Stare into the (economic) abyss

Last Friday, I went to a lunch talk, run by my advisor, who always invites guest speakers to her biweekly shindigs. I attend religiously, partly for the free food (starving med student here) and partly for the opportunity to learn a little more about this crazy crazy world I belong to now.

Friday's speaker was a health administrator from a major hospital system out in the 'burbs. She was very well-prepared -- even had a massive long powerpoint handout -- and spoke quite articulately about what drew her into health administration.

I have to say, though, the content of her talk frightened me. Her job is essentially to track the physicians employed by [Major Hospital System Out In The 'Burbs] and call out the ones that are too expensive. I paraphrase: "Dr. Jones, as you can see in the spreadsheet on page 6, represents a net loss to hospital of $6,000 a month. This is because he treats Medicare patients like private payers."

Now, having spent hours on the phone with Medicaid my clerkship, I'm well aware that Medicaid is terrible insurance that pays for hardly anything. (I wasn't aware, till that talk, that Medicaid pays the hospital a lump-sum per patient/diagnosis rather than a per diem.) But the idea that one should treat Medicaid patients differently -- that is, employ a different, presumably lower, standard of care -- is morally repulsive to me. If the quality differential between antibiotic A and B does not make up for the fact that B is twice as expensive, then we should be prescribing A to both the illegal immigrant in 285-2 and Bill Gates over in the fancy-pants wing.

One other way that the administrator suggested lowering costs was by setting up follow-up appointments for whatever "other" (i.e. non-emergent) tests need to be run. Fair enough, but as one of my classmates pointed out, "What if the patient has a history of not showing up?" There's really no good answer to that, at least from the save-a-dime perspective.*

The rationale for all this cost-cutting is that the hospital can invest in better technology, etc. Great. I just don't see why the poor patients have to get shafted while the private ones sit in rooms fancier than most hotels. (I saw that on the tour at one of the schools I interviewed at. Kind of a shock, to see full-length mahogany mirrors and a window-seat/pullout bed for guests, and a wardrobe in a hospital room.)

This reminds me of a modern definition of chivalry I heard at some point. Treat all men as gentlemen, and all women as ladies.

Unfortunately, I'm not idealistic enough to believe (though I hope) that the system of health care in this country is going to change overnight, or even by the time I graduate. I don't even know if universal health care is a panacea -- probably not. Either way, it's going to be a long slough through politics and government (which are not the same thing, as Yes Minister taught me). But it's something that I fervently believe that everyone in medicine does need to think about, and hopefully do something about.

*I'd just like to point out that I'm probably one of the most frugal people I know. I detest waste of any sort (monetary, mental, or recyclables). I once went into Filene's and was shocked at the shoe prices; that's how frugal I am. But I also happen to think that the dude at the bagel cart deserves the same quality of care as the dude at the White House. Yeah, yeah, filthy pinko commie.

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Now playing: Alexander Scriabin - Etude in G sharp minor, Op. 8, No. 9
via FoxyTunes

Last clerkship

Part of the requirements for first-year medical students at my school is a weekly clerkship, where you interview patients under the supervision of a health care provider (usually a physician, but sometimes an NP, nutritionist, etc -- mine was a social worker). Today was the last day of fall clerkship and hence the last day until February where I get to go to the hospital, sit down with a patient, and just chat.

I met lots of different people during my clerkship -- mostly older adults who needed some sort of post-hospital care, such as home attendants, hospice, etc. I certainly feel a lot more comfortable interviewing now than I did in August, but at the same time I'm very aware that clerkship is unique and not much like the Real Practice of Medicine. For instance, today I spoke with a patient for almost an hour. That kind of thing doesn't happen in clinic.

There was one thing, though. Some time ago, I spoke with a woman who had been diagnosed with a particularly aggressive cancer, hence the SW referral. As I asked her about family, she seemed kind of vague and forgetful of her kids' names, etc. Jerking her head around, not really tracking, very edgy. I mentioned this to the SW and the resident following her case. Today, the SW told me that the doctors had said she was fine (that's relative, I guess), sent her home, and a few days later her daughter-in-law brought her back in, saying she had been forgetting to take her meds. Several tests later, they decided that cancer traveled up to her brain.

As I was sitting there stunned and depressed and remembering my grandfather's struggle with cancer that ended up in his brain, the SW congratulated me on my "insight." Huh?

I guess finding something the teachers missed is every student's dream, but my inclinations that way always leaned more towards "Discovering that some basic mathematical theorem is wrong and watching the entire structure of mathematics come crashing down." (What can I say, I hate math.)

When the "thing" that people missed involves life/death/pain, congratulations are just not in order. I'm glad they caught it and all, but I can't help feeling depressed on behalf of the family, and on behalf of my childhood self.

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Now playing: Benzos - Teach Me
via FoxyTunes

Anatomy syllabus

"This complex movement involves rotation in the suprameniscal compartment about a transverse axis through the femoral condyles and a concomitant anterior gliding movement in the inframeniscal compartment as that transverse axis moves anteriorly."

Why, anatomy? Why must you be so ... vocabularied? And lacking in pictures?

On the plus side, between the snow yesterday and the date -- December already! -- I've started playing Christmas music.

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Now playing: Danny Elfman - Jack's Lament (from the Nightmare Before Christmas)
via FoxyTunes

Tom, Dick, ANd Harry

Do you know what's pretty cool? When you pull on the extensor hallucis longus, the big toe actually moves. Visibly. My entire anatomy group freaked out.

It was probably the highlight of anatomy lab thus far. Aside from the Halloween factor, it was the first moment since we opened the left ventricle that anatomy actually made sense.

Fear not, sweet Reader

I'm still here, albeit swamped with work. I decided to take a real break for Thanksgiving -- studied a bit on the bus ride home but spent four days being a mental vegetable on the sofa -- so I'm now playing catch-up.

I realized the other day that in 3.5 years (give or take a couple months) I'll be finished with my 21 years of continuous schooling ... and earning less per hour than I did the summer I was 17. That's slightly depressing. To quote Scarlett O'Hara, I'll think about that tomorrow.

Perspective

I was going to complain about my day-long fast (too busy to grab anything to eat between 8 and 6), but then I checked my email and learned that someone I know -- the most upbeat guy I've ever met -- has cancer. We knew he was sick because he had been away for a few weeks, but then he returned, bald and as jovial as ever, so I assumed that whatever was wrong had been fixed.

I guess you can't fix all the people, all the time.

This is how we socialize nowadays:

(9:08:14 AM) Rebecca: i need to go shower but i wil talk to you later!!
(9:08:18 AM) Rebecca: where are you studying today?
(9:08:31 AM) Me: probably [the library]
(9:08:37 AM) Me: lower level

I really dislike Monday exams, because it means we don't get weekends. The weekend before is spent cramming (see above) and the weekend after is spent catching up with all the classes you ignored in the pre- and post-exam madness.

Yesterday, I interviewed two real, live patients all on my own.

And when I say "on my own," I mean of course, with an interpreter. My Spanish, though adequate, is not up to snuff when dealing with illness or numbers, which can make it difficult for all concerned. English-speaking patients are a rarity.

Anyway, I ended up filling out the Social Work Assessment on both these patients, one of whom was pretty stable and ready to be discharged, and the other of whom was in a bad state about her cancer diagnosis. She spoke really fast -- the interpreter had to ask her to slow down -- and she kept jerking her head around like a hunted animal. I felt really terrible for her.

And the worst part was, I couldn't sit down with her and help her feel better. Partially there was the language barrier, but more than that, what does one even say to a person whose chronic back pain turned out to be advanced lymphoma?

After returning from the hospital, I went to a reading on gendered illness and women's experiences with illness. I'm still not convinced that there is a distinctly feminine component to the experience of illness. To be honest, the biggest connection I can see is the loss of power/autonomy/agency that often accompanies illness and the loss of power/autonomy/agency that often accompanies the traditional barriers against women. Pretty weak.

Still, the reading was interesting and moving, and it emphasized the use of narrative as a weapon against isolation and marginalization. And there was food.

In which our heroine goes to OR

I was in the OR today, shadowing anesthesiology residents. (Cheesy title, I know.) It was really fantastic -- one showed me how to put in an IV and another let me watch him give a thoracic epidural for a double lung transplant (!) and afterwards explained the differences between thoracic and lumbar epidurals -- what to watch out for, etc. That was particularly exciting because we just did the vertebral column and spinal cord in anatomy. Who would have thought that all those spinal ligaments are actually clinically relevant? I can tell you that I remember them a lot better now. After weeks in the classroom, it's always really exciting to see Medicine in Action.

And then I helped the anesthesiologist set up for an operation and stayed until the pt went under. I thought I wouldn't really like the OR, but it's actually a cool place. There is definitely a vibe of Go Go Gadget O2 Sat! Still leaning towards the medicine side of the med-surg division, though. We do 15 weeks of surgery rotations here (5 gen surg, 10 surg subspecialties), so I'm sure I'll get all the exposure I need in 3rd year. But it's nice to get a little flavor early.

Mostly, I was impressed at how willing the residents were to have me and my classmate there. I'm sure they must be exhausted and everything, and we were these two happy, well-rested first-years bouncing in and being all naive. They all had great things to say about the program, too. It's gratifying to know that not all residencies have malignant "beat you and eat you" mindsets.

Transection

I didn't really have much of an emotional problem in anatomy lab, until today. Today we were told to transect our cadavers just below the rib cage and prop their lower bodies up on goalposts. The rationale for this was so that we could have a good view of the perineal area.

Bullshit.

Gynecologists can get a good view of the perineal area without needing to saw their patients in half. (Yes. We had to use saws to get through the vertebral column.) Ever heard of stirrups? They aren't comfortable, but they are a damn sight better than what we had to do today.

I am extremely upset about this whole situation. Even the first day, when we uncovered the shrouds and looked at our cadaver's face, was not quite so bad. We could say to each other, It's ok -- she donated her body. We'll learn from her." That belief helped us with our first cuts.

If this were the only way to learn, I would rationalize it. But it's not.

Today, there was no pedagogical reason for what we did in the name of "learning." I feel physically dirty for having violated a human body. I feel like a medieval medical student, grave-robbing cadavers, knowing what I am doing goes against every fiber of decency in myself -- and doing it anyway.

Transections seems so innocuous on paper. And yet, looking around the room and seeing red-bagged feet dangling in the air -- it was like something from Dante's Inferno. It was disrespectful, had no academic value, and I am disgusted at myself for having taken part.