Category: Health Professionals

The Impact of “Full Ride” Medical School

Want a good smack in the face with some good old-fashioned common sense? Check this out. What you will see is an article that reviews the impact of NYU’s Grossman Medical School giving, starting in 2018, all current and future medical students free tuition. A generous move for sure, and one likely to attract medical students who otherwise might have gone to the Harvard’s and Georgetown’s of the world. But how about the expressed purpose of the move, i.e., to attract more students who will feed into primary care, and to attract a more ethnically and socially diverse student body? 

Read the piece and think about it. A free ride looks just as good to me if I am going into one of the lucrative specialties, like dermatology or radiology, as it does if I am headed for primary care. Free tuition did nothing to shape the direction of NYU graduates’ specialty choice. Zero. Nada.

Similarly, as long as metrics like GPA and MCAT scores are the primary selection criteria used nationwide, and minority applicant pools remain stagnant, free tuition does little to increase the diversity of the medical profession overall. Sure, more minority students may be drawn to the free tuition at NYU, but only at the expense of other schools. 

Bottom Line. Much talk is heard about “unintended consequences.” Civilians killed in air raids on military installations, etc. But how about “intended consequences?” Shouldn’t somebody be looking at a generous but expensive program like free medical school at NYU and ask the question, “How is that going to make happen what we want it to make happen?” 

How indeed?

What are the Appropriate Boundaries for a “Concierge Practice???”

Ah, to be a concierge internist in Boca Raton, FL. Yup. The website for one such physician is the source of the swipe art pictured above. Idyllic, right? But maybe not so fast! Check this out.

In a Boca Raton concierge practice, you are likely to encounter the kind of patient talked about here. A patient closing in on 90 years of age who apparently had a bad fall, didn’t know why and wanted to come into the office to get “checked out.” Understandably, the physician believed, and explained to the patient several times, that “checking out” here was going to require imaging, and thus a trip to the hospital. Not surprising that the patient didn’t want to go to the hospital during a pandemic, but sometimes you gotta do what you gotta do. 

Here’s the punchline. The patient wants his concierge fee money back because the doctor was not living up to his contract, which promised “same day” office visits for “acute” situations. Somehow, the line of reasoning that said that heart attacks, automobile accidents, possible brain injuries, and similar cases were not the kinds of acute problems that were under discussion here was lost on this patient. 

Bottom Line. Once again, this discussion had me scratching my head. On one side, we have “contract wording.” On the other side, we have “rational thinking” and “common sense.” Somehow, which of those should be the primary consideration in a situation like this seems obvious.

But apparently not!

The Ethics of “Placebo-Controlled” Studies

Funny thing. When we hear the term “placebo-controlled study,” the methodological purists amongst us generally think that is a good thing. After all, without a placebo control arm, how would we know whether benefits apparently produced by a therapy were, in fact, actually placebo effects. But check this out. What you will see is a situation in which the circumstances of “placebo control” raise significant ethical questions. Why? Several reasons. Most tellingly, because the study participants were disproportionately “disadvantaged” inner city children of color.  AND. Because the placebo control involved withholding a standard treatment for patients with Vitamin D deficiency. AND. Because the study lasted almost a whole year, with standard therapy being withheld for this entire time for the control group. 

Bottom Line. Think about this one for a couple of minutes. The real kicker here is that this research could have been done without the placebo control arm. The reason it wasn’t?  It would have taken longer and been more expensive. 

The right question, as posed at the end of this piece, deals with how the heck institutional review boards at several major institutions signed off on this research. Exactly the kind of unethical research such boards are intended to prevent. 

How indeed!!!

Practicing at the “Top of the License”

Check this out. We have done versions of this riff before. Doctors complaining that while NPs and PAs are exhorted to practice at the “top of their licenses,” MDs are increasingly relegated to grunt work. But this time around, the complainant is an anesthesiologist, who wonders why in Europe, anesthesiologists always have an assistant in the OR, while in the US it’s a solo act. 

SO. Here’s the part that confuses me about this. Unless I am missing a point, the establishment of the role of the certified registered nurse anesthetist (CRNA), with multiples thereof working under the supervision of an anesthesiologist, is one of the best examples of the leveraging of physician time with which I am familiar. Check in at our local surgi-center for a procedure, and you get a quick interview with the MD. Into the OR you go, and the CRNA is the one who is hitting you with propofol. Makes sense. Well leveraged. 

Bottom Line. In years to come, it will be fascinating to continue to watch the shifting of roles amongst physicians and other medical professionals. Hopefully, the focus will remain on efficiency and safety of patient care, and politics will be left by the wayside!

The Covid Vaccination Struggle and “Market Forces”

In my most recent round of 10 On Doctors’ MindsSMmonthly conversations with physicians about the impact of the pandemic on their private practices in primary care, cardiology, oncology, etc., I have been asked by several clients to talk about the impact of “market forces” on vaccination acceptance among their patients.

As I predicted in a previous post, the Pfizer vaccine receiving “FULL FDA APPROVAL” didn’t matter in a single practice with which I conversed. Patients simply have no idea of the difference between “Emergency Clearance” and “FDA Approval.”

For practices with large numbers of working patients, the possibility of a “VACCINE MANDATE” was predicted by my discussants to have a significant impact, although not without a lot of rancor as the picture above, on the left, would suggest.

By far, the best conversation I had on the topic of convincing patients to get vaccinated was with a cardiologist in the Bronx, who actually was the first US physician to contract COVID himself at the beginning of the pandemic. He tells skeptical patients that they are right.  The vaccine is a hoax, as is the pandemic. The 600,000 people who have reportedly died of COVID were actually taken to Area 51 in Nevada, where they are being kept against their will. Etc., etc.  At the end of this riff, he asks patients if they believe all of that. Most, not surprisingly, say “No!” His retort? “Then your only choice is to get the vaccine.” One patient shot back that he was going to have to “Evaluate the science further.” To which the cardiologist, obviously no shrinking violet, responded, “You’re a truck driver. How are you going to do that?” Sort of the current situation in a nutshell! 

But check this out. An ICU nurse’s graphic reminder that when you show up at the ER gasping for air, there are no more choices. Everything available for treatment, including intubation, will basically be forced upon you. No volition. No more “bodily autonomy.” 

Bottom Line. One thing that my discussants are telling me this month is that the only “market force” they have seen motivate a recalcitrant patient to get the vaccine is actually seeing someone close to them die of the disease. 

Question. How can we synthesize the impact of that horrendous but impactful experience and get it into widespread public distribution???

The “Power of the Personal”

Check this out. In this brief video, you will see the neurologist pictured above, who pontificates under the pen name “Dr. Wisdom,” describe a trick that he learned over his decades working with his colleagues at Kaiser. One such colleague, a Dr. Edelson, taught him the “My wife had that” technique.” Huh? It works like this. Rather than going off on a long scientific riff to explain a condition to a patient, Dr. Edelson’s approach sounds like this: “You have the HurtsLikeHell Syndrome. My wife had that a few years back, and she’s doing fine.” Especially in a field like neurology, where the pathophysiology is often unknown and treatments are aimed at symptom relief rather than cure, using this tactic rather than a long scientific riff that goes nowhere is likely of great benefit.

Bottom Line. We are now finding this to be true in convincing our 10,000 patients at the Volunteers in Medicine Clinic on Hilton Head Island, SC to get their COVID vaccinations. Rather than making an argument based on science, our clinicians are basing their appeal on trust. Our patients are told: “You can believe that this vaccine is safe, because we all had it and we’re fine.” 

The personal, rather than the technical, often is the better explanation. 

Broken

Check this out. Picture, from a physician’s perspective, the horror of combined pandemics. COVID-19 like the whole world is experiencing, with a dollop of civil war and lawlessness being thrown in at no extra charge. That’s the story in South Africa today, and in many places around the world as well. Dreadful!

Bottom Line. This blogging physician ends his piece better than I could, so I will just use his line.  “Now I know our democracy is broken, and it is time to move on to heal.” Too true in South Africa, too true here, too true in so many parts of the world in 2021. 

It is, indeed, time to move on to heal!

Never Again!!!

Check this out. What you will see here are a lot of important observations and very meaningful words.  Like the assertion that COVID-19 caused the “moral crippling” of ICU nurses. Code for they could no longer do their jobs, the way they used to love to do their jobs, during the pandemic. Too many patients. Too little PPE.

And the irony of hospitals offering ICU nurses $5,000-$6,000 a week in compensation. In exchange for putting themselves and their families at risk. Feels almost like a perverse bribe, although Lord knows they earned every penny and more.

OH. And the balloons and music at the hospital doors. People yelling that they are heroes. But none of them is feeling like a hero. 

Bottom Line. And the greatest irony of all? The phrases toward the end of the piece. “We finally see the numbers go down. A sigh of relief.” This in piece written just over a month ago.

And the prayer. “Never again.” But here comes Wave 4. Can these nurses do this reprise? Their patients have to hope so!

God bless them one and all!

Neurosurgery Meets Cosmetology

Check this out. What you will see is a story of a male Neurosurgeon being taught by some of his female staff the importance of a patient’s hair after surgery. Not just a water and alcohol rinse. Nope. Using a cosmetically elegant shampoo and conditioner! 

The benefit to the patient, he learned, is in realizing that the surgical team had helped her to take the first step back toward human normalcy immediately after the dehumanizing process of having her head opened up to remove a tumor. AND. An unintended consequence was that it also made the OR staff feel more human in the process. 

Bottom Line. Amazing how little dollops of civility can enhance the healthcare experience! 

Cannabis M.D.

Check this out. What you will be led to is the web presence of Jill Becker, M.D.  Trained in Ob/Gyn, Master’s Degree in counseling psychology, ordained Minister, etc.  BUT. Her main claim to fame is that she has extensively studied the use of cannabis used to deal with a large variety of medical problems. She will “work with your care team” to figure out the right cannabis program to cure what ails you. AND. Talk about a practice that is perfect for using telemedicine! She can work with patients nationwide using telemedicine platforms and can also help patients avoid any stigma that might accrue to being seen sitting in her waiting room. 

Bottom Line. Got me to wondering. How many other doctors have figured out this schtick??? Do the Google search and roam around like I did and you will know what I know. LOTS!!! All doing it via telemedicine.

Smart. I can see this specialization filling a real and important need that many (most?) doctors wouldn’t touch with a ten-foot pole!