The Differential: Medscape Med Students Blogs

Discrimination in Science and Medicine

Ben Ferguson -- As a disclaimer, I debated for a long time about whether to even write this post. To be sure, it’s a controversial issue. I’m presenting one side of the story as someone who’s been more affected by this environment than I’d guess anyone who originally meant well in instituting such opportunities ever intended. The opportunities are enormously useful for their beneficiaries, and in general they have revolutionized the societal makeup of those practicing science and medicine. It’s a good thing, a very good thing, but in my opinion, it shouldn’t exclusively employ exclusivity as the means to its end. I’m not looking for sympathy; I’m not looking to complain; I’m merely describing a slightly disturbing trend I’ve noticed that has emerged as a byproduct of the current system.

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Here are two sets of criteria for applying for travel grants and awards from the three most recent conferences I’ve looked into attending:

“The conference will award two (2) travel grants to graduate students/postdoctoral fellows who are underrepresented minorities/women and one (1) travel grant awarded to a junior faculty at the level of instructor or assistant professor within the first three (3) years of their initial appointment, also an underrepresented minority/woman.”

“Every year, approximately ten diversity travel awards are given out to conference attendees. We strongly encourage students to apply for this $500 award that covers registration and travel expenses. Consideration is given consistent with the NIH guidelines for minority recruitment.”

(For the record, the other conference, upon my inquiry as to whether travel grants are available to graduate students, said, “We don’t have any.” Blatant discrimination against graduate students, I tell you.)

In all seriousness, as a white male in both science and medicine, this is one of the most frustrating things I have come across, and I come across it pretty much all of the time, or at least any time I’m looking into such things. (For what it’s worth, my dad’s a doctor, so clearly that’s how I got to where I am today, right? Certainly, then, you wouldn’t want me to be participating in these programs and attending these conferences...I’m much too privileged for these sorts of thing after all. As a matter of fact, I pay cash for all associated travel costs -- that is, if my daddy doesn’t for me.)

In college, in order to gain more research experience, make some money, and boost my then-developing (and crappy) application to medical school, I looked into a lot of summer research programs in my college’s town and also all over the country. What did I find? Dozens of opportunities, great, fantastic opportunities, all for minority and women, and minority women, students. Some of them wouldn’t even accept applications from non-minorities or men. Most of them strongly suggested that white males needn’t even bother applying, some practically coming right out and saying as much. It was, in a word, frustrating.

And it’s been the same story ever since. I’m now reminded of my “struggles” with my recent interest in attending these conferences using their support, which -- I can take a hint -- doesn’t exist for people that happen to have white-skinned penises.

Google “summer research program.” I dare you. Programs that don’t at least make a passing mention to race or gender or some other measure of underrepresentedness in their small print are few and far between.

Come on, society. We’re all graduate and professional students here, and those that are not are aspiring to be in such a position. We’ve all “made it” to a certain extent, and it’s equally up to us as individuals how far we can take our successes and turn them into lifelong careers. Do we really need to continue to exclude people who are “privileged” based on the color of their skin? We’re all making the same paltry stipends; we’re all dead tired and doing -- for lack of a better word -- bitchwork; we’re all throwing ourselves into our projects, much of the time only to experience failure after failure; and -- we’re all the same, pursuing the same things.

All I want to be able to fricking do is fricking apply to get some fricking funds to attend a fricking conference, people.

But I Don't Wanna Study!

Kendra Campbell -- I’m sitting at my desk typing on my laptop in my new apartment in Baltimore, Maryland. I now have a place to live, water, electricity and even an Internet connection. Most of my boxes have been unpacked, and I even have food in the fridge. I have about one month with no classes, and all I really have to do is study for the USMLE Step 1. Today is the beginning of my marathon studying routine.

Okay Kendra, you can study now. But I don’t want to study! Actually, I’ve been so swamped lately with moving, packing and unpacking, and running all the errands involved with moving to another country that I haven't studied in over a month. I don’t even feel like a student anymore. I feel like a professional mover. Over the past month, I kept telling myself that when I finally get everything unpacked, I will buckle down and start studying. But now that that time has finally arrived, I don’t even know where to begin.

I’ve made excuses like, “I can’t study until I have electricity,” or “I can’t study until I have unpacked all of my books,” or “I can’t study until my dogs get all of their vaccinations.” These seemed like reasonable excuses at the time, but when I stop and think about it, I realize that I’ve studied under worse conditions in the past.

In Dominica, I’ve studied without electricity or water. I’ve studied in the middle of a hurricane. I’ve studied right after having surgery. I’ve studied when I could barely keep my eyes open because I was sick and fatigued to the point of wanting to give up. But now I’m saying that I can’t study until my dogs get vaccinated? What on earth is wrong with me?!

I’ve written before about having a study block, but this time it seems a little different. Having a deadline that’s so far away means that I have to put the pressure on myself. I’m also in another country, and it’s been so long since I’ve studied that I wonder if I’ve forgotten how.

I’m wondering how many of you out there have been through a similar experience. Do you have any tips on how to get back into studying after taking so long of a break? I guess I should stop writing about not being able to study and just do it! If only it were that easy.

Obstacles to Learning

Anna Burkhead -- Sometimes, no matter hard you try to avoid them, obstacles are presented in the path to learning. Some of these roadblocks are surpassable, and others, depending on how they came to be or who put them there, are not.

I am finishing up my 8-week surgery rotation with 2 weeks on a urology service. I picked urology from the list of surgical specialties because I didn’t know much about it, and because I heard the surgeries were interesting and never too long.

Now almost done with urology, I have learned a lot about the field, and I agree that the surgical cases are cool. However, there is one attending on the service who has created, in my opinion, some roadblocks to learning for me.

First of all, I get the sense that having a medical student is a nuisance to him. He has, on several occasions, "pawned me off" to nurses or PAs. Of course, I can learn from nurses and PAs as well, but I am supposed to be learning from him, and feeling bothersome is not fun.

Also, he often enlists me to do paperwork. In this regard, I feel helpful, and I don’t want to seem ungrateful for a learning experience in the "red-tape" aspect of medicine, but while I am doing paperwork, he is interacting with patients in a way that would be educational to me. In this way, I am missing out.

The third, and most significant obstacle is the one I’m most disappointed about. Most of the patients on the urology service are men, and most of their clinic visits require genital exams. I thought that spending time in a urology clinic would give me more experience and confidence with this exam, which will certainly be important if I become a dermatologist. However, at the point in the clinic visit when the genital exam is to happen, the attending has a habit of asking me to leave, or taking the patient into another room and shutting the door after them. These are patients with whom I have already had 30-minute conversations, including discussion of urinary and erectile function, so my presence during or participation in a genital exam would have been neither unexpected nor significantly embarrassing.

This is one of the first times I have felt that my presence is a nuisance to a doctor in a clinical setting. It’s also the first time I’ve been blatantly deprived of a learning experience, and I think it’s because I am a female, and a young one at that.

I know that one solution to this problem would be to address my concerns to the attending. Unfortunately, I do not feel comfortable with this option, and with only a few days left in the rotation, I don’t want to rock the boat. So, in my opinion, there’s not much I can do to solve this situation, other than to recommend improvements for next year’s class on my rotation evaluation. Just wanted to share the experience.

To Cry or Not to Cry

Ben Bryner -- I've been thinking about breaking bad news a lot lately, and an interesting article in the New York Times addressed that topic. Briefly, the author presents both sides of the issue of whether crying when delivering bad news is appropriate.

My scant experience with this kind of discussion (limited both in number of cases as well as limited by my student-level role and knowledge) has been that there's wide variability in these discussions, and therefore variability in the appropriate response. While the article tends to pigeonhole individual doctors as criers or non-criers, as Dr. Lerner concludes, it depends mostly on the individual patient. I'm sure all the people in the article do tailor their approach to each individual patient. And it's absolutely true that doctors can convey deep empathy without crying.

But the article takes the study by Dr. Anthony Sung (archived here, scroll down to page 5) a little out of context -- his survey found that a majority of third-year medical students and interns (69% and 74% respectively) had cried in a medical setting, but that "the most common reported cause for both students and interns was burnout," not from discussing bad news with a patient. Also, the abrupt shift in the article from talking about attendings to talking about students and interns is not a trivial difference; the role of an attending is very different than that of a trainee in this kind of situation.

Hopefully the following example will help explain what I mean by that.

I witnessed a very good example of breaking bad news on my neurology rotation. I had gotten to know a patient in his mid-50s with glioblastoma during clinic visits at the beginning of the rotation. At those visits he was talking about going back to work, but over the next couple of weeks his condition deteriorated. It became clear that the several experimental chemotherapy regimens he tried had failed, and that the chance of another regimen slowing down his disease progress was basically zero. He was admitted, and when his neurooncologist stopped by his room to tell him the results of the latest scan, I went with him.

The news was no real surprise to the patient and his wife, but it was still devastating when he heard that the scan was discouraging, the chemotherapy was not working, and that it was almost definitely not worth pursuing more chemotherapy. Importantly, the oncologist still left the option of chemotherapy out there for him to take if he liked, but included his recommendation against it. As the message set in, the patient and his wife began to cry, and so did the oncologist. It was a very appropriate display of emotion from the oncologist, I thought, and the patient later told me how much it meant to him. But I didn't feel like crying, and didn't feel like I needed to. It was fine that I was there, but our brief student-patient relationship was not enough to allow for my crying in that situation. If I had cried too it would have cheapened the experience for them, which was the last thing I would have wanted.

A doctor's emotional display also depends on the type of visit. In the above example, there was plenty of time to talk, the setting was quiet, and nothing needed to be done immediately. (Hospice care was arranged over the next couple of days). But in some of these discussions, especially in the ICU setting, practicalities dominate the conversation and the emphasis needs to be on helping the patient and family through difficult decisions. In these discussions, I can't remember the attendings ever crying, although they were compassionate, helpful, and empathetic towards patients without exception. And for all patients who have strong emotional relationships with their loved ones, those are far more beneficial than the most empathetic doctor's tears could ever be.

Another doctor is quoted in the article as saying it's not a doctor's job to cry with patients. I agree that that's not what a doctor's essential role is. The physician's role is to help the patient through difficult medical decisions (and perform procedures as necessary). Working with the patient, forming a team with him or her, carefully assessing what the patient knows and what he or she still needs to learn, and then making careful recommendations (sometimes very strong recommendations) are the true elements of compassion and empathy in the doctor-patient relationship. Whether the doctor cries or not while delivering bad news is only an outward manifestation of that relationship.

Which brings the topic back around to one of Dr. Lerner's original points, that medical school doesn't teach a lot of these things. Too often, we're taught about things on the superficial level -- what words to use, how close to sit to the patient, whether to cry or not. And while that's a good place to start, medical education has much further to go toward comprehensively preparing new doctors to develop empathic relationships with their patients.

Picking Up the Pieces

Thomas Robey -- Some people write to understand or explain the world around them. Others use the pen as a vehicle to better understand themselves. The fact that one in ten Americans has tried their hand at blogging speaks to the appeal that the written word has in clarifying the mind. For me, my private journals, my personal blog and this column (in order of clarity) offer an outlet that is as important to me as a refreshing stroll at day's end.

Imagine how shocked I was to discover my eyes welling up and my fingers trembling as I wrote an email to my clerkship director about the struggles I described yesterday. Email as therapy?!?!?!??? What began as a simple request for advice on oral presentation skills evolved into a soul-bearing reflection.

By now you're thinking, "What's wrong with this guy?" I mean, really: get over it! In the grand scheme of things, what is a single blown presentation? But it wasn't just that. I had noticed myself getting grumpy, withdrawn, looking forward to the end of my shifts, cutting corners... and when this sort of thing happens, you can bet that you're the last person to see it.

To get to the bottom of all of this, we have to back up a week. Eight days before my bombed presentation, I learned that my grandfather had died. He was a great man, and his life was long. His passing was not fully unexpected, but news like this never comes easily. I mourned his passing that day, but I was also post-call. So I went to sleep at 6 PM and woke up the next morning ready for the wards.

The memorial was scheduled for three weeks after his passing, which happened to be the day of my medicine final. When my family heard about this, they reassured me over and again that the last thing Pappy would have wanted was for me to interrupt my studies to fly across the country for his service. I comfortably chose to stay home to finish the clerkship and take the exam. But in the end, this was the wrong decision.

It only took a week for my personal situation to negatively affect my functioning. I initially blamed this on fatigue incurred from a tough call schedule at a busy county hospital in a course I wanted to excel in. In retrospect, this conclusion was corrupted by the blinders I donned when I decided to delay mourning my grandfather's passing until "after the test."

Medicine is a career of delayed gratification. It takes, at a minimum, a decade to finish formal training as a doctor. There's always something to be sacrificed in the name of medical education. Hobbies. Exercise. Sleep. Friends. Family. We all struggle to maintain balanced lives, and many succeed to one degree or another. But as the end of my formal education approaches, it is clear that the training is just beginning. As such, there will always be something from the medical career demanding attention.

This brings us back to a third year medical student perched before a computer in the Team D workroom, tapping out a short note that brought tears to his eyes. Only then did it become clear to me why the previous week had been so miserable. Sure, I was sleep deprived; sure, I had encountered some stumbling blocks; sure, I was worried about my grade. What I realized while writing that email was that I had an unaddressed deep need to mourn my grandfather's death.

When I met with the clerkship director later, we didn't even mention oral presentation skills. The next day, I arranged to fly to Pappy's memorial service. As important as the medicine clerkship was to me, and as inconvenient as it would be to make up an eight-hour exam, a memorial for a dear loved one held no match. Fortunately, I will not have the option of regretting my choice.

It's strange to say, but the most important thing I learned on my internal medicine clerkship wasn't in any text. I learned to stop compartmentalizing work and family, so that critical needs in one would always trump the other. I am thankful for a mentor who helped me see what I was doing to myself by blindly committing to career. In experiencing loss, and addressing it, I have a new understanding of the proverb, "Physician, heal thyself."

When the Stride Becomes a Stumble

Thomas Robey -- My school's internal medicine clerkship is twelve weeks long. In contrast to shorter rotations, this format makes it possible to hit a stride as a productive member of the wards team. With two months on the floor under your belt, you know how to write admit orders, you can pre-round on three patients in under an hour, and you have the experience that comes from giving a hundred oral presentations. You even know the ins and outs of the electronic medical record. The last two weeks is your time to shine. And rightfully so: you've got a lot of information in that cavernous shell on your shoulders, and a lot of it's actually useful (the hospital cafeteria's night-owl hours, for example.) The tenth week is when you can legitimately take ownership of managing your patients. And at my school, management equals an honors grade.

With that in mind, consider this scenario... My team was on call the first night of our new attending's service; I picked up two patients and helped with a third. Usually that would afford a few hours of sleep before morning rounds, but in a portent of things to come, my admission H&Ps came together a little more slowly. Therefore, I wasn't able to catch my 4 AM beauty nap. No biggie: It's not like I had much beauty to start with, anyway.

In preparation for rounds, I had jotted important notes from the patient's presentation on a notecard; the admission note was tucked inisde my labcoat pocket like a security blanket; and, I'd recited my 4-minute oral presentation in front of numerous mirrors around the county hospital. I was enacting what students in medical centers around the country repeat every four nights: 18 hours of hard work boiled down to a rhetorical device that is partly polished statement of fact and partly persuasive discourse. I was ready.

What followed that morning was the most rambling, incoherent jumble of words I've ever heard emerge from my mouth. Which says a lot -- the oral presentation is what I've struggled with most over my third year's tenure. But I was improving, was gaining confidence, and even was comfortable working within this format to share medical information. You can imagine the frustration I felt when I suddenly transformed into a green third-year clerk in front of a new attending, just as I was supposed to be "hitting my stride." I went home later that afternoon crushed. It hardly mattered that my second presentation was okay and that one of the patients had turned the corner due to a treatment I suggested overnight. That "first impression" was lost. Instead of hitting my stride, I found myself in an uphill trudge.

But all was not lost. I'm probably not alone among medical students in admitting I have a fixer personality. When I see something wrong, I have to get in and wrestle with it; at the very least, I tinker. I woke up the next day resolved to fix this thing. After all, I LIKE clinical medicine! I would not allow my little stumble to precede a precipitous fall. Some of the strategies I came up with that morning could apply to any difficulty encountered in medical school, or (if you have one) in real life. They included:

1. Forget about it, move on, wow the team next time.

2. Acknowledge your mistake; ask the attending for pointers.

3. Practice, practice, practice. Practice again.

4. Consult with a third party adviser about the situation.

5. Take a long run.

Initially, I decided on #1. But I quickly grew impatient with this. (Recall that I'm a fixer.) When the attending offered pointers before I could request them, that took care of #2. #3's a given. And #5 offered a painful reminder of just how much an inpatient service messes with one's conditioning. In the end, it was tactic #4 -- emailing the hospital's clerkship director -- that helped me the most, and may have initiated the most important realization during my three-month medicine clerkship.

Continued Tomorrow...

The End of One Journey and the Beginning of Another

Kendra Campbell -- Everything is so surreal right now. I’m riding in the passenger seat of a rented SUV on a major interstate highway, headed to a major international airport in Baltimore, Maryland. Do you ever have one of those moments in life where you pause and think, “How did I get here?” Well, I’m having one of those moments. There are hundreds of cars all around me. The highway has five lanes, and even has painted markings. At any moment I could stop and buy just about anything I could imagine. I could eat almost any type of food that exists. There is a McDonalds and Starbucks on almost every corner. I am in America.

For those of you who have lived for years in a less developed country, and then moved to a country of excess like the States, you can imagine what I’m going through right now. Culture shock is an understatement. I’m having a grand mal culture seizure right now. I’ve spent almost the entire past week traveling by bus, plane, and car to my home in the States. I somehow managed to get all my worldly possessions and my two dogs home safely. It wasn’t an easy undertaking. During my road trip, I stopped at a Target (a huge discount super store) and cried when I walked through the doors. The amount of stuff to buy was overwhelmingly unfathomable.

I completed one “transition” semester of short rotations in Dominica. I’m officially living in the States for at least the next few years. I’ll be taking the next month to study for the USMLE Step 1, the medical licensing exam for the US. Two weeks later I’ll be starting my first official clinical rotation in Washington, DC. After that, I’ll hopefully be starting more clinical rotations in Baltimore, Maryland. So, at least I do have a rough draft of a plan.

Honestly, though? I don’t really feel like my plans are all that solid. I still feel so jumbled up from all the moving. I feel homeless (technically, I am right now), carless, and pointless. Being in between homes, cars, and schools is a very dissociative experience.

As for my education, I’ve completed all of my basic science schooling. I’ve had an initial introduction to the clinical world, but I really haven’t yet begun that journey. So, once again I’m sort of in limbo with that too.

I feel like I’m teetering on the brink of something huge. Behind me, I see all the work that I’ve done to get here. I see Dominica, and a monumental pile of information that I’ve learned to get to this point. In front of me is the United States of America, and all of the clinical experiences I have yet to have. There’s a part of me that wants to take the easy way out and go running and screaming back to Dominica. But the responsible side of me knows that I must press on ahead. Luckily, there is actually a large part of me that is very excited to be starting a new adventure. So, here’s to the end of one journey and the beginning of another!

Breaking Bad News

Ben Bryner -- As a medical student, I have informed exactly one person that they have a terminal illness and are soon going to die. Of course, this wasn't a real patient, but a "standardized patient"  (or SP), someone trained to act like they have a medical complaint and then answer questions and sometimes simulate physical exam findings like a real patient would. The SP's role has been popularized by Kramer (from the series Seinfeld) who took a job as an SP. However, Kramer's SP performance was a little over the top. Plus, in real life, the session with an SP usually includes a complete history and physical as well as talking about possible diagnoses and treatments, not just med students shouting out potential diagnoses. (Also, isn’t that med student the guy from Lost?)

Any field has some kind of facility for simulation, and this is it for the history and physical exam. Generally, our SPs have been very good. Most of our experiences with SPs are in the first two years, to gain experience in clinical settings before we are sent off to the wards, or in testing situations to formally assess our history-taking and examination skills. But occasionally in the clinical years, our school sets up SP experiences to help fill in gaps that don't get addressed on rotations.

On the surgery rotation, there are plenty of patients who get bad news, but students often are not around when the surgeons inform the family (often because they lack the longitudinal relationship with the family, or they're simply busy in the OR or conference, or other reasons). So during our third-year surgery rotation, we practice giving SPs "bad news." There are some articles to read beforehand, as well as some advice on how to answer the most frequently asked (but impossible to answer) question of "How long do I have?" Maneuvering around this question is one of the hardest aspects of breaking bad news, because the goals of communication in the doctor-patient relationship -- including accuracy, encouragement and openness -- are completely at odds when answering it.

Breaking bad news is perhaps the toughest task in medicine. For that reason, if you Google “breaking bad news” you can find dozens of books and articles devoted to the subject. You may also find the words to 50 Cent’s song “Bad News,” which are actually not very helpful in this case.

But speaking of words, one of the other difficult things we are supposed to learn from this SP experience is using specific language, like the words "dying" and "death" instead of euphemisms that are likely to be misunderstood. This table is about my favorite of all the tables I've ever seen in medical journals. The rest of the article (Berry S. Just Say Die. Journal of Clinical Oncology. 2008;26:157-159) is an oncologist's discussion of how physicians can help their patients by being direct when the situation requires, and how this is compatible with a compassionate doctor-patient relationship.

Dr. Berry sums up: "One of the reasons physicians find end-of-life discussions so difficult is the belief that these exchanges, and in particular using the words 'death' and 'dying,' could distress our patients. Avoiding harm is a central tenet of our ethical conduct as physicians. However, it is possible to use the words 'death' and 'dying' in talking to seriously ill patients, as long as it is done sensitively; their use may actually avoid harm if they clarify the discussion." (And as Dr. Berry points out, calling them "end-of-life issues" is just another euphemism we use to avoid the word "death"; we don't congratulate new parents on their "beginning-of-life event.")

It's worth practicing. Even in an artificial setting, even telling myself beforehand that I needed to be direct, I had a hard time telling my standardized patient that she was going to die. I had to force it out, even though it would have been easier to hide behind phrases like "your cancer is terminal" or "the prognosis is very poor in this kind of situation" that I'd use if I were describing the case to another health-minded person.

Of course, at some point I'm going to have to take responsibility for giving a patient bad news for the first time. Since that rotation I've had a few chances to observe the process of giving bad news, and hopefully I will be able to adapt what I've seen and heard. I was glad for the experience with the SP if for no other reason than to become aware of how difficult it can be for a doctor to speak openly and plainly when discussing bad news, and how important it is to be clear.

Med Student Presents With New-onset Confusion

Anna Burkhead -- Chief Complaint: "confusion"

History of Present Illness: This is a 20-something year old female medical student who presents with new-onset "confusion" over creating her schedule for the final year of medical school. This state of mind has been slow and gradual in its onset for months but has been most evident and distressing since the patient’s required class meeting for planning. The bewilderment is characterized by indecision, staring spells, and detail obsession. Aggravating factors include conversations on the topic of 4th-year planning with peers and the rapidly approaching schedule due date. Alleviating factors include sleep and red wine. There are no associated physical complaints other than those already mentioned.

Review of Systems: As in HPI.

Past Medical History: No significant medical problems. No medications. No allergies.

Social History: The patient is a third-year medical student currently in her 3rd year surgery clerkship. She thinks her main field of interest is dermatology. Non-smoker, no drugs, occasional social alcohol.

Family History: No medical problems run in the family.

Physical Exam:

VS: Afebrile, vitals stable and normal

General: Well-appearing petite female with bitten nails, sitting on examining table and clutching surgery review book.

Neuro: Grossly intact.

Mental Status: Alert and oriented x 4. Calm with periodic psychomotor agitation including toe tapping and hair twirling. Good eye contact. Speech has normal rate, tone, volume. Mood is "sometimes anxious". Affect is congruent. Thought process is linear. Denies AVH, paranoia. Language is fluent, cognition is within normal limits. Recent and remote memory intact.

Assessment and Plan:

This is a young female medical student presenting with stress over 4th year scheduling. Suspect that this is due to the immediate issue of unclear process and intimidating paperwork, as well as the larger issue of major decisions about the future, including applying for residency, that need to be made soon. Will encourage positive actions such as researching electives, discourage obsessive arranging/rearranging of options, and prescribe consulting meeting with career goal advisor, as well as sleep when possible. Return to clinic as needed.

Please Hold

Ben Bryner -- The "hang-up" button on my phone is broken. It's several years old and most of the buttons require some firm pressure to operate, but the button with the little red phone is totally dead. For a while I was at the mercy of the person on the other end of the line; they got to decide when the conversation was over and how many minutes I used up and there was nothing I could do about it. Eventually, I figured out that there was another series of buttons I could press to get the phone to hang up, but it wasn’t very convenient.

I decided my phone is like the health care system (at least in the US); it lacks a good system for "end of life issues" just as my phone fails at ending calls. A stretch, maybe, but stay with me. Most of the time, patients are swept along by the formidable (if not always efficient) process that is modern medicine, and all the stops are pulled out in an attempt to provide the best possible outcome for the patient. But what to do when all our efforts are clearly in vain? Even when the patient knows exactly what he or she wants done for them, it's hard for the health care system to switch out of a maximalist approach to care. Surprisingly, the hang-up button was the only button on this phone that wasn’t absolutely essential to operating of the phone. Similarly, our health care system can move along fine for most patients, but when a patient needs something other than the full court press, suddenly things get complicated.

Hospice, a comprehensive institution devoted to addressing the needs of the dying patient, started in England in the 1960s. Aimed at those with terminal diseases who wish to change the goals of their treatment from curing their disease to making the most of one's remaining time and managing pain, hospice has grown in the U.S. and around the world. I toured a hospice in Ann Arbor during one of my rotations and was very impressed. But the problem is that hospice in the U.S. hasn’t really been integrated into the health care system, unlike in the UK, where many inpatient hospices serve a huge number each year at no direct cost to the patients. A health policy professor once described hospice as having been stuck onto the U.S. health care system like an afterthought, or an annex hastily added onto an already-finished building. Many terminally ill patients aren’t referred to hospice at all, or it isn’t brought up until far beyond the appropriate time. One of the statistics often cited is the proportion of people who die in an intensive care unit (ICU): one in five. Clearly, some of these patients would have preferred to spend their final days at home. Really, of all the places I spend much time, the ICU is the least like my home. And although the lighting's much better in the ICU, it's not as quiet or comfortable as my place -- which is why most hospice care is given in the home.

As it stands, hospice hasn’t become a comprehensive answer to the problem, any more than the series of buttons I pressed to hang up my phone was a permanent answer to my broken phone. None of this is to denigrate the good people involved in end-of-life issues -- there is one surgeon in particular at our VA who leads a team of palliative care specialists who do terrific work and are tirelessly raising awareness of these issues. One of my VA patients had a very unfortunate diagnosis, but having them get involved in his care while he still had time to have a say in his plans for death was truly a silver lining.

Of course, my phone has an easy fix; I can get rid of it and get a new one. But all doctors can't just outsource their end-of-life problems to palliative care specialists; there aren't enough, and all of us from pediatricians to geriatricians have to deal with terminally ill patients and help them manage their final days and weeks. Assisting our terminally ill patients is much more complicated than just calling in a consult. (The standard reading giving the physician's perspective on these complex issues is David Eddy's "A Conversation with My Mother").

Addressing the systemic problem of allowing the terminally ill to die in the way they choose will require innovation, commitment of new resources, and action from concerned physicians throughout our careers. Graham has touched on this issue in his excellent "Health Care's Broke" series. I recommend it -- if you're on call right now, make your fellow student take the next admit while you read the whole series. Thank me in the morning.