Glorfindel of Gondolin

As you already know from my previous posts, I don't often blog about my job. If you want good blogging about emergency medicine, I suggest you read the EM folks on my blogroll. Panda Bear has been especially hilarious lately. Obviously, I disagree with Dr. Bear about politics (I hope it's not obvious exactly how) but I think he's spot on about what it's like working in emergency medicine. His posts almost always leave me nodding my head and thinking, "yeah, yeah, damn straight." Except when he writes about politics, when I usually think to myself "puh-leese." Oh, well, to each his own.

But don't confuse my silence about my job for apathy. Even though residency is kind of grueling and sometimes frankly sucks a$$, it's also pretty damned fun. The variety and (sometimes) acuity of the stuff you see is cool.

To give you a sense of how fun emergency medicine can be, check out some of the practice questions I've been using to study for an inservice exam coming up in February:

• Infection with which of the following helminths is known to cause a fatal hyperinfection...
  
• Which of the following statements regarding lightning strikes is correct?
  
• A 26-year-old man with known hemophilia A presents after being hit in the head with a baseball...
  
• A 23-year-old man is brought in by ambulance after falling off a roof...
  
• A 68-year-old man with a history of Type 2 diabetes and hypertension presents with cellulitis of his arm following a scratch from his cat...
  
• Which of the following is most likely to be a complication of placing an internal jugular central venous catheter...
  
• A 24-year-old woman presents after an altercation at a night club...
  
• Which of the following statements regarding lung abscess is correct?
  

Posted by Carey at 08:55 AM | Permalink | Comments (0)

I've gotten several email requests over the past few weeks from people who are trying to decide whether to pursue a career in law and/or medicine, asking what the professions are like and what the training for each of them entails. Since more people with the same question may find my blog but won't want to email me directly, I thought I'd post a generic version of what I've said about the subject here.

Keep in mind, of course, that my insight is limited. Yes, I've finished both law school and medical school, and I'm now a medical resident. This gives me an interesting perspective on the training programs for both professions. But remember that I've been practicing medicine for eighteen months as a resident. I've never practiced law. My knowledge of law practice comes from my time as a summer associate with a very large firm called Sidley Austin in Chicago, and from talking with law school friends that have been practicing in various capacities and places for eighteen months.

Nevertheless, that's still some pretty unique (*smirk* to you-know-who) experience, and I'm happy to share it.

Both professions are hugely diverse, and this makes it hard to generalize about them. In my opinion this also makes both fields very interesting -- there's a million little niches in each that
suit very different kinds of people.

With the disclaimer out of the way, let's move on to the generalizations:

Medicine is literally a hands-on profession. Most docs end up pushing on stomachs and listening to various organs with a stethoscope. True whether you're an emergency doc or an internist or a surgeon. Even the pathologists and the radiologists are probing individual patients in some way (dead patients and pictures of patients respectively).

The mental work that docs do is usually diagnostic -- pattern recognition -- which sometimes doesn't feel like "thinking." They gather all the data together, recognize from past experience what kinds of data are missing and what questions haven't been asked, and then fit all those data into the patterns they've got floating around in their head. This process of diagnosis is usually instantaneous. "Ok ma'am, you've been vomiting for two days, you've had an appendectomy several years ago, you're not a diabetic, and your abdomen is diffusely tender. Badda-bing, I think you've got a bowel obstruction." Why? Because it fits the pattern.

When you're doing this, it doesn't really seem to be a mental process in the same way that writing out an argument in the social sciences or humanities does. In fact, it can seem mindless. So much so that many docs feel they need to do something else to get their intellectual kicks -- research, philosophy as a hobby, health policy, whatever.

The plus side is that you are actually helping a real person who's standing in front of you (or curled up in the fetal position in front of you). You're doing something in the real world and you see the effects of what you do.

Contrast this with law: this is a writing profession. Lawyers deal with written documents and produce written documents, almost without exception. This can mean that the effects of what you do aren't so immediate as they are in medicine. As a lawyer, you certainly have no special manual skills like most
doctors do -- you can't put a central line into some guy'sneck, you can't do any kind of surgery. The skills you have are all about documents.

Even if you're a trial lawyer that argues to a jury, you're still dealing with words, arranged in a particular way, only this time delivered orally instead of on paper. Even trial lawyers spend the majority of their time going over written depositions, writing motions to the judge, etc. And most lawyers who don't do trials work almost exclusively in writing -- corporate lawyers drafting documents for deals, appellate lawyers writing briefs, government lawyers reviewing policies.

There's a lot of room to think, in the traditional academic sense, if you're a lawyer. (Not so much as a junior associate, but as you get more experienced.) You can strategize, persuade, marshal evidence, and all the other stuff that lawyers are famous for doing. It's not as free-wheeling as arguing with your friends about Barack Obama's health plan, but hey -- it's still an intellectual and creative kind of brain work.

The downside, in my opinion, is that the effects of what you do are often much more difficult to discern in law than they are in medicine. You slave away on a motion for weeks, and then the judge denies it. Or, worse, the motion is granted, but then your client settles. You have to use your imagination sometimes to believe that what you did had some direct effect on the world. True, in medicine the patient may still end up dead, but in general you'll see the effects of what you do in medicine more than you will in law.

If you hate being in a cubicle, realize that most of the really well-paid lawyers do
just that -- sit in a cubicle. Lawyers who like to be on their feet are usually prosecuting or defending small-time crime, or (occasionally) they make a name for themselves and work on the big stuff. But this is only one small niche within the legal profession. Most lawyers are desk-driving wordsmiths.

Then there are other factors. In my own biased opinion based on limited experience:

Lawyers are much better conversationalists than doctors.
Doctors can't write worth a damn, and they're less curious.
Most people in both professions are risk averse.
Lawyers are much more money and status conscious than doctors.
But the doctors who are money-conscious are insufferable.

One other thing I should mention: the road to getting a medical license is a long one. That shouldn't stop you if you want to do it, but you've got to be prepared for the long haul, and you have to enjoy the journey.

Speaking of school: in medicine, the trick is to get into *any* American medical school. There are relatively few of them, and they all have high admission standards. Law school is different. The trick for law school is to get into a *good* law school. There are a million law schools, and for most of them, all you need to do to get in is have a pulse and be able to sign for student loans.

What this means is that in medicine, so long as you get in, it doesn't matter where you go to med school. Sure, Hopkins would be nice, but if you don't like Baltimore you can go to your state med school and do just as well. In law, if you don't go to a good law school, you'll find your employment prospects limited when you graduate. Don't let the schools tell you any different: shoot for the best law school you can get into.

For a list of good law schools, see Brian Leiter's rankings. There are other rank lists out there and these rankings are absurd, but I've said a lot about that already and won't repeat myself here. These list just give you an idea of which schools will give you the most options as a graduate.

Remember, too, that you might want to consider why you want to enter either profession. The word on the street is that both lawyers and doctors don't have as much prestige as they used to. Practitioners of both professions are, more and more, becoming highly-paid employees, and there's nothing very highbrow about that. So if prestige is what you're after, think twice. Think about starting your own business, or becoming an artist. There's many more than two ways to skin a cat.

Posted by Carey at 11:11 PM | Permalink | Comments (3)

The public doesn't really care about the problem of ER overcrowding, right?

Well, maybe as a matter of public policy, Iraq and immigration have a firmer grip on the public's collective attention. But for people who have had to be a patient in an ER, and have had to wait for hours and hours to get a simple medical problem addressed, ER overcrowding is a big deal.

It's certainly a big deal for people who work in ERs. As a resident, I work in three very different ones, and I know that people often have to wait a long time before being seen -- unless they come in complaining of stabbing chest pain and have a blood pressure of 80/40. If you're not one of these lucky few, the typical ER experience is, "have a seat, I hope you brought some knitting with you to keep you entertained." My first job when they finally come back is to apologize for the long wait.

The reasons for overcrowding depend on whom you talk to. Some people say that it's because of the large and growing number of uninsured patients who can get care nowhere else. Some say, bullshit. Here's Michael Saloman, president of the California chapter of ACEP:

Crowding in the ER is actually a symptom of hospital crowding. There is a shortage of nurses and hospital beds in Modesto. Admitted patients are forced to wait on ER gurneys for hours because there is no place to put them upstairs. If all ER beds are occupied, then patients in the waiting room can't be seen. That is the reason ERs are crowded.

Posted by Carey at 09:22 PM | Permalink | Comments (0)

When I ask this question of patients in the ER, it's amazing how often they forget to tell me about serious diseases that completely change the way I want to treat them. It happens so often, in fact, that I'm tempted to say this to all my patients when I first walk in the room:

"Tell me what medical problems you have. And tell me everything. I'd better not go out there and look you up on the computer and find all sorts of shit that you haven't told me about. I want you to come clean with me now. If you have diabetes, you'd better just tell me now and get it over with. Because I'm going to find out, one way or the other. And if I find out that you're a diabetic or that you have lupus or some shit like that and you haven't told me, I'm also going to assume that you also have dementia, or that you've been sniffing glue."

But I suppose that if I had diabetes, or lupus, and I'd been living with it for years and years, I might forget to mention it when I went to the ER. Maybe. Assuming, of course, that I was also hypoxic or hypoglycemic or high from breathing the fumes from a tube of Krylon spray paint.

Sheesh.

Posted by Carey at 08:33 PM | Permalink | Comments (2)

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.

Posted by Carey at 04:40 PM | Permalink | Comments (1)

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.

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?

Posted by Carey at 12:18 AM | Permalink | Comments (1)

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.

Posted by Carey at 08:01 AM | Permalink | Comments (0)

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.

Posted by Carey at 09:00 PM | Permalink | Comments (0)

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.

Posted by Carey at 08:55 PM | Permalink | Comments (2)

I'm in the ICU this month. It's a great place (the only place?) to learn what I need to be a competent ER physician -- but it's no less draining for knowing that.

The medical ICU is a joyless place. It's a place where very sick people stay, usually at the end of their lives, to absorb all the high-tech medicine that we can possibly throw at them, in order to live a few more weeks than they would have otherwise. Yes, there are important exceptions, where we save a patient's life in the ICU and he or she leaves to spend time with their families and go for walks on sunny days in their favorite park -- but this is still an exception.

Add to this the horrendous hours, which makes it impossible or at least very difficult for residents to get to know each other as anything other than tired, overworked, cogs in a machine. Throw in the intern's inevitable lack of knowledge and gross inefficiency, and it shouldn't be surprising that there's not much joy for them in the ICU. Speaking for myself at least, there isn't.

My brother just lost his cat, Huckleberry. He was the greatest cat. Friendly, intelligent, and always hungry! He had some klnd of cancer that deformed his jaw, and he had to have it taken off. For a cat who loved to eat, that must have been a particularly large loss. My brother, because he loved this cat, did the best thing for him in the end, and had him "put down" by the vet. Huck, RIP.

If Huckleberry had been a person, he would almost surely have been laid up in the ICU for the last few weeks of his life. He'd have been unconscious, with a feeding tube down his throat to substitute for the eating he'd loved before the cancer. The people "caring" for him would have been overworked and unfamiliar with him as anything other than a reason for more chores. They'd have been more concerned with writing down all the numbers that the machines hooked to his body were spewing out 24 hours a day than with "caring" for him in any sense that could have mattered.

I'm not saying that we should euthanize people. I'm saying that the end of Huckleberry's long life was probably better, being my brother's cat, than it would have been as a human being.

***

Here's a poem I've posted before that means more to me now that I'm spending so many hours in the ICU.

Three Elegaic Poems
Wendell Berry

I
Let him escape hospital and doctor
the manners and odors of strange places
the dispassionate skill of experts

Let him go free of tubes and needles
public corridors, the surgical white
of life dwindled to poor pain

Foreseeing the possibility of life without
possibility of joy, let him give it up.

Let him die in one of the old rooms
of his living, no stranger near him.

Let him go in peace out of the bodies
of his life --
flesh and marriage and household.

From the wide vision of his own windows
Let him go out of sight; and the final

time and light of his life's place be
last seen before his eyes' slow
opening in the earth.

Let him go like one familiar with the way
into the wooded and tracked and
furrowed hill, his body.

II
I stand at the cistern in front of the old barn
in the darkness, in the dead of winter,
the night strangely warm, the wind blowing,
rattling an unlatched door.
I draw the cold water up out of the ground, and drink.

At the house the light is still waiting.
An old man I've loved all my life is dying
In his bed there. He is going
slowly down from himself.
In final obedience to his life, he follows
his body out of our knowing.
Only his hands, quiet on the sheet, keep
a painful resemblance to what they no longer are.

III
He goes free of the earth.
The sun of his last day sets
clear in the sweetness of his liberty.

The earth recovers from his dying,
the hallow of his life remaining
in all his death leaves.

Radiances know him. Grown lighter
than breath, he is set free
in our remembering. Grown brighter

than vision, he grows dark
into the life of the hill
that holds his peace.

He's hidden among all that is,
and cannot be lost.

Posted by Carey at 08:20 PM | Permalink | Comments (7)

... can sometimes make a difference. This story demands a link.

Notice, though, that the key fact here is that an otolaryngologist "was miraculously in the building." Miraculous might be the right word, because for financial reasons many emergency departments don't have access to on-call specialists when they need it.

Posted by Carey at 11:44 PM | Permalink | Comments (0)

I received another piece of junk mail from the AMA today. Ever since I graduated from medical school in 2002, they've tried to drown me in solicitations for everything under the sun. Especially offers for insurance policies.

But today's envelope was worse. It was a real, honest-to-goodness USPS priority mail envelope containing an invitation to join for half price. Oh, goody: only $210.00 for a six-month membership.

Sorry, but I'll pass. I don't like the thought that if I join, some of my dues money will be used to buy priority-mail envelopes for the next round of solicitations. That seems like a waste of money to me.

There are, I'm sure, many good reasons to belong to the AMA. Physicians can do a lot of good when they act together, and sometimes the AMA itself will entertain some creative proposals (like a tax on soda). But in my limited experience, the AMA just isn't providing the kind of leadership that a physician organization is capable of.

Maybe when I see a few more good policy suggestions, and a bit less junk mail in my mailbox, I'll think again about joining the AMA.

Posted by Carey at 11:03 PM | Permalink | Comments (1)

Should drug manufacturers, assuming they meet all the labeling requirements imposed by the FDA, be subject to liability for failing to meet more extensive or different labeling requirments imposed by the states?

This article in the NEJM ($), criticizing the FDA's new labeling regulations, buries its most important paragraph deep in the middle of the piece:

The most troubling aspect of the FDA's new plan, however, has nothing to do with providing information to prescribers. In an unusual move after the end of a five-year period of comments on the initial rule, the agency used the passage of the new labeling regulations to quietly add a new section to its preamble that will make it extremely difficult for anyone to bring legal action against a drug manufacturer for harm caused by one of its products.

Whether you find this troubling or not will depend on what you think about the trustworthiness of the FDA and drug manufacturers, the appropriateness of private lawsuits in areas subject to extensive government regulation, and the relative role of state and federal law.

For years, the pharmaceutical industry had sought to pass legislation that would prohibit litigation over adverse effects as long as the medication was approved by the FDA; Congress has consistently rejected this idea. But after the comment period for the new labeling regulation had closed, language was added to the final rule stating that any FDA-approved label, "whether it be in the old or new format, preempts . . . decisions of a court of law for purposes of product liability litigation."

Drug manufacturers would love for Congress to explicitly preempt state laws governing drug labeling, but so far, Congress has chosen not to do so. There's nothing that explicitly prevents states from passing drug labeling laws that impose more extensive requirements on drug manufacturers than imposed by the FDA under the federal Food, Drug, and Cosmetic Act.

Usually when an industry wants federal preemption of state laws, but can't convince the Congress to go along, the industry relies on the doctrine of implied preemption to argue that courts should refuse to enforce state laws anyway. Their argument is that when Congress legislates extensively about a given subject, it has implicitly exercised its power to preempt state law. State legislation on the same subject, even if it doesn't actually conflict with federal requirements, would alter the federal regulatory regime in ways that Congress would never have intended.

This doctrine leaves the preemption decision to the courts. But federal agencies do influence the final decisions about implied preemption, and that's why this new language from the FDA is important. When courts are presented with the argument that federal law implicitly preempts state law, they will often grant some deference to the interpretation of that federal law by the agencies charged with implementing it. For example, if the FDA interprets the Food, Drug, and Cosmetic Act to preempt state labeling requirements, it's more likely that a court will find that state law is preempted. That's why this part of the article is misleading:

Beginning at the end of this month, the new regulations would preempt nearly all action by patients in state courts against drug manufacturers for unanticipated injuries resulting from the use of their products. This immunity would apply even if a company failed to warn prescribers or patients adequately about a known risk, unless a patient could prove that the company intentionally committed fraud — a very hard test to meet.

The FDA's opinion about preemption isn't itself legally binding, but it does make it more likely that the courts will go along with drug manufacturers' preemption arguments.

Is any of this a good thing? There's a strong case to be made that in the absence of any state law to the contrary, a state jury shouldn't be able to hold a drug manufacturer liable for a "failure to warn" in a case where the manufacturer complied with FDA labeling requirements. The FDA does rely on clinical trial data to determine what warnings are appropriate. Its judgments shouldn't be routinely discarded by lay juries.

However, things are different when a state passes a specific law requiring warnings in addition to those imposed by the FDA. Contrary to what the FDA suggests, a drug's "safety" isn't something objectively inherent in the drug, and that can be objectively determined in scientific studies. Does a 1 in 5 chance of constipation make a drug unsafe? A 1 in 300 chance of a heart attack? Although the statistical likelihood of adverse side effects can be objectively measured, the safety of a drug is in the eye of the beholder. There's no reason why the FDA's decision that some risks are insignificant enough to be left off a warning label should prevent states from requiring that these risks be disclosed anyway. At least, not until the Congress decides to explicitly preempt state laws that require this additional disclosure.

The FDA argues that "State-law attempts to impose additional warnings can lead to labeling that does not accurately portray a product’s risks, thereby potentially discouraging safe and effective use of approved products or encouraging inappropriate use and undermining the objectives of the act." But this just amounts to an assertion that what's "appropriate," "safe," and "effective" is exclusively a matter for the FDA to decide -- and Congress hasn't explicitly given it this authority.

Implied preemption arguments should be approached skeptically, especially in cases where Congress has considered and declined to exercise its power to expressly preempt state law. The FDA's arguments for preemption should be treated even more skeptically, since they essentially restate the position of the drug manufacturers that has not succeeded in Congress.

The new regulations are here: www.fda.gov/OHRMS/DOCKETS/98fr/06-545.pdf.

Posted by Carey at 02:07 PM | Permalink | Comments (0)

I'm looking forward to starting my emergency medicine residency. I know it's going to be an exciting time, and that I'll have some amazing experiences.

Nevertheless, I can't help but worry a little bit about the risks that a career as a doctor entails. What risks are these? Well, Hospital Impact points out one of them:

Some of the physicians are socially challenged. They are locked up for 12 or more years in college, medical school, residencies or fellowships where they are completely removed from the real world. Unbelievable pressure is placed on them, and then they are set free and told to "Be normal." Hah.

Accustomed to sequential success, physicians are not optimally equipped for the rejections, false starts or dead ends that are part and parcel of life for most of humanity. Practicing medicine today has its woes but we are to an overwhelming degree in demand, valued, respected and well compensated especially in comparison with individuals in most other occupational fields. (HT: GruntDoc.)

Medicine is a demanding mistress, always with its siren call in your ear, signaling you your ever dumber fate. The success of the few does not alter the dynamic for the many. Interests and enthusiasms fade and ultimately wither. Like expectant lovers, promised “tomorrow” too many times, they leave or die.

Some of the best advice I've gotten on these matters came from my Legal Ethics professor in law school. He compared a legal career to a mountain climbing expedition. Your ethical commitments, just like your tolerance for mountaineering risk, are decisions that are often made best in advance -- in base camp. Before peer pressure and high-altitude hypoxia lead you to make stupid climbing decisions high up on the mountain, you should decide how much bad weather you're willing to risk in order to summit. Likewise, new lawyers as much as possible ought to make their ethical commitments before the pressures of a case and the lure of easy money lead them to compromise their values at the expense of their clients and themselves.

The same thing applies to new doctors facing known career risks, ethical and otherwise. Am I going to abandon my interests? My decision now is no. After I develop some expertise, will I be afraid to try anything new? I'll commit myself now to fighting that temptation. Am I going to ignore my friends and family? I'm deciding now that I won't.

Residency is going to be a lot of hard work, and it's going to be exciting. But I'll still pay attention to the unlikely risks, and avoid them if I can.

Posted by Carey at 09:58 PM | Permalink | Comments (0)

"It's impossible to say which is harder -- cooking or doctoring,'' she says. "But they do both share the same goal -- to make people happy and feel good.''

(Via Kevin, M.D.)

Posted by Carey at 02:12 PM | Permalink | Comments (0)

On the interview trail for an emergency medicine residency spot, I was hit with a cold realization. My three blissful years of law school are coming to an end. It's time to go back to the world of medicine, and this means returning to an arena in which virtually every formal presentation is likely to be accompanied by PowerPoint slides.

I'm yawning with anticipation.

At the University of Michigan Law School, professors lecture with all the lights on, and they almost never use PowerPoint. This might surprise all those academic physicians out there who don't think it's possible to convey information without dimming the lights and firing up the projector. Dispite what many doctors seem to think, PowerPoint is not a required teaching tool. My roughly 400 or so classmates who've learned a lot of law over the past three years can all testify to that.

Lawyers do, occasionally, use PowerPoint in the courtroom. But the good ones don't let PowerPoint use them. TaxProfBlog has a post about how trial lawyer W. Mark Lanier -- the guy who persuaded a Texas jury to award his client $252 million in Vioxx suit against Merck -- hired a guy named Cliff Atkinson to help him with his PowerPoint slides. Atkinson is trying to do something about what he calls "PowerPoint fatigue" and TaxProf calls "the deadening sameness of Microsoft Corp.'s commonly used presentation software." This kind of language should rings a bell for a lot of emergency physicians and residents out there (for my sake).

My only worry is that Atkinson might not be quite radical enough. Sure, he talks a tough game. On page 14 of his 5 ways to reduce powerpoint overload (pdf), Atkinson says:

When you think you’re impressing people by putting everything you know on your PowerPoint slide, you’re actually doing the opposite by shutting down their cognitive processing. And when people are sitting there bored, they’re likely not thinking positive thoughts. When it comes to PowerPoint, less is more. . . ." (Emphasis mine.)

Posted by Carey at 05:23 PM | Permalink | Comments (1)

I'm not one of those people who thinks that watching a baby get born is such a miraculous and transformative experience -- I'm just not that transfixed. So I suppose it isn't surprising that the debate over home births and midwives doesn't matter much to me one way or the other. Feminism, the medical establishment, the miracle of birth. . . yawn. If the state made home births illegal, or if they went to the other extreme and stopped regulating midwives altogether, I'd get along either way.

What really gets my goat, though, is that a mom or a newborn baby would encounter an unexpected problem and because of some yawner of a law, not get the emergency care that they need. This is why the prize for the best argument against prosecuting unlicensed midwives goes to:

"The current law, Ms. Welch said, drives midwives underground. "I don't want to have a midwife hesitate to take a woman to the hospital because she is afraid she will be arrested," she said.

Posted by Carey at 05:11 PM | Permalink | Comments (0)

The exclamation points say it all!

More later after I get back from class. Oh, and Kayvon, you're getting a call from me soon.

UPDATE (1.5 days later): Ok, so now everyone knows what match I was hoping for. Chicago is such a great city, and I can't wait to get back to good old Hyde Park. I've been trying to get back, in one way or another, for about twelve years now. . . . My peeps from Sidley and many of my friends from Michigan Law will be there too -- starting their legal careers while I'm starting my career in emergency medicine. We'll definitely have to have some beers.

Apart from the city of Chicago, I'm thrilled to be a resident at the University of Chicago. My rotation there as a fourth-year medical student (November of 2001!) was probably the best single month of medical school for me. It felt like I learned more substantive medicine in that month than in any other. The attendings, the residents, the staff, the patients -- all great. When "they" say that some programs just click for you, that's U of C for me. I felt the same way when I went back for my residency interview last December. Four years had passed, but if anything I came away even more impressed with the faculty. The residents I met all seemed curious and sharp. Most importantly, they seemed like people I'd enjoy working with.

Plus, Chicago has the coolest helicopter in the business. As an undergrad I always loved to watch it flying low over the campus, and now I'm going to be flying on it! *big shit-eating grin*

Ok, off to celebrate some more. . . .

Posted by Carey at 01:25 PM | Permalink | Comments (14)

Today, I learned that I've matched. Somewhere. I don't really know where yet, other than it's at one of the nine programs I listed on my rank order list.

I've avoided the scramble, and that makes me extremely happy. It would have been tough to try to get one of the very few unfilled positions in emergency medicine. Fortunately, I've already got one.

I'm enormously grateful to everyone who's helped me get to this point. Ever since I went to the ED of the old St. Francis Hospital in Colorado Springs as an EMT student and watched the victims of a mass shooting in a biker bar brought in and cared for, I've wanted to be an emergency physician. I've always thought I could be a pretty good one, if only because I think it's so fun, and challenging, and worthwhile. Now it'll be up to me to make the most of my three (or four) years of residency. I'm extremely fortunate to be here, and I'm going to make the most of it.

Wherever I end up.

Posted by Carey at 10:08 PM | Permalink | Comments (8) | TrackBacks (1)

The best way to learn about health care costs is to incur some yourself.

Two weeks ago I got sick from eating bad refried beans, so I went to the ER because I was dehydrated and couldn't stop vomiting. Today I got the bill. It's really amazing.

The folks there took good care of me. They gave me IV rehydration, three liters. They gave me some IV antiemetic meds so I would stop vomiting. They ran a few basic labs. They didn't overtreat me, by any stretch. No abdominal X-rays, no CT scans. No ultrasounds. No crazy labs looking for zebras like porphyria.

Today I got the bill: $1870.56. Ridiculous. Outrageous! But that isn't really the amazing thing.

Why is it ridiculous, apart from its sheer size? First of all, the itemization is insufficient. Take drugs, for example. There's a line for "pharmacy" (298.95), "drugs/detail code" ($91.98), and finally, "other rx services" ($117.00). I was looking forward to finding out how much the ondansetron would cost, but how can I tell from this? I remember how many doses of each drug I got, but how can I tell whether they made a mistake? Are they charging me for five doses instead of three?

I'd like to pay this bill, but not until I'm confident that it's correct. This skimpy information gives me no way to know if it's right or not.

The biggest single charge on the bill is "emergency room." $697.00. Did I incur that cost by just showing up and getting in line? Perhaps there's something to this argument about reducing costs by making them more transparent to patients. If patients know they'll be hit up for seven hundred dollars just by showing up at an ED, a lot of them might choose not to go at all. If people are deciding between going to a movie or going into the ED for some unnecessary medical care, this might be a good thing. But, contrary to the evident beliefs of some of the most reactionary opponents of universal coverage, I don't think many people are like this. I was reluctant to go to the ED, and I want to spend my career in one. Most people, I think, try to avoid the ED until they see no other alternative (which sometimes happens at 3 a.m., I admit). This bill is really huge (but that's still not the most amazing thing).

For the curious among you, here's the entire bill for a simple ED visit for nausea and vomiting:

Pharmacy $298.95
IV Solutions $215.31
Med-Sur Supplies $20.37
Sterile Supply $67.95
Laboratory $23.10
Lab/Chemistry $449.20
Lab/Hematology $140.30
Lab/Urology $49.40
Emerg Room $697.00
Drugs/Detail Code $91.98
Other Rx Svs $117.00

When I was treated, I put a deposit on my credit card. Thus, the last line:

Patient Payment - Thank You! $300.00

Thus, the total bill is $2170.56. Outrageous (but not the most amazing thing). The next step, of course, is to call the hospital to see if I can get a more itemized bill. I'll keep you posted.

But hey -- what's the most amazing thing about this bill? It's not that it's so big, although that's part of it.

The most amazing thing about this bill is that, even if I find no errors in my favor, and I can't get the hospital to come down at all, I'm still coming out at least even with where I would have been had I signed up for the school's insurance plan! Yep, that plan had an annual premium of about 2000 bucks. When you throw in the copay of about 50 bucks, I'd have still been up shit creek -- even with this trip to the ED -- had I signed up for the insurance. I made the judgment that I probably wouldn't incur medical bills this year beyond that, and even with this huge bill, I was right!

Lesson? For someone like me (who's lucky enough to be reasonably healthy) the only thing more outrageously expensive than medical care is medical insurance.

Posted by Carey at 09:11 PM | Permalink | Comments (3)

That's about the only reason I can think of for why I got sick for two days in Sedona over spring break. Heidi and I ate the same food everywhere but at evil Casa Rincon. That's where Heidi laid off the frijoles refritos and I made sure they disappeared down my gullet -- for about 8 hours, at least. Then it was my time to pray to the porcelain God.

(Or should I say, "order Buicks over the big white phone?)

That first day I had to go to the ED for some IV rehydration and antiemetic therapy. Phenergan and ondansetron, baby. I'm curious to see how much it's all going to cost.

Interestingly, the malpractice negotiation exercise that we're doing in my Law, Medicine, and Society class involves a case of missed appendicitis that led to a $25,000 hospital bill after the patient required multiple abdominal surgeries and time on a vent. Even more interestingly, his initial presentation to the ED was exactly the same as mine in Sedona: abdominal pain and vomiting with no abdominal tenderness. The big difference, of course, is that 48 hours later I was better. The patient in our exercise returned with the same symptoms. Still no abdominal tenderness. Of course, he didn't have the benefit of a prescription for antiemetic suppositories, either....

Posted by Carey at 08:58 PM | Permalink | Comments (0) | TrackBacks (1)

Back in the middle ages, we were fond of explaining every problem by attributing it to God's will. That era is over, but we haven't abandoned our love of universal knee-jerk explanations for everything.

The New York Times has an article about the medical "misdiagnosis crisis" that resorts to our era's equivalent of God made me do it. Of course, I'm talking about "economic incentives."

Under the current medical system, doctors, nurses, lab technicians and hospital executives are not actually paid to come up with the right diagnosis. They are paid to perform tests and to do surgery and to dispense drugs.

There is no bonus for curing someone and no penalty for failing, except when the mistakes rise to the level of malpractice. So even though doctors can have the best intentions, they have little economic incentive to spend time double-checking their instincts, and hospitals have little incentive to give them the tools to do so.

While there may be some truth here, let's not forget that doctors are motivated by things other than money (although they sometimes make it difficult to convince others of this).

Posted by Carey at 10:23 PM | Permalink | Comments (0)

Apart from Match Day itself, today is the biggest day in the whole residency match process.

Today is the deadline for submitting my rank order list for this year's residency match. After I submit my list, I'll be contractually committed to accepting a position at whatever program pops out of the Match Computer in March. And the identity of that program depends heavily on how I order my list. So, today is a Very Big Day.

It feels like a big day even though my list has been set for a long time already, and even though I'm pretty excited about most of the programs on my list. Because I'm not in medical school or surrounded with medical students, though, I feel like today is my own private holiday -- with a visit from the mailman to boot!

I think I'll celebrate by doing the reading for my Federal Courts class tomorrow: state procedural foreclosure of federal habeus corpus review. Ok, and a cold beer to go with that.

[For people who aren't familiar with the medical residency match, here's what happens. Residency applications aren't handled like applications for law firm jobs or clerkships. Instead of each firm or judge making you an offer which you are free to accept or decline, each residency applicant submits a list of all the programs they'd like to be considered for to a central organization, the National Resident Matching Program (NRMP). Meanwhile, each residency program submits a list of all the candidates they would like to train. These lists are ordered from the most desired program/applicant at #1, to the least desired program/applicant that's still acceptable. A big Central Computer uses a mysterious algorithm to match applicants with residency programs given how highly each ranks the other. For example, if I rank a program #1, and that program ranks me #1, then the computer will match us up (and we'll both be happy). It's a little more complicated when I've ranked a program #4 and they've ranked me #33.]

Posted by Carey at 08:56 PM | Permalink | Comments (2)

Ask any physician if there's something about the health care system that's broken, and you're likely to get an earful. Malpractice law usually heads the list, followed closely by declining reimbursement and intrusion by insurers and regulators into the doctor/patient relationship. All of these issues are so irritating for doctors in part because they can't be solved by physicians alone. Solving any one of them will involve going up against non-physician interest groups -- insurers, regulators, and trial lawyers -- that have their own ideas of what's best for the public and for themselves. In other words, doctors are going to have to fight and win some political battles.

This, by itself, is why doctors should unilaterally stop accepting all gifts from drug companies and medical device manufacturers.

Forget about whether it's legal. Forget about whether there are some vaguely plausible arguments that consulting fees and free lunches are harmless. Doctors need to convince the public that they, and not the insurers, bureaucrats, and trial lawyers, are the "real" patient advocates. They can't go on assuming that the public will trust physicians more than they will anyone else. Those days, if they ever existed, are long gone.

Because doctors won't stop playing footsie with gift-giving corporations, the public can read about how Medtronic "paid" $400,000 to one surgeon for eight days of "consulting work." They can read about how medical students are "acculturated" to accept gifts from drug companies, and about how "80% [of medical students] said they were entitled to these gifts because of financial hardship." (Here's the JAMA link, for those with a subscription.) Regardless of the propriety of these gifts, doctors can't just assume that patients and the public are going to buy their long-winded defenses of these kinds of lucrative relationships. When physicians are quoted in the newspaper defending questionable practices along with the deeply-distrusted pharmaceutical industry, they're digging themselves a deep political hole. People start to think their doctors are greedily chasing the money like everyone else.

Once we realize that we've got some important political battles to fight, physicians might be more inclined to come down hard on any behaviors that even smell funny. What would help doctors politically more than anything else is if the public could read about how the AMA and their state medical society were enthusiastically supporting a ban on accepting gifts from industry. Sadly, one of the authors of this article is quoted as saying he thinks "it's not very likely" that doctors will endorse the proposal.

I'm sure most doctors agree the consulting fees and the trips to the strip club aren't worth the hassles of a malpractice system that doesn't compensate injured patients or punish negligent doctors. The problem is that physicians don't seem to realize that these two issues are connected. But we're in the realm of politics, baby, and that means that trust is everything. Perhaps more than anything else, doctors must fight to earn the public's trust. Doctors, here's some political advice: get a clue. Stop accepting drug company gifts; make even the suggestion of improper influence manifestly absurd. You might have a chance to recover your leadership role in healtcare debates.

Posted by Carey at 08:35 PM | Permalink | Comments (1) | TrackBacks (1)

Via Random Acts of Reality, watch this video.

"You've got to have badass in your blood."

Posted by Carey at 11:36 PM | Permalink | Comments (2)

Ever since the Bayh-Dole Act was passed, universities have scrambled to patent everything they could in the hopes of reaping rich rewards from the licensing revenues that are occasionally possible when you hold a lot of patents.

This article from JAMA ($) suggests that that revenue is not in fact very significant for the vast majority of universities, and that in many cases the costs of maintaining a technology transfer office to handle the patent applications and the licensing eats up any revenues that flow from technology licenses.

Only a few universities reap large net revenues from licensing. Surprisingly, these aren't always the universities that spend the most on research. Harvard? Stanford? Neither make a ton of money from licensing, at least relative to their research expenses. The universities that score big usually score big because they get lucky. For example, Florida State pulls in big cash because they have the patent on the anti-cancer drug Taxol. The University of Florida cashes in on the Gatorade trademark (wtf??).

The authors argue persuasively that, as a tool for motivating productive research, technology licensing hasn't had a huge effect in the U.S. They point out that other countries considering this model ought to worry that if they don't have a robust system of publicly-funded research, relying on technology licensing is more likely to slant research toward the benefit of the rich, who can pay large licensing fees. That this hasn't happened in the U.S. is probably because we still have a healthy amount of public research funding available.

Posted by Carey at 09:55 PM | Permalink | Comments (4)

By now most of you know that I'm applying for a residency position in emergency medicine. To all of my law school classmates who were jealous of my free time when they were preparing their applications for judicial clerkships: you can gloat now.

Writing the personal statement for my residency application is not an easy thing to do.

After all, it's not really a personal statement, it's an argument. In one page or less, you've got to make the argument that you're a great candidate who is eager to learn, loves patients, is a joy to work with, and is someone who will eventually be a leader in the specialty (among other things). Of course I think I'm all that, but making the arguments on my own behalf isn't easy.

You want to make a powerful argument for yourself without sounding arrogant. You need to reassure the program faculty that although you're confident you'll realize your lofty ambitions, you haven't forgotten that the road to success is paved with patience (patients?) and hard work.

It'd be a lot easier if I could just say that I wanted to practice emergency medicine because it's fun. Even the drunks. At 3 a.m. on Saturday. After the internal medicine attending has chewed you out for what she thought was an inappropriate admission. Even after all that, it's still fun. Maybe I'll say that, too.

"But wait!" the program faculty will say to themselves. "He's too naive. He hasn't considered the fear of random malpractice suits. Silly lawyer!"

Ahem. I just hope that my recommenders don't remember any good military quotes.

Posted by Carey at 06:47 PM | Permalink | Comments (4)

Can medical research benefit from the insights of applied mathematicians?

The problem with medical research to date is that it isn't a mature science, the way physics is. It can draw connections, such as between obesity and lifespan, but it yields little understanding of why or how things are connected. And it can't predict outcomes.

"What we claim to have known is correlative rather than mechanistic," says Dr. Jim Keener, an expert in mathematical biology at the University of Utah who spoke at the centre's opening. "It's historical rather than predictive. It's qualitative rather than quantitative."

Mathematical medicine, which has been growing steadily in the past 10 years, promises to fill those gaps.

Even the physicists can't do that.

Posted by Carey at 09:36 PM | Permalink | Comments (5)

Despite the fact that emergency physicians specialize in identifying and caring for critically ill patients in the emergency department, they do not have access to certification in critical care medicine (CCM). For the benefit of patients, this should change. A few recent articles give me hope that it will.

Huang et. al., in an article published in both Annals of Emergency Medicine (46(3): 217-23) and Critical Care Medicine (33(9): 2104-9) lays out the argument. Recent studies have found that ICU patients do better (for less money) when they're cared for by a trained intensivist. The problem is that there are too few trained intensivists available. Internists, surgeons, anesthesiologists, and pediatricians, if they complete a CCM fellowship, are eligible to obtain certification in critical care, and have been for some time. But there is evidence that interest in CCM fellowships among residents in these specialties is low. At the same time, there are many emergency medicine residents who are chomping at the bit to specialize in critical care and would pursue fellowship training if they had a reasonable expectation that they'd be able to practice in the ICU. Without the ability to obtain certification in CCM, their prospects for finding such opportunities are highly uncertain.

In an editorial published in the same issue of Annals, Dr. David T. Overton writes:

There seems to be little logical rationale to limit critical care fellowship training and board certification only to graduates of internal medicine, anesthesia, general surgery, and pediatric residencies. Unlike some other subspecialties, critical care medicine has always been a multidisciplinary field. Indeed, critical care medicine has as much or more in common with emergency medicine as with these other specialties. As Huang et al point out, emergency medicine residency curricula are Residency Review Committee program requirements–mandated to include at least 2 months of critical care. In fact, they often contain considerably more (mine contains 6 months).

Drs. Somand and Zink point out in their article in Academic Emergency Medicine (12(9): 879-883) that turf wars over CCM between the new specialty of EM and other established specialties played a large part in the struggle to achieve primary board status for emergency medicine. Basically, the American Board of Internal Medicine agreed to support the American Board of Emergency Medicine's petition for primary board status only after ABEM had agreed not to pursue authorization to issue certification in critical care. The history of these turf wars are fascinating, but it reveals that there isn't much patient-care justification for excluding EM physicians from CCM certification.

As I read Somand and Zink's history, these turf wars arose because of the fear that emergency medicine physicians would start to horn in on in-hospital continuous care at the expense of internists. Well, now that we have several decades of experience with emergency medicine as a recognized specialty, I think we can put that fear to bed. EM residents go into EM because, among other things, they want to care for critically-ill patients in the ED. (If they wanted to do what most internists do, they'd have become internists.) The ICU is a quintessentially interdisciplinary place, so it's no surprise that some significant subset of EM residents would want to extend their practice to that arena. At a time when too few internists, surgeons, and anesthesiologists are specializing in ICU care, it's absurd not to welcome the emergency physicians aboard.

Posted by Carey at 08:02 PM | Permalink | Comments (1)

Health care resources, as we all know, are scarce. How has our country chosen to distribute these resources?

In Michigan, family medicine is "dying" as medical students are lured away from primary care.

More than a quarter of Michigan's 12,700 primary care physicians are at retirement age, according to a recent report from the Michigan State Medical Society. At the same time, today's medical students are being lured to specialty fields that promise better pay, more manageable hours and the chance to work with flashy new technologies and treatments. (Via Kevin, M.D.)

At the same time in California, EM physicians are finding it harder and harder to find specialists who will care for their patients:

Hospitals are paying $600 million a year to ensure that on-call physicians are available - and still some communities are having problems finding specialists," Emerson said.

Kivela said that if a patient shows up at the emergency room with a broken jaw and has no insurance, the emergency room physician has a dreadful task of finding an oral surgeon willing to come in and take the case.

"I'll have to call eight or 10 different doctors," he said. "I'll spend two hours making these calls while a bed is taken up in the emergency room while sick patients wait." (Via Symtym.)

This may be absurd, but it's not chaotic. We have a system that draws money and talent away from the most cost-effective fields of primary care and into the less cost-effective specialties, while this same system also makes it more and more difficult for a patient to gain access to those specialists. It's no wonder that our country performs so poorly on virtually all measures of public health like life expectancy and infant mortality.

Of course, we haven't gotten here by accident. We've chosen to endure these piss-poor public health results because we don't want to disturb our unquestioned ability to provide the world's best high-tech medical care to those patients who can afford to pay for it themselves.

We've chosen to lower medicaid and medicare payments to primary care physicians because we're both unwilling to bear the tax burdens of these redistributive public health programs, and we prefer to spend what tax revenue we do collect on the development of high-tech medical treatments. These high-tech solutions are favored by the private sector because they're a lot more lucrative than low-tech primary care. We've chosen to funnel our finite amount of health care resources into the pockets of pharmaceutical companies, medical device manufacturers, hospitals, and specialist physicians who primarily treat the wealthy self-insured. This has been at the expense of cost-effective primary care and low-income chronically ill patients.

Is this a good thing? Some of us think not.