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.