Why would you go into medicine when you can make millions working for youself

A number of students have asked me about going into medicine. My answers is usually that you have to really want it. Don't get me wrong, I love my job, but the road is long and hard. Unlike many years ago, the respect, autonomy, income, and security is no longer what it was. So, why go into it. I cam across this article in the New York Times on Sunday. Now, it does talk about lawyers, but I still think it is an interesting article.

Orthopaedic Surgery Interview

“Whatever course you decide upon, there is always someone to tell you that you are wrong. There are always difficulties arising which tempt you to believe that your critics are right. To map out a course of action and follow it to an end requires courage.”

~Ralph Waldo Emerson

Twice a year, we have mock oral boards. You may say oral boards sound like it's malignant, but it's not. It is just another assessment tool. Like the real orthopaedic mock boards, it always us to assess your understanding of orthopaedic knowledge in a dynamic setting. It does cause many residents a great amount of anxiety, but it is helpful. As the years progress, you can see a increase understanding of orthopaedic surgery. The residents feel that it is a mega pimp session. I guess, by definition, it is a question and answer session done without a #2 pencil and multiple choices. The purpose is not to make the resident uncomfortable and sweat; the purpose is the assess your application of what you learned.

Today, we had oral boards. It got me thinking. When we give the examination, the resident brings a known case and a is given an unknown case. Why don't we give the resident applicants a known question?

Our interview season is beginning this month. For those who are interviewing at out program (St. Louis University orthopaedic surgery), here is your question when you come into my room: "Tell me about yourself." Please keep your answers short and don't recite your resume. You can take a hint from a previous comment I make on the "tell me about yourself" question and answer.

Good luck all

“Thinking is easy, acting is difficult, and to put one's thoughts into action is the most difficult thing in the world.”
~Johann Wolfgang von Goethe

Are we too nice?

“High achievement always takes place in the framework of high expectation.”

~Charles F. Kettering

When I went through all of our applications, it was hard to separate one application from another. The white pages and black lettering blended together after the about 15th application. For a majority of the applications, all I had was a name, school, and their basic statistics.

John Doe

• Medical School: State University of X or X University
  
• USMLE step 1: 235
• Clinical Rotations: 1/2 clinical honors
• Orthopaedic Rotations: honors
  
• LOR's: good to excellent with some stating he is in the top 10% of students rotating this year
• Personal Statement: "... Since I injured my knee playing football, I have always wanted to be an orthopaedic surgeon. ... I have played sports all of my life ..."

I can't count the number of times that I have read this type or similar application. The names of the applicants are sometimes interchangeable. What aspect of their application tells me that this is going to be a stud or a dud? I have received a number of emails and have read plenty of forums that ask the same question, "what do I need to get into orthopaedics?" If I could tell you the exact recipe, I would, but I don't think there is one. In truth, we all know the recipe, good grades, good scores, good rotations, and a little luck. I think what is more important is the special ingredient or special sauce you bring to make you different.

Many applicants get caught up in the numbers of the game. Time and time again the question is asked, "what score do I need to get into orthopaedics" or "what grades do I need" or "how much research do I need"? I can give numbers of the typical solid application, as I have listed some above, but does that guarantee a spot? Not so much. The quoted figures on scores, grades, research, and AOA are just guidelines, not a guarantee. Every year there are applicants with strong numbers that don't get into a residency. So, why didn't they match? Typically, when I have reviewed these non-match applicants, the reason was either glaringly obvious (USMLE score 205, bad letters, failing a subject in medical school) and on other occasions, it was not. When there was no glaring flaw, the applicant looks like every other applicant. There is nothing in their application that makes him/her stand out.

I have asked myself why is it that that most of the applicants so similar. Is it because they have all used performance enhancing drugs to make them all academic superstars? All jokes aside, I think it may have more to do with the way we grade. I blame it on kids soccer, where everyone gets to play and in the and they all get a trophy. Many parents display their honor role student sticker on the rear window of their SUV. All the children are A and B students. Many go to a 4 year university and expect the same. They argue for a better grade and petition for grade changes when it doesn't meet their expectations. The professors that grade on a true Bell Curve are not liked or considered "hard" because they give out fewer A's and B's. Over the past 10 years, I have noticed this trend and I have wondered if we (educators) are too kind in our evaluations?

With a student's application, we receive a copy of the grade distribution for that medical school. When comparing applicants from one school to another, there are definite differences in grading philosophies. I don't know if this is a problem with the grading set up or that we are "too nice." In my experience of clinical grading, unless the student does something drastically wrong (like never show up or cursing out a patient), the student will at least receive a pass. The question is who receives the highly coveted Honors. Each School varies in their grading system. The grades can range from pass/fail only to honors/pass/fail to honors/high pass/fail to honors/high pass/marginal pass/fail and the always popular A/B/C/D/F (with +/-). What puzzles me about all of these systems is that the average tends to be a B or high pass. There are schools with greater that 50% honors in some subjects. You may say, well are these the "lesser schools"? Not so fast young patawan. In my limited research (okay not really research but observation), it is more common for the "very competitive schools" to have more of a top heavy grade distribution and the "less competitive schools" to have a more even grade distribution. It is not uncommon for a school to have grading distribution (in the clinical years) with greater than 50% honors and less that 30% passes. How does this allow for us to assess these applicants? If you score only gives out 20% honors and you received a high pass, should you be penalized? On the other hand, if you went to a school that gave greater that 50% honors, should you be given bonus?

With competitive specialties' concentrating on USMLE scores, students have been crushing this test. The USMLE is one of the only tools we have to compare applicants from different schools and areas of the country. Because the USMLE "powers that be" don't want the test to be used in the manner we use it, they do not provide us with the distribution of scores. In the old days, the mean was in the low 200's (205 when I took it) with a standard deviation of 20. Today, the mean is in the mid 210's. Therefore, a score in the 90's of 225 is equivalent to a score of about 235 in today's scoring (I am guessing). Most of the applicants I have reviewed have an average of a 230 (just a guess, again no true data). Again, when trying to create separation like Randy Moss from a corner back, it doesn't happen. The applicant's are all bunched together like 6 year old children playing soccer.

You may say, "then look at the letters of recommendation (LORs)." This is less helpful than the grading. Most folks have the prerequisite letter from their program chair that says he or she is a supernova or has star like qualities. There are usually 1-2 letters from surgeons that are not known by most interviewers and 1 from a well known surgeon. Although the letters are helpful when pointing out top end and lower end, they to not create the needed separation to differentiate one applicant from another. There have been occasions where I have read the same recommendation on 2 or 3 applicants from the same physician. Although we think we know the code words, I think we kid ourselves at thinking we can read into another's recommendation like it is Morse Code. Usually the true meaning is missed, except when comments are blatant like, "we recommended that he look into other specialties ... "

What is the answer? I have recently begun to reevaluate my own grading system. How is my grading? Am I too nice? The answer is yes. I believe that many of us don't want to be the bad guy. Who wants to be the professor who fails most of his/her students? I don't think that there are many who would answer yes. I believe we do need to re-center. In the clinical setting, the average grade should be a pass. The excellent grades should be give to those who truly stand out for the rest of the students. As an educators, we must communicate our expectations are and explain what passing grade means. Is this a student problem, I would propose it is not. It is a educator problem. We have evaluate honestly. No more just checking the 4 out of 5 box. If they have met expectations, then they should get a pass. You may read this and think I am arguing for more strict grading, but I am not. I think that our grading should be fair. Lumping the average around above average is not fair to those who are truly above average.

“Success is simple. Do what's right, the right way, at the right time.”

~Arnold H. Glasgow

Goodbye my friend ....

“Somebody should tell us, right at the start of our lives, that we are dying. Then we might live life to the limit, every minute of every day. Do it! I say. Whatever you want to do, do it now! There are only so many tomorrows.”

~Pope Paul VI

Sometimes, the days feel long; but in reality, life is short. We complain every day about meaningless things that, in the end, lead to nothing. How will I leave this world? Will I leave the world a better place or will I be just another complainer?

Death of friends and family changes you. It makes you reflect on your life. What legacy do I want to leave? What will be said in my eulogy? How will my children remember me? When it is time to go, I hope I am ready. I hope I do not feel as if I have left unfinished business or work to be done.

Have a safe trip my friend. We will not forget you. Please continue to watch over the babies in death as you did in life. You will be missed.

dying is fine)but Death

?o
baby
i

wouldn't like

Death if Death
were
good:for

when(instead of stopping to think)you

begin to feel of it,dying
's miraculous
why?be

cause dying is

perfectly natural;perfectly
putting
it mildly lively(but

Death

is strictly
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& artificial &

evil & legal)

we thank thee
god
almighty for dying
(forgive us,o life!the sin of Death

E.E. Cummings

“Live as if you were to die tomorrow. Learn as if you were to live forever.”
~Mahatma Gandhi

Feeling Human again ...

"To laugh often and much; to win the respect of intelligent people and the affection of children...to leave the world a better place...to know even one life has breathed easier because you have lived. This is to have succeeded.”

~Ralph Waldo Emerson

As physicians, we treat any number of illnesses, speak to patients about treatment options, and comfort families when bad news is given. Although we are sometimes held to a higher standard, held in high regard, or think very highly of ourselves, we are still only human. Every once and a while one of are own, family, friend or colleges, is struck ill or dies and it reminds us how human we are. We are not gods or immortals, but human.

One of our colleagues was affected this past Christmas eve. I will say a prayer for him and wish his family well. I will hug my children a little longer tonight.

"Carpe diem! Rejoice while you are alive; enjoy the day; live life to the fullest; make the most of what you have. It is later than you think.”

~Horace

Happy Holidays ....

“Sometimes I lie awake at night, and ask, 'Where have I gone wrong?' Then a voice says to me, 'This is going to take more than one night.'”
~Charles M. Schulz

To all that visit my blog, I wish You a Happy Holiday season. Here are a couple of humors holiday songs that take made me smile so I thought I would share.

THE TWELVE DAYS OF CHRISTMAS

OH HOLY NIGHT


TOM CRUISE CHRISTMAS


God bless you and yours.

“It is a curious fact that people are never so trivial as when they take themselves seriously.”
~Oscar Wilde

It always starts with good intentions .... Not everyone will like you ...

“You don't develop courage by being happy in your relationships everyday. You develop it by surviving difficult times and challenging adversity.”

~Epicurus

The other day I went to Starbucks before my clinic. The cashier asks me for my order and shouts it out to the person at the espresso bar. I said hello to the person behind me and walked to the pick up counter. My drink comes up. I thanked the barrister and went to the condiment bar. I smiled at another patron as we put cream and sugar in our caffeinated beverages. Walking to my car, I waved to the person in the car that let me cross the street. Then I was off to clinic. During this time, I counted no less than five interactions with people. For the most part, the day to day interactions with people on the street or in a store do not cause much of a problem. Knowingly or not, we all make quick judgments about people without consciously realizing it. It is human nature.

For the most part, physicians and nurses are well intentioned people. Everyday physicians and surgeons have multiple patient encounters. Just like the patrons of Starbucks or the people we may pass on the street, patients pass judgments on the physician based on a number of factors. Many of the factors used in making the prejudgment are out of the physicians control. Like patients, physicians also prejudge the patients. For the majority of encounters, there are no problems. Patients are either happy or indifferent, and we all go about our day. On other occasions, there are the interactions that don't go as we planned. Because of the volume of encounters physicians have, eventually there will be a bad interaction that cause a patient to fire the physician, or seek second opinions.

The other day one of my residents had a patient fire him. Understandably, he was quite upset. I heard his side of the story and witness' accounts of the interaction. To me, it sounds like the good intentions the resident perceived wrong and the questions of the patients were seen as hostile. I don't think that either party involved intended for this to be the case, but it is what it is. It brought up the topic of how do you deal with these situations. Anyone who has seen patients has had a bad patient encounter. There will be patients who will not be happy with what you say or the way you say it. People will go for second opinions. They will choose another doctor over you. It happens. It is a fact of life. How do we/you deal with it?

When doing an After Action Review (AAR) of the situation, the first step is not to take it personal. Of course, that is easier said than done. Don't blame yourself or the patient and above all, don't "blow off" the incident. Second, you must look at what role you played in making this a bad encounter. You must look at yourself critically and be brutally honest with yourself. Remember, for every bad encounter you have, there is only one common thread, you. Finally, you must look at what changes you can make to prevent a similar situation from happening. It seems like a lot to do, but it isn't. This is a simple exercise to improve your self-awareness. You must be self-aware and/or you must have people around you who will honestly tell you about yourself. This is not a time to have a "yes" man. Although a bad encounter is emotionally distressing and self-deflating, it provides the opportunity for the most growth as a clinician.

When I look at my personal experience and observation of others, the common flaw is communication. In the past, physicians were presumed to learn their "soft" communication skills at patients' bedsides, in their rounds as residents, and as students observing master clinicians and their interactions with patients. Today, the communication and interpersonal skills of the physician-in-training are no longer seen as immutable personal styles that emerge during residency but, instead, as a set of measurable and modifiable behaviors that can evolve. During the typical 15- or 20-minute patient-physician encounter, the physician makes immeasurable choices regarding the words, questions, silences, tones, and facial expressions he or she chooses. These choices either enhance or detract from the patient's perception of the physician's clinical skill. From obtaining the patient's medical history to conveying a treatment plan, the physician's relationship with his patient is built his/her ability to communicate. In these encounters, both verbal and nonverbal forms of communication constitute this essential feature of clinical practice.

What are some tips at improving the effectiveness of our communication?

1. Assess what the patient already knows

Before providing information, find out what a patient already knows about his or her condition. It is important to determine what a patient already understands, or misunderstands, at the outset.


2. Assess what the patient wants to know

Not all patients with the same diagnosis want the same level of detail in the information offered about their condition or treatment. Physicians should assess whether the patient desires, or will be able to comprehend, additional information. For the physician without advance knowledge of the patient, this level of need will emerge by degrees as the discussion unfolds and as the physician attempts to synthesize and present information in a clear and understandable manner.

One telling sign of whether the patient is understanding the information is the nature of the questions patients ask; if questions reflect comprehension of the information just presented, a further level of detail may be warranted. If questions reflect confusion, it is advisable that the physician return to basic information. If the patient has no questions or is obviously uncomfortable, this is a good opportunity for the physician to stop the discussion, ask explicitly how much information the patient desires, and adjust accordingly. Continuing to provide further information is not always the best approach.


3. Be empathetic

Empathy is a basic skill physicians should develop to help them recognize the indirectly expressed emotions of their patients. Once recognized, these emotions need to be acknowledged and further explored during the patient-physician encounter. Further, physicians should not ignore or minimize patient feelings with a redirected line of inquiry relentlessly focused on "real" symptoms. Patient satisfaction is likely to be enhanced by physicians who acknowledge patients' expressed emotions. Physicians who do this are less likely to be viewed as uncaring by their patients.


4. Slow down

Physicians who provide information in a slow and deliberate fashion allow the time needed for patients to comprehend the new information. Other techniques physicians can use to allow time include pausing frequently and reinforcing silence with appropriate body language. A slow delivery with appropriate pauses also gives the listener time to formulate questions, which the physician can then use to provide further bits of targeted information. Thus, a dialogue punctuated with pauses leads to deeper comprehension on both sides.

In situations involving the delivery of bad news, the technique of simply stating the news and pausing can be particularly helpful in ensuring that the patient and patient's family fully receive and understand the information. Allowing this time for silence, tears, and questions can be essential.


5. Tell the truth

It is important to be truthful. In addition, it is important that physicians not minimize the impact of what they are saying.


6. Keep it simple

Physicians should avoid engaging in long monologues in front of the patient. Far better for the physician to keep to short statements and clear, simple explanations. Those who tailor information to the patient's desired level of information will improve comprehension and limit emotional distress. It is wise for the physician to avoid the use of jargon whenever possible.


7. Be hopeful

Although the need for truth-telling remains primary, the therapeutic value of conveying hope in situations that may appear hopeless should not be underestimated. Particularly in the context of terminal illness and end-of-life care, hope should not be discouraged.


8. Watch the patient's body and face

Much of what is conveyed between a physician and patient in a clinical encounter occurs through nonverbal communication. For both physician and patient, images of body language and facial expressions will likely be remembered longer after the encounter than any memory of spoken words. It is also important to recognize that the patient-physician encounter involves a two-way exchange of nonverbal information. Patients' facial expressions are often good indicators of sadness, worry, or anxiety. The physician who responds with appropriate concern to these nonverbal cues will likely impact the patient's illness to a greater degree than the physician wanting to strictly convey factual information. At the very least, the attentive physician will have a more satisfied patient.

On the other hand, the physician's body language and facial expression also speak volumes to the patient. The physician who hurriedly enters the examination room several minutes late, takes furious notes, and turns away while the patient is talking, almost certainly conveys impatience and minimal interest in the patient. Over several such encounters, the patient may interpret such nonverbal behavior as a message that his or her visit is unimportant, despite any spoken assurances to the contrary. Thus, it is imperative that the physician be aware of his or her own implicit messages, as well as recognizing the nonverbal cues of the patient.


9. Be Prepared for a Reaction

Patients vary, not only in their willingness and ability to absorb information, but in their reactions to physician communications. Most physicians quickly develop a sense for the various coping styles of patients, a range of human reactions that has been categorized in several specific clinical settings. Patient responses may range from no response, to blaming the physician and medical team. There may be a display of emotion that rages from the mild depression and anxiety to the extremes of emotions with displays of crying, denial, or anger

In responding to any of these patient reactions, it is important to be prepared. The first step is for the physician to recognize the response, allowing sufficient time for a full display of emotions. Most importantly, the physician simply needs to listen quietly and attentively to what the patient or family are saying. It is extremely important to acknowledge their feelings and emotions. The physician's body language can be crucial in conveying empathic concern in these encounters.

When does the communication break down? Some of the pitfalls in the patient physician dialog are:

• Using technical language or jargon,
• Not showing appropriate concern for problems voiced by the patient
• Not pausing to listen to the patient
• Not verifying that the patient has understood the information presented
• Using an impersonal approach or display any degree of apathy in communications
• Not becoming sufficiently available to the patient

In the end, the patient-physician dialogue is not finished after discussing a diagnosis, tests results, or proposed treatments. For the patient, this is just a beginning. As a surgical sub-specialist, we are not typically the most effective communicators. It is not uncommon for the surgical sub-specialist to be seen as an uncaring technician. In today's ever changing medical world, we need to be better. With internet access to information, patients are becoming more educated consumers. Many patients are not acutely aware of a physician's technical skills, but they do know how a physician makes them feel. Regardless of how technically skilled you are, it is you communication skills that will be remembered.

People in the service industries understand the importance of the initial consumer perceptions. At Starbucks, the young cashier greets you with a smile. Takes your order, asks if you would like anything else, gives you your change, and tells you to have a nice day. We expect this as a consumer. The medical field is a service industry and patients the consumers. Should they expect anything less?

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
~Maya Angelou