Category Archives: Medicine

Bernie Sanders-Style Health Care Would Be a Big Win for Low- and Middle-Income Americans

Bernie Sanders just released his new proposal for a single-payer health care system.  As former US Labor Secretary Rob Reich notes, Sanders’ plan would be “a huge advance over what we have now.”  Reich’s summary:

It builds on the strengths of Medicare. Like Medicare, it’s universal — separating health insurance from employment, and enabling people to choose a health care provider without worrying about whether that provider is in-network: All they’d need do is go to the doctor and show their insurance card. No more copays, no more deductibles and no more fighting with insurance companies when they fail to pay for charges.

Through a single national insurance system, we’ll no longer be paying for the marketing and advertising of private for-profit health insurers, nor their giant executive salaries, or their complex billing systems. Government will negotiate fair prices with drug companies, hospitals, and medical suppliers.

The plan’s release came right before the fourth Democratic debate and after a week of attacks from the Hillary Clinton campaign, which had been simultaneously complaining about not having plan details and distorting the details of a similar proposal Sanders introduced in the Senate in 2013.  Even those sympathetic to Clinton have labeled these attacks “questionable” or “genuinely strange,” while those willing to more accurately describe her team’s “GOP fear tactics” have noted that they are “wildly misleading,” “flagrantly mischaracterizing,” “mostly false,” “nonsense,” “disingenuous,” “stupid,” and “dishonest.”  Sanders’ plan would expand Medicare, not “dismantle” it; cover more people, not “strip millions” from coverage; ensure that insurance is provided in every state, not “empower” governors to “take [it] away;” and save most Americans lots of money, not “cost” them.

That last point in particular deserves more emphasis, as it’s one about which Clinton appears to have been lying outright.  Speaking to George Stephanopolous about single-payer health care on Wednesday, January 13, Clinton said: “Every analysis that I’m aware of shows it’s going to cost middle-class families and working families.”  Yet I have never seen such an analysis, and every analysis I am aware of says the exact opposite: that most families would gain big from a switch to a Sanders-style health care system (as Sanders explained at the debate, their savings from not having to pay premiums anymore would outweigh any increased taxes they would have to pay to fund the program).

Consider, for example, a 2013 analysis of the Expanded and Improved Medicare For All Act from UMass-Amherst economist Gerald Friedman.  Physicians for a National Health Program called this bill and Sanders’ old plan (which, despite Clinton’s suggestion to the contrary at the debate, is not all that different from his new one) “simply two expressions of the one single payer concept;” Clinton spokesman Brian Fallon agreed that the two bills were “similar” in a recent interview.  As shown in the graph below, Friedman estimated that everyone in the bottom 95% would see their after-tax incomes rise under such a proposal.  Fallon is clearly familiar with this analysis – he selectively referenced parts of it in the interview linked above – and it’s been the most common citation for cost estimates that Clinton herself has used; it’s near impossible to believe that Clinton was not “aware of” it.

Friedman HR 676

Distributional analysis, from UMass-Amherst economist Gerald Friedman, of a 2013 proposal for single-payer health care.

Friedman now estimates that, “[f]or a middle-class family of four with an income from wages of $50,000 and an employer-provided family plan of an average price, the Sanders program would save $5,807, or 12% of income.”  Similarly, the Sanders campaign had previously estimated that his old plan would have saved a typical family between $3,855 and $5,173.  PolitiFact argued that employers might respond to the financing scheme in that plan by reducing workers’ paychecks, but still estimated, even under pessimistic assumptions, that “the average family would save $505 to $1,823 a year.”

There have also been analyses of proposed state-level single-payer health care plans.  A proposal in Vermont in 2001 would have saved an estimated $995 on average for families making between $50,000 and $75,000 a year, while a proposal in California in 2006 would have saved families in that same income range an estimated average of $2,942 (the poorest families – those making less than $10,000 a year – would have saved an estimated average of $608 in both states).

Each of these analyses indicates that Bernie Sanders-style single-payer health care is a major win for low- and middle-income Americans.  It’s theoretically possible that Clinton both isn’t “aware of” any of them and that she and Fallon are sitting on credible analyses that say something different, but I’d give that possibility much lower odds than Martin O’Malley winning the Democratic nomination.  And while Clinton shifted gears slightly at the debate in response to Sanders’ new plan, many of her comments, like the assertions that Sanders would “tear [the Affordable Care Act] up” and that Democrats “couldn’t get the votes for” a public option during the ACA debate, were still extremely misleading.

This conversation about single-payer health care has become a perfect window into the choice facing Democratic primary voters.  After receiving millions of dollars from the health insurance industry, Hillary Clinton no longer supports the type of truly universal health care coverage she backed in the early 1990s.  Instead, she has attacked Bernie Sanders’ support of such a plan with very similar tactics to those she herself decried in 2008 as “right out of Karl Rove’s playbook” (see video below).  These attacks, besides being dishonest, undermine key Democratic values.

On the other hand, Bernie Sanders has a consistent record of fighting for those values.  He rejects money from special interests and believes, as his new proposal reiterates and he said at the debate, that health care is a right that “should be available to all of our people.”  As he also pointed out, the real question isn’t whether single-payer health care is desirable – it’s quite clearly “a pretty good deal.”  The more pertinent question is “whether we have the guts to stand up to the private insurance companies and all of their money, and the pharmaceutical industry.”

Sanders certainly does.  Let’s hope the voters choose wisely.

Update (5/29/16): The Tax Policy Center issued an analysis of Sanders’ overall proposals on May 9.  While headlines have tended to focus on their estimates of how much the plan would increase the national debt – estimates which other analysts sharply dispute – less attention has been paid to the fact that the Tax Policy Center also found, consistent with every other analysis above, that Sanders’ plans would bring large benefits for low- and middle-income families.

Sanders Tax and Transfer Distributional Analysis.png

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Filed under 2016 Presidential Election, Medicine

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 Presidential Election, Business, 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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A Person Among Machines

34justice’s first guest author is David Fischer, a student at Harvard Medical School and a Howard Hughes Medical Institute medical research fellow.  In this piece, David discusses how physicians navigate “the gray zone between life and death” when they interact with patients on life support.  David studies the effects of noninvasive brain stimulation on movement and cognition and has authored several articles pertaining to neuroscience research, philosophy, and medicine. He has a B.S. from Haverford College, where he studied psychology and philosophy.

David Fischer

David Fischer

The attending physician sat at the foot of the patient’s bed, while I stood watching. He was smiling, but the look in his eyes conveyed far more kindness than his mouth or words could. He reached for the patient’s hand, which was contorted into a strained position, and took it in his. “You’re a lovely gentleman,” the doctor said, his voice quiet but firm. “It’s my pleasure to meet you.” The patient turned his eyes to meet the doctor’s gaze, his neck twisted and cocked at a sharp angle. The patient said nothing, and could say nothing, but kept his eyes fixed on the doctor’s. Several moments passed in silence, punctuated only by the mechanical sighs of the patient’s ventilator and the rhythmic beeping of nearby monitors. The doctor gave the patient’s hand a final squeeze, smiled, and led me from the room.

There was something remarkable about this encounter. It was, in some sense, a mundane scenario: a physician evaluating a patient with spastic paralysis, altered level of consciousness and dependence upon a ventilator. So what made the doctor’s attitude towards the patient so striking?

Treating patients with diminished consciousness and dependence upon life-sustaining technology poses unique challenges to the cultivation of humanity in patient care. In many areas of medicine, the distinction between life and death is roughly dichotomous. When alive, patients can often interact, remember past experiences, and demonstrate their personality. Following a fatal event, the transition between life and death, from a person to a body, often occurs quickly, save for relatively brief alterations in mentation. However, the technology that has permitted modern life-sustaining treatment, such as mechanical ventilation, has complicated this distinction. Following a severe neurologic insult, patients such as the one we encountered can remain in this transition for prolonged periods of time. Patients with disorders of consciousness or severe dementia may appear to lack the memories and personality that made them who they were in life. Yet, by mechanically preserving basic physiologic functions, we can ward off death. In this way, these technologies, though undoubtedly important, can suspend patients in a gray zone between life and death.

For physicians who care for patients in this gray zone, the encounters can be uncomfortable. The ability to interact with people, a skillset developed through years of human experience, is difficult to apply in these circumstances. The moments alone with such patients can be haunting, as one greets the patient by name and then awaits a response. As the silence lengthens, the patient may seem neither alive nor dead, like a ghost of his or her formal self. When the expectant silence is broken only by the mechanical sounds of equipment, technology can feel like the only presence.

Doctors who regularly encounter experiences such as these may come to treat these patients like bodies, like sets of physiologic processes as inanimate as the technology the patients rely upon. This is not to say that such patients are not treated with respect, but that the respect is similar to that paid to a body in a funeral home. This is an approach that protects the doctor’s psyche in several ways. For one, the doctor must often purposefully inflict pain on patients in order to gauge the extent of neurologic impairment. To summon the strength to deliberately injure a fellow, vulnerable person requires a forceful violation of empathy in what can be an emotionally harrowing task.  To do so to a human body – to transform the ‘experience of pain’ into a ‘noxious stimulus’ – is much more manageable. Moreover, the prognosis in disorders of consciousness can often be poor, and the range of therapeutic options is often limited, rendering the physician largely powerless. With patients viewed as bodies, however, the physician is afforded emotional distance from these tragedies, and the instances of clinical improvement are all the more gratifying. Ultimately, for many physicians, eliminating humanism from these interactions is emotionally protective in the care of these patients.

This context is what made the encounter between the doctor and his patient so powerful. It was not merely that the doctor sat at the patient’s side, was polite, or maintained eye contact. We have all learned to do these things. What was striking was the attitude that appeared to underlie these behaviors: despite the patient’s altered level of consciousness and dependence upon life-sustaining technology, the doctor treated the patient like a full person. The doctor, with no expectation of reciprocation or gratitude, was willing to take the time to speak to and hold hands with a person who may not have understood these gestures. The doctor’s time, however, was the least of his sacrifices; by approaching the patient as a person, he rendered himself vulnerable to the emotional hazards of care, from the discomfort of inflicting pain to the powerlessness associated with management.

In addition to emotional fortitude, the doctor’s willingness to treat the patient as a person reflected a poignant wisdom. Much of the discomfort associated with treating patients in this state stems from confronting the gray zone between life and death. Our binary concepts of life and death provide us comfort, distancing us from the thought of mortality. However, life-sustaining technologies challenge this dichotomy, and threaten the view that the line between ourselves and death is a sharp one. In such cases, it can be easier to circumvent these existential discomforts by treating these patients as bodies, dedicating more attention to the monitors and ventilation settings than to the person before us. This doctor, however, was able and willing to appreciate the spectrum between life and death, and in doing so could comfortably recognize, within that spectrum, an ill person in need of compassion. He could recognize someone who was more than the mechanics upon which he relied. This wisdom ultimately empowered him to accept the emotional sacrifices of care and, as was clear to me in that room, allowed him to see a person when few else dared to see more than machines.

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Filed under Medicine, Philosophy

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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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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