doc w/ Pen

In my last post, I explained how I think that I might have a decent start when it comes to developing a good bedside manner–i.e., working well with patients. What I didn’t take into account in that post, however, is that you don’t only work with the patient. You also work with the patient’s family. And that can create its own set of problems, dilemmas, and conundrums, as a hospice nurse I know explained to me this week.

Take the case of Mr. Martinez,* a terminal lung cancer patient. Most hospice patients have a DNR–a “do not resuscitate” order, which directs hospital and emergency personnel to NOT use life-saving techniques such as CPR or a ventilator, but to let the patient die naturally. Mr. Martinez, a native of Argentina, does not have a DNR, although he would like to have one. Why? Because his son, who still lives in Argentina, wants the father’s life prolonged until he can make it to the United States to say goodbye to his father. The father doesn’t have the heart to disagree. While this seems like a natural desire in a way, it really is very selfish, the nurse explained–it would mean keeping the father alive, perhaps in pain, just so the son can meet his own emotional needs. And it’s not like the son never sees the father; he visits every couple of months, and has had plenty of opportunity to say a meaningful goodbye. Because what do you really gain from seeing an empty, non-communicative shell that’s kept alive by a machine?

The nurse I know said this is a common situation–family members simply can’t let go, even when the end is imminent. So it has become her job to try and convince the son–via e-mail, since he is in Argentina–to encourage the father to have a DNR. Not a task I envy, that’s for sure. It’s one that requires great finesse, compassion, and understanding. And a thick skin, to boot. All done in a one-way conversation, without facial expressions, body language, or vocal inflection–all tools that can be extremely helpful when trying to talk about something so serious and traumatic.

Mr. Martinez’s son, an out-of-town family member, is what one of the nurse’s co-workers calls a “seagull”–someone who flies in, sh**s on everyone and then flies out. They want to help, and they (usually) have the best of intentions, but they don’t really know the day-to-day situation or the intricacies of their family member’s care (or health condition). So they rather muck things up. Often, they step in so aggressively and vehemently because they feel guilty for not being there on a more regular basis, the nurse told me, so they feel they must “fix” what seems “broken” to make up for that absence. When really, the opinionated assistance often does more harm than good.

But it’s not just the “seagulls” who can cause a wrinkle in a patient-care situation. Nearby relatives, even daily caregivers, can create serious problems, the nurse told me. She related the story of one family where two sisters were, in her words, “at each other’s throats.” Just about literally, it seems. One of the sisters actually called 911 on the other sister because she felt that sister wasn’t appropriately administering the patient’s medication.

The kicker? The patient’s problem was agitation. I doubt if sirens, police, EMTs, and whoever else showed up helped alleviate the symptoms the sisters *claimed* they were so concerned about.

This is another situation that, as a health care worker, would be a sticky one to resolve (if a resolution was even possible–a temporary cease fire might be your best bet).

This is not to say that family members are always a source of trouble and ire. As the nurse told me, “Family can also be the greatest resource.” When that happens, it makes the health care worker’s job infinitely easier and richer. So you hope and pray for this scenario.

But for those times when the family members seem to be working against you rather than with you, I imagine you must tap deep into yourself for strength, composure, patience, and endurance. And still, even though it seems undeserved, compassion. Because while the family members may be making your life hell, you have to realize that their life is hell right now, too.

Come alongside. Understand. Empathize. And then maybe you stand a chance not of changing the family, but of helping them to decide to change themselves.

* Names and details have been changed to protect patient anonymity.

The title of my blog is, obviously, My Bedside Manner.* So far, though, I haven’t done much talking about my own bedside manner. Mostly because I haven’t had much of a chance (aside from the summer I spent working in an ICU back in 1999) to develop one, officially speaking.

That doesn’t mean, though, that I haven’t thought about it. In fact, I’ve thought about it a great deal. And I’ve come to the conclusion that, in all likelihood, my initial bedside manner won’t be so bad. It might even be a tad bit good. And hopefully, it will get even better as time goes on.

How did I come to this conclusion? It all started with my grocery cart dilemma. I was at the local Mexican produce market and had just finished loading my trunk with fresh fruit and vegetables for the week. I had parked about as far away as possible (not on purpose, believe me), and it was at least a sun-blazing 90 degrees outside. So when I saw a cluster of about a dozen other shopping carts circling a streetlamp in the parking lot, I was sorely tempted to wheel mine into the bunch rather than back to the storefront. But then I sighed, realizing that I am not the kind of person who leaves the grocery cart in the middle of the parking lot. It just feels wrong to me somehow, unnatural. I would have driven away feeling guilty, and I didn’t want that. So I marched off toward the store, cart in tow.

After my sweaty walk back to the store, I returned to my car and switched on the AC. As I sat waiting for the hot blasts of air to cool down, it occurred to me that my reaction to the cart dilemma might say something about me as a person. It might indicate that I can be thoughtful, even when I don’t know who will benefit from my thoughtfulness. That I don’t like to make extra work for other people if I can help it. That I have a sense of responsibility, and that I take things seriously even when so many people around me (i.e., the other customers) do not.

OK, I will come clean: I am far from perfect. I do not always take the cart back. But I tend to. And so I think what I have just said has some validity.

I got to thinking more about that tendency to take the cart back. Not only what it might mean about me as a person, but also what it might mean for the kind of bedside manner I will have. Thoughtfulness, pitching in where needed, a sense of responsibility? These sound like components of a decent bedside manner to me, as well as a recipe for getting along with my future hospital or clinic co-workers.

“Are there any other clues as to my future bedside manner?” I wondered to myself. Driving home, I thought through some of my other habits (my husband would be more likely to call them “quirks,” but then again he’s allowed that privilege). Of course everyone has habits, but I was looking for habits linked to my ability to relate to others (especially strangers), and to care for them. Sure as Sherlock, I found my clues.

“Eva.” She was my first clue. I don’t imagine she gets called “Eva,” which is her real name, very often during the 9-to-5 workday. But when I stop by the Student Union at the University of Illinois at Chicago for coffee, I do call my barista by her given name. We exchanged names a few weeks ago, and have had little chats ever since. (I’ve had to remind her of my name several times, which is fine–she has dozens of customers every day; I have only one barista.) I don’t pretend that I’ve solved all the problems in her life, but I do believe that I’ve shown her the respect she deserves, but doesn’t often get because she’s working an “unskilled labor” job (and is surrounded by hoity-toity doctors who are more than happy to point that out).

In a hospital setting, that would translate into exactly the same thing: learning people’s names, and using them. Rather than, for example, calling someone “the gall bladder in 241” or “the stroke in 332.” Yeah, not much respect for the person there. Learning someone’s name shows that you care about them as an individual person, and (in the hospital) not just about their disease or what kind of health insurance they have. That’s pretty important for building the patient-doctor relationship.

Using a person’s name is one important aspect of communication. Another is saying “thank you” when someone deserves it. Of course, when you’re at the grocery store, most people say “thank you” when the bagger hands over the plastic sacks. I’m not talking about those automatic situations. I’m talking about going out of your way to thank someone, where it really makes them feel special and rewards extra effort.

I have found that this really goes over well with people. Although that’s not why I do it. I do it, perhaps, because I like being thanked. Or maybe because my mom forced my sisters and I to write thank-you notes for every little gift we ever received as children, so it’s ingrained in my head now. Regardless, I do it. Like when I was at the craft store the other day. The cashier rung something up as regular price. I thought it was on sale. Rather than tell me to go find another item with a more accurate tag, or call someone else to check on it, she went over to the shelf herself. Turns out, she was right. Regardless, I thanked her for making the extra effort to verify the price for me. She smiled, and I think she even blushed.

In the doctor-patient relationship, it’s the doctor who’s helping the patient, and who should be thanked. So my habit doesn’t apply. Right? I wholeheartedly disagree. In any relationship, there is give-and-take. One has to help the other, and vice versa. Sure, the patient has come to the doctor looking for help, and it would be nice if the patient thanked the doctor, but that’s not why the doctor does his or her job. However, the doctor can make his or her job a bit easier by saying “thank you” to the patient. This may not work in all situations, but it will in many. For example, a patient reveals something very personal that was difficult to say, but necessary to treating a condition. “Thank you,” says the doctor. Or the patient comes early as requested to fill out some paperwork. “Thank you,” says the doctor. You get the idea. The obvious corollary of this is for the doctor to say “I’m sorry” when he or she has done something wrong, is running late, etc. Both appreciation and apology go a long way toward building a relationship with someone, and maintaining that relationship. This is the philosophy I have developed so far, and the one I intend to implement in the future.

A common thread here so far has clearly been respect. So if I want to have a good bedside manner, I want to avoid disrespect (this is obvious, but bear with me). One of the most disrespectful inventions in the history of man, in my opinion, is telephone call waiting. It has its purpose, I understand. And I use it from time to time–but ONLY if I am expecting a particular telephone call, and one that is extremely urgent. If I am talking to someone, and another person calls, that second person can either leave me a voicemail message or call me back later. End of story. Because I consider it in very poor taste to interrupt my first conversation to (ostensibly) find out whether the second call is more important, and should therefore be given priority. This call waiting fetish says much about the “NOW” need in our culture, but I will not go into that. Suffice to say I ignore my call waiting 95 percent of the time.

OK, I admit, this one won’t work in the physician setting. If, as a doctor, I am on the phone with a patient, I may very well get a phone call from someone else (another patient, the hospital, a resident, etc.) that may very well be urgent, but I won’t know that until I find out who it is or what it is about. So I will have to make some philosophical adjustments here.

However … my principal still holds in another respect: respecting a person’s time. (Because when you break it down, that’s a large component of the problem with call waiting. You’re saying one person’s time is more valuable than another’s.) For example, if a physician is talking to a patient, that physician should, whenever possible, give his or her full attention to that patient. Doctors filling out patient charts while they talk to a different patient about a potentially life-threatening condition, and having to ask that patient to repeat things because the doctor was busy writing something down on the chart? That’s not respectful. That’s just like saying, “I’ve got another phone call. Hold on.” Again, there will be plenty of urgent, and warranted, interruptions. That goes with medicine. So make those five minutes, if that’s all you’ve got, count. That’s my plan, at least.

Along with paying attention, there’s another aspect to respecting a person’s (and a patient’s) time. That is running on time. Also not always possible, clearly, due to those aforementioned interruptions, emergencies, and so on. But I have seen a number of different medical practices at work–some run efficiently, others not so much. There are ways to running closer to being on time. Those ways sometimes cost money (i.e., salary for additional staff to process patients or shelf charts). But if your patients are happy, they are more likely to come back and pay you again. And if you, your patients’ doctor, is on time, your patients are more likely to be happy. Because their time is valuable, too. Having sat in more waiting rooms than I’d care to think about, I heartily and readily acknowledge this.

None of this is to say that I am extra special, am grandly talented when it comes to interpersonal affairs, am a superhero, or am the next Dr. Schweitzer. Nothing of the sort. I’m just saying that these habits, which really (so far) have nothing to do with medicine, illustrate that I respect people in various ways and that I am willing to put myself in their shoes to make sure that respect comes across. And that, to me, is at least part of what having a good bedside manner is about.

* My Bedside Manner was the title of the original blog I started. When I migrated from Blogger to WordPress, I changed the name to Doc with Pen.

Hormigueo (tingling). Escayalo (plaster cast). Expediente (patient’s file). Presión arterial (blood pressure).

Two weeks ago, I didn’t know any of this Spanish medical terminology. Sure, I’m fluent in Spanish, but these words — as well as a few dozen (er, a few hundred) others — simply never came up in regular conversation. I’m hoping that will change soon, as I have applied to be a volunteer Spanish translator at an urban clinic in Chicago.* Which means, of course, that I will need to know quite a bit of Spanish medical terminology to successfully do my job.

I never took this position lightly. But the more I think about it, and the more I learn about interpreting, the more I understand that “professional” interpreters can make the difference between a successful and an unsuccessful clinican-patient encounter, and between helping a patient making an informed versus an uninformed medical decision. I can help make that difference. I want to help make that difference.

When it comes to demand for Spanish interpreting, the need is only going to grow. According to a 2008 report from the U.S. Census Bureau, the Hispanic population is expected to grow from its level of 15 percent in 2008 to 30 percent in 2050. The percent of non-Hispanic whites is expected to fall from 66 percent to 46 percent — meaning whites are expected to no longer be in the majority, although they will still be the largest minority. And my home state, Illinois, is one of the centers of the Hispanic population. A 2006 U.S. Census Bureau document ranked Illinois as number 5 in the nation in terms of size of Hispanic population (1.89 million). Cook County, IL, my home county, was also ranked number 4 in the nation in terms of Hispanic population size, with 1.2 million Hispanic people.

Along with that increasing number of Hispanic people comes an increasing number of “Limited English Proficient” (LEP) patients in the medical context. These are people whose primary language is not English (Spanish, in this case), and who have difficulty reading, writing, speaking, and understanding English. According to a number of scientific studies, this language barrier can cause many health care problems, as summarized in an article published in Health, Research and Educational Trust in 2006 (“Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency?”):

• less access to routine care
• fewer physician visits
• lower rates of preventive care
• less follow-up for chronic illness
• poorer understanding of Emergency Room visits (i.e., diagnosis and treatment)
• less satisfaction with care
• more medication complications

When it comes to Spanish, the problem is often not the lack of a translator. The problem is more frequently with the quality of the translation. Very often, “ad hoc” interpreters — people who are untrained, such as family members, receptionists, or other people in the waiting room — are used, which results in inaccurate and sometimes disastrous consequences. Sometimes, it is that the interpreters who are used are simply poorly trained. Because unlike courtroom reporting, there are no  national standards, or even guidelines, for health care interpreting at this time. The National Council on Interpreting in Health Care, an organization dedicated to promoting professional and culturally conscious interpreting, is working to develop a set of training standards (which are set to be done at the end of 2010). The idea is to eventually have national certification for interpreters.

Right now, though, we are far from that. And it is affecting patient care, sometimes dramatically. One study, published in 2007 in The Society of General Internal Medicine (“Are Good Intentions Enough?: Informed Consent Without Trained Interpreters”), found that Latina patients who were at a prenatal clinic being given the choice of whether to have amniocentesis were unable to truly give their informed consent to the procedure. In some cases, their interpreters did not fully explain what the medical practitioner was saying, either because of a lack of fluency in Spanish or a lack of medical understanding in general. In other cases, the procedure was not presented as being “optional,” but as “simply the next step in the clinical process.” In addition, it was often not communicated that there were any alternatives to amniocentesis (while a woman could have an ultrasound instead, although this test is not as definitive).

In short, the complicated nature of translating medical terminology, risks, benefits, potential complications, alternatives, etc. is something that requires more than being bilingual or “good” at speaking Spanish. It requires training and a fluency in medical terminology, in addition to privacy practices and other issues related to health care.

At the clinic where I want to volunteer, there is an orientation/training seminar where volunteers are tested on medical terminology to ensure they meet at least a minimum of requirements. In addition, I have spent hours (and I mean HOURS) studying literally hundreds of flashcards with words copied from my new best friend, the Spanish Medical Dictionary. I may not have to pass a set of national standards at this point, but I have my own standards. And I have set the bar high. Because I am serious about this job — it’s an important one, and it’s even more important to do it right.

*I’m still waiting to hear back regarding my application; apparently they are currently reviewing my references.

Good news, if you’re a roundworm: researchers at Stanford reported last month that blocking the expression of a particular protein can extend a worm’s life span up to 30 percent.

That is good news . . . right?

It depends on whom you ask. Clearly, the Stanford researchers, as well as other researchers who have studied caloric restriction (another method purported to promote long life) think so. But there is another camp of scientists dedicated to improving not so much life span, but health span.

So what does “health span” mean? According to the Macmillan Dictionary’s online “Buzzword” feature, “health span” is “the period in a person’s life during which they are generally healthy and free from serious or chronic illness.” So the focus is on living better, as opposed to living forever.

Sounds simple enough, doesn’t it? But this concept is really a very complex one which scientists are only beginning to grapple with, understand, and research. Ironing out some of the complexities, and getting more scientists, policy makers, and regular people to think this way, though, is key to making sure that “aging gracefully” is not just a catch-phrase.

One major problem in the world of aging research is a disconnect between the viewpoints of clinicians and “basic” science researchers on this very topic. In an article published in the Journal of Gerontology in 2009, authors Drs. James Kirkland and Charlotte Peterson write that “Geriatricians and others providing health care for the elderly have long recognized that disability, frailty, and age-related disease onset are the critical end points that need to be addressed in older populations.” Hence, many clinicians are on the “health span” wagon. However, Kirkland and Peterson also claim that “Most investigators in the basic science of aging use survival curves and maximum life span as key end points for studies of effects of interventions, rather than health span or function.” Hence many basic science researchers are on the “life span” wagon. And when researchers and clinicians are on two different wagons, little if any progress will be made in terms of going from the scientific “bench” to the bedside with new treatments.

What needs to happen, writes Marc Tatar, a biologist at Brown University, is first clarification of the health span concept. While Tatar explores a more scientific definition of health span than the one I previous listed, his comments relate to our more simple definition as well. For example, how do you define “healthy”? What is the threshold between healthy and unhealthy, in terms of time and quality of life? And even if you use baseline performance as a judge, that baseline performance declines over time — how do you factor that in? These issues need to be resolved before any progress can be made, Tatar says.

Once some of that ambiguity is resolved, the next step is to develop a better animal model for studying health span, Tatar says. That will allow researchers to take results and translate them to human models. For example, researchers should look at how best to study osteoporosis — clearly a factor in human health span — in mice, flies, or worms (three of the best animals for studying aging issues).

Kirkland and Peterson agree that better animal modeling is needed, although they focus on the concept of frailty: “Frailty usually describes a condition in which a critical number of impairments occur in parallel, becoming evident after a threshold is reached, and if a stress such as an infection or injury is applied.” They say that indicators of “frailty syndrome” include weakness, fatigue, weight loss, impaired balance, decreased physical activity, slowed motor performance, social withdrawal, mild cognitive dysfunction, and increased vulnerability to physiological stress.

According to Kirkland and Peterson, screening for frailty in humans is being developed and validated, and could be adapted for use in animals. Testing animals for frailty — after giving them an anti-aging compound, for example — could help show whether the added longevity compromised health span, and therefore whether the compound was potentially appropriate for trials in humans.

Living longer, obviously, can be a good thing. But only if that extended life is a healthy one. That’s what the study of health span is about. And while the idea is catching on, it has some catching up to do.

Of the dozens of patients I encountered the summer I worked in an ICU in the Chicago area, the person I remember the best is Mr. Chesterfield.* Rather, I remember Mrs. Chesterfield — her husband was on a ventilator and was unconscious and unable to talk the whole time I was there. But Mrs. Chesterfield and I had some lovely conversations while I stocked the nurse’s cart in Mr. Chersterfield’s room, brought in new boxes of gloves, and changed the sharps box. She even sent me a thank-you note, telling of her appreciation for how I had encouraged and comforted her during that difficult time.

At the time, I knew the machine hooked up to Mr. Chesterfield was pumping his lungs full of air, breathing for him. But I had no idea how it worked, or what damage such a life-saving device could potentially cause. Until today’s lab meeting.

Clearly, if someone cannot breathe on his or her own, having a machine do it is a good thing. There are several problems with using a ventilator, however. One is that using a ventilator at “high-tidal volume” — which is sometimes required, when a person’s lung capacity is diminished (from what I understand) — can “hyperinflate,” or overstretch, the lungs. This excessive stretching breaks the cell-cell junctions (sticky stuff that keeps the cells together). This necessary (but damaging) overstretching results in a condition called “volutrauma.” In this condition, the permeability of the lung cells (specifically, alveolar epithelial cells) increases, which affects gas (i.e., oxygen and carbon dioxide) exchange, the spread of micro-organisms (and infection/inflammation), and the build-up of fluid. When volutrauma is taken to the extreme, according to one person in my lab meeting, you basically drown to death because your lungs fill with fluid. Not good.

Of course, when you breathe normally, you are also stretching your lungs — perhaps about 8 percent. High-tidal volume ventilation might stretch your lungs about 20 percent instead. With that extra stretch comes increased permeability and the cell-cell gaps that create all the problems.

What one of my fellow researchers has found is that decreased levels of a particular protein seem to be linked with those cell-cell gaps and increased permeability. Increased levels of that protein may be associated with fewer gaps, called a “partial rescue.” This means the protein could be a “therapeutic agent” for ventilator-induced lung injury. Which would be a huge deal, especially considering that many ventilator patients are older, and that the ratio of elderly people in the overall population in the United States is about to jump sky high.

Of course, there are plenty of issues to work out with this research. (I won’t even start on those.) This is basic science, not even close to a clinical trial. But it’s exciting to see how something happening in the lab next door could potentially save lives a few years (or decades) down the road.

And who knows? Maybe by the time I’m an anesthesiologist (a thought that has occurred to me more than once) this is a treatment I’ll be using.

*Name has been changed to protect the patient’s privacy.

While some of my friends are busy planting and harvesting strawberries, artichokes, or melons to earn coins on FarmVille, I am also likely on the Internet. But not on Facebook. These days, you’re more likely to find me on http://www.PubMed.gov, a Web site run by the National Center for Biotechnology Information, the U.S. National Library of Medicine, and the National Institutes of Health.

And yes, this is more proof that my brain has been taken over by an alien being. Or perhaps an entire colony of them.

Seriously though. PubMed is incredible. It’s an online database of more than 20 million citations to scientific/medical articles dating back to 1865. Nearly 3 million of those citations include FREE full text. (The vintage-bargain-hound in me loves this.) It’s a fantastic resource if you want to know, say, the role of caveolin 1 in embryonic lung development (something my mentor, Olga, is writing about for a textbook chapter). Just like with Google, you type in your search terms and hualah! Article citations.

Of course, quite often the article I want is NOT free … so I must be satisfied with a mere abstract, or perhaps a less recent (or somewhat less relevant) article. If it’s a matter of life and death (er … success and failure of an experiment, more likely), I can just buy 24-hour rights to read the article from the publishing journal.

It’s that easy. And anyone can do it. You don’t have to be a scientist (or a pre-med student) to enjoy the pleasures of PubMed. For people whose brains haven’t quite mastered the technical language (I include my alien-infested gray matter in this category), reading “reviews” of articles instead of the actual articles themselves is a much easier way of digesting and understanding the information. Just a little tip I picked up from Olga.

So what are you waiting for?

“Wait and see.”

How often has your doctor spoken those words to you after handing you a prescription? Too often, it seems to me. And this is not where we should be in the year 2010, says Dr. Bryan Schneider, an oncologist who was interviewed in June on Indiana University’s Sound Medicine podcast.

Instead of “wait and see,” Schneider thinks doctors should be able to predict a patient’s reaction — both in terms of positive effects of the medication and its negative side effects — saving both lives and money.

This idea — called “personalized medicine” — is not really new. But it’s gaining traction and speed, with recent support from the Food and Drug Administration and the National Institutes of Health. And while the government is behind on regulating this new field (which has led to a number of problems, including reports of women unnecessarily having their ovaries removed), there are promises to catch up on that front.

So why isn’t all of our medicine personalized? Good question. It would be nice. But we are not there in terms of technology.

Personalized medicine is really about genetics. People react differently to medications because of variations in their DNA. The Mayo Clinic’s Web site explains it well: For example, one genetic variation might cause a drug to remain in your system longer than normal, leading to dangerous side effects. Another variation might make your body less sensitive to a medication, meaning it won’t work as well, and you might need a higher dose than other people.

If doctors could test for different genetic variations, and how those variations affected your body’s response to a medication, they could prescribe more efficiently. Doctors could choose both more effective medications, and more effective dosages, for individual people. This would save not only in terms of a “grief” factor, but it could save lives — according to the Mayo Clinic, some 100,000 Americans die each year from reactions to medications, and more than 2 million wind up in the hospital. If a doctor knew someone would react poorly, he or she could avoid prescribing a medication entirely. This philosophy would also save money (always a selling point). Many treatments — especially those for long-term illnesses such as cancer — cost tens, if not hundreds, of thousands of dollars per year. Prescribing selectively and effectively eliminates guessing, grief, and waste.

The problem is that there could literally be millions of genetic variations (no one’s sure how many). And sometimes a response to a medication may not be governed by one gene, but by many genes interacting with each other. We simply do not know enough about the interactions between genetics and medications.

There are, however, a few genetic tests available today that allow doctors to personalize a patient’s medical care, most of them related to cancer treatment.

One example a test for HER2, a gene involved in breast cancer. If a woman’s cancer is HER2 positive, the results indicate use of Herceptin, a drug that can shrink the tumor, get rid of HER2 cells that have spread beyond the original tumor, and possibly prevent recurrence of the HER2 positive cancer. HER2 negative tumors do not respond to Herceptin, so before Herceptin is used, patients are tested with either an immunohistochemistry test or a gene-amplification test.

Another example involves metastatic colorectal cancer. If the cancer expresses the protein epidermal growth factor receptor (EGFR), then a medication called Erbitux may be used in combination with other treatments. Erbitux inhibits EGFR (which helps the cancer grow), so the medication may slow or stop the spread of the cancer. But Erbitux only works if the cancer expresses EGFR, so a genetic test called an EGFR immunohistochemistry test is required first.

So where do we go from here?

Scientists are making great strides in discovering those genetic “variations” that interplay between disease and medications, according to a recent article in The New England Journal of Medicine (published online on June 15). The problem, according to this article, is that “there is insufficient evidence of a downstream market to entice the private sector to explore most of them [the genetic variations].”

Basically, drug companies don’t see the dollar signs. So they don’t invest anything.

The purpose of that New England Journal of Medicine article (called “The Path to Personalized Medicine”) is to lay out a plan to show how the Food and Drug Administration and the National Institutes of Health plan to “fill that void.”

The FDA and NIH plan to do this in several ways. The first step is an “integrated pathway” between academic research and approving treatments for clinical use. The FDA and NIH promise public-private partnerships, as well as a program called Therapeutics for Rare and Neglected Diseases (TRND), aimed at accelerating the development of drugs, developing “targeted” drugs, and rescuing “failed” drugs by finding certain groups of patients who might benefit from them.

A second step is collecting information about genetics and treatment outcomes. For this, the NIH is relying on its various research centers and hospitals.

And last but not least, the FDA has established the “Critical Path Initiative” to regulate this up-and-coming industry and science. It is, in my opinion, about time they did this. As the article authors admit, there have already been instances of regulatory failure: “Increasingly, however, the use of therapeutic innovations for a specific patient is contingent on or guided by the results from a diagnostic test that has not been independently reviewed for accuracy and reliability by the FDA.” In other words, doctors may be using tests that the FDA has not approved to guide their treatment decisions. Not good.

For example, the FDA approved the drug Rituxan for certain cancer treatments in 2006. According to the NEJM article, a particular lab company has since then been marketing a test that claims it can tease out the 20 percent of people who will not repsond to the drug from those who will respond to the drug. Says the article: “The FDA has not reviewed the scientific justification for this claim, but health care providers may use the test results to guide therapy.”

Huh?!?!

In addition, the article’s authors point to other issues with laboratory tests that lacked FDA oversight, including situations where women were given “false readings that reportedly led to the unnecessary removal of women’s ovaries.”

Apparently, these glitches will now be taken care of. I sure hope so, because personalized medicine might just be the future of medicine.

My middle school nickname — “turtle” — was a comment on my overpreparedness.

When I was in middle school, my friend Jaime Truitt used to call me “Turtle.” The nickname didn’t really catch on with anyone else, which actually surprises me because the moniker was truly appropriate. I carried a bluish-green backpack (right color), the pack was stuffed to bursting (hence looked like a shell on my back), and I had everything I needed in there (in Jaime’s words: “You carry your house on your back!”).

To this day, I tend to be very prepared, if not overprepared, for most situations (when I have the time). From going on vacation (typed up and formatted checklist) to going to the grocery store (hand-written list this time, but organized by where the food is located in the store so I’m not wandering).

The same applies, of course, to getting ready for medical school. Which is, obviously, a little more important than remembering the sunscreen or that the ketchup is in the same aisle as the olives (why that is, don’t ask me). One of the things I’m doing to prepare is to look at potential medical school interview questions. Because those interviews–of which I will hopefully have several–are do-or-die situations. They can make or break a borderline (or even a stellar) application. No pressure, right?!

It’s not hard to find sample questions. Google the phrase “medical school interview questions” and you come up with “about” 14,800,000 (yes, that’s 14 million 800 thousand) hits. I copied and pasted questions from a few sites that appeared to be reliable (i.e., Harvard’s pre-med advising office) into a chart.

So I’ve got them … now what? Clearly, this isn’t the kind of thing I can cram for. And the ADCOMS (that’s pre-med lingo for “admissions committees”) may not ask me ANY of the questions I prepped for. But practicing will get me in the right frame of mind. Thinking about why I want to be a doctor, what I want to do, how I feel about the current health care system, etc. I will start to approach these topics very critically, which is both good for the interview, and for when I am a practicing physician.

Over lunch today, I was casually glancing over the questions. I groaned a few times, rolled me eyes, laughed, scratched my head, smiled. The questions are really all over the place, in terms of difficulty, subject matter, length of response, required background knowledge, and so on. Then I came upon the dreaded “strengths and weaknesses” question. You know, the one they ALWAYS ask in job interviews, trying to trip you up. Such an insidious question, one you can hardly answer without making yourself look bad.

So I stared at the question. Then I stared off into space. Sure, I have weaknesses–everyone does. And I could think of a few. But I thought to myself, “Hell if I’m going to sabotage myself in a medical school interview!”

Then I realized something: the weaknesses that kept popping into my head were really strengths, but taken to an extreme. Therefore if I could harness those weaknesses, rein them in, I could transform them into the strengths that they had the potential to be. Whoaaaaa … (my Cartman moment)

For example: take my overpreparedness. It can get a little excessive. And, as my husband will attest, a bit irritating to a partner / companion (romantic or otherwise). Too much baggage, too much planning, too much fretting. Toning it down, though, and planning a little less than I do now would relieve that pressure (on both me and the person with me), while still allowing us to be prepared for whatever adventure lay ahead. Whoaaaaa … (yet another Cartman moment)

Maybe I’ll still be somewhat of a turtle. (I do, after all, have another green backpack, although this one is more of a mossy color.) My goal for the future, though, is to be a smaller one. That’s a good place to start.

A few weeks ago, my mom went to see her doctor. While there, Mom decided to ask the physician if she had any advice for her daughter (me), a doctor-to-be.

“Yes, actually I do,” the M.D. replied. “Do NOT go into Internal Medicine, Family Practice, or Pediatrics!”

Why not? It comes down to one word: money. Or rather, the lack thereof. And this is at the heart of one of the biggest controversies and most serious issues facing the medical community, and perhaps our country, today. It was also the subject of Indiana University’s “Sound Medicine” podcast on June 13. But that story is coming up shortly.

What’s the big deal? Don’t doctors earn bank? Well … depends on who you are. The three specialties my mom’s doctor mentioned–Internal Medicine, Family Practice, and Pediatrics–have the lowest annual salaries of all specialties. Here are some average yearly salaries, according to Becker’s Hospital Review, an organization that surveys doctors every year about their income. (This data is from Becker’s 2010 study. You can find it on the Web at: http://www.beckershospitalreview.com/news-and-analysis/current-statistics-and-lists/physician-generated-revenue-and-average-salaries-by-specialty.html.)

While I’m sure part of it is about lifetime earning potential, part of it is also solvency potential. When you finish medical school and residency–and perhaps a fellowship as well–with some $300,000 in debt, you need a decent income to pay that off in a reasonable time frame. Because the longer it takes, the more interest accrues. And you don’t want to be paying back that loan in your retirement.

Now refer back to the list of specialists and their salaries. Note that the difference between one of the lowest (Internal Medicine, at $173,000) and the very highest (Neurosurgery, at $571,000) is nearly $400,000. Put another way, the neurosurgeon makes 330 percent more than the family practitioner. Granted, brain surgeries are complex, and becoming a neurosurgeon requires more training than most specialties. But taking care of people of all ages, with all types of conditions, is pretty complex, too. So why such a disparity?

The answer is so simple … and yet, not. The short story is that the higher-paid specialties are the “procedure” specialties. Those doctors–such as surgeons and cardiologists–do a lot of “billable” work. In other words, they tend to get paid for most of what they spend their time doing. Primary care docs, on the other hand, don’t do as much billable work. In fact, they spend a lot of time doing things that earn them absolutely ZERO money: refilling prescriptions, answering e-mails and phone calls, and looking at lab results. This is still “doctor” work–it can’t be done by anyone without that $300,000 M.D. after their name–but neither HMOs nor Medicare will pay you to do it.

Basically, primary care docs are overworked and underpaid. Sounds like fun, right? So no wonder many medical students these days shy away from those specialties–a trend that is expected to leave us with a huge shortage of primary care physicians in the coming years, especially as the Baby Boomer generation ages and requires more and more care.

In reality, none of what I’ve just written is news. (HA! Gotcha there, didn’t I? You thought this was supposed to be a NEWS column? Well … I’m getting to that.)

What is news is that this spring, an internist from Philadelphia named Dr. Richard Baron did a quantitative study of this issues. (I heard Dr. Baron interviewed on “Sound Medicine,” a podcast produced by the Indiana University School of Medicine. Check it out on the Web here: www.soundmedicine.iu.edu.) Dr. Baron’s results, conclusions, and the actions his practice (Greenhouse Internists) has taken based on those results are pretty amazing.

Dr. Baron’s study was quite simple actually, and relied on data the practice had already gathered and stored in its electronic health record. This electronic health record, which the practice adopted in 2004, is used “exclusively to store, retrieve, and manage clinical information,” as Dr. Baron writes in his paper, which was published in The New England Journal of Medicine (April 29, 2010). Physicians and other clinicians can enter clinical information into different categories such as “office visit,” “phone note,” “lab report,” and “imaging.” Dr. Baron and his colleagues then studied the volume (and corresponding categories) of their 2008 records. For more detailed content analysis, they looked at one week’s worth of phone calls and e-mails.

Below, I have reproduced a chart from Dr. Baron’s study. Note that the only work the physicians are paid for is the patient visit. From this chart, you get an idea of how much work–and how much time–goes into doing things that insurance companies don’t consider to be billable.

Dr. Baron already knew that the physicians in his practice (as well as other primary care physicians) were doing “unpaid” work. This detailed look at his practice’s records shows just how much.

These results, while more reinforcement and quantification than new evidence on this topic, still do highlight the need for a redesign of the primary care payment system. This is Dr. Baron’s opinion; it is also mine. It is, as Spock would say, “only logical.”

But what might those changes be? That is the million dollar question. It is one that the politicians, lobbyists, insurance companies, physicians, and other interest groups must pound out. And sooner rather than later, preferably.

In the meantime, Dr. Baron has made some changes in his own practice as a result of his research. First, Dr. Baron and his colleagues took a hard look at the “administrative” work (the phone calls, e-mails, looking at lab reports, etc.) that the physicians were doing. While doing much of it required an M.D., some of it could be done by a registered nurse or other (less expensive) clinician. So hiring more nurses, in many situations, is one way to cut costs and therefore boost salaries.

Another change Dr. Baron and his colleagues made was to their “productivity formula.”Greenhouse Internists, like many other practices, uses a combination of base pay and productivity to determine their physicians’ total salaries. What Dr. Baron and the others quickly realized was that their formula–which calulcated productivity based on the number of patients seen–simply mimicked the same payment system they were claiming was so unjust and arcane. Their response? Include that administrative work–the calls, the e-mails, etc.–in their own productivity formula. So while insurance companies might not reimburse a doctor for refilling a prescription, Greenhouse Internists does, in fact, consider such a duty to be “work.” And so it pays its staff physicians accordingly.

These changes do not make up for the payscale differential or the disparity in billable procedures between primary care and the “procedure” specialties, but they are a step in the right direction. Policy makers would do well to read Dr. Baron’s paper and take a look at how his practice is handling these issues. They might learn something. (God forbid.)