Thursday, August 30, 2007

Hoops Versus Learning: Why Does No One Want to Go to Morning Report?

This is really just a rant. I'm annoyed this week.

Perhaps it's just some sort of personality flaw, but I've generally never been very good at jumping through hoops. I mean, I always did the bear minimum to get through any hurdle that I couldn't find a way to walk around, but I always grumbled and rarely did it with a smile. On the other hand, I've always been very good at doing what needed to be done. Like many people, I'm also very dedicated to things that I find interested and/or valuable.

I was a sub-par student at a sub-par high school. I learned nothing, and the thing was one giant hurdle. Did I graduate? Yes. I sure grumbled though, and my grades were a reflection of my commitment. When I got to college, everything changed. I studied things that I liked. I made very good grades (as all of us in medical school did), I published some abstracts, I was disciplined and motivated. As I worked myself through college, my weeks were generally of the 80 hour variety, but I never burned out. As time has gone along in medical school, I notice some of my high school habits coming back. I try to duck out of classes, I grumble a lot, I try to avoid responsibility.

I've put a lot of thought into it, and I realize that it's because I'm jumping through hoops. I will not pretend like some that I'm not learning anything. I'm learning a lot. I'm just learning it in a ridiculously inefficient way. I'm not afraid of hard work. I usually embrace it, but not when it's pointless. Is there some practical value to learning how to do a pap smear even though I find it personally revolting (you know you do too)? Yes, so I did it. Is there any value to anyone rounding four times on the same patient? No. It is highly inefficient, and I twiddle my thumbs most of the time. This is what qualifies as a hoop.

I think different people have different levels of hoop tolerance. As I said, mine is low. The problem is, that post-hoop threshold, your desire to engage in the rest of the activity is significantly impaired. Thus, if I'm on a rotation, and I feel like half of my time is wasted, It hurts the learning value of the rest of the time. I become disillusioned with the whole thing.

This brings me to morning report. On a certain rotation, morning report was a 15 minute to 1 hour get together with the entire department each and every morning. The value of this particular activity was highly variable. Sometimes an interesting patient would be presented, and there would be a lot to think about. Sometimes people would ramble for an hour. The problem was, I was spending about 80 hours a week at the hospital. MANY of these hours were spent sitting around waiting for admissions while on "call." This was a complete waste of time. By the second week, I was simply sick of sitting around the hospital, because half of the time I was there was useless in terms of educational value. I would have been happy to perform tasks with educational significance during this time, but it was not to be. Thus, when morning report came, I was sick of it. I wanted nothing to do with it. I though to myself, "I could have slept an extra hour without this," or, "I haven't seen my kid in two day because of this." The hoops overtook the value. I probably learned less that way.

The funny thing, is that the residents didn't usually look too pleased either. The post call residents had a longing in their eyes that screamed, "shut up and let me finish my floor work so that I can go to bed." They learned nothing. For them, it was a hoop. The attendings didn't get paid to be there. I couldn't figure it out.

Morning report isn't like some of the other hoops with obvious beneficiaries. It's obvious that certain interests are vested in maintaining training monopolies, long resident work hours, and a myriad of other hoops you have to jump through (ERAS *cough* *cough*). There is no such obvious interest for morning report. It's nothing but a culture of hoops and useless hurdles that keeps them going. Honestly, I hope I make it through medical school with enough interest intact to actually enjoy being useful as a physician. The hoops will remain, but I should atleast get paid for dealing with them. Money motivates me to jump. One can only hope.

Sunday, August 12, 2007

There is no Direct Correlation Between Devoted Effort and Final Value

As I make my way around the blogosphere and the internet medical community, I consistently hear an argument that is blatantly false. This is the argument that physicians should be well paid because they train for so long and pay a lot of money for the training. This argument is based on a fundamental lack of understanding of basic economics. It is also dangerous, because it detracts from a legitimate understanding within the medical community as to why we are worth a lot of money. In this blurb, I'm going to attempt to tease out the subtle, but extremely important, difference between a truly valuable good and service and a good or service that requires a significant amount of effort to produce.

I majored in Anthropology in college. I once had an advisor tell me that Anthropology had the longest average graduate school period, which is approximately 9 years between receiving ones BA and receiving ones PhD. Anthropology graduate school is a tedious process, one which I was frequently exposed to during my undergraduate training in the discipline. Many graduates would spend years in a laboratory, sorting microscopic pottery fragments that they had spent previous years tediously digging out of the ground in a variety of inhospitable places. This often included sleeping in the dirt, spending all day covered in mud, and exposing oneself to all sorts of vile insects and other not so pleasent creatures. This is the life of many anthropology graduate students. It will be followed by many months typing hundreds of pages explaining the above findings in details after which the graduate will have to defend those tedious notes to a group of people that will attempt to tear him apart.

The first thing that one might notice about this, is that the average time between college graduation and completion of training is the same for an anthropology graduate student and a general surgeon, nephrologist, and a whole host of other medical specialties and subspecialties. As a specialty that is reasonably attainable and representative of what we'll call the "average physician," I'll make most of my future comparisons with Internal Medicine. It is also close to the bottom of the salary scale, so most physicians should find internist income attainable. According to the Allied Physicians salary survey at: , the average internist starts at $154,000/year. Since total graduate and post-graduate training in this specialty is only 7 years, this puts the internist $308,000 ahead of the anthropology student in income, more than enough to offset the differences in total debt (which are large, but not as large as many medical students would like to think).

So, what is the average salary of a starting professor of anthropology? In sociology (which is if anything higher paid), average salaries of an associate professor according to (and academic positions are highly competative) hover around $60,000/year. This is about 40% of the internist, whose position is relatively non-competative compared to those who he is competing against.

So, why is the internist paid more? In fact, why has he consistently been paid more over the course of an ever evolving healthcare system ever since the advent of medicine based on science? It's simple. His services are considered more valuable to more people. As I've said in previous posts, economic value is subjective. Anthropology is a fascinating field, but it's also an esoteric discipline, with very minimal value to the average person.

Physicians are valuable because their position on the supply and demand curve makes them so. In other words, the number of people with physician skills matches a level of demand at a high comparative salary. This isn't to say that the training period isn't important. In fact, the large training period, with all of its expense and effort, is the reason that physicians are less common. This relative scarcity in the face of high demand is what makes physicians valuable. The training period in anthropology training period is also long, and skilled practicioners are also scarce, but the demand isn't there on the other side. Thus, physicians are valuable because they are a scarce commodity in the face of high demand, not because the training period or hours are long.

As a final note, if hard work was the only thing that made workers valuable, we would all look up at mansions owned by farmers, migrant workers, and fisherman. I once worked over 60 hour weeks at a warehouse job in an unairconditioned warehouse here in South Florida. I can assure you that the physical assault on my body was significantly worse than anything that I have encountered in medicine. I was paid $6/hr for that. In fact, were hard work the top mechanism for determining payment, we'd probably all be servants of the Amish. If education were the mechanism, we'd all be watching the Anthropologists drive Ferraris down the street.

To the current or future physician:
The general public could really care less how much effort you've put into your training or the financial sacrifices that you've made. They care that you are a skilled practicioner who can solve whatever problem they present to you with. Complaining that you are underpaid for your time invested will earn you ZERO sympathy in the rest of the world. It should, because it's irrelevant. However, demanding to be well paid because you can provide a valuable skill that is hard to provide is perfectly within your right. In fact, that is the argument made by all professionals. Don't be afraid to demand to be paid for your hard work, but make sure that you're basing your demands on the reasons that they're valid.

Some Words from Our Friends at Yahoo

I think that the conclusions are a little off, but it's interesting

U.S. life span shorter

August 11, 2007 05:08:02 PM PST

Americans are living longer than ever, but not as long as people in 41 other countries.

For decades, the United States has been slipping in international rankings of life expectancy, as other countries improve health care, nutrition and lifestyles.

Countries that surpass the U.S. include Japan and most of Europe, as well as Jordan, Guam and the Cayman Islands.

"Something's wrong here when one of the richest countries in the world, the one that spends the most on health care, is not able to keep up with other countries," said Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington.

A baby born in the United States in 2004 will live an average of 77.9 years. That life expectancy ranks 42nd, down from 11th two decades earlier, according to international numbers provided by the Census Bureau and domestic numbers from the National Center for Health Statistics.

Andorra, a tiny country in the Pyrenees mountains between France and Spain, had the longest life expectancy, at 83.5 years, according to the Census Bureau. It was followed by Japan, Macau, San Marino and Singapore.

The shortest life expectancies were clustered in Sub-Saharan Africa, a region that has been hit hard by an epidemic of HIV and AIDS, as well as famine and civil strife. Swaziland has the shortest, at 34.1 years, followed by Zambia, Angola, Liberia and Zimbabwe.

Researchers said several factors have contributed to the United States falling behind other industrialized nations. A major one is that 45 million Americans lack health insurance, while Canada and many European countries have universal health care, they say.

But "it's not as simple as saying we don't have national health insurance," said Sam Harper, an epidemiologist at McGill University in Montreal. "It's not that easy."

Among the other factors:

• Adults in the United States have one of the highest obesity rates in the world. Nearly a third of U.S. adults 20 years and older are obese, while about two-thirds are overweight, according to the National Center for Health Statistics.

"The U.S. has the resources that allow people to get fat and lazy," said Paul Terry, an assistant professor of epidemiology at Emory University in Atlanta. "We have the luxury of choosing a bad lifestyle as opposed to having one imposed on us by hard times."

• Racial disparities. Black Americans have an average life expectancy of 73.3 years, five years shorter than white Americans.

Black American males have a life expectancy of 69.8 years, slightly longer than the averages for Iran and Syria and slightly shorter than in Nicaragua and Morocco.

• A relatively high percentage of babies born in the U.S. die before their first birthday, compared with other industrialized nations.

Forty countries, including Cuba, Taiwan and most of Europe had lower infant mortality rates than the U.S. in 2004. The U.S. rate was 6.8 deaths for every 1,000 live births. It was 13.7 for Black Americans, the same as Saudi Arabia.

"It really reflects the social conditions in which African American women grow up and have children," said Dr. Marie C. McCormick, professor of maternal and child health at the Harvard School of Public Health. "We haven't done anything to eliminate those disparities."

Another reason for the U.S. drop in the ranking is that the Census Bureau now tracks life expectancy for a lot more countries — 222 in 2004 — than it did in the 1980s. However, that does not explain why so many countries entered the rankings with longer life expectancies than the United States.

Murray, from the University of Washington, said improved access to health insurance could increase life expectancy. But, he predicted, the U.S. won't move up in the world rankings as long as the health care debate is limited to insurance.

Policymakers also should focus on ways to reduce cancer, heart disease and lung disease, said Murray. He advocates stepped-up efforts to reduce tobacco use, control blood pressure, reduce cholesterol and regulate blood sugar.

"Even if we focused only on those four things, we would go along way toward improving health care in the United States," Murray said. "The starting point is the recognition that the U.S. does not have the best health care system. There are still an awful lot of people who think it does."

Sunday, August 05, 2007

On a Personal Note

To those who read this blog with any regularity, I apologize for my recent absence. I have had a couple of major shakeups in my personal life recently, which have significantly detracted from my time to write and kept me distracted at that. Such is life.

At risk again of blowing my anonymity, I'll let you in on my situation. Sometime early next year, assuming that all goes well, I will be the father of 5. This is somewhat more complicated by the fact that I currently have only 1 child, and my wife is pregnant with quadruplets. As soon as I manage to bring some normalcy back into my own life, I will continue writing. Perhaps I'll let you in on the economics of bringing a family with a net income of $-35k/year to 7 people.

If anyone has any questions or suggestions regarding pregnancy or children in medical school, please feel free to talk to me. Different studies show average gestational age at birth to be somewhere between 29 and 32 for quadruplets, so I expect the magic moment to occur sometime in January (based on current estimates). I'll be on surgery then. On the bright side, my wife and children will probably get to live at the hospital with me. Wish me luck.