Is there a doctor in the house?

First off, you're probably thinking that I never intended on blogging EVER since I'm actually too busy with school and all that. BUT, you're all wrong, I'm just saving up awesome stuff to blog about. I'll bring them out as time goes on, it's mostly about patient confidentiality issues and all that stuff.

So, recently, I had my first experience of medicine in the public world. Emergency medicine, even. It has made me fall in love with the field even more.

Okay, onto the story. No names or identifying information is included for the protection of patient confidentiality. Yup, I uphold my HIPPA stuff.

Background: Earlier in the day, I was on call for my surgery clerkship. I got off around the afternoon after spending most of the day in surgery and lectures. Got dinner and all that and finally going out again for the evening. I spent the latter half of the evening at the ice skating rink with some newly made friends and meeting new people and having a grand time.

Incident: Near the end of the night, someone got injured and a couple of people that I met earlier that night pulled me aside and said, "Hey, you're the med student, right? Come help us out with this guy, he's cut up."

At the scene of the incident, there was a young teenager with a paper towel covered in some amounts of blood. While I was walking over, the history was related to me by an observer that the patient was cut by a ice skating blade and has been bleeding. I surveyed my environment and noted there was an open first aid kit on the bench, the patient, the patient's friend, and maybe a good 50 bystanders getting ready to leave for the evening.

Patient: Young teenager with several paper towels with some blood, in a lot of pain, vocalizing about his pain and covering his mouth. He appears otherwise in good health at first glance.

The patient's friend immediately told me that she is going to get the car around and asked me to do whatever it is that needs to be done and immediately left the scene. I examined the patient and asked him to let me take a look at the wound.

Wound: It appears to be an open incision made by a sharp object, it appears to be a 2 cm incision made through the upper lip at a 60 degree angle to the mouth from the midline towards the left just below the nose. The wound continues to bleed and the paper towel seems to be soaking up most of the bleeding.

I obtained additional history from the patient at this time. He had not yet washed out his wound and had only cut himself moments before I arrived on the scene. There were no immediate danger in the environment, I asked the patient to head over to the bathroom and wash his wound out as best he can. While the water may not be sterile saline that we wound normally use to wash out the wound, but irrigation of the wound seemed the best idea at this time to remove any contaminants that might have gotten into his cut.

While he went to wash out the wound, I looked through the first aid kit for anything to further disinfect the wound and prep him for the ER visit. I found a bottle of hydrogen peroxide, some povidone iodine wipes, alcohol hand sanitizer, and a small band-aid. The patient came back at this time drying his face with a fresh paper towel and avoiding the wound.

Tools of the trade:

Hydrogen peroxide - this is good to kill off a good amount of bacteria and viruses for surface wounds and cuts and it gets into the cut itself to kill off any Clostridium tetani (anaerobe that causes tetanus) that might get into a deep wound like this; this also causes a mild amount of damage to the tissues in open wounds and is quite effective at stopping capillary bleeding.

Povidone iodine wipes - this is the stuff that is used in scrubbing incision sites for surgical procedures as well as cleaning skin wounds; which is ideal for this situation as he has an open cut.

Alcohol hand sanitizer - this is obviously very important for the safety of the patient as I would not want to contaminate his wound with bacteria on my own hands.

Small band-aid - this is especially useful in this case to keep the incision closed, normally, this is done with steri-strips, stitches, skin glue, and various other techniques found in the hospital environment, but here, band-aid will do.

Having gathered all of my tools, I started my work. Patient was still in pain. I sprayed the incision with hydrogen peroxide, the patient yelped in agony for a bit. Sprayed it again, same effect. The wound was bubbling appropriately with the hydrogen peroxide. I then rubbed the wound's outer edges with povidone iodine wipes to clean off the edges and around it. And finally applied the band-aid, taking care to keep the wound together and prevent further contamination during transport.

During the time, the patient asked about scarring and what they would be doing in the ER to him. This wound would likely leave a scar if it doesn't close nicely, but given the straight incision and immediate care, the scar may be unnoticeable in weeks to months. And I advised him that they would likely stitch this wound up at the ER as it is fairly deep. I also gathered from him how he came to receive this incision. It seems that the patient had tried to remove his ice skate and had done so too aggressively and gotten too close to the edge, so to speak.

The patient's friend came back with the car and I sent them on their way to the ER and packed up the first aid kit and washed my hands.

Aftermath: The patient then spent 3 hours at the ER and got stitches for his incision. I later found this out from the friend at a later date.

So, that's how it went and I felt like a superhero and was treated pretty much like one for a lil' bit. It was exciting and fun and rather rewarding. I think I confirmed my calling in emergency medicine that night. Yup, this is what being a doctor will be like in the upcoming years, and I'm excited about it. =o)

End of Day 1

So I'm starting on Family Medicine. For those of you that don't know about the breakdown of specialties, doctors that specialize in Family Medicine (hence forth shortened to FM) are generally the family doctor, the American version of the General Practitioner or GP as it is commonly known as. Requires 3 years of residency training after graduating from medical school and treats patients from all ages and medical conditions. The FM doc also does a ton of procedures in the office, prescribes medication and treatment plans, refers patients to community resources and specialists for additional help. You'll often hear the FM doc described as the Quarterback of patient's care.

For those of you not familiar with how the clinical rolls, I'll explain briefly. We go through rotations that are 4, 6, 8, or 12 weeks long to learn about different specialities and how to diagnose and treat a variety of diseases. The core rotations are as follows: OB/GYN, Family Medicine, Psychiatry, Neurology, Pediatrics, Internal Medicine, and Surgery. Internal Medicine itself is broken down into multiple subspecialties and a med student gets rotated through different ones to get a sense of subspecialized internal medicine care. And all of these have hospitalized patients at the hospital setting and ambulatory (walk-in) patients at the clinic setting. I'm starting with Family Medicine this month, and specifically, we don't have in-patient care for this rotation, but we are allowed to sign up for a rotation in our 4th year through the in-patient family medicine wards.

So, for the first day, we learned about musculoskeletal problems and dermatological problems as well as getting oriented to the whole rotation as a whole. I'm basically scared of how much stuff I need to learn within the next 4 weeks. I mean, really, you're talking about anything that you could possibly go see a doctor for. This includes that sore throat, the cough that won't go away, the blood in your stool, the menstrual period being irregular, feeling tired, lower back pain, pain in any part of your body, weird mucus or smell coming out of different places on your body, a rash, acne, the list can really go on and on. It's going to be crazy, so....I'll start reading and start learning....fast! 'cause I'm seeing patients tomorrow!

A Pray Before Starting Clinical Rotations

So I'm going to start my clinical rotations tomorrow. My prayer is that I will care as much about medicine, the patient, society, the big picture, and people in twenty years as I do now. I pray that I don't become jaded by the ways of the health care system. I pray that I stay committed to advancing the rights and interests of the patient and do so in the best interest of my patient and society. I pray that I practice what I preach in preventive care, diet and exercise. I pray that I never stray from the path of doing what is good and right for the patient, myself, and society. I pray that I will become a dependable doctor, a leader, an advocate-activist, and a role model for others. I pray to become the best that I can be and never settle for my own second best. These are the prayers that I will carry with me as I begin my clinical training and hope that I will carry through with them.

Delusional...

I think I get delusional after I write for more than an hour. -.-;; So if the previous post sounds like a madman's ranting in terms of organization and stuff, it's 'cause it's past midnight and there's too many tangents to go off on. =oX

Fixing Medicine in America: Debt & Compensation

Alright, this is going to be an ambitious blog entry. So ambitious that I don't think I'll be able to possibly do it adequate justice with one post that I'll probably blog a bunch more times on it. So, I'm going to blog on a subtopic this time around.

So in the midst of my furor of studying, I took some time out to chat with my dad about the health system in the US and he proposed a couple of good ideas. I'm going to take those ideas and add my own twists to them and apply them in a practical manner. Because this topic is going to span across multiple areas throughout the health system, I'll do my best to explain how everything works to the best of my understanding. So, instead of studying like I should be, I'm gonna blog a few hours on this topic.

I'll lay it out, eliminate medical school tuition and pay doctors purely on salary with bonuses on performance. Now, this may sound extremely radical, but hear me out, it will sound reasonable by the end of all of this.

As you already know from my previous entry that med school costs about $300K USD in today's money for all 4 years. So, there is a built-in financial burden for the student to choose specialties that may not necessarily be a specialty that a student wants on a purely interest basis. But instead, students may be motivated to choose a specialty that pays better, has better hours, and doesn't require as much effort, especially after enduring 8 years of living as a starving student. There will be a financial component built into whatever specialty a student chooses simply because of this huge amount of loans that a student needs to pay back over, say....a 10 year timeframe after med school. So, essentially, a medical doctor has the financial incentive to pick a specialty that will likely reduce this "time to net inflow of cash" to catch up with his/her peers that have been working in other fields for the 4 years while he/she was in school collecting Stafford Loan statements.

This financial aspect of medical school you understand now. We'll move onto how the system has created financial incentives to choose specific fields. As much as the counselors and elders tell you to choose what you love, there's always an inherent bias to point you towards lucrative fields. This is why we have people aspiring to be lawyers, accountants, CEOs, I-Bankers(before this crisis), engineers, and doctors. While, yes, we should be paying these people more because they add value to companies and generate more cash flow and do things that no one else can really do properly or they keep you healthy and alive so you can make money, too. So, 6 figure salaries are justified, 7+ figures are pushing it, but that's a topic for another time and another blog. In any case, within the field of medicine, there is a hierarchy of well-paying specialties and less-well-paid specialties.

I'll list some of the commonly known ones, ROAD ones, and a few other less commonly known ones. I'll list with them the years it takes to come out and practice, how much they get paid in clinical practice because academic medicine pays much less.

Specialty - Years of Residency+Fellowship - Step 1 Median Score - median estimated starting clinical practice pay
(1+3 means a year of internship and 3 years of residency in that field)
(3+3 means 3 years of residency and 3 years of fellowship)

General Practice Specialties

Family Medicine - 3 years - 209 - $150K

Pediatrics - 3 years - 217 - $150K

Internal Medicine (General) - 3 years - 222 - $180K

OB/GYN - 4 years - 213 - $230K

General Surgery - 5 years - 222 - $260K

ROAD Specialties (so-called "Lifestyle" specialties)
Radiology (Diagnostic) - 1 + 4 years - 235 - $310K
Ophthalmology - 1 + 3 years - 235(mean) - $240K
Anesthesiology - 1 + 3 years - 220 - $330K
Dermatology - 1 + 3 years - 240 - $330K

Subspecialties

Internal Medicine (Cardiology) - 3 + 3 years - $340K

Neurology - 4 years - 219 - $220K

Others

Psychiatry - 1 + 3 years - 208 - $200K

Preventive Medicine - 3 years - Only 3 people in the US bothered to apply last year.

Of course, the compensation data is from surveys, I doubt highly compensated folks would be as likely to fill out the survey. So, of course, there's not enough data from certain fields and I expect many of the fields are underreporting their numbers. For instance, Plastic Surgery doesn't have enough or any data for Clinical Practice compensation, but I'm sure you can imagine 7 figures already. Comestic Dermatology could easily make more than $300K; think Botox, Chemical Peels, and Microdermabrasion. Then factor in the practices that don't take insurance. Then you've got yourself a bunch of money grubbing docs that feel entitled to a ton of money taking care of richer folks while the rest of the docs are taking less money to take care of the underserved folks, ie. the family practice docs in underserved urban areas.

So, if we eliminate the debt and normalize salaries for doctors, the competition for specialties should flatten out into purely interest based specialities and a greater flow of brilliant students into medical specialities with greater need rather than the lucrative ROAD specialities. By paying doctors salaries with bonuses on performance, we can focus more on health problems that net the greatest amount of benefit in terms of mortality and morbidity for everyone.

For instance, I believe that a doctor should be paid more for convincing a patient to quit smoking than a doctor that gives a patient a botox injection. But the way the system works now, a doctor doesn't get paid to convince a patient to quit smoking nor is he encouraged to do so due to the time necessary to do so. Also, a botox injection isn't covered by insurance, so the dermatologist can charge whatever rates the market will bear. So, in this example, a patient that gets less wrinkles will pay the doctor a lot of money, but will not pay the doctor much anything for getting him to quit smoking. And this example works because quitting smoking would have prevented much of the wrinkles in the first place and prevent the patient's early death from complications from pneumonia, COPD, heart disease, or cancer, all of which would've costed the health system a ton more money. So the family practice doc would have saved the health system tens of thousands of dollars by getting one person to quit smoking but gets paid peanuts for doing so.

Right now, there is a financial link of doing procedures to the doctor's paycheck. Right now, every time a doctor does a mammogram, colonoscopy, pulmonary function test, or whatever other test, the doctor gets paid for his time and efforts. So, a doctor is financially incentivized to do as many procedures as he is allowed to do to net himself more pay.

Also, the current malpractice environment incentivizes a doctor to do every possible lab test on a patient to rule out every possibility should there be a hint of a possibility of being anything other than the most common diagnosis. This will help to prevent the doctor or the institution from being sue because the doctor had covered all of his bases, warranted or not.

Of course, there are ways for labs to give doctors kickbacks for sending them more labs to run that don't show up on financial statements. This is obviously highly unethical, but you have to realize that many medical students do go into medical school with stronger financial motivations than altruistic motivations. And, despite the efforts of medical schools to teach ethics and screen for ethical individuals, we know that ethical behaviors and personalities cannot be taught and unethical individuals may be pathological liars. Ethical people have upbringings that emphasize ethical behavior and thinking, these are not things that we can expect to infuse into people that aren't ethical to begin with.

By severing the connection between the number of procedures and financial gain, we can expect to see a better rationing of procedures as needed. By linking salary levels to experience, performance, and level of training may be the more reasonable way to go about everything as to encourage doctors to continue to improve their skills, learn more, and follow their interests.

Now, we should put performance bonuses into the whole fray of things because medicine is about improving lives and extending life. A doctor should get more bonuses for saving the health system money that would have been spent on treating a patient for potential COPD. For instance, we should pay a doctor a bonus for doing any of the following things: getting a patient to successfully quit smoking, getting a patient to maintain a healthy diet and exercise plan, getting a patient to follow a drug regimen, improving a patient's health literacy, among others. These are all things with long-term cost-reduction benefits that should be encouraged. The reason why this isn't done already is because a doctor is forced to see as many patients as possible and 15 minutes is all a patient gets with the doctor because the health insurance system rewards a doctor for efficiency and doing more procedures than taking the time to get to know the patient. This is why you all should get a doctor friend that knows you well, it's cheaper and probably healthier for you.

In any case, performance bonuses for extending and improving a patient's life while saving the health system money. So, base salary is probably very basic, like a low number with everything else focusing on improving patient lives. A family practice doc should be making a good living if he can convince all of his patients to stop smoking and have healthy diet and exercise. Much as a surgeon could if he can convince patients to take up the healthy diet and exercise after performing a coronary bypass on the patients. Emergency room doctors can prevent future visits by teaching patients how to prevent future traumas. So, everyone could potentially get bonuses by intervening at the right places. Granted, we would need implement fail-safe systems to prevent fraudulent bonuses from doctors claiming they have gotten someone to quit smoking, but that's more of a details and implementation issue for another time. If we had this sort of a system, we can definitely help fix our obesity epidemic and cut health care spending by an extraordinary amount.

Of course, back to the medical school tuition deal, we eliminate tuition and pay for living expense for going to Medical school and salaries during residency training and beyond. (This is a model that University of Central Florida Medical School is doing.) By doing this, students will be free to choose specialities based on their own interests and strengths rather than their financial situations. Then, we eliminate the salary differences among specialities and pay according to experience, skill, training, and performance to eliminate financial incentives to pick any particular speciality over another based on financial reasons. By turning medicine into a sort of government employment with paid training and graded pay scales, we would eliminate disparities across specialties and recruit people by interest and skill. Then we incentivize clinical performance with performance bonuses based on cost-cutting measures and life enhancing and extending activities and procedures. And of course, we need a single payer system, cut out insurance entirely, and have the entire system taxpayer funded. We cut out overhead costs of administration by insurance companies and eliminate the middle man and everyone gets equivalent care across the board. With more money left over from eliminating unnecessary health costs from before due to all the efforts spent on preventive care, we can expand medical education and churn out more doctors and have better care and research all around. All this will be good and all of this is possible, but the financial motivation of keeping high paying jobs will outweigh any altruistic motivation of serving the underserved populations. AMA and most, if not all, of the other medical societies will not support something like this because it cuts into their own paychecks and they feel entitled to having higher pay.

Who knows? Maybe a few of you will listen and help me fix our system.

Well, that took 3 hours to research and write, now I've gotta get some sleep and get back to studying so I could actually become a doctor rather than worry about fixing the system that I'll be a part of.

Update 2 on schedule

M-F schedule

8:30 AM Wake up (no alarm clocks, yaya)
9 AM Run
9:15 AM Shower + chat
9:30 AM Breakfast + Chinese cartoons
10 AM LM City Computer Resource Center
12:30 PM Lunch + chat
1 PM Study SOMEWHERE
6 PM Dinner
7 PM Study or take night off
9 PM Shower
9:30 PM Study
11 PM Chill / Chat
12 AM Sleep

So... that'll be 2.5 + 5 + 2 + 1.5 --> 11 hrs on a good day, or 2.5 + 5 --> 7.5 hrs with the night off.

I think I might be able to do this. Once I'm settled into my routine, I'll update more on things that are non-boards. =o)

But yah, I've abandoned my plan to have zero chat time, I figure I still need to contact people about stuff. So, it's chat when there's time, but no chat when it's time to study. This should work. I'll let you know.

Update on schedule

Okay, so maybe I was being too ambitious with my previous scheduling... or just suck at adhering to an insane schedule like I plotted out.... some sort of 12 hr study-fest with no life. -.-;;

Here's the new version:

8 AM-ish -- Forced wake-up by sunlight and human activity in the house
8:40 AM -- Out for a run
9:00 AM -- Fatigued by run (yes, I'm that out of shape while in the Obese State of Michigan, it's a cultural thing, this should get better soon)
9:30 AM -- Breakfast after shower
10 AM -- Drive out to look for a place to study
10:15 AM -- Hopefully have ended up at a Starbucks to start studying
11 AM -- Zoning out
12 PM -- Thinking of food instead of studying
1 PM -- Eat lunch somewhere, somehow
1:15 PM -- Go somewhere else to study
1:30 PM -- Probably at another Starbucks (I think I need to change this up with some Panera, City of LM computer lab, or even some Ten-Ren)
2 PM -- Food coma setting in (I'm blaming the compensatory respiratory acidosis, see? I learned something...that's totally non-testable)
3 PM -- Trying to study again.
6 PM -- Figuring out what to do with the evening...
7 PM -- Probably out for the evening for whatever reason, visiting a friend, eating dinner, etc.
10 PM -- Head home and hang around and get ready for sleep.
12 AM -- Sleep

It'll be a miracle if I pass the Boards at this rate, haha.... I think the time of studying dropped from the previous ambitious 12 hrs to the current causal 6-7ish hours of studying. Coming home to LA to study might've been a bad idea... despite the great food and gorgeous weather.

Cutting out chat didn't exactly do too much, now I'm just looking for other ways to distract myself. I think, subconsciously, somewhere deep inside, I just really want to go into PM&R. Some of you will get that, the rest of you, I'll explain this one in a later post.