Treating a pediatric patient at a mission clinic in Albania (courtesy Joel Mundall)

“In Africa, we wash and re-use the gloves,” said one of our resident physicians who was doing clinic procedures with me.

When he graduates from our Family Medicine Residency Program at Loma Linda University, he is planning to work in the mission field in Africa where he spent time as a medical student. We had been discussing principles of “universal precautions” and discussing the use of medical gloves.

I looked at him as he was wistfully staring at the boxes of gloves that line the exam rooms in our Family Medicine clinic at Loma Linda University in California. Gloves that are ubiquitous here in the United States are so precious in the mission field. I remembered seeing mission photos, from our doctors who went to Africa and Papua New Guinea, showing gloves drying on clotheslines ready to be re-used. All day, I thought about medical gloves and the hands that wear them, the hands that are extensions of the doctors we are training to care for patients in the United States and around the world.

At Loma Linda University School of Medicine, students are encouraged to take elective rotations at mission hospitals and clinics around the world. The program, called Students for International Mission Service (SIMS) exemplifies the university’s commitment to global service. It empowers students to become compassionate, socially responsible health professionals and helps to promote the health of global communities. SIMS offers students opportunities to do mission work of various lengths. There are weekend interdisciplinary trips to mission clinics in Mexico and longer trips to various other countries. Students can also participate in an International Service Learning program (I-Serve) in which they do a month long observational or hands on clinical experience at a mission hospital. There is funding available through the Dean’s office to help defray travel costs. The students are usually housed at the mission site.

Mother with newborn at clinic in Nigeria (courtesy Joel Mundall)

Resident physicians at Loma Linda University (LLU) are also encouraged to do a mission elective either domestically or overseas. Some of our residents have recently returned from mission work in Malawi, Mexico and Nepal.

When resident physicians (at our institution or other institutions) plan an elective rotation, they must consider if their salary, malpractice insurance and benefits such as health insurance will carry over during their elective. At LLU, residents can choose from the “big book” of approved mission clinics around the world which will allow their salary and benefits to be uninterrupted.

Resident physicians and other health professionals often face the dilemma that they want to enter mission service but they are concerned about how to pay their student loans. For non–medical students who wish to serve in the mission field, they can apply for the Global Service Scholarship Program (administered by the Loma Linda University Global Health Institute in conjunction with SIMS) and they can get their student loan indebtedness amortized while they volunteer in an international setting.

At Loma Linda University Family Medicine Residency Program, several of our residents have chosen to participate in the Deferred Mission Appointment (DMA) Program. This program enables medical or dental students to work in overseas mission service with financial stability. During medical school they receive a stipend to cover room and board. After graduation they are placed in one of the Seventh–day Adventist Church’s many health care organizations world wide. In the DMA program, they receive a salary and competitive benefits such as health insurance, licensure fees, one month furlough (vacation time) plus continuing medical education time each year, and a percentage of their student loan indebtedness is amortized each year they serve in the mission field.

“The DMA program was an obvious choice because it makes it possible to work internationally without any delays after residency for repaying my loans,” said Dr. Joel Mundall. “Without this program, if I were to try to work for a little while to repay my loans before going, I would be at risk for never leaving this country or going where God wants me to be.”

The mission hospital in Nepal (courtesy Aaron Sartin)

Most of our residents will serve a six year term in the mission field and they may choose to stay on afterwards. At their mission site, they staff medical clinics or possibly a hospital and train indigenous people to provide health care services. This program is administered by the World headquarters of the Seventh-day Adventist Church in Silver Spring, Maryland.

As Dr. Aaron Sartin, a third-year resident in the DMA program explained: “A large barrier to doing mission service after residency is the enormous medical school debt, which grows exponentially after years of in-school and residency deferments. That barrier is removed with this program as the medical school debt is amortized over a six year mission term overseas. At the time I signed up for the program it seemed like seven years was so far away and would seemingly never arrive. Now in my third year and last year of residency in Family Medicine this reality is less than a year away.”

Although our residents in the DMA program may be placed around the world, most of them will be heading to Asia or Africa. They can request their first choice but they will not know until they complete their residency where they will be going.

“Recently, my wife and I returned from a three week mission elective to Nepal where we witnessed first hand the poverty and great need (physical, emotional and spiritual) as well as the beauty of the people,” continued Dr. Sartin. “We were awakened as never before to how blessed we are in the United States and reminded of our responsibility to use these gifts to be a blessing to others, both here and abroad. Where will we end up? That remains to be seen but as a Christian physician I am confident that God will direct us to the right mission field.”

As I put on my gloves for the next procedure, I couldn’t help but wonder where the skills I was teaching my residents would be used to provide health care around the world.

For more information, access http://www.llu.edu.

Dr. Conrad Fischer

Despite the growing number of scientific advances over recent years, the ability of doctors to cure or deal with diseases that were fatal not ten years ago, and heightened recognition by patients for those in the medical profession, a study conducted by Dr. Conrad Fischer suggested that many in the medical field were highly dissatisfied with their careers. Armed with these alarming results, Dr. Fischer set out to let everyone know that now is an exciting era in medical history and, quite possibly, the best time to be in medicine. The result is his book, Routine Miracles.

Dr. Conrad Fischer, author of Routine Miracles, is an infectious diseases specialist and a prolific teacher of medicine; he has published twelve books for the medical community. He is also an influential medical advocate. He was instrumental in the construction and passage of legislation that led to the near eradication of pediatric AIDS in the United States. He was formerly the Associate Chief of Medicine for Educational and Academic Activities at SUNY Downstate School of Medicine. He has been Chairman of Medicine for Kaplan Medical since 1999, and has held Residency Program Director positions at both Maimonides Medical Center and Flushing Hospital in New York City. He lives in New York City with his two boys.

Dr. Fischer recently sat down to talk to the Student Doctor Network about his research.

Please explain a little about your research for Routine Miracles and what surprised you the most?

There is an enormous disconnect between patients who feel the “miraculous” nature of what they receive in terms of treatments and a near-numb “routineness” of flat emotionality from doctors.  I can’t help but feel the root of the problem stems from our own medical school faculty and senior physicians poisoning the minds of medical students.  In our own research data it shows that 80% of medical students feel that medicine was better 25 years ago and that the public does not trust them. They identify senior physicians and faculty as the source of this impression. So, our best role models for a life of practicing medicine, and pursuing a life of investigation turn out to be the most damaging influence of all.

Why is this the best time to be practicing medicine and why is it the worst time?

Treatment is the best it has ever been by far.  We now have brain operated artificial limbs, hearing restoration, cancer cures, corneal transplants in four minutes, and cures that seemed like science fiction a few years ago.  It is hard to write good science fiction because the facts catch up so fast. Paradoxically, a recent study showed that more than 90% of primary care doctors are dissatisfied.  There is an unprecedented level of demoralization at a time when we can heal people in so many amazing new ways.  The worst news is that our freshest and newest members, students, interns and residents firmly believe medicine was better before and we are devolving as a profession.  They are not motivated to follow a life of investigation that will give us the next generation of scientific and medical breakthroughs.

You work with students every week. How are they different from you and your colleagues 20 years ago?

Students and especially residents are less cynical, less sarcastic and more professional than they were 20 years ago.  This is because of the mandatory decrease in resident work hours. You couldn’t possibly expect the same energy and compassion when you were up for 36 hours straight.  Now residents rest a little and you are kinder, warmer, and not burnt out and cynical.  Most MDs do not see this.  They look down on new students telling them it was better before.

Students on the other hand seem more concerned with personal economic issues.  They think the sky is falling in medicine, so they should find a nice high paying subspecialty to hide in.  There is virtually NO drive to consider careers of investigation that might lead to new cures.  So, you have nicer and kinder people taking care of patients, but who rarely question how they might find a cure.  In 20 years I predict the rate of medical advancement will be dramatically diminished.

In your opinion what three things need to happen quickly to help fix our healthcare system?

1. Universal coverage
2. Doubling of the research budget at National Institutes of Health
3. Decrease or supplement the cost of Medical education so that students choose a future that is not based on income potential or concerns about paying off student loans.

Why are you such a fervent advocate of universal health insurance coverage for all U.S. citizens?  How do you respond to arguments against—and fears surrounding—implementing a system of socialized medicine?

First off, universal coverage is just the right thing to do. I think the concern about financing is ludicrous. We did not worry about financing when the military budget went from 350 billion to 750 billion, which is considerably in excess of the amount needed for healthcare reform.

“Socialized medicine” is a scary word to frighten ignorant people. We have Medicare as a government run system as the largest insurer in the country. We have the veteran’s hospitals as the largest system in the country and it all works well.

Doctors are scared for their paychecks. Other people are, frankly, just unconcerned with people who will be sick if they think they have to pay for it.

If we are to live in a Great Civilization, we MUST take care of all our citizens, Period.

Routine Miracles

As you stress in Routine Miracles, young doctors are frequently weighed down by hundreds of thousands of dollars in student loan debt.  What would you change about how we finance medical school education?

I would subsidize the medical schools to lower tuition and I would add trading a year of tuition for every year you spend in a lab during research. We do it for the military, why not for research?

It only costs about $2.4 billion a year for EVERY student in the country.  That is about what we paid for ‘cash for clunkers’ car program.

What is your relationship with insurance companies like?

This is the only thing that 95% of MDs and students agree on – it is HORRIBLE!  If I had to deal with insurance companies full time, I would drop out of medicine.  I also find it unconscionable that while facilities are closing because of budget gaps, the CEO of Aetna insurance is getting a 32 million dollar salary.

What do you hope people will take away from reading Routine Miracles?

Unless we take better care of the emotional well being of our best and brightest students and trainees, in terms of seeing the grandeur of finding new cures and treatment, the amazing advancement in medicine will screech to a near stop.   There is action to take here. It is about fixing the disconnect between breakthroughs and the complete lack of excitement and engagement of the “Best and Brightest” new doctors.  Routine Miracles is about how, in an age of extraordinary advances, we need to get our students into the lab and in a life of investigation and discovery.  If we don’t do this now, the future will be a lot less bright.

Charles Q. North, MD, MS

Students may not be aware of the variety of opportunities available within the Indian Health Service (IHS).

To learn more about IHS and the volunteer, scholarship, and employment opportunities available, the Student Doctor Network recently spoke with Dr. Charles North, retired Chief Medical Clinical Officer for Indian Health Services.

Charles North attended medical school at the University of Pittsburgh and completed his residency at the University of Minnesota.  Currently, he serves as Professor of Family and Community Medicine at the University of New Mexico School of Medicine.

Would you explain what the Indian Health Service is?

Gladly. The Indian Health Service (www.ihs.gov) is an agency within the United States Department of Health and Human Services (HHS). Since IHS is designated as an agency or “Operating Division” within HHS, it is a parallel organization to the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA) and several others.

The IHS was created in 1955 when Congress transferred responsibility for health of American Indians and Alaskan Natives from the Bureau of Indian Affairs to the federal department that preceded HHS. The IHS is the principal federal health care provider and health advocate for Indian people.

The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

The goal is to ensure that comprehensive, culturally acceptable, personal and public health services are available and accessible to all American Indian and Alaska Native people.

The foundation of the Indian Health Service is to uphold the Federal Government’s obligation to promote healthy Indian people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. It is charged with providing direct medical care in the broadest sense, elevating their health status to highest level possible.

Congress passed the Indian Self-Determination and Education Assistance Act in 1975 to provide Tribes the option of assuming from the IHS the administration and operation of health services and programs in their communities, or to remain within the IHS-administered direct health system.

The IHS has around 15,000 employees and Tribes probably employ about an equal number of tribal employees. Over 70% are Indian or Alaska Natives. There are about 1,000 physician positions in the system, about half of whom are primary care physicians.  As of July 2009, 21% of the physician positions were vacant.

There are 35 states that have significant Indian populations and/or reservations, mostly in the western United States and Alaska. About half of the health care for Indians and Alaska native populations is administered by the tribes and reservations themselves and half by the “feds” (i.e., directly by the federal IHS).

The Indian Health Service might be an appropriate career path for certain health professional students. Is this mainly a program for students who are from Native American Indian communities, or is it open to any qualified health professional?

The IHS’ first priority is indeed to the Native students themselves. We have a scholarship program for Native students and Indian preference for all federal positions.

But there is a shortage of qualified Native students, with not enough people in training to meet the projected need of the rapidly growing population. Even though there has been a steady increase in numbers, we do not expect that Native students will be able to meet the human resource needs of either the IHS or tribal programs in the foreseeable future.

What type of background do you look for in the IHS and whom do you think would find this an appealing career?

The most successful students are those oriented towards working with service to underserved populations, who enjoy cross-cultural and “transcultural” experiences, who have a special appreciation for an American Indian or Alaskan Native community or who want to work with indigenous people.

If you have a background working in the Peace Corps, or AmeriCorps or have done missionary work, you may be attracted to the populations and communities that the IHS serves.

Say you are a college student interested in pre-med or in one of the health professions.  How would you get information about eligibility for the scholarship programs?

There is a national IHS office in Rockville, Maryland that helps anyone interested in scholarships. However, the criteria for scholarships are quite rigorous. Most of these opportunities would be for enrolled members of tribes. If you are in this category, ones’ tribal administration or the Rockville office can guide you through the application processes.

The Native Health Initiative funds summer health and justice internships. The IHS does provide some opportunities nationally in the Commissioned Officer Student Training and Extern Program (COSTEP) that lead to early commissioning in the United States Public Health Service (USPHS) Officer Corps and provide exposure to health professionals in federal agencies, including the Indian Health Service Commissioned Officer Corps.

Are there experiences for baccalaureate students on Indian reservations and other places?

Several reservations and tribal clinics have developed programs, such as the “health and justice” initiatives mentioned above. An interested person should contact a local site. There may be a volunteer program that would suit your interests and background. I am aware that anthropology majors, linguistics majors – even persons interested in law enforcement – have found things to do on some reservations. Undoubtedly, an experience of this kind early in one’s education might reinforce an early interest in this kind of service.

I would expect that there are more opportunities for students who are already enrolled in health professions schools?

Yes, such students have several options. The summer COSTEP program mentioned above requires that one signs up for the commissioned corps. We get a lot of students. Most of the interest is from pharmacy and engineering programs, but other health professionals are eligible.

Many of the schools in the 35 states with federally recognized Tribes have relationships with IHS and Tribal sites. Some programs in Alaska will pay room and board and airfare to get students to remote Alaskan communities.

Other programs will cover transportation and room and board for fourth year medical school elective rotations. You should check with your school and see if there are options for you to work in Indian Health facilities.

In Albuquerque, the IHS has a formal affiliation with the University of New Mexico. One of its Tribal sites takes students from all over the country. The Navajo, Tucson and Phoenix IHS Areas in the Southwestern United States also take students from throughout the nation.

Oklahoma has many local affiliations, so there are many opportunities there. The Northern Plains, Montana, Minnesota, North Carolina and Washington State regions all have some active and dynamic relationships. Check with your school.

How did you personally decide on a career in the Indian Health Service?

I was interested in service to needy populations even when before I was a medical student at the University of Pittsburgh. After taking a senior year elective in preventive medicine on the Navajo reservation, I entered a residency at the University of Minnesota and took an “outstate” (rural) rotation in Cass Lake, Minnesota, home of the Leech Lake Ojibway.

At that time, having a residency rotation at a remote Indian Health Service site was considered so different an experience that my University of Minnesota department chair and several professors flew up to Cass Lake to see it.

If you are a student or resident and want to do something like this, check with your school. Most likely you have faculty that are IHS veterans. The school may work something out with you.

Are there particular lifestyle interests that you find make a good match?

Generally, people who like to live in rural areas may find this is a good fit. Those people who love riding horses, rodeos, backpacking into “frontier” areas, mountain biking, long distance running, skiing, fishing, hunting, and so on often find the rural and frontier IHS settings attractive.

But for those who are oriented to urban life, you could live in a city and work at an Indian Health urban or rural site.  It is a fact that over 50% of the Indian population lives in urban areas. Urban Indian programs exist in some of the largest cities in the US. For some specialties, the only positions that exist are at the urban sites.

Beside the scholarship program for Indian students, do you have “loan repayment for service” programs?

The IHS has a loan repayment program, similar to the federal Health Resources and Services Administration (HRSA) National Health Service Corps program for community health centers. It has been funded at a lower level than the need, but it is quite possible that there may well be more money allocated to this program in the future.

It currently is set at $20,000 a year covering all the health professions, not just physicians. Because of the financial resources of some of the tribal sites, such as the Navajo, there are supplemental funds for loan repayment. One should check with local sites.

In the IHS, to date, loan repayment has been used mainly for retention, rather than recruitment. Stay tuned on on loan repayment, as this may be augmented in this era where health care reform is a legislative priority.

There are a number of IHS Indian health Health centers sites that get HRSA “Section 330” funding – a principal program for funding community health centers. They may be eligible for HRSA loan repayment program for either an urban Indian or Tribal site.

Not every person who went through the University of Pittsburgh medical school chose careers in the Indian Health Service. How did you get interested in this field?

I grew up in Seattle and observed that Native people there had both lower health status and lower socioeconomic status. I was interested in civil rights and social justice. I met Native students in in college and found we had many interests in common.

When I went to medical school in Pittsburgh, they had an elective on the Navajo reservation rotation for fourth year medical students. I went to a preceptorship at Fort Defiance, Arizona, where I worked in the hospital, clinic, and community health program and did some epidemiological research.

Personally, I love the Southwest, and liked working with tribal people, feeling that I was responding to a tremendous demand for health services. I found that the IHS healthcare services were extremely well organized into a rational system, unlike most of the rest of the country.

The IHS integrates public health and primary health care in such a way that one could make a difference quickly in meeting healthcare needs. I found this system of community oriented primary care very satisfying compared to private practice. Then I did a third year residency rotation in Minnesota and found that the system there was very similar and comfortable for me.

I loved the IHS system that existed in both Fort Defiance and Cass Lake. The population needs far exceed our ability to meet them, but I felt that I was fighting the right battle, that the organization’s core values were congruent with my core values. So after residency that is all I wanted to do.

I went to the Hopi Reservation in Keams Canyon, Arizona and served as a family physician, director of community health services and eventually became the chief executive officer of the health system there.

The integration of public health and medicine in team programs made great sense . The health care team is much better developed in Indian health.

It’s a given that there are healthcare professionals out there with substance abuse problems. But, as we prepare to enter practice, many of us find it difficult to imagine that we’ll be working with affected individuals, or that we could become affected ourselves. Few professional programs ask students to consider what they would do if they suspected or knew that someone in their workplace was impaired. And, still fewer programs formally acquaint students with recovery resources.

No one really knows how widespread substance abuse is within the healthcare professions. With their livelihoods at stake, few people are going to admit to having a problem. Additionally, most health professionals are smart people who are relatively good at hiding their problems. A lecture given by Brian Fingerson, the president of the Kentucky Professionals Recovery Network, indicated that the figure is 12-16% for “pharmacists and some other healthcare professionals”¹.  Given that one out of every nine Americans over the age of twelve was found to have a problem with substance use or dependence in the 2007 National Survey on Drug Use and Health², the suggested range seems quite reasonable.

As healthcare professionals, we may be more likely to develop substance abuse problems than members of the general population due to high work-related stress, increased access to controlled substances, and our knowledge of drug effects. Those of us who do become addicted may be shielded from discovery by the trust of our patients and coworkers. Plus, we may work very hard to avoid discovery, fearing harsh professional, social, financial, and legal consequences.

By this point, it should be clear that you should expect to encounter impaired healthcare professionals during the course of your career. What is less clear is what role you will play in the situation and how you will feel about it.  When you aren’t sure about what is going on, it can be hard to take action. You may only suspect that a coworker is coming to work intoxicated. Maybe there are narcotics missing on a regular basis but you aren’t sure who is taking them. It is reasonable to have fears about accusing an innocent person. You may worry about losing rapport with your coworkers if your suspicions aren’t proven true. There are many other reasons that you may feel compelled not to act. Perhaps you are worried about feeling guilty about turning in a close friend, or taking a provider away from a family. Or, maybe you feel like it’s not your place to take action since others are already aware of the situation.

The bottom line is that an impaired colleague is a danger to both themselves and their patients and needs intervention. If you suspect that a coworker is impaired, you need to connect with someone who can investigate and assess the situation or refer you to resources to do so. This could be your employer, the state board, or a representative from a Professional Recovery Network (PRN) or Caduceus group. If you know that a coworker is impaired, they need to be relieved from duty immediately. But, in order to fully do the right thing, you should also make an effort to connect them the unique support, advocacy, treatment, and recovery resources available through a PRN program. It is may be best to shield yourself by giving the PRN their information and letting the program initiate contact. It is not necessary for the affected individual to know who made the referral.

With the advocacy and monitoring offered by PRN programs, many healthcare professionals are able to regain licensure and return to work while in recovery. These individuals are typically required to sign a contract with the PRN organization and are subject to practice restrictions such as not being allowed to work unsupervised or not being able to work more than a specified number of hours per week.³

While employers or partners must know whether or not a healthcare professional is in a PRN program, coworkers may not.³ They often choose not to identify themselves because they don’t want to deal with the stigma, have their work overly scrutinized, or be judged on a daily basis. If you do discover that a coworker is in a PRN program, I encourage you to be supportive. While there is potential for relapse, PRN programs are used because they work. One pharmacy PRN program coordinator at The Utah Conference on Alcoholism and Other Drug Abuses shared that the drug abuse rates in his state’s PRN program were lower than that of the general pharmacists population. So, with proper monitoring, it may be less risky to hire an individual in a PRN than it would be to hire the average applicant.

For students or professionals interested in learning more about substance abuse in the health professions, I recommend attending the University of Utah’s School on Alcoholism and Other Drug Dependencies, now in it’s 58^th year. This annual week-long event is designed to help students and professionals understand and cope with substance abuse and incorporates a mix of speakers, discussions, social events, and open meetings for recovering addicts and families. Exposure to and interaction with recovering health professionals is one of the most valuable aspects of the program. For students and professionals in recovery the school also offers a unique opportunity to connect with a supportive network of people who share similar experiences. The pharmacy section, which I attended this June, is the largest section of the group, with around 300 participants, mostly students. Other healthcare sections included physicians, dentistry, and nursing. Both college and continuing education credit and are available at a reasonable cost. For more information, please visit http://uuhsc.utah.edu/uas/

1) Fingerson, Brian. “Chemical Dependency Among Healthcare Professionals.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

2) http://www.drugabusestatistics.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch7

3) Quigley, Michael. “Issues in Relapse Prevention and Monitoring.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

Dr. Talya Miron-Shatz

Talya Miron-Shatz, PhD, is a decision scientist, studying the way people interpret medical information. She teaches consumer behavior at Wharton and is a keen public speaker, advocating the importance of understanding the psychological aspects of medical decision making.

She recently sat down to speak with SDN about how consumers and health care providers make medical decisions.

What is decision science, and how does it apply to health care decisions that consumers make?

Imagine you are designing a sticker promoting flossing. Should you say, “Flossing helps you prevent gum disease,” or should you emphasize the loss of protection that results from neglecting to floss? It turns out that people are more motivated to act when something they have is about to be taken away from them. So, when you’re in the bathroom at night, being aware of the potential risks to your gums might prompt you to dedicate a few extra minutes to the fine art of flossing. This, in a nutshell, is what decision science is about.

Decision scientists make sense of people’s judgment and decisions, even when these seem random, erroneous or irrational. Decision science was developed by Amos Tversky and Daniel Kahneman, Nobel Laureate of Economics, 2002, with whom I had the honor of working closely at Princeton University. This science draws on psychology and, rather than concluding that people are unpredictable, or just plain dumb, helps explain their behavior.

A really cool thing that decision science does is that it incorporates emotions into the equations. After all, the facts don’t change in the flossing example – what matters is how the information is presented. We show that the way alternatives are presented often dictates, or at least influences, how people feel and the choices they make.

Does this apply to every medical setting?

I always tell my students that there is no such thing as a neutral way of presenting information. The beauty of decision science is that the principles apply across the board, even where you least suspect it.

Consider an expectant mother who arrives at a prenatal clinic. The genetic counselor presents her with a list of the available screening tests for the fetus. Some tests are standard at the clinic, while others need to be specifically opted into. This varies across clinics. When a woman receives a list of, say, seven standard tests and five optional ones, adding the optional tests seems unnecessary, perhaps even overly anxious.

Now consider an expectant mother who arrives at a clinic where all 12 tests are standard, and the counselor tells her she can opt out of five of them. Opting out feels different from opting in. The woman may feel that by neglecting to take some of the tests, she is jeopardizing her unborn child. Thus, she will keep all 12 tests.

Most people tend to stick with the standard option or the default, which means that medical students need to be mindful of what they set as the standard.

What trends do you see in health care decisions by consumers that will impact current health professional students?

The emerging trend is patient autonomy – delegation of choice and decision to patients.  The premise is that, given sufficient information, patients will make the health choices that are best for them. This shift poses a huge challenge to doctors, who are trained to treat patients but not to explain treatment options in a way that patients will easily comprehend. Medical students and residents seldom receive training on these types of communication skills.

Nowadays patients have access to online medical information. Does this make a provider’s work any easier?

You would think that greater availability of information should relieve some of the burden off of doctors’ shoulders, but such is not always the case. Medical information is often presented in a way that is confusing and hard to grasp. Probabilities, which are key in risk evaluation, are a particularly tricky concept.

I showed people text from reputable websites that supposedly cater to a wide audience. It is distressing that fifty percent of the participants misinterpreted what lifetime risk probability means – and this concept is broadly applied.

I also inquired about a test for the BRCA 1 or BRCA 2 gene mutations, associated with increased risk of breast cancer. Half the participants knew that the test could not tell them with certainty whether they will develop breast cancer. Yet about a third of the participants expected this kind of certainty from the test. Just imagine how misguided they were.

Doctors cannot assume that their patients are in the know just because there’s more information out there.

Don’t issues of misunderstanding apply only to certain patients?

People with low numeric skills and low health literacy are more prone to misunderstandings. However, doctors are not so good at detecting patients with low health literacy. Moreover, patients are good at hiding their bafflement, because it is embarrassing to tell your doctor you do not know what he or she is talking about.

Recently I heard about a man who had a prostatectomy. Before the surgery the doctor said, “You are going to be impotent,” to which the man replied, “It’s ok. I already have children.” The doctor had assumed that “impotent” is a common term.

The same thing happens when a doctor explains how to titrate medication. The patient nods, then returns weeks later having never increased the dosage.

Are doctors and medical students themselves immune to miscomprehensions and judgment biases?

Not quite.  In one of the most inventive studies, conducted by Gerd Gigerenzer and his colleagues, a healthy heterosexual white male went to a few dozen doctors’ appointments with a positive HIV test result. Almost all of the doctors told him he had HIV. Only a minority remembered that the test is not 100% diagnostic, that there is a 1:10,000 chance of a false positive result. Various ways of presenting probabilities and risk information help medical students and doctors understand those concepts.

How did you become involved in medical decision making?

I was a grad student in psychology, studying decision science, when the mission of making medical information comprehensible snuck up on me.  One of my professors asked if I might be interested in teaching a decision making course to Masters’ students of genetic counseling. I accepted, then realized I had no idea what knowledge would most benefit my future students.  So I sat in on genetic consultations.

I will never forget the first couple I encountered. The father was albino, and both parents were hearing impaired, so they were accompanied by an interpreter. They also brought their two year old, for want of a babysitter. The wife was pregnant, and the couple wanted to know what to expect from the newborn – what were the chances that he or she would also lack pigmentation and/or be deaf. They just wanted to know. They were also curious as to whose “fault” the baby’s condition would be, mom or dad. It mattered to the mother-in-law, who constantly blamed the husband for the first child’s lack of hearing.

The genetic counselor was just the kind of health expert you would want to meet – highly professional, well-prepared, and very caring. She spread out the charts of paternal and maternal heritage, then methodically explained how genetics worked, starting with chromosomes and genes.

None of this was redundant for me despite my education. I did not major in science and had not taken a biology class since, I believe, the 9th or 10th grade – it had been quite a while. Remembering which was the bigger unit, chromosome or gene, was not easy. I had to dig in my memory to figure out that there were 23 pairs of chromosomes and, well, lots of genes.

Meanwhile, the counselor was explaining this to the translator, who would explain it all to the couple. The interpreter seemed no less bewildered than I was. Information just kept coming in, which had to be conveyed to the couple through sign language. I could not help but wonder what they would say if we asked them to translate back what they’ve just been told.

The couple was physically there, but they were not really listening, and it wasn’t because they required hearing aids. They had gotten lost fairly early. You could see it in their faces. Chromosomes, genes, dominant, recessive – lots of terms, but not a lot of meaning.

Of course, the confusion had nothing to do with being hearing-impaired or albino. It had everything to do with being a patient. For all my fancy graduate training, I don’t think I would have fared any better than they did. The added layer of concern for the baby certainly did not make things easier.

Knowledge doesn’t just pour out of the medical system and into the patients’ minds, I realized. It has to be understood, processed, and dealt with emotionally. It was the counselor’s job to explain and the patient’s job to get it. Leaving the medical center that day, I still thought I was just going to teach decision making to genetic counselors. I did not realize that making medical information comprehensible was going to take over my interests to become my vocation. I did not realize it just then, but that was when my mission began.

For more information on medical decision making, please visit “Baffled by Numbers”, Dr. Miron-Shatz’s blog published on the Psychology Today website:

http://www.psychologytoday.com/blog/baffled-numbers

“Boutique” or “retainer” medical practices have been steadily growing since 2005.  In this practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. (1)

While it is growing in popularity, some physicians, ethicists, and policy makers are concerned about the trend. (2)

“Concierge care…is like a new country club for the rich,” Representative Pete Stark, Democrat of California, said at an economic committee hearing to Congress in April 2004. “The wealthy will pay for exclusive access to quality care, and everyone else will continue to have inferior access to primary care physicians, specialists, and basic medical advice.” (3)

Proponents of concierge medicine, on the other hand, say that it enables doctors to provide the best possible care and remain in a clinical setting.  Dr. Bernard Kaminetsky, an internal medicine physician in Florida, told the New York Times he would be working for a pharmaceutical company if he hadn’t been able to move to a concierge model.  “I’m really helping a lot of people.  I feel good about what I do,” he stated. (2)

To learn more about this growing trend, the Student Doctor Network spoke with Arney Benson of SignatureMD located in Santa Monica, California.  SignatureMD helps primary care physicians transition their practice to a retainer medicine model.  He is a graduate of the Massachusetts College of Pharmacy & Allied Health, and has over 25 years of healthcare consulting experience. He currently serves as President of AB Consulting and Senior Vice-President for Physician Development for SignatureMD.

How do you define “concierge” or “retainer medicine”?

Retainer medicine, sometimes referred to as “concierge” or “boutique” medicine, is a different type of care delivery experience in which physicians limit the size of their patient panel in order to provide more proactive health care services and greater convenience and access to their patients.  Patients pay a defined fee to experience this type of care, the specifics of which vary among physician practices.

How do retainer practices fit into the current health care structure (i.e., Medicare, insurance companies, etc.)?

A retainer practice focuses on patients in a proactive continuum of care.  You get to know your patients well and help them to coordinate their healthcare.  Instead of building your practice up to a panel with thousands of patients, you will have a panel between 300-500 patients.  While you can still accept insurance, you will also assess a yearly membership fee from your patients.

This retainer model typically requires fewer supporting personnel because of the lower patient load.  Therefore, you will have fewer patients and fewer staff to manage.

The retainer practice also offers a different service level that might include cell phone and/or e-mail access, same day appointments, longer physicals and routine appointments, coordination with fitness and nutrition providers and 24/7 access.

However, any practice continuing to participate in insurance plans must take into consideration the view of retainer fees by those insurance providers.  When the legality of retainer medicine comes into question, it’s typically because an insurance provider has a provision that does not allow the patient to be billed a fee for such management.  It is wise to work with a team of legal advisors, or a company like SignatureMD, to mitigate your risk.

One needs to always remember that a retainer fee is for non-covered services. If you stick to that, there should be no added issues for the current carriers.

Arney Benson

What do you see as the benefits of the retainer medicine model for patients?

Many patients complain today that by the time they get in to see their primary care physician, they have 10 to 15 minutes to explain their concerns before the physician is exiting the exam room.  Your patients need a relationship and a physician that knows them and thinks about the bigger picture.  A retainer practice allows for more time and more questioning.  A retainer practices focuses on prevention and the overall continuum of care.  Many physicians who practice in this manner also include their patient in the process in a more educational manner so they work on wellness plans together and discuss options in an informed (and un-rushed) manner.  If you were the patient, wouldn’t this type of care be what you prefer?

What do you see as the benefits of the retainer medicine model for physicians?

Here are the benefits we find:

• Increased income
• More time to spend with patients:  This increased time available to spend with each patient will allow you to address all of their problems, rather than just one or two. It also gives you the luxury of having the time to truly explain their diagnosis and treatment, which will enhance the patient’s trust, education, compliance, and satisfaction.
• More compliant patients
• Patients who value and respect their physician
• Less time at the office

Our company, and others like it, also provide help with practice management, such as:

• Secure online electronic medical records (EMR)
• Ongoing patient marketing
• Help with business operations
• Help with regulatory and legal issues

What types of personalities enjoy a retainer practice versus a more traditional structure – do your doctors tend to be more entrepreneurial, for example?

Not necessarily more entrepreneurial … but what that physician is: a forward thinking healthcare service provider that wants to deliver a quality of care model, and not the run of the mill reimbursement model (which is) stealing the only commodity necessary to function well in medicine, and that is the time factor.

The typical physician, if there is such a thing, that would do well has to have a driving force to change the status quo and deliver the kind of medicine and diagnostics as he or she sees fit and not be buried under the bureaucracy of the reimbursement model of short time diagnostics and paperwork equal to the time, and sometime more, than the treatments the physician delivers.

Is this a model that a physician could enter immediately out of residency?

Typically no. However, one could start a retainer practice, advertise the concept and build it from there. Realistically, that would take the better part of 24 months to 36 months to get to a reasonable patient enrollment to support the overhead of an office and earn a living. However, a better suggestion would be to seek out a retainer medical clinic for employment to build a relationship with patients so in 3-5 years, once your “affinity” relationship is such to support a retainer model, you can consider a boutique or concierge model.  By the affinity relationship I mean, would the patient be willing to pay a retainer to keep you as their primary care physician.  We find that a good professional relationship takes between 3 to 5 years to establish.

How would you anticipate retainer medicine changing if universal healthcare is implemented?

I think that’s it’s not a matter of if universal healthcare were to be implemented but a matter of when.

That being said, the retainer practice model will continue to gain popularity, as it has, as an example, in Massachusetts where healthcare for all has been implemented for the last two years. The reasons are many, but the driving force for many patients is that they are already frustrated with the existing system, including the wait times and care they receive from a 5 to 10 minute appointment.

The system will be a tiered system where everyone will have healthcare and those that wish a different service offering will seek out an alternatives, i.e. retainer model or a different delivery option for their primary healthcare needs.

Footnotes:

1)    Jeff Levine, “Boutique Medicine: For Your Well-Being?  Or the Doctor’s?”, AARP Bulletin Today, April 18, 2008 (http://bulletin.aarp.org/yourhealth/policy/articles/boutique_medicine.html)

2)    Abigail Zuger, “For a Retainer, Lavish Care by ‘Boutique Doctors’”, New York Times, October 30, 2005 (http://www.nytimes.com/2005/10/30/health/30patient.html)

3)    Congress of the United States – Joint Economic Committee Hearing, Opening Statement, Representative Pete Stark, April 28, 2004 (http://www.jec.senate.gov/archive/Documents/Releases/starkopenstate28april2004.pdf)

As an active member and advisor on the Student Doctor Network forums, I’ve received countless questions from medical students (and recent graduates) about jobs and opportunities in the non-clinical world of medicine. There are many medical students who are seriously asking themselves whether clinical medicine is really the “right fit” and they want to learn more about the various types of non-clinical opportunities available. Some may choose radiology or pathology to avoid patient contact. Others pursue non-clinical jobs in healthcare industries that avoid the clinical setting completely.

Why Consider Non-Clinical Options?

Why look at non-clinical opportunities?  Some medical students were pressured into attending medical school. I personally know some who went to medical school because it was an expectation while they were growing up. Now, they’re looking for other opportunities because they never really wanted to pursue a medical career.

Do you see yourself enjoying a lifelong career in medicine based on your unique strengths, talents, interests, and personal qualities? Some may feel like they’re stuck in medicine because they can’t imagine any other type of career. After all, where can you go to learn about non-clinical opportunities? Plus, if you have significant student loans, then you may feel like you have to find a high-paying job so you can make loan payments and still survive.

Additionally, academia tends to look down on non-clinical opportunities.  When I was a medical student, one of our attending physicians left the world of academia to work for a pharmaceutical company. This individual was criticized by others for moving over to the “dark side.” You’ve probably heard that euphemism before, even if you’ve never watched Star Wars.

Residency and Non-Clinical Jobs

Let me start with the most common question I get from medical students who don’t see themselves practicing medicine: “Should I do a residency?” Residents often ask: “Should I complete my residency?”

I generally try to encourage every medical student to pursue residency because I’ve found that physicians have many more non-clinical opportunities if they complete a residency and become board certified in a specialty. At a minimum, complete an internship so that you can gain some clinical experience. This way, you won’t look back and wonder “what if I had done a residency?”

I realize that some students are completely convinced that they want to get out of medicine. They have no plans of pursuing a residency. As a result, they often approach me with questions about non-clinical opportunities for medical school graduates who lack residency experience.

In this article, I will focus on opportunities in the world of medical writing.

Medical Writing 101

What is medical writing? This field is so broad that I could write several articles about it. In a nutshell, the world of medical writing can be many things at once. It can be: flexible, lucrative, enjoyable, boring, stressful, and mundane. If you’re confused, you should be. Most people don’t understand what medical writers do.

If you enjoy writing and you consider yourself to be a strong writer, then you may wish to pursue this career.  I recommend starting by joining the American Medical Writers Association (AMWA) and learning more about the field of medical writing. Keep in mind that most medical writers are not physicians. However, physicians make some of the strongest medical writers, especially when it comes to projects that involve a heavy amount of clinical science and first-hand patient experience.

Allow me to expand on this a bit further by providing you with a few examples of medical writing opportunities.

• Professional medical communications and medical education: There are many small, medium, and large companies that focus on medical communications. Some are large print publishers. Others like WebMD are mainly online publishers. There are also many private companies that develop medical education activities. It’s important to clearly delineate between promotional medical education and certified medical education.
  • Promotional medical education: This is also commonly known as marketing, but promotional sounds better though, doesn’t it? This ranges from content presented at promotional “dinner meetings” (which are not occurring as frequently due to budgetary constraints), journal advertisements, to direct-to-consumer (DTC) television advertisements. Companies may be called “promotional medical education companies” or even “ad agencies.” Publishers also get involved in this space.
  • Certified medical education, also called Continuing Medical Education or CME: In the past, CME was a loose term that people threw around when they were talking about any type of formal or informal education that took place after residency completion. Today, CME specifically refers to certified education that meets the criteria set forth by the ACCME (Accreditation Council for Continuing Medical Education). CME dinner meetings still occur and they are clearly labeled “CME” or even “certified CME.” Private companies that develop CME activities are not allowed to develop promotional activities. The only exception to that rule applies to entities that declare themselves to be “publishers.” You’ll still find CME in medical journals like JAMA along with full-page drug advertisements (but they won’t be on the same pages as the CME activity). Universities and professional medical societies produce a large amount of CME, so you may find some opportunities there as well.
• Consumer-level health education: WebMD is well-known for educating patients about health topics. These types of companies rely on medical writers and reviewers for content that is written on a consumer level. This can sometimes mean a fourth to sixth grade reading level. There are many other companies that offer similar services and most jobs in this area would fall under the “medical writing” category.
• Clinical research: Research opportunities for medical school graduates are abundant in university settings. In fact, this is how many foreign medical graduates enter the U.S. if they are unable to secure a residency. Research can obviously also occur in academia or in government institutions. Be prepared to write grants, research papers, abstracts, posters, and more. You can also find opportunities within Contract Research Organizations (also known as CROs). Medical writing in the world of research often involves regulatory writing, drug safety reports, protocols, etc. Once you gain some experience in this space, you may have the chance to work in pharma/biotech.
• Freelance/contract medical writing: Many successful medical writers work from home or telecommute. In fact, a large number of writers have a busy freelance business that keeps them busy all-year long. The nice thing about freelancing is that it gives you tremendous flexibility. The major downside is the potential for unsteady income. However, if you want to work on various types of writing projects, you may enjoy the life of a freelance writer.
• Market research and survey writing: I actually meet medical students who don’t know what the term “market research” means, so if you happen to be one of them, you’re not alone. These types of students typically have no business training prior to medical school. Market research is often performed through surveys that are written by clinicians or medical writers. If you have an analytical mind, then you may enjoy writing market research survey questions and analyzing the data for marketing purposes.
• Medical blogging: Yes, you can be hired to write for medical blogs (or even non-medical blogs). You don’t have to be a professional writer, but it helps if you have a unique communication style. You may have read the NY Times article about a nephrologist who left clinical medicine to go into full-time blogging (about Apple rumors).

Other Non-Clinical Opportunities

If you don’t enjoy writing, then keep in mind that there are other non-clinical opportunities in industries such as public health, venture capital, executive search, health information technology, public health, consulting, pharma/biotech, and more. You can learn more about these types of opportunities by visiting www.NonClinicalJobs.com.

Preparing For Non-Clinical Work

Finally, let me provide a few tips for those medical students who don’t plan to go into residency (or if you’re thinking about quitting in the middle of your residency – which I do not recommend to anyone):

• It’s critical that you grow your social network if you plan to look for non-clinical jobs immediately upon graduation. This may be the most important step in determining what type of position you land.
• Connect with executive recruiters. You may have heard of them as “head hunters.” These individuals can be very helpful in providing you with job leads and they are eager to help you. They shouldn’t charge you anything since they get their commission from the hiring company.
• There are many positions that may be considered “springboard” jobs. In essence, these jobs will provide you with the necessary corporate experience to then “jump” you into another career or industry. You may gain tremendous experience by working in a “springboard” position for 2-3 years before making a major move. Consider the gains if you’re willing to make such a sacrifice (sounds like residency).
• As you work in the non-clinical setting, you’ll meet more and more people who may become invaluable leads and contacts for the future. Continue to grow and maintain your social network because you never know when you may to find a new job.
• Enhance your computer and technical skills. You’ll be expected to be very proficient and productive on the computer. You’ll be working in Microsoft Outlook, Word, Excel, and PowerPoint. You probably won’t carry a pager, but you may be expected to use a mobile e-mail device like a smartphone.

Have specific questions? I’m a volunteer advisor on the SDN forums and I welcome your questions and comments. Please note that this article is not meant to discourage medical students from pursuing a career in clinical medicine. This article is also not meant to encourage residents to leave residency. Rather, the purpose of this article is to provide some education about non-clinical options so that students can make informed decisions about their career path.

About Joseph Kim, MD, MPH

Dr. Joseph Kim is an active physician blogger and he blogs daily about non-clinical issues at www.NonClinicalJobs.com. He is a strong proponent of strategic social networking and he has used his personal network in various situations to help people find non-clinical opportunities in different healthcare industries.

by Tony Guerra, Pharm.D.

We have a hiring freeze. Call us in a couple of months. We have a position, but it’s in a small town. Do you need benefits? How much experience do you have? Did you do a residency?

These aren’t supposed to be answers to our interview questions as pharmacists. We’re supposed to be able to fog a mirror and get a job. We should get to negotiate for a higher salary with a nice sign on bonus where and when we want. What happened to the good old days? You know, last year.

Supply and Demand

As the United States population has grown older and heavier, the demand for prescription medications has skyrocketed. Working to fill the need, chain pharmacies have gobbled up independents and kept their doors open later (many overnight), requiring greater levels of staff. As HMO’s, hospitals, clinics, universities, mail-order services, and the military all need pharmacists, they have been willing to pay handsomely for them.

At the same time, women have entered pharmacy in far greater numbers than ever before, many opting for part time positions or taking extended leaves to raise children. Complicating things further, when bachelor’s programs were phased out in favor of Pharm.D. programs, a year’s worth of graduates were lost.

All of this created an historic shortage of labor. State pharmacy schools could not keep up with demand, so the private schools started adding pharmacy programs at a rate of almost two per year (up from one every three years). In 1990, there were 74 pharmacy schools operating in the United States. Today, there are 103 with an additional nine in pre-candidate status. As salaries begin to stagnate or worse—drop, this may end up as a game of musical chairs, forcing a number of pharmacy programs to close their doors as quickly as they opened.

Tony Guerra, Pharm.D.

What does any of this have to do with finding a job you’re passionate about? To put it simply, you must work smarter to get it. If a PGY1 could have landed you a faculty spot before, then now you may need a PGY2 to get that same position. You may need to know a couple of people at the college or at the place you want to work. You may need to take a job that you don’t like as much so that you can build the skills and relationships to get exactly what you want.

But I want it now!

I understand. The truth is you can have it now, if you are willing to go outside the box.

I ask residents, “What are you going to do after your graduation or residency?” Nine times out of 10, the answer is, “I don’t know.”  Like being an Olympic athlete who has worked their entire life to win a gold medal, you will stand at the graduation platform thinking about the moment rather than what might satisfy you in the future. But there are actionable steps to arrive where you want to be.

Step One – Decide what you love to do on the most basic level.

Do you want to teach? Lead? Write? Advise? Manage? Whom do you love to help? Kids? Adults? Students? When you close your eyes, where do you see yourself smiling at work? By answering these questions, you can start moving in the right direction.

A pharmacist herself, my wife loves being the trusted advisor. Whether with family or patients, she loves to sit down and help people because she is a talented listener. With this in mind, she focused on becoming a diabetes expert through a program at Drake and in her practice. After showing a local free clinic how she could help them, they offered to create a 16-hour position due to the great work she had accomplished with diabetic patients. Because her passion was in line with her work, an opportunity was made.

Step Two – Volunteer.

Too many people ask for something then expect to get it, as if getting the career of your dreams is a one step process. The real order of service is to give, then ask, then receive. Since I wanted to teach and didn’t care if I got paid, I volunteered in a middle school math program. Later, I got paid to tutor, proctor, and teach test prep at Kaplan. It wasn’t a pharmacist’s salary, but their training program was great. After that, I volunteered to teach in pharmacy courses at the University of Iowa.

Each succeeding experience has made me more confident and more able. When the opportunity finally arose to teach a full-time course at a local community college, I was accepted right away. Yet, all of this began in a public school classroom with the willingness to give.

Step Three – Build your own practice.

The job you make for yourself is the job you’ll love. The day I left retail and started my own business, I was scared. But once I bought my own health insurance, I realized it wasn’t that bad and the freedom is amazing.

While I certainly had responsibilities to my customers, I could schedule them around other things in my life. I could coach in the afternoons, take trips with my family, and spend evenings at home. I was there for people when they needed me while building deep relationships one-on-one instead of trying to do the same through a plate glass drive-through window.

Building your own practice is life changing. It’s like going to a restaurant and ordering from the à la carte menu and getting exactly what you want.

Step Four – Start Now.

If you haven’t already, soon you will see the real impact of this economy. There are likely to be two kinds of responses. The first: you can cling to a job that you may not like out of fear of the unknown. The second: you can go forward, today, and start building a practice that you love. Involve the friends you missed while you were on that lonely pharmacy island.

Entrepreneurship is back in a big way. It can be your ticket to the work you love. Take the smallest step right now by writing down what you want. My own mission is to “build a service business so I can train in the mornings, teach during the day, coach in the afternoon, and be with my family and friends nights and weekends.” Write yours out, and it will become a reality.

In 1987, NOVA’s cameras began rolling to chronicle the lives of seven medical students embarking on their years-long journey to become doctors. From their first days at Harvard Medical School to the present day, none of them could have predicted what it would take, personally and professionally, to become a member of the medical community.

The final installment of NOVA’s Doctors’ Diaries is a two-part special premiering Tuesday, April 7 and 14 at 8pm ET/PT on PBS (check local listings).  The longest-running U.S. documentary of its kind, Doctors’ Diaries begins by reuniting the physicians on the steps of Harvard Medical School 17 years after graduation.

The seven physicians profiled in NOVA's "Doctors' Diaries" (photo credit: NOVA - Betsey Cullen)

Footage from the previous four installments in the series offers a rare and candid look at the rewards and personal sacrifices each has made over the last two decades – from the stress of medical school exams, to the first cut into a cadaver, through first wedding ceremonies (and sometimes second or third), internship, residency, and life as a certified M.D.

The seven physicians featured in Doctors’ Diaries have taken divergent paths:

• Tom Tarter, Bloomington, IN – The Bronx-born, long-haired, tattooed ER doctor has constantly grappled with how he is perceived as a physician. After his contract was terminated at the local hospital he became an itinerant M.D., forcing him to look for work in distant locations. Once a bouncer, an Olympic-hopeful weight lifter, and a mechanic, Tom is now on his fourth marriage and struggles to make ends meet.
• Jane Liebschutz, Boston, MA – Currently an internist specializing in underserved populations, domestic violence, and addictions. NOVA was there for the gut-wrenching moment when Jane experiences a patient dying in the operating room for the first time.
• Jay Bonnar, Belmont, MA – This private practice psychiatrist is also involved in outpatient group therapy and teaches at the hospital.
• Elliott Bennett-Guerrero, Durham, NC – A successful anesthesiologist who picked his specialty partly based on the less demanding hours-this now affords him more time to be at home with his second wife and two young sons and pursue his new passion: golf.
• Luanda Grazette, Thousand Oaks, CA – Originally trained as a clinical cardiologist, Luanda now works for a pharmaceutical company to develop drugs that will help heart patients.
• David Friedman, Baltimore, MD – As an ophthalmologist and professor at Johns Hopkins University, David aims to one day establish a hospital to provide eye care to the millions of people worldwide who currently have no way to improve their poor vision.
• Cheryl Dorsey, New York, NY – Although she eventually completed her pediatrics training, she never practiced. Cheryl put her residency on hold to found a program that provides free curbside health services for minority communities; today she is the president of the same nonprofit that funded her Family Van mobile clinic.

Producer and director Michael Barnes recently spoke with The Student Doctor Network about Doctors’ Diaries.

Michael Barnes (photo credit: Jim Murphy)

How have you seen the profession of physician change over the course of the series?

Managed care was well entrenched in 1987 when we started filming at Harvard. A couple of the doctors we followed are the sons of physicians. They describe that it was their fathers who saw the biggest changes in the profession. Under Ronald Reagan’s presidency, Congress encouraged the transition of the insurance industry from a not-for-profit ethos into a for-profit approach as enabled by Health Maintenance Organization Act of 1973. Without exception all seven doctors in the series believe the for-profit approach is flawed and that the healthcare system is broken. But this is the model under which they became doctors. Perhaps the biggest change for them is yet to come if the healthcare system can be reformed.

What do you think you would find if you started this series over in 2009 with a new set of first-year medical students?  Do you think the experiences would be similar?

Over the past two decades most medical schools have improved the curricula for the first two years of training (as Harvard did back in 1987 with the New Pathway). I understand 3rd and 4th year students at Harvard now do their rotations at one hospital rather than switching every month. Since we filmed, legislation has resulted in Interns working less hours with fewer nights on call. Despite these changes I am certain the medical school experience would be almost identical to those we recorded in Doctors’ Diaries. There are no short cuts to the process of becoming a fully initiated member of the medical tribe.

Over half the doctors that were featured in the program were married and divorced during the 21-year span of the program.  Do you feel that medical students, residents and physicians are more likely to have negative incidents in their personal lives due to the stresses of their profession?

In the UK, and I suspect in the United States too, physicians do have a higher risk of divorce (as well as drug abuse and suicide) than other professions. Based on our seven physicians it seems that the most difficult time to sustain intimate personal relations is during medical school and residency. Relationships that began later seem to be faring better, perhaps because a reasonable work life balance has been achieved. A couple of the doctors described how their tendency to treat their spouses “like interns” led to conflict.

One of the students (Cheryl Dorsey) is not currently a practicing physician.  Was her journey the most unexpected, or did another student surprise you more with his or her choices?

Luanda’s choice to stop seeing patients and work fulltime in research at Amgen was a surprise. But I am sure her love for patient care will pull her back in to clinical practice at some point soon. Although she kept to herself any misgivings about going to medical school I did sense that Cheryl was ambivalent. Although Cheryl took a circuitous route to get there it is wonderful to see how completely fulfilled she is in her job leading the Echoing Green foundation (that provides seed money for social entrepreneurs).

At the time that the original series was produced, 1987, the whole “reality TV” concept did not exist.  Today, documentary and “reality” television is common.  Do you think that the numerous medical reality shows give a realistic or unrealistic vision of the life of physicians, based on your experience with Doctors Diaries?

I don’t watch a lot of reality TV about doctors. But shows that trade on reality should respect it. Doctors’ Diaries will influence how these seven doctors are perceived and judged by viewers. Even though we shot around 500 hours over two decades for the NOVA series making a film that is completely true to their lives is impossible. Real life is a muddle and as storytellers we must impose structure by deciding which scenes to keep in and which to leave out. As we edit ever more finely it comes down to choices about individual words and frames. The NOVA series only documents a tiny fragment of their lives. But our guiding principle is always to portray the spirit of their careers. In striving to achieve authenticity I have found a good test is to imagine the doctor watching the scene in question in the same room as myself. If that would be an embarrassing experience I have probably made a bad decision. At a recent preview screening which a couple of the doctors attended Jay remarked, “I recognized myself”. I hope the others can say the same.

The Student Doctor Network targets pre-health professional and health professional students.  What key message or messages should they take away from this series?

As Luanda once said becoming a doctor is only for people who cannot imagine doing anything else. Tom agreed and said that if you have any doubts about giving up a decade of your life there are several careers such physician’s assistant and CRNA, which do not require quite so many years of training.

For more information on Doctors’ Diaries, please see the NOVA website at http://www.pbs.org/wgbh/nova/doctors/.

Based on a series of polls conducted by the Student Doctor Network, students generally understand the current salaries they can expect to receive as a health professional.

The polls asked SDN users to select the salary range for an occupation “without Googling” to find the correct answer.  The results of the polls are available in the SDN poll archive.

Students were most likely to select the salary range into which the actual mean annual wage falls for all occupations except Dentists and Optometrists.  Actual wages used for comparison were determined by the Bureau of Labor Statistics and are accurate as of May 2007.

The range was underestimated for Optometrists and overestimated for Dentists.  In both cases the mean wage lay very close to a break point for the salary ranges available, and a majority of respondents selected either the correct range or the next closest range.

The table below details these wages:

 

For most occupations, while the answer most likely to be selected was the correct one, incorrect responses skewed higher than the actual wage.  For example, 61% of students overestimated the wage for Occupational Therapists (OTD), versus only 12% underestimating the wage.

“The internet makes it easy for students to identify what they can generally expect for a wage following completion of their degree,” said Michael Magatelli, an employment expert and executive coach with the Magatelli Leadership Group of Sacramento, California.  “No student should invest in a degree without understanding the value they are going to receive from it.”

To gain further insight into wages beyond the average salaries referenced above, Magatelli recommends students conduct four to six “informational” interviews.  These interviews will help illustrate any unique costs or required investments associated with setting up their desired practice model.

“Informational interviews, in addition to internet salary information, will provide a more complete picture of the costs of becoming a practicing health professional in your geographic area,” said Magatelli.