Yesterday I worked at my dad’s office again, but our “patient accounts manager” (translation: office bill collector) Betsy, was back. She showed me some more of the ropes–new patient forms, drug refill requests, the whole shabang. A few comments:

* I’m curious if other private practices–or even other private psychiatric practices–are as understanding about late bills. Because patients have conditions that may keep them from remembering to pay–or not having the money to pay (mental illness can cause people to lose their jobs and insurance)–it doesn’t seem like a very strict policy at my dad’s office. I know there _are_ discussions when patients are way overdue, but in every doctor’s office I’ve ever visited, the co-pay is the ticket to see the doctor.

* It’s a sad state of mental health stigma and/or insurance companies’ “pre-existing condition” crap when a fellow health care professional that’s seeing a psychiatrist prefers to pay out of pocket instead of having his insurance billed. Then again, if at *any* time you were prescribed a drug to treat depression or anxiety, insurers may deny you individual coverage , according to the Georgetown Health Privacy Project .

* I think it’s great if patients can get all the drugs they need from free samples, but the drug companies are clearing doing it to make a profit; some of the patient-assistance programs are easy to navigate, while others, like GSK’s Bridges to Access require proof of income statements and all these means testing hoops.

* If the technology revolution is already here, it missed the medical community. My dad’s as much of a techno-geek as anyone, and even though he still manages his patients through a secure online database, he still has to print out the webpages for drug refill approvals instead of just clicking a button. Maybe e-ink is just around the corner, and it it’ll be easier to patients to provide their information digitally, but we still have to take address, phone, and social security number data over the phone, write it down, and then later enter it _manually_ into a computer billing database. Technology’s supposed to make our lives easier, not add another step of work (or just a different one) into the day. I know there’s security and privacy issues, especially now with HIPAA in place, but you’ve gotta be kidding me that there’s nothing cheap enough for small private practices that could link up securely with other practices’ databases and the hospital. Jason made a small CMS for his hospital–maybe I could do something similar for the Arbor Free Clinic .

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From Metafilter comes a fascinating fotolog from ekavet, a tumor surgeon and medical photographer, as far as I can tell. Be forewarned, if you’re a needle or blood phobic (that’s aichmophobiacs and hematophobiacs), you might not want to visit; the pictures are pretty graphic. As a medical student who’s still waiting to work in the anatomy lab, these pictures are interesting and well-documented. Ekavet replies to people’s questions about each picture–from pediatric cases to hands to small intestines . Definitely one to add to your blogroll.

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My dad’s secretary and billing manager was out for the day, so just as children do in the family business, I came to help out for the day. I’m kind of surprised–out of all these years of both wanting to be a doctor and my dad as one–I had never spent a day in his office before. I’ve shadowed plenty of doctors in the hospital, and even interviewed some, but never spent much time in a private practice.

The day started out pretty damn early (7am); most doctors that have their own private practices are basically small businesspeople, and if they’re small enough practices like my dad’s, the doctor is the office manager, accountant, and everything in between.

I mostly answered phones all day, scheduled appointments, took messages, and greeted patients. The highlight of the day was my very first drug rep cruising ! I use such a term for a reason: you’re totally being hit on when a drug rep stops by. And I’m only the secretary fill-in for the day. The Scrubs Heather Locklear stereotype isn’t that far off–the Effexor lady was a gorgeous, tall blond, and the others were all incredibly friendly, cheerful, laugh-it-up and ingratiate-thyself people I’ve ever seen. You could ask these people to just about anything and they’d happily comply. A Sopranos *hitman* would hesitate more than a drug rep if you asked each of them to off their own mother (as long as the rep made a sale off it). Don’t get me wrong, I’m sure they’re knowledgeable and nice people, but their jobs are basically to schmooze on overdrive.

And granted, the psychoactive pharmaceuticals are some of the most heavily pushed (erm, _advertised_) in the country, but *five* drug reps droppng off pens, stickie pads, M&Ms, and a 20-dollar Hormel Party Pack (“since you doctors are on the Atkins diet, I thought I’d help!”) over the course of an uneventful Tuesday seems a little extreme. The office is covered, blanketed, and pretty much _littered_ with catchy logos on magnets, pyramid-shaped Kleenex boxes, phone message pads, coffee mugs, highlighters, staplers, clipboards, and anything else you could imagine. I even found one of those huge 100-stick red licorice Twizzler tubs , with a drug company logo conveniently stickered on top.

I got a better idea of how private-practice docs work–they get tons of calls from patients and pharmacies requesting prescription refills, calls from nurses and doctors in the hospital requesting consultations, and see patients during the day.

It put things the most in perspective when I found out a bit about some of the patients: my dad had seen one since the time I was born , another had had bipolar disorder for 10 years and now has colon cancer, and another is depressed, had several deaths in her family, and is currently going through chemotherapy for breast cancer. I’m more fortunate than ever for my health, and the health of those around me.

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The International Virtual Medical School is a new institution planning to open in 2004, that would allow people around the world to do their first two preclinical years online. Students would then do their clinical years in an associated teaching hospital.

From what I’ve read, I’m still a little skeptical, if only from my personal experience. The project has some great medical school partners in the US and in the UK, but I’ve never had much success with online courses. Maybe others learn just fine online, but it just doesn’t work for me. Jakob Nielsen reports that most of us don’t read on monitors, we skim , and even if I print out the webpages or PDFs for a course, I still don’t get as much out an online course. I’ve always run into problems with the interaction between the instructor and student; in the classroom, you can ask questions immediately, and get feedback and followup just as quickly. Online, communication just isn’t as helpful to me (maybe I’m an audial learner). No matter how great the bulletin board system, students have to post questions, the professor has to respond, the student asks a followup question, and voila, two days later, the student has another question that will take two days to answer. Plus, you have to wade through other questions, pages and pages of other comments and questions–it’s just not a viable medium–especially on the professor’s side, where they have to respond to 80 emails a day from students, or 80 messageboard posts. Even chatting is tough. Chatrooms can get noisy and messy quickly. Maybe they’ve thought of a way to get around these problems.

There are bright sides, however. I don’t think that this should be a _replacement_ for an actual medical school, but in areas of the world where medical training is rare or non-existent, this could be a godsend. In most cases, some medical education is better than none; even basics like understanding that bacteria and viruses can cause illness and disease, that different organs do different things in the body, and that wounds need to be cleaned to prevent infection–could be life-saving to those in developing countries. I also like the idea of students finding real-world connections to online course work; in one example, a sample online patient is an HIV+ drug addict, and the student needs to find resources in his or her local area to help connect the patient to local services.

Practicing medicine requires interpersonal skills as well as medical knowledge, and hopefully the IVMS has a way to foster this offline. If it can overcome some of the challenges that face online communication, I think it has the opportunity to train medical students in an entirely new way.

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Second only to “Shouldn’t You Know That?” , I’m constantly asked “ What kind of doctor are you going to be? ” (I guess most people don’t realize you don’t have to officially “choose” until the end of third year.)

Who knows. Maybe it’s one of those “it just feels right” things. Maybe several of them will “feel right.” Only time will tell. Right now, I’m very public health oriented, very focused on trying to the type of doctor that the country needs. I can’t find the statistics right now, but I believe we churn out more specialists than we do primary care (internists, pediatricians, family practitioners) docs–leaving us specialist-heavy, even when most health care systems require primary care doctors (for us, they act as HMO gatekeepers). So maybe I should do primary care.

But on the other hand, if I turn out not to be happy with primary care, then I can’t exactly choose something I won’t enjoy for the rest of my life. Everything in moderation usually fits the bill for me pretty well–maybe something in between would be better? Some primary care work and some speciality? Or some teaching? Or public health? Or health policy?

On your third hand, my parents will be aging quickly (about a year per year), we’re due for a squaring of the population pyramid , and we’re fairly low on gerontologists…

On your fourth hand, I’m pretty sure that my dad (psychiatrist) has brought me up in such a way that I could do psychiatry, too.

I guess this is one of those questions like “What’s your major?” that’s more for small talk than anything, and you can only wait, shadow, and volunteer to try to get a better sense.

UPDATE: Maybe if I’m lucky, I’ll like Emergency Medicine . And if I’m extra lucky, I’ll get to do a Powerpoint presentation on boners .

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