Boards

I'm fast entering the "dedicated study period" for the national boards exam. The boards exam, called Step 1, is an eight-hour-long multiple-choice standardized test that will largely dictate how competitive an applicant I am for residency.

Although the boards broadly concern medical knowledge, many questions are about minutiae of marginal importance: obscure diseases, medications that are no longer used, and detailed biochemical mechanisms. Medical students nationwide tend to use the same test prep materials from the same companies to prepare for those otherwise-untaught topics that perennially appear on the exam.

Although standardization can be a force of good, I do wonder if it is wise that so many students spend so much time learning from the same resources. It seems like it will reduce the diversity of knowledge that we medical students as a group will possess when we are practicing doctors.

Resistance

The CDC publishes Morbidity and Mortality Weekly Report, a weekly bulletin describing recent disease outbreaks as well as long-term public health trends.

This week's issue (perhaps to coincide with Valentine's Day?) discusses multi-drug resistant gonorrhea. Gonorrhea is a common sexually-transmitted bacterium that, if untreated, can cause pelvic inflammatory disease, infertility, and predisposition to ectopic pregnancy in women. Having gonorrhea also makes it easier to get infected with HIV, by damaging some of the body's innate defenses to the virus. In many people gonorrhea causes no symptoms, hampering its recognition.

Gonorrhea has quickly become resistant to an increasing variety of antibiotics, leaving us with a precious few that remain effective (at least, for the time being) against the bug. The report also states that "only one antimicrobial is undergoing clinical study as a potential treatment for gonorrhea." The specter of totally-antibiotic-resistant gonorrhea is frightening and increasingly possible.

A number of factors drive antibiotic resistance, among them:

• unwarranted prescriptions of antibiotics by medical providers;
• excessive use of antibiotics in livestock; and
• a lack of investment in new vaccines and new antibiotics.

Hopefully our legislators will find the latest news about gonorrhea alarming enough to craft policies that engender more-judicious antibiotic use.

Cartoon: "Pelvic Exam"

What do you want to know?

"I set it down as a fact that if all men knew what each said of the other, there would not be four friends in the world."
              —French mathematician Blaise Pascal

Pascal's quote reminds us that ignorance can sometimes be blissful.

How much should a patient be told about their medical condition? The knee-jerk reaction is to reply: "as much as possible." But as with most things, the truth is more complex.

_____

For a couple of years as a kid I played Magic: the Gathering. It's a card game where you buy up cards at the local comic book store and then assemble your favorites into decks. Your cards attack and defend in various ways. You duel against other players, using a combination of luck, strategy, and the planning you put into assembling your deck. It was a fun game to play. It also proved quite lucrative for its manufacturers. Like lots of other kids, I trooped to the comic book shop to buy sets of cards, because sometimes thrown in with the junk and the mediocre ones were some rare cards that conferred some special advantage over an opponent.

Upon outgrowing my Magic phase, I sold all of my Magic cards to a middle school buddy for a grand total of $20. That is, except for one, which I set aside because I remembered hearing that it was rare and valuable. A few weeks ago, I was cleaning out my room and came across the card. For a moment I thought I should get on the computer to look up how much the card was worth. Then I decided it was probably garbage (what are the odds that anyone even plays Magic these days?), and I tossed it in the trash.

The other day, I spoke to someone who casually mentioned that he plays Magic. I told him that I had just thrown out my last card, and I asked him if it was actually rare. We looked online and found that it would sell on eBay for $150.

I couldn't help but beat myself up for tossing out the card. Why didn't I take a few moments to check its value? I tried to rationalize away my nagging feeling, but I still felt bummed. I could have put the cash towards some extra white coats, or some excellent tickets to the symphony.

Then I felt stupider still for ever asking my friend if the card was rare, for ever going online to check the card's value. Yes, perhaps by learning its true value I might have learned a life lesson, and I can adjust the way I clean my room in the future accordingly. But I'm convinced that I would have been happier never knowing that I had chucked $150 into the garbage.

_____

A number of diseases are in some way avoidable, meaning that many patients end up second-guessing or regretting past decisions. I'm sure some of the patients I've seen dying of cirrhosis wish they had never picked up a can of beer, that some patients dying of lung cancer regret ever smoking a cigarette, that some trauma patients regret ever climbing onto a motorcycle.

But sometimes a disease's link to past behavior isn't obvious to the patient. For example, it's widely known that smoking is strongly linked to lung cancer. But did you know that bladder cancer is strongly linked as well? I doubt that most smokers are aware of that connection. If a former smoker comes in and is found to have widely metastatic and untreatable bladder cancer, should the doctor point out bladder cancer's link to smoking? Bear in mind that there's nothing the patient can do at that point to improve his prognosis. It's hard to take that sort of news, that you've probably caused your own undoing, in stride.

Sometimes, doctors perceive a link that the patient does not. Checking the blood type of multiple family members can expose that the dad did not actually father the child. In such cases, should the father be informed? In an interesting FRONTLINE interview, a doctor discusses a time that a husband-and-wife pair came in, both of them HIV-positive. Over the course of the visit, the doctor figured out that the husband must have known that he was HIV-positive for at least 10 years, but had hid it from his wife the whole time. The wife continued to have no idea. Privacy laws prevented the doctor from informing the wife that her husband had lied about his HIV status. Should the laws be changed?

 _____

As for the bladder cancer patient and the wife of the husband with AIDS, I believe that medical ethics dictates that the doctor should withhold the information.

An interesting concept in medical ethics is that the although the patient needs to be well-informed, some things should not be shared. Sometimes, full disclosure harms. This can be tough on doctors, as well, because they possess their patient's secrets, secrets that even the patient doesn't know. It is another counter-intuitive aspect of medicine, and another reason why this field truly is an art.

Cartoon

"What if practicing medicine were more like our med school exams?"

Busywork

One of physicians' main complaints is the overwhelming amount of paperwork, bureaucracy, and red tape that they encounter. The causes are manifold, and include the reluctance of insurers to pay for medical expenses, the omnipresent threat of malpractice litigation, and the growing trend of physicians' working for large, bureaucratic health-care conglomerates.

The closer I come to being a physician, the more I become mired in useless paperwork that wastes my time and saps my soul. To spend a couple of hours observing a physician, I had to fax in 37 pages'(!) worth of forms. These forms included several quizzes which asked me questions like what phone number to call in the case of a chemical spill. Beyond attesting that I was current on my vaccinations, I had to list the date of each vaccination I've received. The forms were repetitive. Several times I had to input the same information, like my emergency contact and my relationship to them, what year I will graduate medical school, and my medical school's address and phone number.

It is only getting worse. I was informed that I needed to provide proof of certification in CPR, forcing me to scramble to enroll in a 4.5-hour-long Saturday morning class. The class was taught by a college freshman. Is that who we want instructing our medical students about how to practice medicine?

On top of that, we are required to complete several online modules introducing us to electronic medical records. The modules have hours of mind-numbing videos, and we are awarded credit only when the videos play through in their entirety. I had already learned the content of some of the videos, and so, like my classmates, I simply played them in the background on mute and then answered the questions at the end.

I think part of the problem is that it costs my institution almost nothing to mandate paperwork and computer modules. Now that forms and courses are electronic and online, our school doesn't have to hire an instructor, doesn't have to reserve a classroom, doesn't even have to pay for copy paper and toner. There also is no accountability and no mechanism for feedback. I don't even know who mandated that I fill out the online modules, who to complain to about how bad they are, whether whoever assigned the videos ever watched them himself. I was informed of my assignment because an automated assignment notice was sent to my e-mail account. There's no point in fighting it. Not that I would have the time to fight even if I could.

I can't allow myself to get upset over having to jump through these ridiculous hoops. But it feels like I lose a part of myself when I submit uncomplainingly to this unnatural and impersonal labyrinth of paperwork and bureaucracy. I am starting to see why so many physicians burn out.