Getting sick

Since getting here, almost everyone has gotten sick. There seem to be two different things going around, but maybe it’s a variation of the same bug. One illness has people with upper respiratory symptoms – congestion, cough, runny nose, fatigue etc. The other one seems to be fever, chills, GI symptoms with vomiting and diarrhea. I’ve been extremely lucky so far – I haven’t gotten sick yet. Neither has Lisa or Josh. I’m pretty sure it’ll happen, but I just hope it’s not over the weekend. And I hope I get the first one rather than the later one.

Drug Dinners

In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."

I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.

The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.

On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.

I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.

All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...

Camping in the Kalahari!

We went camping in the Kalahari this weekend! Joanne, Amy, Jeremy and I went with Johannes (Jo), a guide that works with Tim. It took us 3-4 hours to get there, we had lunch at the campsite, and set up our lion-proof tents. We were staying in Khutse game reserve, which is connected, or adjacent to, the huge Central Kalahari Game Reserve (CKGR) – the largest game reserve in Africa.

We had a huge lunch – quiche, salad, other things – and then went on our first game drive. We saw a few funny things, but no huge game. We did see this huge flock of vultures near the air strip – very impressive. Of course, we saw many springbok and steembok, some oryx gazelle, these cute ground squirrels that ran fast everywhere and use their tail to shade themselves. And we saw a ton of birds – the lilac-crested roller, hornbills, some weavers, and the kgori (or kori) bustard (which we were saying bastard the entire time) – apparently it’s largest flying bird in the world. We also collected some firewood and saw a beautiful sunset! Here are just a few pictures of the things we saw:

Vultures

Ground squirrel

hornbill

kgori bustard










After we got back, Jo made dinner. It’s funny – there were 3 Jo’s on this trip so it was very confusing when Jeremy or Amy tried to talk to one of us. They would say Jo, and three heads would turn. Dinner was delicious – we had steak, garlic bread, and green beans with pap. And we also had chocolate cake for dessert. We sat around the campfire for a while, and eventually crawled into our tents. I slept with Amy, Jeremy slept alone, and Jo(anne) slept with Jo(hannes). J We were a little afraid of lions – they often go right into the campsite at night although they stay away from humans for the most part. So I didn’t make it out to the drop toilets all night because I was so worried! I think that was a good decision because apparently campsite 5, which was right next to us, had a lion visit them!

We went on another relatively uneventful game drive the next morning after breakfast, and Jo took us to a relocated village of the San-people (they’re also called bushmen, which is derogative, or Basarwa, also derogative since it literally translates to “stick-people”). I thought it was the most interesting part of the trip, but it’s a pretty sad story. I’ll talk more about it in the next blog entry. After visiting the San-village, we stopped at the Khutse Lodge, which is right on the border of the Khutse Game Reserve, for a light lunch of sandwiches and salad. We were there for a couple of hourse, so we went swimming in their pool to cool off, and then drove home. Even though we didn’t see any big game, it was still a great experience, and I’m totally glad I went. It was so quiet and beautiful out there. I think it was a good preview of what our safari will be like…

Being a health care professional in bad economic times

One good thing (of many, I think) of being a doctor during bad economic times - you pretty much are guaranteed a job. Especially in this day and age, with more and more people living longer and longer, people will always need doctors and nurses, and other health care professionals. In fact, there's an increasing demand for them. I'm sure salaries may go down, and people may have to work (even) longer hours and care for more patients in a shorter amount of time, but at least they're usually not at danger for losing their jobs. At the worst, people may have to relocate or take less-than-ideal jobs or situations in order to keep their incomes flowing in.

It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.

Transfer of Care

At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.

As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.

However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.

the genetics of race

When I was in high school, I got into a debate at school. I said that if different races were separated long enough to evolve different skin colors, then other things could have evolved differently too. For example, blacks are stereotypically thought of as good athletes. Asians are thought of as good at math. I know this is really oversimplifying it, but it's certainly possible that over time, blacks developed a "strong muscle" gene (or set of genes) or maybe a "hand-eye coordination gene" and Asians developed a "math" gene (or set of genes). I'm not saying that's what happened... it's just what is possible.

I was watching a TV show (I think it was Without a Trace) and although I'm sure nobody really picked up on it, there was this one part that I think really made this statement. In this episode, there was this white kid who disappeared, partly because he was having an identity crisis. His mother was white and the father who raised him with his mother was white, and the kid looked white, but his father was black, and he just found that out. In one of the flashback scenes, they show the kid when he really young, and he's talking to his adopted father, saying that he doesn't "feel right". I'm not getting the words completely right, but he basically says that he feels different from his father and all the other (white) kids - they don't like the same things, act the same way, or even look the same. And after the flashback, the father says about his adopted son, "he always knew" (that he was different).

Now at first glance, this doesn't seem to mean much. But actually, what's it's saying is that even though there was no difference in skin color for this kid, there were other characteristics - facial or other body features, personality, attitudes, etc. - that made him feel different. And then he finds out he's half-black. The point is that this one scene in the show is suggesting that there may be other differences to race than skin color (whether genetic or otherwise). It's interesting to me that this was brought up, albeit in a very subtle way, on TV, while in reality, it's something that society as a whole isn't really ready to talk about yet.

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