“Sweeping generalizations should not be made about any [field of medicine]”.
I couldn’t agree more with that statement. The premise to the last post was not to slam nurse practitioners and physician assistants, but rather identify the flaw inherent in the retail clinic model of healthcare reform.
Often these clinics are staffed by younger, less seasoned professionals who are not well supervised and often work within the shadow of the behemoth that employees them. They feel the pressure to move patients, treat them similarly based on error prone algorithms, and give drugs for anything that looks infectious. That is not simple hyperbole, but a fact. I’ve been informed by several people who’ve either worked in or for these types of clinics of these types of pressures and have experienced a similar form of medicine early in my third year of medicine in an office that employed two PAs and 1 NP so that the doctor could manage his “businesses”. The pressures levied on those three providers to get as many people in and out as possible was tremendous. I could understand, as faulty as it was, to give amoxil for a 12 hour case of sore throat.
What scares me is the fact that you are being treated by people with less education than I’m at currently and have to deal with administrative bullying. When I enter the medical field as an intern I will have some autonomy, but leveled with so much restriction and guidance it will make me feel powerless - like a med student again. By it's nature, a residency allows young doctors the chance to improve slowly, while their training and skills are evaluated and redirected as needed by more experienced faculty. They are taught to be brutally critical of their and other's performance as it related to outcomes and current clinical practices.
I don’t feel that someone with three years of post graduate education who receives little to no feedback on their patient performance beyond “move more meat!” can be expected to improve. In fact I feel that these clinics will only dampen the skills these providers have developed in order to get patients in and out more quickly.
Certainly there are physicians out there that are less than admirable about their patient encounters and prescribing practices (since I’ve worked with a few I should know), but I truly and honestly believe that once they completed their education they were far more capable of handling patient’s complaints and evaluating them properly using evidence based medicine than a 3rd year medical student. Because that’s honestly what you’re getting with a retail-clinic provider fresh out of school.
Tuesday, November 20, 2007
Monday, November 19, 2007
Thursday, November 15, 2007
Automatic Automatons
There are some things in medicine that irk me beyond rational thought. These quick, “urgent care” clinics are definitely a topic that incites rage and hatred in me. They are, to a word, pathetic. Pathetic excuses for healthcare, pathetically trained or motivated people caring for patients, and pathetic attempts to “fix” the healthcare system in the US.
Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:
This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.
For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.
Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.
“What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.
Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.
Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.
If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.
Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.
The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.
Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.
Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.
Part of the reason they are such a poor medical facility is due to the people treating most of the patients. NPs and PAs, free from a great deal of medical supervision, are often found handing out erroneous and falsified diagnoses - only to then treat everything with antibiotics or other unnecessary medications. An example of this irresponsible behavior is a story I heard recently encompassing most of these qualities:
A mother whose adult son had a sore throat and was too busy to get it evaluated, went to an urgent care clinic knowing that she could fake his symptoms and receive a Z-pack. This was done because her doctor wouldn’t normally give medicines unless specific tests were positive. She, of course, received the antibiotics (despite having ANY illness) and proceeded to give it to her adult son.
This kind of malpractice (for it really is irresponsible medicine) only increases the drug resistant bacteria that we’re seeing and encourages patients to demand drugs they don’t need. What’s worse is the notion that medicine is like a cookbook and all symptoms should be treated the exact same, regardless of testing and patient profiles.
For all the complaining patients do about their long waits, the doctor’s refusal to give them some drug they read or heard about, or their increasing dubious belief that they are as able to diagnose themselves as effectively as their PCP these clinics are not the answer.
Consider the story above: what if the antibiotics given reacted badly with another medication, or had to be altered due to liver or renal failure, or caused a severe allergic reaction? All things that a PCP would most likely catch through charting or questioning but would characteristically be missed by a NP or PA trying to get as many people in and out of their fast-food-medicine chain as possible.
“What the hell do I care about giving medicines without proper test results? It’s a pain in the ass to do it any other way and it takes up valuable time. That's not what Walmart/ Walgreen's/ Target is paying me for”.
Instead of responsible and smart medicine, what you have are people who will not use medical evidence to properly treat patients and essentially run a medical McDonald’s – have it your way. Sore throat? STREP! Neck hurts? LORTAB! Sniffles? SINUSITIS! To add to this obvious disparity is the fact that these clinics are often owned by corporations who want people to be sick and have to go to their pharmacies. It's not rocket science to see how there's a conflict of interest.
Now I don’t think NPs, PAs, and CRNAs are entirely bad - quite the opposite. They are important in that their job role allows overworked physicians time to focus on the more complicated patients and running their practice while more minor ailments and procedures are analyzed and treated - after a quick review with the physician. However what I do find absurd is the idea that they can take care of patients without strict physician guidance as often occurs in these retail medical centers. Regardless of their time, they haven’t received the training requisite in order to differentiate between disease processes that appear very similar, nor is it expected.
If you still haven't jumped on the bandwagon, realize this: a nurse is trained in a very different way than a physician. They are not expected to figure out the pathophysiologic basis of a disease, the subtle interactions between comorbidities, the ever increasing need to be smarter about treating seemingly simple infections, and the evidence that alters treatment regimens amongst patients. Their training is based on recognizing a defect or a problem, alerting the appropriate people, and following a procedure or "order". If a patient has X, then give Y. If this happens, call the house officer or the patient’s doctor for direction. Adding a couple of years to the training does not inculcate the need to think beyond this automatic process, no matter how much you “shadow” a physician.
Experience certainly lends itself to making people think they know more than they really do. Twenty years in the ICU will definitely make you appear smarter than the intern or second year resident rotating through that service, but only for a brief period of time. Of course you’re going to know more about vent settings, how to respond to codes, etc. than a newly minted MD; but a seasoned physician, who has spent some of their time in the critical care arena will run circles around you - no matter how long you've worked there.
The physician trains in a wide array of specialties for which they are expected to understand a great deal of complexities, is responsible for the outcomes of their patients, and understands more about the overall process leading up to and currently occurring in that patient than an NP, PA, or tenured nurse could hope. A few decades of experience does not overcome the difference in education. A physician with twenty years including residency will always come out on top.
Residency is designed towards this goal. It is the resident’s training, adding on top of the knowledge procured through four intense years of medical school, that makes a physician more than just a “medical mechanic”. Performing a task a million times is not the same as medical knowledge. It is habit, and, as often seen when new policies are passed, is often hard to break.
Urgent care clinics are not the answer to the healthcare crisis. If we expect to take care of patients in better ways, to reduce drug resistant bacteria like the current MRSA “epidemic”, and have more advantagous outcomes we must realize that physicians are not replaceable by technicians. The years of training that doctors receive and the strict environment that they receive their education in makes a physician far more capable of truly evaluating patients. What you are receiving when you see a physician is a decade or more of increasingly detailed knowledge and arduous training that enables them to treat people effectively. Four to six years of training is not even close.
More Money
How much do I want to party? Is it worth $100 or more for a bash?
Our class dues this year were elevated to help pay for some items that the senior class has traditionally done. This includes a class gift, planning an event the day of match as a celebration for 4 years of hard work, etc. However, I have recently seen that the dues are to be increased by over 200% for the year to pay for these “responsibilities”.
I was planning on paying for the initial class dues this year, but more than $100 is way too much for this guy. I mean, God, I’ve had to increase my debt further in order to even interview this year since the school’s tuition hike killed any travel money I was set to receive. I have a couple private loans that will be due upon graduation and cannot be deferred through my residency. The fact that the “elected” class officials (ran unopposed) are now increasing the amount they want from us in order to throw some fucking party irritates me.
I guess I just won’t plan on going to our match celebration if this is how they’re going to try and fund it. Citing low class participation in fundraisers as a reason to increase the amount needed as an entry fee isn’t reason enough. There are people who are on aways, are too busy with life, and just don’t care anymore about helping “the class” out anymore. Personally, I’ve been trounced one too many times in the past to give a shit now.
It’s sad to think I won’t be able to hang with some of my friends and celebrate our accomplishments, but I thought the amount last year was ridiculous and we’re doing the exact same thing here.
Our class dues this year were elevated to help pay for some items that the senior class has traditionally done. This includes a class gift, planning an event the day of match as a celebration for 4 years of hard work, etc. However, I have recently seen that the dues are to be increased by over 200% for the year to pay for these “responsibilities”.
I was planning on paying for the initial class dues this year, but more than $100 is way too much for this guy. I mean, God, I’ve had to increase my debt further in order to even interview this year since the school’s tuition hike killed any travel money I was set to receive. I have a couple private loans that will be due upon graduation and cannot be deferred through my residency. The fact that the “elected” class officials (ran unopposed) are now increasing the amount they want from us in order to throw some fucking party irritates me.
I guess I just won’t plan on going to our match celebration if this is how they’re going to try and fund it. Citing low class participation in fundraisers as a reason to increase the amount needed as an entry fee isn’t reason enough. There are people who are on aways, are too busy with life, and just don’t care anymore about helping “the class” out anymore. Personally, I’ve been trounced one too many times in the past to give a shit now.
It’s sad to think I won’t be able to hang with some of my friends and celebrate our accomplishments, but I thought the amount last year was ridiculous and we’re doing the exact same thing here.
Monday, November 12, 2007
Lo Siento - mi amigos
If you haven’t noticed, which I’m sure most of you are painfully aware, the posts recently have been…well…of a poor variety. I attribute this to a phenomenon that I call “blog running.”
Blog running is essentially trying to keep a blog updated regularly, regardless of the content, while being too busy to really formulate anything of substance. The last few months I have been either too busy or too involved with interview crap to really do much meaningful writing. Unfortunately I don’t see that changing too soon – at least until my break in December (when I’ll be interviewing through most of the 1st 2 weeks so you're still SOL).
Part of the blame lies in the fact that I’ve tried to post while at home, when Wife is around, and have just typed as fast as I could while trying to not get caught. Remember, she still doesn’t know about this little project and I like it that way. So whenever I’m on the computer and believe I can get something posted in less than 5 minutes I try to get something out.
So I have to apologize for the lack of substance recently. I will try to keep some backburner drafts going in order to at least have one or two interesting articles.
Blog running is essentially trying to keep a blog updated regularly, regardless of the content, while being too busy to really formulate anything of substance. The last few months I have been either too busy or too involved with interview crap to really do much meaningful writing. Unfortunately I don’t see that changing too soon – at least until my break in December (when I’ll be interviewing through most of the 1st 2 weeks so you're still SOL).
Part of the blame lies in the fact that I’ve tried to post while at home, when Wife is around, and have just typed as fast as I could while trying to not get caught. Remember, she still doesn’t know about this little project and I like it that way. So whenever I’m on the computer and believe I can get something posted in less than 5 minutes I try to get something out.
So I have to apologize for the lack of substance recently. I will try to keep some backburner drafts going in order to at least have one or two interesting articles.
Sunday, November 11, 2007
BFE
Image of the parking lot at the hospital where I’m doing a rotation. I have to catch the shuttle from here to get to the hospital. Clearly the lot is so far away from any building that they feel porta-potties are needed – since you won’t be able to hold it.Saturday, November 10, 2007
One Down - Many More to Deal With
Interview season is already quite strange. I see people behaving in ways that are clearly not acceptable and seem quite immature, but they seem to not care. Chewing gum while talking with a director, leaving to take a call during a presentation on the program, and getting wasted at dinner in front of the residents (only to continue to get wasted as the night goes on afterwards and end up sleeping in another candidates room because you pass out) – all of which don’t seem to phase these candidates.
It makes me feel rather superior to them based on a certain level of maturity, gathered from years of real world employment and family responsibilities, but who really knows. Perhaps that’s what programs want – young blood. Certainly there’s enough old curmudgeons out there so who really wants one more?
Anyway, I feel the interview went well and am looking forward to being done already – very tiring process.
It makes me feel rather superior to them based on a certain level of maturity, gathered from years of real world employment and family responsibilities, but who really knows. Perhaps that’s what programs want – young blood. Certainly there’s enough old curmudgeons out there so who really wants one more?
Anyway, I feel the interview went well and am looking forward to being done already – very tiring process.
Wednesday, November 7, 2007
Getting Back To Basics
So here’s the thing. I like writing posts where I know there might be some reaction. I like checking the comments to see who’s upset or what agreement, if any, there is amongst my few readers. It’s fun.
The last post was for me, but also for that simplistic pleasure. That’s part of the reason the heat gets going as a post continues– to get a rise out of you. Unfortunately I may have caused some of my med school buds to feel I don’t support starting a family while in school. Simply put – I completely support anyone who can juggle this craziness with kids. I don’t have any qualms about women having children during residency or afterwards either. My beef was not with med students taking time to have children or their need to have accomodations afterwards. My beef was with the student in question only - because she sued. What does that say about her? That was my point.
So, that’s that. If you’re still upset or irked then there’s nothing I can do. It’s my blog and I write what I want.
Anyways, the Tassimo poll has completed and basically more people have no idea what Tassimo coffee is than those who either love it or hate it (which tied BTW). No idea where to go with this information, but at least I know that I'm not the only one who loves it...
…and I’m looking at my veins as I type this dreaming about sticking large bore IV’s in those juicy ass rivers of blood. Part of wanting to be an Anesthesiologist I guess. 2 days from my first interview and I'm wondering why all of this is necessary. $4,000 in travel expense thus far without hotels for most trips - yet. Damn.
The last post was for me, but also for that simplistic pleasure. That’s part of the reason the heat gets going as a post continues– to get a rise out of you. Unfortunately I may have caused some of my med school buds to feel I don’t support starting a family while in school. Simply put – I completely support anyone who can juggle this craziness with kids. I don’t have any qualms about women having children during residency or afterwards either. My beef was not with med students taking time to have children or their need to have accomodations afterwards. My beef was with the student in question only - because she sued. What does that say about her? That was my point.
So, that’s that. If you’re still upset or irked then there’s nothing I can do. It’s my blog and I write what I want.
Anyways, the Tassimo poll has completed and basically more people have no idea what Tassimo coffee is than those who either love it or hate it (which tied BTW). No idea where to go with this information, but at least I know that I'm not the only one who loves it...
…and I’m looking at my veins as I type this dreaming about sticking large bore IV’s in those juicy ass rivers of blood. Part of wanting to be an Anesthesiologist I guess. 2 days from my first interview and I'm wondering why all of this is necessary. $4,000 in travel expense thus far without hotels for most trips - yet. Damn.
Friday, November 2, 2007
Not Enough, Too Much
Since I am a member of AMSA I receive their monthly love-fest newsletter, The New Physician. Often this is just a sounding board for medical students trying to show that they care about patients more than the medical education system that tries to destroy that bond and are fighting “The Good Fight” for patients and students alike.
Mostly, however, I find it to be just a whine fest with people complaining about shit that I don’t care about. Their most recent issue, though, sparked some anger in me (yeah, I know, big whoop).
What got me upset was a short letter about a medical student who sued the NBME because she didn’t get additional time to pump her breast milk while taking Step 2 CK. On the outside it seems quite agreeable – I mean who wouldn’t want to have a few extra minutes to avoid soaking the front of your shirt all the while obtaining that precious fluid for your child?
The issue I had was the fact that she sued at all. Apparently this student has a some issues related to ADHD and dyslexia and had received 8 additional hours to take the exam, encompassing 2 days. Because of her concerns she took the test in an isolated environment and was allowed to have her breast pump with her in her room, all prior to her suing.
Her complaint? She wasn’t allowed enough time for breaks to pump her breast milk!
WTF? Seriously, what’s this girl's problem? How are you going to handle regular resident duties if you can’t handle 2 days, 16 hours, and accommodations that were more than reasonable to take a fucking exam? The fact she sued and the people at The New Physician are supporting her demonstrates a great deal of the medical student attitude that’s concerning medical educators. The whole "hold my hand with everything" demeanor.
The fact that she won her lawsuit simply shows how screwed up the legal system is in this country as well. Where has common sense gone? Why are we allowing crap like this to be taken seriously? For all of us who've taken this exam we know that the time she received was more than adequate.
So, to this princess, this coddled little bitch, I'd like to ask: How much more time do you need to take a damn test!?! Do you think you're going to actually be able to take care of more than one patient at a time while a resident? I'm sure you're residency programs will be dying to land you and your suing ways! GOD!
Mostly, however, I find it to be just a whine fest with people complaining about shit that I don’t care about. Their most recent issue, though, sparked some anger in me (yeah, I know, big whoop).
What got me upset was a short letter about a medical student who sued the NBME because she didn’t get additional time to pump her breast milk while taking Step 2 CK. On the outside it seems quite agreeable – I mean who wouldn’t want to have a few extra minutes to avoid soaking the front of your shirt all the while obtaining that precious fluid for your child?
The issue I had was the fact that she sued at all. Apparently this student has a some issues related to ADHD and dyslexia and had received 8 additional hours to take the exam, encompassing 2 days. Because of her concerns she took the test in an isolated environment and was allowed to have her breast pump with her in her room, all prior to her suing.
Her complaint? She wasn’t allowed enough time for breaks to pump her breast milk!
WTF? Seriously, what’s this girl's problem? How are you going to handle regular resident duties if you can’t handle 2 days, 16 hours, and accommodations that were more than reasonable to take a fucking exam? The fact she sued and the people at The New Physician are supporting her demonstrates a great deal of the medical student attitude that’s concerning medical educators. The whole "hold my hand with everything" demeanor.
The fact that she won her lawsuit simply shows how screwed up the legal system is in this country as well. Where has common sense gone? Why are we allowing crap like this to be taken seriously? For all of us who've taken this exam we know that the time she received was more than adequate.
So, to this princess, this coddled little bitch, I'd like to ask: How much more time do you need to take a damn test!?! Do you think you're going to actually be able to take care of more than one patient at a time while a resident? I'm sure you're residency programs will be dying to land you and your suing ways! GOD!
Catching Up
Halloween has come and gone. Unfortunately we live in a rather humdrum apartment complex where the only partying going on is the college-aged crowd who either, a) don't believe in giving out candy b) are too wasted to care about giving out candy 0r c) have spent all their money on beer and drugs and can't possibly come to the door out of shame and intoxication.
Yes, another Halloween where we had to uproot and go somewhere else for the trick-or-treating that is apparently becoming less and less important these days. I feel that the generation of tomorrow is going to fuck us all over because they're far too involved with themselves to give a shit about anything else.
Daughter had a great time, despite the expedition, and was very excited to get her candy. She went as Jessie the cowgirl from the Toystory movies and was adored by almost everyone. Stepson was with his dad, but I heard he had a good time with his friends.
I would like to post some pics, but because I don't want to have my daughter's face on the internet for any pervert to, um, enjoy I won't.
Yes, another Halloween where we had to uproot and go somewhere else for the trick-or-treating that is apparently becoming less and less important these days. I feel that the generation of tomorrow is going to fuck us all over because they're far too involved with themselves to give a shit about anything else.
Daughter had a great time, despite the expedition, and was very excited to get her candy. She went as Jessie the cowgirl from the Toystory movies and was adored by almost everyone. Stepson was with his dad, but I heard he had a good time with his friends.
I would like to post some pics, but because I don't want to have my daughter's face on the internet for any pervert to, um, enjoy I won't.
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