Monday, July 30, 2007

Top 10 List: Pieces of advice for pre-med students

Overheard during the interviewer lunch break at my med school's interview weekend: one old doctor to another - "The very first student we interviewed blew us away. She'd summited Mt. Kilimanjaro, competed in the Olympics, and was an honours student with incredible research experience and publications. You know, if applying to medical school was like this back when I applied, I don't think I'd be admitted."

Getting in to medical school is tough. In Canada, less than 30% of students who apply each year are admitted to a school, and on an individual basis Canadian schools accept as little as 3% of the people who apply (that's more competitive than some Ivy League schools in the USA!) (source). That's not counting the thousands of students who wanted to be doctors when they started their undergrad degree, and had to face the realization that thanks to things like the MCAT and the competitiveness of the pre-med world, and perhaps the odd slack semester or difficult year, they would never even make it to the point of applying for medical school.

Here's some advice I would give to any pre-med student applying to medical school, though non-pre-meds might find it interesting as well as it might give you a unique perspective into the mind of a pre-med student. I wrote this list assuming you know all the basic info - what the MCAT stands for, what an application involves, and the like, though keeners at any level of their training - high school, college, or university - might find this useful as well. Given that, what I've written below something I hope every pre-med could have the chance to read before they apply to med school.

10. Have a backup plan...
This is one of the hardest thing for pre-meds to do: plan what you'll do with your life should you not 'get in' this year (or ever). Why's it so hard? It just sucks to think about the fact that you might not be accepted. But, you can't put your eggs all in one basket... you need to be realistic and know that even some applicants with the highest marks aren't accepted anywhere. Nothing is for certain. So, have a backup plan if you don't get in this year... and also consider what you could do with your life should you not get in at all. This might even mean considering taking a 'pre-med' degreee other than biology, since you don't need a biology degree to apply; if the only job you'd be interested in doing that you can get with a biology degree is medicine, you might want to do something else.

9. ...but don't give up if you don't get in your first time.
It's turning out more and more now that getting into medical school is more about learning how to "play the game;" because it's such a crap shoot, anybody who doesn't get in their first time applying would be stupid to throw in the towel right away. Even if you didn't get an interview, go to an advising session if any of the schools you applied to offer one, and give it another go.

8. If you do get in, don't do anything the summer before you start classes.

Seriously - don't work. Travel, but only for part of your summer, since travelling around can be stressful and you want to have time to veg. Give yourself at least a few weeks to sit around like a bum and do nothing, maybe see some friends that you won't be able to hang out with when things get busy. Let me put it this way: you now only have a couple of summers left (unless you chose to apply to a 3-year program!).

7. Know what doctors do before you decide you want to be one.
It would be devestating sacrifice so much energy, effort and free time just to keep up in the pre-med rat race and realize later on that medicine isn't for you, so learn what a doctor does - not just daily, but learn what the lifestyle is like, the stress level, the impact on family life. How? A few ways: you can read books and biographies about physicians, you can shadow physicians where you live, or you can go to a developing nation and volunteer your services at a medical clinic or hospital. The third one shows commitment and could have much better opportunity for clinical exposure, thanks to different policies on liability; though if you do that, please make sure you're going to a place where you can actually contribute and not just be watching or being a pain, and remember that some med schools actually use the length of time you spend away as a 'filter' for resume padding; a former dean of admissions in Canada, as quoted in a newspaper article: "only the affluent can spend six months in Africa volunteering at an AIDS clinic. ... it's become sexy to put stuff like that on an application.... but they're not necessarily going to get extra points for it."

6. Know what other health care professionals do before you decide on medicine.

What does a perfusionist do? What's within a Respiratory Therapist's scope of patient care? Did you know that there are nurse anesthetists? How do you know that you want to be a doctor, not a nurse? As well, getting to know other health professions will help you respect other health care professionals once you start working with them. Finally, it will add depth to your understanding of your own motivations if you can be positive that you want to be a doctor, and not some other type of health care provider. Following #4 (below) can play a huge role in satisfying this, but make sure you still get the chance to see what these people do in real life as well. From my experience, anyone in these professions is more than happy to tell a future doctor what their job involves, if they're approached with interest and respect.

5. Don't kid yourself: Training to become a doctor is one of the most difficult things you can do.
Even though it may appear easy at first, when finals come around (even in first year) you will realize that you've never done anything more difficult, more demanding mentally, intellectually, and emotionally. It will take over every minute of your free time and you will have to set aside time usually devoted to family, friends, and yourself; literally my entire days the month before finals was wake/study/sleep, even though in undergrad I never had to study very much for most courses. The only people who don't feel this way around finals are the ones who have spent their entire semester studying, literally every day and weekend, or are exceptionally brilliant - and there will only be 1 person of the latter kind in your class so chances are it won't be you. And that's just first year. For third year, add all that stress to being on call, having to deal with patients, nurses and doctors daily, having a pager go off while you're sleeping, and having to study for finals in the midst of all that. In all honesty, I've always said that the only thing I can think of that is more demanding and draining than becoming a doctor is boot camp, and boot camp only lasts 12 weeks. However, that was until I read about a U.S. Marine turned doctor, who discusses "How Residency is Different from the Marines" (scroll down to find it). Even though he says the Marines was harder, training to be a doctor must be pretty hard in order to even deserve the comparison.

4. There is much value in reading the online medical blogosphere.
See my post titled 'why pre-meds should read medical blogs,' then for a place to start, check out my 'guide to medical blogs for beginners' . Here, though, I'll just list a couple of the several reasons. You'll see from jaded residents and medical students just how hard med school can be (try reading the Don't Become a Doctor series on iFindings' blog, as an example). You'll learn what being pimped means and how med students react to it and the subtle, unspoken rules involved. You'll hear about the most exciting moments in the OR, what it's like to be sued and sued again, learn from the mistakes of medical students and read what residents wish they had done differently. As well, you'll learn more about different health care professions if you take the time to read their blogs, fulfilling piece of advice #6. Beyond that, medblogs can give you a perspective on how these different professions work together in the same problem - see, for example, the story Perspectives, written in three parts: part I by a cop, II by a paramedic, and III by a nurse. And, you'll get involved with the profession in a unique way - by engaging in discussion, leaving comments and e-mailing blogging doctors, you can get 'face time' and advice from physicians that you might not get elsewhere.

3. Make sure that going into medicine is your own decision.

Are you doing this because an expectation has been imposed on you by your friends or family? Is this a dream you once had that has now faded, but it's just too hard to tell everyone that you are switching career plans? If you do go into medicine just to satisfy someone else's plan for your life, you are going to hate yourself, and you'll have nothing to keep you going when you have to give up everything for medicine.

2. Marks come first. You can always add volunteer activities after you graduate; you can't go back and increase your undergraduate GPA.
You don't want to look back on a year or a degree and say, "Those marks don't reflect my true potential...I wish I would have worked harder." My dad has told me over and over again of a man he knows who wanted to get into medicine, but when it came down to applying, his GPA was too low because he'd had more fun than study time in his first year of university. More than a few times I've been having conversations with people who say "My brother / cousin / friend tried to get into medical school, but couldn't..." and often it ends up being a GPA issue.
Some people end up having to take a master's degree just so that their undergrad marks aren't considered... they have to work extra hard to make up a first semester where they played more billiards and pranks than studied, or a year when they didn't figure out that they understand organic chemistry until the last week.

1. Be 1000% sure that medicine is what you want to do.
...and make sure that you've completed #7 so that you are making an informed decision. Please do not go into this profession if you aren't completely and utterly sure that this is what you want to do. You'll only end up hating yourself for it, and if you stay in the profession, everyone around you will hate you, too.

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Thursday, July 26, 2007

New Poll on VM: Sicko (and Grand Rounds Poll results)

For RSS readers of this blog who can't see the updates on Vitum Medicinus -

Check out the newest poll at Vitum Medicinus, and provide your opinion on the question:

Did the movie Sicko change your outlook on American healthcare?

  • Yes, made it better
  • Yes, made it worse
  • No, it didn't
  • Haven't seen it yet
  • Won't see it

Find the poll in the right-hand column on any page in this blog, under the heading "Vitum Pollicus."

Previous Poll Results:

Vovici Online Survey Software

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Tuesday, July 24, 2007

Grey's Anatomy...Scrubs??

Wow, people must really have a thing about wearing what they see people wear on TV.

Some company decided to market a new line of scrubs. Not just any scrubs . . . Grey's Anatomy scrubs, as worn by the actors on the show models that resemble the actors on the show. As seen on Grey's Anatomy!*

*As seen in Grey's Anatomy Magazine. Not to be confused with the popular TV show.

(Hmm, I suppose if they really want to resemble the actors on the show they need to get rid of the Dr. Burke lookalike in their catalogue. Oooooh. Burn.)

Actually, this is great! I'll admit it - Grey's Anatomy is the real reason I wanted to become a doctor, so now I can look and live the overdramatized soap-opera disguised as medicine that I rarely watch!

(I actually don't watch Grey' be honest, I had to look up the name of the black actor on The Angry Medic's blog).

Too bad the tv show Scrubs can't make their own set of scrubs. Who would buy "Scrubs scrubs"?

Then again, I'll stop making fun of these now that I realize - if they were House scrubs, I'd probably actually buy them.

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Monday, July 23, 2007

Stolen moment, shattered life

"Before you interview this next patient, Vitum, there's something you should know."

"Sure, what is it?"

The doctor closed the door to his office, and handed me the patient's chart.

"This patient came to me a couple of years ago. He's a very successful architect, he lives downtown, and he's overall quite healthy. But before you go in there, I just wanted to give you the heads up - he was sexually assaulted when he was a young boy. Just, you know, so if anything along those lines comes up in your interview you can be sensitive to that."

Ha, I thought. Warning me so that I don't put my foot in my mouth.
Again. I guess he knows me better than I thought.

I appreciated the warning, even though the patient was there for something entirely unrelated and that issue never came up in the interview. The guy was obviously very successful, clean-cut, and seemed quite confident and professional. He took good care of himself and seemed to have a really good head on his shoulders. I wrapped up with the interview pretty quickly, told him the doctor would be in to see him, and then went back to the doctor's office.

When the doctor is with another patient and I'm waiting, I'll generally review my class notes if I've got them, brush up on a few drugs, look over the drug samples in the office wondering if I could just take some pills just to try them out. Or I'll look over the various diagnostic journals piled high on the doctor's desk, or read a patient's chart if I've got it. Not really thinking of the warning the doctor had given me, I habitually cracked the patient's chart and began reading.

In just a few minutes, what I learned about the lingering effects of child abuse will stay with me forever. I caught a snapshot of how a brief moment stolen from this poor man's childhood has in one way or another affected every aspect of this patient's life.

The chart read like a paperback story that would be too depressing to ever make it to print. It was packed full of the effects about how this patient's life had been dramatically and irreperably changed because of this incident. Here were the carbon copies of emergency room charts depicting the patient's multiple visits for anxiety attacks, thanks to post-traumatic flashbacks of the experience. There were the notes from a psychiatry consult that the patient had undergone shortly before, which contained more terrible, heartrending details of not so much the experience, but how it had affected him.

The patient had initially told his brother, his closest friend, about what their hockey coach had done to him. His brother's response? He didn't believe him. That's pretty much the worst thing you can do if someone approaches you saying they've been assaulted. After that, the patient didn't bother telling anybody else about it, until he needed to seek medical attention for the stress; even still, there are only a few people that he's told.

Now, he suffers from frequent flashbacks, most of which land him in the ER with anxiety attacks. He has trouble with commitment (more than the average guy) or sexual intimacy - I wonder if he'll ever be able to settle down with someone. He can't be alone in a room with an older male - must be hard to have a job interview under those circumstances. He can't have anything to do with hockey games, arenas, or the game in general - that must make it difficult to go to a bar with the guys.

I had heard that sexual abuse can be a tragedy that significantly affects a person's life, but I had had no idea that it was that pervasive. My heart went out to this patient when I finally went in with the doctor. I was one of maybe five people on earth that knows about his secret, and as much as I wished I could do something to help him get back to a normal life, I couldn't. All I could do was be shocked at how unbelievable it is that one brief, disgusting, selfish action that lasts a brief moment can literally ruin a victim's life. It literally made my stomach turn.

The worst part is, the creep who did this is still free, probably still working with young kids, quite possibly still assaulting children, ruining lives by taking one moment at a time.

One of the things that attracted me to medicine is how a doctor is much more than just one thing - a doctor is an expert in chemistry, biology, pharmacy; a manual labourer, a thinker, a problem-solver; a teacher, an advocate, a counsellor. I'm not sure, but judging by how nervous I am to have to someday be the listening ear to someone who confides in me the details of their painful past, that last one might be the hardest one.

While this story is based on an actual experience I had in a hospital, and the effects of sexual assault on a person are real and devestating, the patient and experience depicted here is entirely fictional. Confidentiality of my patients is my highest priority, just as it would be if you were my patient. For more info, please see the disclaimer at the bottom of the page.

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Friday, July 20, 2007

Top 10 List: Foods that Med School has ruined

Not for the faint of heart...

I've written more than once about medical school taking over my life, but now, I'm about to demonstrate another, entirely new and different, way that being a medical student is invading every aspect of my daily existence.

In the words of the evil resident, pathologists love food anologies. Thanks to pathologists who drew the analogies, and who provided photos that in many cases didn't need an analogy to be verbalized in order to cause irreprable harm, I now have trouble eating some foods.

Without further ado, here is the list of foods that are hard to eat now, and why, thanks to medical school.

Actually, there will be further ado, a warning that certain individuals may find the following quite disturbing. If you fall into that camp, I don't mind you choosing to not read this post, so long as you shower me with empathy anyways.

(You're lucky I provided a warning, by the way. I didn't give my sister a warning before I took her on a tour of my school's pathology museum. She lasted about 6 seconds. Bless her soul.)

1. Lasagna
An anatomic specimen of an athersclerotic aorta seen in pathology lab bore a stunning resemblance.

2. Cocktail shrimp
A procedure called "Transurethral Resection of the Prostate" (TURP!), where they shove a large, narrow .... up male patient's... nevermind ... results in tiny "cores" of the prostate gland being removed. When collected on a surgical towel and photographed, they look like shrimp. In case any student failed to make the visual association, the professor was kind enough to draw our attention to it.

3. Popcorn
Fortunately, my mind has blocked out this reference. Must have been too traumatic. I only remember that it was mentioned in a pathology lecture.

4. Tomato Juice

5. Cream Cheese
Doesn't help that the actual term to describe many pus-esque exudates is "cheesy."

6. Pulled Pork
Frighteningly stunning resemblance to certain human muscles that have been thorougly examined by anatomy students.

7. Beef Jerky
Frighteningly stunning resemblance to human abdominal muscles that have been drying out in a body bag for several months.

8. Sheep Brain
Though I enjoyed this delicacy before medical school, it just reminds me way too much of human brains now. (Okay, just kidding. I never ate sheep brain.)

9. Fettucini
One word: Tapeworms. Actually, it technically wasn't medical school that ruined this - I found this one on a blog post.

10. Cream of Broccoli Soup
Turns out this was the food that my body donor had chosen as her last meal. Please don't ask me how I know. As sad as it is gross.

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Tuesday, July 17, 2007

Patient Billed $49 million - This is news? Okay, maybe it is.

I may have appeared to sympathize with the San Francisco hospital that billed a patient $12,000 supposedly "for a broken rib," (Patient "billed $12k for broken rib" - this is news? [7/14])...

... but I'm not sure than any amount of explanation will make anybody believe that a $49,000,000.00 hospital bill is reasonable.

Glad I live in Canada.

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Monday, July 16, 2007

The Official Grand Rounds, Volume 3, Number 43

Welcome to Grand Rounds, Volume 3.43, hosted for the first time ever at

Having used Grand Rounds as a springboard into the world of medical blogging when I first started reading medblogs, it is truly an honour to be hosting Grand Rounds.

The template for this Grand Rounds is as follows:

Blogger's favourite food: SushiDescription: In his quest to bring you Grand Rounds, Vitum Medicinus went from excitement to panic to enjoyment. Excitement = signing up for Grand Rounds months ago. Panic = when 22 submissions had arrived in my inbox by Friday morning. Enjoyment = putting GR together. Once I got started, it was actually nothing to be panicked about.
Why you should read it: There are some stellar posts in this edition, and for every post I’ve spelled out why it’s worth your time. As well, for the bloggers observant enough to notice that I requested they submit their favourite food along with their blog post, you’ll notice their dish of choice represented pictorially beside their entry. Just one more way Vitum Medicinus is going above and beyond in an utterly pointless and time-ineffective manner.
Award: Grand Rounds 3.43 gets the Vitum Inclusivus award, for subscribing to the age-old (and very childish) “Everybody Wins” concept. This has been manifested in the following manner: Each of the 35 blog posts that were submitted and received a confirmation e-mail have been included, and every one has also received a cryptic Latin-ish award of some sort. (If you need a certificate of your award for your office or bedroom, for reasons of ego-bolstering or personal gratification, you are welcome to print one for yourself.)

Please enjoy Grand Rounds volume 3.43. Feedback, discussion, and criticism of this edition of Grand Rounds are requested and are very much welcome.

Blogger's favourite food: None submittedIt’s pretty annoying to have to deal with a spoiled kid who says “I’m telling my dad!” when they don’t get what they want. Val Jones, MD at writes about a young man with VIP syndrome, who does just that, and complains to his dad that he wasn’t admitted when there was no medical indication that he should have been. This guy treats the hospital like it’s a casino – at the end, he expects that his care should be comped because his dad threw a lot of money into it. (This would rarely happen in Canada, by the way.)
Why you should read it: You’ll be disappointed to read how elaborate this becomes, involving the CEO of the hospital and the patient’s insurance company… especially when you find out who gets the shaft at the end. As well, you might be interested reading or contributing to the discussion generated by this post.
Award: The Geographicus relocaticis award, for rightly putting this arrogant, snotty, spoiled brat in his place; as well, placement in Vitum’s Top V.

Blogger's favourite food: None submittedIf somebody tells you that after this year’s Running of the Bulls, they have “reviewed with interest the reports and video clips of the bulls goring the runners,” they are either a) a bit out to lunch or b) a surgeon. Having not done clerkship, I have no bitterness towards surgeons (yet?) so I will not take the well-set-up opportunity to say something like “you have to be ‘a’ to be ‘b’.” Won’t go there.
Instead, I will simply say that the editors at
Inside Surgery have put together a unique post they call “Possible Types of Injury after being Gored by a Bull.” I don’t think any more explanation is necessary. Strangely enough, this submission is eerily similar to my medschool friend’s desire today to discuss “Possible Types of Injury after being Beaten with a Hammer” (he came up with two thanks to his ER shadowing shift last night).
Why you should read it: Because you don’t want to be in the situation, inevitably someday, when you wish you did. Read it, and then you’ll be the hero who knows what to do when you’ll have to provide first aid to / assess / refer a patient who has been gored by a bull. Subsequently, eligible members of the opposite gender will flock towards you. (Not guaranteed.)
Award: The Practicalus improbabalus award, for being practical advice for an unlikely situation; as well, placement in Vitum’s Top V.

Blogger's favourite food: None submittedMaria at hosts a Literary Medblogging Project called A Picture is Worth A Thousand Words. The writing in this little project is so good that I can’t even top the description that Maria submitted: “Five medbloggers of the more literary persuasion collaborated on what has become an (at least) annual event--you know, to take a break from the usual randomized, double-blind, placebo-controlled rants that usually occupy our blogs.”
Why you should read it: Stunning writing. Times five.
Award: Serialus excellencissimus award, for high-quality writing over and over; as well, placement in Vitum’s Top V.

Blogger's favourite food: Mint Chocolate Chip Ice CreamIn an old man’s final hours, a nurse came into his room with a syringe and hooked it up to his IV. When the patient’s son asked what she was administering, she said, “Oh, just some morphine. Just to make him comfortable. We don’t want him in any pain.” It wasn’t long after that my grandfather breathed his last.
Geena at
Code Blog submitted a story that reminded me a lot about this incident with my grandfather, and her and I actually got into a little bit of a discussion about this practice that happens in real life but isn’t taught in nursing school. In her post “On the verge of what society finds acceptable,” she reacts to a physician in the UK who took this one step further, administering not a sedative but a paralytic to an infant with agonal respirations.
Why you should read it: You should know where you stand on topics like this one. If it happened to my grandfather, it could happen to yours, or to your child, or to you. And if doctors are apparently taking this one step further, you might want to know about it.
Award: The Contemplatus arresticus award, for discussing something that goes on in the hospital that makes you really stop and think for a minute; as well, placement in Vitum’s Top V.

Blogger's favourite food: None submittedOver my med body!'s Graham Walker gets top points for putting together ... get this ... The Clerkship Video Workout Guide, specifically targeted at preclinical students who are about to enter the world of the wards. This video answers a lot of my questions about clerkship, especially the burning one, "What physical manoeuvers can I practice to prepare for my clerkship?" My favourite exercise: "Surgery Exercise Number 1: I like to call it... Just stand there." It's almost as good as the final surgery exercise. Anyone who will one day hold (or has held) a retractor at an uncomfortable and awkward angle will identify quite well with this video.
Why you should read it: Because it’s not even a blog post that you have to read; it’s one you watch. And laugh at.
Award: The Goldenglobus Oscarifficus award, for putting his dashing likeness on camera; as well, placement in Vitum’s Top V.

Blogger's favourite food: None submitted"A patient refuses a life-saving treatment. What do you do?" Virtually every medical student has looked over ethical cases in an effort to prepare for their medical school interviews. This is all well and good, until you realize that an ethical situation takes on a whole different meaning from reading about it in a book, to when you're on the wards and it's a patient staring you in the face. Sid Schwab writes a post at Surgeonsblog called "Blood Oath" on one of the classic med school interview ethical cases... and talks about how in real life, finding the edges of the often blurry ethical 'line' can be a lot harder than citing a textbook on ethics - or simply falling back on legal precedent.
Why you should read it: Instead of reading about an ethical dilemma discussed by a philosopher sitting in an office, try reading about an ethical dilemma by a physician who has had to put ethics into action in a life-or-death situation. Trust me, it's much more compelling.
Award: Honorarius medicinus, for having the honour to respect patient's wishes, even when some ethicists would say he's wrong, and when colleagues have said they won't do it. As well, a placement in Vitum's Top V (which I suppose is now the top VI) as a way to apologize for my oversight in not including his post in Grand Rounds from the start.

Blogger's favourite food: None submittedBongi, the surgeon who writes at
Other Things Amanzi, submitted two equally disgusting stories of experiences in the operating room. If you think the job of Grand Rounds editor is easy, it is making decisions like this which choosing between these two posts that would convince you otherwise. I went with the one that doesn’t have the high likelihood of ruining a popular food for you…(medicine tends to do that with food…check back here soon for a post on that, in the works) though I’m sure you’ll easily be able to find the post I chose not to include, if you look for it.
Why you should read it: To prove to yourself that you have a strong stomach, and to catch a glimpse of just how big that mythical creature known as the Ego of Surgeons actually is.
Award: The Incitus Vomitus award for the most disgusting post to Grand Rounds this week. (I won’t translate the name of this award into English. If you really want to know, look it up in any reputable Latin textbook).

Blogger's Favourite Food: Dark ChocolateIt’s a medical student’s greatest dream come true. They are standing in the wards, when, all of a sudden, “CODE BLUE” comes squaking out of the intercom. All of a sudden, the student gets to witness one of medicine’s greatest orchestrated lifesaving ballets in action: running a code. After reading about CODE RED at Rickety Contrivances of Doing Good, I found out that a CODE RED is just like a CODE BLUE - the only difference is, in a code red, nobody knows what to do. Random fact: “Paging Dr. Pyro” is used by some hospitals to mean “Code Red,” according to the infallible Wikipedia. As a patient, I’m not sure which would be more unsettling to hear over the intercom.
Why you should read it: Because experiencing a real live Code Red, albeit vicariously, is pretty exciting (at first).
Award: The Combusticus avoidicus award, for averting certain disaster by fire.

Blogger's favourite food: Any kind of chocolate cake with a warm molten centerFrom Counting Sheep, Tales from the Nurse Anaesthesia Front comes a story of a combative nurse who wrestles a patient into TKO, despite the patient being the greatest heavyweight boxing champion of all time. Pretty macho for someone who claims that their favourite food is “any kind of chocolate cake with a warm molten center.”
Why you should read it: This story has to be read to be believed.
Award: The World Heavyweight Boxing Championship Trophy. For obvious reasons.

Blogger's favourite food: Moose Tracks Ice CreamA post from Musings of a Distractible Mind called “Joi de vivre” talks about how life and work can really get to you. “Life often seems like a hamster wheel - the harder you run, the more tired you get, but you never get ahead,” writes Dr. Rob – sound familiar?
Why you should read it: Because that’s not the end of the story; Dr. Rob has found “a ray of sunshine” to light up the dreary days, and you should read to find out what it is.
Award: Employerus exemplari, for making “Equal Opportunity Employer” more than just an empty statement stamped on his office’s want ads.

Blogger's favourite food: None submittedIn a post titled simply “Loss,” Neonatal Doc writes an incredibly touching story that outlines one of the most tragic moments in any parent’s life – the loss of a child. It’s a moment that admittedly neither a fresh medical student like myself, nor a seasoned physician like neonatologist looks forward to.
Why you should read it: Because it is better to be in a situation of consoling grief once you have read a post like this, which (along with its reader comments) tells you what you should and should not do in that situation.
Award: Lacrimarum nostrum, the tear-jerker award, for making us cry. Have a tissue handy.

Blogger's favourite food: None submittedJust as in the previous post, the McCanns are suffering from a lost child, but in another, entirely different and equally devastating, manner – their daughter simply disappeared, victim to abduction. Dr. Rima Bishara at The Doctor Blogger has passed on what was originally an e-mail the family hopes will be forwarded extensively so that this four-year-old girl can be found. (Of course, should you choose to donate money to any cause online, make sure that you are looking at a legitimate website - some pathetic criminals have tried to profit from this family’s loss, defrauding people into giving to fake funds by setting up fake websites).
Why you should read it: Because Madeline has such a unique birthmark that unlike many other missing children’s photos, you won’t forget her’s.
Award: Compassionatus empathaticus, for showing the compassion and empathy characteristic of an excellent physician by petitioning for this child’s speedy return to her family.

Blogger's favourite food: Anything at home with the family (aww...)Bruce Campbell, MD writes a reflection on the difference between “knowing” and “understanding,” as he was taught by a five-year-old boy. Let’s just say that it happened on the 5th of July, many years ago, and like a good dramatic story, this one contains a good dose of suspense.
Why you should read it: Generally, any time a story starts with “This is something I have never forgotten,” it’s usually a pretty good story. As well, this post was designated by a reader as a piece of wisdom worth saving for her unborn grandchild.
Award: The Paternalis aureus award, for providing golden, fatherly medical advice in the form of high-quality writing.

Blogger's favourite food: Chocolate CakeDean Moyer describes himself as “a guy who discovered one day that he had a bad back and then spent 10 years ignorantly seeking chiropractic treatment for it.” And yet, for an anti-chiropractic blog, it’s actually really well put together and respectable – arguments are objective, the website takes a tone of contemplative disappointment rather than ignorant rage, and he’s not trying to sell quack creams or potions. As you might expect, there are people who take offence to his website, particularly people who stand something to lose should the chiropractic profession be challenged. The post “Dumb Day and Disk Decompression of Delaware” talks about the unusual response of one of these people to Dean’s website. Make sure you click through the “Continuing Saga” links at the end of the post to get the full story.
Why you should read it: A few reasons: 1. The alliteration in the title of his post. It’s incredibly impressive, in its intelligent idiosyncrasies (I spent more time on that sentence than I did on all of Grand Rounds). 2. Hillbilly humour. Always gets a laugh (what I like to call a ‘universal punchline,’ kindof like Chuck Norris jokes). 3. In all seriousness - you might be surprised at the way these “professionals” have responded to Dean’s website when you get to Part 3.
Award: A Bloggisimus novicus award, for being a First-time submitter to Grand Rounds! Welcome Dean!

Blogger's favourite food: MangoERnursey at, uh, ERNursey writes a post just like the ones that got me hooked on medical blogging, called “Dumb reasons to come to the ER.” I don’t know why I get such a kick out of patients demonstrating lapse in judgement, when they’ll inevitably be a source of major frustration to me once I actually become a doctor.
Why you should read it: Because you won’t believe how dumb some of these people are, and because you should leave a comment encouraging ERnursey to provide more stories like this.
Award: Toothicus clenchicus award. For being able to clench her teeth and get through having to deal with these stupid, stupid patients.

Blogger's favourite food: Chocolate Cake with Ice CreamSuffer the children who don’t fit the mould,” by nurse Sandy Szwarc at Junk Food Science, is another one of those posts best described by the author. It begins: “Imagine having a daughter with a rare condition that is poorly understood and health authorities seem disinterested in helping to diagnose. It’s not that girls and boys just like your daughter haven’t been seen throughout history, but today she’s mocked and viewed as a freak and everyone is pointing the blame at you — so much so, that government officials have taken your daughter away and made her a ward of the state.”
Why you should read it: Because you’ll be shocked to read the ridiculous reason this girl was taken away from her family. And, Sandy uses rational discussion to propose that a dramatic blanket crackdown on childhood obesity may NOT be that well thought out.
Award: The Advocatius familii award, for using her background in clinical medicine and scientific education to advocate for the unfortunate parents.

Blogger's favourite food: Gnocchi at Assenzio in NYCDr. Linda Regan, a contributor for the NY Emergency Medicine blog, discusses some of her experiences as a female physician ranging from breast feeding to ordering morphine that suggest gender disparities still exist in the world of medicine.
Why you should read it: Because when you read the first story of how she was treated by a chief, you’ll be shocked that things like this actually happen in real life.
Award: The Feminatus commendibus award, for being a female having to put up with what is, in many ways, a male-dominated profession.

Blogger's favourite food: None submittedDr. Paul Auerbach talks about a trap that caught his friend during a camping trip. You will be surprised to see how dangerous such simple consumer products can be.
Why you should read it: Because pictures tell a thousand words, and you should click the link lest ye end up in the same trap.
Award: Solutionatus ingenious award, for coming up with more than one possible solution for an unexpected problem. . . and choosing the better one.

Blogger's favourite food: Carmelatus Frappuchius...WITH an add-shot. (None submitted...Editor's assumption, based on the blog post)When I put out a call for posts containing drama, action, OR humour, I never expected to get a post that tried so hard to fit all three (and did so successfully). Interestingly enough, it doesn’t seem like Kim at Emergiblog had to try so hard – she was treated to all three elements during a shift on her 50th birthday.
Why you should read it: Because a) you need to click on the link so that you can comment and wish Kim a happy 50th birthday, and b) because once you read this you will be convinced to take off work any birthday of yours that ends with a zero (or two).
Award: Kim basically begged for an award, so she gets the Desperatus inclusivus award, for working hardest to fit the theme of this week’s Grand Rounds. You’re one in a million, Kim. (well, one in 35.) Look, you even got your own category!

Blogger's favourite food: SteakAt first I misread the e-mail and thought that a ham and cheese sandwich was Anonymous Therapist's (Keep Breathing) favourite food, but later realized that a ham and cheese sandwich is instead an integral part of the plot for The Tale of Mr. Bignose, one of AT’s favourite patients.
Why you should read it: Uses a ham and cheese sandwich as a plot device, as well as the word “curmudgeon.” And stories about favourite patients are always worth reading.
Award: The Keenerificus maximus award, for being the first blogger to submit a post to Grand Rounds v3.43.

Blogger's favourite food: Fruit with Ice CreamWritten from a patient’s perspective, Ileana’s blog Beating Social Anxiety holds more than one post about feeling like a medical condition rather than a person. In this particular post, “Are you ready to use props,” Ileana tells about a medical student who leaves a much better impression than either the doctor or a resident. (If this ever happens to you, make sure you encourage the medical student. They can always use some positive reinforcement.)
Why you should read it: Anyone in the health care profession should always jump on any chance to see how things are viewed from the patient’s perspective, especially when we need to learn from another health care provider’s screwup. This post is also a solid reminder that you never know if something deeper is going on.
Award: The Bloggisimus novicus award, for being a First-time submitter to Grand Rounds! Welcome Ileana!

Blogger's favourite food: 'Anything, because I'm pregnant!'Kristie McNealy, MD of NICU 101 tells the story that explains why she would put a residency on hold, and instead focus on family-centered care to advocate for families of premature and critically ill newborns. Unfortunately, it’s another rude healthcare provider story. Fortunately, Dr. McNealy chooses the positive way out, instead of brooding in anger and resentment, she actually uses it to motivate her into making a difference.
Why you should read it: Because this post uses a touching story to show that in the same way that it is important to see things from a patient’s perspective, healthcare providers need to learn to see things from the family’s perspective as well.
Award: Transformus Obstacalis Opportunisticus, the Transforming Obstacles into Opportunities award, for being treated rudely by a doctor . . . and working hard towards making something positive come out of it.

Blogger's favourite food: Green beansType I diabetic Kerri Morrone at Six Until Me reviews a highly technical product that promises to revolutionize the medical industry. The only dilemma it presents is whether to use the product when your blood sugar is low, or not.
Why you should read it: Because this product could change your life, and I’m not going to tell you what it is. It even lights up. Personally, I can’t wait to get my hands on one.
Award: Jealousum incitum, for inciting jealousy in me. Yes. This product is that good.

Blogger's favourite food: FajitasThe FDA issued a warning in 2004, stating that antidepressant use in patients less 25 years old can increase suicide rates, after hearing anecdotal evidence from mothers who had lost their children to suicide and implicated their children’s medication. Jake Young at Pure Pedantry lashes out against the FDA for this “black box” warning, citing a recent publication in the American Journal of Psychiatry which wields evidence to contradict the FDA’s anecdotal conclusion.
Why you should read it: Because this issue is a hot topic, and you should get involved in – or at least take a look at – the already hot discussion going on in the comments section under Jake’s post.
Award: Thermophilus symposius, for inciting the most heated discussion topic of any post in this issue of Grand Rounds.

Blogger's favourite food: None submittedDr. Jolie Bookspan, also known as The Fitness Fixer, talks a bit about her past research with the Navy. Apparently, Viagra has been tested for use against altitude sickness. Grand Rounds was almost left incomplete as I spent most of the weekend trying to find out how to apply to the navy.
Why you should read it: Because you want to know, just like I did, what role Viagra could play in air travel. (Get your mind out of the gutter.)
Award: The Aviatus Erectus award, for encouraging flight medicine researchers who walk uprightly in both posture and morality. (You! Mind…gutter…out….now.)

Blogger's favourite food: None submittedAmy at Diabetes Mine has submitted a post called “Help Cure MI,” in which she reviews MI – a condition described as invisible, chronic, and suffered in silence by millions. You might even have it and not know it yet.
Why you should read it: Because you don’t know what either MI or the award below mean, and reading this post will let you find out both.
Award: Paedis ravinus honourificus, or the Crow’s Foot Badge of Honour.

Blogger's favourite food: None submittedAlvaro at The Sharp Brains blog presents an interview with a paediatrician, discussing a cognitive skill called Working Memory. There are some good examples that help explain what Working Memory is, and how it has helped patients with seemingly insurmountable challenges due to ADD / ADHD.
Why you should read it: Brains are fascinating, and everyone wants a sharp brain. Where better to start than reading a website called Sharp Brains. And it’s exciting to learn of a technique to help children who suffer from ADHD.
Award: The Intellectus stimulatus award, for provision of brain teasers elsewhere on the website. I’ll admit, I got sidetracked.

Blogger's favourite food: Swiss cheese fondueMousetrapper at Med Journal Watch describes the latest in Type II Diabetes research: The practice of taking selenium to prevent diabetes has been disputed, with reports in the mass media that it actually can cause a 50% increase in diabetes risk.
Why you should read it: So you can see Mousetrapper’s level-headed recommendation on how to handle this latest perspective.
Award: Cuttimus edgimus award, for staying on the cutting edge of medical research.

Blogger's favourite food: BurgerYour mother had breast cancer. So did her sister, and your two sisters have both been diagnosed in the last year. What’s the reasonable thing to do? Get genetically tested for breast cancer. Or is it? Dr. Lei writes at about public perception of genetic testing, and – get this – a recent article published in NEJM suggesting that BRCA mutation carriers with breast cancer actually don’t have a worse prognosis.
Why you should read it: Because Dr. Lei addresses the question, “Given the above, should you still undergo genetic testing?”
Award: Advicum practicalus, for providing practical advice on a topic that can be pretty confusing for medical students, let alone patients.

Blogger's favourite food: None submittedMy mother taught me not to sign my organ donor card. “You never know,” she said, “maybe if they need the organs they’ll let you die, then scoop them up.” TC, an organ procurement transplant coordinator who writes at Donorcycle, tells why this kind of view is more of a myth than anything.
In case you’re wondering, I did sign my donor card. This, by the way, was one of the first times I went against my mother’s wishes, and it has become progressively easier since then – I have now come so far as owning my own motorcycle (okay, just kidding. I’m only at about staying awake past 8:00 pm) .
Why you should read it: Because it’s up to you to decide if TC’s argument should be believed…especially with a title like “Organ procurement transplant coordinator.” (Just kidding. I believe it.) It might also help answer that question which is undoubtedly in your mind, “When I am around an organ procurement transplant coordinator, should I keep a careful hold on my organs?”
Award: The Scooper Dooper award, for being an organ procurement transplant coordinator.

Blogger's favourite food: None submittedDo doctors owe anything to their patients if they write a book? Even if the book doesn’t include that patient? Or if it does include the patient but alters all details? What about the above scenarios in relation to blogging? LMF, the author at Ad Libitum, tackles these questions in a post entitled “From Hippocrates to HIPAA” in which the subject of blogging about patients comes up yet again. Included is a helpful list of recommendations for medbloggers.
Why you should read it: Because if you are a patient, or a blogger, it is in your best interest to be fully aware of the privacy issues that are paramount to blogging health care providers, and it’s hard to get to the point where you’ve read too many reminders about HIPAA.
Award: The Checkissimus realitus award, for providing a reality check for anyone who runs a blog and reminding us all that we must be accountable for what ends up being published.

Blogger's favourite food: None submittedBob Vineyard publishes a post at Insureblog akin to playing “taps” in memory of Dekalb General Hospital’s emergency room. This shutdown is putting the residents in its area an additional 20 minutes away from the nearest trauma centre
Why you should read it: So you can find out why it closed; and, so you can read if an ER near you could be next on the chopping block – Bob lists some other ERs that are within reach of the axe.
Award: Elevatus routus (the High Road award), for taking the effort to actually propose a solution to a healthcare crisis, rather than simply complain about it.

Blogger's favourite food: Veggie BurgersDavid Williams hosts an interview at MedTripInfo (a blog about international medical travel) with Stephanie Sulger, a nurse and founder of Medical Tours International. MTI organizes trips for patients to receive medical care in other countries, safely and cost effectively. (Unfortunately, due to Canada’s waitlist issue – don’t believe how Canada was painted in Sicko - this is a business that would do well in Canada).
Why you should read it: Very interesting reading, especially the discussion about how Stephanie’s company decides if a hospital is a “top hospital” worth sending patients to or not, or what it’s like suing a doctor overseas, or how some patients are retaining a primary care physician overseas.
Award: The Contemplatis exterioris award, for a solid interview with someone who is thinking outside the box when it comes to getting your health needs addressed.

Blogger's favourite food: Toast At Hope for Pandora, Thomas writes about the upcoming confirmation hearings for America’s Next Top Doctor. Thomas suggests that the previous Surgeon General was muzzled by the Bush administration on a couple of controversial topics.
Why you should read it: This is one dramatic, conspiracy-esque plot. Sounds like an episode straight out of The West Wing.
Award: The Artistico award, for having great taste in Blogger themes.

Blogger's favourite food: No favourite foodJust when you think that health policy in a state is taking a step in a positive direction in terms of reducing costs, what would expect to happen next? A complete 180° in policy, of course, and costs go up instead of down. Go figure. David Williams writes at the Health Business Blog about one more aspect of the sad health care system those Americans have. (This probably wouldn’t ever happen in Canada, by the way.)
Why you should read it: This could affect you, if you have a health plan through your company.
Award: Flagicus rougeicus, or the Red Flag award, for drawing attention to another concerning aspect of American health care.

Blogger's favourite food: BBQ Pulled PorkA post from Medopedia discusses Pediatric Sibling Transplants, Ethics and Futility in a way that really makes you believe there could be is some reason in trying medical treatments that have been deemed futile in the past.
Why you should read it: Because this post could really make you look differently at the ethics of so-called futile procedures.
Award: Perspectivus broadendii, for having the potential to broaden your perspective on the ethical considerations about futility of medical treatments.

And that’s a wrap! Thank you for reading Grand Rounds Volume 3.43.

Again, feedback, discussion, and criticism of this edition of Grand Rounds are requested and are very much welcome.

Of course, thanks to Nicholas Genes for starting this fabulous tradition. Here's the schedule for the rest of the upcoming Grand Rounds.

Grand Rounds Volume 3.44 will be hosted on July 24, 2007 by Laurie Edwards at A Chronic Dose - click here for the submission guidelines.

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Saturday, July 14, 2007

Patient Billed $12k for Broken Rib - This is news? Give me a break.

From page C-1 of the San Francisco Chronicle a little while back:

Uninsured patient billed more than $12,000 for broken rib

Synopsis: Some gentleman was in a motorcycle accident. The paramedics who arrived on scene were concerned that he might have some internal injuries, so they sent him to a hospital. A few X-rays, a few CTs, and eight hours later, they give him the good news: You had a broken rib, and nothing else. Sounds like he got off lucky, eh? I mean, a motorcycle accident! Could've broken every bone in his body and he gets to walk away. Lucky guy.

But no, all of a sudden some reporter looks for something to complain about... and apparently makes a headline twisted enough to make the front page of section three.

$12,000? for a broken rib? How could this be? This is horrible. Surely, this is news.

This is something that Vitum will find on when he is killing time, with plenty of points because lots of readers think it's an atrocity.

Well, first of all, surprise. This guy is uninsured. He lives in a country where insurance companies negotiate with hospitals to reduce the costs of hospital bills. He is not an insurance company, nor does he have one on his side, so he is going to have to pay the premium. Any kid who's seen Sicko could tell you that.

Beyond that, there is no way that a hospital charges $12,000 to tell a patient "We let you sit in one of our beds for 8 hours, and in that time we simply took an X-ray of your ribcage. You have a broken rib." In fact, if you skim the article, you quickly see that the article disputes its own headline: the patient is paying for much more than a broken rib. You don't even have to hunt for it. Everything done to the patient is itemized in the article.

So then why is it still news?

Apparently some people don't understand what actually goes on in a hospital. The patient, for one, claims he only got "fifteen minutes of care."

Let me tell you something. From my limited experience, I can vouch for the fact that hospital emergency rooms are always trying to EMPTY beds, not keep people there as long as they can. If he was there for 8 hours, I would bet a lot that he got 8 hours of care. During every minute of those eight hours, something was probably being done during that whole time, or he was in line for something to be done - a lab test being run, a CT being read, etc.

Anyone who thinks this is "news" clearly fails to comprehend the ancillaries that come with, say, an X-ray being ordered. You need to pay the doctor to order the X-ray (not free, and a doctor may not be able to see a patient to do this); you need to pay someone to bring the patient to the X-ray machine; you need to pay for the X-ray tech's salary, undoubtedly unionized; you need to pay for the cost of the X-ray film; the cost of using the X-ray machine; and the cost of the radiologist who reads the X-ray. Same goes for CT, and for lab tests.

Agreed, each item in this patient's bill is overpriced, but there were undoubtedly costs that the hospital incurred, and good reason for him to have been in the hospital for 8 hours.

Someone who read this article told me that with an explanation like that, okay, sure, everything in that article makes sense. Everything except the $4,650 "trauma page." According to the article, "a page was sent to doctors and anesthesiologists on call at the time. That page alone cost Palmer $4,659, and he hadn't even set foot yet inside the hospital."

Yeah, okay. The hospital can really get away with billing almost five grand for thirty seconds of work by their switchboard operator. You have to be dense to not think there must be more to it than that.

When a trauma page goes out, it means that the entire trauma team is assembled and is standing in the trauma room for when the trauma patient arrives. I've seen it.

This assembly of hospital staff can be up to a dozen different highly trained health care professionals. This can include a hospital clerk to document the patient's arrival and details, a nurse to write down what the doctors are shouting out during the initial assessment, the attending doctor who oversees, a resident doctor who does the assessment, any other residents who respond to the page to watch learn and gain experience, an anaesthesiologist in case the patient needs to be intubated or sedated, a respiratory therapist to run the ventilator if needs be, another nurse to start doing the things the doctor orders such as place a foley catheter, a trauma X-ray tech to start setting up a bedside X-ray machine, and the lab tech to be able to draw blood and rush it to the lab ASAP, to name a few.

What are you paying all those highly-trained, highly-paid people for? You are paying for them to drop everything they were doing, and be at the trauma bay for when the patient arrives, and for their salaries for the next hour or so, which is assumed to be how long they will be standing there working on the trauma patient to get the patient stabilized.

Of course, once this patient comes in and they see he is awake, breathing, and ambulatory, perhaps some of these people will leave (ie. the respiratory therapist) but the bill is still issued to the patient for them even showing up. Most of them do their job, anyway; the lab tech still draws blood, the doctors still assess the patient, an X-ray is still taken.

You are also paying for the use of the trauma room, one of the most high-tech and largest patient rooms in the hospital. Rent doesn't come cheap, especially with all the fancy dillybobs on the wall. That is an extra amount of money.

As well, the lab tests that are ordered come standard; you need to be able to find out if the patient, say, has a bleeding disorder, or was drunk or high, or is running low on blood, or has an infection, or any other condition that would change the way the patient is handled. For example, if he had a huge crushing injury to a muscle, this could release a large amount of potassium (there's more potassium inside the cells than outside), which if this gets into the blood, could stop the heart. Doctors look out for these things.

Of course, I could also mention the incidentals - the receiving triage nurse's time on the radio with the paramedic, the hosptial switchboard operator's time to send the page, and the cost of sending 14 pages to all those people. Total cost for this is probably about $3, but it's included in the $4,600 trauma page.

Okay, fine. I'll admit. Even though they still did most of the workup, this patient probably didn't get his $4,600 worth for this trauma activation page because he was much healthier than anticipated. The respiratory therapist, for example, wasn't needed, and he probably still paid for the RT to show up.

So why would they page the trauma team for a guy with a broken rib? Isn't that overkill?

Let's see. Your typical trauma page might say TRAUMA MVA ETA 5 MIN NEED U ASAP. Beyond that basic indication of what's going on (in that page, motor vehicle accident) the doctors and hospital staff have no idea of what the actual case is. Nine times out of ten, the information that comes in before the patient does isn't entirely accurate.

So in this case, the trauma team likely heard that a trauma patient was coming in from a motorcycle accident, and that's it. Because the paramedics were concerned of internal injuries, they called it a trauma. At this point, there is no way for the paramedics - let alone the trauma team - to know for sure that this patient has only a broken rib.

In fact, based on that info alone, the hospital has to be ready for a patient with anything from a broken fingernail, to multiple broken bones / internal bleeding / pavement abrasions all over his body / possible c-spine injury / burn wounds from a gas tank explosion / the list goes on. For all they know, the ambulance is also bringing two other bystanders who got shrapnel embedded in their torsos. So, they assemble the entire trauma team. And when he gets there, they fully work up this guy.

You might still think this is overkill. But think again. If things weren't like that, this would be the headline instead, and the article would be much more newsworthy: "Hospital Takes 1 X-ray, Uninsured Patient Pays $11.95 and is Discharged in 24 Seconds; Patient was Hemophiliac and Later Dies Bleeding from Lacerated Spleen"

"$12,000 for broken rib." Yeah, right. Try "Hospital thoroughly checks out patient after his motorcycle accident; patient gets lab tests, nice room, pain meds, doctor supervision, X-rays, CTs, full trauma workup, and 8 hours of top-noch hospital care for only $12,000" - oh wait, that wouldn't make the news.

I see how it is. Twist the headline, and then people will be interested in reading the story.

You want a headline that screams injustice and ignores the fact that there might be another side to the story?

How about this one: "After hearing of doctors involved in London terrorist plot, Royal Bank clerk tells Canadian medical student from Middle East: 'I don't feel comfortable giving you a large line of credit anymore.'"

Actually, I didn't really twist the headline at all. You'd think that would be straight from The Onion. Too bad that poor kid says it actually happened to him.

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