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Should iPads Be Mandatory For Medical Students?

The e-reader battles are clearly heating up, with the recent introduction of the Apple iPad (color!), the aggressive marketing of the Kindle with newer models, and the Nook trying to sneak its way into the conversation. What does this mean for medical students? Should iPads be mandatory in medical school?

Joseph Kim of Mobile Health Computing argues that it certainly should be, but I think the argument is not well formed. Of course we want medical students to have the latest whizbang technological gadgetry, but the real question is: what role will this technology play? For example, we could provide all medical students with electron microscopes during their study of histology, but clearly this would be ridiculous: the knowledge yield would not justify the cost at all.

So, let's consider what we want our ereaders to do. Clearly, Kim wants a Swiss Army Knife type tool - a tool that lets students become fully engrossed with their study materials, interacting in a way that was never possible before. One can easily imagine an iPad with a digital cadaver, first years carefully "finger dissecting" away layers to reveal deeper structures, or sweeping their fingers to rotate and pan the images to see other angles. Because its digital, such anatomy could much more easily linked to its practical application in medicine via linked diagnostic images, intraoperative findings, and even path results.

But, is this what we really want? Or rather, is it the only thing we want? Clearly, even with all this neato technology, there is an ocean of information to absorb and comprehend in a limited amount of time. Sorry, first years, but you will still have to spend hours in the library pouring over textbooks. This is where the argument gets a bit murkier, primarily because of technological issues. The iPad is backlight; the Kindle is not. For medical students spending hours staring at text, the Kindle actually provides a much better user experience. And, imagine being able to carry the entire library in this one lightweight device! Yes, the iPad can do it too, but do you really want to read an iPad for that many hours?

The question of whether devices should be 'required' of medical students is not a new one. Ever since portable devices became popular, medical schools have struggled with whether to mandate that their students have a laptop, or PDA, or now, e-reader. Until technology advances far enough that we can have all the functions we desire in one device with a user interface we like, medical schools may be better off simply supporting the purchasing choices of their students without mandating any particular device. Let students choose how they like to learn, and what tools they want to use to accomplish that, and they will be the better for it.

Updated 2015-12-20

Would More Medical Students Choose Primary Care if They Received Specialist Salaries?

This is a guest post by James over at poorMD.com

Fewer and fewer medical students are choosing to go into primary care fields despite the emphasis and growing need for more internists and family practitioners. When choosing a medical specialty, medical students have many factors to consider: lifestyle, personality match, competitiveness, length of training, and salary (compensation) are some of the major considerations. Let's break down each of the considerations a poor medical student must make when choosing a career: 

Lifestyle: The generalist's lifestyle, while not the greatest, is also not the worst.  In terms of hours worked, it is not as demanding as something like surgery or obstetrics.  

Personality: All sorts of personalities could fit into a primary care field such as family practice, internal medicine, or pediatrics.  Wasn't the whole reason for going to medical school was so you could help patients?

Competitiveness: If you choose not to go into family practice because of competition, you probably never should have made it into medical school.

Length of Training: With generalist training only needing three years as opposed to the five plus years required of specialists, this should be considered an incentive to go into primary care.

Salary (Compensation): The average earnings of a primary care doc is about 55% of the average earnings for all other non-primary care specialties.  Here, I think we've identified a reason for the primary care shortage.

There are many reasons why fewer med students are choosing to go into primary care, but the financial aspect must be a huge consideration.  If I'm graduating with $180,000 of medical student loans, having deferred gratification by going to college, med school, and then residency, and am looking to buy a house and raise a family in the near future, why would I go into primary care, when I could make double or even triple as much as a specialist?

According to the AAMC, family practitioners can expect to make about $142,200 after three years of residency where as a radiologist's salary can see $325, 438 after five years of residency. Sure, the training to become a radiologist is two years longer, but for those extra two years, you can potentially see more than a doubling of your income. 

The fact is, medical training is long and grueling.  Individuals pursuing a medical degree have made huge investments into our futures and hope to see a good return on investment or ROI.  Specializing takes just a few more years and produce greater returns; I've already come this far, what's a few more years?  Show me the money!  So to answer the question posed in the title of this article, YES more medical students would choose primary care if they were compensated better!

The American College of Physicians in their "State of the Nation's Health Care 2009" said:

Medical students and young physicians should make career decisions based on their interests and skills, instead of being influenced to a great extent by differences in earnings expectations associated with each specialty. Yet there is extensive evidence that choice of specialty is greatly influenced by the under-valuation of primary care by Medicare and other payers compared to other specialties.

As the old adage goes, "Do what you love and the money will follow."  I wonder how much in student loans that guy must have had or how long he spent in school.  While I enjoyed my family practice and pediatrics rotations in medical school, I also enjoyed radiology and orthopedic surgery.  But after evaluating what was most important to me, I decided that spending time with and supporting my family would bring me the most fulfillment.  Luckily, I loved radiology and so far it has happened to be a perfect fit.

James, a radiology resident, runs poorMD.com, a website dedicated to providing financial tips and other practical advice to medical students, residents, and fellows. If you're interested in reading more about the situation with primary care, check out Why Incentives Matter (Even For Physicians), A Shortage of Primary Care Physicians?, and Why Primary Care Matters.

How To Register For USMLE Step 1

This is a guest post by Medliorator, editor of Medliorate.com

Registering for USMLE Step 1 is a multi-step process that will take up to two weeks. After the initial registration on the website, you will have to have your school's registrar verify your enrollment and good standing. Only after the verification will you be able to schedule your exact test location and date. In order to ensure you get your ideal location and date, it is suggested that you begin this process three to six months prior to when you want to take USMLE Step 1. 

What You'll Need To Register For USMLE Step 1:

• Social Security Number
• Visa / Mastercard number and expiration date
  
• 2 x 2 photo of yourself

How To Register For USMLE Step 1:

1) Click "first-time user" at NBME's examination services website.

• Enter SSN, idenitification, and medical school information
• Enter your name as it will appear on the identification card you intend to bring with you to the test

2) NBME will email an ID number & temporary password.  Write down your USMLE ID# somewhere for reference.  Login to the examination services website with the temporary password.  Click Apply for USMLE. 

3) Skim the first page, check the box at the bottom of the page (Check this box to certify …therein), and click NEXT.

4) Follow the instructions, and have a Visa/Mastercard ready for the $495 registration fee.

5) Print a 2 x 2 picture of yourself as well as the Certification of ID and Authorization Form.

6) Affix the photo to the form, and check the appropriate box above the signature field at the bottom before signing.

7) Turn the form in to your medical school's NBME official or registrar.

While awaiting the next step, bookmark Prometric's website as you'll likely visit them later when the time comes to select a testing date.

Medliorator is the editor of Medliorate.com, a content aggregation service for self-improving medical students

Help for Poor Medical Students

While researching ways to save money on all these trips for residency interviews, I came across a blog dedicated to just that: Poor MD

Sounds like the blogger is a former 'poor' medical student who applied to a competitive field (radiology) and had to really watch every penny because (s)he has a family and three kids to take care of. Anyway, maybe some of you will find it helpful.

How Open Should Hospitals Be About Errors?

An interesting attempt by the CEO of Beth Israel Deaconess Hospital in Boston to be more open about the errors that occur in his facility (via KevinMD). Openness about hospital errors has its price though:

For the past year, Paul Levy, president of Beth Israel Deaconess Medical Center, has more than ever before staked his reputation on "transparency," particularly about medical errors inside his Harvard teaching hospital. 

In January, he made a splash when he announced the hospital would aim to eliminate all preventable harm to patients within four years and would publish quarterly reports on its progress. Whether speaking from a podium or writing on his blog, Levy maintains that admitting and learning from serious mistakes is far more important than avoiding public-relations blows. 

This stance has won him praise in some quarters - and, in recent months, has sorely tested him as well. 

In late June, news broke that a cosmetic surgeon was fired after he appeared to be dozing while performing a liposuction procedure. A few days later, a veteran surgeon completed surgery on a woman's ankle - only to discover it was the wrong ankle. 

Earlier this month, an anesthesiologist, who had battled drug addiction and been terminated a year earlier, was found dead in a hospital closet, a possible suicide. And just last week, a 37-year-old Medford woman died during an emergency caesarean section at the hospital; her baby has survived. 

Other controversies have erupted under Levy's leadership this year as well, including a management shake-up in the surgery department, complaints of overworked surgery residents, and bitter volleys between Levy and a national union trying to organize the hospital's workers. The union chronicles a range of complaints on a website called "Eye on BI" and on bus shelter advertisements, and accuses Levy of promoting "corporate-style medicine." 

Yet sitting in his office last week, the 58-year-old chief executive officer displayed an upbeat attitude, saying he refuses to let the publicity about these issues rattle his mission to make his 621-bed hospital, which performs about 9,000 surgeries a year, one of the most aggressive in confronting problems.

While the efforts deserve to be applauded, I think there is a risk that such errors will be sensationalized to the detriment of the hospital. As the article notes, without putting the error rate in context (ie, with a comparison to the error rates at other hospitals), the CEO is putting the hospital at risk of garnering a negative public impression, even though the hospital is likely outperforming its peers. Still, I guess someone has to lead the way, so kudos to BID.

Common Things Being Uncommon?

Often in medical school we learn about esoteric things, in order to prepare us for the "once in a lifetime" occurrence when we may see it. The training is important, but sometimes we go too far, to the detriment of more common presentations. Here is an interesting example of things you don't learn in medical school from one ER physician's blog (via KevinMD):

Emergency Medicine is notable as much for its drama as for the pedestrian and mundane things that come through the door. Every time I meet someone new and tell them what I do for a living, I always get the "Is it as exciting as it is on TV?" question, or some variant.

Truth is, of course not. Headaches, abdominal pain, weak & dizzy, etc account for a substantial majority of our cases. In fact, the critical care stuff is generally less than 10% of what we do. Now sure, if I see 16 patients per shift, then yes, I do perform critical care daily. But it turns out that the simplest cases can be the most challenging.

You see, in residency, there's a lot of focus on critical care. I spent months working in the cardiac ICU, the medical ICU, the pediatric ICU, the surgical ICU, the burn ICU, the OR, anesthesia, and on the floors. I could line, intubate, and resuscitate in my sleep (and did, on a few notable occasions). I could recite the Killip classifications for MI and knew the DeBakey versus the Stanford classifications for aortic dissections. So I was well prepared and very comfortable with caring for severely ill and unstable patients, which is an important qualification for the job. Internal medicine also was highly emphasized: complex physiology, the key things not to miss in chest pain, electrolyte management, etc.

All this prepared me very poorly for some of the more mundane elements of my practice in "the real world." Stuff you might call "family medicine," though I don't know if that's the right phrase. For example, I remember the first time I saw a new mother bring in her week-old infant who was vomiting blood. Holy crap but I was scared. I knew all about GI bleeds -- in adults -- and vomiting blood was really bad. I didn't think kids even got GI bleeds. I was wracking my brain over it, wondering if the baby had some sort of vascular malformation in the stomach, and the nurse just stared at me when I told her to put in an IV and draw blood. "Why would you want to do that?" she asked

Keep reading to find out why the nurse questioned the ER doc's actions. You gotta love ER nurses - they've seen everything.

Emergency Medicine / ER Blogs

Lately, I've found myself reading emergency medicine blogs more frequently. The posts tend to cover interesting cases and their initial presentations, including all the confounding variables of 'the real world.' Furthermore, it seems to me that ER physicians tend to share a sort of dry wit that I tend to like.

Here's a list of a few of the blogs I have enjoyed (in no particular order):

• Movin' Meat
  
• ER Stories
  
• WhiteCoat Rants
  
• Edwinleap.com
  
• Emergiblog
  
• Scalpel or Sword?

Have any more Emergency Medicine / ER blogs that I should add to the list? Feel free to add them in the comments.

The Web 2.0 EMR?

Kevin M.D. has an interesting post about the poor implementation of current EMR efforts. As his post notes, none of the innovation people see in online apps like Facebook or Google Docs are being used in EMR services. The post primarily refers to a piece by hospitalist Bob Wachter. So yea.. Why hasn't social networking affected EMRs yet?

One problem is that much of health information technology is staffed and programmed by has-beens. There is very little innovation, with most of forward-thinking ideas confined to sites like Google, Facebook, and MySpace.

It would be nice if an electronic record was designed with the singular focus being the end-user experience. They should make physician's lives immeasurably easier, and significantly decrease the time spent charting and tracking patients.

There are very few record systems that meet even this minimal standard.

An EMR like Facebook? We can only wish.

Indeed, a EMR with a Facebook-style interface would be a godsend. I think the real problem currently though is not necessarily a lack of technological know-how, but rather the high cost of implementing such systems and the relatively poor demand. Furthermore, the medico-legal environment also contributes to physicians being unwilling to abandon the old forms that worked on paper. Hopefully one day physicians will take that step en masse into the brave new world of social networking-based EMRs.

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Hanging Up Stethoscopes For Laptops

Arnold Kim's story is only indirectly tied to medicine, but I think it is striking nonetheless. As a recent article noted, Kim has made his "hobby" his full-time job and decided to stop practicing medicine:

Jay Paul for The New York Times

For eight years, Arnold Kim has been trading gossip, rumor and facts about Apple, the notoriously secretive computer company, on his Web site, MacRumors.com. It had been a hobby — albeit a time-consuming one — while Dr. Kim earned his medical degree. He kept at it as he completed his medical training and began diagnosing patients’ kidney problems. Dr. Kim’s Web site now attracts more than 4.4 million people and 40 million page views a month, according to Quantcast, making it one of the most popular technology Web sites.

It is enough to make Dr. Kim hang up his stethoscope. This month he stopped practicing medicine and started blogging full time.

While many people may say 'Oh cool' and move on, if you really think about it, this is quite unbelievable. Imagine if 50 years ago, a doctor had left medicine to write poetry. Some may have praised it, but no one would have seen it as a lucrative career move. This speaks volumes about both the rise of network economies as well as the fall in medicine's perceived value as a career. It no longer carries the prestige or the financial renumeration to even compete with a blog (albeit a pretty darn good one)!


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Medgadget

Not much to say today, other than check out Medgadget, a blog devoted to emerging medical technologies. I particularly like the post about C-arm / DynaCT, a relatively new technology to let interventional radiologists take CTs of their patients during procedures. Perhaps a bit dated, but it was interesting to read about the cutting edge technology and then see how far behind the stuff we learn in med school is.