In Color

I’m starting to understand why graphic pictures on cigarette packs are so effective.

We are studying pathology, which is the human body gone wrong.  The photos–taken from autopsies–are gross, meaning their structures can be seen with the naked eye.  Cirrhotic livers are littered with bumps and scars, the heart dies and leaves a band of black tissue behind, the lungs are stretched so far that they can’t pull in the air they need.

There is something very different and disturbing about seeing things that you can actually “see”–as compared to the symbols and cartoons that we use to represent molecules and pathways on a micro level.  Even when we observe microscopic slides of real damaged tissue, it is easy to underestimate how dysfunctional things are.  We see waves of immune cells, distended vessels, air spaces filled with dark masses (bacteria).  Yet these light and dark splotches, lines, and dots are still too abstract to scream “disease” to the novice eye.  Looking at a slide of a healed pulmonary embolism (blood clot in the lung), one of my classmates asked how we could be so sure it had even been there.  It looked like a bump, an outpouching of the vessel it blocked–a slightly different shade of pink, with a few wavy layers of scarring.  We squint and analyze, trying to distinguish it from “normal.”

The instructor then showed a gross photo of a similar “bump” at autopsy.  It was big.  It was brown.  It looked rotten.  It was impossible to miss.

Color is important.  Microscopes show our bodies in hues of pink and blue from staining; textbooks are overzealous for learning’s sake and use the colors of rainbow to differentiate.  However, real color is difficult to forget.  A gangrenous foot turned black.  A yellow scar on the heart, refusing to pump blood.  A vessel spilling bright red blood into a cavity reserved for fluid or air.  The sickness is sickening–to any eye.

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"Med School Just Got Real"

There’s nothing like a massive physiology exam that sucks all the words and thoughts out of you. They’re somewhere inside my brain, but the nuances of respiratory/cardiology/renal/GI/endocrinology keep rising to the top. That, and the desire to nap for the umpteenth time today.
I believe this is the first course that has broken the barrier between student and student-doctor. It’s not biochemistry, or anatomy, or epidemiology, or health policy–it’s medicine. The nuts and bolts of how our bodies function. The exquisite mechanisms our organs and cells use just to stay normal. Integration. Complexity. Regulation. Secretion, absorption, growth, flow. Feats of chemistry, physics, engineering (premed requirements make a cameo!). How we can meddle with it all when something goes awry.
It’s fascinating how far research has come in explaining how everything works–and still, how much is conjecture, yet to be elucidated via a precise pathway or even concept. It is humbling to learn about the big picture… but frustrating to study the pixels.
We’ve covered a textbook’s worth of physiology content in just over a month. Some sticks, some bounces away. Thank goodness they tell us we’ll re-learn this in future classes, and on the wards as well. My brain’s RAM is nearly maxed right now.  The last few days have been mundane–hanging on by a thread to pass that next exam. I suspect I’m not alone, but others seem to be hiding it well.
As one of my classmates said, “Med school just got real.”
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Can Seven Comments Help Explain $17,000?

Update: Now on the Hastings Center Bioethics Forum.

A study this month in Health Affairs found that the gender pay gap for starting physicians had widened from $3600 to nearly $17,000 over the last ten years (after adjustments for specialty and hours worked).  The authors hypothesized that the main reason for this was that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits.  Though they do not deny that gender discrimination may exist, they have doubts that it has gotten worse in the last decade.

“…it would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years,” they write.

I do not know if gender discrimination is on the rise.  I do believe it is still a major problem in the medical community.  I have taken flak for this perspective, and I have elicited considerable backlash.  But, I present the content of these reactions as evidence of the problem. 

I am a student blogger for Medscape’s The Differential, a community composed of medical students and residents around the world.  In other words, these are the people who will eventually be our colleagues and employers.

I wrote a post on Medscape linking to my analysis on this blog, as well as adding few anecdotes.

I received the lowest average rating I have ever gotten for a post.

I also received comments (36 total, discounting my own).  I have excerpted seven of them.  Six of them were within the first eight responses to my post.

Right off the bat (comment #1), a commenter argued that gender discrimination was logical.  Why?

“If a male and female both apply for an important position (suppose, a physician at a hospital, or CEO of a large company) and they have the exact same qualifications, and perform exactly as well as each other in the interview, (and seeking the same salary, if this is negotiable)…

As the employer, who would you hire?

For a female, the opportunity cost of childbearing (i.e. working for your hypothetical hospital / company) represents a huge loss of utility for you, the employer. She would be unable to work during the final 6 weeks of her 40 week gestation (and will most likely have maternity leave for much longer than that). Furthermore, the hormonal and mechanical factors of childbearing will greatly reduce her ability to perform at her best during weeks 28-34 of gestation (e.g. going to the toilet every 30 seconds).” 

 [Later on, this same poster added:

“- The employer has the right to decide his (or HER) own strategy for choosing the “BEST” candidate. This is what I believe a rational employer MIGHT do (for a position such as a physician or a CEO):

– If a male and female candidate had the SAME qualifications, SAME interview performance, and are negotiating for the SAME salary – and everything else is equal – then without further information (about future childbearing status), I would DEFINTELY choose the man. (Because they have equal likelihood of having a child, but if/when it happens the woman will require more time off work).

– If I knew the female had a Tubal ligation (but I am clueless about when/if the man intends to father a child) then I would DEFINTELY choose the female. (i.e. I am choosing the “sure thing” over a risk)

– If I knew that neither of them intended to start a family, then I would be INDIFFERENT.”] 

Some commenters agreed with this biological rationale:

“I’m not saying sexism doesn’t exist, but like the first commenter… intelligently said I believe this difference in pay check has more to do with pregnancy and the inevitable loss of money and utility for the company than anything else…. After all, if equality is what you are looking for, you can not work less than a man and expect the same pay check just because you are a woman. So, because of the biological diferences between men and women, I think job opportunities, salaries, roles, and available activities for both men and women will never be totally equal, and that has nothing to do with sexism but biology.” [Comment #2]

“I think the only way a woman (or a man, for that matter, if the idea of paternal leave is a policy) could demand equal payment with the other sex is to prove that they are incapable of having children….which is fairly extreme. I’m very sensitive to the equality of women, but we must also be careful about ‘overswinging’ the pendulum.” [Comment #8]

Other commenters questioned behaviors of women:

“There are dozens, literally, of other factors that congtribute to salaries in addition to simply hours worked. It is the misunderstanding of this issue, or the failure to recognize the true nature of this issue, then causes people to scream sexism… Of course there are those people who want to see sexism every where because it helps explain their own lesser position.” [Comment #6]

“Here is my question for the self-titled “hyperfeminist”, sexual organs aside, do you believe that men and women are different?  If not, I have no further comment. If so, do these characteristics differences translate to some sort of difference in their ability to perform work?”  [Comment #32]

Still other commenters argued that discrimination did not exist or that women were actually being favored:

“Men are judged solely on how much money they make and therefore work harder to make more money. Women are not judged solely by their salaries and numerous studies that are not ideologically biased have shown that women make different choices in where they study, what they study, how long they study, what extra work they do, etc that all explains the gender gap in salaries. Work done by Professor Stephen Cole at SUNY Stony Brook shows that there has not been gender bias in medicine since the 18th century… look at med school admission rates that far back and it has been proven.”  [Comment #4]

“I completely agree, after reading this article I feel that these feminist views further support my belief that no matter how equal job opportunities, salaries, roles, etc becomes, certain women will never be satisfied. I feel “Hyperfeminists” are the reason why some men make sexist jokes or feel that women are treated unfairly well (i.e. admission into higher education is highly favorable for women at this time).” [Comment #3]

I am disturbed by the immediate responses for two reasons: 1) the community they come from, and 2) the fact that comments are fairly thought-out and presented as logical, non-sexist perspectives.
Commenters believe that it is legitimate to discuss average differences between two groups (males and females); I do not disagree.  

But when does a preference for particular individuals constitute an “ism” (which we have laws against)?  As the original poster pointed out:

“You want to hire a junior doctor at the local hospital. Two candidates – Andrew and Brett, are applying. They came from the same medical school, with the same marks, and perform equaly well on the interview. They desire the same, fixed salary. 

During the interview, you are impressed that Andrew is an extremely talented violinist in his spare time… and you are equally impressed that Brett is an extremely talented vert-ramp skater (i.e. “skateboarder”).

However, Brett reveals “I am very passionate about my skating, and don’t think I will stop any time soon. I’m always very careful, but there is a 50% chance that I’ll have a fractured tibia in the next 10 years. It’s a risk that I’m willing to take, and life is all about risk – however it means I might be out of action for 4 months”.

Moral question: is it fair to choose Andrew over Brett for this reason alone? (All else equal).”

The obvious point the poster is trying to make is that yes, in this case, the discrimination is fair.  I would like to distinguish employer judgement in a hiring decision in a particular instance from an “ism,” though.

In my opinion, an “ism” that should not exist occurs after a few criteria have been satisfied:

1) When group generalities become rules for individuals–e.g., in who to hire and how much to pay them.

2) When individuals have no control over the group to which they belong.

3) When one cannot (or reasonably be expected to) hide the group to which he or she belongs.

4) When it is nearly impossible to predict how an individual will do the job based on the group he or she belongs to.

Where it gets sticky, of course, is where to draw the line.  Gender, race, height, weight, religion, age, health.  The list goes on.  And what about certain professions with different standards?  At what point can employers choose their workforce without being accused of an “ism”?  

I don’t pretend to have all answers for all situations, and so I am narrowing my scope to gender in medicine.  The aforementioned comments, I believe, constitute a form of sexism.

Commenters claim their views are grounded in the economic model we work within. That is fair, but–wrongly, I believe–there is nothing said of the normative, or “what ought to be.”  Without this consideration, there is no impetus to address existing inequalities on a larger scale.
Later on, one commenter summed it up particularly well:

“Reading this thread I am impressed by the amount of tacit sexist comments and thoughts made by supposedly intelligent, ‘progressive’ students. I think it partly explains why we see this widening of the gap- just bringing up the idea of gender equality elicited such responses as, “we must also be careful about ‘overswinging’ the pendulum,” (um, aren’t we talking about how we’re actually moving in the opposite direction?), and “there are those people who want to see sexism every where because it helps explain their own lesser position” (the entitlement of this comment makes me nauseous). Even more troubling is that these students seem to lack the awareness of how their comments come across, as if they wouldn’t consider themselves sexist in the first place. I’m grateful to see some responders on here that seem as equally appalled as I, but the ratio of ignorant sexist comments to intelligent ones is disheartening.”

Perhaps comments only select for the most vocal opponents.  But these are their attitudes, and one day they will be choosing our starting salaries.
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"Don’t You Want to Know What I Used to Do?"

Ms. R, a retired nurse, lives with her husband in Dorchester.  She has two adult children living nearby who she sees regularly.

By the time I get to a patient’s social history–almost always elicited last after an exhaustive 25-minute interview–I have about one or two minutes to learn about their marital status and children, who lives with them, other social support, occupation, and hobbies and interests.

With my head spinning from trying to create a coherent narrative from non-chronological, incomplete, inaccurate retellings of current and past medical problems, I often do what a first-year on autopilot would: I skimp.  I rush.  I don’t think.  I use standard questions.

“You mentioned your husband.  How long have you been married?”

“Do you live alone or…?” (We give the least agreeable option to normalize it.)

“Do you have children?”

“Do you still work?”

“What did you used to do?”

Those questions usually suffice to sum up a patient’s identity for the write-up.  I have his daughter’s age, so I cut his ramblings about her college accomplishments short.  He’s an avid fisher; it’s unnecessary to hear which fish get him most excited.  She’s a homemaker; the fact that she’s always longed to go back to school doesn’t merit a place in the chart.  Tick, tick.  We move on to items I can write down.

It’s a nonintuitive balance.  Though we’re told to inquire about our “patients as people,” their most interesting details get truncated in favor of the bland standard summary.  I suppose this makes practical sense.  But I don’t particularly appreciate the sixth sense I’ve developed to gauge when a patient is getting “off track”–when I know I can stop listening and not miss anything pivotal, when I think about my next question or my last question, when I configure a strategy to guide the patient back to what I need in my write-up.  When it’s just not “important” or “relevant.”

Some months ago, I interviewed Ms. S, a 94-year-old woman with an ear infection.  Her medical history was fairly uncomplicated, she was incredibly talkative and intelligent, and she laughed a lot.

“You mentioned earlier that you sprained your ankle a few years ago when you were trying to move a table.  Do you live alone?”  Yes.

“Have you ever been married?”  No.


I stopped.  I couldn’t ask how long she had been married.  I couldn’t ask about when her husband passed away, or what from.  I couldn’t ask about her children or grandchildren.  My brain, on autopilot, stumbled to make some sort of transition.  This lady was missing a large chunk of her social history.

She gently asked, “Don’t you want to know what I used to do?”

Over 70 years ago, she worked on the atomic bomb (unbeknownst to her at the time).  For thirty years after that, as part of her job with the government, she had traveled around North America, South America, Europe, and Asia.

“I had a lot of boyfriends,” she volunteered, unsolicited.  “But if I married, I’d be discharged.  I didn’t want to lose that part of my life.”

“It sounds like you enjoyed that,” I added dumbly.  She rightfully took that as a cue to share even more.  I know most of it wouldn’t make the write-up, but this time I listened and made no attempts to guide.

I walked away humbled.  Social history had always seemed so straightforward and formulaic.  Yet this woman had defied the formula, and 70 years later, she seemed happy and complete.

I aspire to that.

Happy Valentine’s Day.

Note: Certain medical, social, and temporal details and quotations have been changed to preserve anonymity (while hopefully not altering the narrative and message).

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This is a story without a title

This is a story about a story that may or may not be mine.

Sleep is the only thing that makes sense to me.  No one tells me that it isn’t real.

A lot of things aren’t real.  I wake up–late, because the sun is already on its way down–in a bed that I think must be mine.  That part is real.  The bed is there, and I’m in it.  Of course it’s mine.

My clothes are on my chair, right where they’re supposed to be.  My mother puts them there each night.  She doesn’t like it when I call her my mother, for some reason.  She says I’m married to her, and that her name is Sadie.  Which is funny, because that’s my mother’s name.  I think it’s also my wife’s name.  My wife sometimes lives with us.

I wish she’d stop coming in.  I want to sleep.

There’s something about food and pills.  Something about me and what I need to do with them.

I know she’s doing her best.  I want to sleep.

It’s not nice not to listen to her.  If she wants me to eat and take pills, of course I need to do it.  She’s usually right about these things.

She talks to me, and I listen and sometimes talk back.  I’m sure I’m saying things that are tiresome; not because I remember saying them but because anyone who visits will eventually look tired of me.

No one really visits.

My brother lives across the street and I’m supposed to meet him outside.  I am trying to get the door open, but it must be stuck.  For some reason, my mother is screaming at me.  I usually stop when she does that, but this is important.  I need to meet him to tell him the thing we will talk about when I meet him.  Good God, why is she still yelling?

Anger.  It’s been many minutes since the door got stuck.  It’s dark outside and my brother is probably dead by now.  I know he’s dead.  I remember his funeral; we shivered in our thick wool overcoats and gloves because it was winter in New York.

I really, really, really hate when this happens.  When things that are supposed to make sense make sense but backwards.  It’s like I can see the future, except the future is sometimes the past.  She knows that I know that there are horrible things wrong going on inside my head.

She’s short with me today.  I must have said something recently.

I think it’s time to go back to bed.  My mother wishes I could stay away from the bed since I use it so much.  I’m tired.  It makes sense to use it when you’re tired.

I want to sleep.

The sun is still outside my window.  It’s on the wrong side of the sky.

It feels less bad to be here than in another place.  It feels good especially when I close my eyes and when real and not-real no longer matter.

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How to Finance Health Care, Part 2

Four weeks of Health Policy and it’s over.  For those who can’t understand why anyone would choose a profession being around sick people all the time, I would say that it seems infinitely more depressing to spend a career analyzing our impending economic collapse due to advances in medical technology.  As for what we’ve learned?  More about that in future posts, but suffice to say it’s all about trade offs.  (Pro: it could be beneficial for the patient.  Con: it’s expensive.)

How did the course alter our knowledge and opinions?  Seems that our self-proclaimed enlightenment did not persuade us to change our views on financing health care.  (Note: this is a different survey from the last and thus a different sample.)

At the beginning of the course (N=49):

At the end of the course (N=39):

At the beginning of the course (N=49):
At the end of the course (N=39):
Perhaps it’s a good thing that we managed to be educated while holding steadfastly to our views.  This sample size of one learned quite a bit from a very unbiased course.
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Don’t Rule Out Sexism So Quickly

The media is abuzz about a recent study that found that the gender pay gap for newly trained physicians is widening compared to ten years ago.  Adjusted for specialty and hours worked, new female physicians made an unexplained average of $16,819 dollars less per year than new male physicians in 2008.
These adjustments counter the claim that the pay gap exists because women go into low-paying specialties and that they tend to work fewer hours.  That’s good.
However, what’s not so good is that the authors favor some hypotheses over others when explaining the gap.  They speculate that women are intentionally choosing lower-paying jobs because these jobs provide greater flexibility and family-friendly benefits, such as not being on call after certain hours.  Women may negotiate these conditions of employment which come at the price of commensurately lower pay.  This is certainly a fair hypothesis.
This is also the hypothesis that the media is picking up on.  It’s intentional and not imposed; it’s unfortunate but not unjust is the subtext.
But there is perhaps too widespread of an acceptance of this theory.
Why do the authors prefer this explanation over others in the first place?
The authors state that they cannot rule out other theories, such as gender discrimination and women being worse negotiators than men.  The main reason they say these theories are not consistent with observed data hinges on a single, pivotal point: that, in 1999, using the same adjustments, starting salary differences between men and women were not statistically significant.
“…we are unwilling to accept the theory that women have become worse negotiators in recent years,” the authors write.
“…it would be difficult to believe that discrimination, after a period of quiescence, has actually been on the rise in recent years,” they also write.
“…by the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for,” they add.
I think we need to look at 1999 more closely.
Time to get back to basic stats: what determines a significant difference?  The answer is usually a p-value of 0.05, which is arbitrary but accepted.  This means that if the study were conducted repeatedly, 5% of the time, the “significance” found would be a false positive, due purely to chance.
In 1999–without adjusting for specialty or work hours–new women physicians earned an average of $151,600 versus $173,400 for men (a 12.5% salary difference).  About 17% of this difference ($3,600) remained after adjustments.
In 2008, women earned $174,000 compared to men’s $209,300 (a 17% difference).  Roughly half of this difference ($16,819) remained after adjustments.  Clearly, the unexplained adjusted starting gap widened.
But unexplained starting salary differences between men and women in 1999 were not found statistically significant.  Why?  The p-value was 0.08.  In other words, there was only an 8% chance that the difference in findings were due to chance.  But, in the world of statistical significance, 8% is simply not 5%.  (In contrast, p < 0.001 in 2008.)
So, if we repeated this study 100 times in 1999, 92 times we’d find a difference between starting male and female salaries.
Is it misleading to state that the pay gap in 1999 was not statistically significant?  No.
Is it misleading to state by the late 1990s, women and men earned roughly equivalent salaries after observable factors were adjusted for?  Only if you think that a $3,600 difference (~17% of the unadjusted salary figure) with a p-value of 0.08 is “roughly equivalent.”
Onto the bigger questions: how does the 1999 data affect the author’s conclusions for 2008?
The authors toss the sexism hypothesis mainly because they suggest that gender discrimination has been in a “period of quiescence” due to the 1999 data.  This is a far greater leap than what the 1999 data actually suggests.
The authors toss the women-are-worse-negotiators theory for the same reason.
All of this lies on the very large assumption that in 1999, things were fine and dandy.  They could have well been.  But there is only an 8% chance that they were.

(Update: additional thoughts here.)
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Third Space Magazine Linked in Wall Street Journal

It’s an honor to be listed alongside such established, prestigious magazines as the Bellevue Literary Revue and Pulse.

We currently capture the voices of HMS students and physicians, but we are looking to expand to other medical communities.  As a free online journal, we are accessible–and we want to access more!  Featuring prose (nonfiction or fiction), poetry, artwork.

Submissions welcome at  

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Do Medical Students Know How It Feels to Be Uninsured?

Up in the Ivory tower, do tomorrow’s doctors know what it feels like to be without insurance?  About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is.  Harvard requires us to have insurance while we are in school.  Have our classmates ever been without?

N=55 for this survey.

Age (N=53)

The mean age of the respondents was 23.75 years, and the median was 23 years.  About 90% of those who answered were between the ages of 22 and 25.  The oldest student was 33.

Types of Insurance (N=55)

Respondents were not restricted to a single choice, and no time period for a type of coverage was specified.  Thus, coverage types may or may not have overlapped.  All students had had at least one type of insurance: 11 students had had one type, 22 had had two types, 19 had had three types, and 3 had had four types.  Age did not correlate with how many types of insurance a student had had.

All but one student (with private non-group) had been on either dependent or school-based coverage at some point.  All three students on Medicaid had also been on school-based insurance at some point.  One student (“other”) had received coverage via an international organization during an internship.

Uninsured at any point? (N=55)

Since Harvard requires that we have health insurance to attend (and Massachusetts has an individual health insurance mandate), the base assumption was that all students are currently insured.  Only one student mentioned in the free-response that s/he was between insurance plans and was planning to get insured soon.

Just over one-third of students had been without insurance.  The average age of this group was 24.5 years, and the median was 24 years.

Regarding the two-thirds of students who had never been without insurance: the average age of this group was 23.35 years, and the median was 23 years.

An F test revealed equal variance between the two groups (p=.00015).  A two-tailed homoscedastic T test revealed a significant difference between the ages of the two groups (p=.039).

Characterization of uninsured period (N=20)

To determine the nature of the uninsured period, I asked two questions: 1) How long total have you been uninsured, and 2) Why were you uninsured?

Answers ranged from one month to 10 years, so a strict average would not be helpful for characterization.  Instead, I will divide time periods into short- (<6 months) and long-term (>1 year) periods.  The reason I chose this classification is that no one was uninsured for a time between 6 months and 1 year, suggesting a natural break in the data.

Short-term uninsured period (N=9)

Three students answered one month; the rest answered “several” or answers between 2 and 6 months.

Six of the nine students described the reason as being in an “in-between” period: either between schools, jobs, or plans.  Two more mentioned simply not buying a plan, and one mentioned being unable to afford private non-group insurance.

Long-term uninsured period (N=11)

All three students who had been on Medicaid were in this group.  Six students mentioned cost, four students mentioned that their parents did not have coverage, and one student mentioned having a part-time job without health coverage.

Revised graph of insured vs. uninsured
No other questions about demographics or attitude were asked.  This is simply a snapshot of 55 first year HMS students.  Slightly over one third of them have been without insurance at some point, and one fifth of them have experienced being uninsured long-term.
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Sufficiently Indoctrinated

Rather than teaching physiology or immunology, our school devotes this entire month to population health, epidemiology, and health policy. The three subjects complement each other well: we learn statistics to analyze epidemiology papers and use such studies to devise policies that affect population health. The most eye-opening course for me so far has been health policy. I didn’t realize how little I knew about health care economic infrastructure and payment schemes until they were explained to us in great (and sometimes tedious) detail.

Health care coverage is relevant, nonintuitive, and downright confusing. Economics, policy, and politics are certainly not topics I have learned much about from sources other than the media. Every day, for four weeks, we learn about geographical variations in health spending, insurance, Medicare and Medicaid, cost growth, managed care, medical malpractice, health care quality, and health care reform.

If the purpose of a mandatory health policy course is to get future doctors to think about costs more frequently and intelligently, the short-term results seem pretty good. Now, during our population health lectures, it is not uncommon to hear a student ask the lecturer about the cost-effectiveness of an intervention–and then apologetically explain the fiscal interest as, “It’s just that we’re taking health policy now…”

I don’t remember these sheepish questions ever surfacing before.

Additionally, I have wondered if my classmates–and tomorrow’s doctors–know what it feels like to be without health insurance. About one in three Americans between the ages of 18 and 24 is currently uninsured, and about one in four of those ages 24-64 is. We are required to have insurance while we are in school. But have we ever experienced any time without it?

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