Victory!

As of May 2010, Michigan will go smoke-free. That means when I go out to restaurants, bars and clubs my hair and clothes will no longer reek of cigarettes! Even better, I won't be increasing my risk of practically every medical ailment for the sake of being social.

Joke's on me

I went on a date with a MBA student this weekend and during our conversation he asked how our classes work (since we don't really get electives or any control over our schedule at all). I honestly had never looked at how many credit hours we take because it never seemed relevant. So I looked it up. I also looked up the requirements for the MBAs for comparison.

Total credit hours in 2 years for b-school: 57
Total credit hours in 2 yrs (pre-clinical) for med school: 97

Years it takes an MBA to earn back the debt and lost salary: 5
Years it takes an MD to earn back the debt and lost salary: 20-40

The non-medicine side of medicine

The MI chapter of the American Academy of Pediatrics had an open forum meeting tonight, which I attended. It was interesting to attend a meeting of physicians that really had nothing to do with medicine or providing care. The two hours were spend discussing Medicaid reimbursement, disproportionate share payments and the requirements for re-certification; specifically the quality initiative requirement. I have strong opinions on all of these issues, but the one I will disucss now is re-certification.

Re-certification, which must be done every 10 years, requires four things:

1. Send in your license
2. Complete lifelong learning modules
3. Pass an exam
4. Complete an approved quality improvement project

An example of an improved quality improvement project is to plug data from 10 patients with asthma into some software which analyzes your management practices against accepted asthma guidelines. It will then suggest areas you could improve. You choose one, change your care appropriately and put the new data into the program. You can then look at how your patients are doing based on the change in your practice. The idea is to continually be evaluating your quality as a practitioner and actively identify and implement potential improvements.

My issue is this: it seems a lot like research without informed consent. The patient does not know they are part of this quality initiative. Their management is not being changed based on an individualized assessment by the physician, but by a national guideline or software program.

Apparently, if the intent is not publishing, it's not "research". I think this is an ethical gray area. Comparing your practices in a systematic way against the national guidelines is a good thing - it can help you identify ways to improve. But altering the treatment of your patients then merits thought about their individual case. I would like to believe that when my doctor makes a decision about my care, he has done so because he thinks it's best for me, not because he needs to meet his re-certification requirements. And as far as I'm concerned, if you run a systematic intervention with the intent of producing altered outcomes - that's research, published or not.

Lastly, patient outcomes are reliant on two (controllable) factors: the ability of the physician and the compliance of the patient. The physician can follow all the guidelines, run the right tests and prescribe the right meds, but if the patient doesn't take responsibility, the outcomes are still going to be poor. We should absolutely measure and track physicians performance, but we have to remember that the doctor cannot be there every day to put a pill in your mouth, put the ice cream away and get you out the door for a run.

For example, the pediatricians were discussing how they are held accountable for vaccination rates in their practices. Some parents simply don't make appointments and don't bring their kids in, so those kids hurt the physician's numbers (which hurts their reimbursement). The docs were seriously considering renting a van and going to the local school, rounding up the kids who hadn't shown for the vaccinations and vaccinating them. Are you kidding? In order to get paid for the services they provide the kids who do show up they have to track down all the rest and accost them at school? I'd rather fine the non-compliant parents. The money would help pay for child health insurance, incentivize care and remind the parents of a little thing called personal responsibility.

Wednesday night procrastination

My much-anticipated new shoes came - limited edition pinstripe Jack Purcells. I love them. Super preppy with a twist. So perfect. They took their inaugural walk to get me to IV clinic and back.

IV clinic is where the emergency department docs teach us how to place IVs and subsequently give us equipment to practice on each other. My friend J and I stuck each other three times. It turns out placing IVs in the hand is both more difficult and more painful than in the arm.

I watched the premiere of Scrubs season 9 and was disappointed. What the hell were all the first year medical students doing on rounds, in scrubs and working with patients? Your first two years (until you take and pass the boards) you are lucky if you shadow rounds - you are definitely not let loose in the hospital. Not to mention you would definitely not have a class called internal medicine before you've completed something as basic as anatomy. C'mon writers. Seriously.

Speaking of boards, I've turned in my registration for mine. I'm aiming for April 26... USMLE step 1 is officially on my radar.

I haven't been in the OR since Oct 14th, but I'm on call this Thurs-Sun. Here's hoping for a liver. Except maybe not Sat night (day is fine) because I have a date and I would kinda like to make it. Even if I have to show up with a pager and track marks (from IV clinic). Actually, Sat would be a good time to get my autopsy requirement out of the way. So here's hoping for a dead body and a life-saving liver, all in one weekend.

Sounds like...

One of the blogs I read recently had a patient come in with Flea-bitis. It reminded me of a mother who brought her son in to neurology clinic for a second opinion. Apparently he had been diagnosed with something that sounded like Gardenias. The neurologist and the NP threw out a series of potential neurologic conditions... Guillian-Barre, maybe? After a quiet moment, I volunteered, do you mean Myasthenia Gravis? Yes, she did.

Why I never call anymore

Recently, characters on tv have taken to enrolling in medical school. For example, the revamped Scrubs show will be set in medical school (the original started in residency). I'm actually quite curious to see what Scrubs does with this as the first few seasons were a fairly realistic portrayal of life as a resident.

On Brothers & Sisters, the youngest son and war vet, Justin, started medical school this season. His classes don't really seem anything like mine, but that could simply be a curricular difference. Medical schools all teach the same facts the first two years, but the approach to disseminating the information is quite varied. What was interesting though, it that they wrote him as a stressed out character that became removed from everyone else in his life. He lost track of much of the family gossip and was not there to support his girlfriend during his midterms; even telling her "there are going to be times when I'm not there for you."

I actually really appreciated this portrayal because honestly, that's how it happens. Like it or not, everything else comes second to medical school. Right before a final exam, your laundry, the dishes, phone calls to parents, gchat - everything is put on hold. If you're dating a medical student and you have bad news - hold on to it until the exams are done. Think of it as a preview for life to come: if you marry a doctor you will always come second to whatever patient is on the other end of that beeper. My 10 year anniversary? My daughter's first ballet recital? Your father's funeral? If I'm on call and that pager goes off... I have to go.

We joke about it sometimes, but I'm a little scared. In not too long I will be responsible for people's lives. I am leaning towards pediatric subspecialties; that could be your child. And if it was your child - consider - aren't you glad that I put everything else second to my education?

Body Surface Area

While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.

Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.

Results: Women showing more or less than 40% exposed skin were approached less frequently.

Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.

My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".

No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.

picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml