Tuesday, December 21, 2010

Work & Money

Being a physician is a strange thing.  One of my patients compared it to a religious order.  The strangeness revolves around being paid for our work.  While this is the subject of debate on the national level, I would like to look at it from a different perspective--the resident.  The Internal medicine resident is paid a salary, low compared to our years of schooling, for our time and training.  An interesting phenomenon arises, which is payment does not change based on work.  What does this mean?  Some weeks I push the limits of legal and work 80 hours, with many of those hours consecutive (up to 30) and overnight.  And I receive my weekly check.  Other weeks, I am in clinics from 9-5 for 4 and half days a week, never on the weekend.  And I receive my weekly check.  Effectively, residency has separated the natural relationship between work and income.  I am paid the same no matter how much, or little I work.  My friends ask questions that seem silly to me, such as "Do you get paid more for overnights, or weekends, or overtime?"  No I tell them, I barely get paid at all. 

Take in contrast moonlighting--working short medical shifts for pay.  Last week I worked overnight for 13 hours with 3 admissions.  Those well compensated 13 hours were more than my weekly salary.  And for every extra admission and every extra hour, I was paid.  Very different feeling.   My desire to be productive and do things was much higher, as I am paid for them.

This mental separation of work and money pervades health care, and puts us at risk to be taken advantage of by our money-comfortable colleagues in other industries.  Politics, health care, manufacturers are all very comfortable with work and money, profit and loss.  And we are not, and yet we complain. 

Residency is funded by the government, paid to our institutions who then pay us in turn.  The money comes no matter how productive we are, as long as we have worked on a given day.  Well, that changes too....

Monday, November 1, 2010

Hospital Medicine and the details of revolution

My next rotation after the CCU (see previous post(s)) is something called "The Hospitalist Elective."  Although this is a bit of an enigma, I am quite excited for the 3 weeks course.  First off, my fellow residents and our faculty for the course are all top notch, making it a fun experience.  Second, Hospital Medicine is the most recent (successful) revolution in Internal Medicine, and there is much to be learned from their ascent.  One specific area we touched on today in the now ~15 year history of the field, was the resentment and resistance from entrenched primary care physicians and other specialists that felt that their profession and their patients' care may suffer from hospitalists. 

1.  Suffering patient care.  Perhaps this is a radical statement, perhaps it is not, but patient care is not that great in the United States.  Individual physicians are very dedicated to patients, but the systems set up with perverse incentives, government and employer interference, and many many third (and fourth, and fifth) parties really muck up patient care.  Despite all of these non-physician reasons, there is rarely a change to medical practice that does not result in affected but not participating physicians that the most recent change will harm patient care.  This leads more truly to complaint number 2.

2. Money.  Medicine is currently set up to be a zero sum game, with a fixed pie taken from the American tax payer in the form of Medicare/Medicaid and redistributed back to physicians via a centrally planned scale known as the RBRVS (Resources-based Relative Value Scale). This mentality of a fixed pie, abandoned in most the free world with the fall of mercantilism in the 1800s, is a direct roadblock to any change.  Any new physician action necessarily decreases the portion of the pie dedicated to other physicians, and therefore leads to backlash.  It is as though we have designed a perfect non-changing system through our finance.  There are at least two basic assumptions to challenge here. 

The first, is that there is actually ought to be a fixed pie of health care.  In the rest of the free market world, value and money are created with new ideas, technologies, and mutual exchange.  There is more total money in the world (inflation aside) because there is more stuff in the world.  The same COULD be true for medicine if we departed from our centrally planned failure of a payments system.

The second is the notion that physicians ought to consider the opinion of other blocks of physicians.  While I do not directly seek to anger or enrage my colleagues, I am unsure how important buy in of potential competitors really is?  Southwest doesn't care if United is on board with their routes and rates, they just fly.  In the same way, why do we really care about the opinions of physician groups that complain we are taking their money?  What made it their money in the first place?  Did they earn by best serving their patients, or by just serving as many patients in as many ways as possible?  Shouldn't we really be going after buy in from our patients.... our customers?

I was told that one of the founders of the Society for Hospital Medicine was booed off stage when he presented his ideas at my "home" organization, the Society of General Internal Medicine... now a much smaller organization that the Society it failed to spawn.  On hearing this I smiled, because if you aren't pissing anybody off, are you really making a difference?

Out of the CCU!

I am out of the CCU (Coronary Intensive Care Unit) which means my nights will now be spent at home again.  A welcome change, and hopefully a boon to my writing.  Not to tempt fate, but I have no more *scheduled overnight call remaining in my residency.

Wednesday, October 20, 2010

Public Health Survey

This evening I received a call from the Boston Department of Public Health, conducting a survey about my level of healthiness.  Well, to be honest, this is the second call, but the last one was post-call mid afternoon on a weekend, so I got off the phone quickly.  Understanding my civic duty as a health care and public health professional (and I knew they would keep calling), I undertook the litany of questioning. 

There were approximately 50 questions in topics moving in an orderly progression from demographics to general health to diet (vegetables, fruits and soda), exercise, mood/depression & social support, workplace smoking, walking & biking, neighborhood safety and availability of healthy food, smoking and program awareness.  Notably absent were alcohol related questions.  There were probably more questions if I had answered yes, but that is only conjecture.  (No, I have never smoked a cigar, cigarillo or mini cigar that looks like a cigarette, not even a few puffs.  No, I have not served active duty in the military).

The gentleman calling me had no idea that I was a health professional, and so some of the questions were awkward to answer:  "How often have you felt nervous/jittery/hopeless in the last 30 days?"  I am in the ICU, so the answer is sometimes.  "Has a health professional asked you about smoking in the past 30 days?"  Yes, because my colleagues and some patients are health professionals.

All in all it was an interesting but quite tedious experience.  Given my experience in public health, the data from this survey will inevitably be used as evidence to increase "awareness" funding to various health related programs.  I find this to be unfortunate, because the libertarian in me still thinks that if a program works, it should be so popular as to be self-sustaining and not require an ever enlarging "awareness" budget, culled from the earnings of the citizens it purports to help, but do not voluntarily give over their money.  But alas....

Sunday, October 17, 2010

In Support of Overnight call

One of the greatest fictions in medicine (if you look at how we staff) is that somehow people are less sick on the nights or weekends.  At the same time, continued political pressure without good evidence to support is shortening resident work hours, now to the point of ludicrous 16 hour shifts.  While this seems long, a 30 hour shift requires 1 commute to work each way, and 1 sign-in and sign-out, a 16 hour shift doubles these requirements. Depending on how far away one lives from the hospital, this can be hours out of each day wasted in minimally productive activities that are neither educational or providing a service to patients.  The mentality of a resident on overnight call is different than one going home that day.  When we are trying to get out, anything and everything that happens to delay our exit (and eventual return) to the hospital increases stress.  Our goal becomes to provide the care that we need to provide so we can finish our day.  There is less time to delve into interesting findings, spend time with patients, and think. Education time gets squashed out.  When on overnight call, we know we aren't going anywhere.  This produces a relaxed atmosphere.  Rather than the always intense pace of a normal day with an uncertain end, intensity varies.  There is time to teach, learn and discuss. It is frankly more fun to do the job all the way and stay overnight, than do it almost all the way, but just as stressed and tired, but without the benefit that comes at the cost of the few extra hours.

But most importantly, as one of my great attendings once said, all of the good things happen at night.  While on call this past week I was able to spend several hours observing an attempt to *cure* a stroke by direct removal of clot in the brain... through a catheter placed in the groin.  I had only heard/read about this before, but I got to experience every minute of it.  This took place between 9pm and 2am.  If I had the choice of whether or not to stay, knowing a full day was ahead of me, would I?  Was it worth it?  These are questions each of us have to answer for ourselves, but I am certain I would not have had this amazing experience if not on overnight. 

The decision to continually and arbitrarily limit work hours for all specialities of medicine equally, without individual program flexibility is inherently a political one.  The root decisions all stem from the tragic loss of a politically connected young woman in New York.  There is not nor has there ever been evidence that spending less time with patients as a result of limited work hours would have saved that girl's life.  And yet we keep moving in that direction, for fear that if we, as a profession, do not appear to be regulating ourselves, that some worse bogeyman of the government will do it for us.  I ask if we really have self-determination if we regulate ourselves to appease regulators waiting in the wings.  And I ask if it does anybody- patients, residents, any good.

There is another way to ensure that residents have fair and equitable hours in which to work, learn and live... but that is another post!

Thursday, October 14, 2010

On Medicine Shortages

We received an interesting e-mail yesterday that there is a nationwide shortage of a medicine called furosemide, or Lasix (no relation to the eye-surgery).  Without going to much into detail, Lasix is a mainstay generic/old medication in the treatment of any condition in which a patient has too much fluid and we'd like to get it off of them.  Conditions such as heart failure, kidney failure and liver failure are commonly treated with Lasix.  More acutely, Lasix is a mainstay drug for patients on cardiology or intensive care services.  It just so happens that I am spending this month in the Coronary intensive Care Unit, hereinafter referred to as CCU.  In the CCU, we use Lasix commonly and on nearly every patient.  There are other medications that work similarly or accomplish the same thing, but rarely at such nice dosing intervals or at low cost. 

We received the following information via email:
furosemide 40mg is $0.30

bumetanide 1mg is $0.68
Torsemide 20mg IV is $6.55
Ethacrynic acid 50mg IV is $511.58

These are all per dose costs.  Note that Lasix, the least expensive, is on shortage.  How could this have happened?  According to a Bulletin from the American Society of Health-System Pharmacists, there is no available reason for the shortage.  According to the FDA it is due variously to manufacturing delays and increased demand. So no factory burnt down, or was contaminated, or at least not to public knowledge.  It does appear that one manufacturer will no longer be making the drug.  And therein lies the issue.

Why does Lasix cost $0.30 per dose?  It would seem as though this price is too low.  In a reasonably free market, when supply diminishes and demand remains constant, suppliers will raise prices and demanders will either pay the higher prices or substitute where available.  Our hospital plans to substitute. However, when prices are not allowed to rise to signal the market that supply is decreasing (because of government price controls or regulation) shortages just happen, without the clear warning that a price increase signals.  I will not pretend to justify the logic behind price controls, but I will clearly present such controls as a cause of shortages.  Shortages can only happen in the presence of government intervention....  See the Philippines as a case study.  We do not have direct price controls in the US, but in order to participate in Medicaid maximum drug prices must be adhered to.  Even if Lasix is not price controlled, the decreased price of other medicines made by the same manufacturer may force them to scrap production of margin generics.  Combined with exceedingly high barriers to entry for pharmaceutical manufacturers and it is surprising that there not more shortages.

I return now to the hospital where I am curious as to how this will play out.  We are told that we have ample supply for several weeks and that more is coming to replenish our supply.  The question is, will we physicians prescribe as usual, not believing the shortage, or will we change our behavior.  It is a classic issue within medical training of individual patient vs. systemic thinking.  My prediction is that nothing will change unless pharmacy begins to dictate our prescribing habits, which will cause mild grumbling but no real outburst from the physicians.  Then we will return to prescribing as regular once the shortages ends.

Tuesday, October 12, 2010

4 Stages of Creativity

This weekend I had the pleasure of travelling home to NJ for my brother's birthday.  On a walk through the woods Sunday morning with my wife, my father and two family friends, (one of whom has become clinically addicted to wood turning) and the topic of creativity came up.   Mostly this was a way to get our wood turning friend to shut up about wood turning for just a few minutes.  Given my designs as a medical entrepreneur, the creative process is something that I have thought and read on greatly. It appears to me that creativity comes in 4 stages:

1.  Copying.  Everyone has to start somewhere.  We all learn our first skills by copying those around us.  It is frowned upon to submit your copied work as original, but copying itself allows us to reverse engineer the creative process.  Even though we know the "solution" that we are copying, the manner in which we arrive begins to define a personal style.  I started writing by copying sentences painfully out of grammar books.  Any great band starts as a cover band.

2. Mixing.  Once we have copied enough different people, we begin to put granular elements of their style together.  Mixing is a crude form of creation, and the borrowed components are often easy to identify. 

3. Amalgamation.  The difference between mixing and amalgamation is the easy recognition of the underlying parts.  Mixed copied styles are easy to sort out, but amalgamated styles are subtle.  It is likely that only experts could tease out the components beneath, but there may not be true creation.  It is also here that the line between plagiarism and original work is blurred.

4. Creation.  Perhaps a semantic argument, but true creation occurs when the artist develops something new and novel.  It is not just a mixing or rearranging of underlying parts, but rather a new form that has not been seen before.  Notice that our artist has been producing for quite some time before this phase, and most people fail to create just because they give up to soon.  So don't give up. 

In the case of our wood turner, he is convinced that he has no talent but just works really hard, I really cannot see the difference.

A fair disclaimer, it is possible that the thoughts within this post are copied, mixed, or amalgamated from others, not actually created.  Special thanks to Malcolm Gladwell and Marc Andressen for their writing on the matter that has inspired this piece.  And thanks to Alan... when am I getting that pen?

10/23/2010-- The pen arrived, and it is fantastic!
Thanks Alan!

Thursday, September 30, 2010

Center for Innovation

I am sitting in an interesting talk given by the Chief Medical Officer of the Center for Medicare and Medicaid Services, Barry Straube. The talk is an interesting one, with his vision for healthcare and government an optimistic one. This organization has been funded 10 billion dollars over 10 years, and I am excited to see what innovation they help foster.

Sunday, September 19, 2010

Back to work...

It has been about 3 weeks since my previous post.  So much has passed since then-- my time on the road for week, my sister-in-law's wedding in Lake Placid, and our wonderful trip to Iceland (more to follow, I promise).  Having just returned from a few days back home for the holidays it is quite unsettling to know that good old fashion honest work starts up again tomorrow.  I have really enjoyed the travel, time on the road, meeting new people that do the same things that I do differently.  I have also let some of the defense mechanisms that get me through residency lie dormant, and I am loathe to reactivate them.  Oh well, onward we go!

Tuesday, August 24, 2010

Galena, IL

While at family beer and liquor in East Dubuque, IL I received a recommendation via voicemail to head to Galena, IL 20 miles down the road. What a great idea! Galena is an old Lead mining town with an old fashioned main street. I am sitting now in e new but classy Rendezvous coffee bar (with free wifi). I will attach pictures once I am home, but this place is very cool. Charcoal drawings courtesy of the owner adorn the wall, old style furniture, and expensive But tasty coffee. Dinner lies ahead!


One of the oddities of this trip is an opportunity to dine alone. Given a challenge I received recently to "eat, sleep, or do something significant" in all 50 states, I am heading to Wisconsin for dinner. I have family in Madison, but that is a bit far for the evening. Instead, at the recommendation of the nurses at the clinic, I set my sights on Potosi. That's
Right, Potosi, Wisconsin, population around 700 and home of the Old Potosi brewery.

The dinner was delicious,and I recommend the Beglian WIT to anyone travelling through. This is two nights in a rowof dining outside, and two nights of swatting flies. The country drives are beautiful... At least in the summer.

Journal from the road 2, Iowa

First disclaimer.. There will be three posts in a row dated today, but I promise they are representative of the last few days. Also, blame all typos on the iPad keyboard with its no feedback keyboard.

So I am in Iowa. This is the result of a negotiation with a mentor and a great opportunity. As you may have figured out by now, I endeavor to disrupt and improve primary care through redesign and entrepreneurship. I am here in Dubuque, IA, the city by the river, to spend time studying the practice of a known innovator. Look for the summary piece in the SGIM Forum October edition. While not at the clinic, I have had some time to explore.

On arrival, my lovely hosts picked me up at the airport in their sweet Audi convertible and we drove first to their home with a great view of the hills and onto downtown where I will be staying. We stopped for dinner at the Star brewery on the Mississippi river for dinner. The river is a bit different all the way up here. I am tempted to send a message in a bottle to my old home at the other end of it.

Chris and Tom are wonderful hosts, showing me around and sharing the history of this storied town, which they themselves moved to from Wisconsin. For those not up on their Hawkeye geography, Dubuque is nestled right up against Wisco and Illinois. Tonight I sleep in my temporary home, borrowed from a kind friend of a friend.

Wednesday, August 18, 2010

Journal from the road (train)

My residency has kindly granted me a few weeks time dedicated to my Area of Concentration (AOC), usually time to do research or another scholarly pursuit. As usual, my interests are a bit different than everyone else, and so I have been using this time to travel and learn from a physician-entrepreneur in the world of primary care redesign. We have met with venture capitalists, union leadership, large corporations and we are currently on the way to meet with a health plan (hence the train). All of it is fascinating.

A recurring theme of all of these meetings is that health care is a big problem, redesigning primary care is the start of the solution, and there is now interest in being a first mover.

More from the road!

Thursday, August 12, 2010

On medical education

As part of the traveling during my AOC research time I have had a chance to continue/catch up on some reading. In this case, in one of the final chapters of The Innovator's Prescription, I can across this gem:

Two different faculty groups have emerged at most medical schools... Members of e science faculty teach the first two years of science courses, and typically conduct leading edge, NIH-funded research in the fields in which they teach. The clinical faculty members teach the bedside art of diagnosing and treating patients in the third and fourth years. Because the faculty are different, and because of student limitations as to how well they can retain what they learn, some of what is taught in the first two years, though deemed important by the faculty, is seldom if ever used in clinical practice... In other words, the first two years in these medical schools are not and efficient experience.

I am proud to have attended a medical school that recognized this basic issue and worked like crazy, even through certain destruction from natural disaster to improve this model.

Schutzblog from the iPad

Quite an impressive little device, especially considering that it will help accomplish what no one or thing ever has before... Schutzbank doing research! Any word on an OS4 release date? I am already finding needs to multitask.

Thursday, July 15, 2010

Like what you read? Want more?

May I kindly direct you to some of my more formal (read: edited) work through the Society of General Internal Medicine (SGIM) Forum.  My articles appear in October & November of 2009, February, May & June 2010.

Prescient Dreams

While the clinic day officially ends at 5:30 (or 6 or 7), it is not quite as easy to let go of the day.  A mix of feelings follow me home, anxiety, hope, frustration, concern and sometimes good old fashion curiousity.  Most recently, I saw a wonderful gentleman who reported that he was feeling vaguely unwell, but similar to a time when he had a blood & heart valve infection in the past.  He looked well, so we drew appropriate bloodwork (probably more extensive than normal given his history) and sent him home.  But apparently my mind did not. 

That night, I was plagued by a recurring dream of a heart, isolated from the body, floating in space.  (Disclaimer, I have recently been playing Super Mario Galaxy 2 which features many isolated planets, floating in space).  Anyway, in this dream, one of the valves was clearly off/infected, and was the focus of my attention.  I awoke several times feeling uneasy, unable to shake the dream. 

The next morning, after this poor night of sleep, I received an early morning page that the patient did indeed have positive blood cultures, and after admitting him to the hospital, a formal diagnosis of endocarditis It seems my brain was working overtime, trying to warn me of the obvious. Medical residents, working even as we sleep... work hours violation?

Tuesday, July 13, 2010

The Most Poetic Description of Clinic I Have Ever Heard...

From Ben Chesuk & Eric Holmboe's How Teams Work- Or Don't- In Primary Care: A Field Study On Internal Medicine Practices, Appearing in Health Affairs, May 2010.

"The physicians we observed experienced a workday as a series of nonstop, one-on-one interactions with a
stream of patients, with little or no interaction with others on the team. Physicians at all three practices worked within a bubble of frantic activity, right from the start." 

That's about right. 

Friday, July 9, 2010

Incompetent or Evil?

Often times in residency I have had the experience of being the recipient of a patient from another care team.  Outside or inside hospital transfer, Emergency Room sign out, ICU admission for worsening status.  A common sentiment amongst my colleagues on the medical and nursing side, is that patients are never quite as billed, usually sicker/more complex.  Now, I acknowledge the inherent bias in being on the receiving end--simple/non-ill patients are rarely transferred.  We only see the tough cases, and that is one of the benefits of being a tertiary referral center. 

But that is not my focus here.  When a transferring team sends us information ahead of a patient that does not match the patient's history (allowing for reasonable status changes in transit), the failure lies along an axis that runs between incompetent and evil.  On the one hand, maybe they are overworked, poor systemic support, just came on shift, have a different perspective or information, have not had a chance to look at the whole picture, etc.  On the other hand, maybe they just want a difficult (medically or socially) patient transferred quickly, no questions asked and will say or do whatever is necessary within reason to accomplish the transfer. 

Incompetent or Evil, that is the axis.  I would also argue that lazy is on that axis, right about at the center of it.  A little incompetent, a little evil, but the wrong information story told no matter the reason.

Glad to be done with night float...

Thursday, June 24, 2010

Teaching kids to be Entrepreneurs

An amazing TED Talk (If you don't know what that means, it is time to find out). 

Tuesday, June 22, 2010

Cape Air- Making customer service easy

So for those of you that know me... I can be an idiot.  It turns out that I booked my flights and my wife's return flight from her sister's wedding in Lake Placid... on the wrong days.  Entirely wrong.  Her outbound flight was correct, as she is not an idiot.  I called Cape Air, was put on the phone with Andrea in about 2 minutes.  Approximately 2-3 minutes later, courteous as can be, Andrea had us switched on to the proper flights. No charge, no hassle. 

Hey big airlines... pay attention as Cape Air just created an enthusiastic customer for life!

Mocha Hagotdi it is!

Due to Hurricane Earl, my flight was cancelled and I had to drive from Boston to Lake Placid.  Which I did with the assistance of Starbuck's new 31 oz Iced Coffee....  Cape Air offered to refund my flights and my wife's return flight but I have not yet seen that refund.  I e-mailed them yesterday so we will see how this goes.

--Update 2
I never received a reply from Cape Air, so I e-mailed Tricia, the person who first prompted me to start this entry.  She called today and then followed up with an email refunding the whole thing.  Go Cape Air!

What's Really Wrong with Healthcare

An extremely well reasoned piece, courtesy of Lew Rockwell.  http://www.lewrockwell.com/orig11/boyapati1.1.1.html

Tuesday, June 8, 2010

Approach to Medical School Interviewing

I wrote this awhile back for a colleague's daughter, built on my experience and mentorship advice I've received..  I'd love to get feedback.

Approach to Medical School Interviewing
The first thing I would do is pick up a copy of "How to Win Friends and Influence People" by Dale Carnegie. While the title sounds a bit manipulative, the book is actually just a primer/reminder on how to be a good person and communicate effectively. It is a bit old (some of the stories are odd and almost all about men) but excellent stuff.

With regards to med school & interviewing, each institution will have a strange mix of recruitment and screening. Remember, they have plenty of applicants to their program and do not need you specifically. They do not even *need* to fill their class. With that in mind, it is your job to get across why you are special (you would be or they would not have interviewed you) while still remaining fairly conservative in your dress and manner.

Each day is fairly similar (and becomes tedious after enough of them).

7ish: Meet in the morning for mediocre coffee/pastries. If you do not eat these things, that is breakfast so plan ahead. This is the time when other interviewees will begin to psyche you out, intentionally or otherwise. I would spend your time learning about your colleagues and asking questions because:
1. No one actually cares what you have to say, they want your spot
2. People like people that ask them about themselves and you can break tension in the room

7:30ish-10:30ish: The dog and pony show begin. They will gather all of you to a seated position and some number of people, hopefully some medical students along the way, will come out and talk to you about why their program is great. They will hide logistical information in there about living, financial aid, class statistics, etc. They will ask if you will have any questions. You won't. Someone will have like 50. Again, don't be intimidated AND don't be annoyed.

10:30-noon  or 1-3:
2 choices here, flip flopping by institution
1. Interview time. You will have X interviews in Y places and plenty of time to get to them. You will not know your interviewer other than their name in your folder in the morning. (Protip: you can leave the folder in the main room and just take the interviewer paper & map, everything else is not essential and you look cooler without a goofy folder in your hands for the first handshake). This is just a thought, but if you have smartphone access, googling your interviewer may be helpful. Can't say, we didn't have 'em. I will talk about interviews later.

2. Tour time/Student time: The tour is a great way to learn about the institution, not because of the facilities, but because of how many students pass your tour, and how they interact with your group. Tulane's facilities looked like a 1950s high school pre- Katrina. But we could not go anywhere without students coming by, high-fiving the tour guide, joking with us and telling us how great it is. This kind of spirit cannot be faked and will be central to your experience for the next 4 years. Talk to the tour guide, other students, ask to see the lounge/cafeteria/starbucks where students go in between class. Again, you will haunt the same places and you want to know that there is love there.

With regards to interviews:
Stay calm and gauge your interviewer. The more they talk, the better you are doing (How to win friends...). Also, end every answer to their questions with a question that ties in with them/their research/the program so that you can keep them talking. Most interviewers decide in the first 30 seconds (or before) if they like you or not, and if they do, they will recruit you. If they do not, or are awkward themselves (rare in an interviewer but not impossible), they will ask you a bunch of stitled questions with no good answers:

1. Why do you want to be a doctor: Now, if 4 years of great work at college, pre-med, MCAT, applications are not enough to convince them that you want to do this, I am sure that your 4 minute answer to this question will suffice. Everybody wants to work with people/help them and incorporate science in that effort. That's because that's what medicine is. Just because it is common, does not make it a bad answer. Think a little about this one, but hope that you don't get asked this question because it is silly. End with a... "How did you get involved in medicine..." unless they cut you off with:

2. What is your greatest weakness? A terrible question. I was taught to answer this in the following manner. Talk about something that you have been improving, not an actually weakness or worse, a fake weakness like "working too hard." "Throughout four years of college I have really been working on my.....(research presentations). It is such an important skill that I want to really excel at it." Done. DON'T end this one with a question, just move on.

3. Tell me about yourself. You will be attempted to start with name rank and serial number. Try and start mid story. "Growing up in Boston in a medical family I...." "And for the last few years I have been working on..." Etc. Great time to ask them their story.

4. What kind of doctor do you want to be? Unless you know, it is OK to say you don't (you don't anyway). Great time to tell them what you are thinking, but then to launch into how they got into their field. Very useful both practically and for them-talking purposes.

5. Any questions for me? Good luck on this one, never was good at overcoming question-constipation.

GET BUSINESS CARDS (or contact info)

12:00-1:00 Lunch. Pray for students. If they keep you from students (that are too busy for lunch!?!?!) consider not going to that institution. Ask students everything, living, going out, groceries, study environments, friends, things they do at school, away from school. This is your chance to get the information you really need.

3:00pm- End of day. Cue the Dean of admissions or appointed representative. This is the time for the final pitch on their end. You still won't have any questions. Thank someone in person, and if you have a specific interest or anywhere along the way you met someone, see about future meetings.

After the day: The topic of thank you notes is always sticky.
1. Thank you notes, handwritten: Classy, formal (get good stationery) and never unappreciated, but not opportunity for ongoing communication for your interviewer. Have something personal/memorable in there from your interview to jog their memory if possible.

2. E-mail: Less classy, less formal, easier, BUT they can e-mail you back, which can be priceless!

What to do? Both.
Buy Thank you notes prior to interview day. On your mode of transportation home, or at home that night, write them and mail them the next day. In 2-3 days time, send an email with:

At this time I hope you received my formal thank you, but just in case I wanted to be sure that I really appreciated you taking the time to interview me.

Now they can email you back and start a mini-mentoring experience which is exactly what you want.

Good Luck!

Monday, June 7, 2010

How would you like to pay your doctor?

It occurs to me in all of this national fervor about health insurance people have forgotten other ways in which to pay for health care.  Given that it is directly within my area of interest, I would like to put out a few questions.

1) How much do you spend on total health care every month or year- insurance, copays, all doctors visits, drugs, tests, everything you can think of--all in?

2) How much would you like to spend every month, or every year on the above?

3) Would you like to pay your regular doctor:
a) Market rates every time you see him/her in the office only?
b) For every interaction (phone, office, email)?
c) Bundle or membership payment for the year to cover everything?
d) Membership style payment for phone/email access, then pay for in office visits?
e) Another way that you describe in the comments?

4) Would you prefer health insurance purchased directly or continued through your employer?

Thursday, May 20, 2010

Innovator's Prescription

Thanks to one of my mentors, I have been tasked to read The Innovator's Prescription by Christensen, Grossman and Hwang, and assigned to speak with one of the authors.  This book has a fantastic vision of where health care needs to move in order to improve by uncomingling business models and service lines that have nothing to do with one another.  As a caveat, I am only 5 chapters in.  I will get more out as I read more. 

Tuesday, May 4, 2010

Blood Culture effect

Stepped out of M&M (Morbidity and Mortality Conference) for a second to get this one out...
I am sure there is a better name for this in the quality/process improvement literature, but there is a strange phenomenon in medicine where we react all aggresively to the notification that blood cultures have turned positive.
To give you a little background- blood is taken from ill patients in whom we suspect infection, and grown on culture media (think buffet for bacteria).  In the next 12-36 hours, bacterial colonies will grow (if present in the blood) and become large enough for us to see, identify and test.  By the way folks, that's why blood cultures take so long to come back relative to other tests, the things have to grow.
Anyway, it is common practice to receive a call from the Micro lab that your patient's cultures are positive for something.  Upon getting this news, the typical thing to do is have a small moment of panic, then go check on the patient.  Now, think this one through.  The blood was taken 2 days ago.  They have been fine/stable/sick the entire time.  But now that we have received the information, we are all of a sudden worried.
I am unsure why this phenomenon exists, but it seems that alarm bells bother us because they are sometimes all we have to know that a system is malfunctioning---even though it has been doing so for the last two days!  Illogical, yes, but I also wonder how responsibility/liability comes in, because positive blood cultures tend to become a hot potato.

Back to M&M...


Not to start too many thoughts with... "I Can't believe it is 2010 and..." but I have to say, what a surreal weekend in the Boston area, with the basic concern of clean water taking up so much of our time.  Saturday morning, after a busy night shift, I spent a good 3 hours in the process of boiling, cooling, and filtering water, while attempt to locate bottled water in my neighborhood.  Feels strange in 2010.

The Joys of Working Nights

I love working nights, because it allows my brain to wander and in its fatigued state, think things like-- "Maybe it is so humid in Boston because everyone is boiling water."

Back to days, reality and accountability.... sigh

Saturday, April 24, 2010


I had the pleasure of reading this article right at the end of last year, and it is one that I continually bring and up and send on to folks.  10 obsolete technologies to kill in 2010 by Mike Elgan : orignially appearing in Computerworld (somehow Google brings up the Macworld version first. This article touches on once useful technologies that have outlasted their usefulness and have better, cheaper alternatives.  Nowhere are these thoughts more prevalent than in Medicine.  I recall early 2010, late at night working in the Emergency room, having to fax a signed document to a clinic to receive one piece of information about a patient that they had forgotten. 
Fax.... in 2010!  We are past the foreboding dates of two Arthur C. Clarke novels and still have to put up with faxing!

Along the same lines, I read this intersting historical fact today in Meet Marty Cooper - the inventor of the mobile phone at BBC News: "Handheld phones were originally produced to help doctors and hospital staff improve their communications.  Amazing, given that we are just about the only profession that still uses beepers! At some institutions, on weekend coverage, physicians have to carry multiple pagers, until recently necessitating a "pager bucket" to carry them.  

It is curious that our industry needs massive government spending to "incentivize" electronic medical technology.  What is it about health care that causes it to defy useful technology so? 


Thursday, April 15, 2010

Negotiation, MD

Earlier this week, I had the pleasure of attending Paul Levy's seminar on negotiation. http://runningahospital.blogspot.com/2010/04/how-much-would-you-bid-for-10-bill.html

It was a great seminar, and covered many of the fundamentals of the art and science of negotiation in a 3 hour period. What I found most interesting, is how innately uncomfortable many physicians are with negotiation, especially with monetary negotiation. I have often thought about this problem as it applies to physicians as a group, as our negotiation skills lag far behind, especially given our training on rigorous analysis, decision making, and interpersonal skills.

Having grown up in a household whose sport was negotiation, I feel I can shed a little light on this issue that has often puzzled me about my colleagues. I can come up with at least three reasons why physicians fail at negotiation:

1. We never hear "No."
As physicians, we are not used to being told No. A real No, the kind that sticks. Sure patients, nurses and colleagues will often say no, but it is usually transient and we can move them to yes very quickly by leveraging our knowledge and positional power. We never have to develop the more subtle mechanisms for reaching agreement, because these tools work so well. In the negotiating world outside of medicine, we often have neither, and yet try in vain to invoke our favorite tools.

2. Physicians are risk averse.
By the nature of our profession, we endeavor to prevent the worst from happening, and it is always on our minds. We see risk as something to be minimized, and when we do balance risk and benefit, it is always on behalf of our patients, rarely for ourselves. We never feel the primary burden of our decisions, only the secondary consequences of a bad decision. If you want to beat a physician in a negotiation, instill him or her with the fear of loss.

3. Our training teaches us to be suspicious of money and tolerant of abuse.
We are the "good people," sacrificing our time, energy and potential earnings to help those around us. In order to rationalize how we earn so little for so much work in our training days, we develop a culture that places money in a strange place; a necessary evil but not for us. Therefore, the people that want money must also be evil, and we are willing to give it up in a negotiation, to rise above. Additionally, we learn from early in medical school that those above us in the hierarchy may act inappropriately, but it is in the best interest of our patients that we accept this abuse. While this phenomenon has improved over the years as professionalism standards grow in import, we still tolerate abuse from colleagues, other non-physician staff and patients themselves all so that we may benefit our patients. Appeasement does not work as a negotiating strategy.

So what do we do about all this? How can physicians improve?
1. Read about negotiation-- it is a skill and an extremely important one, study it
2. Attend workshops, seminars, etc.-- Negotiation is a performance sport, you must have practice time in order to succeed.
3. Develop negotiating mentors-- find someone that helps you think through problems critically, and with negotiating experience.  My father often fills this role for me.
4. Negotiate-- As Jeff Wiese always taught us at Tulane, Playing time makes all of the difference.

Some recommended reading:
Roger Dawson- most of books are great
Getting to Yes by Fisher, Ury and Patton
Bargaining for Advantage by G. Richard Shell

Thursday, April 8, 2010

Write already!

After encouragement from several sources, I have decided to just write already. If anyone out there could make me aware of cheap/easy portable dictation software, preferably Palm Centro compatible I would greatly appreciate it. Given that most of my ideas come while driving, showering, running or in conversation, it is damn near impossible to capture them.