8 Days

8 Days

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(Not So Brief) Book Review: Catastrophic Care

One of the most fascinating books I have read, “Catastrophic Care: American Healthcare Killed My Father” (http://www.amazon.com/Catastrophic-Care-American-Health-Father/dp/0307961540) offers no answer to its central question of how to save the lives of hundreds of thousands of Americans who die each year of “iatrogenic” causes. Instead, in a long, repetitive and begrudingly persuasive diatribe, it offers a sensible economic solution to our health care crisis while steadily losing sight of its ostensible raisôn d’ètre.

For me, Goldhill’s persuasive hook was that health insurance is not insurance in the traditional sense of the term insurance. It does not seek to spread risk of rare events across a large population. In a world which has medicalized human existence from cradle to grave, it is not a rarity but a certainty that we will rack up huge hospital bills somewhere along the way. The only question is when – not whether – six figure bills will be thrown our way. Health insurance purports to protect us from those oscillations. .

Lost in the shuffle, somehow, is any evidence that market-based reforms can improve quality and outcomes. Ironically, for a book motivated by the death of his father due to medical error, Goldhill offers slim evidence that increased marketplace competition will reduce medical errors. One need only to read the newspaper for a few days (or go to a store or restaurant) to note the alarming rate of errors made even in the most competitive marketplace segments. Now, one might argue that the marketplaces disciplines those actors over time, and that might be true, but I would like to see some evidence before believing that claim.

Also lost in the shuffle is the evidence that many physicians are motivated by pecuniary gain. In the training and practice environments that I am familiar with, financial considerations are minimized. Granted, I don’t work at a private institution and have never trained at one (few training programs are based at for-profit hospitals, for obvious reasons). And while “efficiency” and profit concerns are always present in the background, I have not yet seen a treatment performed or not for financial reasons.

And what would a more blatant capitalist system look like? As a model, I propose the only market-based physician I am aware of, Dr. Mehmet Oz. A recent fantastic article by one of my favorite nonfiction authors, Michael Specter, in the New Yorker showed a fascinatingly terrifying glimpse into this world (http://www.newyorker.com/reporting/2013/02/04/130204fa_fact_specter).

For instance, in neurosurgery, one of the core competitive areas is the treatment of intracranial aneurysms. Thanks to a few clinical trials in the early 2000’s, most people believe that endovascular therapy (treating aneurysms using wires threaded through the blood vessels) is superior to open brain surgery if endovascular therapy is deemed possible, except in a few specific conditions. Having spent a good bit of time around cerebrovascular surgeons, I can say that the biggest determinant is the opinion of the open surgeon vs. the interventionalist – and while financial considerations don’t exactly get into play openly, I am sure that job security is always present in the back of the surgeon and interventionalist’s minds when they compete/bargain for cases. I’m not sure that the open competition, though, is really best for patients since both sides push the limits of their technology and skills.

Anyhow, this post is now 300 words longer than “brief” – so I’ll wrap up by saying that the book is well written and a worthy read for anyone who will participate in health care as a physician or patient, and I strongly recommend it.

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Wow, it’s January.

Interview season has finished. Look for more posts in the days and weeks to come.

At this point, all I can say is that I’ve interviewed broadly, at almost everywhere I wanted to interview, and the rest is up to the robots who run the match (and human politics).

Congratulations to all of those who will be training in Urology and Ophthalmology (YES! I SPELLED IT RIGHT THE FIRST TIME!) – and best of luck to those who are taking a longer path to those fields.

Rank lists for the regular NRMP match are due 2/20 and the fateful days are 3/11 (when we find out if we matched) and 3/15 (when we find out where). Thoughts & prayers appreciated.

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Monthly Interview Trail Update and Musings

Interview Status:

63 Applications Sent

37 Invitations (2 complete, 28 scheduled, 7 unable to schedule)

6 Pending (programs who have not yet sent any invites)

2 Waitlists

4 Rejections

14 Pending (invites sent to others but I have received no response)

Mostly, I’ve managed to schedule my interviews on three two-week swings, one each in November, December and January, with breaks interspersed.

Overall I think the system is shockingly inefficient. Programs often choose one or two dates, which commonly conflict with each other, forcing candidates to choose between several similarly desired programs. This is bad both for programs (because applicants cancel at the last minute and because programs don’t get as many desirable applicants due to scheduling) and for applicants (since they cannot interview at all the programs where they have been invited).

The system could be improved by strongly suggesting that programs to coordinate their dates (e.g. via a central SNS calendar). There are ~100 programs: if each program wants 3 dates, then there could be 300 possible dates. Ideally a central schedule ensure that the same tiers/locations of programs don’t conflict at every opportunity, and that programs in a single location had contiguous interview dates to minimize airplane travel costs (in terms of time, money and fatigue on applicants).

Additionally, interview days are often too long and involve many faculty asking similar questions. I’m not sure what the programs gain from having the program director, multiple senior faculty, and multiple junior faculty speaking with candidates in a (seemingly) uncoordinated fashion. At smaller programs, admittedly, I understand the desire to have every faculty member interview every resident. Applicants *could* gain a lot from speaking with all of these faculty, but the reality is that at most an applicant might get to ask a single question or two since the interviewer (rightly) controls most of the conversation. I often try very gently and tactfully to tie the end of my interview answers with questions for the interviewer, but this works more often in theory than practice. It’s also very difficult to ask most of the questions you really want to ask during a structured interview.

I actually liked the UK system where (as I understand it from speaking with one of the consultants/attendings) there is a more centralized and more practical interview attended by all of the departments (think NFL combine), followed by interviews with each program.

There are some logistical difficulties in translating that system into the larger world of US Neurosurgery with 100 programs and 200-300 applicants, but if the NFL can do it with their pre-draft Combine then so can we. I’m envisioning a one week process with 2 days of knowledge and skills testing, followed by invitations for a further 5 days of interviews with faculty from the program at a centralized location. If the individual school interviews were 2 hours each, one could easily accommodate up to 20 program interviews per applicant in addition to the “combine” testing.

Applicants would then be able to travel to programs of their choice for visits that are more akin to current “second look” visits where they get a better behind-the-scenes glimpse of the programs. Of course, if a program or an applicant wanted to have more than the 20 interview slots available, they could schedule those during their visit.

You are all invited to comment on how terrible this system would be and why my idea sucks.


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In the event that you haven’t seen …

And, here’s a little JDS for you, easily translatable to surgery (one of my favorite blog posts of all time, particularly when I start to feel a bit lost):

You won’t be asked if you were working on a wonderful, moving piece when you die. You won’t be asked if it was long or short, sad or funny, published or unpublished. You won’t be asked if you were in good or bad form while you were working on it. You won’t even be asked if it was the one piece of writing you would have been working on if you had known your time would be up when it was finished—I’m so sure you only get asked two questions. Where all of your stars out? Where you busy writing your heart out?

If you only knew how easy it would be for you to say yes to both of those questions. if only you’d remember before you ever sit down to write that you’ve been a reader long before you were ever a writer. you simply fix that fact in your mind, then sit very still and ask yourself, as a reader, what piece of writing in all the world Buddy Glass would most want to read if he had his heart’s choice. The next step is terrible but so simple I can hardly believe it as I write it. You just sit down shamelessly and write the thing yourself. I won’t even underline that. It’s too important to be underlined.

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Last Call

I recently had a bittersweet last call as a medical student. I can’t say it was one to quit on, but it certainly made me glad to have that chapter of my life finished. On the last service I rotated on, we took call every third night, meaning that we would stay overnight until 6AM, then round as usual on our regular service, and either stay to assist and observe operations or clinic the following day, or go home if we weren’t feeling up to it (the residents never stayed post-call). The end result is often a 30-36 hour “shift” with 1-3 hours of sleep squeezed in between there somewhere. The longest I stayed was 38 hours, which is fine until you remember that I left at 7PM and had to come back at 5 AM the following day.

Call as a medical student feels particularly self-flagellating – you aren’t working, so there isn’t ever anything you actually need to do. No one is actually counting on you being there. You’re following your resident around hoping to be included, hoping that they don’t ditch you or disappear since you often don’t have access to the call rooms or resident lounges. Hopefully you’ve managed to grab their cell phone number – they are definitely not answering your pages – and hopefully you are familiar with the hospital by now.

You can rarely be helpful, and this is a time when residents are almost always looking to be as efficient as possible so that they can snag a little sleep. You spend a lot of time watching someone else perform procedures, put in orders, or see a patient. And believe you me, shadowing someone else working at 2 AM when you’ve been up since 4:45AM the previous day is a particularly difficult experience.

It’s also, in many ways, a uniquely educational experience. You get a taste of what it’s like to be a resident, but I wouldn’t ever equate the frustration and annoying shadowing of medical student call to the pressure and stress of call as a resident. You get unique access to your residents and you see what they are really like – and you can get to know them and bond with them. Occasionally, if your lucky stars line up, you might get to play a bigger role in an operative case or bedside procedure that you might not ordinarily get to perform during the daytime. You might get to be the first person sent to see a consult and have the experience of trying to organize your thoughts and write a coherent note under time pressure and fatigue. You get to know the other staff and your patients much better than if you clocked out at 5 PM.

Of course, there are some technicalities worth mentioning. Most medical schools mandate that their medical students do not exceed PGY-1 work hour restrictions (80 hours a week, 1 day free in 7, 16 hour shifts maximum with 10 hours free from duty). This is of course incompatible with call. However, it’s not clear on whether the rules apply to those who are “voluntarily” taking call … whatever that means …

I’m glad that this phase of my life is over, and I can’t wait to be on to the next thing, which for me is a series of interviews and classroom / didactic rotations mixed with lighter clinical rotations (with no call). I will have many residency overnight calls during the coming years, and I do look forward to those. Onwards …

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Interviews are a-comin’

10 interviews scheduled. 53 pending. My goal is to go on 30 interviews and I am well on track for that. However, most of the programs who haven’t yet offered interviews are more competitive and thus less likely to offer me (or anyone else) an interview.

Of my preliminary top 20, I’ve 2 interviews and 0 rejections. However, I’m excited and honored to be offered interviews at all of the programs who have invited me.

Most of us applicants check uncleharvey.com obsessively. Some of the other applicants who have accounts there have been posting the list of programs who have offered interviews already. It’s a valuable and appreciated service.

I’m exhausted from my last sub-I as I prepare heading off for my first interview shortly. I’m excited to see what the entire process is like. It’s going to be a great adventure over the next three months – my travel schedule already has me crossing the country two or three times and I still have another 20 interviews to schedule.

To pack, to sleep, and hopefully to blog more later.


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