April 30, 2008

This is my lazy post.

The last week has felt about as mundane and routine as medical school can be. I am sure there are some hidden insights and jokes in there, but I'm too busy just cruisin' along to notice I guess. So, this is my opportunity to poll you, my wonderful 13.8 unique visitors a day, about what you want to know. The question box is now open:

April 24, 2008

MedZag: Socially Isolated, Unloved Medical Student

So we recently had a series of sessions on "breaking bad news." The scenario we focused on was trying to tell a woman that she had leukemia - the crux of the series being that from the moment you break the bad news, Joanne goes from simply being "Joanne" to "Joannne: Leukemia Patient," until the point she becomes "Joanne: Leukemia Survivor" or "Joanne: Leukemia Victim." She will never be able to remove herself from that moment when the word "leukemia" comes out of your sorry mouth. It will forever come to define who she is and who she will be, and be a part of her from that moment on. Truly thought-provoking stuff. With all the reverence given to such a serious subject, I began to think of other correlary conversations that are equally life changing:

"Mom and dad, I'm gay."
Jenny goes from being "Jenny" to "Jenny: The Black Sheep"

"I'm sorry we didn't tell you sooner Betsy, but, you're adopted."
Betsy goes from being "Betsy" to "Betsy: Unloved Child"

"Joe, I love you." "WTF Brock?!?"
Joe goes from being "Joe" to "Joe: Object Of Man Crush"

"Suzie, I have something to tell you. Your mother, she is also your sister."
Suzie goes from being "Suzie" to "Suzie: At Risk Of A Plethora Of Consanguinous-Related Genetic Disorders"

I could offer some real and meaningful insights now about the difficulty and anxiety associated with difficult bad-news conversations, but for now I think I'll just ride the funny wave.

April 23, 2008

Because I Can't Treat Myself

So I've been pretty sick this week. I attribute this to a conversation I had on Sunday about how it was remarkable I had escaped the winter unscathed by any illness, the karma gods hearing my brash comments, and proceeding to strike me down with an acute upper respiratory tract infection.

Now being sick sucks, but being sick in medicine seems to step beyond that... it's almost taboo. Part of it makes sense, I guess - akin to a Banana Republic employee showing up to work in 10 year old sweats or an interior designer having an apartment that looks like it's a bachelor pad from the mid 70's (though I guess retro is in these days, or so my cosmo tells me). There seems to be a perception, even subconsciously held by health care practitioners, that since we deal all day with studying and treating sickness, we should be able to avoid the black magic we conjure. There does seem to be some truth to this. As a gross generalization, people in medicine seem to be much more vigilant about taking the vitamins, washing the hands, and living healthy than the general public. Maybe its a self-imposed responsibility. Maybe its hospital protocol. Maybe its expectations that in medicine we have too much to do, too much work to afford the time to give our bodies time to heal.

But being sick still sucks, and really is unavoidable in the grand scheme of life. Trying to focus your mental energy on learning the clotting cascade simply does not seem to mesh when your body is focused on fighting an infection. And my preceptor seemed almost offended that I would not be able to report to clinic because I was under the weather. Who cares if I was going to be around immunosuppressed children and could at any moment break into a coughing fit that would deposit my right lung onto said child's face? How dare you be sick. I've heard grand stories of physicians battling through their illnesses. Residents taking call with a nasty case of gastroenteritis - running to the bathroom in between patients. Surgeons operating days after having an MI. It's admirable, and I'll probably be guilty of similar shenanigans in my lifetime, but also strikes me as kind of stupid. What if that resident makes a stupid mistake because the acidic taste in their mouth haywired their brain function? What if that surgeon goes down in the OR with a recurrent MI from pushing too hard when their heart is too weak?

I guess it comes down to the age old debate of where one's responsibility to their patients clashes with one's responsibility to their self. Most would argue your allegiances lie primarily with the patient. Most would also argue that you can't adequately serve the patient if you cannot first serve yourself. Still, I wonder what a patient's reaction would be if they got a call from their doctor's office saying their appointment was canceled because the doctor called in sick?

April 9, 2008

Can I get my marrow in gunmetal silver?


That's a lot of money. That will buy you a lot of cool things. For example:

A Rolls Royce Phantom

A Necklace

A Yacht

A Nice House

And most importantly, it will buy you this:

A Bone Marrow Transplant.

$350,000. That's a mortgage to some people, but its also the mortgage on your life for people with leukemia and hematological diseases. Most insurance companies will cover some of it. Only the really good insurances cover all of it. And patients have worked out some really creative ways to raise the difference. Bake sales, fund raisers, church gatherings, newspaper ads, dances, concerts, you name it, it's been used to try to gain a cancer patient a second lease on life.

My preceptor's least favorite clinical encounter is when a patient comes in expecting to talk about their transplant, and instead has to talk dollars. Such is the reality in medicine where monetary value is assigned to human life. I was blissfully naive on the state of the health care system coming into medical school. During one of my admissions interviews, a physician asked me what I thought was the #1 problem with health care today. I replied, essentially, "Drug companies. Hiking those prices. Gotta cut 'em down."

*smacks forehead* It's a wonder I got accepted there.

But the more I learn, the more I learn there aren't easy answers. The system is broken and propagated by all members of it. Drug companies propagate it through advertising propaganda and skyrocketing drug prices, which are necessitated by the financial reality that they are just a few failed drug away from bankruptcy. Insurance companies propagate it by cutting corners (aka peoples' lives) to compensate for a drying up subscriber base as more people choose to hedge their bets and go insurance-less than pay unreasonable premiums (though I definitely have less sympathy for insurance companies). Patients propagate the system by expecting a level of care beyond which our economic model can support, refusing to budge in the voters booth when it comes to lowering their standards in order to raise the standards of the uninsured. And yes, physicians are culprits, having to walk the tightrope act between all parties, often having to compromise small aspects of their own personal beliefs in the name of the evil reality called "doctors don't make as much anymore, you got a family, and you're in a crapload of debt."

Last monday, we had to talk $350,000. A woman came into clinic with her 1 year old child - diagnosed with Hurler's Syndrome, a rapidly progressing genetic disorder which, if left untreated, kills its victims by the age of 5. A successful marrow transplant means a cure - even more so than kids with cancer can look forward to. The mom is in clinic and ready to talk transplant. Only problem is, the insurance doesn't add up. The policy is bizarre. It will pay for transport of the donor marrow to the hospital of transplant. But it won't pay for the HLA typing and searching required to find a donor. It will cover part of the cost of the stay during chemo and transplant, but not all of it. All in all, the mother's policy falls about $30,000 short of the full cost of transplant, and thats if the transplant goes without any complications - opportunistic infections, prolonged acute GVHD, and such. If such things happen the hospital bill can reach 7 figures, all on the mother's tab. The mother is not poor, so she fails to qualify for state aid. She is not rich, so $30,000 would essentially financially cripple her. My preceptor can do certain things behind the scenes to cut cost - ordering diagnostic tests from the endocrinologist so it doesn't count toward the transplant cost, using cord blood instead of a full marrow donor, etc, but we're talking fractions of total cost.

I found this case essentially profound for several reasons. (1) Hurler's syndrome is a ticking time bomb with rapid progression. In the time it takes to raise the difference, the poor child's bone, liver, and brain are slowly deteriorating, to the point where he may not tolerate the necessary chemo to produce ablation of the marrow, he may develop lifelong cognitive and orthopaedic disability (2) The transplant is a cut and dried cure. There is no risk of relapse, and we've gotten very good at managing transplant complications. (3) This is a 1 year old child. A child with a chance at a normal life, or just as easily a life riddled with hardship.

Like I said, there are no easy answers. And navigating the financial landscape of medicine is one of those areas we are simply expected to learn and find our way in. We can read articles and spout statistics, but ultimately it comes down to the human relationships we build with our patients and our oath to treat these patients to the best of our ability. It's hard to treat when your hands are in handcuffs. Every physician wishes they had an easy button to push to deal with these difficult situations, a money tree to go harvest to make everything better. But unfortunately the botanists are still working on that one.

Sorry for all the depressing posts lately. I guess thats a byproduct of rotating through a difficult specialty. But its the difficult cases that ultimately hold the truest lessons. I promise a couple more humorous posts soon. We start our last integrated class tomorrow, which will take me through mid-June and freedom. The light at the end of the tunnel is finally in sight.