Tag Archives: Ideas

Allergies, Alerts, and Assessments: The Information Age of Medicine

If you have a pulse and have visited an American physician, you have surely experienced this bizarre situation. They have you show up early for your office visit to fill out a packet of paperwork on every medicine you have every taken and every orifice you have ever had examined, yet when the doctor shows up in the room he asks for all of the same information over again. MAYBE he glances at the packet, otherwise it gets scanned and filed and stored securely and uploaded “to the system”. Sometimes a nurse will even come in and confirm the info on the sheet, followed by the doctor who has no knowledge of any of this information gathering.

Or picture this. You visit a local hospital ER for some urgent thing that came up. You fill out another huge packet of info. They transfer you over to the local county hospital, where the process will surely be repeated. There’s also a good chance they forgot to send the disc with your CT scan on it, instead sending a sheet of paper with a report of what their radiologist thought it showed. I deal with these sorts of situations every single day, and the cost usually comes at the expense of the patient, with increased wait times, repeat scans, and extended hospital stays due to administrative headaches. “Transfer paperwork” is usually dozens of pages of worthless charting by nurses (patient does not have an ostomy, patient is not an Alaska native, patient does not drive a vehicle manufactured before 2004), with one short paragraph actually written by an ED doc on the patients problems, followed by another dozen pages of medical necessity for transfer and financial information.

Ambulance

This is the current culture of healthcare. There are two issues I want to discuss, but first some juicy secrets about how doctors interview and evaluate patients.

When I am talking to a patient, every question has a hidden purpose.  There are directions that I am leaning for a diagnosis and treatment, and I am looking for specific answers that guide me in the right direction. When I ask, “When was the last time you had anything to eat?”, I don’t actually care a lot about your food choices over the last 24 hours. I don’t care if you crushed a Chipotle burrito, I usually just want to know if you can or can not be operated on today. Please don’t walk me through each and every thing you’ve eaten. When I ask about your medications I am usually asking about your health problems in a roundabout way, asking you describe the problems you have that are severe enough to require medicines instead of saying “I’m actually a healthy guy doc. Little bit of the sugars is all!”. This also gets me around the incredibly confusing segment of the population that seems to think, “I don’t have high blood pressure because I take 3 medicines for it and it is treated.” So my questions are very directed to get me what I think is the sufficient amount of knowledge need to treat you effectively. I try to start with open ended stuff just to see what you say when I ask “What brings you in today?”, but when we get on a tangent I need to bring it back to the important stuff.

This is particularly true on morning rounds, I have to see 22 patients by 530am and I am ruthlessly efficient. Are you alive? Have you pooped? Is your pain being treated? Are you actively bleeding anywhere? I can sort out any number of issues during the day, but first I need to get a handle on the things that I need to know.

coffee

I always round with a horrible cup of coffee. It inspires me to get done in time to get an actual breakfast.

So that’s the first issue we have, and it plagues healthcare. We have all of this information about you, your meds, your vitals, you name it. We know so much about you, but not very many people know what to do with any of this information. As a surgeon, I am particularly concerned about certain vitals, labs, and physical exam findings to determine if you are going home, going back to the OR, cleared to eat, whatever. Medical doctors care about all sorts of other stuff that they order that doesn’t actually matter (looking at you, pro-calcitonin and activated protein C). Anesthesiologists care about the structure of your mouth and the ease with which you can be intubated. Since we have done a relatively poor job of identifying what we absolutely need to know about each patient, we have gone ahead and decided to record every single thing about each patient at all times, just in case it turns out to matter.

This is probably the hardest on nursing staff and CNAs. At our hospital, nursing tasks are measured per hour, and an average of 42 minutes per hour is spent documenting on the computer, leaving a lousy 18 minutes for patient care (divided amongst their 3-6 patients each day). They document the patients bed position, what food is delivered to the room, visitors to the room, the temperature of the room, and the programming on television. This became an issue a few years ago at a hospital I worked at in undergrad, with nursing leadership complaining that documentation was hindering them from providing patient care. Instead of addressing concerns with workload and documentation needs, the hospital purchased 600 computers on wheels so that the nurses could wheel around the halls and do their charting. These computers initially were called COWS, but that term was deemed insensitive by the nurses who used them and they are now WOWs (workstations on wheels). I did not make any of this up.

charting

The result of this is a massive pile of poorly utilized, very sensitive information that we must not only keep protected at the risk of heavy fines and legal repercussions, but also pick out the important parts that could lead to poor patient outcomes.

The best example I see every day regards the allergy section of a patients chart. Actual allergic reactions are life threatening emergencies. The throat swells, you can’t breathe, and you die if you don’t get treated. Bad things that happen when you take medicines are not allergies, they are actually side effects (or sometimes intended effects). Morphine making you sleepy is NOT an allergy. Lisinopril making you cough is not an allergy. Taking a medicine while you also happened to have a viral respiratory infection is not an allergic reaction. Regardless, each thing gets dutifully logged by nursing as an allergy into the EHR. EVERY SINGLE TIME I try to place an order for medications for a patient I get that stupid chart blasted at my face to review allergic reactions. I am so used to clicking through and overriding (trust me, you really do want something for the pain after your open abdominal surgery), but I worry every day that I do miss a true allergy to sulfa or something.

The second issue revolves around documentation. Taking the critical amount of information for a patient and distilling it into a usable progress note or discharge summary is an incredibly difficult task. In the days of paper charts, notes from docs tended be brutally short. “Doing well, advance diet, monitor fevers”. Nowadays since so much is automatically generated our notes contain all vitals, labs, and a plan that (more often than not) is automatically carried over from the prior day. Again, we seem to be forgetting what the critical information really is, and instead just copying everything down.

Part of this is related to money. We get payed for what we do or do not document, and if the choice comes between losing money or writing more things into charts, you know which direction medicine will head. We have a weekly conference where one of our CDI (Clinical Documentation Integrity) docs goes over how we lose money by not writing the correct coding diagnosis in our notes. It is so ridiculous that it makes me angry to write about it on a rainy Saturday morning from my couch. We don’t get full reimbursement on a trauma patient if we don’t do a complete assessment of history on their intake. This means that if we don’t specifically ask our 90 year old patient with an intracranial bleed about diseases that run in their family, the goverment pays us less money. It doesn’t matter that it’s actually poor patient care, it is a box on the form that must be filled out so it must be done. In the trauma bay, with often critically ill patients, we end up asking about family history, mental health screens, and vaccination status (tetanus is important but others not so much in trauma) to get the boxes checked. It’s absurd.

The other part of this data is related to patient care. We need better tools to analyze big data to see what really matters for outcomes. We track re-admissions and complications because they are easy to measure, and it has made us defensive physicians. We need to measure outcomes in an efficient manner so that we become better physicians. This will be it’s own post down the road, for now I will just drop a quick link to a recent Wall Street Journal article that discusses an aspect of this idea.

If you have skills in data analytics, interface development, or programming of any kind, you could make an actual mountain of money in healthcare. Build us a system that lets us document efficiently and share our documentation with our colleagues across the street and across the country. Build us a system that allows us to study all of our data, our financial measures, our outcomes, and our complications. We need to see it often, not locked away in the medical records department. The last decade of medicine has been dominated by the Epics and Powercharts of the world, who have made it this long for being not as bad as their competitors, but my generation of physicians sees these systems as the dinosaurs that they already are, and we are ready for something better.

This is frustrating to me because I am still boots on the ground slogging through surgery residency. I lack the computing skills to even know where to start, but I know we absolutely need something better. This is the information age of medicine, but right now we aren’t using any of our info, it’s just weighing us down. Healthcare is still using a flip phone, it’s time we catch up and break new ground.

Thanks for reading!

Advertisements

Surgery, Metaphors, and the Story of Your Life

Most of us have a very limited understanding of the world in general. It’s not really our fault. Our perspective is pretty well limited to our immediate circle of family and friends, and of course you have only your direct sensory perception of the world to actually create the framework of your consciousness. There’s a big world out there, surrounded by an incomprehensibly huge universe, and we’re pretty much blips. Because our own experience through our lives is very limited, humans have traditionally told stories about their lives and the experiences of others. So many ancient texts and myths have been passed down to us today as oral tradition, or essentially campfire stories that were told for generations before we finally started writing stuff down, which turned out to be a pretty big deal. Nowadays we have the entirety of the internet to connect and share (and in some cases overshare) our life stories. We have even managed to make obscure stories from long ago available widely online, expanding our collective knowledge an incredible amount in a relatively short amount of time. My story on this blog is technically contributing to that collection of knowledge, though it is admittedly drastically limited by my unwillingness to proofread and the limited sphere of influence of both of my readers (hi Mom!).

I think stories are important. I should mention here that I have read an incredible number of books over the years, mostly because I am a huge nerd. I continue to read (at a much slower pace) even during surgical residency. I love the structure of a story, the ebbs and flows, climaxes, and suspense. I like to view my life as a story, as it gives me a framework to look at my family, friends, and goals in a larger setting that may be difficult for me to grasp otherwise.

Stories work especially well when discussing shared experiences. Laughter, fear, embarrassment, stress, relief, and grief are all common across mankind, and sharing stories about how those feelings have affected our lives draw us closer to each other. People generally like to tell stories because they usually like to talk about themselves, but listening to stories is almost as good. I like telling stories so much that I take time to write them down to people on the internet.

Some stories are difficult to share effectively if the experience is relatively unique to you personally. You can communicate the facts and the sequence of events, but you won’t be able to really convey the meaning of the story unless the person listening has had a similar enough experience. I have found this particularly true when it comes to incredibly stressful events such as natural disasters, traumatic events, and surgical residency.

It’s hard to tell stories about residency to people that aren’t residents. Most people don’t have any similar experiences to relate with, and so it’s tough to get that understanding across. This is why many residents only hang out with other residents (also no money, shockingly little spare time, and poor social skills). I recently had the opportunity to catch up with some old friends and this was made very clear as we shared about our lives. I worked more than double the amount that my friends (who have full time jobs) work each week, with far less compensation, WAY fewer benefits, and a much more hostile work environment. It was actually a little depressing as I realized how sad my life was. I found myself saying things like “I can usually do my laundry” and “I’ve been sleeping in until 5am or so lately”. I can still tell funny stories about crazy people, or gross stories about traumas, but it’s tough to actually relate with how I get through my life. I don’t get off at 5, take a lunch break, or even have my own chair. I do have a small locker all to myself, which I think is pretty great.

I really like metaphors. I think they are useful both for teaching and for communicating with others who may have some things in common with you, but not necessarily the experience you are discussing. I have an attending surgeon who overuses metaphors. He will start teaching with a sports metaphor, switch to fishing, then make a pop culture reference from 30 years ago to end it, and I can’t keep up with all that. Medical students definitely don’t, but they will laugh at his jokes, which are terrible. His metaphors are even worse, there needs to be some similarities in your metaphors for them to work.

I like to compare anatomy to cities. Surgeons love anatomy. Every little thing in the body has a name, a function, and variants to know. Then add in the insertions, origins, innervation, vascular supply….it really adds up. Anatomy is often the first traumatic experience medical students have in their schooling. Though it may cause PTSD in medicine residents, it’s a working language and constant learning challenge in surgery residents.

Learning surgical anatomy is like learning to drive around a new city. You can look at maps and get a good idea of the layout of the city, but once you get there you need to start driving and see signs to confirm that Main Street is actually Main Street. Experienced surgeons are essentially the cabbies of the city, having spent years making their living driving on every single block, watching accidents happen (and causing a few), taking alternate routes for traffic, and knowing how time of day affects traffic flow. Medical students don’t know simple things because they are still getting their bearings, they still need to drive down Main Street and see the big attractions.

 

Hong_Kong_Cedric009-1500x792

This is Hong Kong, by the way.

Surgery residency is a strange beast, but I think it has a lot of similarities with baseball. Both are long seasons or careers that require endurance and daily performance. In baseball you can strike out with the bases loaded in one inning, then hit a game winning home run the next at bat. You can play extremely well and the team will lose, then vice versa the next day. No matter how well or poorly you are playing, there is always your next at bat, the next inning, the next game, and you have to continually prepare yourself to perform at your best when that time comes.

Baseball Infield Chalk Line

In the same way, surgery is tough business. Patients live and patients die. The hours are long, and the stress is real. The stress comes in different intensities, like a fire. Each morning there is the distant, soft, constant burn on the way to work. “I don’t want to hurt anyone today. I hope I can help at least one of my patients. How can I be my best?” Then there’s the anxiety when you aren’t at the hospital, but you know have a huge case the next day, or a sick patient back in the ICU. There’s the intense heat and focus in critical situations, when everything is beeping and you are the first to respond to a code, or have the MAC blade in hand to intubate a patient. Everything is on the line, and you’re up to bat. No games to win or lose, but the lives of others are at stake. Finally, there’s the huge weight of fatigue when you walk into the hospital for your 18th shift in a row, or walking out late at night knowing you’ll be back early the next morning.  Batter up.

The story of general surgery is not good. 20% attrition in residency. Huge egos competing for operating room time and influence, each person convinced in their own skill and decision making. A long, antiquated tradition of training surgeons by breaking down medical school graduates and molding the pieces into surgeons. That story is changing very, very slowly, but is still the reality for surgery residents all over the country today, tomorrow, and the next day for the remainder of our training.

If our lives are stories, each of our stories is made up of layers. Starting broadly, there are the events of our lives, or the circumstances that we either create of find ourselves in without our doing. Next, there is our conscious interpretation of those events and their effect on our lives. Separate from that are the actions we take and the decisions we make.

Finally, and most importantly, there is the internal story that you tell yourself about what is happening in your life and how you are going to respond to it. We all have inner voices, or an inner dialogue, and I think that voice is the single most important factor that drives who you are as a person. That inner voice is you, or at least as close as anything can be to you as a person. Whatever you are doing, or whoever you want to be, that voice is going to get you there. It’s remarkable how much I can affect my own day and my own well being despite the circumstances of the day, and that is the single most important thing I have learned in residency.

Intern year has been ROUGH, and there have been life circumstances that have made it more difficult as well, but it hasn’t changed who I am.  The challenge will be to maintain this for the next few years of training without burning out. I’ll probably write about that if it happens, but I hope to just keep telling you all funny stories and letting you know what’s on my mind instead.

Thanks for reading!

 

 

 

 

 

The Hardest Day

Second year has started off with a bang. If you are paying attention, you’ll see some crazy stuff in any medical school. Whether it’s an official lesson, or people watching, or patient encounters, or something you learn on accident while researching something else, there will surely be something to learn. Recently we had a deep lesson that I wanted to share, but first I need to set the stage.

All of the MS2 students are packed into our lecture hall. This isn’t the nice, new lecture with comfortable chairs that we used last year. This is the older lecture hall that doesn’t have enough seats for the whole class, the one with the terrible chairs, and the one with not enough room for your laptop and anything else on the desk. There are students standing in the back, and everyone looks sharp because we all are wearing our white coats and professional clothes.

On stage are six people. Standing at the podium is a Pediatric Hematologist who is running the event. She has a very serene demeanor, but seems to radiate strength from her small stature. Sitting at the table on stage are 5 others. There is a couple in their 40’s. He is lean and tan, with the muscle tone and hands of a construction worker. She sits next to him, well dressed and confident, if somewhat anxious. Another lady sits next to them. She is African American, somewhat heavyset, with a joyful face, floral blouse, and somewhat excessive afro. Next to her is an elderly little lady with thin gray hair and a stooped posture, and she is in deep conversation with the woman beside her, who is wearing scrubs and has two phones and a pager.

This is a lecture panel on handling the death of patients, specifically children. The couple on the end lost twin boys, their 5th and 6th children. The first died before being born. The second lived for 10 months, but had a debilitating matrix of health problems and lacked any ability to develop. The lady next to them had a daughter who developed bone cancer at age 11, which metastasized to her brain and took her life when she was 13. The older was a chaplain, and the last lady was a NICU nurse. Everyone was there to talk to us about handling death.

Most learning in medical school is very clinical and sterile. We learn about our bodies from distinguished looking old professors who wear white coats and use technical language to describe anatomy and physiology of organs and diseases, of which they are experts. That approach is obviously not practical when talking about handling death, so we learned from “experts” in their own way, people who had gone through this and were willing to talk to us about their experience.

I don’t like thinking about death, and I don’t think many of my fellow students do either. We are all young and vigorous, filled with the energy and optimism of youth. In my mind, death is something far off. It’s not that I’m scared of it, I just prefer not to think about it. I have been very fortunate to have made it this far in my life with living parents and grandparents.

This forum was not the first time that I had focused my heart and mind on this idea of death, and current events will tell you why. On Saturday evening the violence in Ferguson, MO erupted after a young man was shot and killed by police. Even as I write this tensions remain high, with protests and heavy police presence keeping the conflict in the national spotlight. It was only a few days ago that the world was shocked to discover that Robin Williams had ended his own life. Violence in Iraq and the Middle East have created a summer that will go down in history as a violent, restless summer.

I don’t want to talk specifically about any of those subjects listed above, at least not in this post. Instead, I want to talk about dying. The way someone reacts to death will tell me a lot about the way they view the world.

Death is a part of life, just like birth. Everyone is born, and everyone will die. What we do in between is what makes the difference. Death is also a great equalizer. I learned this lesson at a young age helping my dad clean our boat after a day on the lake. He always said that the boat ramp was the great equalizer. At the end of the day, everyone comes back to the ramp and goes home after a fun day of boating. It doesn’t matter how big your boat was, how big the truck you used to tow it, or how many fun inflatable things you could pull behind your boat. At the end of the day everyone comes back to the ramp sunburned and tired, and everybody had fun.

So when we die, as we know we will, we are all equalized again. Your influence, your money, and your responsibilities are all lost and left behind. What happens to you after you die? What or where do you think you will be after you die? Some believe that death causes you to cease to exist, but I find that hard to accept and impossible to believe.

The hardest part of the last few weeks has been actually organizing my thoughts on this matter. It’s not easy to do, when my cell phone keeps ringing, emails keep arriving, and the world flies by on my laptop screen. It’s easy to ride the wave of now, caught up in an endless progression of thinking about what happens next. Thankfully, I found the time to take my dog to a local state park and hike. So it was there that I hiked miles from any road, on trails not commonly traveled, and sat down for a water break. The sun was high in the sky, coming through the trees to turn the world green. Except for my trampling feet, the world was perfectly still. So I sat there for a long while, and I’m glad I did, because that’s how I was finally able to write this.

Lastly, I wanted to leave with the words to a poem. It was written in the 1600’s, but people then died at the same rate as they do now, and the words speak to people today just like they did 400 years ago.

Death, be not proud, though some have called thee
Mighty and dreadful, for thou art not so;
For those whom thou think’st thou dost overthrow
Die not, poor Death, nor yet canst thou kill me.
From rest and sleep, which but thy pictures be,
Much pleasure; then from thee much more must flow,
And soonest our best men with thee do go,
Rest of their bones, and soul’s delivery.
Thou art slave to fate, chance, kings, and desperate men,
And dost with poison, war, and sickness dwell,
And poppy or charms can make us sleep as well
And better than thy stroke; why swell’st thou then?
One short sleep past, we wake eternally
And death shall be no more; Death, thou shalt die.
Thanks for reading!

How To Be My Favorite Teacher

I wrote this post several years ago for a different blog. In talking to some friends tonight, I was inspired to dig it up, re-polish it, and publish it again. I still think the idea is great, and I hope to teach at some point in my future. I think this idea works, and it’s fun to talk about. So here we go. Gamification. 

Gamification is not a word I just invented. While it is a newer word (first coined in 2002), it is a real thing.

If you try to gamify something (ok…I may have made that one up), you apply gaming principles to something that is not a game in order to create a better experience, enhance participation, or make something more enjoyable for others.

You may be familiar with many of the modern applications of gamification. Achievement badges, leaderboards, challenges, and progress bars are all common examples. Many iPhone apps have these features to keep you playing (talking to you, Farmville). Every xBox game comes with a list of achievements to unlock, intended to encourage players to continue playing the game even after they have beaten it once or twice.

Turning chores into a game certainly makes them more entertaining. Why not teach classes in the same way? Please don’t tell me that college courses currently place an emphasis on attendance and participation. As a system, the college lecture format is dated and often amazingly inefficient (especially considering the price many students pay to attend college).

So here is my idea. I am going to pretend that I am a Chemistry professor, teaching a class called “Introduction to Chemistry” for incoming freshman science majors. I have 400 students in my class. The class teaches basic chemistry, and most of my students will continue to take harder chemistry classes later in their academic careers, so I can assume they are at least reasonably motivated to do well in this course

I will format my class somewhat traditionally:
5 Tests x 100 pts each
5 Quizzes x 10pts each
5 Pop Quizzes x 10pts each
5 HW Assignments x 40pts each
1 Final @ 200pts.

=1000 points total. In my experience as a science major, this is a fairly common syllabus. Here’s where I change it up. I will also distribute a “Game Card” to each student. I would probably create a point system called “moles” or something dorky like that. You could achieve up to 100 mole points in the semester, perhaps. Some you can get automatically, others would require direct effort. At the end of the semester, your mole points are converted to extra credit points. For the math wizards, that’s 10% extra credit available for free. A whole letter grade.

How do you get mole points? Stuff like this..

Attend Office Hours and Ask Questions- 5 Mole Points
Most students will never attend office hours and ask for help, but will instead futilely struggle, search the internet, and ask friends. I’m no expert, but I bet that getting individual help from a professor will improve classroom performance.

Achieve 90% or Greater on an Exam- 10 Mole Points
This rewards students who perform well. It offers a clear motivation to excel on exams. You could argue that students who receive this achievement don’t need it, as they are already smarter than the average bear. I argue that a C student could conceivably study hard, get a 90%, and would deserve a 10pt bonus for his effort. Also, see next achievement.

Improve Your Test Score by 10% or More -10 Mole Points
This one is not for the smart kids. If you scored a 94% on my first exam, you got the previous achievement and don’t really have hope for this one. For the C student above, who maybe got a 75% on the first exam, this doubles the incentive to buckle down and perform better on the next test.

Other incentives could include activities like writing a short report on a current research topic that you find interesting, exposing the student to some practical applications of their studies while forcing them to take some initiative and break new ground. Scheduling an appointment with a tutoring service (if the school supports one-mine does) during the week before a test will help their test score and increase retention. Other “achievements” would reward class attendance, for example, or perhaps encourage participation. I thought about including one that would reward students for finding an error that I would purposefully include on the slides each week, so that they are encouraged to ask questions and think critically about what I write instead of blindly memorizing it.

The weather is awful, can't go to class The weather is beautiful, can't waste it in class  Lazy College Senior

There is a valid argument against my little game I created. Students would need to have a level of motivation and achievement to do more than just immediately lose the “game board” I gave them on my first day of class. Also, the teachers likely to implement this game would be good teachers already. They would teach dynamically, interact with students, and have their own ways to implement all of the same things I am attempting to do with my game. 

I think that’s fantastic. Maybe they use part of my games, maybe they use their own system. Whatever. I think that a system like this (or similar to it) would improve the classroom experience for teachers and students alike.

Facets of gamification are already working. The Khan Academy incorporates these ideas into their online lessons. At the end of the day, doing your chemistry homework will never be as fun as playing real games, pursuing hobbies, or spending time with friends. If these ideas will give people extra motivation, and if that extra motivation translates to academic success, then I think they are worth pursuing. It may not be incredibly fun, but there are much worse games to play.

P.S. I first published this in 2011, so the Hunger Games reference was less dated. Also, I think I am a better writer now, but I’ll let you decide.

4 Kinds of People Who Must Love/Hate the Internet

We all live in a new age. Since the Internet has connected all of us in ways previously thought impossible, our very culture has changed in so many ways. Some companies have profited greatly from the rise new technology (Google), while others have been ruined (Blockbuster). Some people, however, have a mixed bag. These people include

1. Photographers

Despite my own complete artistic ignorance, I am aware of the fact that there is a group of highly skilled artists who take pictures. They understand concepts like lighting, focus, mood, color, and other artsy words to create pictures that are dramatic and inspiring. I think about guys like Robert Capa, who covered five wars. He was quoted as saying “If your pictures aren’t good enough, you aren’t close enough”. To put that in perspective, this is the same man who covered relatively dangerous situations like…oh, D-Day.

Doesn’t get much closer than this.

These kinds of people still exist today, I am sure of it. The problem is that they are completely overwhelmed by millions of teenagers with Instagram. Having an iPhone and access to the internet virtually guarantees pictures with sepia filters will be posted #nofilter to Facebook at some point in time.

The upside to being a photographer nowadays is also the internet. Building a portfolio, maintaining a website, and social networking give easy access to potential employers and give an aspiring photographer more exposure than was possible years ago. It’s also possible to edit all of your pictures with photo shop, but that’s an entirely different story. In college I had a roommate who was a photographer. He would shoot weddings and senior pictures, and actually rented out a studio in his hometown (which was ~2 hours away). He was very talented, and would upload his pictures directly to an iPad so his clients could see them immediately after he took them. Keep in mind he was about 20 at this point. He made thousands of dollars in cash every weekend (which he unwisely decided to keep in his desk drawer for a long time), and he now works for ESPN, shooting college sports and parts of their annual swimsuit edition. He relied absolutely on the internet and 4 different computers to keep all of his projects straight, but he was very successful.

2. Cable Companies

Cable companies want you to buy their big cable packages. That’s where they make their money, and it’s also why I get ads in the mail every week to upgrade to cable and phone. It is becoming increasingly common for people (like me) to skip out on the cable part and just pay for monthly internet. Cable costs about triple the price, and I know we won’t watch it, so we don’t pay for it. From their perspective, they just lost a significant part of their “income” from me, their customer, while still having to maintain the infrastructure necessary for me to have that service. Netflix, YouTube, and medical school suck up huge amounts of data, and the race is on to keep up with society’s insatiable need for bandwidth (upgrading to fiber optic cables, for example). This is expensive for them, but it might also save them in the future as more people ditch the traditional cable packages but remain customers for the internet access.

3. Actors

Admittedly, celebrities have always had many people paying close attention to them. In fact, there are other people paid to follow them around and report on what they are doing, which is ridiculous, but whatever. This applies mostly to people who are already rich and famous, so it isn’t the worst thing that could happen, but it must certainly be annoying. They used to run the constant risk of having unattractive pictures taken and then finding those pictures on magazine and newspaper covers everywhere.

Now things are much worse. Paparazzi still follow celebrities around, like those little fish that attach themselves to sharks, but now they can post things to the internet. Once things hit the web, they will never ever go away, just like when you eat a single piece of pizza for lunch and you can still taste it two days later. Instead of having yourself on a magazine cover at the grocery store checkout for a week or two, you now have thousands of copies of that picture or news story circulating on the internet. Forever. Awesome. Paparazzi are also assisted by people who attempt to hack cell phones, Facebook accounts, and laptops to produce scandals and generate publicity for themselves, and they do it for free.

Most celebrities are also benefiting from their ability to use the internet to generate positive publicity. They can maintain an online presence and still generate attention, even if they aren’t in any upcoming movies or TV shows. I follow a few celebrities on Twitter just because they are funny (I have absolutely no idea if they are in any recent movies).

4. Musicians

Becoming a professional musician that makes a gazillion dollars is a lot like becoming a professional athlete. At one point, most boys in this country played baseball. Only a fraction of a percent of them ever sign an MLB contract. Tons of kids learn to play the piano, guitar, or drums. Very few of them ever play for Maroon 5 and make tons of money. Becoming a successful musician isn’t always about talent. Certain Disney stars have turned into “musicians” and continue to make money and sell songs despite their (sometimes) questionable musical ability.

I would hate to be a professional musician. It’s one of those fields where, no matter how good you are, there is always someone better than you. Nowadays, thanks to the internet, those people can be anywhere on Earth. Even when popular mainstream bands create good songs, it won’t be long before some talented teenagers with good equipment make a cover that is better than the original song.

One more thing. Remember when we bought actual CDs? From music stores? From the perspective of the band, that’s actually a good thing. How many times did you really like 4 (or less) of the songs on the CD, but you ended up buying the whole CD for those 4 songs? That created a good margin for groups, who got a whole CD of sales, even if they only had a single good song. Now nobody buys CDs. Instead, we buy music on iTunes, if we buy it at all. I haven’t bought music in years, I just listen to Pandora, YouTube, and the radio and I’m fine. Even if there was a song I absolutely had to buy, I’d get it on iTunes for $1.29. That doesn’t work out nearly as well for the band, since I am no longer paying $12 for the CD.

I could add to this list, and you probably could too. Authors lose money from illegally downloaded PDF copies of their hard work, but the Fifty Shades of Grey series started out as a PDF and that lady made a gazillion dollars. Many doctors who lecture at medical school complain about patients who are convinced they have cancer (thanks, WebMD), but huge advances in electronic health records have changed the way we do medicine. I’m convinced that an internet outage at my medical school would cause some students to have serious anxiety attacks. I am on the internet for hours and hours every single day, and many of my hobbies (like writing this blog) rely on the internet. I love it, but I hate it.

Thanks for reading! Thanks to a recent guest post featured on Student Doctor Network, I have had a huge influx of new readers from more than 15 countries, which is awesome. Thanks for the emails and comments, it’s been a lot of fun.

sortadrwordpress@gmail.com

Standardize Me

I didn’t post at all last weekend, even though I really wanted to do so. There are a few good reasons why. Besides unsuccessfully fighting off a cold and studying for three exams this week, I am also incredibly lazy and didn’t have the time or motivation to sit down and write the post that has been on my mind for several weeks. It’s only fitting that I find this motivation shortly before my pathology final, most likely using a blog post as another reason to avoid studying  for this test. As one classmate posted on Facebook so accurately: “I find that I Netflix better with study going on in the background”.

I don’t even have to study all that hard for this exam. Because of our grading system (pass/fail) and the assignments and tests I have already completed give me all but six points I need to pass the class. To put in another way, I need to get just 6/100 questions correct to pass this class. I could do that in my sleep. Don’t worry, I will study hard and do fine. (Edit: I actually did pretty well on it).

Our Pathology overlords are doing us a bit of a favor, they tell us. All of their exam questions are “board style”, similar to the format we can expect when we take Step 1 next year. This means that we take the exams on our computers through secure browsers, and that some of the multiple choice questions have options a-h instead of a-e.

Our questions are slightly harder than this, by the way.

Another way we are being prepared for Step 1 is that we are doing everything way faster than previous classes have ever done anything. As I write this in the first week of March, we have already completed all of the Year 1 curriculum. Next week we will begin Year 2 curriculum. The benefits to us include more time to study for Step 1, and more time in rotations before having to make important residency decisions. This all seems like a good idea to me, but we are the guinea pigs in this little experiment, so only time (and our board scores) will tell how it worked out.

This got me thinking about all of the standardization we are receiving. The main goal of the first two years of medical education is to perform well on Step 1. My understanding is that this test makes sure new medical students have an appropriate amount of basic medical knowledge before entering the wards and practicing on real patients. This actually works out very well for me, as I have a long history of crushing standardized tests (including NBME pathology most recently).

Recently my brother-in-law graduated from the police academy. Police officers have a very important and challenging job not unlike a doctor. They have a huge body of knowledge to learn, including the geography of their city, procedures of their department, legality issues, physical ability to drive, arrest, restrain, and I know many cops that have a highly developed “sixth sense” that gets them out of dangerous situations. Even my limited EMS experience has shown me the value of this sixth sense, but I doubt it could be taught.

Now if the police academy worked like medical school, they would spend 2 years in a classroom watching powerpoint presentations on street layouts, with the dangerous areas highlighted. They would take multiple choice exams on how to handle interactions with dangerous suspects, maybe watch videos on driving skills. Thankfully, my brother’s academy didn’t work like this at all. He rode with cops, listened to their advice, and saw firsthand dangerous areas of town. He went to an abandoned runway and spent an afternoon learning defensive driving techniques.

Medical school isn’t taught like that, and I’m not even sure it should be. All I know is that medical school has been taught the same way for a very long time, which is why it is so standardized. There is a well defined process to becoming a doctor, steeped in tradition and learning. If improving the quality of medical education came at the cost of leaving behind those traditions, would anyone attempt it? Will there be a series of huge sweeping changes in the coming years, or will innovation come in small steps, creeping along over the years?

I’ll have to think more about this, but it’s something that will be on my mind as I work my way through medical school.

This post is now very late, but thank you for reading!

 

Everything Wrong With College

It’s been another busy week of medical school for me. We are preparing for our comprehensive pharmacology exam, along with finishing up final exams in toxicology and microbes. There is plenty of studying to be doing, and I have also been busy working on a final presentation for my clinical elective. Yesterday, in fact, I spent my last day at the dermatology clinic. It just isn’t a Wednesday until I help the resident freeze genital warts. Too much info? That’s medical school for you 🙂 Thankfully, I gave an “superb” presentation (on a subject that isn’t even a tiny bit interesting, so I’ll leave that part out) so it’s safe to assume I earned at least a letter of recommendation from her. Sweet. I take the time tonight to write about education, specifically college, so that I can piece together a short narrative describing not only the problems with college education today, but also what it means to Americans as a whole.

Like most twenty somethings, I grew up with a pretty clear picture of what success in life looked like. It came from teachers, parents, school counselors, and other adults, but the message was the same: successful people went to college, got a degree, and then earned more money and were happier because they did. The not-so-subtle indication was that I, too, should go to college if I wanted to be happy in life. Smart people went to college, I was told, or at least college made people smart. I don’t know when this idea was perpetuated on Americans, but I suspect it was around my parents generation. My dad didn’t go to college, although the pressure to get a degree certainly existed when he graduated high school.

I played the game very successfully. After graduating top of my high school class, I took a full ride scholarship to a good state school. According to the “rules” I was taught when I was younger, I had won the game. I was virtually guaranteed four years of education and a degree of my choice (with no debt upon graduation). Of course, I started college in 2009. This was not a good time for the economy, and college graduates suffered for it. I spent my college years reading news stories about how hard it was for grads to find a job, and feeling secretly glad that I had a few years for the economy to turn around before I graduated. Despite this, my university set enrollment records for all eight semesters I attended. Of course, now I am in medical school and have nearly a decade of school still ahead of me, so take that with a grain of salt.

So now I wonder why people still rush to take out loans and attend school for degrees they may never use. I watched many friends amass huge debts and drop out after 3 years. I saw people waste huge amounts of time, money, and energy, and now they have nothing to show for it. I saw friends take a semester off and 4 years later wish they had stuck with it. So here are some of the things I wish people would really know about college.

1) Colleges Are Businesses

dollar for dollar

We are coming up on the time of year when high school seniors everywhere begin posting acceptance letters on Facebook, listing the college/university they plan to attend. That’s great for them, but it perpetuates a myth that sucks people in every year: that colleges are somehow exclusive. To put it another way, University of _______ actually wants you to attend their school. There are a small handful of uber elite schools that are competitive to gain admittance (MIT, Harvard, etc). The other 99% of schools want you to attend because they need your tuition to make money. It doesn’t stop there, either. They need your fees, parking passes, textbook purchases, and other expenses as well. I’m not saying that these schools aren’t trying to give you a stellar education. Just know that they want to give you a great education and also make money. But mostly the money.

2) College Is Not About You

This will be shocking to anyone who has seen any marketing materials for any school anywhere, been to college, or even heard anything about college, but I think it’s crazy that it goes unrecognized. Think about any university advertisement, and it’s usually some combination of the following ideas:

“Follow YOUR passion, pursue YOUR dreams”

“Create YOUR OWN major”

“Classes that fit YOUR schedule”

This was the third result after Googling “University Brochures”.

It’s like the whole school is expressly designed to help you along in life. False. The school wants you to pay money to them, or at least do something awesome later so they can get the publicity. Of course they’ll let you take a semester off. Of course they’ll let you do your degree in six years instead of four. Of course they offer online classes. They are a business and they’ll do what it takes to earn your tuition dollars.

If the version of success I learned in school is to be believed, your degree should show that you are qualified, diligent, hardworking, ambitious, or some mixture of those. If your degree is four years long and you are going to “normal” college (not night school or a non-trad), get it done in four years. Chances are that a marketing degree is not your passion, so don’t pretend like it is. Work hard, get your degree, and spend your extra time pursuing your other hobbies and interests. Those are also qualities that define your character, and while they may not be on your CV they will certainly impact your chances at landing your job/achieving your goals after school. This leads me to…

3)  College Can Be a Huge Waste of Time

College is not hard. You may hate me for saying that, but I’m telling the truth here. My degree was in Molecular Biology and a little bit of Chemistry, and I know that my four years of college were significantly more difficult than any of my peers. How do I know that? Well, I lived with them, and I know I spent way more time in class and studying than they did. So how hard did I work during school? Not that hard. Each semester I attended class for 20 hours a week and studied about 10 hours, sometimes 15 hours. That adds up to less than a normal work week. Also take into account that I lived on campus, so I had no commute. I also ate dorm food from a cafeteria that was 30 seconds from my room. We also went to school for 32 weeks of the year. I spent lots of time exercising, playing video games, and doing lots of whatever I wanted. It was great.

Fact is, college classes should not keep you busy. My class schedule was about as bad as undergraduate schedules can get, and I still managed to work all eight semesters, get married, earn my EMT certification, and complete an Ironman triathlon. My most memorable moments from college have nothing to do with school.

In this sense, I think college is actually bad for many young adults. As a country and a society, we are taking our most energetic young people and forcing them into a 4-year holding pattern. The 18-24 age group is full of young, talented, motivated, technologically competent, people who are the future of our nation. We are bright enough to have terrific ideas, and naive enough to not know when something can’t be done. But we have to attend classes for just long enough each week to not actually get a real job, but not enough class that it’s truly “full time”. Those classes can range from being interesting (wine tasting) to being totally useless (most of my humanities courses), and after 4 (or more) years of sitting through classes, they will finally graduate into the real world, often with crippling debt.

This is the hardest part for me. I am (or at least I was) a perfect candidate for college. I’m naturally curious, enjoy learning, and am prone to obsessively mastering new hobbies and subjects. Yet after four years I had only one or two good professors who actually made the class worth attending, and honestly I was a little burned out. I have thought long and hard about what I could have done with those four years if I could have them back.

4) You won’t learn much during college

This might seem like a continuation of my last point, but it’s not. College classes are still largely taught in a lecture format, often in huge lecture halls. One of the few things I remember from Abnormal Psychology was that students typically remember only 5% of the material presented in lecture format (10% if multimedia graphics are used). This is a bad situation, even if you assume that the professor is awesome and the students care. Small wonder that employers are struggling to find qualified applicants among graduates that they interview. What happened? I thought that undergrad degree was the key to landing a good job? Now that everyone seems to get a degree, I guess not.

College has become like bonus high school. More and more people seem to be going to college, and it hasn’t been working out like we thought it would. Maybe this trend will reverse itself in the next few decades. I will certainly think long and hard before I help my future son finance a $80k degree. I get that college will always be required for some professions (hello medicine, law, etc), and that makes sense (sort of, I will someday write about that too).

It’s not that I’m too good for college, or that our generation is too good for college. It’s just that college isn’t good enough for what it costs. It’s not just the huge debt, it’s the years and time being lost as well.

If a college degree is the vehicle for success, it’s a taxi. It works great for getting you directly from one place to another, but if you just jump in and ride around for four years you’ll be broke and lost.

I need to stop writing now, and this seems like a good place to do it.

Thanks for reading!

As always, feel free to comment below or directly to my face at sortadrwordpress@gmail.com

/