Wartime Medicine

Medicine in the context of war spurs innovation while staying streamlined and minimalist. Several mainstays of modern medicine have been developed because of battlefield medicine - the concept of triage was beget by the need to do the greatest good for the greatest number of casualties on the battlefield when resources were overwhelmed, the modern blood bank and the use of morphine for pain management emerged out of necessity in WWII, and the use of air medevac by helicopter began to be implemented in the Korean War. Medicine in the military is a trial by fire; war produces trauma with mechanisms of injury often unseen in the civilian world - and military physicians and their teams have to manage these extreme cases with limited resources, producing new technology, protocols, and procedures.

Modern war medicine has produced a new kind of progession in the care of critically wounded soldiers in the form of "damage control", where performing the minimum intervention necessary for stabilization is preferred to immediately doing everything possible. Forward Surgical Teams (FST's) follow closely behind combat troops and are able to deploy a functioning hospital with surgical suites in an hour with just a handful of backpacks. They are the first point of surgical intervention following EMS battlefield casualty evacuation, and they exist to stabilize casualties until they can receive definitive care at a later point. The frequent major traumas caused by recent prolonged wars, though tragic, have spurred changes in protocols that will improve outcomes for all. For example, the onslaught of severe limb injuries in Afghanistan and Iraq have shown that rapid, appropriate tourniquet use can significantly improve mortality. Improvements in extrication and transport time in battlefield medicine have encouraged their use. In civilian emergency medicine, the use of tourniquets is discouraged and used only as a last resort to control bleeding. In cases such as these, wartime medicine can overturn conventional medical wisdom.

The Doctor-Patient Relationship

Doctors are in a unique, influential, poweful position in taking care of patients. They are priviliged and trusted with intimate details of their patients' lives with the expectation that they will be understanding and professional in advocating for the most appropriate treatment plan for each patient. Treating the patient requires an understanding of their disease and their personhood - their desires, beliefs, and worries, in addition to having a warm beside manner. But the doctor-patient relationship can vary widely by specialty, and it can manifest as anything from "following someone’s hypertension for 10 years" in internal medicine or family practice to "what you have when someone gives you a chart with a patient’s name on it" in emergency medicine. In radiology, pathology, or any specialty that does not involve much patient interaction, there is no doctor-patient relationship - but as we have seen, some doctors in these specialties can come up with interesting ways to connect with their cases as human beings simply through looking at a picture.

A healthy doctor-patient relationship can make every difference in patient compliance, but its effectiveness has been limited. Recent developments in health care have changed the game completely by sterilizing the interaction between doctor and patient. Declining time spent actually speaking with patients, the emergence of the informed patient, and fear of litigation, among other things, have created an environment in which a new kind of doctor-patient relationship must form. Striking the correct balance of efficiency and warmth in this system is a challenge, and one that may become easier with time as health care reform is legislated.

Big Pharma

This week we explored the aggressive and sometimes insidious tactics of the U.S. pharmaceutical industry. In clinics, big pharma makes its presence known with a constant stream of sharply dressed, attractive drug reps. Ads and promotional materials for drugs are frequently found strewn about clinics: pens, clipboards, posters, etc. In the media, the pharmaceutical industry has leached into television with consumer-directed advertising. In one physician's office where I worked, news of a drug (or medical device) rep coming through the office spread joy and thoughts of free lunch throughout. Frequently, the reps bought the entire office lunch for the chance to give their spiel. I asked one doctor how he felt about the reps and whether he actually seriously considered their peddling; he said that takes what they say with a grain of salt, but that he cannot possibly keep up with all the current literature, so on some level there is little fact-checking. He continued, saying that drug reps pushing their products are a reality of modern medicine. For the particular rep that visited on the day I asked, he expected nothing more out of the encounter than free lunch. I see no moral imperative to accept their gifts, nor to do anything in return for them given the thinly veiled expectation of reciprocity.

Private Practice

Currently, the number of doctors entering private practice is decreasing while the number of doctors taking salaried positions is increasing. Do the benefits of running your own business and being your own boss outweigh the stability and certainty of being a salaried physician? I have worked for small business owners for years and have done some freelancing myself, and I understand why this trend has become so prevalent.

Running a business adds a lot of additional stress to an already stressful job and it is not conducive to a favorable work-life balance. Additionally, most medical students never receive training in managing a practice and must pick up business-savvy skills from other sources, and apply them to build a referral network. Taken with the start-up costs associated with getting a practice off the ground, entering private practice seems a daunting task. However, the independence and freedom of choice that comes with running the show and managing/scheduling patient care as one sees fit (within the confines of necessary bureaucracy) can be alluring for some.

Ronald Arky, M.D., of Harvard Medical School, posits: "The patients you see in either system can be the same. The difference is all about the money and where it goes". While these differences are profound, the most salient difference for me is the extra responsibility and worry of running a business. Group practices, where there is division of responsibility, are an interesting solution to the problem of always having one's livelihood on your mind. I am all for "Be[ing] adventurous. Be[ing] willing to go out and earn your living. Be[ing] willing to take chances", but I also want the peace of mind that comes with a salaried position.

Shadowing

For my shadowing experience, I spent one Saturday night from 10pm to 3am at RIH ED following around a second-year resident in Brown's EM program. We spent most of our time bouncing between the ED's six critical care rooms and following up on labs and imaging studies. Over the course of the night, I watched one patient die while another balanced on the brink of death; I stood by as a doctor told a patient that his cancer had most likely returned; I was given quick tutorials in the radiology and CT suites, and I got a great sense of the ebb and flow of ED.

The resident was soft-spoken and calm, with a cool head. It seemed like he had great relationships with the team of ED personnel responsible for patient care. Despite the chaos and emotional toil of a weekend night at the ED, there were times when laughs could be had all around - from security to the nurses to the techs, everyone got along seamlessly in mutual respect. Everyone had a job even in the most complex cases, and shadowing the resident reinforced the concept of emergency medicine being a 'team sport'. Trauma teams, medical teams, and consults from neurosurg and cardiology all assembled in my time in the critical care rooms at Rhode Island.

The biggest impression I took away from the experience was the level-headedness of the staff amongst the unruliness, the violence, and the onslaught of human suffering. They could not be shaken. Some patients in the ED, many intoxicated and/or injured, take their inappropriate behavior to the nth degree. No one is ever safe from certain patients' vicious tongue lashings or spat blood. The doctor, as part of the ED team, needs to be able to objectively evaluate and treat these patients with respect after walking away from something as draining as a failed resuscitation. I admire their ability to take the tragedy with the victories all while putting up with the BS.

RIH ED Shadowing

For my shadowing experience, I visited the Rhode Island Hospital Emergency Department Saturday November 7th. There are countless doctors who work there on any given shift, but I stayed mainly in "trauma alley" where the most critical patients are cared for, nearest to the ambulance bay. As it was a Saturday, an overwhelming majority of he patients we saw were intoxicated, complicating their diagnoses and care and often causing the injury or illness that led them to the ED. More than one patient required mechanical restraint either by security or soft-restraints and one patient was given Haloperidol to chemically restrain him and facilitate his treatment. There were numerous assault victims, many of whom arrived around 2 am, when most of the bars downtown close.

This was by no means an unusual situation. I had the opportunity to ask one of the ED residents about what role alcohol plays in patient care and he responded that it causes and complicates far too many injuries whether through drunk driving, poor judgment, or extreme intoxication. During my time there we saw a pair of Rhode Island State Troopers arrive with a patient implicated in a car accident. These officers are often at the ED, but are not privy to a patient's medical information. Dr. Wang, a third year resident explained to me that even if nurses have already taken a breathalyzer reading from a patient, but police must obtain separate permission for this information--permission that most under investigation will not provide.

Doctors in the ER acted coolly and professionally. Although faced with a myriad of bizarre and often belligerent patients they still used "sir" and "ma'am" when talking with patients and were not easily flustered. One doctor, visibly pregnant through her scrubs, had a particularly calm and authoritative demeanor. When a patient began to get violent during their assessment, she belted "security" down the hall and took a few steps back.

In addition to the doctors that I observed and spoke with, there are many other important players in the ED. Security personnel work hard to protect the other workers and patients themselves. At one point a security officer translated for a nurse who didn't speak Spanish, allowing her to better communicate with her patient. EMTs and paramedics also play an integral role in allowing the ambulance triage area of the ED to run smoothly. Many are familiar with the nurses and will help transport a patient or restrain a patient if extra hands are needed. Those from the Providence Fire Department could often be seen grabbing a short break at the hospital with one another while waiting for their next call. Usually they would get a call before they could even get back to their station. Nurses and CNAs had a majority of the patient contact during a patient's stay. They did everything from administering medications to getting blankets and making patients comfortable. A number of times, they had to endure belligerent patients yelling obscenities at them for an hour on end while they did their job. There were even official ER observers who walked through the trauma rooms with high risk teens and emphasized the consequences of risky behaviors behind the wheel and with drugs and alcohol.

ER doctors had to be team players. They worked with numerous colleagues, whether their respective attendings/residents or specialists and, as shift workers, transferred patient care at the beginning and ends of their shift. I heard them often consult one another while making difficult decisions, and even compare general impressions with a few highly experienced nurses. Because it was a generally slow night for the ED, a number of different doctors took time to answer my questions and explaining what they were doing and the rationale behind it. At one point, they motioned for me to follow them into the CT scan and I was able to watch one performed on the head of an intoxicated patient and explained the procedure. I enjoyed the opportunity to see so many different physicians interact with their patients forming patient-doctor relationships rapidly out of necessity.

Alternative Medicine

Physicians should be concerned about the widespread use of complementary and alternative medicine (CAM) -- if only because it's giving them a run for their money. The study we read comparing CAM use from 1990 to 1997 demonstrates equal or higher rates of CAM as compared to visits to allopathic physicians. Such physicians should be asking themselves what they are doing wrong.

Is it a lack of available primary care? We studied a month ago how difficult it is for many patients to access affordable primary care. Too few medical school graduates are choosing primary care specialties and more and more Americans are without adequate health insurance. Alternative medicine offers simple remedies for many of the common chronic conditions for which Americans may be unwilling or unable to seek physician care.

Are physicians failing to address emotional and spiritual needs of their patients? The Eisenberg study also highlighted the number of therapies addressing these less concrete, but no less real issues. With the increasingly limited time that physicians have to spend with their patients, how will they be able to address such complex and intimate aspects of health?

Finally, do physicians settle for a cure over health for their patients? "Cure" has become a mystical and revered goal in medicine as medicine looks to define cures for cancer, AIDs, and other life-threatening diseases. However, promoting health involves more than removing disease. Physicians must also seek to bring patients to a point of optimal quality of life. Our readings on life and mortality clearly demonstrated the deficiencies in our healthcare system regarding the value of a person's final days and weeks as opposed to the length of their survival.

A primary care physician educated in the various forms of alternative and complementary medicine will be better equipped to support their patients who utilize these therapies and more willing to refer patients to such practitioners. They can use CAM to supplement a faulty and inadequate system.

Shadowing Experience: Pediatric Infectious Disease

As soon as I entered the office, I was warmly welcomed, then immediately transferred to a team of fellows. Unlike previously planned, the attending physician had to be at a conference at another hospital; the fellows would take me to Women & Infants’ Hospital, where a team member would be presenting on S. aureus to pediatricians from the NICU. When you shadow, you’re really following whoever is doing the most exciting thing, I was told. It was true. The team of the attending physician, fellows, and residents moved busily back-and-forth through conferences, the outpatient clinic, inpatient rounds, and in-between paper-work. Because of swine flu, the outpatient clinic was physically delegated to another building, making the delegation of tasks more formidable. The coordination of the team-members, and their ability to physically re-convene at various points of the day to discuss patient cases (and also to catch up on personal life) seemed almost a refined art. Though I had always envisioned working in a hospital setting, I had never quite realized the intensive amount of teamwork required, nor the central role that interactions with colleagues played on an hour-to-hour basis.

At the outpatient clinic, I was filled in on the routine paperwork. Before the patient enters is ushered into the examination room, the fellow reviews the medical history of the patient and the plans made at the last meeting. During the actual conversation with the family, the fellow writes throughout much of the meeting. Though I saw this as inevitable, and would have done the exact same thing, I wondered if there could possibly be more continued eye contact and undisrupted conversation. Would it help if the more straightforward facts, like recent patterns of symptoms and drug use, were pre-recorded and sent to the doctor? No, this could actually lead to more mistakes and reduce opportunity for more spontaneous conversation. The fellow then informed the attending physician on how the patient is doing, and her recommendations and plans. The attending physician-fellow duo then talked to the patient’s family. After the patient left, loads of paperwork ensued. The attending physician filled out forms for re-imbursements, whereas the fellow filed papers on the patient’s chart and for a fellowship-program database. Because of the paperwork surrounding each visit, the doctor-patient relationship seemed to become a more 2-D one, at least before and after the actual interaction. This was disappointing to see, because this seems to be the reality of medicine in actual practice. In theory, the doctor-patient relationship seems much more noble and idealistic.

Since so many of the patients were very young, the parent (often, the mom) was the main individual communicating with the doctors. In fact, the phrase “According to mom…” seemed to be the most central part of the team’s lexicon. In classes like our GISP, we often talk about enhancing the doctor-patient relationship. For those in pediatrics, though, a new type of communication and relationship seems necessary—a form that integrates the patient-child, the parent(s), and the other family members (like grandmas!) involved in the care of the patient.

I was surprised at the great diversity of patient needs. Since pediatric infectious disease requires both a residency and fellowship as training, I considered it to be a highly specialized sub-specialty, and expected less variety especially during this swine flu season. However, though swine flu/pneumonia was the common factor among all the patients I saw that day, there was such a wide variety of patients and circumstances. For example, there was an older male patient with developmental disorders. Unlike most of the other patients, he was eligible for the swine flu vaccine as a high-risk individual. Since he had to use equipment to clear his respiratory tract throughout the day, his recent medical history was very much based on his usage of the equipment. Much of the appointment was also spent talking about the interactions the patient has with the other students in his special education-classes. I was surprised even more by how familiar the fellow and attending patient was with the details of this patient’s case. Until I observed this specific case, I remained set aback at the realization of the paperwork-dominated nature of the doctors’ work. However, this close, intimate interaction restored for me the hopeful expectation of solid future relationships with my patients.

CAM

I agree with Rakel’s assertion that calling everything except current Western medicine “complementary and alternative” relegates these therapies to a second-class status. Language is a powerful indicator of status, and can shape people’s expectations and perceptions of something. These therapies are not consistently “alternative” or "unconventional"-- from anecdotal experience, I know that in China, traditional Chinese medicine is preferred to Western medicine by a good proportion of people, especially for sensitive concerns such as reproductive health and chronic pain.

One of the most interesting issues for me in CAM is categorization. In my disability class, we discussed (and failed to find a satisfyingly concrete answer to) the question of how one can group together such disparate disabilities as multiple sclerosis, schizophrenia, paraplegia, and locked-in syndrome as “Disability.” Similarly, the question here arises: how can one group together therapies as diverse as spiritual healing, support groups, hypnosis, traditional Chinese medicine, and massage under the same heading of “CAM?” Many of these therapies share little in common.

That being said, many of these therapies do stress the importance of treating the whole person, not curing a person’s disease reductionistically. However, if CAM is to gain greater influence in medicine, it cannot be seen as a vague, floating entity of quasi-mystical and unscientific healing properties. Greater efforts need to be put into researching the effects of specific CAM therapies—just because these treatments are holistic doesn’t mean that they defy the methodical approach of science. This is important, because as the Eisenberg paper shows, those who seek alternative treatments are willing to pay out of pocket (and substantially so), which has huge financial implications. If the government can regulate the use of CAM in a federally managed healthcare system, it stands to benefit greatly.

I appreciate Rakel’s proposal for integrative medicine instead of the multi-pronged, subspecialist approach that makes up our current medical system. However, one cannot expect that 100% of patient’s health concerns will be met by the incorporation of CAM. CAM places more responsibility on the patient, perhaps more responsibility than some are willing to take at first after a lifetime of being told what to do by doctors. While I like to think that patients will be eager to take control of their own health, the additional education and responsibility that CAM requires are legitimate obstacles that need to be addressed in the future. What CAM begins to get at, but cannot fully treat, is the social fabric of a person’s life that impacts his/her health—doctors need to respect that while they should do everything in their power for a patient whom they perceive in need, certain social inequities will always confound completely satisfactory health outcomes. This is a matter of political action and advocacy that while obviously necessary, I think, goes beyond the realm of medicine.

Shadowing Experience: Dr. Jennifer Jeremiah, Primary Care Internal Medicine

Dr. Jeremiah is a part of University Health Foundation, a group of physicians associated with RIH. She has responsibilities both as a clinician in the UHF office, as well as a ward attending and as someone involved in the internal medicine residency program.

I stayed with Dr. Jeremiah from 10:30 AM to 1:30 PM. We saw six patients, all women, mostly elderly. They varied across race, education, class, and age; the visits were approximately all 15 minutes long. Dr. Jeremiah said that she felt rushed a lot of times because of the need to be reimbursed by fee-for-service payment, and that it forced her to budget her time with each patient. I noticed the way in which she talked with patients, professionally and with an objective in mind (trying to be efficient with time), but allowing them time to talk about their issues and always asking if they had any questions for her. Dr. Jeremiah seemed like a wonderful PCP: caring, kind, and able to pick up on subtle cues and put them in context of patient history.

I was really impressed by the familiarity with which she addressed the patients. You don’t have to be a “country doctor” to have healthy, long-term relationships with your patients. Some of these people she’s known for 15 years! She said she was able to understand their situation, which allowed her to better assess their queries and complaints; for example, an old woman who enjoyed being miserable and making her daughter feel guilty, a man in a wheelchair who liked to argue with his case manager, which you wouldn’t be able to pick up on if you had just gotten to know a patient. She said that this allows her to understand if their complaints are serious, she can tell when they look sick and when they look healthy, and to understand their history and what their baseline health is—so one woman who had terrible lab results was actually doing well because she had eight chronic conditions, and she knew that because of the history. I felt that these long-term relationships were really valuable to creating trust. For instance, the patients trusted me, an undergrad, to be there because Dr. Jeremiah was there, too.

Trust is important for honesty, as when one patient said that she couldn’t afford her Advair even though she was on Lipitor. PCPs are often the ones to break bad news like new diagnoses, cancer, etc. They are in it for the long run with the patient. They refer patients to specialists, get the information back, and then discuss the results with the patients. If the problem develops further, they send the patient to see the specialist for that reason. A PCP is a coordinator, and has to know a little bit about a lot, whereas a specialist has to know a lot about relatively little. But even though the specialist may ultimately “solve the problem” a PCP is the one who facilitates that meeting in the first place. There's a lot of potential for the PCP to become a powerful coordinator of a patient's health...if reimbursement and legislative issues can be addressed.

Dr. Jeremiah said that cost is a huge issue, and she tries to do everything they can to reduce costs for patients. So for that above patient, she told her to call her cardiologist and request the generic. She gives out samples, even though it’s not a long-term solution. Interestingly, she also said she was feeling “trepidation” towards EMRs, which everyone has been so enthusiastic about. she explained that (1) it’s difficult to transfer literally thousands of pages of documentation/labs/etc. to a computerized system because the practice is already established, though it’s not that difficult if you’re just starting from scratch and (2) having a template doesn’t allow the doctor to make individualized notes or talk about random symptoms that may lead to something later—the checkbox syndrome, I suppose, an interesting contrast to Dr. Gawande's article. She talked about how she used to get these personalized letters from a GI practice she often refers patients to, and now they just send her papers with four lines with codes on them. it’s just different. She also insinuated that EMRs were really touted by the insurance industry as a way to reduce medical waste, which is good, but no one would listen if doctors were touting the same thing for patient care reasons.

I asked her if there were differences between her office appointments and her ward visits. She said her ward visits were basically acute care; to make sure that person’s immediate problem is fixed, and then also to do a basic maintenance checkup because you might as well treat them for other existing problems while they’re in the hospital. Whereas for her office visits, the patients are insured, and the goal is to keep them out of the hospital, and just make sure that they’re doing okay.

A couple of the patients were also doing acupuncture, which I thought was interesting, and Dr. Jeremiah said that she didn’t go out of her way to recommend it, but she didn’t dissuade people from pursuing it if it was from a reputable source. She was involved in a trial where one of her patients was scammed by someone claiming to have found “green parasites” in his blood at the price of $6,000.

She said that there was a desperate need for primary care doctors, and whenever she explained why I was there to the patient, she said that she hoped she could convince me to join the field. I have great respect for what she does every day: in 3 hours, she saw 8 patients for follow-ups and physicals, having come from a residency workshop at the hospital that began at 7:30 AM, and the other half of the work day ahead. I don’t think she was going to have lunch. She said she thinks that primary care will be much better in the future…by the time we're in residency, basically. Overall, I really enjoyed my visit today. I felt like it was a good mix of detective work and just talking with patients, getting to explore the non-biomedical aspects of their health.

Alternative Medicine

Whenever I hear the words alternative medicine, I usually do not hear the words coming from a doctor. It might be through word-of-mouth from a friend or co-worker referring someone else to a therapy that they underwent and made them feel good afterward. My first thoughts toward alternative medicine is to be skeptical even if the word medicine is part of it. If it is really as effective for health problems, why don't doctors advice their patients to try some of these therapies?

It is interesting to me that according to Kessler's study the number of visits to unconventional therapies was higher than the number of visits to physicians. With the current health care system, alternative medicine might be a less expensive choice than visiting a primary care physician. However, alternative medicine is still limited to a certain sociodemographic that can afford to go to a chiropractor, for example.

I think that alternative medicine can be an untapped biotechnology that physicians could learn more about in order to inform their patients of the risks and benefits or to supplement treatments and drugs. In order to this, primary care doctors would need to be taught about alternative therapies like acupuncture as early as medical school. I do not think alternative medicine needs to be included in health care reform. Instead, more research should be invested to find the benefits and whether the effects would be worth the expenses.

Shadowing Experience

This semester I was given the opportunity to shadow Dr. Gary Frishman (who also came to speak to our class during the week of Paternalism), an OB-GYN who specializes in reproductive endocrinology. Not only did Dr. Frishman work at the IVF Clinic at Women and Infants Hospital a few times a week, but he is also the director of the Residency Program for OB-GYN at Women and Infants and former Professor at the Medical School. This was my experience with him.

8:30am I got lost looking for the IVF Clinic at Women and Infants Hospital. Luckily, Dr. Frishman gave me his number in case this happened and I called him. Somehow with my bad sense of direction, he was able to direct me and I saw him standing in his blue scrubs outside the hospital.

8:45am I quickly changed into scrubs. Although he was running around making sure patients were ready for the procedure, Dr. Frishman took the time to sit with me in his office to explain what was going on. From the EMR (electronic medical record) system that Women and Infants already uses to his basic background information, Dr. Frishman made sure to explain everything to me, but not in a condescending manner. As he spoke, different nurses would pop their head in, say hello, and give a quick update. Dr. Frishman made sure to introduce me to each person and explain what each nurse did at the clinic.

9:00am After a brisk walk to the procedure room, Dr. Frishman had me wait outside while he spoke to the patient about me observing and making sure that they were comfortable with what was going to be done. I couldn't help, but notice the trust these patients had in Dr. Frishman. I can just tell by looking at their faces that they knew Dr. Frishman would get them through this.

9:15am While waiting for the patient to be dressed for the surgery, I sat and thought about how uncomfortable it could be to talk with women about IVF. I guess IVF itself could raise some ethical concerns and so I entered the procedure room and asked Dr. Frishman. While he aspirated the 15-20 or so follicles (the patient had been given drugs to stimulate more follicles being produced), he told me that he was comfortable with his patients because he worked with many women and men who had infertility issues and was happy to offer them an alternative way to having a family. Some of his patients had been going to him for years about these issues while others were referred to him from the OB-GYN. If the eventual implant was successful, most of these patients went back to their lives and didn't come back to the clinic again. Dr. Frishman said the doctors did make a point of keeping up with the patient to follow up after they gave birth. There was also the issue of the stored embryos that could be frozen in case the patient wanted to implant them in the future.

9:25am The procedure is done in 10 minutes! The nurse whispered to me that the other doctors in the clinic usually only get 8-12 follicles, but somehow Dr. Frishman seemed to outdo everyone else (not in a competitive way). She said he could also be eccentric at times, but in a good way that made the atmosphere fun and lively to work in.

9:45am We are back in Dr. Frishman's office. He talks to me about the many hats he wears and how he loves working on a salaried position while being able to teach at the same time. He also talks about how he is still able to have time for his family because of the flexibility of his position. I was quite amazed since it sounded he had a lot of responsibilities with his work, but he must balance everything really well.

10:15am I go back into the procedure room with Dr. Frishman. This time he is going to implant 2 embryos that were kept frozen for the patient after she had her first child. He speaks to the patient about how I would be observing and I get introduced to her. The patient is awake the entire time during the procedure. The entire time Dr. Frishman explains each action he performs before doing it and shows her on the ultrasound what he is doing. Even if this is her second time doing IVF (she already had one child), she talked about how thankful and happy she was to be able to have another one through IVF.

I really enjoyed my glimpse into Dr. Frishman's life. He is in a unique profession and the way he handled himself with how he talked to patients about IVF reassured me (even if I wasn't the patient) that I could trust him if he were my doctor. I don't know if OB-GYN is a field I am looking into. However, I appreciated this experience because it showed me that a good doctor not only has technical skill and expertise, but is someone who is able to connect with his or her patients especially when the patients are talking about such personal issues such infertility and explaining the different options for them.

CAM Perceptions and Realities

I've always been a believer in the power of pharmaceuticals and science-driven healthcare. While I don't know enough about CAM to justify my apprehensions with alternative forms of medicine, I have been guilty of assuming that it is less efficacious than standard forms of medicine.

Many people I know have mentioned great personal experiences with therapies such as acupuncture, I often feel that if the healing potential of these therapies was truly as great as certain alternative practitioners posit that they would be mainstream practices.

When reading this week's articles I was surprised to learn that in the early 90s, the time that most of the articles were written, that more Americans had seen CAM practitioners than primary care physicians and had been willing to pay more. I was also surprised that the main cohort of people interviewed who used these therapies were well-educated, middle-aged, white people. This defied many of the assumptions surrounding "alternative" medicine, suggesting that this therapy might be far more main-stream than expected. While most of the people studied who used this therapy admitted that they used CAM in conjunction with a medical doctor, it still speaks to a great following and belief that a more holistic, less biomedical approach may be what patients prefer.

Based on this trend for healthcare, it seems sensible that doctors should place a higher premium on learning about the medical habits of their patients. Even void of possible dangers (ie drug interactions) it is important to understand where patients derive hope and comfort.

One of my major qualms with the articles is the inclusion of self prayer or group prayer as a form of CAM. I think that some of the therapies considered part of alternative medicine, are not truly medically related. There is no way to prescribe optimism or hope, granted neuropharmaceuticals attempt a very obtuse form of this. I think that the lose definitions of medicine aren't truly adequate and under this standard almost anything that confers good health can be considered medicine or in this case CAM, a rather glorious attribution to a field.

Shadowing Experience: Radiology

I have spent this semester shadowing a really amazing interventional radiologist at Rhode Island Hospital. Watching someone with patients for an entire semester provides unique insight into the realm of doctoring and medicine.

One of the overwhelmingly apparent things about Dr. Dupuy is that he is well liked by everyone, including the nurses, technicians, residents, billing staff, and patients. His good report with people is likely connected to his brilliance (which certainly gives him credibility and helps to inspire ease) but also because he is a genuinely nice and engaging person. When I watch him doing procedures and talking to the nurse techs in the room, he treats them as equals. He has everyone (even me, an undergraduate student, surely the lowest end of the totem pole) call him by his first name. This sense of familiarity and humanity really leads to a great sense of camaraderie. While I've seen residents treat nurses and other hospital workers as subordinates, giving them orders and being terse, I've never seen Dr. Dupuy lose his temper or treat people poorly.

It is this wonderful "workside" manner that allows Dr. Dupuy to be one of the most productive doctors and researchers around. People are always willing to help me with my research project, simply based on my association, as a student doing research with him. Everyone has a great anecdotal story of a patient that Dr. Dupuy helped live longer or better.

Another thing that I've noticed while working with Dr. Dupuy is his sense of perfection. He is exact, calculating the placement of each probe prior to an ablation and talking to patients throughout the procedure, gauging their pain and comfort. He keeps the patient aware of where they are in the procedure, knowing that most people are extremely nervous while having their cancer treated. He is professional and thorough, but unlike the stigma surrounding most radiologists he is very personable.

One of the most striking things I've noticed while shadowing Dr. Dupuy is that he remembers everything. He'll recall a patient he ablated years ago. While I think this is far from the norm, simply because most humans don't have his recall abilities, I think it is amazing that he's humanized every single one of his patients, that they are not simple anonymous cases or an array of diseases, rather they are people.

I do find the ablation procedures to be interesting and high-tech and certainly an effective treatment for certain small, solid tumors. However, I've been far more captivated by the personality of the doctor I shadow. He is a fantastic doctor not only because of his incredible skill but because he managed to be humble and caring. He is truly the kind of doctor all of us should aspire to be like.

The Media and Medicine

While the average television viewer obsesses over details from last week's episode of Grey's Anatomy, Scrubs, or Discovery Health's reality shows, many involved in the health care system criticize the accuracy of medical shows in representing American health care. Their concerns are not unfounded. Numerous studies have demonstrated that what we see on TV is not what happens in hospitals-- one investigated CPR and the marked difference between reality and television (Diem et al, 1996). Ultimately, however, these shows serve as entertainment and do not purport to have any other purpose. To this end, writers producers, and networks are incredibly successful. Such shows are advertised as entertainment, no more -- consumers must take responsibility for this fact and look for education elsewhere.

It would seem that in recent years television programing has made the distinction between entertainment and education clearer than ever. Unlike the melodramatic shouts to shock a heart or order "CBCs" heard in ER, many newer shows don't take themselves so seriously. Scrubs takes the form of a sitcom, engaging the reader with realistic issues and emotions interspersed with musical interludes, hyperbolic characters, and protagonist J.D.'s daydreams. Episodes go so far as to show a medieval reenactment of an amputation, a daydream of the doctors as cavemen during prehistoric times and an entire episode in the style of a musical. Even the traditional "doctor dramas" have jumped the shark, distinguishing themselves from medical advice or realistic portrayal. Grey's Anatomy and House, MD both include doctors and medical conditions that entertain because of their outlandishness. They focus increasingly on the personal lives of doctors -- the drug addiction of Dr. House or the incestuous relationships in Grey's -- clearly delineating themselves from reliable sources of medical information.

On the other hand, reality shows such as Trauma: Life in the ER shown on the cable channel, Discovery Health, do not attempt to fictionalize medical drama, but instead film the actual events that occur in an Americanb hospital. While the events that make it to viewers are no doubt the result of careful selection, such shows still portray actual conditions, procedures, and doctor-patient interactions. At the end of the day, any television with medical content will not be representative of actual medicine -- it aims to entertain, not inform -- but a savvy viewer can easily make this distinction.

Medicine in the Media

“Media” is a broad word that refers to the substance through which matter moves—in the case of medicine, the various technological forms of communication through which information moves. The advancement of communication technology, ranging from TV to the Internet, has led to advancement in medical culture, both in terms of healthcare management and treatment and the exposing of doctors’ personal lives.

The recent focus on doctors’ personal lives reveals a public fascination with doctors rooted in a cultural ideal of the stoic caregiver. For so long, doctors have been regarded—and have protected their image as—omnipotent healers whose personal motives are not relevant to patient care. Now, under the influence of standpoint history and increasing concern for emotional exploration and health, memoirs, often deeply personal and philosophical, of the medical training experience or medical practice are commonplace in bookstores. News sources have jumped on this trend as well. For example, Pauline Chen is a regular columnist for the New York Times, and Atul Gawande is a staff member of the New Yorker. Doctor dramas, such as ER or Gray’s Anatomy, show that doctors are human, too (what a surprise!). However, since doctors are the main characters in these shows, they still gain a hero-worthy status (one has only to look to House, MD), often at the expense of other people in the healthcare system. One study in the readings showed that patient characters, when they did show up, were usually overly anxious, demanding, or unconscious/dead. Given that the patient is one half of the doctor-patient relationship, it would be better to portray patients in a more sympathetic, or at least realistic, light. However, this might detract from the drama and hero-making of doctors that producers seek to create. The portrayal of patients also hints at the intended viewership of these shows. The creators understand that these shows are most popular among aspiring medical students or people with some knowledge of the healthcare system, who may not be most interested in the mundane aspects of healthcare, realistic portrayals of human interaction.

While I think that doctor dramas can be a good venue for explaining doctors’ thought processes and discussing controversial issues in medicine, in the real world, medical journalism does not seem to be living up to its full potential. Doctors are wary of journalists, who can “make” a career by reporting medical success, or break a career by reporting medical error. While it is understandable that doctor dramas would not take on policy or economic issues in healthcare, the failure of journalists to generally do so is not. One of our readings shows how Dr. Kevorkian gained publicity for his pro-euthanasia acts, but instead of broadening the story to bioethical concerns, the news media spun it as a crime-and-personality story. There is a place for entertainment and catching the audience’s attention, but journalism is supposed to report on broad-reaching societal issues. The news media can enliven the discussion about important issues such as end-of-life care and consequences of lack of insurance in a way that human dramas cannot. Doctors need to be involved in the accurate portrayal of facts in the media and be vigilant about making sure that journalists are not sensationalizing the story.

Medical Drama: Accuracy Issues!

Sometimes, the widespread wariness towards the accuracy of medical dramas is seems a bit over-rated. Of course, my perspective is likely limited since I never watched any medical shows that existed before ER, cited by Goodman as the beginning of more accurately-portrayed medicine in drama. By definition, drama has the inherent license to stretch facts and stimulate each individual viewer’s imagination, from minimal to great extents. No accepted standard upholds the drama genre to clearly demarcate where fiction and fact cleanly divide. In this sense, I find that a simple gesture, like an additional written note at the beginning of each episode indicating that the ensuing presentation has not been meticulously prepared to give accurate medical facts, can answer much of the public concern. Goodman captured my perspective well in writing: “The relationship between audiences and media texts is more complex than is commonly recognized in popular discourse. Audiences do not passively receive messages in media texts, they actively engage with them to negotiate meanings according to their personal sensibilities, but also according to socially determined categories such as race, class, gender and nationality.”

Dramatized, abridged, and emotionally and ethically charged drama most often serves as a starting, versus ending, point for most engaged audiences. I personally grew up watching ER every Thursday evening. Perhaps more so because I was a kid, with minimal knowledge of medical terminology or politics, I loved the show because of its high level of person-to-person interactions and emotions. For me, the most that the show taught me about the medical profession or field itself is that, like many other settings, it is a site where all sorts of human interactions, emotions, and circumstances converge and interact dynamically.

That said, as more and more medical dramas are produced and enthusiastically received by the global public, standards for accurate portrayal are definitely on the rise. Because of this (in some ways, beneficial) trend, I think it has become harder for audiences to passively separate out aspects of fiction from those of fact in medical dramas. To discern, for example, whether the director is purposefully and artfully exaggerating insurance-related social issues to make a political statement in an episode, or is accurately and objectively portraying a truly dire situation, can require much active reflection and inter-personal debate. However, I believe this is part of the merit of medical drama—that it can galvanize critical thinking of societal issues (both specific and non-specific to medicine) and open up conversations outside the political floor.

Media and Technology in Medicine

The relative newness of the debate of how media and the internet should coexist with medicine creates an interesting and evolving discussion. My generation was raised on the accessibility of information via the internet and electronic technology sources. I still remember my family’s first computer, an oversized (and now incredibly outdated) PC that would keep me entertained for hours as I would look things up on the encyclopedia software my grandmother gave me as a gift. It is incredible that today I can find information on everything, from clinical trials to disease treatment plans, prognoses, and the best doctors in a particular field.

I think that it’s relatively archaic for doctors to argue against access of information for their patients. Sure, things get misinterpreted and there will often be patients who will attempt to self-diagnose but it also gives patients a sense of empowerment over their healthcare that they’ve never had before. The beauty of the medical system is that although patients may come to false conclusions it is ultimately their doctor who will prescribe drugs and treatment plans. The reality is that doctors are over-emphasizing the power of the internet as a “healthcare provider.” Even relatively popular sites such as WebMD provide many possible differentials for a patient’s set of symptoms; it is by no means a diagnosis but a good way to gauge the urgency of a patient’s healthcare needs.

Additionally, I think it’s crucial for doctors to consider the likely evolution of healthcare as our nation undergoes what will likely be a drastic change in doctoring practices. If our country goes to a universal healthcare system doctors will be further overworked and the doctor-patient relationship will surely deteriorate as primary care physicians (an already underserved field) receive an influx of new (and likely needier) patients. It is astonishing to me that doctors argue that the internet is a “depersonalizing” or deteriorating entity for the doctor-patient relationship. Low reimbursement rates lead doctors to see more patients in a workday, so the days of long doctor visits of an invested knowledge in one’s patients has been reduced to a fifteen minute visit that results in a perfunctory run through of symptoms.

In addition to being a source of information for patients, the internet offers the great potential for patient records to be accessible at all times by the patient and doctors. Considering the great number of subspecialists that the average American sees these days a comprehensive list of a patient’s healthcare history and drugs could greatly increase the efficiency of the health system.


Another issue in Media and Medicine that arises is the prevalence of doctoring shows that offer an unrealistic image of the medical field and potential for treatments. I agree that there is a huge dichotomy between what is presented in these shows and what is actually medically feasible; however, I don’t know if the entertainment industry has an obligation to “inform” the public about medicine, this could be done more efficaciously by organizations such as the AMA or NIH (or better yet the government could place more money into public awareness campaigns and rather than cutting down screening guidelines it could practice medicine that will provide better health outcomes rather than cheaper healthcare).

The bigger concern should really be on how the news media depicts medicine. One of the points in our reading was that shows such as Grey’s Anatomy present unrealistic depictions of procedures such as organ transplantation, which usually occurs under very rigid guidelines. However, in my local newspaper The Miami Herald there was an article a couple of years ago about a young boy who immigrated to the US and lacked any familial support system and was thus not a candidate for organ transplantation. However, public outcry led to the boy eventually receiving the life-saving transplant. I don’t think that news stories such as these are any less harmful than the “fiction” presented in TV dramas since they both posit that healthcare functions very differently than it actually does. Yet I would say that it’s far more deleterious for the local newspaper to perpetuate these falsities since people tend to take these as truth.

Honestly I think that increased involvement of the media and internet in medicine will only continue to grow as our society becomes more technological proficient. This change (like all others) poses both benefits and challenges as patients will inevitably be better education but also face an influx of either false or exaggerated information that they will have to shift through. However, I think that it’s irrational to assume that just because some people will misperceive information that we ought to maintain a level of ignorance over society at large. So we should accept it, learn from it, and find ways to have the media make medicine more efficient and effective.

Military Medicine

It is difficult to believe that the military bureaucracy cannot provide adequate medical care to its own soldiers who are returning from wars in Iraq and Afghanistan. I believe there should even be a priority for the soldiers who sacrifice their lives for their country to receive the best medical care available and the emotional and mental support needed to help them transition back into civilian life. The article from the Washington Post gives a short description of what it is like for a soldier returning home.

The typical soldier is required to file 22 documents with eight different commands -- most of them off-post -- to enter and exit the medical processing world, according to government investigators. Sixteen different information systems are used to process the forms, but few of them can communicate with one another. The Army's three personnel databases cannot read each other's files and can't interact with the separate pay system or the medical recordkeeping databases.

No wonder soldiers are frustrated in addition to being plagued by stress, depression, and PTSD. Instead of the warm welcome and treatment the soldiers expect for being heros, the soldiers are isolated and neglected. Civilian care coordinators, case managers, and social workers who work at medical military facilities with good intentions are supposed to track injured soldiers and help them with appointments, but they often do not understand the bureaucratic system of the military and are also helpless to the system that they work in.

Why has no one noticed? I am sure if this issue was brought to the public attention, there would be a large public outcry that would lead to more structure and reorganization. In turn, the demand could facilitate more funds and legislation to provide support and medical services for soldiers. Before all of this, I think there needs to be more attention placed on the services of soldiers and the least we can do is to assist them when they get home because they are deserving of the same level of care that any of us receive at our medical facilities.

Medicine in the military

Military medicine, in many regards, is unlike the other branches of medicine that we have discussed so far in class. Coming into this class, I had a vague idea that doctors on active military duty would see horrific injuries and have to make harrowing triage decisions. I also knew from various emails sent through the PLME listserv and a couple of physicians I know who are in the Army that the Army generously pays for their doctors’ education and gives them all the privileges of being a member of the Armed Forces. However, after the readings, and the insightful presentation by Dr. Hayda, I have come to realize that military medicine is much more complex, and yet also simpler, than I had imagined.

The patients that military doctors must treat usually have more severe injuries, of a traumatic sort rather than chronic diseases—unfortunately, they also tend to be younger, and otherwise healthy. It was interesting to note that military doctors don’t seem to have to triage on a regular basis like ER doctors, but employ a “damage control” model that allows them to treat multiple patients in steps. The use of leaner mobile units reflects an overall revised strategy in the military, and their use will continue to grow. I think that our discussion about the role of biotechnology in medicine last week ties nicely into the NYT article on the use of new technologies like QuikClot that aim to improve mortality rates from traumatic battlefield injuries. It is apparent that in addition to public health agencies and private companies, the military also has a stake in developing new medical technologies, for the purposes of sustaining its soldiers—however, this military technology may also become available to the civilian population.

I was struck by the NEJM’s account of military officials’ insistence that becoming a physician is “not a sacramental vow” and that the military doctor “is a combatant, not a physician”—this goes against the other works we have read which portray medicine as a calling, as a noble lifestyle rather than vocation. The conflict of interest that arises then is interesting. Does the doctor follow Hippocratic/civilian protocols of do no harm, and are they beyond the chain of military command? Or does the doctor obey orders and carry out the wishes of higher-ups? As the authors suggest, the answer lies somewhere in-between: they imply that a doctor should follow commands insofar as they do not cause harm to another human being. With this conclusion, it was disturbing to read evidence that doctors willingly participated in the abuses at Abu Ghraib by helping to design interrogation techniques and sharing detainee information with interrogators. As Atul Gawande writes, civilian physician codes of conduct are often inadequate for military doctors, who face sometimes very different challenges, and it is evident that greater attention needs to be paid to creating effective, ethical military medical guidelines.

I was horrified by soldiers’ accounts of shoddy treatment and profound bureaucratic unhelpfulness at Walter Reed. However, their complaints do not surprise me, as they echo those of people with disabilities all across America that I have learned about in Pathology to Power (a class on people with disabilities). In general, there is a weak and vague structure of compensation and rehabilitation that is exacerbated by bureaucratic demands—brutal overhaul of the system is necessary. The public is also somewhat to blame for this sorry state, though, since there are many people who claim to support the troops and applaud enlisted men and women, but also become infuriated by the idea of these same men and women receiving governmental aid for injury/disability paid for through taxes.

Military Medicine for Local Civilians

For civilians in developing countries, the presence of the American military can be a lifesaving source of medical care where such resources are scarce. For example, the U.S. Navy has its own medical laboratory for the study of diseases endemic to certain regions of the globe. Because U.S. servicemen have no built immunity against diseases specific to these regions, the young children native to that region serve as a good model for researchers. Treatments for children are used for studying the natural course of certain diseases and the effects of possible vaccinations or therapies. Though, throughout history, various legitimate ethical concerns have been raised of this self-interest, it has on the other hand benefited civilian populations significantly in some, though not all, cases. This self-interest, then, has had a role in promoting global health in some of the places where such attention is most needed.

Our speaker’s extensive work in working with local healthcare providers to bring surgical services to civilians near his base, confirms the potential this relationship has for the future. As he pointed out, however, there does not seem to be an official system in bringing medical attention to local populations. Though the unofficial work is great when it comes to individual clinicians and their work for individual patients, I would advocate a more formal relationship when it comes to working with local populations to study endemic diseases for the goal of benefiting U.S. servicemen. To this system, there should also ideally be a built-in formalized process to overlook ethical concerns, in the general or case-by-case basis.

Biotechnology

Biotechnology has mobilized the globalization of medicine. In Good's article, she states that "the dynamics of the global-local exchange challenge our notions of “universalism” in clinical science and “local” knowledge in clinical practice, stimulating a rethinking of the boundaries not only between science and society but also between “the local” and “the global.” Medicine has been able to expand to remote areas in parts of the world that have not been reached before. The growth and development of the practice of medicine and biotechnology go hand in hand. When I think of the word biotechnology, I imagine robots and artificial organs. In the United States, biotechnology and the important research in this field has helped prolong lives especially of the rapidly growing elderly population. However, the implications of biotechnology in developing countries also have profound effects. Medicines and drugs created by pharmaceutical companies take on a different context in various cultures. Americans depend on drugs from ailments ranging from headache to depression. Other countries use drugs as well as traditional therapies like acupuncture in a new type of hybrid biotechnology. I believe biotechnology has definitely positively influenced the international cooperation of medicine.

notes from the M&M Conference

1st case: 18 year old woman presented with neck lump and pain in right hip

-panelists seem to consider diagnoses from their own specialty perspectives (infectious disease doc says mono, IBS possibly, “HIV is always a possibility, however much you believe someone’s sexual history”; oncologist says diffuse lymphoma).

-How much does specialized knowledge help/hurt the differential?

-although the patient didn’t present all the symptoms of LeMierre’s disease, the point of M&M is to find foolproof ways of diagnosing it next time. This is a learning experience. Quantifying symptoms, putting them in a checklist, and teaching doctors to recognize them next time.

-detective novels!

2nd case: 80 year old British man presented with shortness of breath, dyspnea, hoarseness

-panel members should and can ask questions

-the multiple lab data bits, EKG, types of scans, were all standard procedure.

-How do we actually know what a “disease” is? Just an accumulation of lots and lots of cases that have the same/similar pathology and we extrapolate from there/continue to add new symptoms/subdivide and name it after the “discoverer”

-if you sit up there on the panel and say nothing, you don’t look so good. Or when you say things like, “Lifespan doesn’t cover chimney sweeps.” Seriously? Apropro?

-the docs discuss the mechanism of death, not the emotional experience per se, though I suspect that it means something to these people, to know what it “feels like” when you have a certain biological condition

-they constantly compare patient to the available literature. Staying up to date with research and clinical cases is important!

-“it would be crazy” to aggressively treat someone in such poor condition. This man was resuscitated instead of being allowed to die in his sleep, but to what avail? Dr. Flanigan (!) makes the point of “delivering bad news” and the presenter said that he “made no bones” about telling him that it looked bad… discussion with wife and the patient was made CMO.

Technology and Medical Innovation

Hanson’s The Edge of Medicine touches on many pertinent issues in the increasing importance of technology and medical innovation in our healthcare system. Some rhetoricians have the belief that even though Americans may not have access to universal healthcare, American medical innovation continues to make our system one of the best in the world. Whether or not this is true is disputable, but Hanson’s timely and optimistic book shows that technology and research are vital to the practice of providing healthcare in this country. Some may argue that this comes at the expense of humane patient treatment, but Hanson shows that technology may be incorporated in a way that actually benefits patient care.

One case in which this is true is his exposition on the growing number of laparoscopic surgery. These surgeries are less invasive and quicker than traditional surgeries, and probably improve the doctor-patient rapport as a result. In addition, electronic medical records are a godsend for many hospitals and clinics that would otherwise have to juggle easily damageable paper records. Of course, EMRs raise questions of privacy and are also not foolproof, but they represent a way in which medical innovation has been not just physical or on a biological level, but organizational as well. Overall, technology has been the driving force in improving patient care—although we cannot let it draw a veil over the importance of maintaining humanism in medicine and extending the benefits of that technology to every citizen in this country.

However, the increasing amount of technology raises the question of whether computer-run machines and “intelligent algorithms” will one day render people obsolete. This is most evident in Hanson’s description of Tug, an affable little robot who can deliver drugs to patients’ rooms, performing the same task that would ordinarily be done by a human. Thus, technology has profound economic implications that I think are not unlike those encountered in the Industrial Revolution, when artisans found themselves being outmatched by machines that were more accurate, more reliable, and less likely to complain. In addition, doctors may struggle to keep up with all the new medical techniques (see http://www.bmj.com/cgi/content/full/313/7064/1062) or may even find their diagnostic powers being challenged by an algorithm that can weight patients’ symptoms against illnesses.

Medicine truly continues to evolve before our very eyes. In face of the intersection between medicine, technology, and science, it is obvious that medicine will only continue to advance technologically as new scientific discoveries can be applied. However, I find it interesting that Hanson did not devote more attention to the relative paucity of funding for pioneering medical technologies. In addition, it seems that technology affects different specialties and different practices to varying degrees. I wonder if it has increased the divide between various specialties because of the increasingly specialized information that a doctor in that particular field would need to stay up-to-date on.

Biotechnology Fever

Since the 1980 law enabling universities and hospitals to profit from research through licensing new drugs, biotechnology has had an increased need for ethical surveillance. Given our capitalist market economy, it is unsurprising that this financial incentive for academic institutions has generated more momentum in the biotechnology industry. I would even argue that this intersection of academic and business medicine is ultimately beneficial for more aggressive, albeit money-driven, research & development. The qualm I have on this academic-industrial relationship, especially from reading of cases like that of Jesse Gelsinger and U. Penn. (1999), is the impact for patients in the clinical setting. This issue coincides in part with our discussions on the relationships of doctors with pharmaceutical companies. In that case, I argued that hospitals take greater control over checking and balancing this relationship. In this case, however, I wonder how efficient more communications and awareness-training for physicians, especially younger ones in training, at the individual level would be. More fast-acting structural changes might be needed, however, since currently, it is the older, more powerful physicians in the hospital or research administrations that might be heavily influencing choices on trials for patients.

At the more microscopic level, in the article “The Biotechnical Embrace”, Good argues: “Enthusiasm for medicine’s possibilities arises not necessarily from material products with therapeutic efficacy but through the production of ideas, with potential although not yet proven therapeutic efficacy.” Good goes on to argue that patients tend to invest in this “medical imaginary” enterprise—culturally, emotionally, and financially. As doctors invested in our patients’ health, I think that we need to be cognizant of the fact that conversations involving biotechnology-trials can have a sentimental effect, which in turn, can significantly affect life-altering decisions. However, I would argue that for many patients, hope is urgently needed in battling disease, and that this hope is sometimes simply clothed in the form of hope in the promising future of biotechnology. As discerning doctors, then, our job might be to recognize and continue to foster this need for hope, but not let it coincide 100% with a trust in the “medical imaginary.”

Emergency Medicine

Although emergency care is necessary, the system is definitely being abused by too many people. The number 9-1-1 is not just for emergencies anymore, but may also present the idea that maybe we can get free medical care without having to see a primary care doctor and pay a co-pay. This mindset is common, but if one stops to think is it really worth it to pay $10,000 per night if one ends up getting admitted to the hospital? What about all of those real emergencies that we do not have enough ambulances to respond to? It is selfish for people to use and abuse our health care system. I can see that although it is wrong for people to do this, these are definite consequences of the current state of the health care system.

Within the Emergency room itself, there is the issue of overcrowding. Doctors provide care to thousands of people especially to those who are uninsured and have a lower socioeconomic status. People cannot afford insurance and cannot afford to see a health care provider and thus, wait until they are in dire need of medical attention to even go to the hospital. Doctors who work in the Emergency room are faced with these new challenges day in and day out. I am impressed by the obstacles they overcome outside of the clinical cases that they see. These obstacles can be anything from a language barrier to financial issues and not being able to pay without insurance. It is in the ER that many of America's health care issues surface and are brought to light. These are complex topics that I hope with the health care reforms will be addressed.

Reflecting on the E.D. Advantage

It is upsetting that the emergency department has become a source of primary care for so many Americans. I agree with Woo that the quintessential component and reward of primary care is longitudinal relationships. For example, she describes the joy of “[seeing] firsthand how social factors affect patients who have chronic diseases.” She also describes her fascination at witnessing how patients’ symptoms are a manifestation of various pathological, social, and personal factors. The use of emergency departments as primary care undermines this long-term and comprehensive patient-doctor relationship. And quite frankly, as a member of the future physician workforce, I feel a bit “cheated” of a fully meaningful relationship with my future patients as the American healthcare system depends more heavily on emergency rooms.

However, I tried out reflecting on this matter from a slightly different angle. I tried identifying myself as a member of the future generation of healthcare workers, or of social justice advocates, versus of physicians. From this angle, I was able to see more optimism in current trends of American healthcare usage. For example, the recent rise in emergency department use opens a critical portal for social workers to reach those who need such help. Were I a social worker, this trend would indicate the inadequacy of the current system to fully and timely meet individuals’ or communities’ health-related needs. However, because disease is often a physiological manifestation of less-than-ideal social, economic, and mental conditions, this national trend would identify for me a pool of individuals who could benefit from social services. I realize, though, that finding people in need of a social worker’s expertise is hardly a high-ranking enigma for the social work task force. There are probably plenty of people in America who would benefit from social services, and, as is the case for the health care system, need is not the factor in short supply.

Life and Mortality

Death is probably one of the most difficult issues that I would personally feel uncomfortable dealing with. After reading Pauline Chen's Final Exam, her experience reassured me that death isn't something that one will get used to even after many years of experience in medicine. The words, "I'm sorry for your loss," may unintentionally lose its meaning after being used thousands of times, but the emotions surrounding the death of a patient is a new and different one for the doctor every time.

What interests me the most are the various ways doctors handle discussing death and coping with death afterward. Doctors enter medicine in order to save lives. It is hard for them to give up on a patient when they have entered a field to learn the skills that could possibly help people with their illnesses. Who wouldn't want a doctor that will not give up and will do everything in their power to keep their patient alive? Although I think all of us want this to be our doctor, doctors are humans too. They get fatigued, cry, and laugh. A quote from Pauline Chen's novel reads:

"To complete the initiation rite successfully, however, we need to learn to separate our emotional self from our scientific self; we must view this dead human body not as “one of us” but as “one of them,” a medical case to be understood but not embraced."

I have to disagree with Dr. Chen. Doctors need both their emotional and scientific selves together in order to remain human and humane. Dying want care in their last hours and doctors should be able to provide it. Doctors shouldn't take one look at a patient and see medical cases. They should see the patient as a human too.

Emergency!

In Hospital, the chief of emergency medicine at Maimonides explains why ER medicine is different from other kinds: our goal, he says, is not to cure the patient, but rather to make sure that the patient doesn’t die. ER doctors take particular pride in their line of work, as well they should—as seen in the Emergency! stories, they work brutal shifts, see bizarre and terrifying cases, must triage overflowing waiting rooms, and often deal with the sickest members of society, who have waited to seek medical care at the ER because they are not insured or their insurance does not cover them adequately.

One of the ironic things about emergency medicine is that it is probably one of the specialties that generates the most “press” about medical oddities and stories that might be found in News of the Weird, but it is also one of the most financially strained specialties as well. Similarly to the articles we read about financial disincentives behind the shrinking number of primary care doctors, ER doctors also feel that they are not entirely well-compensated for the life-saving measures they must take on a daily basis. Although many doctors complain about the sheer number of patients they have to see in order to keep waiting times down, the fact of the matter is that they are compensated per patient and not for the quality of work that they do, so that if the number of patients were reduced, their financial disincentives would be even greater. They must take on more and more cases just to stay in the red. This has to change in healthcare reform efforts. In addition to ER doctors’ woes, here is a New York Times article that reveals just how much EMTs and firefighters are becoming a part of peoples’ primary care as well: http://www.nytimes.com/2009/09/04/us/04firehouse.html?scp=1&sq=EMS%20firefighters%20medical&st=cse. I find it troubling that for so many, the ER has become the last and only resort for medical attention. Getting more people better primary care access must be pushed in legislation so that ER doctors can focus on truly life-threatening cases and so that these peoples’ health doesn’t deteriorate to the point at which they need to be taken to the hospital by ambulance for preventable diseases.

Many of the people who are taken to the ER for preventable diseases are also among the poorest and most stigmatized members of society. I feel that that the inconsistencies and emotions surrounding unequal economics really comes out in Rescuing Providence. Morse repeatedly admonishes the alcoholics, gang members, and other so-called “plagues” on society for not pulling themselves up by the bootstraps. Although they are victims of an inadequate social support system, they have to pull themselves out of the gutter to make it to the street, and although I found myself agreeing with Morse, I was also uneasily reminded about discussions about moralizing health and attaching stigma in my health inequality class. When and how can we blame people for their health condition? How can we convince people to take preventive measures? If more people took preventive measures, hopefully we would see less people in the ER.

The Chaos of the American ER

I’ve always thought of emergency medicine as one of those fascinating realms of medicine and hospital culture that are only attempted by the true “cowboys” of medicine. The men and women who crave the late hours, the adrenaline rush, and the truly frightening and fascinating cases. It is a realm of medicine that I would love to try for a month and probably burn out from within the course of a year.

Emergency is clearly the source of extraordinary fodder for medical drama shows. The “couple” who presented with a fork in the head and an injured groin was clearly adapted by Grey’s Anatomy. It is crazy and at times heartbreaking and leaves you with a group of stories that either reifies or makes you question your desire to go into medicine.

Some of the most impactful stories in Emergency were certainly those pertaining to the death of young children. It is one of those experiences and references that shakes one’s faith in healthcare and seems to defy the very point of medicine, to save the (once) young and healthy. The anguish felt by parents and as a result the human emotion perceived by doctors is one of those things that I imagine is and will be impossible to forget.

Another aspect of emergency room culture that becomes very clear while reading the book is that one will inevitably face bizarre and “unbelievable” patient encounters and as future doctors we are still expected to deliver healthcare in a judgment free way. The bizarre (and even gross) situations that patients get themselves into, whether it be self-castration or the insertion of foreign bodies into one’s body, will undoubtedly be jarring and even horrifying to deal with. Another apparent trend in emergency medicine is the increased use of hospitals as primary care facilities for the poor. Amidst the true emergencies and medical dilemmas that enter the emergency room each day, doctors and residents also face the time commitment of treating people for more common illnesses. While the number of cases treated in ERs are clearly trying, the stress felt by the doctors becomes apparent in books such as the House of God where one of the interns paid a patient to leave the ER.
The nature of ER medicine seems almost fantastical to me. In internal medicine or primary care one generally has a certain sense of normalcy or predictability that they can expect. Hopefully most patients will be scheduled and a doctor can plan accordingly. However, in EM the expectations are entirely different; a doctor must be able to respond to and treat a patient with little notice and often in the most trying of situations.

Morbidity & Mortality

In her book, Dr. Pauline Chen discusses the role Morbidity & Mortality workshops play in doctors’ professional and personal lives. She discusses first her reactions at the ironic futility of it all—the emptiness that is left when a patient’s life and death are concisely summarized in such a workshop, then dismissed from conversation for eternity. She talks about the realistic mindsets of surgeons presenting in these sessions, defendants in a covert tribunal to decide where blame, if any, should be allocated. But then, later along in the book, Dr. Chen states that she finds such formalities to be potentially powerful, as long as their limitations are always kept in mind. I agree that there must be such formal avenues for doctors to discuss the morbidity and mortality of patients. By nature, these workshops can seem largely bureaucratic, or overly simplifying. However, as with Dr. Chen, these can and should play a role in stimulating often uncomfortable sentiments and further thinking for physicians at the individual level. Human words can sometimes play the role of gross and ironic understatement, especially in genuinely grave situations, I believe that formally set-up efforts to discuss or explore death is useful in helping physicians re-see the irony of how little words can account for human life and death.

Something that has been discussed during class throughout the semester is the morbidity and mortality of doctors themselves. Hacib Aoun, whom Dr. Chen writes about, experiences this first-hand when he is transmitted with HIV from the blood of one of his patients. In his lecture in published in Annals of Internal Medicine, he writes of seeing the artwork created by one of his patients: “It hit me violently that I had lost sight of my patients as human beings and had begun to see them as a different species: the patient species… The process of becoming a doctor is so protracted and arduous that it is easy to forget along the way the initial reasons and ideals for wanting to become a doctor, especially because the current medical curriculum is disease-oriented, not patient-oriented.” Dr. Chen discusses recent re-structuring of the currently Flexner-based medical curriculum around sessions that resemble M & M workshops. I also wonder if the medical curriculum could additionally incorporate opportunities for medical students and residents to reflect on and discuss their own vulnerabilities. This might prove to be a potent angle from which to develop more compassionate doctor-patient relationships that can deal more maturely with the morbidity and mortality of future patients.

Death and Mortality

As Chen writes in Final Exam, death is one of the most common experiences that physicians are not prepared for. I appreciated her completely open writing, and found that my own thoughts and experiences with death mirrored hers. Like her former medical student self, I have little experience with death, but am realizing that it is something I will deal with more and more as my family and friends grow older.

One of the medical student’s first experiences with a dead body is the anatomy lab. I have heard stories before about medical students moving from uneasy respect to nonchalance around their cadavers, developing affections like naming them, or what would seem like insults, like playing football over the bodies. This indicates that there are many responses to these cadavers, which are the manifestation of death. I found it interesting that Chen reconstructed her cadaver’s life through dissection. It is nigh-impossible, and perhaps not desirable, to overcome the empathetic instinct of trying to feel for a patient’s life story. Chen was attaching herself to her cadaver even though, as she writes, doctors are taught to exhibit “detached concern, secure uncertainty, and humanistic technology.” These descriptors, while they might seem to describe ideal clinical standards, are incredibly difficult to learn, and are truly ideals that medical students undershoot and overshoot until reaching some semblance of equilibrium. There is an illusion that all doctors can indeed be clinically detached, and when it comes to an issue as sensitive as death, this illusion can be difficult to maintain. Along with this notion, there is the expectation that a doctor, in being able to save lives, also has command over death, which is not true. Doctors struggle to reconcile external and internal expectations of being all-powerful medical professionals with the inevitability of death.

Similarly to Chen, I think that I have conceived of death as something mystical, that defies ordinary description and has an air of solemnity attached to it. It is a “big deal” as Dr. Israel writes in her New York Times piece, that doctors have to face on a weekly, if not daily, basis. Like many things, with repeated exposure, death can lose meaning, and a medical student might develop the coping mechanism of treating it as if he didn’t care, or even derisively. I wonder if doctors might have something to learn from the therapeutic methods that other groups of people who witness death teach. Doctors have the unique position of being the caregivers, the ones held responsible for a patient’s life or death, but could they learn from the experiences of nursing home workers? Soldiers’ accounts? Residents of neighborhoods with high homicide rates? One of the most powerful works I have encountered that explores the concept of death is All Quiet on the Western Front. While violent death by barbed wire is different from death on the operating table, I think it is the powerful idea of someone’s innate spark fading from existence that we can look at as some kind of shared human understanding.

'Whose body is it, anyway?'

"Little more than a decade ago, doctors made the decisions, patients did what they were told. Doctors did not consult patients about their desires and priorities., and routinely withheld information - sometimes crucial information, such as what drugs they were on, what treatments they were being given, and what their diagnosis was" (Complications, 210).

Gawande points out a striking turnaround in attitude towards patient competance and points out a crucial fact later in the same passage--while doctors are the experts on medical knowledge, only patients can have the fianl authority on personal matters. At the junction of these two pools of information, views and values is where the doctor-patient relationship ought to reside. He additionally highlights that patients do not want that autonomy, especially under stressful circumstances. Some sort o fbalance is required respecting botht eh patient's right to information and control in their care as well as the physician's abilities and experiences--without which a doctor would be nothing more than a gatekeeper to prescriptions and procedures. It seems that both patient and doctor need to be open and honest about their preferences and recommendations so that a consensus can be reached between them.

Paternalism as less than Evil

In his article, McKinstry categorizes the doctor-patient relationship into four classes: the autocratic doctor, the paternalistic doctor, doctor as agent, and patient yielding autonomy. Reading through these descriptions, I couldn’t help considering these as rather absurd and highly theoretical lines with little practical applications. As Dr. Pacheco, the family physician who came to speak last week, suggested, many patients actually come to her needing some level of hand-holding. Although we might feel it unfair, as physicians, we’re bound to frequently be asked questions like, “What would you do if it were you or your beloved one?” Especially in a society like modern America, the patients are asking their doctors for a genuine personal opinion, with the fundamental understanding that their ultimate choices are their own.

Therefore, I wonder if “paternalistic” medicine is necessarily something to be bashed. Years ago, in settings where widely accepted customs deified doctors to the levels of figures whose opinions had to be upheld, paternalistic medicine might have been manipulative, even abusive. However, today, “paternalistic medicine” to me sounds a lot less cold and more personal, even more intimate.

McKinstry’s categories of the doctor-patient relationship must all be mixed and balanced. To say that the figures of the autocratic and paternalistic doctor must completely be demolished, however, would be ignore a pragmatic need by today’s human patients.

Paternalism in the Doctor-Patient Relationship

One of the biggest issues in the doctor-patient relationship is the worry about paternalism: are doctors too forceful in their patients’ treatments? What is the appropriate balance between doing what you think is best for a patient, and respecting that patient’s wishes if they don’t agree with your medical opinion?

Paternalism springs from the idea of the “father knows best” physician whose authority is unquestionable. I was moved by Gawande’s book because he reveals doctors as human beings. It is natural to think of a machine as unyielding, but it is hard to believe that is impossible to change a human’s mind. Doctors are under a lot of pressure to deliver, and when a patient’s wishes deviate from their idea of excellent medical treatment, they may feel as though the patient is actually trying to hinder their plans. In order to take on paternalism, we have to decide if the doctor’s obligation to provide the best medical care possible or to respect the patient’s wishes is more important. It’s possible to strike a balance, but the specter of paternalism will always loom so long as these two obligations are in conflict.

This is complicated by the rise of the consumer-patient, who is armed with online medical advice and bombarded by the seductions of DCTA. Many have argued that the age of information has allowed the patient to take greater control of his health and healthcare. However, others worry that this deluge makes patients more susceptible to quackery. It’s important to remember that this kind of changed relationship is only possible among those who have access to these online advice sites in the first place, and who have the confidence to interpret them, giving the doctor-patient relationship new sociopolitical implications. But a similar phenomenon has existed for much longer with regards to so-called “folk” remedies, which were taken not as a form of alternative medicine, but the medical truth. It is paternalism to reject a patient’s right to perform bizarre rituals, or to disallow a patient to pray in lieu of medical treatment, etc.?

As Kiminstry argues, just as it is paternalistic to deny a patient’s wishes, so too is it paternalistic to deny the right of a patient to yield authority. Many patients, especially those who don’t frequent WebMD, still defer to doctors, asking, “What would you do if it was you?” Just because a doctor doesn’t want to be perceived as paternalistic doesn’t mean he should take a hands-off approach and serve only as a distant provider of options—he should be allowed to infuse his medical opinion into that presentation, but realize that it is just that, an opinion.

Paternalism: Are we overreacting?

I think that like all ethics movements, the medical ethics debate can at time take on an extremist stance. There's such a fear in stating medical opinions or best options (among healthcare professionals), that this fear ultimately ends up affecting medical care. I think that doctors should hopefully have the experience and knowledge to ascertain what is the best medical option/treatment for patients.

Dr. Gawande discusses how most "well" people say that they would like to dictate their healthcare decision, while only 12% of cancer patients say they wouldn't want to defer to the advice of their doctor. I think that doctors have a duty to provide explanations about all possible treatment options and to provide objective advice about medical therapies and risks; however, I do think that patients and families appreciate a certain degree of subjectivity and personal preference.

Dr. Gawande recounts his own experience when his youngest child was hospitalized for a respiratory infection and the doctors and him debated whether or not his daughter should be intubated. He emphasizes that he wanted the doctors to be the decision makers so he wasn't forced to feel the guilt of a (possibly) wrong decision. I think it's fair to say that even for non-doctors there is a certain comfort and deference in responsibility in having someone else decide the best healthcare option. As patients we assume that the specialist has more exposure to a various condition and treatment options and we acknowledge that the medical profession exists as a remedy to our own limited knowledge.

I understand the sentiment that patients have a right to know about their medical condition. However, I think it's ironic to note that many families ask doctors to withhold information about a prognosis or disease. But I think that allowing patient's to be "autonomous" decision makers who are embarking on a bad decision creates a whole new frustration for doctors. It goes against medical training and the professional teachings to withhold treatment or allow patients to choose a bad alternative. I think that medical ethicists ought to acknowledge that medical care cannot always be simply reduced to preserving patient autonomy. This becomes clear in Gawande's recount of a patient with pneumonia who was certain to die without ventilation but refused the treatment. Subsequently, when the patient passed out he was intubated. I think that these scenarios are not clear cut and doctors feel a professional obligation to do what they believe is in the "patient's best interest" in spite a patient's explicated desires. If a person presents themself to a doctor or medical institution for care, I think it is fair for doctors to act in a manner to provide them with the best possible outcomes- it seems to be a deference we should make to their training.

Technology in the Doctor-Patient Relationship

It’s no coincidence that both of our selected readings mention advanced medical technology in discussing the doctor-patient relationship. In a field constantly changed and shaped by the biomedical engineering and technology industries, it’s almost as if the doctor, patient, and technology must form a troika to get the job done. Without doubt, even the now-jaded technologies like the phone enables closer-knit patient-doctor relationships. Primary doctors, surgeons, and technicians have the necessary information to contact their patients with updates on diagnoses and treatments at any time. Though this has helped many doctors be more professionally active and personally caring, it’s important to note that only a fraction of doctors actually use the phone to regularly make home calls. There is probably no doctor without a phone in his or her office, and certainly no doctor without a cell phone that can reach any of his or her patients. There are many technologies available out there, and infinite possibilities for advantageous manipulations that can render existing technology even more powerful for interpersonal relationships. Therefore, availability and innovative ideas are not the limiting factor.

More and more physicians are getting board-certified to appeal to potential patients. Private clinics and hospitals flaunt national acknowledgements of their facilities’ cutting-edge technology or renowned house staff. I wonder if there could also be a more standard system for ranking or acknowledging genuinely superior doctor-patient relationships, for either individual doctors or whole institutions. These analysis systems should incorporate a measure of how well medical technology is adapted to strengthen the doctor-patient relationships. To ‘prove’ an honest effort at better doctor-patient relationships, doctors and institutions will surely become pressured to adopt and utilize more measurable tools for effective communication and personal caring. Wider use, higher standards by patients, and continued demand will in turn help the bio-medical technology market to flourish with more economical and innovative technological tools for strengthening doctor-patient relationships.

The Doctor -Patient Relationship

The Doctor-Patient relationship seems to be the most elusive of all of the aspects of medicine that we are seeking to understand and one day participate in. As we looked at in previous weeks, medical schools seem to spend most of their energy teaching students basic sciences, and about normal and diseased human bodies. However, it is often the doctor-patient relationship that has the most impact upon patients and is most sought after by doctors.

In Bedside Manners we read of a patient who, despite every effort put forth by his physician and surgeon, died due to noncompliance. On the other hand, some patients benefit simply from the care and support they receive from an accessible and compassionate physician. How future doctors learn to embody this example? What opportunities are there for those entering into medicine to learn or fine-tune their abilities to communicate, empathize, and collaborate with patients? Is this something that can even be taught?

In our med. student panel last Thursday we heard of a new "doctoring" program in the Alpert Medical School that allows students to follow physicians as well as to practice patient skills on patient-actors. This step is certainly evidence of strides that are being made to answer the questions above, but can students be taught empathy? I've heard of certain phrases offered to medical students to use in difficult situations such as "That must be hard for you" -- does this undermine a doctor's ability to develop genuine relational skills and bonds with their patients by providing a 'one-size-fits-all' script?

Doctor-Patient Relationship

I was very moved by the readings in Bedside Manner this week. The field of medicine itself is so complex, but for me, nothing more so than the doctor-patient relationship. It is important to practice personalized medicine and treat each patient with an open mind while taking into account individual differences that may not necessarily follow the studies or statistics or textbooks one learns in medical school. The misdiagnoses in the cases we read show that people are unpredictable- the book cover may look the same for many books, but we still need to open it and read it in order to understand the entire story.

Modern medicine has definitely seen a general trend on the emphasis of the patient in the doctor-patient relationship. With greater access of medical information to the general public, patients are coming into offices more knowledgeable about their condition. It is interesting to be a pre-medical student who is still a patient, but trying to understand what it is like on the other side of the fence. As a patient, the internet is a useful tool in understanding a physician's diagnosis or (as I personally think many people do) self-diagnose one's symptoms. Self-diagnosis can mean weeks or months without seeing a doctor, which can lead to serious illness that WebMD can't diagnose. This is also contributing to a growing doubt in the skill of a once revered profession. I admit that I have used the internet to find out good questions to ask my doctor, but I draw the line at report cards on my doctor.

Where is the trust in medicine? Are patients putting more trust in technology than in their doctors? It would be difficult for anyone to accept nowadays that even with all the new, advanced technologies and improved teaching of future doctors, medicine is still limited. Who can really say if there is really a difference in prolonging a life 10 days or 10 weeks? I think that there is something wrong if medicine is starting to substitute quantity for quality.