Author Archives: Jon Zaid

Resident Perspective: waiting for test results

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Sunday, March 29th

Although I’m a resident and I’m able to access my own medical chart through the electronic medical record, I’m not allowed, per hospital policy. I’m relegated to waiting for my results once “released” to me. While waiting for results in self-isolation, at a certain point you don’t really care whether it’s positive or negative, you just want to know something. Unfortunately, we still don’t know if being coronavirus positive prevents you from getting infected again so I’m not at the point where I would prefer to be positive just to get it over with.

Finally, five days after having the back of my throat swabbed I get an email saying my results are back: SARS CoV-2—undetected. Whew, negative. I was able to isolate for 5 days while my wife worked and took care of our baby simultaneously. Many other households aren’t that fortunate and either the other parent would have to take unpaid time off from their job (if they are able) or the person in quarantine would have to watch the kids and therefore expose the entire family to coronavirus. This is problematic for many obvious reasons.

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A picture of me and Jack at the tail-end of my quarantine. I still smiled under the mask for some reason.

The responsiveness from the government to obtaining and manufacturing tests was bungled from the very beginning. Quick turnaround time for testing is beneficial for giving patients a diagnosis promptly and is beneficial for epidemiologic prediction models that guide how much a region will be impacted and which locations that will be hit hardest next.

There are two main testing locations. In-patient testing for those that are hospitalized, where the test is performed in the hospital’s own microbiology labs (“in-house”) which have continuously improving turnaround times. Once the tests became available to hospital labs across the country, waiting times went from 48 hours down to about 4 or 5 hours (and in some hospitals turnaround is under an hour). The other main testing sites are commercial labs (LabCorp, Quest Diagnostic, etc.), where your test would be performed if your outpatient doc sent in a referral or if you went to a screening center. Unfortunately wait times are getting much longer as the public demand goes up for testing, and along with it, any part of the supply chain that is lacking—from swabs to reagents to protective gear for the providers—will back up everything.

The answer to better prediction models and better care isn’t just faster turnaround time for tests. The media has really honed in on getting quick results as a major issue in the epidemic because the news can show a long queue waiting to be swabbed or interview people frustrated by the lack of knowing their status. Arguably just as important is the accuracy of these tests. Swabs of the nose and throat are analyzed by something called polymerase chain reaction (PCR), which is designed to multiply the virus genetic material—RNA in the case of coronavirus—and detect the presence of the virus itself. A couple of problems arise from PCR as there have been reports of high rates of false negatives—meaning getting an inaccurate “undetected” reading when in fact, one is coronavirus positive. This is called low sensitivity in a test.

Because PCR looks for the virus itself from the swab, there have been studies in which essentially, if you go lower down the trachea (“wind pipe”) and obtain a sample closer to the lungs there are higher concentrations of virus located there so you will get a better sample and potentially provide more RNA material to amplify and detect with PCR. The issue with going down the trachea, in addition to being very unpleasant, can cause more of the virus to be coughed up during the procedure potentially infecting more people. So it seems not only possible, but likely that the swab going to the back of the throat either by way of mouth or nose just doesn’t pick up enough virus to be amenable to detection in many instances.

A blood test was recently approved by the FDA under Emergency Use Authorization which will test for antibodies (our own immune system response to the virus). These tests are already in use in China and other countries and can return results in under an hour. The benefit is that these tests aren’t dependent on obtaining an adequate swab and they could potentially tell us if someone’s been exposed in the past. It will also lead to more data regarding immunity to future infections with SARS CoV-2. The downside is that the test may not be accurate either and potentially detect non-COVID-causing coronavirus like CoV-1. There also arises questions like: is it better to know with 80% accuracy with one method vs 70% accuracy with another but it takes half the time to get the results back? There are no clear-cut answers because there are pros and cons to both.

The good news amongst all of this is that there is high “specificity” with these tests, meaning that if you get a positive result then you almost certainly have COVID, however comforting that may be. Keep in mind, for the time being these only apply to people that are having symptoms. I haven’t even touched upon the messed up screening guidelines and how they’ve morphed over the past few weeks. All of this is really to say we don’t know how many people are SARS CoV-2 positive currently for lots of reasons, and looking at the current positive cases on the news only tells part of the story.

At our institution there have been patients that we’ve been so sure are COVID positive that we’ve performed multiple PCR tests yet have all returned negative. Unfortunately, the answer to those that are so sure they are positive with coronavirus but have received negative testing is to assume the test is wrong. Given the rapidity with which this is all developing there just isn’t enough data regarding how accurate these tests are and how they should be employed.

I finally received a call from occupational health telling me the test results and to go back to work. Typically I’d be starting on outpatient weeks at this time, meaning I would be seeing patients in the office and go to morning and afternoon conferences with other residents. The pandemic has disfigured outpatient life for a resident, so now I start with telemedicine appointments and we’re given strict instructions to stay away from the hospital until it is our turn again—I’ll gladly oblige.

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Resident Perspective: Who is “Essential”?

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Friday, March 27th

I’m not having any symptoms at all at this point, really itching to get back to work. All residents have been instructed to check their temperatures before and after every shift since last week, in the hopes of catching any early signs of infection. We were not supplied any thermometers by the program, local drug stores are all sold out, and checking online the cheapest thermometers that will arrive in fewer than 4 days are all over $50. Luckily, I have my son’s infant forehead thermometer but I’m pretty sure doesn’t really work—I use it anyway and consistently have a temperature below 95 degrees, whatever that’s worth. I hadn’t felt feverish so I continued to go in to work at the hospital.

I’ve been reading a lot of self-congratulatory posts on social media from those in healthcare, selfies with a mask on, a team posing for a picture in all their protective gear, etc. For the most part it’s pretty benign but important stuff—reminding people to wash hands and stay home. The other intention is to self-promote and remind others they’re putting themselves at risk for the greater good. A troubling type of post I’ve been seeing is from providers (often not directly taking care of any COVID patients) excited and proud at the prospect for the medical community to come together to defeat this invisible foe. Maybe these sentiments are posted because morale is low and physician burnout is even higher than typical at this time? Bully for those that go into the fight ready, willing, and able. This mentality seems to say that as healthcare providers we should all rush to the frontlines as it’s a commendable action. I suspect many people not working in healthcare may not realize that residents are not really given a choice whether to participate or engage with high-risk coronavirus patients.

Residents are at an even higher risk of burning out at this time because all “non-essential” employees are not permitted in the hospital and they are limiting the number of employees for the essential roles as a way to decrease overall exposure. Medical students typically make discharge appointments, obtain outside hospital records, and other vital tasks—but medical students are no longer permitted in the hospitals because in many ways they’re paying for the privilege of being there. That topic in and of itself could be another blog post.  Gone or restricted hours also apply to many case managers, social workers, patient transporters, nutritionists, physical therapists, drug or alcohol rehab representatives, etc. The burden of caring for patients and providing a safe discharge now falls more squarely on the remaining, smaller medical teams, which includes residents (and more specifically the interns—first year residents). This is time-consuming and no doubt will hasten burnout. In our program we’ve been fortunate enough to be able to take certain measures to mitigate this, like shorter duration spent on COVID teams for residents, but we may not have that luxury in the coming weeks.

Is this what we signed up for as trainees? My institution for now has been remarkable in being able to accommodate residents that are particularly vulnerable or have vulnerable household members; others may not be so lucky. Hospital administrations have to make the decision as to who to put in harm’s way. It’s not always cut-and-dry—should we protect older attendings or younger trainees? Is the duty to provide the best care for these current patients or to minimize exposure of budding physicians who will be practicing for decades to come? We have no idea if there are any long-term repercussions to the lungs or any other organ systems in people with asymptomatic coronavirus, and they may confer a higher rate of complications not seen for years or decades—we just don’t know. The vast majority of residents and clinicians in Internal Medicine are very hesitant to jump right in, and understandably so. Initially no med students, interns, or residents were to take care of COVID patients. As the epidemic grew into a pandemic more and more hands needed to be on deck. But still, the decision regarding which specialties will be taking care of these patients is growing. The public may not realize it either, but some residents and even attendings from subspecialties that don’t have much clinical patient exposure (e.g. Radiology) may have to dust off their stethoscope and start taking care of loved ones in your hospital.

Similarly to reports about physicians having to decide which patients get a ventilator, we are also making the decision as to which providers get greater amounts of exposure, which is a morbid endeavor. In Philadelphia, we’re fortunate enough that we haven’t had the same patient burden as New York so it hasn’t been all-hands-on-deck, but we may have to start asking which residents can handle more exposure than others, sooner rather than later.  Does taking care of an elderly family member, or a child at home come into consideration? What about providers with immune system issues? Where does my duty to provide for my patients trump my duty to keep my family’s risk of exposure at a minimum? Is it moral to ask a young, healthy, single resident to have repeated exposure or is it better to spread it out over several residents but lessen their daily exposure?

Although I personally hope to continue to be at or near the front lines, I understand those that are in a compromised position, and they shouldn’t feel bad for wanting to protect themselves or their family. There is no portion of the Hippocratic oath that implicitly or explicitly states that physicians have a duty to patients above their own safety. This is a nuanced situation that doesn’t have a blueprint in place. There are many features that as a society we’re having to figure out in real-time, which is just adding to our collective anxiety.

Healthcare workers are put in an awkward situation in these times. We need to be discussing this openly, with transparency about the treatment of healthcare workers, especially nurses and residents. How to improve the healthcare system is an important topic that hopefully will not be able to be ignored after we pass the emergency of the pandemic. It will not be easy to address this because the goals of the industry are not aligned with the goals of the public or those providing care. Even though we’re in the midst of the pandemic it’s a beneficial practice to reflect and think about the way we can improve the safety and efficacy of those delivering care.

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Resident Perspective: It Begins

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, March 25th

Today was my first day of quarantine and now I feel like I’m a part of society. In the prior weeks, working on the general hospital floor I was constrained by daily ritual –nothing said on the news or by the government about isolating or “staying home” applied to healthcare workers, or residents, more specifically. Those working in hospitals are in the thick of it, but we have a completely different experience because we have to continue to go to work and do our jobs while everyone else has just had drastic changes dictated for their daily lives. I was working long hours every day so I didn’t observe any special social distancing; my daily routine recently had been to come home and only have about an hour before turning in for the night so I wasn’t doing much socializing. Now home and quarantined, I found out quickly how fast things could change as I spend most of the day sequestered in our bedroom away from my family and where they typically are during the day.

My wife’s mother watches our son but we’ve collectively decided that while I might feel fine, because of my high risk exposures it would just be best for her to not come until things cool off. We’re lucky that we have the opportunity to actually have this option as many families in our situation would either have to choose exposing a loved one to potential coronavirus or have the parent take time from work to watch their kid. I fully appreciate we’re privileged enough to even have that possibility.

I look out my closed bedroom window and think it’s a shame that the weather’s so nice as I’m sure everyone is itching to be outside. Spring is in full swing even on our street, as the trees are approaching full bloom, and I’m pretty sure a bird’s nest is being built in our gutter as I hear constant chirping with rustling of leaves and tin behind the upper corner of my bedroom. I can hear neighborhood kids outside playing. I look down and see groups of 4 or 5 parents awkwardly try to stay 6 feet apart on our narrow street. I’d like to kindly remind them to keep their distance, but like Jimmy Stewart in Rear Window, I just gaze at them from the safety of my newly shuttered life.

Hearing the kids play, I wondered, what are they thinking is going on? How much have their parents told them? I don’t know what age you go from being elated you’re off from school to being worried about whether or not you and your family will survive. Do they think this is a normal occurrence and something they’ll have to deal with frequently in their lives? This must have a major impact in many different ways on kids of varying ages. I remember getting talks at school about fire safety and going home every night and practicing an escape plan with my family because I was so terrified. I don’t know what 8 year old me would be feeling about the invisible yet much more real confrontation with a virus. I couldn’t imagine having a 2 or 3-year-old that doesn’t understand that they can’t go outside to play with friends and then have to keep them entertained throughout the day. Then do it again the following day indefinitely.

I’m now realizing there will be so many unforeseen consequences, namely impacting those on the lower socioeconomic scale. When you work in healthcare during a crisis all you care about is how it impacts you and your patients. When suddenly removed, I’m forced to take a step back and come to grips with how this affects literally everything and everyone else in society. Maybe it’s because I now have my own child to look out for, but children have been on the forefront of my thoughts related to the pandemic. They may not be medically the most vulnerable in this case but they are in terms of long-lasting impact. Every facet of their lives are being disrupted—psychologically, educationally, nutritionally, and overall developmentally. Many families rely on food provided for kids at school. Expansion of SNAP benefits under Families First Coronavirus Response Act, which recently passed, may lead to unhealthier food choices for children as well, as this isn’t regulated like nutrition guidelines for school lunches. I’d also have to assume that kids aren’t getting the same quality of education if it’s all strictly remote, let alone the meaningful and necessary bonding that takes place at school. No doubt there will be a wealth of data to supply research to tell us what we intuitively know, which is when society stops functioning as usual the most vulnerable among us are impacted the greatest.

This time away from the hospital is allowing me to reflect on the many facets of life that are touched by this pandemic, so I’ll treat it like sabbatical.

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Filed under coronavirus, Education, Food, Health Care and Medicine, Pandemic, Poverty and the Justice System, Residency

Resident Perspective, cont’d

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Tue March 24th 2020

I couldn’t sleep. I knew I would have to get tested in the morning.

 

I called our occupational health hotline when it opened up and I was instructed to go to the “walk-thru” testing facility that was set up outside in a parking lot adjacent to the hospital. All the staff there were wearing full body suits accompanied by masks, face shields, and bouffants. There were traffic cones strewn about seemingly directing the patients to different locations, various designated lanes for people to register, and about 3 dozen empty folding chairs spaced out to preserve social distancing. There was an ominous large Winnebago covered in sheet metal for some reason, and tents with presumably more staff inside them. Also, there were police officers, about 4 or 5 huddled together but they weren’t directing traffic and I couldn’t surmise what role they could possibly play in all this. Cars making their way along pothole-riddled Sansom street would now slow down to gawk at the impressive sterile facility not only for the sole intention of protecting the integrity of their tires and suspension. As a patient now, I was sitting in one of the empty 36 folding chairs while I waited for my name to be called. Outnumbered about 15 to one by occupational health employees, I could imagine the public believing this was overkill.

 

I was told I won’t find out the results for three to five days, but there was a rumor about occupational health potentially getting a 24 hour test up and running the following day. I didn’t want to risk being in the same boat again tomorrow so I took the swab today. My name was called, I went to the proper lane then was summoned into one of the tents where the very back of my throat was thoroughly wiped with an elongated Q-tip. Per hospital policy, I was now on mandatory leave to be on quarantine in my home until the results returned.

 

I called my wife and updated her. I would stay in the bedroom by myself for the next several days, leaving only for bathroom breaks, grab food from the kitchen, and to sanitize anything I touched. If I were to leave the room I had a facemask ready. I didn’t come close to my 7-month-old son, which was probably the hardest part of all this. On my way home I thought about how it felt like the virus had been preoccupying everyone for months but in reality it was only a couple weeks. I was exhausted by it already but this was only the beginning.

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Resident Perspective

I was encouraged by my wife to keep a journal for thoughts and feelings surrounding the developing coronavirus pandemic because I may be able to offer a unique perspective as a resident in medicine who is also a new parent and attempting to overcome fear of the unknown and what’s to come. I will try to update as frequently as I am able.

Monday March 23rd 2020

I found out that the Attending Physician I had been working with all last week and who was coughing during rounds was getting tested for coronavirus last night in the emergency department. I can convince myself I’m having symptoms of fatigue, sore throat and maybe a headache but I’ve also been working in the hospital for almost four weeks straight and this could just be general exhaustion mixed with a touch of seasonal allergies. I try not to think about it too much.

I haven’t been wearing any masks or other personal protective equipment around the hospital yet. At this point I feel like we are still in the nascent stages of the impending unknown so wearing a mask right now seems premature. The practice isn’t mandatory but I see more and more random staff in the hallways with facemasks on, many of whom aren’t clinicians which is a greater indication that I should probably get on board. Every now and then I’ll check a supply closet or outside a patient’s room to see what the surgical mask inventory is like. There are constant rumors floating around that, like the N95 facemasks, other equipment will be locked up and parsed out by a charge nurse on an “as needed basis”. If a run-on-the-banks situation were to occur, I want to make sure I hit the sweet spot where I don’t contribute too much to the hysteria but ensure I’ve got a mask without having to fight for scraps. I’ll continue to assess the situation.

Meanwhile, I observe more PAPRs (Powered Air-Purifying Respirator—special protective equipment) next to rooms on the wards, awaiting their donning by newly trained hands. They’ll be used for all COVID patients but since there aren’t any confirmed as of yet in our hospital, the purpose is to be used by all COVID “rule-outs” for now–those that are being tested and don’t have results back. We have a three to five day turnaround for test results right now, meaning we simply don’t know if the virus is already in our presence. The increasing numbers of PAPRs seen daily act as a surrogate for the proximity of the disease to Philadelphia and as a gauge for the level of concern amongst residents.

Over the last several days quite literally every discussion between residents in the hospital is about the coronavirus. Either discussing potential treatments; rumors as to what’s going on in China, Italy, or New York; sending memes or chatting about our trepidation and general anxiety that has gripped the entire hospital. Even when seeing my patients, every TV seems to be tuned into the news, all of which are giving up-to-the-minute global figures alternating between death tolls and economic indices. Patients ask questions for which I don’t have answers. No families or visitors are allowed in the premises. No students or “non-essential personnel” permitted to the hospital. Residents are instructed to follow social distancing protocols and there are to be no gatherings of more than five.

I went to a stroke alert today at a patient’s room for a patient that I wasn’t directly taking care of, I just happened to be nearby. The patient was in a designated “rule-out” room meaning all personnel involved need to treat the patient with extreme caution, and to limit those in contact with the patient to only those “essential.” Two nurses and a tech were in the cramped room already while the neurology resident was outside the room, not wanting to unnecessarily expose herself, miming the actions for a neurologic exam to one of the nurses. She gave instructions through the patient’s door window and into a speakerphone in a patient’s room a mere 4 or 5 feet away. The nurse and the tech cautiously proceeded to ask the patient to perform the maneuvers coached by the neurologist. It was an odd scene as clearly the patient could hear the instructions from the hallway through the door as well as the speakerphone but was polite enough to not mention that to the nurse directly in front of him. The nurse dutifully relayed the commands, “can you follow my finger with your eyes and keep your head still?” and the patient dutifully followed them. It would be funny if it weren’t so bizarre. Turns out he wasn’t having a stroke but it was good to have the opportunity to work out kinks regarding the protocol for patient emergencies. Residents are instructed to make note of instances in which normal protocols can’t be followed given the extra necessary precautions we now have to take. No doubt there will be plenty.

The hospital is both quiet but buzzing lately. Most of the services only have a few patients on each team and I walk down the wards and can find four-five-six! rooms in a row without any occupants. I’ve never seen more than two consecutive empty beds during my years here. The hospital policy is to discharge as many patients as possible with the impending influx of COVID cases to come. No elective surgeries and if you don’t absolutely need to be hospitalized you’d be safer at home. The atmosphere was akin to the episode of Game of Thrones just prior to the final battle in the last season. Nervous and anxious, we have no overflowing wine to keep us preoccupied and stumbling about. The morale is low and the silence in the hallways and in the former resident-gathering areas from our lounge to the cafeteria forces it to reverberate. Philadelphia has the temporary advantage of being able to watch from the shore as the tidal wave from China picks up steam as it makes its way across Europe, to New York City and crashing down I-95.

That night at home I continued to mentally scan my body for any possible symptoms. I hardly ever get sick so I don’t know if I’m short of breath at the top of the stairs because I’m out of shape or because I have a deadly infection. Best to push it to the back of my mind as there’s nothing I can do about it at this moment.

Bedtime routine completed. I get a text message at 10:00pm from a co-worker saying that the Attending I had been working with came back positive for coronavirus.

Image from Getty Images.

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Big Pharma: Don’t Hate the Player, Hate the Game

Martin Shkreli is a man I admire in an odd sort of way.

The recent controversy involving Mr. Shkreli and his price hike of the toxoplasmosis drug, Daraprim, seems to have caused misguided furor towards the 32-year-old CEO of Turing Pharmaceuticals. He may epitomize a major problem with the pharmaceutical industry but he is simply playing by the rules his pharmaceutical executive contemporaries and predecessors have helped set in place. Much like Donald Trump and his history of bankruptcies, he’d be foolish not to take advantage of every oversight weakness or loophole set up by a corrupt system that affords advantages to those who are shrewd enough and willing to exploit them. The public’s anger is directed at the man and not the system.

If Shkreli were to step down or be forced to resign, do people think that the next CEO of Turing Pharmaceuticals won’t be as zealous or brash in exploiting the system? People dislike him for the price hike, but loathe him for the way he defiantly acted in response. If I were a board member I would demand that my CEO rigorously investigate every pathway to make the company more profitable and therefore more financially stable, but I would also want them to exhibit a measure of temperance so as not to attract unwanted public spotlight. It seems as though people would be willing to forgive and forget a less brazen pharmaceutical executive. Every public dollar not claimed by Turing Pharmaceuticals is a dollar that will be spent elsewhere, or heaven forbid end up in the coffers of the competition.

As for the relationship to medical students, pharm and biotech industry sales reps are not seen or heard from during the first two years of our schooling. We are in the classroom and there is no official school-sanctioned time allotted to these groups unless specifically invited by a student organization. There are no events or talks sponsored by companies, and all faculty must divulge any real or perceived conflicts of interest when lecturing.

This changes in the clinical years (third and fourth year) when the students are out and about amongst the physicians, nurses, and patients in the hospitals and clinics. Students are left to their own devices and are sometimes in rooms with Big Pharma reps during presentations for a new product or during demonstrations of a new surgical device. The “good” reps will gravitate towards the students after they’ve made their pitch to the higher-ups and start chumming it up with those at the bottom of the totem pole and those with the least decision-making capacity.

My first encounter with a sales rep was right before entering the operating room (OR). Gowned in scrubs, all entrants into the OR look nearly identical and no hierarchy can be discerned readily, like it can be up on the patient floors. There doctors wear long white coats, nurses wear scrubs, and students wear short white coats paired with a look that can only be described as confident confusion. There the pecking order is clear. The OR is murkier—we’re all wearing blue scrubs so the nurses and students are dressed like the doctors are dressed like the students. The man approached me and asked if I was a student and we began chatting. I assumed this guy was of some import—he was tall, he spoke confidently, and he knew everyone’s name entering the OR. As the conversation shifted from what my first few days at the hospital were like, he started extolling the sophistication and ease of use of this new surgical device that would be employed for this particular operation. Then it hit me that this guy was just a salesman.

He knew who I was, right? Him selling me on his product would do absolutely nothing for his company’s bottom line and his quarterly sales wouldn’t see the slightest uptick whether or not he had ever spoken to me. He gave me his card and told me to be on the lookout for his company’s reps in all my future endeavors. Man, I thought, he was such a nice guy. As the weeks went on I encountered other reps while in the hospital. All of who were just as nice. What an endearing industry.

Drexel had done a superb job at shielding its first and second year students from the influences of third party companies. We had almost no exposure to the sales pitches coming out of the mouths of these charismatic salespeople. We were being released to the world as naïve students. Were these reps being nice for the sake of being nice? Of course that’s a possibility. What’s much more probable, however, is that they are all planting the seeds of merchandising as soon as they are able. I wouldn’t be advising any hospitals to buy any new surgical devices, nor would I be prescribing any meds for a few years, but when the time comes, I will already have that brand recognition stored somewhere in my brain.

As students we are never given formal training in how pharmaceutical companies operate and what we can expect to deal with for the rest of our careers, regardless of our specialty. We have a Business of Healthcare course that does a great job of outlining the history of US healthcare, how it came to be the way it is, and how insurance companies fit into the puzzle that is the US healthcare system. I once believed that it was a good thing that med school limited exposure to Big Pharma, and that this limited access to its students would offset some of the pernicious effects of physicians becoming beholden to a drug company. As our system is set up now, students or recent med school grads will be inundated with free luncheons, demonstrations, and gifts that are designed to both inform and persuade physicians and future physicians to prescribe certain medications. There seems to be real value in these demonstrations, as it is a way for those in healthcare to stay current with advances in research and technology.

The FDA and Big Pharma continue to battle about how much free speech the for-profit pharmaceutical companies can claim when marketing their drugs and devices. Students are not given much information regarding the politics of what is going on in Washington, D.C. It is important to learn about how our healthcare system works and to truly be advocates for our patients, doctors need to be versed in the discussions going on in the capital. Perhaps to steer clear of politics and controversy, medical schools opt to leave this discussion out altogether.

Or perhaps not; in order for physicians to best advocate for our patients and their health, we need to know the rules of the game. Med schools need to find the balance between creating competent, knowledgeable physicians who understand their field very well but that are also aware of all of the players in the game and what’s at stake. I’ve found that many of my colleagues find the political aspect of medicine tedious, boring, and too time consuming to delve into the intricacies of policy creation. It is this lack of knowledge or fundamental misunderstanding of the relationship between physicians, pharmaceuticals, and the government that makes doctors more susceptible to persuasion by the sales reps as conflicts of interest in the health practitioner field aren’t readily apparent.

The relationship between pharmaceutical and biotech companies with medical schools shouldn’t be adversarial, but when the goals of the healthcare provider and healthcare-related companies don’t coincide, the physician and the patients need to be made aware. Talks by prominent physicians that are on the payroll of drug companies need to be scrutinized. Papers applauding new breakthrough treatments need to be rigorously investigated because even peer-reviewed journals are not free from bias. There is no ideal time during the course of our education that this information would naturally fit, but it is vital and it should be taught early on so that when we are released into the hospitals we will have practice with critiquing sources and being mindful of current legislature concerning what parties are spending money and where they are spending it. If you set up a system that can be exploited you will attract those that are the best at this exploitation.

It is easy to set the ire and pent up aggravation at a wasteful system onto the figurehead with the likeness of a James Bond super-villian, but the release of the collective frustration still does not change the underlying current of how our healthcare system is run. If we’re not educating future doctors on how to effectively combat an (at best) unfair or (at worst) corrupt system, then who can we rely on to give patients a better handle on their own health?

As far as Mr. Shkreli is concerned, he’s just a example of what can happen when an arrogant, young, former hedge-fund manager gets his hands on a product that people need. He’s willing to be the face of a controversy and actually exemplify to the public how screwy the system is. Like Donald Trump proclaiming to donate heavily to both parties in order to personally benefit, Shkreli is opening our eyes to the nature of business side healthcare. Rather than being angry at why someone would do this, be angry at how someone could do this. Don’t hate the player, hate the game.

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Filed under 2016 Election, Business, Health Care and Medicine, US Political System

Anti-Vaxxers: Why Medical Students Aren’t Being Trained to Weigh-in

With increasing frequency I have been asked by friends and well-wishers about how “anti-vaxxers” are being broached by my medical school professors. Simply put, we aren’t being taught anything on the matter. This is insight on how future physicians are being groomed to handle public misinformation and media outcry. Obviously we are given the molecular biology and public health angles as to how vaccinations work from the micro to macro scale, but we aren’t supplied with the tools on how to discuss these seemingly controversial topics with our patients. This could be for a few reasons.

First, the rising trend in vaccination refusals and recent measles outbreak, coupled with subsequent media hysteria, will raise awareness of the harm of not vaccinating children—and this trend will correct itself. After all, it seems affluent Millennials are seeing the greatest raise in foregoing vaccinations. They understand that chemicals are pervasive in today’s world, and while they might not buy that vaccines cause autism, they certainly don’t believe that injecting children with man-made concoctions at an early age increases their biological fitness. Therefore, when the educated anti-vaxxers see the harm they may be causing society as a whole, let alone their own kids, the trend will inevitably correct itself. One would hope.

It isn’t only the Millennials; some of the unvaccinated come from isolated religious communities, and the poorer counties within a state tend to have lower levels of vaccination rates. Each patient is unique and asks questions regarding vaccinations with different levels of background knowledge. Therefore different ways to convey the same message about the effectiveness of vaccines would need to be employed by the physician. This is a technique developed more during third and fourth year of med school (I’m still in my second year which is primarily classroom-based) so maybe it is more appropriate to have these discussions later in schooling. Sometimes a patient’s anecdotal evidence (e.g. “My friend’s sister had a normal child until they got vaccinated and then the child became autistic”) is too ingrained and no amount of sound evidence can dissuade them from their preset justification. My school might just be trying to allow its students to form their own ways of picking and choosing their battles when it comes to handling these issues with the patients.

Lastly, perhaps doctors feel that by and large they are above the entire “debate” about whether vaccinations are good or bad. Let the 24-hour news cycle run its course. Football just ended, it’s too early for 2016 elections, Russia and Ukraine’s ceasefire is mildly interesting, and by national news standards there’s not really much going on besides the latest ISIS comings and goings. By physicians engaging in a discussion about the merits of vaccinating your kids, it may lend credence to the extreme minority’s position as a legitimate conversation starter. Last year, noted scientist Bill Nye entered a debate with noted Amish-look-alike Young Earth Creationist (YEC) Ken Ham on whether creationism and a 6,000-year-old Earth is a viable model for our origin. Many people felt that Nye showing up to the debate was essentially giving YECs publicity and a form of legitimization, even though they are an extremely small and vocal minority without the backing of any evidence or scientific merit—much like the anti-vaxxers. The biggest difference being that someone believing Earth is 6,000 years old won’t necessarily raise the chance that my child gets a debilitating illness.

As far as med school teaching is concerned, we are urged to strongly recommend for vaccinations for inquiring patients, but maybe we should also be discussing issues on a larger scale and how it relates to public health. Although we have a bioethics course, which excels at giving students the facts regarding the law and why and how the law was passed, we are never given the tools for how to make more permanent change in the community. We are not instructed on how to engage in ethical discussions about whether or not something like vaccinations should be mandated by the government. In the last decade there have been failed or short-lived attempts at making HPV vaccinations mandatory throughout the U.S. The issue has been up for legislation in nearly half of the states and has failed in all but Virginia and D.C. (it was passed and later repealed in Texas). Perhaps not surprisingly, people would prefer to have the opportunity to make the wrong decision rather than having the right decision forced upon them.

I believe that people are very much products of their environment and will naturally gravitate towards the path of least resistance. Change on a macroscopic scale, like how society views public health mandates, can be unnecessarily slow to develop, except in rare cases like the polio vaccine—which was almost literally an overnight sensation. If many of the medical aspects of how we treat our bodies are dealt with in an “opt out” fashion I believe that we may see a significant increase in the quality of life across all strata of society. A great example of this is Spain’s organ donation rates. They have the highest rates of organ donation on the planet primarily due the country’s policy that each individual is automatically enrolled as an organ donor. If you want your organs to stay in your body to take them with you to heaven (or hell) after you die, you would have to fill out some paperwork. Well guess what? People generally find paperwork to be a nuisance and a tedious endeavor. You want me to fill out these forms just to be able to fill out more forms like we’re in some bureaucratic Soviet state? I’d rather just let you have my organs.

And that is the idea: create a society in which it is commonplace for people to generously donate their unneeded organs and they will eventually do so, not because it is the path of least resistance because it is the right thing to do to save other people’s lives. I envision after years or perhaps generations with a certain policy in place (like having to opt out of donating blood) that when the opt out policy is removed people still donate at the same rate because donating blood is something that people should feel compelled to do to help their fellow man. In the meantime, don’t incentivize performing a positive action, simply tack on some form of negative reinforcement to make a negative action (such as not donating blood or organs) more difficult. This way only those who have a true objection to the task will take these necessary steps.

In all likelihood there is no formal teaching for medical students on how to deal with anti-vaxxers in our pre-clinical years because it may not come up in doctors offices as much as the cable news-watching public may think. According to the CDC, vaccination rates have only had a very modest dip over the past decade and it should be far down the list of concerns doctors have for their patients. Some combination of it being a trendy topic, each patient’s situation being unique, and that it’s just beneath us as physicians to discuss, is what’s most likely being employed by our professors. There is already so much packed in our ever-expanding curriculum that we simply might not have time to really delve into the issues surrounding medical trends. Plus, by the time I actually become a doctor seeing my own patients, the medical landscape could be so vastly different that people questioning vaccinations would be a relic of a bygone era.

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What Did I Just Pay For?

One year down and the greater part of a decade to go. As a first year medical student, having finished class for a couple months has allowed for ample time to digest much of what happened to me over the last twelve months, I can’t help but ask the question: what did I just sign up to pay for?

Students aren’t afforded the time to process the new information, surroundings, and lifestyle that comes with being a med student—it just sort of happens to you whether you like it or not. Medical school confronts students with a unique problem from the very first day of class: too many teaching resources to learn from and not enough time to use them all. It is up to the student to determine the most efficient way to retain information and stick with it for the year. The problem is that different subjects require different types of learning—some rote memorization, others require more critical thinking and problem solving—so there isn’t a magic bullet for getting by. Most students would agree that the material offered in medical school is not particularly difficult, there is just a lot of it. A policy at my school, along with many other medical schools, is to record all lectures and to ease restraints on mandatory attendance. This decision has deep ramifications that may end up changing the face of not only medical school, but higher education in its entirety.

The motivation behind recording all lectures with the professor’s corresponding notes is presumably to make life easier on the students, and in doing so, move medical education into the 21st century. The theory is that if all students have the ability to go back and listen to old lectures surely test scores will rise, as will the scores for the all-important and ever-looming United States Medical License Exam (USMLE) Step 1, which is a national standardized test given to all medical students following completion of their second year.

I’m not complaining. Streamlining content and making it accessible from anywhere on the planet is certainly more beneficial to students than having to attend each lecture and furiously scribble notes while simultaneously attempting to comprehend what is being dictated. I have it easier than classes before me and classes after me will have it easier than me. This is a good thing.

Not all courses involve professors standing in a lecture hall speaking to students. There are several courses in which students are taught how to interact with patients, colleagues, and peers, as well as using small groups and teams to discuss and work through cases. These require the students to be present because some things—like interviewing patients and teamwork—just don’t translate to the digital world yet. While watching lectures at a time and place of my choosing I can pause, rewind, and increase the lecture speed to ensure that everything I need to spend more time on I can go over slowly, and material that I know well I can just skim through.

Every now and then a lecturer will get called into an emergency and cannot attend class, so the lecture from last year on the same topic will be posted online. This is also good. No classes are ever really canceled or postponed due to unforeseen circumstances because there is always the previous year’s lecture ready to be posted at a moment’s notice. Lectures that were canceled but would have discussed updated material to reflect new findings in the field would have an emailed addendum with the additional slides or lecture notes to reflect such changes.

During this year alone our class had over 20 lectures used from last year (out of over 450), most of which came during the unusually snowy winter. I appreciate the option to learn medicine while in my pajamas and not having to go to campus each day, but what if every class simply used the previous year’s recorded lectures and then addenda were sent out addressing the newest research or pertinent clinical findings so that students are current on the given topic? Since the vast majority of students don’t attend lectures anyway this would only affect 2 groups: the professors themselves and the students who do attend lectures in person. I am usually hesitant to call for automation at the expense of other people’s labor, salaries and livelihoods, but if it can be shown that the cost of paying the salaries for lecturers can be used on other important learning tools then I believe it is an interesting proposition. The average medical school tuition is over $40,000 per year with an average class size of 135 students, meaning about 8 full-time professors/faculty making $85,000 a year would need to be laid off in order to reduce tuition just $5,000/year per student. Keep in mind the cost of medical school is far greater than just tuition, and more accurately comes to $60,000 and upwards each year (with many students coming out owing well over $200,000) and does not even include interest. All of this to say that saving $5,000 or so on tuition each year is really only a drop in the bucket from a student’s perspective and money should be spent on technology and facilities that find innovative ways improve learning. Additionally, most of the professors do not teach full time but perform research on campus and use teaching as supplemental income (or it’s part of their contract), or hold other positions on the medical school staff such as advisors, committee members, etc. I’m sure many of the professors would prefer to spend more time in their laboratory and less time in front of students teaching, but would they really wish to do so at the expense of a decreased salary?

However, the real question is: if the vast majority of lectures are posted online, how far away is medical school from becoming an online degree? Facilities such as the simulation laboratory (a robot patient that interacts with student doctors and responds to treatments given), and micro and gross anatomy laboratories have difficulty translating into the virtual world, but with new technology we are not far from having a fully interactive human body that looks and responds to our scalpels in the same way that our actual cadavers do. As technology streamlines education, how will this affect students’ abilities to learn the required material? Most schools have the same core curriculum that covers standard topics that are required for the USMLE. Doesn’t it make sense to have a centralized database in which there are only a handful of professors lecturing on topics to every med student in the U.S.? This somewhat exists already for students studying for the USMLE exams. The vast majority of students use only a handful of resources to prepare for the test. Couldn’t this be adopted for actual school material throughout the year rather than only for USMLE prep?

Curriculum for U.S. med schools is not completely uniform, however, as a school in a rural area will be more likely to have classes that are geared towards illnesses afflicting the surrounding population than a school in an urban environment. This variation can also be accounted for in recorded lectures and shouldn’t deter the schools from adopting more online-only content.

The reasons for having a physical campus for medical school is to be able to put in face time with peers to create a sense of community and attend the occasional classes in which groups of students are required debate and discuss case studies. Extracurricular activities and student groups also need places to meet. Students should meet with their advisors and professors for office hours, although I will admit that the increasing ease and frequency of video conferencing programs such Skype makes this less pressing. Students need to be face to face with their “mock patients” when conducting interviews and physical exams, but even the traditional doctor-patient relationship is becoming a thing of the past. As of this point, learning the hands-on aspects of becoming a physician cannot be substituted for an internet connection. In the same vein, gross anatomy needs to be attended by students because getting close to the cadavers is an important experience that means more than just learning to cut flesh and identify organs. It is important to strip away much of the excessive or redundant amount of information coming at the student, yet keep the humanistic and emotional aspect of learning to become a more complete physician intact.

The physical med school will require adequate study space, but a library with books is certainly not as necessary as it once was. As a matter of fact, I recently received an email from my school notifying all students that librarian hours will be cut to 20 hours per week due to the lack of student demand. Of course the library will remain open 24/7 but faculty and staff will no longer be available for as many hours. With almost all textbooks having digital formats, less and less space will be needed on bookshelves but students should have the opportunity to order physical books through their library, or a central library in a city or region. I began college in 2004 and all textbooks in biology were over 500 pages, weighed 10 lbs. and cost hundreds of dollars with a new addition of the book arriving every other year, making the books resale value almost nil. My younger brother recently graduated from college studying biology and all of his textbooks were digital, much cheaper, contained animations of biological pathways and reactions, and have the added benefit of being able to download updates so that the book always has the newest material. This is how the new generation of doctors will be studying. I still like the feel of paper between my fingers but there’s no reason to prefer it beyond familiarity and nostalgia. Digital formats are superior in every aspect except maybe they’re a little harsher on the eyes (but that could also be because I didn’t grow up staring at monitors).

The med school of the future still needs to contain conference rooms and an auditorium for notable lecturers or guest speakers so that more ears can be reached rather than speaking to a mostly empty room but with a digital camera pointed at the speaker. Something needs to be said about being in the presence of a great speaker who can advocate passionately about their novel ideas, and the sound of clapping that gives energy to a room can really make their notions hit home.

Ultimately if students are doing 80% of their learning in front of their computer screen is there a point where administrators have to be careful so that students don’t start to ask, “am I getting my money’s worth?”

If more schools develop online-only learning tools, how will teachers and professors be viewed by society? Will they be marginalized in their own classroom and become relegated to only answering the sparse questions from the student that can’t find his answer on Google? Will this shift free up more time for professors at higher institutions to pursue their own research or projects regardless of the field? These are the questions that medical schools will begin to face as more universities begin to shift their content into online databases that can be accessed by enrolled students as well as the public.

As tuition skyrockets and students are saddled with hundreds of thousands of dollars of debt, many feel as though they need to make up for lost time not spent earning a paycheck in the workforce and become highly specialized physicians. Highly specialized physicians are great when there is a pressing need for them, but the Association of American Medical Colleges (AAMC) reports that there will be a shortfall of 45,000 primary care physicians by 2020 so more needs to be done to incentivize students to pursue more broad (and often lower paying) types of doctors. There is also projected to be a shortfall of specialty physicians, but if primary care is emphasized in America, the use of specialty physician will wane as diseases and other illnesses will be caught and treated earlier rather than being able to progress to more difficult-to-treat stages which ends up increasing health insurance premiums across the board.

Another effort to lower costs of medical school is being explored by New York University, and having a 3 year medical degree. Although this is a new frontier for U.S. schools, where is the incentive for a private university to completely forego millions of dollars from its students by axing a year of payable tuition? This is another example where the profit-motive and efficient and effective healthcare do not coincide. The medical school industry, much like healthcare in the U.S., needs to reduce costs but maintain its efficiency in pumping out quality physicians. There is a difference between taking shortcuts and cutting corners and right now medical schools in the U.S. aren’t doing either, which is hurting both medical students as well as the future delivery of healthcare in America. The shortsightedness of the medical education system is forcing students to rack up enormous amounts of debt which ultimately will end up harming the population decades down the line either because the debt will discourage enrollment, or students will feel compelled to pursue higher-paying specialties rather than serving in a more utilitarian role. Medical schools would be wise to implement cost-saving measures that may prove to enhance student training while by embracing the latest technological advances. In many circumstances bloated industries and less-effective methods would be phased out by new and cheaper start-ups. In the highly regulated medical school field this type of progress is impeded by old ways of thinking and layers upon layers of bureaucracy. The last thing anybody wants to think walking out of the supermarket, a car dealership, or a campus is, “What did I just pay for?”

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The Tactful Hypocrite

The World Cup, and more specifically its international organizing body, FIFA, has come under immense scrutiny leading up to its 2014 iteration in Brazil. Most criticisms of the situation are aimed at the host country’s inability to provide adequate hospitals, schools, and shelter to its citizens while FIFA, a tax exempt non-profit organization that is expected to rake in $4 billion plunders what it can from its host nations. The tournament’s conclusion will see FIFA leave the host country with a projected $15 billion tab but with beautiful new stadiums that history has shown have little utility once the games have been completed. All this while the vast majority of Brazilians live in an underdeveloped nation where, according to Pew Research they cite their most pressing concerns are crime, government corruption, and healthcare.

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I’ve seen City of God. I know how this ends, and it isn’t good.

Late night comedian John Oliver had an especially poignant if not sardonic (let’s just say I did reputably on the SATs) take on FIFA. I won’t rehash any more of it, but in the end he remarks that he will still watch the games because ultimately he is passionate about the product/sport. Like a drug dealer that knows he’s got the best product around, FIFA essentially has free reign to charge whatever it wants to obtain the largest profit (see: Qatar). It can make ridiculous demands as countries bid for the prestige and exclusivity that comes with being a World Cup host. That irony isn’t lost on me, in which citizens protesting this “coveted” honor have their elected government sending out its own soldiers to protect, well not the nation’s but someone’s interest.

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I am not a huge soccer fan but I will watch some of the World Cup. I image that there are a lot of people that aren’t happy with how FIFA conducts its business but will keep their eyes glued to the TV regardless. After all, it is the most widely viewed sporting event in the world by a large margin so this is the biggest game out there in terms of advertising revenue. I fear that if the Philadelphia Phillies were found to be using sweat shop labor to make their frog lawn accessories I still don’t think I could let myself root for another team—some sacrifices are non-negotiable. But why is this and what is the conscientious sports fan to do? Should I swear not to purchase any products I see advertised during the World Cup for a year? Or should it be two? Maybe I should just agree to only buy the competitor’s products (hello RC Cola, Powerade and Hydrox!) for a time. If I truly wanted to stay away from companies that promote suffering in the world be it directly or indirectly, I’d be a) spending a lot of time doing research and b) lead a much more bland lifestyle. If I don’t wish to separate myself from all companies that promote harm, at what point do I say, “I’m okay with the level of public harm that is caused by Target, but I won’t dare touch any Nike products”?

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What John Oliver doesn’t quite approach but hints at during his monologue is a real problem for those who wish to promote the greater good. For many people to watch the World Cup and turn a blind eye is as easy as can be. For some, like the Danish reporter who got paid to be in Brazil to cover the tournament, he could no longer cover the sport while stomaching the idea of the destruction that FIFA and the government are causing to line the pockets of the few. FIFA is a prime example of a dilemma presented to the public in which an entity that controls a popular and addictive product could be performing a net disservice to the world. Sepp Blatter, President of FIFA, has become the corrupt, sycophantic face of much of the ire. There have been calls on him to not seek re-election as FIFA President, but Sepp, being the consummate professional, has no plans to step down or cease his attempt at being elected for a 5th term. And why should he? FIFA has been widely criticized for its vast—and quite honestly, impressive—displays of alleged corruption for years but people keep coming back in record numbers to watch the sport they love. Changing heads of this often-called mob-run organization will do little to change its destructive ways. If anything, FIFA will find less overt ways to extract money and resources from nations, and perhaps they will skim a little less of the top, but no doubt they will still leave poor nations worse off than before they arrived. This will subdue calls for the abolition of FIFA for a long enough time until people forget about the destruction in their wake.

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Of course FIFA is not the only party at fault, as politicians from the host country use the initial World Cup excitement as a platform on which to seek re-election or push through less than popular agendas. For countries like South Africa and Brazil (and perhaps Qatar in 2022), being awarded the World Cup is a signal to the rest of the world that your country is an official player in geopolitics. Never mind the crumbling infrastructure, protests, and mass strikes, Brazil as a part of the BRIC economies was on its way to playing with the big boys as far as world leaders believe, but now, almost as importantly, it is cemented in the minds of the international public too.

How can I criticize these entities’ clear apathy towards the treatment of the poorer citizens of their host country, even find ways to profit off of it, yet participate in the excitement and pageantry that this spectacle has become? Justifying watching the games at a bar is just one way. Telling myself that I’m not tuning in on my own TV and ratings companies have no way of tracking that I am indeed contributing as one out of those hundreds of millions of viewers. That doesn’t sound so bad actually. I could also justify that not wearing a few pieces of Nike clothing won’t shut the sweatshop down so it couldn’t be all that bad. If everyone thought this way then of course activism wouldn’t accomplish much and corporate interests would consistently triumph.

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Being aware of a cause, although perhaps not actively engaging in protests, writing letters to politicians, or boycotting their sources of funds holds value as well. As Malcolm Gladwell outlined in The Tipping Point, prior to blood doping becoming popular among bicyclists at the turn of the century, there was a time when many honest riders held off on cheating until they believed that they were no longer in the majority of being a clean athlete, or that they felt their chances of winning were too compromised not to cheat. This point from inaction to action (aptly termed the tipping point) can send a shockwave through a movement and can facilitate its growth exponentially. In his example, when the tipping point for doping was reached, a large number of bicyclists suddenly began to dope even though they were initially morally against or ambiguous towards it. There are personal decisions that I can make to try to speed up this point of no return for causes, but being preachy or a wet blanket at jovial events isn’t really as fun as it sounds. Oh I see you’re drinking a cold, refreshing Coke. Did you know Coke is alleged to be involved in murder and torture of union-affiliated employees over the past several decades in Guatemalan and Colombian bottling plants? See, moralizing kinda sucks for everyone involved. On the flip side, going to bed without a roof over your head and with an empty stomach in a dangerous favela also seems pretty sucky.

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Perhaps the salt in the wound for the poor and those that take advantage of the public works is that soccer is their game. One of the biggest reasons that soccer is so prevalent throughout the world is because a ball can be easily stitched together with all kinds of materials, it can be played nearly on any type of ground surface, and it is a fundamentally simple sport to pick up and play with virtually no learning curve. This is not ice hockey that FIFA is “forcing” countries to take on massive amounts of debt and build stadiums for. They aren’t erecting coliseums for polo. Soccer is their game that is getting marketed, re-branded, and sold back to the people for an exorbitant cost. It would somehow be more appropriate if FIFA was displaying games that didn’t interest the very people it screws.

Even in a country like the U.S. that has many adequate facilities already in place to be able to support a large, multi-city “mega-event” such as the World Cup, it doesn’t necessarily make economic sense to become a host. According to economics professor Dr. Dennis Coates in World Cup Economics, on whether the U.S. should seek the World Cup in 2022:

“A study of the 1994 World Cup hosted by the United States found substantial lost output, with the final result showing that the pre-World Cup predictions were up to $13 billion off-target. The existing evidence of negative economic impact from other World Cups, combined with the self-interested motivation of the Bid Committee members and the lack of disclosure of the economic impact study all point to the conclusion that the US taxpayers are better off saying no to an expensive and secretive World Cup bid.”

This dilemma has no easy solution. The name of the game is deciding how much time/effort/money to put towards some causes while justifying to yourself that you don’t have enough time/effort/money to put into other causes. Do you go for the bigger national or international causes because they can help more people, or do you support the smaller or local ones because your contribution can have a greater impact? It’s a balancing act that I haven’t even come close to mastering. Perhaps you’d enjoy stretching yourself thin and just support every cause you believe in, while noble, that route isn’t for everybody. Even if boycotting the World Cup was shown to effectively change FIFA policies how many people have the will power to do so? When sympathizing with those being taken advantage of, it’s a tough decision that often gets overlooked. Everyone has that point that no matter how much you love a team or a product, when the company behind the brand does things that outweigh your personal satisfaction with that product, action needs to be taken. How thoroughly do we really want to investigate companies whose products we utilize? For soccer fans like Oliver it’s a cut and dry decision to watch the games, but more needs to be discussed about the struggle to find your own tipping point.

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On Becoming a Bat

I have volunteered in almost a dozen hospitals and clinics on both coasts, worked thousands of hours in the ER, and I’ve been exposed to the hospital setting for just over a decade. But January 24th 2014 was the first time I was there on the other side of healthcare.

I was out to dinner with my girlfriend of over seven years, Amanda, and a med school friend of ours at a little restaurant around the corner from our apartment in Philly. While we were discussing the motivation and the merits of entering the field of dermatology, Amanda turned to me and calmly said that her face was tingling, pointing to her right cheek. Although Amanda has a long history of migraines this was an unusual presentation. As she was describing the sensation the right side of her mouth was drooping in a manner that I will never forget. Her eyebrows curled up towards each other as if to do the expressing of the fear that her brain and mouth couldn’t do for her–something’s wrong and I don’t know what it is. The look cannot be replicated without actually having facial paralysis, and it is the physical manifestation of a neurological haywire. I tried to remember my EMT training and go through the quick physical exam of a possible stroke patient, but we were in a busy restaurant and I could only ask what I believed to be the most obvious questions that came to mind. After about 15 seconds Amanda’s facial droop subsided and she reported her tingling was gone. Luckily we had already paid the check and we were on our way out after bundling up.

As we stepped outside into the 10 degree chill, we knew we were about the same distance away from two different ERs, and actually had the opportunity to choose. Amanda then thought that she should contact her insurance provider to see which hospital would be most appropriate. The fact that this even enters someone’s thought process during a possible emergency is a sad testament to how ingrained debt and healthcare pervade the American public’s consciousness. Amanda instead decided to call her mom, a nurse at one of the hospitals, and she said to just walk to the closest one, which we did.

Upon registering, Amanda and I sat in the clean, quiet, waiting room for a short while until Amanda’s name was called in for triage. Even though I know that patients that exaggerate their symptoms tend to get seen by the doctor sooner, I was hesitant to advise Amanda to embellish hers, because I somehow felt like this is insider knowledge and “tampering” with the doctor-patient relationship. If Amanda didn’t currently have dizziness or tingling I didn’t want her to lead the doctors on a breadcrumb trail of false symptoms so that she can be seen before other patients. She said that she felt like she may have had a stroke, an honest and serious enough problem that would garner immediate attention. After being sent back to the waiting room again, Amanda was called into a “multi-patient room” which I was not allowed access to. Sitting in the waiting room with a loved one not 100 feet away behind giant doors and a giant security guard and having no information as to when I’ll be able to see her or ask her how she’s feeling was absolute torture.

Having limited knowledge on what the possible causes for stroke-like symptoms are, the worst case scenario always runs through your mind. Trying to keep composure in front of Amanda and even claiming that it’s, “surely not that big a deal if it came and went so quickly”, it is much harder to be confident in what modest clinical skills you have when you are isolated. Having waited over an hour with no news on what the upcoming steps are regarding treatment, the only thing between me and insanity is a shitty TNT or TBS or FX movie with the sound off in the waiting room. I finally received a text from Amanda (I had been texting her asking for updates), telling me to go home and feed the cat because she saw the Resident who would be getting the Attending Physician and that it could be “a while”. I took the opportunity to get some fresh air and walk home (we only live a few blocks away) to gather some things that Amanda might want for a long night…and to feed the cat.

Walking back alone around 11pm on the icy streets, a light snowfall began and somehow made Amanda’s diagnosis even more dire in my mind and me feel more isolated and desperate for answers. How could a healthy 28-year-old who doesn’t have any risk factors suddenly develop partial paralysis out of the blue? Was it a brain tumor, a TIA, does something even more serious exist that I just haven’t learned about yet? Should we have rushed right to the ER, were precious moments wasted when we were weighing the pros and cons of our next move? My thoughts turned toward taking care of her if need be. Would this be a longterm thing? If I had to leave school is it even possible to just take a semester off? Would I have to decide to leave immediately or do I get some time, and who do I contact about this anyway? Perhaps my selfishness was getting the best of me, but every scenario concocted pushed me deeper and deeper into this hole of responsibility that I didn’t know how to get a grasp of. I reached the apartment, gathered my backpack, threw in our phone chargers, brought a book to study and the iPad for Amanda to help pass time. It was 11:15 and I received a text from Amanda saying I was allowed to join her in her room in the ER. I flung my backpack over my shoulder and headed out again, this time a thin layer of snow covered the ice on the cobblestones allowing me to step right on them for traction rather than daintily avoiding their glassy palms. Ah shit, I forgot to feed the cat.

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When I met up with Amanda, she was alone in a corner room of a quiet ER, blood already drawn and an empty urine cup beside her gurney. I gave her a hug as she caught me up on this situation. A resident, followed by the Chief Resident then the Attending Physician had been in to see her and asked her many of the same questions that the nurse, registration and triage had asked her earlier. The next step was for Amanda to get a CT scan of her brain. We chatted away as midnight came and went. The worst part of waiting in the exam room is that you have no idea what is going on around you. As far as we knew, ER techs would be coming to take Amanda to get a CT, but we weren’t given a specific time. Working in an ER, I have dealt with patients that want to know what’s going on, and usually nurses and other staff can really only say just sit tight, we haven’t forgotten about you. Although I knew what the answer would be before the nurse told us CT will come by “soon”, the ambiguity of the answer almost made me feel like these people don’t know what they’re doing. The fact that this even crossed my mind made wonder what the lay person thinks, since I know that the staff is often over-worked and usually is buzzing around from patient to patient, but I still had the audacity to wonder if the ER techs were standing around making small talk. This was my foray into the other side and it didn’t sit well.

Techs came and took Amanda to CT in a wheelchair. She was back within 15 minutes and more waiting ensued. Still with no answers in sight we were told after about an hour that the neurologist would be coming to speak with us at some point to discuss the CT results. Is this good or bad, I wondered? I was trying to piece together the clues that would lead me to how serious the doctors thought Amanda’s condition was. Well, she was not under close supervision–that’s good. She also wasn’t hooked up to any monitor for vital signs–I guess that’s good. She didn’t receive any other meds besides Tylenol–that’s also good. At the same time, is this just standard practice in a neglectful, busy ER where patients are always forgotten and maybe even sometimes left for dead? Also, why would a neurologist need to speak to a patient with a completely normal CT scan, couldn’t the ER doctor just tell us the news? I feared that I knew too much in making me wary of the situation, but not enough to recognize that everything was fine and the hospital was just following it’s standard procedures. Does a family that has no medical background and no idea what could be going on take solace in that their outcome is strictly in other’s hands, or does that make it even more nerve-wracking?

What was taking the neurologist so long? Were they verifying the CT with other expert neurologists in the area giving their thoughts on a rare disease, were they debating how best to deliver terrible news? The longer we waited and the more in the dark we were, the worse it seemed. At 1:30am the neurologist came in to speak with us about what they believed happened–which was nothing. The neurologist was 27 years-old, smooth and confident. I’d like to be like that one day, well except for the 27 part, which I can never be again, but I rather like the smooth and confident part. Amanda had what the neurologist believed to be a “complicated migraine”. Nothing serious it seemed, but Amanda would need a follow up appointment. It’s apparently one of those things that can simply happen to someone that has migraines for no explicable reason, and this could be the only incident that ever occurs in Amanda’s entire life. The doctor performed a neurologic exam, asked if we had any questions, then said she would be back with the discharge papers. About an hour later a different doctor came in with the discharge papers for Amanda to sign. While we were waiting we had thought of some questions to ask about her condition, but when it was a different physician that had entered the room we thought that was a little strange. Amanda asked some questions and the resident said he didn’t know how to answer them because he wasn’t a neurologist and that Amanda would have to call them on Monday. But, but, but the neurologist said she’d be back “shortly”, and not only was it not her that came back, it certainly wasn’t “shortly”. I am truly grateful for the attention and care Amanda received and I realize that in these situations, nothing is ever enough. I get it, 30 years ago if you said you could walk up to a hospital, people could take images of your brain, a doctor could look at it and diagnose you, and you’d be out of there in a few hours, you would be incredulous. This is not lost on us.

As far as I remember, I don’t recall any loved ones having cancer, a dramatic disease, or even getting a phone call about a serious traumatic incident. I am very lucky. I don’t know what it’s like to have someone I love seriously ill, let alone lose someone so close. Every now and then while working in the ER I would come across a patient that would remind me of someone dear to me. A 60-year-old man that has no history of heart problems that suddenly has a heart attack and dies. I think about my father and what it would be like to lose him. Empathy is funny in that it can make you feel profoundly, but that emotion is not genuine. I can think about how sad it would be to lose Amanda, but until I came face to face with that prospect there’s no way to make it real. Every now and then I think of philosopher Thomas Nagel’s paper, “What is it Like to Be a Bat?”, that I read in an undergrad class. The gist is that a human being can never feel what it is like to be a bat, they can only feel like what a human feels like it is to be a bat. This is an important distinction. Prior to getting accepted to medical school I would frequently fantasize about what it would be like to open my mailbox and see a large envelope. Would I jump up and down and shout like a nut, or would I play coy and act like this is to be expected and it’s just a bit of good news? Even when I look back on how happy an event it was, I can never replicate that exact feeling–I can only recall what that feeling felt like–which is not nearly the same thing.

In medical school we are taught and trained to be empathetic and exhibit compassion towards our patients and those that we are providing care for. We spend time in the classroom and watching videos online and writing short essays that exhibit what we’ve learned about how to better understand patients. I have spent countless hours amongst patients in various capacities, and I always thought that I was empathetic towards them, when really I was only sympathetic. I don’t believe it is possible to train someone in empathy. They can learn the tools to becoming empathetic, but without experience we are just doing the best we can. We shadow doctors and even see patients as first year students but unless we have experienced what the patient has experienced we don’t know what it really feels like to be in their situation. Does empathy from a provider really affect patient outcomes, and how would that even be measured? The staff at the hospital Amanda and I went to were courteous, professional, and performed their jobs well. But something in healthcare is missing, and it’s like being a bat. Is spending all the time and resources on trying to get students to become caring individuals actually making better doctors, or better actors? Being on the receiving end of healthcare it is easy to see which providers are going through the motions and which ones are feeling what you’re feeling. Although Amanda and I didn’t admit to each other at the time, while silence filled the hospital exam room between ominous beeps sounding from foreign machinery in the early hours of Saturday morning, we were both terrified. I could describe the feeling to you in as much detail imaginable but you would never know what it was like in that room unless you experienced something similar yourself. And for me, I could try to remember the emotions I felt in the pit of my stomach that night while flipping through a textbook, reading the same sentence over and over again, as I sat next to an energy-depleted best friend–but it will never be as frightening as it was in that moment.

We shuffled home at 3am, hours after we embarked and thankful that nothing serious came about this trip to the ER. Amanda felt fine now, just tired. The heat was left off in the apartment but it was still much warmer than outside. The cat was fed and all was right in the world.

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