What I Did on My Birthday

Today I turn 25, so to celebrate I took the morning off to solve Einstein’s riddle. It was a good day.

The Health Care Debate

This has been an interesting week in the blogosphere. The debate over Health Care, whether it should be universal, whether it is a right, and how or why we would strive to enact it has been healthy. I’m incredibly interested in this and have been reading as much as I can. What follows is a synopsis of the debate as I have seen it. Throughout, something has not been sitting well with me, and that I finally figured it out is why I’ve brought these excerpts together. My conclusion is at the end.

Kevin M.D. posted this under the heading “Health Care is Absolutely Not a Right.” The comments that follow are fascinating, and I would encourage everyone to read through them.

This is the fundamental philosophical difference between what I (and others) believe and the stance of the single-payer supporters. Thanks GruntDoc for linking to the money quote:

As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call “medical care” a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world . . .

The debate that followed in the comments circled around the EMTALA law, which mandates that any hospital must accept emergency medical cases, regardless of ability to pay. Hospitals abide by this law at considerable loss because the governement has threatened to remove funding for any hospital that does not. This would mean loss of Medicare, Medicaid, etc. One poster, Okulus, had the best comment:

In my view EMTALA is bad law. It mandates services under the threat of withdrawal of funding for unrelated services, which is extortion, particularly given that the taxpayers are providing that funding. (No different than threatening to take away a state’s allocation for highway subsidies if that state fails to comply with an unfunded mandate regarding education). Certainly I have a right to vote for candidates who want to repeal EMTALA. But even if I didn’t, that does not make EMTALA any more a good law. And it doesn’t make expropriation of services a right.

So is health insurance a right? Of course not. It is neither a de facto nor de jure right. And neither is postal service or 911 ambulance service or sewage disposal. They are services, available to the public when the public chooses to pay for them, and the converse when not. Any one of them could be here today and gone tomorrow, unlike real rights, which are far more durable.

So with the link to Graham Azon’s blog as the “single-payer supporter,” he responded with a two-parter (1)(2). These excerpts are truncated, so for his full argument you should visit his site:

Honestly, I think many people in the media use “socialized medicine” as a scare term, a blanket term for any sort of “government” health care. If that’s how you’re using it, fine, but if you’re presenting information as policy arguments, you sound a little sophomoric if you use it incorrectly. (This is like referring to the rectum as “the poop chute.”)

Socialized medicine is what the UK has.

Socialized insurance is what Canada has.

“Pay or play” is an employer-based system, where employers either have to offer coverage, or contribute to a fund to provide coverage to the uninsured.

***

From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?

Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.

So, what’s your better solution?

So from all of this, it strikes me that people are either holding steadfast to their philosophy that no resource can be mandated as a right (as that necessarily limits the rights of those providing the service), or they are holding steadfast to their pragmatism (that leaving people with their injuries because they cannot pay is not something that we are comfortable with as a society, so let’s fix that). I like Graham’s challenge though: what is the better solution?

So here’s mine.

FUND EMTALA. The Emergency Treatment and Labor Law was enacted in 1986 as a response to the act of “patient-dumping” by hospitals. In essence, the statute:

• imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an “emergency medical condition” exists;
• imposes restrictions on transfers of persons who exhibit an “emergency medical condition” or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;
• imposes an affirmative duty to institute treatment if an “emergency medical condition” does exist.

That last bullet point costs money. Lots of money. Where does it come from? EMTALA is an unfunded mandate, meaning that it was decided that providing medical care was so important that it required a law to be passed to ensure it, but not important enough to be supported financially. The weight of this law rests inapprpriately on the hospital, not where it belongs on the taxpayers whose interests are represented in Congress. Why would any hospital agree to this? The guillitoine of severed Medicare payments should they not comply.

Unless you run a hospital, why should you care? Imagine a hospital that is running without making a profit. They make enough money to cover all of their expenses and meet all of their salaries. Everything is only as expensive as it needs to be and all the prices charged are fair. If this hospital had to abide by EMTALA, it will begin to lose money. It’s options at this point are to ignore EMTALA (in which case it loses money anyway as the governemnt withdraws payments for patients on Medicare), go bankrupt and close (happens way more often than you think), or make up the loss by charging paying customers more.

I give you the $10 tylenol. Now we can debate the many factors for the rising costs of health care until we’re too dead for it to matter, but the fact that a hospital that abides by EMTALA must then overcharge paying customers is inescapable. It is also unfair. If you cannot pay for your own healthcare (and receive it anyway because of this law), then you are making healthcare more expensive for those that can pay. If this doesn’t happen, then the hospital closes and you’ve not only lost that resource, but you’ve stressed the remainging hospitals that now experience increased patient loads.

I give you a downward spiral. So for anyone that will ever need hospital care, this does matter. The solution seems pretty straightforward to me, and that is to reimburse the hospitals for their costs. It makes no sense to demand that hospitals pay for your service so that it is free to you. If we are as serious about giving everyone care in an emergency regardless of insurance as we claim to be, then that requires a serious sacrifice on our parts. Our taxes are going to increase. You will have, in effect, given universal accident insurance to the nation.

The details of payment can be left to the hospitals and lawyers to discuss, but the hospital should be able to demonstrate its expenses and the US government should send a check in the mail. So that’s my first solution: fund EMTALA.

Of course, what happens next would be interesting. If hospitals were able to do this and still saw all of the current cases in the ER, they would likely welcome the non-emergency cases that they currently detest. If the governement (and by that I mean all 300 million of us) were to see the bill, there would likely be some sticker shock. “We can’t afford to fund EMTALA,” we’d realize. “We’ve got to figure out a way to keep these non-emergency cases out of the ERs,” we’d decide. And it’s because we would likely be pushed into this future that I like Graham’s second point.

To paraphrase, emergency cases cost a lot of money, and these emergencies are sometimes the result of an uncontrolled chronic condition (amputation of a diabetic’s foot) that could have been prevented at a much lower cost. So if we’re going to have a funded EMTALA with effective universal accident insurance, wouldn’t the taxpayers save even more money with universal and comprehensive medical insurance?

I stumble with his conclusion. Not every American presents to the ER, and while providing preventative care for the person that does would save tax dollars, I can’t know which person’s preventative treatment to target. In other words, universal medical insurance has perfect sensitivity but poor specificity. It seems to me that any preventative measures should be specifically targeted and if that was truly cheaper the investment would be worthwhile.

Joe Paduda at Managed Care matters has a good point and I’ll let him have the last word. He’s absolutely right that we have to define our goals and these have to be in line with our principles. So in the interest of openness, I’ll be very specific about mine:

No one can claim a right to anyone’s service. It follows, then, that health care is not a right, but a want. It also follows that the weight of any proposed solution should fall on the backs of those who benefit (the tax payers) and not on the backs of those that provide it (hospitals, physicians).

No one can arbitrarily decide the worth of a service. By capping what a physician (lawyer, artist, whomever) can charge for his service, you are robbing him of his value and destroying the distinction between good and bad service by removing its incentive. It is for markets to decide what a service is worth, not governments.

I am open to (and would support) any program that successfully makes health care more accessible while not conflicting with these first principles. It remains to be seen if Single Payer is the solution to this, and I think everyone is going to be very interested with the results from the single-payer experiments in Main, Mass, Maryland, etc.

Joe Paduda’s last word at Managed Care Matters

What are we trying to accomplish with health care reform?

Lower costs today? A sustainable trend rate so care is affordable for the foreseeable future? Better outcomes, defined as healthier people and/or fewer avoidable deaths and/or higher levels of functionality? Coverage for all so no one goes without? Equitable reimbursement? Less interference in the doctor-patient relationship? Greater self-responsibility on the part of consumers? A reduced financial burden on employers, especially small ones and really big ones with lots of retirees? Ever healthier, longer-lived citizens?

All of the above?

Diamonds in the rough.

A Day in the Life of an Ambulance Driver.  Started writing recently, all of it good.

I gotta confess…I love it all. Aside from my professed world-weariness and cynicism, this is what I was born to do. So if you want a real Day In The Life of An Ambulance Driver, here is what we REALLY do…

We make far less money than our health care brethren with similar education. And the sad fact is, a whole lot of us do not even deserve the pittance we’re making.

We bitch and moan about low pay, yet we steadfastly oppose any attempt to advance our profession through higher educational standards.

We make a Big Deal of the whole lifesaving myth, smugly convinced of our own inflated sense of worth, yet we ignore the actions of the untrained bystander who probably made the greater difference.

We eat our own young.

How to Prepare for the USMLE: USMLE WORLD

When choosing a QBank, I went with USMLE WORLD (UW). It is much cheaper than the competitors Kaplan and USMLE Rx, it gets higher reviews from students that have used more than one QBank, and everything else (interface, online stats) was equal. Something of a no-brainer.

After using it for almost a month, I can say a few non-comparative things.

It’s fair. I haven’t had a question yet where I felt the wording was ambiguous or the answer was a stretch. Every time that I have looked at the options and thought to myself, “I have no idea,” it was because I really didn’t know (instead of knowing the answer and not knowing how to apply it).

It’s interesting. Each question has a full explanation (usually with an illustration or table) for right and wrong choices with a summary “Learning Objective” at the bottom. This is just a smart thing for the company to do, as every wrong answer leads to a new concept learned. I regularly go through my incorrect responses and copy down the new objective into my notes.

It’s hard. While at SGU, my favorite tests were in Pathology. Whoever wrote those tests was a sadist of the fourth order. For example:

1. The test stem would have symptoms. [appendicitis with Hx of appendectomy]
2. You’d have to figure out the disease. [Crohn’s]
3. You’d then have to realize what the appropriate treatment was. [Cortisol]
4. You’d have to know the side effects of that treatment. [abd striae, bull neck]
5. Finally, you can answer the question: Given this patient’s symptoms, what is the most likely side effect of his treatment? [weight gain]

Everyone complained about how hard those tests were, but I had been waiting for that type of challenge in a course my whole life. I loved those tests, and for similar reasons, I love the questions in the UW Qbank. There have been a few times where, after reading a question and figuring out the answer have thought, “That was the coolest way I have ever seen that asked.” I couldn’t give it higher praise.

If you’ve decided to use UW and are working through the questions, it might help to know how you’re doing. With each question, it will tell you the percentage of people that answer it correctly. With each subject, it will tell you your percentile against other test takers. Useful, right? I’m having a few problems with this.

The stat for “percentage that answer correctly” doesn’t say if that is on the first try or includes all attempts, including repeats. I wish there was a separate statistic for this. Your overall percentile is based on your test average against the mob, but again this can be manipulated by taking the same questions over and over (I’ve tested this myself). For the person going through the questions once without repeating, you may feel that your percentile is a little low (or just hope that it is).

Here are my percentiles on first past through all the available questions in a section. I will expand this list as I continue to cover material. You’ll notice that the scores are very low. As I mentioned before, these aren’t true percentiles as they are not compared against the mob’s first attempt and I list them here just so that people don’t feel so defeated when they take the questions themselves.

• Biostatistics (74th) – I felt very well prepared
• Behavioral Science (waiting to do Psych until later)
• Embryology (71st) – I felt well prepared
• Genetics (48th) – Curse you, Dudek and your horrible book.
• Biochemistry (79th) – I felt very well prepared
• Immunology (70th) – I felt well prepared
• Histology (32nd) – I wrote this off. Maybe I should look at it.
• Anatomy (74th) – Just for fun. I’m an Anatomy geek.

ADDENDUM: I sent an email to the USMLE WORLD team about these questions and I was pleasently surprised to see them respond the next day.

The “percentage that answer correctly” only records the first attempt of the user if the question in taken in the unused mode.

The cumulative performance is based on the entire test percentage and you are correct in assuming that the percentile might be manipulated if a person repeatedly takes the test and answers all the questions correctly. However for the percentile to skew greatly, a large number of users will have to “cheat” the system this way by repeatedly taking the same questions.

However, most of our users take the test first in unused mode and then they use other modes like incorrect or marked questions if they have sufficient time left. This might skew their overall percent by 2-3 % but over a significantly large data set this offset becomes negligible.

Hence, the presented percentile should only be used as a rough indication of where the user stands and preferably should be ignored during the initial tests.

Return to USMLE Step 1 page.

How to Prepare for the USMLE: Learning from Mistakes

I have always insisted on making my own mistakes. I often have to repeat my mistakes. This eats up a lot of my time.

I’ve griped before about not knowing how to handle this period of studying for the USMLE. What I have really meant is that I don’t trust anyone else’s advice and insist on screwing up a little before getting it right.

“You’ve bought too many books, you’ll never read all of those.”
“I never did a single question and got a 99.”
“Just stick with First Aid. It’s all you need.”
“You don’t have to study Emrbyo. There were hardly any Embryo questions on the test.”
“Do nothing but questions. Questions, questions, questions.”
“Man! There were a lot of Emrbyo questions! It’s definitely high yield.”

I still believe now what I believed before: that I have one shot at this test (I have no intention of failing it). In statistical parlance, this means that n=1 and df=0. You cannot draw conclusions from that study. People peddling specific advice to you forget this. Both people that stopped me in the library with their two cents about Emrbyo forgot this. And I will slowly forget this.

Since I broke up the subjects into General and Systems (the organization of the 2007 First Aid), I’ve tried to work on each section a little differently to see what is working. So after Biostats, Behavioral, Embryo, Biochem, Immuno, Autonomic Pharm, Basic Path and Micro, n=8. What follows is a breif chronical of my personal mistakes.

Biostatistics – 1 day

I read through the First Aid section briefly before slowly going through my old notes. I then opened up the Kaplan Lecture notes and read their Biostats section. For the first time, I started to notice that there were disagreements between sources. This sort of thing drives me mad, so I would often waste ten minutes on a piece of minutia to protect the house of cards. I then read the HY Biostatistics by Glaser. It was, by far, the best thing out there. I can’t say enough nice things about this excellent book. Finally, I took out a few pieces of paper and wrote a few pages of notes that I will later use to refresh the week before the test. I spent too much time on this section. I should have just used HY Biostats and taken my notes straight from it. Could have saved half a day.

Behavioral Science – 2 days

Going in, I am less than enthusiastic. Behavioral Science has always felt a little soft and doesn’t lend itself to learning a few core principles and then extrapolating the rest. It’s low yield. I start with Kaplan. It’s overkill. All of the epidemiology is over the top and I am falling asleep. Many of the tables and charts start to conflict with each other (two sentences each claiming different #1 killers for this or that) and I pitch it. After taking a look at the First Aid, I’m desperate to believe that there isn’t much I need to know as I finally turn to the HY Behavioral by Fadem. Everything is compact, well explained, and of a manageable size. This is what I wanted from the beginning. I take all of my notes for later review from this book and move on.

Embryology – 2 days

I wanted to work on Embryo as its own topic, and in the Kaplan notes it is intertwined with each system under Anatomy. Trying to learn from the previous three days, I head straight for the HY Embryo by Dudek (the BRS is also written by Dudek). This book is long, filled with pictures, and weighs in at 177 pages. I really liked this book for its clear explanations. There were several shaky concepts that were finally made clear (meiosis v mitosis, I’m embarassed to say) and it was worth the investment. It was detail heavy, but not to the point of being irrelevant and included plenty of pages devoted to genetic disease. All of this ended up tying in neatly with Biochem, so I consider it time well spent. Two days is a lot to devote to this, but I figured it was worth it on the assumption that it would help me make more connections down the road. I took all my notes onto Post-Its and put them in the First Aid section. I would do this the same way again.

Cell and Molecular Bio – 2 days

At SGU, genetics was a sort of half-assed course. Unfortunate, because I love this stuff and was completely put off at the time. I tried to repeat the success of Embryo with the HY Cell and Molecular Biology book by Dudek.

What trash.

This book has a bizarre number of typographical, illustrative, and conceptual errors. To be sure, there were some bright spots. The first chapter on cell signaling is fantastic and chapter 10: The Human Nuclear Genome was just fascinating, but I spent so much time trying to fact-check this book (after you find one error, you find another, and another) that I reached the point where I just couldn’t trust it any more. It’s largely cobbled together from his other books (almost twenty pages are straight from his HY Embryo) and the patchwork shows. This book was far from high yield and cost me two days before I gave up. I would never recommend it. I decide to cut my losses (Chapter 17 of 27) and go to the next topic.

Biochemistry – 5 days

I spent the first two days doing nothing but looking at the First Aid and reading through the corresponding notes from my first year. At the time, we were using Lipincott’s Illustrated Biochemistry, so having the book next to me made it easy to make sense of my chicken-scratch. I was cruising through the topic, confident, and then an amazing thing happened: I realized how much I didn’t know. You forget about it at the time, but going through Lipincott in first year, every term is alien, every disease and drug tie-in is ignored, and you’re happy to just get a “feel” for what’s going on. The second time around, it’s like seeing the world with new eyes. You understand every reference and all the things that haven’t made sense in other courses are finally connected. It was relevatory. I had originally planned to skim this book but finally decided to reread the whole thing. I didn’t have time to take any formal notes for later review (the Fed-Fast chapters were too engrossing), so I’ll have to carve this out later. This was also the weakest section in the First Aid, and I found myself wasting valuable time fact-checking Lipincott against First Aid against other texts to keep my head on straight.

If I had it to do again, I would have read through my old notes once, and then started on the book. I would have then used the two days that I wasted on Dudek’s HY Cell and Micro to write some review sheets. Oh well. My roommate spent the entire period going through Kaplan’s notes and had positive things to say. I wish I could confirm, but I ran out of time.

Immunology – 2 days

This was another SGU course that fell short for me. Fortunately, you can’t escape it, so that I didn’t learn it formally didn’t stop me from picking it up in Micro, Path, Pathophys, and Pharmacology of Immunosuppression. To get a feel for the scope, I cruised through First Aid and found that I had already covered a great deal of the material in Dudek’s HY Embryo. At this point, I’ve stopped looking at Kaplan all together. I went through the first four chapters of Rapid Review: Immunology and Microbiology. It is bare bones. They make it very obvious what they think is important and I did manage to make some new connections in these chapters, but it was not good enough to be a stand alone. There were several things (like lymph tissue anatomy) that were covered more in depth in the First Aid. I didn’t think that was possible, but there you have it. Between the two of them, I was reintroduced to everything that I saw in Path and my bases are covered. I even had time to take some good review notes for later. For the material I covered, I spent too much time in this book. That said, I didn’t have the time to read a proper text, so, c’est la vie.

Pathology of Neoplasia and Inflammation – 1 day

Path, how I’ve missed you. I’ve been looking forward to cracking open my brand new beautiful Path BRS since the day I bought it, and it was hard to limit myself to these two sections. I like the layout of the book, that the pages are thick enough that highlighter doesn’t bleed through (a previous problem), and the pace. The questions at the end of each chapter are inappropriately easy, which disappoints me. The subject came as a welcome break and I took one page of notes from the BRS and the First Aid.

Pharmacodynamics, kinetics, and ANS – 3 days

I started by reading the sparse entry in the First Aid on dynamics and kinetics before opening my Pharmacology for the Boards and Wards book. It covers these topics in the first 12 pages. It took my three hours. I’m probably just dense, but I didn’t feel this was well presented in either place, so if you already understand the topic, then FA might be enough. I floundered in this, but by the end was happy with my understanding. That left two days to cover autonomic pharmacology. That might have been enough, but the pace to date was too exhausting, and my roommate and I decided to quit for a day and recharge. It was necessary and we felt like a million bucks, but this means that I haven’t covered adrenergic drugs yet and will have to make it up later. If I had this to do over again, I would have traveled back in time and learned it correctly the first time. I also wouldn’t have tried to plow through three weeks of work without a single day off. Live and Learn.

I took a look at the Kaplan pharm section, and they have some very interesting pictures and graphs for conveying difficult topics. There pictures on the effects of cholinergics and adrenergics on the heart rate and BP are amazing, and the picture showing the ionization of drugs in the urine at varying pHs and resulting excretion is one of the most amazing pictures I have ever seen. As Pharm for the Boards and Wards is frustratingly filled with errors, I think I’ll switch over to Kaplan’s pharm when it comes to the systems.

Microbiology – 8 days

This is our first big topic, one of our weakest topics (competing with Pharm), and something I was afraid to begin. I decided to take a completely different approach and this has been the most successful to date.

I read the basic information in my main text, the RR: Immuno and Micro. Although it was painful to admit, I had to relearn about gram negative, positive, and the differences therein. After making some very basic notes, I used the FA bacteria-trees for gram positive and gram negative bacteria. I then wrote out all of the toxins for each bug and came up with some mnemonics for them. This would be my base. I spent the rest of the day writing the best notes that I could, trying to combine all the relevant information from the FA and the RR so that I would never have to look at either again. This took all day.

The next day I spent the first two hours trying to recreate the list of toxins from memory and draw the bacteria trees from memory. I accomplished this by noon. For the next two days, I did nothing but read about antibacterial drugs, their mechanisms, targets, and side effects. Every morning I would reread the notes I had made from the previous day until they were almost second nature. I tweaked my mnemonics.

By the time I had to sit down and learn about each bacteria, I found I knew almost everything I needed to simply from the drugs, the bacteria tree, and their toxins. Everything new that I was reading fell neatly into my pre-existing framework and this made everything before and after more solid for me. All in all, I spent four days on the bacteria alone, two days on viruses, and two days covering the remainder (protozoa, helminths, fungi). Nothing I have done has worked out so well.

Because the pharm section in the RR is small, I had to supplement it with the FA (suprisingly complete) and the Boards and Wards book (this section wasn’t too bad).

General Reference Book

Of all my decisions so far, the best one has been to have the Merck Manual with me at all times. It covers Micro, Pharm dynamics and kinetics, Path, Phys, EVERYTHING. It has been the great oracle whenever my review books conflicted and I would be lost without it. Of course, you could always study with your computer on and the internet running, but that would be a disaster for me. Instead, I keep my focus and have this book in front of me at all times

So what have I learned?

Less is more. Some books should generate automatic refunds for all the mistakes in them, and I would have done much more research on reviews before buying many of them (as it was, I went by First Aid’s recommendations alone). Instead of finding one incredibly solid book for each section, I have at least two books for every section (considering Kaplan) and sometimes three (Pharm, Path). This has been a mistake so far and one I’ll try to avoid as we enter systems.

First Aid is not enough. It has errors and will not give you an understanding of the topics. The First Aid is for someone that already knows everything and is looking for reinforcement and an idea of concepts previously tested. While it may be true that most questions you’ll see have their answers in the FA, that’s a far cry from being able to say that the FA helped me answer all the questions. After you read it, you’ll understand what I mean.

Repetition goes a long way. I find that writing out the information and making my own set of notes has worked for every class I have taken in medical school and this is no different. To paraphrase the late Frank Netter, “you can’t lie in a painting.” I feel the same way about writing: the things that are unclear to you become obvious when you try to take notes. It is, however, incredibly time consuming and I’m 3/4 towards my very own carpel tunnel syndrome. I’ve also found that taking notes on a piece of paper folded down the center is helpful, with prompts on the left and the information hidden on the right. It’s an idea stolen from teh Cornell method of note-taking, and it makes it very hard to lie to yourself as you read something that, “yeah, I remember that.”

When the answer is hidden, there’s no way to fake it.

So if you believe my experience, here’s what you keep and what you throw away from my original list:

• HY Biostatistics (great)
• HY Behavioral (great)
• HY Embryo (for the motivated student)
• HY Cell and Molecular (trash, don’t buy)
• Lipincott’s Biochem (long, great if it was your text book. Might want to consider Mark’s BRS)
• Pathology BRS (great)
• Pharmacology for the Boards and Wards (look for something better)
• RR: Immunology and Microbiology (Straight to the point, no frills)
• Kaplan lecture notes (Biochem and Pharm are strong sections. Biostats and Behavioral are weak. A wash).
• Merck Manual (my rock)

Hope it helps, topher.

Return to USMLE Step 1 page.

My Favorite Reads

These are blogs I feel lucky to have found and, after the first post, compelled me to begin from the beginning and devour the archives. Each contains a link to one of their earliest posts and I’ve included the first thing that I read from each of them that made me want to read them all.

PURRTY GUD

Battling a sinus infection. The notes were few from my standardized pelvic exam. The major good one was “Good pressure!” The bad one was “Must learn to avoid clitoris.”

If only they knew how many years of conditioning I’m working against.

PANDA BEAR MD

Empathy training is the latest fad to hit medical school. Large quantities of your time will be wasted on this sort of thing. I didn’t dislike empathy training. In fact, because it is so non-rigorous and intellectually vaccuous it provided a pleasant distraction from the usual boring lectures. What’s not to like about sitting in a circle listening to some idiot drone on about the wonderful things you are going to do for your patients once you learn to relate to them? It was even more entertaining to listen to the small minority of students who take this kind of thing seriously and wax orgasmic about making a difference and touching the lives of patients.

MED SCHOOL HELL

Welcome to med school hell. This is a blog about my life as a medical student and the “truth” about medical training. I thought I’d get started with a little introduction.

I’m a senior medical student training in the US. I hate medical school with a burning passion like I have never before felt. In future posts, you’ll get to share what it’s like to be in my shoes on the wards. You’ll get to really experience what it’s like to be a medical student or a physician in training. You won’t hear any pansy-ass crap, basically because I don’t give a fuck. You’ll hear it like it is, and I promise I won’t hold anything back.

The administration hates me about as much as I hate the school that pays their salary. I tell it like it is, and they don’t like that. They really don’t know how to take it. I’m more C=MD and FYIGML than they have ever seen. I walk by the Dean and he thinks “that’s the guy who doesn’t give a fuck.” Yep, that’s me.

VERITOGRAPHY

I can feel his blue eyes locking onto my own with a grip I’ve not experienced outside a battlefield. They are not the eyes of the desperate dying, they are the eyes of someone who knows exactly what he is doing and exactly what he is saying. I’ve seen that look in someone’s eyes before. Mr. Smith isn’t giving me advice, he’s giving me an order.

How to Prepare for the USMLE: Which QBank is the Best?

I’m just going to assume that I feel the way most people do about the unknown: I don’t like it. Even though I’ve known about this test for two years, it still feels like it’s springing up on me and I’m frantically trying to prepare.

What’s on it? Where there a lot of Biochem questions or was Neuro more stressed? Were the Path questions hard? And on, and on.

For most of us, it’s also the first time we’ve ever taken a test like this on a computer. Like most, I have my habits of underlining key words in a question stem, putting *’s by things that I have to skip now but may get later, putting an “X” next to a question that I could never answer correctly, etc. That I’ll be staring at a mouse, keyboard and glowing screen on test day is an unnerving thought.

To get over all of this, we look for practice questions. The good news is that there are thousands of practice questions on Al Gore’s internet and the companies worth their salt have some great supporting software. There are free questions and expensive questions and you get what you pay for. Let’s look at some free/semi-free sources first.

Free/Semi-free sites

• Official USMLE tutorial and practice questions (2007)
  • Gives you four blocks of 50 questions for practice with the testing interface FRED. No explanations for answers and reviewing your questions is awkward.
• Tulane’s Medical Pharmacology Exams
  • I wish I had known about this site when I took Pharmacology. The questions are broken down by subject with explanations of all answer choices. Straightforward multiple choice and great for review.
• Web Path
  • I used this site religiously when I took Path and it was an enourmous help. I recommend it to anyone and everyone. Great questions, great pictures, great format.
• Anatomy at University of Michigan
  • I used this site throughout anatomy and I still give thanks to this site.  Surface anatomy, gross anatomy, radiology, and Anatomy Jeopardy. After the Boards, I owe these guys a bottle of wine and a nice card.
• Lipincott Williams and Wilkins
  • 350-question comprehensive USMLE test, available to anyone that has registered with the site. If you have bought one of their books (Physio BRS), there is an access code in the jacket.
• Student Consult
  • I have access to this because of the two Rapid Review books that I bought (Gross and Developmental Anatomy, Microbiology and Immunology). This site also has 350-question tests for you to use (with the scratch-off code, of course).
• Facts in a Flash
  • Not USMLE format, but if you like working on flashcard questions without the rubberbands and mess, this might be for you.

So after looking at those sites you decide that, while very good for your normal review, you need some professional help for the Boards. You need this enough that you’ll part with some loan money. Whichever company you choose, you should look for the following:

1. Their question bank (QBank) should have enough questions for you to give yourself a fair evaluation, there should not be so many questions that you could not comfortably do them all, and the quality of the questions should be more important than the quantity.
2. The questions are given in the FRED computer format that you are going to see on the USMLE, complete with question marking, annotation, highlighting and strikethrough.
3. Detailed explanations for right and wrong responses.
4. Questions broken down by both subject and system, i.e. Cardiovascular Pharmacology.
5. The software shows your strengths, weaknesses, progress, and performance against all other students using the same questions.
6. THE HOLY GRAIL: The questions are of equal or greater difficulty compared to those on the USMLE.

Question Bank Subscriptions

• KAPLAN ($279, 3 months, 2100 Qs, FRED)
  • This was likely the first company that sprang to mind. Kaplan runs review courses where you live in a hotel for 6 weeks cramming, they have online course content, video lectures, on and on. This company has worked the USMLE inside and out, and it seems a right of passage that students slog through the 2100+ questions before sitting for the exam. I was a little wary of this company, though, as people told me that by the end of the course, they were scoring in the 90s on each block and that the actual USMLE was much harder.
• USMLE WORLD ($110, 3 months, 1730 Qs, FRED)
  • I had never heard of this program, but three people that I consider intelligent (each scored 95+) told me that UW’s questions were more difficult than the actual USMLE. Each of them also subscribed to Kaplan, used its program, and found the programs to offer the same features. After hearing this, visiting their site, and considering the prices, I had to take them seriously. It seemed like a great deal (less than half of Kaplan with a higher rating). The reviews at Prep4Usmle were positive as well. I also like that UW let’s you try their product for a month and if you like it, you can buy more months at a discount. My review of UW Qbank.
• USMLE Rx ($199, 3 months, 2000 Qs, FRED)
  • Written by the same authors of the First Aid for the USMLE. On glance, they seem to be doing everything correctly. They let you test their product and they offer integration between their online product and the First Aid book. The reviews that I have found put it on par with Kaplan. I’m intrigued.
• SCORE 95 ($99, 3 months, 4300 Qs, FRED?)
  • That this site is slick and has a string of testimonials (which read like a third grader’s homework assignment) is not impressing me. I am also having a lot of trouble actually learning about their program (does it run off your computer, what features does it have, etc.). What I am impressed with is their accompanying note set, that they show you the breakdown of their questions, and that they offer a daily podcast to anyone that wants to listen to a new subject each day. The reviews I was able to find online say that the program is poor and the questions are disappointing. Quantity > Quality. In fact, the number of questions scared me off well before my research. 4,300 questions comes to 360 questions a week for 12 weeks. I currently average 150, and that pace is keeping me busy. I cannot fathom the amount of work it would take to complete these questions, so why have them?
• EXAM MASTER ($179, CD, 8,700 Qs)
  • Absolutely not. On first glance: no. After reading reviews: no. If this program helps your score, it’s probably a placebo effect.

So where does that leave us? If you’re going to start doing questions 3 months before the exam, anything more than 2500 questions isn’t practical. You have to realize that you’ll be spending all day learning the material, and that it might take 3 days to cover a topic. At a reasonable pace, you can expect to do 150-200 a week (which will take you 3 hours and 15 minutes, remember). Anything more than this might burn you. So let’s just throw Exam Master and Score95 right out.

If you believe the worst reviews of the anonymous, Kaplan, UW and Usmle Rx are the same difficulty. If that’s true, then you should go with the cheapest program: UW. If you believe the best of the reviews, UW is harder than Kaplan and Rx, and you should go with UW. Though it has fewer questions, I got the strong feeling that the Quality >>> Quantity, and since I only have so much time to devote to questions, I want them to challenege me and teach me something new. I dropped the $110 and am incredibly happy with it. The questions are stout, and with all my over-preparing for each section, I have yet to crack an 85% in any discipline. This was a good choice for me.

However, if you don’t have much time, are planning on putting all your eggs in the First Aid basket, and would benefit more from reasonably challenging questions (whereas harder Qs might hurt your confidence more than help your score), then I can see a strong case for buying the Rx. It’s twice as expensive as UW, but the formats are indistinguishable and the integration with the First Aid book is appealing. If this wasn’t priced at $199, I might have bought this after finishing UW.

I’m sorry to beat up on Kaplan here, but after going through their QBook and the questions in their Lecture Notes, I’m just not impressed. I have consistently felt that the questions were either written to make me feel good about owning the notes, or that the notes were written to prepare me for those exact questions. Either way, I never had the feeling that Kaplan’s questions were independently difficult (if that makes sense) and from what I’ve read and heard from others, my concerns have merit. And for $279! Get over yourself, Kaplan.

So those are my thoughts on picking a QBank. I assure you that all the research was anecdotal and supplemented with gossip. I suggest heading over to the forums at prep4usmle to read for yourself, and if you have any comments on these products, I’d love to hear them.

Hope it helps, topher.

Return to USMLE Step 1 page.

Recycling is Garbage

My world has been flipped. I had to take some time away from the books to absorb this article from the New York Times (1996). Brilliantly written, it took me on a journey of discovery that recycling is garbage, we’re not going to suffer a “garbage landfill crisis,” and that the solution to excess waste is beautifully simple and already practiced by places like Minneapolis, San Francisco, and Seattle.

Recylcing is Garbage, by John Tierney.

“We’re not running out of wood, so why do we worry so much about recycling paper?” asks Jerry Taylor, the director of natural resource studies at the Cato Institute. “Paper is an agricultural product, made from trees grown specifically for paper production. Acting to conserve trees by recycling paper is like acting to conserve cornstalks by cutting back on corn consumption.”

Fifty years ago, for instance, tin and copper were said to be in danger of depletion, and conservationists urged mandatory recycling and rationing of these vital metals so that future generations wouldn’t be deprived of food containers and telephone wires. But today tin and copper are cheaper than ever. Most food containers don’t use any tin. Phone calls travel through fiber-optic cables of glass, which is made from sand-and should the world ever run out of sand, we could dispense with wires together by using cellular phones.

By now, many experts and public officials acknowledge that America could simply bury its garbage, but they object to this option because it diverts trash from recycling programs. Recycling, which was originally justified as the only solution to a desperate national problem, has become a goal in itself–a goal so important that we must preserve the original problem. It’s as if the protagonist of “Pilgrim’s Progress,” upon being informed that he could drop his sinful burden right there on the road, insisted on clinging to it just so he could continue the pilgrimage to get rid of it.

Why is it better to recycle?

I also learned where the term “muckracker” came from. Good day, all around.

Errors in First Aid for the USMLE (2007): Biochemistry

The following is from an email sent to the First Aid Team concerning errors/corrections/suggestions to their 2007 edition.

Biochemistry (reference: Lipincott’s Illustrated Biochemistry)

1. P.79, Vitamins
   1. Fat soluble: in any deficiency of these vitamins, liver and egg yolk are a source in the diet.
   2. Tox: D>A>K>E, Vit D is Deadly (toxic), Vit A is Also bad.
   3. Synthesis by microbes: K and B12
   4. Antioxidant: C, E, and beta-carotene
   5. Liver storage: DAKE + B12
2. P.79, Vitamin A (retinol)
   1. Excess – Arthralgias, fatigue, headaches (cerebral edema), skin changes…
3. P.79, Vitamin B1 (thiamine)
   1. Diagnose: [up arrow] RBC transketolase activity after thiamine treatment.
4. P.80, Vitamin B12 (cobalamin)
   1. In the right column under causes for B12 deficiency: “lack of intrinsic factor (pernicious anemia, total gastrectomy)”
5. P.83, Chromatin structure:
   1. Heterochromatin – Condensed, transcriptionally inactive – methylated histones
   2. Euchromatin – Less condensed, transcriptionally active – acetylated histones
6. P.84, Genetic Code features
   1. “Methionine encoded by only one codon (AUG).”
7. P.85, DNA replication and DNA polymerase
   1. Within the replication bubble, only the lagging strand creates fragments. The description of DNA poly III elongating “until it reaches primer of preceding fragment,” while true for one leading strand meeting another replication bubble, confuses the issue here. I think it could read:
      1. “On the leading strand, elongates the chain by adding deoxynucleotides to the 3′ end until it reaches another replication bubble. When on the lagging strand, it performs the same action repeatedly as the replication bubble grows, creating Okazaki fragments.”
      1. This would of course have to be preceded by an explanation of the replication bubble that might also incorporate a definition and illustration of a helicase.
      1. 1. Helicase – an enzyme that separates the two strands of DNA into single strands allowing for replication to occur. The position of these separated strands is called the replication fork.
         2. Replication bubble – area of DNA between two replication forks that marks the site of replication in each direction along a chromosome. There are several replication bubbles along the chromosome during DNA replication.
      1. To avoid confusion, state upfront that
         1. DNA poly III reads 3′-5′, makes 5′-3′ and proofreads 3′-5′ “Poly III proofs 3′ first.”
         2. DNA poly I reads 3′-5′, makes 5′-3′ and proofreads 5′-3′
8. P.88, tRNA
   1. The figure is very confusing. The accompanying paragraph makes reference to syntheTase scrutinizing the amino acid before and after, but the figure shows only one syntheTase and one synthAse. Further, the image flips over its vertical axis for some reason, and the “AA” attached to the middle tRNA’a 3′ end is changed to a “Methionine-ACC” without explanation. The figure should be changed to clearly show:
      1. The first step is the attachment of a methionine to AMP (leaving PPi), creating an aminoacyl-AMP (not attached to tRNA).
      2. The second step is the attachment of the Met-AMP to the tRNA’s ACC site, creating an aminoacyl-tRNA (attached to tRNA).
      3. tRNA syntheTase and tRNA synthAse are two different proteins or two regions of the same protein.
9. P.88, Protein synthesis
   1. Figure shows a eukaryotic ribosome while the description is of a ” 30S ribosomal subunit.”
10. P.89, Cell cycle phases
    1. The description of Permanent cells suggests that “neurons, skeletal and cardiac muscle, RBCs” all “remain in Go, regenerate from stem cells.”
11. P.91, Cilia structure
    1. Iinclude the following:
       1. Dynein = retrograde (towards nucleus)
       2. Kinesin = anterograde (from nucleus )
12. P.91, Kartagener’s syndrome
    1. Include the following: “…male and female infertility (sperm immotile, immotile fallopian cilia)…”
13. P.95, Hexokinase vs. glucokinase
    1. Glucokinase is found in the liver and the Beta cells of the pancreas.
14. P.96 , Regulation by F2,6BP
    1. This is a difficult concept. In the figure, the arrows are pointing in the wrong directions, i.e. PFK-2 is shown dephosphorylating F(1,6)BPate into fructose-6-P. The problem with most diagrams is that it is difficult to take into account the following in a single picture:
       1. Fed and Fasting states
       2. PFK-2 and F2,6BPase (the bifunctional protein’s two states of activity)
       3. Stimulation of glycolysis and inhibition of gluconeogenesis.
    2. To capture these three variables, you effectively need three circles in your diagram. This is my best effort at such a diagram. See below.
15. P.96, Glycolytic enzyme deficiency
    1. “glucose phosphate isomerase (4%)” ??
16. P.98, Electron Transport chain and oxidative phosphorylation
    1. The outcomes of the oxidative phosphorylation proteins are not correct.
       1. Electron transport inhibitors will cause a decrease in O2 consumption; this is not mentioned.
       2. ATPase inhibitors will cause an increase in O2 consumption; this is not mentioned.
       3. Uncoupling agents increase the permeability of the membrane to H+ ions; it is listed as decreasing permeability.
       4. Uncoupling agents will cause an increase in O2 consumption; it is listed as causing a decrease.
17. P.99, Pentose phosphate pathway (HMP shunt)
    1. The two sentences beginning, “All reactions…” and “Sites: lactating…” are immediately repeated within the section. One should be deleted.
    2. The HMP shunt is locating in RBCs, allowing them to handle oxidative damage by replenishing glutathione. RBCs are excluded in the following sentence : “Sites: lactating mammary glands, liver, adrenal cortex – all sites of fatty acid or steroid synthesis.”
18. P.100, Disorders of galactose metabolism
    1. “Galactosemia ” is a symptom. Classic Galactosemia is the name of the disease described. In addition to the later symptoms of “cataracts, hepatosplenomegaly, mental retardation” the more immediate symptoms (not included) are galactosemia, galactosuria, vomiting, diarrhea, jaundice.
19. P.101, Amino acids
    1. Everyone has there own take on which are and are not essential, but I’ve found the following to be useful:
       1. Conditionally Essential (3) “Babies CRY,” important early in life and during periods of growth.
          1. Cysteine (Cys), glucogenic
          2. aRginine (Arg), glucogenic
          3. t Yrosine (Tyr), gluco/ketogenic
20. P.101, Transport of ammonium by alanine and glutamine
    1. I found the layout of these diagrams to be confusing. The first diagram does not indicate that B6-dependent AminoTransferases are involved with each exchange of the NH3, and the last step showing Glutamate going straight to Urea is incomplete. The interesting point about alanine transport versus glutamine transport is the different enzymes used and the different tissues involved, and the diagrams do not make this clear. Further, the second diagram shows glutamine transport of ammonium as ending with Aspartate and NH4. While these are the substrates for the Urea Cycle, Glutamine is the amino acid donating the NH4 in Glutamine Transport. Lipincott’s Illustrated Biochemistry has a great diagram on P.251 (3rd Ed).
21. P.101, Transport of ammonium by alanine and glutamine:
    1. Treatment: Arginine should include (see Urea Cycle).
22. P.102, Phenylketonuria
    1. The diagram shows a double arrow, implying that THB to DHB is a reversible reaction through Phenylalanine Hydroxylase (PAH). This is not the case. I also feel that this section should address that elevated levels of Phe are what cause the side effects, and that this can come from a deficiency of maternal or fetal PAH. I think the following table should be included (see below).
23. P.102, Alkaptonuria
    1. This section does not make mention of the striking symptom of black/blue cartilage of the nose, cheek, ear, and splotches in the sclera. I think it should be changed to:
       1. Congenital deficiency of homogentisate acid oxidase in the degradative pathway of tyrosine; often benign. Resulting alkapton bodies deposited in various connective tissues may result in
          1. Erosion of large joint cartilage, causing debilitating arthralgias
          2. Blue/black discoloration of cartilage in the nose, cheek, eyes and black splotches of the sclera
          3. Urine that turns black on standing.
24. P.103, Homocystinuria
    1. The neat thing about this pathway is that a block at cystathionine synthase can be treated with vitamins to reverse or continue the pathway and that a build up of homocysteine is associated with the side effects. I think this section should be changed to reflect this:
       1. 3 forms (all autosomal recessive):
       1. 1. Cystathionine synthase deficiency (treatment: [down arrow] Met, [up arrow] Cys, [up up arrow] B12 and [up up arrow] folate in diet)
          2. [down arrow] affinity of cystathionine synthase for pyridoxal phosphate (treatment: [up up arrow] B6 in diet)
          3. Homocysteine methyl transferase deficiency
       1. Results in [up arrow] HomoCys, [up arrow] Met and [down arrow] Cys in blood and urine. Cys becomes essential.
       2. Side Effects: mental retardation, osteoporosis, tall stature, kyphosis, lens subluxation (downward and inward), and atherosclerosis (stroke and MI; associated with [up arrow] HomoCys)
25. P.103, Maple syrup urine disease
    1. The severe side effects of this disease only occur if left untreated. Patients with this disease typically present early in infancy. I think the following should be added:
       1. Classic type presents in infancy with difficulty feeding, vomiting, dehydration and severe metabolic acidosis. Diaper smells of “burnt sugar.”
26. P.104, Purine Salvage Pathway:
    1. Arrows show AMP going to IMP in two steps; IMP going to AMP in one step. This is backwards.
    2. Could mention that Allopurinol inhibits Xanthine Oxidase here.
27. P.105, Insulin
    1. The diagram with all of its +’s and -’s is confusing and requires time to “translate” what it means for the phosphorylation/dephosphorylation of the enzymes shown. I’ve attached a diagram that shows the controls and also makes the regulators unique to the liver and muscle more obvious. See below.
28. P.105, Glycogen
    1. Enzyme converting Glucose-1-phosphate to UDP-glucose is incorrectly labeled as Glycogen Synthase (should be UDP-glucose phosphorylase). Glycogen synthase is involved in the next step for extending the chain of glycogen.
29. P.106, Glycogen storage diseases
    1. Deficient enzyme in Von Gierke’s is listed as “Glucose-6-phosphate.” Should be “Glucose-6-phosphatase“
30. P.111, Heme Synthesis
    1. This drawing shows Lead inhibiting ALA synthetase.
    2. Lead inhibits ALA hedehydratase and ferrochelatase, not ALA synthetase (correctly noted in following section, Porphyrias).
    3. Heme -> Hemin -> inhibits ALA synthetase. This is a great feedback inhibition and represent the emergency treatment of porphyrias, i.e., the administration of IV Hemin.
    4. In the right margin, it should mention that this pathway is in the liver (P450) and Bone Marrow (hemoglobin synthesis). This is why phenobarbital, griseosulvin, etc can cause attacks of porphyria, by inducing the increased expression of P450, increased need for Heme, and exacerbation of deficiency.
31. P.111, Porphyrias
    1. In addition to the “5 P’s” of Porphyria, I suggest making an addition
       1. Painful Abdomen
       2. Pink Urine
       3. Polyneuropathy
       4. Psychological disturbances
       5. Precipitated by drugs
       6. Pruritis
       7. Photosensitivity

Return to First Aid Errors page.

American Medical Oath

More interesting reading today. This came to me from Medscape and I thought I’d share it. As an aside, I would have no problem reciting the Weill Cornell Medical College’s Hippocratic Oath. Some excerpts:

Oaths for Physicians — Necessary Protection or Elaborate Hoax?
Erich H Loewy, MD

The ritual of taking an oath upon graduating from medical school is, with a few exceptions, a routine requirement for graduation. Albeit that many students believe that they have taken the Hippocratic Oath, this is virtually never the case.

According to the oath, physicians (in virtually all formulations) swear that social standing (and by implication economic factors) will not change the way in which patients are treated. This becomes impossible.”

I think that the prospective physician having to take an oath that promises to place the biopsychosocial interests of the individual patient first while at the bedside and to work for a healthcare system that is accessible to all is not coercive to students as long as students are aware before they enter medical school that taking such an oath will be one of the requirements for graduation — no more and no less than anatomy or a clerkship in medicine

[I]t is a problem that we must at least start to recognize as an imperative and consequently to work on setting up fair but strict criteria, which are known to the student. For example, it seems obvious that convicted felons should — even after they are released from prison — not be allowed to enroll in medical schools or practice. This sounds harsh: After all, the felon “has paid his price to society” (whatever that means) and should now be able to engage honorably in an honorable profession.

In my experience — and that of many of my colleagues — we have graduated the undoubted sociopath or psychopath, and have graduated students who falsified records, stolen books, and repeatedly made obviously demeaning remarks about patients or colleagues.

It is surprising — and disheartening — that medical boards are quite ready to either reeducate or otherwise sanction physicians who have a record of consistent malpractice or to give help to those who are substance abusers, but that medical societies are hesitant to deal with ethical violations.

I think this author has the current attitude among medical students dead to rights; I spend no time thinking about this oath and I don’t think others do. He’s also right about the ethical “slips” in medical school. I wrote previously about a student in my class that tried to cheat on a test (feigning sick, then asking about the test before his makeup) and I know plenty of students that take advantage of the “I’m sick” route test after test after test. And while it’s easy for me to agree with him that, if we take these promises seriously, then we should punish those that break them seriously, I stop short of his conclusions.

I think throwing all types of felons together is lazy and ignores the difference between a murderer and a drug offender (and he addresses this, indirectly, by the support that medical boards give to MD’s abusing drugs). I think sanctioning physicians with a history of malpractice fails to draw the distinction between suits that represent Deriliction of Duty resulting in Direct Damage (you need all four D’s for it to be malpractice) d those aimed at gold (the courts can’t even draw this distinction).

I DO AGREE that any of these precursor infractions in medical school should be grounds for immediate dismissal, if for no other reason than it’s easiest to monitor. Like him, I already know two sociopaths that (God help us all) will earn an MD and practice.

So, no, the oath doesn’t seem to be taken seriously in house, but it will probably make everyones’ chests swell with pride against the buttons of their white coats just the same.

As for me? I believe in all the parts that don’t conflict with my right to earn a living that correlates with my skill in whichever discipline I choose. If I end up being a shitty doctor, I shouldn’t get to charge as much as a great one. As I said before, the Weill Cornell Medical College’s Hippocratic Oath looks solid.

But while we’re talking about professional duties and the good of patients, the honor of the guild and role in society, how about we introduce one more oath? With all that is demanded and expected of physicians, shouldn’t the State remove some of its barriers to make it easier for us to fulfill these expectations?

The State’s Oath to the People’s Health:

The State does vow, to that which society holds most dear:

That the State will honor the Profession of medicine, be just and generous to its members, and help sustain them in their service to humanity; The State and its legislature will recognize the limits of its knowledge and allow physicians to pursue their lifelong learning to better care for the sick and will support physician-recommended programs to prevent illness; That no legislation will be passed that affects the practice of medicine without the expressed support of the physicians of the State as the State recognizes that physicians are more expert in medical matters; That the State will not withdraw from patients in their time of need; That the State will govern with integrity and honor, using its power wisely; That whatsoever the State shall learn of the lives of patients shall not be spoken, but kept in confidence; That the State will maintain this trust, holding itself to the highest standards, from corruption, from the temptations of industry, from any disruption to the practice of medicine and its physicians; That above all else, the State will serve the highest interests of the patients through the support of those providing their care, and the institutions that seek to suport it. The State enters this promise with its physicians to preserve the finest medical traditions, with the reward of long service and a well-served populace. The State makes this promise upon its honor.