Yesterday:
Swimming in the 33 meter pool that Luca trained in as a boy. Pizza con funghi e prosciutto. Shopping. Saw friends. Our friends' three year old daughter liked the glitter markers we bought for drawing on T-shirts. Our friends were relieved that we also got her some new t-shirts to draw on.
Today:
Gnocchi in the mountains. Saw parenti. Pisolino. My Italian is getting better. I guess speaking a little to Luca at home has helped afterall. I was able to talk with parenti who previously did not understand me at all. There are some enormous sweet red pomodori growing in the back yard that are as good as the ones we picked at Linvilla a few weeks back. Word of the day: zanzare (would show pictures, but can't figure out how to turn off pop-up blocker here). There were a ton of them as we were setting up the RV. We only got bitten a few times.
Tomorrow:
Drive to Cortina with RV. Fish in Lake. Eat fish. Hike. Relax. Read. Play scopa. Sleep.
Non torniamo mai.
Friday, August 28, 2009
Wednesday, August 26, 2009
Frankfort Airport
Luca and I dislike flying through Frankfort. Not as much as Paris or London (with the dreaded Heathrow-Gatwick connection), but if we had it our way, we'd go through Munich every time.
It's just.... the airport is so big. And the gate for your connecting flight only gets put up on the giant board 90 minutes or so before it departs. So, if your flight from the US arrives at 7:30 AM, and your connection leaves at 12:50, you have to wait in the lobby for hours until you know where to go.
Because they can and do change gates. Like from terminal B to terminal E.
Did I mention that there is little to no seating in the lobby? And sitting on the floor is not an option. Airports are revolting enough as it is.
Usually I get off the plane, and am like, "OK, I can do this. I still have energy. I am reasonably alert. This won't be so bad." And then after about an hour of that (with 4 hours left until my connection), and I've been standing around the whole time, I pretty much feel like like I want to curl up into a ball in the middle of the terminal and go to sleep. Then you look at the floor in contemplation and go, "Ew. No."
Each minute lasts an eternity.
Fortunately today, Luca found an alternative. We found the airport hotel (which had CLEAN BATHROOMS -- Lemony smelling as though it had been recently cleaned, with NO PEE ON THE TOILET SEATS, SOAP IN THE DISPENSERS, and ABUNDANT PAPER TOWELS) and got to clean up a bit. And there were some smooth immaculately polished granite surfaces tolie down sit on on the walkway leading toward the hotel that we took advantage of on our way back to the lobby.
We were there for about an hour. I kept nodding off, only to wake up every time someone walked down the walkway. Finally, some young American child said, "Mommy, why are those people sleeping there? Are they homeless?" and we decided it was time to check on our gate assignment again.
(I don't even want to think about what we must have looked like to the people who walked by us, but I can tell you I feel about 1000% better than if I hadn't caught those few accidental zzzzz's.)
Well whatever. It doesn't matter now anyway, because we're in Verona now, and will be going out for pizza in a few hours. I am freshly bathed and newly relaxed. My Italian isn't even as bad as I remember.
Ah.
It's just.... the airport is so big. And the gate for your connecting flight only gets put up on the giant board 90 minutes or so before it departs. So, if your flight from the US arrives at 7:30 AM, and your connection leaves at 12:50, you have to wait in the lobby for hours until you know where to go.
Because they can and do change gates. Like from terminal B to terminal E.
Did I mention that there is little to no seating in the lobby? And sitting on the floor is not an option. Airports are revolting enough as it is.
Usually I get off the plane, and am like, "OK, I can do this. I still have energy. I am reasonably alert. This won't be so bad." And then after about an hour of that (with 4 hours left until my connection), and I've been standing around the whole time, I pretty much feel like like I want to curl up into a ball in the middle of the terminal and go to sleep. Then you look at the floor in contemplation and go, "Ew. No."
Each minute lasts an eternity.
Fortunately today, Luca found an alternative. We found the airport hotel (which had CLEAN BATHROOMS -- Lemony smelling as though it had been recently cleaned, with NO PEE ON THE TOILET SEATS, SOAP IN THE DISPENSERS, and ABUNDANT PAPER TOWELS) and got to clean up a bit. And there were some smooth immaculately polished granite surfaces to
We were there for about an hour. I kept nodding off, only to wake up every time someone walked down the walkway. Finally, some young American child said, "Mommy, why are those people sleeping there? Are they homeless?" and we decided it was time to check on our gate assignment again.
(I don't even want to think about what we must have looked like to the people who walked by us, but I can tell you I feel about 1000% better than if I hadn't caught those few accidental zzzzz's.)
Well whatever. It doesn't matter now anyway, because we're in Verona now, and will be going out for pizza in a few hours. I am freshly bathed and newly relaxed. My Italian isn't even as bad as I remember.
Ah.
Monday, August 24, 2009
7 good things
Yesterday I was having a conversation with Luca about regrets.
I think in many ways, my stint at The Industrial Supply Company From Hell (TISCFH) was a total and utter waste of my time. I keep in touch with practically nobody from the company. Working there raised my blood pressure and gave me an anxiety disorder. I have completely abandoned a lot of the things I learned there.
In some ways, I regret that I did not have the balls to quit the consulting firm and to go to a post-bac program or other research job right away. I already knew that I wanted to go to grad school, and I knew it wasn't going to be an MBA that I sought. I think how much farther along in my career I might have been. This happens most often when I talk to friends from my cohort who are attendings already.
On the flip side, I probably wasn't actually ready. I didn't know how to go about getting the research experience I needed to apply to grad school. I didn't know how to get the letters of recommendation, or what the other requirements were. I didn't know anything, and I was afraid to jump, or even to try and find out.
I was afraid of failing.
So I ended up at TISCFH in a job I hated with a boat-anchor boyfriend.
Can you say, "Wasted three years," boys and girls?
On the other hand, I probably wouldn't have gotten into THIS MD-PhD program had I applied straight away. I probably wouldn't have met my husband.
So I thought about it, and I came up with 7 things I learned from working at TISCFH that have helped me in the long run.
1) Know when to keep your mouth shut when you're getting BS constructive criticism. This is a completely invaluable skill that is worth mastering in any field.
In fact, I got so good at eating s*** at that company that when one of my not-favorite OB-Gyn residents gave me constructive criticism that was just as BS, I managed a sincere sounding, "I really appreciate the time you took to alert me to these problems. I will do my best to prevent that from happening again in the future." I was so sincere sounding that they even mentioned how gracious I was on my eval.
And sometimes when you think about constructive criticism in retrospect that you thought was BS, you realize there might have been something to it. And now you haven't burned that bridge with the person who gave it to you. Isn't that nice?
2) You can run a very effective and efficient organization without the aid of gadgets and the latest expensive technologies. I alluded to this in a previous post, and in many ways I think TISCFH was a little draconian with this philosophy. On the other hand, I have seen first hand how effective processes are completely vital to an organization, and also how idiotic technologies can screw even the best process up.
For this reason, I am skeptical any time someone touts an Electronic Medical Record as the panacea of health care quality improvement. An EMR won't fix a thing if the underlying processes are crap. It may even make things worse.
3) I learned how bad it can be. Granted, I never (and still have never) pulled an all-nighter at TISCFH, but as a receiving supervisor, I had to be at work by 5AM 5 days a week, and was there until 5PM or later most days. Add this to two hours in the car every day and a hostile work environment that at times made me want to vomit all over the warehouse floor.
All I can say is that my rotations were not the shock they might have been otherwise. And I felt really grateful that I no longer had to spend my days watching my employees unpack boxes.
4) I got to manage my first group of employees. I cannot tell you how helpful this has been in the hospital. I began to learn something about what makes a "good" employee versus what makes an "ok" employee, and that it's not just a matter of a boss liking one person better than another.
When I'm in the hospital, every time I am at a loss for what to do, I think to myself, "If there were nobody here to ask, and I had to figure this out by myself, what would I do?" I also think actively about the following question: If I were a resident, what would I want my med student to do. Looking back, my ability to stay consistent with these internal reminders has been directly associated with my performance.
5) I learned how a business runs. What accounting sheets look like, and how an accounting database might be organized. How to measure productivity. How to improve processes. How to figure out if your company is being screwed by an outside organization. How decisions get made.
Doctors often think it's offensive when I say that patients in the hospital are not unlike packages moving through the warehouse. It's true though. They are.
6) The real world is like high school. It's important to work in an environment with people whom you respect, and with at least a few that you like personally. After that though, it's all about how well you do the job.
When entering a new work environment, rather than worrying about whether everyone likes you, worry first about learning what constitutes a good job. If you do that, the people who matter will notice. Some people will dislike you no matter what you do, so it's best to not let it get to you if you can help it. And if it turns out your company culture is toxic to you, don't be afraid to get a new job.
7) How to run a meeting and manage your boss. Some people are easier to work with/for than others. Looking back at some of my not-so-fantastic relationships with some bosses, I can see how things could have been better had I managed the relationship more effectively.
Always come with an agenda, and stick to it. Don't be afraid to ask questions or to ask for clarification when you don't understand -- even if your colleagues tell you to stop asking questions. It's shocking how often that happens -- and in my case at least, the colleagues were always wrong. Don't giggle. Make sure you leave the meeting with a clear understanding of next steps. Speak and act decisively and with authority and people will respect you and give you more responsibility. Take ownership of your work and your mistakes.
It also helps if you are right from time to time, but that gets better with practice.
******
So maybe it's good I spent those three years in hell afterall. I'll let you know again how I feel about that when I'm 43 and still slogging through residency or fellowship.
I think in many ways, my stint at The Industrial Supply Company From Hell (TISCFH) was a total and utter waste of my time. I keep in touch with practically nobody from the company. Working there raised my blood pressure and gave me an anxiety disorder. I have completely abandoned a lot of the things I learned there.
In some ways, I regret that I did not have the balls to quit the consulting firm and to go to a post-bac program or other research job right away. I already knew that I wanted to go to grad school, and I knew it wasn't going to be an MBA that I sought. I think how much farther along in my career I might have been. This happens most often when I talk to friends from my cohort who are attendings already.
On the flip side, I probably wasn't actually ready. I didn't know how to go about getting the research experience I needed to apply to grad school. I didn't know how to get the letters of recommendation, or what the other requirements were. I didn't know anything, and I was afraid to jump, or even to try and find out.
I was afraid of failing.
So I ended up at TISCFH in a job I hated with a boat-anchor boyfriend.
Can you say, "Wasted three years," boys and girls?
On the other hand, I probably wouldn't have gotten into THIS MD-PhD program had I applied straight away. I probably wouldn't have met my husband.
So I thought about it, and I came up with 7 things I learned from working at TISCFH that have helped me in the long run.
1) Know when to keep your mouth shut when you're getting BS constructive criticism. This is a completely invaluable skill that is worth mastering in any field.
In fact, I got so good at eating s*** at that company that when one of my not-favorite OB-Gyn residents gave me constructive criticism that was just as BS, I managed a sincere sounding, "I really appreciate the time you took to alert me to these problems. I will do my best to prevent that from happening again in the future." I was so sincere sounding that they even mentioned how gracious I was on my eval.
And sometimes when you think about constructive criticism in retrospect that you thought was BS, you realize there might have been something to it. And now you haven't burned that bridge with the person who gave it to you. Isn't that nice?
2) You can run a very effective and efficient organization without the aid of gadgets and the latest expensive technologies. I alluded to this in a previous post, and in many ways I think TISCFH was a little draconian with this philosophy. On the other hand, I have seen first hand how effective processes are completely vital to an organization, and also how idiotic technologies can screw even the best process up.
For this reason, I am skeptical any time someone touts an Electronic Medical Record as the panacea of health care quality improvement. An EMR won't fix a thing if the underlying processes are crap. It may even make things worse.
3) I learned how bad it can be. Granted, I never (and still have never) pulled an all-nighter at TISCFH, but as a receiving supervisor, I had to be at work by 5AM 5 days a week, and was there until 5PM or later most days. Add this to two hours in the car every day and a hostile work environment that at times made me want to vomit all over the warehouse floor.
All I can say is that my rotations were not the shock they might have been otherwise. And I felt really grateful that I no longer had to spend my days watching my employees unpack boxes.
4) I got to manage my first group of employees. I cannot tell you how helpful this has been in the hospital. I began to learn something about what makes a "good" employee versus what makes an "ok" employee, and that it's not just a matter of a boss liking one person better than another.
When I'm in the hospital, every time I am at a loss for what to do, I think to myself, "If there were nobody here to ask, and I had to figure this out by myself, what would I do?" I also think actively about the following question: If I were a resident, what would I want my med student to do. Looking back, my ability to stay consistent with these internal reminders has been directly associated with my performance.
5) I learned how a business runs. What accounting sheets look like, and how an accounting database might be organized. How to measure productivity. How to improve processes. How to figure out if your company is being screwed by an outside organization. How decisions get made.
Doctors often think it's offensive when I say that patients in the hospital are not unlike packages moving through the warehouse. It's true though. They are.
6) The real world is like high school. It's important to work in an environment with people whom you respect, and with at least a few that you like personally. After that though, it's all about how well you do the job.
When entering a new work environment, rather than worrying about whether everyone likes you, worry first about learning what constitutes a good job. If you do that, the people who matter will notice. Some people will dislike you no matter what you do, so it's best to not let it get to you if you can help it. And if it turns out your company culture is toxic to you, don't be afraid to get a new job.
7) How to run a meeting and manage your boss. Some people are easier to work with/for than others. Looking back at some of my not-so-fantastic relationships with some bosses, I can see how things could have been better had I managed the relationship more effectively.
Always come with an agenda, and stick to it. Don't be afraid to ask questions or to ask for clarification when you don't understand -- even if your colleagues tell you to stop asking questions. It's shocking how often that happens -- and in my case at least, the colleagues were always wrong. Don't giggle. Make sure you leave the meeting with a clear understanding of next steps. Speak and act decisively and with authority and people will respect you and give you more responsibility. Take ownership of your work and your mistakes.
It also helps if you are right from time to time, but that gets better with practice.
******
So maybe it's good I spent those three years in hell afterall. I'll let you know again how I feel about that when I'm 43 and still slogging through residency or fellowship.
I don't deserve a vacation right now,
But I'm taking one anyway.
It turns out that the entire Epidemiology department shuts down during the month of August until after Labor Day. Even if I WANTED to get work done now, it would be difficult. As it is, all I've been doing for the past week is slowly slaughtering the paper that will not die for my soon to be ex mentor.
It's his turn to slaughter it now.
And I'm taking a vacation, dammit! It's pointless to sit around in my house waiting for him to get back to me, for goodness sakes.
My husband needs a vacation badly. So we're going to visit the fam in Verona. He's taking me to Cortina for a few days, and we're planning a trip to Ravenna also. I'm sure it will all go by way too fast. Of course all of this will involve consuming large quantities of food. I hear his dad has bought a 2kg salami for us to consume together.... But then, what else is vacation for, really?
I'm also looking forward to running up the hill through the vineyard behind his parent's house. I want to see whether all the hills I've been running around West Philly has made a difference.
I hope so.
I also plan to sleep a lot.
It's going to be awesome.
It turns out that the entire Epidemiology department shuts down during the month of August until after Labor Day. Even if I WANTED to get work done now, it would be difficult. As it is, all I've been doing for the past week is slowly slaughtering the paper that will not die for my soon to be ex mentor.
It's his turn to slaughter it now.
And I'm taking a vacation, dammit! It's pointless to sit around in my house waiting for him to get back to me, for goodness sakes.
My husband needs a vacation badly. So we're going to visit the fam in Verona. He's taking me to Cortina for a few days, and we're planning a trip to Ravenna also. I'm sure it will all go by way too fast. Of course all of this will involve consuming large quantities of food. I hear his dad has bought a 2kg salami for us to consume together.... But then, what else is vacation for, really?
I'm also looking forward to running up the hill through the vineyard behind his parent's house. I want to see whether all the hills I've been running around West Philly has made a difference.
I hope so.
I also plan to sleep a lot.
It's going to be awesome.
Sunday, August 23, 2009
The definition of irony
I want to tell you a little story about Satan.
Back when I started working at the industrial supply company from hell, there were no computers.
Alas, friends. I am not that old. This was in the year 2000. We conducted all transactions through a "tube" which was linked to the mainframe. We didn't even have work email.
About 3 months after I started working there, one computer was added to the purchasing department. It was communal.
Shortly after this, management -- which was largely computer illiterate -- discovered that the young bright kids they hired just out of local colleges could use the computers to do....
ANALYSIS.
Which could potentially help business.
Anyhow, eventually more and more of us got computers. I remember when I got mine. I'd been there for a year, and had had to do all my analysis by hand up until that point. It was one of the best days I had working there. It was when my ability to actually add value to that company took off.
They added computers to the warehouse too.
Until one day, Satan was walking through the warehouse and saw one of his supervisors downloading and printing off tax forms from the IRS web page.
From that moment on, computers were banned from the warehouse floor. And thus, it was impossible to get analytic work done while working on the floor.
Oh, and that employee was fired shortly thereafter.
Irony: When you see that Satan himself has a profile on facebook (and it has been suggested that you add him as a friend).
I guess Satan finally familiarized himself with the technology of the 20th century? I wonder if there are still no computers on the warehouse floor......
Back when I started working at the industrial supply company from hell, there were no computers.
Alas, friends. I am not that old. This was in the year 2000. We conducted all transactions through a "tube" which was linked to the mainframe. We didn't even have work email.
About 3 months after I started working there, one computer was added to the purchasing department. It was communal.
Shortly after this, management -- which was largely computer illiterate -- discovered that the young bright kids they hired just out of local colleges could use the computers to do....
ANALYSIS.
Which could potentially help business.
Anyhow, eventually more and more of us got computers. I remember when I got mine. I'd been there for a year, and had had to do all my analysis by hand up until that point. It was one of the best days I had working there. It was when my ability to actually add value to that company took off.
They added computers to the warehouse too.
Until one day, Satan was walking through the warehouse and saw one of his supervisors downloading and printing off tax forms from the IRS web page.
From that moment on, computers were banned from the warehouse floor. And thus, it was impossible to get analytic work done while working on the floor.
Oh, and that employee was fired shortly thereafter.
Irony: When you see that Satan himself has a profile on facebook (and it has been suggested that you add him as a friend).
I guess Satan finally familiarized himself with the technology of the 20th century? I wonder if there are still no computers on the warehouse floor......
Thursday, August 20, 2009
Mind tricks
Ever wonder what goes through the minds of (almost) doctors?
A few weeks ago, a friend updated his status on facebook to:
"F is SO PROUD of his wife for completing a 100 mile bicycle ride only 6 weeks after giving birth!!!"
Somewhat surprisingly, none of the comments said, "I hope her vagina is doing ok!" I suppose that's because the word "vagina" does not belong on a facebook wall.
I contemplated whether she was more likely to have had a c-section (no damage to the perineum) versus a vaginal delivery (no post-op recovery time).
I concluded she'd had to have had a vaginal delivery. The post-op recovery post c-section can be a real bitch.
Poor perineum.
I struggled to restrain myself from commenting, "I'm so pleased that your wife's vagina was sufficiently healed post-delivery to participate in a 100 mile bike ride. No 4th degree tears, I take it?"
Instead I just asked who her ob was.
They didn't respond.
Maybe she has some sort of collagen mutation that makes her extra stretchy.
Ahem.
Either way, you will not catch me near a bike 6 weeks post-vaginal delivery. No freaking way. 100 miles does a number on a perineum even without also pushing a baby through it a few weeks prior.
See how medical school has warped my mind?
A few weeks ago, a friend updated his status on facebook to:
"F is SO PROUD of his wife for completing a 100 mile bicycle ride only 6 weeks after giving birth!!!"
Somewhat surprisingly, none of the comments said, "I hope her vagina is doing ok!" I suppose that's because the word "vagina" does not belong on a facebook wall.
I contemplated whether she was more likely to have had a c-section (no damage to the perineum) versus a vaginal delivery (no post-op recovery time).
I concluded she'd had to have had a vaginal delivery. The post-op recovery post c-section can be a real bitch.
Poor perineum.
I struggled to restrain myself from commenting, "I'm so pleased that your wife's vagina was sufficiently healed post-delivery to participate in a 100 mile bike ride. No 4th degree tears, I take it?"
Instead I just asked who her ob was.
They didn't respond.
Maybe she has some sort of collagen mutation that makes her extra stretchy.
Ahem.
Either way, you will not catch me near a bike 6 weeks post-vaginal delivery. No freaking way. 100 miles does a number on a perineum even without also pushing a baby through it a few weeks prior.
See how medical school has warped my mind?
Imagine
Another way to think of moral hazard in health care is via the following thought experiment:
Imagine you are an insurance company, and a person who was just diagnosed with cancer inquires about insuring herself with you.
What do you do?
I can tell you what I wouldn't want: I wouldn't want to give her cheap insurance.
Suppose then, that the government forced me to provide insurance to this person.
I could then choose between charging her what I expect her treatment to cost me, or I could spread that cost among my other customers, with the caveat that if I did that, they might defect to a cheaper plan.
Suppose then, that the government told me that I HAD to give her cheap insurance. Well, then I'd have to spread the cost to my other customers, who are becoming more and more dissatisfied.
Imagine that the same thing is happening to other insurance companies all around you. Eventually a healthy customer has no inexpensive option anymore and opts to go without insurance, except those who are very risk averse.
Your pool of customers then becomes only those with health problems. You have fewer and fewer healthy customers to spread costs among, and the costs for your sick customers goes up even more.
Suppose then, the government places price caps on insurance because they feel that it is unfair that insurance costs so much for sick people.
Then your insurance company will go out of business.
Or, suppose that you are forced to charge your customers more in order to cover your costs of insuring them, such that they cannot/will not pay. Then they become uninsured and you go out of business anyway.
And this is why the private insurance market is only suitable for catastrophic and/or unexpected events.
I don't like the idea of government run health care either. But when you think about it, it is actually impossible for a private insurance market to cover patients with chronic illness or any sort of pre-existing condition because of the scenario I just described.
It is possible that the government will mess things up and that health care delivery won't be perfect.
But it is an absolute guarantee that the private insurance market will.
Imagine you are an insurance company, and a person who was just diagnosed with cancer inquires about insuring herself with you.
What do you do?
I can tell you what I wouldn't want: I wouldn't want to give her cheap insurance.
Suppose then, that the government forced me to provide insurance to this person.
I could then choose between charging her what I expect her treatment to cost me, or I could spread that cost among my other customers, with the caveat that if I did that, they might defect to a cheaper plan.
Suppose then, that the government told me that I HAD to give her cheap insurance. Well, then I'd have to spread the cost to my other customers, who are becoming more and more dissatisfied.
Imagine that the same thing is happening to other insurance companies all around you. Eventually a healthy customer has no inexpensive option anymore and opts to go without insurance, except those who are very risk averse.
Your pool of customers then becomes only those with health problems. You have fewer and fewer healthy customers to spread costs among, and the costs for your sick customers goes up even more.
Suppose then, the government places price caps on insurance because they feel that it is unfair that insurance costs so much for sick people.
Then your insurance company will go out of business.
Or, suppose that you are forced to charge your customers more in order to cover your costs of insuring them, such that they cannot/will not pay. Then they become uninsured and you go out of business anyway.
And this is why the private insurance market is only suitable for catastrophic and/or unexpected events.
I don't like the idea of government run health care either. But when you think about it, it is actually impossible for a private insurance market to cover patients with chronic illness or any sort of pre-existing condition because of the scenario I just described.
It is possible that the government will mess things up and that health care delivery won't be perfect.
But it is an absolute guarantee that the private insurance market will.
Wednesday, August 19, 2009
What *I* want from health care reform
1) I want the severe injury or illness of one family member to no longer result in bankrupting whole families.
2) I want services that one cannot reasonably expect the free market to cover (birth, or breast cancer in a known BRCA+ patient, for instance) to be covered by a public option.
3) I want more transparency of medical costs when I go to the doctor.
4) I want the incentives of doctors to be aligned with those of patients. I.e. Can we please try to reduce unnecessary procedures? Can we incentivise providers to meet quality standards?
5) I want an incentive structure that encourages innovation of new and better products (drugs, devices) in the private sector, yet allows for negotiation on the part of the consumer.
6) I want my doctor not to be a patronizing ass to me (ha ha! I doubt we can make a law to prevent that!).
7) If some of the changes above result in lower salaries for doctors, I want some debt forgiveness.
8) I want some people (you know who you are) to stop complaining that everything isn't free. People who CAN pay SHOULD be paying. This includes my medical school classmates who complain that they are "too poor to pay for birth control."
9) I want more transparency in the private insurance market. With a public option. There needs to be some alternative, even if it isn't as comprehensive as the posh private insurance you can get working for a big company.
10) I want people to stop talking about preventive care as though it is going to save the system money. It won't. Preventive care is often cost-effective, but rarely cost-saving. The only reason that "the government" should ever consider covering preventive care is because it is the "right thing to do," and even then, there need to be limits on what is covered so that we don't bankrupt the system.
And example of such a service might include.... routine blood pressure/HbA1c checks for patients with those problems, or follow-up appointments for patients recently discharged from the hospital. Or perhaps cholesterol lowering drugs/aspirin. Not sure what the latest data shows about the cost/QALY of these though, so I put these suggestions forward with that caveat.
What do you want?
2) I want services that one cannot reasonably expect the free market to cover (birth, or breast cancer in a known BRCA+ patient, for instance) to be covered by a public option.
3) I want more transparency of medical costs when I go to the doctor.
4) I want the incentives of doctors to be aligned with those of patients. I.e. Can we please try to reduce unnecessary procedures? Can we incentivise providers to meet quality standards?
5) I want an incentive structure that encourages innovation of new and better products (drugs, devices) in the private sector, yet allows for negotiation on the part of the consumer.
6) I want my doctor not to be a patronizing ass to me (ha ha! I doubt we can make a law to prevent that!).
7) If some of the changes above result in lower salaries for doctors, I want some debt forgiveness.
8) I want some people (you know who you are) to stop complaining that everything isn't free. People who CAN pay SHOULD be paying. This includes my medical school classmates who complain that they are "too poor to pay for birth control."
9) I want more transparency in the private insurance market. With a public option. There needs to be some alternative, even if it isn't as comprehensive as the posh private insurance you can get working for a big company.
10) I want people to stop talking about preventive care as though it is going to save the system money. It won't. Preventive care is often cost-effective, but rarely cost-saving. The only reason that "the government" should ever consider covering preventive care is because it is the "right thing to do," and even then, there need to be limits on what is covered so that we don't bankrupt the system.
And example of such a service might include.... routine blood pressure/HbA1c checks for patients with those problems, or follow-up appointments for patients recently discharged from the hospital. Or perhaps cholesterol lowering drugs/aspirin. Not sure what the latest data shows about the cost/QALY of these though, so I put these suggestions forward with that caveat.
What do you want?
Tuesday, August 18, 2009
I believe in Murphy's Law
It's been a real struggle to get my soon to be ex-mentor to focus on this paper we've been writing these past 6 weeks. I'll send him a draft, and he will complain that I sent it too close to our weekly meeting for him to go over it.
So the next week I'll send him another draft giving him 3 extra days and he STILL won't read it. He'll show up to the meeting with a couple illegible scribbles and some comments that don't address any of my questions. Comments on things that we went over and resolved months (technically, years) ago.
Sigh. He's a busy man, and I suppose he has other more pressing things to focus on now. Still. It would nice to get this done. Both for me AND for him!
Anyway, at our last meeting we agreed to just get the thing out so I can transition to my new mentor this fall and start working on what I will actually be getting my PhD in. The paper is pretty much written. I am putting in citations and polishing up the introduction and discussion sections as we speak.
My theory is that if I send it to him the day I leave for Italy and don't take my computer, he will be able to get to it immediately. Why? Because I won't be able to work on it for two weeks and he'll then be able to think again that I am slacking off!
All of this subconsciously of course. Because I believe in Murphy's Law.
Hmmm.... I wonder if I shouldn't blog about these things.... Could get into trouble. Well, if I take this post down later, you'll know why!
So the next week I'll send him another draft giving him 3 extra days and he STILL won't read it. He'll show up to the meeting with a couple illegible scribbles and some comments that don't address any of my questions. Comments on things that we went over and resolved months (technically, years) ago.
Sigh. He's a busy man, and I suppose he has other more pressing things to focus on now. Still. It would nice to get this done. Both for me AND for him!
Anyway, at our last meeting we agreed to just get the thing out so I can transition to my new mentor this fall and start working on what I will actually be getting my PhD in. The paper is pretty much written. I am putting in citations and polishing up the introduction and discussion sections as we speak.
My theory is that if I send it to him the day I leave for Italy and don't take my computer, he will be able to get to it immediately. Why? Because I won't be able to work on it for two weeks and he'll then be able to think again that I am slacking off!
All of this subconsciously of course. Because I believe in Murphy's Law.
Hmmm.... I wonder if I shouldn't blog about these things.... Could get into trouble. Well, if I take this post down later, you'll know why!
Monday, August 17, 2009
Stomps Foot!
Last night we met our new two doors down neighbor. My husband was mostly concerned with whether he was going to be quiet and whether he was going to attract more mice. I was mostly not concerned.
So we were making a run to DSW last night (Oh yes, we went shopping this weekend! For ME!!! So I just HAD to buy shoes to go with my new outfits....) and we ran into this dude.
It is just that dude who lives there. Anyway.
So we come introduce ourselves. Luca does most of the talking. I am thinking, "It's hot out here. Can we please get into the air conditioned car??"
Luca's like, "Blah blah we just moved too, we love the street, everyone is so nice.... etc.," and the guy then decides to ascertain where he works.
(My husband works for a company in the area and he wants to keep his job, so you'll excuse me if I keep that information private.)
Anyway, the dude then starts in on how he used to do consulting for that company (though in a completely and totally unrelated area), and that he's an econ professor(?) at [my institution]. Lists off all the classes he teaches. Some undergrad and some PhD level.... "Oh, really advanced math things," waving his hand offhandedly in my direction and smiling cloyingly.
(Grrrrrrrr......)
He and Luca talk, with Luca trying to divert the conversation away from his job so we can GO ALREADY. And plus, he hasn't said anything to me since being introduced 5 minutes ago. A small (ok, not so small) part of me on the inside is like, "You think my HUSBAND can help you in your career? And yet you never consider the possibility that part of what I DO IS IN YOUR DAMN DEPARTMENT. Oh wait, you wouldn't know that because you never asked what *I* did."
So anyway, he eventually got around to asking.
But I still felt a bit slighted. It really seemed the guy fixated on my husband because naturally he's the man and would have something to talk about with him.
I don't want to be THAT person who automatically assumes that this was sexism. In fact, I doubt it was even intentional. But then, that's part of the problem isn't it?
Anyway, I discussed it with Luca later, and I'm still not sure how I feel about the whole thing. Probably shouldn't give it too much more thought though, since nothing good ever comes of letting things like this fester. It's like worrying about whether people think you're stupid. Best not to even consider such things.
And like I said, I doubt the guy even meant anything by it. And maybe he just has no social skills. He is an econ professor afterall. :-P
So we were making a run to DSW last night (Oh yes, we went shopping this weekend! For ME!!! So I just HAD to buy shoes to go with my new outfits....) and we ran into this dude.
It is just that dude who lives there. Anyway.
So we come introduce ourselves. Luca does most of the talking. I am thinking, "It's hot out here. Can we please get into the air conditioned car??"
Luca's like, "Blah blah we just moved too, we love the street, everyone is so nice.... etc.," and the guy then decides to ascertain where he works.
(My husband works for a company in the area and he wants to keep his job, so you'll excuse me if I keep that information private.)
Anyway, the dude then starts in on how he used to do consulting for that company (though in a completely and totally unrelated area), and that he's an econ professor(?) at [my institution]. Lists off all the classes he teaches. Some undergrad and some PhD level.... "Oh, really advanced math things," waving his hand offhandedly in my direction and smiling cloyingly.
(Grrrrrrrr......)
He and Luca talk, with Luca trying to divert the conversation away from his job so we can GO ALREADY. And plus, he hasn't said anything to me since being introduced 5 minutes ago. A small (ok, not so small) part of me on the inside is like, "You think my HUSBAND can help you in your career? And yet you never consider the possibility that part of what I DO IS IN YOUR DAMN DEPARTMENT. Oh wait, you wouldn't know that because you never asked what *I* did."
So anyway, he eventually got around to asking.
But I still felt a bit slighted. It really seemed the guy fixated on my husband because naturally he's the man and would have something to talk about with him.
I don't want to be THAT person who automatically assumes that this was sexism. In fact, I doubt it was even intentional. But then, that's part of the problem isn't it?
Anyway, I discussed it with Luca later, and I'm still not sure how I feel about the whole thing. Probably shouldn't give it too much more thought though, since nothing good ever comes of letting things like this fester. It's like worrying about whether people think you're stupid. Best not to even consider such things.
And like I said, I doubt the guy even meant anything by it. And maybe he just has no social skills. He is an econ professor afterall. :-P
Sunday, August 16, 2009
On anonymous comments
Regular readers will notice that I have started moderating comments and that I have new comment guidelines:
- No posting my real name
- No cursing at me
- No ads
Initially I had changed my profile to not allow anonymous comments as well. I later changed it back. It turns out I have a lot of anonymous commenters, and I missed them.
Getting comments is one of the most fun parts of having a blog. Over time, you see the same people come back, and a sort of blogging community develops. You get to know one another.
When comments are anonymous, it does prevent the development of community to a certain extent. You don't know who's leaving the comment, you can't trace back to their blog, and you don't know if it's the same anonymous posting a number of times.
Also, it is free license for people to say exactly what they want. With no repercussions other than your wrath or the wrath of your other readers. Thus, the troll was born.
The thing is, not all anonymous comments are from trolls. Some people just don't feel like inventing a name or logging in at that time. Others disagree with you and want to say something, but worry that the entire blogging universe will come crashing down on them with 100s of mean comments directed back at THEM if they say something even remotely contrary. It happens.
In the end I've found that anonymous comments are often the ones that make me think. Sure, I get my fair share of "F*** you, stupid c***!!!" But guess what? I can be wrong and whiny sometimes. I mean, it is my right to be whiny on my blog. Those sorts of comments (i.e. "OMDG, you're being really whiny." when I post about how much I hate working for my ex-mentor) are not especially *helpful* but you are entitled to your opinion. And well? I really do need to move on (I am!) sometimes, anyway.
Incidentally, blogging helps me do that, which is one of the reasons I blog.
Sometimes the anon comments sting a bit. But if people want to tell me what they really think, and feel they can only do it under a veil of anonymity, at least they CAN.
Some people have said that anonymous comments allow people not to be accountable for their words. They allow them to "behave badly" when if they were face-to-face with you they would never say these things. I think that sometimes being able to say something that you WOULDN'T be able to say to someone's face can be a very valuable thing. I'm not ready to throw that away at this point.
Anyway, I hope this doesn't open the flood gates to a slew of comments on how obnoxious and petty my readers think I am. For now though, this is my position.
I'm keeping the comment moderation, though.
- No posting my real name
- No cursing at me
- No ads
Initially I had changed my profile to not allow anonymous comments as well. I later changed it back. It turns out I have a lot of anonymous commenters, and I missed them.
Getting comments is one of the most fun parts of having a blog. Over time, you see the same people come back, and a sort of blogging community develops. You get to know one another.
When comments are anonymous, it does prevent the development of community to a certain extent. You don't know who's leaving the comment, you can't trace back to their blog, and you don't know if it's the same anonymous posting a number of times.
Also, it is free license for people to say exactly what they want. With no repercussions other than your wrath or the wrath of your other readers. Thus, the troll was born.
The thing is, not all anonymous comments are from trolls. Some people just don't feel like inventing a name or logging in at that time. Others disagree with you and want to say something, but worry that the entire blogging universe will come crashing down on them with 100s of mean comments directed back at THEM if they say something even remotely contrary. It happens.
In the end I've found that anonymous comments are often the ones that make me think. Sure, I get my fair share of "F*** you, stupid c***!!!" But guess what? I can be wrong and whiny sometimes. I mean, it is my right to be whiny on my blog. Those sorts of comments (i.e. "OMDG, you're being really whiny." when I post about how much I hate working for my ex-mentor) are not especially *helpful* but you are entitled to your opinion. And well? I really do need to move on (I am!) sometimes, anyway.
Incidentally, blogging helps me do that, which is one of the reasons I blog.
Sometimes the anon comments sting a bit. But if people want to tell me what they really think, and feel they can only do it under a veil of anonymity, at least they CAN.
Some people have said that anonymous comments allow people not to be accountable for their words. They allow them to "behave badly" when if they were face-to-face with you they would never say these things. I think that sometimes being able to say something that you WOULDN'T be able to say to someone's face can be a very valuable thing. I'm not ready to throw that away at this point.
Anyway, I hope this doesn't open the flood gates to a slew of comments on how obnoxious and petty my readers think I am. For now though, this is my position.
I'm keeping the comment moderation, though.
Friday, August 14, 2009
Updates from Real Life
I've been writing a lot about policy lately and it has occurred to me that this is BORING!!!
The rest of my life has been really nice since I finished my sub-i two months ago. Two months! I can't believe it's already been that long. My husband and I moved into our new house, I started working on my garden, I've begun to get back into shape, I've read a couple of books, I started and finished my first biostats class, and I've been figuring out The Plan for my PhD.
I still haven't selected a mentor, but I have narrowed down my area of focus. I am likely going to study decision making. More specifically, I would like to study how physicians make decisions. I could get into Kahneman , game theory, and my theories about rationality and some other stuff that I doubt anyone cares about (feel free to let me know if you DO care), but I won't. Not right now.
I also am interested in the consequences of these decisions. Do they matter? And if so, do we correctly anticipate HOW they will matter.
I am 150 pages from finishing What is the What? I've been reading this book for about a month now, and have had a hard time sitting through more than 10-20 pages at a time. It's ok though. It's about the life of a Sudanese refugee in the US, and so far I've enjoyed it. It makes you think about what it would be like to lose everything. Repeatedly.
In the same vein, I've noticed that our Netflix cue has been producing a lot of movies about the Holocaust lately. We saw The Pianist this week, and a documentary on Simon Wiesenthal. Both were interesting, though the Pianist felt at times like it was trying too hard to be deep. Maybe I should switch to something more light-hearted before I start having trouble sleeping.
I have to admit that every time I think of the movie The Pianist, I think about that joke about the genie with the three wishes and the 12" pianist.* Sorry. Inappropriate I know. But I can't help it.
Luca and I also saw Gran Torino, which we also enjoyed.
In the exercise domain, I've still been going about 6 days/wk for at least a 2 mile run or something. My swimming has improved so much, but I feel like I still have a long road of improvement ahead of me. I've been going in the mornings before school/work and two days a week with a friend, which -- you have no idea how much it helps me get out of bed in the morning. I hope to be able to keep this up throughout the year. I took down the exercise log because, well? Old news!
And in a little less than two weeks, Luca and I will be going to Italy to visit his parents, which should be fun.
Then fall semester starts.
I had lunch with a friend last week who told me how much more relaxed I seemed now compared to last year. Ya think? I wish I could be as relaxed when going all out in the hospital as I am now, but sadly, I doubt that will ever happen.
I've also beenbeating my head against the wall working with the ex-mentor on a paper. He seems to be putting in as little as possible, and has developed the theory that I am trying to "get him to write the paper." He won't even do track changes on my various versions anymore -- he prefers to TELL me, I think so that he doesn't have to actually write anything down or think about what he's saying.
He'll say, "I like what this paragraph says, but I would write it differently," and I think, "Well why DON'T you then." And he'll say, "I'm not going to do your work for you." So working with him becomes an exercise in clairvoyance and his bullshit version of the Socratic method. There's a reason he is my EX-mentor, afterall. So even that annoying gray cloud has a silver lining.
Anyhow, that's what's up!
*The 12" pianist joke:
A man walks into a bar and notices his friend sitting alone staring at a tiny man on the table playing the piano.
"Wow, look how small he is, where did you get him?!" Says the man.
"Oh, well there's this genie round the back of bar, and he grants you whatever wish you want."
Sure enough, the man goes round the back of the bar and there sits a genie.
"You grant wishes right?"
"Yes." replies the genie.
"Hmm, gimme a million bucks."
Then, out of no where, a million ducks appear, and waddle behind the annoyed man as he goes back into the bar.
"Look, that stupid deaf genie gave me ducks instead of bucks!"
His friends sitting at the table replies-
"Well yeah, do you really think i asked for a twelve inch pianist?"
The rest of my life has been really nice since I finished my sub-i two months ago. Two months! I can't believe it's already been that long. My husband and I moved into our new house, I started working on my garden, I've begun to get back into shape, I've read a couple of books, I started and finished my first biostats class, and I've been figuring out The Plan for my PhD.
I still haven't selected a mentor, but I have narrowed down my area of focus. I am likely going to study decision making. More specifically, I would like to study how physicians make decisions. I could get into Kahneman , game theory, and my theories about rationality and some other stuff that I doubt anyone cares about (feel free to let me know if you DO care), but I won't. Not right now.
I also am interested in the consequences of these decisions. Do they matter? And if so, do we correctly anticipate HOW they will matter.
I am 150 pages from finishing What is the What? I've been reading this book for about a month now, and have had a hard time sitting through more than 10-20 pages at a time. It's ok though. It's about the life of a Sudanese refugee in the US, and so far I've enjoyed it. It makes you think about what it would be like to lose everything. Repeatedly.
In the same vein, I've noticed that our Netflix cue has been producing a lot of movies about the Holocaust lately. We saw The Pianist this week, and a documentary on Simon Wiesenthal. Both were interesting, though the Pianist felt at times like it was trying too hard to be deep. Maybe I should switch to something more light-hearted before I start having trouble sleeping.
I have to admit that every time I think of the movie The Pianist, I think about that joke about the genie with the three wishes and the 12" pianist.* Sorry. Inappropriate I know. But I can't help it.
Luca and I also saw Gran Torino, which we also enjoyed.
In the exercise domain, I've still been going about 6 days/wk for at least a 2 mile run or something. My swimming has improved so much, but I feel like I still have a long road of improvement ahead of me. I've been going in the mornings before school/work and two days a week with a friend, which -- you have no idea how much it helps me get out of bed in the morning. I hope to be able to keep this up throughout the year. I took down the exercise log because, well? Old news!
And in a little less than two weeks, Luca and I will be going to Italy to visit his parents, which should be fun.
Then fall semester starts.
I had lunch with a friend last week who told me how much more relaxed I seemed now compared to last year. Ya think? I wish I could be as relaxed when going all out in the hospital as I am now, but sadly, I doubt that will ever happen.
I've also been
He'll say, "I like what this paragraph says, but I would write it differently," and I think, "Well why DON'T you then." And he'll say, "I'm not going to do your work for you." So working with him becomes an exercise in clairvoyance and his bullshit version of the Socratic method. There's a reason he is my EX-mentor, afterall. So even that annoying gray cloud has a silver lining.
Anyhow, that's what's up!
*The 12" pianist joke:
A man walks into a bar and notices his friend sitting alone staring at a tiny man on the table playing the piano.
"Wow, look how small he is, where did you get him?!" Says the man.
"Oh, well there's this genie round the back of bar, and he grants you whatever wish you want."
Sure enough, the man goes round the back of the bar and there sits a genie.
"You grant wishes right?"
"Yes." replies the genie.
"Hmm, gimme a million bucks."
Then, out of no where, a million ducks appear, and waddle behind the annoyed man as he goes back into the bar.
"Look, that stupid deaf genie gave me ducks instead of bucks!"
His friends sitting at the table replies-
"Well yeah, do you really think i asked for a twelve inch pianist?"
Thursday, August 13, 2009
Moral Hazard
What is moral hazard, you may ask?
Per Wikipedia: Moral hazard is the prospect that a party insulated from risk may behave differently from the way it would behave if it were fully exposed to the risk.
Why do I bring this up? Because I am tired of reading about the awful, evil, morally bankrupt insurance companies who won't cover the cost of pregnancy and delivery.*
Ok fine. I will admit. Insurance companies are all of these things (awful, evil, and morally bankrupt). But think one minute. Who buys insurance? People who anticipate that they will be going to the doctor. Like those who plan to get pregnant. The problem is that insurance is designed to protect you from risk, not to subsidize your life choices. And it is priced accordingly.
Suppose the government were to pass legislation that required these insurance companies to fully cover the costs of labor and delivery/ c-section. What do you think would happen to the price of the insurance? It would rapidly approach the cost of labor and delivery in direct proportion to the number of women of childbearing age who bought the policy.
And then it wouldn't be insurance anymore. Nobody would want it. What 25 year old self-employed mom who wants a baby would be willing to pay $20K for one year of insurance? It just makes no sense.
Do I think that women should be left out to dry? To pay for everything on their own, pregnant bellies swinging in the breeze?
No.
See, it is probably good for society to have moms who get prenatal care and have healthy babies. Perhaps there *is* a role for government in a situation like this. Maybe pregnancy/childbirth should be treated like a public good (like a highway, an army, or public school). Depending on how pro-natalist the government wanted to be, it could subsidize part of to all of the cost of the delivery. Some countries even go so far as to provide subsidies to parents to further encourage them to have children -- not that I'm advocating this in the US.
Taxes would probably go up, yes. But private insurance could then be left to cover what it's meant to cover: risk.
I don't really like the idea of government run health care. I worry that we'd all get saddled with a big and inefficient system like the VA (albeit with a fantastic electronic medical record) with long waits, rude federal employees who don't really want to be there but can't be fired, and sub-standard care. Bureaucracy on top of bureaucracy. Rationing on waiting times rather than on urgency. But I really don't see the current insurance market that caters to individuals working out very well for moms or for families in the end. Not with the moral hazard problem.
Maybe this is a case where government could be part of the solution.
*Let's be clear about one thing: I'm talking about insurance policies that individuals buy -- not medicaid or a policy supplied by an employer where risk is spread out over a large group of people.
Per Wikipedia: Moral hazard is the prospect that a party insulated from risk may behave differently from the way it would behave if it were fully exposed to the risk.
Why do I bring this up? Because I am tired of reading about the awful, evil, morally bankrupt insurance companies who won't cover the cost of pregnancy and delivery.*
Ok fine. I will admit. Insurance companies are all of these things (awful, evil, and morally bankrupt). But think one minute. Who buys insurance? People who anticipate that they will be going to the doctor. Like those who plan to get pregnant. The problem is that insurance is designed to protect you from risk, not to subsidize your life choices. And it is priced accordingly.
Suppose the government were to pass legislation that required these insurance companies to fully cover the costs of labor and delivery/ c-section. What do you think would happen to the price of the insurance? It would rapidly approach the cost of labor and delivery in direct proportion to the number of women of childbearing age who bought the policy.
And then it wouldn't be insurance anymore. Nobody would want it. What 25 year old self-employed mom who wants a baby would be willing to pay $20K for one year of insurance? It just makes no sense.
Do I think that women should be left out to dry? To pay for everything on their own, pregnant bellies swinging in the breeze?
No.
See, it is probably good for society to have moms who get prenatal care and have healthy babies. Perhaps there *is* a role for government in a situation like this. Maybe pregnancy/childbirth should be treated like a public good (like a highway, an army, or public school). Depending on how pro-natalist the government wanted to be, it could subsidize part of to all of the cost of the delivery. Some countries even go so far as to provide subsidies to parents to further encourage them to have children -- not that I'm advocating this in the US.
Taxes would probably go up, yes. But private insurance could then be left to cover what it's meant to cover: risk.
I don't really like the idea of government run health care. I worry that we'd all get saddled with a big and inefficient system like the VA (albeit with a fantastic electronic medical record) with long waits, rude federal employees who don't really want to be there but can't be fired, and sub-standard care. Bureaucracy on top of bureaucracy. Rationing on waiting times rather than on urgency. But I really don't see the current insurance market that caters to individuals working out very well for moms or for families in the end. Not with the moral hazard problem.
Maybe this is a case where government could be part of the solution.
*Let's be clear about one thing: I'm talking about insurance policies that individuals buy -- not medicaid or a policy supplied by an employer where risk is spread out over a large group of people.
Wednesday, August 12, 2009
Magic Hands and Magic Eyes
Do you think a PA or nurse could be trained to do colonoscopies as effectively as a gastroenterologist? How about a primary care doctor?
Food for thought:
A few years ago, an orthopedic surgeon at an affiliated hospital got in trouble because he was letting his PAs do his knee replacements. Did he get in trouble because of bad outcomes? Noooooo.....
He got in trouble with the insurance companies because of how he was billing. The bill said that HE did the surgery.
Not that I'm advocating this, I'm just saying. In this day and age of outpatient specialty surgery centers, one wonders what proportion of the colonoscopies -- and procedures in general -- that happen today are performed by rather than overseen by the MD.
I wonder how many patients know this sort of thing happens?
But before we get all upset about this, let's pause to consider the potential downsides.
Potential con #1: If there's unusual pathology, will a PAs/nurse know what he'she's looking at?
But then I wonder: Did I miss the class in medical school where they taught us future doctors how to have MAGIC EYES.
The more you see, the more you know what normal is. I'll take a gander that a PA/nurse who does 35 colonoscopies a week will be better at it than any GI doctor who does only 5.
Potential con #2: Won't PAs/nurses have higher rates of complications than MDs?
With all procedures, your dexterity and speed increase as your n increases. Did I miss the class on MAGIC HANDS too, where they poured medical school holy water over our hands and told us that God had anointed doctors (and only doctors) to wield the ass camera and snare?
Alas, not all people are endowed with manual dexterity to an equal degree, MD or no. Practice makes perfect. See con #1.
But what do I know about any of this? I'm just a medical student who doesn't know anything (still). What do you think about the idea of having a highly skilled non-doctor performing your colonoscopy? What if there were standards and training guidelines? Do you think it's a reasonable way to start thinking about curbing some of the escalating health care costs?
Discuss.
Food for thought:
A few years ago, an orthopedic surgeon at an affiliated hospital got in trouble because he was letting his PAs do his knee replacements. Did he get in trouble because of bad outcomes? Noooooo.....
He got in trouble with the insurance companies because of how he was billing. The bill said that HE did the surgery.
Not that I'm advocating this, I'm just saying. In this day and age of outpatient specialty surgery centers, one wonders what proportion of the colonoscopies -- and procedures in general -- that happen today are performed by rather than overseen by the MD.
I wonder how many patients know this sort of thing happens?
But before we get all upset about this, let's pause to consider the potential downsides.
Potential con #1: If there's unusual pathology, will a PAs/nurse know what he'she's looking at?
But then I wonder: Did I miss the class in medical school where they taught us future doctors how to have MAGIC EYES.
The more you see, the more you know what normal is. I'll take a gander that a PA/nurse who does 35 colonoscopies a week will be better at it than any GI doctor who does only 5.
Potential con #2: Won't PAs/nurses have higher rates of complications than MDs?
With all procedures, your dexterity and speed increase as your n increases. Did I miss the class on MAGIC HANDS too, where they poured medical school holy water over our hands and told us that God had anointed doctors (and only doctors) to wield the ass camera and snare?
Alas, not all people are endowed with manual dexterity to an equal degree, MD or no. Practice makes perfect. See con #1.
But what do I know about any of this? I'm just a medical student who doesn't know anything (still). What do you think about the idea of having a highly skilled non-doctor performing your colonoscopy? What if there were standards and training guidelines? Do you think it's a reasonable way to start thinking about curbing some of the escalating health care costs?
Discuss.
Monday, August 10, 2009
Primary Care
Today, the toilet paper blog posted a "day in the life of a Family Practice doctor."
It consisted of:
Diabetes, type 2, poorly controlled
Hypertension
Obesity
Vaccinations (tetanus and pneumonia)
Low back pain in elderly man
Increased thoughts of suicide
Attention deficit disorder
Acne
Bronchitis
Insomnia
Emotional stress (marital and child issues)
Weight loss, unexplained
Infant - well child check
Complete physicals, father and son (camp forms completed)
Ringworm
Premature breast tissue development in infant
Toenail fungal infection
Dyshidrotic eczema
Lipoma (a benign fatty growth)
Allergic conjunctivitis
Sliver of fiberglass in finger
Alcoholism
High cholesterol
Asthma
I think it was supposed to be a tacit reprimand to all those evil specialists who do things like fix people and make money. And toilet paper said she found the list of diagnoses FASCINATING.
What did the list do for me? I was reminded instantly why primary care didn't appeal to me. The only diagnoses that were interesting AT ALL to me in there were suicidal ideation and unexplained weight loss. And maybe the fiberglass sliver (procedure!). Nevermind that the PMD who gave these various diagnoses as a "typical" day no doubt cherry picked the interesting ones from a series of days. I say that because my days in the primary care clinic consisted of this:
*Hypertension
*Hypertension
*Really bad hypertension (this one was actually interesting since we treated her in office)
*Diabetes
*Hypertension
*Bronchitis (antibiotic demander)
*Upper Respiratory Infection (antibiotic demander, part 2)
*Hypertension
*Diabetes
*Obesity counseling
*New neuropathy (interesting! oh, turf to neurologist)
*Low platelets (interesting! turf to hematologist)
*Hypertension in patient with Sjogrens (already treated though so nothing to do)
*Rash on groin (usually a man, med student waits outside)
*Hypertension
*Diabetes
*Alcoholic patient with liver disease and edema (interesting! but NTD except counsel re: alcohol abstinence and taking the meds, which she has never done despite repeated hospitalizations)
*Hypertension
*Diabetes
*Low back pain
*Low back pain
*Low back pain
*Low back pain in patient on steroids (oh! potentially interesting.... except that it wasn't)
Did I mention the smattering of well patient visits on patients with seasonal allergies? I guess people go into Primary Care because they like the long term relationships they forge with their patients. And you'd think I'd be into that because talking to my patients is for me absolutely and positively the best part about being an (almost) doctor.
Except these days it seems that patients all hate their primary care doctors.... Hmmmmm. And then they refuse to take a statin for their high cholesterol because granny had sore legs when she took hers.
Burnout anyone?
I like taking care of inpatients. At least I do at this point in my life. Maybe that will change as I get older.
Frankly, we should all be grateful that there are doctors who like all kinds of specialties.
And God bless anyone who really loves primary care. Also? Can you be my doctor? Thanks.
It consisted of:
Diabetes, type 2, poorly controlled
Hypertension
Obesity
Vaccinations (tetanus and pneumonia)
Low back pain in elderly man
Increased thoughts of suicide
Attention deficit disorder
Acne
Bronchitis
Insomnia
Emotional stress (marital and child issues)
Weight loss, unexplained
Infant - well child check
Complete physicals, father and son (camp forms completed)
Ringworm
Premature breast tissue development in infant
Toenail fungal infection
Dyshidrotic eczema
Lipoma (a benign fatty growth)
Allergic conjunctivitis
Sliver of fiberglass in finger
Alcoholism
High cholesterol
Asthma
I think it was supposed to be a tacit reprimand to all those evil specialists who do things like fix people and make money. And toilet paper said she found the list of diagnoses FASCINATING.
What did the list do for me? I was reminded instantly why primary care didn't appeal to me. The only diagnoses that were interesting AT ALL to me in there were suicidal ideation and unexplained weight loss. And maybe the fiberglass sliver (procedure!). Nevermind that the PMD who gave these various diagnoses as a "typical" day no doubt cherry picked the interesting ones from a series of days. I say that because my days in the primary care clinic consisted of this:
*Hypertension
*Hypertension
*Really bad hypertension (this one was actually interesting since we treated her in office)
*Diabetes
*Hypertension
*Bronchitis (antibiotic demander)
*Upper Respiratory Infection (antibiotic demander, part 2)
*Hypertension
*Diabetes
*Obesity counseling
*New neuropathy (interesting! oh, turf to neurologist)
*Low platelets (interesting! turf to hematologist)
*Hypertension in patient with Sjogrens (already treated though so nothing to do)
*Rash on groin (usually a man, med student waits outside)
*Hypertension
*Diabetes
*Alcoholic patient with liver disease and edema (interesting! but NTD except counsel re: alcohol abstinence and taking the meds, which she has never done despite repeated hospitalizations)
*Hypertension
*Diabetes
*Low back pain
*Low back pain
*Low back pain
*Low back pain in patient on steroids (oh! potentially interesting.... except that it wasn't)
Did I mention the smattering of well patient visits on patients with seasonal allergies? I guess people go into Primary Care because they like the long term relationships they forge with their patients. And you'd think I'd be into that because talking to my patients is for me absolutely and positively the best part about being an (almost) doctor.
Except these days it seems that patients all hate their primary care doctors.... Hmmmmm. And then they refuse to take a statin for their high cholesterol because granny had sore legs when she took hers.
Burnout anyone?
I like taking care of inpatients. At least I do at this point in my life. Maybe that will change as I get older.
Frankly, we should all be grateful that there are doctors who like all kinds of specialties.
And God bless anyone who really loves primary care. Also? Can you be my doctor? Thanks.
AC
So far, the new house has done ok this summer without central AC. We have a window unit that we use about 20% of the time in the bedroom when we sleep, and that's about it.
Today, though. Ugh. It's only 90 now (down from 96). I'm not sure I'm actually going to survive the walk home.
Today, though. Ugh. It's only 90 now (down from 96). I'm not sure I'm actually going to survive the walk home.
Sunday, August 09, 2009
Grades and medical school
Gabbiana brought up a good point in her comment on why medical students grade grub. We've been trained to do it. We are finely tuned ass-kissing machines. It's more or less a requirement for success.*
It's funny, while we stand back and mock the fellow who was mad she got a 29/30, you have to understand where this behavior came from. Which can be summed up as follows:
DO YOU HAVE ANY IDEA HOW PERFECT YOUR GRADES HAVE TO BE TO GET INTO MEDICAL SCHOOL AT ALL?? MUCH LESS, A MEDICAL SCHOOL THAT WILL PERMIT YOU TO GO INTO YOUR SPECIALTY OF CHOICE??
Especially directly out of undergrad.
All I can say is, it really sucks to have this, "You need a 4.0...." hanging over your head, when you really want to focus on what is interesting to you. Including (the horror) your boyfriend or (double horror) having fun.
I remember when I did my post-bac, and was taking O-Chem with the undergrads at my alma mater, there was a rumor going around that the professor saw it as his job to determine which students got to go to medical school.
"That's weird," you might say, "You don't really need O-Chem at all in med school."
Ah friends. See, he didn't see it that way. HE felt that medical school should BE organic chemistry. And he felt that "smart" people were good at organic chemistry. And don't you want your doctor to be "smart?"
Also, the mean grade in his class was a C.* Less than 5% got As.
There was some crazy arbitrary grading happening in that class. I remember answering a question on a test about delta G -- the kind where you have to draw the delta G for the reaction -- and I drew the entire reaction, and then put a box around the part that they were asking about in the question. And I got zero points out of 20 because I drew the whole reaction and not just the part in question. Even though I put a box around the relevant part. That's 10%, people.
The thing was, if you ever questioned something like this, the course administrator would yell at you, and then hand grade the REST of your test in a really harsh way so that you'd end up with a score that was lower than when you started. Because she hated grade grubbers too. And also pre-meds. (Though interestingly she didn't do that when I asked her about this question....)
It's enough to give any aspiring doctor an anxiety attack.
Anyway, not condoning the grade grubbing behavior in any way. Especially when you're a fellow in your specialty of choice and have already "made it" so to speak. Good thing you can't "grade grub" the NIH for grants. (Or can you? I'll have to look into that.) It's just a pattern of behavior that is reinforced in the medical education process, so I guess we shouldn't be surprised when we see it.
*Ass kissing is actually a requirement for success in any profession, but medical students like to think we're special and that our lives are EXTRA hard.
*You can get into med school with a C in O chem (one C only, however). I know someone who got into Hopkins with a C. But! She was perfect in every other way. :-P
It's funny, while we stand back and mock the fellow who was mad she got a 29/30, you have to understand where this behavior came from. Which can be summed up as follows:
DO YOU HAVE ANY IDEA HOW PERFECT YOUR GRADES HAVE TO BE TO GET INTO MEDICAL SCHOOL AT ALL?? MUCH LESS, A MEDICAL SCHOOL THAT WILL PERMIT YOU TO GO INTO YOUR SPECIALTY OF CHOICE??
Especially directly out of undergrad.
All I can say is, it really sucks to have this, "You need a 4.0...." hanging over your head, when you really want to focus on what is interesting to you. Including (the horror) your boyfriend or (double horror) having fun.
I remember when I did my post-bac, and was taking O-Chem with the undergrads at my alma mater, there was a rumor going around that the professor saw it as his job to determine which students got to go to medical school.
"That's weird," you might say, "You don't really need O-Chem at all in med school."
Ah friends. See, he didn't see it that way. HE felt that medical school should BE organic chemistry. And he felt that "smart" people were good at organic chemistry. And don't you want your doctor to be "smart?"
Also, the mean grade in his class was a C.* Less than 5% got As.
There was some crazy arbitrary grading happening in that class. I remember answering a question on a test about delta G -- the kind where you have to draw the delta G for the reaction -- and I drew the entire reaction, and then put a box around the part that they were asking about in the question. And I got zero points out of 20 because I drew the whole reaction and not just the part in question. Even though I put a box around the relevant part. That's 10%, people.
The thing was, if you ever questioned something like this, the course administrator would yell at you, and then hand grade the REST of your test in a really harsh way so that you'd end up with a score that was lower than when you started. Because she hated grade grubbers too. And also pre-meds. (Though interestingly she didn't do that when I asked her about this question....)
It's enough to give any aspiring doctor an anxiety attack.
Anyway, not condoning the grade grubbing behavior in any way. Especially when you're a fellow in your specialty of choice and have already "made it" so to speak. Good thing you can't "grade grub" the NIH for grants. (Or can you? I'll have to look into that.) It's just a pattern of behavior that is reinforced in the medical education process, so I guess we shouldn't be surprised when we see it.
*Ass kissing is actually a requirement for success in any profession, but medical students like to think we're special and that our lives are EXTRA hard.
*You can get into med school with a C in O chem (one C only, however). I know someone who got into Hopkins with a C. But! She was perfect in every other way. :-P
Saturday, August 08, 2009
Once a pre-med...... Always a pre-med
One of the TAs of my Stats class told us a story about a fellow who forgot she wasn't a pre-med anymore. Turns out she got a 29/30 on the final exam.
She wanted a 30/30.
He told her when she requested he change her grade, "You got this question COMPLETELY WRONG. It was clear you had no idea what you were doing. And I STILL gave you 1/2 credit. I should have given you nothing!"
She went and complained to the professor.
The professor caved.
How disappointing.
What I really want to know is, how do these people do it? I suppose if you grade-grubb often enough it must become second nature.
She wanted a 30/30.
He told her when she requested he change her grade, "You got this question COMPLETELY WRONG. It was clear you had no idea what you were doing. And I STILL gave you 1/2 credit. I should have given you nothing!"
She went and complained to the professor.
The professor caved.
How disappointing.
What I really want to know is, how do these people do it? I suppose if you grade-grubb often enough it must become second nature.
Version 100
Soon-to-be-ex-mentor: You realize this paper isn't going to be done in just a few iterations.
Me: Why do you think I change the version number every time I send it to you? I want to be able to say, "See version 86, and we're finally submitting."
Soon-to-be-ex-mentor: Haha. I don't think it will be that many versions.
Me (In head): At the rate we're going now, it will be.
Me: Why do you think I change the version number every time I send it to you? I want to be able to say, "See version 86, and we're finally submitting."
Soon-to-be-ex-mentor: Haha. I don't think it will be that many versions.
Me (In head): At the rate we're going now, it will be.
Friday, August 07, 2009
Duh.
After I did my first two weeks of medicine last year, I became convinced that all patients did cocaine. Very little I've seen since has caused this viewpoint to change.
It sometimes amazes me that things like this still surprise people.
Of COURSE Billy Mays did coke! How the heck do you think he acted so up all the time?
Sheesh.
It sometimes amazes me that things like this still surprise people.
Of COURSE Billy Mays did coke! How the heck do you think he acted so up all the time?
Sheesh.
Thursday, August 06, 2009
PF
At the retreat I talked with one of the other non-trads about Paul Farmer (you may recall I recently finished Mountains Beyond Mountains). She was someone who has done work in that area for her dissertation project, and who is familiar with his organization and international health aid.
Actually what I asked her if she thought he was an a**.
She had an interesting perspective.
She said that he's an interesting individual who probably really would be happiest living in Haiti caring for patients, but who has been so good at it and so unique and successful in his approach to caring these types of populations that he actually does more good to society giving speeches and running aid organizations. That it was kind of sad, actually. He'd not getting to do what he really loves.
Ironically, a lot of people want to be like the famous Paul Farmer. The one who gives speeches, gets grants, and travels around the world making global health policy. The famous one. People do what he says. They want that. What's ironic is that she felt that he didn't really care about his notoriety or fame. He just wanted to care for sick patients in Haiti.
She did think he may have been a little bit of a jerk, maybe, but that overall his life was actually kind of tragic in a way.
I supposed she was right. Tragic in a Happy Gilmore kind of way maybe.
Anyhow. I thought it was an interesting perspective.
Actually what I asked her if she thought he was an a**.
She had an interesting perspective.
She said that he's an interesting individual who probably really would be happiest living in Haiti caring for patients, but who has been so good at it and so unique and successful in his approach to caring these types of populations that he actually does more good to society giving speeches and running aid organizations. That it was kind of sad, actually. He'd not getting to do what he really loves.
Ironically, a lot of people want to be like the famous Paul Farmer. The one who gives speeches, gets grants, and travels around the world making global health policy. The famous one. People do what he says. They want that. What's ironic is that she felt that he didn't really care about his notoriety or fame. He just wanted to care for sick patients in Haiti.
She did think he may have been a little bit of a jerk, maybe, but that overall his life was actually kind of tragic in a way.
I supposed she was right. Tragic in a Happy Gilmore kind of way maybe.
Anyhow. I thought it was an interesting perspective.
Little Sib #2
Finally met little sib #2, and he turned out to be pretty awesome, actually. Really interesting guy, with a lot of intelligent things to say. I was even able to withhold judgment when I first met him and not be a bitch. You all would have been proud.
Actually, I met a whole bunch of other non-traditional MD-PhDs at our yearly retreat yesterday. I was the only one for three years, and aside from one who is graduating in 8 months and my Epi little sib (#1), I had never met any of the others. They actually have 4 new non-trads this year -- 2 anthro and 1 history and sociology of science, and 1 health services research, and each one of them seemed unpretentious, interesting, and very nice.
It makes me feel like more of a part of a community than I had felt previously. It's really nice!
Anyway, now I'm back to the ole grind. Work on paper. Work on stats. Swim. Sleep. Repeat. But only 19 more days until Italy! I am so excited.
Actually, I met a whole bunch of other non-traditional MD-PhDs at our yearly retreat yesterday. I was the only one for three years, and aside from one who is graduating in 8 months and my Epi little sib (#1), I had never met any of the others. They actually have 4 new non-trads this year -- 2 anthro and 1 history and sociology of science, and 1 health services research, and each one of them seemed unpretentious, interesting, and very nice.
It makes me feel like more of a part of a community than I had felt previously. It's really nice!
Anyway, now I'm back to the ole grind. Work on paper. Work on stats. Swim. Sleep. Repeat. But only 19 more days until Italy! I am so excited.
Tuesday, August 04, 2009
Visiting the In Laws
At the end of August, I'll be spending my last weeks of vacation visiting my in-laws.
In Italy.
Perk of having in-laws overseas = awesome vacation + requisite yearly visit all in one happy package.
In Italy.
Perk of having in-laws overseas = awesome vacation + requisite yearly visit all in one happy package.
The right amount of clutter
I am not a neat freak. My OCD husband can attest to this, and it is a testament to how much he loves me that he is able to live in the same house with me. Ok, this is a slight exaggeration. I am much cleaner now that I live with him.
One of the things that made me happiest about my move to academia is that people stoppednagging me incessantly about commenting on how messy my desk was. It was still full of clutter, mind you, but rather than seeing a piece of paper out of place as a symbol of laziness and filth (as is the case in the private sector), my clutter was actually tolerated, and people mostly left me alone.
It was at that point that I invented the phrase: An empty desk = An empty mind.
You can tell a lot about someone by how neat their desk is.
Doctors tend to have neat desks.
Doctors also tend to have obsessive compulsive personality disorder.
I remember the first mentor interview I had, I entered an IMMACULATE office. The potential mentor immediately started apologizing about how filthy it was.
I remember thinking, "I'm not sure this is going to work out...."
By contrast, I met up with an economist today.
His office was so messy that you could not even see the floor. There were papers every where. Not even stacked. EVERYWHERE. 18" deep, sometimes more. I commented on that it wasn't as messy as [grand puba health economist at the U of C]'s office (which was a lie). Potential mentor then complained that maintenance wouldn't let him stack papers on top of his cabinets because they were afraid that he would cause the building to collapse.
Yeah. They actually told him that.
The feng shui was just not happening for me in there either.
So I guess there are limits to how much clutter even I can tolerate.
One of the things that made me happiest about my move to academia is that people stopped
It was at that point that I invented the phrase: An empty desk = An empty mind.
You can tell a lot about someone by how neat their desk is.
Doctors tend to have neat desks.
Doctors also tend to have obsessive compulsive personality disorder.
I remember the first mentor interview I had, I entered an IMMACULATE office. The potential mentor immediately started apologizing about how filthy it was.
I remember thinking, "I'm not sure this is going to work out...."
By contrast, I met up with an economist today.
His office was so messy that you could not even see the floor. There were papers every where. Not even stacked. EVERYWHERE. 18" deep, sometimes more. I commented on that it wasn't as messy as [grand puba health economist at the U of C]'s office (which was a lie). Potential mentor then complained that maintenance wouldn't let him stack papers on top of his cabinets because they were afraid that he would cause the building to collapse.
Yeah. They actually told him that.
The feng shui was just not happening for me in there either.
So I guess there are limits to how much clutter even I can tolerate.
Monday, August 03, 2009
I win!
Do people in your MD-PhD program compete with each other over who is going to finish their program first? Over who has more papers? Whose name appears in Nature the most frequently?
Because they do in my program.
Adding fuel to this are the people who email around to our list-serv competi-congratulating each other on their recent publications.
It's not a freaking race, people!
In a way it's nice that I'm not getting my PhD in anything even remotely related to what they do. They have no yardstick with which to measure my success. No conversion chart for them to size themselves up against me. Mostly they just ignore me. If you can't defeat someone, what's the point of even talking to them, I suppose?
They size themselves up against my husband instead (who is a basic science person about 10 years further along in his career than they are). To them, he is a "failure" because he is not in academia. This is what they tell me if I ever dare to say something like, "The academic job market is difficult," or, "Very few grants get funded these days."
Without using that word, of course.
They aren't going to be "failures." They're all going to win Nobel Prizes.
Because they do in my program.
Adding fuel to this are the people who email around to our list-serv competi-congratulating each other on their recent publications.
It's not a freaking race, people!
In a way it's nice that I'm not getting my PhD in anything even remotely related to what they do. They have no yardstick with which to measure my success. No conversion chart for them to size themselves up against me. Mostly they just ignore me. If you can't defeat someone, what's the point of even talking to them, I suppose?
They size themselves up against my husband instead (who is a basic science person about 10 years further along in his career than they are). To them, he is a "failure" because he is not in academia. This is what they tell me if I ever dare to say something like, "The academic job market is difficult," or, "Very few grants get funded these days."
Without using that word, of course.
They aren't going to be "failures." They're all going to win Nobel Prizes.
Sunday, August 02, 2009
Help
I remember on my sub-i when I told my attending that I was going to PhD-land after that rotation. That I was getting a PhD in Epidemiology.
She looked at me thoughtfully for a moment.
"So, you're good at statistics," she said.
"Mmmmm... I will be eventually," I replied.
"Which statistical software do you use?"
Uh. Oh. She was getting ready to ask me for statistical help. I knew it. I told her I used STATA and a little bit of SAS.
Then came the battery of questions.
How do you get STATA? How much does it cost? Can you do my statistics for me for this project I'm doing, or at least give me help? Which stats package is best for what I'm trying to do?
On one hand, it was nice to speak to someone who appreciated what I was going to be studying (as in contrast with the other attending who said, "I don't see you as the research type," which I took as a compliment, well, since HE'S not the research type....). On the other hand? I was in the middle of killing myself on this rotation. I didn't have time to sleep, much less help my attending with her research project. And what if I didn't help her? What if I did, and her results didn't turn out the way she wanted them to? Would she take it out on me? Give me a bad grade? Say nasty things about me to other attendings?
It all seemed a little coercive, frankly.
I wonder if people who do basic science encounter this problem at all.
Perhaps in the future it will be useful to me in finding people to collaborate with, but as a medical student, with such a large power differential between me and the attending, it was attention that I didn't need or want. Maybe I'll feel differently about it when I actually know something. For now however, I need to learn how to deflect these things.
She looked at me thoughtfully for a moment.
"So, you're good at statistics," she said.
"Mmmmm... I will be eventually," I replied.
"Which statistical software do you use?"
Uh. Oh. She was getting ready to ask me for statistical help. I knew it. I told her I used STATA and a little bit of SAS.
Then came the battery of questions.
How do you get STATA? How much does it cost? Can you do my statistics for me for this project I'm doing, or at least give me help? Which stats package is best for what I'm trying to do?
On one hand, it was nice to speak to someone who appreciated what I was going to be studying (as in contrast with the other attending who said, "I don't see you as the research type," which I took as a compliment, well, since HE'S not the research type....). On the other hand? I was in the middle of killing myself on this rotation. I didn't have time to sleep, much less help my attending with her research project. And what if I didn't help her? What if I did, and her results didn't turn out the way she wanted them to? Would she take it out on me? Give me a bad grade? Say nasty things about me to other attendings?
It all seemed a little coercive, frankly.
I wonder if people who do basic science encounter this problem at all.
Perhaps in the future it will be useful to me in finding people to collaborate with, but as a medical student, with such a large power differential between me and the attending, it was attention that I didn't need or want. Maybe I'll feel differently about it when I actually know something. For now however, I need to learn how to deflect these things.
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