When even the gravitational pressure from resting my head on a pillow became unbearable, I decided it was time for a visit to my local ER. Believe me: I did not look forward to this visit. When you tell someone in the ER that you have a migraine, they usually smile and nod, and then put your name at the bottom of the list with a little sticky note next to it that says "NO NARCOTICS." Little did I know that it was medical judgment -- not my medication habits -- that would get me in trouble this particular evening.
This was my first trip to the ER for a migraine, although I've been getting them for years. Since about 2008, my doctor and I have had them mostly under control with Topamax as a prophylactic (daily preventive medication) and Fioircet as a PRN ("as-needed" medcation taken right away to squash the headaches when they start). But this time, nothing worked. And I was honestly not sure how I would make it through the night with such intense, knifing pain. I know this is a cliche, but it really did feel like someone was trying to penetrate the area above my right orbital bone with an ice pick. Or it could have been a chisel ... anyway, you get the idea. It hurt. A lot.
Surprisingly, once I arrived at the ER, I got called into the triage area less than 10 minutes from when I checked in. "OK, I can live with this," I thought. The nurse took my vitals, which were pretty normal for me, and then asked me how bad my pain was, on a scale of 1 to 10. I didn't even hesitate. "10."
The nurse quickly and efficiently ushered my to room "number C" (that confused me a bit, in my addled state -- a number, and a letter, together ... never mind). After a few minutes, a physician's assistant, Stephanie, came in. She promised me pain meds and a CT scan. The former, I expected. I would have gotten down on my hands and knees and kissed Stephanie's feet for a shot of something, ANYTHING. But an emergent CT scan? At 9:30 p.m. on a Wednesday night? Hm. "OK, they pay those guys the big bucks for a reason," I told myself, and decided not to argue. Even though, in the last five years, I've had one CT scan and two MRIs, all completely normal. (Thank you, BlueCross & BlueShield of Illinois.)
Got my shot, went to the CT room. Not too much of a wait at 9:30 p.m. I think the tech was glad to see me, in all honesty. He looked bored, and was quite chatty. Once that was all done, it was back to the ER waiting room to (guess ...) wait for the results.
My husband, Geoff, and I had a bit longer to sit this time. But finally we made it into another curtained-off room. This time it was "Kevin," another PA, who came to greet us. As I expected, the test results were normal. Not that I really cared, because what I'd come for -- headache relief -- had arrived more than an hour earlier.
But Kevin had it in for me. "When you come in here and say your pain is a '10,' that means it could not get any worse," he told me. "That means you could have a gunshot wound and it wouldn't be any worse."
I just sat there, confused. "Well," I thought to myself (though I didn't dare share any of this with Kevin), the nurse asked me how bad my pain was. I rated it based my pain experience, and this was the worse pain I'd ever had, so giving it a 10 seemed a natural resposne." Based on my understanding of the pain scale.
Now Kevin was telling me that I'd mislead the medical personnel, which had caused an unnecessary CT scan, and unnecessary time in the ER for both of us. But that was based on his understanding of the pain scale.
I'm not about to say that I'm right, and Kevin is wrong. He is the PA, after all, and is trained in such matters. I'm just a lowly pre-med student, with aspirations of someday doing a rotation in the ER and handling just such a situation.
What I am saying is that there was a serious breakdown in communication. And a serious mishandling of that breakdown.
First of all, it was the nurse's responsibility to explain to me what she meant by a "1" and a "10" on that pain scale. I Googled it just now, and there is conflicting information on the Web. The National Institutes of Health simply states that pain of 7 to 10 is "severe" and "disabling" and intereferes with "ADLs" (the activities of daily living, such as eating, brushing your teeth, etc.). Another chronic pain Web site I looked at described people experiencing a 10 as "bedridden" and "possibly delirious." The site stated that "few people will ever experience this level of pain." These two sites obviously have different ideas about the intensity of a degree-10 of pain.
So ... who is right? Answer: It doesn't matter. What matters is that people on both ends of the scale understand, and are using, the same rubric for comparison. Otherwise, the results are meaningless. It's like transferring a hockey score to a basketball game, without using any kind of conversion factor. For example, picture this game score: Chicago Bulls -- 92; Chicago Blackhawks -- 5. Ummmm ... Who won? Right. Makes no sense. Because they're on a different scale, and the numbers mean different things.
It's about communication, first of all. And that communication was certainly lacking during my ER visit this week.
Beyond communication, working in any medical environment -- ER or otherwise -- requires some empathy and understanding. And Kevin just didn't have it that night. Maybe it had been a long shift, or a really hard day. I get that. But that's still not a reason to blame a patient for not "getting" something that wasn't properly explained.
When I think about spending time in the hospital, I usually think about spending time there as a volunteer, or a shadower, learning the "how-tos" of taking care of people. Developing a good "bedside manner," if you will. Hence the title of my blog. But sometimes you learn just as much by watching people and observing what you don't want to repeat. That was my experience this time around. And as unfortunate as it was, I learned an important lesson from it.
Thursday, July 8, 2010
Confessions Of An Addict
While some of my friends are busy planting and harvesting strawberries, artichokes, or melons to earn coins on FarmVille, I am also likely on the Internet. But not on Facebook. These days, you're more likely to find me on www.PubMed.gov, a Web site run by the National Center for Biotechnology Information, the U.S. National Library of Medicine, and the National Institutes of Health.
And yes, this is more proof that my brain has been taken over by an alien being. Or perhaps an entire colony of them.
Seriously though. PubMed is incredible. It's an online database of more than 20 million citations to scientific/medical articles dating back to 1865. Nearly 3 million of those citations include FREE full text. (The vintage-bargain-hound in me loves this.) It's a fantastic resource if you want to know, say, the role of caveolin 1 in embryonic lung development (something my mentor, Olga, is writing about for a textbook chapter). Just like with Google, you type in your search terms and hualah! Article citations.
Of course, quite often the article I want is NOT free ... so I must be satisfied with a mere abstract, or perhaps a less recent (or somewhat less relevant) article. If it's a matter of life and death (er ... success and failure of an experiment, more likely), I can just buy 24-hour rights to read the article from the publishing journal.
It's that easy. And anyone can do it. You don't have to be a scientist (or a pre-med student) to enjoy the pleasures of PubMed. For people whose brains haven't quite mastered the technical language (I include my alien-infested gray matter in this category), reading "reviews" of articles instead of the actual articles themselves is a much easier way of digesting and understanding the information. Just a little tip I picked up from Olga.
So what are you waiting for?
And yes, this is more proof that my brain has been taken over by an alien being. Or perhaps an entire colony of them.
Seriously though. PubMed is incredible. It's an online database of more than 20 million citations to scientific/medical articles dating back to 1865. Nearly 3 million of those citations include FREE full text. (The vintage-bargain-hound in me loves this.) It's a fantastic resource if you want to know, say, the role of caveolin 1 in embryonic lung development (something my mentor, Olga, is writing about for a textbook chapter). Just like with Google, you type in your search terms and hualah! Article citations.
Of course, quite often the article I want is NOT free ... so I must be satisfied with a mere abstract, or perhaps a less recent (or somewhat less relevant) article. If it's a matter of life and death (er ... success and failure of an experiment, more likely), I can just buy 24-hour rights to read the article from the publishing journal.
It's that easy. And anyone can do it. You don't have to be a scientist (or a pre-med student) to enjoy the pleasures of PubMed. For people whose brains haven't quite mastered the technical language (I include my alien-infested gray matter in this category), reading "reviews" of articles instead of the actual articles themselves is a much easier way of digesting and understanding the information. Just a little tip I picked up from Olga.
So what are you waiting for?
Wednesday, July 7, 2010
Health In The Headlines: Personalized Medicine
"Wait and see."
How often has your doctor spoken those words to you after handing you a prescription? Too often, it seems to me. And this is not where we should be in the year 2010, says Dr. Bryan Schneider, an oncologist who was interviewed in June on Indiana University's Sound Medicine podcast.
Instead of "wait and see," Schneider thinks doctors should be able to predict a patient's reaction -- both in terms of positive effects of the medication and its negative side effects -- saving both lives and money.
This idea -- called "personalized medicine" -- is not really new. But it's gaining traction and speed, with recent support from the Food and Drug Administration and the National Institutes of Health. And while the government is behind on regulating this new field (which has led to a number of problems, including reports of women unnecessarily having their ovaries removed), there are promises to catch up on that front.
So why isn't all of our medicine personalized? Good question. It would be nice. But we are not there in terms of technology.
Personalized medicine is really about genetics. People react differently to medications because of variations in their DNA. The Mayo Clinic's Web site explains it well: For example, one genetic variation might cause a drug to remain in your system longer than normal, leading to dangerous side effects. Another variation might make your body less sensitive to a medication, meaning it won't work as well, and you might need a higher dose than other people.
If doctors could test for different genetic variations, and how those variations affected your body's response to a medication, they could prescribe more efficiently. Doctors could choose both more effective medications, and more effective dosages, for individual people. This would save not only in terms of a "grief" factor, but it could save lives -- according to the Mayo Clinic, some 100,000 Americans die each year from reactions to medications, and more than 2 million wind up in the hospital. If a doctor knew someone would react poorly, he or she could avoid prescribing a medication entirely. This philosophy would also save money (always a selling point). Many treatments -- especially those for long-term illnesses such as cancer -- cost tens, if not hundreds, of thousands of dollars per year. Prescribing selectively and effectively eliminates guessing, grief, and waste.
The problem is that there could literally be millions of genetic variations (no one's sure how many). And sometimes a response to a medication may not be governed by one gene, but by many genes interacting with each other. We simply do not know enough about the interactions between genetics and medications.
There are, however, a few genetic tests available today that allow doctors to personalize a patient's medical care, most of them related to cancer treatment.
One example a test for HER2, a gene involved in breast cancer. If a woman's cancer is HER2 positive, the results indicate use of Herceptin, a drug that can shrink the tumor, get rid of HER2 cells that have spread beyond the original tumor, and possibly prevent recurrence of the HER2 positive cancer. HER2 negative tumors do not respond to Herceptin, so before Herceptin is used, patients are tested with either an immunohistochemistry test or a gene-amplification test.
Another example involves metastatic colorectal cancer. If the cancer expresses the protein epidermal growth factor receptor (EGFR), then a medication called Erbitux may be used in combination with other treatments. Erbitux inhibits EGFR (which helps the cancer grow), so the medication may slow or stop the spread of the cancer. But Erbitux only works if the cancer expresses EGFR, so a genetic test called an EGFR immunohistochemistry test is required first.
So where do we go from here?
Scientists are making great strides in discovering those genetic "variations" that interplay between disease and medications, according to a recent article in The New England Journal of Medicine (published online on June 15). The problem, according to this article, is that "there is insufficient evidence of a downstream market to entice the private sector to explore most of them [the genetic variations]."
Basically, drug companies don't see the dollar signs. So they don't invest anything.
The purpose of that New England Journal of Medicine article (called "The Path to Personalized Medicine") is to lay out a plan to show how the Food and Drug Administration and the National Institutes of Health plan to "fill that void."
The FDA and NIH plan to do this in several ways. The first step is an "integrated pathway" between academic research and approving treatments for clinical use. The FDA and NIH promise public-private partnerships, as well as a program called Therapeutics for Rare and Neglected Diseases (TRND), aimed at accelerating the development of drugs, developing "targeted" drugs, and rescuing "failed" drugs by finding certain groups of patients who might benefit from them.
A second step is collecting information about genetics and treatment outcomes. For this, the NIH is relying on its various research centers and hospitals.
And last but not least, the FDA has established the "Critical Path Initiative" to regulate this up-and-coming industry and science. It is, in my opinion, about time they did this. As the article authors admit, there have already been instances of regulatory failure: "Increasingly, however, the use of therapeutic innovations for a specific patient is contingent on or guided by the results from a diagnostic test that has not been independently reviewed for accuracy and reliability by the FDA." In other words, doctors may be using tests that the FDA has not approved to guide their treatment decisions. Not good.
For example, the FDA approved the drug Rituxan for certain cancer treatments in 2006. According to the NEJM article, a particular lab company has since then been marketing a test that claims it can tease out the 20 percent of people who will not repsond to the drug from those who will respond to the drug. Says the article: "The FDA has not reviewed the scientific justification for this claim, but health care providers may use the test results to guide therapy."
Huh?!?!
In addition, the article's authors point to other issues with laboratory tests that lacked FDA oversight, including situations where women were given "false readings that reportedly led to the unnecessary removal of women's ovaries."
Apparently, these glitches will now be taken care of. I sure hope so, because personalized medicine might just be the future of medicine.
How often has your doctor spoken those words to you after handing you a prescription? Too often, it seems to me. And this is not where we should be in the year 2010, says Dr. Bryan Schneider, an oncologist who was interviewed in June on Indiana University's Sound Medicine podcast.
Instead of "wait and see," Schneider thinks doctors should be able to predict a patient's reaction -- both in terms of positive effects of the medication and its negative side effects -- saving both lives and money.
This idea -- called "personalized medicine" -- is not really new. But it's gaining traction and speed, with recent support from the Food and Drug Administration and the National Institutes of Health. And while the government is behind on regulating this new field (which has led to a number of problems, including reports of women unnecessarily having their ovaries removed), there are promises to catch up on that front.
So why isn't all of our medicine personalized? Good question. It would be nice. But we are not there in terms of technology.
Personalized medicine is really about genetics. People react differently to medications because of variations in their DNA. The Mayo Clinic's Web site explains it well: For example, one genetic variation might cause a drug to remain in your system longer than normal, leading to dangerous side effects. Another variation might make your body less sensitive to a medication, meaning it won't work as well, and you might need a higher dose than other people.
If doctors could test for different genetic variations, and how those variations affected your body's response to a medication, they could prescribe more efficiently. Doctors could choose both more effective medications, and more effective dosages, for individual people. This would save not only in terms of a "grief" factor, but it could save lives -- according to the Mayo Clinic, some 100,000 Americans die each year from reactions to medications, and more than 2 million wind up in the hospital. If a doctor knew someone would react poorly, he or she could avoid prescribing a medication entirely. This philosophy would also save money (always a selling point). Many treatments -- especially those for long-term illnesses such as cancer -- cost tens, if not hundreds, of thousands of dollars per year. Prescribing selectively and effectively eliminates guessing, grief, and waste.
The problem is that there could literally be millions of genetic variations (no one's sure how many). And sometimes a response to a medication may not be governed by one gene, but by many genes interacting with each other. We simply do not know enough about the interactions between genetics and medications.
There are, however, a few genetic tests available today that allow doctors to personalize a patient's medical care, most of them related to cancer treatment.
One example a test for HER2, a gene involved in breast cancer. If a woman's cancer is HER2 positive, the results indicate use of Herceptin, a drug that can shrink the tumor, get rid of HER2 cells that have spread beyond the original tumor, and possibly prevent recurrence of the HER2 positive cancer. HER2 negative tumors do not respond to Herceptin, so before Herceptin is used, patients are tested with either an immunohistochemistry test or a gene-amplification test.
Another example involves metastatic colorectal cancer. If the cancer expresses the protein epidermal growth factor receptor (EGFR), then a medication called Erbitux may be used in combination with other treatments. Erbitux inhibits EGFR (which helps the cancer grow), so the medication may slow or stop the spread of the cancer. But Erbitux only works if the cancer expresses EGFR, so a genetic test called an EGFR immunohistochemistry test is required first.
So where do we go from here?
Scientists are making great strides in discovering those genetic "variations" that interplay between disease and medications, according to a recent article in The New England Journal of Medicine (published online on June 15). The problem, according to this article, is that "there is insufficient evidence of a downstream market to entice the private sector to explore most of them [the genetic variations]."
Basically, drug companies don't see the dollar signs. So they don't invest anything.
The purpose of that New England Journal of Medicine article (called "The Path to Personalized Medicine") is to lay out a plan to show how the Food and Drug Administration and the National Institutes of Health plan to "fill that void."
The FDA and NIH plan to do this in several ways. The first step is an "integrated pathway" between academic research and approving treatments for clinical use. The FDA and NIH promise public-private partnerships, as well as a program called Therapeutics for Rare and Neglected Diseases (TRND), aimed at accelerating the development of drugs, developing "targeted" drugs, and rescuing "failed" drugs by finding certain groups of patients who might benefit from them.
A second step is collecting information about genetics and treatment outcomes. For this, the NIH is relying on its various research centers and hospitals.
And last but not least, the FDA has established the "Critical Path Initiative" to regulate this up-and-coming industry and science. It is, in my opinion, about time they did this. As the article authors admit, there have already been instances of regulatory failure: "Increasingly, however, the use of therapeutic innovations for a specific patient is contingent on or guided by the results from a diagnostic test that has not been independently reviewed for accuracy and reliability by the FDA." In other words, doctors may be using tests that the FDA has not approved to guide their treatment decisions. Not good.
For example, the FDA approved the drug Rituxan for certain cancer treatments in 2006. According to the NEJM article, a particular lab company has since then been marketing a test that claims it can tease out the 20 percent of people who will not repsond to the drug from those who will respond to the drug. Says the article: "The FDA has not reviewed the scientific justification for this claim, but health care providers may use the test results to guide therapy."
Huh?!?!
In addition, the article's authors point to other issues with laboratory tests that lacked FDA oversight, including situations where women were given "false readings that reportedly led to the unnecessary removal of women's ovaries."
Apparently, these glitches will now be taken care of. I sure hope so, because personalized medicine might just be the future of medicine.
Saturday, June 26, 2010
I am the eggman. They are the eggmen. I am the ... TURTLE?
When I was in middle school, my friend Jaime Truitt used to call me "Turtle." The nickname didn't really catch on with anyone else, which actually surprises me because the moniker was truly appropriate. I carried a bluish-green backpack (right color), the pack was stuffed to bursting (hence looked like a shell on my back), and I had everything I needed in there (in Jaime's words: "You carry your house on your back!").
To this day, I tend to be very prepared, if not overprepared, for most situations (when I have the time). From going on vacation (typed up and formatted checklist) to going to the grocery store (hand-written list this time, but organized by where the food is located in the store so I'm not wandering).
The same applies, of course, to getting ready for medical school. Which is, obviously, a little more important than remembering the sunscreen or that the ketchup is in the same aisle as the olives (why that is, don't ask me). One of the things I'm doing to prepare is to look at potential medical school interview questions. Because those interviews--of which I will hopefully have several--are do-or-die situations. They can make or break a borderline (or even a stellar) application. No pressure, right?!
It's not hard to find sample questions. Google the phrase "medical school interview questions" and you come up with "about" 14,800,000 (yes, that's 14 million 800 thousand) hits. I copied and pasted questions from a few sites that appeared to be reliable (i.e., Harvard's pre-med advising office) into a chart.
So I've got them ... now what? Clearly, this isn't the kind of thing I can cram for. And the ADCOMS (that's pre-med lingo for "admissions committees") may not ask me ANY of the questions I prepped for. But practicing will get me in the right frame of mind. Thinking about why I want to be a doctor, what I want to do, how I feel about the current health care system, etc. I will start to approach these topics very critically, which is both good for the interview, and for when I am a practicing physician.
Over lunch today, I was casually glancing over the questions. I groaned a few times, rolled me eyes, laughed, scratched my head, smiled. The questions are really all over the place, in terms of difficulty, subject matter, length of response, required background knowledge, and so on. Then I came upon the dreaded "strengths and weaknesses" question. You know, the one they ALWAYS ask in job interviews, trying to trip you up. Such an insidious question, one you can hardly answer without making yourself look bad.
So I stared at the question. Then I stared off into space. Sure, I have weaknesses--everyone does. And I could think of a few. But I thought to myself, "Hell if I'm going to sabotage myself in a medical school interview!"
Then I realized something: the weaknesses that kept popping into my head were really strengths, but taken to an extreme. Therefore if I could harness those weaknesses, rein them in, I could transform them into the strengths that they had the potential to be. Whoaaaaa ... (my Cartman moment)
For example: take my overpreparedness. It can get a little excessive. And, as my husband will attest, a bit irritating to a partner / companion (romantic or otherwise). Too much baggage, too much planning, too much fretting. Toning it down, though, and planning a little less than I do now would relieve that pressure (on both me and the person with me), while still allowing us to be prepared for whatever adventure lay ahead. Whoaaaaa ... (yet another Cartman moment)
Maybe I'll still be somewhat of a turtle. (I do, after all, have another green backpack, although this one is more of a mossy color.) My goal for the future, though, is to be a smaller one. That's a good place to start.
To this day, I tend to be very prepared, if not overprepared, for most situations (when I have the time). From going on vacation (typed up and formatted checklist) to going to the grocery store (hand-written list this time, but organized by where the food is located in the store so I'm not wandering).
The same applies, of course, to getting ready for medical school. Which is, obviously, a little more important than remembering the sunscreen or that the ketchup is in the same aisle as the olives (why that is, don't ask me). One of the things I'm doing to prepare is to look at potential medical school interview questions. Because those interviews--of which I will hopefully have several--are do-or-die situations. They can make or break a borderline (or even a stellar) application. No pressure, right?!
It's not hard to find sample questions. Google the phrase "medical school interview questions" and you come up with "about" 14,800,000 (yes, that's 14 million 800 thousand) hits. I copied and pasted questions from a few sites that appeared to be reliable (i.e., Harvard's pre-med advising office) into a chart.
So I've got them ... now what? Clearly, this isn't the kind of thing I can cram for. And the ADCOMS (that's pre-med lingo for "admissions committees") may not ask me ANY of the questions I prepped for. But practicing will get me in the right frame of mind. Thinking about why I want to be a doctor, what I want to do, how I feel about the current health care system, etc. I will start to approach these topics very critically, which is both good for the interview, and for when I am a practicing physician.
Over lunch today, I was casually glancing over the questions. I groaned a few times, rolled me eyes, laughed, scratched my head, smiled. The questions are really all over the place, in terms of difficulty, subject matter, length of response, required background knowledge, and so on. Then I came upon the dreaded "strengths and weaknesses" question. You know, the one they ALWAYS ask in job interviews, trying to trip you up. Such an insidious question, one you can hardly answer without making yourself look bad.
So I stared at the question. Then I stared off into space. Sure, I have weaknesses--everyone does. And I could think of a few. But I thought to myself, "Hell if I'm going to sabotage myself in a medical school interview!"
Then I realized something: the weaknesses that kept popping into my head were really strengths, but taken to an extreme. Therefore if I could harness those weaknesses, rein them in, I could transform them into the strengths that they had the potential to be. Whoaaaaa ... (my Cartman moment)
For example: take my overpreparedness. It can get a little excessive. And, as my husband will attest, a bit irritating to a partner / companion (romantic or otherwise). Too much baggage, too much planning, too much fretting. Toning it down, though, and planning a little less than I do now would relieve that pressure (on both me and the person with me), while still allowing us to be prepared for whatever adventure lay ahead. Whoaaaaa ... (yet another Cartman moment)
Maybe I'll still be somewhat of a turtle. (I do, after all, have another green backpack, although this one is more of a mossy color.) My goal for the future, though, is to be a smaller one. That's a good place to start.
Friday, June 25, 2010
Health in the Headlines: The Primary Care Dilemma
A few weeks ago, my mom went to see her doctor. While there, Mom decided to ask the physician if she had any advice for her daughter (me), a doctor-to-be.
"Yes, actually I do," the M.D. replied. "Do NOT go into Internal Medicine, Family Practice, or Pediatrics!"
Why not? It comes down to one word: money. Or rather, the lack thereof. And this is at the heart of one of the biggest controversies and most serious issues facing the medical community, and perhaps our country, today. It was also the subject of Indiana University's "Sound Medicine" podcast on June 13. But that story is coming up shortly.
What's the big deal? Don't doctors earn bank? Well ... depends on who you are. The three specialties my mom's doctor mentioned--Internal Medicine, Family Practice, and Pediatrics--have the lowest annual salaries of all specialties. Here are some average yearly salaries, according to Becker's Hospital Review, an organization that surveys doctors every year about their income. (This data is from Becker's 2010 study. You can find it on the Web at: http://www.beckershospitalreview.com/news-and-analysis/current-statistics-and-lists/physician-generated-revenue-and-average-salaries-by-specialty.html.)
While I'm sure part of it is about lifetime earning potential, part of it is also solvency potential. When you finish medical school and residency--and perhaps a fellowship as well--with some $300,000 in debt, you need a decent income to pay that off in a reasonable time frame. Because the longer it takes, the more interest accrues. And you don't want to be paying back that loan in your retirement.
Now refer back to the list of specialists and their salaries. Note that the difference between one of the lowest (Internal Medicine, at $173,000) and the very highest (Neurosurgery, at $571,000) is nearly $400,000. Put another way, the neurosurgeon makes 330 percent more than the family practitioner. Granted, brain surgeries are complex, and becoming a neurosurgeon requires more training than most specialties. But taking care of people of all ages, with all types of conditions, is pretty complex, too. So why such a disparity?
The answer is so simple ... and yet, not. The short story is that the higher-paid specialties are the "procedure" specialties. Those doctors--such as surgeons and cardiologists--do a lot of "billable" work. In other words, they tend to get paid for most of what they spend their time doing. Primary care docs, on the other hand, don't do as much billable work. In fact, they spend a lot of time doing things that earn them absolutely ZERO money: refilling prescriptions, answering e-mails and phone calls, and looking at lab results. This is still "doctor" work--it can't be done by anyone without that $300,000 M.D. after their name--but neither HMOs nor Medicare will pay you to do it.
Basically, primary care docs are overworked and underpaid. Sounds like fun, right? So no wonder many medical students these days shy away from those specialties--a trend that is expected to leave us with a huge shortage of primary care physicians in the coming years, especially as the Baby Boomer generation ages and requires more and more care.
In reality, none of what I've just written is news. (HA! Gotcha there, didn't I? You thought this was supposed to be a NEWS column? Well ... I'm getting to that.)
What is news is that this spring, an internist from Philadelphia named Dr. Richard Baron did a quantitative study of this issues. (I heard Dr. Baron interviewed on "Sound Medicine," a podcast produced by the Indiana University School of Medicine. Check it out on the Web here: www.soundmedicine.iu.edu.) Dr. Baron's results, conclusions, and the actions his practice (Greenhouse Internists) has taken based on those results are pretty amazing.
Dr. Baron's study was quite simple actually, and relied on data the practice had already gathered and stored in its electronic health record. This electronic health record, which the practice adopted in 2004, is used "exclusively to store, retrieve, and manage clinical information," as Dr. Baron writes in his paper, which was published in The New England Journal of Medicine (April 29, 2010). Physicians and other clinicians can enter clinical information into different categories such as "office visit," "phone note," "lab report," and "imaging." Dr. Baron and his colleagues then studied the volume (and corresponding categories) of their 2008 records. For more detailed content analysis, they looked at one week's worth of phone calls and e-mails.
Below, I have reproduced a chart from Dr. Baron's study. Note that the only work the physicians are paid for is the patient visit. From this chart, you get an idea of how much work--and how much time--goes into doing things that insurance companies don't consider to be billable.
Dr. Baron already knew that the physicians in his practice (as well as other primary care physicians) were doing "unpaid" work. This detailed look at his practice's records shows just how much.
These results, while more reinforcement and quantification than new evidence on this topic, still do highlight the need for a redesign of the primary care payment system. This is Dr. Baron's opinion; it is also mine. It is, as Spock would say, "only logical."
But what might those changes be? That is the million dollar question. It is one that the politicians, lobbyists, insurance companies, physicians, and other interest groups must pound out. And sooner rather than later, preferably.
In the meantime, Dr. Baron has made some changes in his own practice as a result of his research. First, Dr. Baron and his colleagues took a hard look at the "administrative" work (the phone calls, e-mails, looking at lab reports, etc.) that the physicians were doing. While doing much of it required an M.D., some of it could be done by a registered nurse or other (less expensive) clinician. So hiring more nurses, in many situations, is one way to cut costs and therefore boost salaries.
Another change Dr. Baron and his colleagues made was to their "productivity formula."Greenhouse Internists, like many other practices, uses a combination of base pay and productivity to determine their physicians' total salaries. What Dr. Baron and the others quickly realized was that their formula--which calulcated productivity based on the number of patients seen--simply mimicked the same payment system they were claiming was so unjust and arcane. Their response? Include that administrative work--the calls, the e-mails, etc.--in their own productivity formula. So while insurance companies might not reimburse a doctor for refilling a prescription, Greenhouse Internists does, in fact, consider such a duty to be "work." And so it pays its staff physicians accordingly.
These changes do not make up for the payscale differential or the disparity in billable procedures between primary care and the "procedure" specialties, but they are a step in the right direction. Policy makers would do well to read Dr. Baron's paper and take a look at how his practice is handling these issues. They might learn something. (God forbid.)
"Yes, actually I do," the M.D. replied. "Do NOT go into Internal Medicine, Family Practice, or Pediatrics!"
Why not? It comes down to one word: money. Or rather, the lack thereof. And this is at the heart of one of the biggest controversies and most serious issues facing the medical community, and perhaps our country, today. It was also the subject of Indiana University's "Sound Medicine" podcast on June 13. But that story is coming up shortly.
What's the big deal? Don't doctors earn bank? Well ... depends on who you are. The three specialties my mom's doctor mentioned--Internal Medicine, Family Practice, and Pediatrics--have the lowest annual salaries of all specialties. Here are some average yearly salaries, according to Becker's Hospital Review, an organization that surveys doctors every year about their income. (This data is from Becker's 2010 study. You can find it on the Web at: http://www.beckershospitalreview.com/news-and-analysis/current-statistics-and-lists/physician-generated-revenue-and-average-salaries-by-specialty.html.)
| Average Physician Salaries (2010) | |
|---|---|
| Specialty | Salary (dollars) |
| Pediatrics | $171,000 |
| Family Practice | $173,000 |
| Internal Medicine | $186,000 |
| Neurology | $258,000 |
| OB/GYN | $266,000 |
| Pulmonology | $293,000 |
| General Surgery | $321,000 |
| Hematology/Oncology | $335,000 |
| Cardiology (invasive) | $475,000 |
| Neurosurgery | $571,000 |
While I'm sure part of it is about lifetime earning potential, part of it is also solvency potential. When you finish medical school and residency--and perhaps a fellowship as well--with some $300,000 in debt, you need a decent income to pay that off in a reasonable time frame. Because the longer it takes, the more interest accrues. And you don't want to be paying back that loan in your retirement.
Now refer back to the list of specialists and their salaries. Note that the difference between one of the lowest (Internal Medicine, at $173,000) and the very highest (Neurosurgery, at $571,000) is nearly $400,000. Put another way, the neurosurgeon makes 330 percent more than the family practitioner. Granted, brain surgeries are complex, and becoming a neurosurgeon requires more training than most specialties. But taking care of people of all ages, with all types of conditions, is pretty complex, too. So why such a disparity?
The answer is so simple ... and yet, not. The short story is that the higher-paid specialties are the "procedure" specialties. Those doctors--such as surgeons and cardiologists--do a lot of "billable" work. In other words, they tend to get paid for most of what they spend their time doing. Primary care docs, on the other hand, don't do as much billable work. In fact, they spend a lot of time doing things that earn them absolutely ZERO money: refilling prescriptions, answering e-mails and phone calls, and looking at lab results. This is still "doctor" work--it can't be done by anyone without that $300,000 M.D. after their name--but neither HMOs nor Medicare will pay you to do it.
Basically, primary care docs are overworked and underpaid. Sounds like fun, right? So no wonder many medical students these days shy away from those specialties--a trend that is expected to leave us with a huge shortage of primary care physicians in the coming years, especially as the Baby Boomer generation ages and requires more and more care.
In reality, none of what I've just written is news. (HA! Gotcha there, didn't I? You thought this was supposed to be a NEWS column? Well ... I'm getting to that.)
What is news is that this spring, an internist from Philadelphia named Dr. Richard Baron did a quantitative study of this issues. (I heard Dr. Baron interviewed on "Sound Medicine," a podcast produced by the Indiana University School of Medicine. Check it out on the Web here: www.soundmedicine.iu.edu.) Dr. Baron's results, conclusions, and the actions his practice (Greenhouse Internists) has taken based on those results are pretty amazing.
Dr. Baron's study was quite simple actually, and relied on data the practice had already gathered and stored in its electronic health record. This electronic health record, which the practice adopted in 2004, is used "exclusively to store, retrieve, and manage clinical information," as Dr. Baron writes in his paper, which was published in The New England Journal of Medicine (April 29, 2010). Physicians and other clinicians can enter clinical information into different categories such as "office visit," "phone note," "lab report," and "imaging." Dr. Baron and his colleagues then studied the volume (and corresponding categories) of their 2008 records. For more detailed content analysis, they looked at one week's worth of phone calls and e-mails.
Below, I have reproduced a chart from Dr. Baron's study. Note that the only work the physicians are paid for is the patient visit. From this chart, you get an idea of how much work--and how much time--goes into doing things that insurance companies don't consider to be billable.
| Dr. Richard Baron's Study Results | ||
|---|---|---|
| Type of Service | Total Number (2008) | No. Per Physician Per Day |
| Visit | 16,640 | 18.1 |
| Telephone call | 21,796 | 23.7 |
| Prescription refill | 11,145 | 12.1 |
| E-mail message | 15,499 | 16.8 |
| Laboratory report | 17,974 | 19.5 |
| Imaging report | 10,229 | 11.1 |
| Consultation report | 12,822 | 13.9 |
Dr. Baron already knew that the physicians in his practice (as well as other primary care physicians) were doing "unpaid" work. This detailed look at his practice's records shows just how much.
These results, while more reinforcement and quantification than new evidence on this topic, still do highlight the need for a redesign of the primary care payment system. This is Dr. Baron's opinion; it is also mine. It is, as Spock would say, "only logical."
But what might those changes be? That is the million dollar question. It is one that the politicians, lobbyists, insurance companies, physicians, and other interest groups must pound out. And sooner rather than later, preferably.
In the meantime, Dr. Baron has made some changes in his own practice as a result of his research. First, Dr. Baron and his colleagues took a hard look at the "administrative" work (the phone calls, e-mails, looking at lab reports, etc.) that the physicians were doing. While doing much of it required an M.D., some of it could be done by a registered nurse or other (less expensive) clinician. So hiring more nurses, in many situations, is one way to cut costs and therefore boost salaries.
Another change Dr. Baron and his colleagues made was to their "productivity formula."Greenhouse Internists, like many other practices, uses a combination of base pay and productivity to determine their physicians' total salaries. What Dr. Baron and the others quickly realized was that their formula--which calulcated productivity based on the number of patients seen--simply mimicked the same payment system they were claiming was so unjust and arcane. Their response? Include that administrative work--the calls, the e-mails, etc.--in their own productivity formula. So while insurance companies might not reimburse a doctor for refilling a prescription, Greenhouse Internists does, in fact, consider such a duty to be "work." And so it pays its staff physicians accordingly.
These changes do not make up for the payscale differential or the disparity in billable procedures between primary care and the "procedure" specialties, but they are a step in the right direction. Policy makers would do well to read Dr. Baron's paper and take a look at how his practice is handling these issues. They might learn something. (God forbid.)
Health in the Headlines: An Introduction
The journalist in me is coming out. And so is the future physician. "How can this be?" you might ask. Well, read on.
My love of news and my understanding of the news business have come together with my passion for medicine to inspire an idea: a weekly column, written by me and presented here on this blog, about current events in medicine and related subject areas (such as medicine and politics, etc.). I call it "Health in the Headlines," as indicated by this blog post's title. This feature may be, in part, what we referred to at my old newspaper job as a "news roundup." As in, it may contain summaries of news stories that I have found throughout the week from various sources. Another possibility is my choosing a controversial issue that has been in the headlines steadily and drawing from several weeks, even months, of stories for information. This feature may also contain aspects of an editorial. Or if time is short, perhaps I'll just post links to a handful of really great stories or podcasts and leave it at that. Oh, yes--pictures are great too. And they fill a lot of space. (This is one thing you learn very early as a journalist.)
The point is, I am going into this "feature" with flexibility. I do not want to hem myself in by saying I will ALWAYS do this, or I will NEVER do that. Nope, I want to do what I feel like doing, when I feel like it. Because after all, I want to have fun with this. But I promise that it I will try my best (as I do will all my blog posts) to make it interesting.
One more thing. You might be wondering why I'm trying to keep track of current events in health, medicine, research, etc. One reason is that when I'm interested in something (in this case, medicine), I want to learn more about it. Obviously, I will learn a great deal in school. But what you learn from the New York Times is very different. First of all, you hear from real people--not academic textbooks that are dry and technical. From those "real" voices, you get a sense of what other physicians are doing and how medicine is moving forward (or not). You get a sense of what interests you and what doesn't. You start to develop passions and opinions and your own sense of morals and ethics.
Another reason I am doing this is to form good habits for the future. When I am a doctor, it will be necessary to keep up with this type of information (especially that pertinent to my specialty). If I start now to keep myself in the loop, it will be but a small step when I have to keep up with medical journals.
Furthermore, it's simply good--no, necessary--to be prepared with both background and contemporary knowledge of your field. Not only will it come in handy when I am a physician (knowing the most recent treatments for X, Y, and Z), but it is also useful now. For example, when I shadow a physician, knowing something about his or her specialty allows me to ask intelligent questions (which you should do not for the brownie points but so you can actually learn something). This in turn yields specific answers. And at the dreaded medical school interview, there will also be current events questions. Cramming for that interview--which is what most people do--is a horrible idea, just as cramming for anything is a horrible idea. But if you've followed what's been happening in medicine all along, those questions will be cake. (And I very much like cake.)
So this is the idea. We'll see what happens. Maybe I'll try it and it'll fizzle out, who knows. For the time being, consider yourselves journalistic guinea pigs. Hope you enjoy the ride.
Note: I will post the first in this series later today (Friday, June 25).
My love of news and my understanding of the news business have come together with my passion for medicine to inspire an idea: a weekly column, written by me and presented here on this blog, about current events in medicine and related subject areas (such as medicine and politics, etc.). I call it "Health in the Headlines," as indicated by this blog post's title. This feature may be, in part, what we referred to at my old newspaper job as a "news roundup." As in, it may contain summaries of news stories that I have found throughout the week from various sources. Another possibility is my choosing a controversial issue that has been in the headlines steadily and drawing from several weeks, even months, of stories for information. This feature may also contain aspects of an editorial. Or if time is short, perhaps I'll just post links to a handful of really great stories or podcasts and leave it at that. Oh, yes--pictures are great too. And they fill a lot of space. (This is one thing you learn very early as a journalist.)
The point is, I am going into this "feature" with flexibility. I do not want to hem myself in by saying I will ALWAYS do this, or I will NEVER do that. Nope, I want to do what I feel like doing, when I feel like it. Because after all, I want to have fun with this. But I promise that it I will try my best (as I do will all my blog posts) to make it interesting.
One more thing. You might be wondering why I'm trying to keep track of current events in health, medicine, research, etc. One reason is that when I'm interested in something (in this case, medicine), I want to learn more about it. Obviously, I will learn a great deal in school. But what you learn from the New York Times is very different. First of all, you hear from real people--not academic textbooks that are dry and technical. From those "real" voices, you get a sense of what other physicians are doing and how medicine is moving forward (or not). You get a sense of what interests you and what doesn't. You start to develop passions and opinions and your own sense of morals and ethics.
Another reason I am doing this is to form good habits for the future. When I am a doctor, it will be necessary to keep up with this type of information (especially that pertinent to my specialty). If I start now to keep myself in the loop, it will be but a small step when I have to keep up with medical journals.
Furthermore, it's simply good--no, necessary--to be prepared with both background and contemporary knowledge of your field. Not only will it come in handy when I am a physician (knowing the most recent treatments for X, Y, and Z), but it is also useful now. For example, when I shadow a physician, knowing something about his or her specialty allows me to ask intelligent questions (which you should do not for the brownie points but so you can actually learn something). This in turn yields specific answers. And at the dreaded medical school interview, there will also be current events questions. Cramming for that interview--which is what most people do--is a horrible idea, just as cramming for anything is a horrible idea. But if you've followed what's been happening in medicine all along, those questions will be cake. (And I very much like cake.)
So this is the idea. We'll see what happens. Maybe I'll try it and it'll fizzle out, who knows. For the time being, consider yourselves journalistic guinea pigs. Hope you enjoy the ride.
Note: I will post the first in this series later today (Friday, June 25).
Getting Better All The Time . . .
"Practice makes perfect."
I hate that phrase. In fact, I wish they (I'm not sure who "they" is, though) would strike it from the annals of common English phrases.
As an eldest child, and a dyed-in-the-polyester (I prefer vintage to chic) perfectionist, I have been working, for the last several years, to deconstruct my desire for perfection. Because absolute perfection, as pictured in my perfectionist brain, is absolutely impossible. Striving for the impossible is pretty pointless. And, as I have discovered, exercises in futility are infinitely frustrating.
So, here is my replacement phrase: "Practice makes improvement." Or, as the Beatles put it: "Getting better all the time ... "
And this morning, as I was discussing my recent work at the lab with my husband, Geoff, I realized something. I am practicing. I am improving. I am getting better all the time.
Here are a few of my observations:
1. My speed and technique have improved dramatically.
When I first started at the lab, I had to start from scratch: learning to pipette. My hands were shaky with nervousness (and sometimes over-caffeination), and I often contaminated the tip of the pipette by touching what I wasn't supposed to--the outside of a flask, the countertop, you name it. I just didn't have the mentality of keeping things completely sterile. Of course, I would realize my mistake right after doing it, but by then it was too late and I had to discard the pipette (and what was in it) and tear open a new one. This wasted not only money and supples, but also time.
These days, I rarely contaminate the pipettes. I move more quickly from bottle of solution to test tube or flask. My hands are more steady. I have better aim when releasing liquid (again, less waste, more accuracy, and time saving). Olga even trusts me to "passage" the cells now--divide them from, say, four plates (dishes) into eight through a series of washes and "trypsinization" (which dissolves the cells' hold on the plastic plates and allows them to be sucked up and released into new plates--a very delicate procedure). This process has to be done very quickly or the cells can be severely damaged, even destroyed. I'm fast enough--and accurate enough--to do this now.
2. I am more autonomous.
These days, contrary to my first few weeks in the lab, Olga will give me an assignment and pretty much leave me to it. Of course, if I have questions or a problem, she is available to help, but she has the confidence--and the expectation--that I will remember the techniques, processes, and steps that I have learned and can (and will) repeat them succesfully and in the proper order.
Thankfully, Olga is an amazing teacher and explains things extremely well, so that by the time she expects me to do them on my own, I am more than prepared to do so.
The fact that I am more autonomous forces me to rely on myself more, and learn the techniques for myself, rather than rely on Olga to re-explain them every time. This dynamic also allows Olga and me to accomplish more because we can both be working on different things at the same time. Even though I work more slowly than Olga, slow work is better than no work. As she put it the other day, "If you hadn't done this [set up a reaction], I wouldn't have had time to do it at all." That was the best compliment she could have given me.
3. I am more self-confident in my work.
Self-confidence has never been one of my strong points. Or so I thought.
When I was a reporter, I remember walking away from finishing the newspaper on deadline day thinking to myself, "Did I spell that commissioner's name right?" or "Did I put the right date in for that park district event?" or "Did I write a caption for that photo of the dog park?" Heart pounding, sweating, a total nervous wreck as I walked the few blocks to my car, fighting the urge to turn back to check on whether I had done those things or not. I knew that I had, but I doubted myself anyway. I was sure I had forgotten something, so I mentally went through just about every possible mistake I could have made trying to find my error (or errors).
With my lab work, I have very few such thoughts. And if one starts to creep in, I immediately squash it like the ugly, infectious cockroach that it is. I trust in my precision, my accuracy, my work ethic, my knowledge, my understanding, and my ability to follow directions.
One thing that has really helped me is to develop a process for myself when I work on a task. For example, if I am making multiple "master mixes" for a polymerase chain reaction (also called PCR--a process that creates a bunch of DNA from a very small sample), I create a checklist for the "ingredients," along with the microliters needed of each. First, I will load the magnesium chlorite into each test tube, then put the MgCl off to the side so I know it has been added. Next I will load the "super clean water," check it off, and put it off to the side, and so on. This way I don't duplicate any ingredients, and I know when everything has been done (and in the proper amount). This, of course, also contributes to speed and efficiency--which never hurts.
For times when those "cockroaches" scuttle up, I have, already prepared, a list of battle phrases (or cans of RAID, if you like) to use against them. An example: "I acknowledge that I am concerned about whether I added the cDNA to the master mix, but I have checked it off on my list, and the tube has been put off to the side. So even though I don't specifically remember adding it, I know that I did because I followed my process. As a result, there is no need to be worried about this."
Maybe it sounds hokey, but using these phrases, for the few times I have to deal with worrisome and negative thoughts, really makes a difference.
I have more self-confidence now to begin with, and when I struggle, I have another "tool" in my mental "toolbox" to help me.
4. I better understand the science involved in what we (and other scientists) do.
On May 11, my first day at the lab, I understood ... um ... maybe 10 percent of what Olga was telling me. OK, perhaps a little more, but it was bits and pieces, not a comprehensive picture. So I spent a lot of time being really confused and doing things but not really understanding why.
Please note--this was not Olga's fault; she explained (and continues to explain) things very well. I simply did not have the background, nor the scientific vocabulary, to comprehend even the most elementary of explanations.
Boy, how things have changed. And I especially noticed it this week. On Wednesday, Olga had me set up the PCR reaction (see explanation of PCR in observation No. 3). Before I started pipetting, she gave me the background on what exactly we were going to be looking for in the end (with the gel electrophoresis). I took very careful notes, both so I could set up the reaction properly and so I could remember the details of what I had done. The same buzz words came up as had come up before: transcription factors, differentiation markers, fetal organoids, endogenous control. This time, though, I actually knew what she meant. In fact, I knew enough to ask intelligent (and genuine--not pedantic) questions about what she was telling me! It was a true victory. I'm not much of a hymn-singer, but I totally got what John Newton meant in "Amazing Grace," though in a scientific, rather than religious, context: "I once was lost, but now am found / was blind but now I see."
The second example of this "understanding" phenomenon came at yesterday's (Thursday's) weekly afternoon lab meeting. Each week, the usual procedure is that one of the lab's scientists presents his or her recent work for discussion. This week however, we did something a little different. Lab Director Rich Minshall and one of the PhD candidates, Aaron, picked out a research paper for us to read and discuss.
When I read the title early Thursday morning, I groaned. My eyes glazed over, anticipatorially, sure that the paper was going to be a total drag (i.e., completely incomprehensible to me). It was indeed just the title that gave me this impression: "Transcellular migration of leukocytes is mediated by the endothelial lateral border recycling compartment." *GROAN* indeed. But I started reading anyway--that damn Puritan work ethic again. And to my surprise, I was understanding things. Sure, I had to reread parts, sometimes multiple times, and look up certain concepts on the Web, but I was getting it. In fact, I was getting into it--I even started highlighting the text onscreen (I'd never done that before; it was pretty cool) so I could remember and review the highlights and main conclusions / points of the paper before our 4 p.m. meeting. I didn't really understand the visuals that accompanied the paper, but that was OK. I understood the ideas. And at the lab meeting, I actually contributed--for the first time. Not on the level of the Phd'ers, but who would expect that? The fact remains, I contributed, because I was able to understand what was going on--something that had never happened before.
I felt kind of like a surfer who, for weeks, had been trying to catch a wave, only to be knocked down to the ocean floor. But one day, she manages to hold her balance, and hold the wave's crest, and ride it through. Pretty cool.
Surfing science ... I kind of like that.
I hate that phrase. In fact, I wish they (I'm not sure who "they" is, though) would strike it from the annals of common English phrases.
As an eldest child, and a dyed-in-the-polyester (I prefer vintage to chic) perfectionist, I have been working, for the last several years, to deconstruct my desire for perfection. Because absolute perfection, as pictured in my perfectionist brain, is absolutely impossible. Striving for the impossible is pretty pointless. And, as I have discovered, exercises in futility are infinitely frustrating.
So, here is my replacement phrase: "Practice makes improvement." Or, as the Beatles put it: "Getting better all the time ... "
And this morning, as I was discussing my recent work at the lab with my husband, Geoff, I realized something. I am practicing. I am improving. I am getting better all the time.
Here are a few of my observations:
1. My speed and technique have improved dramatically.
When I first started at the lab, I had to start from scratch: learning to pipette. My hands were shaky with nervousness (and sometimes over-caffeination), and I often contaminated the tip of the pipette by touching what I wasn't supposed to--the outside of a flask, the countertop, you name it. I just didn't have the mentality of keeping things completely sterile. Of course, I would realize my mistake right after doing it, but by then it was too late and I had to discard the pipette (and what was in it) and tear open a new one. This wasted not only money and supples, but also time.
These days, I rarely contaminate the pipettes. I move more quickly from bottle of solution to test tube or flask. My hands are more steady. I have better aim when releasing liquid (again, less waste, more accuracy, and time saving). Olga even trusts me to "passage" the cells now--divide them from, say, four plates (dishes) into eight through a series of washes and "trypsinization" (which dissolves the cells' hold on the plastic plates and allows them to be sucked up and released into new plates--a very delicate procedure). This process has to be done very quickly or the cells can be severely damaged, even destroyed. I'm fast enough--and accurate enough--to do this now.
2. I am more autonomous.
These days, contrary to my first few weeks in the lab, Olga will give me an assignment and pretty much leave me to it. Of course, if I have questions or a problem, she is available to help, but she has the confidence--and the expectation--that I will remember the techniques, processes, and steps that I have learned and can (and will) repeat them succesfully and in the proper order.
Thankfully, Olga is an amazing teacher and explains things extremely well, so that by the time she expects me to do them on my own, I am more than prepared to do so.
The fact that I am more autonomous forces me to rely on myself more, and learn the techniques for myself, rather than rely on Olga to re-explain them every time. This dynamic also allows Olga and me to accomplish more because we can both be working on different things at the same time. Even though I work more slowly than Olga, slow work is better than no work. As she put it the other day, "If you hadn't done this [set up a reaction], I wouldn't have had time to do it at all." That was the best compliment she could have given me.
3. I am more self-confident in my work.
Self-confidence has never been one of my strong points. Or so I thought.
When I was a reporter, I remember walking away from finishing the newspaper on deadline day thinking to myself, "Did I spell that commissioner's name right?" or "Did I put the right date in for that park district event?" or "Did I write a caption for that photo of the dog park?" Heart pounding, sweating, a total nervous wreck as I walked the few blocks to my car, fighting the urge to turn back to check on whether I had done those things or not. I knew that I had, but I doubted myself anyway. I was sure I had forgotten something, so I mentally went through just about every possible mistake I could have made trying to find my error (or errors).
With my lab work, I have very few such thoughts. And if one starts to creep in, I immediately squash it like the ugly, infectious cockroach that it is. I trust in my precision, my accuracy, my work ethic, my knowledge, my understanding, and my ability to follow directions.
One thing that has really helped me is to develop a process for myself when I work on a task. For example, if I am making multiple "master mixes" for a polymerase chain reaction (also called PCR--a process that creates a bunch of DNA from a very small sample), I create a checklist for the "ingredients," along with the microliters needed of each. First, I will load the magnesium chlorite into each test tube, then put the MgCl off to the side so I know it has been added. Next I will load the "super clean water," check it off, and put it off to the side, and so on. This way I don't duplicate any ingredients, and I know when everything has been done (and in the proper amount). This, of course, also contributes to speed and efficiency--which never hurts.
For times when those "cockroaches" scuttle up, I have, already prepared, a list of battle phrases (or cans of RAID, if you like) to use against them. An example: "I acknowledge that I am concerned about whether I added the cDNA to the master mix, but I have checked it off on my list, and the tube has been put off to the side. So even though I don't specifically remember adding it, I know that I did because I followed my process. As a result, there is no need to be worried about this."
Maybe it sounds hokey, but using these phrases, for the few times I have to deal with worrisome and negative thoughts, really makes a difference.
I have more self-confidence now to begin with, and when I struggle, I have another "tool" in my mental "toolbox" to help me.
4. I better understand the science involved in what we (and other scientists) do.
On May 11, my first day at the lab, I understood ... um ... maybe 10 percent of what Olga was telling me. OK, perhaps a little more, but it was bits and pieces, not a comprehensive picture. So I spent a lot of time being really confused and doing things but not really understanding why.
Please note--this was not Olga's fault; she explained (and continues to explain) things very well. I simply did not have the background, nor the scientific vocabulary, to comprehend even the most elementary of explanations.
Boy, how things have changed. And I especially noticed it this week. On Wednesday, Olga had me set up the PCR reaction (see explanation of PCR in observation No. 3). Before I started pipetting, she gave me the background on what exactly we were going to be looking for in the end (with the gel electrophoresis). I took very careful notes, both so I could set up the reaction properly and so I could remember the details of what I had done. The same buzz words came up as had come up before: transcription factors, differentiation markers, fetal organoids, endogenous control. This time, though, I actually knew what she meant. In fact, I knew enough to ask intelligent (and genuine--not pedantic) questions about what she was telling me! It was a true victory. I'm not much of a hymn-singer, but I totally got what John Newton meant in "Amazing Grace," though in a scientific, rather than religious, context: "I once was lost, but now am found / was blind but now I see."
The second example of this "understanding" phenomenon came at yesterday's (Thursday's) weekly afternoon lab meeting. Each week, the usual procedure is that one of the lab's scientists presents his or her recent work for discussion. This week however, we did something a little different. Lab Director Rich Minshall and one of the PhD candidates, Aaron, picked out a research paper for us to read and discuss.
When I read the title early Thursday morning, I groaned. My eyes glazed over, anticipatorially, sure that the paper was going to be a total drag (i.e., completely incomprehensible to me). It was indeed just the title that gave me this impression: "Transcellular migration of leukocytes is mediated by the endothelial lateral border recycling compartment." *GROAN* indeed. But I started reading anyway--that damn Puritan work ethic again. And to my surprise, I was understanding things. Sure, I had to reread parts, sometimes multiple times, and look up certain concepts on the Web, but I was getting it. In fact, I was getting into it--I even started highlighting the text onscreen (I'd never done that before; it was pretty cool) so I could remember and review the highlights and main conclusions / points of the paper before our 4 p.m. meeting. I didn't really understand the visuals that accompanied the paper, but that was OK. I understood the ideas. And at the lab meeting, I actually contributed--for the first time. Not on the level of the Phd'ers, but who would expect that? The fact remains, I contributed, because I was able to understand what was going on--something that had never happened before.
I felt kind of like a surfer who, for weeks, had been trying to catch a wave, only to be knocked down to the ocean floor. But one day, she manages to hold her balance, and hold the wave's crest, and ride it through. Pretty cool.
Surfing science ... I kind of like that.
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