Excerpted from

The rancor over how to reform America’s healthcare system rages on, as millions of uninsured and underinsured people struggle to find affordable medical care. Meanwhile, volunteer health professionals from across the country, like those at the Greater Milwaukee Free Clinic, do their best to put a bandage on a serious national wound.

Author Stephen J. Busalacchi highlights the work of internist George Schneider, MD, of Milwaukee, in his oral history, White Coat Wisdom: Extraordinary doctors talk about what they do, how they got there and why medicine is so much more than a job.

In this excerpt from the chapter titled, Sick, Huddled Masses, Dr. Schneider reveals that the vast majority of patients he sees at his free clinic twice per week are working people who can’t afford health insurance.

Visiting the Greater Milwaukee Free Clinic is like walking back in time. It’s as if it was preserved from the 1970s, even though this space had been a private practice doctor’s office until the early 1990s. The carpet is drab, the chairs are worn and the other furnishings are a mish-mash of donated stuff that fills the gap. Even the clock on the wall has a pharmaceutical company name emblazoned on it, as do other free supplies.

The office has “crappy file cabinets,” according to Dr. George Schneider, the medical director, but he’s grateful for them and all of the other donations, because they allow him to help people who are not getting medical care.

When you’re sick and have nowhere to go, you probably don’t give a damn about these frivolous details. Patients come here in droves twice a week to receive care from the dozens of physicians, nurses and others who volunteer their services.

Although the doors don’t open until five, Dr. Schneider says it’s not unusual to have somebody waiting at three. By the time the clinic opens, a crowd is huddled in front of the building.

Schneider, who founded the free clinic with his wife, Kathleen, in 1995, sees its popularity as a bellwether for the failings in our current health care system.

Dr. George Schneider, Medical Director, Milwaukee Free Clinic

Dr. Schneider:  Growing up, the idea of doing something charitable was something that went on in our family. My mother was from Northern Wisconsin, from a small farm in a small town, and it seemed to me there were always people coming to the house and staying for a while, who were moving from northern Wisconsin to the city. They heard about her. They stopped in, maybe had a meal. Maybe spent a few nights. I remember my mother giving things away.

“Here are some clothes. Here are some pots and pans and plates and pencils, to help get you started.”

My father was a garbage man who worked for the city of Milwaukee, but he also had an interest in real estate and had multiple duplexes in town. Some of his tenants were not always very timely in paying their rent, but he let them stay, as much as he could. He did not evict anybody. There was always that background in our house about doing things for people who were kind of down on their luck. The free clinic maybe was a natural evolution of that.

Last year, we saw about 1,930 patients. The volume has probably increased by about 25% a year over the last several years. Volume has increased over the past several years, compared to the first seven years of the clinic.

Does that worry you?

Yeah, it’s a concern because the very existence of free clinics is a reflection on the whole health care system. The system is breaking, and it’s broken in some areas. So yeah, it’s nice to say your numbers are going up, but not at the free clinic.

One of our original goals when we started back ten years ago was for the clinic to go out of business, but it doesn’t look like that’s going to happen anytime soon. We see more immigrants who come to the clinic. We see more working people whose employers are making them pay more of the premium and the cost is prohibitive. It’s basically, a question of fairness and justness.

The current model based on employment isn’t working. In my practice, I see people whose deductibles are going up. The employers are paying less and less their share of the premium, and so more of my patients are raising issues of cost and testing and primary care services, especially drugs.

Covering the uninsured is an issue society has to deal with. That number keeps rising every year, and society and politicians sort of dance around the issue and nobody really does anything. The uninsured, that’s not really a group of people anybody is looking to take care of and get their support and vote.

Single payer is really the way to go. Whether that’s national health or some other model, I don’t know. I don’t have enough knowledge to answer that question. I feel the current system with private insurance companies—that’s a very expensive system. The overhead is high. Their overhead runs anywhere from 15 to 20 percent. Medicare runs with three or four percent overhead. You could cover all the uninsured on savings from administrative costs.

Will it happen?

I think, slowly. The system is crashing, slowly, but inevitably. More and more people are complaining about it, everything from the uninsured poor to those who are working, who have insurance. The deductibles are higher, and the co-pays are higher.

The clinic’s open two nights per week. When we first started, we had one physician working. But because of the volume increase over the past two years, I’ve gone there pretty much two nights per week to work along with the regular physician of the night, and probably working three to three and a half hours a night.

The doors don’t open until five, but lots of times there’s somebody sitting out there at three. We have twenty chairs in the waiting room and they’re usually all filled. We start seeing patients around six and we leave when we’re done. An early night, we might get out by eight-thirty. Some nights we’re there until ten or eleven.

Who are these people who come to the free clinic?

The typical patient we see reflects my practice—an adult with hypertension, diabetes, smoking, bronchitis, or arthritis. It’s really the working poor. Our mission statement says that we see low-income, working, uninsured people—people who fall through the cracks, those that don’t have health insurance, but they make a little more money and they don’t quality for other programs.

We see a lot of people who work part-time jobs, who maybe earn $15,000 a year and live on that. Some of them work multiple part-time jobs. Some have full-time jobs, but they can’t afford the insurance that’s offered, or maybe insurance just isn’t offered.

Benefits aren’t provided for those who work for a temp agency. We see people who—and this is a situation we’ve become more aware of recently—who qualify for disability, and get on social security and disability, so that raises their income, which in turn, disqualifies them from participation in government programs because their income went up. We do see more and more people chronically unemployed, chronically not working.

I saw this patient who had lost his job and noticed some swelling in his abdomen. He went to another physician, and was told, based on the examination, that, “You have cancer. You’re going to be dead in two months.”  So this guy was just going downhill from already being down and depressed. We asked a few questions. Where were you? Who said this? He was a little vague, so we ordered the $800 x-ray.

He didn’t seem that ill, just very depressed. He was kind of getting ready to die. We did a CT scan of his abdomen, and there was nothing wrong with him. There was nothing wrong with him, so we told him that, gave him the good news. It kind of turned his life around. He was ready to cash in his chips and die. He never came back to the clinic, so I assume he went out and got a job.

How much satisfaction do you derive from this?

It’s a great feeling to see somebody who comes in who’s not feeling well, who’s not doing well, who is sick—and you’re able, with just an examination and some testing and interpretation of the results, to cheer them up, and get them feeling better. Yeah, it’s very satisfying. You get a real high from that.

They’re grateful, but we’ve noticed an attitude develop over the past few years, kind of an entitlement mentality. You give somebody something and they want more. That’s very discouraging for volunteers, and being at the free clinic it gives us a little freedom to say, “No, we don’t have it. That’s all you get.” Some people we’ve kind of told, “We don’t want you to come back here anymore. Go someplace else.” We might be free, but we’re not stupid. That’s just a small minority, but it only takes one a night to ruin the whole night for everybody.

We’ve fired patients from the clinic just because we don’t want one bad apple to ruin it for everybody else. The volunteers see that, and it typically happens with a new volunteer, and it’s easy to say, “I don’t need this. I’m not coming back here. These people are abusive. I could be doing other things.”

Is the demand going to keep increasing?

I think so, until something is done. In the United States, we have a wonderful health care system, but we don’t have a fair health care system. The resources aren’t going to the people that need them. You see the people who need it the most, but can’t get it because they don’t have insurance. It’s a fairness issue more than anything.

Stephen J. Busalacchi is author of White Coat Wisdom: Extraordinary doctors talk about what they do, how they got there and why medicine is so much more than a job www.whitecoatwisdom.com ©2009 Apollo’s Voice, LLC

For most residency applicants, the arrival of November marks the beginning of the interview season. This often brings back memories of the medical school admission interview, with the ubiquitous “Why do you want to be a doctor?” question.

Four years later, you find yourself in a similar situation – this time, hoping to land a position in the specialty and residency program of your choice. “Why do you want to be a doctor?” is now replaced with “Why do you want to go into [this specialty]?” and “Why are you interested in our residency program?” While the questions will differ to some extent, you may be experiencing the same gamut of emotions – uncertainty, nervousness, and perhaps even fear.

Given the highly evaluative nature of the interview process and its importance in the residency selection process, this anxiety is well-placed. Over the years, many surveys of program directors have inquired about the importance of the interview. Recently, the National Resident Match Program surveyed 1,840 program directors representing the nineteen largest specialties to determine the factors used for ranking applicants.¹ Ranked number one, even higher than clerkship grades and USMLE scores, was the residency interview. A number of previous studies substantiate this finding. In one study done at the Children’s Hospital of Pennsylvania, interview scores were found to be the most important tool for the ranking of applicants.² In a survey of family medicine and obstetrics/gynecology residency program directors, the residency interview was found to be most valuable in the ranking of applicants.³ Program directors of internal medicine residency programs have also rated the interview as most useful for ranking decisions, with 96% of respondents reporting the interview to be highly or moderately useful.⁴

While receiving an interview invitation is an honor, simply being interviewed does not guarantee a place on a program’s rank list. In a study of emergency medicine residency programs, with data obtained from 3,800 individual interviews, a total of 14% of interviews resulted in unranked applicants.⁵ In another study, one third of applicants were actually ranked less favorably following the interview.⁶ Dr. Reilly, former program director of the University of Texas medical school at Houston psychiatry residency program, states that a “good interview can save someone with the less than perfect application. A bad interview cannot always be salvaged by a paper record.”⁷ The conclusion here is that the interview is critical to your chances of a successful outcome.

Recognizing the importance of the interview, we have devoted four chapters and nearly fifty rules to the interview process in our book, The Successful Match: 200 Rules to Succeed in the Residency Match. In this column, we discuss three of the most important rules for interview success.

Dig deep

The primary goal of an interview is to impress upon the decision-makers that your unique qualifications are exactly what they seek.  Many decision-makers refer to this as “fit.” Will your strengths and aspirations help the program achieve its own goals? Are your proven qualities the type necessary to achieve success as a resident in their program? In order to convey this message, you need to know yourself, and you need to know the program, and you need to be able to convey this knowledge during the interview.

Conveying this message starts with demonstrating a strong and sincere interest in this particular residency program. One of the easiest ways to impress an interviewer is to arrive well prepared, having thoroughly researched the residency program. Start with the program’s website. What is the program’s philosophy? Is the program known to produce academicians? Is it recognized for its contributions to community service? Is research an area of key emphasis in the department? What is the program looking for in a resident?  With this knowledge in hand, you will be better prepared to demonstrate to the program that you are precisely the type of individual they seek. Equally important, the information that you gain will help you decide if this is a program where you would like to train.

While most applicants will review the program’s website, too often the research begins and ends there. We recommend that you dig deeper. Perform an internet search to learn more about the program, its faculty, the hospital, and the city. Well before your interview, contact graduates of your medical school who are residents or faculty at the program. Locate physicians in your area who trained at that program. These individuals can provide valuable information about the program, which you, in turn, can refer to during the interview. For example, “Dr. Ran, the chairman at my medical school, was recently a visiting professor in your department. In speaking with him, I learned about how your program really pioneered human simulation training as a teaching tool. I’ve been looking forward to learning more about that during this interview.” Candidates who make the effort to take these steps can convincingly demonstrate that they are truly interested in the program.

Many applicants do an excellent job in researching a program in advance. Unfortunately, many don’t know how to, or don’t feel comfortable, demonstrating this knowledge. They may end up making no reference to the specific information that they have read or learned about the program, or they may ask the type of basic questions that could have been asked by any other applicant.  The end result is a generic interview, and a lost opportunity to demonstrate your strong interest in the program.

First impressions can make or break you

Multiple studies have shown that creating a favorable first impression is critical to interview success.  In one study done by Thomas Dougherty, chair of business and economics at the University of Missouri, a favorable first impression led to an easier and more successful interview. Interviewers who are more favorably impressed by interviewees during the first few minutes went on to treat those applicants more positively. They spoke with a more positive vocal style, engaged in more active recruiting of the applicant, and asked less questions.⁸ Although this study was in another field, medical faculty interviewers are not unlike those in other fields. The impressions they form of you through your first interactions will play a pivotal role in your interview success, or lack thereof.

The obvious measures in managing first impressions remain critical. One should arrive early and be well-dressed and impeccably groomed. The ability to maintain appropriate eye contact and shake hands properly are little discussed in medicine, yet are no less important. One article in the Lancet found a strong correlation “between a firm handshake – as evidenced by strength, vigor, duration, completeness of grip, and eye contact – and a good first impression.”⁹ It is important to be able to walk into a room and project self-confidence through your body language, facial expressions, and tone. In addition, the ability to engage in small talk is more important than many applicants realize. Dr. Jamie Collings, program director of the emergency residency program at Northwestern University, states that “whether the topic is the weather, current events, or sports, you’re expected to participate.”¹⁰ She encourages applicants to get “up to date on current events, see a movie, read a non-medical book, and read the paper regularly.”

Dr. Ziegelstein, associate program director of the internal medicine residency at Johns Hopkins Bayview Medical Center, states that “individuals who interview and judge others for a living (e.g., program directors) often form very strong first impressions. Typically, those individuals are flexible and those impressions are changeable, but those first impressions are nevertheless important.”¹¹ In our experience helping applicants prepare for interviews, we know that applicants spend considerable time preparing for anticipated questions. Unfortunately, most applicants then give little or no thought to the factors involved in a favorable first impression. Preparing for the subjective factors involved in first impressions is just as important as preparing for the typical interview questions. If you’re uncomfortable with small talk, practice with others. Mock interviews with friends, colleagues, and mentors may highlight weaknesses, and are an important tool in interview preparation. Make sure you’ve received honest feedback on your interview performance.

Stand out from the rest of the crowd

You are competing with, perhaps, hundreds of other applicants. It is critical that you ask yourself “What is it that sets me apart from the other candidates?” Through our own experiences interviewing applicants, and through discussions we have had with other faculty interviewers, we know that few applicants make a concerted effort to stand out from the rest of the pack. We agree with Dr. Krogh, former faculty member of the department of family practice and community medicine at the University of Minnesota, who reminds applicants that “programs interview hundreds of applicants, many of whom are compatible with the program. Make yourself noticeable enough. How you do it is up to you but many unfortunately do not even try to do it.”¹²

We understand that you may not consider yourself unique. In fact, parts of your background and qualifications are likely to be similar to other applicants – good grades, solid USMLE score, and good medical school. Is there anything truly unique about this package? Not on the face of it. But there can be. Many applicants have remarkable accomplishments, but fail to recognize or discuss them. Others have unique strengths or particularly strong qualities that they fail to emphasize in their application materials and interview.

Did you have a fantastic overseas international health experience during medical school? Were you involved in cutting edge research? Do you have a special or unusual talent? Have you gone out of your way on clinical rotations to emphasize patient education and the provision of patient educational materials? Do you have an aptitude for teaching, and have you demonstrated that through your activities in medical school? Were you the founder of your medical school’s pathology club or the president of AMSA? If so, the interview represents a wonderful opportunity to highlight these accomplishments.

We’ve spoken to applicants who brainstorm, and don’t feel as though they can discuss anything remarkable or unique about themselves. While that’s hardly ever the case, you can still utilize additional ways to stand out. Impress your interviewers with your level of preparation. Showcase your strong communication skills. Answer each question by taking it one step further than most applicants. For example, applicants often answer the question “What are your strengths?” with a short list of qualities. “My strengths include my attention to detail, interpersonal skills, and ability to persevere.” Most applicants stop there. The few that continue with an example that highlights their strengths succeed in leaving a memorable impression. “My ability to persevere has been central to my success. The pathology interest club that I wanted to set up at my medical school was initially applauded, but my cofounder and I hit many obstacles. Even though I started during first year, the club didn’t come into existence until my third year, and it was my perseverance that kept me going and dealing with all the roadblocks.”

Asking insightful questions is yet another way to distinguish yourself. These can highlight your individual qualities, as well as your interest in the individual program. Dr. Ksiazek, program director of the Pritzker School of Medicine ophthalmology program at the University of Chicago, states that “You do not want to blend into a sea of other applicants by asking the same old questions.”¹³ As interviewers, we’ve all heard the typical “What do you consider to be the weaknesses of the program?” Contrast that with: “In medical school, I have had several international health experiences which I have found very fulfilling. That’s why I was particularly excited to learn about the global health track your residency offers in Kenya. What kind of impact has the global health track had on residents in your program?”

And finally…

As you approach your interviews, focus on how far you’ve come.  By offering you an interview, the program has essentially informed you that you are a competitive candidate. Given that programs routinely receive hundreds or even thousands of applications, an interview invitation is a real honor. Programs only extend these invitations to candidates who are being seriously considered for a residency position. Having come so far, it is essential now that you devote the effort, time, and preparation necessary to sell yourself effectively and convincingly to programs.

References

¹Results of the 2008 NRMP Program Director Survey. Available at http://www.nrmp.org/data/programresultsbyspecialty.pdf.  Accessed on October 26, 2009.

²SwansonWS, Harris MC, Master C, Gallagher PR, Maruo AE, Ludwig S. The impact of the interview in pediatric residency selection. Amb Pediatr 2005; 5 (4): 216-220.

³Taylor CA, Weinstein L, Mayhew HE. The process of resident selection: a view from the residency director’s desk. Obstet Gynecol 1995; 85 (2): 299-303.

⁴Adams LJ, Brandenburg S, Blake M. Factors influencing internal medicine program directors decisions about applicants. Acad Med 2000; 75: 542-543.

⁵Martin-Lee L, Park H, Overton DT. Does interview date affect match list position in the emergency medicine national residency matching program match? Acad Emerg Med 2000; 7 (9): 1022-1026.

⁶Gong H, Parker NH, Agar FA, Shank C. Influence of the interview on ranking in the residency selection process. Med Educ 1984; 18 (5): 366-369.

⁷Reilly E. Career counseling: psychiatry. Available at www.uth.tmc.edu/med/administration/student/ms4/2003CCC.htm.  Accessed October 22, 2008.

⁸Dougherty TW, Turban DB, Callender JC. Confirming first impressions in the employment interview: A field study of interviewer behavior. Journal of Applied Psychology 1994; 79: 659-665.

⁹Larkin M. Getting a grip on handshakes. Lancet 2000; 356: 227.

¹⁰Available at www.saem.org/…/0/…/MSS_CollingsTheInterview2009SAEM.doc.  Accessed on October 22, 2009.

¹¹Ziegelstein RC. “Rocking the match”: applying and getting into residency. J Natl Med Assoc. 2007; 99: 994-999.

¹²Krogh C, Vorheis C, Abbott G. The residency interview: advice from the interviewer. The New Physician 1984; 8.

¹³Ksiazek S, Taylor TL. Pritzker residency process guide: ophthalmology. Available at http://pritzker.uchicago.edu/current/students/ResidencyProcessGuide.pdf.  Accessed on October 22, 2009.

“Is there a doctor in the house?” is a Hollywood cliche.  But when it comes to the houses of the United States Congress, the answer is always “Yes.”  Physicians have served in every Congress from the first in 1789 through the current 111th Congress.(1)

Currently, there are 16 physicians who serve as members of Congress (1), 14 in the House of Representatives and two in the Senate (2). With health care reform a pressing issue currently facing the United States, several additional physicians are seeking election to Congress this year in races across the country (3).

Dr. Ami Bera

The Student Doctor Network recently spoke with physician candidate Ami Bera about what health care professionals bring as candidates, and what life is like on the campaign trail for a physician.

Dr. Ami Bera is a Clinical Professor of Medicine and former Associate Dean of Admissions at the UC Davis School of Medicine. He also served as former Chief Medical Officer for Sacramento County, CA where he directed SacAdvantage, a program providing access to care for 200,000 uninsured.

Tell me about the office that you seeking.

I am running for the Democratic nomination for the 3rd U.S. Congressional District in California. The seat is currently held by Republican Congressman Dan Lungren, who has served eight terms and is a former California attorney general. There are three candidates running in the Democratic primary so far: myself, Elk Grove City Councilman Gary Davis and Sacramento Municipal Utility District Director Bill Slaton.

What motivated you to enter the race?

Honestly, it was never a stated goal for me to run for elected office. But after I stepped down from my position as Associate Dean of Admissions at UC Davis, I found myself looking for a way to serve. In the past I have done service behind the podium and have been disappointed by the follow-up on important issues by our elected officials. I realized that I have a desire to change the political conversations we have been having: to move away from doing what is best for one’s polling and promotion to advancing some of the great work on issues that is done by those behind the scenes and at non-profits.

What steps did you take before entering the race?

The idea of entering this race first occurred to me last October. I decided that I would explore the idea instead of focusing on “why shouldn’t I do this.” I started by speaking with some friends who are in the state legislature. They told me I had a great resume on healthcare, and that my experience growing up in an immigrant family would make me a compelling candidate. But they encouraged me to run for city council first and to work my way up the political escalator.

I had no desire to be a career politician and when looking at the race from an intellectual perspective it seemed like the time was right for me to enter. This district is now 40% Republican and 38% Democratic. The demographics have shifted with an increase in minority voters and migration from the Bay Area. With approval ratings for elected officials at record lows and the focus on healthcare, this is the perfect election to run as a non-career politician and a physician. It is a potentially winnable race, an opportunity for me to change our political conversations, and to fix healthcare.

What is your day-to-day life like as a candidate?

After filing in April, the first phase in a campaign was to establish legitimacy. A sad reality of the U.S. political system is that legitimacy is measured by fundraising ability. Generally a day starts around 5:30 am with email and internet communication. I meet with people for coffee and lunch. It is essential to build relationships with potential donors. Also, we have focused on getting people engaged with the campaign and on collecting small donations of $5-$20.

This next quarter ends September 30 and we are still focused on fundraising. I am going to Washington, D.C. to meet with Democratic leaders and to build a buzz about the race.

We have been able to focus more on voter outreach through townhalls and house parties. In the evening I usually attend multiple events. I am working as hard as I did during residency and I do miss having some quiet evenings at home to relax. But I love what I am doing.

What do you love about being a candidate?

When I first started in the race I had to see if I enjoyed being a candidate. I very quickly found that I love it. Being a candidate and talking with voters is a lot like what we are trained to do as physicians. I listen to other people sharing their suffering, ask questions, listen, and reflect back to them. As a physician I am trained to engage with people in tough subjects and this has been an asset as a candidate, especially when discussing controversial topics that can inspire passionate responses in voters.

What have been the most rewarding and challenging aspects of the campaign so far?

It has been very rewarding to put my ideas out there and to see them resonate with people. I try to present my ideas in an authentic way and I want to understand where people in the community are coming from. I have found that by doing this communities have really let me into their lives. This has been a very humbling experience.

The greatest challenge with campaigning is that it involves a lot of talking about myself. I know I have a healthy ego, but I always want it to be less about myself and more about the voters. So I try to find a balance by focusing on my values, telling my story, and presenting the stories of other people I meet. It has been hard because I am not a “sound bite” guy. How do you focus on a topic as complex as healthcare reform in a sound bite? But I have focused on stories and hope that they will stick better than sound bites.

How has being a candidate affected your work as a physician and educator at UC Davis?

I took a leave of absence from UC Davis at the end of June to focus on the race. The medical school has been supportive but as an apolitical organization, they cannot overtly support me.

The students are mostly aware that I am running. I would love to get the students more engaged in the race because I think it is a unique opportunity. But I am very conscious not to push myself on them. I will be teaching periodically, but am largely removing myself from the medical school’s daily activities.

How have your wife and daughter responded to your candidacy?

When I first verbalized my idea to run this past December and January, Janine, my wife, was in disbelief. But after she realized I was serious, she raised questions about how it would impact our family. Would we have to move to Washington, D.C.? To split time between two locations? She did not embrace it at first, but as she has seen it unfold she is in it with me to win. Janine is my best asset and I expect that as we get busier she will represent the campaign at events.

My daughter just started 7th grade, so she does not fully grasp the implications of my candidacy yet. As we get further along we will have lots to talk about and some big decisions to make if I win. In the end I am most concerned about being authentic and running as hard as I can. If I do that and I lose, it is okay. But I am not willing to compromise my self, my values, or my family to win.

Have you always had an interest in politics?

Most of the people in my life who have known me well are not surprised that I am running. I have always been engaged in politics, mostly focused on the politics of change and how to move forward on issues that I care about. My mom would say that I was a pain as a child, always questioning and exploring new ways of doing things. I was very fortunate to grow up in a family that allowed exploration and offered safety and support whenever I fell down.

How have the positions that you have held in the past helped to prepare you for elected office?

My experiences as a physician have given me perspective on all aspects of healthcare delivery. My life has unfolded unexpectedly and I have taken opportunities as they have presented themselves. As chief resident I realized I was interested in working on systems issues. After residency I spent four years in practice at the county medical clinic and as the medical director of care management for the five hospital Mercy system. This experience allowed me to focus on systems issues and way to increase efficiency in care delivery.

I then served as the Chief Medical Officer for Sacramento County and worked on ways to increase coverage for the uninsured. I was then offered the opportunity to look at how we train the next generation of physicians by serving as the Associate Dean of Admissions at the UC Davis School of Medicine. While I never planned to set up these experiences, they have built upon each other and given me a very unique perspective on healthcare.

Tell me more about the program you started to increase coverage for the uninsured.

Using two million dollars from the county and one million from the federal government, we created a program called SacAdvantage that targeted low wage workers and small businesses with two to fifty employees that had not previously offered health insurance. It was built on the employer-based model of care and provided a subsidy from the county to make it affordable for small businesses to cover their employees.

The main problem I see with it now is that it still ties coverage to employers and people could lose coverage if they moved to another state or changed jobs. I now favor offering all Americans a compassionate baseline of health care that is not tied to employers. Additional coverage could then be provided by employers or purchased by individuals.

What do you see health professionals being able to bring to elected office?

All of the training that we have will help us in politics. What makes a good doctor—having compassion, good listening ability, the ability to make hard decisions quickly, and leadership skills—are all essential in politics. As physicians we have a particular ability to articulate the story of healthcare in this country. If voters ask me about “death panels” at a townhall I can tell them about what happens in the ICU regarding end-of-life issues. I find it embarrassing how silent physicians are given that we are held in high esteem by many. As a group physicians need to step up to the plate on healthcare.

If health professional students have interests in politics what do you advise they do to pursue a career in this realm?

I think it is most important for students to discover their passions and what is most important to them. Too often students look decades into the future and try to plan out every step of their career. But it is better to focus on the present than to try to be calculating. Look at what you are passionate about today and work on issues within your sphere of influence, for example resident work hours. It takes courage to address these issues and the skills you build will help if you choose to run for office later. You will learn by doing.

It is also important to know your strengths and weaknesses. Embrace your flaws and your ignorance. That way you will know when to delegate tasks and to let others with greater knowledge take over for you.

How can health professionals with limited time get involved in politics?

I would advise that they find a local organization that does work on an issue that they really care about. Focus on finding one project that can be done to really make an impact. The skills that one builds working at the local level are the same ones that are used in elected office. In politics there is just a bigger stage.

References

1. “Doctors on Hill seek voice in reform debate”, June 15, 2009, AMEDNEWS.com, http://www.ama-assn.org/amednews/200…5/gvl20615.htm

2. http://www.ama-assn.org/amednews/200…3/gvsa0223.htm

3. http://www.beraforcongress.com/, http://www.trivediforcongress.com/, http://www.jayfleitman.com/,  http://wargotzforussenate.org/

Dr. Al Berg

by William Burnett

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding that science is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health. 

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.

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)

A key component of the successful match is a full understanding of the residency selection process, and the factors that influence it. Program directors are key decision-makers in this process, and their insights and experience are invaluable. In future columns of The Successful Match, we will present conversations with program directors and other key decision-makers across the different specialties.

We would like to preface these upcoming columns by highlighting the results of an important study done by Dr. Marianne Green. Dr. Green is the Associate Dean for Medical Education at the Northwestern University Feinberg School of Medicine. She is the former associate program director of the internal medicine residency program at Northwestern. Dr. Green is the recipient of multiple teaching awards, and her peers have recognized her as one of the “Best Doctors in America.”

In March 2009, her article ”Selection Criteria for Residency: Results of a National Program Directors Survey” was published in Academic Medicine.¹ The study findings were based on questionnaires submitted to 2,528 program directors across 21 medical specialties in 2006. Dr. Green and her colleagues sought to determine the relative importance of various residency selection criteria. Recently, we had the opportunity to talk with Dr. Green about the study’s results.

Before your study was published in March, deans, residency advisors, and applicants relied primarily on the results of a similar survey published in 1999 by Dr. Norma Wagoner, former dean of students at the University of Chicago Pritzker School of Medicine. What were the factors that led you to revisit this area now?

As I became increasingly involved in residency advising for our students, I felt uncomfortable relying on older data, and realized it needed updating. My colleagues and I approached Dr. Wagoner and she graciously let us modify her survey for this updated study. In addition, several specialties were not represented in the 99 study, the competiveness of specialties had changed, and new data (CSE, MSPE etc) were now available.  Charting Outcomes in the Match has a lot of detailed information that is very valuable, but several domains (e.g. clinical grades, preclinical grades) are not included and this information becomes important when advising students.²

What are the key findings that residency advisors and students should take away from your study?

Clinical performance as measured by clerkship grades is the most important thing that program directors look for across all specialties.  Letters of recommendation are extremely important in most specialties with the exception of Internal Medicine, Family Medicine and Radiology.  USMLE step 1 scores remain very important, but USMLE step 2 scores may even be more important in the primary care specialties.

In the article, you wrote that you hope to “highlight possible misperceptions that may affect student advising for residency application.” What do you believe are the more common misperceptions?

Many medical students believe that research is an essential part of their application to residency. With the exception of Radiation Oncology and Plastic Surgery, program directors in other specialties ranked published research among the lowest of the available selection criteria.  (see below for more on this)

Many students believe that their grades in the preclinical years are very important.  With the exception of a course failure, preclinical grades are not important.

Students should consider taking USMLE step 2 in time for residency application especially if they are looking at the primary care specialties like Pediatrics, Internal Medicine or Family Medicine; many of the less competitive specialties are putting increasing emphasis on Step 2 scores.

In Dr. Wagoner’s study, grades in required clerkships received top ranking from both competitive and less competitive specialties. In your study, grades in required clerkships were once again found to be the most important academic selection criteria. Students are often surprised to learn that grades in required clerkships are so important, ranked ahead of other criteria such as USMLE step 1 score and grades in senior electives in the chosen specialty. Why do program directors place so much emphasis on core clerkship grades?

Our study did not address the question of “why” for any of the selection criteria. I can only answer this as a practicing internist responsible for supervising residents and former associate program director.  Program directors and selection committees are looking for people who are going to become excellent physicians with the primary emphasis on patient care and teamwork.  A student’s performance on a clinical team in the direct care of patients is perceived to be the best assessment of these skills.  It is the job of the medical schools and faculty to insure that clerkship assessments are an actual representation of the achievement of competence.

You found that the USMLE step 1 score was the second most important criteria. Many students who seek residency positions in competitive specialties are concerned that their USMLE step 1 score is too low. What advice would you offer to these applicants?

The NRMP’s Charting Outcomes in the Match provides excellent data for the percentage of students with certain USMLE Step 1 scores matching in a given specialty.  I would certainly refer students to this source.  This can provide some realistic information for students.  I would never discourage a student from applying to a specialty that he/she is passionate about.  I would however, be sure that the student understands his/ her chances with whatever data is available.  Often schools track the success of their own students, and that data can be a very valuable tool for an individual student.  If a student’s chances of receiving an interview are low, he/she needs a “back up plan” and this often includes application to a less competitive specialty as well.

Overall, published medical school research and research experience were ranked next to last and last, respectively, in importance among academic selection criteria. However, you did note that some specialties highly value research, particularly competitive specialties. Students are often told that research experience and being published can strengthen their residency application. In light of your study’s findings, how should we advise students in this area?

Only Radiation Oncology and Plastic Surgery program directors ranked research highly; however even among some of the less competitive specialties, research may be an important part of the student’s application.  In my experience advising students, those that are looking at the top 5 programs in a certain specialty are competing with other highly qualified students across the country. Scores and grades are all outstanding, so something else may be needed to highlight the student as a competitive candidate.  Personally I believe that depth in any area (not necessarily research) can make a student stand out.  Extensive international experience or experience in patient safety & quality outcomes are two examples from our own institutions.  Certain residency programs are looking to train research scientists. Clearly a background in research will be a necessary qualification for these programs.

The medical school performance evaluation (MSPE), previously known as the Dean’s letter, is a standard component of the residency application. Critics of the MSPE maintain that these letters are often lacking in key information that programs need to assess and compare applicants. In an effort to make the MSPE more effective and useful, the AAMC has made efforts to standardize and improve the quality of these letters. In your study, program directors ranked the MSPE lowest of all criteria. Did you find that surprising given the AAMC’s efforts in recent years?

There are a few possible explanations for this finding.  The November 1^st deadline may be too late for program directors to use the MSPE extensively in decision making regarding the granting of interviews.  Students can begin applying on September 1^st and many interview offers start going out as soon as applications are received.

More importantly, most of the information contained in the MSPE is available elsewhere.  The grades and narratives for courses and clerkships may be on the transcript.  USMLE Scores are available directly. The ERAS application contains a lot of the “extracurricular information” about a student and so the MSPE is not necessary to view this information.

Probably the most important piece of the MSPE is the students “rank” in comparison to his/her classmates.  Although the AAMC has attempted more standardization in the reporting of class rank, many medical schools do not comply with this request and residency selection committees are faced with interpreting a student’s rank using vague terminology.

Your study did not address the importance of the interview in the residency selection process. As someone who has interviewed many residency applicants, what recommendations can you offer students preparing for interviews?

Relax and be yourself!  Most interviews are not high stress situations. Faculty are looking to see if you can interact effectively with others and would “fit in”. Certain specialties and programs may have some unique interview questions, but these are not common.  Departmental advisors can shed some light on the idiosyncrasies of certain specialties. (One year, some of the ENT programs were asking students to carve a bar of soap while they answered questions!) If you are someone who gets very nervous in an interview, I would recommend practicing a mock interview with a faculty member, advisor or dean.  Be prepared to talk about your interest in the field and why you would be a good addition to the program.  Know something about the program you are applying to.

References

¹Green M, Jones P, Thomas JX Jr. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-367.

²Charting outcomes in the match: characteristics of applicants who matched to their preferred specialty in the 2007 NRMP Main Residency Match. Available at www.nrmp.org.

By Jessica Freedman, MD

AMCAS 2010 opens in early May and the next wave of applicants is preparing to submit applications, so it seems apropos to summarize some key observations I have made while privately advising medical school applicants. Here is my list of some essentials for medical school applicants to improve their chances of acceptance.

1. Submit an early application
   Everything you read tells you that the #1 rule of medical school admissions is to apply early. But, I find that many applicants still ignore this advice. You should not only submit your application as early as possible but also make sure that your transcripts and letters of reference are sent in promptly.
2. Take your MCAT exam early
   Again, the key word here is “early.” Your application will not be reviewed until your pending MCAT scores are in so, if you have worked hard to submit your AMCAS application in June, don’t negate this effort by taking an August MCAT.
   
3. Don’t apply once for “a practice run”
   Yes, people do this. I suggest applying only when you are truly ready. While the stigma of being a reapplicant is declining, being a third-time applicant does trigger a negative bias, so it is best to try and make your application as perfect as possible the first time around. Take an honest inventory of your stats, experiences and accomplishments and decide if you are ready to apply or if you must do something to enhance your candidacy.
   
4. Apply broadly
   It may be your dream to attend a top 10 medical school, but be realistic. Too often, applicants apply to only a few schools initially and limit their chances. It is important to apply to a broad range of schools both in terms of geography and ranking. Around this time of year, I receive calls from applicants who say “Well, I didn’t get in last year but I applied only to five schools because I wanted to stay in California.” If you really want to increase your chances of being accepted, do not limit yourself.
   
5. Think about your story
   I encourage applicants to think about their unique story and path to medical school. What motivates you? What are the overarching themes in your background and experiences? Why do you want to be a physician? Really thinking about who you are, how you got there and what you hope to do in the future will set the stage for your entire application process. Think about this throughout your education. And, remember, nothing is set in stone. As you develop new interests, expertise and hobbies, your story will evolve and change. Just make sure that your story doesn’t have any major unaccounted gaps in time because admissions committee members often regard these gaps as “red flags.”
   
   
6. Make your application entries descriptive
   While some applicants write a bulleted and brief description for each AMCAS entry, my advice is always to give as much information as possible in your written activities descriptions. You have a 1325 character limit per entry so, unless you have nothing to say about your experiences (which would be a red flag in my book), use this space to your advantage. The person who wants to read less can opt to skim your entries but the person who wants more information won’t take the time to pick up the phone and inquire about your experiences. These descriptions present an opportunity to write about your insights, experiences, accomplishments and observations.
   
7. Do not regurgitate your application entries in your personal statement
   It is important to say something new, different and fresh in your personal statement that does not repeat your application entries. Interestingly, I find that many applicants shy away from the very topics and aspects of their backgrounds that make them unique. Applicants also lament that they don’t really have a story or anything special about them. Boloney. Every applicant has a compelling story, but sometimes you need an outsider to bring it into focus. Often applicants are self conscious about the very experiences that will make them more compassionate providers (and more attractive applicants), such as being an immigrant, growing up with few opportunities or having their own encounters with illness. Applicants often say, “I don’t want anyone to feel sorry for me and I don’t want to tell a sob story.” As long as you present your story in a matter- of- fact way and write about the positive direction of your path, you won’t be perceived as a whiner. It is often the most challenging times in our lives that are the most catalytic, and any experienced medical educator understands this.
   
8. Fill out your secondary essays in timely fashion
   Here is that theme again. Early, early, early.   For schools that have secondaries, your application won’t be screened until the secondaries are in.
   
   
9. Practice Interviewing
   Many applicants think interviewing is easy and, for some, it is, but everyone needs practice. Even if you are a great public speaker, sitting down and talking about yourself one on one with a person in a position of authority does not usually come naturally. Also remember that you can guide your interview and highlight what you think is most important about you. Most medical school interviews are fairly low stress and conversational, so enter your interview knowing which experiences and thoughts you want to discuss and emphasize. When I do mock interviews with clients, I am often surprised at how many people, including those with a long list of impressive achievements, are not able to present their stories cohesively and comprehensively.
   
   
10. Make every interview count
    Every interview is an opportunity for an acceptance. Be sure to smile, be positive and be personable on your interview day. Regardless of “scoring systems” or “rankings,” there is a huge subjective component when evaluating an interviewee. This “halo effect” works both ways; if someone perceives you positively, this will likely carry over to everything about you and your candidacy, whereas if someone perceives you negatively, the opposite is true. I have several clients who received only one interview invitation which resulted in an acceptance. So, approach every interview, literally, as if it is the only one.
    
    
11. Get good advice
    This isn’t as easy as it sounds. Seek out individuals who are knowledgeable about medical school admissions and provide sound guidance. When I used to evaluate applicants as an admissions officer, it was often obvious when an applicant received bad guidance because they did not have the best mix of experiences, had poorly written documents or weak interview skills.
    
    
12. Stay objective and be honest with yourself about your chances
    If it is late in the season and you have not received any interviews or only have wait list offers, consider what went wrong and correct your mistakes. If you plan on reapplying, you must, once again, do so early. If you reapply in August after you realize you won’t get off a wait list, you may again be unsuccessful. Inevitably it is the waitlisted applicant who reapplies in June who gets off a waitlist in August just before classes start.

Learn from my collective experience working with medical school applicants and try to make the most of your candidacy. What I have learned from my clients, most of all, is that the new generation of physicians is a motivated, well-intentioned and inspiring group with a positive outlook.  Apply well because our patients need you. Good luck!

Jessica Freedman, MD, a former medical admissions officer, is president of MedEdits (www.MedEdits.com), a medical school, residency and fellowship admissions consulting firm. She is also the author of the MedEdits blog, a useful resource for applicants: (www.MedEdits.blogspot.com).

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/.