Island Med Student

Have you ever seen a doctor for a simple complaint and been subjected to a plethora of blood tests, scans, x-rays, urine screens and other investigations, only to be told that you had something obvious that could have been diagnosed without a single test being performed? Perhaps you were sent home with a prescription, or maybe you were just told to go home and see if the symptoms resolved on their own? Many people would feel relieved to know that their doctor ruled out every possible diagnosis with all the various tests. Some people might feel frustrated that they had to be poked and scanned so many times, only to be told that they just needed to wait and see if they felt better in a few days or weeks.

An article recently published in the New York Times touched on this very topic. The author describes how medical testing has been on the increase for a while. He suggests that because of reductions in Medicare payments and the decline of reimbursement rates, doctors have to subject patients to many unnecessary tests just to break even. In addition, many people demand that doctors perform as many tests as possible. There’s a perception that more tests equals a more thorough investigation, and a higher quality physician.

I think there is some truth to his argument, but I think the problem is multifactorial. The number of medical investigations that can be performed has increased substantially over the past few years, for many different reasons. Part of the problem, however, is that many of these tests don’t necessarily rule in or rule out any diagnoses. While I’m not arguing that these tests aren’t important, I’m just saying that they don’t always aid in diagnosing a patient or even lead to a treatment plan.

All of these tests come at a hefty price. According to the article, the overuse of healthcare services probably cost hundreds of billions of dollars last year. And the data suggest that this increase in services is not causing a concomitant increase in the quality of healthcare in the U.S.

The question of whether or not to pay for expensive medical testing was really drilled home with me during the past two months. I’ve been rotating at a hospital in Dominica with much fewer resources than U.S. hospitals. In addition, the average patient is not wealthy and does not have health insurance. Not long ago, I met an elderly gentleman with obvious signs of a stroke. Unfortunately, he could not afford a CT scan, nor an MRI, for which he’d have to be sent off island. We ended up doing the standard interventions with the assumption that he did in fact have a stroke. He ended up faring about as well as he would have if he had the proper diagnostic tests. Obviously, it might not have turned out this well. It’s possible that he could have needed a surgical intervention, but since we don’t have a neurosurgeon on the island, he wouldn’t have been able to get the surgery anyway.

I’ve been amazed at how well the hospital here runs, even with very little means. Patients still get a good quality of care. Of course there are exceptions, but many patients are successfully treated at very low costs. The clinicians at the hospital are all too aware of the deficits, but they use low-tech methods of good history taking and physical examination to diagnose patients.

Because of the current structure of the healthcare system in the States, I don’t predict that rising healthcare costs and the misuse of diagnostic testing will decrease any time soon. But I think that as doctors and future doctors, we should all do our best to not add to the problem. The next time a patient comes in and we consider performing a huge barrage of investigations, we should ask ourselves how much information we really stand to gain, and whether or not it will actually benefit the patient.

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I just completed my HIPAA awareness training via an online application. The training involved reading a bunch of text, and then taking and passing (with a 70% or higher) a final quiz. We were told that it would only take 2-3 hours to complete. It took me about 20 minutes. These sort of training applications always crack me up. I used to have to take these kinds of quizzes at my old job at the AAMC. I’m convinced that a monkey could probably pass it with a 70%, and even if you don’t pass on the first try, you get as many attempts as you need. And I’m pretty sure that they use the same questions on the re-take (and you have access to the answers as you take it). I realize the importance of “compliance” and “adequate training” on various laws and policies such as HIPAA, but it all just seems so dumb downed, and it makes me wonder how much is really learned. Anyway, I passed, so I can now rotate at US hospitals with the confidence that I’ll never violate any confidentiality laws. Ummm, yeah.

I recently got a chance to watch Michael Moore’s latest film, “Sicko.” I’m not going to launch into a critique of the movie, but I’ll say a few things. I think that in general, it was a wonderful film. While I don’t necessarily agree that socializing the American healthcare system is the panacea for our healthcare problems, Moore did an exceptional job of bringing the issue of our healthcare system woes to the forefront. Honestly, I cried during a good portion of the film, because I take the problems with healthcare quite seriously, and I couldn’t help but empathize with the stories of all the people who had lost so much because of our fragmented system.

When I decided to enter medical school to become a physician, one of the issues on my mind was the current status of the American healthcare system. As someone who has worked in both hospitals and for a healthcare association (not to mention being a patient), I’ve seen the healthcare equation from many different angles. And none of the angles look very promising. The American system is broken. I don’t believe it’s hobbling along, or having difficulty, or needs a “fixer-upper.”No, it’s really broken beyond repair. It simply doesn’t work. It doesn’t matter if you’re rich or poor or black, white or purple, you will have to come in contact with the healthcare system at some point. And chances are, it won’t be a pleasant experience.

So, deciding to be an employee of a system that is failing just about everyone was a very difficult decision to make. In fact, it was one of the reasons that I hesitated even taking on this monumental task. But I eventually decided that crippled system or not, I was going to be a part of it. Honestly, I think it was the dreamer in me that decided to go for it. I wanted to believe that if I did everything I could possibly do, I might be able to navigate the system and still help everyone who needs help. Of course, every day that goes by I see the realities of the system (and I’m not even in my clinical years yet), and the dreamer in me is beginning to lose sight of my dreams.

I don’t know what the solution is to our broken healthcare system, and I don’t know if anyone really does. But at least most of us do agree that it is broken. I guess that is an important first step. Perhaps within my lifetime, I’ll see the next step. Hopefully, someone will find a way to cure the sick system, and do it with the same sense of urgency that they would to cure a sick patient.

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According to the dictionary, the definition of compassion is, “a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering.” I have always believed that compassion is a necessary prerequisite for a physician, yet I have met some physicians and physicians-to-be who don’t appear to have a well developed sense of compassion.

After a conversation that I had with a fellow medical student the other day, I started thinking about which qualities are inherently necessary for a medical student to possess, and which ones can be learned from instruction. Can common sense actually be taught? Is a knack for science a necessary prerequisite for being a good doctor? Must a doctor actually be compassionate in order to be effective?

I can’t help but think that compassion is most definitely an integral component in effective healthcare. Perhaps I just can’t comprehend a world in which people would be able to heal the sick without being compelled by a need to alleviate suffering. But, we’ve probably all known a few doctors who don’t seem to truly care about their patients. The reality is that they exist, and the truth is that it is sometimes the educational system, as well as a largely disjointed healthcare system, that actually contribute to the apathy of physicians.

I look around at my fellow classmates and I wonder if all of them are inherently compassionate people. Do they even need to be? Should the educational system be designed in such a way that compassion is taught with the same fervor as biochemistry? If medical students are not compassionate to begin with, will the system end up helping them grow into caring doctors, or will it have a deleterious effect on their humanity?

To me, it seems like compassion should either be a prerequisite to medical school, or it should be integrated into the curriculum. I know that admissions committees do everything they can to only accept qualified candidates, and that many of them value compassion as an important quality. But would they be more apt to admit the 4.0 GPA student who doesn’t have any obvious compassionate qualities, or the 2.0 GPA student who truly believes in alleviating the suffering of the sick? It certainly is a tough decision.

Many medical school administrations are taking active steps towards guaranteeing that they are producing proficient, as well as compassionate doctors. But I’m not convinced that they are always successful. It seems harshly ironic that the very system that is dedicated to producing skillful, compassionate doctors, is the cause of many students’ declining empathy towards patients. Perhaps the real question we should be asking is, “can compassion even be taught?”

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We had a lecture last week on hypertension for our “Doctor, Patient and Society” class. Our professor made an interesting comment, which I’ve been pondering over for the past couple of days. He mentioned that untreated hypertension is an important cause of kidney failure. If left untreated, hypertension can lead to a patient having to go on dialysis and can eventually lead to death. For more affluent patients in the U.S. and other developed countries, this is not something that they’ll ever have to face. With the proper medical attention, a patient with hypertension can live until a ripe old age and will never have to worry about facing the frightening prospect of undergoing dialysis. But there are many people who are not so lucky as to have the benefit of adequate medical care.

My professor used an interesting analogy to describe the current situation of hypertensive patients worldwide. He said that if you blindfolded him, and placed him in the dialysis unit of any hospital in the world, he would immediately be able to ascertain how developed the country was, merely by looking around at how many of the dialysis patients were there because of untreated hypertension. The reality of healthcare in America is that the dialysis unit of a hospital in Kenya, compared to a hospital in an impoverished neighborhood in Chicago, may look exactly the same. Most of the patients on dialysis are not there because all attempts at preventing kidney damage had failed, but because they had not received any preventive medicine which would have treated the hypertension before it led to organ damage.

The solution to our international healthcare problems is certainly not obvious. Everyone has their own version of the answer. The reality is that improving the health of humans on this planet is a task which will never be completely finished. But it seems obvious to me that one of the easiest things we can do is focus on preventive medicine. If we can do something now to address the health of the world’s population, perhaps we can alleviate the need later on to find ways to heal the sick.

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