Tuesday, April 6, 2010

Believing in what you do

This story (from the NY Times) about the young palliative care physician in New York who died at age 38 from metastatic breast cancer is pretty harrowing. Dr. Desiree Pardi was a rising star, apparently, in the field of palliative care medicine. She was first diagnosed with cancer at age 31 and battled the recurrences with surgery and chemotherapy while maintaining a full work schedule over the subsequent 7 years. As a palliative care doctor, she spent her days having frank conversations with patients who had no chance for recovery and helped guide them down the road toward a resigned acceptance of death.
About a year ago, she was asked to speak to a young woman who refused to accept that her life was limited. Dory Hottensen, a social worker who was there, later recounted how Dr. Pardi sat down and held the woman’s hand.

“I could see that Desiree had an unusual connection with her,” Ms. Hottensen said. Dr. Pardi spoke kindly, and “told her that she was not going to get better. In fact, she was going to die very soon. What did she want for her last days? How did she want to die?”

In her own battle with cancer, however, Dr Pardi chose to pursue every means of aggressive treatment, no matter how futile, up until the very end. When it became apparent that there was nothing more to be offered and doctors broached the possibility of hospice, she vehemently refused to cede the hopelessness of her situation.

A doctor asked if she would like a palliative care consultation. She was shocked; she interpreted the question to mean that she had been identified as someone who was dying, and she did not think of herself that way.

She had crossed to the other side of the mirror, from doctor to patient, and she no longer saw an orderly path to death.

It's easy to sit here and condemn Dr Pardi as a poor soul in denial, as someone who turned her back on the very principles of the field which had made up her life's work. I mean, she counseled patients to accept the inevitability of forthcoming death while refusing to consider the possibility that her own terminal illness had reached a stage of futility. It just doesn't seem very consistent does it?

But I would caution against standing in judgment of this unfortunate woman. We all make a thousand little betrayals to ourselves every week. We all have those grand visions of the Ideal Life we hope to lead. But real life has a way of trashing our best laid plans. We're never as courageous or ethical or as kind as we envision ourselves to be lying in bed at night, staring at the ceiling. We fail to live up to our standards. We compromise our goals and aspirations to an alarming degree. I'm not always the father, the husband, the surgeon I aspire to be. We do the best we can but it isn't always easy. Life rarely conforms to the neat little algorithms of personal conduct we've laid out in our minds.

Those who have read this blog for any length of time will know that I am staunchly opposed to absolutism and inflexible ideological fervor. The contingencies and tribulations of life demand a reasonable pragmatism that allows for some flexibility in choosing unexpected pathways. Don't condemn Dr Pardi for turning her back on her life's work when the chips were down and her own life was at stake. Maybe in her own private moral computations it was more honorable to fight her cancer until the very end. She was too young to die. It wasn't fair. Perhaps the bigger betrayal in her mind would have been the acceptance of an arbitrary early death. Who knows. But we owe her the respect and the autonomy to make those tough decisions for herself.

Monday, April 5, 2010

Medical School Debt

From the AMA:
Student debt statistics
*$156,456 – According to the Association of American Medical Colleges (AAMC), the average educational debt of indebted graduates of the class of 2009.
*79 percent of graduates have debt of at least $100,000.
*58 precent of graduates have debt of at least $150,000.
*87 percent of graduating medical students carry outstanding loans.
Source: AAMC 2009 Graduation Questionnaire

Why medical education debt has increased
Medical education debt is driven by rising tuition. AAMC data show that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period. Other recent 20-year periods show similar trends.

Tuition is just one source of increasing debt burdens. Other causes include:

Interest accrued on loans over time significantly adds to the total cost of student debt.
Students are now entering medical school with more education debt from undergraduate education.
Increasing numbers of “non-traditional” students who have children to support.

Those are the numbers. The road to being a physician in this country is long and arduous enough. Factor in the absurd debt load one must take on to obtain that degree and it becomes very clear why many young docs are electing to pursue careers in the higher paying specialties. It's an unsustainable track.

We just passed Obamacare. 30 million uninsured people will have affordable health care. You won't get denied coverage for a pre-existing condition. But what are people supposed to do when they find out there aren't enough primary care doctors to handle the workload? The negligent attitude of Obamacare toward this forthcoming crisis is just astounding. So much political capital was expended throughout the year long battle. And to think it could all come crashing down because nothing was done about lessening the debt burden of medical school. Oh, and there's no tort reform either. And reimbursements are going to get cut. So who wants to sign up for medical school, kids? Anyone? Someone?

Friday, April 2, 2010

Weekend Image

Yeah, it's a femoral hernia with a loop of transverse colon incarcerated in it. We get to operate on these.