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March 30, 2007

Super powers

As I approach the check-out lines in the grocery store, wouldn't it be cool if all the people who are going to be paying with a check would just glow blue or something? That way, I could tell which line was likely to move the slowest, based on the reasonable assumption that paying with check = takes frigging forever.

That's one super power that I'd like to have -- even if it isn't as cool as caped flight or x-ray vision.

More on resident work hours

Assuming for the moment that excessive resident work hours is a problem, it would seem to be one of those problems that isn't likely to be solved by either professional self-regulation or by the market.

Daniel Goldberg's nice post about resident work hours reminds me that even if residents weren't as accepting of their brutal schedules as they seem to be, they probably wouldn't be able to do very much about it. As Goldberg points out, medical students and residents don't have a lot of bargaining power compared with their hospital employers, who benefit economically from low-cost resident labor. Moreover, there aren't a lot of other players in the current health care market who should be expected to argue forcefully for reduced work hours. Insurers and employers in our fragmented system would find it hard to capture the economic benefits of fewer medical errors made by overworked residents.

Professional self-regulation shouldn't be expected to solve the problem either. The medical professional societies and hospital groups that comprise the ACGME (the organization that regulates work hours) are all served nicely by the current system. The professional societies benefit because the total number of residents is kept small. Residents in training may suffer, but after graduation they benefit from larger salaries. Hospitals of course like cheap resident labor paid for mostly by the government. Although each additional resident usually means more money for the hospital, in the face of restrictions on the number of residents Medicare will pay for and the relatively higher costs of PAs, NPs, and attending MDs, the hospitals are not going to support limiting resident work hours. Residents are the cheapest hospital laborers available.

So if the market won't fix things, and professional self-regulation won't fix things either, who's left? Yep, the government. What's the likelihood that the government will step in to limit resident work hours? Almost nil, because "patients" as a group aren't as focused a lobbying group as are the hospitals and the professional societies. So absent another high-profile case like Libby Zion's, nothing is going to happen.

Of course, I've ignored the serious argument that shorter work hours do not directly correlate with increased patient safety. There is evidence that medical errors are more likely with an increasing number of handoffs and signouts -- the happy medium between overworked residents and too many handoffs hasn't been identified yet. Add to the fact that this happy medium is likely to be different depending on the specialty, the severity of illness, the number of patients, and the stability of the resident's schedule, even if the government did want to do something, it wouldn't be clear what exactly it should do.

This uncertainty about how to solve the work-hour problem doesn't mean that I dislike excessive hours any less. It doesn't make me any more sympathetic to the simplistic non-arguments advanced by traditionalists that amount to "more time in the hospital = better training." It just means that I'm glad to be going into a specialty where I can limit my own hours if I want. And I think we ought to spend more time and money gathering information about what kind of training systems work best.

March 29, 2007

Reevaluating Wendell Berry

It's satisfying whenever I hear that someone else agrees with me that Wendell Berry isn't merely an "elegist for a way of life that [will] likely never be reclaimed."

Here's Rick Saenz:

Later when I read Allan Carlson’s book The New Agrarian Mind I more or less agreed with his assessment of Berry as an elegist for a way of life that would likely never be reclaimed. Which led me to downgrade my opinion of Berry some, since by then I was persuaded that agrarianism could be reclaimed, at least in my little corner of the world. But now I think that assessment is unfair; I read Berry and not only find much to agree with but even concrete guidelines on how to proceed. . . .

March 28, 2007

Young and uninsured in America

I know what this guy is talking about. For the past four years I, too, was one of America's young invincibles:

Andrew Kuo, a 29-year-old painter, told me he made a vow to be insured by the time he turned 30. “But that was when 30 seemed like a ways away,” he added. “Now I find myself making all these stupid calculations. Like, it would cost me around $3,000 a year to have insurance, right? Okay, isn’t that about what it would cost out of pocket if I broke my wrist? Chances are I’m not going to break my wrist once a year, so why not save the money for that onetime emergency?” Like many I spoke with, Kuo said he’d happily pay for insurance, if only the cost-benefit analysis tilted more in its favor. “What’s ironic is that I would never live without my cell phone, but I won’t consider buying health insurance. It sounds ridiculous to say that out loud, but the fact is insurance is just too expensive. If it was the same price as my phone”—$150 a month sounded reasonable to him—“I’d buy it in a second.”

March 21, 2007

Far Cry

The official Rush website has the new single from Snakes&Arrows.

It's got a good bass timbre like the best songs from Vapor Trails. Like most Rush songs, it doesn't grab me by the throat initially, but probably will after I listen to it a few times. Can't wait for the tour.

Rush fans, check out the gallery too. Good stuff.

On-call hours

Via Gruntdoc, this post from former infantryman in the United States Marines (a group who aren't generally known to be weak whiners) and now emergency medicine resident Panda Bear M.D. about on-call hours in medicine:

....The fact that your program has bitten off more than it can chew and cannot maintain it's commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program's problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates.

Read the post, and read the comments. Everyone who knows me knows that I hate call -- give me the power to change one thing in medical training and it would be this. Residents are on-duty without sleep for far many hours in a row. The threat of federal legislation a few years back led the ACGME to implement an 80-hour work week rule, but this rule is often violated, and the rule itself isn't strong enough. Believe me, you can be worked beyond physiological reason under the current 80-hour rule.

The most fascinating thing to me about the whole thing is the seeming complicity of the residents. Panda Bear describes it thusly: "their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy." Even if you don't agree that the residents are brainwashed, it's clear that they aren't the ones pushing for a more rational and physiologically sound schedule.

Consider this study performed at the University of Chicago by Dr. Vineet Arora and her colleagues. Despite finding that a nap period significantly reduced overall fatigue for on-call medicine interns, "use of coverage by interns on the nap schedule was impaired by their desire to care for their patients and concerns about discontinuity of care." In other words, when given the opportunity to sign over their pagers in the small hours of the night and sleep, medicine interns chose not to do it (although they did sign over their cross-cover patients).

These residents gave different reasons for not signing out their pagers, including a concern for patient care and a desire to stay informed about what was happening with "their" patients. Is this reluctance to just go to bed the result of brainwashing? The study can't tell us. There's really no way to know. The question is whether the reluctance of interns to sleep is something we ought to encourage, defer to, or override. I tend to think the latter, because I don't think sleep-deprived interns deliver good patient care. But, as Panda Bear's post points out, there's no definitive study out there that tells us how many hours are too much.

Given the economic incentives of hospitals, the absence of such a study means that the problem will probably get worse before it gets better. And we should be asking: what kind of evidence must we have before we take action to solve the problem?

March 15, 2007

Today is Match Day

Today is the day when we find out which lucky souls will get to spend the next three years doing emergency medicine at the University of Chicago. If things work out right, they'll all be as happy as I was last year. (Kayvon... we still need to talk!)

One year later, I'm still just as happy. I'm chronically sleep-deprived, occasionally cranky, and sometimes downright bitchy, but I'm still happy.

March 13, 2007

A good fit for the Bush cabinet

Attorney General Alberto R. Gonzales is the 80th attorney general of the United States and if recent events in the law and at the Justice Department are any indication, he is rapidly staking a claim to being among the worst.
I'm looking forward to the rest of this series...

One of the best private med schools: the University of Colorado

In the mail today was an envelope from Richard Krugman, chair of the AAMC and dean of my medical alma mater, the University of Colorado School of Medicine.

It contained good news and bad news. The good news: CU placed 15th among medical schools in the AAMCs ranking of NIH research expenditures, the school placed 4th among public medical schools in its research earnings, and the school just received a $6 million private research grant for a stem cell biology program. It sounds as if the medical school's budget is healthy, at least from a research perspective, and the state of Colorado ought to be proud of its accomplishments.

But, um... the bad news is that the state legislature continues to withhold its support from the school's educational mission. Less than 2% of its operating budget comes from the state, and because research dollars can't be used to support educational activities, tuition has increased to cover the shortfall. The average debt of CUs graduating students is now over $100,000 (although this is probably in line with the median debt of all public medical schools).*

I've posted about medical school tuition and debt before (1, 2). It is reasonable to assume that high med school debt makes primary care careers less attractive to new graduates relative to specialties like interventional cardiology (some studies cited here). Given that we all keep complaining about the rising costs of medical care, and that these costs are in part driven by an oversupply of high-cost specialist physicians relative to an undersupply of primary care doctors, high medical student debt should bother us.

The question we have to answer has never been whether or not to spend tax dollars on the public good called "physician training." Rather, the question is when should we pay, and how much. Right now, we've decided to pay later -- cutting funding for medical education up front and paying for the consequences of increased student debt at the end. We subsidize the medical care provided by high-cost specialists -- through medicaid, SCHIP programs, and tax breaks, among other things. We continue to contemplate some kind of national health care system. We fund loan-forgiveness programs for new graduates who elect primary care despite the relatively paltry incomes that these fields offer.

But we ought to wonder whether we might get a bigger bang for our buck if we paid more up-front to ensure that medical school tuition at public medical schools was reasonable. We might save a lot of money by eliminating the administrative waste that accompanies loan-forgiveness programs if new M.D.s didn't start out with staggering debt to begin with.

The letter I got from Dean Krugman says that a current student will call me soon to ask for my contribution to the school. I'm looking forward to talking with that student about some of these things, and about the new curriculum that (finally!) is in place at Colorado.

Here's some more materials about the debt issue from the AAMC.

* Jolly, P. Medical school tuition and young physician indebtedness. Health Aff. 2005; 24:527-35.

March 11, 2007

glorfindel's movie reviews: 300

This movie is bad ass. See it.


March 08, 2007

How to be a considerate ER physician

Spending time on off-service rotations gives you a good view of the ER from the outside. Here's something that I used to know in my head, and that I now know in every organ of my body:

If an ER doc calls a trauma consult for a patient with abdominal pain from trauma eight hours after the patient first came to the ER, that doc should have done a rectal exam already. It's just considerate, not to mention good patient care.

I'll try to remember this when I'm back in the ER.

March 07, 2007

Barack Obama on the HLR

As you can see by the banner to the left, I'm excited about the possibility that Barack Obama might become the next President.

One reason that I like Obama is that he doesn't act like a partisan hack, even though he's clearly a forceful advocate for his positions. This comes through in the recollections of a former Harvard Law Review colleague (via Hugh Hewitt). When you consider how rare it is in the partisan blogosphere to read complementary pieces about one's ideological opponents, this one really stands out:

No doubt it’s a long, long road to The White House, even for politicians with significantly more experience than Illinois' junior senator. But many of the qualities that he manifested during our joint tenure on The Harvard Law Review help explain why so many enthusiastically contemplate the prospect that Barack Obama's journey to the Oval Office will be both a short and a successful one.

March 03, 2007

A few more good books

I read this book last summer, sitting outside of the Istria Cafe under the Metra tracks and trying to chase the occasional hornet away from my cranberry scone. Mark Helprin is a brilliant fantasy writer whom the publishing industry hasn't consigned to the fantasy/sci-fi ghetto. Go through the reasons why this might be the case, and you'll convince yourself that the difference between the "fantasy" and "literature" sections in the bookstore is a marketing distinction that has almost nothing to do with the content of the stories. Helprin comments on modern politics? Well, so does China Miéville (though usually from the other side of the political spectrum). Helprin sets his fantasies in real-world locales? So do Guy Gavriel Kay and Charles deLint.

I'd read Helprin's Winter's Tale several years ago and loved it -- I still can't forget the white horse walking through the snow in Manhattan. After Freddy and Fredericka, I find it hard to think about dentists without thinking about Prince Charles. Yep, it's a strange, funny, and touching book that made me laugh and cry both.

King Rat is the first novel that Miéville published and the fourth one that I've read. Compared with Perdido Street Station or the other novels set in Bas-Lag, the characters and settings in King Rat are commonplace. The city is regular old London, and the characters are mostly run-of-the-mill human. Sure, there are a few human/animal demigods running around, but not really any more so than in a typical Neil Gaiman novel. The background music that most of the characters either play or at least appreciate is drum and bass, which I didn't know existed until I read this book. Now I'm damned curious what it sounds like. Thanks, China Miéville!