King and King

We've been going to the library and randomly grabbing children's books to read to mxh jr (he has no idea what they're about, so any book will do), and we happened to grab a book called "King and King," about a prince who needs to get married and can't seem to find the right person. All the princesses don't cut it out for him. Finally, he sees the person of his dreams (and from the title you could guess that it wasn't a princess). Pretty cool. It's about time that children get exposed to all types of relationships and learn that love isn't about gender.

Of course, some people aren't happy to see this book in libraries. The Amazon reviews bring out some less-than-enlightened reviews. And someone tried to sue a school for having the book, claiming that "the book in school constituted sexual education without parental notification." Pretty lame... with that logic, you'd better get rid of every other book that ends with "and they lived happily ever after." Luckily, the judge threw the lawsuit out saying, "Diversity is a hallmark of our nation."

4th year and radiology

So, I've decided to go into radiology and am starting the last year (#8 - can't believe I've spent nearly a decade here) with a radiology clerkship. Since I last took radiology before 3rd year actually started, now that I've actually experienced a lot of what medicine has to offer, sitting behind a resident or attending while they look at images actually isn't that bad. In a previous post I complained about how med students don't get the most exciting experience in radiology, but I've learned on this rotation, that you actually can. The best way to enjoy radiology is to do it yourself. With 3rd year behind me, I can actually make a reasonable attempt at reading some images. So the advice that I've been given (which works pretty well for me) is to find a free computer in the reading rooms and look through the new studies on your own and try to come up with a diagnosis. Then when the resident or attending go over them, you'll get much more out of their discussion. Amazing how in a few weeks those images that I could make little sense of actually start being somewhat meaningful (I'm looking at you ultrasound).

USMLE Step 2 CS: A waste of $1000

I recently took the clinical skills (CS) portion of step 2 of the US medical licensing exam (USMLE). It's a whole day of interviewing standardized patients (actors), writing notes, coming up with possible diagnoses and ordering lab tests. It definitely covers what every physician should know. What's upsetting though, is that it's a recently-introduced exam that costs $1295 and has a 96% pass rate (and supposedly 100% at our institution). So essentially, every medical student in the country (something like 15,000 students each year) has to take the exam so that only 600 (most of whom probably also have terrible grades and are unlikely to match into a residency program anyway) could be weeded out. We live in a culture of standardized testing. There are whole industries surrounding it (books, tutoring, computer programs, testing centers, patient actors, etc.). So, its not surprising that the company administering the medical licensing exam would like to add yet another exam for students to take. What's disappointing is that physicians in charge of medical licensing go along with it. Residency programs don't care about your Step 2 CS score and I highly doubt that there will be less dangerous physicians around because of this new exam. My cynical opinion is that someone decided that they could make an extra $20 million each year off of medical students and "convinced" those in charge of medical licensing to go along with it.

Oh well, at least I'll never have to deal with fake patients anymore.

Seven alternatives to evidence-based medicine

Two more days of 3rd year left... can't wait.

This article is a pretty funny (but in my experience true) description of how some doctors justify their treatment plans. My favorite:

Eloquence based medicine---The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

Bad science in clinic

I was very disappointed by my recent preceptor, who's pretty good with practicing evidence-based medicine (even when it contradicts the current trends), at recommending an unproven treatment to a patient. We had a patient with reflux disease who was well-controlled with a proton-pump inhibitor (PPI). He suggested that acupuncture might be a good alternative. Then went on to describe this study, in which patients who failed standard therapy with a PPI were randomized into one group that received a double-dose of PPI and another group that received acupuncture in addition to the standard dose. Surprise, surprise, the acupuncture group got better. This is a terrible study that is doing nothing but comparing apples to oranges. First of all, if patients failed standard therapy, the chances of failing a double dose is pretty damn high. Second, where is the control for acupuncture? How do we not know that the acupuncture group is getting a placebo effect? They could have easily placed needles in the wrong places as a control. Third, this doesn't even apply to the patient we were talking to, she was responding to PPIs. Overall, terrible advice by an otherwise well-informed doctor. At least he described the methods to the patient. Luckily, the patient preferred sticking to her trusty PPI.

The one thing I learned from the paper: In the UK, GERD is called GORD (gastro-oesophageal reflux disease).

In the donut hole

Ms. X is a 80-something year-old woman with congestive heart failure, high blood pressure, diabetes, rheumatoid arthritis and asthma (among other things). She on about 15 medications that adds up to nearly $4000 a year. Unfortunately, this falls right in the middle of the famous donut hole of Medicare Part D (the prescription coverage part of medicare). I never really thought much about it until I saw how this affects Ms. X. Here’s Medicare Part D’s payment schedule from 2010:

If your drugs cost between $2830 and $6440 per year, you get no coverage, but if your drugs cost more than $6440, you get 95% of it covered by medicare. This makes absolutely no sense to me. I was wondering how the hell this came about and it turns out that it’s the consequence of two separate coverage plans (one clearly made completely independently of the other). There’s Medicare initial drug coverage that covers 75% of all drugs on the formulary from $310 to $2830 (there’s a $310 deductible). Above $2830 there is no additional coverage by Medicare’s initial drug coverage. However, if you have to spend (out of pocket) more than $4550 (that’s your prescription drug costs go over $6440) Medicare’s catastrophe coverage kicks in. At this point, Medicare pays 95% of anything that goes over. Medicare does have an “Extra Help” program that includes coverage of the donut hole, but you have to make less than $16245 a year to qualify (not really much). Ms. X is a widower who rents an apartment in town. She has an income of about $18000 a year. She makes too much to qualify for the extra help. She can’t really afford to pay an extra $60-$80 a month that the extra “gap coverage” insurances cost. Now, I don’t spend much money, but I know that you really can’t do much on $18000 a year, especially if you have numerous chronic medical problems. Ms. X has gotten to the point that she is not eating well, she’s not filling some of her prescriptions and has even resorted to taking her son’s albuterol (he has private insurance) for her asthma.

Luckily, the healthcare reform package that recently passed will start closing this donut hole, but it looks like it won’t be until 2020 before the gap is completely closed. I’m not sure why it should take 10 years to fix it. I’d bet that none of the people who set this system up or who decided that it's ok to wait 10 years before closing the gap have an 80 year-old grandmother who steals their albuterol.

4th year will be sweet

Just about done scheduling 4th year and it looks like it'll be nice. Right now I actually have 22 weeks off! Of course some it will be taken up by taking the boards and interviewing for residencies, as well as research (and maybe I'll add a few more rotations later on), but it sure will be less hectic than 3rd year has been. What I'm really excited about is the end of working for grades, good evaluations, exams, busy work, etc... I will finally (with few exceptions) be able to spend 100% of my time in the hospital on learning what I am interested in. I kind of wish all of med school was like that.