Sunday, January 27, 2008

A lifetime of learning, no kidding

I'm in the last week of my month-long outpatient rotation, and I had a long list of tasks to accomplish before entering the CCU next week. In addition to seeing friends and cleaning my apartment, I also wanted to slog through the tall pile of journals that has accumulated since last time I was on an outpatient month. Flipping through the January 17th issue of the New England Journal of Medicine, I was reminded how medicine is ever-changing. There is constant revision of therapies in addition to the social and political aspects of the medical field, and I need to keep up! Here are a few excerpts for those interested in what I've been reading.

I've had the opportunity to work with foreign medical graduates in the past, but this article really describes the sacrifices they make and the hoops they jump through in order to practice medicine in the Western world.
[Foreign medical graduates] must not only relearn the theory, which many of them first studied decades ago, but also master the social and behavioral nuances of being a doctor in the West. Some must do so while supporting themselves by driving taxis or picking fruit; others rely on meager personal savings or small government handouts. They are driven by the dream of becoming doctors again, but the reality can be a nightmare.

I need reminders like this so that I remember how lucky I am to do my crazy job everyday. I've heard about publication bias, but this article really lays the numbers out there.
Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published ... Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive.

I haven't had an ethics course since I was a first-year medical student, but there are still many unanswered questions. When I read this case about cell lines derived from a patient's splenectomy specimen, I couldn't believe that the law wasn't more clear.
Under ancient Roman law, when agricultural crops were in the ground, they were owned by the landowner, but picked fruits and vegetables were owned by the farmer who worked the land. Trees taken from the land, however, belonged to the landowner. Is a removed spleen more like an ear of corn or an oak tree? ... Since the cells in human tissue are living and reproduce, perhaps they are more analogous to farm animals than to fruits or vegetables. The progeny of animals are the property of the mother's other. Is the cell line equivalent to [the patient's] "progeny"? Similar, an owner wrongfully deprived of livestock is owed the value of the eggs from converted chickens and milk from converted cows. Are [the patient's] immortal cells like chickens, and the protein products derived from them like eggs? The need to resort to cases that involve the ownership of corn, trees, cows, and eggs demonstrates the need to create modern rules that deal directly with the ownership and use of human tissue.

I remember in my medical school application essay I stated I wanted to enter medicine due the ever-change challenges the field encountered requiring a lifetime dedicated to learning. Boy, I don't think I knew what I was getting myself into!

Thursday, January 24, 2008

Health Care in an Election Year

Our health care system is broken. I see examples of it everyday. People who can't afford their medications in the emergency room, hospital wards, or ICU due to poor control of their chronic medical problems. I am going into primary care praying that there will be meaningful change in the system that will allow me to take better care for my patients, but how does that translate into who to vote for? Well, I've been pouring over this site comparing the candidates' plans today. There are flaws in each of these plans as I really do believe in a single payer system, but they are all a step in the right direction. The devil will be in the details of how these plans are implemented. I'm still struggling with which candidate understands the deficiencies of the current system the best. I want my candidate to know which of the many parts of their plans to push for and which will have to be sacrificed as the plans are made into law.

I'm excited that I will be able to make it to the voting booth for my state's primary on Super Tuesday. I'll be post-call from the CCU and will go directly from the hospital to my polling station. I just don't know yet who to vote for.

Monday, January 21, 2008

Planning the future

As an intern, I take days one at a time. Once in a while, I'll actually look a few days ahead and plan to do something fun on my day off. However, I rarely look much further in the future. One of my medical students was bemoaning that the school was asking them to put in schedule requests for their rotations next year. It does seem difficult when you've only finished half a year to figure out what you want to do the next year, especially when these years are supposed to shape your future career. I told my medical student to suck it up because it doesn't end. I just submitted my schedule requests for the 2008-2009 year.

Filling out that form was mind boggling. When do I want to take vacation next year? I had to email all my engaged friends and ask if they were planning weddings before July 2009. When do I want to be in the ICU? Which ICU? What about electives? What do I want to be doing on July 1st? That's when I'm a brand new resident with brand new interns. I'll be a resident in less than six months!

Luckily, I'm on emergency coverage now with more than average free time. (Thank goodness my co-interns haven't been inflicted with that raging diarrhea that's going around.) So, I was actually able to step back and look at myself. I found that a lot of me is the same. I still want to spend vacations with my husband when he's on break from school. I'm still interested in outpatient medicine despite the copious amount of time I have spent in the hospital this year. And I'm still terrified that I will make a mistake and kill someone. Those were my guiding principles in filling out my requests.

What's changed about me? Less than I thought. While I'm on the wards or in the ICU, time is limited, so I don't get to indulge myself in my hobbies. Yes, spending time cooking or watching TV seems like an indulgence. (Luckily the writers' strike is making it easy for me to stay away from my television.) However, now that I have more free time, I have found happily that I am much the same person that I remember I was. And I'm relieved. Yes, I've changed as a clinician, but I'm still me.

Is the silence deafening?

So, it's been a long time since I've posted. I've started a bunch of entries, but in the end, I justified my long pause between posts by saying that the silence was saying a lot.

The greatest skill of an intern is the ability to prioritize. There's always lots to do each day. After rounding each morning, I think, "Should I write my notes? Go to morning report? Call my consults? Put in orders? Teach my medical students?" The ranking of priorities extends beyond the walls of the hospital, too. A few weeks ago, my car ran out of gas. That's never happened to me before, but time is limited. On my list of priorities, filling my car with gas was probably lower than it should have been. However, getting home to spend time with my husband is pretty high, and the gas would have been helpful in getting that task accomplished. I'm still learning how to prioritize, but on the list of priorities, this blog is somewhere below filling my car with gas.