Smartest or Nicest?

The NYT ran an article recently on using personality tests as part of the criteria for medical school entrance. Apparently they gave personality tests to 600 students to look for which traits correlated with future success. Big surprise, those who stressed easily did poorly and those who were extroverted did well.

The thing is - I don't agree with their proposition that doctors all need to be super-nice people. Sure, a physician should treat you with respect and courtesy, but you're not there to make friends. When did it become an expectation that your doctor also be your confident and therapist?

Let's put this another way. If you found out tomorrow that you had cancer or HIV or needed a triple bypass - do you want the nicest kid in the class or the smartest?

I know what you're thinking, can't I have both? Sometimes yes. There are some very smart people who are also very friendly. But the traits that get you through training are not the traits that win friends. In medical school and residency you sacrifice a lot of your personal time to your training; thus your relationships are neglected. The divorce rate for doctors is above the national average. You have to be willing to study for hours alone - be independent and driven. The decisions you make and their consequences are weighty; they require detachment and objectivity.

Everyone's job has stress, but not everyone will find themselves leaving their son's baseball game because their pager went off. Your patient is in respiratory failure because they developed graft vs host disease after their bone marrow transplant, which you recommended and without which they would have died. And it's not just cancer doctors - it's the primary care physician whose patient has a hypertensive crisis or a stroke. It's the ER doctor that has to call the organ donation team when a 24 year old comes in from a motorcycle crash. It's the pediatrician who pronounces the unlucky child who got meningitis or the ob/gyn that tells a first-time mom that her baby has hydrocephalus. Every doctor sees these cases in training and no practice is immune from tragedy.

Why is the system built this way? Why do we make it such a stressful process to become a physician? Are we turning good people into bitter ones? I say no. I think we're pushed because there is a lot of medicine to learn and not enough time to learn it in. We spend two years in lecture halls learning biochemistry, anatomy, pharmacology and histology - no patients in sight - a lot of which we won't use in everyday practice. But those years are the difference between a doctor and everyone else on the medical team. They are they difference between memorizing a standard protocol to treat a disease and understanding on a molecular and cellular level how the disease and it's treatments work. You can't reassemble an engine if you don't understand how the parts work.

I promise that when I graduate and begin practicing that I will make every effort to treat you with respect. I will explain my reasoning and answer your questions. I will be professional and courteous. But I will not be your therapist or your best friend. I will not hold your hand or cry with you. It will have to be enough that you had the smartest kid in the class, trained in one of the best schools, using all of their intellect to save you.

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.

Different and unequal

Nicholas Kristof took a break from the third world to write a column on the public perception of women leaders.

This creates a huge challenge for ambitious women in politics or business: If they’re self-effacing, people find them unimpressive, but if they talk up their accomplishments, they come across as pushy braggarts. The broader conundrum is that for women, but not for men, there is a tradeoff in qualities associated with top leadership. A woman can be perceived as competent or as likable, but not both.... Professor Duflo and her colleagues found that by objective standards, the women ran the villages better than men. For example, women constructed and maintained wells better, and took fewer bribes. Yet ordinary villagers themselves judged the women as having done a worse job, and so most women were not re-elected. Professor Duflo asked villagers to listen to a speech, identical except that it was given by a man in some cases and by a woman in others. Villagers gave the speech much lower marks when it was given by a woman.

In response there were the expected anti-Clinton posts, the sexism-is-dead posts, and the not-feminism-again posts, but the one that pissed me off enough that I had to write was this one (by Nathan N):

To think that gender or race is even remotely relevant and anything other than a complete “red herring” is an intellectual confusion. To illustrate my point, it may be interesting to wonder whether horses or oxes as a group run faster. But when you have one actual horse and one actual ox and want to know which one runs faster, all the statistics and knowledge about how fast or slow the members of the two classes of animals generally run become completely useless. All we need to do would be to let them race and see which one runs faster.

Actually, Nathan, I believe you are intellectually confused. And to boot, you totally missed the point. In your horse and ox example, Kristof's point would most closely be translated to the observation that even if the horse and ox raced with the same time, the ox would be thought of as the faster animal. In fact, your argument is negated by the example in Kristof's article - in an objective measure of governing fitness women did better but were kicked out more often.

Not to mention the fact that in a timed race there is an objective standard whereas a public election is not only subjective, but filtered by the media. The effects of this subjectivity are seen for both genders; some of the most qualified candidates lost early in the primary season due to a lack of media exposure and having more substantive credibility than stylish panache.

And to all the people who responded to his column, Kristof wasn't making a case for Hilary. He was making a statement about how in some situations democracies can empower the very prejudices the system is trying to protect against. If you're going to respond to an article, at least read it first.

Why I sometimes don't like people

While waiting for the trolley this afternoon, I found myself standing near two young men and one older gentleman. In the five ish minutes we were waiting, all three of them spat at least twice. Which begs the question, when did it become kosher to spit in public? And not into a trash can, but onto sidewalks and public platforms. No one enjoys the spectacle of watching someone hock a lugie and I'm fairly sure no one wants to step on said mucus so why, oh why, do people spit in public? This is not the wild west - we are not all chewing tobacco and furnishing our living rooms with spitoons; I mean, come on, use a tissue, please?

Le Nozze Di Figaro

On Saturday night we headed to the Metropolitan opera to see Bryn Terfel and Simon Keenlyside in The Marriage of Figaro. It was a spectacular performance, but Anja Harteros stole the show. She played the Countess and received a longer standing ovation than either Terfel or Keenlyside. Her act II aria "Porgi, amor" and act III aria "Dove Sono" were riveting. Ekaterina Siurina was a lackluster Susannah in the midst of such a powerhouse cast; really only shining in her act IV aria "Deh! vieni, non tardar." It was only too apparent in the act III duet "Sull'aria" which soprano was carrying the show. There were two hilarious moments; one when a prop rolled off the stage and hit a cellist in the head (she finished the act and left), and another when Figaro motioned to Susannah to spank him in Act IV. Clearly, the Met and Terfel have a sense of humor.

On a different note, the dinner we had afterwards was also quite spectacular. Yum.

Defending the men

Apparently there is a happiness gap between men and women: the women are less happy. When economists and readers of the New York Times were asked to explain the gap, the usual suspects were brought up: women are expected to do more (paid work and house work) and suffer under the societal standard of being and looking perfect. This whole problem was then laid squarely at the feet of the men and their apparent expectations and laziness.

This is totally unfair.

First, a huge percentage of what we do is to impress other women, not men. A decent proportion of these "standards" come from women's magazines - one big reason I don't read them. It's time to accept that you cannot and will not be perfect at everything and that the only person annoyed by that is you, not your husband/boyfriend/father.

Second, men do no expect us to look like supermodels all the time. In fact, there a lots of men who prefer a girl in jeans who will eat a burger and go for a hike than one who is in 3 inch heels, a mask of make-up, and refuses to eat non-lettuce items. And this cuts both ways, the perfect male physique is shown in movies (Brad Pitt) and on magazine covers, they have the same pressure we do.

Third, when was the last time you asked a guy to help with the housework? I am willing to bet if you sat down and divided the duties, you would be pleasantly surprised with how much they're willing to help out. In fact, I know plenty of men who are quite happy to stay at home more while the wife builds a career.

It's time we stop blaming men for our lot as women and shoulder some of the responsibility ourselves. Why are young girls unhappy? Because other girls are so mean (remember the book on sororities... girls can be vicious). Who is creating this pressure to be the perfect everything all at once? We are.

Paying doctors less

There was an article in the New York Times recently arguing that the best and fastest way to decrease the cost of health care in the short term was to pay doctors less. I think the best way to decrease health care costs is to pay lawyers less. After all, less pay means fewer lawyers, fewer lawyers means fewer lawsuits, fewer lawsuits means lower malpractice insurance, lower malpractice costs leads to lower patient care costs. And honestly, what part of society, health care or otherwise, wouldn't be better served with fewer lawsuits?

Regardless of my lawyer pay scheme, there are several important reasons not to lower the pay of doctors and arguably, to increase it.

First, becoming a doctor incurs more debt than any other profession so salaries are needed that can cover the cost of living and the cost of paying back loans. In 2006, the average medical student graduated medical school with $130, 571 in educational loans (that does not include loans to cover the cost of living, which average another $16,689) with 72% of graduates carrying a debt load greater than $100,000. That's an 8.5% increase over the previous year (1). Assuming a 5% interest rate, a graduate needs to budget $7,363 per year just to cover the interest on the loan.

Which brings me to the second point. Doctors make almost no money until after their residency. For example, the pay schedule for residents at UT Southwestern in Texas is listed below (2). That's a 3-4% increase annually, which barely tracks the current inflation rates (3). So a medical resident is carrying a six figure debt load and earning roughly the same salary as the maintenance workers (4) (who I assume have less school debt and little specialized training). Now lets consider that residents work at least 80 hours per week, while the maintenance worker pulls only 40. Hourly, a resident makes less than a babysitter. Compare that to a law school graduate who gets a job at a large law firm and receives an average starting salary of $99,000 (5).

Third, there is the effect on lifetime salary. While most twenty-somethings are paying nice sums into their401K and reaping the benefits of matching funds and compounding interest, medical graduates are paying all their money to their creditors. Considering the average entrance age into medical school is 24 (6) and most residencies are at least 3 years, a medical graduate will be 31 before they have a chance of receiving a salary that would allow them to save for retirement or pay off the principal on their loans.

Lastly, let's look at who in the medical field is getting particularly high salaries and why. Your GP is probably barely covering the cost of his/her practice, not making millions per year. At the hospital I work in, there are some doctors pulling seven figure salaries, but they are highly specialized: pediatric cardio-thoracic surgeons for example. That surgeon did 13-14 years of post-medical school training so he was in his forties before he made any money. If you paid doctors like him less, no one would go through the incredibly lengthy training, take on that level of risk, or be able to retire before 80.

There are a few rock star dermatologists or plastic surgeons who command high salaries, but there are a few people like that in every profession. Their wages are not indicative of the thousands of doctors practicing every day and those are the doctors that will be put out of business if salaries are lowered. Not to mention how many fewer bright young people will aspire to become physicians instead of bankers or lawyers. Paying doctors less is not the answer; the result from reduced pay is fewer doctors and therefore longer waits and a lowered standard of care.


Sources
(1) http://www.ama-assn.org/ama/pub/category/5349.html
(2) http://www8.utsouthwestern.edu/utsw/cda/dept200270/files/214265.html
(3) http://inflationdata.com/inflation/inflation_rate/CurrentInflation.asp
(4) http://www.co.monterey.ca.us/personnel/SalaryPost.asp?jt=72C19
(5) http://www.collegejournal.com/salarydata/law/
(6) http://www.vault.com/articles/The-History-of-Medical-Schools-in-the-U.S.-27653519.html

Hear me roar

Fortune has an article in it's current issue describing the entrance of Gen-Y into the post-collegiate working world. Apparently we are the most demanding, least loyal, most connected, least apologetic generation to date. That sounds about right.

I am a prototypical Gen-Yer. I left my cushy banking job for exactly the reasons this article outlines: I did not have a sense my career was moving anywhere. I did not feel like I was doing any meaningful work. I had no real responsibility. In fact, I had more responsibility running the job fair for my university than I had at work; why would anyone stay at a job that feels like a demotion?

We did have international training exercises, which were a good idea: we networked with other young hires at the bank and got a sense of the global business. Our mentors on these exercises were upper management (again, good idea). But there was no follow-through. We would perform well, get fantastic feedback, and go back to 60 hour weeks pushing F10 and occasionally F12.

I was willing and ready to work 80 hour weeks and solve real problems. Hard work and little work-life balance were fine with me if I had a sense I was invested in my job, if I felt like I was needed and making a contribution. I wrote a strategy paper on how to make our entire North American derivatives business client focused and the comment I received back was: it's 200 words too long. In true Gen-Y style I cut 203 words from one section and replaced them with "see Appendix C". Then I quit.

If I'm going to "do my time" I'm at least going to do it somewhere I can make a difference. I am training to become a physician and during my internship and residency, my "slog", I will at least be making a contribution to the health of the people I meet. It may be a smaller scale than global finance, but it's also a more meaningful one.

I expect great things of myself. Call it hubris, but I find it insulting if you expect less of me than I do. I do not accept that I should work at less than my full capacity because I am young. Age should not determine responsibility; ability should. I am superwoman.

And apparently there are 79.8 million of me.

Back...ish

Unlike many of the more considerate bloggers out there, I simply disappeared rather than formally announcing a break. And it was a month long. Oops. Ah, but now we're heading into finals, which can mean only one thing: procrastination! And what better way to procrastinate than to write things and assume you have nothing better to do than read them?

I did my first alumni interview for my alma mater today and the student whom I was interviewing is also applying to my current institution. This worked out well for her since I was able to offer perspective on two of her choices, but now I have no formal way to notify my current school that while she's probably quite smart, she lacks that pizazz that I associate with the people I matriculated with.

In fact, she is planning on going to business school. She is the second person in the past few days that has expressed this future plan and in both cases I have proven to be a huge hippocrite. I have a business degree. I chose to get that degree. I switched out of a science degree to earn it. But I counseled both these young ones to get something else. Economics maybe, but not business. The unfortunate thing about a business degree is that is qualifies you exclusively for business jobs and you're actually still fairly likely to lose the spot to an engineer or an economist. Quant is in, so if you have the brains you are better served getting a more quantitative degree and taking the spot from a business major. I'm not saying you can't get a job with a business degree, but you better be a business kid with a whole lot of real math (not watered down business math). Well, at least in finance.

You know what the frustrating thing is? I was a business kid with a whole lot of math and do you know what I actually used when I got to my oh-so-coveted finance job? Differential equations (not required by business curriculum), writing (something employers ought to be looking at), statistics, databases, and programming. The last two also landed me my current job. It's a very good thing I got my business degree from the institution I did.

Business degrees prepare you for a job managing people, which is a job you won't actually hold in business for quite some time. Your first years are spent doing a lot of scutwork and the way you differentiate yourself is to teach computers to do the scutwork for you. That, and be able to form coherent, articulate sentences and say them without five "ums" and a "you know?". You spend four years learning how to effectively give orders and then graduate to 10 years of taking them.

There should be a new class added to the curriculum to supplement the strategy lessons: Interpersonal Politics. It should cover:
- How to get people to do what you want when you have no leverage
- How to differentiate the people you want as your allies
- How to recognise the ones trying to take you down
- How to maintain network contacts without looking like an idiot
- How to get around people in your way
- How to work with people that annoy the hell out of you
- How to deal with a boss that's dumber than you
- How to read between the lines

Actually, adding a class in No Limit Texas Hold'em wouldn't be a bad idea for the finance concentration. Poker is the Wall st. golf.