Dr. Abraham Verghese, critically acclaimed author and widely respected clinician, is now featured in the Medical Commencement Archive. Dr. Verghese’s commitment to medical humanities, teaching, and the art of medicine is one that students have the pleasure and honor of learning from through various platforms.
In his speech, Timelessness in the Ever-Changing Medical Field, Dr. Verghese calls upon the Stanford University School of Medicine graduates to find the connection between their technology-laden careers and the careers of their predecessors.
“I hope that sense of history will make you conscious that when you are there with the patient, you are also participating in a timeless ritual. Rituals, like this one today, with all its ceremony and tradition are about transformation, about crossing a threshold — indeed the ritual of our graduation ceremony is self-evident. When you examine a patient, if you think about it, it is also a timeless ritual, a crossing of a threshold.”
In his speech, Dr. Verghese discusses the graduation speech boycotts of 2014, patients from his past, memories of medical school examinations, and opinions about medical licensing techniques. Dr. Verghese currently serves as Vice Chair for the Theory and Practice of Medicine at Stanford University, among many other appointments. Ending his speech, Dr. Verghese leaves the graduates with words that resemble a blessing:
“May you celebrate the rituals of medicine, recognizing their importance to both you and the patient. May you find courage to face your own personal trials by learning from your patients’ courage. May you minister to your patients even as they minister to you. When there is nothing more medically you can do for patients, remember it is just the beginning of everything you can do for your patients; you can still give them the best of you, which is your presence at their bedside. You can heal even when you cannot cure by that simple human act of being at the bedside — your presence. May you discover as generations before you have, the great happiness and satisfaction inherent in the practice of medicine, despite everything”
Interested in reading about Dr. Verghese’s work with infectious diseases? Check out My Own Country which features stories of the rise of AIDs in rural Tennessee. Interested in reading about mental health and creating balance within the medical field? Check out The Tennis Partner which explores the drug addiction and familial struggles of medical professionals. Fancy yourself a great fiction read in medical drama? Take a look through Cutting for Stone.
Further, Dr. Verghese writes on a variety of other interesting topics through New York Times, Newsweek, and Washington Post articles. Expounding upon the importance of the patient-physician relationship, Dr. Verghese has had a number of talks and interviews including TED talks.
A trip through my apartment is a serious lesson in buyer’s remorse. My iPad? What I thought would be a useful note taking and studying tool is more of a $500 YouTube and Netflix consumption machine. My spiffy dual monitor setup that I thought would amp up my productivity? Most of the time I forget to plug in my other monitor and spend my computing sessions staring at my 13” MacBook screen. In fact, that exact situation is occurring right now as I write this. My fancy Bluetooth speaker that I thought would be useful for jamming out when I had friends over? I’ve used it a handful of times, lost the charging cable so the thing won’t even turn on, and have absolutely no desire or intention to either find or buy a new cable.
You may be asking yourself what the point of that rant was, and I don’t blame you. What unifies all those examples is that they are situations when I either purchased or was given a new tech toy that I thought would be life changing, but instead turned out to be unnecessary or obsolete. What I’ve learned from years of accumulating new technology is that while everything comes with copious advertising and monstrous hype, few devices actually deliver as promised.
The medical field is no stranger to this. Hospital administrators and clinical program directors are people too, and they enjoy new toys just as much as the rest of us. Hospitals and universities try to justify their actions by citing journal articles and claiming that having “X” item allows them to remain “on the leading edge of Y specialty.” Let’s be honest, no one is being fooled here. Those new collections of surgical mallets aren’t any better at impacting components than the ones made 20 years ago.
The American Congress of Obstetricians and Gynecologists, in a March 2013 statement issued by President James T. Breeden, denounced the use of robotic surgical systems.4 Dr. Breeden claims, “There is not good data proving that robotic hysterectomy is even as good as – let alone better – than existing, and far less costly, minimally invasive procedures.”4 This speech came after studies published by researchers at Columbia University cast doubts about the perceived advantages of robotic surgical systems.2
These two examples only represent a few of the many opinions divulged about the topic of robotic surgical systems. The literature is rife with both positive and negative opinions, and it is up to hospital administrators and faculty to gauge the worth of these systems.
Why do so many hospital centers have this technology?
Implementation of these robotic surgical systems has occurred in major surgical centers in the US, France, Italy, Germany, Spain and many other places. If the literature is conflicting on the efficacy of these systems, why is implementation so widespread? I believe the answer is marketing. Top medical centers have a need to “keep up with the Jones’.” If one renowned medical center acquires certain technology, all of the other medical centers instinctively implement that technology as well to avoid a perception of inferiority. There is also a marketing aspect in terms of patient recruitment, as new technology and the promises of a “superior” surgical experience may lure prospective patients away from competing hospital systems. Whether or not the added income from patient recruitment offsets the initial and recurring costs of these systems is, to my knowledge, yet unknown.
My conclusion on this topic is that these surgical systems are akin to my iPad. They are good in theory, but their cost and relative utility make them a bad investment at the moment. However, this is not to say that these systems will never find justifiable use. With new innovation these systems may find a niche that makes them both efficacious and profitable. Just as a new app may breathe more life into my iPad, new research and better training with the robotic surgical systems may lead to advancements that will justify their implementation.
References 1.http://www.intuitivesurgical.com/ 2.http://online.wsj.com/news/articles/SB10001424127887323764804578314182573530720 3.Bochner, B. H., Sjoberg, D. D., & Laudone, V. P. (2014). A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med, 371(4),389-390. 4.http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Statement-on-Robotic-Surgery
This week’s Medical Commencement Archive speech comes from Dr. John C. Hitt at the University of Central Florida College of Medicine. In his speech, he congratulations the newest UCF COM graduates on choosing to attend the new medical school. What goes into establishing a new medical school? Read Dr. Hitt’s speech for an inside look. Addressing the successful UCF COM graduates, Dr. Hitt states,
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“The biggest game changers in life dare to envision a better society, and then go about creating it.”
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Dr. Hitt is an accomplished educator and leader in higher education. He graduated cum laude from Austin College where he received his Bachelor’s in Psychology. He earned both his Master’s degree and Doctoral degree in Physiological Psychology from Tulane University. Dr. Hitt has served as the president of University of Central Florida for over 18 years, during which he has achieved such remarkable accomplishments as planning and winning approval for a new college of medicine, and expanding research funding by over $114 million a year. Among his many notable positions of service, he has served as Chair of the State University Presidents Association and a member of the Florida Council of 100, and is the founder of the Florida High Tech Corridor Council.
Today the Medical Student Press kicks off Volume 1 of the Medical Commencement Archive. The Archive will now release a new speech each Friday. Stay tuned for spectacular reads which speak directly to the future of medicine with wise reflections from the past. The inaugural speech entitled, Who is Your Doctor?, comes from Dr. Timothy E. Quill, M.D., at the University of Rochester School of Medicine and Dentistry. Read Dr. Quill’s full speech and bookmark the Medical Commencement Archive here.
Dr. Quill is an accomplished physician and author in the field of Palliative Care. He earned his undergraduate degree at Amherst College, and received his M.D. at the University of Rochester. He completed his residency in Internal Medicine and a Fellowship in Medicine/Psychiatry Liaison at the University of Rochester. Dr.Quill is now Professor of Medicine, Psychiatry, and Medical Humanities at the University of Rochester School of Medicine and Dentistry. He is also the Director of the URMC Palliative Care Program. Dr. Quill has published extensively on the doctor-patient relationship, with an emphasis on the difficult decision-making processes toward the end of life. He was the lead physician plaintiff in the 1997 Supreme Court case Quill v. Vacco challenging the law prohibiting physician-assisted death.
In his speech, Dr. Quill spoke to the class about the need for competent and personal medical care in this complex and fast-paced world of biomedicine with all its specialties and subspecialties. He drew upon his extensive clinical experience in palliative care to illustrate how a deep understanding of the patient and their family can help physicians not only guide patients through the plethora of medical options, but also make,
“…clear recommendations among those options based on their medical knowledge and their knowledge of the patient as a person.” Dr. Quill believes, “that kind of guidance and engagement, which is both medically competent but also very person, is what will make [one] a really exemplary doctor.”
Dr. Quill’s speech is indeed very touching and inspirational. His personal clinical anecdotes are moving, as they illustrate how competent and personal medicine improves patient care. His focus and dedication to understanding and treating patients as opposed to diseases is evident and serves as a role model to all, including medical students. His words inspire medical student to,
“become one of those doctors who is not only technically very competent, but also very willing to engage with patients and families in difficult decision-making.”
The MSPress encourages you to read his commencement speech to not only gain insight into Dr. Quill’s wisdom, filled with powerful anecdotes, but to learn from an accomplished and very thoughtful physician. Read Dr. Quill’s full speech and bookmark the Medical Commencement Archive here.
Thanks to Stephen Kwak, MSPress Editor, for his contribution to this blog post.
Franco-German and Anglo-American models of emergency medical care differ. The first brings the physician to the patient on scene, while the latter brings patients to physicians in hospital. In a recent German study, physicians remarked, “Do we really have to study whether a high density of less qualified EMS personnel leads to similar or even better outcome than a system in which highly qualified physicians, providing better transportation stability, take care of the critically ill patient?” Are physicians needed in pre-hospital emergency care settings? If so, in what medical setting is such a system tenable?
On-scene time
Time is of such importance in medical emergencies and trauma that the term, “golden hour” has been designated to the period during which treatment is most likely to have a positive effect on a patient’s outcome. The two EMS models make an effort to treat the patients as soon as possible using different approaches. The Anglo-American model revolves around the “scoop and run” idea, bringing the patient to the physician in a hospital as quickly as possible. The Franco-German utilizes the “stay and play” concept, reflected in longer on-scene time. This time is not wasted though, and may even be considered better utilized as the physician is brought to the patient and can begin advanced and/or aggressive treatment on scene, improving the outcome and chances of survival. In the Anglo-American model, time is lost on many minor cases, because paramedics and EMTs must transport most patients to hospitals in order to be cleared by physicians, whereas in the Franco-German model, physicians can treat patients at the scene and decide which patients do not require hospitalization. Another factor that may prolong on-scene time in a negative way in the Anglo-American model is the skill level of paramedics and EMT. Lastly, there are situations with unavoidably prolonged pre-hospital time, for example when ambulating the patient may be difficult and transport to hospital delayed. In this case, the presence of a physician significantly improves survival rates. A large group of studies has demonstrated that the benefit of helicopter emergency medical service (HEMS) is not to be attributed to faster transportation, but rather to the presence of a physician.
Expertise and skill
The length of EMT and paramedic training programs ranges from a few months to two years depending on the policy of the country and the specific degree. EMTs are required to follow standard operating procedures, whereas physicians may, in certain circumstances, act autonomously. There is an ongoing debate on skills which paramedics should or should not be allowed to utilize. It has been found that there is a relatively high rate of misplaced endotracheal tubes in patients intubated by paramedics. Even with adequate training, skills deteriorate over time, as is the case with paramedics who mostly attend minor cases and do not regularly utilize practical skills such as endotracheal intubation, and intravenous drug administration. Physicians usually practice these skills in their hospital settings as well as in pre-hospital environment, allowing them more of a chance to practice their skills. In addition, specialists are more qualified to perform such skills in non-standard conditions.
Photo courtesy of Dr Gregor Prosen
Quality of care
Skills and expertise of EMTs and physicians reflect in quality of care. A large number of studies show a significantly better first hour and first day survival rate, a better functional outcome, as well as less time spent in intensive care unit in trauma patients; as well as survival of patients with acute myocardial infarction and respiratory diseases when treated by physicians. These results may reflect the higher level of expertise and the more profound knowledge of the physicians, as well as their ability to make clinical decisions and use aggressive treatment on scene. Studies have, however, found a difference in survival even when standard procedures were followed by both physicians and EMTs, such as in cases of cardiac arrest. Physicians administer a higher number of drug dosages per minute, they have shorter hands-off intervals and pre-shock pauses, and intubate a greater proportion of patients.
Issues
One of the biggest problems of maintaining a physician-based EMS is the financial “loss”. Is it worth overcrowding the Accident and Emergency (A&E) waiting rooms with myriads of “minor” patients who EMTs have to bring in, rather than clearing the A&E departments and allowing the staff to treat the more serious cases requiring advanced hospital equipment? Looking at the larger picture, survival of patients after CPR may be less costly in the Franco-German model than in the Anglo-American model. A study showed the expense of 0.7 euro per patient after CPR in Birmingham, compared to 0.17 euro in Bonn. Another problem, arguably more evident in the Americas than in the Europe is the litigious concerns. Many physicians who volunteer or work in ambulance services in the USA have malpractice insurance, which only covers their practice at their respective facilities, not in the pre-hospital environment, making them vulnerable to malpractice law suits. Some hospitals have overcome this problem by rewriting their insurance policies to include pre-hospital coverage for physicians working in those capacities.
While I support the involvement of physicians in pre-hospital emergency care, there remains a question of which physicians should be sent on the scene. Not all countries have enough physicians or adequate finances to allow all ambulances to be manned by anesthesiology or emergency medicine specialists, and instead send out newly qualified doctors with little experience. The right answer may lie between the two extremes: the use of both physicians and EMTs. For example, in Portugal dispatchers communicate with patients and decide whether to dispatch an emergency vehicle, as well as whether to man the vehicle with a physician and a nurse, or two EMTs.
Sources:
1 Timmerman A, Russo SG, Hollmann MW. Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Current Opinion in Anaesthesiology 2008; 21:222-227.
2 Fischer M, Krep H, Wierich D, et al. Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzther. 2003 Oct;38(10):630-42.
3 Garner A, Crooks J, Lee A, et al. Efficacy of prehospital critical care teams for severe blunt head injury in the Australian setting. Injury 2001; 32(6):455-60.
4 Osterwalder, J. J. Can the “golden hour of shock” safely be extended in blunt polytrauma patients? Prehospital Disaster Medicine 2002; 17(2):75-80.
5 Apodaca A, Olson CM Jr, Bailey J, et al. Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom. J Trauma Acute Care Surg 2013; 75(2 Suppl 2):S157-63
6 Katz SH1, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med 2001 Jan; 37(1):32-7.
7 Klemen P et al. Effect of pre hospital advanced life support with rapid sequence intubation on outcome of severe traumatic brain injury: a prospective multicentre study. J Trauma. 2006.
8 Botker MT, Bakke SA, Christensen EF. A systematic review of controlled studies: do physicians increase survival with prehospital treatment? Scandinavian journal of trauma, resuscitation and emergency medicine 2009; 17:12.
9 Dickinson ET. The impact of prehospital physicians on out-of-hospital nonasystolic cardiac arrest. Prehosp Emerg Care 1997; 1(2):132-135.
10 Olasveengen TM, Lund-Kordahl I, Steen PA, et al. Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome. Resuscitation 2009;80(11):1248-52.
11 Fischer M et al. Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzther 2003 Oct; 38(10):630-42.
12 Skow G. Docs On Ambulances. EMS World, 1 October 2010. http://www.emsworld.com/article/10319194/docs-on-ambulances?page=2
13 Page C, et al. Analysis of Emergency Medical Systems Across the World. Worcester Polytechnic Institute. MIRAD Laboratory, April 25, 2013.
“It’s so unfair that you have to pay for your flights for residency interviews!” George, my fiancé, was indignant. “In addition to hotels, applications, and everything else!” I looked over, surprised at his outburst. It was justice, not stinginess that lit the fire in his eyes.
“Dear, we pay for everything when it comes to medical education.” I said. It made sense to me—that’s the way medical training worked after all. Debt, debt, debt, and years later, a paying job.
“But why? It doesn’t seem right that corporations pay for potential employees’ travel fare and hotel on their interview days and universities arrange for PhD candidates to come and see their programs, but medical schools and residency programs won’t. The way I see it, that’s unprofessional.”
Unprofessional? Medicine is all about professionalism. And tradition.
“That’s just the way things are,” I told George.
From what I can see, medicine leans heavily on prestige and people to entice candidates to its programs. It can’t afford (and perhaps doesn’t need) perks to do the job for them. But George has a point. In a world where money is valued so highly, the medical field remains a privileged one. Why is that so? The answer is complicated.
My first year of medical school concluded less than a week ago. I think back to the $70,000+ spent on my one-quarter-MD and part of me cringes a bit. It is a well-known (and well-accepted) struggle that enormous loans are often necessary to make it through the four years of medical school. Yet, even with the MD in our hands, at least one year of internship and, more likely than not, another two to five years of residency is needed to practice. Often, physicians-in-training will continue on to do a fellowship and subspecialize in their field, which can take another one to three years. And the cost of applying to residency? It is not unheard of for medical students to take out additional loans during their fourth year for the sole purpose of “residency and relocation.”
Beyond the monetary expenses of medical education, there is often an underlying complaint of lost time in medical school, something that is a mix of lost sleep and lost opportunities for making money, exploring the world, and even, of developing relationships. Somehow, it seems that there is the notion that medical education has a way of sucking the marrow out of life. The best years, prime years often in one’s 20s, are spent studying in libraries or wrapped up in cases in the hospital.
Still, a large part of me is idealistic. I see the pursuit of medicine as inherently sacrificial. Student doctors spend their time buckled down in books or the wards, learning how to bring others into health and wellness. I admit to oftentimes believing that it should be so—that in this field of caring and healing, our focus should always be on the other, the sick patient, and not on ourselves and our own sacrifice and debt.
I told this to my friend Arnav and he laughed at me. “You know, it would be way easier to get into medical school if being a doctor wasn’t a high-paying job.”
I thought about it and after a while, I nodded. I guess it’s true.
“Plus, there are no poor doctors; only doctors in debt.”
Hmm. True again. Indeed, it seemed an oxymoron to imagine a starving doctor. The idealist in me heaved a sigh. Arnav, as always, was deeply practical about his decision to go into medicine.
Like Arnav, many of my classmates have reasoned away the burden of their loans. Being a doctor is a secure and respectable job. Their debt pushes them to pursue fields that reimburse well. As one of my medical school friends shared with me, no one wants to stay in debt forever. The less time needed to pay it all off, the better.
Nevertheless, I believe that most of my classmates would agree that in the end, all those numbers fading away from our bank accounts will be forgotten. Already, the payments to AMCAS for applying to medical school are long-gone, lost amidst the moving process of dissecting a human body, the willingness of busy physicians to be my mentors, the privilege of being so trusted by another in clinic. Many years from now, I believe that my exorbitant tuition will be long-gone too, forgotten amidst the incredible experiences I have had, the colleagues I have met, the patients I have walked with on their journeys. These opportunities are indeed worth so much more than the entry fee that is medical school.
My first year blew by. The end was jerky—I performed badly on the final exam for neurology. Yet, even in feeling unable to remember any information, I told myself this: medicine is not about numbers. Medicine is about listening, caring, healing— things that are so human and valuable.
Interested in reading about Dr. Verghese’s work with infectious diseases? Check out My Own Country which features stories of the rise of AIDs in rural Tennessee. Interested in reading about mental health and creating balance within the medical field? Check out The Tennis Partner which explores the drug addiction and familial struggles of medical professionals. Fancy yourself a great fiction read in medical drama? Take a look through Cutting for Stone.
