Archive for the ‘Medical career’ Category

For Episode 2, go to Cartoon Network

Sunday 10:30 PM on Cartoon Network Adult Swim


by Mike Hale

BY Rob Corddry’s own count, he did a hundred interviews when his Web series “Childrens Hospital” appeared in 2008 in which he said that it was “in no way a television idea,” and that a television version “will never happen.”

So, of course, it happened. “Childrens Hospital” begins its new life as a television series Sunday night, part of Cartoon Network’s Adult Swim programming, making Mr. Corddry either a liar or a very bad prognosticator. As he did postproduction work recently at a North Hollywood editing studio, he chose to plead ignorance when asked why his show, among hundreds of online series, should be one of the few to make the jump to the slightly bigger screen.

“We have a very good relationship with the people over at Warner Brothers,” he said, referring to the company that owns, where his show first lived, and is a corporate sibling of Adult Swim. “Beyond that I have no idea.”

He’s more definitive about the inspiration for “Childrens Hospital,” which was born out of the enforced idleness caused by the 2007-8 Writers Guild strike. (The strike was the seedbed for other high-profile Web projects like “Dr. Horrible’s Sing-Along Blog,” with Neil Patrick Harris, and the Lisa Kudrow show “Web Therapy,” which will be seen on Showtime later this year.)

“The idea was born of child abuse, essentially,” Mr. Corddry said. At a hospital with his daughter, who had injured her arm, he was taken by the comic possibilities of the terrifying scene: “scared parents, crying mothers, tiny bodies on tiny gurneys.”

A result was an unsparing parody and, in its twisted way, a celebration of mainstream hospital shows, packed into 10 episodes of about five minutes each. The primary target was “Grey’s Anatomy,” with nods to “ER” and “Scrubs” and a subtext of deep affection for “M*A*S*H.”

Doctors committed darkly humorous varieties of malpractice when they weren’t breaking up or making out, sometimes with their young patients. Mr. Corddry wore slasher-movie clown makeup as Dr. Blake Downs, who refused to operate, believing instead in the healing power of laughter.

Getting the online show made wasn’t necessarily a huge challenge. “Studios were green-lighting tons of Web shows and treating it as near-free development,” Mr. Corddry said. But what made “Childrens Hospital” stand out from the start was its cast, an unusually accomplished group in the anonymous and poorly paid world of Web series.

In addition to Mr. Corddry, with his “Daily Show” and film credentials, it included Megan Mullally (“Will and Grace”), Lake Bell (“Boston Legal”), Erinn Hayes (“Parenthood”), Ken Marino (“Reaper,” “Party Down”), Nick Offerman (“Parks and Recreation”), Ed Helms (“The Office”) and Jason Sudeikis (“Saturday Night Live,” “30 Rock”).

“I don’t know what to say,” Mr. Corddry said. “We got everybody we wanted. We went up to our friends and, uh …. ”

Jonathan Stern, an executive producer and writer on the show along with Mr. Corddry, leaped in. “It was faith in Rob and his abilities and what he’d bring to it,” he said. “And knowing that they’d have a good time on it with their friends, and knowing, what’s the worst that will happen? We’ll have two days of doing so-so material.”

After the Web series was posted, both Adult Swim and Comedy Central approached Warner Brothers with the idea of adapting it for television; Adult Swim won what Mr. Corddry called “a very low-stakes bidding war.” He, Mr. Stern and their fellow executive producer David Wain managed to keep most of the cast together for the television show (Ms. Bell, committed to the HBO series “How to Make It in America,” will appear in only four episodes) while adding new regulars like Malin Akerman, Henry Winkler and Kurtwood Smith.

The quality and familiarity of the ensemble is a large part of the answer to the earlier question Mr. Corddry left hanging, regarding why “Childrens Hospital” has been able to follow the path to television blazed by Web series like “quarterlife” and “Sanctuary.”

“Megan Mullally, herself, green-lights a show,” he acknowledged. “I think that’s our main strength.”

Ms. Mullally plays the Chief, an oversexed chief surgeon who flails about on crutches and is an obvious take-off on Dr. Kerry Weaver, the character Laura Innes played for 15 seasons on “E.R.” She said she called Ms. Innes, a fellow Northwestern alumna, before shooting the Web series: “I was like, mmm, just in case. Just in case. But she thought it was great.”

The actors and writers have more room to breathe now that “Childrens Hospital” is a television series, but not much. The episodes for Adult Swim are 15 minutes long (11 ½ minutes after commercials); they will be shown in a half-hour slot at 10:30 p.m. with another 15-minute show, “Delocated.” The original Web episodes have been combined, two at a time, into television episodes that will be shown beginning Sunday. The new episodes will begin on Aug. 22.

The difference between making 5-minute and 11.5-minute shows was substantial. “Essentially the Web series was a series of sketches,” Mr. Corddry said. “The TV series, there has to be some semblance of a story. Unfortunately, because I have no idea how to write that.”

Mr. Winkler and Mr. Smith help carry the expanded story lines, as a wacky administrator and a villain intent on suppressing a cure for cancer. Mr. Stern cautioned against putting too much stock in the plot, however.

“Eleven and a half minutes made us create the veneer of actual story lines and character growth without requiring that we be committed to that,” he said. “We hit all the beats as if the characters were developing and important things were happening and as if there were a beginning, middle and end to the story, but we don’t really have to get too emotionally invested in any of that.”

One change you might expect would be some toning down of the show’s humor, an alternately surreal and raunchy mélange of situations and jokes involving sex, body parts, sex, children, Sept. 11, Puerto Rican midgets and sex. But Mr. Corddry said that editing the original Web episodes for television had just meant bleeping “about a handful of words.”

“It’s sort of the same tone,” he added, speaking of the new episodes. “We get away with a lot on Adult Swim.”

That freedom is part of the attraction for the actors, who find time for “Childrens Hospital” between or during their better-paying gigs. “This show is like any other show we do except the words on the page were much wackier,” said Mr. Marino, who plays the yarmulke-wearing Dr. Glenn Richie and who has also directed an episode.

He was one of several cast members who had gathered at the studio to do audio looping, talk with me and trade jokes. Rob Huebel, who plays the spectacularly clueless Dr. Owen Maestro, had his own reason for sticking with the show: “It’s opened up a lot of doors for me sexually. I can literally have sex with anyone in this room. Anyone. If I wanted to.”

Mr. Corddry’s hopes were more prosaic, if equally unrealistic in the arena of Web series and 15-minute television shows. “I have no ambitions besides keep doing more seasons, as many as they give us,” he said. “And then eventually we’ll just sit back and make money. Right?”

from the New York Times
Published: January 14, 2010

Not long ago, a friend confessed that her son, who spends much of his free time volunteering at a children’s hospital and who is applying to medical school, has been particularly anxious about his future. “His test scores are just O.K.,” my friend said, the despair in her voice nearly palpable. “I know he’d be a great doctor, but who he is doesn’t seem to matter to medical schools as much as how he does on tests.”

Her comment brought me back to the many anxious conversations I had had with friends when we were applying to medical school. Over and over again, we asked ourselves: Do we really need to be good at multiple-choice exams in order to be a good doctor?

We were referring of course to not just any exam, but to the Big One — the Medical College Admission Test, or MCAT, the standardized cognitive assessment exam that measures mastery of the premedical curriculum. Back then, as now, American medical school admissions committees required every applicant to sit for the MCAT.

While medical schools have since taken pains to assure applicants that recommendation letters and essays also weigh heavily, many candidates continue to believe, erroneously or not, that the MCAT can make or break one’s chances. Competition to get into medical school remains fierce, with over 42,000 highly qualified individuals vying for just a few more than 18,000 slots at medical schools across the country.

With those kinds of statistics and no reliable standardized way to evaluate personality, it is inevitable that the MCAT will have a crucial role in medical school admissions. But does that guarantee that the applicants admitted are also destined to become the best doctors?

Maybe not.

According to a recent study in The Journal of Applied Psychology, there is another kind of exam that may be more predictive of how successful students will be in medicine: personality testing.

For nearly a decade, three industrial and organizational psychologists from the United States and Europe followed more than 600 medical students in Belgium, where premedical and medical school curriculums are combined into a single seven-year program. As in the United States, the early portion of their education is focused on acquiring basic science knowledge through lectures and classroom work; the latter part is devoted to mastering clinical knowledge and spending time with patients.

At the start of the study, the researchers administered a standardized personality test and assessed each student for five different dimensions of personality — extraversion, neuroticism, openness, agreeableness and conscientiousness. They then followed the students through their schooling, taking note of the students’ grades, performance and attrition rates.

The investigators found that the results of the personality test had a striking correlation with the students’ performance. Neuroticism, or an individual’s likelihood of becoming emotionally upset, was a constant predictor of a student’s poor academic performance and even attrition. Being conscientious, on the other hand, was a particularly important predictor of success throughout medical school. And the importance of openness and agreeableness increased over time, though neither did as significantly as extraversion. Extraverts invariably struggled early on but ended up excelling as their training entailed less time in the classroom and more time with patients.

“The noncognitive, personality domain is an untapped area for medical school admissions,” said Deniz S. Ones, a professor of psychology at the University of Minnesota and one of the authors of the study. “We typically address it in a more haphazard way than we do cognitive ability, relying on recommendations, essays and either structured or unstructured interviews. We need to close the loop on all of this.”

Some schools have tried to use a quantitative rating system to evaluate applicant essays and letters of recommendation, but the results remain inconsistent. “Even with these attempts to make the process more sophisticated, there is no standardization,” Dr. Ones said. “Some references might emphasize conscientiousness, and some interviewers might focus on extraversion. That nonstandardization has costs in terms of making wrong decisions based on personality characteristics.”

By using standardized assessments of personality, a medical school admissions committee can get a better sense of how a candidate stands relative to others. “If I know someone is not just stress-prone, but stress-prone at the 95th percentile rather than the 65th,” Dr. Ones said, “I would have to ask myself if that person could handle the stress of medicine.”

While standardized tests like the MCAT and the SAT have been criticized for putting certain population groups at a disadvantage, the particular personality test used in this study has been shown to work consistently across different cultures and backgrounds. “This test shows virtually none or very tiny differences between different ethnic or minority groups,” Dr. Ones noted. Because of this reliability, the test is a potentially invaluable adjunct to more traditional knowledge-based testing. “It could work as an additional predictive tool in the system,” she said.

One perennial question that personality testing could help to answer is whether hard work can make up for differences in cognitive ability. “Some of our data says yes,” Dr. Ones said. “If someone is at the 15th percentile of the cognitive test but at the 95th percentile of conscientiousness, chances are that the student is going to make it.” That student may even eventually outperform peers who have higher cognitive test scores but who are less conscientious or more neurotic and stress-prone.

But these standardized tests, personality or cognitive, can be useful only after medical schools, and the public they serve, decide what characteristics are most important for the next generation of doctors. “If a medical school is all about graduating great researchers, then I would tell them not to weigh the results of the personality test that heavily,” Dr. Ones said. “But if you want doctors who are practitioners, valued members in terms of serving greater public, then you have to pay close attention to these results.”

She added: “When you ask your friends, they will describe you in terms of your personality. Rarely will you get a description of your cognitive ability. Personality is what makes us who we are.”

Sleepy resident

Report Recommends Increasing Rest Among Residents

from The Boston

POSTED: 3:46 pm EST December 2, 2008

BOSTON — Doctors-in-training are still too exhausted, says a new report by the Institute of Medicine. Five years ago, the IOM capped how long residents can work, 80 hours per week.

But as NewsCenter 5’s Ed Harding reported Tuesday, the IOM is calling for hospitals to allow doctors to get more rest.

For young doctors fresh out of medical school, on-the-job training can be grueling.

“Everyone realizes that resident fatigue is something that we have to deal with,” said Dr. Matthew Eisenberg, a senior resident of pediatrics at Children’s Hospital Boston. “Thirty hours is the longest shift I’ve ever worked,” he said.

Five years ago, the Institute of Medicine capped how long residents could work, up to 80 hours per week.

“About 75 percent of residents before the 80 hour rule were burnt out. They were not feeling good about their job. About 25 percent were depressed,” said Dr. Ted Sectish, the program director for the Boston Combined Residency Program in Pediatrics.

Sectish admits that sleep deprivation can also lead to medical mistakes, putting patients at risk.

A new report by the IOM found young doctors are still too tired, despite the 80 hour a week limit issued by the IOM. It has recommended easing the workload a bit more, so doctors can get more rest.

“In those 30 hour shifts they recommend they only care for new patients for the first 16 hours, and they recommended there be a five-hour period of sleep,” Sectish explained about the IOMs recommendations.

The report also calls for:

– Experienced physicians to more closely supervise residents

– A better overlap of schedules during shifts to reduce errors

– An increase in the number of mandatory days off each month, and extend hours off between shifts depending on how long the resident working, during day or night.

“So they’ve asked that the string of nights be no more than five nights. And that when you go from four night shifts to day shifts, you should have 24 hours to catch up on some sleep,” Sectish said.

The accreditation council did not immediately say if it would follow the recommendations. However, Sectish said the recommendations are taken very seriously by hospitals.

IOM Report: Resident Duty Hours
Sleepy Heads
Neurosurgeons Raise Concerns About IOM Resident Work Report

from Medscape

WASHINGTON (Reuters) Nov 18 – Primary care doctors in the United States feel overworked, and nearly half plan to either cut back on how many patients they see or quit medicine entirely, according to a survey released on Tuesday.

More than half — 60% — of 12,000 general practice physicians would not recommend medicine as a career.

“The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome,” the Physicians’ Foundation, which conducted the survey, quoted one of the doctors as saying.

The survey adds to building evidence that not enough internal medicine or family practice doctors are trained or practicing in the United States, although there are plenty of specialist physicians.

Health care reform is near the top of the list of priorities for both Congress and president-elect Barack Obama, and doctor’s groups are lobbying for action to reduce their workload and hold the line on payments for treating Medicare, Medicaid and other patients with federal or state health insurance.

The Physicians’ Foundation, founded in 2003 as part of a settlement in an anti-racketeering lawsuit among physicians, medical societies, and insurer Aetna, Inc., mailed surveys to 270,000 primary care doctors and 50,000 practicing specialists.

The 12,000 answers are considered representative of doctors as a whole, the group said, with a margin of error of about 1%. It found that 78% of those who answered believe there is a shortage of primary care doctors.

More than 90% said the time they devote to nonclinical paperwork has increased in the last 3 years and 63% said this has caused them to spend less time with each patient.

Eleven percent said they plan to retire soon and 13% said they plan to seek a job that removes them from active patient care. Twenty percent said they will cut back on the number of patients they see and 10% plan to move to part-time work.

Seventy-six percent of physicians said they are working at “full capacity” or “overextended and overworked.”

Many of the health plans proposed by members of Congress, insurers and employers’ groups, as well as Obama’s, suggest that electronic medical records would go a long way to saving time and reducing costs.

The character of a doctor

Commencement address by Atul Gawande, M.D.
Yale Medical School
May 24, 2004

It is an honor to have been asked to come before you on this momentous day. Today marks your graduation not just into a new profession but, more than in almost any other profession, into a new identity. You are a doctor. No matter what you do from here on out—whether you see patients, work in a laboratory or leave science and patients altogether—it will now be a central part of who you are, and over time perhaps the most important part of who you are.

It will be how you’re introduced, for example, no matter how much you might try to avoid it. At a baseball game, a hair salon, fifty years from now at, God forbid, an impotency clinic—they will say, “This is Dan Prince. He’s a doctor, you know.” There is no escape, my friends.

The fact that you are a doctor now will define you not just to patients, but to your friends (who will turn to you in their most desperate moments), to your grocery store clerk (who will figure you are rich), to teenagers (who will know you’ve seen a lot of naked people and ask all kinds of rude questions). Most of all it will define you to our larger society as someone of a potentially distinct and valued character. It’s important to think about what that character is on this day. Not all doctors have it, by any means, and no one has it all the time. But all doctors can have it. And what it is, I think, is a particular kind of strength.

I tend to think in stories. So let me tell you one. When I was a fourth-year medical student, I had a patient who still sticks in my mind. I was on an internal medicine rotation, and I was nearly finished with medical school—in fact, it was right around this time of year. The senior resident had assigned me three or four patients to take primary responsibility for. One was a crinkly, Portuguese-speaking woman in her 70s who, as near as I could tell, had been admitted because—I’ll use the technical term here—she didn’t feel too good. Her body ached. She felt run down. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some labs revealed her white count was up. A chest X-ray showed a possible pneumonia—maybe it was, maybe it wasn’t. So her internist admitted her to the hospital and now she was under my care. I took a sputum culture and, following the attending’s instructions, started her on some antibiotics for this possible pneumonia. I went to see her twice each day for rounds. I checked her vital signs, listened to her lungs, looked up her labs. To me, she stayed more or less the same. Her heart rate went up. Her heart rate went down. Sometimes she was warm. Sometimes she was cold. We’d give her antibiotics and wait her out, I figured. She’d be fine.

One seven a.m. morning on rounds, her heart rate was a little up and her skin was a little warm. She had a low-grade fever. Keep an eye on her, the senior resident told me. Of course, I said, though to me she seemed just as she had been. I made a silent plan to see her in the early afternoon before our usual rounds. But the senior resident went back to check on her twice himself that morning.

It is this little act that I have often thought about since then. It was a small thing, a tiny act of conscientiousness. He had taken the measure of me on morning rounds. And what he saw was a fourth-year med student, with a residency spot already lined up in general surgery, on his last rotation. Did he trust me? No, he did not. So he checked on her himself.

That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, everything we had to do that day were on the bottom two floors. The elevators are notoriously slow. He was supposed to run one of the morning teaching conferences. He could have told a junior resident to go up and see her. But he didn’t. He made himself go up.

The first time he went up, he found she had a high-grade fever. The second time, he transferred her to the intensive care unit. To my great embarrassment and her great fortune, by the time I had a clue about what was going on, he already had her under treatment for what had developed into septic shock from a resistant, fulminant pneumonia.

What makes you do the right thing? The distinctiveness of medicine is that you are called upon to ask yourself this question almost everyday. And I can tell you—if I may be blunt—that the answer is not joy. Oh sometimes it really is fun. But the truth of medical life is that doing the right thing is often painful—and yet you find a way to do it anyway.

There can be more than one kind of pain involved. There is, for example, what I call the Back Pain. You have one last lab result to check before you go home. But the computer is down. You call the lab. No one’s picking up. So you walk down to the lab and ask someone for the result in person. But no one at the lab can find the sample. You try to ask a phlebotomist to draw another sample. But the phlebotomists have already gone home. So you have to go find the patient and draw the lab yourself. And now they don’t want to be stuck again. That is the Back Pain.

Then there is the pain of humiliation—because there is always something important that you do not know or are not very good at yet. There is the pain of uncertainty—because nothing is ever sure about people and what goes on inside them and what happens with what we do to them. And finally, there is the pain of failure—because all of us will fail.

Yet a doctor—the doctor others count on and see in you—finds a way to make him- or herself do the right thing. Why? Because you said you would. Because it’s what you chose to do.

* * *

We have certain theories about why people become who they become in life. The most common theory—especially about doctors and artists—is that you are born to what you do. And I know for sure that this isn’t true. Because of all things I could have become a writer was not going to be one of them.

The truth is that before seven years ago, I never really knew how to write and I did not much care. I grew up in a small Ohio town in a family of immigrant doctors. My sister and I were not raised with books around us. The magazines on our living room coffee table were my parents’ medical journals. My high school English classes only required us to read one book cover to cover each quarter. And that was fine with me.

I got a C on my first paper in freshman writing at Stanford. (And if any of you know Stanford, you know how hard it is to get a C there.)

In college I did take a fiction writing class once, but it was mainly because there was a girl taking it I had a rather keen interest in—we married a few years later—and the professor half way through took me aside and suggested I find something to do other than writing.

I can tell lots of stories like these, unfortunately. After college I used to write rock songs with the most abominable lyrics—“Oh the pain, oh the misery,” that gloomy, Morrisey, ’80s sort of thing.

I liked imagining myself as some kind of writer or artist. But I never took the time to actually write—to think carefully and rigorously and unsentimentally about words. What I liked imagining, really, was just being important. But you know where that gets you: nowhere.

Where I eventually ended up after college was medical school. If I was going to be born to do anything, medicine was it. I grew up in a medical family. My father is a urologist, my mother a pediatrician. I don’t like the idea that I became a doctor just because my parents are doctors, and I never did. I like to think of myself as an autonomous being, the master of my own fate. One of my favorite books in the world is Tobias Wolff’s memoir This Boy’s Life. It is the tale of his childhood growing up in Concrete, Washington, with a loving but poor and abandoned mother, a malevolent new stepfather, and a decision he made when he was 12 years old—he simply decided—that he was meant for a better life. During school he stole some letterhead, made up a transcript, several stunning letters of recommendation, and got into a private eastern boys school on scholarship. From there he went to Princeton. And with that he became almost exactly who he had wanted to be—a writer, for one thing, and a person with a certain place in the world.

I took a lesson from this: not that you have the power to simply make up who you are. But you can choose to put yourself in a new and specific world and that will change who you are. Ernest Hemingway was the son of a prominent surgeon and like almost every child of doctors he found it difficult to escape the belief that a doctor is what he had to become. But it was not what he wanted and against his father’s deepest wishes he removed himself to Paris and submerged himself in the expatriate community of artists and writers there and emerged a writer himself.

And yet no one entirely invents themselves. Indeed, a recurring theme of Hemingway’s Nick Adams stories—his first short stories—is the struggle of young Nick to establish his own identity and beliefs separate from his surgeon-father. And by Tobias Wolff’s second book, In Pharaoh’s Army, Wolff has clearly not entirely escaped Concrete, Washington, and his absent, alcoholic father has come out of the woodwork and inserted himself disastrously back into Wolff’s life.

Well, after college I too removed myself to Europe, to Oxford for two years to study politics and philosophy, and put a hold on medical school plans. I hoped to become transformed, to become a thinker, perhaps a professor of philosophy. But it took all my capacity just to understand the questions philosophers asked, let alone offer anything like original answers. I had no natural ability in this and, though I came back a bit better educated and better traveled, I was not fundamentally changed. I spent a further year working in Washington politics. But by 1990 I was a student in medical school and right back where everyone had always predicted I would be.

Later in medical school, however, I chose surgery because I thought that perhaps this would make me more like the kind of person I wanted to be. Certainly I loved technique and using my hands and the sheer blood and guts of it all. But what most attracted me was the predicament of surgery—the combination of high stakes and uncertainty—and the character of those who could deal with it well. Surgeons are faced every day with unknowns. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. The risks of unforeseen consequences and terrible mistakes always loom. And yet they are able to act. “Sometimes wrong, never in doubt,” people say about surgeons, and it is meant as a reproof. But this seemed to me their strength—the ability of the best surgeons (like the best politicians) to make wise decisions under conditions of deep uncertainty and accept responsibility for the consequences.

I have always had a tendency to indecision. I could imagine myself in that old New Yorker cartoon with the gravestone inscription that said: “He kept his options open.” So I put myself in the surgical world—where decisiveness is valued not despite the stakes being high but because they are.

This is, in fact, a central trait of good doctors in any part of medicine, I learned. They struggle against the pain of uncertainty, tedium, and error, knowing they will sometimes fail, but doing so because the stakes are high. I also found, much to my surprise, that trying to understand this struggle would lead me to become the writer I did not expect to be.

The life of a doctor is an intense life. We are witnesses and servants to individual human survival. The difficulty is that we are also only humans ourselves. We cannot live simply for patients. In the end, we must live our own lives. Still, to live as a doctor is to live so that your life is bound up in others’ and in science and in the messy uncertain connection between the two.

The legendary baseball coach Lou Pinella once remarked about a young player he thought was not good enough: “He will never amount to much. He never became comfortable with being uncomfortable.”

Graduates, we are the ones who must become comfortable with being uncomfortable—and it is so that others may be comforted.

Thank you.

“Better” by Atul Gawande

Excerpt from
Harvard Medical School 2005 commencement address
by Dr. Atul Gawande
I must point out, however, that my rules for medical practice should be distinguished from the laws of medical practice. Rules are personal instructions you might follow in your life as a doctor. Laws are the immutable realities you come up against in that life. For example, one law is: The labs are always normal, the lumps are never cancer, and the sixteen year-olds are never pregnant, unless you don’t check them. Or: If your new patient is on five or more drugs, you will not have heard of at least one of them.
Many other laws exist. There are, for example, thirty-five laws governing the behavior of pagers alone. But these are not what we want to talk about today. What we want to talk about is how one survives among the hundreds of thousands who make their life in this strange and teeming world—and, moreover, having survived, how one might make a worthy difference.
My Rule #1 for you comes from a favorite essay by the writer Paul Auster: Ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them?
On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see, two pages to return, and the hour is getting late. In the instant, all you will want is to get things over with. Where’s the pain, the lump, whatever it is? How long has it been there? Does anything make it better or worse? What are your past medical problems? You all know the drill by now.
But I want you, at an appropriate point, to take a small moment with your patient. Make yourself ask an unscripted question: “Where did you grow up?” Or “What made you move to Boston?” Or “Did you watch last night’s Red Sox game?” I’m not looking for a deep or important question, just one that lets you make a human connection.
Some people will not be interested in making that connection. They just want you to look at the lump. That’s okay. Look at the lump in that case. Do your job.
You will find that many respond, however—because they’re polite, or friendly, or perhaps in need of that human contact. When this happens, see if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn. This is not a 46 year old male with a right inguinal hernia. This is a 46 year old former mortician, who hated the funeral business, with a right inguinal hernia.
You can do this for more than just patients, too. Ask a random question of the ICU nurse you see on rounds, the medical assistant who checks their vitals. It’s not that doing
this necessarily helps anyone. But you will start to remember the people you see, instead of having them all blur together. Sometimes you will discover the unexpected.
I learned, for instance, that an elderly Pakistani phlebotomist I saw every day in residency had been a general surgeon in Karachi for twenty years, but emigrated for the sake of his children’s education. I learned that a quiet, carefully buttoned-down nurse I work with had once traveled with Jimi Hendrix on tour.
The machine will gradually feel less like a machine.
My Rule #2 is: Don’t whine. To be sure, doctors have plenty to complain about: computer system crashes, 2 a.m. pages, insurance companies, work getting dumped on you at 6 o’clock on a Friday night. We all know what it is to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors whine.
Anyone who has played high school sports knows the dynamic I’m talking about. Morale is an elusive and fragile entity. My southern Ohio hometown high school tennis team traveled up to 75 miles through Appalachia for matches against other teams. We were undefeated. But when the weather got hot, a few bad calls went against us, the matches grew close, and that long un-air-conditioned van-ride home began to loom, the griping would begin to well up. It was all Coach Roach could do (that really was his name) to keep us from giving into defeat. He’d yell and stomp—“What are you cry-babies belly-aching about?”, and since he was also the school psychologist, we’d finally remember what we were there for.
The practice of medicine can go the same way. It is a team sport with two differences: the stakes are people’s lives and we have no coach. This latter is the most relevant difference. Doctors are supposed to coach themselves. We have no one but ourselves to buck us up. But we’re not good at it. Wherever you find doctors—sitting with fellow residents in the hospital cafeteria, waiting in a conference hall for grand rounds to start—you will find the natural pull of conversational gravity is toward the litany of woes all around us.
Resist it. It’s boring, and it will get you down. I’m not saying you have to be all Julie-Andrews-Mary-Poppins about everything. Just be prepared with something else to talk about: An interesting patient you saw, an idea you read about, even the weather if that’s all you’ve got.
Then see if you can keep the conversation going.

Rule #3 is: Count something. No matter what you ultimately do in medicine—whether you go into purely clinical practice or work in research or business and never touch a patient again—a doctor should be a scientist in his or her world. In the simplest terms, this means that we should count something. The laboratory researcher may count the number of tumor cell lines with a particular gene defect. Likewise, the clinician might count the number of patients who develop a particular complication—or even just how many are seen on time and how many were made to wait. It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you.
When I was a resident I began counting how often one of our patients had something forgotten inside them after surgery—either a sponge or an instrument. It wasn’t very frequently: about one in 15,000 operations. But they could be badly injured. One patient had a 13 inch retractor left in him and it tore into his bowel and bladder. Another had a small sponge left in his brain, which caused an abscess and a permanent seizure disorder.
Then I counted how often such cases happened because the nurses hadn’t counted all the sponges like they were supposed to, or because the doctors ignored nurses’ warnings that something was missing. It turned out to be hardly ever.
I got a little more sophisticated and compared patients who had stuff left inside them with ones who didn’t. It turned out that the mishaps predominantly occurred in patients with emergency operations or operations in which something unexpected was encountered—like a cancer when one expected appendicitis. Things began to make sense. If nurses have to track fifty sponges and a couple hundred instruments during an operation, already a tricky thing to do, it is understandably much harder under emergency circumstances, or when unexpected changes require bringing in lots more equipment. Punishing people more therefore wasn’t going to eliminate the problem. Only a technological solution would—perhaps a way of scanning for sponges and instruments in everyone.
If you count something interesting to you, I tell you: you will find something interesting.
My Rule #4 is: Write something. It makes no difference whether you write a paper for a medical journal, five paragraphs for a website, or a collection of poetry. Try to put your name in print at least once a year. What you write does not need to achieve perfection. It only needs to add some small observation about our world.
One should not underestimate the effect of one’s contributions. The physician and poet Lewis Thomas once pointed out, “The invention of a mechanism for the systematic publication of fragments of scientific work may well have been the key event in the history of modern science.” For by soliciting modest contributions from the many, it has produced a store of collective know-how with far greater power than any one individual could have achieved. I think this is as true outside science as inside.
One should also not underestimate the power of the act of writing itself. I did not write until I became a doctor. But once I became a doctor, I found I needed to write. Medicine is retail. We provide our services to one person at a time, one after another. It is a grind. For all its complexity, it is more physically than intellectually taxing. But writing let me step back, engage as something more than a retailer, and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness.
Furthermore, by putting your writing out to an audience, even a small one, you connect yourself to something larger than yourself. The first thing I ever published was a diary in an online magazine of five days as a surgical resident. I remember that feeling of having it come out in print. One is proud but also nervous. Will people notice it? What will they think? Did I say something dumb? An audience is a community. The published word is a declaration of membership in that community, and also of concern to contribute something meaningful to it.
So choose your audience. Then write something.
Rule #5, my final rule for a good life in medicine, is: Change.
In medicine, as in any human endeavor, people respond to new ideas in one of three ways. A few become early adopters, as the business-types call them. Most become late adopters. And some remain persistent skeptics, who never stop resisting. A doctor has good reasons to adopt any of these stances. When Joseph Murray and Francis Moore performed the world’s first successful kidney transplant in the hospital behind us fifty years ago, but also had 30 deaths; when a French gynecologist first pointed his laparoscope in a new direction and used it to take out a gallbladder; when cholesterol-lowering drugs first came out; when the first electronic medical record was invented—who was to say whether these were truly good ideas or not? We have seen plenty of bad ones. Frontal lobotomies were once done for control of chronic pain. Vioxx turns out to cause heart attacks. Viagra, it was recently discovered, may cause partial vision loss.
Nonetheless, make yourself an early adopter. Look for the opportunity to change. I am not saying you should take on every new thing that comes along. But be willing to recognize the inadequacies in what we do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.
You become a doctor today, and the choices you will make with your patients will be imperfect but nonetheless alter their lives. There will come a time when, because of that reality, it seems safest to do what everyone else is doing—to be just another white-coated cog in the machine.
Don’t let yourself be. Find something new to try, something to change. Count how often it succeeds and how often it doesn’t. Write about it. Ask a patient or a colleague what they think about it. See if you can keep the conversation going.

To read the full text, go to:
Harvard Med School 2005 Commencement Address

“Better” by Atul Gawande

by Tara Weiss
No one ever said being a doctor was easy. School and training go on seemingly forever; once graduation arrives, doctors work long hours and are faced with life-and-death decisions daily.

But there were rewards. For decades, doctors earned hefty paychecks, had autonomy and respect. But those benefits are fading, and as a result, so is the number of doctors. Within the next 15 years, the United States will experience a shortage of between 90,000 to 200,000 physicians, according to the recently published Will the Last Physician in America Please Turn Off the Lights: A Look at America’s Looming Doctor Shortage.

The American Medical Association recognizes there are shortages in certain geographic areas and in certain specialties. Part of that is due to the aging population and a stagnant number of medical-school applicants.

But there are other significant reasons. They include the increasing costs of medical malpractice coverage, higher practice costs, lower insurance reimbursement rates and insurance-company restrictions resulting in less autonomy over how patients are cared for.
Read Full Article at

INTERN: A Doctor’s Initiation

Posted: February 8, 2008 by Doc in Medical career
Tags: ,


First Chapter

Published: January 11, 2008
New York Times

I had been an intern less than an hour, and already I was running late. The sloping footpath leading up to the hospital was paved with gray cobblestones. My feet ached as my oversize leather sandals slipped on the rounded irregular rocks. The hospital was an old building browned by the passage of two centuries, with spidery cracks in its façade. Founded in 1771, New York Hospital is the second-oldest hospital in the United States, a mecca for doctors and patients from all over the world. I had been in the building once before, six months ago, for a residency interview. I spun through a revolving brass door, nearly running into the burly security guard reading the New York Post. He looked up from the tabloid just long enough to point me in the direction of the elevator.
The tiled corridors were dark and dull, mixing shadow and light.

I darted past the chapel, past the café, around the information desk, which sat in the middle of the huge atrium like a fort, and entered a bank of elevators. Hanging on a wall was a portrait of a gray-haired lady in a blue dress sitting in dignified repose before an open book. She was a graduate of the medical school, class of 1899, ninety-nine years ago, who built a medical college for women in Northern India, on the banks of the Ganges, near where my father had his early college education. Nearby was a metal tablet in bas-relief: “She cared for all in need. For each, she made time to guide, to teach, and to heal.”

When I arrived on the fourth floor, other interns were still filing into the auditorium. A woman handed me a manila folder, and I went inside and sat down. The orientation packet contained several essential documents: a house-staff phone card, directions for obtaining autopsies, instructions on how to use the hospital dictation system, and the residency contract. I leafed through it quickly. My salary was going to be $37,000 a year, about eight dollars an hour, I calculated, given the number of hours I was going to be working, but I didn’t mind. Though I was a year shy of thirty, it was more than double what I had ever made.

My classmates, though younger than I, appeared older than I expected, casually dressed, all thirty-five of them, in khakis and polo shirts, faded jeans and sequined tops. Some of them evidently knew each other, because they were already chatting in small, insulated groups. They were from some of the best medical schools in the country: Harvard, Yale, Cornell, Columbia. Though I too had gone to a top school-Washington University in St. Louis-I had been feeling insecure about the prospect of working with them. For months I had feverishly been reading Harrison’s tome on internal medicine and review articles in The New England Journal of Medicine to prepare for this day.

Someone in the front row stood up and turned to face us. It was Shelby Wood, the hospital’s residency director. He was a serious-looking man of medium build, with straight brown hair and a long, aquiline nose. He was wearing a white coat and a fat blue tie that might have been in fashion twenty years earlier. My elder brother, Rajiv, a cardiology fellow at the hospital, six years ahead of me in his medical training (though only two and a half years older), had warned me that Dr. Wood was a bit of a grouch, but had added that he was also fair and decent and a strong advocate for his house staff. Wood, I was to learn, hailed from the old school, where you were expected to live and breathe medicine, stay late in the hospital, neglect your family for the sake of your patients, and emerge on the other side a seasoned physician.

He cleared his throat and began to speak. His voice was deep but incongruously soft, and because I was sitting in the back of the sixty-seat auditorium, I only managed to catch snippets of his remarks. It was going to be a busy year, he said, as thirty-five heads stared motionlessly back at him. We were expected to devote ourselves fully to medicine. “You don’t learn French by taking classes at Hunter College. You learn it by going to Paris, sitting in the cafés, talking to people.” Likewise medicine: we would learn it by living it. “You are now ambassadors for the profession,” he said gravely. “So don’t let the students hear you complain. It sets a bad example.” If everything went as planned, he added, by next June we’d be ready to supervise the next batch of interns.

I glanced over at the pretty brunette sitting next to me. She looked back at me, rolled her eyes, and opened her mouth in mock panic.

Continued at New York

‘Intern’ by Sandeep Jauhar

Young Doctors in Debt

Posted: January 2, 2008 by Doc in Medical career


By George Mannes, Money Magazine senior writer
in Money Magazine
November 16 2007

(Money Magazine) — It’s Wednesday evening and Megan Reis can’t remember when she last saw her husband Chris. Small wonder. Since Sunday morning, Meg has worked more than 60 hours at Advocate Hope Children’s Hospital, the Chicago-area facility where she is training in pediatrics.

Chris, meanwhile, has put in a 24-hour day followed by a 12-hour one at the nearby Loyola University Medical Center, where he’s learning anesthesiology. Meg guesses she hasn’t seen him since Saturday.

Actually, Chris recalls later, it was Tuesday morning: They saw each other for 10 minutes in the parking garage of their nondescript condominium building, crossing paths as Chris returned from a marathon workday and Meg headed off to one in her parents’ old Ford Escort. “She was actually late getting to work,” says Chris. “That’s the only reason I saw her.”

Such are the lives of medical residents: med school graduates getting years of on-the-job training, putting in brutal hours for salaries that, on an hourly basis, work out to a little more than they could earn stocking the shelves at Costco.

From six figures to student loans
It’s all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they’ll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.

But for this generation of doctors, and for Meg and Chris in particular, financial security won’t come guaranteed with their medical licenses. As health-care economics squeeze physician salaries, rising college and med school tuitions are putting young doctors ever deeper in the hole.

Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they’re also on track to finish their medical training in the next few years with a staggering $700,000 in debt.

And in the near term, their austere, stressful and sleep-deprived lives are about to grow even more so. Meg, 28, is due to have their first child in November. Although they’ve lined up day care, they still aren’t sure about babysitting help for the early mornings and late nights that they’ll both be working.

They’d like to have more children. Meg also dreams of working part time once Chris’ training is finished in three or four years, but they don’t know if they’ll be able to afford it. They’re entering uncharted territory. “I just don’t really know what the cost of having a baby is,” Meg confides.

Small-town sensibility, big-city debts
Chris, 29, grew up in a small town in southern Illinois. He was always interested in science but didn’t consider becoming a doctor until he was in a graduate program studying neuroendocrine physiology. “I wanted to be able to talk to people,” he says. “I didn’t like sitting in a lab dissecting rat brains.”

He was accepted to medical school at the University of Illinois, where tuition would have been just $9,000 a year, but chose instead to go to Midwestern University’s Chicago College of Osteopathic Medicine, in large part because he thought it would improve his chances of getting a residency in the Chicago area. Starting tuition: $29,000.

Chris, who left his master’s program owing $17,000 in student loans, was well aware that he’d finish med school with at least $200,000 in debt. But the message he got from the school, he says, was “Don’t worry about it. You’re going to be able to pay it off someday. It’ll all be taken care of.”

Soon after he arrived at Midwestern, Chris met Meg, another first-year student. Meg had small-town roots too – she had spent her teen years in farm country outside Peoria and had triple-majored in premed, biology and psychology at a small college less than 100 miles from home. They found each other easy to talk to and started going out in their second year.

Well, not exactly going out. With both of them conscious of how fast their student loans were piling up – Meg had finished her undergrad days debt-free but had no financial assistance for med school – their courtship was low-key. They didn’t hit the bars as often as classmates did; instead, says Chris, “Our dates were studying for the test the next day.”

College costs keep rising
Chris and Meg went through four years of medical school – two years of classes followed by two years in what are known as rotations: one- to three-month blocks spent learning about different medical specialties and passing standard milestones such as assisting in the delivery room. “I like it when the dads cry,” says Meg. “I always watch them.”

They got married in October 2005, their last year of school, and celebrated in their characteristically thrifty way: The honeymoon was a midweek, three-day Caribbean cruise. “We found the cheapest boat, the cheapest tickets,” says Chris. Married on a Saturday, they were back the following Friday to start their next rotations.

Already they had selected the specialties they wanted for their residencies and effectively, for the rest of their careers. Chris, drawn to both orthopedics and anesthesia, picked the latter because of the likelihood that he’d have a more predictable schedule as a practicing physician.

Meg chose pediatrics. “I love working with kids. The really sick ones, you can help them and make a difference to their families,” she says. “And then you have the well kids whom you get to know right from the minute they’re born. You’re like a part of the family in some ways.”

By the spring of 2006, as med school was drawing to a close, Meg and Chris had a total of more than $450,000 in debt. Soon they added $200,000 more: Matched with residency programs in the Chicago area, they bought a condo unit convenient to their hospitals. They didn’t seriously consider renting, since they knew their residencies would keep them in one place for at least four years. And they didn’t want to move farther away from Chicago in search of cheaper housing. “When you come off a 30-hour shift, you don’t want to drive an hour home,” explains Meg.

View of the 7-Eleven
They ended up in a quiet town called Willow Springs, near a forest preserve bursting with deer. It’s a nice place but, like their careers, is not quite as glamorous as it sounds. In the couple’s living room, they can hear the horns of Amtrak trains racing along 25 yards from their building; from their balcony, they have a perfect view of a 7-Eleven convenience store.

No matter: Their lives, for now, revolve around work. A short day for Chris – one in which he isn’t at the hospital for 24 hours straight – starts at 6:15 a.m. and lasts 12 hours, through back-to-back surgeries. He loves the physical, mechanical aspects of his job inserting a breathing tube or putting an I.V. catheter in a neck vein. “It makes my day go by pretty fast,” he says, “when I get to do a lot of hands-on stuff.”

And although one might not regard a doctor who knocks patients out as a people person, Chris likes the contact he has meeting people before they go into the operating room, administering medication and monitoring their vital signs during surgery, and escorting them to the recovery room. “I enjoy making sure that I took care of them the way they wanted to be taken care of,” he says.

Meg’s days are spent admitting and discharging children, learning what has happened to them on prior shifts and addressing any problems that come up on hers, and assisting part time in a private practice. In the hospital, she’s often dealing with the most heartbreaking of cases: kids diagnosed with cancer, families grappling with whether to remove their child from life support.

“It’s not something you can get used to,” says Meg. At the same time, she adds, even the hard cases remind her why she became a doctor. “You see both sides of it. You see the kids who don’t make it, but you see the ones who do well and go home and hopefully you never see them again unless they come back to visit you.”

The couple’s work is rewarding, but not in the monetary sense. Their combined earnings are around $88,000 which, given their exhausting schedules, averages out to about $12 an hour. They go to great lengths to avoid taking on more debt. When their bikes were stolen a week after they moved into their condo, they didn’t buy new ones; instead, they used reward points from their credit card, which they pay off each month, to buy a single replacement. Next year, they hope, they’ll have enough points for the second one. They rarely go out. For dinner Chris has been working his way through a cookbook filled with 30-minute recipes.

Not even special occasions merit a splurge these days: Meg, a theater fan, had missed The Lion King before it closed in Chicago, so this year, for their anniversary, Chris wanted to get tickets for Wicked. “She said, ‘No, no, the baby’s coming,’ ” recalls Chris. “So she got flowers and candy.”

At the same time, they’re trying to save what they can. They have an $18,000 emergency fund in a high-interest savings account. They contribute regularly to Meg’s 401(k) and Chris’ 403(b) plans.

While they don’t have to make student-loan repayments yet, their low salaries qualify them for hardship deferrals the interest keeps accumulating, and the amount they owe keeps growing at the rate of about $17,000 a year.

“A little panic attack”
The magnitude of their debt hits Chris every time he logs on to his student-loan provider’s Web site to check their accounts. “While I’m sitting there, I have a little panic attack,” he says. The numbers are sobering: If he and Meg started repayment soon, they’d be out a total of $2,553.41 a month. That’s like two additional mortgage payments on top of their existing one. And they could be paying student loans until they’re nearly 60 years old. “People hear ‘doctor,’ and they think, ‘Oh, high salaries and luxury lifestyle,’ ” says Meg. “But I don’t think people are aware of the debt you accumulate.”

Pediatricians’ salaries, meanwhile, are on the low end of the scale for physicians, and if Meg works part time, she could earn as little as $40,000. Chris will likely make at least $250,000 a year, but he may opt for extra training in pain management, delaying his big salary hike and adding more interest onto their loans.

For now, Chris and Meg are short on time and money. And with a baby coming, they’re going to have less of both. “Plenty of people say we’re nuts for having kids in residency,” says Chris. But of all the things they’ve put off having or doing, they don’t want to delay starting a family anymore.

The advice
Money Magazine set Chris and Meg up with Donald Duncan, a Chicago-area planner and investment adviser with D3 Financial Counselors. (They later get additional advice from Victoria Ofenloch of Mediqus Asset Advisors, a Chicago financial management firm for doctors.) As Duncan, Chris and Meg sit around the couple’s dining-area table, Emmy, their cat, finds a seat under Meg’s chair. Snickers, their aging, foggy-eyed dog, stretches out on the carpet next to Chris’ feet.

Ignore the usual advice You won’t often find a financial planner telling a young couple to stop putting money away for retirement, but that’s what Duncan advises Chris and Meg to do. “Don’t get me wrong I’m a big advocate of saving for the future,” Duncan says. But given how short on cash they are and how much their earnings will jump in a few years it makes no sense for them to struggle to put away the $3,500 a year they do now. They could better allocate that money for unexpected child-care expenses, for a vacation fund (Duncan senses from Meg’s lament that they’re going overboard on the delayed-gratification thing), for debt repayment and, most important, for life insurance.

Get protected Meg has no life insurance. Chris has $50,000 in term coverage through work. That’s a problem, says Duncan; if one of them were to die, their remaining expenses would swamp the survivor (even though the student-loan debt of the one who passed away would be forgiven). He does a back-of-the-envelope calculation: $200,000 to pay off the condo, $8,000 for their single car loan, $72,000 for seven years of child care and $100,000 for that child’s college expenses. Add it up and $400,000 of coverage for each will do the trick. Given their ages, they should be able to find policies for a mere $25 a month combined. They can buy more later when their incomes rise.

Ofenloch suggests other ways they should be protecting themselves. They need to look into disability insurance in case one or the other is incapacitated. She also points out that they need to title their assets in a way that protects them in the event of a malpractice suit. (Chris consults his paperwork and finds they’ve done that correctly with the condo.)

Deal with debt To buy their apartment last year, the Reises took out an interest-only adjustable-rate mortgage. They’re expecting to sell before the rate resets, but Duncan suggests they refinance into a fixed-rate 30-year mortgage in case they end up staying; perhaps they’ll get jobs in the immediate area or their salaries won’t be big enough to easily absorb an interest-rate jump. Chris questions whether the transaction costs of refinancing would make it worthwhile. Duncan responds, however, that given the Reises’ outstanding credit ratings and their small mortgage, lenders hungry for refi business might absorb the closing costs and appraisal fees. “If you can’t do it for no cost,” Duncan says, “don’t do it.”

As for their student debt, which comprises a number of loans with interest rates ranging from 2 7/8 percent to 9¾ percent, Duncan has several ideas. One is to pay off as many of their high-interest loans as possible, since that will guarantee them a high return for their money. Duncan points out a $2,777 loan at 9¾ percent that could be knocked off with spare cash. He suggests they look into borrowing from relatives; instead of paying a stranger 8 percent, he asks, why not give someone they know 7 percent? He also advises them to be in no hurry to pay off loans that carry rates under 4 percent. “String them out as long as you can,” he says. “That’s the cheapest money you’ll ever see.”

Keep plugging away Chris and Meg’s debt looks overwhelming, but Duncan assures them that there’s light at the end of the tunnel. He shows them his calculations indicating that once they’re both attending physicians, they could pay off all their student loans in only seven years. (Not that they ought to, given those low-interest loans.) They could even upgrade their standard of living and start saving for college and retirement, he says.

The bad news: If Meg really wants them to minimize the payback time, she might have to revise her plan of switching to part-time work when Chris finishes with his training. “Have that as a goal,” says Duncan, “but don’t have it as a cut-and-dried idea in your mind.”

A few days later, Chris is already working his way down the checklist of planner suggestions. He’s lined up a possibility for a refi and learned that he can’t buy additional life insurance through his hospital. He started researching disability insurance too but put that off temporarily. “I had to go back to the O.R.,” he says. “My pager was beeping.”

Dr. Drug Rep

Posted: December 16, 2007 by Doc in Medical, Medical career
Tags: ,

I have been doing some speaking on behalf of several pharmaceutical companies in the course of the launch of their new products. I found this article compelling, it made me assess my own behavior during these talks. It can’t be denied that there is some pressure to put the best light on the sponsor’s drug, but the pressure varies. Fortunately for me, I feel I’ve been honest in my interaction with my audience, and have never gotten any sort of flak from the sponsor, except for one company, which is well known for its aggressive marketing. I subsequently quit speaking for that company and refuse to do any more talks for them.
Dr. Drug Rep
Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report.
Published: November 25, 2007, The New York Times
I. Faculty Development

On a blustery fall New England day in 2001, a friendly representative from Wyeth Pharmaceuticals came into my office in Newburyport, Mass., and made me an offer I found hard to refuse. He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. He told me that I would go around to doctors’ offices during lunchtime and talk about some of the features of Effexor. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session, and he quickly floated some numbers. I would be paid $500 for one-hour “Lunch and Learn” talks at local doctors’ offices, or $750 if I had to drive an hour. I would be flown to New York for a “faculty-development program,” where I would be pampered in a Midtown hotel for two nights and would be paid an additional “honorarium.”

I thought about his proposition. I had a busy private practice in psychiatry, specializing in psychopharmacology. I was quite familiar with Effexor, since I had read recent studies showing that it might be slightly more effective than S.S.R.I.’s, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world. S.S.R.I. stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods. Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was more powerful and effective than S.S.R.I.’s.

I had already prescribed Effexor to several patients, and it seemed to work as well as the S.S.R.I.’s. If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication.

A few weeks later, my wife and I walked through the luxurious lobby of the Millennium Hotel in Midtown Manhattan. At the reception desk, when I gave my name, the attendant keyed it into the computer and said, with a dazzling smile: “Hello, Dr. Carlat, I see that you are with the Wyeth conference. Here are your materials.”

She handed me a folder containing the schedule of talks, an invitation to various dinners and receptions and two tickets to a Broadway musical. “Enjoy your stay, doctor.” I had no doubt that I would, though I felt a gnawing at the edge of my conscience. This seemed like a lot of money to lavish on me just so that I could provide some education to primary-care doctors in a small town north of Boston.

The next morning, the conference began. There were a hundred or so other psychiatrists from different parts of the U.S. I recognized a couple of the attendees, including an acquaintance I hadn’t seen in a while. I’d heard that he moved to another state and was making a bundle of money, but nobody seemed to know exactly how.

I joined him at his table and asked him what he had been up to. He said he had a busy private practice and had given a lot of talks for Warner-Lambert, a company that had since been acquired by Pfizer. His talks were on Neurontin, a drug that was approved for epilepsy but that my friend had found helpful for bipolar disorder in his practice. (In 2004, Warner-Lambert pleaded guilty to illegally marketing Neurontin for unapproved uses. It is illegal for companies to pay doctors to promote so-called off-label uses.)

I knew about Neurontin and had prescribed it occasionally for bipolar disorder in my practice, though I had never found it very helpful. A recent study found that it worked no better than a placebo for this condition. I asked him if he really thought Neurontin worked for bipolar, and he said that he felt it was “great for some patients” and that he used it “all the time.” Given my clinical experiences with the drug, I wondered whether his positive opinion had been influenced by the money he was paid to give talks.

But I put those questions aside as we gulped down our coffees and took seats in a large lecture room. On the agenda were talks from some of the most esteemed academics in the field, authors of hundreds of articles in the major psychiatric journals. They included Michael Thase, of the University of Pittsburgh and the researcher who single-handedly put Effexor on the map with a meta-analysis, and Norman Sussman, a professor of psychiatry at New York University, who was master of ceremonies.

Thase strode to the lectern first in order to describe his groundbreaking work synthesizing data from more than 2,000 patients who had been enrolled in studies comparing Effexor with S.S.R.I.’s. At this time, with his Effexor study a topic of conversation in the mental-health world, Thase was one of the most well known and well respected psychiatrists in the United States. He cut a captivating figure onstage: tall and slim, dynamic, incredibly articulate and a master of the research craft.

He began by reviewing the results of the meta-analysis that had the psychiatric world abuzz. After carefully pooling and processing data from eight separate clinical trials, Thase published a truly significant finding: Effexor caused a 45 percent remission rate in patients in contrast to the S.S.R.I. rate of 35 percent and the placebo rate of 25 percent. It was the first time one antidepressant was shown to be more effective than any other. Previously, psychiatrists chose antidepressants based on a combination of guesswork, gut feeling and tailoring a drug’s side effects to a patient’s symptom profile. If Effexor was truly more effective than S.S.R.I.’s, it would amount to a revolution in psychiatric practice and a potential windfall for Wyeth.

One impressive aspect of Thase’s presentation was that he was not content to rest on his laurels; rather he raised a series of potential criticisms of his results and then rebutted them convincingly. For example, skeptics had pointed out that Thase was a paid consultant to Wyeth and that both of his co-authors were employees of the company. Thase responded that he had requested and had received all of the company’s data and had not cherry-picked from those studies most favorable for Effexor. This was a significant point, because companies sometimes withhold negative data from publication in medical journals. For example, in 2004, GlaxoSmithKline was sued by Eliot Spitzer, who was then the New York attorney general, for suppressing data hinting that Paxil causes suicidal thoughts in children. The company settled the case and agreed to make clinical-trial results public.

Story continued at NY