Reflections on my first semester in medical school

1)  Medical school is hard. Yes, it’s true–medical school is as hard as people who have been through it make it out to be.  I was skeptical when I started mostly because I felt I had challenged myself while doing my undergrad degree and in graduate school.  I had taken heavy loads of difficult classes in both of my degrees.  My last semester of graduate school I took 18 hours of the highest level epidemiology classes at one of the top programs in the country.  I didn’t see much daylight that semester and thought I was prepared for anything med school could throw at me.  But the difficulty is not conceptual, but sheer volume of information.  Probably the biggest contributor to the large amount of information medical students must internalize is lingo.  Medicine truly does have its own language.  I read somewhere (and I wish I could find the source now) that the average English speaker’s vocabulary consists of roughly 15,000 words while medical vocabularies run in the neighborhood of 18,000 (don’t quote me on those figures).  Thus, medical students effectively have to double their vocabulary (most of which are Latin derivatives that are impossible to pronounce, let alone spell).  Internalizing all of the vocabulary plus learning the complicated science behind the inner workings of the human body is a daunting task.

2)  Half the battle is knowing where to be and when to be there. Maybe other programs are different, but at my medical school you are put into various groups to do different activities.  I have one group for histopathology lab, another for anatomy lab, one for small group discussions of cases and “problem based learning”, another for the clinical skills lab, an academic society, plus the multitude of student organizations.  None of these groups meets on a regular basis and only a few meet in the same place every time.  Thus, a big hurdle in the beginning is organizing your time, not only so you make sure you use your time wisely, but also so you are at the right places at the right times to fulfill your obligations as a student.

3)  Medical students are cool people. During our white coat ceremony one of the speakers threw out the statistic that the people admitted to the school of medicine are in the top 3% of their peers.  I’m not exactly sure how they came up with that figure (I don’t think I’m in the top 3% of anything), but the overall point of the statement was that those admitted to medical schools are high achieving people.  It is true.  I’m amazed by the things my fellow medical students have done.  It seems almost all of them have traveled abroad, most speak a second language (on some level), many have done some cool research, some have done extensive volunteering or work with underserved populations, and all are very nice people.  Yes, medical students are nerdy in the sense that they actually applied themselves during undergrad and enjoy learning things.  However, unlike some graduate students, med students tend to have excellent interpersonal skills and are generally pretty fun people (sorry other grad students).  My advice to future med students–get to know your peers.  They will amaze you.

4)  Not a lot of “medicine” is learned in the first semester. During the first semester, it’s actually really hard to feel like a “true” med student.  Depending on the program, most of the classes are continuations of the pre-med basic sciences with additional emphasis placed on the role these sciences play in human physiology.  You learn a little about drugs and certain disease processes, but it seems very abstract and much more about the science (possibly due to the fact that most of the first and second year classes are taught by PhDs and not MDs) than the actual medicine.  Some schools start in the cadaver lab right away (mine does not), which is where people really begin to feel like they’re actually training to be a doctor.  Obviously you have very limited patient contact.  But there are instances where you do get to interview patients or perform exams on patient-actors–these were the best days of the first semester.  It’s pretty much a necessity that the first semester has to be pretty bland, med students really have to crawl before they can even think about walking.  Knowing that the best doctors understand the basic science aspects of medicine very well was (and is) the biggest factor motivating me to truly internalize this information.

I hope to have a few more reflections, but they may have to wait until this summer.  School has truly become all-consuming.  Just when I thought they couldn’t cram any more material into a 4 week block, they surprise me with something new.  Look for more posts, but they may have to be limited in length.

“Number Needed to Treat” Statistic in the Wild–III

From a meta-analysis of Chron’s disease treatment in the journal Clinical Infectious Diseases:

For patients with active disease, the number needed to treat was 3.4 (95% CI, 2.3–7.0) for nitroimidazoles and 4.2 (95% CI, 2.7–9.3) for clofazimine. The corresponding numbers needed to treat for inactive disease were 6.1 (95% CI, 5.0–9.7) and 6.9 (95% CI, 5.4–12.0).

Unfortunately, the full article is gated, but check out the abstract if you don’t have access.

Enthoven’s response to Gawande’s latest New Yorker piece

Alain Enthoven provides the thoughtful analysis of Atul Gawande’s latest writing in the New Yorker I was looking for. When I wrote about Gawande’s article earlier I had expressed my own doubts.  Enthoven provides a much more in-depth critique of Gawande’s argument, essentially calling it wishful thinking.  I couldn’t agree more with Enthoven.  Powerful forces exist within the medical industrial complex and these forces make a lot of money under the current system, so they are not going to sit and do nothing as they lose billions of dollars.  My heart wants to believe that Gawande is right, but the available evidence suggest otherwise.  I’m beginning to agree more and more with Jay Parkinson that radical reform is necessary and that such reform will come from individual innovation sparking a revolution in the delivery system.

Selective outcome reporting in medical journals

Slate has an interesting article implicating selective outcomes reporting as a major contributor to pervasive off-label drug prescribing. This practice can be summarized in the following from this article:

According to a remarkable analysis of the Neurontin documents, published last month, many clinical trials of the drug took a shotgun approach. Study patients took the drug, and researchers measured tons of possible outcomes (like pain with touch, pain with cold, excessive pain with pinpricks, more than a dozen different scales for psychiatric symptoms, and so on). By random chance, if you measure enough outcomes, at least some of them will appear better after drug treatment. When the time came to report the findings, however, the researchers systematically omitted the outcomes on which the drug had no effect—and presented only the data showing benefit. That’s like dealing dozens of hands of poker to yourself but showing only the hand with good cards.

Such research practices can be characterized as sloppy–at best–or, more accurately, as unethical and fraudulent.  In the case of Neurontin, the researchers seem to have clearly set out to circumvent the scientific method in their work.  However, researchers conducting properly designed and ethical projects are also likely to omit at least some results in the presentation of their work.  Space is limited in a journal article.  Most major or original research articles published in leading medical journals are limited to around 3,000 words and generally three or four tables and figures.  For a large study with dozens of secondary outcomes, this is not enough room to detail all results.  Thus, outcomes are selectively omitted.  Hopefully, only less meaningful or non-clinically relevant outcomes are omitted.  More often than not, a result will be omitted if “no difference” or equivalence is shown.  This seems like a sensible approach when space is so limited.  However, as the Slate article points out, this can become very important when considered in terms of off-label prescribing.

So, what’s the solution?  It would be nice if researchers weren’t limited by a word count when presenting their work in medical journals.  Unfortunately, this is unrealistic.  We would likely see 15,000 word articles.  Obviously, the medical journals can’t publish book-sized journals each week.  Paper is expensive.  Bandwidth, however, is relatively cheap.  Thanks to the internet, publishers can put supplemental materials online in conjunction with what is physically printed in the journal.  A few medical journals already do this in certain instances.  This practice needs to become more prevalent and should be encouraged by editors.  Not only will this give more information to physicians when considering something like off-label prescribing, future research can be guided by more information from previous work.  Medical journals (along with the rest of the medical world) have been very slow to adopt new technologies.  This is one area where they can jump ahead and set a new precedent for peer-reviewed research.

Natural Parenting

As somebody interested in pediatrics, I’m a little concerned about this mentality:

[original]

Man As Industrial Palace

Original via Jay Parkinson

The True Cost of Bottled Water

Here and there you hear about the waste involved in producing and supplying bottled water, but I had no idea of the actual figures.  The cost per gallon is the most amazing (I really like standardized measures). Having lived in a few places where I didn’t have drinkable water really helped me appreciate how incredible the water coming out of our faucets actually is; we shouldn’t take it for granted (or give more money to Coke and Pepsi).

[via Jay Parkinson]

Presented by Online Education

Gawande and Hope for Health Care Reform

Atul Gawande has an interesting article in the New Yorker about the current reform bills circulating through Congress.  Like everything else Gawande has written, this piece is insightful, concise, and inspiring.  He draws a parallel between American agricultural reform during the early part of the 20th century and the current debate over health care.  Given I am not well-versed in agricultural reform in the US (I did see a PBS special on it once), I’m not exactly certain of the appropriateness of this analogy.  What Gawande does accomplish in this piece (and why you should read it) is a sense of hope in our collective ingenuity to actually accomplish effective health care reform.  He believes this goal will be achieved through provisions in the current Senate reform bill for dozens of pilot programs to test new payment structures and delivery systems.  Although Gawande makes a strong, eloquent argument, I am only partially convinced.  How will these pilot programs generate substantial change?  How long will it take for these programs to demonstrate substantive value and then how much longer would it take to scale up their lessons?  I actually like the idea of pilot programs, but they need to have scale to make an impact.  As I have argued many times before, different approaches should be tried at the state level (like Massachusetts) and then scaled up when appropriate.  Such larger programs offer two distinct advantages: (1) their relative scale means evidence of effectiveness (or ineffectiveness) will be generated more quickly and (2) scaling such programs to multiple states or  the national level will take less time and effort since the original scale is more proximate to the end goal.  But read Gawande’s article, it really is quite good (despite my skepticism).

Why are electronic medical records so poorly designed?

Kevin MD recently stated on his blog that electronic medical records systems are basically useless (I’m paraphrasing, but I don’t think I’m too far off here).  I don’t disagree with this sentiment.  You only have to spend 5 minutes in a clinic with an EMR system to realize that physicians end up spending more time looking at their computer monitors than their patients, clearly a serious problem.  Most of the complaints about EMR systems from health care professionals are about their poor design–Kevin MD points to the “archaic interfaces that the current generation of EMRs have, which is akin to a user interface circa Windows 95.”  My question is–why?

Why are current EMR systems so poorly designed?  The technology sector in this country has become a dominant economic force and a major source of innovation within our economy.  It has churned out revolutionary products like the iPhone, Google (and all of its other services), and Facebook.  Why does it seem like the tech world is ignoring the medical world (and turning its back on a sector that is rapidly approaching 20% of GDP)?  It seems that with such a huge potential market and billions of new government spending tech companies would be falling all over themselves trying to come up with the “Windows” of EMR systems.  I have yet to read any satisfying commentary as to why a revolutionary EMR system has yet to be developed, which leads me to believe that there is a yet unidentified problem stymieing the development of good electronic records systems.

AIDS research

In honor of World AIDS Day, here is an interactive map of AIDS research around the world.