What To Do When 'Scrubbed In'

Smoking costs U.S. economy billions each year

Expenses directly attributable to death and disease caused by smoking are estimated to be costing the U.S. economy more than $301 billion annually, according to a study released recently by the American Lung Association. In the study, researchers at Penn State University calculate that smoking results in workplace productivity losses of $67.5 billion, costs of premature death totaling $117.1 billion and direct medical expenditures of $116.4 billion (see below).



The study, titled "Smoking cessation: the economic benefits," provides a nationwide cost-benefit analysis that compares the costs to society of smoking with the economic benefits of states providing smoking cessation coverage. The AMA fully supports the report, which provides state governments with compelling economic reasons to help smokers quit.

"Smoking cessation programs have been shown to successfully help smokers quit—lowering the risk for smoking-related diseases and the high costs associated with treating them," AMA Board of Trustees member Barbara McAneny, MD, said. "No other public health measure, including breast cancer or diabetes screening, sees the economic benefits of smoking cessation."

The AMA offers various online tools that physicians can use to help their patients quit smoking, as well as educational resources about the dangers of secondhand smoke. Among them are a webinar to help physicians counsel parents about secondhand and third-hand smoke exposure, a podcast to help physicians incorporate counseling about secondhand smoke into their practices, a self-learning curriculum that explains office-based prevention and intervention strategies regarding secondhand smoke and a module about managing tobacco dependence.

In addition, the AMA’s Healthier Life Steps™ program offers tips and resources to help physicians talk with patients about the dangers of tobacco use. The program provides patient self-assessment questionnaires, action plans, tracking calendars and other resources to help physicians counsel patients who smoke or use other tobacco products.

Learn more about what the AMA is doing to help physicians help their patients quit smoking, stop using other forms of tobacco and avoid exposure to secondhand smoke.

Burnout in Medical Students Linked to Self-Reported Unprofessional Conduct

September 14, 2010 — Burnout in medical students is highly prevalent and is associated with self-reported unprofessional conduct involving patient care, according to the results of a Mayo Clinic study reported in the September 15 issue of the Journal of the American Medical Association.

"Our findings suggest future physicians' altruism, professionalism, and commitment to serve society are eroded by burnout," lead author Liselotte Dyrbye, MD, from the Mayo Clinic in Rochester, Minnesota, said in a news release. "This is concerning since burnout is a pervasive problem among medical students, residents, and physicians in practice."

The goal of this cross-sectional survey was to examine the association between anonymously reported measures of professionalism and burnout among 4400 eligible students from 7 leading medical schools (Mayo Medical School, University of Washington, University of Minnesota, University of Alabama, University of California–San Diego, University of Chicago Pritzker School of Medicine, and the Uniformed Services University of the Health Sciences). The survey included the Maslach Burnout Inventory (MBI), the Primary Care Evaluation of Mental Disorders depression screening tool, and the SF-8 quality of life (QOL) assessment tool. Response rate was 61% (n = 2682).

More than half (52.8%) of the respondents were found to have burnout on the MBI, and those students were more likely to report some form of unprofessional conduct. Although relatively few (<10%) reported academic cheating, up to 43% percent of third- and fourth-year students admitted to some form of unprofessional conduct involving patient care. For example, they may have reported a physical examination finding as normal even though they had not examined that area.

Because the students knew that the reported behavior was inappropriate, the investigators suggest that some elements in the educational process may promote dishonesty.

Burnout was the only aspect of distress independently associated with reporting at least 1 unprofessional behavior, based on multivariable analysis with adjustment for personal and professional characteristics.

For 6 different scenarios, the opinions of only 14% of the students regarding relationships with industry were in line with the American Medical Association policy regarding appropriate interactions between physicians and pharmaceutical companies.

The study authors therefore called on medical schools to "do a better job teaching students about conflict of interest and appropriate relationships with industry."

Altruistic feelings concerning a physician's role in society, such as a desire to provide medical care to the underserved, were less often reported by medical students suffering from burnout.

"As our nation reforms its health care system, it is essential that physicians advocate for patients, promote the public health, and reduce barriers to equitable health care," Dr. Dyrbye said. "Burnout appears to be a threat to this process."

Limitations of this study include response bias, assessment of only a limited number of behaviors and attitudes representing professionalism, reliance on self-reported behavior, and inability to determine causal relationships.

"Future research should investigate whether interventions designed to reduce burnout help students cultivate professional values and behaviour," the study authors conclude.

The Mayo Clinic supported this study. The study authors have disclosed no relevant financial relationships.

JAMA. 2010;304:1173-1180.

The Drug Pushers' Free Lunches

Joshua Batt, Medical Student, Emergency Medicine, 12:41PM Sep 25, 2010

"Big Pharma", as it is affectionately called, has medical providers in the crosshairs. Despite laws prohibiting the extent to which they "promote" their products, they continue to push the latest medications at any cost. As medical students we enjoy the "free" pens, stationary, and lunches. After all, there is a free lunch every day and it is our job to find it.

The controversy of the pharmaceutical giveaways is becoming tamer, but reps are always on the hunt for a few to jump on command. Of course I enjoy having food brought to my facility and offered for a mini lecture on the new drug or medical device. In all reality I probably would never hear about the medicine on my own and they give some education as to indications, contraindications etc. The problem is that their drug is usually "the best" on the market, so there is a little research to be done in my spare time to see what may be lurking in the shadows that I have not been told.

Many will argue that it is not right to receive the free handouts because it drives up costs for the patient. There is certainly some cost involved on that end which pays for the representatives to market the products. That's business. Without the drug reps making their rounds, some of the latest drugs would go unused, meaning patients may be missing a medicine that could have a potential benefit in their situation.

Round and round the battle goes. With little pharmacologic didactic sessions in the clinics I am willing to spend a little time pleasing my palate while learning something new and pertinent to my career. This month in particular has been unique in that representatives visit us four days each week. I just plan on it for lunch and learn a little in the process.

Perhaps I have overlooked a glaring flaw in this model of medicinal dissemination and by all means I would love to hear your opinions or stories.

What if I Don't Want to Do a Residency?

Question:

I didn't enjoy my third year of medical school and now I'm not sure if I want to do a residency anymore. What should I do?

Response from Sara Cohen, MD Fellow, Department of Physical Medicine and Rehabilitation, Harvard University, Boston, Massachusetts; Fellow, Department of Physical Medicine and Rehabilitation, VA Boston Healthcare System, Boston, Massachusetts

Near the end of my third year of medical school, I went out to dinner with a few of my classmates. Naturally, the conversation quickly turned to which residencies we wanted to get. My friend Ben, who had just finished his surgery rotation and still had circles under his eyes, said, "I don't think I want to do residency. I hate patient care."

We were all aghast. "So what are you going to do?" someone asked.

"I don't know," Ben admitted. "But there must be some options out there for an MD who doesn't want to do a residency, right?"

Since my conversation with Ben, I've heard that question posed many times by exhausted medical students. Some students thrive on the excitement of third year, but some hate waking up early, working weekends, being constantly sleep-deprived, and missing out on time with their families. Other students find that they hate procedures or dealing with difficult patients.

The first question to ask yourself is why you don't want to do a residency. Is it because of the long hours and difficult call schedule? If so, you might consider some of the specialties that have less grueling residencies. The infamous ROAD specialties (radiology, ophthalmology, anesthesiology, and dermatology) are known for combining high pay with reasonable hours, although for that same reason, these residencies are generally very competitive. Emergency medicine also has reasonable shift work, even during residency. Other specialties with reasonable hours that tend to be less competitive include psychiatry, pathology, and physical medicine and rehabilitation (PM&R). As a PM&R resident, I worked mainly 8 to 5 with rare weekends and call from home. It was nowhere near as grueling as, say, a surgery residency, and I didn't miss my family or feel sleep-deprived. (Learn more about PM&R in an article I wrote previously for Medscape.)

If your main concern is that you dislike direct patient interaction, consider one of the specialties where patient care is minimal, such as radiology, pathology, or preventive medicine. Whereas radiology and preventive medicine require a clinical transitional year, pathology does not. That means that if you enter a pathology residency, you'll never have to see another patient.

If you like patient care but hate procedures, consider psychiatry. If you love procedures but hate long-term patient care, consider anesthesiology or emergency medicine.

The field of medicine is incredibly broad, with many specialties, and it is likely that a good "fit" can be found for everyone, depending on individual likes and dislikes. Residency is probably the best option for someone who has completed medical school, and just because you complete a residency doesn't mean that 100% of your future job must involve patient care. A lot of clinicians do some research, teaching, or administrative work in addition to their clinical duties, so you can divide your time and create the lifestyle you want.

Try to remember why you went to medical school in the first place, and allow yourself some time to recover from your exhaustion. Medical students can get discouraged when they don't immediately love one of the core clerkships during third year, which is why you should try to set up interesting electives that are potential career choices. Also, you might see things differently when you've had a few good nights of sleep.

If after thinking it through thoroughly, you still decide that residency isn't for you, you can pursue several options. It's a good idea to complete at least 1 year of residency so that you can get a medical license. That way, if you ever decide to return to medicine, you will be in a better position if you already have a license.

A physician who doesn't want to do clinical work has many other options. If you have a mind for business, you may want to consider getting an MBA (Master of Business Administration) and working in the administrative end of medicine. Alternately, you can get an MPH (Master of Public Health) and find work in public health. Careers in medical writing, informatics, engineering, and consulting are also possible.

Dr. Joseph Kim hosts an extensive Website about nonclinical medical jobs, including actual job opportunities as well as general guidance about pursuing a nonclinical career. But keep in mind that each of these fields has its own set of challenges, so you should thoroughly investigate these options before making a dramatic career switch.

As for my friend Ben, after a nice long shower and a nap (and possibly some research), he decided that residency wasn't such a bad option after all. He matched with the rest of us.

Depressed Medical Students More Likely to Link Stigma With Depression

September 16, 2010 — Depressed medical students have a higher prevalence of stigmatized attitudes than their nondepressed counterparts, a new cross-sectional study suggests.

In fact, 56% of those with moderate to severe depression said that their fellow medical students would respect them less, and more than 83% worried that faculty members would question whether they could handle their responsibilities.

The survey also found that although the depressed medical students had higher rates of suicidal ideation compared with the nondepressed students, those in their third and fourth years of school were more likely to report it than first- and second-year students.

"It was somewhat worrisome and concerning to see that students with high depression scores experienced really quite a wide range of stigma, and that it came from many directions. Perhaps most unsettling was that it came from their fellow students, faculty members, and counselors," lead author Thomas L. Schwenk, MD, professor and chair of the Department of Family Medicine at the University of Michigan, Ann Arbor, told Medscape Medical News.

"Now, we don't have any way of knowing: Is this real or is it perception?" added Dr. Schwenk. "But of course it doesn't really matter so much because for them, perception is real. Feeling that this stigma comes from so many different places makes it difficult to know where to go to safely disclose and safely seek care."

The study authors note that overall, "medical students experience depression, burnout, and mental illness at a higher rate than the general population, with mental health deteriorating over the course of medical training."

However, they are also less likely to seek appropriate treatment. "Students may worry that revealing their depression will make them less competitive for residency training positions or compromise their education, and physicians may be reluctant to disclose their diagnosis on licensure and medical staff applications," the investigators write.

"We just think that caring for oneself and for each other should be part of the attributes of an outstanding physician and being receptive to treatment of mental illness and to the needs of colleagues should become part of the construct of professionalism," added Dr. Schwenk.

The study appears in the September 15 issue of the Journal of the American Medical Association, a theme issue on medical education.

High Prevalence of Stigma

For the study, the investigators evaluated data from all 769 students enrolled at the University of Michigan Medical School. The Web-based Patient Health Questionnaire survey was completed by 505 (65.7%) of the students (58.4% women) between September and November 2009, and all identities were kept confidential.

Because of the anonymity of the participants, no follow-ups were conducted or referrals to mental health resources offered. However, existing medical school resources were described throughout the survey process.

Results showed that the overall prevalence of moderate to severe depression in the students was 14.3% (95% confidence interval [CI], 11.3% - 17.3%).

Of these, female students were found to be twice as likely as male students to have moderate to severe depression (18% vs 9%, respectively; 95% CI for difference, −14.8% to −3.1%; P = .001). There was no significant difference in depression found between the first- and second-year students (13.4%) and the third- and fourth-year students (15.4%).

Suicidal ideation at some point during medical school was reported by 4.4% of the overall students. However, it was more likely to be reported by third- and fourth-year students than by first- and second-year students (7.9% vs 1.4%; P = .001).

There was no significant difference in suicidal ideation found between the women and the men (5.1% vs 3.3%, respectively).

When looking at the stigma questions, students with moderate to severe depression agreed more frequently with the statement "If I were depressed, fellow medical students would respect my opinions less" than did those without depression (56.0% vs 23.7%; P < .001). They also agreed more frequently that fellow students and faculty members would view them as being unable to handle their school responsibilities (83.1% vs 55.1%; P < .001).

"Students with higher depression scores also felt more strongly than did those with no to minimal depression that telling a counselor would be risky (53.3% vs 16.7%) and that asking for help would mean the student's coping skills were inadequate (61.7% vs 33.5%)," report the study authors.

Men agreed more often than women that others would not want to work with a depressed medical student (49% vs 29.4%; P < .001) and that they could endanger patients (36.3% vs 20.1%; P = .002).

Finally, first- and second-year students agreed more frequently than did third- and fourth-year students that seeking help for depression would make them feel less intelligent (34.1% vs 22.9%; P < .01) and that "depressed medical students would provide inferior patient care" (79.3% vs 66.9%; P = .007).

"The male vs female and first-year vs third- and fourth-year student data are important and certainly provocative, but we did not explore them in great detail in terms of other factors," said Dr. Schwenk. "If you take the data at face value, however, it suggests that men are somewhat more critical of students who are depressed than women are. That's somewhat worrisome, given the fact that women experience depression at a higher rate."

Overall, the study's results "suggest that new approaches may be needed to reduce the stigma of depression and to enhance its prevention, detection, and treatment," summarize the authors.

Dr. Schwenk reported that his team hopes to expand this study and to "reach out to other schools" with the survey. "Clearly, one school does not constitute an adequate sample." Also, "in short order," they hope to design some intervention programs to be used in a medical school environment.

Deconstruct Stigmatized Attitudes

This study "serves as a reminder of how difficult it is to be a medical student. The initial encounters with severe illness and the extremes of life are poignant and profoundly affecting," writes Laura Weiss Roberts, MD, from the Department of Psychiatry and Behavioral Sciences at Stanford University, California, in an accompanying editorial.

Dr. Roberts, who was not involved with this study, writes that the study showed some encouraging results. "Third- and fourth-year students expressed less stigmatized views of depression in peers. These data suggest that the iterative experiences of medical training may inspire more accurate and empathic understanding of the illness experience, whether in a patient or a colleague."

She notes that the findings also "issue a clear invitation to intervene" with depressed and at-risk students. "Whether the stigma perceived by depressed medical students is a sign of illness...or an accurate 'read' of the culture of medicine, it is important to deconstruct stigmatized attitudes toward mental illness.

"Such efforts will be seen as superficial unless secure, affordable, and confidential pathways to mental healthcare, preferably outside of their usual training settings, are created for physicians in training across all levels," she adds.

Dr. Roberts writes that "few funds" are currently dedicated to medical education research, although it is a critically important area to explore.

"The future of medicine rests on the shoulders of today's medical students, and the care with which medical school administrators and faculty attend to their learning and well-being may bring good to them, as well as to the patients of tomorrow," she concludes.

This study was supported by the Department of Family Medicine at the University of Michigan. The study authors have disclosed no relevant financial relationships. Dr. Roberts reported receiving research funding from the National Institutes of Health, the US Department of Energy, and the Medical College of Wisconsin, and being the owner of Terra Nova Learning Systems.

JAMA. September 2010; 304:1181-1190.

How Should I Prepare for an Interview?

Question

I’m looking ahead to my residency interviews and was wondering: What should I be doing now to prepare for them?

Response from Daniel J. Egan, MD Associate Attending Physician, Department of Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

Preparing for an interview is different for each individual. Much of what takes place in interviews involves information you provided in your application, so if you have blemishes on your record, you will need to work out explanations of those elements. On the other hand, if you are a stellar student, you will be able to focus more on your achievements.

In general, the most important goal of preparation is to actually be prepared. Here are some basics:

1. Learn as much as possible about the program to which you are applying. An unprepared applicant who does not know obvious details about a program would stand out to me as someone who did not do his or her homework. Your questions about the program can focus on elements not included on their Website (or perhaps on more recent events if the Website is outdated).
2. Prepare responses to basic, common questions. Know your strengths and weaknesses; be prepared to discuss your choice of a specialty; prepare a concise explanation of your research; know why you would want to live in that program's city and train at that institution. Many interviewers ask all applicants similar questions. Talk to your friends and find out what they were asked.
3. Prepare your own questions. Some interviewers prefer not to ask questions and would rather have the applicant take the lead in the conversation. Try to engage the interviewer.
4. Give off a good vibe. Ultimately, interviewing is about finding a fit between a program and an applicant. Avoid coming across as aggressive or overconfident (but also not too shy).
5. Be knowledgeable, but avoid being overly rehearsed or boring in your responses.

Finally, it is probably worth practicing your interview. Many medical schools hold mock interviews with older students or faculty members playing the role of interviewer. You can get good advice from more senior students who have recently been through the process. A mentor in your specialty may also be willing to practice an interview with you. Compare notes with your friends who are going on interviews to review their prepared questions and "rehearsed" answers. If you are very nervous and think you need more formal advice, you may want to hire a consultant.

At the end of the day, this is your chance to explore a program and to let them see you as an individual. The more conversational the experience you have, the better.