Inversely Proportional

I didn't discover the connection, but seem to be living it now.  On a daily basis I can't believe how much emphasis is placed on memorization in medicine. It's rewarded, encouraged and even used to flagellate others in person. It is clear to me though that the relationship is present. As the need for memorization increases, understanding decreases proportionally.

There really is no need to memorize the genus and species of microbes, or the pharmacological reactions and actions that can be easily looked up. Portable technologies and the references they provide have changed the game in clinical practice. The world of information is at our finger tips and accessible. I don't need to know the Krebs Cycle. I need to know how to use it in taking care of my critical patients though. When will medical education move from memorization to that of focus on understanding with the user end point in mind....medical practice.

The use of information is much more important that memorizing it. Yet that is the emphasis found on exams in medical school and on national boards.  The emphasis on memorization in many ways determines our future by selecting out memorizers from users of information for residency based on test scores.

The reality is that medicine is controlled by memorization and performance on exams, guided by results on Step USMLE. Performance on that exam is, for the most part, the determining factor in residency selection. And that system isn't going away easily with the multi-millions that system makes.  Exam, boards and pimping performance (hallway pop quizzes perpetrated on unsuspecting learners) is the core of how medicine teaches and expect learning. But is it really learning at all? Is it really providing insight and apprenticeship to the insight of knowing how to apply the knowledge memorized?

We need more formative and summative assessment that is "application" based and less memorization based exams in medicine. We need a return to a real apprenticeship system that values moving knowledge from teacher to student in clinical practice with application in mind. As a colleague recently wrote, "medical education is failing us" all, both practitioners and patients. It has certainly failed me and gutted my passion on so many fronts.

Terror : Part of Public Health

Imagine riding a bus in Atlanta, Miami or Denver. You are going to the mall to meet your mates and hang out. About 10 minutes into your ride a "blast" rips through the bus throwing you backward. You cut your face on glass, the back of your head on the post behind you. You can't hear clearly due to the blast "ring" in your ears and you are bleeding profusely all over yourself. Your new boots are ruined. You can't find your smashed cell phone on the floor 10 feet back. The man sitting in front of you is more injured and unconscious.

That's sort of what happened in Tel Aviv today. I don't have a dog in this fight. I have no family or political ties to Israel or the Gaza Strip. But it's difficult to imagine living that way; living the reality that rockets are falling from the sky and buses can blow up at any time. This is the reality in Israel today.

And that made me wonder why my Syrian born colleague (a foreign/international medical graduate or FMG/IMG), gaining a great future in medicine training in the U.S., pondered out loud about the "villain and murdering Israelis". Why is it that some believe there should be equal mayhem and death on both sides for there to be a fair fight. That's what he explained.

So I asked our campus police, an officer at a nearby table at lunch..."Does engagement with a terrorist require that the police lose as many officers, killed, as the terrorist they confront on the street?" He laughed. And I already knew the answer. Defense of freedom, justice, democracy and rule of law does not require fair. It requires "superior force" to stop the aggressor. Center mass stops. That is what the hospital police officer said.

It is regrettable that modern terrorist organizations use civilians as shields to deploy arms. As careful as any protective force can be, injuries and death to civilians will then happen. I hate that part about modern warfare viz. a vie, Iraq, Vietnam, Afghanistan etc etc. It's the reality of urban combat and there are no easy answers. But let's not confuse who the aggressor and who the protectors are in any such conflict.

My Syrian colleague and I will remain colleagues and I trust him not to blow up the hospital. I'm not sure my colleagues in Tel Aviv today feel the same confidence in their neighbors. I pray this Thanksgiving for peace and rational clarity at what is really happening in the Middle East and in many corners of the world. I'm thankful for many things, but in this day, I'm very thankful for "superior force", a center mass mentality and safe bus rides to the mall.

Public Health: Terror

Some Stuff I Learned & Read

1. Take a 10-30 minute walk every day. And while you walk, smile; the ultimate anti-depressant.

2. Sit silent for at least 10 minutes each day. Talk to whatever God is for you. Buy a door lock.

3. When you wake up complete, 'My purpose is to____ today. I am thankful for____'

4. Eat more foods that grow on trees & plants and eat less food that is manufactured in plants.

5. Drink green tea and plenty of water. 

5a. Eat blueberries, wild Alaskan salmon, broccoli , almonds & walnuts.

6. Try to make at least three people smile each day.

7. Don't waste energy on gossip, the past, negative thoughts or things you cannot control.

7a. Invest energy in the positive present moment.

8. Eat breakfast like a king, lunch like a prince and dinner like a college kid on a budget.

9. Life isn't fair, but it's still good.

10. Life is too short to waste time hating anyone.

11. Don't take yourself so seriously. No one else does.

12. You are not so important that you have to win every argument. Agree to disagree.

13. Make peace with your past so it won't spoil the present.

14. Don't compare your life to others. You have no idea what their journey is all about.

15. No one is in charge of your happiness except you.

16. Frame every so-called disaster with these words: 'In five years, will this matter?'

17. Forgive everyone for everything.

18. What other people think of you is none of your business.

19. GOD heals everything - but you have to ask Him.

20. However good or bad a situation is, it will change.

21. Your job won't take care of you when you are sick. Your friends will. Stay in touch!!!

22. Envy is a waste of time. You already have all you need.

23. Each night, complete "I am thankful for______. Today I accomplished_____."

24. Remember that you are too blessed to be stressed. 

25. When you are feeling down, start listing your blessings. You'll smile.

26. When in doubt, start with #1 again. Repeat often.

27. Listen more to your heart, gut and less to your head.

Professional Education

There is a science called education.

There is a psychology of communication and information.

There are well tried adult learning tenets.

Medical educators, for the most part, don't know them & don't practice them.

Happy Diwali Fall Festival

Happy Diwali to all of my Hindu colleague brothers and sisters!
सभी मेरी कत्थई भाइयों और बहनों के लिए हैप्पी दीवाली!
For Hindus, Diwali is one of the most important festivals of the year and is celebrated in families by performing traditional activities together in their homes. Diwali marks the attainment of moksha or nirvana by Mahavira in 527 BCE.
Studying and working with many Hindus these past years, Diwali has become part of my Fall Thanksgiving celebration. We should all attain Nirvana and celebrate life and "colors and many sparkles" around us.
Happy Diwali - हैप्पी दीवाली

Gender Regrets

I don't have many regrets in life. I don't regret things I've done that have failed; Still learned. I regret not doing medical school earlier in life. But I don't regret the decision to go late in life. But today I have a new regret.

Where I am, medicine is a man's world. It's dominated by male attendings and women who think they are men or have to make pretend they are periodically. So when a female joins the ranks, you tend to notice. Such was the case recently when a new medical student joined rounds with us boys.

There she was, 5 foot something, with curves from her pony tail to her painted toes all reddish-blonde with a cute Southern accent. All the boys made sure they mentored, led, guided and pimped her. She got more attention than the last Krispy Kreme donut in the nurses break room. She remembered kool little factoids about medicine from her recent reading and studying for Step 2 and was sure to walk briskly with the attending so everyone behind could see her, uh, ya...see her. The boys loved it. I didn't get spoken to, pimped or looked at the whole day. I got no new patients and didn't have to present the few I had. There wasn't time. She was there.

So my regret? I regret not being born reddish blonde, 5 foot something, with curvaceous curves, a cute Southern accent and a decent memory for medical text factoids. Maybe my next life?

Uncertain Certainty

"The problem in medicine is, the body is complex and our knowledge is incomplete. People who want certainty – physicians or patients – are kidding themselves"

The patient perspective is sometimes sobering.

E-patient Dave deBronkart, writing online from the patient's perspective, grabbed my attention with "Expecting Doctors to be Perfect is a Setup for Dysfunction"

And the corollary from the e-doctor perspective is "Expecting ourselves to be perfect is dysfunctional", yet it is the core of performance in post-doctoral training. And with so any being intellectually perfect, the stakes are higher and more significant.

Mr. deBronkart quotes a study involving after death autopsies stating that 10-15% of "cause of death" and "final diagnoses" are actually incorrect. I'm not surprised. We have so much technology but so little real insight into disease particularly when it involves multiple systems. It's not that we don't care, or don't want to do good...we do. But..."the body is so complex and our knowledge so incomplete" that we can't be certain at all.

But the system deals regularly in absolutes, teaches great certainty, extolls the virtues of greater insight into our belief system. It's a mismatch with the true reality of what is. And it's what makes learning in this bad system even worse. I'll go out and do my best today, with the limited knowledge I have, about the complex systems we deal with, and try to make sense of the environment that creates uncertain certainty. At least, I'll certainly try to be as certain as uncertainly possible. Of that, I'm certain.

A Year Inside a Medical Residency

In a recent Atlantic opinion piece, Dr. John Schumann speaks of the sometimes cavalier nature of medical practice and education among new physicians. In  the article

http://www.theatlantic.com/health/archive/2012/11/a-year-inside-medical-residency-part-2/264523/

Dr. Schumann notes talks about overconfidence and the confidence-knowledge gap present in the early phases of learning.

"This confidence-knowledge gap is normal in medical trainees. Coping with stressful environments like residency necessitates that learners find some element of near-mastery in the early phases, or else the ego can be severely bruised."

My ego was thrashed long ago. I have none left. But the bruising continues.

Morphed Discussion, From Here to There

We did it! Moved in one conversation from a city in Texas to Mongo, of Blazing Saddles fame.  I think this is how it happened.

Patient has a fungal infection of some type the requires special testing to determine it's species.

There is a great lab in Tyler, TX that apparently is quite good and known for genotyping and/or categorizing such infections for ultimate prediction of best antimicrobial to use on the patient.

Know what else Tyler TX is famous for? Earl Campbell, great football player.

Football players have short "sport" lives. Earl had about 8 years. Most, particularly linemen, get about 3-5 on average.

Know what a linemen made playing football way back when? Under $50,000. Many had to work extra jobs in the off season to maximize year round income.

Alex Karras was a football player who had to work in the off season. He chose acting.

What character did Alex play in Blazing Saddles? Mongo!

http://www.imdb.com/name/nm0440090/

So from Tyler TX to Mongo....No wonder rounds take so long to finish.

Models Abound Elsewhere

We spend way more, and get way less. And worse, we train future doctor to behave the same way. There is no end in sight to this madness called U.S. medicine in my very humble opinion. I don't have the answers but I believe that only through regulation and strong oversight can we make it succeed. Leave it to the local entities (hospitals, etc) and they'll make improvements with profit in mind. Because in the end, medicine is a business guided by legal and clinical experience and guidelines developed over many years of trial and error.

The real bottom line is providing the best care, with the best outcomes to everyone while not spending ourselves, nationally, to disaster. I get that this is not easy, because it's really not. But I see clearly that much of it emanates from antiquated institutional policy providing misguided medical education to poorly chosen future physicians. The system is thick with politics (no matter what you call it) and won't change easily if at all, without strong outside intervention....outside of academics, medical associations, politics and the pharma/insurance mega beast.

What do all the countries who do better have in common? Centralized, one payer medical systems funded by national health taxes or equivalents. They also free institutions and individual physicians from "trying to figure it out daily" and provide a framework for both clinicians and patients to flow into. We need strong reforms in this area in the U.S. and the models in other civilized countries is clear. Not easy, but certainly clear. And they have been doing it for much, much longer than we. Why can't we fast forward, and take back medicine to it's rightful place in society?