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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Body Donation Preferences After Taking Anatomy: Take 2

Medscape’s The Differential is a collection of medical student blogs. Garnering about 1000 views each day, the international audience is (presumably) composed mainly of medical students of all years, with a smattering of residents and higher-ups.

We (the bloggers) are allowed to create a single-question poll with our post.  So, how does national/international medical student/resident opinion on body donation compare with that of Harvard first years’ fresh out of anatomy (original post here)?  The results are fairly similar.

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Dear The Atlantic, We Have Opinions

When I was applying to medical school, a big part of my spiel was on the importance of connecting the medical profession to the outside world by those inside the community (in my case, I wanted to do it via writing).  It’s quite easy and tempting to speak candidly and frequently with colleagues, who by definition share our professional backgrounds: we are trained similarly, learn similar material, undergo similar challenges on the job, face similar frustrations, and basically just “understand” what it’s like in fewer words.  It’s more of a challenge to communicate to those without a similar professional currency.  It’s time, it’s effort, it’s frankly patience that can sometimes be difficult to muster.

But the alternative is to have those outside the community describing to others outside the community what it’s like from inside the community.  And sometimes it’s misleading, or hits on precisely the wrong points… or both.  If we do not have the time to write, we should at least correct such misinterpretations:

In September 2009, The Atlantic published a piece on teaching ethics to medical students.

The premise was that medical students were getting a surprisingly inadequate foundation in ethics, buttressed by a study published in JAMA by Mayo researchers.  Used as major support for the article’s premise was a startling statistic apparently found in the Mayo study:
Also surprising was the study’s finding that only 14% of those students had an opinion about “appropriate interactions between physicians and pharmaceutical companies.” How could 86% of medical students not even have an opinion on such a hot subject? 

The short answer is, they don’t.  The study did not find that students did not have opinions on these issues; rather it found that students “frequently had opinions inconsistent with the AMA policy on conflicts of interest in relationship with [pharmaceutical] industry.”  When researchers presented scenarios to students, “only 14%… of students’ opinions on relationships with industry aligned with the AMA policy of all 6 scenarios.”  Only about 5%–not 86%, as the journalist claims–did not answer at least one of the industry questions.  So, about 5% of students have at best “incomplete” opinions and at worst no opinions on industry.

We may not agree with the AMA, but we do have opinions.  Quite a difference.

Perhaps most disheartening is the fact that this result was in the abstract of the paper, right under Results.  It is accessible to all and is a mere 342 words long.  (This blog post is 417 words long.)
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We’re Not Taught to Do That in Medical School

Doctors vs. nurses (or doctors vs. nurse practitioners, or doctors vs. physician assistants, or what have you). The debate over superiority is old, tired, unimaginative, divisive, and wrong-headed–for reasons that are too obvious even to list. Does it get perpetuated because it garners comments?  

The New York Times recently ran a column by one of its editors, “In Praise of Nurses.”  Nothing wrong with gratitude for nurses, who are certainly under-appreciated or mistreated, both in real life and in media portrayals of them.  Where it gets gnarly, apparently, is how to praise nurses in a vacuum, without comparing them to physicians, and without the snarky jabs.

To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)

The rhetorical question begs a response.  So… this is what we learn in medical school about how to interact with patients.  Keep in mind this highlights solely psychological factors.  How we learn to put together the relevant information to generate a differential is another story for another time.

-Consciously keep “patient as a person” in mind while we conduct our interviews. While starting, we even had a separate category entitled this, which would often include vocation, home life, and hobbies.

-Ask for a patient’s explanation of his/her illness. “Why do you believe that?” is usually a good question and leads to better care.

-It’s not an interrogation.  Seat ourselves during the interview at a slight angle to 180 degrees, so that we are not directly facing the patient.

-Body language, body language, body language.  It’s like a first date.  Encourage conversation; it’s information you need.  Make direct eye contact, nod, say “mmhmm” or “go on.”

-Attend an AA meeting.  Watch alcoholics who have been sober for decades counsel alcoholics who have decided yesterday to quit.  “Today is a new day.”

-Listen to victims share their domestic abuse stories. Ask questions. Listen some more. It happens at the most unexpected times to the most unexpected people.

-Learn how to take an appropriate and sensitive sexual history.  Don’t assume anything–married or not, “straight” or not, “educated” or not.

-Make a home visit to a patient.  We see “disease”; he experiences “illness.”  What is it like?

If something is going wrong with the author’s doctors, unfortunately it is in spite of what our dedicated and caring preceptors teach us in medical school.

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Another Quick-and-Dirty Survey: How to Finance Health Care?

Thank goodness the Health Policy course at Harvard is not optional.  Health care coverage is relevant, nonintuitive, and downright confusing.  Economics, policy, and politics are certainly not topics I have learned much about from a source 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.  This is week one.

I am curious about our class’s sentiments about how health care should be funded.  I am also interested whether that sentiment will change after we are (presumably) better educated by the end of this month.  (I plan to send out an identical survey at the end of the course.)

The survey simplifies almost to the point of ridiculousness.  Should funding for health care head in a private or public direction?  Of course, there are many, many different and complicated models of coverage: for example, “universal coverage” does not necessarily entail a single payer or even completely public funding.  I intentionally left out the concept of mixed (public and private) funding, since that is what exists today and I suspect most of my classmates would fall into that camp.  I am more interested in the direction that they think health care coverage should go–should we encourage private or public entities to fund it?  Which way do we lean, on a very superficial level?  Does it correlate with self-reported knowledge of policy?  Will it change after this course?


Correlation between “self-reported knowledge” and leaning?  Size of private funding group (N=7) is too small to draw any conclusions.

Caveat: “Self-reported knowledge” is an incredibly subjective measure.  It could also reflect ego more than knowledge.

The average knowledge score for those who leaned toward private funding was 2.9, and for those who leaned toward public 2.3.

No one who self-rated a 1 on knowledge leaned private.

40% of those who self-rated a 4 on knowledge leaned private.

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Idioms That Are Now Off the Table

Now that we are in medical school, stereotyping specialties seems unsavory.  So long to brain surgeons as an off-the-cuff representation of intelligence.

From our Population Health lecturer today (emphasis added by me):

“What do we do to reduce the harms of tobacco? It doesn’t take a….[pause] rocket scientist…. People shouldn’t start smoking, and if they do smoke, you should help them quit.”

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More and Less

It started with a simple question my classmate asked me while we were on the shuttle: “After taking anatomy, do you think you’re more or less likely to want to donate your body to medical science?”  I paused, sat back.  It was–to borrow a cliché–really complicated.

How much did I know about the fate of a donated body before I stepped into the anatomy lab in scrubs with scalpel in hand?  On one hand, thinking of young aspiring physicians, I could have romanticized the role of a donor.  The invaluable experience of learning from flesh rather than books.  The indelible impact of feeling for organs, finding them, taking them out of their cavities, scrutinizing them, remembering them, and using the knowledge gained to cure others.

However, the past six weeks have been graphic.  Sterile donor consent forms are not sensual experiences.  They do not show the prodding of genitals and orifices with probes.  They do not replicate the sound of sawing the skull in two.  They do not convey the smell of rummaging through the bowels, or the feel of dry, leathery flesh.  Now that we are “informed”–in every sense of the word–would we want the same fate for our own bodies?

Or–now, do we even more acutely realize and appreciate the significance of such a gift?  Would this inspire us to want to give back to future generations of those like us?

Curiosity led me to send out a one-minute, five-question survey to my 200 classmates.  I received 75 responses.  The raw results are below.

Rather predictably, more students–nearly 50% more–began to think about their own body donation after taking anatomy.  No one who had answered “yes” for the former question answered “no” for the latter.

Before taking anatomy, about one third of students considered themselves “likely” or “very likely” to donate their bodies.  After taking anatomy, this fraction dropped a bit.

The more striking difference was the increase in students unlikely to donate their bodies after taking anatomy.  Fewer than half considered themselves “not likely” or “not at all likely” to donate beforehand.  After the course, that number grew to greater than half.

To note:

No one in any instance who had answered “yes” for the previous questions (they had thought about body donation) left these questions about likelihood blank.

Before anatomy: Since only 44 students claimed they had thought about body donation, I expected to receive this number of responses for the follow-up question.  However, 11 people most likely interpreted the question conditionally (“If you had thought about body donation, how likely would you have been to donate?”) and thus answered.  I kept their responses for completeness.

After anatomy: Once again, based on the last question, I expected to receive 65 responses.  Similarly, I am including the extra 5 answers for completeness.

These results are consistent with the findings that taking anatomy caused more students to become less likely to donate their bodies.  Several questions remain.  How often did students experience complete changes-of-heart, such as switching from “likely” to “unlikely”?  Did students with stronger feelings about their likelihood of donating stick with them more steadfastly?  How did the 21 students who had not thought about donating their bodies before anatomy feel after it?

Since I have the individual surveys, I can be transparent and specific.  Analysis at some future date.
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Dear Third Space

Third Space Magazine is a student-run literary magazine for Harvard medical students, residents, and faculty. It publishes fiction, prose, poetry, and art biannually.

I am currently involved in the Chief Complaints section, a mock advice column.  My first contribution:

Dear Third Space,

I dislike my anatomy lab partner, but I dislike confrontation even more.  Do you have any suggestions about how I can passive-aggressively voice my displeasure? 


– Silent Rage Behind the Scalpel
Dear Silent,
The important thing to remember is, when donning the blue scrubs and gown, one must remain professional.  As we learned during Introduction to the Profession, being professional involves not raising your voice, not using your scalpel to nick your partner’s forearm, not burying fat in your partner’s hair, not naming your cadaver after your partner, not spraying formalin in your partner’s locker, not hiding your partner’s pants in the changing room, and not taking a hammer and chisel to your partner’s kneecaps.
It is also important to remember that every medical student in the anatomy lab is nervous and frightened to be there.  She may have had bad experiences in anatomy labs before.  Maybe she mistrusts the anatomy directors.  Maybe the anatomy labs here are not like the anatomy labs she is used to.  You must find out more about your partner as a person.  Instead of making assumptions about your partner’s expectations regarding anatomy lab, take the time to talk to her about them.
A good place to start would be to ask her what brings her into the anatomy lab today.  Try to obtain her explanatory model for why she thinks she is here.  It is also important to make empathic statements.  If she accidentally cuts the phrenic nerve, you may say, “This must be hard for you.”  Try to make your questions non-judgmental, and make the transitions natural but clear. Perhaps while she is dissecting the liver, ask her how many drinks she has each week.  While she is looking for the bulbospongiosus muscle, inquire “men, women, or both?”  While you both dig through fat, ask her if she is interested in exercising more.   Try offering advice about STD testing, AA meetings, or birth control in passing, just to let her know your door is open for additional questions.  Ask her how many children or grandchildren she has, and what she is most looking forward to doing when she leaves the anatomy lab.
No matter what, it is important to maintain an air of professionalism and understanding.  Remember, not all of this has to be accomplished in just one session.  Sometimes you may have to broach sensitive issues repeatedly on follow-up meetings until she eventually gives you satisfactory answers.  The partner-partner relationship is a unique, delicate, and long-standing one and should be treated as such.
Always Professional
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The Fifth Member

In this post, I am not going to be a hypocrite.  We have not called our “donor” “our donor” in a very long time.  In fact, I don’t think we ever did.  He is “our body” and “our guy.”  It doesn’t feel right in writing.  It is jarring, but it is honest.  So I will call him that now.

One night, alone in the anatomy lab, I was reviewing our body’s abdominal and pelvic organs.  I knew that the next time I saw him, I would be dissecting his face and neck.  There would be little time for reflection.  I lifted the sheet that had covered his face for the last month.

Our guy was entirely dissected, in some places far less than perfectly.  During lab, I no longer mused about the now bloated, skinless hand while I was wrist-deep in intestines and embalming fluid.  I no longer thought about “the person” or “the patient” while I cursed the smell–an unfamiliar and unpleasant mixture of embalming fluid and bodily contents–that strongly emanated from our body, particularly when we dissected near the rectum.  (I had long given up trying to breathe through my nose.)  I often wished that our guy weren’t so darn moist, and yellow, and fatty–that, like our classmates, we could easily distinguish among arteries, veins, nerves, and ducts.

It is amazing what a difference a face makes.  I looked at his face, completely intact, feeling a combination of awe and shame.  His eyes weren’t completely closed.  His nostrils flared a bit.  He had strong, gray stubble.  Who was this person?  What would he think if he knew what we were doing to him?  How much worse was it than what he’d imagined?

I thought about this man with the metal knee replacements, the hardened coronary and femoral arteries, the strong tan arms, the large amounts of visceral fat.  Sometimes during lab, we would hazard guesses about who our guy used to be: a fisherman?  A construction worker?  A park ranger?  We were probably horribly, offensively wrong.  My three labmates and I knew him in ways that no one else, including he, ever would.  Yet at the same time, we knew nothing about him at all.

If this were a movie, we would probably we treated to flashbacks about this man’s life while we puzzled over his innards.  Maybe he would be shown at the dinner table, eating a hearty meat-and-potatoes meal while his arteries slowly calcified.  Maybe we could see how he developed such strong muscles, surprisingly well-formed even years after death.  Perhaps we would see him contemplating what he wanted to do with his body after death, having deep discussions with his wife and children.  Was he ever in a hospice, on a “death bed”–or did he die suddenly, perhaps of a heart attack?

Who was this man?  Would he have laughed along with us as we surreptitiously tried to get our instructor’s attention with some well-placed coughs?  Would he too have flinched at the smell?  Been frustrated by the layers and layers of fat?  Felt disappointment when we accidentally cut a major nerve instead of preserving it?  Felt that same awe when we held his heart and lungs in our hands?  When he donated his body to science, how much did he know what the aftermath would look like?  That he would be groped deeply in cavities he probably never knew he had.  That he would get a circumcision.  That he would be seen every day by at least forty students–but not really seen so much as “looked past,” as though he were part of the decor. This sounds more like a horror story than a gift.

The moment I stared into his face was oddly sad.  In some way, I felt as though he were witness to our work all along, a fifth member of our group.  I wished I could have a conversation with him.  I wished I could tell him what he looked like inside.  I wished I could tell him that we are just kids, to ignore our pouts and moans when we can’t find what we’re looking for and when we’re tired of digging.  I wished I could tell him that holding his heart was the most humbling experience of my life.  Throughout lab, I sometimes imagined I could find a clue as to who he was by searching through his body, that physical signs could somehow magically impart answers.  Of course, this was fruitless.

If this were a movie, perhaps we would be rewarded with a final scene, a culmination of our efforts and his.  A meeting, of sorts.  A brief but meaningful conversation that would change how we viewed each other.  A videotape delivered by his family.  A hand-written letter.  A spiritual epiphany.  But there are no such endings here.  Our reward is learning anatomy.  This is the psoas muscle.  Sometimes I wish it were all bit more Hollywood.

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Internal Happenings

There was a certain ignorance I had about the body before dissecting it from shoulder to foot (head and neck are up next and last).  Some of what I’ve learned was surprising, disconcerting, and fascinating:

1. The female urethra is very, very short.  I was aware that it was only a few centimeters in length, but seeing the bladder so close to the outside world (and the anal opening) made me wonder why every woman doesn’t always have a UTI.

2. The body is almost entirely shades of brown, yellow, gray, and red.  The gallbladder and its contents are the only exception: a stunning bright olive-green (in live people, it is robin’s egg blue).

3. We have an internal apron: a layer of visceral fat, several inches thick, that hangs from our stomach.  It helps protect our stomach, accessory digestive organs, and small and large intestines.  This is different from subcutaneous fat, which is what we usually think of when we put on weight.  The female “apron” is thicker than the male (she has more internal organs to protect)–which unfortunately leaves the door wide open for sexist jokes.

4. Even if you do not smoke, your lungs will probably end up black and speckled from what you’ve breathed in over a lifetime.

5. The appendix elicited a large amount of anger from my labmate.  It looked puny, flat, and unnecessary.  Since it is at the beginning of the large intestine, it easily gets infected.  Appendix pain has been said to be the most agonizing pain there is.

6. Our bodies can differ substantially, with apparently no impact.  There are certain things we’ll never know about ourselves unless a careful anatomist dissected us.  Some arteries, veins, and nerves run in different directions, taking tortuous routes–and some simply do not exist.  Sometimes the right kidney is higher; sometimes the left is.  A thigh can have a large benign mass, made entirely of fat.  Cysts are very common, sprinkled throughout the body.

7. Your body gets hard when it ages.  Calcifications develop in the cavity holding your lungs, coronary arteries harden, cartilage disappears and leaves rough bone in its wake.

8. In one day, our kidney filter 150-180 liters of blood.  We can survive with reduced kidney function or just one kidney.  One kidney is only about the size of a computer mouse.

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