Saturday, September 26, 2009

Best things I learned in medical school

I'm in a contemplative mode and thinking about the lessons I learned in med school. Also, I am writing a novel that is loosely based on my med school experiences. So these kinds of things are fresh in my mind. Please feel free to add to my list.
  1. Many of the patients you "treat" will have taught more future physicians than you have seen patients. Their lessons are valuable. Treat these "frequent flyers" with respect.

  2. The most important, and hardest thing to learn is the difference between sick and not-sick. Everything else is largely irrelevant.

  3. Think of your med school friends not as fellow students but as future physician peers. In other words, be as professional in med school (and in social media such as FB and Twitter) as you would on the wards.

  4. Stress is contagious. Stay as far away from groups of med students when studying. Pick one person to study with, and avoid the library at all costs.

  5. There is always someone above you. Achieve your goals but don't lay your happiness on getting to the next level or else you will be forever unsatisfied. Because when you are a first year med student, you are at the bottom. But when you are a first year resident you are also at the bottom. When you are a fellow, the attendings are above you. And when you are a new attending, the older attendings/medical directors are above you. If you own your own group, there are bigger groups than you trying to steal your contract. Everyone has their own stresses at every level of life. Enjoy where you are now and continue to challenge yourself from within; not as a comparison with someone else.

  6. Just when you think you've seen everything, something else happens to blow your mind.

  7. Compassion is the most important quality in a physician. Anyone can memorize facts from a book. But if you don't truly care for your patients, you should go into banking or some other profession.

  8. If you feel like the walls are closing in on you, and you can't handle the stress, and that you are the only person who feels this way-take to heart the fact that you are not alone. Everyone has felt this at some point in their career. If you experience this, reach out; you will be surprised at how many others are in the same boat.

  9. Don't ever be so overconfident and think you know everything. Nobody knows everything. And if you did, it would not matter, because tomorrow everything you know will be proved wrong by a new study. Instead acknowledge that there are some things you might not know and be open to learning new things. Ask questions. Don't ever pretend or "fake it." It is okay to look up information. Even surgeons study an anatomy text just before going into a surgery. That isn't admitting a weakness. The ability to know one's limitations is actually a strength.

  10. Remember the idealistic reasons you went into medical school in the first place. Medicine can be difficult, but never lose sight on what brought you here.

Saturday, September 19, 2009

The Unstable Business of Emergency Medicine - Interview Questions for New Grads of Residency

Normally I do general health care issues in my blog. However, this being the beginning of the interview season for residents looking for work when they graduate, I thought I'd dedicate this blog to that. I hope this is helpful, and for those who don't "need" this advice, I hope you find this behind-the-scenes look at Emergency Medicine insightful.

Last year, I found myself, once again, looking for a new job when my company was taken over by a previous employer of mine. This situation led to me having held jobs with six different employers over only seven years. It is not because I've been flighty; I held one job for four years before moving on to new challenges.

While in the midst of the job-hunting process, I uncovered a file I created for myself when I finished residency. It had a list of Interview Questions to ask a potential employer. Many of the questions were very good, however, now having had a chance to look at the questions through the eyes of experience, I discovered that much more information should be given so the new graduate can truly understand what they can expect from their first job.

Words in black are the original, and the comments in red are my...err...improvements:

Group Structure:
  1. What type of group? How does it work? Is this a shady partnership where everyone has equally poor reimbursement? Is this a shady partnership where only the partners make good money and nobody else can actually achieve partner? Is this a democratic group? If so, does everyone share equally? Does that mean that you don't value experience? Is this a shady corporate group where the corporation gleans large amounts of income for "administrative" expenses or for stock market productivity gains?
    How are administrative positions assigned? That is, can someone work their way up to Director? Will I be asked to serve time on one or more committees without any hope of reimbursement for my time and travel expense?
    Are there other meetings that members see each other than on shift change? Do members like seeing each other outside of chance encounters on overlapping shifts?

  2. How long has the hospital contracted with this group? When is it up for renewal? How stable is the relationship between the group and the hospital? These are great questions that mean nothing. If the hospital wants to fire the group, they can find a way, regardless of when the contract is up for renewal. Even if the group has held the contract for 25 years, there is no loyalty amongst thieves, and the hospital will think nothing of handing your contract (and your job) over to complete strangers. This happened to me on my very first job-the contract was yanked early before I worked my first shift.

  3. What is the group composition: e.g. female, male, Board certified EM MD? Are you a young group with little experience that are there because you don't know any better yet? Or are you an aging group of docs that may or may not be Emergency Medicine Residency Trained and are resistant to "new" trends such as Etomidate for RSI and use of computers/pdas. Is there an opportunity for mentoring or will I simply be thrown to the wolves? (If female): Will you freak if I get married because it means I might want to work less and have a life? (If male): Are there a lot of women in the group of prime birthing age that will make me have to work more shifts when they deliver?

  4. Staffing Patterns: Any double coverage times? 8/10/12 hour shifts? PA/NPs? Will there be too much coverage or too little coverage? Will I have to work a bunch of long painful shifts that never seem to end, or will I have to work a lot of short painful shifts where nothing much gets accomplished? Will I have to work with the physician extenders who will be paid to have me teach them how to do their job? Or will I have to work with physician extenders who have worked for decades and resent any opportunity to be taught anything? Will their salaries come out of my salary or does the group pony up the cash for them?

  5. How do you pay? Monthly? Salaried with benefits? Independent contractor? Hourly? Productivity Incentives?

  6. Do you pay malpractice with tail? *Note: this is not always advantageous as many companies will remove more from your reimbursement than your malpractice policy actually costs. Also, if they buy the policy, they control the policy and its terms. Important things you want in your policy: 2mil/4mil coverage, ability to refuse settlement, and ability to choose your own attorney. Therefore, it is more ideal to get extra money in salary, but purchase the policy on your own (using your group for risk pooling). In fact, If I were a new grad, I would make sure not to get too dazzled by groups that offer malpractice w/tail. It is not always a good thing.

Nurses and Ancillary Staff:
  1. Nursing Turnover? Can you retain nurses? How long have most of the nurses worked here?
    Ratio of nurses to patient? Are the nurses expected to see more patients than they can handle safely, with little tech support? Are the nurses expected to see new patients in addition to managing all the ED boarded patients?

  2. Relationship with MDs? Do they resent women MDs giving them orders?
    Is there a shortage of nurses in the ED? DUH! Is there a hospital that doesn't?

  3. Phlebotomists? Are there people who draw the blood for the nurses? Does that mean the patients have to wait longer for labs since the nurses won't/can't draw blood on their own?

  4. Social Services? Do you have it at night? At all?
    Grief counseling? Is there someone to call when the deceased patient's family shows up in hysterics?
    Psych? In-patient? Is there a way to get the crazy people moved out of the ED in less than 24 hours?

Clinical Practice:
  1. Do ED MDs provide code service for the whole hospital? Are ED docs the only ones who will care for the inpatients overnight? Will we be forced to abandon our own patients for someone else's and incur huge liability in the process? Will we have to run up to pronounce patients who have recently died?

  2. How fast does it take to get EKGs in the ED? Can we easily get old EKGs? Respiratory treatments/ABGs? Will the respiratory techs be dedicated to the ED or will they have to abandon the sick ICU patients for ours and vice versa?
    Is x-ray and CT in-house? Also, will the x-ray tech spend the last few hours of my night shift up on the floor and thus ignore all my emergency x-rays?
    At night? Will someone have to come from home every time I need a CT scan?
    Is there a radiologist reading x-rays 24 hours a day? From some one in India?

  3. U/S availability? Can we do our own? Will you do ours promptly? Will you have an in-house tech or will you make pregnant patients wait 1-2 hours for an ultrasound? Can I get peripheral venous doppler ultrasounds at night or do I have to just waste a bed in the hospital (and a lovenox shot) to admit them for a potential clot?
    Can I get V/Q scans 24 hours if needed? Will you be out of dye whenever I need one? *answer: yes (out of dye) as there is a current radionuclide shortage*

  4. What is the average patients seen per hour for ED physicians? Is it above or below the 2.5pph that ACEP/AAEM recommend as a max for safety reasons?
    How many beds in the ED? Critical ones? Is there a fast-track? Staffed by MDs or Midlevels? Are most beds full of boarded patients?

  5. Admission Rate? Acuity? The key question here is not how many people are very sick and need admissions. It is how many patients get admitted and occupy their room in perpetuity, thereby preventing any new patients from being seen (especially important if you work on a productivity model)
    %Trauma? Do you have an official trauma designation?
    %Pediatrics? What percentage of patients are pediatric? If it is high, are there any pediatricians who run a peds ER for certain hours of the day? Does the hospital admit pediatric patients? Up to what age? Do 17 year olds get the unfortunate designation of not being pediatric and not being adult? Can you ask our pediatricians for advice? Is there an agreement with this hospital and the nearest Children's Hospital?

  6. How is the relationship between the ED and Medical Staff? Do they hate us? Do we hate them? Are they vindictive; sending tons of our charts to QI?
    Easy to admit? Can you get a doctor on the phone in ten minutes or less? Are they agreeable about admissions? Are there hospitalists? Do you have agreements with other hospitals for admissions?
    How are admission conflicts resolved? Has it happened that you have tried to consult and can't reach anyone? Problems on Nights and Weekends? How long to get beds?

  7. What specialties are in hospital? The better question is what specialties DON'T you have in the hospital and/or on call?
    What types of patients do you transfer? How often? These are good questions since in some hospitals the bulk of your time will be spent getting your patient dispo'd (for non ER docs, that means dispositioned).

  8. What are the strength and weaknesses of this group and hospital practice?

  9. Do medical staff see their own pts in the ED? I laughed reflexively at this one...Other than hospitalists and surgeons, and sometimes not even the surgeons, you won't have too much of this no matter what they tell you.

  10. Any specific protocols for the ED? Can nurses initiate orders? How do you treat MIs-Tnkase medicine or emergency catheterization? Do you have 24 hour heart catheterization or do the patients get shipped out to one?
  11. Observation areas? Is this a separate area run by the ED? Is it properly and independently staffed? What kinds of patients can we admit to observation status?

  12. How late do you typically stay after a shift/if at all? Do you sign out? Does the doctor signing out get credit for the patient or the doctor who finishes the dispo of the patient (important for productivity models)?

  13. Type of record-keeping?
    Computer order entry? (depending on the system/MD can be cool and can be painfully slow and complicated)
    Computerized H&Ps too? (again, depending on the system and the level of physician expertise/typing ability this could be painfully slow and complicated and is hard to get a good narrative. If not careful, can be a medical liability nightmare.)
    T-sheets? (fast but illegible and bad for medical liability)
    Dictation? (double the work, good for narrative, but if you are not careful to make notes during your shift, you will often leave out important information. also, you can't draw pictures.) Will I spend all my free time dictating?

  1. Any administrative responsibilities/opportunities? (See Group Structure Q#2)

  2. How is the schedule made? Who makes it? Is it made on a hospital by hospital basis, or is it made by a group scheduler who accomodates many hospitals? Is there a defined holiday work schedule? If you want someone to fill in an open shift, do you pay extra?
    How far in advance does the schedule come out? For this you will probably have to ask one of the docs in the ER, your interviewer likely will give an idealized time frame. Can I make plans far in advance but also that prevent me from taking a trip that comes up with less than two months notice? Or do the schedules come out on the 30th (has happened to me multiple times) of the month, preventing me from making any definite plans whatsoever?
    What kind of distribution of shifts? Are weekends/nights/holidays evenly distributed? Is there a night shift differential or shift preference for all nights?

  3. Who does billing? Does the group get a monthly printout of charting and revenue? Reading over your billing is a good way to learn about the business of medicine and can make you a better biller. It is also a good way to find out if your company is down or up coding your patients. Plus, you are more likely to notice if patients are "missing" (important [and common] in productivity models).

  4. CME time? Do you pay for CME?

  5. Voting rights? What type of issues? *I've never worked anywhere where I had a vote*

  6. Hospital financial stability? Not sure if you'd get an honest answer to this one.

  7. Number of hospital beds that are useable? # of ICU/Tele beds? Do they get filled up frequently? For instance, are there mythical beds that exist but just can't be used (e.g. reserved for "private" patients)?
  1. Can I have an opportunity to shadow in the ER for a few hours to see what it is like? Good idea. This may be the only way you find out the "real deal" with the ER job.

  2. Number of positions open? And expected in the near future? Part-time opportunities? Could you find something for a nights person?

  3. What are you looking for in a candidate?

  4. When will you be making your final decision? Do you have second interviews? When will you make a decision for that?

  5. How many hours per month do you go on diversion status? What kind of diversion are you typically on most commonly? Neuro/Critical Care/ED saturation/Hospital Saturation?

  6. What is the typical waiting time in the waiting room? What is the wait time RIGHT NOW?
So that's it folks. Every question you should ask (or wish you had asked) in your quest for the perfect job. Good luck.

Wednesday, September 9, 2009

Health Care Reform Will Happen - And other predictions

Once Obama got elected, I knew it would happen. I knew we would get healthcare reform. This is not said out of some partisan bias. I have simply observed the last 8 years of largely republican rule where the only healthcare reform that occurred - Medicare Part D, was a confusing morass that is more a giveback to pharmaceutical companies than a benefit for seniors. It encompasses everything that is bad about government today.

While the republicans "support" tort reform, I never saw tort reform come to a vote and get signed by W. It simply wasn't a priority.

For the democrats, health care reform is a priority. And the new president is acutely aware that he will be a one-term wonder if he does not enact dramatic changes. Passing comprehensive healthcare reform-something that hasn't been able to happen for >60 years-would be change.

I have heard the naysayers amongst friends, colleagues, bloggers and twitterers. The issue is too political; too locked into lobbyists' interests and influence. The democrats are weak. They'll cave in to pressure. While these arguments aren't untrue, the cynics forget one thing. The healthcare crisis isn't about poor people anymore. When your trauma center closes down and you-a rich person-has to be sent to a facility farther away with less resources, you suffer. When you can't find a neurosurgeon to treat your aneurysm, the rich person suffers. When your ambulance is diverted from your favorite institution because of Hospital overcrowding, the rich person suffers.

And for the average joe with "good" health insurance, rates are skyrocketing, out of pocket costs are increasing, and when you get a serious illness, maximum coverages are reached quickly. Approximately 40% of insurance claims are denied. You were supposed to feel safe having insurance coverage. There is no safety.

Now that the majority of the population is facing this healthcare crisis, there is a mandate, and the president is acutely aware that his support came from people wanting change. If he doesn't get health care reform, the advantage his party has will fall to pieces just as the advantage the republicans' had did.

So my prediction:
The only two people who determine healthcare reform are Max Baucus and President Obama. There are others who might have some influence if they are acting in good faith, such as Olympia Snowe. But most other republicans are simply trying to weaken a democrat initiative so that moderate dems won't vote for it, and those republicans wouldn't vote for it anyway. If republicans won't vote for a bill for political reasons, then they won't have a vote in what it looks like.

Thus, if you want to know what healthcare reform will look like, read the BaucusFramework.pdf. In my next blog I will discuss this further, but read this, then compare it to the Baucus Whitepaper. There are some differences, such as the public option issue. However, the whitepaper is his real views. The framework is his compromise. I think Baucus is making a political move to hide his intention for a public option, and then slip it in at the last moment.

As far as tort reform, Baucus supports it, and Obama supports it as long as there are attempts to maintain quality in the system. Obama NEEDS it if he is to exact cost savings that will make it succeed. So in some manner, there will be tort reform. Maybe not along the lines of what I would like and have suggested, but something will happen on that front.

The cynics will say I'm naive and deluded. I think they aren't looking at the big picture, because if they did, they would see that this is the year. By 2010, we will have healthcare reform passed. It likely won't translate into immediate results as it will take years to enact. But it will happen.

Wednesday, September 2, 2009

Anything You Tweet Can and Will Be Used Against You

I wrote an article in the latest edition of with the above title:

Just as you were getting comfortable with Facebook, detailing every moment of your life through status updates and photos, Twitter came to town. If you don’t already know, Twitter is a “micro-blogging” social media site which allows users to “tweet”– or post – short status updates. Thousands of docs have signed up, raising an interesting risk management question: Can my tweets come back to bite me?
The short answer is Yes. Take the example of a personal diary that details your life experience, or a medical diary that lists the patients you’ve seen and their medical problems. These diaries are dangerous because anything that has dates can be used as evidence against you. Let’s say you log in your diary going out for drinks with friends. Then, years later you are sued, and the plaintiff’s attorney discovers your “drinking orgy” the night before you treated their client. They will use this information to paint you as a physician just steps from requiring the Talbott Recovery Campus. If you are an EP who likes to keep detailed logs of your patients, you can’t anticipate how your innocent log can be twisted out of context to hurt you.

When it comes to the Internet, everything you do is stored somewhere. In essence, the Internet is an electronic diary. Some Internet services are more private, such as email and Facebook. Others, such as blogs and twitter, are public. Anything you say publicly, whether through a comment feed or a tweet, is searchable and can theoretically be used against you in court. Also, sites like Sermo and Ozmosis are not peer-review protected (in states that have those laws) and those “innocent” evaluations of case studies could be used against you if your lawsuit happens to be on one of those topics...

For the rest of the article, click HERE.