big on loading doses. They load Coumadin (which I'm pretty sure is flat-out wrong, even though they have their adaptations and apparently haven't had any major problems). I've also seen loading doses of Vancomycin and aminoglycosides. That's something I almost never saw at University Hospital, though it's not necessarily wrong.

And of course, sometimes it feels just like home. Their pharmacy, like all others, is in the basement. Clinical pharmacy there works pretty much the same as it does at University Hospital - you make recommendations to the intern and/or the residents, and you're responsible on rounds for knowing all about drugs. And the interactions among pharmacists, doctors, and nurses are about the same as what I've seen other places.

It's a little reassuring to know that some things never change. Next year I'll (hopefully) be doing a residency year, and my top two choices are 600 miles away from here. So hopefully, this experience will help me learn to adapt to a different hospital in a different place. The students from Other Nearby Pharmacy School have occasionally said that they wish they could do rotations in other places, just to see what it's like. I'm glad my school gives us that option.

Alb: If some of the terminology is above your head, refer to the comments for a bit of clarification from Shari. :-)

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.

We had to watch this film in class today, and I must say I was thoroughly impressed. Emotionally rattled (not sure if this is the best expression). It quietly makes the tears run down your face. Plus great camerawork and otherwise a well-made film.

Basically it's a story about a woman who has to live with AIDS.
She lives the kind of life that probably is a good representation of a lot of other people in the same situation, but it is her spirit that sets her apart and blows you away.

We must be grateful for what we have and make the most out of our future...

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.

Over the past decade or two, the profession of pharmacy has undergone a sort of identity crisis. As an adjunct healthcare professional, where do we fit in the grand scheme of medicine?

The easiest answer to that question is basic retail and hospital pharmacy. We dispense drugs. A doctor writes a prescription, or (in a hospital) orders a drug, the pharmacy makes sure it's a valid prescription and that the doctor didn't make any obvious errors, and the patient gets the drug.

A broader definition, though, and one that lets us fulfill a larger role, is that a pharmacist is a drug expert. In the community, the pharmacist is the most readily accessible healthcare professional. They get questions from patients, family members, and occasionally doctors, and if they're lucky and don't work for a high-volume store, they talk to as many patients as possible about their prescriptions. In drug companies and insurance companies, the pharmacist is the drug information specialist, and answers questions and makes formularies and such. In the hospital, this has given rise to the idea of the clinical pharmacist, who is able to play a much more active role in a patient's care.

A clinical pharmacist (which is what I want to do) is the hospital's expert on drugs. They round with doctors and follow patients, make recommendations, do the dosing on things like gentamicin and vancomycin (which have to be calculated), deal with anticoagulation, catch any drug-related medication errors, and whatever other drug-related things they can fit into their day. Some have become nutrition specialists and handle all the TPN orders; some go into academia and do research and teaching. The job really is whatever you want it to be.

And essentially, they are a consult service for other healthcare professionals. A nurse might ask if two IV medications can be mixed together without precipitating; a doctor might ask for help calculating a dose. A student might ask about pharmacology or pharmacokinetics, and a patient might ask about side effects.

It's a new and ever-changing field, but it's getting bigger, especially as younger doctors graduate and have some idea of the kind of resource a pharmacist can be. And as new pharmacists (like me!) graduate and work to make pharmacy a bit more progressive in the next decade.

I've had the pleasure of being paired with a pediatrician in private practice, Dr. D, as a part of the M1 Mentorship Program at my med school. He's already told me many things that one simply doesn't learn in the classroom - some of them are common sense but need to be said anyway. There are things he told me that I would do well to remember. Simple things that can make all the difference in the world:

- show proper respect to patients and colleagues (including doctors, nurses, PAs, etc)

- check up on your patients and call them back in a timely manner

- be conscientious and hard-working

- be good at what you do

If one meets the above criteria, word spreads and patients will come. It actually somewhat amazes me when he calls patients* 3-4 days after a visit just to check up on them, or make a call to let a patient know about the results of a lab test. Most patients don't expect him, as a doctor, to be taking the time to call them back.

But in the spirit of the holiday season, I will comment on the compassion that great physicians should ideally possess.

During my first visit to shadow Dr. D, he told me of instances where some of his patients lost their health insurance or were otherwise unable to pay. Yet he saw them and treated them anyway as their doctor by accepting what they could afford or even without repayment. He just reassured them to pay him next time when they get health insurance again. Most of the time patients respond in good conscience but a handful have "abused" his altruism. Often at the harping of colleagues and with great reluctance does Dr. D let these patients go. Alas, private practice medicine is ultimately a business and needs to be in the black, not in the red.

During my latest visit to shadow Dr. D, a patient came in with his mother. Dr. D instantly noticed that the mother didn't seem to be well either and inquired why. It seems the mother has had a rather severe headache for the past week, severe enough to be almost debilitating. So after treating the patient, Dr. D went to lengths to find a number for a neurologist at my med school's hospital. After spending almost half an hour (with some help from one of his nurses), he was able to locate the secretary for a neurologist and helped the mother schedule a visit for that same week.

This instance, that I had so fortuitously observed, demonstrated Dr. D's compassion as a physician. That he was willing to go to lengths at all to help out a patient outside his "jurisdiction" within medicine - this is a hallmark of a great physician. It had me in a momentary awe that after decades of practicing medicine he was still able to let his altruism and compassion guide his actions, rather than becoming jaded and burnt out as reported on so often nowadays in the news.

Perhaps this was part of his secret that has "second generation" parents (formerly kids that he once treated as patients) bring their own kids to see him. He even has some "third generation" families, where he used to treat not only the parents, but the grandparents as well. o_O

Happy holidays everyone and have a happy New Year! :-)

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* Note: For the purpose of this post, when I say "patients" it almost always means the parents of the patients, by the very nature of a pediatric population.