The End of Merv Logging, for now...

I just can't keep up with blogging, logging and my journal. I end up shortchanging all of them.
I've read a number of interesting things recently, the most notable being my stopwatch.
Hopefully I'll clear it more often in the future.
here are the laps, and best guesses as to what they correspond to.
I run almost daily so these go back through all of November.

25:09 -- 11/3/11
34:56 -- 11/4
32:53 --  11/5
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44:34 -- 11/6
39:10 -- 11/7
36:50 -- 11/12
Didn't run much this week because my foot hurt after stepping on a giant rock on an old railroad bed.
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57:35 -- 11/13
12:17 AM shakeout --11/14
28:52 -- 11/15
41:12 --  11/16
27:05 --  11/17
25:39 --  11/18
1:03:31 -- 11/19
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53:37 --11/20
12:21 AM shakeout

47:05 -- 11/22
Drove out to Mendon ponds with Gears and Mguy.
Didn't have much time because we had to get me back to school for end of semester orchestra concert.

23:41 -- 11/23
Quick graveyard loop before drive to Boston with classmates.

1:15:29
Thanksgiving day. Perfect and sunny in Providence, RI.
Some cool trail by the harbor.

36:26
Day after thanksgiving.
Run ended on closed open drawbridge. The bridge was closed to trains and open to boats. Good old relativity. Wish I had a camera because I climbed up quite high.

1:10:42
Glastonbury with Paul and friends.
Slowest run in months.
Thank goodness.
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47:47 --11/27
Pinnacle hill and area after long drive from Elo's to Rochester.

40:04 --11/28

41:09 -- 11/29

1:07:36 -- 12/1
Loop of Hill with Mguy.

29:45 -- 12/2
Lunchtime run with Gears.
Found the most industrial part of Rochester in mixed rain + snow.

1:21:01 -- 12/3
Long run with Gears. Abandoned railroad beds make for very flat runs. We kept it uptempo though...
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39:03 --12/4
Night run solo after preping for my hour long interview + physical exam tomorrow. I'm playing doctor and the whole thing is getting video taped.

Personal Best: top athletes and singers have coaches. Should you? by Atul Gawande

Read the full article here.

The search for constant improvement was introduced to me by Tom Donnelly, my track coach at Haverford College. Excellence to him is something that we can all attain, in any number of pursuits.

Really interesting how all but one of the teaching departments here is really good. I've noticed that these departments always have faculty in attendance that are not teaching, but instead evaluating how well the presenter is getting across information. They also keep tabs on how many people come, how many people are asleep, and can write test questions based on the information provided in lecture.

The department that is not good at teaching does not send anyone but the presenter to the lecture. Thus I feel that they have a lack of coaching within their department.

Unfortunate to see how much of our curriculum being test driven, without any more meaningful outcomes extrapolated from beyond the test. (referring to the USMLE step 1s here)

Fun fact.

Our brains are oil cooled and air cooled. Cavernous sinus us filled with venous blood on it's way back from near the surface of the skull. This blood cools arterial blood (the internal carotid artery runs through the cavernous sinus) without mixing and makes the blood 

Tests and More Tests

I'm writing this post during a lunch hour in which I should be preparing for a written final for interviewing and physical examination skills. Unfortunately, I lack all motivation to cram these things into my head because I am unconvinced that a written test about skills that are fundamentally not written will make me a more skilled doctor.

Frustrating that changes are made without measuring outcomes.

I read another blog post last night that speaks to the same issue.

http://well.blogs.nytimes.com/2011/11/03/being-a-med-student-take-two/?ref=health

Yes it would seem bad that some people would take an open book test and not actually learn something, but are there any data to suggest this is what was happening? Instead, these tests were changed from open book to closed book based on some perception, without getting a baseline on performance and then seeing if making the tests more formal actually improves patient care.

Public perception perhaps drives many things in the end. If the American Board of Pediatrics wanted to go back to open book re-certification exams, the media might have a field day reporting how you could just "cheat" on your exam to be a pediatrician. 

Whatever the media says, I would bet that if outcomes were actually measured, it would turn out that people who were better at accessing accurate up to date information from literature and colleagues probably provide better patient care.

Seem to remember reading something else about standardized testing in MA reducing teacher freedom and leading to poorer outcomes, not on the tests, but in some things that matter more than the tests, like getting into college. Anyway, just thinking...

Cardiology

I went on rounds this afternoon with a cardiologist.

We went around and listened to people's hearts, felt their impulses, percussed and asked questions.

I don't think I want to have such a specific focus in medicine, on one organ, but it was a fascinating window into an interesting profession.

The second exam quickly approaches, and I find myself settling into this ebb and flow of these three week blocks. There is a ton of information, but also enough theory and logic to hold it all together where the data scientific understanding puts its rubber on the life roads of real life patients.

Now I'm calculating everything I can think to calculate regarding cardiac output and oxygen delivery for a case I'm working on in a small group. The case was real, and we're being presented the information piecemeal, just the way it would come into our view in the CCU. Difficult stuff and I'm really not sure we can save her, as she's still bleeding 16 hours after delivering a baby. Ironic that it could be because she didn't breast feed to trigger the natural release of hormones that would have completely tightened up her uterus. The more and more we intervene, the more we learn that nature had it right in the beginning.

Re: anatomy

On Mon, Oct 17, 2011 at 5:47 PM, Tim wrote:

"Dude, how's it going?"

It's going well!

Anatomy is particularly fascinating as we explore the secret chambers of the heart.

Of course I am tempted to write about all the grisly cuts that we have to make in lab, but that stuff is by far overshadowed by the knowledge and understanding that come with actually fingering a tricuspid valve as we study determinants of cardiac output in physiology class.

The amount of information is sometimes overwhelming, and the intelligence and maturity of my classmates is admirable in tackling such a large task. I was spoiled at BMC with time to learn every word of Dr. W's lecture and time to practice Orgo concepts repeatedly. Here, that extra time is needed to learn physical exam skills, motivational interviewing and the stages of child development. This means that averages on each exam are much lower than at BMC, despite steady 12 hour work days. I almost forgot about all the time we spend in labs (Anatomy, Histology, Physiology). We were dissecting the neck for over 3 hours yesterday. Very detailed dissection that must be performed in a very small space.

Of course to maintain sanity, I've joined two orchestras and continue to exercise every day. Next race will probably be on snow shoes, as I've been recruited to join a relay team for a series of races in January and February.

Off to lab!

Health Insurance: A Primer for Medical Students

What follows are my notes from a friend who is a md/phd up here.

He researches the economics and policy of health care.

Why do I care?

1. Reimbursement for medicaid and medicare are not enough to cover overhead, so the policy affects how I can serve those who need it most.

Also best practice is affected by what things are reimbursed, because I'll prescribe things and they must be covered to ensure that my patients take their meds.

2. Many people will seek my advice and opinion as a physician.

3. Issues of cost are becoming more pertinent and resources become scarcer.

Why do we have health care?

The costs of healthcare are extremely unpredictable. Risk aversion to income variations make people willing to pay some amount to avoid the huge fluctuations in their income.

What are the pros of insurance?

1. Shields against risk and uncertainty.

2. Insurance companies can buy service in bulk.

3. Can encourage the use of better services.

a. Vaccines as example because better for society than for the individual.

b. Improves efficiency especially with preventative services. Some individuals won't do preventative care unless insurance pays for it to prevent future costs. 

4. There are proven consequences that living without insurance is more dangerous (strong literature supports this).

What are the cons of health insurance?

1. Cannot guarantee good health care.

2. Inefficiency of the middle man.

3. Overuse due to the moral hazard, because if you don't have to pay for it, you'll use more of it.

How much insurance is enough?

1. Most important to cover catastrophic events.

2. Services that are worth more than they cost.

a. preventative services

b. vaccines

How much should patients pay out of pocket?

Some out of pocket costs can reduce moral hazard overuse.

Good patient care does not always equate to good health population.

The greater good is often different.

Antibiotic resistance was in part caused by all kids getting antibiotics for ear infections.

So now individual patients have to suffer for a little longer in order to prevent multiply resistant bugs.

Another example is the use of CT scans in the emergency departments.

The good of the population is better served by not scanning everyone even though the individual would be better served by getting the scan, just in case something is very wrong.

Is a mandate to buy health insurance a good idea?

Yes, premiums will go down if penetration is high enough.

Companies can drop premiums if they get both sick and healthy patients.

Comparative effectiveness vs. rationing

rationing already exists.

Infinite need and finite resources.

Allocation decisions are being made all the time, but not backed up by evidence.

Prostate screening as example, very well funded but relatively irrelevant test, because all old men get prostate cancer and very few die from it.

Let's use evidence.

How do you make sure policies actually work?

12 year old kid had tooth ache but couldn't find dentist who would take him (because medicaid reimbursement sucks), then ended up in the hospital getting $280,000 and then dying from brain infection.

But maybe this is an extreme case?

It's not, because upwards of 10% of uninsured patients that hospitals see were on medicare.

Death panel controversy which got blown out of proportion started as a provision that would provide physicians with reimbursement for end of life counseling. The major push was a facebook post by Sarah Palin that was based on no truth whatsoever. 

Misinformation is powerful and the American public is susceptible to believing whatever the media supports.

Good news is that when people understand the truth, they generally choose correctly.

Solutions will require rational discourse informed by 

Suggesting Reading

Health Economics Phelps, 2009

The Social Transformation of American Medicine, Starr, 1984

Kaiser Family Foundation (kff.org)

"Rationing Health Care: What Does it Mean?" NYTimes, July 3rd, 2009. Uwe E. Reinhardt

"Providing High-Value, Cost-Conscious Care: A Critical Seventh Generation Competency for Physicians." Annals of Internal Medicine" Steven E. Weinberger

Sleep

This afternoon we had brief lecture on behavioral psychology and it's applications toward depression and insomnia.
Really interesting to learn how sleep is cyclic, with deep, slow wave sleep at the beginning of the night and REM toward the morning.

The behavioral modification part was cool as well. The doc presented data on the success of sleep rationing to increase sleep time vs. various drugs. The behavioral methods worked much better.

In other news, I took my first serious exam of medical school on Monday.

Started with 25 questions about various structures tagged/pinned on cadavers or x-rays.
I felt pretty good about this part, but definitely forgot some simple information from the very beginning of the block. (each block is three weeks, so we're on to block II now)

Then I had 45 questions about various micrographs and light microscope images pertaining to tissue types and classification.
This went fairly well I think.

Monday morning finished with 37 multiple choice questions about cardiac physiology and ECG interpretations.
These were really challenging.
There were also some more short answer anatomy questions that were clinically oriented. I had not read enough of the textbook to feel really comfortable with these.

After lunch, we immediately started in on block II. Intensity is good.