Adding to the problem

There exists in society this cliché that doctor's have terrible hand writing. In fact, I have had more than one person in my past tell me that I was fated to be a doctor because of my terrible hand writing (backwards logic I know, but apparently they were right). In my limited experiences in the health care environment, this cliché has been borne out in full. At first I couldn't understand why this was; upon further thought, however, it makes a lot of sense.

After watching a few doctors go about their daily practice, I have noticed two key things that should have been obvious: one, they don't have a lot of time; two, they fill out an inordinate amount of paper work. I think putting these two factors together is what generates pages and pages of illegible scrawl. This mode of speed-writing quiclky transfers from the clinic to the rest of the clinician’s life, and presto, we have another member of the club.

To counter this problem, many of the more streamlined environments have moved towards computerized systems that only require the physician to sign printed documents that contain all of the clinical notes etc. In my mind, this only solves half of the problem. It saves other healthcare people from having to read hurried pen scratching, but does nothing to fix the actual problem. What about all of those poor government worker's out there who have to read doctor's passport applications, drivers license renewals, and other Jurassic documents that still need to be filled in by hand? Are we simply going to make them suffer?

And now another addition to the problem: e-curriculum. It has to be said that until my genetics tutorial today (from which I am writing this post...) I had written next to nothing by hand. A few minutes ago I started to write out an answer that the tutor gave to a problem, and I was shocked at how bad my writing was- and this is my writing, which is bad on a good day.

Needless to say, I don't think doctors (especially those of us doing e-curriculum) will be shedding this stereotype anytime soon.

For the money?

In a Life section article today, The Star has a story (sorry, this link will only last a few days) about a twenty-something year old person who was on the "well-beaten path to a doctor's salary when a colourful side trail [in filmmaking] beckoned". It goes on to say that "many so-called "enjoyable" careers, such as filmmaking, are rife with countless tales of failure, and don't often bring in big money", but "taking a job mainly for the dough can leave a person unhappy".

I should first thank the author for such insight. Who could have possibly known that going into a career solely for money would probably be a bad idea? I am fortunate to have come across this article, as I am- the article implies- one of those dark souls that need enlightenment on career choices.

I think that most of us chose medicine for other reasons. I personally opted for medicine over other careers that I was considering because of its deep humanity and its scope of possibilities. For me, these values come from many nights talking to my dad about his experiences in the completely unrelated field of management accounting; in these conversations I learned about the enjoyment that comes from helping a wide range of people out of distressful situations, and the necessity of variety in maintaining an interesting work environment. These are what I value personally, and I am sure my classmates and colleagues have many other, completely different, reasons for choosing medicine.

I think attitudes similar to those found in this article are far too prevalent in the media; it is unfair to assume people choose lucrative careers simply because they are lucrative.

Ah, push it - push it real good

Today, we had a medical equipment sale at the University. One of the big suppliers was allowed to set-up-shop in the school atrium, and then proceeded to get the business of nearly the entire class. The prices seemed pretty good, so I don't have much of an issue with them bringing the sale to us directly. What was disturbing to me was the way that they were pushing a certain type of more expensive stethoscope, saying to those who wanted to buy the cheaper one that it really was "an entry level scope that is standard issue for nurses, not doctors". Using marketing ploys that play on some medical students' urge to have a higher status than nurses is pretty slimy, and made me feel a little sick about giving these people my money.

Put in my place

I don't think that I was very pompous about the fact that I got into medical school, as I fully understand that- as of yet- I have nothing to really be proud of. In fact, all I have really done for the last 23 years is suck the government tit, going to school as I wished, having extended programming provided to me so that I wasn't bored, and having affordable tuition at university so that I could examine my interests in this and that until I was really certain that medicine was the calling for me; all the while, other people in society worked their asses off to make the world around me keep on going. However, I will say that I HAVE been a bit pompous in my thinking that I am intelligent enough to be a doctor, and that I really don't think it's going to be all that hard to become a good doctor. This all changed yesterday.

I started my first afternoon of electives yesterday, for which I have chosen to tag along with an academic medical oncologist who specializes in lung cancer. The job description pretty much reads:

(1) treat who you need to with known therapies in order to cure the disease or improve life
(2) try out new therapies on those who don't respond to the tried and tested methods
(3) tell those who are not responding to either treatment that they will soon die
(4) console families of dying or deceased patients
(5) make sure you publish some academic papers (or forget about promotion)
(6) teach pesky medical students about your job and convince them that 1-5 isn't so bad

The doctor that I was following was on "paternity leave" because he has a 6-week-old baby and his wife is also a doctor, so they have to share the time away from work; in this sense of the term, paternity leave means that he has to fit all of his old patients from 3 days-a-week into one day. Add to this the fact that his house just burned down, and that he is presently sleeping on an air-mattress on the floor of his in-laws, and you would expect him to be a worn-out mess. Instead, he was as warm and humorous as anyone I have ever met.

At the end of the afternoon, I was asked "so are you now wondering about why you want to be a doctor?", and I answered, "No, actually I am wondering about HOW I am going to be a doctor".

Trying hard to make the switch

So I'm finally getting down to some serious studying (yes, yes, I know that it is already the end of week two), and I've run into a bit of a wall: e-curriculum. The medicine program here is all organized around the fact that we have paid the university an exorbitant amount of money for our laptops, and they feel obliged to make sure we use them.

As bitter as that last sentence may read, I am actually a proponent of the program; however, as a student who has relied on the same, paper-based studying methods for over 7 years now, I am having a hard time changing my habits. As I see it, there are two major transformations required to use this system effectively, and I am having trouble with both of them (one more than the other).

Firstly, the e-curriculum allows us to go to class armed with our own personal copies of the PowerPoint lecture on our laptops, and type our notes in the file directly. I say 'allow' because the faculty has been farsighted enough to still provide us all with paper copies of all of the slides (a 5 kg binder of paper per 6 week block, in case anyone is wondering), for those who feel that they still want to write class notes out by hand. I jumped right into the electronic notes, as I saw some immediate benefits, despite my terrible typing skills.

Foremost for me is the fact that years down the road I can go back and see the annotated lectures without having to pull a dusty, fragmented binder out of a storage bin in my basement closet (given that the software is all still compatible- but I'm not even going to open that box). I feel that if used effectively, this will give more value to my undergraduate medical education, as the information will not be lost after I have learned it once- unlike my undergrad biochemistry education.

The second benefit is unlimited space for notes; when annotating a printed page of PowerPoint lectures in the past, I always ended up running out of room to add more notes. Despite arrows linking all of my scribbles on the page to points in the slide, I inevitably had to leave some things out because I couldn't legibly add any more points. With the laptop, the notes section can be as long as one pleases, so I can type every word that comes out of the professor’s mouth that is not on the slide. Now I just have to work on being able to type that fast.

There is one major problem that I am having with this system though. In my paper-based past, I frequently annotated figures presented in slides with arrows, circles etc. to identify key features. Using PowerPoint, it is pretty hard to do this quickly enough to keep up with the pace of the lecture. One has to click on the 'add arrow' or 'add ellipse' buttons, use the touch pad to place it in the right spot, and then switch back to typing the corresponding notes. A bit annoying, yes, but a problem that I think can be fixed by better software, quicker typing, and the use of hot-keys. For me, these are not reasons to stop trying (or to not start in the first place).

The second requirement of the e-curriculum is studying from typed notes. Like most students used to memorizing (a.k.a. "learning") a lot of material, I find it most effective to write out my notes over and over, making them more concise each time. Optimally, in a paper-free curriculum, students could learn to type the notes out instead, or simply read and re-read the notes from the screen. Unfortunately, this is a step that I haven't been able to make yet. I still have been re-writing everything that I study, copying the material from the screen into a notebook used for studying only. I do see this as a failure to use the system to its full ability, as concise study notes would make a useful reference later on, and I think it would be best if they were also stored electronically. I hope to be able to do this by the end of the year, but it will take practice.

Having first hand experience with trying to adapt to electronic learning, I can see why the 'techies' are having such a hard time convincing older doctors to make use of the benefit of computers. I think it is well worth the effort though, as some of the available new technology has the potential to revolutionize care if used by willing, trained professionals; teleconferencing with patients in rural areas to do follow-ups and using instant-messaging based programs to discuss interesting cases with colleagues on the other side of the globe are just two examples that come to mind immediately.

PDAs are already becoming the standard way that residents and new doctors manage their patient's files, make medical calculations, and reference medical literature, which I think demonstrates that a push to get those of us now entering the profession comfortable with computers is definitely not a bad thing.

Yes, it is a stange name for a site

When I started this site last weekend, I was aware that my choice of name might be a bit off-putting for some ("quick, quick, the boss is coming, close the window that has the words finger and rectum in the same sentence..."). However, besides being humorous, I think it is representative of a number of the key themes that will arise in my postings.

Firstly, the original source of the quote is Sir William Osler:

"Failure to examine the throat is a glaring sin of omission, especially in children. One finger in the throat and one in the rectum makes a good diagnostician."

As I mentioned in my first post, Osler is one of the original inspirations for starting this journal. I thought it appropriate to draw on him for the title, as his tradition of writing on life and medicine is one I intend to follow.

Secondly, the quote describes the activities required 125 years ago for a physician to make a complete examination. In my mind, a complete examination in today's world includes -more than ever- an analysis of healthcare policy and medical education. These are the throat and the rectum that I am going to stick my fingers into quite often in this journal.

Lastly, I think the quote conveys the idea that the study and practice of medicine may not always be glamorous. I have little idea what to expect over the next 8-10 years, so my posts will often describe those things about the profession that catch me off-guard. I can't predict right now if these posts will more often describe the gory aspects of medicine - involving rectums and other organs- or what life is like on-call, in debt, and living like a student until I am 30 years old.

Colonel Mustard, with the wrench, in the kitchen

I've listened to the clues. I've seen a few cards. I'm ready to make my guess about who is going to kill the healthcare summit and how.

Colonel Mustard

To me, this is the character that best epitomizes the current mindset of my prime suspects: the premiers. In a militaristic fashion, using their power in numbers, with ulterior motives, the premiers are marching to war under the banner of healthcare. Just like so many wars (hmmm, can I think of any recent examples???) the real deal is money. The premiers want more dollars from Ottawa in general, and healthcare is a convenient way of getting public approval to demand it.

Comments by Paul Martin and Ralph Klien make it pretty clear that the parties are at the table for much different reasons.

Paul Martin:

"At the end of this we have got to walk out of here with a long-term plan so that we don't come back and argue about a bunch of numbers"

"If money alone could improve our health-care system, it surely would have succeeded by now"

Ralph Klien:

"Health-care renewal is not something we are here to start"

"Ottawa's commitment to partnership (with the provinces) can best be demonstrated by addressing the long-standing health funding inequity"

The Wrench

The murder weapon as I see it will be the numbers game played by the premiers. Clearly, by approaching the summit with an agenda that does not match its original vision, the premiers are setting the entire meeting up for failure. Furthermore, since the 'entire' meeting is televised, the boring back-and-forth financial speak is certain to make anybody in Canada who actually wanted to hear about the issues and take an informed view tune out immediately. No better way to throw a wrench in Ottawa's plans for a lively public debate on healthcare.

The Kitchen

The Globe and Mail today recalled how the 1981 televised debate about Canada's constitution ended up having its main compromises reached in a fifth-floor kitchen of an Ottawa conference centre. For me, it is becoming more and more obvious that any of the real deals that will be made at this summit will occur behind closed doors. As I see one of the main points of this summit being the public presentation of the issues surrounding healthcare reform, this type of dealing will murder the summit.

Dead. Lifeless. Useless.

As Osler would have

As yet another twenty-something liberal academic starting a BLOG, I feel I should explain what I hope this will add to the web-publishing community.

From what I have seen, there are a multitude of fantastic personal journals being published by people from all types of academic backgrounds- history, journalism, politics, English, biology, math etc. - and this is creating a stimulating environment of cross-specialty idea exchange. However, I feel that there are a few groups that are underrepresented in this exchange, and that we could all learn more if they would join in. As a newly admitted member of one of these groups, I would simply like to join in.

Professionals- and medical professionals in particular- are notorious for "not having the time" to do anything but their profession. I am only in the first year of medical school and I may be naive to the demands of the years to come, but I still think that it is no excuse to be silent.

One of the most celebrated physicians of all time is Sir William Osler. His historical influence on the practice, teaching, and organization of medicine in Canada, Britain, and the United States is a result of his extensive writing. Although I cannot claim to equal his eloquence, and I cannot expect to equal his influence, I can attempt to follow in his footsteps through participating in the social dialogue.