Frustrating Patients

My attending and I have a pretty good relationship. Good enough that we can have a back and forth about politics (typically a no-no in the world of medical education and "professionalism"). He tends to point out my leftist tendencies and I point out his right-winged nuttiness. After 3 weeks of working in his clinic, which serves a rather impoverished part of the state, I can see his point of view.

Nearly half his patients have their healthcare covered by the state. This is great, but it seems like those same patients tend to do the worst at taking care of themselves. I don't mean eating right and exercising. I could understand if they didn't have the resources to do that. I mean they ignore doctor recommendations, then get an exacerbation of their disease, get admitted and have a hospital work-up that costs tens of thousands of dollars, get better, then go back and ignore every recommendation made to them. It's frustrating for a physician when a patient who is unemployed (and has no trouble with transport or any responsibilities at home) misses important appointments repeatedly or a patient who has all their medications paid for not taking them. Yes, some patients with good insurance also fall into this pattern, but from my admittedly short experience so far, it's a nearly universal pattern with those that are under the public health plan (and my attending agrees). One assumption I could make is that they have trouble following recommendations because they have a lot of other problems in their lives, but it's hard to tell if that's the case.

No, fear not dear readers (both of you), I'm not becoming a Republican (though my attending keeps on telling me that it's a matter of time). Rather, I think that there needs to be a shift in healthcare resources. Covering expensive medications and procedures is great, but I'd rather give those up for increased education of patients and more access to social workers. Preventative care looks great on paper, but in the real world, it only goes as far as patients know to take it.

Refill on the Vics

So two weeks into a non-academic community setting, I've learned what the real world is like. I'm not so surprised by fact that there are a lot of patients who are addicted to narcotics. I'm more surprised by how there are so many doctors that are feeding their addiction. It's so easy for a patient to find a doctor that will prescribe them some heavy-duty narcotics without too many questions that things that I learned in med school like counseling, pain contracts and limiting refills just plain doesn't work. If legitimate doctors to try to manage their patients' chronic pain without overly relying on narcotics they risk losing the patient and likely the patient's other chronic medical conditions won't be taken care of. Or, they can just write the refill to bring them back and make sure that they have their diabetes, high cholesterol, heart disease, asthma, etc. under control. It's a hard decision to make, but many of the patients in this area just won't see a doctor unless they need their pain meds refilled.

Slow Start

So, I'm officially a doctor. July 1st was supposed to be a mind-numbing experience where I get thrown into the medical system, overwhelmed with things to do and actually get to feel like I'm making a difference in people's lives. Unfortunately, I feel like I've gone back a few years. I start with a primary care rotation. Primary care is not my thing, but I can appreciate the value of health maintenance and getting to know patients and I was looking forward to actually acting like a primary care doctor. To my surprise, I find out that all I do is shadow a physician while he sees his patients. It's worse than 3rd year. At least then I got to see patients beforehand. The clinic I'm at doesn't have electronic records, so I can't even read about the patients. I go in not knowing what's going on and about 30 seconds later come out not knowing what happened. The physician knows his patients and doesn't really need to go into the details that I would have needed in order to diagnose and treat (actually, I'm a little wary of how quickly he goes through patients). It's a complete waste of time. All I can say is that at least I get paid for it.

Last day of vacation

After nearly 3 months off, I'll finally be getting back to the medicine mindset with the start of intern year tomorrow (actually, it's just orientation tomorrow, the real intern year won't start for another week or so). I'm a little worried (ok, terrified might be a more accurate description). I've been calming myself down with the thought that lots of people have been through the same thing and have done fine, but with a 3-month break, I'm sure I'll be a little rusty. I suppose I took a 4-year break from medicine during graduate school and did ok when I got back into things, but med school is not the same as being an actual doctor who's orders actually get carried out. I was thinking of spending some time studying medicine, but there's little motivation to pick up a book and I figure that anything I could have learned on my own during the break would be minimal compared to the vast amount of information I'm about to get forced down my throat.

My mindset right now consists of many conflicts: I'm looking forward to actually starting work (I'm getting tired of being home all day), but at the same time, I know I won't have much of a chance for a break for a long time. I'm excited to see patients, apply my knowledge, try to help people and maybe have some fun along the way, but I'm also terrified I might make a mistake and hurt someone. I'm looking forward to meeting new people, but I'm afraid that they actually might know medicine. I'm terrified that I won't be able to handle the workload, but I'm calm because life at the community-hospital based intern year that I'll be going through won't be anything close to that of the academic-hospital based interns that I got to vicariously live through during my recent sub-I. I'm hoping for starting with something light so that I can get my bearings before getting slammed, but at the same time, I want to get the tough months over with before I get burnt out.

I figure it's no use worrying too much about it. It's not like I can change anything.

Setting up shop in a parking lot

So, after a crazy month, I officially have my MD and have moved to where I will spend my intern year. I'm excited (and scared) for it to start. Orientation is next week, I'm sure you'll hear about it.

In the meanwhile, Mrs. mxh has started her job as a pharmacist. She works one day a week at a pharmacy in a sketchy part of town and it turns out that the doctors there are more sketchy than the patients. There are a few doctors in that part of town that are notorious for prescribing large amount of narcotics, a lot of the times without even seeing the patients. The only thing that comes out of their primary care clinics is narcotics prescriptions and their patients have a suspicious pattern of getting new prescriptions too soon. What really makes it bad, though, is that one of the doctors has a habit of just hanging out at the pharmacy and writing prescriptions for narcotics in the parking lot! Yikes! This isn't something new either, it's well known among pharmacists in the area. Why do these people still have jobs? Why isn't the state medical board stripping their licenses from them? Why aren't they arrested?

Part of the problem is that not too many people report them. But, I think, a major problem is that medical boards are notorious for not punishing their own. Medical schools emphasize fitting in and keeping the status quo. If you bring up a problem, it's better that it is discussed quietly. I think this attitude carries on to medical boards. If they punish a doctor, it'll make the news and that type of attention is something that medical boards don't like. If they ignore a problem, then everything will go an as it has. So far, it's been working, but some day, the narcotic ring that these two physicians are running will make front page news and the state medical board will wish that they have dealt with it sooner.

More bad journals

Synthese - Apparently criticism of intelligent design is frowned upon.

Psychology Today - Racism dressed up as science in the form of an essay by a regular contributor to their website called "Why are black women rated less physically attractive than other women?" Yes, it was quickly removed, but the fact that it was written in the first place is disturbing. How can this guy have evidence that "black women are objectively less physically attractive than other women"? Has he seen Halle Berry?

Both are added to the list.

Torture still doesn't work

I expected the right to give all the credit of Bin Laden's death to Bush (even though he said he doesn't care about finding Bin Laden), but I'm pretty upset that they would try to rewrite history by saying the information leading to it was because of "enhanced" interrogation techniques. Torture is inhuman and the fact that half the country supports it is the most worrying sign about our future. This analysis shows how Cheney and the rest of the criminals in the Bush administration are completely wrong about torture helping the US get Bin Laden.