Disappointment (money in medicine)

Depending on many different factors in your life, your view of a medical doctor probably varies wildly from your peers. That's even true among medical students. Find one medical student who thinks that doctors should be enriching the lives of their fellow humans and you'll find another who thinks doctors are just workers found in any other banal profession: lawyers, astronomers, sea captains. Which is what makes fourth year so disgusting: there are people who will graduate with me who have terrible ideas on what it means to be human, have no idea what compassion is, and who will probably continue to drive the healthcare machine in this country over a metaphorical cliff into a rift of soul-crushing, human-endangering failure.

Too hyperbolic? Probably. Let me explain:

It really bothers me that there are people who went to medical school because they had a passion for a certain career, and find themselves sending in applications to programs they know they will be denied from because they are terrible applicants. They lack the grades, the board scores, or something as extracurricular as research. They are not.... competitive.

I think dermatology is stupid. I will pick on derm a lot because eyes creep me out and medical imaging was a great advancement, so I optho and radio will be spared my ire in this discussion. The field of dermatology disgusts me because what do dermatologists know that an oncologist (skin cancers) or a well trained primary care physician (rashes) don't? And yet they somehow get paid more for doing less work. It is an artificially competitive field when you compare it to its value in society. And yet some people legitimately like dermatology. The study of skin. I can't fathom why. But they like it--not because they like that there are no emergencies. Not because they will get paid so well and work so little that they will be able to vacation in the fanciest of places atop beautiful yachts. But because they actually like skin and when they see someone with a rash they legitimately want to help them because they see skin as the most important organ of the body. Good hours and ludicrous paychecks are secondary gains--not the prime objective. The prime objective... is people.

And yet this year there will be at least one--from anecdotal evidence--individual who will in all likelihood not match into the field of dermatology despite a strong conviction that that is what they will want to do for the rest of their lives, simply because there are a lot of jackasses out there who see money as the sole solution to all of their ills and who have done so much better on exams that they can and will crowd out the people who would make the best dermatologists.

The best doctors aren't the ones who test best. The best doctors are the ones who are determined to improve the lives of their patients. Studying well and testing well is not the same as staying up late at night worrying how you can implement better care for your patients. Those are two types of hard workers. But only the latter will actually act selflessly whenever possible and improve the lives of others.

Once we start recognizing that--yes--doctors should be smart but they also need to be enthusiastic and deeply invested in their jobs instead of seeing their jobs as a money making venture we can start really making changes to medical machine for the better. For example... why not pay all doctors the same? No matter the field? Remove the pay gaps and see what happens. That would be a fun experiment. It might improve things.

When I was a first year medical student I had an interesting argument with my cousins--who were and continue to be--more conservative than I am. We were discussing healthcare in socialist societies (read: Northern Europe). They were arguing that when you pay doctors not much more than any other profession, you get doctors who really don't want to work hard because there's no point in working harder if you're just going to make the same amount. I actually think this is absolutely wrong. I think if you remove monetary incentives, only the people who actually want to be physicians will become doctors and they will thus work harder because they will love what they do. I think money is great! I love it. And I miss it when I have to spend it on things. But if I knew I would get the same amount of money whether I was an elementary school teacher or a doctor... well I'd still become a doctor because I am really passionate about being a physician. There are things that being a physician provide you that can't be found in other fields to the same degree. There was, and still continues to be although to much lesser a degree, respect for physicians. There is the sense of accomplishment you get from knowing that you know more than most other people. There is the appreciation you receive from patients who will share with you their most intimate of feelings, fears, concerns. My father is a surgeon. He has had the opportunity to be paid a lot of money many times in his life. But he continues to work in inner city Chicago because he enjoys helping people who wouldn't be able to get such surgeries done, even if he knows he will never get paid for operating on them because they have no money, they have no insurance. There were years when my dad made less money from operating than his malpractice insurance cost. That's right--you can make negative money as a physician. But he never considered quitting. Because he has a love for surgery which I don't understand, but which motivates him to work with little consideration to how much money he will make. More physicians should operate (pun intended) in this manner.

I am not an economist. I do not understand the "economy". I simply acknowledge that economic issues must be way more complicated than they appear. Still, just imagine a world where medical school wasn't any more expensive than an undergraduate education. Imagine a world where it was actually free. The person who loves skin diseases--however weird she may be--goes to medical school, falls in love with the study of dermatology, and in her fourth year decides to apply to some dermatology residency programs. Because there are no extrinsic powers enhancing the appeal of dermatology, only those with an intrinsic interest apply. And because skin is such a specific field, much fewer people apply to it. Perhaps the number of applicants correlates with the number of dermatology resident positions available in the field? Dermatology is no more competitive than any other specialty and everyone medical school graduate gets to work in the field they love. They may still not get into their ideal program, but at least they get to be in the OR, or the community, or in the ER, or in a dark room staring at radiographs all day. Which is what they love and want to do well for the rest of their lives. 

So what are doctors supposed to be? Well paid or hard working? Money is a great reward for hard work. But it's also a great incentive for people who should not be physicians to enter the field.

I've struggled with how I feel about how much physicians get paid. Honestly, being a medical student, being a resident, and being an attending are all difficult and they should be paid well. But now that I have started to see my friends struggle to get interviews when people who have developed reputations for "getting drunk and beating up people" or "saying really racist things in class" are getting a plethora of invites, I have to question how well this system was set up.

And I will continue to question it. Because money shouldn't drive the motivation for anything. Especially something as important as taking care of people.

Money & Politics

So the other day I attended a speech at my medical school entitled "The State of the Medical School Address." I was one of a handful of senior medical students in attendance. The majority of the crowd was a mix of underclassmen--present despite the absence of free food; professors--who looked almost human with their absence of papers and folders and textbooks tucked under their arms; and administrators--eager to be absent from another boring weekday noon meeting.

Overall it was an illuminating presentation. The slides were presented in Prezi, which can make anything look like a Ted Talk, and our school's newly inaugurated Dean, Dr. Tomkoviak, is a psychiatrist so he possessed the appropriate vocabulary and ethos to motivationally interview everyone in attendance--further adding to the Ted Talk vibe. It was nice to hear where our school was going in a suspiciously positive light. But I tried to temper my suspicions with my generally optimistic attitude. It kind of worked, although my cynicism wouldn't completely shut off. Chicago has many highly ranked medical schools and despite being The Chicago Medical School it is hard to stand out and be exceptional. We were also placed on probation by the LCME, as well. Another insult and another reason to wonder if this speech wasn't just a publicity stunt filled with half-truths and full lies.

Our dean talked about what he would be doing as our leader. Essentially he vowed to help everyone work together, allowing the staff and the students to work towards a similar vision of excellence. At times it almost sounded as though he would start telling us that we were "poised to shift paradigms by synergizing our individual strengths" -- it was one of those kind of talks that seemed displaced from the 1980s. I tried not to roll my eyes or laugh. I stayed optimistic.

Finally he mentioned some highlights of the work our administrators were doing for the good of the students, important additions to our school's plan: the creation of more residency programs affiliated with our school and the creation of a 5th year program for those students who fail to match, two wonderful additions for future graduates. He also talked about finding more clinical opportunities for students. All wonderful things. This part of the talk I didn't roll my eyes, I didn't scoff. I was in awe. I was grateful.

But in the end I found two things deeply upsetting. The first was the almost complete omission of our outrageous tuition. At almost 60k a year it's no wonder our school has struggled with diversifying our student population in recent years, a problem which the LCME noticed and used to place us on probation, along with the high debt among graduating students. Our tuition is the most expensive in Illinois--even more than Northwestern's medical school, whose students purportedly are given rental cars to commute to clinical rotations lest they lack a car of their own. A diverse student population is something our school has always been committed to, even from its start in 1912. Something that no other medical school still standing in Illinois today can claim. But how can we ask people--even the most driven among them--to jump into nearly a quarter of a million dollars in debt? That's insane. This shouldn't be happening. And even though, sadly, escalating student debt is not a unique problem to Chicago Medical School, I think students of our school should know exactly why our tuition is so high. What are we paying for? If it's the renovated and lovely cafeteria that closes absurdly early at 2 PM, I hate to say this... but I think we could have made do without. As somebody who's been well briefed about the political corruption in the City of Chicago, I can't believe that any entity with 'Chicago' in its title is free of any monetary mismanagement. Where's our money going? Understandably to hospitals and professors--for our education. For standardized patients and to purchasing online scholarly journals--also for our education. But I can't believe with a class size of almost 200 students (and at 60k a year that's roughly 12 million dollars in revenue), all that money is being used wisely. Where's the waste? What can we do about it?

Which leads me to the way the speech ended and the second thing that ticked me off. During the talk, the dean mentioned a new twitter campaign and offered a prize to a randomly drawn tweeter using the hashtag #CMSPLEDGE. Social  media at its finest! The winner was a medical student. The dean proudly handed her a gift bag and asked her to open it. She pulled out an IPAD mini. To help her with her studies in the evolving world of medical education. A nice symbolic gesture. And a nice gift. Almost as an aside he mentioned: "And to all of you students wondering, I didn't use any of your tuition money to buy this. I paid for that myself." A comment that garnered many laughs. Yet I was outraged. Sure our tuition money didn't go directly into buying gifts. That would be--and the only course I ever failed was accounting so I'm sure I'll mess this up but--that would be some form of money laundering, right? Regardless, it has been proposed that one of the causes for the ever increasing cost of higher education is the money paid to top administrators. Like deans. Like CEOs. Like non-essential and inept staff who don't respond to your emails on time and who belittle you once they finally respond to your originally non-urgent but now emergent requests because it was sitting, neglected, in an inbox for three weeks. Okay, so not so much that last one. But that's an inefficiency all the same. And if the CEO of our university is making $500,000 dollars a year for essentially being a figurehead, I've got to ask if that money would be better used to give eight to ten medical students 100% tuition assistance.

I'm not claiming to know anything about business models or how to run a university. But I do know that in some small way my peers and I helped pay for that IPAD mini and I would much rather have had assistance paying for any number of the many additional fees of medical school few people tell you about.

I love my school. The students represent--in my personal and likely biased opinion--some of the most hardworking and honest medical students you can find in Chicago. And whether or not it was motivated by being placed on probation, I like the way our school keeps thinking up innovative changes to the curricula. Our school has emphasized liberal arts to the long term benefit of every one of its graduates. And I appreciate that. I truly due. But the fact that tuition wasn't addressed heavily tells me that either it was too difficult or too depressing of a topic to put into a motivating speech or that nobody at the top cares about this specific problem. And if tuition isn't seriously addressed, I fear that the quality of the CMS graduate will decline not because of any weaknesses in the school's academics, but because it will be admitting only those students who can look at a quarter million dollar pricetag and not flinch.

Hospital Billing and Insurance

The prompt for this next clinical reflection meeting at school was the following: To what extent are physicians' values and decisions responsible for the cost of health care, and what responsibility do we have to control costs? How cost-conscious have the physicians you have worked with been, and what rolled does financial stewardship have in the professional responsibilities of physicians? 

But like so many other things, I was still angry about dropping $175 at Walgreens the other day for 3 vials of lantus and two boxes of test strips, so I had trouble focusing:

I think it is fundamentally irresponsible to be a physician unaware of the costs of medicine and health care services. That being said, a lot of physicians don't want to worry themselves with the details. Have I ever worked with a physician who seemed to understand how much things cost for patients? Not really. No. But consider this: how many physicians actually have chronic illnesses? How many doctors are on a ton of prescriptions at any one time?

On the Eve of ERAS (applying to residency programs)

I'm on the floor with my head cradled into my pillow. I'm dragging in slow but shallow breaths, smelling the scent of leave-in hair conditioner that has diffused into the pillow cover since last washing it several weeks ago.

There's a bottle of extra strength Excedrin and a bottle of antacids sitting on the table that I was previously sitting at. They've done nothing. My head hurts and my stomach hurts and I don't know why. Or rather, I either gave myself food poisoning via homemade balsamic vinaigrette for a delicious salad eaten midday or I am so stressed out that my body is forcing me to give up on what was previously a fun challenge:

Write the Great American Personal Statement.

I believe my psychogenic pain is telling me it's impossible.

Tomorrow I will have to submit 28 to 30 applications (depending on if I delete/add any new programs in the next 24 hours) to family medicine residency programs that are literally all around the country. Or maybe I'll splurge and apply to 75 programs, like some people I know who are applying to more difficult specialties. They will shell out more than $3,000. But the common motto is: "It's cheaper than having to apply next year." Implying that many of us won't get interviews and ultimately match unless we apply far and wide and broadly because we're.... what? Not motivated? Not dedicated? Not humane? No the answer is "less competitive." But what the hell is competitive? I don't know. I really don't. It's different for every specialty and every program within that specialty.

Each application will include a copy of my personal statement. The Great American Personal Statement.

Oh hell. And then there's the added anxiety that is trying to end up in the same location as my significant other who is also going to attempt to match this year. The likelihood of us matching in the same geographic location is so... unlikely that honestly we should probably just break-up right now and stop prolonging a fantasy that is doomed to fail.

Unless I can write the Great American Personal Statement.

Because then maybe I'll get interviews everywhere.

And then all my dreams will come true. I'll become an awesome resident who will have an awesome career, and despite it being "impossible" to have a private practice, I will have one. I will have it all.

But literally, only if I write the Great American Personal Statement.

So I'm whimpering through and over-analyzing every sentence, every paragraph, every idea, every phrase.  This is impossible. Everything's impossible. What is medicine? Why am I doing this?

Because I'm a smart young adult willing to dedicate my life to years like this last one. With days like this one. Spent over analyzing the smallest of details. Because I want to improve the lives of those around me. Because I want to serve communities in a way that will make lives healthier, happier, and more productive.

Because I want to be happy with the life I've lived. I want to die knowing that what I have accomplished has made a difference in this world, if only for a moment in the grand scheme of things. But that I've effected change. That I've made others happy.

Oh my god. I'm crying. I'm literally crying right now. Because all I want is to help people. Which sounds so stupid and has been said so many goddamn times. But it's true. Why can't I just write that? Why can't I just put that in my personal statement? The Great f***ing American Personal Statement. I want to help people. My name is Elora Apantaku and I will literally do everything I can to help people until the day I die.

Socially Valuable

"Remember that competitiveness does not equate to what is rewarding or socially valuable. The least competitive specialties, Family Medicine and Internal Medicine, are highly rewarding and are perhaps in the greatest social demand." - Dean of Students in an E-mail to fourth year students