Well, interviews are done! I had the great pleasure of meeting one Dr. Nick Genes whilst in New York. My first-ever in-real-life blogger meeting. He is even cooler in person!

Expect posting to be light for the next month or so: I’ve got both parts of Step 2 (“The Boards”) to take, which I’m already loathing.

There appears to be no published information about how we’re truly graded for Step 2 CS (“Clinical Skills”) besides if we went through the motions of “listening” with our stethoscope and speaking English. The patient note we have to write tells us to list “up to 5 possible diagnoses” and “up to 5 tests or procedures for workup.”

A mysterious physician apparently grades us, but on what basis we’re not told. For including a broad differential, or a narrow one? Can I, and should I include the great imitators, like HIV, TB, or syphilis on my differential? How about malingering? Should I go all out for the million dollar workup for patients? Classic ankle sprain. Ankle MR and X-Ray, please. But maybe we should tap it and send the aspirate for analysis. Or maybe he has disseminated gonococcus? Might as well get a CBC and test for GC/CT, too. Throw in an HIV there too, just for completeness’s sake. Is it honestly more important for me to know how to order a bunch of worthless, expensive tests than have a clue how to treat someone with an ankle sprain? (Treatment is not part of the “Clinical Skills” exam.)

Not that any of this matters, though. I speak English, am a pretty compassionate guy, pretty socially adept when talking to patients*, and know where to put my stethoscope. So I probably won’t be one of the 10 people that don’t pass this year — yes, that’s right, I have a 0.05% (those decimals are correct, 0.0005) chance of not passing the exam.

* I find it totally fascinating that I actually have a pretty darn good rapport with strangers-turned-patients, but put me in a social situation at a bar, club, party, or other social gathering and I freeze up socially pretty consistently. Little know Graham fact.

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In which I agree almost completely. I’d add in a course on medical ethics, and one on health policy as well.

I think Organic Chemistry serves a purpose, but it’s not because Orgo is useful to a clinician. It’s to see if a person has the dedication and ability to memorize an insane amount of very abstract material in a very short span of time, and then be able to apply said material to a specific problem. (Which you have to do in med school.) This also does a good job of weeding out people.

I’d love to see a mandatory second language of one’s choosing in there too (which most of my classmates probably already meet anyway). Similar to the organic chemistry metaphor, medicine is learning a language. (And it also comes in handy with patients. Just two days ago I was doing a second look at a program and helping an intern with a lumbar puncture, and my seemingly-useless French allowed me to communicate with our patient.)

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Sorry for the dearth of posting lately; I’ve been busily hitting city after city on the interview trail–and the residencies, unfortunately, continue to be great (making my ranking decision next to impossible).

Two quick bits: Thanks to the LA Times for the mention about the placebo study (and very cool that the reporter found me via my blog).

And thank you to Chicago, where I’ve been interviewing as of late. After 11 years driving without a single parking ticket, thank you, Chicago, for welcoming your forgotten son (I went to undergrad in the area) back with open arms. Two tickets and my car towed today for a tow away zone sign that was crumpled and gnarled away. I missed you too.

(I’m really not that happy about it. I swear.)

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• My favorite article today–because it’s in line with my own experience– the quality of one’s workout music is directly proportional to the quality of one’s workout . With scientific proof and everything! I wish it’d be legal to share workout playlists with people–I swear I’ve got a knack for them. Currently playing: Rihanna’s Please Don’t Stop the Music , via Songza , an awesome site that lets you play almost any song you can think of–if it can find it. (thanks dad!)
• On to more serious matters– Harvard docs have found over 200 proteins that appear to be important to HIV’s success , using RNA interference, a technique I blogged about in the first month of med school ! What a long time ago.
• And your daily policy reading: Ezra Klein (I wish I had time to read your whole blog, Ezra, but I couldn’t keep up) on the Commonwealth Study on amenable mortality : “in English, it assessed how effective health systems are at reaching the sick.” Again, we pay the most, we’re doing the worst, and our amenable mortality worsened while most other countries improved. (These are, of course, in scary “socialized medicine” countries. They’re not doing as bad as people would like you to believe, according to economist Paul Krugman .)
• The Executive Physician has a very fair analysis of Grady County Hospital’s problems and retail clinic unfairness . He says county hospitals need to compete for health patients, but that retail clinics shouldn’t be able to quietly sneak away from complicated patients (cherry-pick), and that governments shouldn’t allow them to, either.
• It’s the economy, stupid.
• And finally, Joe Paduda on HSAs, the rebuttal version . “One noted that they make “health care more affordable for the majority of consumers”; I think the commenter is conflating health insurance with health care. HSA plans may make insurance more affordable, but health care costs are not any cheaper under HSA plans. In fact, HSA plans’ higher out-of-pocket costs may make health care costs less affordable.”

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There’s certainly plenty we don’t agree on in the blogosphere–but plenty we do. That our primary care system is falling apart; that our Emergency Departments are severely overcrowded; that some laws and regulations (HIPAA, EMTALA, among others) need some serious re-thinking; that our health care system as it currently stands may seriously fail its citizens, especially with the coming-of-age of the baby boomers. The list could go on.

And yet our representatives in Washington have done nothing, and are not listening. (Granted they have plenty of issues on our plate–but if this one is not addressed soon, it’ll be too late. It may already be.)

So I say let’s stage a sit-in.

Of a certain variety, of course. We can’t simply ignore our patients. Many often depend on us to keep them… alive.

I suggest we demand all of Congress to spend a week of their vacation with the health care US health care system. Where and how we work in the United States, they sit and watch. 2 days with a primary care physician. 2 days with specialists. A day in the ED. And follow a patient from admission to discharge.

They’ll see how swamped we are; they’ll see how sick our patients are, what treatments are recommended for them, and how it’s impossible to provide proper care in 15 minutes. They’ll see how overcrowded our hospitals are. And that we must. Do. Something.

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• I’m going to start with Health Beat Blog’s great summary of the US’s terrible ranking with preventable deaths . Great summary of the data, and the implications. Shadowfax agrees. In the comments, The Happy Hospitalist says no country is really doing all that great with preventable deaths, which I agree with, but as Shadowfax reminds us, “We pay $7000 per capita. Again, we pay the most, and get the least.” (France, the leader, pays less than half of that.
• Catron takes issue (“load of BS”) with my highlighting a recent poll showing support for single-payer over our current system, saying that the poll isn’t scientific and flawed. Well of course it is, Mr. Catron–all polls are. They also leave out all us young adults who have no home phone number and have unlisted cell phone numbers, too. Either never cite polls or surveys yourself, or be honest. All polls suffer from selection and other biases. (Still, having half of respondents say they support a system where “all Americans would get their insurance from a single government plan” is pretty damn impressive to me. I never would have expected the number to be that high.)
• Nick (who I’m meeting next week!) satirizes the talking heads describing the ER . Keep this stuff coming!
• Lower co-pays make patients less likely to skip meds. Not a surprise. When it’s food versus medication (especially anti-hypertensives which often have side effects patients don’t like), not a surprise they pick food for themselves or their kids.
  

  Many companies are already paying for disease management programs to help patients with chronic diseases such as diabetes. So why not encourage people to take the medicines they need. You “pay a nurse $65 an hour to call call a diabetic [employee] and say, ‘Take a beta blocker.’ And the employee says ‘I know it’s important, why did you raise my copay from $15 to $30,” Fendrick says. “It’s a classic example of the misalignment of incentives in the U.S. health care system.”

• Out of state licensing rules are a mess, according to California Medicine Man. Would definitely frustrate any physician trying to help.
• Nice interview in the WSJ Health Blog, Kevin!

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Sadly we apparently have to keep doing the studies, because parents who don’t understand science don’t believe it.

Autism rates in California continued to increase despite California removing the thimerosal-containing vaccines in 2001.

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The type of Emergency Medicine story that gets your heart racing. (Also got a nice kick out of him linking to MDCalc for the Parkland Formula .)

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Scary “rationing” be damned (we ration here in the US, by ability to pay), take a look at the numbers this poll from last month :

Associated Press-Yahoo Poll
Interview dates: December 14 – 20, 2007

14. Which comes closest to your view?

34% – The United States should continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance

65% – The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers

2% – Refused / Not Answered

15. Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?

54% – Yes

44% – No

2% – Refused / Not Answered

So much for that whole “Americans would never support government-run medicine” bit.

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