Movin' on Up

I'm just letting everyone know that I haven't stopped blogging. I am in the process of completing a move across the country, so I'm a little slow. Check back in a week or two at the latest for more.

New Blog Link

As some of you may have noticed, I am a little bit stingy with handing out links on my blog. After recently speaking with a blog author however, I think that I've found a good one to add to the list. The blog is entitled, "Are You A Doctor?" It is written by a physician's assistant who works in the ED at the Mayo Clinic in Rochester, MN. We agree on a number of things, though healthcare policy unfortunately seems to not be one of them. Yet, I respect his perspective. He is intimately familiar with some of the recent developments in US healthcare policy, and his position at the Mayo Clinic gives him first-hand knowledge as to how some the ideas are being handled by the country's healthcare big-whigs. Plus, it's always good to have a spy at the mother ship.

All joking aside, I hope you check him out. You can find the link to his blog in my sidebar with the others.

OH MY GOD!!!!! IT'S THE SWINE FLU!!!!!!!

I have been reading so much media hype over the swine flu, that my head is beginning to hurt. For my readers that have been living under a rock, there is apparently a horrible flu in Mexico that has killed a few people while simultaneously sending the entire world into a frenzy. Infectious disease is certainly not my forte, but I can explain a little bit about influenza. I can also explain a little bit about my personal opinion on this disease.

What lay people consider the flu is actually a variety of similar ailments. The most common causes are from a couple of different types of influenza virus. Similar symptoms may come from the parainfluenze virus, as well as a couple of other outliers. The only "flu" that is actually the flu comes from influenza virus. This particular virus that is causing the swine flu is of the Influenza A type of influenza virus. This type of virus may express a variety of different antigens. The antigens to which antibodies are commonly made are generally knows as H and N antigens. The variation within these antigens is why there are so many different strains of flu and why unlike say the chicken pox, you can get infected with the flu virus repeatedly. Different influenza viruses can exchange DNA with each other to produce genetically distinct daughter strains and promote variation.

Humans are not the only species that can be infected by the flu. Strains of the flu can affect other animals, including species of birds and pigs. Generally, bird flu and pig or swine flu are not infectious to humans. However, a flu that can afflict these species may exchange some DNA with human flu. Occasionally, a flu that is infectious to another species may, either by spontaneous mutation or by exchange of DNA with a human virus, become infectious to humans. Most of the time, this infection is isolated to a specific person or group of people that have contact with the infected animal or animals. However, there are cases where this new infection will further mutate to allow transmission from human to human. This introduces a bunch of new DNA into the human influenza genome.

Humans usually walk around with some immunity to the flu. We have a part of our immune system that fights viruses in general, but most humans have been exposed to flu before, and thus most people walk around with additional immunity. The different strains of influenza are distinct enough, that they can re-infect the same host. However, they are similar enough that a previously exposed host can usually mount a partial response to the infection. We could think of this as damage control. You're sick with the flu, but your immune system can hold it at bay with relative ease due to its similarity to other strains that you have been exposed to. You are also part of the way towards developing immunity to the new flu, so the response is quicker.

In cases where there is exchange of DNA from an animal to a human flu (or worse yet when an entirely new flu virus crosses over from animal to human), people will lack this immunity. This gives the infected person fewer resources to hold the disease at bay up front, and it takes longer to develope a specific response to the virus. The VAST majority of the time, this makes for a bad long lasting flu. It is usually NOT fatal. However, occasionally an extremely virulent strain will cross over, and the previously unexposed human population will have very few big guns to stop it up front. Major flu pandemics (such as the flu of 1918) can be the worst-case scenario result of this sort of event.

There are a few more facts to keep in mind about the flu. Common everyday influenza is already the bane of the very young and old, the immunocompromised, and the sickly. Every year, 30,000 people will die in the US from the common everyday flu. Most of these people will fall into one of the above categories, though there will be some who will end up susceptible in the not obviously sick adult population. To put it into perspective, the flu kills as many people every year as 6 world trade center bombings.

The fear and panic over the swine flu seems to come in large part from the fact that a number of young people have died in Mexico, and the strain seems to be a swine strain of the flu that has crossed over to humans and mutated so as to be transmissable from human to human. I agree that this little set up is exactly how most pandemic flu starts. However, there are some things which make me seriously doubt the current degree of crisis, and more importantly, make me doubt whether this will really turn into a global pandemic spreading death in its wake.

The official number of deaths in Mexico currently sits at ~7 per the WHO, with estimates up to 200 of actual victims. There are over 27 known cases of flu in the country, but we all know that the majority of cases probably never sought medical attention or made an official statistic. This 27 number is only laboratory confirmed cases. These are people who made it to the doctor, had signficiant symptoms, were suspected, were tested, and came back positive. We have no way to assess these numbers. Were these really healthy people? Is the number really 7 or 200? Is it possible that there is a group of immunocompromised patients that got hit with the flu?

The flu has currently spread, per the WHO website yesterday, to 9 different countries. The CDC this morning has confirmed 109 cases of swine flu in the US, with one solitary death. This death, though unfortunate, was in a toddler in Texas at the age where children may be susceptible to death from any flu. No one outside of the US and Mexico has died of this flu. The fact that no is dying of this flu outside of Mexico alone makes it suspect. Are we dealing with two different strains of swine flu? Is there some other contributing public health disaster in Mexico to which we are not privy? Are the official deaths all immunocompetent hosts?

Lastly, this whole thing is essentially starting after flu season. The flu just doesn't generally reach peak virulence when it starts this late.

Here's what we should do (this is if someone were to ask me of course). We should work on a vaccine for this particular strain to offer to individuals who are likely to be susceptable before next flu season. This flu very well may attack at the beginning of the next flu season. We should also make sure that there are sufficient stockpiles of anti-viral drugs to address the possibility of a bigger problem. We should really only use these when people are very sick or start dying in real numbers. The last thing we want to do is breed resistance in a virus that seems to be doing minimal damage in our country now, only to have it develop resistance if it becomes more virulent. We should also watch the virus and its spread. A sudden rise in flu related death should necessitate further investigation.

Here's what we should NOT do. There is zero reason to panic at this point. We should not be stockpiling Tamiflu and N95 masks. We should not be cancelling events. We should not be living in fear. Every few years, we panic over a new strain of flu (remember the whole avian flu debacle). These sorts of things happen all the time, and it would really be ridiculous if we all shut down ever couple of years over the small possibility that a flu could become a pandemic. Most flu pandemics come from the crossing over of flu from species to species, but most crossing over doesn't result in a pandemic.

As I have always maintained on this blog, one of the few legitimate roles of government in healthcare is the control of infectious disease. It is appropriate for them to watch this. Remember however, that the vast majority of infected people have probably never been tested or even sought medical attention. The death rate amongst known cases (which are probably the worst cases) is still less than 1%. Let's keep this in perspective. Right now, the rate of death from this swine flu in the US really isn't any higher than the rate from regular flu (something we do not panic about).

It is smart to stay vigilant, but we cannot panic over every potential problem, because the possibilities are endless. If I see one more person walking around in a surgical mask (a mask that probably doesn't protect the person) here in my state where we have no cases of the swine flu, I may lose it. The panic is ridiculous. Could a swine flu pandemic occur? Sure. So could a nuclear war with China. At this point, I don't see a reason to panic about either of them.

Some Definitions (And Maybe Even Some Practical Examples)

In case it isn't obvious, I've had a little bit more time to post lately. As I wind down my medical education, my responsibility is approaching zero. I don't start residency orientation until June, so I've really encountered an unprecedented amount of time off. With some of the responses to my posts in the past, I realize that there is some distinct confusion as to the meaning of words related to politics and economics. Consider this post a bit of a dictionary for economics, government, and healthcare. I've got the time to clear it all up, so why not.

Economic Schools and Political Terms-

Capitalsim- Private individuals own the ways and means of production. Property is all or largely private, with the individual owners having sovereignty over the use of what they own. There is zero central directing of production or the use of resources. Free individuals trade without any central interference with the rules or prices, with all of these things being set up on a cases by case basis based on uncoerced agreed upon contracts by individuals. There is a lot of capitalism in the US system, and it is not dependent on large corporations or well connected business entities. Every time you walk into a store and buy something that the owner decided to sell without being coerced, you are engaged in capitalism. There are no good examples of capitalism in modern healthcare.

Fascism- Individuals own the ways and means of production, but the government controls what they can and cannot do. Usually, companies are directed to engage in activities for the "socal good." If a factory owner is ordered by the government to build tanks, but the government then reimburses him and lets him keep the money, that would be fascist. In medicine, the best example of a system that is defacto fascist is the Canadian healthcare system. Individuals (private physicians) own the ways and means of production, but the government controls what they must produce and how much they get paid based on the "social good."

Socialism/Communism- Socialism and Communism are really two peas in a pod, with one simply being further along the spectrum than the other. In a socialist system, the government owns some of the ways and means of production, where in a communist system, the government usually owns all of the ways and means of production (though it supposedly does so on behalf of the workers). The British healthcare system is a form of socialism, in which the government owns the healthcare system, but private competition is allowed. The Cuban healthcare system is a communist system, in which the government owns the healthcare system and private competition is not allowed. These systems often rely on strong unions as representatives for the workers' collective interest.

Austrian School- The Austrian School of Economics is a purely libertarian school of economic thought. Though there have been a number of famous economists that subscribe to this school, the most famous is Ludwig Von Mises, who was an Austrian Jew who fled Hitler to the US during WWII. This is the only school that supports complete unhampered free market capitalism. Austrian economists tolerate zero government involvement in the economy. This school subscribes to the theory that peaceful trade between willing participants with no coercion from the outside is the way to prosperity. Austrian economists tend to be extremely fond of open borders, no tarrifs, and private production of everything. They vehemently oppose the existance of a central bank. The Austrian School blames the Federal Reserve for the business cycle and would like to see the bank dismantled and replaced with a gold standard.

Chicago School- The Chicago School has a lot in common with the Austrian School. It was named after the group of economists that founded it, who were largely based out of Chicago's Universities in the mid-20th century. The Chicago school supports an economy mostly based on capitalism and free trade. They do differ in the sense that they are much more tolerant of a central bank, and there is no striking desire to return to a gold standard. The chicago school tends to be more tolerant of collectivisation in both bargaining and production. You could still probably call the Chicago School capitalist, but it isn't as pure in that respect as the Austrian School. Probably the most notable Chicago economist is Milton Friedman.

Keynesian School- This school is based on the writings of John Maynard Keynes. Keynes was a somewhat flamboyant academic economist who lost a significant amount of money in the stock market crash of 1929. Keynes believed that the business cycle (boom-bust cycle) was caused by an inappropriate supply of money. The Keynesian system is completely dependent on a central bank. Keynesian economists believe that a recession is caused by too little money in the economy, often due to hording of capital. It is then the central bank's responsibility to increase the money supply during a recession (lower interest rates, print money, etc...). On the flip side, inflation is caused by too much money supply according to Keynesians, so the bank must decrease the money supply during a period of inflation. This is the general system by which most modern economies operate, though there is some pressure to change it. This is NOT a capitalist system, though it clearly relies on some elements of capitalism to function. It is sort of like capitalism blanketed on top of central control. Individuals own the ways and means of production, but all trade goes through the filter of very strictly controlled money supply. When everyone keeps talking about how capitalism has failed, this is really the system that is in place.

Marxian School (Communist Theory)- This economic school is based on the writings of Karl Marx. Marx believed that the ways and means of production had been co-opted by a few wealthy individuals who were taking advantage of everyone else. He believed that the way to economic prosperity (and the natural course of man's evolution) was to a world where everything was collectivised and owned by the workers who worked within it. There is no real free trade under Marxian theory. Prices are set at the "appropriate" price. All businesses are owned by the collective of the workers who work within the business. There are no entrepeneurs, and there is no private ownership of property or business. There is no real reason from a purely economic perspective that a strong governmnent would have to be involved in Marx' theory, though all attempts at creating it on a national scale have provided exactly that.

The US Healthcare System

The US healthcare system is a strange hybrid of a number of different systems. It is NOT a capitalist system, though it does incorporate some capitalist elements. It is capitalist in the sense that people can pay cash for services, and that a lot of contracting with insurance companies is private and uncoerced. However, all of these entities are heavily regulated. Insurance companies are private but heavily regulated and directed by the government. This makes the insurance system fascist. Medicare/Medicaid is really a socialist system. These are owned by the government. The fact that they contract with outside firms for both the distribution and occasionally the regulation of healthcare place them a bit in the fascist category as well. The government owns Medicare, funds it with tax dollars, provides it as a regulated benefit for whom it sees fit, but then uses the money as a way to force providers who take those funds to adhere to a plethora of government regulations. The government also directs, controls, and largely funds medical training. I will repeat, it is NOT a capitalist system.

Medical Training Terms

The Path to Becoming a licensed physician- In the US, to practice medicine, the most common path after high school is as follows:

College (4 yrs)-->Medical School (4 yrs)-->Residency/Fellowship(3 to 10 yrs)

There are some variations on this path, with some people completing differing numbers of years in college or medical school (though all medical school is ATLEAST 4 years).

College- There is no requirement as to what someone must major in to become a physician. As a general rule, applicants to medical school must have completed one year of general chemistry, one year of organic chemistry, one year of biology, and one year of physics. Common extra requirements that vary between accepting medical schools are a course in biochemistry, calculus, or some amount of english or literature. Students at the completion of college have no medical training, but they should have the scientific background that allows medical training to make sense. Those that wish to apply to medical school must complete and exam called the MCAT. In general, the applicant pool is reasonably self selecting, and from year to year, 1/3 to 2/3 of self-selected applicants will fail to get into medical school.

Medical School- To be accredited, a medical school must offer 2 years of basic and medical science and 2 years of clinical training. Some schools offer or require additional years of research. The first two years is largely classroom based. Different schools will also teach clinical skills in a variety of different ways during this time. The curriculum may be based on broad concepts (ex: courses in anatomy, physiology, pathophysiology, etc...),on specific organ systems (ex: cardiac system, renal system, etc...), or as a hybrid of the two. All of the same material must be covered, however it is presented. After the first two years, a medical student must take, and pass, the first step of a three part licensing exam called the USMLE. In the second two years, students must work at the hospital. While curriculums vary, ALL schools require some amount of medicine, pediatrics, surgery, psychiatry, obstetrics and gynecology, and general primary care or family medicine. Electives are also usually available to tailor the education to the needs of the student. Students then apply to residency through a process called the match. When a medical student graduates from medical school, he is given the title of Medical Doctor (or Doctor of Osteopathy at a limited number of institutions). This, along with the completion of the second step of the USMLE gives him the right to practice medicine only under the supervision of a residency program.

Residency- All residents are physicians. Post graduate training used to require an internship, but this internship has largely been incorporated into residency. The rules vary by state, but as a general rule, physicians may complete one to three years of residency and drop out to practice independently as a general practicioner (assuming that they pass the third part of the USMLE). No one ever does this anymore for practical reasons. Upon completion of a residency (which is 3-7 years depending on the residency), physicians become board eligible or board qualified in a specialty. At this point, the physician may practice independently as a specialist, though physicians increasingly need to complete a seperate specialty board to qualify for compensation as a specialist. Residents work in hospitals and practice medicine under supervision. Depending on the program, they can prescribe medication, perform surgery, and complete documentation.

Fellowship- For those who want further training as a sub-specialist, fellowship training is also available. This generally takes 1-3 more years. For example, if a general surgeon wants to become a cardiothoracic surgeon, he may train for 2 more years in a fellowship dedicated to teaching this type of surgery. The same would apply to an internist who wanted to become a nephrologist or a cardiologist.

USMLE- Each state licenses its own physicians, but all states now accept a single licensing exam called the USMLE. The USMLE is broken down into three parts (or steps), with the second part having 2 sub-parts:

Step I- This is an ~300 question exam taken at a computer center that covers all basic science as it pertains to medicine. The minimum passing score is changed every so often, but at this point in time, a score of 185 is required. This does NOT mean answering 185 questions right. The test is on a scale that no one really knows or understands. As of now, a score below 200 is acceptable but poor, a score of around 215-220 is average, and a score over 240 is really good. Residencies rely heavily on Step I to screen applicants. It is taken between the second and third year of medical school.

Step II- This test is broken down into two individual parts, a CK (clinical knowledge) and CS (clinical skills). The CK portion is similar to Step I, though it requires ~350 questions, and those questions are more clinical. CS is administered at one of 5 testing centers in the entire country. Students have to interact with 12 different standardized patient actors, treat them in a manner deemed appropriate, come up with a differential diagnosis, and write a coherent note on each actor. This portion of the test is a bit subjective and is generally abhorred by students required to take it. It was originally started as an exam for foreign medical graduates coming to the US to prove that they could speak english. These tests are completed some time in the fourth year of medical school.

Step III- This test is also similar to Steps I and IICK per my understanding (I'm not quite at this one yet). It tests patient management, and completion is the last testing step towards medical licensure. If you've completed all of the steps and completed your states residency requirements, you can be licensed as a doctor.


I hope all of that helped. Feel free to ask any questions if you still have 'em.

It's Hard to Stop a Moving Train: A Primer on Inertia in Modern Medicine

As a senior medical student, I recently went through the match. The match is the process within which senior medical students (or anyone else seeking a residency) are accepted to residency positions. Most schools release a match list after the process is over. This allows everyone to see who is going where and which specialties are being pursued. A match list is more than just a list. It is largely a reflection of the interests, philosophies, priorities, and successes of a medical school class. It is also interesting to see how these things change over time. Specialties come in and out of vogue, priorities change, and what was once the pinnacle of achievement becomes a dumping ground for those that couldn't get in to some specialty that was itself a dumping ground not too many years before.

While these things wax and wane, it is clear within my own institution (and really amongst medical school graduates at large) that the last decade has ushered in a paradigm shift. The traditional medical school class is full of extreme type-A overachievers who have been at the top of everything forever. The traditional rank order list of the years of yore reflected a desire amongst the top applicants to continue this type of function. Once upon a time, and this was before any work hour restrictions or attention to resident health, students fought over the right to work 120 hour weeks in surgery pyramid programs or gruelling schedules at large academic medical centers as internists. Those days are clearly gone. In those same years of yore there were a cadre of specialties which brought a more friendly lifestyle, sometimes without a significant pay cut. Specialties like Dermatology or Radiology were a way out for those who were done with the intense pace that categorizes life in the hospital. From the medical community at large, these jobs have often been considered secondary. I know an old internist who referred to essentially all radiology as "scut." No one speaks like that anymore. In fact, the current shift has made these specialties the most attractive to the creme de la creme.

The classic lifestyle specialties are known as the ROAD specialties (Radiology, Opthamlmology, Anesthesiology, and Dermatology). My class, which is graduating around 170 people, had over 20 people apply to radiology in the match. 5 More matched (with several not matching) into Dermatology. We had 15 match into anesthesia (which is also become more attractive to the lifestyle conscious). We had 9 match into Opthalmology, with atleast 2 more taking time off for research to apply more competitively next year. If you add it up, this puts 49 people (or nearly 30% of the class) in the four most most lifestyle friendly specialties. We have more people in all but one of the ROAD specialties than in General Surgery. We have more people going into these specialties than internal medicine.

The other divergence of members of the top of the class is to direct surgical specialties. It seems like in many cases, the broad training of general surgery is no longer required or desired. It really does make some sense. You can cut a year or more off of your training or enter a field which requires the same number of years it takes to train to be a generalist to be a specialist. Applications to Neurosurgery, Orthopedics, ENT, and Urology are stable to way up. Direct Plastic Surgery and Direct Vascular Surgery are insanely competitive, with the former being the most difficult to attain residency in all of medicine.

So why the paradigm shift? We could blame it all on our lazy generation, but I think that there's much more to it. This is still the extreme Type-A hardworking group at the top of the academic curve that it was in generations past, and I'm not sure that the true underlying ethic is extraordinarily different in this group.

I've heard different explanations:

1.There are more women in medical school today, which tend towards more lifestyle friendly specialties. This is however nowhere remotely true in a universal sense (In fact, the fields with the fastest growing percentages of women residents are the difficult surgical fields, and the field with the highest percentage of women is OB/GYN, which is hardly lifestyle friendly). This also doesn't explain why a higher percentage of men are going after lifestyle friendly or direct specialty fields.

2. Medical School isn't as hard as it once was. This is probably true in the sense that the total number of hours required of a student is probably less than it once was. On the flip side, the amount of standardized testing and the overall knowledge requirement has probably increased. This is certainly not a slam dunk.

3. Medical Students aren't socially conscious anymore. This one is almost hilarious. Students today flippantly bounce from one cause to the next, with what has to be record enrollment in every social justice group in existance. Medical missions and the "underserved" are the thing du jour. Students are so busy being socially conscious, that it is sometimes hard to figure out when they have time to study medicine. Students in the 70s were probably far less likely to intentionally pursue something in order to fall on the grenade.

So you've probably guessed that I've got a theory. You're right. You may have also guessed that it boils down to simple economics. You're also right. Atleast, it boils down to a combination of respect and simple economics.

Physicians (nearly all physicians) used to tower above their communities in a financial sense. From the ushering in off Medicare until the HMOs of the 90s, physicians were usually amongst the wealthiest in town. This was true of all specialties. Student loans were relatively low, and training time was MUCH less in many specialties than it is today. Money, while important, was really much less of an issue. Everyone could do well. Today, through a combination of declining physician reimbursement and everyone else getting richer, the relative wealth of medicine is much less. It makes the financial factor more important in specialty selection. Students are often sitting on a student loan mortgage or two. My personal student loan payments will be approximately 5 times my mortgage payment, and still 3 times my mortgage payment if paid off over the same 30 years.

Additionally, specialty physicians (while often of questionable added value compared to their generalist counterparts) are virtually always better compensated. Lifestyle specialties are usually much better compensated on an hour to hour basis.

Today, there is an inverse relationship between pay and value. The most critical jobs, or atleast the most logistically complicated important jobs (middle of the night emergencies and such) pay much less than most of their elective outpatient counterparts and come with the added sucker punches of higher rates of being sued and an inability to select your patients.

In the past, the difficult specialties like primary care or general medicine were respected. They are clearly not in the same way today, and they are clearly not respected above their counterparts in more friendly specialties at all. To be a generalist today is to be hit with a mountain of paperwork (no reimbursement for completion), lower reimbursement, higher rates of lawsuits, and generally poor public opinion. No wonder people are running from it. Reading CT scans from home at 10:00 AM is a heck of a lot less demanding than poring through dead bowel at 2:00 AM, and you get paid a lot more to read the scans.

There will always be people who find some sort of inherint satisfaction outside of direct specialization or lifestyle friendly specialties. I for one chose general surgery because the I am personally satisfied with the idea of being able to handle everything, having a broad scope, and being the last line of defense. There is a growing number who agree with me, but that number is dwarfed by those running for the hills away from all that really matters.

Here's the problem. You can't run a medical system in which everyone is a Radiologist. You cannot operate a system in which everyone wants to perform cool new endovascular or robotic surgical procedures, but no one is willing to do the midnight appy. People really need a PCP to be the first line of evaluation in many cases. I am in no way denigrating specialists or radiologists, but we need all types. The problem is that the train has left the station and is moving. The medical system will continue to move people away from where they are needed most. Our skewed payment system in concert with a confused legal system and laws limiting physician's ability to be compensated in a relatively appropriate manner have taken the medical train on a one way track towards a cliff, and we all know its hard to stop a moving train.

Spam Blog

I have apparently been identified as a spam blog. I can't begin to speculate as to why this is (I have no links to commercial sites, I post consistently but rarely, etc...). If you are receiving a message that this is a spam blog, please disregard it. I have no idea how what I write could be identified as this, but I've contested the label. I sincerely hope that Blogger corrects whatever flaw is in its software that would identify my blog as spam.

Winding Down

I saw my last patient as a medical student on Wednesday last week. I'm going out on a two week rotation in pathology (so I'm not quite finished yet), but I have seen my last live patient as a medical student. As I approach graduation, I have some time to reflect on the experiences that have defined the last four years of my life. If I had to guess how all of this would end four years ago, the only thing I know is that I would have been off the mark, possibly about 180 degrees.

Four years isn't that long, and it seems that every four year cycle in my life takes just a little bit less time than the one before. Yet, the changes in my own life are profound. I've more than doubled the size of my family, changed career trajectory, watched people die, been exposed to tuberculosis (fortunately never became positive myself), and I'm ending the whole thing off with a move from a hot steamy flat metropolis to a small cold mountain town. I would have never guessed it, but I couldn't be happier in the end with how it all worked out.

It's strange how a few years in medicine changes your perspective. I suspect that this was uniquely exacerbated in my case by my near omnipresence in a large county hospital and level I trauma center. There was once a point in my life where being cursed at in spanish by a drunk guy who showed up at my door via helicopter with numerous pieces of long bone protruding through the skin would have been a bit odd. Now it really feels far too normal. In fact, I started this journey by dissecting apart a decaying corpse. I watched my wife lie in the same beds on the same wings of the hospital where I rounded on some of the nameless, nearly faceless, morass and prayed to God that someone who knew more than me was watching. I watched my son go into full respiratory arrest and drop his O2 saturation to 19% after extubating himself in the ICU. The second time I saw it, it seemed eerily normal. As those close to me suffered, I was still bombarded by strokes, gunshots, heart attacks, cancers, and more. I feel as though I ought to be suffering from some sort of post-traumatic stress syndrome. Yet, it all feels quite normal. It's as though it was meant to be the way it was, and I've made peace with the whole thing in a way in which I'm starting to forget how disturbing it all once was.

It's not that I'm jaded. I'm not. I appreciate the gravity of what I'm seeing and what I saw. Some of my patients still tug on my heartstrings in a way that makes me reflect on the meaning of it all. It's just that I'm used to it. I guess that this is one of the successes of my training.

I have also learned such an incredible amount, that I can no longer remember what it's like to not know some of it. I've picked up some amazing skills. I can safely pull fluid out of a swollen belly or out of an infected spinal cord. I am comfortable closing relatively complex lacerations and stab wounds. I feel comfortable assisting a surgeon in those which are even more complex. I actually know what all of those weird numbers written between strangely constructed lines mean, and I can identify whether they signify a problem. I've had to hold the hands of patients when I was in the unfortunate position of telling them that the problem those numbers signified was severe. I've also picked up and distributed this data in English and Spanish. I've also done so with written notes, through interpreters, impromptu sign language, and sometimes I've had nothing to go by but old notes on an indigent comatose patient with no family to be found.

Different people come out of this experience with extremely different perspectives. People enter medicine for a variety of reasons (save the world, make money, love science, etc...). People's expectations for medical school are all over the place and rarely on the mark. There is no consensus on the quality or value of this education. I have classmates that would take any offer of student loan repayment and take a job at Starbucks over another day in the hospital.

I am one of the people who would absolutely do it all over again. If I knew what I know before medical school, I would still absolutely sign up and do it all over again. The experience is incredible. The extraordinary becomes ordinary. Even with all of the paperwork, beauracracy, physical strain, and student debt, there are still very few other fields where everyday is part of an epic struggle between life and death. It's not all exciting, not all of your patients are good people, and it seems like all of the problems of society have been dumped down upon the decaying structure where you spend 80+ hours a week, but the upside is incredible. Every encounter brings a true window into someone's life. People trust you, often because they have no choice. Whether that patients are sitting in a clinic for some medication adjustment or flailing, screaming, naked and bleeding, in the trauma bay, they have at that moment put some portion of their lives into your hands. It is an awesome responsibility. I do not regret taking it.

I'm looking forward to the next step. While the location is quite different, much of the struggle will be the same. I will continue to compete in this epic struggle as long as the patients continue to bring me something worth fighting for. When I speak with my next patient, it won't be as a med student (or student doctor, or trainee, or whatever). I will introduce myself as Dr. Miami, and the title will be appropriate. I've earned it, and I never intend to lose it.

If Only it Were a Joke

The following quote is directly from an MSNBC article:

"France and Germany especially have suggested that the better response is not more government spending but tighter regulation.
The Obama administration has urged European nations to do more to restart their economies through financial stimulus. Mr. Obama is hoping that by showing a serious commitment to tighter regulation he can more easily persuade other countries to increase government spending and stimulate demand by consumers and businesses that would help pull the global economy out of a serious decline."

This would almost be hilarious if it weren't true. This argument is sort of like this:

Obama:You all should print a bunch of fake money.
Europe:We would much rather strangle the economy to make sure it never totally recovers
Obama:If I strangle the economy too, will you print a bunch of fake money?