Neurosurgery or Seeing patients?

After two days of observing in both the OR and the outpatient clinic at Chang Gung Hospital in Linkou, I think I have a better idea of what area of medicine I want to pursue. Between spending 3-4 hours
operating on a immobilized BODY that is barely breathing versus seeing and interacting with a living breathing PERSON with real economic, social and medical problems, I prefer the latter. It seems more real to me somehow. The problems and the human contact are aspects of medicine that I like more. Perhaps some area of medicine in which I see patients most of the time and spent 1/4 or 1/5 of my time on procedures may also be good.

Deciding which Med School

This weekend, I attended Visiting Days at Dartmouth Med School. I met with incoming and current students, faculty and administrators and even looked at some properties to buy.

Today, as I depart DMS (I am now in Narita in transit on my way home for two weeks), I have decided to attend DMS. I suppose you could say that they sold me on the school but part of me also feels like it was forgone conclusion. This school really fits me well.

Its appropriate then that I explained the Chinese word ‘yuan’ or fate/destiny to Deo this weekend as we were sitting down to a meal together. Is it fate that the first student host I contacted was busy that weekend and I got to live with and get to know Deo back in October? Was it Yuan that I interviewed with the Chairman of the Admissions Committee who recognized my achievements in business instead of holding my non-medical background against me? Was it fate that I had a great conversation this weekend with the former Dean of DMS who incidentally was stationed in Taiwan in 1955 as an Army doc and urges me to get involved in US-China affairs?

I don’t suppose it always works out this way for all pre-meds, but somehow I think choosing DMS was yuan fen.

Health care in America

Read today`s piece by Paul Krugman in the NYTimes called The Best Places to Get Sick which is a commentary on rising US health care costs. He analyzes the so-called privatized healthcare system in the US which he argues is increasingly expensive relative to other rich country`s health systems while not yielding desirable results in health indicators like overall life expectancy and infant mortality. He cites some interesting stats:

In 2002, the United States spent $5,267 on health care for each
person ($2,364 – 45% by the government on Medicare and Medicaid) while Canada spent $2,931 per person ($2,048 from the government) and France spent $2,736 per person ($2,080 was government spending).

His main argument is that Americans spend more on healthcare than their counterparts but do not receive more care. He attributes this difference to higher doctor`s wages, American health care system overpays for the same drugs, and too much is wasted in admin costs (31 cents per dollar compared to 17 cents in canada).

Not bad but I wish he went more in depth about things like legal system and practice (we are much more litigous in this country than France or Canada) which contributes to admin costs (ie HIPA), or compares the health care quality of the top 10% of income earners (more and better tertiary care in the US) and also that American consumers subsidize research and development cost of new drugs for the world while french and canadian consumers have the benefit of buying the cheap generics that are made possible by the American pharmaceutical market. And what about consumption? Doesn`t the average american lead a much unhealthier lifestyle than their counterparts (longer working hours, more stationary, higher caloric intake, less fiber, etc etc)

I can`t say I am a big fan of the increase in doctors salaries (driven by the increase in salaries of specialists that are getting paid more for treating a smaller and more focused patient base than before while primary docs salaries have stayed relatively constant) but I do believe there are other factors at work which complicate the problem. The solution may be a combination of many behavioural changes over a long period of time: work-life balance, diet, exercise, doctors that value what they do rather than how much they are paid.

The only problem with such a long term solution is that the American consumer increasingly values short term solutions. We think that with all the breakthroughs in medical science, there are (or will soon be) fast acting magic pills that will fix all our problems and allow us to get back to running the rat race ASAP.

Even so, how does one ultimately counteract capitalism which incentivizes doctors to specialize and make more money, consumers to extract more and more services they don`t need from insurers, and already unhealthy people to eat, drink and smoke more?

Pain Management

ROAD to life
(Radiology, Opthamology, Anesthesia, Dermatology)

I shadowed an attending at the UCSF pain management center today. Learned several useful things. First, that personality match really determines what kind of residency a person ends up in. In addition, a balance of what kind of impact you want with the economics of how to make enough money to support a family seems to play heavily into this (I guess considerations when you are in your 30s with a family is very different from the 20s). And specialties like Dermatology are not just important for their money making potential and lifestyle but also seem to offer a wide range of options for practice anywhere from myeloma to private cosmetics clinic.

Research is important in getting into such competitive residencies because most people want folks that will advance the field. Note to self: shadow and participate in research early in med school so I can know if I want or don’t want to go into these fields early on.

In addition, I was not that happy about a few things I saw today in the treatment of patients. First of all, an outpatient clinic may be a great place for seeing VIPs (CEOs, presidents of companies and institutions, professors, etc) but the doctor I worked with didn’t seem to like poor people much and used words like “crazy”, “draining”, “waste of time” when it came to describing the Medi-Cal patients she HAD to see. I also did not like the general trend of very specialized tertiary care in which you really stick to what you know and although you “Communicate” with psychiatrists, neurologists, etc you don’t really know enough to form a unifying diagnosis about the underlying cause of some pain and can only treat the symptoms. Seeing the patients also allowed me to better understand some of the problems of western medicine. For instance, many chronic pain patients will live with pain the rest of their lives and the drugs can only help control and “manage” the pain, not cure it. Meanwhile, many do not respond to certain drugs, most have to take a combined regimen and will experience varying degrees of side effects. Dosing is very much an idiosyncratic art form (based on experience and trial and error) rather than a science since it varies patient to patient.

Also the very existence and marketing of “miracle” drugs creates a dependence mentality whereby some “treatment or diagnosis seekers” just go around trying everything because they think there MUST be ONE single scientific diagnosis or magic pill they can take to make the pain all go away.