Are Youthful Medical Idealism and Adult Realities at Odds?

Philip R. Alper, MD, clinical professor of medicine at UCSF, writing in the San Mateo Country Medical Association Bulletin, draws an important parallel between the idealism of young physicians and the realities they experience during their training and early careers.

Weren’t we all idealistic at one time? And if that’s the way we were, what happened to us? Why, for example, did one study show women OB-GYN residents have measurably more compassion than their male colleagues at the outset of their residencies, but no difference by the time they completed training? Is this the effect of wider responsibilities or wearing down and becoming cynical?

Dr Alper feels physicians have become strident. We gripe. We complain bitterly. We reach new highs of self-righteousness when commenting on insurers, government, the drug industry, and even patients. If you think this is overblown, Alper advises us to listen carefully the next time we are in the surgical lounge or the doctors’ lunchroom.

There’s a lot we’ve overlooked, such as the grossly inflated retail charges of the hospitals, laboratories, pharmacies, and their impact on the uninsured. The distorted economics of managed care let some patients get too much for their money, while we sock it to others pretending not to know what’s happening. The plight of the poor, the uninsured, and the underinsured is something we’d prefer not to think about.

Some people believe doctors are uncaring or just in it for the money. They have lots of anecdotes to support their point of view. Haven’t we seen or even participated in instances of debatable testing or surgery? But we also observe tough-minded physicians take care of lepers, teach medical students and contribute unpaid time in other ways. Those that volunteer at the Samaritan House aren’t always the ones you’d expect to see there. Alper is convinced that what brought us into medicine is more likely to be partially submerged than to have entirely disappeared. That hard crust may conceal “the rest of the story.”

These observations were provoked by Dr. Alper’s attendance at the World Health Care Congress in Washington, D.C. in January. There were 45-minute addresses by Bill Frist, Hillary Clinton, and other luminaries. CEOs, CFOs, and CIOs of dozens of health care corporations mingled and broke into small groups for presentations and discussion.

In addition to the political and economic types, the medical directors of many health plans were also invited, something that he was told was highly unusual in such high-level gatherings. Clinical guidelines, best practices, error prevention, pay for performance, and value for the dollars expended dominated the discussion designed to facilitate the reshaping of medicine.

By the third day, Alper observed that the perspective of the practicing physician was considered superfluous. Physicians had been studied and were “known.” To health policy “players,” doctors appear to resemble a herd of cattle, to be maneuvered, manipulated, and molded. The same powerful corporations that have their own crack Human Resources departments approach physicians as if we are inhuman resources. Bizarre as it sounds, the very people who dehumanize us desire humanity from us.

Alper concludes that doctors aren’t saints. We can’t legitimately blame all our shortcomings on others. But we are not ready to walk away from our patients despite the increasing stresses of practice. It helps that the spark that brought us into medicine continues to warm us from within.

Go to http://www.smcma.org/ and click on Bulletin to read the entire article.

Never Leave Children Unattended in a Car: Not Even for a Minute

Marilyn Gunnell became aware of the “Not Even for a Minute” project developed by the state of New Jersey. She brought the project to two organizations of which she is a member: her Rotary Club, and the Los Angeles County Medical Alliance. Debbi Ricks, president of the Alliance of the Santa Clara County Medical Association writing the cover story for The Bulletin, has enlisted the Alliance Board to underwrite this project. You can order brochures and posters in several languages. The email addresses are given at http://www.notevenforaminute.org/. She invites physicians and others to participate in this effort to prevent child tragedy.

Are Physicians Part of the Problem in the Epidemic of Childhood and Adult Obesity?

Emily Lambert Dalton, MD, writing in The Bulletin of the Humboldt-Del Norte County Medical Society, observes how the feeding advice given to parents of newborns five or six decades ago is so much different than now. In that era new mothers were told to feed their babies on a strict schedule such as every four hours and never feed early. The schedule was based on the clock, not the infant’s cry, demeanor or anything else. It was strict and inflexible.

Nowadays we scoff at that old-fashioned approach, thinking (based upon what evidence?) that “on demand” feeding is highly superior. She thinks this may have come about because of the notion that this pattern more closely resembled the feeding pattern of a breast-fed infant.

Dalton opines that breast feeding, even if proffered liberally, is limited by physical and logistical factors. Breast milk needs time to replenish once a breast is drained. A child nursing on an empty breast doesn’t get much. Breasts get sore and mothers need to stop nursing to do other things.

Bottles can dispense an unlimited amount of formula at any time. Babies have a need to suck and if their bottle dispenses calories, they will take them in. To assume a newborn will regulate the caloric intake if offered an unlimited supply is ludicrous. Most adults don’t know when to stop eating; how can we expect an infant to know?

Most infants are bottle-fed at some point during the first year. Without a schedule, the parent can never be exactly sure when the infant is hungry. They soon begin to offer bottles at the first sign of infant discomfort or fussiness. A strict feeding schedule makes the answer clear: if it is feeding time, the infant is hungry. If it isn’t, the problem is gas, boredom, discomfort, or something else.

An infant who becomes accustomed to getting fed every time it experiences any discomfort learns that the proper response to pain, boredom, irritation, or any discomfort is to suck on a bottle and take in calories — usually more than needed. The number of adipose cells increase. By the end of the first year, both the parents and the infant have undergone powerful conditioning that encourages both to turn to food frequently and for the wrong reasons. Dr Dalton recommends that we all break out the first edition of Dr Spock’s Baby Care for his wisdom and sound feeding advice.

The Human Mind

Robb Smith, MD, the new editor of the Fresno-Madera Medical Society’s Vital Signs (he was jettisoned into this position because he was late for the Editorial Committee meeting) has the above title and the following “filler” after his editorial for the month.

Aoccdmig to a rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat lteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit probelm. Tihs is bcuseae the hmuamn mnid deos not raed ervy lteter by istlef, but the wrod as a wlohe.

Amzanig huh?