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It’s time to stop the foreign doctor kabuki

Residency application season has just started. Many of the applicants, a few of whom I know in person, will be foreign medical graduates, or FMGs, meaning that they are doctors who want to work in the US but are not US citizens. Most FMGs, but not all, will also be international medical graduates — IMGs — meaning that they have graduated from a non-US medical schools. Something called the Education Commision for Foreign Medical Graduates, or ECFMG, acts as their medical school when interacting with most of the sprawling US bureaucracy. These are our personae dramatis, if you will.

Disclosure: I am both an FMG and an IMG, and first began working in the US on an ECFMG-sponsored J1 visa.

America is a net importer of physicians, that much should obvious to anyone who’s ever been in an American hospital. The country depends on FMGs to keep the system running, get the less lucrative specialties, work in underserved areas, etc. Not so obvious is that most FMGs get to America by lying; ICE-approved, foreign-government sponsored lying for sure, but lying nonetheless.

Here are the lies FMGs tell when they come in: that their country has a need for doctors of such-and-such specialty, and/or that their government is sending them to the US for training in the said specialty, and/or that at the end of training they will go back to their country of origin to work in the (sub)specialty they came in to obtain. Those are the three postulates of the J1 physician exchange visa, the very name of which is also a lie as there is no exchange taking place: foreign doctors do come in, but no American doctors come out.

The postulates are incompatible with reality, and imply foreign government competence that just isn’t there in second and third-world countries1. Because over there, no one is keeping statistics on specialist needs, and if they are there is actually a surplus, and if there isn’t they wouldn’t be able to afford the (sub)specialists once they come back, and if they could then they would be chosen by party or family lines, and you wouldn’t want them in your hospitals anyway.

So to get a J1 visa FMGs need to obtain a letter from their Ministry of Health or equivalent stating the above (the postulates, not the actual truth; I’m sure that in some of those countries people have gone to prison for saying the truth). But is there a functioning Ministry of Health? Does anyone there know that the letter they are supposed to provide about lending a medical graduate and wanting them back is a piece of kabuki theater, and not a commitment to employ that person if and when they come back? And because this letter is supposed to come in a sealed envelope directly from the Ministry to ECFMG: does anyone there speak English? So here are all those FMGs whose main reason to emigrate to America may have been to escape their kleptocratic governments, being dragged into a game of Whom do I bribe next? and Which newspaper do I threaten them with?2 by the rules of the country they were hoping was less crooked than their own.

Which is fine for America, because it doesn’t care as long as it gets its steady stream of MDs one way or another. Only it should care because 1) the amount of person-hours wasted is on par with if not greater than the amount spent writing grants, and that one’s a whopper, 2) it relinquishes control over a part of its healthcare to foreign governments, and 3) it introduces an air of subterfuge and deceit at the very beginning of the FMG-USA relationship. I would like to think this is an aberration to be fixed, and not a preview of things to come in other areas of governance.

The process was probably fine 50 years ago, when both demands of the medical system and the influx of foreign doctors were but a fraction of the current monstrosity, when USMLE was taken on paper if you had to take it at all, when it wasn’t so obvious to a non-aligned physician whether they should go to the US or USSR (or Yugoslavia, for that matter) to get more training. But healthcare has changed and so has the world: it’s time do drop the pretense of an exchange, America, and be honest about what’s going on here.

  1. The transitioning and developing world, if you will. 

  2. In 2019 the correct answer is, for most countries of this sort, None. 

What I believe that most people probably don’t (no data behind this, just the armchair)

The world in general, and the US in particular, is spending too much on goal-directed, targeted biomedical research while undervaluing both applied and theoretical physics. Picture Leonardo da Vinci drawing helicopters: that’s the modern-day cancer researcher. The universal cure for cancer — and there should be one, if humanity survives long enough to create it — will not come from an NIH grant. If grants are involved at all, it will be something initially funded by the National Science Foundation. The current system of funding (government, non-profit, biotech, you name it) is broken, and if you account for the opportunity cost it is a complete disaster. Each of these statements deserves at least a paragraph, but I am saving my carpal tunnels for a manuscript, an LOI, and a couple of protocols (oh, the irony).

In the meantime, a few things physician-scientists should do for the overall good: * find causes and create better prevention strategies, because a look at the SEER database will tell you that it’s not just bad luck; * eliminate barriers for administration of known curative therapies world-wide (do we really want to leave this to politicians and economists?); * ensure rapid and honest evaluation of the many new treatments, procedures, and diagnostic/prognostic methods coming out of the biomedical behemoth.

How beneficial any of this would be for one’s career is a different question altogether, but let’s not get into incentives because RSI. I am also very open to opposing opinions, since my being wrong would make my life easier.

→ Annals of internal medicine: Curiosity

Old (1999), but still good.

When I was a house officer and installing one of the first right-heart catheters, the machine that showed intrapulmonic arterial pressures was enormous and was equipped with strain gauges rather than computer chips. Making it work was difficult. After the line was in, the attending, the nurse, and I tried desperately to adjust the machine to show the pulmonary arterial pressure waves. We could not get them. The line on the screen remained flat. We manipulated toggle switches and strain gauges for about 15 minutes. Nothing. Finally, I glanced at the patient: He was dead.

The story that follows is even better.

Level up

The next time someone asks me about books to read before residency, I will direct them here. You don’t have to be a medical trainee to benefit from these, but that period of anxious anticipation between match day and orientation is perfect for buffing your attributes.

How to read a book, by Mortimer J. Adler

What better way to start learning about learning than by reading a book about reading books?

The Farnam Street blog has a nice outline of the book’s main ideas. The same establishment is now hocking a $200 course on the same topic. It’s probably good, but at $10 the source material is slightly more affordable.

Getting things done, by David Allen

The first few months you will be neck-deep in scut work no matter what you do. After that, though, you will have to juggle patient care, research, didactics, fellowship/career planning, and piles of administrative drek—and that’s just inside the hospital. At the very least, this book will help you make time for laundry (and maybe some reading).

Thinking, fast and slow, by Daniel Kahneman

Superficially, similar knowledge to what is in these 400+ pages can be found in a few Wikipedia entries. But you would miss out on the how and why cognitive biases and heuristics are so important. Medicine and research are bias-driven endeavors, and not understanding them is not knowing real-world medicine.

Only three? Yes. If anything, the two and a half months between mid-March and July 1st won’t be enough to read them all with the attention they deserve. But you should try.

A yearly welcome

July 1st is when most US residency programs let their new interns loose after a week of corporate compliance training and ACGME-mandated talks about burnout.

If you are a medical student or a new intern, read this.

And this short post of mine still applies.

In addition, remember that it is easy to become very cynical very quickly. That is not the best of defense mechanisms, but it is better than substance abuse, domestic violence, or suicidal ideation. So, if you have to be cynical, do it up the chain of command, not down or laterally. That way you will avoid preconditioning medical students, observers, and your fellow interns. The senior residents will either support you in your jadedness, or will get to feel smug when they tell you that you are too young for that much cynicism. Your attendings should, ideally, teach you why you are wrong—though the younger they are the more likely it is they will behave like senior residents. So it’s a win for everyone, really, unless someone dings you for lack of professionalism.

Also, please remember to eat.

The overhead

There are many misnomers in American medical English. Patients walk into your clinic (from Greek kline, bed) to learn whether their scan was negative (good) or positive (bad). Those who have severe chronic pain may ask for their pain medicine (that relieve pain, not cause it), usually opioids. Some physicians would call them pain-seeking (though what they are seeking is relief). If they don’t get a prescription, they may rate their doctor poorly on a patient satisfaction survey, which is a big thing if you are into quality improvement. Quality improvement. There’s a misnomer.

Quality improvement in medicine is by definition limited to improving things you can measure, i.e. quantify, i.e. judge by criteria that are the ying to quality’s yang. Those measures may be valid or not, and may improve patients’ lives, longevity, etc. (or not) but they are not quality. Because they are measures. Numbers. You know, quantities.

The movement is dangerous in at least three ways. Firstly and most obviously, many of the things being measured haven’t been validated in prospective trials. They are either (poor) conjecture—like tight glycemic control for type II diabetics assumed to help because of good outcomes in type ones (since, you know, a skinny teenager and a morbidly obese 60-year-old are similar that way.) Or they came out of a corporate think-tank cocaine-fueled outside-the-box brainstorming session, like patient satisfaction scores1.

Secondly, even if they were the best measures in the world, tying them to promotion and compensation would have the unintended consequence of having practitioners loose sight of all other aspects of medicine, including the patient. There are many accounts of how it can happen—this one from Dr. Centor comes readily to mind—but since (1) identifying and (2) addressing the patient’s actual problem is difficult to measure objectively, it is not one of the benchmarks.

And finally, wherever there are numbers and money, techniques will evolve to game the system. David Simon’s account of how this happens in law enforcement is applicable. Want fewer central line infections? Enact a policy not to draw blood cultures from central lines! Too many nosocomial urinary tract infections? Urinalyses on admission for everyone! Hospitals create teams with dozens of people whose only job is to find new and better ways to do this. And they have to—because everyone else is doing it. A depressing amount of time, money, and effort wasted because of pointless exercises of anonymous pencil-pushers.

This is how you get to a near 3000% increase in the number of hospital administrators over 30 years. I am sure they are all good people, with good salaries, but they are, for the most part, insignificant. An epiphenomenon induced by someone’s desire to turn healthcare into an industry, forgetting that the six sigma ideology that works so well for toaster ovens can’t be forced onto moist, squishy, and fragile humans.

Which is also a good working definition of quality improvement.

  1. Some speculation on my end there. They might have been on LSD

Talk therapy

She makes the mistake of talking to patients.”

Overheard from a fellow discussing the consult attending’s rounding habits

Is there such a thing as spending too much time with a patient? The question seems preposterous, when recent time motion studies showed that physicians in general, and residents in particular, clock embarrassingly few face-to-face minutes. The quote above was said with a wink and a nudge, but there are situations when it can be true, particularly if you talk to a patient—or get talked to—instead of having a conversation.

Two groups are at highest risk of talking too much—trainees and consultants. Many an internist remembers having to pick up the pieces after a consulting physician flew by the bedside to throw an unasked for opinion bomb. Think hematologists talking about insulin regimens, cardiologists about causes and treatment of back pain, or orthopedic surgeons about code status. “But one doctor said…” and a perplexed look is the usual outcome, more so if the consultant debated him or herself out loud.

Fellows are even more efficient sowers of confusion. Unlike some of their superiors, they still remember other fields well enough to a) have a valid opinion, and b) keep it to themselves. Where they are at highest risk for foot-in-mouth is the area of their future expertise—picking up just enough from the attendings to sound knowledgeable, yet not knowing enough to tell the patient what they don’t know. Even at later stages of training, a fellow’s best plan shared with the patient may tumble down when the attending gives a diametrically opposed recommendation. The common scenario is one in which there is no evidence, and clinical judgment rules. You can either not share your own view, or punctuate every conversation with “But we’ll see what my attending says.” More time wasted, and for nothing.

Patients themselves can be talkative, sometimes to their detriment. The reasons are many, and understandable: they have much to say about themselves—relevant to why they are in the hospital and not so much, they might not have anyone at home listening, they may have some level of delirium, dementia, or other cognitive disorder. Being able to identify such a person, and then knowing how to direct the conversation, is an unknown skill for most trainees and goes against today’s dogma of giving patients time to talk. No harm done to the chatty ones, but there are only so many hours in the day, and some of them should be spent thinking.

To be clear, we don’t have an epidemic of young doctors staying in the hospital until 2am while demented World War II veterans regail them with half-made up stories from Normandy. If only. But more isn’t always better, and physicians need to know when to speak up (to get their patient back on the topic), and when to stay quiet (not to overwhelm them with half-baked ideas).

Why be a chief resident?

For the first time since joining Quora, I found a question to which I can meaningfuly contribute. Thought you might like to see my answer.

Why would someone choose to be a chief resident (in internal medicine)?

Why indeed.

The cynical answers would be “out of a misguided sense of loyalty to your program”. The correct and not very useful answer is—it depends.

Most positions entail primarily administrative responsibilities, with some teaching and clinical duties, and a salary just slightly higher than that of a PGY-3. So, you can expect your patient care skills to languish unless you work on maintaining them, your teaching skills to be slightly improved—or at least no worse if you’ve had some prior experience—and your knowledge of hospital administration, people management, dealing with email, and making the most out of seemingly pointless meetings to go through the roof. If you have any interest in academic medicine, as a generalist and sub-specialist alike, this last skill set will be invaluable. It is also a stamp of approval of sorts for any fellowship program director looking at your CV if and when you apply.

You also have much more free time. Depending on how many chiefs your program has, it will be most or all weekends, and almost all federal holidays. This is a good time to study for the boards if you haven’t taken them already, write up the research you’ve been working on, or spend some time with your family (the chief’s maternity/paternity leave is usually more flexible, but that’s program-dependent).

The downsides: you will have one fewer year of attending-level salary, so if you have a large debt or other financial responsibilities think twice before saying yes; some friendships you made with the junior residents will be undone or temporarily put on hold, unless you are very careful about not playing favorites; you may lose some respect for your higher-ups, as it goes whenever you peek behind the curtain; you will need to develop a thick skin, if you don’t have one already. Some would say these last two are actually pluses. It depends.

Visa issues complicate the matter, but I won’t go into details—bureaucracy shouldn’t play a role in determining a career choice, and when there is will (your own as well as the program’s) there is a way to bypass any obstacles.

Hope this helps.

How to say “I don’t know” like an intern

A key skill to have during oral exams back in med school was never to admit not knowing. Avoid the areas you’re uncertain of, dodge the examiner’s field of expertise as much as you can, and never ever say “I don’t know”.

These sage words were passed on from generation to generation, propagated by everyone, including me. Only, this wasn’t what I or any of my friends actually thought. It was a poke at the climate of intellectual dishonesty at our school, not a guide to success in medicine.

Starting residency, though, flips the sarcasm switch somewhere and the funny guidelines become instructions to be followed verbatim. The knowledge in question is different—patient data instead of textbook medicine—but the idea is the same. Observe the modern American intern’s vocabulary:

  • Not that I know of (means I don’t know).
  • I wasn’t aware of that (means I didn’t know).
  • I don’t think it is (means I don’t know if it is).
  • I belive so (means I have no idea, but yeah, maybe).
  • It probably was (means I don’t have a clue but I did a D6 roll in my head and it was a 5).

I used all of the above, and more, during internship, but still get frustrated hearing it from others1. If you are an intern, or anyone reporting patient data to a person above you in the pecking order, try using “I don’t know, but I can find out in a second” instead. Then start practicing your EMR skills to trully make it a second.

  1. That makes me a liar and a hippocrite, yes, but at least I’m being honest about it. 

On medical euphemisms

Observe George Carlin discussing how euphemisms are invading the English language:

I first heard a version of this years ago, back in Serbia, while I was still a med student. It hadn’t left much of an impression, but I can imagine myself nodding my head and thinking ha ha, yes, stupid Americans, ruining their own language, or something comparably obnoxious.

Well, I’ve, erm, matured since then. True, some euphemisms now inspire rage instead of vague amusement, like my two favorites:

  • I just wanted to let you know” instead of “I’m telling you”, and its relatives “Please let me know”, and “Thank you for letting me know”. Physicians are particularly fond of this, for we are the gatekeepers of knowledge, and the only reason you know something is because we are letting you. Don’t worry though, it’s not just you, we say that to each other all the time.

  • I don’t feel comfortable doing xyz” instead of “I don’t want to do xyz”, as mentioned here.

Most of them, though—particularly ones we use with patients—have a good reason to exist. The Radiolab segment which inspired this post made fun of “making someone comfortable” being used for dying ICU patients. Instead of… what, exactly? Euthanasia? There is a difference between giving someone drugs usualy meant for comfort—opioids, primarily—in order to kill them, and giving them opioids for pain and comfort knowing it may shorten their life.

Then there are turns of phrase used because they are euphemisms. “You should get your affairs in order”, “your time is becoming limited”, “at this point we should concentrate on quality of life, not quantity” are all ways of saying “I don’t know when you’ll die, but it will be soon, so start planning the funeral”. I am sure Mr. Carlin would appreciate getting it straight, but not every patient is as stoic. We can easily be more blunt if asked to do so, but you cannot un-hit a patient with a sledgehammer like that. So the default is to err on the side of softness.

Then again, most of the euphemisms we use with patients also make us more comfortable with the sitation. What I wrote above may then just be my rationalizing it away with a convenient it’s-best-for-the-patient mantra. In truth—to use another common phrase—euphemisitis is a multifactorial condition (as in, I have no idea what the reasons are, but it’s probably a little bit of everything).

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