Dallas Buyers Club →

This movie should be required viewing for medical students, residents, pretty much any health care professional. Though there are several themes, I think it does an excellent job portraying the gulf that exists all too often between patients and doctors. Physicians tend to take a broader, more complex view while patients just want to do whatever it takes to get better. Both perspectives are valid and necessary, but are incompatible with one another without empathy. This is why I believe we need to be more inclusive of patients in all aspects of health care and do more things like patient-centered outcomes research.

Teaching Doctors the Art of Negotiation | Well Blog (NY Times) →

Something I didn't expect when I started medical school—the importance of negotiation and 'selling'. Doctors are constantly negotiating with patients, which includes 'selling' them on a particular diagnostic or treatment plan. Those who do this best meet that patient halfway. They empathize with the patient's situation while estimating their health literacy (which requires knowing your patient) and think creatively how to present options in a logical, understandable way. And that simple sentence encompasses what 7 years of training is largely about. 

There's got to be a better way... | Controversies in Hospital Infection Prevention →

Great post on the bureaucratic nightmare that is the 'compassionate use' process for using unapproved drugs.

I recently had the misfortune of experiencing the compassionate use process...I did a quick Google search to see how I could obtain IV zanamivir and learned that I needed to contact the drug manufacturer, the FDA and my IRB. I soon learned there were numerous forms to complete, almost all of which required me to record the same information over and over. From start to finish it took approximately 4 hours and the best word to describe the situation was kafkaesque...Maybe I'm just a simpleton, but couldn't there be a website where information is entered once and then routed to the appropriate agencies?...All of this makes me wonder how many patients don't receive treatment with potentially lifesaving drugs because the process is so painful, duplicative, time intensive and byzantine.

Similar byzantine processes exist for things like reporting adverse drug events...you know, not important stuff we don't want to have good data about.

Australian researchers sum up risks with medical apps | MobiHealthNews →

Nice summary of the potential pitfalls for medical apps intended for use by medical professionals. Their last major area of concern:

Finally, the researchers cite concerns about medical app developers. Developers may lack an understanding of healthcare contexts and standards. They may be using data mining tools as mentioned above. They may also have included very little (if any) end user input during the design of their apps, which could lead to safety risks and inaccurate information or algorithms.

We need to generate a robust developer community that includes physicians in order to create a generation of great digital tools specifically designed for doctors.

✚ Healthbook - Apple's foray into mHealth

A few days ago, rumors surfaced about Apple’s upcoming release of their next iPhone operating system (iOS 8) and the much-rumored ‘iWatch’ device. The rumors include details of a new health and fitness app with the code name ‘Healthbook’. Here are a few links:

I highly recommend each of these articles to get a broad picture; for those who are time limited, the first post from 9to5Mac gives great overall context while the analyses from Fred Wilson and MG Siegler (two tech VCs) discuss important questions.

To Fred Wilson’s point about hooking collected data into existing health infrastructure via APIs, not only does there need to be data exchange but there also has to be demonstrated value. We always think more data is better. More data is only better when it is actionable. The big elephant in the mHealth/quantified self room is that no one has quite figured out what to do with all the data. Some highly motivated quantified selfers are using it to change their habits, but what impact will it have on the rest of the world?

✚ The Real Problem with Medical Student Debt—Investors, Look Here!

[The following is an annotated Twitter chat between myself, Karan Chhabra, and Allan Joseph about the medical student debt problem. The quoted sections are our actual tweets and clicking the at the end of each will take you to the original tweet. I want to thank Karan and Allan for having the foresight to put this together. You can read more of their excellent writing at Project Millennial. Enjoy!]

America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors. Few people are more aware of the stress of medical student debt than med students themselves and there is evidence that it affects our specialty and practice decisions later on down the line.

The costs of American medical care are obnoxiously high. On this, few disagree. Part of these costs stem from the high salaries of our physicians. But their salaries might (or might not) be justified by their astronomical debt levels upon graduation. Few people are more aware of the stress of medical student debt than med students themselves, and there’s evidence that it affects our specialty and practice decisions later on down the line.

Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem. We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.

@JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded

@krchhabra: ARGH RT @JoshHerigon: Median med school debt today = $170k vs in 1978 = $48K (adjusted for inflation). http://goo.gl/iTtMH9 #meded

@allanmjoseph: @krchhabra @JoshHerigon Yes, but…more demand than ever for spots, & vastly higher teaching/resources since then. Complex issue.

AJ: The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.

@krchhabra: @allanmjoseph @JoshHerigon I’m skeptical that teaching is any more resource-intensive than it once was (except perhaps for standardized pts)

KC: Standardized patients are actors paid by medical schools to act out clinical scenarios as we pretend to be doctors. They’ve been a useful component of clinical skills instruction for several decades—but their help isn’t free.

@allanmjoseph: @krchhabra @JoshHerigon At least here, our student:instructor ratio is insanely good, and so are our useful support structures.

@allanmjoseph: @krchhabra @JoshHerigon Not saying it’s all reflected, but I also don’t think it’s an apples-to-apples comparison.

@JoshHerigon: @allanmjoseph @krchhabra Our campus is probably nicer…

JH: Even more than a decade ago when I was an undergraduate, the arms race between universities to build bigger and better facilities was well underway. Examples are not hard to find. Medical schools and academic medical centers are active participants in this trend. In 2007, my own institution announced a 10 year, $800 million expansion. It’s not clear how capital improvement projects impact student tuition—administrators argue such projects are paid by dedicated capital funds, supported by the state, private donations, and/or bond initiatives. But, new facilities increase annual maintenance budgets and in the face of shrinking annual operating budgets, where do administrators make up the difference? Again, the impact of capital projects is not obvious; what is obvious is that tuition rates have not decreased with these projects.

@krchhabra: @JoshHerigon @allanmjoseph But we’re talking about secular time trends. Is your student/teacher ratio better than it was 20 years ago?

@krchhabra: @JoshHerigon @allanmjoseph of course there’s more small group learning than there used to be. But that doesn’t justify 3x price increase

@krchhabra: @JoshHerigon @allanmjoseph I use “price” intentionally - schools can charge whatever they want; the govt and students will always oblige.

KC: Once an English major, always an English major. I’m trying to highlight the difference between prices and costs here–costs the amount of resources expended in providing a service (a pretty objective quantity), whereas prices are chosen by the seller (often based on the highest amount the market will tolerate). What I’m trying to say is, the rapidly rising price of medical education doesn’t necessarily reflect increases in its underlying costs.

JH: Federal support of education through student loan programs has increased access to higher education, but at what cost? Students are now insulated from the true price of their education. Their tuition payments are abstract numbers on a page they see once a semester. Financial aid counselors (in my limited experience) fail to explain the true financial impact of student loan payments. Students are sold on the various deferrment options, repayment plans, and forgiveness programs (most of which students won’t qualify for or will increase the overall cost through deferred interest payment). Even with sufficient explanation, it’s hard to fully conceptualize until you make that first payment.

@allanmjoseph: @krchhabra @JoshHerigon Fair enough. Aside: I also think med students whining about debt can come off as tone-deaf, even if justified.

AJ: Quite frankly, when physician unemployment is nonexistent and even the lowest-paid specialties average six-figure salaries, we don’t have a lot to whine about. The reasons to care about this, from a policy perspective, are the positive externalities (that don’t accrue to doctors) from having the best and brightest students enter medicine.

@krchhabra: @allanmjoseph @JoshHerigon in light of future incomes? Perhaps. Though I think the average doc’s income will drop vs those trained in 78.

@allanmjoseph: @krchhabra @JoshHerigon From a systemic standpoint, they probably should, at least in many specialties. (Shh, don’t let the AMA hear!)

@krchhabra: @allanmjoseph @JoshHerigon it’s okay. There will always be surgicenter facility fees for when we need a quick buck (right?)

KC: Historically, doctors and hospitals have been paid separately for work that happens within a hospital’s walls. Doctors get a “professional fee” for their time and expertise, and hospitals get a “facility fee” for nursing care, materials, and all the other costs they incur in providing care. But in physician-owned surgical centers, doctors get both the professional fee and the facility fee. It’s as lucrative as it sounds, though Obamacare plans to curb these arrangements.

@JoshHerigon: @krchhabra @allanmjoseph Ha! Or you can always moonlight during residency…

JH: Moonlighting is when a doctor works outside their regularly scheduled hours (typically overnight, hence the name). Residents have historically done this during their training to supplement their paltry salaries. However, resident work hour restrictions are now decreasing this (moonlighting hours count against the total hours worked).

@JoshHerigon: @krchhabra @allanmjoseph Not saying med school should be free or even debt-free, but we need lower prices and better loan terms.

JH: I believe loan terms are the core issue and have been for a long time.

@krchhabra: @JoshHerigon @allanmjoseph You nailed it with loan terms. Super generic, don’t account for reliable, delayed income doctors get

AJ: Most medical students borrow for medical school through the federal government’s Stafford loan program, as well as the Graduate PLUS program if needed. It looks like there’s a lot of repayment options, but when you dig into it…they’re all variations on very few themes.

KC: And the problem with that is, the incomes of med school grads have little in common with those of other grad schools. Most grads (law, business, PhD, etc.) see a healthy income soon after graduation, increasing steadily thereafter. Medical school grads look forward to 3–10 years of paltry income while they’re training, followed by a huge jump once they’re board-certified. Loan payments can be suspended while in training, but the debt still accrues interest at a rate equal to other graduate loans. This makes little actuarial sense when you consider how low physicians’ default rate ought to be, compared with graduates of other programs. (Physicians’ unemployment rate is 0.8%, versus 2–3% for graduates of any graduate/professional school.) A tailor-made loan for medical students would adjust for physicians’ comparatively low incomes at graduation as well as their substantial, reliable incomes after residency. Though I’m not an actuary, I think loans on this terms would be much more fair and affordable.

@allanmjoseph: @krchhabra @JoshHerigon Absolutely. 100 percent agree with you there.

@JoshHerigon: @allanmjoseph @krchhabra One of you guys should create a start-up that buys up med school debt at better terms. ;)

@krchhabra: @JoshHerigon @allanmjoseph I’ve actually given this some thought. Just need a few wads of money I don’t currently have ;-)

@JoshHerigon: @krchhabra @allanmjoseph Me too.

@allanmjoseph: @JoshHerigon @krchhabra And now I’m giving it thought instead of reading about NK cells. Let’s find an angel investor.

@allanmjoseph: Hey, followers, @krchhabra, @JoshHerigon and I have a killer business idea. Who wants to give us a few million to make it happen?

AJ: We joke about this, but it’s moderately surprising some enterprising financial firm hasn’t found a way to make this happen. (There’s probably a regulation about federal student debt that hampers it, but still.) More obviously, though, there’s room for policy changes to improve this system.

The academic diet of the 21st-century medical student | Scope Blog →

Mihir Gupta:

The two most popular resources [for med students on their internal med rotation] were both banks of practice questions, while the next two included a review book and a pocket handbook. (The top four resources: MKSAP question book, USMLE World question bank, Step Up To Medicine review book, and Pocket Medicine.)

This is in no way surprising. Look at almost any med school grading rubric and you will see that for clinical rotations, the Shelf Exam (a multiple-choice test) accounts for the majority of the grade. Medical schools do a poor job of evaluating how well students care for patients and develop clinical reasoning.

…As one surgery faculty put it, “Would you really want your life in the hands of a doctor who aced his multiple-choice boards questions but hasn’t read a textbook?”

I don’t want my life in the hands of a doctor who only aced his multiple-choice boards questions nor one who just read textbooks [1]. I want a doctor that did both of those things, but also completed intensive clinical training under the guidance of expert clinicians. We can easily measure performance on multiple-choice exams and even textbook content; it’s very difficult to objectively measure clinical expertise.

Until medical schools and the National Board of Medical Examiners develop methods other than multiple-choice exams for evaluating students [2], students will continue to use the most expedient resources to learn material for such exams (e.g.—question banks).

  1. I wonder how much this surgical faculty member has relied on Step scores and class rank for choosing residency candidates for his program. The high stakes of Step scores for residency selection drives students to study in terms of exams instead of clinical knowledge.  ↩

  2. Let’s be clear—multiple-choice exams are problematic for evaluating students. It’s not because our heavy reliance on them incentivizes students to use question banks instead of in-depth studying with textbooks. Multiple-choice exams are problematic because they limit the scope of topics to well-characterized diseases and treatments. For example, chloramphenicol is an antibiotic developed 1949 and one student’s studying for Step 1 typically memorize as it may appear on the test. Why? Because it has a well-characterized and unique side-effect—gray baby syndrome—that lends itself to biochemistry questions. Unfortunately, chloramphenicol is rarely used in clinical practice. The only people who may use are infectious diseases doctors and only as a last resort. So, students spend time learning about this drug they may never encounter in practice instead of dedicating time to more commonly used antibiotics.  ↩

Why Aren't Doctors More Tech-Savvy? | The Atlantic →

This hassle is exacerbated by the fact that healthcare is one of the few consumer-focused industries where being a few minutes late is a sin so grave that it’s punished with a total cancellation of the appointment, and sometimes even the forfeiture of the fee.

I was ten minutes late to an appointment the other day, and the doctor poked his head out the door to let me know I’d have to reschedule.

“Can I come tomorrow?” I said.

“Give me a call.”

This article is full of such great quotes it’s hard to choose a single one to highlight its awesomeness.

One problem with American healthcare is that it attempts to staple a simple documentation system favored by doctors, who prefer to focus on patient care, onto an increasingly convoluted payment system favored by insurers. Nothing compares with the agony of losing the paper itemized receipt from an out-of-network doctor that you were planning to file for reimbursement using your insurance website. (Also, be sure you have a scanner at hand! Remember scanners? You bought yours in 1998.)

I pulled out this paragraph because I see this as a major problem. Medical records, which have traditionally functioned as a physician-to-physician communication tool, are now driven by billing considerations. Since payment by insurers is dictated by what is contained in the medical record, doctors are bastardizing their records to conform with what the insurers want. No longer are they about the patient; they’re about insurers.

✚ Shorten med school, but not overall training

This past week, the Washington Post published an article detailing some recent efforts to shorten med school to 3 years. The illustrious Dr Cranquis weighed in with his usual acerbic, dead-on commentary.

Pauline Chen MD took on this issue back in October in the NY Times, primarily in response to point-counterpoint essays in the NEJM. As with this most recent article, it generated quite a bit of commentary. One of the most thoughtful and informative pieces I read in response to Dr Chen’s article was from Josh Freeman MD, a professor of Family Medicine at my own institution and graduate of a 3 year med school program.

One lesson I’ve taken to heart in medical school is that good education takes time. In order to truly learn something, you have to read and think about it, breathe it in and live it [1]. Doing so takes time. The implication of this is that appreciably shortening the time to train a doctor will likely be difficult.

However, just because shortening total training length seems unwise or difficult does not mean we still can’t reform the structure of medical training. Ideally, I think we should shorten medical school to 3 years but lengthen residency training to 4 years (which would maintain 7 total years of training for most specialties). A greater emphasis needs to be placed on premed education so that basic science education can be completed in the first year of medical school. Some of this can spill over into the clinical training in second and third year. For example, intense anatomy education with time in the cadaver lab seems better suited to occur during a surgery rotation rather than 1–2 years prior. Basic clinical training—which now occurs solely in the 3rd—could be spread over two years.

In terms of residency, such a schedule could help cope with the increased focus on limiting work hours and patient safety. Residencies would have an additional class to help with patient care. The interns would gain more active patient care experience while the senior residents will have additional time supervising trainees.

Our current training paradigm poorly allocates time. Nearly everyone in medical education will agree that active patient care is where the most useful and longest-lasting education occurs. Instead of blindly trimming a year off of training, let’s reallocate that time to more useful education and contribute to taking care of our ever-increasing patient population. [2]

  1. This is why the bulk of medical education (3rd &4th year of med school + a minimum of 3 years in residency; 5 of 7 years) is hands-on, seeing and learning from real patients.  ↩

  2. Will such a restructuring ever happen? Almost certainly not; it would disrupt the current economics of medical education too much. Medical schools would get one less year of tuition and residency programs would have to find ways to support an additional class. Residency programs can’t even find money to expand their classes to cope with the increased number of med students. How are they ever going to deal with a seismic shift like adding a full residency class?  ↩

How doctors choose doctors | The American Resident Project →

Zack Permutt MD:

Why is it so difficult to find a good doctor?

Why are we still using word of mouth when it comes to choosing doctors? 

Why is the health care industry so far behind in bringing the basics of social media to help improve the patient experience? 

Great post on the arcane methods we use to select some of the most important people in our lives.

Evidence based medicine—it’s time to be critical | BMJ Blogs →

Speaking of evidence-based medicine, here is a great piece by William Cayley:

It takes effort to go beyond what the guidelines, experts, and adverts give us, but that work is part of medicine—and critical thinking about how to do a better job of curing, comforting, and caring is at the heart of being a doctor.

✚ 'Real Science' is so much more than controlled trials

During this past week’s #meded chat [1], I stumbled upon the following tweets from Joel Topf MD:

The thing about resident research is that real science is multi-center with hard outcomes. #MedEd 1/3 [original]

The time and $ limitations of residency prevent implementation of these types of research studies so… #MedEd 2/3 [original]

We really are teaching residents to think small and how to do poor research. This is not a good idea. #MedEd 3/3 [original]

The same day, I heard a prominent researcher giving Grand Rounds state, ‘We have to do real science and randomized-controlled trials are real science.’

The notion that ‘real science’ is solely the purview of large, multi-center randomized-controlled trials is a dangerous one. Yet it is a refrain I hear often.

All things being equal, a large, multi-center, randomized, placebo-controlled trial is the strongest method for answering a question [2]. But things are never equal. Research is constrained by the real world. Ethics, time, and money all participate in the process of systematically answering a clinical question.

Often, it is not ethically possible to randomize one group to treatment and one to a placebo. This is generally true when a known effective treatment exists—antibiotics are a good example—and it would be harmful for the patient to withhold the existing treatment. In such cases, non-inferiority or equivalence trials are conducted.

Time also plays a major factor in answering clinical questions in which the clinical sequelae take years or decades to develop. Cancer studies are the classic example here [3]. It is nearly impossible to conduct a randomized trial of almost any exposure we believe leads to cancer (or is protective) because cancers can take decades to manifest themselves. Such a study would be plagued by loss-to-follow-up and high costs. In such situations, we use case-control studies.

Even though we don’t like to admit it, money frequently determines research priorities and design. One area where large, multi-center, randomized, placebo-controlled trials are routinely conducted is pharmacologic prevention of heart disease. Why? Because pharmaceutical companies can make billions of dollars on a single blockbuster drug to support such research. They use very large trials because these are convincing to doctors and they invariable demonstrate ‘statistical significance’ even for very small improvements. In most other areas—especially pediatrics—there is generally not such a free flow of money for expensive controlled trials.

This past week, we were reminded about the Surgeon General’s 1964 report on the ill effects of smoking. This report relied on over 7,000 documents. None of the evidence used in this report included human randomized trials. In fact, the lack of controlled trials is what the tobacco companies used for years as a rebuttal to the medical evidence against smoking. Are we any less convinced today of smoking’s ill effects because it is not supported by the ‘real science’ of controlled trials?

The BMJ illustrated the many limitations of randomized-controlled trials in their classic article, ‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.’ Given such constraints, controlled trials are only possible for a fraction of our clinical questions, yet we answer meaningful questions with good research all the time. Our problem is not a dearth of controlled trials, but an overabundance of bad research of all types. A bad, poorly designed randomized trial never trumps good cohort or case-control studies. Our focus should not be on study type, but the overall quality of research.

To Dr Topf’s point about ‘teaching residents to think small and how to do poor research,’ I will grant that I think this happens frequently [4]. However, it’s not because time and money constraints preclude us from engaging them in randomized trials, but because mentors seem complacent with involving residents in bad research. Too often, resident research projects seem to be poorly designed chart reviews. This is an exact recipe for how to turn residents off to research—tedious data collection with little prospect of wide interest.

I am enthusiastic about research in large part because I have avoided projects that require lots of tedious data collection and because I’ve had some early success. The first paper I led was picked up by the mainstream media and has been cited dozens of times. This should never be one’s sole measure of success, but it certainly helps to know that some people think the work you’re doing is worthwhile.

How do we ensure similar success for residents? First and foremost, make sure we are asking clinically meaningful questions. Mentors are crucial for this. While a resident (or med student) may see a pattern in their clinical experience and want to explore that further, a mentor must guide the question with their knowledge of the research world’s context. This involves shaping the original question to be meaningful in light of existing research. Mentors have the unique perspective of ‘knowing the field’. I have proposed many research questions that were subsequently modified or outright turned down because my mentors correctly recognized they would be low-value in light of existing or planned research.

Second, use the power of electronic medical records to avoid tedious data collection. EMRs and large databases allow us to extract datasets in a fraction of a second to answer clinical questions. I truly believe if residents are given the opportunity to spend the bulk of their time manipulating data, instead of collecting it, they will enjoy the research process much more. Alternatively, give residents access to an existing dataset for subanalysis; anything to avoid tedious data collection.

Finally, it is important to champion residents’ research. While it is great to support the dissemination of resident research through an institution’s own conference or research day, it much more fruitful to present elsewhere. Here, mentors can make sure they target the proper conference or journal for dissemination. Such targeting should begin as early as the conceptualization and design phase (an ‘insider’s trick’ not often talked about).

I truly believe research should be an integral part of medical education, both at the undergraduate and graduate levels. Evidence-based medicine is pervasive throughout health care today. Trainees need an understanding of the utility of evidence and, more importantly, its shortcomings. The best way to gain this understanding is to participate in generating such evidence. It gives trainees a rare, behind-the-scenes look at the outwardly glossy, but inwardly messy research world.

  1. I was not able to participate in this #meded chat. If you also missed it, you can read up using the transcript.  ↩

  2. Arguably, a meta-analysis is the definitive research study. However, in terms of single studies, controlled trials still reign.  ↩

  3. To be clear, I’m talking about carcinogenic exposures, not oncologic therapeutics.  ↩

  4. Prior to medical school, while working full-time as a researcher, I had the opportunity to work with a few residents on research projects. I’m not coming to this topic completely cold.  ↩

✚ Make waffles for your residents

Nobody likes to work on the weekends. However, people obviously get sick and need to be taken care of on most other peoples’ days off. In academic medical centers, attendings (the physicians in charge) try to make weekends a little bit more palatable for residents and medical students by not asking too many educational questions (i.e.—“pimping”) and running a relaxed schedule.

Let me suggest an even better solution: make waffles

This has many benefits:

  1. Everybody loves waffles
  2. They are easy to make (use a dry ready-to-make mix) and can be accomplished with little equipment and effort
  3. You can get really creative with some simple toppings
  4. Waffles fulfill a basic and persistent need among residents and med students (i.e.—food)
  5. It is a fun, team-building exercise

This last point is actually the real reason why I think you should make waffles in one of the resident rooms after morning rounds. Bring multiple teams together in the house staff area and delegate tasks (usually to the med students because…well…because why not). A few can mix up the batter, others can slice up toppings while someone runs the waffle iron and another makes coffee. While all of this is going on, people are talking, making jokes, enjoying each other’s company, and may be doing informal education in the form of discussing difficult cases they had over the past week or talking about something they just can’t figure out.

Bottom line—making waffles gets people out of their silos. All of medicine hinges on communication. Anything we can do to improve communication—by meeting the other residents and students on other teams/services—will improve health care. So, next weekend try making some waffles.

Health care in America: Going public, and private | The Economist →

...by the early 2020s the taxpayer will be footing the bill for half of America’s health spending, which will have risen to a staggering $5 trillion, equivalent to one-fifth of the country’s entire economic output.

I find this a bit unnerving...all parts of it.