Charon

The anesthesiology resident who writes at the Asclepion blog has likened his work to that of Charon, the ancient Greek ferryman of the underworld:

I have wondered if anesthesiologists are similar (but distinctly different) mariners [to Charon].  We dare to cross that threshold with the faith that our trips are not one-way. We take those, coin in eye, who have some need of transient depth, who trust us as navigators and cartographers. Are patients the modern day Heracles and Orpheus? Do we carry them across some mythical river and return them safely from their katabasis?

An experience in clinic had made me compare my work to Charon's, but in an entirely different way. Given the wonderful ambiguity of some Greek myths, it's only fitting that we'd establish different connections to this same character.
 
My patient was an impoverished illegal immigrant with a shockingly low potassium level, so low as to be fatal for most people. His blood pressure was also quite elevated. The attending and I whittled down his differential diagnosis until it pointed strongly to primary hyperaldosteronism, an oversecretion of a particular hormone that is often caused by a tumor. We scheduled him for a more extensive work-up.

And yet, beyond treating symptoms, there would probably be little our free clinic could do. We lacked the capacity to perform CT's, MRI's, X-rays, or ultrasounds, any of which we would need to find a tumor. If the presence of a tumor were confirmed, our patient would not be able to afford the life-saving surgery. As an illegal immigrant, he lacked insurance and was ineligible for county services. He could only be admitted to our university hospital if he became so ill that it would be illegal for the ER to discharge him. Entirely because he could not access care, his prognosis looked grim.

Here, I felt like Charon, who ferries people to the underworld. Our laws and medical system prevented us from healing this human being. All I could do was briefly and helplessly accompany him as he traveled to the other side.

Last year, Congress shot down a proposal that would have allowed tax-paying illegal immigrants to purchase health insurance. It's fortunate for our legislators that they don't have to witness the consequences firsthand.

On a happier note, children under 18 are insured by the state and federal government, regardless of immigration status. I haven't seen any in clinic, and that's the way it should be.

Secret hospitals

My favorite television program, FRONTLINE, recently ran an extraordinary piece on the ongoing Syrian uprising. The reporter went undercover with the underground resistance and experienced firsthand the brutal repression of the Assad regime and the public's noble attempts to gain democracy.

Heartrending for me was the segment on Syria's underground hospitals. Wounded protestors face arrest, torture, and death at the hands of state police if they seek treatment at a public hospital. Doctors who treat protestors risk a similar fate. Sympathetic doctors have improvised, treating seriously-wounded protestors in secret homes, using spartan donated equipment and in constant fear of discovery. This is not what medical care should have to look like. It is a forceful argument for why everyone in our country, including our prisoners, ought to have health care as a basic right. It also argues for non-judgmental regard in medical practice, a complex ethical concept that I haven't entirely come to grips with.

The particular segment on hospitals is below.

Watch Syria Undercover on PBS. See more from FRONTLINE.

I encourage you to watch the entire "Syria Undercover" piece at FRONTLINE's website.

Double vision

The patient was impoverished and had been in and out of jail for years. His health was poor, and among our many worrying clinical findings was the possibility of undiagnosed advanced colon cancer.

A fellow med student and I spent almost an hour taking the patient's history. We noticed that many of the patient's problems had started two years ago. A fall two years ago had caused his left eye to permanently deviate outwards ("acquired exophoria"). No one had ever treated it, and he had been seeing double ("diplopia") ever since. Later on, he told us the story of how, two years ago, he went for a drive even though he wasn't supposed to. Just across the street from where he started his car, he crashed at full speed into a parked vehicle. The crash badly fractured his hip, altered his gait, and sent him to prison. He hadn't driven since.

The patient had communicated something important here that I had entirely missed.

My med school class just had a lecture about the eye, and I mentioned to a professor that I had recently examined a patient with diplopia and acquired exophoria. The professor replied that diplopia is very serious and, if uncorrected as in this patient, can thoroughly mess up someone's life. He said we should have made it our priority to identify the underlying cause and come up with a treatment plan. "You can't do much while seeing double," he said.

It was only then that I put two and two together: you can't drive a car while seeing double, either. The diplopia almost certainly caused the car crash, which caused the hip fractures, which wrecked his gait and caused him constant pain. Dominoes.

I've only just begun getting an intuition for which medical problems are most pressing. As it improves, I'll be able to do better for my patients.

Safety net

Imagine: you're at an interview for a residency program. It's your fourth and final year at an accredited allopathic medical school in the United States. You listen to a voice mail from a classmate: your school has lost just its accreditation and the accrediting body says the decision is final. Effective immediately, you are ineligible for any American residency program. Unless you miraculously find another medical school that is willing to admit you and grant you advanced status, you will either have to start medical school over or find a new career. Your hundreds of thousands of dollars in loans are still due.

This account is not fiction. On October 3, 2011, the Liaison Committee on Medical Education (LCME), the accrediting body for allopathic medical schools in the U.S. and Canada, revoked the accreditation of San Juan Bautista School of Medicine because of "inadequate clinical resources". Although the school's administration knew that it was in danger of losing its accreditation, it had kept its students in the dark until the bitter end. The school enrolled 65 students in each class year.

A couple of schools are accepting a small number of San Juan Bautista students, but the majority of students appear to be absolutely out of luck.

It concerns me that not every medical students makes it. A fraction of those who enter medical school end up unable to practice medicine and saddled with a crushing load of debt. As the sizes of medical school classes increase nationwide and the number of residency spots remains the same, more students (especially those from studying at schools in the Caribbean) will find themselves stuck.

I wish there was a safety net. I'm not sure what it would be, but just some reassurance that if medicine doesn't work out, there's another viable career path that allows a student to pay off his debts.

As I go farther in medical school, I am increasingly committed to the profession. With that, I am increasingly entrusting some of my well-being to things beyond my control. All I can do is work to succeed and hope that everything turns out for the best.

UPDATE: The school's accreditation has been temporarily reinstated per a federal court injunction. Its fate remains in limbo.

MMI, oh my

Some medical schools have altered their admissions process by replacing the traditional applicant interview with the Multiple-Mini Interview (MMI). MMI resembles speed-dating: applicants rotate through numerous interview stations, where they act out scenarios and solve puzzles, sometimes alone and sometimes in groups. A July New York Times article presented a good overview of MMI, as implemented by Virginia Tech Carillon.

As you might expect, schools that have adopted MMI (UCLA and UC Davis among them) maintain its superiority to the traditional interview. For example, Stanford administrators praised the school's MMI program in a recent editorial:

Considering that as future physicians, candidates for medical school admission will be interacting with patients with diverse personalities and communication styles, we believe that it is essential to identify those skilled at interacting with multiple types of communicators...Scenarios are designed to probe candidates' ability to reason; to describe and support a particular point of view; or to analyze and discuss an ethical dilemma. There are no "right answers"; the effective communication of critical thinking skills is of the essence.

I've interviewed under both formats. While I see strengths in both, I see many reasons why it would be a mistake for MMI to entirely replace the traditional interview:

• Only the traditional interview deters applicants from embellishing their credentials.
  Interviewers often try to confirm that elements of an application are truthful: if an applicant claims fluency in Spanish, an interviewer might introduce himself in Spanish. And for good reason--there is clear evidence that some medical students cheat. For example, researchers at Brigham & Women's Hospital established that at least 1 in 20 applicants to their most competitive residency programs had plagiarized their personal statements. MMI refuses to evaluate applicants in the context of their application, a huge drawback that encourages cheating.
  
  
• MMI questions can be found out ahead of time, and MMI can probably be coached.
  Many schools purchase a bank of MMI questions from McMaster University in Canada and reuse their questions day to day and year to year. Some schools request that interviewees sign non-disclosure agreements (NDAs) to keep the MMI scenarios they witness a secret. Not all applicants abide by the NDAs and a well-connected student would have little trouble finding out the questions. For that matter, a publicly available fact-sheet put out by McMaster lays out two of the MMI scenarios that I encountered on the interview trail.
  
  My impression is that MMIs are coachable: most of the stations involved extemporaneous acting, and having taken improvisational acting as an undergraduate was a tremendous help. After all, if MMI weren't coachable, why would schools need interviewees to sign NDAs? I've already noticed that colleges are putting on "mock MMIs" for their pre-meds. The coachability of MMI will increasingly limit its ability to objectively evaluate interviewees.
 
• The main research studies on MMI are not as relevant as they might appear.
  The main studies on MMI come from McMaster University (the school that profits by licensing MMI questions, which strikes me as a substantial conflict-of-interest). Researchers asked applicants undergoing traditional interviews to volunteer to participate in a trial MMI. Neither the student's performance in the MMI nor his decision whether to participate would be considered in the admissions process. The study looked within this sample of volunteers and found that higher scores on the MMI moderately correlated with better evaluations on clinical clerkships. Universities cite this study as evidence that MMI ought to replace the traditional interview.
  
  The fallacy in citing this study is that it only examined applicants who performed well enough on the traditional interview to be admitted. The study does not tell us that MMI by itself is better than a traditional interview at assessing candidates. Rather, it suggests that succeeding on both correlates more strongly to good clerkship evaluations than does succeeding on the traditional interview alone. It's not clear that MMI alone is any better than the traditional interview, and indeed, MMI alone may be much worse. The study is analogous to my asking, "of the girls who I would have an excellent time with on a long date (traditional interview), does how much I enjoy talking to them at a cocktail party (MMI) correlate to how good of a couple we would make?" Even if the answer is yes, it doesn't mean that when I seek out mates I should abandon dates and only attend cocktail parties.
  
  I agree with the Stanford administrators that the traditional interview and MMI test different skill sets: the interview requires depth and is a one-on-one exploration of someone's person and character; the MMI assesses how well someone communicates and improvises in different situations. It makes sense that the best doctors have both of these skills, but I have not seen evidence that one set of skills is better than the other.

In sum, I'm not convinced that MMI ought to replace traditional interviews. MMI's utility is unproven. Should more schools adopt MMI, I would expect students to adapt by obtaining schools' questions ahead of time and by practicing their acting skills. Lastly, because MMI does not evaluate an interviewee in the context of his application, it offers additional temptation to embellish one's qualifications.

MMI might be a great supplement to the traditional application process, but it strikes me as a poor replacement.