Toast

Want one for yourself? Go to Obamicon.me.

The Nitty-Gritty of Interviewing

I've been blogging over at The Differential for a year, and have a few more stories/rants/ideas to broadcast in that venue before I finish medical school. This week, I've reflected a bit on the logistics of interviews and the parts that I'm not so keen on.


But this isn't my standard refer you to The Differential post. I must also alert you that the whole blog has migrated from the Typepad interface to the Medscape platform. That's good for me because I can post entries myself and not have to email them to my editor first. But it COULD be bad for you because you'll have to sign up for a free Medscape account. If you want to bask in the old, all of my articles are available here.

Its Rightful Place

Some pundits have commented that President Obama's inaugural address lacked the catch phrase or memorable line that JFK or FDR offered us in "Ask not what your country can do for you, ask what you can do for your country" or "We have nothing to fear but fear itself."

Perhaps this is true, but what I remember is:

We will restore science to its rightful place, and wield technology's wonders to raise health care's quality and lower its cost.

Let's focus on that first part:

We will restore science to its rightful place.

Does that mean the science adviser's office will be moving back into the West Wing???

Of course the inaugural address has the potential to be all talk. In his weekly address, he indicated that he will triple the number of fellowships in science. Initially, I wondered if this was at the graduate student, post-doctoral fellow or some other level. But then I found a report on whitehouse.gov with more details about the recovery plan.

With regard to the science in its rightful place goal, it looks like one step is

tripling the number of undergraduate and graduate fellowships in science, to help spur the next generation of home grown scientific innovation.

I wonder where all of those students will go after they have their science degrees? Will industry support them? Because I'm pretty sure academia won't. What about those young scientists who are finding it difficult to get their first grants?

Moving on, I think we should talk about the inaugural promise to wield technology's wonders to raise health care's quality and lower its cost. How exactly will we wield the wonders? According to the same Recovery Metrics document, the US government hopes to

computerize every American’s health record in five years, reducing medical errors and saving billions of dollars in health care costs.

Riiiiiggght... This one needs a little talking about.

I recently finished interviewing at 12 emergency medicine residency programs. As part of this, I toured some of the country's busiest emergency rooms; in many places I donned scrubs and saw how things worked 'on the inside.' Many places do have an electronic medical record (EMR), but some hospitals said that they probably wouldn't have a system in place by the time I finished residency (that's in four years). So that's a first strike against this goal. If the emergency departments - who provide primary care for more than 50 million Americans and are the first access point for unscheduled medical problems for everyone else - don't have an EMR, how will everyone's record be computerized?

This problem aside, there are additional barriers that need to be overcome if a 5 year goal is to be achieved.

1. A standard computer laguage that all EMR platforms use, so when patients move from one office to another or from one system to another, their info can be brought up in the same interface. As it stands now, this is not even standardized in the same hospital. In many places the emergency room's EMR is different from and cannot communicate with the hospital's!
2. For patient safety to be increased, more time and/or staff needs to be allowed for computer entry. In emergency rooms with medical records, I was amazed by the amount of time residents and attendings spend in front of computer monitors instead of with patients. In place of noting information on a clipboard while talking with patients, doctors have an extra hugely time-intensive step of data entry. Technology needs to improve. What about notebook style touch screen terminals? Except that would increase cost...
   
3. Is computerized care better? This seems to be a moot question, because everyone's headed in the digital direction. I'm probably just not well enough read on this topic, as the VA health system and large HMOs like Kaiser are all computerized. Are improvements to care there because of computers, or because everything's in the same system?

I see the computerized record as one of the important first steps in developing a single-payer model of health care, but the biggest impediment I see is getting the companies who make EMRs to talk to each other.

I applaud both of these goals of training more scientists and making health care safer, but want some more details, too.

Pride

What! You haven't heard of pyroptosis?

It's the hottest thing in cell death!

Well, except for my wife...

Illegal Questions

How old are you? Do you have kids?

My latest article at The Differential focuses on one component of my interview experience: illegal and inappropriate questions. Check it out, and if you are so inclined, back me up! And while you're there, check out a companion piece by co-blogger Anna Burkhead ponders another ageism related issue.

By the way, special thanks to DrugMonkey for inspiring the legwork to sort out the legal and social rules for this topic.

January 20, 2009

Thank you David Horsey.

Next Stop: Rank Lists

Interview season is finally over for me. So I've removed my handy reference of programs and interview dates from the side banner. I still need a convenient link list to organize program websites for the places I've been. Here's a chronological list.

• UCSF Nov 20
• U of Chicago Nov 25
• Northwestern Nov 26
• Harvard Dec 1
• Boston Medical Center Dec 2
• Yale Dec 3
• NYU/Bellevue Dec 5
• Highland (Oakland) Dec 23
• NY Presbyterian Jan 5
• Penn Jan 6
• Wash U (St. Louis) Jan 12
• Stanford Jan 16

I suppose I could have built a bookmark folder, but this cut-and-paste enables me to check back from any compy... The next deadline is February 25. That's when rank lists are due. We haven't decided if we will publicize our list, but I'm guessing the cards are going to fall close to the electronic chest.

I Blog, Therefore I Am

Instead of attending the ScienceOnline'09 conference, I was working on sorting out where my life's next stage would be set. But that didn't keep me from following some of the discussions about web publishing. One really interesting conversation worth your attention is the argument over the dichotomy between writers' lives online and in the real world. Dr. Free-Ride makes an insightful statement about the topic.

We may think of ourselves as being a particular kind of person on the inside, but from the point of view of the world we share, it's hard for me to believe that we aren't largely constituted by the stuff be bring out of ourselves. And I don't think that there's a principled difference between the stuff we bring out of ourselves in a three-dimensional conversation transmitted by sound waves and the stuff we bring out of ourselves in a blog post. Both are instances of communication that give others at least circumstantial evidence about what kind of person we are.

This supports my own approach to blogging. I blog because the internet affords a potentially interested audience for expressions that it is logistically difficult to find interest in off-line. And the people I meet on- or off-line will hear the same story, whether the word are printed or spoken. In the end both forms of communication end up shaping our futures, whether by design or accidental. Dr. Free-Ride continues,

Our past is out there on the internets. But testimony about our past would be available even in the absence of the internet (unless, once the recommendations are signed and sent, you've arranged for the speedy demise of all those who mentored you -- something against which I recommend in no uncertain terms). Opting out of leaving an online footprint is not going to give you full authority to tell the story of who it is you are and how it is you came to be that way. Your "authorial intent" in living your life matters, but the lives your life touches give their own testimony, and sometimes the story takes a turn you neither expected nor intended.

Right on! Would I be involved at Virtual Mentor or at WebMD or as an ethics teacher if I hadn't tried out this blogging thing a few years ago?

No Way!

I Would Walk How Many Miles?

I'm working on a post over at The Differential about all the traveling I've been doing to interview at residencies around the country, and am curious about the number of miles that residency applicants travel (by plane, train or auto) in a given interview season. Anyone have any ideas?

Virtual Mentor

In the process of preparing for my Ethics in the ER course, I've encountered a number of resources that folks interested in medical ethics may find useful. Every so often, I'll review and link them here. The first feature is Virtual Mentor. This is an online open-source journal published by the American Medical Association as a resource for teaching medical ethics. The content is decided by a panel of resident physicians and medical students with interests in ethics. The outcome is a forum for important conversations about current topics in health care. This month's issue, for example, addresses homelessness.

Each month, the journal posts editorials, literature reviews, policy positions, and my favorite section: case analyses. In general, the articles are interesting and accessible. Contributions are short to medium length, are written by qualified authors, and most of the time include varied viewpoints. The journal exists on a platform that is easy to use with .pdfs of every article and has some extra features like a podcast and a quiz from every issue. I understand that the entire journal will soon be listed in Pubmed. VM also compiles an excellent library of case studies and analyses from each of its issues. If you ever are curious about a particular issue in medical ethics, I recommend you consult this case index first.

Disclosure: I am an issue editor for Virtual Mentor's 2009/2010 year and am looking forward to assembling an issue related to emergency medicine ethics.

Ethics in the ER

This recent Wednesday was the first meeting of the Ethics in the ER course that I am co teaching with Harborview ER doc Stephanie Cooper. Our goals are to expose medical students to how the complex medical decisions made in the emergency department often demand a quick assessment and resolution of ethical dilemmas. The ER (especially in urban hospitals) is one place where physicians will rely on ethical principles every day.

So we've put together a course that features 20 minutes of lecture, 30 minutes of instuctor-led case reasoning, and an hour of student group reasoning. As the class moves forward, we will increasingly role play the fast pace neeed in the ER.

Since I'm a blogger, we're using a blog to enhance learning. If you want to follow along, feel free to stop by and read the students' posts. I'll be posting thinking exercises and links to relevant stories over there every week. There is also a course website, where you can peruse our reading list and syllabus. We're hoping to publish some of our motivations and experiences with this venture, as we are unaware of other efforts along these lines...

Vote for The Differential

The Differential, a blog written by medical students for medical students (and others) has been nominated for a 2008 Weblog award. (I write articles over there.) If you read that blog or are inclined to vote for it, visit this site before January 13, 2009. You can vote every 24 hours.

Caged Animals

While my wife and I were recently on furlough to her hometown in Oahu, we learned of a remarkable attraction: The Honolulu Zoo is currently the custodian of three tiger cubs. Now, I'm no huge fan of zoos. For me, it's a fine balance between sadness for caged wildlife and animal exposure and fundraising for conservation. When it comes to baby tigers, though there's something else at play. For example, in my wife's and my search for a residency, Washington University is high on our list because, yes, the St. Louis Zoo has FIVE baby tigers. (Actually, their lab medicine program is awesome - I haven't interviewed there yet.) But when we were visiting my in-laws and heard about the baby tigers, we took the day with the worst weather to visit the zoo.

It wasn't just caged tigers we saw... The first clue that something was up was that on a reasonably nice December afternoon, the longest line in Waikiki was not at the surfboard rental shop or the shave ice shack. It was at the zoo!!!

Exhibit A:The astute observer will find my wife in this image and the reason for our visit in the upper right corner. I wasn't about to stand in a line to see ostriches and elephants, so when I went up to the entry to ask if the tigers were on display, I was told bruskly that I needed to return to the line and wait to get the answer. Not the friendly zoo staff you'd imagine helping a lost child find her parents... The reason for the line was clear at the ticket counter. Everyone was being frisked by large crew-cut men with cords hanging from their ears. Why, what a nice purse you have there, sir! Broad shoulders, too. Do you work out?

But you know what an increased prevalence of body fat less than 10% linebacker types in "casual apparel" means...

...Barack Obama was at the zoo!

When we arrived at the tiger exhibit, not a feline was to be seen. Evidently, they were 'back-stage' for a special tour by some special guests. The perimeter was well secured.

See Exhibit B:
Those are some pretty heavy duty tiger-guards! You'd think the jungle predator (the tiger) could fend for itself. Note: the people behind the security were not ordinary zoo-goers. They were part of the Obama party. I think the Obama girls are seated on the park bench just over the Red Sox fan's right shoulder. They had just come out from a special feeding, play or education session with the tigers. At that point it came to pass that the first caged animal I actually saw at the zoo emerged from the brush. The tall man in the picture is Mufi Hannemann, Honolulu's mayor and presumably Obama's host. All joking aside, it was pretty amazing to be so close to the president-elect. I thought it would be more likely to see the family-elect in my wife's hometown: Kailua. It's unlikely that I'll ever see him in his natural habitat (Washington's corridors of power). After I got this photo, I moved on to the real attraction of the day: the tiger cubs. I was on crude digital camera videography duty. (My sister-in-law is the photographer of the family.) But I did snap this shot of one of the cubs.
Now if only there were a residency for Susan or me in Hawaii...

The Open Laboratory 2008

Remember when I used to blog about science?

Lately I've been defending a position that scientists and engineers ARE needed in emergency rooms. But these arguments have been confined to physicians' offices in Boston, Chicago and San Francisco. I've neglected (or spared) you my vision (or opinion). So too have posts at my other blogs trailed off, the correction of which would be on my list of resolutions, if I made them.

But here's some good news to jump start my 2009 blogging efforts: Hope for Pandora has been included in The Open Laboratory 2008 for contributing one of the top 50 science blog posts of the year.

Those of you who've been with me the longest may remember my "Dear Reviewer" post from about a year ago. It's a lovelorn account of the complex relationship between author and peer reviewer.

I've read several of the other posts (over the year and this morning) and am honored to be in such good company. Head over to A Blog Around the Clock for the full list, and stay tuned for how you can get your hands on a hard copy or .pdf.

Interviews Continue

In the process of making some of my last reservations for airfare and hotel, I cannot help but think about how fortunate in these ever-worsening economic times we senior medical students are to have a say in where we will work next year. It seems more of a pain than a privilege to have to jet across the US in search of the best-fit residency. But as each interview unfolds and as I'm toured the guts of America's hospitals, and as I observe how emergency departments operate on this coast or that, I feel tinges of conflict. Here I am with great opportunities - only one of which I will pursue - while the patients I'm chomping at the bit to meet, treat and advocate for face the converse: evaporating opportunity, escalating suffering and vanishing resources.

When framed this way, I ponder canceling the rest of my interviews. My pro&con lists from each program pick out relatively small differences between places. In the end, I know I must continue on for another few weeks. While the next month may consist of greenhouse gas guilt, travel fatigue and missed loved ones, the four years of residency will consist of lost sleep, steep learning curves, stresses of responsibility and the anguish of bearing witness to great pain and suffering. It will be important to live in a context of a supportive environment. Academic, social and even political and geographic context will play a part in my decision to rank programs. After then, it is up to the big computer in the sky to decide where is best.

We Escaped!

We flew on a different airline and to a different city than initially planned, but on Sunday night, my wife and I escaped the clutches of the winter storm currently incapacitating Seattle. I overheard one Southwest Airlines employee say we were the last plane to leave Seatac. I'm not sure if that was on Southwest, or in the whole airport. I wouldn't be surprised if it was the latter: we had to wait for more than 30 minutes just so the snow could be cleared on the tarmac between the plane and the runway. Our departure insured that our luggage did not make it into any "sorry, your flight was canceled, please collect your belongings in baggage claim" collections like this:


Susan was able to get to her interview at UCSF on Monday. I spent the day in the UCSF emergency departments for a 'second look.' Today, I interview across the bay at Oakland's Highland Hospital.

There are several reasons to be glad not to be in Seattle! It would be fun to play in the snow and all, but it turns out there's a reason why the city couldn't handle an inch of snow last week: Seattle refuses to use salt on its roads and the sand they do use is not enough to ensure safe motorist transit. The stated reason is the salt might impact Puget Sound's endangered salmon populations. Some biologists argue sand is actually worse because it fills the spaces between streambed pebbles such that insects and other fauna important to waterway health perish. Seattle is the only municipality (according to one article) that has a ban on salt. Sand is also 20% the cost of salt. My guess is that only the tincture of time and climate would benefit this picture:

With grades up to 20% in places, it's Mr. Sun who can restore normalcy to Seattle. Given this time of year's 8 hours of sunlight and perpetual winter clouds, I wish everyone there a hearty good luck! That packed ice takes a lot longer to melt than the fluffy stuff the kids are playing in. From a distance, Denny Way looks more like a ski slope than a road. In fact, there were intrepid young men snowboarding down Queen Anne Ave., NE 70th St., and I'm sure many others.

Snow Geese and Flying Home

On this Solstice Eve, the Pacific Northwest is getting slammed with a winter storm. And winter storms, we do not need! On Wednesday night Seattle received 1-2 inches (in most parts of the city), and look what happened:

Yes, that is a passenger bus that slid down a steep grade and plowed through a guard rail resulting in a cantilevered installation over I-5. Note the topography in the background. It's a good thing Seattle doesn't get winter weather very much. Susan and I are visiting our parents for the next two weeks, and hope to be able to leave Seattle tomorrow by plane. We also interview in the Bay Area on Monday and Tuesday! We'll be heading to the airport by bus extra early to account for difficulties from the the expected 4-8 inches of snow. If you want to see the view of the weather, here is a webcam view from the NOAA station across the street from where we live.

But we wanted to experience just a little bit of the current snow, so just as this evening's snow started to fall, we took a stroll around the golf course near our apartment. We were surprised to see a flock of about 30 large white birds circle and land on a nearby snow covered fairway. Upon closer inspection, I confirmed that it was a small gaggle of snow geese. I can only assume that they were in transit from the North Slope of Alaska to winter grounds in California or beyond.

At the time of writing, the snow has completely obstructed our view across Lake Washington. Unlike this Seattle-softened Midwesterner, I expect these birds to know what to do in the cold...

Science News

Among many other strong choices for science advisers, it appears an outspoken advocate for curbing greenhouse gasses has been selected to serve as chief science adviser for the Obama administration. John Holdren, a past president of American Association for the Advancement of Science, had to cancel a meeting at Harvard to fly to Chicago. According to journalists who are familiar with these escapades, this probably means he is meeting with Obama about a job. The AAAS blog reports this, as does a NYTimes blog. About climate change, he says,

I am one of those who believes that any reasonably comprehensive and up-to-date look at the evidence makes clear that civilization has already generated dangerous anthropogenic interference in the climate system…. What keeps me going is my belief that there is still a chance of avoiding catastrophe.

Sounds pretty okay to me. He also was involved with Pugwash and was part of the crew that accepted a Nobel Peace Prize in 1995 for nuclear non-proliferation work.

What I want to know is if he will get an office IN the White House. You may recall that GWBush kicked his science advisers out in favor of them occupying space down the street.

Random Musings

• 14 gauge needles are huge.
• Work hours debates continue.
• Teaching is fun.
• An electrified skeleton of a deer is feeding on the tundra that is our balcony.
• Did I mention how large 14 gauge needles are? I mean, an arm vein with a 14 gauge catheter seems to lose more blood (and faster too!) than a catheterized wrist artery... I've the bloody scrubs to prove it!
• Must... Get... Out... Into... Sun.... SOON!
• Thanks fto an anesthesia rotation, not only do I now check out people's veins when I meet them ("Could I get a 16 gauge into that antecubital?") but I inspect their chins. ("Start with the MacIntosh, or go straight to the Miller?")
• There are plenty of real people out there that think about more than, well... see above.
• Soon, I will be pulled in only one direction: the beach.

Note to Self:

Hey Robey!

When you have the time, write some blog entries about the latest Papal statement ("Dignitas Personae,") about in vitro fertilization and stem cell science and some of the responses to it.

Or maybe something about the scandal of free religious expression in the Washington State capitol building.

Or even about how the magi's part in the Christmas story provides a pretty good metaphor for a healthy interplay between science and religion.

I'd imagine each of these to be a good fit over at Clashing Culture, the blog I started about science and religion, which I have sorely neglected in the past few months. In the interim, get back to work!